On Friday, Mary and I had an opportunity to view a modified barium swallow study in the radiology department. It was a neat opportunity to have, and I’m glad we were able to squeeze it into our last day of rotations at Mon Gen hospital!
If a patient appears to have a problem or claims to have a problem with swallowing (dysphagia), they can get a referral from their doctor to get a modified barium swallow study done. The patient we saw was an older gentleman who claimed he had been occasionally experiencing a choking sensation when eating foods so he was sent in to see if there was any aspiration. Aspiration of liquids or food into the lungs can be a serious problem as it can cause partial or complete obstruction of the airway and can even cause aspiration pneumonia.
Dysphagia can be seen in patients who have had a traumatic brain injury, stroke, cancer of the head and neck, recent intubation, or those with Parkinson’s disease, Multiple Sclerosis, Lou Gehrig’s disease (ALS), Alzheimer’s, Cerebral Palsy, Huntington’s disease, Down’s Syndrome, or dementia.
A patient who is participating in a modified barium swallow study will sit down in front of an x-ray machine and are told to drink/eat certain foods that have had barium added to it; the barium is a chalky-white powder that is easily identified on the x-ray image. The swallow study I observed used a regular/unthickened liquid, nectar-like, honey-like, and pudding-like consistencies. There were also canned peaches cut up into small bite-sized pieces that were mixed and coated with barium and graham crackers dusted with barium as well. The swallow study went in order from unthickened liquid, to gradually thicker liquids, to the solid foods. The patient we observed had no abnormal swallowing patterns, so the choking sensation he said he has when eating may be an occasional symptom due to an esophageal stricture. Here is a video showing what a modified barium swallow study looks like:
While radiologists, speech pathologists, and physicians are more involved with the modified barium swallow study, registered dietitians are involved to some extent as well. Dietitians can see patients and through asking questions or observing the patient, they may come across signs of dysphagia. In my experience during clinical rotations at Mon Gen, I came across several patients with dysphagia. One patient was an elderly woman who had recently had a stroke. She had some trouble swallowing so her meals were all mechanical soft. Other patients have more severe forms of dysphagia so their diets consist of thickened liquids, as swallowing liquids of thin consistency (juice, water) require the most coordination and control and are easily aspirated into the lungs. Foods can be thickened to nectar-like, honey-like, or pudding-like consistency, or patients can be put on a puréed or mechanical soft diet. The diet they are put on at the hospital depends on the results of their swallow study.
An example of a thickener is shown above. Liquids can be thickened with nonfat dry milk powder, cornstarch, modular carbohydrate supplements, or commercial thickeners that contain a modified cornstarch thickener.
It is important to evaluate a patient for dysphagia so they can be put on a safe diet that is adequate in calories and nutrition. Dysphagia often leads to malnutrition because of inadequate intake, so weight loss is a key concern. In addition, patients with dysphagia can be dehydrated due to their decreased liquid intake, which can lead to fatigue and malaise.
Nutrition intervention depends on each patient’s severity of dysphagia and the extent of their malnutrition, dehydration, or weight loss. Dietitians should ensure that a patient with dysphagia is put on is palatable and nutritionally adequate diet. Patients may need to have vitamin or mineral supplementation, and some patients may benefit from nutritional support such as 8oz of Ensure or 4oz of Healthy Shakes BID or TID.