Speech Therapy With A Patient On NPO: 10 Steps to Assess & Treat Dysphagia

Treating dysphagia can be challenging, especially in complex cases such as patients who can’t safely eat or drink by mouth.

In this article, you’ll learn the 10 steps to assessing and treating dysphagia with a patient on NPO.

What To Expect With A Patient on NPO

NPO (Latin for ‘nil per os’) is when a patient should not eat or drink by mouth for a period of time (Cimoli et al., 2024). 

Patients can be made NPO for many reasons, including:

• Pre-surgery
• Acute or severe stroke (Teuschl et al, 2018)
• Hospital stroke protocol requires NPO status until a Clinical Swallow Evaluation (CSE) is completed by speech therapy
• Failed a swallow screen (hospital setting) and are waiting for a CSE by speech therapy
• Severe dysphagia was noted during a bedside swallow examination, and they were made NPO until an instrumental assessment (VFSS, FEES) is completed
• Decreased levels of alertness 
• Trauma resulting in the inability to safely breathe or swallow
• Gastrointestinal issues such as a blockage or inability to pass food
• An instrumental swallowing assessment indicated they’re unsafe for any PO intake, despite compensatory strategies
• Agitation (typically severe and/or combative, making any PO intake unsafe)

How To Assess Your First Patient On NPO 

Once you get the swallowing assessment referral, you’ll complete a clinical swallow evaluation. However, depending on their medical status, you may not be able to complete a full CSE with patients on NPO.

Below are the 4 steps to completing a CSE for a patient on NPO. For more guidance on speech therapy assessment, see The Adult Speech Therapy Roadmap Course.

1. Chart Review for Patients on NPO

Complete a thorough chart review for all patients on NPO. Track down the following information:

• Primary diagnosis or reason for admission
• Reason for NPO status
• Past medical history (applicable to dysphagia)
• Labs, imaging, vital signs
• Allergies
• Current diet level
• Environmental, behavioral, and psychosocial status
• History of receiving speech therapy
• Any speech therapy notes
• Instrumental assessment results (VFSS, FEES)
• Precautions (hip precautions, isolation precautions, etc.)

After the chart review, consult with the nurse to check if the patient is stable for a CSE.

Ask about their cognitive status, oral hygiene, and ability to participate. Check if oral care has been consistently completed.

2. Patient/Care Partner Interview For Patients on NPO

• Verify details of the patient’s medical history and symptoms
• Explain the reason for your assessment and what your assessment will entail 
• Ask about their nutrition and hydration intake before being made NPO
• Ask how their swallowing was before being made NPO
• Ask how they typically take their medications (whole with water, in applesauce, crushed, etc.)

3. Oral Mechanism Examination for Patients on NPO

Complete a thorough oral mechanism examination (OME). During the OME, observe strength, range of motion, and symmetry of the cranial nerves and oral-motor structures.

• Note any asymmetry, weakness, and red flags, such as hypernasality or lack of sensation
• Check the oral mucosa of the mouth and note if oral thrush, xerostomia, or excessive saliva and/or mucus is present
• Assess their cough and secretion management
• Refer to neurology, gastroenterology, or otolaryngology for any underlying structural or neurological issues

For a detailed OME, read our guide to Oral Mechanism Examinations.

4. Food and Liquid Trials For Your Patient on NPO

Recommend an instrumental assessment (VFSS or FEES) if your patient hasn’t already had one. 

Use the results of their instrumental assessment to guide your swallowing and diet recommendations, including food/liquid trials during your CSE.

How To Treat Your First Patient on NPO 

If your patient demonstrates severe dysphagia and you recommend continued NPO status, there is still plenty to work on.

Remember that the main goal of swallowing therapy is to improve your patient’s swallowing safety and efficiency (Suiter & Gosa, 2019).

As you set goals and plan treatment, focus on the patient’s quality of life and practice active listening.

How To Practice Active Listening

Practice active listening to validate the patient and care partner’s thoughts, feelings, and desires (Tennant & Toney-Butler, 2023):

• Be aware of your tone and body language. Be kind and respectful when discussing your therapy plan 
• Give your full attention to the speaker and listen for what they’re saying (vs. for what you want to hear)
• Repeat back what they said to ensure you understood their message and the intention behind it
• Ask for clarification if you don’t fully understand their message
• Avoid distractions and assumptions. Again, give your full attention to what they are saying
• Listen fully before responding

Next, we’ll review 6 common treatment areas for patients on NPO.

1. Intensive Oral Care For Patients on NPO

Consistent oral care is essential. The goal of oral care is to decrease bacteria in the mouth and pharynx.

Aspiration does not automatically cause pneumonia. Even if water or ice is aspirated, if it has a neutral pH (such as water swallowed in a clean mouth), there’s a decreased risk of developing pneumonia.

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 proper oral care and how to do it with patients on NPO. 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 For Patients on NPO

Patients with severe dysphagia may have trouble managing their secretions. They may not swallow as often, making them drool or even aspirate on their secretions.  

Train your patient to do the effortful swallow to help them manage their saliva. Encourage them to cough or clear their throat and re-swallow often.

Practice swallowing fast, hard, and often.

Even if your patient can’t complete a volitional swallow on command, still focus on swallowing by asking them to visualize swallowing while attempting to swallow.

Take breaks as needed and provide plenty of encouragement.

3. Directed Cough for Patients on NPO

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 mucus from their pharynx, airway, and/or lungs.

Download our free PDF handout for how to do a directed cough (from the Dysphagia Pack)!

4. Incentive Spirometer For Patients on NPO

An incentive spirometer is an exercise device that can help clear mucus from the airway and lungs. This is important when recovering from certain lung diseases and surgeries, as well as to improve saliva management.

If your patient received an incentive spirometer from their physician, surgeon, respiratory therapist (RT), or other professional, you can incorporate it into your treatment. 

Check with your physician first if you suspect a respiratory tract infection, uncontrolled hypertension, dementia, or other possible contraindications (Franklin et al., 2024).

How to use an incentive spirometer:

1. Set the incentive spirometer to the target level (per physician or RT recommendations)
2. Blow all the way out
3. Place lips around the mouthpiece and INHALE slowly and deeply. The goal is to achieve the set target.
4. Release the mouthpiece from the lips and relax
5. Repeat for a total of 10 reps (or follow physician/respiratory therapy recommendations)

5. Rehabilitative Exercises For Your Patient on NPO

Patients on NPO often have weakened swallowing muscles.

They may also have difficulties with airway protection when swallowing. When possible, use the results of an instrumental assessment (FEES, VFSS) to choose exercises for swallowing.

Read How To Treat Dysphagia for a step-by-step guide to treating dysphagia and to learn effective treatment exercises.

6.  Frazier Water Protocol 

The goal of NPO dysphagia treatment is to advance your patients to the safest diet and consistency while maintaining adequate hydration and nutrition. Starting with the Frazier Water Protocol is often the safest way to improve hydration.

The Frazier Water Protocol allows patients who aspirate on thin liquids to have clean, thin water without increasing their risk of aspiration pneumonia (Panther, 2005). 

Evidence shows that, with proper oral care, this protocol is safe for many who aspirate on thin liquids (Gillman et al., 2017).

Patients on NPO must meet certain criteria to safely enjoy water with the Frazier Water Protocol. Read our guide to the Frazier Water Protocol for all the details!

More Dysphagia Materials

References

• American Speech-Language-Hearing Association. Adult Dysphagia. Retrieved November 30, 2024 from https://www.asha.org/practice-portal/clinical-topics/adult-dysphagia/
• Brewer, C., Aparo, M. (2021) The Adult Speech Therapy Starter Pack. Harmony Road Design Publishing.
• Cimoli, M., Gibney, J., Lim, M., Castles, J., & Dammert, P. (2024). Nil per os in the management of oropharyngeal dysphagia-exploring the unintended consequences. Frontiers in rehabilitation sciences, 5, 1410023. https://doi.org/10.3389/fresc.2024.1410023
• 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
• Panther, K. (2005). The Frazier Free Water Protocol. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 14(1), 4-9. https://doi.org/10.1044/sasd14.1.4
• 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. https://doi.org/10.1044/2023_PERSP-23-00203
• Stranberg, S., Childers, J.; Leslie, P., Wasserman-Wincko, T. (2015). From “NPO, Needs Feeding Tube” to Palliative Dysphagia Management: How to Collaborate with Speech-Language Pathologists (SA534). Journal of Pain and Symptom Management, 49(2), 398-399. DOI: 10.1016/j.jpainsymman.2014.11.166
• Suiter, D.M. & Gosa, M.M. (2019). Assessing and treating dysphagia: A lifespan perspective. New York, NY: Thieme. ISBN-9781626232143    
• Tennant, K., Long, A., & Toney-Butler, T. J. (2023). Active Listening. In StatPearls. StatPearls Publishing.Varkey B. (2021). Principles of Clinical Ethics and Their Application to Practice. Medical principles and practice : international journal of the Kuwait University, Health Science Centre, 30(1), 17–28. https://doi.org/10.1159/000509119  
• Teuschl, Y., Trapl, M., Ratajczak, P., Matz, K., Dachenhausen, A., & Brainin, M. (2018). Systematic dysphagia screening and dietary modifications to reduce stroke-associated pneumonia rates in a stroke-unit. PloS one, 13(2), e0192142. https://doi.org/10.1371/journal.pone.0192142
• 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