Assessment and management of swallowing problems: SLT perspective

Question 1

The international dysphagia diet standardisation initiative (IDDSI) framework for foods

Answer 1

0= think liquid (water)
1= slightly thick (juice)
2= mildly thick (milkshake)
3= moderately thick/liquidised food (soup) 
4= extremely thick/pureed food 
5= minced and moist 
6= soft & bite-sized 
7= regular food

Question 2

Benefits of a speech and language therapist

Answer 2

• avoids ‘revolving door’ admissions
• reduces reliance on NG and IV feeds
• reduced nil-by-mouth days

Question 3

Definition + description of the swallow and coughing reflex

Answer 3

• swallowing reflex: coordinated neuromuscular response to food/drink in the mouth, usually takes 1 second (can take 4 seconds for someone with dysphagia)
• cough reflex: where vocal cords close together and protects the airway from foreign material, which prevents aspiration. Someone with a weak cough probably has dysphagia

Question 4

Anatomy of the swallow: oral prep + oral phase, pharyngeal phase

Answer 4

• oral prep phase: this is the voluntary phase. Where recognition that there has been transfer of food into the mouth. There is lip closure and mastication of the bolus in the mouth with saliva
• oral phase: bolus moved to the posterior oral cavity towards the soft palate while the airway remains open
• pharyngeal phase (reflextive): head of the bolus moves down to the pharynx. The hyoid bone moves up, with a the larynx, the soft palate moves up and closes off nasal cavity (seal to prevent food coming out of nose). Epiglottis retroflexes allowing food down the oesophagus and past the oesophageal sphincter. There is brief apnoea to prevent food going down airway

Question 5

Causes of swallowing problems (neurological, structural, surgical, other)

Answer 5

• neurological: stroke, Parkinson’s disease, dementia, Wilson’s disease, cerebral palsy, delirium, brain tumour
• structural: pharyngeal pouches (ENT needed), damage to larynx with intubation, cleft palate, oral cancers, radiotherapy
• surgical: damage to the laryngeal nerve, head and neck cancers
• Other: COPD (in the end difficult to coordinate breathing and swallowing at the same time), candida infection, inhalation burns, medically unexplained

Question 6

Signs of dysphagia

Answer 6

• wet/horse voice
• coughing between mouthfuls/ constant throat clearing
• recurrent chest infections (particularly lower right lobe)
• any comorbidities which would impact glottal closure
• shortness of breath when drinking and eating
• unable to sit up for 20 minutes
• taking a long time to eat
• drooling
• holding food in mouth for a long time
• dehydrated or unexplained weight loss
• having a nasopharyngeal airway (this allows for suction tube to remove vomit from throat)- these patients need to be nil by mouth

Question 7

Assessment of dysphagia: clinical and instrumental

Answer 7

• clinical: at bedside, see how communicate/voice changes after eating or drinking, feel their oral musculature
• instrumental: fiberoptic endoscopic evaluation of swallowing (FEES) nasoendoscope to the epiglottis and give feed and watch swallow. Videofluoroscopic evaluation of oropharyngeal swallowing function (VFS) patient consumes barium-containing meal in X-ray so whole swallow function can be monitored (but patients need to be pretty robust to go down to X-ray)

Question 8

Management of dysphagia: 3 strategies + mouthcare

Answer 8

• Strategy 1: if can sit upright and alert, encourage self-feeding where possible . Encourage small sips/mouthfuls and go slowly, saying ‘AHH’ after each mouthful and re-swallowing if sounds wet. Dietetic referral may be needed to ensure getting enough food and fluids
• Strategy 2: Fluids and thickening powder. Thicker fluids are easier to swallow, just make sure the powder is stored out of reach from the patient
• Strategy 3: Ensure modified food/fluid textures using IDDSI chart. SLT will record what foods they are sfat to eat. May need a NGT or PEG (but oral foods should be made first priority)
• mouth care: ensure good oral hygiene twice a day to prevent caries and candida infections which may impair dentition and swallowing function. Need to also avoid xerostomia (dry mouth which can affect teeth and gums)

Question 9

Dementia and dysphagia: causes, management

Answer 9

• causes: often concurrent with sight, hearing or smell loss. Typically under-recognised by families. May not be able to recognise that food is food. Inability to coordinate swallowing and breathing, and may have a lack of thirst or hunger sensation
• management: ideally want them to feed themselves so encourage oral feeding with their favourite foods. Could use NGT/PEG but need to discuss if likely to manage. Another option is ‘risk feeding’ where SLT will conduct risk assessment to ascertain IDDSI levels of fluids and foods they can tolerate