[Dysphagia] PEG to PO feeding

[jzweier at comcast.net (jzweier)]

I'm a part time SLP in a SNF and am in need of help determining the 
best methods to evaluate a patient's ability to start PO feeding after 
over 3 months of PEG feeding.  I apologize for the length of this ....  
I wanted to include all information I felt was pertinent to his 
situation.

History:  87 year old gentleman s/p massive (R) CVA and (L) hemi. 
4/21/04.  NGT feeding was initially started, along with OM/thermal 
stim. tx. and PO trials for about 1 month.  PEG finally placed 5/27/04 
after little improvement seen in swallow function.  Pt. developed an 
aspiration pneumonia sometime after the PEG placement as well.  Now, 3 
months later, pt. is expressing a desire to eat (previously he did not 
seem too interested in food).

Today's bedside assessment showed a mod-sev. dysphagia w/ decreased OM 
ROM/strength, delayed initiation of swallow (up to 10 sec.), mod. 
delayed swallow reflex and decreased laryngeal excursion.  Upper airway 
congestion/throat clearing heard, although actual cough was weak.  Pt's 
mouth was coated with secretions throughout the assessment.   I gave 
him small amounts of ice chips, which he appeared to swallow with some 
delays; however, several minutes later, he had to spit out 
liquid/secretions pooling in his mouth.  Additional information:  pt. 
is mod-sev. dysarthric, has significant  (L) side neglect, and has some 
cognitive deficits.  His alertness level has improved since I saw him 
in April/May.

So, basically, I'm asking for any feedback regarding what to do at this 
point (i.e. OM ex. program again, incl. thermal stim; ice chip trials; 
MBS; all of the above; anything I haven't though of???).

Thanks for any help you can provide!

Jill B. Zweier, M.A., CCC-SLP
Petaluma, CA