Dysphagia
An approach to symptom management to guide decision-making in the management of patients with life-threatening illness
Definitions
Dysphagia is a subjective awareness of difficulty in swallowing.
Odynophagia means painful swallowing.
Swallowing is a complex phenomenon involving the brain stem, the cranial nerves and the skeletal muscles. Swallowing is dependent upon the normal functioning of the buccal cavity, pharynx, upper oesophageal (crico-pharyngeal) sphincter, the body of oesophagus, lower sphincter of the oesophagus and the neurological pathways that supply them.
Appropriate assessment to identify cause and severity of symptoms
Associated problems
Coughing whilst eating, dribbling, aspiration pneumonia, poor oral intake, hunger and thirst, weight loss and dehydration.
Causes of dysphagia
| Mouth problems Dry mouth Radiation induced mucositis Candidiasis Herpes Sore mouth | Peripheral nerve Mono-neuritis multiplex Diabetic neuropathy |
| Infection Candidiasis Herpes simplex CMV (Cytomegalovirus) Pharyngeal abscess | Myopathies Dermatomyositis Muscular dystrophies Thyroid myopathy |
| Neurological Cerebral tumour MND Multiple sclerosis Huntington's Chorea CVA Parkinson's disease | Obstructive Oro-pharyngeal malignancies Malignant lymphadenopathy Surgical resection/radiation induced oesophageal/gastric neoplasm Bronchial carcinoma |
| Inflammation Reflux Radiation induced mucositis NSAID | Psychogenic |
Explanation to patient and family at all stages
Explain the causes of difficulty in swallowing. Providing food to one’s family is an essential part of nurturing those we love and when a patient cannot eat and/or refuses food it is very distressing for family members. The palliative care team will attempt to reverse those causes that are reversible; but towards the end of life the desire for food and the need for food diminishes and this needs to be explained to the family so that it does not become a source of conflict.
Correct reversible factors: such as candidiasis, infections, drug-induced oesophagitis/gastritis – stop NSAIDs.
Consider disease-specific palliative therapy:
Radiation for tumour impinging on oesophagus.
Institute non-pharmacological interventions
Dietary advice:
- Recommend suitable soft food
- Use of liquidiser / blender
- Add cream to soup (high calorie content)
- Offer general advice about managing mealtimes, frequent small meals rather than large meals at set times
Prescribe appropriate first-line treatment
Apart from disease specific treatment e.g. to control infections, there may not be appropriate first-line treatment
Consider adjuvant/second-line treatment
- Trial of dexamethasone (4-8mg / 24 hourly) if it is likely that oedema surrounding a tumour is aggravating problems of dysphagia
- Endoscopic dilation or stent
- Radiotherapy
- PEG tube as an alternate method of feeding. This will depend on the patient’s health, general condition and on agreement with the patient and family.
- If a patient is not able to swallow medication these can be administered via alternate routes such as a syringe driver.
Review assessment and management regularly
- At all stages of management consider:
- Involvement of interdisciplinary team
- Referral to appropriate service/more experienced clinician