Saliva choking and looking ahead?

ninalu

Hi everyone,

I'm looking for some advice about what to expect with aspiration of saliva. 

Mom is late stage Alzheimer's, in a SNF, on Hospice. She's no longer walking, but she isn't bed-bound. She is up in her chair and visiting with others on a regular basis. 

She has had a long-standing cough (last ~3 years) which was treated as a swallowing coordination issue. She was evaluated and followed by speech therapy and has been on and off a softened diet multiple times. Currently she's on a honey thick regimen. Mostly she eats liquids or liquified foods (like shakes, ice creams, purees.)

Periodically over the last year, I've been with her during some distressing sputtering and choking episodes. They always happened in the setting of having eaten or had a drink.
Today she had a violent choking episode that came out of the blue. We were sitting there holding hands quietly, not speaking, and she coughed a few times lightly and then suddenly was choking, gasping, sputtering. It was clear from her expression that she was in pain and terrified. (Fortunately, she seems to forget the fear once the distress has passed.) 

Her nurse gave an under-the-tongue medication to dry secretions (Hyocyamine sulfate.) She gets it as needed and that seems to be every couple of days right now. It's not preventive, but as needed.

Can anyone who's been down this path tell me what happens next? Today's episode shook me up. It's never been so violent or hard on her as it was today. I understand that pneumonia is a risk but what about choking to death? Should she be sleeping upright? 

I'm a very worried daughter tonight. Thank you for helping me better understand this part of the journey. 

SunnyAB

Here’s some info that might enable you to mentally sort out what’s happening with your Mom: 

True choking is when the airway is blocked and little to no air can get through. This is how someone can choke to death. If she’s coughing, especially if it is strong coughing, she’s got plenty of air. The violent cough is a response to something entering the airway. The body is trying to expel it. If she’s not eating or drinking when it happens, the substance that entered the airway can be from 1) reflux of previously eaten food/liquid up from the esophagus. Aspiration from this often happens when someone is reclined. 2) something left in her throat from a previous meal. A strong swallow clears all material from the throat, but a weak/disordered swallow can leave bits of food on the walls of the throat and in some pockets in the upper throat (this may be why she’s on a liquid/pureed diet). If these bits later fall on their own, not during a swallow, the airway will be open and they’ll drop in and trigger a violent coughing episode. 3) Any other gunk hanging out in the throat, such as mucus when someone has pneumonia. 4) saliva. If someone is not able to handle their own saliva and it is just pooling in the mouth and then coming out the front as drooling and also spilling down the throat without awareness or ability to swallow, that is a sign of imminent end of life. (Swallowing is a reflex and when reflexes start to go you’re in trouble.) However you’ve mentioned a couple things that don’t fit perfectly with this scenario: 1) Your Mom feels the penetration of ?? into her airway and her coughing reflex is strong. When someone is at end of life, they can sometimes have food and liquid pouring right into their airway with no coughing or awareness whatsoever. And 2) You state that your Mom has previously been diagnosed with a delayed swallow, which is very different from not being able to swallow. This coughing, when not eating/drinking, would be more occasional. You would likely not see drooling, and your Mom would be able to swallow on command (she’d need a little sip of something to help if she has a dry mouth from the meds.) 

Raising the head of the bed at least 30 degrees helps to keep reflux material out of the airway, due to gravity, but it won’t keep the saliva from spilling into her throat & airway since that’s coming from above the airway. Do whatever makes your Mom most comfortable, keeping in mind that it’s also not comfortable to wake up throughout the night with violent coughing (if that's happening). 

Assuming this issue is frequent enough that you’d be able to note a difference, how your Mom responds to the med to dry up secretions will likely tell you something. (Meanwhile, stick with liquids and slick and loose purees for safe eating. Saliva is an important part of a safe swallow when someone is still eating drier foods.) 

Obviously you don’t want her having frequent, violent coughing episodes but try not to be too scared when she’s coughing. Coughing has a purpose and as I said above, requires lots of air. Once she’s done sufficient coughing, if she doesn’t seem to be coming out of it, you can try to cue her to breathe through her nose. And try to remain relaxed yourself since she may also be frightened. Trying to relax and and taking some slow deep breaths thru the nose can calm a coughing fit that continues after the airway is cleared.  

I'm thinking of you and your Mom and hoping that you feel calmer after a decent night's sleep.  It's great you have hospice onboard and that they are attentive. 

ninalu

Thank you Sunny AB, your reply is very helpful. 

It sounds like most of what's happening with my mom now is due to unswallowed / pocketed food that becomes dislodged and causes a temp blockage of her airway. 

Mom also does have some pooling of saliva when not eating, as well as dripping from her nose / eyes. They've covered the allergy avenue and reflux. The dripping from her eyes, nose and mouth may be why they are using a med PRN to dry secretions. 

There are times when she is able to cough and times when no air is getting through and she's purple, unable to breathe. But clearly the reflex and awareness and ability to swallow are still there. 

Thanks again for the very helpful education in all the factors involved. It's reassuring and calming for me, and helps me to be more present for what is happening for her.