140 Chapter 7
Case Study 7-2: Dysphagia and Gastric Tube Placement in a
92- Year- Old Woman
Her name is Audrey, but because of her French accent, the people in the nursing home simply
call her Frenchy. She immigrated to the United States when she was a teenager. Frenchy spent most
of her life in New Mexico, where she fi nally retired from the nursing profession. After suffering
a stroke that robbed her of communication and left her with global aphasia, she was placed in
a nursing home. Soon afterward, she began to lose weight and seemed to lose interest in life. A
dysphagia evaluation was ordered.
The speech- language pathologist enters the patient’s room and greets her with a smile and
a left- handed shake of her hand. Frenchy acknowledges the clinician’s presence by returning
the smile and saying, “Tula.” Frenchy remembers the clinician from previous visits when her
communication abilities were evaluated. After making small talk, the clinician tells her that
the purpose of the visit is to evaluate Frenchy’s swallowing abilities. This is done using speech,
gestures, modeling, and pictures. Frenchy appears to understand the purpose of the visit and
indicates nonverbally that she will cooperate.
The clinical/bedside screening is quick and to the point. Because of Frenchy’s communication
prob lem, the clinician does a cursory oral- facial evaluation. She notes that since her last visit
2 weeks ago, the patient has developed a right facial sag, her tongue deviates to the right on
protrusion, and she drools. The therapist leaves the patient’s room and goes to the nurses’ station.
Calling the attending physician, she reports that a video swallowing study will be necessary. Both
clinicians agree that this procedure will be expensive because the patient must be transferred to a
nearby hospital. They also agree that it is necessary.
The next morning, an ambulance takes Frenchy to the hospital. The clinician arrives a few
minutes later, and soon the patient is positioned for the procedure. She is physically able to sit
upright in the specially designed chair. The radiologist and a technician enter the room and
explain to Frenchy what will happen during the study. Frenchy is more than a little frightened
when every one but her dons a lead apron.
The monitor is located above and to the right of Frenchy. The clinician tells Frenchy to drink
the white, chalky barium liquid. Frenchy, still ner vous but cooperative, drinks it. The swallow
is observed on the monitor as it moves from her lips to the back of her oral cavity and then
down her throat. Most of the barium goes down the esophagus and, at first glance, the swallow
appears successful. On closer inspection, barium is seen to pool on the vocal cords. When
Frenchy inhales, it is sucked into her lungs. The patient makes no attempt to clear her throat or
to cough the liquid out of her lungs. Because of Frenchy’s global aphasia, she is unable to follow
instructions about dry swallowing, clearing her throat, head and body positioning, and other
therapies to help the swallow.
Frenchy is given a second opportunity to swallow the barium liquid, but this time with a
thicker consistency. Most of it is propelled down her esophagus, but there is still pooling at the
vocal cords, and this time, at the base of the tongue as well. Frenchy appears oblivious to the
substance in her respiratory tract, and when she inhales, much of it is aspirated. Because of her
communication disorder, she cannot understand instructions and alter her swallowing patterns.
The radiologist, technician, and speech- language pathologist agree that Frenchy has failed the
swallowing study. That after noon, the physician and speech- language pathologist confer about
options for meeting Frenchy’s hydration and nutrition needs. After reviewing the radiologist’s
report and viewing the videotape of the f luoroscopy, they decide that Frenchy should be given an
NG tube. Because of the severity of her dysphagia and the global aphasia, therapies to improve
her swallowing are contraindicated. They agree that after 2 or 3 weeks, another video swallow