What is dysphagia?

Dysphagia is a condition in which the individual has difficulty swallowing. Proper swallowing relies on a complex coordination involving more than 30 nerves and muscles. When even one of these elements fails to work properly, dysphagia can result. 

There are four stages of swallowing and each stage relies on multiple muscles working together:

  1. The oral preparatory stage –  This stage involves chewing food and mixing it with saliva to form a bolus.
  2. The oral propulsion stage – In this stage, the tongue pushes the food into the throat and swallowing is initiated.
  3. The pharyngeal stage – This stage occurs within one second so it relies on the fast action and coordination of the muscles involved. It begins with the initiation of the swallow which moves the bolus through the pharynx and into the esophagus by way of peristaltic contraction. At this stage, the vocal folds close to prevent food or liquid from entering the lungs. This stage ends when the bolus passes through the upper esophageal sphincter.
  4. The esophageal stage – In this stage, the bolus is transported through the esophagus by peristalsis and ends once it passes through the lower esophageal sphincter.

What causes dysphagia?

Dysphagia can occur due to a variety of functional or structural abnormalities at any stage in the swallowing process.  Conditions that put a patient at high risk for dysphagia include: 

  • Conditions that affect the neurological system such as stroke, multiple sclerosis, Parkinson’s disease, head injury, amyotrophic lateral sclerosis (ALS), cerebral palsy, and even dementia.
  • Conditions that affect muscle function such as myasthenia gravis, muscular dystrophy, and esophageal spasms.
  • Structural abnormalities such as cleft lip/palate and esophageal atresia.
  • Complications related to acid reflux such as peptic or esophageal strictures and esophagitis.
  • Cancers of the mouth, neck or esophagus.
  • Radiation to the thorax, head or neck.
  • Certain autoimmune disorders such as Sjogren’s disease and scleroderma.
  • Medications that reduce awareness or cause sedation such as opioids, benzodiazepines, anti-seizure medications, and muscle relaxants.
  • Topical medications that depress the gag reflex such as lidocaine used for upper endoscopy or bronchoscopy.
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What are some signs a patient may have dysphagia?

Because dysphagia can cause serious complications, it’s important to recognize signals that someone may have difficulty swallowing.

A key sign someone may have trouble swallowing is the presence of dysarthria or slurred speech. This often occurs after a stroke, so if your stroke patient has slurred speech, you’ll want to avoid giving them anything by mouth until you verify it is safe to do so by the speech language pathologist (SLP). In fact, even without dysarthria, most hospitals have a policy of keeping stroke patients NPA and ordering a SLP evaluation because the risk for aspiration is so high.

Other signs and symptoms associated with dysphagia include:

  • Hoarse voice
  • Drooling
  • Coughing with swallowing food or liquid
  • Pain with swallowing
  • A feeling of fullness in the throat after swallowing
  • Choking when eating or drinking
  • Regurgitation (may be through the nose)

In some cases, the patient may not show outward signs of difficulty swallowing, yet show signs of aspiration such as frequent lung infections, decreased SpO2, tachypnea, or an abnormal chest X-ray. When this occurs it is called “silent aspiration.” 

Complications of dysphagia

The most significant complications of dysphagia are aspiration and choking. Aspiration leads to a particular type of pneumonia called “aspiration pneumonia” which can be very serious especially if gastric contents enter the lungs. Choking is, of course, immediately life-threatening and requires emergent treatment to clear the airway. Other complications of dysphagia include malnourishment, weight loss, dehydration and electrolyte imbalances. 

Bedside swallow evaluations

There are two types of bedside swallow evaluations used for a patient with dysphagia. A commonly used screening tool is the Barnes-Jewish Hospital Stroke Dysphagia Screen. This validated tool takes the nurse step-by-step through a screening process that helps identify patients at risk for dysphagia. 

The screening tools asks the nurse to determine:

  • If the GCS is less than 12
  • If there is asymmetry or weakness with the face, tongue, or palate

If the answers to those screening questions is no, the nurse then administers three ounces of water to the patient and observes for signs of coughing, throat clearing or a change in vocal quality. If any of these signs are present, the patient is referred to a speech language pathologist (SLP) for further evaluation. 

The evaluation by the SLP is more detailed and extensive. It involves interviewing the patient about possible signs of aspiration or associated medical conditions. The therapist inspects the mouth and muscles of swallowing to check for symmetry, strength, coordination and range of motion. Next, the therapist provides the patient with water and a variety of foods to eat such as applesauce, soft solids (peaches are common) and crackers. Throughout the evaluation, the therapist is observing the patient’s swallowing ability, looking for food that remains in the mouth after swallowing, and for any signs of distress. The therapist then writes their recommendation for the patient’s specific diet texture. 

Diagnostic tests for dysphagia

In addition to the speech language pathologist evaluation, other tests may be utilized in the diagnosis and evaluation of dysphagia. 

Barium swallow test – In this test, the patient drinks a barium solution that is visible on X-ray so the process of swallowing can be evaluated. This is especially useful in cases of silent aspiration as the barium solution is visible in the airway and lungs. 

Fiberoptic endoscopic evaluation of swallowing (FEES) – In this test, a small camera is inserted through the nose to visualize the larynx and esophagus as the patient swallows foods and liquids containing a visible dye.

Upper endoscopy – Using a scope inserted through the mouth into the esophagus, the gastroenterologist can identify structural abnormalities that contribute to dysphagia such as esophageal strictures or tumors.

Esophageal manometry – A tube is inserted through the nose into the stomach and connected to a device that measures esophageal contractions as fluid is swallowed.

Diet textures for dysphagia

Depending on the individual’s swallowing ability, the SLP will write a recommendation for a specific texture or level of diet. Note that there is no universal terminology for modified foods and what is level 1 at your facility may be level 5 at another.

  • Pureed: All foods are pureed to a pudding-like consistency including meats, vegetables, and even dessert. Examples of foods include applesauce, cream of wheat cereal, mashed potatoes and pudding.
  • Minced: In addition to being minced (cut up very small), foods are soft textured and moist so they’re easy to swallow. Examples include minced chicken served with gravy, oatmeal, and minced vegetables.
  • Bite-sized: Foods in this category are cut a bit larger but are still soft and easy to eat. Examples include scrambled eggs, fruit cocktail, and macaroni.
  • Soft or easy-chew: This texture consists of foods that are simply easy to chew such as pasta, eggs, well-cooked vegetables, tender meats.

The SLP will also determine if patients need their liquids thickened, as thick liquids are easier to swallow than “thin” or standard liquids. Liquids are thickened with a special thickening agent, and the consistency will depend on the patient’s needs.

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Safe feeding and aspiration prevention

When you care for a patient with dysphagia or who is at risk for aspiration due to medications or decreased LOC, you must always be thinking about patient safety. 

  • Know which patients are at risk for difficulty swallowing and aspiration.
  • Ensure suction equipment is functional and available at all times, and suction the oropharynx as needed.
  • Maintain HOB 30-degrees at all times to prevent the aspiration of oral secretions or gastric contents (such as in GERD). This is especially true for patients receiving continuous enteral feedings.
  • Position the patient in high-Fowlers or sitting up in a chair for eating and drinking. Remain upright for 30 to 60 minutes after eating.
  • Encourage the patient to eat slowly and to chew each bite thoroughly before swallowing. Remove all distractions and allow the patient to fully focus on the process of eating safely.
  • Follow all SLP guidelines for eating, which can include things like having the patient tuck their chin toward their chest as they swallow, checking for food pocketed in the cheek, and possibly holding liquids until the end of the meal.
  • Monitor for signs of aspiration or swallowing difficulty such as coughing, drooling, clearing the throat, or respiratory distress. If any signs are noted, stop the meal and notify the physician and SLP.
  • Ensure medications are swallowed safely by administering them with an easy-to-swallow substance like applesauce, crushing those that can be crushed, or requesting alternative formulations such as liquids. 
  • Perform oral care after each meal to ensure no bits of food remain in the oral cavity.

Review dysphagia for your exams, clinicals, and NCLEX while you’re on the go by tuning in to episode 342 of the Straight A Nursing podcast. Tune in wherever you get your podcast fix, or straight from the website here.


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BJH. (2006). Figure 1. The BJH Stroke Dysphagia Screen. ResearchGate. https://www.researchgate.net/figure/The-BJH-Stroke-Dysphagia-Screen-Abbreviation-BJH-Barnes-Jewish-Hospital_fig1_255175667

Cleveland Clinic. (2022, October 10). Silent Aspiration: Symptoms, Causes & Treatment. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/24271-silent-aspiration

Gastroenterology Associates of Beverly Hills. (n.d.). DYSPHAGIA 5 LEVELS. Gastroenterology Associates of Beverly Hills. Retrieved March 20, 2024, from https://www.gastrobh.com/contents/patient-info/dietary-education/dysphagia-5-levels

NHS inform. (2023, December 13). Dysphagia (swallowing problems). NHS Inform. https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-tract/dysphagia-swallowing-problems/

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Ramsey, D., Smithard, D., & Kalra, L. (2005). Silent aspiration: what do we know? Dysphagia, 20(3), 218–225. https://doi.org/10.1007/s00455-005-0018-9

St George’s University Hospitals. (2016). IDDSI Diet Levels & Information. St George’s University Hospitals NHS Foundation Trust. https://www.stgeorges.nhs.uk/service/therapies/speech-and-language-therapy/our-new-fluid-and-diet-terminology/iddsi-diet-levels-information/

Tracheostomy Education. (2019, April 19). Normal Swallowing. Tracheostomy Education. https://tracheostomyeducation.com/normal-swallowing/