Nil per os except medications order in the dysphagic patient

To demonstrate why the 'nil per os except medications' order is contraindicated prior to dysphagia testing and to recommend ways to prevent aspiration of medications in the dysphagic population.

A 71-year-old male deemed at-risk for aspiration due to coughing when drinking thin liquids was made nil per os except medications and referred for dysphagia testing. Swallowing was analyzed objectively with trans-nasal fiberoptic endoscopic evaluation of swallowing.

Aspiration on the initial 5 cc puree bolus swallow trial elicited a cough reflex. A 325 mg, 1 cm diameter, enteric coated aspirin pill emerged from the trachea, progressed through the glottis and remained transiently in the laryngeal vestibule before lodging, along with pudding residue, in a mucosal fold of the left vallecula. Neither volitional coughing nor single 5 cc water bolus swallows dislodged the pill. Otolaryngology was called and removed the pill trans-orally under direct visualization with a Kelly clamp. The pill maintained both its enteric coating and integrity for a total of 7.5 h after being aspirated.

The nil per os except medications order is contraindicated in the dysphagic population. When aspiration is suspected, nil per os including medications is recommended until dysphagia testing determines what form of medication can be swallowed safely.