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Swallowing Problems
More than ½ of all people who have a stroke will find it difficult to eat and drink afterwards. This is called dysphagia and is caused by damage to some of the nerves and muscles used for chewing and swallowing.
Most people recover their swallow within a few weeks. Some will take longer, and a few people find that their ability to swallow does not come back.
Indications
- coughing and choking when you try to swallow food or fluids
- food sticking in your mouth or throat
- dribbling or drooling
- difficulty ‘getting food over’
- taking a long time to eat and drink
- your voice sounding wet and ‘gurgly’ after eating or drinking
- feeling anxious or embarrassed about eating or drinking, particularly in front of others
- losing weight
- feeling food or drinks are going down the wrong way
- if food or drinks go down the wrong way you may develop a chest infection with difficulty breathing and a high temperature
Who Will Help?
Speech and language therapists (SLTs) work with dieticians, occupational therapists, doctors and nurses to help you with a swallowing problem.
What Is The Immediate Treatment?
When you have a stroke you should not eat or drink anything until you have had your swallowing checked by a health professional (usually a nurse) in hospital. This is done with a simple water swallow test, during which you are given a few teaspoons of water.
If you manage to swallow this without coughing or choking, you are given a larger amount of water to drink. If you can also swallow this without any problems, you will be allowed to eat and drink normally.
If you have swallowing difficulties your swallowing should be monitored daily by staff and you are likely to be referred to the SLT for a fuller swallowing assessment (see below).
If you feel you are having any discomfort or difficulties swallowing food or drinks, it is really important that you let your nurse or doctor know.
Swallowing Assessment
If you still have swallowing problems after the first few days, you will be assessed by an SLT and a dietician. The SLT will carry out a full assessment and screen for the risk of food or fluid getting into your lungs.
You may have another test at this time called videofluoroscopy. This involves you swallowing a small amount of fluid containing barium, which shows up on a video X-ray machine. This highlights where your swallowing problems are occurring.
What Happens Next?
If the doctors and speech and language therapist feel that you are at risk of inhaling food or drink into your lungs (aspiration), you will not be allowed to eat or drink at all for the time being (nil by mouth). You will be started on fluids through a drip into a vein and the dietician will prescribe any nutritional supplements you need.
If appropriate, the speech and language therapist will show you some swallowing techniques, and positions or exercises which can help food and drink to go down more easily and safely.
How Is Food Reintroduced?
In some cases you may be started on thickened drinks. Thickened drinks move more slowly through the mouth and throat and maybe easier to begin with. You may be prescribed pre-thickened juices and milk drinks. Alternatively a thickening powder can be added to almost any drink to provide the right consistency. A softer, moister diet is appropriate for some people with swallowing problems. The speech and language therapist will advise on what is best for you.
Making Food More Appetising
Sometimes pureed food can look unappetising, particularly if all the components are pureed and mixed together as one.
The latest Scottish Intercollegiate Guidelines Network (SIGN) guidelines state that people with swallowing problems should be offered a choice of dishes and that pureed food should be attractively presented.
In some hospitals dieticians are now experimenting with putting pureed foods into shaped moulds. This means that when it is served it has the colour and shape of the food it actually is, for example a chicken fillet and a portion of peas rather than both mixed together making a thick greenish soup.
Poor Appetite
You may find that your appetite is poor particularly if you have not been eating for a while. It may be easier to have smaller, more frequent meals. Discuss with your dietician what you like to eat and whether the different components of your meals could be separated out (see previous).
The dietician will make sure you are getting enough nourishment and may recommend you have nutritional supplement drinks to provide you with some extra vitamins and calories.
Special Equipment
If your stroke has left you with a physical disability, the occupational therapist can provide special cutlery, plate guards and non-slip mats. You may find that you need help to feed yourself from nursing staff at first.
Simple Tips For Easier Swallowing
- sit in a quiet place and keep distractions to a minimum. Don’t try to talk and eat at the same time.
- sit in an upright position while you are eating and for half an hour after meals to aid digestion
- avoid tipping your head back
- take smaller mouthfuls, and don’t mix food and drink in the same mouthful
- chew your food well
- make sure your mouth is empty before taking another mouthful
- taking smaller, more frequent meals may be less tiring
- avoid foods that you find difficult, such as hard, dry or stringy foods
- avoid using straws unless an SLT has recommended these for you
- ask your doctor to prescribe your medicines in syrup or liquid form. Check with your doctor or pharmacist before crushing any tablets.
What Is The Longer Term Treatment?
It is extremely important that your body is kept well-nourished and hydrated with plenty of fluids so that you stay healthy and aid your general recovery from stroke. If you are unable to take foods and fluids in normally because of a swallowing problem, tube feeding may be necessary.
Nasogastric Tube Feeding
If you are still unable to swallow and take any food by mouth after a few days, you will need nasogastric (NG) tube feeding.
Your nurse will pass a narrow tube up through your nose, down the back of the throat and into your stomach. This can be a bit uncomfortable, but it is usually quite a quick procedure and should not be painful.
The tube will be securely attached to your nose with medical tape to prevent it from falling out. The dietician will prescribe a balanced liquid diet specifically tailored to your needs, and this will be dripped slowly into your stomach through the NG tube.
The NG tube is only suitable for short-term use because your nose and throat can become irritated or even ulcerated from the pressure of the tube, if it is left in place for more than a few weeks. The dietician will assess when you are able to swallow again without problems and the NG tube can then be removed.
Percutaneous Endoscopic Gastrostomy Feeding
However, if you need artificial feeding for longer than 4 weeks, a PEG tube (Percutaneous Endoscopic Gastrostomy) may be needed. A PEG tube is a flexible, fine tube which is inserted under local anaesthetic, directly into your stomach through a small incision in your abdominal wall.
The PEG tube is held in place by a plastic disc like a button so you won’t need any stitches. When required an external tube is attached, and liquid supplements and medicines, and even pureed foods are administered through the tube.
You will be advised to sit upright for 30-60 minutes during and after feeding. The ‘button’ can be covered up by clothing when not needed.
Living With A PEG Tube
Before leaving hospital, your nurse will explain to you or your carer
- how to attach the tube
- how to prevent it clogging by flushing it with water before and after use
- how to care for the skin around the tube
- how to recognise any sign that the area might be infected
- what to do If the tube blocks, or there is infection. The dietician will offer advice about types of liquid food which can be taken.
- how to hide your tube under your clothes
- how to take a bath with a PEG tube
- when you will be able to get back to your normal daily activities
It is important to remember that your ability to swallow can return even months after your stroke, so your speech and language therapist or doctor should continue to reassess your swallowing regularly.
Useful Contacts
Patients On Intravenous And Naso-Gastric Nutrition Therapy (PINNT) or via
Mrs Sharon Bell
59 Loanfoot Avenue
Knightswood
Glasgow G13 3DG
Telephone 0141 959 6701
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