Dysphagia Final

Compensatory strategies for delay in swallow initiation to the vallecula with thin liquids via straw (with loss of the bolus into the airway)

• alter mode of presentation (cup first, then spoon if delay persists)

• modify bolus size

• chin tuck

• alter consistency

Rehab strategies for delay in swallow initiation to the vallecula with thin liquids via straw (with loss of the bolus into the airway)

• supraglottic swallow - to protect airway before the swallow

• sensory stimulation/thermal tactile stim

Compensatory strategies for severe Pyriform Sinus residuals with honey thick liquids

• alter consistency (this hopefully reduces residual, and the thinner consistency will be more palatable)

• head turn to the weaker side if residuals are unilateral

Rehab strategies for severe Pyriform Sinus residuals with honey thick liquids

• mendelsohn (prolong UES opening)

• effortful swallow (encourages bolus propulsion through increasing pharyngeal pressures)

• masako (improve posterior movement of tongue and anterior bulging of PPW)

Compensatory strategies for oral residue in the left lateral sulcus with regular solids

• place food on the right side of the mouth

• demonstrate finger sweep to clear material

• alter size of bolus

• alternate solids and liquids

• recommend moist solids with sauces and gravies to promote bolus cohesion

Rehab strategies for oral residue in the left lateral sulcus with regular solids

• lingual ROM exercises

• lingual strengthening exercises

• buccal strengthening exercises

Compensatory strategies for aspiration before the swallow with thin liquids via cup

• present thin liquids vis tsp

• alter temperature/taste of bolus (sensory)

• chin tuck

• alter consistency - moving to nectar and then honey as appropriate

Rehab strategies for aspiration before the swallow with thin liquids via cup

• super-supraglottic swallow

• oral control exercises (lingual ROM, strength, etc)

Compensatory strategies for moderate vallecular residuals following puree solids

• alter consistency to less viscous material if possible

• alternate solids and liquids

• recommend two swallows per bolus

Rehab strategies for moderate vallecular residuals following puree solids

• masako may be beneficial for tongue base movement

• mendelsohn may be beneficial if epiglottic inversion is reduced

what are the guiding principles of health care ethics

1. preserve life

2. do good (beneficence)

3. respect autonomy (consent & advanced directives)

4. uphold justice (fairness)

5. be honest

6. be discreet

7. keep promises (do what you say you will do, establishes trust with pts)

8. do no harm (nonmaleficience) - standard of care

What influences a person’s ethical decision-making

religion, history, personal experiences, culture, family, eduction

what is the purpose of a professional code of ethics

to ensure high-quality care and guide ethical decisions by promoting ethical consciousness, decision-making, and professional behavior

what does beneficence require from a clinician

acting in the patient’s best interest - listening carefully, understanding culture, explaining procedures, identifying needs, providing appropriate instruction

what is autonomy

a patient’s right to make their own decisions

what is a living will/advanced directive

written instructions outlining desired care if the patient cannot decide in the future

what is the purpose of a healthcare surrogate / durable power of attorney

appoints someone to make decisions if the patient cannot

what factors may create justice-related dilemmas

limits on hospital stays, insurance limitations, etc

what is malpractice

professional negligence - failing to meet the expected standard of care

what are the clinical reasons for tube feeding

• inability to sustain nutrition orally

• need for calories to overcome illness

• severe aspiration risk

what nonmedical benefits of tube feeding should be considered

reduced stress, psychological relief, decreased pressure around eating

what nonmedical risks of tube feeding should be considered

social isolation, depression, negative impact on QOL

what increases the risk of aspiration pneumonia

polypharmacy

dependence for feeding

poor oral care

smoking

prior aspiration PNA

suction use

being bedbound

feeding tube placement

in an ethical dilemma, what is the first priority

the well-being and safety of the patient

A patient with moderate dysphagia insists on continuing to drink thin liquids even though you know they aspirate on them. They are fully alert, fully competent, and understand the risks. What ethical principle guides your decision, and what should you do?

Respect autonomy — the patient has the right to make an informed decision.
Your role is to educate, document, and support the safest possible plan within their choice.

A patient is aspirating on all consistencies but refuses a feeding tube. The physician pressures you to “convince them it’s necessary.” What ethical conflict is present?

Beneficence (do good) vs. nonmaleficence (do no harm).
The SLP must provide accurate information and avoid coercion.

A patient with a PEG tube is now able to take some oral intake. The family wants the tube removed immediately, but the patient currently meets only 50% of nutrition needs by mouth. What is the ethical approach?

Follow a clinical plan + ethical monitoring:
Document oral intake, track calories, ensure safety, involve patient & family, and avoid premature removal.
Principle: Preserve life + beneficence.

Your hospital restricts the number of instrumental swallow studies per month due to cost. A patient clearly needs one for safe diet recommendations, but the quota is full.

Question:
What ethical principle is involved?

Justice — ensuring fair and equal access to necessary care.
You advocate for the patient or find alternatives.

A patient arrives for a swallowing evaluation and sits in the exam chair. You prepare to conduct the oral mech exam. You have not yet explained what you will do.

Question:
Does the patient’s behavior count as consent?

Yes — implied consent for routine, non-invasive procedures.
For instrumental exams, express/informed consent is required.

A patient with dementia is still legally competent and expresses that they do not want thickened liquids. The family insists they must have them “for safety.”

Question:
Whose wishes guide care?

The patient’s — autonomy takes priority if they have decision-making capacity.

A patient’s living will states they do not want a feeding tube. After a stroke, the family pleads with the team to place one anyway.

Question:
What should guide your decision-making?

The advance directive — it reflects the patient’s autonomous wishes.
Ethical principle: Respect autonomy.

A patient technically qualifies for a feeding tube and is medically stable for the surgery. However, the patient is socially isolated, depressed, and repeatedly states they “don’t want to live like this.”

Question:
What two questions must the team ask?

The clinical question: Can we place a feeding tube?
The ethical question: Should we?
Principles: Autonomy, beneficence, quality of life.

During dysphagia therapy, a patient reveals to you that they are being physically abused but begs you not to tell anyone.

Question:
What must you do?

Report the suspicion — legally required.
Ethical principle: Justice + nonmaleficence (prevent harm).

An older adult with dysphagia aspirates mildly on thin liquids, but has excellent oral hygiene, is mobile, not on many medications, and has no pulmonary disease.

Question:
Can they still have thin liquids?

Possibly yes — aspiration pneumonia risk is low without the additional risk factors.
Principle: Do no harm + beneficence.

A family wants a feeding tube for their loved one “because they’re too slow at meals.” The patient is otherwise safe orally with supervision.

Question:
What ethical issue should you raise?

Nonmedical risks of tube feeding — social isolation, depression, reduced quality of life.
Principle: Do good + do no harm.

A supervisor asks you to “add a few more therapy sessions” for a patient to meet billing goals even though the patient is about to be discharged and no longer needs dysphagia therapy.

Question:
What ethical principle is violated?

Honesty (avoiding fraud) and nonmaleficence (avoid unnecessary care).

A confused patient tries to get up during a swallow session. Staff suggest restraining them “just for safety” without consent.

Question:
What legal/ethical issue is this?

False imprisonment — restraint without consent is unlawful.

What is food chaining and what is its purpose?

A feeding approach that expands a child’s diet by building from a highly preferred food to new foods that are similar in taste, texture, temperature, or shape. Used for sensory-based feeding issues and picky eaters.

Give an example of a food chain starting with McDonald’s fries.

McDonald’s fries → Wendy’s fries → Burger King fries → potato wedges → tater tots → mashed potatoes → baked potatoes → roasted potatoes.

What is the exposure hierarchy used in sensory–motor feeding approaches?

• Tolerate food being in the room

• Interact with it (touch with utensil)

• Smell the food

• Touch the food (fingers)

• Kiss/lick the food

• Bite the food (spit out OK)

• Chew and swallow small amounts

• Eat typical amounts

What is the core idea behind the Sequential Oral Sensory (SOS) approach?

Gradual, sensory-based exposure to foods through play, interaction, and hierarchy steps to decrease aversion and increase comfort.

What indicates sensory feeding issues vs motor issues?

• Sensory: gag at sight, liquids > solids, pocketing, no mouthing

• Motor: difficulty with all textures, swallowing whole pieces, inefficiency, pocketing

(This matters because sensory kids need exposure; motor kids need skill-building.)

What is fading/shaping used for in feeding?

Slowly transitioning from a preferred food to a new food by gradually adjusting taste, texture, or color (e.g., mixing strawberry yogurt with small amounts of cherry yogurt).

What is the primary aim of sensory–motor feeding approaches?

Improve tolerance, exploration, and comfort with new foods before focusing on full oral intake.

Why is it important to understand medication side effects when evaluating dysphagia?

Because many medications have side effects (e.g., xerostomia, muscle weakness, dizziness, GI irritation) that can indirectly worsen swallowing safety and efficiency. Dysphagia may appear to be physiologic, but the underlying problem may be medication-related.

Why is dysphagia rarely caused solely by medications?

Medication effects usually exacerbate or contribute to swallowing issues rather than directly causing them. Dysphagia is usually secondary to side effects like dryness, weakness, sensory changes, or esophageal irritation—not a primary effect of the drug.

How can medication side effects indirectly contribute to dysphagia?

• Xerostomia: impairs bolus formation and transport.

• Drowsiness/dizziness: reduces alertness and timing for safe swallowing.

• Muscle weakness: reduces oropharyngeal muscular control.

• GI irritation/reflux/pharyngitis: causes pain and inflammation.

• Nausea: decreases intake and coordination.

• Esophageal irritation: makes swallowing painful or inefficient.

What is xerostomia, what causes it, and why is it a problem for swallowing?

• Definition: Dry mouth due to reduced salivary flow.

• Causes: >400 medications including antidepressants, antihistamines, antipsychotics, antiparkinsonian drugs, diuretics, opiates.

• Why it's a problem:

  • Poor bolus formation and transport

  • Difficulty with mastication

  • Increased oral infections

  • Ill-fitting dentures

  • Increased risk of residue and difficulty initiating swallow

What are the most common side effects of frequently prescribed medications that may affect swallowing?

• Muscle weakness

• Nausea

• Dizziness

• Diarrhea

• Drowsiness

• Stomach upset

• Tiredness

• Headache

• Insomnia

• Lightheadedness

• Constipation

• Dry mouth (very important)

These can affect alertness, coordination, appetite, or oral moisture—impacting swallow safety.

How can GI-related medication effects (e.g., reflux, pharyngitis, esophagitis) contribute to dysphagia?

• They cause inflammation, pain, and edema in the pharynx or esophagus.

• Pain → reduced swallow efficiency and avoidance.

• Edema → narrowed lumen or impaired motility.

• Reflux → secondary pharyngitis → sensation of difficulty swallowing.

What is medication-induced esophagitis and why can it affect swallowing?

Medication-induced esophagitis occurs when pills dissolve in the esophagus (often due to poor water intake or lying down), causing chemical burns.
Impact on swallowing:

• Pain (odynophagia)

• Inflammation + ulceration

• Difficulty with esophageal transit

• Sensation of stuck food or pills

Common offenders include NSAIDs, tetracycline, erythromycin, potassium chloride, and bisphosphonates (e.g., Fosamax).

What patient factors increase the risk of pill-induced esophageal injury?

• Taking pills at bedtime

• Lying down shortly after taking medication

• Taking pills with insufficient water

• Large pill size

• Elderly individuals (reduced motility)

• Pre-existing esophageal motility disorders

• Anatomical compression (e.g., left atrial enlargement)

Why do local anesthetics (e.g., dental numbing) temporarily create swallow difficulty?

They reduce sensory input to oral and pharyngeal tissues, which disrupts timing, awareness, and coordination of the swallow. Sensory loss → delayed swallow initiation and reduced self-monitoring.

What is swallowing like after a stroke in the lower brainstem - medulla

oral = functional

pharyngeal = impaired triggering/control of swallow (possibly absent)

significant oropharyngeal impairment

What is swallowing like after a stroke in the high brainstem - pontine

severe hypotonicity (LOW MUSCLE TONE)

oral = functional (ish?)

pharyngeal = delayed or absent swallow

has poor response to head rotation

What is swallowing like after a stroke in the subcortical structures

TIMING issue

impacts motor and sensory pathways

oral = mild delays in transit

pharyngeal = mild delays in swallow

What is a swallow like after a stroke in the LEFT cerebral infarct

oral = delay in initiation and transit, & limited tongue control

pharyngeal = delays

What is a swallow like after a stroke in the RIGHT cerebral infarct

oral = mild delays in transit

pharyngeal = mild delays & delayed laryngeal elevation

aspiration BEFORE the swallow

What is the difference between the right vs. left cerebral infarcts

right has more cognitive impairments than left

What is a swallow like after multiple CVAs

oral = slowed function, repetitive tongue movements, transit time may exceed 5 seconds

pharyngeal = delayed swallow, reduced elevation, & unilateral wall weakness