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:
- Dysphagia Diet Levels
- Yale Swallow Protocol
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.
Do a chart review of your patient’s medical and clinical history. Look for:
- Primary diagnosis and/or the reason for the swallow evaluation
- Medical status
- History of head and neck cancer including radiation treatment
- Current diet/nutritional status
- Labs and imaging (including brain MRI/CTs, chest X-rays)
- Current medications
- Environmental, behavioral, and psychosocial status
- Check if any previous swallowing evaluations (including FEES or VFSS) were completed
Ask the patient’s nurse about:
- Any difficulties swallowing meals or medications
- Cognition and level of alertness
Ask the patients and/or caregivers about their swallowing, nutrition and hydrate intake, and any signs and symptoms they have noticed. Confirm relevant medical history.
Throughout the oral mechanism exam, you’ll observe strength, range of motion, and symmetry.
Asymmetry may signal innervation or neurological issues (stroke, nerve injury, etc.) While decreased strength and range of motion may signal atrophy or dysarthria.
Record any significant findings (e.g. obvious strength difference between pushing their tongue to the right versus the left), and note other findings that you’d like to examine further (e.g. possible reduced hyolaryngeal excursion).
If you suspect underlying structural or neurological issues, refer out to neurology, gastroenterology, or otolaryngology, as appropriate.
Monitor oxygen levels and heart rate throughout and note any changes between activity and rest.
OME: Mandible (Cranial Nerve V)
- Observe the symmetry of their mouth and jaw at rest.
- Also observe dentition and oral mucosa.
- Say, “Open your mouth.”
- Observe range of motion and symmetry during opening and while open.
- Ask them to close their mouth.
- Observe symmetry as their mouth closes.
- Place a few fingers under their chin and say, “Open your mouth again.”
- Observe strength, range of motion, and symmetry as you gently apply pressure.
- Place a few fingers on their chin (just below their lower lip), and say, “Close your mouth.”
- Observe strength, range of motion, and symmetry as you gently apply pressure.
- Say, “Move your jaw from side to side,” modeling as needed.
- Observe range of motion and symmetry. For example, are they able to move their jaw over to one side significantly more than the other?
- Say, “Jut your jaw out” or “Move your jaw out,” modeling as needed.
- Observe range of motion.
- Then, place a clean gloved hand on their chin and gently push.
- Observe strength. For example, are they able to maintain protrusion against resistance?
- Observe symmetry as they release the protrusion.
- Say, “Pull your jaw in.”
- Observe range of motion
OME: Lips (CN VII)
- Observe symmetry of their lips at rest.
- For example, one side is drooping, one side is drooling, etc.
- Say, “Move your lips side to side,” modeling as needed.
- Observe range of motion and symmetry.
- Say, “Pucker your lips like you’re about to whistle,” modeling as needed.
- Observe range of motion and symmetry.
- If range of motion seems limited, test their stimulability by prompting them to protrude their lips even more.
- Press a tongue depressor or a clean gloved finger on their lips. Say, “Push against this.”
- Observe strength.
- Say, “Smile wide.”
- Observe range of motion and symmetry.
- Prompt them to, “Pull your lips back more,” as needed.
- Say, “Pucker, smile, pucker, smile,” modeling as needed.
- Observe coordination, range of motion, and symmetry.
- Say, “Puff up your cheeks [with air] [like a blowfish].” Then say, “Keep them puffed up,” as you gently press using a clean gloved finger.
- Observe strength.
- Say, “I’m going to gently touch your cheeks. Please close your eyes and raise your hand when you feel my touch.” Use the stick-end of a cotton swab and touch various parts of their lower face.
OME: Tongue (CN XII)
- Say, “Open your mouth,” and observe tongue at rest.
- Note symmetry, fasciculations, atrophy, etc.
- Say, “Stick out your tongue.” Test their stimulability by prompting them to stick their tongue out even further.
- Observe symmetry and range of motion.
- Place a tongue depressor against the tip of their protruded tongue. Say, “Push against this.”
- Observe strength.
- Say, “Stick your tongue out and up.” Test strength using the tongue depressor.
- Observe range of motion and symmetry.
- Say, “Stick your tongue out and down.” Test strength using the tongue depressor.
- Observe range of motion and symmetry.
- Say, “Press your tongue inside your cheek,” modeling as needed. Then, place a clean gloved finger against their cheek and say, “Push against this.”
- Observe strength.
- Switch sides and repeat, noting any differences in strength.
- Say, “Pull your tongue back.”
- Observe range of motion and symmetry.
- Say, “Lick all around your teeth.”
- Observe range of motion and symmetry.
- Say, “Lick all around your lips.”
- Observe range of motion and symmetry.
- Say, “I’m going to gently touch your tongue and mouth. Please close your eyes and raise your hand when you feel my touch.” Use the stick-end of a cotton swab and touch various parts of their tongue and inner cheeks.
OME: Velum
- Say, “Open your mouth,” and use a penlight to observe their velum at rest.
- Say, “Say ‘ahhh.’”
- Observe range of motion and symmetry.
- Say, “Say ‘ah ah ah ah ah.’”
- Observe range of motion and symmetry.
OME: Reflexes (CN IX, X)
- Say, “I’m going to place this in your mouth. Open your mouth wide,” then gently touch the back of their throat with a tongue depressor.
- If you already observed that their gag reflex is intact (e.g. they gagged on a drink earlier), you don’t need to subject them to this.
- While their mouth is open, observe faucial arches at rest.
OME: Other Observations
- Keep track of your patient’s oxygen stats and heart rate at rest
- While their mouth is open during any of the above tasks, observe dentition and oral mucosa.
- Look for dentures, partials, missing teeth, and oral cleanliness.
- Ask, “Do you use dentures or partials?” if you’re unsure.
- Note any discoloration of oral mucosa.
- Provide or assist in oral care at this time, as needed.
- Say, “Lift your eyebrows.”
- Observe range of motion and symmetry.
- You may also say, “Smile” while they are lifting their eyebrows to test the branches of CN VII.
- Say, “Cough.”
- Observe strength of cough and if cough was productive.
- Say, “Clear your throat.”
- Observe strength of throat clear and vocal quality
- Sustained phonation
- Observe breath support and vocal quality
- Diadochokinetic rate
- Observe for signs of motor speech and oral apraxia
- While gathering their case history and completing the patient interview, note any observations about dysarthria, oral apraxia, voice, and resonance.
- Perform oral care before the swallow screen.
- Perform the Yale Swallow Protocol, 3-ounce water test, or trial ice chips. Ice-chips are often attemped first when a patient is NPO.
Observe the following:
- Labial closure while liquid is in the mouth
- Hyolaryngeal speed and elevation
- Signs and symptoms of dysphagia:
- Possible bolus holding
- Anterior leakage
- Multiple swallows
- Coughing and/or throat-clearing
- Respiration changes
- Gurgly or wet vocal quality (“Say ahhh” and “Say eee”)
- Fatigue
- Monitor oxygen levels and heart rate throughout
(ASHA, n.d.)
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 is900+ pagesof print-and-go adult speech therapyworksheets,handouts, andtemplates.
- Evidence-based
- Designed for speech therapy patients
- Save time, stress, and cognitive load
- 4.9/5 stars out of 12,000+ sales (our shop)
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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