Prior to watching the presentation on dysphagia, I never thought about how complex the act of swallowing is and how devastating swallowing impairment can be for a patient. I used to think that the act of swallowing was a simple physiological process but now know the act of swallowing is incredibly complex and requires the activation and coordination of 50 pairs of muscles and 6 cranial nerves.1 When learning that swallowing includes behavioral, sensory, and motor acts, I became especially curious about the sensory portion of the swallow. Prior to this lecture, I didn’t realize how important visual, auditory, or olfactory sensory stimuli are for saliva production, which allows the swallowing of foods or liquids to occur.1 I decided to read further on the matter and found it interesting to learn that the subconscious pharyngeal swallow is triggered by sensory inputs, and this modulates the sequential motor activity of muscles that then transport the bolus through the pharynx.2 Most interesting to me was that esophageal swallow intensity is modified by sensory input, which then triggers secondary peristalsis.2 Learning this fascinated me and underscored that swallowing a bolus takes much more than visual, auditory, or olfactory stimuli to increases salivation,2 but also takes the coordination of 6 cranial nerves and 50 pairs of muscles.1 Additionally, I used to think that a bolus solely resulted from the mastication of ingested food mixed with saliva, which forms a food bolus mass.3 I now know that a bolus can also be a “volume of liquid,” and is known as a fluid bolus.4 When learning this, I quickly realized that I once thought dysphagia was only a problem with the ingestion of food. I did not realize dysphagia also included liquids. This was very eye-opening as I once thought liquids would not pose a problem to patients who struggled with swallowing food. I also realized that I have taken swallowing for granted. I have never truly thought about swallowing physiology or thought about what would happen if an individual lost the ability to safely eat or drink.1 I also did not think about the mental and/or social devastation that may occur when a patient experiences dysphagia. Because dysphagia can occur in all age groups and has no bias for gender or culture, it is important to realize that dysphagia may impact mental health, social aspects of life, and overall quality of life.1 I now realize that not being able to eat or drink can throw off the family dynamic, may significantly impact mental health, and may cause feelings of social isolation as eating and drinking are important aspects of socialization in a variety of cultures.1 Interestingly, a systematic review of 30 studies found that dysphagia is associated with depression and anxiety in patients with Parkinson’s Disease (PD), multiple sclerosis (MS), stroke, head and neck cancer, oral cancer, and tongue cancer, which underscores the impact dysphagia may have on mental health and overall quality of life.5 I was shocked to learn that dysphagia is not a disease process but instead a symptom of an underlying disease.1 Learning that dysphagia is a symptom that may be related to brain injury, stroke, or a progressive neurological disease like PD or MS is important to know and understand because as a future RD, I may conduct direct or indirect swallowing screenings for these patients in the future.1 From a clinical perspective, I learned that dysphagia requires an integrative healthcare team that may consist of a medical speech-language pathologist (medSLP), registered dietitian (RD), medical doctor (MD), respiratory therapist (RT), physical therapist (PT), and occupational therapist (OT) to manage and treat a patient with dysphagia.1 It was interesting to learn that this is particularly important for patients with respiratory compromise, such as patients who have been on a ventilator or have had a recent tracheotomy, as these patients may struggle to coordinate breathing and swallowing.1 It was shocking to learn that these patients may severely struggle as it is hard for respiratory compromised patients to stop breathing for the one-second it takes to swallow.1 I never knew that not breathing for the one-second it takes to swallow could be so detrimental to a patient, but now know that a care plan must be in place to ensure these patients can both breath and swallow safely.1 Knowing this knowledge will help me as a future RD as I will know that these patients may require meticulous monitoring to sustain both nutrition and hydration until they can breath and swallow safely. I used to think that dysphagia only occurred in geriatric patients, but now know that dysphagia can occur in all age groups and has no bias for gender or culture.1 This is very important to remember as a future RD because it taught me that any patient, from pediatric to geriatric, can suffer from dysphagia and that I must always be meticulous when assessing a patient. Learning that dysphagia can present as acutely (stroke or TBI) or progressively (progressive neurological diseases or tumors) was important as this will help me as a future RD recognize when swallow screenings may be necessary. Additionally, I was thankful to learn that there are three major subtypes of dysphagia, which consist of neurogenic, mechanical/anatomical, and psychogenic.1 Knowing and understanding the three major subtypes of dysphagia will help me, as a future RD, initiate and conduct the best possible bedside direct swallow screenings, such as The Repetitive Saliva Swallowing Test (RSST), Yale Swallow Protocol/3-ounce Water Test, and the Gugging Swallowing Screen (GUSS); or indirect swallow screenings, such as the Eating Assessment Tool (EAT-10), Swallowing Quality of Life questionnaire (SWAL-QOL), and Swallowing Disturbance Questionnaire (SDQ).1 I also know that if a patient has difficulty managing their own saliva, this is a red flag and I should consult with a MedSLP immediately for further evaluation. As a future RD, learning about the direct and indirect swallow screenings was important because MedSLPs and RDs now have the shared responsibility for the screening of dysphagia.1 Additionally, I learned that practicing these swallow screening assessments on healthy patients, such as family members or friends, will help me identify and understand what a healthy swallow feels like so that I may better identify a dysfunctional swallow when in clinical practice. I also learned that, when conducting the RSST, if less than 3 swallows are observed within 30-seconds, I should immediately refer the patient to MedSLP.1 For the Yale Swallow Protocol/3-ounce Water Test it was important for me to learn that this test is often referred to as the gold standard and is a reliable, validated screening tool for both adult and pediatric patients.1 What stood out to me the most about the Yale Swallow Protocol/3-ounce Water Test was that one of the exclusion criteria is no thin liquids due to preexisting dysphagia.1 This particularly stood out to me because, as mentioned previously, I used to think that swallowing difficulty only pertained to food and did not pertain to liquids. However, I now know that all liquids are not created equal, and I must be diligent when assessing a patient swallowing both food and liquid. Additionally, in keeping within the RD scope of practice, it was important for me to learn that though a patient may pass the Yale Swallow Protocol/3-ounce Water Test, I should still collaborate with MedSLP to determine diet safety recommendations.1 Importantly, I also learned that it is better to fail a patient on the Yale Swallow Protocol/3-ounce Water Test if I have a clinical intuition that something is not quite right.1 I learned it is better to exercise caution and fail a patient than put the patient at risk for possible silent aspiration or swallowing difficulty.1 As a future RD, it was important to learn that if a patient does fail the Yale Swallow Protocol/3-ounce Water Test, they must remain NPO until the healthcare team can better understand the integrity of the patient’s airway patency and further investigate swallowing safety.1 However, if a patient shows signs of clinical change or improvement, it was helpful to learn that the test can be re-administered in the subsequent 2-24 hours.1 I also learned that GUSS is the true merger of the SLP and RD professions as the GUSS is one of the best, direct multidisciplinary swallow screening assessments that investigates drooling, voice, sustained attention, deglutition, and involuntary cough across semi-solids, liquids, and bolus.1 This is due to the GUSS test being a stepwise, graded evaluation in which a patient must earn all five points from each category before moving on to the next step, and that this assessment is all or nothing.1 This test contains 20 points maximum, and if a patient fails to reach all 20 points, a SLP must be contacted immediately for further investigation.1 What stood out to me the most about the GUSS assessment is that semisolids are tested before liquids, which again, underscores the importance that liquids can be more dangerous than semi-solids in certain situations! This aspect was shocking to me, and I am glad I now know this. Additionally, it was also important to learn about the indirect (clinician facilitated) swallowing screenings, which consist of the Eating Assessment Tool (EAT-10), Swallowing Quality of Life questionnaire (SWAL-QOL), and Swallowing Disturbance Questionnaire (SDQ). I now know that these screenings ask a series of questions to get patient (and caregiver) perspective on swallowing and that the SDQ may help detect early dysphagia in patients with PD and other neurological disorders.1 What stood out to me about the indirect swallowing screenings is that they empower patients by giving the patient “a voice,” as these screenings are patient guided and the patient/caregiver perspectives are obtained to identify any major concerns in addition to the impact dysphagia has on the patient’s quality of life.1 It was terrifying to learn that silent aspiration can occur as a consequence of dysphagia.1 I used to think that anytime foreign material entered the airway, a patient would automatically produce an overt response, such as coughing, to try and expel the material. However, I now know that silent aspiration can occur when foreign material enters the airway, and that there are often no overt signs and symptoms of aspiration.1 However, I learned that an indicator of silent aspiration is a gurgling-sounding voice, which suggests foreign material is hovering near or has gone below the level of the vocal cords.1 I also learned that silent aspiration may cause aspiration pneumonia, which may occur when foreign material collects in the lungs.1 After learning about aspiration pneumonia, I became curious and found that aspiration pneumonia may be a leading cause of death in PD patients as studies suggest that aspiration pneumonia accounts for 70% of death for PD patients and may contribute to more than 10% of deaths for MS patients.6,7 As a future RD, it was important to learn that if a patient takes too long to eat (>30 minutes), they may be expending too much energy, which may be detrimental to their health and contribute to malnourishment or dehydration.1 Additionally, learning that patients have a range of awareness is important. For example, patients who have progressive dysphagia development due to a neurological disorder may be less aware of their swallowing safety as they have compensated for this over time by possibly eliminating food groups or have made micro-compensations throughout the years and may not realize they are at risk for dyspahagia.1 In contrast, acute dysphagia is sudden and occurs with stroke or TBI. Learning that swallow screenings should take place within 24 hours of an acute trauma occurring was important to learn, as unscreened individuals are at a significant risk for developing pneumonia.1 It was also important to learn that 60% to 70% of patients who have undergone radiation for head or neck cancer may present with dysphagia.1 This is important for all RDs to understand, but especially oncology RDs, as these patients are at significant risk for malnutrition and dehydration. Prior to learning this, I would have thought that head or neck cancer patients may be malnourished or dehydrated due to radiation therapy and would not think of dysphagia as the symptom. I now know that if I work with head or neck cancer patients in the future, I must work closely with the medSLP to screen for dysphagia. Overall, learning about dysphagia has taught me so much. I now know how to identify the patient populations most at risk for dysphagia, and also know how to properly conduct direct swallow screenings and indirect swallow screenings to better identify patients who may be at risk for dysphagia.1 I now plan to practice swallow screenings on family and friends to get comfortable with the screening process so I can better identify swallowing impairment in my future patients. I also learned that complex patients must be referred to medSLP for further investigation and that dysphagia can be a multidisciplinary disorder that requires RDs, medSLPs, MDs, PTs, RTs, and OTs working together to ensure that the patient can eat and drink safely and to also work together to maintain and improve overall quality of life for the patient.1 I am thankful I learned about dysphagia and feel that I have been given a foundation that will help me better serve my future patients. References 1. Barrera M, O’Connor-Wells B. Swallow Screen for Dysphagia: What RDs Need to Know. Accreditation Council for Education in Nutrition and Dietetics webinar. September 19, 2023. Accessed November 2, 2023. https://kings.hosted.panopto.com/Panopto/Pages/Viewer.aspx?id=759efa65-068b-4cc9-8354-b0a500b45a48&instance=Moodle 2. Steele CM, Miller AJ. Sensory input pathways and mechanisms in swallowing: a review. Dysphagia. 2010;25(4):323-333. doi:10.1007/s00455-010-9301-5 3. Heda R, Toro F, Tombazzi CR. Physiology, Pepsin. In: StatPearls. Treasure Island (FL): StatPearls Publishing; May 1, 2023. 4. Burbidge AS, Cichero JAY, Engmann J, Steele CM. "A Day in the Life of the Fluid Bolus": An Introduction to Fluid Mechanics of the Oropharyngeal Phase of Swallowing with Particular Focus on Dysphagia. Appl Rheol. 2016;26(6):10.3933/applrheol-26-64525. doi:10.3933/applrheol-26-64525 5. Khayyat YM, Abdul Wahab RA, Natto NK, et al. Impact of anxiety and depression on the swallowing process among patients with neurological disorders and head and neck neoplasia: systematic review: Egypt J Neurol Psychaitry Neurosurg. 2023;59(75). doi:10.1186/s41983-023-00674-y 6. Won JH, Byun SJ, Oh BM, Park SJ, Seo HG. Risk and mortality of aspiration pneumonia in Parkinson's disease: a nationwide database study. Sci Rep. 2021;11(1):6597. Published 2021 Mar 23. doi:10.1038/s41598-021-86011-w 7. Harding K, Zhu F, Alotaibi M, Duggan T, Tremlett H, Kingwell E. Multiple cause of death analysis in multiple sclerosis: A population-based study. Neurology. 2020;94(8):e820-e829. doi:10.1212/WNL.0000000000008907