Chapter 74- Dysphagia and Aspiration

Question 1

Which CNs are involved in swallowing?

Answer 1

V, VII, IX, X, XI XII

Question 2

does an inflated cuff prevent aspiration?

Answer 2

no, liquids can leak around

Question 3

Name 5 phases of swallowing

Answer 3

Preoral anticipatory
Oral preparatory
Oral transport
Pharyngeal
Esophageal

Question 4

Describe preoral and oral phases of swallow

Answer 4

Pre: produce saliva –> easier chewing

O Prep: chew, tongue, lips, cheeks, palate, jaw form bolus by tongue

O Trans: propel to anterior pillar - swallow reflex initiated. This phase takes 1 second

Question 5

Describe pharyngeal phase

Answer 5

Velopharynx closure
Pharyngeal constrictor contraction (peristaltic)
Laryngeal elevation/closure
Upper esophageal opening

Question 6

Describe esophageal phase

Answer 6

constrictor peristalsis

Question 7

4 general lesion sites that can lead to dysphagia

Answer 7

cortex
brainstem
CNs
muscles

Question 8

Penetration vs Aspiration

Answer 8

Penetration: food/liquid enters laryngeal vestibule, stays above TVC
Transient penetration: no residue left after swallow completed
Aspiration: below TVC

Question 9

what oral mechanism exam evaluates

Answer 9

structures, movement fxn tongue/lips, sensory

Question 10

How to reduce aspiration risk with trach patient

Answer 10

finger occlusion
obturator
one way valve (INC subglottic air pressure/activation of mechanoreceptors)

Question 11

Penetration Aspiration Test

Answer 11

1- does not enter airway
2- stays above VC, ejected
3- not ejected
4- contacts VC, ejected
5- not ejected
6- below VC, ejected
7- not ejected, despite effort
8- no effort made to eject

Question 12

3 oz water test

Answer 12

Drink 3 oz without interruption
If cough/choke/wet voice within 1 min, failed
Detects 80% of aspiration pts (MBS gold standard)
Does not detect silent

Question 13

Incidence of post-intubation dysphagia and what makes it more likely

Answer 13

3-62%

55+, comorbid, prior dysphagia, >24 hr

Question 14

How soon does pharyngeal muscle atrophy occur after intubation?

Answer 14

within 24 hr

Question 15

Treatments for oral preparatory phase dysphagia

Answer 15

Pincer grasp/labial strengthen/neuromuscular electrical stimulation if labial insufficiency
Isometric tongue exercises/mirror/modified spoon/syringe/finger sweep/lingual sweep of cheek sulcus/head tilt if tongue weak/pocketed material
Thermal stimulation can improve sensation

Question 16

Treatment of pharyngeal dysphagia

Answer 16

Delayed pharynx initiate: thermal, sour bolus trial, verbal cueing, NMES

Muscle dysfunction: Mendelson maneuver keeps larynx elevated and cricopharyngeus open longer, head turn to weaker side, NMES

DEC tongue base retraction: more pooling in vallecula, DEC epiglottic tilt…may use supraglottic swallow, Masako maneuver increases tongue base function

Poor larynx elevation: Shaker exercise, Mendelson maneuver, biofeedback, effortful swallow, chin tuck, head turn

Question 17

why does increased viscosity help with oralpharyngeal dysphagia

Answer 17

If issue is delayed initiation of pharyngeal swallow, then increasing viscosity –> slower transit time –> gives pharynx more time to initiate swallow

Question 18

Frazier Water Protocol

Answer 18

allows dysphagia patients free access to water
neutral pH, well tolerated by lungs, absorbed by bloodstream
must maintain good oral hygiene
decreases dehydration risk, improves compliance with swallowing precautions, INC QOL

Question 19

Meds that can cause dysphagia due to DEC muscle function/coordination/sensation/saliva

Answer 19

Antichol/musc (atropine, oxybutynin, tolterodine)
Neuromusc block (atracurium)
TCA/Antihist/diuretics (dry mouth)
benzocaine/lidocaine
Haldol/chlorpromazine/loxapine

Question 20

Meds that cause dysphagia due to long term/high dose use –> muscle deterioration

Answer 20

AntiCA/ImmunoSupp (cyclosporin, azathioprine, daunorubicin, carmustine)
high dose steroids
Gabapentin
Phenytoin (dilantin)
Carbamezapine (tegetrol)
alprazolam (xanax)
clonazepam, diazepam (valium)
baclofen (lioresal)
Cyclobenzaprine (flexeril)

Question 21

How does breathing pattern influence aspiration risk?

Answer 21

Exhale-Exhale is most common breathing pattern during swallowing
Over 65/chronic dz: pattern changes (any inspiration can increase aspiration risk)
H/N cancer treatment pts usually have inhale/inhale pattern (highest aspiration risk)

Question 22

Radiation changes to swallowing

Answer 22

Decreased epiglottic retroflexion
delayed swallow initiation
uncoordinated swallow/respiration
Decreased BOT retraction (does not meet post pharyngeal wall) –> decreased cricopharyngeal opening –> pooling in pyriform sinuses/vallecula

Question 23

How do post-swallow aspirations differ from intra-swallow aspirations?

Answer 23

Typically silent, or the cough that is elicited is delayed/ineffective
This type of aspiration occurs with pooling in pyriforms/vallecula

Question 24

NMES or no NMES?

Answer 24

Study of 120 patients –> estim in addition to traditional treatment was significantly more beneficial than traditional alone

Opponents say NMES reduces hyolaryngeal mobility

Question 25

Do trach tubes alter laryngeal elevation?

Answer 25

Some studies say yes, some say no

Need for trach tube indicates comorbidities that may be the cause of increased aspiration risk in trach patients