Dysphagia EXAM

dysphagia

an impairment of emotional, cognitive, sensory, and or motor acts involved in transferring a substance fro the mouth to stomach, resulting in failure to maintain hydration and nutrition, and posing a risk of choking and aspiration- symptom of another disease/disorder

bolus efficiency

moving food and or liquid into the esophagus in a timely manner without significant residue, effort, or repeat swallows

airway protection

preventing food and/or liquid from entering the larynx and /or trachea

penetration

bolus enters the airway above the level of the true vocal folds

aspiration

bolus enters the airway below the level of the true vocal folds

silent aspiration

entrance of food or liquids into the airway below the level of the true vocal folds without symptoms

iatrogenic risk factors dysphagia

prolonged ventilation

tracheostomy

anticholinergic drugs

neuromuscular disorders

neurological disorders

postsurgical risk factors dysphagia

vocal fold paralysis

certain skull base procedures

head and neck

altered levels of consciousness risk factors

head trauma, coma, cva, seizures, general anesthesia, altered drug states etc

gastrointestinal risk factors

scleroderma, gerd, laryngopharyngeal reflux, esophageal cancer, pregnancy

common disorders in pediatric impairments

-prematurity

-respiratory and cardiac disorders

-gastrointestinal disorders

-ingestional injuries

-neurological disorders

-congenital abnormalities

-maternal and perinatal issues

-iatrogenic -tube feeding, trach, etc

signs of dysphagia

-coughing

-change in vocal quality

-throat clearing

-drooling

-anterior loss of bolus

-choking

-oral residue

-dehydration/malnutrition

-inadequate breathing and swallow coordination

-more

aspiration pneumonia

infection in the lungs caused by inhaling food, liquid or stomach content, most commonly associated with right lower lobe infiltrates, patient positioning when aspiration event occurs is a factor in infiltrate location

3 pillars of aspiration pneumonia

aspiration

poor medical status

poor oral health

predictors of aspiration pneumonia

dependency for feeding (1)

-number of teeth in decay

-tube feeding

-more than 1 medical diagnoses

-number of medications

-smoking

locations of dysphagia services

acute hospitals, acute rehab, long term acute, skilled nursing, home health, schools, outpatient clinic, dayhab

role of slp

-identify individuals at risk

-evaluate swallow function/diagnose

-develop intervention plans

-make recommendations

-provide education and training to patient, family, caregivers and other professionals advocate

team

-OT

-respiratory

-social worker

-dietician

-PT

-nurse

-doctor, NP, PA

diet textures

compensatory strategy for swallowing

-regular

-advanced mechanical soft/advance/ground (soft and bite sized)

-mechanical soft/mechanically altered/moist ground (minced and moist)

-puree (pureed)

-spoon/pudding thick liquids (extremely thick)

-honey thick (moderately thick)

-nectar (mildly thick)

-thin

nasogastric

-NG

-most common

-inserts through nose and terminates in stomach

-short term

nasoduodenal

-inserts through the nose and terminates at the small bowel

-short term

-used when esophageal reflux or gastroparesis is suspected

nasojejunal

inserts through the nose and terminates at the midsection of the small intestine

-short term

-used when stomach cannot tolerate food or liquids

When are gastronomy tubes used?

-used when longer term solutions are needed

-in stomach

-inserted endoscopically (PEG), surgically, and radiologically (PRG)

gastronomy types

continuous- formula is cycled continuously over a set period of time based on calories needed and patient’s absorption tolerance

bolus- set volume of formula is fed through the tube a set number of times per day (like meal limes )

jejunostomy tube

-longer term solution

-similar insertion to g tube

inserts into jejunum- midsection of small intestine

-used when concerns regarding stomach’s ability to tolerate direct feeds

-continuous feeds only

total parietal nutrition

nutrition is provided in a formula format via the vein

used when individual does not have ability to access nutrition via the digestive tract due to difficulty with digestion and or absorption

-can be used for day, weeks, months or years

normal swallow characteristics

-1 suck per second

-respiration is 40-60 breaths per minute

-during feeding, breaths per second are reduced, exhalation time is increased and inhalation time is decreased

-need quick passage of bolus through the pharyngeal phase to allow for safety of swallow and proper oxygen/co2 exchange (SUCK SWALLOW BREATHE)

pediatric differences in structures

-smaller oral cavity

-smaller, retruded jaw

-tongue takes up more space

-palate is wide u shape and flexible

-tongue deeply cups when suckling

-buccal fat pads

-enlarged gums

-higher larynx

-uvula and epiglottis in contact

-horizontal positioning of eustation tubes

first trimester

1-13 weeks

second trimester

14-27 weeks

third trimester

28-40 weeks

preterm

before 37 weeks

early term

37 weeks, 6 days GA

full term

39 weeks, 6 days GA

True or F: neurological development is bottom up

true

neurological development includes:

spinal cord

brainstem

then cerebral cortex

at birth, brainstem is most highly developed area of brain

swallow function at birth is solely reflexive

when does cerebral cortex formation happen?

after birth

-volitional aspects of swallow after birth

pharnygeal swallowing in utero

10-15 wks GA

anterior posterior tongue movements in utero

18-28 wks GA

establishment of swallow rhythm in utero

32 wks

increased stability of suck rhythm in utero

32-40 wks

suck linkage to swallow in utero

greater than 34 wks

coordination of suck swallow breathing

32-42 wks

adaptive reflexes

-rooting-3rd trimester

-turns to stimuli and opens mouth

-suckling- 3rd trimester

-stimulation to top of tongue or middle of hard palate elicits forward to backward tongue movement

protective reflexes

tongue protrusion, tongue lateralization, phasic bite, gag reflex, coughing, swallow reflex

tongue protrusion

stimulation to anterior part of tongue elicits anterior movement of tongue

tongue lateralization

stimulation to lateral surface of tongue elicits tongue movement towards stimuli

phasic bite

stimulation to gums elicits biting pattern

gag reflex

stimulation to posterior 2/3 of tongue and pharyngeal wall

what are the benefits of chestfeeding?

decreased risk for infections, allergies, designed for babies needs

promotes oral development-palate, jaw and teeth

what are the signs of a good latch?

-mouth is wide on breast

-lips flanged out

-babies chin touches breast

-tongue cups under breast

-babies chest and stomach touches your body, head is straight

nutritive suckling

initiating: purpose to stimulate milk let down and flow for feeding

-60-90 seconds of continuous suckling

high flow

-1:1:1- suck swallow breathe , swallow more frequently with higher flow

end of feeding

-2:1:1 to 3:1:1

milk flow slows

nonnutritive suckling

-about 2 sucks per second

-burst of sucking with pauses between

-6:! to 8::1 swallow pattern

positive pressure (compression) and negative pressure (suction)

Because of this negative pressure difference, milk is passively drawn out of the end of the nipple. Positive pressure is created by upward movement of the tongue and jaw toward the palate, which compresses the nipple, actively forcing fluid out of the end of the nipple.

0-4 months (pedi develop)

-fluid

-suckling pattern

-dependent for positioning

4-6 months (pedi develop)

-fluids

-suck

-solids- thin purees

-supported positioning

-starts to hold bottle

-more hand to mouth movements

7-8 months (pedi develop)

-fluids, some straws and cups

-solids-thicker purees, soft chewables

-able to sit upright

-hang to mouth- better with fingers, utensil intro

9-12 months (pedi develop)

-fluid intake starts to decrease

-solids-chewing maturing

-sits upright, minimal support

-able to self feed finger food, improving utensils

12-18 months

-fluids -switch to milk at 12 months, wean off bottles

-solids assess choke risk

-sit independently

-mostly able to self-feed

18-24 months

-fluids-milk, some chestdfeeding, cups

-solids-harder foods

-sits independently

-self feeding with no assistance

what is the swallow continuum?

-disordered (dysphagia)

-within functional limits(WFL)

-within normal limits (WNL)

abnormal swallow

-passing through the UES, retrograde flow, some bolus escape back from UES

what are the phases of the swallow?

oral phase, pharyngeal phase, esophageal phase

oral phase

prepare the bolus, send information to the brainstem to what is coming so than an appropriate swallow can be planned, volitional, posterior lingual propulsion

pharyngeal phase

movement of the bolus through the pharynx to the esophagus, closure of the airway to prevent entrance of the bolus, reflexive

-bolus efficiency and airway protection

-pharyngeal swallow trigger-result of sensory stimulation

-occurs after posterior lingual propulsion

-cascade of sequential swallow-velar elevation, laryngeal vestibule closure, pharyngeal elevation/constriction, UES opening, occurs on the exhale

esophageal phase

movement of the bolus into the stomach, reflexive

-esophagus collapsed at rest

-UES at the top

-LES at bottom

-peristalsis moves bolus through

oral prep

process the bolus, airway is opening, nasal breathing, bolus is placed in the oral, bolus prepped in oral cavity, lips maintain a seal to prevent anterior loss, cheeks maintain tension to prevent pocketing, mastication, tongue and teeth work together to break down bolus

oral transit

-transport the bolus posteriorly into the pharynx for swallowing, bolus is pushed between the tongue and the palate as it is propelled posteriorly

-posterior lingual propulsion-responsible for movement of the bolus into the pharynx

-aids in epiglottic deflection/inversion

-aids in elevation of the velum

what is presbyphagia

-swallowing characteristic changes during aging found in healthy older adults, natural part of aging, natural swallow changes

healthy older adults characteristics

-sensory changes

-strength and speech changes

-respiratory changes

-accompanying disease

-medication

presbyphagia: oral phase

-longer duration phase

-decreased lingual pressures

-piecemeal deglutition

-consider dentition

-reduced saliva production

presbyphagia: pharyngeal phase

-later swallow trigger, reduced hyolaryngeal excursion compared to younger individuals

-decreased UES opening compared to younger individuals

-occurrences of penetration without aspiration-shallow and transient

-suspected that the occurrence of normal aspiration increased

-pharyngeal residuals

presbyphagia: esophageal phase

-slower transit time- esophageal dysmotility, increases esophageal retention

important fact about presbyphagia

penetration without aspiration

antibiotics

infections

anaglesics

pain relievers

antivirals

viral infections

antihistimines

allergies

what is a screen?

a measure used to identify individuals at risk for dysphagia and rule out individuals not at risk

-identify individuals who need a full assessment

-performed by disciplines other than SLP

-not a billable service

standardized screening measures

yale swallow protocol, GUSS, acute storke dysphagia screening

burke dysphagia screening test

presence of 1 or more of the following features is a fail

-bilateral stroke

brainstem stroke

pneumonia history/acute stroke

coughing

reduced po intake

prolonged time for feeding

nonoral feeding

nonstandardized screening

chart review

interview

observe patient during a meal

why do slps evaluate impaired swallowing

typical and atypical structures and functions affect swallowing

-effects of swallowing impairment on participation and performance in daily activities

-contextual factors that serve as barriers to or facilitators of successful swallowin/participation

-don’t rely on single symptom

framework for clinical assessment

-clinical signs of dysphagia

suspected etiology

cranial nerves that originate in/near lesion location

muscle group impaired in motor/and or sensory function

contextual factors

recommendations

clinical swallow assessment

includes chart review, interview, oral mech/cranial nerve exam and texture trials

beside swallow

-relies on observations and signs/symptoms of aspiration and dysphagia

-inferring swallow impairments from pharyngeal and esophageal phases

-contextual factors

limitations of clinical swallow

cannot assess larynx or pharynx

cannot definitely determine if penetration or aspiration occurs

true or false: presence or absence of a gag reflex is a predictor of dysphagia

false

types of instrumental assessments

VFSS

FEES

FEESST

manometry and video manometry

scintigraphy

VFSS pros

patient is xrayed while eating and drinking different textures mixed with barium

assesses bolus efficiency and airway protection

visualizes all 3 phases of swallow

visualizes spinal column and esophagus issues that impact swallow

able to test compensatory strategies

frame by frame

VFSS/MBs limitations

patient needs to be able to sit in a chair and travel to machine

depending on type of machine, chair size may be limited

positioning may impact clarity

patient is exposed to radiation

not able to see a video quality picture of pharyngeal area/vocal folds

FEES pros

-patient eats food and liquids while device is in place

-bedside

-gives video quality view of pharyngeal structures and mucosa

-no radiation exposure

-no barium

-sensory testing

Fees limitations

inserted through the nose-barriers for agitated patients

does not allow visualization of oral and esophageal phase of swallow

white out during pharyngeal swallow

scintigraphy

used to track movement of the bolus and quantify the residual bolus in oropharynx, larynx and trachea

patient swallows a small amount of radionuclide material and gamma camera to obtain image

remain sitting or standing in front of camera

goals of dysphagia treatment

safety and efficiency

reduce risk of aspiration

maintain nutrition and hydration

independence

quality of life

compensatory strategies

immediate intervention to ensure safety

generally, no long term change in swallow function/physiology

rehabilitative

exercises or techniques that aim to change swallow function/physiology over long term

aspiration precautions

-feed when alert

-upright for meals and for minutes following meal

-monitor for signs symptoms

check lung sounds

oral care guidelines

individualized swallowing care plan

education

positioning

-upright for PO intake

feeding techniques

rate of presentation, pattern of presentation, bolus placement, promote self feeding, carryover of strategies

supraglottic swallow

protect the airway during the swallow and then clear any residuals from the laryngeal vestibule before breathing again