In this episode of Hospital Medicine Unplugged, we tackle hospital-acquired dysphagia—spot it early, screen systematically, intervene fast—to cut pneumonia, malnutrition, and mortality.

We start with the big drivers: critical illness, intubation/mechanical ventilation, tracheostomy, prolonged stay, and neuro disease (esp. acute stroke). In the ICU, post-extubation dysphagia (PED) hits ~12–26%—higher after emergency admits, severe illness, and long ventilation or RRT. Mechanisms stack up: airway trauma, impaired sensorium, neuromuscular/ICU-acquired weakness. On the wards, stroke leads the pack (up to 78%), and older adults/dementia carry heavy risk and consequences.

Why it matters: aspiration pneumonia, malnutrition/dehydration, longer LOS, higher costs, and higher mortality. Dysphagia is under-recognized and under-screened—especially after extubation.

How we find it—screen, then scope:
• Universal nurse-led screening before PO in stroke and after extubation in ICU. Fail = NPO + SLP.
• Bedside tools (e.g., Yale, GUSS, TOR-BSST) flag risk but miss silent aspiration.
• Instrumental testing when unclear or high-risk: VFSS (gold standard) or FEES (bedside, repeatable).
• Separate oropharyngeal vs esophageal patterns: initiate EGD/barium/manometry when transport symptoms dominate.

Management—protect the lungs, feed the patient, train the swallow:
• NPO until safe plan; upright 30–45°, slow assisted feeding, small sips/bites.
• SLP-led strategies: posture (e.g., chin tuck), pacing, exercises; reassess after any neuro change.
• Diet texture & liquids per IDDSI—individualize thickened liquids (benefit ≠ universal; watch hydration).
• Early enteral nutrition (NG/PEG) if unsafe or inadequate PO.
• Oral care bundle to lower pneumonia risk.
• Medication hygiene: limit sedatives/anticholinergics/opioids that blunt swallow or sensorium.
• ICU specifics: routine PED screen post-extubation, cuff management, early mobility, and wean plans; avoid reflex “regular diet” orders after tube removal.
• Stroke specifics: screen before first sip, rapid SLP + VFSS/FEES as needed, start rehab early, and adapt as deficits evolve.
• Elderly/dementia: simplify mealtime environment, cueing, hydration prompts, goals-of-care; monitor for silent aspiration.
• Esophageal causes: treat the cause—PPI/EoE diet, endoscopic dilation/oncologic workup, or motility therapy—while maintaining safe intake.

Red flags for higher-level care: recurrent coughing/wet voice, oxygen dips with PO, recurrent pneumonia, failure of bedside screen, bulbar weakness, or new neuro deficits.

Quality & safety pearls:
• Screen everyone at risk, every time (stroke, post-extubation, neuro, frail).
• Don’t “test with a tray.” A failed screen mandates NPO + SLP.
• Instrumental confirmation guides targeted therapy and prevents over- or under-restriction.
• Track hydration & calories—thickened liquids can quietly dehydrate patients.
• Build order sets that auto-trigger SLP, dietitian, oral care, and aspiration precautions.

We close with the Dysphagia Bundle that sticks:
(1) Screen before PO (stroke/post-extubation/elderly/neuro).
(2) Failed screen → NPO + SLP + VFSS/FEES pathway.
(3) IDDSI diet + compensatory maneuvers with education at bedside.
(4) Oral care, hydration checks, and med de-sedation.
(5) Escalate to GI (EGD/esophagram/manometry) when esophageal features present.
(6) Reassess after status changes; step-up/step-down diet based on data.
(7) Discharge plan: home exercises, texture guidance, and follow-up SLP.

Bottom line: screen early, instrument wisely, individualize diets, and rehabilitate relentlessly. That’s how you make dysphagia safer in the hospital—and keep aspiration off your problem list.