Dysphagia

Swallowing is

• a sequence of neurologically controlled movements involving the muscles of the oral cavity, pharynx, larynx, esophagus and stomach

Dysphagia

• when the muscles or nerves of this process are damaged, swallowing is no longer normal

Due to neuroplasticity (brains ability to rewire/change over time)…

• individuals that experience this damage may still be able to swallow certain food/drinks and/or use certain strategies to aid in swallow safety and regain function

  • what they regain can vary (factors)

  • compensatory strategies

Dysphagia =

whereas

Aphagia=

difficulty swallowing

whereas

inability to swallow

Dysphagia is

• difficulty swallowing due to damage to or removal of muscles and/or structures involved in swallowing

  • disordered, disrupted, damaged, destroyed

Dysphagia is NOT primary diagnosis [i.e.dysphagia following stroke] it is a

• SYMPTOM of a neurological disease or structural abnormality

Dysphagia is often described most often by its “signs” including

• coughing/choking during or after meals

• food sticking in throat

• regurgitation

• odynophagia =pain on swallowing

• drooling

• unexplained weight loss

• nutritional deficiency

  • last two could be peds/old

SWAL QUAL

• a survey of quality of life of patients with dysphagia

Impact of Dysphagia

• functional limitations

  • ex) limited to specific diet of foods they don’t like

• Activities and participation

  • patients on NPO may be reluctant to go out to eat

• Environmental factors

  • use of personal care providers may be needed

As SLPs' we want to prevent the complications of Dysphagia

• aspiration

• dehydration

• malnutrition

• weight loss

• elderly/weight loss

Aspiration

• food, liquid, pill or secretions pass into airway below the level of the TRUE VFs

• may lead to pneumonia and/or other respiratory complication

dehydration

• state when not enough water in the body to maintain healthy fluid levels

• may be caused by

  • drying medications

  • forgetting to drink

  • excessive perspiration

malnutrition

• when body doesn’t get enough nutrients

• may be due to inability to ingest food safely, fear of eating/drinking, reluctance to eat [inability to digest/absorb nutrients=GI]

• results in inability to maintain health, muscle weakness and strain on heart

Weight loss

• may impact coordination of muscles and muscle mass (those used to swallow), immobility, delayed recovery from injury/illness

• unplanned weight loss may be a result of swallowing disorder ESPECIALLY ELDERLY

  • to combat

    • temporary NPO

    • nutritional consultation

Elderly and weight loss

• affects recovery from medical problems

• may be a subtle sign of depression

• may be due to inability to eat preferred foods

• fear of pneumonia

• dental problems

• dementia

Aspiration Pneumonia

• pulmonary infection from acute or chronic aspiration of fluid, food or oral secretions from mouth OR stomach (reflux) into the airway/lungs

• can be life threatening

• not all aspiration leads to pneumonia

  • 45% of adults aspirate in sleep

• Treated with antibiotics; however if the CAUSE isn’t ELIMINATED, INFECTION = RECURRENT

  • weak cough/pulmonary disease higher risk

Community/hospital acquired pneumonia

• result of acquired bacterial infection

• hospital=nosocomial 48-72 hours following admission

• complicated by pre-existing conditions (age, illness, aspiration, GERD)

• TX= antibiotics

DX of PNA —> symptoms

• symptoms

  • dyspnea (short of breath), fever, crackles during lung auscultation (Stethoscope)

  • completed with CXR interpreted by physician

DX of PNA —> presentation

• CXR RIGHT LOWER LOBE most frequently involved with aspiration related

• bilateral lower lobe = aspiration upright

• right upper lobe more common = aspiration prone position

Impact of Dysphagia on quality of life

• general health

• psychological well-being

• financial well being

• voice

general health

• inability to swallow may lead to a decline in overall health

Psychological Well-being

• eating is SOCIAL FUNCTION + nutritional necessity

• individual may no longer be able to participate in preferred, social activities

• food=enjoyment

• dysphagia =diet=regain health

Financial well-being

• may be need for special foods, supplements, enteral (FT) or parenteral (vein) dysphagia therapy, devices (prepare food)

• cost of healthcare system for TX of PNA, recurrent hospitalizations

voice

• evidence suggests patients with swallowing disorders often have voice changes

• repeatedly coughing (aspiration)

• GERD erodes VF’s stomach acid

• laryngopharyngeal reflux, excess mucus and/or laryngitis —> dysphagia indicators/causes

Causes of Dysphagia

• Natural aging (not necessarily dysphagia)

• neurological/degenerative diseases

• esophagitis

• CVA - stroke

• Head injury/ TBI

• dementia (middle to late)

• Head and neck cancer and/or TX (radiation/chemo/surgery)

  • weakens/stiffens/removal of structures

• Medications

if dysphagia is from the brain stem =

severe

Causes of Dysphagia Cont’d

• tumors

• trauma

• intubation/extubation (breathing tube pulled in and out VF’s)

• systemic (parkinsons, diabetes, high blood pressure)/autoimmune disease

• infection

• inflammatory disease/chronic reflux

• congenital disorders (at birth —> down syndrome)

• reflux gastroesophageal, laryngopharyngeal

• muscle tension dysphagia

Infants and children

• sucking, swallowing, feeding disorders often overlooked until failure to thrive condition

• significant impact on the inability to achieve nutrition enough to grow and develop

• CAUSES —> gestational (utero) factors, preterm birth, neurological disorders, anatomical disorders

• improvement in neonatal care, instrumentation and study of nutritional impact

Early Intervention

• reduced PNA rate in acute care (no aspiration=no pneumonia)

• may improve recovery from head and neck cancer

• reduces length of hospital stays ($/emotional)

• positive impact of dysphagia TX for neurological disease accompanied by dysphagia

• Prevent extensive comorbidities that result from the interaction of swallowing disorders w/ other diseases

  
  SCREENING procedures target patients early for swallowing intervention

Testing for Dysphagia

• no single test that is 100% accurate for DX dysphagia or its cause

• prevalence of dysphagia dependent upon Dx

  • screening procedures (history/caregiver)

  • Clinical swallow evaluation CSE/Bedside swallow eval cost effective

  • instrumental evals: more invasive

    • modified barium swallow MBS OR VFSS videofluoroscopic swallow study

    • flexible endoscopic evaluation of swallowing FEES

Acute Care

• length of stay

• example

• short 2-5 days

• hospital (ICU or NICU)

Subacute Care

• length of stay

• example

• 5-28 days

• hospital rehab unit

Rehabilitation facility

• length of stay

• example

• varies (few weeks-months)

• MOST INTENSIVE THERAPY

• skilled nursing short term rehab section; outpatient clinic

Skilled nursing facility

• length of stay

• example

• patients too medically complex to go home and/or unable to manage independently

• may have dysphagia due to disease effect AND aging process

• LONG TERM

• nursing home

Dysphagia team

• SLP

• GI

• nurse/CNA (skilled nursing/hospital)

• dietition/nutritionist

• OT

• Respiratory therapist

• patient/family

• radiologist (MBS)

• medical doctor/NP

• oncologist/neurologist/ENT

ASHA roles + responsibilities

• must be possessed, required to complete, and based upon education and experience

  • identify signs/symptoms of dysphagia

  • practice interprofessional collaboration

  • advocate for services for individuals w/ feeding/swallowing disorders

code of ethics

• set of ethical guidelines to which we adhere

• reflects what we value as professionals and establishes expectations for our scientific and clinical practice based on principles of duty, accountability, fairness and responsibility

• intended to ensure the welfare of the consumer and to protect the reputation and integrity of the professions

• all members have right to bring allegations of ethical dilemma to ASHA board of ethics —> sanctions when violated

4 principles of ethics

• Put the client’s welfare first (including research participants).

• Stay competent—keep learning and improving (CEUs).

• Be honest with the public and share accurate info.

• Respect the profession, work well with others, and follow professional standards.

Ethical considerations and swallowing

• ethical dilemmas arise when clinical recommendations conflict w/ patients wishes = advanced directives [patients preference medically] OR the decision maker/health care proxy

Health care proxy

alt. person who makes decisions if patient isn’t capable

1) respect for autonomy

2) beneficence

3) nonmaleficence

4) justice

• Each competent individual should have the rights to decide how one is medically managed

• Clinicians should take positive action to do good for patients and act to prevent or remove harm

• Don’t cause deliberate harm to patient

• Patients needs should be addressed in a fair and equitable manner

THEMES OF THESE GUIDELINES

• involve the patient and family in decision making

• educate family about risks and benefits

• accurately identifying progress/prognosis

• encourage regular follow up to ensure fair/consistent care for all patients

Impact of Dysphagia

Estimated that in the U.S.,
300,000-600,000 people
with clinically significant
dysphagia are diagnosed
annually
● Nearly 70% of these are older than 60
older than age 60

Epidemiology

• prevalence and cause of a disorder

Swallowing difficulties may arise from

• mechanical problems of the swallowing mechanism

• neurological disorders

• GI disorders

• loss of organs due to surgery or traumatic injury

dysphagia/aphagia may involve

• disruption of the timing of the events needed to swallow

xerostomia

• dry mouth

With the onset of Dysphagia, the body is

• not able to cope as well with the primary disease

  • dysphagia exacerbates the primary disease