Chapter 10: Dysphagia

Dysphagia

• Dysphagia - a difficulty in swallowing or an inability to swallow
• A swallowing problem affects a person’s ability to eat, which serves 2 primary purposes:
  • Nutrition and hydration
  • Pleasure
• Dysphagia impairs a person’s ability to participate in social gatherings or events

Examples of Dysphagia

• Aspiration - when food enters the airway
• Aspiration occurs because - weak or paralyzed pharyngeal and laryngeal muscles

Role of the SLP

• Approximately 30% of SLP are involved in the management of swallowing

• SLPs are a key component of a dysphagia team (ENT, OT, SLP, radiologist, PT, primary care physicians, nutritionist, nurses)

• Communication and swallowing problems co-occur because these two activities share some common structures and functions

  

Stages of Swallowing

The Anticipatory Stage

• Occurs before the food reaches the mouth
• Sensory information
• “prepare to eat”

The Oral Stage

• Voluntary control
• Preparatory phase part of the oral stage, the bolus is being readied for the swallow
• Transport phase begins when the tongue pushes the bolus against the palate, moving it in a backward direction toward the pharynx

The Pharyngeal Stage

• Begins with the triggering of the pharyngeal swallow
• Purposes - to protect the airway, to direct the bolus toward the stomach
• Velum elevates and contracts to close off the velopharynx so that food cannot enter the nasal cavity
• Larynx and hyoid bone move upward and forward
• Larynx closes to prevent food from entering the airway
• Epiglottis comes over the larynx to provide additional airway protection
• When the swallow is triggered, pharyngeal peristalsis is initiated - contractions that move the bolus through the pharynx toward the esophagus

The Esophageal Stage

• Begins with the lowering and backward movement of the larynx and the resumption of breathing
• Upper esophageal sphincter contracts
• Bolus moves through the esophagus to the stomach in a series of peristaltic waves

Dysphagia in Adults

• Swallowing requires both cognitive and motor skills
• Causes of Swallowing Disorders
  • Cerebrovascular Accident (CVA) - aka stroke
  • Brain Stem Stroke
  • TBI
  • Dementia - cognitive issues/hold food in mouth
  • Neuromuscular Disease - MS, ALS, PD, MG
  • Cancer - surgery changes the anatomy, radiation causes tissues to become “stiff”

Symptoms of Dysphagia

• coughing or choking during swallowing
• change in voice or speech (sounds gurgle-y)
• repetitive swallows or progressive need to clear throat
• regurgitation, immediate or delayed (pharyngeal and nasal or esophageal and gastric)
• weakness; lack of control of head and neck musculature
• fullness/tightness in throat
• pain, localized or radiating (e.g., functional chest pain may occur in patients with somatic concerns, anxiety, or depression)
• odynophagia (pain on passage of bolus)

Management of Adult Dysphagia

• History
• Bedside evaluation
• Instrumental evaluation
• Determine treatment plan based on these results
• Team - SLP, OT, PT, nurses, nutritionists, radiologists, neurologists, gastroenterologists, pulmonologists

Assessment

Questions to be Determined

1. Is the patient aware of the food on his plate, can he feed himself?
2. Are the muscles of the tongue, lips, and jaw able to adequately prepare a bolus?
3. Do the pharyngeal and laryngeal muscles have enough strength and movement to elevate the larynx to close off the airway and direct the bolus to the esophagus?
4. Can the patient eat safely (with no aspiration) and maintain adequate nutrition?

History

• Collect relevant feeding, behavioral, and medical information
• Pre-existing conditions, medications
• Medically stable?
• Respiratory status
• Current cognitive functioning

Current Medical Status

• How the person is presently receiving nutrition
  • IV
  • NG tube - placed in the nose and goes to the stomach
  • G tube - tube surgically placed directly into the stomach
• People can still aspirate on an NG or G tube if they have reflux

Bedside Clinical Assessment

• Meets with the patient and assesses his/her ability to take food off the plate, prepare the bolus, and safely swallow
• Oral Mech Exam, assesses ability to follow directions, level of alertness
• Directly observe the oral phase
• Unable to view the pharyngeal phase, but can watch for signs:
  • Neck along with placement of 2 fingers under the chin to determine whether there is upward and forward laryngeal movement
  • Listening for coughing, which would mean the bolus went down the wrong way
  • There could be a silent aspirator - they aspirate but do not cough
  • Listening for a “gurgly” sound after swallowing which might indicate that part of the bolus is on the vocal folds
• Pharyngeal stage of the swallow can not be diagnosed by the bedside evaluation
• When pharyngeal stage problems are suspected, the SLP can conduct an additional assessment procedures

Instrumental Assessment of Dysphagia

• An instrumental assessment is used to gain a better understanding of pharyngeal stage functioning

Modified Barium Swallow Study (MBS/MBSS): this procedure is a fluoroscopic image that is recorded on videotape

• SLP and radiologist perform this procedure together
• SLP places barium coated food and liquids into the patient’s mouth
• Radiologists takes a moving picture
• Pharyngeal stage functioning can be visualized

Endoscopy (FEES)

• Flexible scope is inserted through the nose and positioned just above the epiglottis
• Patient is given food mixed with dye
• Patient east the examiner observes the pharyngeal structures and functions

Treatment Planning

• Team determines treatment
• Plans often include:
  • Positioning - chin tuck
  • Environmental modifications - eat in a quiet environment (need more cognitive status to follow strategies)
  • Adaptive feeding equipment - Provale cup, Safe straw
  • Bolus modification
  • Swallowing techniques - ex. effortful swallow - concentrate on tensing all of the throat during swallows
• Chin Tuck - Decreases airway diameter
• Safe Straw - Limits sip size
• Provale Cup - Limits sip size

Examples of Modified Diets

Dysphagia in Children

• Pediatric dysphagia: the SLP treats children who have yet to acquire normal eating skills
• Various etiologies have prevented the development of normal swallowing patterns
• Respiratory: suck/swallow/breathe
• Sensory deficits: food textures
• Cleft Lip/Palate
• Goal of dysphagia assessment and treatment with children is to - Aid in the development of skills needed to keep the child safe and well nourished
• Prematurity
  • Ability to suck/swallow develops prenatally
  • Premature baby may not have the ability to suck milk from a nipple
  • Weak facial muscles, underdeveloped lungs
  • Uncoordinated suck/swallow, weak suck, breathing disruptions
• CP
  • Wide range depending upon the degree of motor deficit
  • Often see increase in muscle tone, decrease in ROM
  • Cognitive deficits
  • Child with CP is often a slow, inefficient eater with a high risk for aspiration

Pediatric Dysphagia Evaluation

• Review Medical and Feeding History and Current Feeding Methods
• Bedside Clinical Assessment
• Instrumental Assessment
  • Conduct the MBS in the child’s current seating system
  • Use food textures that are similar to what the child currently eats
  • Use the child’s own utensils- bottle, special cup, spoon, etc.

Pediatric Treatment Planning

First goal - Child meet current nutritional needs while remaining safe so the child can grow and remain healthy

Second goal - Normalizing the child’s eating and swallowing skills

• Dietician, SLP, Physical Therapist

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