What do you do if your speech therapy patient is unable to eat or drink by mouth?
How do you assess an NPO dysphagia patient? What treatments should you choose? In this article, you’ll get step-by-step guides on how to do both!
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Why NPO?
There are many reasons why a physician might put your speech therapy patient on NPO.
Reasons for NPO include:
- The patient is lethargic and unsafe for any PO intake
- A physical reason, like a mandible resection, pharyngeal trauma, or GI blockage
- Hospital stroke protocol requires they be NPO until a speech therapy assessment
- An instrumental swallowing assessment found that they’re unsafe for any PO intake (even after attempting compensatory strategies and modified consistencies)
- They demonstrated severe dysphagia during a bedside swallow examination and are waiting on an instrumental swallowing assessment
- They failed a swallow screen (hospital) and are waiting for a speech therapy assessment
While your patient is deemed unsafe to eat by mouth, they’ll receive alternative means of nutrition and hydration.
More Dysphagia Articles:
How To Evaluate An NPO Dysphagia Patient
You can still complete parts of a clinical swallow evaluation with a patient who is on NPO.
Click for step-by-step instructions on how to do each.
Treatment Options for NPO
What are your options if an evaluation finds that your NPO patient still isn’t safe to eat or drink by mouth?
Patients on NPO often have severe dysphagia. So this means that your treatment will likely address the fundamentals of swallowing safety.
Use the result of their instrumental assessment to guide your swallowing and diet recommendations. And ask and listen to your patients about what they want and need.
Here are 7 common treatment options for NPO.
1. Intensive Oral Care
The goal of oral care is to decrease bacteria in the mouth and pharynx.
This is so that even if your patient aspirates on saliva, ice chips, or water, they’ll have less bacteria in their mouth when it happens.
Aspiration in and of itself doesn’t automatically cause pneumonia. And if what’s aspirated has a neutral pH (like water swallowed in a clean mouth), the risk of developing pneumonia decreases.
On top of reducing bacteria, intensive oral care may also decrease the incidence of pneumonia by improving cough reflex sensitivity (Watando et al., 2004).
Educate staff about the importance of oral care with NPO patients. Ensure that they’re helping their patients complete it, as needed.
Read The 7 Steps of Oral Care for more guidance.
2. Improve Secretion Management
You may need to help some patients with severe dysphagia not aspirate on their secretions. Teach them to manage secretions by swallowing hard and fast.
Here is a secretion management protocol:
- Effortful swallow of their saliva
- Cough or throat clear
- Re-swallow, if able
3. Volitional Swallow
Patients with severe or profound dysphagia may also have difficulty swallowing at will. The simple practice of swallowing can be an effective and functional exercise in and of itself.
Do volitional swallows with saliva or the Frazier Water Protocol (if appropriate for your patient). Practice swallowing often.
4. Directed Cough
An effective cough is vital for airway protection and clearance (Novaleski et al, 2024). Teach your patient how to produce a stronger cough to protect their airway and clear sputum settled in their lungs.
Here’s a directed cough protocol:
- Take a big, low breath. Keep your shoulders relaxed.
- Hold it tight for a moment.
- Cough!
5. Incentive Spirometer
An incentive spirometer is an exercise device that can improve lung health. It helps patients take slow, deep breaths and clear secretions from the lungs. This is important when recovering from certain lung diseases and surgeries.
If your patient received an incentive spirometer from their physician, surgeon, respiratory therapist (RT), or other professional, you can incorporate it into your treatment.
How to use an incentive spirometer:
- Set the incentive spirometer at the target (per physician or RT recommendations)
- Blow all the way out
- Place lips around the mouthpiece and INHALE, trying to hit the target
- Release the mouthpiece from lips and relax
- Repeat (per physician or RT recommendations)
If your patient has a respiratory tract infection, uncontrolled hypertension, dementia, or other possible contraindications, check with their physician first (Franklin et al, 2024).
6. Deep Breathing/Diaphragmatic Breathing
Practice deep or ‘diaphragmatic’ breathing to improve breath support.
7. Swallowing Exercises
Swallowing exercises may be useful for your patient on NPO.
Which exercises will be effective depends on the results of their instrument and bedside swallowing evaluations. For example, if your patient’s swallow is weak, you may recommend the Mendelsohn Maneuver.
Read How To Make Dysphagia Treatment Exercises More Effective for help choosing swallowing exercises.
And visit our shop for Safe Swallowing Strategies Handouts and other materials to make your job easier.
Can An NPO Dysphagia Patient Drink Water?
Sometimes, yes!
The goal of NPO treatment is to advance your patients to the safest diet and consistency while maintaining adequate hydration and nutrition. If a patient can’t safely advance their diet, they’ll often start on the Frazier Water Protocol.
The Frazier Water Protocol helps certain patients who aspirate on thin liquids to drink water without increasing their risk of aspiration pneumonia (Panther, 2005).
Evidence suggests that, with proper oral care, this protocol can be safe for many who aspirate on thin liquids (Gilman et al, 2017).
NPO patients must meet certain criteria to safely enjoy water with the Frazier Water Protocol.
Patients must:
- Be able to remain awake and alert while drinking
- Not be impulsive and not have severe cognitive impairments
- Not have degenerative neurological dysfunction
- Have a pharyngeal swallow response (per instrumental assessment)
- Be able to consistently get out of bed
- Be able to maintain an upright posture while drinking
- Not experience: excessive discomfort, coughing, or choking when drinking
- Not have current or suspected aspiration pneumonia or acute pulmonary issues
- Not have thrush or oral bacterial infection
- Be able to complete appropriate oral care (e.g. they have consistent daily help if dependent for oral care)
Learn how to do the Frazier Water Protocol.
More Resources
Adult Speech Therapy Starter Pack
The Starter Pack is 900+ pages of print-and-go adult speech therapy worksheets, handouts, and templates.
What a treasure trove! So excited to have access to all these helpful downloads! I like that I can print just what I need a little at a time.
Susan
Excellent resource for any grad student who doesn’t know where to start!
Kersten
Adult Speech Therapy Roadmap Course
The Adult Speech Therapy Roadmap is an online course that teaches you how to assess, treat, and document all major areas of adult speech therapy, from Day 1 to Discharge.
I loved having PDFs I can reference and easily search when I have a specific question in any field of SLP.
Sarah Clover, CCC-SLP
What I liked best about the course were the great handouts and examples. Loved the course!
Amy A., CCC-SLP
References
- ASHA (n.d.) Swallowing Screening. Retrieved May 2024 from https://www.asha.org/practice-portal/clinical-topics/adult-dysphagia/swallowing-screening.
- Brewer, C., Aparo, M. (2021) The Adult Speech Therapy Starter Pack. Harmony Road Design Publishing.
- Franklin E, Anjum F. Incentive Spirometer and Inspiratory Muscle Training. [Updated 2023 Apr 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572114/
- Gillman, A., Winkler, R., & Taylor, N. F. (2017). Implementing the Free Water Protocol does not Result in Aspiration Pneumonia in Carefully Selected Patients with Dysphagia: A Systematic Review. Dysphagia, 32(3), 345–361. https://doi.org/10.1007/s00455-016-9761-3
- Novaleski, C.K.; Near, L.A; & Benzo, R.P. (2024) Cough: An Introductory Guide for Speech-Language Pathologists. Perspectives of the ASHA Special Interest Groups. 9(1), 75-91.
- Panther, K. (2005). The Frazier Free Water Protocol. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 14(1), 4-9.
- Puntil, J. & Suiter, D. (n.d.) Screening and Bedside Swallow Evaluation Across the Continuum of Care [Online Course]. https://www.medbridge.com/course-catalog/details/screening-and-bedside-swallow-evaluation-across-the-continuum-of-care-jo-puntil-and-debra-suiter/
- Watando, A., Ebihara, S., Ebihara, T., Okazaki, T., Takahashi, H., Asada, M., & Sasaki, H. (2004). Daily oral care and cough reflex sensitivity in elderly nursing home patients. Chest, 126(4), 1066–1070. https://doi.org/10.1378/chest.126.4.1066