When a loved one is placed on tube feeding for a while, their lips and inside their mouth may become very dry. This is especially so in elderly persons who tend to keep their mouths open all the time.
Reason the inner layer of their mouth become very dry is because liquid and food items no longer passes through the mouth. And if they are no longer able to swallow, providing fluid orally would pose the danger of fluid going into the lungs and causing infection or pneunomia.
My mom has been on tube feeding for more than 3.5 years. Her dry mouth condition is made worse by the fact that over 20 years ago, her salivary glands and mucus membrane had been destroyed due to oral radiotherapy treatments on her throat as treatment for her tonsil cancer.
Prior to her Alzheimers, she has to carry around a small water bottle with her everywhere she went and would take few sips of water frequently to prevent her mouth and throat from becoming too dry. She also would consume a tablespoon of Manuka honey each morning.
When my mom developed Alzheimers and lost her swallowing ability, we can no longer give her any sips of liquid. Her mouth started becoming very dry and without the protective layer of the mucus membrane, it often cracked. Also, a thick yellow deposit started to stick within the upper and sides in her mouth. These are secretions from her lungs and throat that had moved upwards to her mouth and remained there as she had forgotten to either spit or swallow it (normally we would swallow or spit the secretions hence they would not have the chance the accumulate inside our mouth). Attempts to remove the thick yellow membrane often resulted in bleeding.
How to manage the dry mouth and build up of yellow deposits
These are a few methods I have tried based on advice from nurses and doctors.
1. Cleaning with a wet gauze
I would perform phlegm suction for my mom each time before her meal. After the suction, while still wearing rubber gloves, I would take a piece of gauze, wet in water and then squeeze it dry to prevent water from dripping. Then I would wrap the gauze around my finger and gently wipe within the inside of her mouth. This method was suggested to me by a nurse.
This is done at least 4 times a day before her meals- it has to be done frequently or else if the yellow deposits build up in the mouth and stuck to the tissue, it would be hard to remove.
2. Nasal spray
My mom’s ENT doctor prescribed a nasal spray to be used to manage the dryness in her mouth.
3. Dealing with bleeding inside the mouth- oral paste
In Thailand, they have a oral paste which is very effective to treat bleeding in the gums or inside the mouth. It is Trinolone oral paste (Triamcinolone Acetonide) under Nida Pharma Incorpration. Squeeze out a little bit on the finger (wearing gloves) and then gently rub it on the bleeding area.
4. Monitoring water intake
During a recent visit, her doctor recommended that we increase the dosage of water given to her. He had suspected my mom was dehydrated as blood test results show a slight elevation in bicarbonate levels in blood which he said is shown in patients who are dehydrated. He suggested giving my mom more water after her feed, as well as a total of 200 ml in between feeds (distributed throughout the day).
When I gave my mom more water, I noticed that her lips no longer appeared dry or cracked. However, after about two weeks, I noticed swelling on her right hand and foot. I then gradually reduced the volume of water till an optimal level where the swelling no longer occurr which for my mom, it is about 100 ml which I split out into two times between her meals. Do note that this is additional on top of her daily fluid intake ie:
- tube feeding (300x 4 times a day) and
- water (about 100 ml x 4 o pass on the tube and to accompany supplements medication after meals).
Removing the yellow layer of dried secretion
If we use a wet gauze to wipe the inner mouth, it can help to prevent the yellow layer which is secretions from hardening. However, for elderly who often keep their mouth open, the air entering would cause dryness quickly, thus causing the secretions to dry and then stuck to the mouth.
To remove the layer, I would use a wet cotton swab (size L) with one hand, and a wet gauze on another. Using the wet gauze, I gently drip the area moist and then gently probe using the cotton swab to remove the layer. One cannot get impatient or do it quickly as any yank or tug would immediately result in bleeding. However, sometimes even when done gently, bleeding still occur. Use a gauze to press for a while to stop the bleeding then apply the oral paste.
Important: Do not leave the gauze inside the mouth.
During the initial years, I always had to remove the dried secretions immediately when I see them to prevent the dried up substance to fall into the lungs. However, despite continous efforts, she would still have solid mass from dried up secretions that obstruct her breathing and cause lung infection. This has resulted in frequent visits to the hospital and hospitalization due to pneunomia. The hospitalization happens few times a year.
Through the recommendation of the ICU doctor (she was sent to ICU once in critical condition where she was placed on a ventilator), a tracheostomy was done. It has then helped tremedously as I was able to suction out a lot of phlegm and secretions from her lungs and hence they did not get pushed upwards to her lungs, nor did she experience frequent inability to breathe due to hardened secretions obstructing her breathing. If she has secretions and I was in the room or am sound asleep, she would cough it out on her own. Due to the opening of the trachestomy, it enables the secretions to move out easily. In other words, she can now help herself.
