INTRODUCTION — Difficulty swallowing is a disturbing symptom that occurs in the vast majority of patients with a serious life-limiting illness. In fact, swallowing disorders, distinct from diminished appetite, are part of the natural process at the end of life, irrespective of the etiology. Difficulty swallowing can impact the quality of life of the patient as well as of caregivers, whose natural instinct to nurture and comfort with food is curtailed. Dysphagia is a poor prognostic sign in patients nearing the end of life, and for many patients with a life-limiting illness, the inability to swallow may represent a pivotal symptom that prompts the decision to consider end-of-life or hospice care.

Swallowing disorders occur frequently in patients with malignancies of the upper aerodigestive tract and brain as well as with progressive degenerative neurologic disorders, including dementia. But they can occur as a result of the general debility that develops in patients with a variety of medical illnesses who are near the end of life. Dysphagia can be a cause of and/or result of dying. Muscle wasting, cachexia, and asthenia affect the coordination and muscle strength needed for swallowing, which in turn, can lead to poor appetite and inefficient oral intake. In addition to inefficient swallowing, dysphagia is a major predisposing condition for aspiration, which can lead to pneumonia and can contribute to malnutrition, dehydration, and, in some cases, death [1,2].

The consequences of aspiration can vary widely, from no injury at all to pneumonia or asphyxiation due to airway obstruction. Sometimes the impact is immediate, as occurs with asphyxiation, or it may develop slowly, depending on the volume and chemical composition of the aspirated material. Most importantly, the effectiveness of the patient’s pulmonary defenses and airway clearance mechanism can predict the implications of aspiration of food or liquid into the airway. Providers, patients, family, and caregivers would be well served in recognizing the signs of dysphagia, securing airway protection, and determining appropriate ways to provide nutrition and hydration and to administer medications.

Management of swallowing disorders is especially challenging in this unique patient population, and the risk for aspiration may persist even with therapeutic intervention. Adherence to recommendations for safe swallowing is problematic. Patients may not choose to change their diet consistency, and serious illness may impact their vigilance and attention to treatment recommendations. Given these multiple variables, it is daunting for providers to quantify the true implication of aspiration, even if swallowing is only somewhat impaired.

With their expert knowledge of the assessment and management of oropharyngeal dysphagia, speech-language pathologists (SLPs) play a critical role in the multidisciplinary team by providing careful assessment to determine swallowing potential, prognostication to assist in decision-making, and guidance in safe and appropriate feeding methods. The SLP provides patients, families, and the medical team with an increased understanding of the normal and dysfunctional swallowing processes and suggests methods for maximizing comfort and quality of life in the face of the progressive symptoms of dysphagia that accompany the patients at this stage [3,4].

This topic review will cover the assessment and management of swallowing disorders in patients with life-limiting illness. A review of normal and disordered swallowing and a description of types of swallowing disorders are presented elsewhere, as are reviews of speech and swallowing rehabilitation for patients treated for head and neck cancer, aspiration pneumonia in adults, and aspiration due to swallowing dysfunction in children.

●(See "Swallowing disorders and aspiration in palliative care: Definition, consequences, pathophysiology, and etiology".)

●(See "Speech and swallowing rehabilitation of the patient with head and neck cancer".)

●(See "Aspiration pneumonia in adults".)

●(See "Aspiration due to swallowing dysfunction in children".)

WHEN TO SUSPECT A SWALLOWING DISORDER — Specific clinical features, disease states, patient characteristics, and medical interventions that can predict an increased risk of swallowing dysfunction are outlined in the table (table 1). Recognizing factors that are clinically associated with or cause a swallowing impairment can guide referral for appropriate assessment and management.

Detection of a swallowing disorder may elude the attention of both patients and caregivers. Silent aspiration (where food enters the upper airway without overt signs of coughing or choking) is a common correlate of dysphagia. In fact, 40 percent of patients who aspirate are said to aspirate silently, and this is more likely in individuals with a serious life-limiting illness where multiple causative factors coexist [5]. Clinicians should be alert for surrogate markers of dysphagia, such as general frailty, unexplained fever or cough with chills, alterations in secretion volume, color, or viscosity, chest pain, or dyspnea. Weight loss and poor appetite are predictable at the end of life, but when they coexist with respiratory findings and signs of struggling during eating, a swallowing disorder may be the possible cause.

ASSESSMENT — Speech-language pathologists (SLPs) assess and manage oropharyngeal swallowing disorders across all care settings. The goals of a clinical swallowing assessment are to identify the pathophysiology of the disorder and to determine relevant interventions [6]. The assessment must be framed by an understanding of the overall health status of the patient in conjunction with the patient and caregiver’s wishes and preferences, particularly in relation to nutrition and hydration. As such, the evaluation reaches beyond the physiology of swallowing. Together with the multidisciplinary team caring for patients with advanced life-threatening illness, the SLP must carefully weigh which swallowing interventions might benefit the patient against those that will be excessively burdensome.

The following principles of palliative care should be considered: patient and family are the unit of care and their wishes and preferences guide collaborative decision-making; prevention and relief of suffering with an emphasis on ensuring comfort; a care plan which reflects the prognosis and overall goals of treatment of the underlying life-threatening disease, and can be adjusted as the disease evolves; and optimization of care within an interdisciplinary team framework, whereby each specialist contributes expert knowledge.

Clinical history — A detailed clinical history and patient description of swallowing complaints is essential in framing the nature of the swallowing problem and establishing the diagnosis. Frequently encountered patient complaints regarding swallowing and their potential physiologic counterparts are outlined in the table (table 2). As an example, the swallowing history may suggest a mechanical obstruction from tumor burden or stricture, or an underlying neuromuscular weakness. Patients who complain of dysphagia with solid food and who localize the area of difficulty to the throat may have either esophageal or pharyngeal dysphagia, and thus both locations must be investigated [7].

Alterations in eating behaviors, the severity and specific nature of the complaints, the details of disease progression, and prior treatment can provide clues to factors that might predispose the patient to silent aspiration. (See "Swallowing disorders and aspiration in palliative care: Definition, consequences, pathophysiology, and etiology".)

Length of meal time and effort required are indicators of eating efficiency. Dependence for feeding, changes in eating habits or diet, and total calorie intake should be investigated. Additional areas of inquiry include factors that alleviate or exacerbate the problem, such as body position and time of day, the ability to swallow medication, and the presence of pain on swallowing. Potential indicators of a swallowing disorder, based upon the clinical history and direct observation, are outlined in the table (table 2). (See 'Direct observation of swallowing function' below.)

Understanding the emotional and psychologic impact of the swallowing disorder on the patient and family is as important as ascertaining the physiologic correlates of the problem and provides a helpful framework for determining the next steps in the workup and management of the problem. A patient with a poor appetite, fatigue, and a sense of hopelessness may be less motivated to engage in a complex diagnostic and treatment program. Alternatively, a patient who derives much satisfaction from eating and drinking and wishes to continue with a regular diet may not be satisfied with significant alterations in food texture, smell, and consistency. There are often competing benefits and risks regarding swallowing function and nutrition, and attention to the patient’s preferences is paramount in providing appropriate psychosocial support. Sometimes there is an imbalance between the patient and caregivers’ goals around nutrition, a dynamic that should be factored in when decisions are being considered.

Cultural norms and preferences play a distinct role in relation to nutrition and feeding across the lifespan but especially at the end of life. Food preferences evoke memories of family and connection, and food preparation and the act of feeding can be intrinsically associated with demonstrating love. Often families hold on to specific and favorite cultural foods and liquids that are believed to bring comfort and relief and may butt up against physiologic indicators of dysphagia. Cultural factors should be explored using the shared decision-making framework of open communication, creative problem solving, and respect for difference and patient autonomy.

Physical examination

Assessment of oral hygiene — The status of the oral mucosa and general oral hygiene reflect the patient’s ability to manage secretions, patient comfort, and ease of swallowing solid boluses and can provide prognostic clues regarding the impact of aspiration if it occurs. Oral health is often compromised in those who are seriously ill, and oral hygiene may be neglected. (See "Palliative care: Overview of mouth care at the end of life".)

Severe illness and polypharmacy may alter the normal oral environment, salivary production, and growth of oral bacteria [8]. Aspiration of colonized bacteria can introduce inoculum into the lower airways that may be difficult to clear. Saliva is essential for the maintenance of oral health as it neutralizes acid, lubricates the hard and soft tissues, and aids in bolus formation. Persistent dry mouth (xerostomia) is also a strong predictor of patient comfort. Xerostomia may cause, contribute to, or exacerbate dysphagia. Xerostomia is a frequent complication of radiation therapy to the head and neck region, polypharmacy, and the use of supplemental oxygen. (See "Management of late complications of head and neck cancer and its treatment", section on 'Salivary gland damage and xerostomia' and "Management and prevention of complications during initial treatment of head and neck cancer", section on 'Salivary gland damage and xerostomia'.)

It is not uncommon to find dry secretions and/or thrush crusted along the tongue, palate, and pharynx in patients who have not eaten orally in some time. Dental caries and dentures that are not well cared for can also contribute to poor oral hygiene. Dried oral secretions may also loosen during trials of oral food or fluids and inadvertently obstruct the airway. Before giving the patient food or liquids, even for assessment purposes, the oral cavity should be carefully cleared of extraneous secretions using mouth swabs, tongue scrapers, toothbrushes, and oral suction, if necessary.

Cranial nerve examination — Findings from the examination of cranial nerve (CN) function is pertinent to swallowing (CN V, VII, IX, X, and XII) (table 3). Motor responses are evaluated for symmetry, speed, strength, accuracy, and range of movement. For example, unilateral tongue weakness may affect formation of a solid bolus, a facial palsy may cause drooling, and a weak cough may be associated with aspiration. Sensory input is also a key contributor to swallowing integrity and can influence the force of mastication, the timing of the pharyngeal swallow response, and the intensity of the pharyngeal and/or esophageal motion [9]. (See "The detailed neurologic examination in adults".)

Direct observation of swallowing function — Observation of the patient while eating, drinking, or taking medications can yield valuable information regarding not only the likelihood of aspiration but also the efficiency of swallowing function. Additional indicators of a potential swallowing disorder, derived from the initial clinical examination, are outlined in the table (table 1). (See 'Assessment' above.)

Effective airway protection is a critical predictor of safe swallowing and entails timely and complete laryngeal closure during swallowing, with a strong cough at the glottis and pharyngeal expectoration in response to aspiration. Patients with a weak voice and/or reduced expiratory strength for coughing are at a higher risk for impaired airway clearance after aspiration. A delayed cough, even if it is strong, may signal impaired airway protection. (See "Swallowing disorders and aspiration in palliative care: Definition, consequences, pathophysiology, and etiology", section on 'Normal swallowing'.)

Patients who do not respond to aspiration with a cough or throat clear are “silent aspirators,” a phenomenon that cannot be definitively discerned from the clinical observation alone [5,10]. Occult signs of aspiration include a wet vocal quality or gurgling; other signs/symptoms include frequent throat clearing, delayed coughing, and/or oral or pharyngeal residue after a swallow [11,12]. (See 'When to suspect a swallowing disorder' above.)

“Silent” aspiration can only be confirmed definitively with an instrumental examination, such as videofluoroscopy, or laryngoscopy [10,13].

Impaired swallow efficiency is reflected in protracted chewing, inattention, holding food for prolonged periods, drooling, and regurgitation.

Instrumental evaluation — When the clinical swallowing evaluation reveals concerning but indeterminate findings, and further investigation aligns with the patient’s clinical status, goals, and preferences, videofluoroscopic or endoscopic evaluation of swallowing can provide valuable diagnostic information and suggestions for management [14]. (See 'Facilitative swallowing strategies' below.)

It should be emphasized that each of these examinations involves moving the patient and some degree of discomfort. Sometimes pain, difficulty positioning, and wakefulness preclude an instrumental examination.

Videofluoroscopic swallowing study — Videofluoroscopic swallowing study (also known as modified barium swallow study) is a noninvasive radiographic procedure that examines the oral, pharyngeal, and cervical esophageal stages of swallowing (image 1A-B) [13]. SLPs perform these studies in collaboration with radiology staff. A digital video recording is made and can be replayed at slow speeds to facilitate accurate analysis.

The patient is seated upright and swallows a variety of consistencies of barium-coated foods (liquids, semisolids, and solids). Videofluoroscopy identifies the pathophysiology of the swallowing disorder, including the biomechanical reasons for aspiration and the patient’s protective response. The clinician can directly evaluate the effectiveness of interventions that may decrease the risk of aspiration and increase swallowing efficiency. (See 'Facilitative swallowing strategies' below.)

Barium swallow — This study examines esophageal function fluoroscopically and concentrates on the anatomy of the esophagus and passage of barium liquid and pill into the stomach. It can identify mucosal and anatomical abnormalities, esophageal strictures, and assess esophageal motility. (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults", section on 'Esophageal manometry' and "Oropharyngeal dysphagia: Clinical features, diagnosis, and management", section on 'Manometry' and "Clinical manifestations and diagnosis of gastroesophageal reflux in adults", section on 'Ambulatory esophageal pH monitoring'.)

Flexible endoscopic examination of oropharyngeal swallowing — The oropharynx and larynx are visualized transnasally with a laryngoscope while the patient swallows food and liquid dyed with food coloring for contrast. Laryngeal penetration (contrast in the laryngeal vestibule), aspiration (contrast below the vocal folds), and pharyngeal retention post-swallow can be observed. Flexible endoscopic examination of oropharyngeal swallowing (FEES) provides information about mucosal integrity and laryngeal function, such as vocal fold adduction and secretion management, but its view excludes the nature of the oral or esophageal stage dysfunction. As with videofluoroscopic swallowing study, therapeutic strategies, such as postural modifications or swallowing maneuvers, can be evaluated for their efficacy during FEES. (See 'Facilitative swallowing strategies' below.)

Esophagogastroduodenoscopy — An esophagogastroduodenoscopy (EGD) is an endoscopic evaluation of the esophagus, stomach, and upper small intestine and is completed by a gastroenterologist while the patient is sedated. EGD can confirm the presence of strictures and mucosal anomalies. Management of strictures with an esophageal stent, laser ablation of an intraluminal tumor, or dilatation can be accomplished during this procedure, if indicated. (See "Endoscopic palliation of esophageal cancer" and "Endoscopic stenting for palliation of malignant esophageal obstruction".)

MANAGEMENT — Dysphagia management in patients with life-limiting illness will vary according to where the patient is in their illness relative to the end of life. The speech-language pathologist (SLP) and the care team closely align the dysphagia plan of care with the overall treatment goals, preferences, and life prognosis [15].

The goal of managing dysphagia in patients with life-limiting illness is facilitative, rather than rehabilitative, to retain safe and effective oral feeding for as long as possible [16]. Comprehensive dysphagia management may use a variety of approaches concurrently, including alterations in food and liquid consistency, use of alternative routes for nutrition and hydration, direct swallowing therapy (where appropriate), and other medical interventions.

Shared decision-making — Patient autonomy and shared decision-making are critical ethical principles; however, a patient’s choice to continue with oral nutrition must be accompanied by a clear understanding of the possible risks and consequences (eg, aspiration pneumonia or malnutrition) [16,17]. Distress due to conflicting goals between caregivers and the medical team can arise. Involving the family at the outset may help prepare them for ensuing decline in oral intake and provide enhanced patient empowerment [18].

Family members are more likely to adhere to specific feeding strategies if they understand the physiologic and psychologic rationales for the recommendation and if they have been included in the decision.

Making decisions about optimal nutrition can be time consuming and emotionally exhausting. Continuing to orally feed a patient who is a known aspirator or the corollary (withholding food and liquid because of the danger of aspirating) causes medical providers and caregivers to feel that they may be willfully inflicting harm on the patient. Many family members forgo the option of nonoral feeding because of the attendant complications and the possibility of increased suffering. A frequent concern is of “starving the patient” if nutrition is inadequate and the decision is made not to pursue artificial nutrition. These fears often stem from long-held personal and cultural beliefs. Decisions about feeding entail some of the most difficult decision making faced by patients with a serious life-limiting illness and their loved ones and may require several meetings among the patient, caregiver, and treatment team. Decision aids regarding the pros and cons of non-oral nutrition can be useful to assist in advanced care planning [19]. (See "Stopping nutrition and hydration at the end of life".)

Swallowing interventions

Swallowing exercise — In general, direct swallowing interventions, such as strengthening exercise programs [20-23], are of limited value as the disease process progresses in the palliative care population and may result in increased burden and limited benefit [24]. More recently, greater attention has been placed on optimizing health and preserving functional reserve starting in early diagnostic stages of degenerative diseases such as dementia and amyotrophic lateral sclerosis. Resistive strength swallowing exercises may help to maintain physiologic swallowing function for longer [25]. The level of patient engagement, endurance, and cognitive ability to follow directions may preclude optimal participation in exercise attempts.

Facilitative swallowing strategies — The physiologic information obtained from clinical and instrumental swallowing assessment facilitates the selection of interventions that are aimed at increasing swallowing safety and efficiency. These strategies may compensate for impaired swallowing function by altering head or neck posture to redirect bolus flow, heighten sensory awareness, or change bolus characteristics to improve the safety of swallowing; their purpose is not rehabilitative in nature. The chief advantage of these strategies is that they are simple for the patient and caregiver to implement and require no complex instruction.

Postural modifications — Postural changes or changes in head position are described in the table (table 4) [20-22].

The chin tuck posture, a commonly used strategy, narrows the lumen of the pharynx by increasing tongue base retraction and pressure on the bolus and restricts the opening of the larynx during swallowing. These functional effects potentially reduce the risk of laryngeal penetration and aspiration. In cases of delayed onset of the swallow response, however, the chin tuck posture may induce or exacerbate aspiration, and therefore it is not safe in all cases.

Head rotation toward the weak side may benefit patients with asymmetric swallowing function, such as neurologically based dysphagia or following treatment for head and neck cancer. This postural change may promote bolus flow down the intact side by obstructing the weak side, thereby preventing post-swallow residue or aspiration.

These and other postural modification strategies may be used in isolation or in combination, depending on the nature of the underlying swallowing pathophysiology (table 4).

Increased sensory awareness — Intact sensation is essential for a timely and organized swallow. Sensory input for swallowing can be impaired due to certain neurologic dysfunctions, such as brainstem stroke and dementia, as well as in patients treated with radiation therapy for head and neck cancer. Some patients benefit from receiving food or liquid at a slower rate, changes in flavor characteristics, while others are more efficient with larger boluses [20,26,27]. Enhancing the bolus properties to include more texture can sometimes induce mastication more readily than a bolus that is both flavorless and homogeneous in texture. This is particularly relevant for patients with advanced dementia.

Diet considerations — Developing a safe and efficient nutritional plan for patients with life-limiting illness requires creative solutions. If the decision is to continue with oral intake, the safest diet should be suggested, and aspiration precautions should be introduced using data derived from the swallowing assessment. (See 'Assessment' above.)

The guiding principle is to ingest the maximum amount of calories and hydration for the least amount of effort. Nutritionists can provide individualized suggestions for calorie-dense foods or high-calorie supplements, taking the patient’s metabolic status into consideration.

Alterations in food and liquid texture and consistency — Modifying the texture of solid foods and consistency of liquids is widely used in the management of patients with dysphagia and may improve the safety and/or ease of oral consumption (table 5) [28,29]. However, low acceptability, resulting in poor adherence to modified food textures and liquids, can contribute to an increased risk of inadequate nutrition and hydration. As such, these modifications should be used judiciously and in the context of shared decision-making. Alterations in texture and viscosity must be balanced with foods that are pleasurable and appetizing for the patient in spite of their texture modification.

The International Dysphagia Diet Standardisation Initiative (IDDSI) is an international effort to standardize the terminology and definitions surrounding texture-modified diets to improve patient safety and interprofessional communication among health care professionals (table 6) [30]. This classification system uses a continuum of eight levels of thickness and texture using common terminology to describe liquids and foods [31].

Solid foods — The texture of solid foods may be modified to accommodate dysphagic symptoms. Foods may be pureed, chopped, or diced; prepared soft; and served with gravies and sauces to moisten them. Patients are frequently loathe to relinquish favorite foods and may prefer to eat less of a more textured item than to alter the food to a consistency that is easier to chew and swallow. However, altered food consistency or high-calorie nutritional supplements may offer a way for the patient to continue to eat orally.

Liquids — Aspiration on thin liquids is extremely common in dysphagic patients, especially those with weak lingual and pharyngeal musculature. The properties of slower flow and increased viscosity in thick liquids may reduce misdirection of the bolus into the airway. Liquids can be thickened to a range of viscosities from slightly thick to extremely thick [32]. Unfortunately, few naturally occurring dietary fluids are sufficiently viscous to offer protection from aspiration. Typically, liquids are thickened with a powder form of modified cornstarch, but sometimes these substances are unstable in fluids and can become too thick over time and lose their appeal. Xanthan gum or cellulose gel-based thickeners are more stable and have a greater likeability factor [33]. Thickened liquids release the fluid in the gastrointestinal tract and do not alter the body’s absorption rate of fluids. Poor adherence to recommended thickened liquids may lead to reduced fluid intake and an increased risk of dehydration as well as reduced comfort from dry mouth [34].

Additional suggestions — Additional suggestions for oral feeding include:

●Remove distractions at mealtime. This is particularly important for patients who need to concentrate on swallowing to increase safety (eg, patients who are using postural swallowing strategies) and for those who easily lose their focus and need to be fed (eg, those with dementia). (See 'Postural modifications' above and "Care of patients with advanced dementia", section on 'Eating problems'.)

●Provide assistive feeding utensils to patients who have difficulties associated with hand tremors or weakness. Devices such as weighted cuffs or built-up utensils may be helpful. Occupational therapists are often able to provide individualized assistive devices.

●Ensure optimal positioning when eating, drinking, or taking medications. The tendency to slump forward may cause loss of food from the oral cavity, while head extension can promote an open airway and make the patient more vulnerable to aspiration.

●Schedule meal times to coincide with greater levels of function (either due to effects from fatigue or medications) to enhance swallowing efficiency and safety. More frequent small meals may help patients who do not have sufficient endurance to complete an entire meal at one time.

●Where possible, patients should be encouraged to feed themselves. Consider hand feeding in patients with advanced dementia. Although hand feeding is time consuming, it allows for continued intimate contact between the patient and caregiver. Hand feeding as compared with tube feeding has been found to produce similar outcomes [35]. (See "Care of patients with advanced dementia", section on 'Oral versus tube feeding'.)

Artificial nutrition and hydration — The decision to pursue the option of nonoral nutritional support has significant ramifications for both the patient and the family. While aspiration of food or liquid could result in aspiration pneumonia, the decision to commit a patient who is aspirating to nonoral feeding or to nil per os (NPO, nothing by mouth) status is difficult and must be carefully considered [36]. Some patients with progressive disorders may already have a feeding tube in place prior to the terminal period. For others, patients, families, and caregivers may have to consider nonoral feeding options as the terminal stage approaches. The presence of a feeding tube does not inherently imply NPO or freedom from aspiration risk. Some patients may continue to take food or liquid for their pleasure and comfort. Families may feel that they have neglected their obligation to nourish their loved one safely. At the same time, patients and families may feel a sense of relief because the tube feeding formula may provide the patient with more strength and endurance, and perhaps enhanced quality of life. (See "The role of parenteral and enteral/oral nutritional support in patients with cancer", section on 'Head and neck cancer' and "The role of parenteral and enteral/oral nutritional support in patients with cancer", section on 'Esophageal cancer' and "Symptom-based management of amyotrophic lateral sclerosis", section on 'Management of swallowing and nutrition' and "Care of patients with advanced dementia", section on 'Oral versus tube feeding'.)

Maintaining airway clearance — An overabundance of secretions or change in secretion viscosity and composition may result from impaired swallowing. Airway clearance can be compromised in dysphagic individuals because of weak cough and/or capacity to expel secretions from the upper airways. This significant functional deficit can increase the risk for infections as well as affect oxygenation and respiration. Additionally, a struggle to clear the airway and resume comfortable respiration is concerning and potentially frightening for patients and their caregivers. A reliable and readily available mechanism for physical removal of secretions can be extraordinarily helpful [37]. The following are common secretion clearance techniques that can be used by family members or caregivers regularly, as in each case, the effect is short lived:

●A simple portable suction device with an oral wand can assist with clearance of oral and pharyngeal secretions. This device can give patients and their caregivers a sense of security that offending materials can be cleared, albeit temporarily.

●A mechanical insufflator-exsufflator or cough-assist device may help patients with weak cough, diaphragmatic dysfunction, and respiratory muscle weakness to achieve greater pulmonary clearance [38,39] (see "Respiratory muscle weakness due to neuromuscular disease: Management", section on 'Mechanical insufflation-exsufflation'). This device can be used at regular intervals throughout the day, or after meals as a means of removing aspirated food or liquid particles.

●High-frequency oscillating devices generate intra- or extrathoracic oscillations either via an oral route (positive expiratory pressure valve) or externally at the chest wall (vest-like apparatus). Their purpose is to mobilize secretions and mucus, and by extension, aspirated material, which eventually is expectorated. These devices can be used by the patients themselves or can be administered by caregivers. There is anecdotal evidence that these relatively noninvasive techniques are effective as part of a comprehensive airway clearance program in patients with life-limiting disease [40]. (See "Respiratory muscle weakness due to neuromuscular disease: Management", section on 'Secretion mobilization techniques'.)

Secretion management

Sialorrhea — Sialorrhea, or excessive drooling is common. Sialorrhea can contribute to skin irritation, poor oral health, and dehydration and can increase the risk of aspiration pneumonia. Furthermore, it is embarrassing and socially disabling.

There are several objective rating scales that can be used to document the extent of sialorrhea, guide clinical decisions, and measure treatment effects [41-44]. These include the Oral Secretion Scale (OSS), the Sialorrhea Scoring Scale (SSS), and the Clinical Saliva Scale for Motor Neuron Disease (CSS-MND) [43,44]. (See "Palliative care: Overview of mouth care at the end of life".)

Reversible causes should be addressed, such as treatment of oral infection, elimination of precipitating medications (if possible), and improvement of hydration. In the early stages, first-line management includes behavioral and compensatory management by an SLP to enhance oral motor function and sensation, to teach self-management of saliva and triggers/reminders to swallow, and to provide physical therapy and/or supportive neck collars for optimizing body and head posture.

Anticholinergic medications can be used to block parasympathetic stimulation to the salivary glands and thus reduce saliva production in cases of pervasive sialorrhea (eg, as experienced by those suffering from motor neuron disease) (table 7). These may include amitriptyline, benztropine, scopolamine patch, scopolamine (hyoscine) butylbromide, and sublingual atropine drops. Botulinum toxin injected subcutaneously into the submandibular and parotid glands has been shown to be effective in select cases [41,42]. (See "Management of nonmotor symptoms in Parkinson disease", section on 'Sialorrhea' and "Symptom-based management of amyotrophic lateral sclerosis", section on 'Sialorrhea'.)

Dry mouth — An equally debilitating symptom is dry mouth (xerostomia), which affects quality of life and increases frustration when the problem cannot be eliminated. Management largely focuses on alleviating, rather than eradicating, symptoms. Frequent moistening of the mouth with sips of fluid or crushed ice is recommended for those who are able to swallow. Swabbed mouthwash may increase comfort if the patient is unable to swallow liquids. The lips should be kept moist at all times.

Pharmacologic agents such as cevimeline or pilocarpine (cholinergic agonists) may improve saliva production more than nonpharmacologic means (eg, chewing sugarless gum, sucking on sugar-free hard candy) [45]. Commercially available saliva substitutes and products containing xylitol promote saliva production, reduce discomfort, and reduce dental caries, but they have been found to be of limited value [46]. Patients treated with radiation therapy for head and neck cancer have derived some benefit from acupuncture for dry mouth [47]. (See "Management of late complications of head and neck cancer and its treatment", section on 'Salivary gland damage and xerostomia'.)

Managing oral medications — Swallowing oral medications can present enormous challenges to patients with dysphagia. In one study, more than 60 percent of subjects with chronic dysphagia had difficulty swallowing tablets, and this is more pronounced at the end of life [48,49]. Some common complaints include multiple swallows to clear the pill, residue in the pharynx after swallowing the pill, increased time needed to swallow pills, or use of additional liquid to assist in swallowing the pill. In addition, patients are often fearful that medications will be aspirated.

Because difficulty swallowing may impact patient adherence to medications, finding alternative modes of presentation can be critical [50] (see "Palliative care: The last hours and days of life", section on 'Non-oral routes of medication administration'):

●Medications can be crushed or buried whole in a semisolid food, such as applesauce or ice cream, to create a uniform consistency. However, crushing can alter the pharmacologic properties and impact safety and oversight, and review by a pharmacist is essential before crushing medications. Delayed-release medications (eg, extended-release morphine or oxycodone) should never be crushed as this may result in rapid release of a potentially fatal dose [51].

●Seek alternative routes of administration, including transdermal, intravenous, rectal, or buccal.

●Compounding, done by a pharmacist, can create a medication tailored to the specialized needs of an individual patient by producing an alternative form, such as a powder, inhaler, liquid, lozenge, or suppository. Health care providers and patients should refer to the US Food and Drug Administration (FDA) statement on regulation of compounded drugs.

●Some medications are formulated in a tablet that rapidly disintegrates in the oral cavity (orally disintegrating tablets or orodispersible films). A summary of the medications that are available as an orally disintegrating tablet is presented in the table (table 8). In addition, medications that can be administered sublingually or buccally are presented in this table (table 9).

Medical/surgical interventions — Medical and/or surgical management of aspects of swallowing dysfunction can be undertaken within the context of shared decision-making with the patient and caregiver team. While some of the interventions described below are noninvasive, others may require anesthesia or constant monitoring, and this may or may not conform to the patient/family goals and preferences. (See 'Shared decision-making' above.)

Pharmacologic interventions — There are no pharmacologic agents that directly act on oropharyngeal swallowing function. However, certain medications may alleviate specific symptoms/conditions contributing to dysphagia. Topical or systemic antifungal medications, such as nystatin or fluconazole, treat Candida esophagitis, thus reducing pain and discomfort with swallowing [52] (see "Oropharyngeal candidiasis in adults"). Therapeutic interventions for the treatment of gastroesophageal reflux disease (GERD) that is not managed with behavioral modifications include proton pump inhibitors, prokinetics, or histamine 2 (H2) receptor blockers. The long-term use of proton pump inhibitors over the last decade has declined as understanding of negative side effects from long-term use has risen [53-55]. (See "Medical management of gastroesophageal reflux disease in adults", section on 'Initial management'.)

Surgical palliation for vocal fold paralysis — Intractable aspiration may occur in debilitated patients with life-limiting disease as a result of vocal fold paralysis. In these cases, clearance of aspirated material is compromised by a weak glottic cough. Vocal fold augmentation and medialization with injection of a hyaluronic-based acid or collagen-based substance can be performed at the bedside by a trained otolaryngologist. This procedure can have the added advantage of improving the voice. Surgical medialization laryngoplasty is a more invasive and permanent option and requires careful consideration before the clinician can recommend this procedure [56].

Management of esophageal stricture/obstruction/tracheoesophageal fistula — If appropriate, intrinsic or extrinsic esophageal obstruction by tumor or stricture can be managed endoscopically with dilation or with placement of an intraluminal self-expanding stent [57]. A stent can also be placed to occlude a tracheoesophageal fistula. Laser ablation can be used to palliate cases of intraluminal esophageal obstruction [58]. However, the increased risks of stent migration, aspiration pneumonia, and restenosis, as well as of severe pain, hemorrhage, and fistula formation, should be taken into consideration when making recommendations for these procedures. (See "Oropharyngeal dysphagia: Clinical features, diagnosis, and management" and "Speech and swallowing rehabilitation of the patient with head and neck cancer" and "Endoscopic stenting for palliation of malignant esophageal obstruction" and "Endoscopic palliation of esophageal cancer".)

Tracheostomy tubes — Tracheostomy tubes are placed to relieve an airway obstruction, as a means of mechanically ventilating the patient, or for secretion clearance. The presence of a tracheostomy tube, with or without mechanical ventilation, does not preclude safe oral intake in and of itself. In addition, an inflated tracheostomy tube cuff is not fully protective against aspiration as secretions and/or liquid material may collect above the inflated cuff and can be aspirated [59,60].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Palliative care".)

SUMMARY AND RECOMMENDATIONS

●Difficulty swallowing occurs frequently in patients with life-limiting illness and may represent a pivotal symptom that prompts the decision to consider end-of-life or hospice care. (See 'Introduction' above.)

●Dysphagia can predispose the patient to aspiration and impair the ability to maintain nutrition and hydration and to adhere to medication regimens. Swallowing disorders significantly impact quality of life and cause distress and burden on both the patient and caregiver.

●Specific clinical features, disease states, patient characteristics, and medical interventions predictive of an increased risk of swallowing dysfunction are outlined in the table (table 1). Recognizing factors that are clinically associated with or that cause a swallowing impairment can guide referral for appropriate assessment and management. (See 'When to suspect a swallowing disorder' above.)

●A comprehensive swallowing assessment by the speech-language pathologist (SLP) aims to identify the underlying physiologic nature of the disorder and determine interventions that may alleviate dysphagia. (See 'Assessment' above.)

●Management of dysphagia in patients with serious illness is facilitative, and goals focus on preventing functional decline, retaining safe and effective oral feeding, and maximizing quality of life and comfort. Swallowing intervention should be closely aligned with the goals of care and should support the patient’s wishes. (See 'Management' above.)

●Patient autonomy and shared decision-making are critical ethical principles. A patient’s decision to continue with oral nutrition must be accompanied by a clear understanding of the possible risks and consequences (eg, aspiration pneumonia or malnutrition). (See 'Shared decision-making' above.)

●Modifying the texture of solid foods and consistency of liquids is widely used in the management of patients with dysphagia and may improve the safety and/or ease of oral consumption. These modifications should be used judiciously and in accordance with patient preference. (See 'Alterations in food and liquid texture and consistency' above and 'Shared decision-making' above.)

●Medication administration can present enormous challenges to patients with dysphagia. Finding alternative modes of presentation (liquids, crushed, orally disintegrating tablets, compounded) can be critical to providing the patient with comfort at the end of life (table 8 and table 9). (See 'Managing oral medications' above.)

●The decision to pursue non-oral artificial nutrition and hydration has significant ramifications for both the patient and caregivers. The patient-caregiver unit must be appropriately informed about the benefits and risks of nutritional options in order to make decisions that reflect consent and refusal. (See 'Artificial nutrition and hydration' above.)

●An overabundance of secretions or change in secretion viscosity and composition may result from impaired swallowing. In addition, airway clearance can be compromised in dysphagic individuals. Effective cough to clear secretions and aspirated material can reduce pulmonary infections and respiratory difficulties. (See 'Maintaining airway clearance' above.)

●A tracheostomy tube, with or without mechanical ventilation, does not preclude oral intake. However, careful evaluation of swallowing function is needed. Tracheal suctioning to improve pulmonary toilet can be performed after meals. (See 'Tracheostomy tubes' above.)

●There are no pharmacologic agents that directly act on oropharyngeal swallowing function. However, certain medications may alleviate specific symptoms contributing to dysphagia. (See 'Pharmacologic interventions' above.)