SLP 410 feeding and swallowing

Cranial nerve V

Trigeminal nerve

Cranial nerve VII

Facial nerve

Cranial nerve IX

Glossopharyngeal nerve

Cranial nerve X

Vagus nerve

Cranial nerve XI

Accessory nerve

Cranial nerve XII

Hypoglossal nerve

Oral prep phase

Prepare bolus

• chewing

• Saliva mixes with food

• Tongue manipulates bolus

Oral transport phase

Moves bolus posteriorly

• tongue pushes bolus back

• Vocal folds close

• Respiration stops briefly

• Tongue base connects the posterior pharyngeal wall.

Pharyngeal Phase

Airway protection + move bolus to esophagus

• begins when bolus reaches vallecula

• Ends when PES closes

Esophageal phase

Moves bolus to stomach

• LES relaxes

• Bolus enters stomach

Penetration

Bolus enters larynx BUT:

• stays ABOVE vocal folds

Aspiration

Bolus goes BELOW true vocal folds into trachea

Aspiration Pneumonia

Risks depends on FTA

• frequency ( how often aspiration occurs)

• Type ( what is aspirated )

• Amount (how much aspirated)

Why Are Patients With Tracheostomies at Higher Risk for Aspiration?

Frazier water protocol

Allows certain dysphagia patients to drink WATER despite aspiration risk.

Ideal candidate for the Frazier water protocol

Patient who:

• is medically stable

• has GOOD oral hygiene

• can follow directions

• ambulatory/active

• cognitively appropriate

• NOT actively sick with pneumonia

• can complete oral care

Compensatory treatment

Immediate safety changes

Compensate right now

• chin tuck

• Head turn

• thickened liquids

• Posture changes

• Diets

Rehabilitative treatment

Attempts to CHANGE long term

Rebuild the swallow

• OMes

• NMes

• Thermal tactile simulation

Pros of Videofluoroscopic Swallow Study

• See ALL swallow phases

• See oral + pharyngeal + esophageal phases

• See aspiration during swallow

• Good overall physiology view

Cons of Videofluroscopic swallow study

• Radiation exposure

• Time limited

• Requires transport

• Breastfeeding difficult/impractical

FEES

Flexible Endoscopic Evaluation of Swallowing

Pros

• Portable

• No radiation

• Great view of pharynx/larynx

• Good for secretion management

• Can do bedside

• Better for repeated exams

Pros of FEES

• Portable

• No radiation

• Great view of pharynx/larynx

• Good for secretion management

• Can do bedside

• Better for repeated exams

FEES has during swallow

Whiteout

NG Tube (Nasogastric)

Nose → stomach

• short term

• normal gastric emptying

Pros

• easy

• cheap

• noninvasive

ND tube ( nanoduodenal)

Nose → duodenum

Used for:

• poor gastric emptying

• higher reflux concerns

Important

• continuous feeds

• pump required

NJ Tube (Nasojejunal)

Nose → jejunum

Used when:

• severe GI/stomach issues

• aspiration/reflux concerns

Important

• short term

• lower in GI tract

• radiographic confirmation needed

G-Tube (Gastrostomy)

Directly into stomach

Used for:

• long-term feeding

• permanent dysphagia

Important

• can do bolus feeds

Bolus feeds

Given all at once
ONLY if tube feeds into stomach

Mimics normal eating.

Continuous feeds

Slow pump feeds over time

Used when:

• feeding below stomach

• poor tolerance

0-3 months milestones

8-12 months

• more mature chewing

• self-feeding develops

• transition to table foods

• increased textures

• cup/straw skills emerging

• 9 months are closer to 1 year-so yes the eat food

Body’s #1 priority

Breathing

Lowest aspiration risk food

Ice chips

Steak requires

mastication

Swallowing =

high pressure → low pressure system

• VFSS equals

FEES =

endoscope through nose

Aspiration is necessary but

insufficient for pneumonia

Thickened liquids slow

Bolus flow

Chin tuck improves

Airway protection

Head turn=

Toward weaker side

Tracheostomy bypasses

Upper airway sensation

Penetration

Above vocal folds

Aspiration

Below vocal folds

Which feeding tubes are short term

ND, NJ,NG

Which tube is long term

G tube

What are the two major treatment considerations?”

Airway protection

Nutrition/hydration

2 hallmarks of dysphagia

• Delay in bolus propulsion

• Misdirection of bolus

What begins the pharyngeal swallow?”

Bolus reaching vallecula.