Dysphagia Flashcards
What is a normal swallow?
It is a life sustaining skill. A swallowing disorder involves impaired execution of the oral preparatory, oral, pharyngeal, or esophageal phases of a normal swallow.
Signs & Symptoms of Dysphagia
- inability to recognize food
- changes in diet
- inability to control food or saliva in mouth
- pocketing
- coughing right before, during, or after swallow
- recurring pneumonia
- dehydration
- reflux
- unexplained weight loss
- gurgly voice quality
- patient complaint
- temperature spikes after meals
What are some complications and symptoms of dysphagia
-pneumonia, dehydration, & malnutrition
These are both symptoms and complications of dysphagia which result from either an unsafe swallow (which causes aspiration and risk of pneumonia) or inefficient swallow (which results in an insufficient intake of food and/or liquid)
Muscles & innervations of Lips
Sensory= Trigeminal V Motor= facial VII
Muscles & innervations of tongue
Sensory= trigeminal V, facial VII (anterior 2/3 of tongue), glossopharyngeal XI (posterior 1/3) Motor= hypoglossal XII
Muscles & innervations of palate
Sensory= trigeminal V, glossopharyngeal IX Motor= Vagus X, Accessory XI
Muscles & innervations of Pharynx
Sensory= glossopharyngeal IX Motor= glossopharyngeal IX & Vagus X
Muscles & innervations of Teeth
Sensory= trigeminal V
Muscles & innervations of Jaw
Sensory & motor= trigeminal V
Average deglutition frequency
2400 swallows per day
*****Swallowing and respiration are reciprocal functions
Phase 1 of a normal swallow: Oral Preparatory Phase
Begins: Sensory recognition of food
Middle: Food enters mouth and labial seal is maintained, mastication and manipulation begins until semi-cohesive bolus is formed
Ends: Bolus begins anterior to posterior movement on the tongue
Oral Preparatory phase Requires:
- open nasal airway and nasal breathing
- Larynx & Pharynx are at rest and nasal breathing continues
- For a liquid bolus no mastication needed, held in “Tippers position” (food held between midline of tongue and hard palate with tip elevated against alveolar ridge) OR “dippers” (bolus held on floor of mouth in front of tongue) 20%
- For solid bolus: mastication needed. Requires rotary lateral movement of mandible & tongue.
- tongue positions material on teeth
- upper and lower teeth meet, material is crushed and falls medially toward the tongue which pushes it back onto the teeth as the mandible opens (cycle repeats)
- Tension in the buccal musculature closes off the lateral sulcus and prevents food from falling into sulcus
- After chewing tongue pulls food into bolus before oral phase is initiated.
- *airway is still open during this phase
Phase 2: Oral phase
- Starts when the tongue begins posterior movement of bolus
- “stripping action” occurs where the midline of the tongue sequentially squeezes the bolus anteriorly against the hard palate
- Sides and tips of tongue remain firmly anchored against alveolar ridge
- Thicker food require more pressure and slightly more time to propel through oral cavity and pharynx
- Phase ends when bolus is propelled back to the “trigger point”
- *Oral Transit Time (OTT): time taken from posterior movement of bolus to when bolus reaches trigger point (normal 1-1.5 seconds)
Phase 3: Pharyngeal Phase
- Starts at the trigger: when bolus passes any point between the anterior faucial arches and the point where the tongue base crosses the mandible.
- *Pharyngeal delay time (PDT): begins when the bolus head reaches the point where the lower edge of mandible crosses the tongue base and ends when swallow is triggered
- *Pharyngeal Transit Time (PTT): time elapsed from triggering pharyngeal swallow until bolus passes through UES (usually less than 1 sec)
Phase 3, once swallow is triggered what physiological activities should occur?
- Elevation and retraction of velum & complete closure of VP port so bolus doesn’t enter nasopharynx
- Elevation and anterior movement of hyoid and larynx (hyolaryngeal elevation)
- Closure of larynx at all 3 sphincters to prevent food from entering airway (TVF–> FVF–> epiglottis)
- opening of the UES to allow material to pass from pharynx to esophagus
- ramping of the base of tongue to deliver bolus to pharynx
- followed by tongue base retraction to contact anteriorly bulging posterior pharyngeal wall
- progressive top to bottom contraction of pharyngeal constrictors to squeeze the bolus through the pharynx
Phase 4: Esophageal Phase
- Transit time is the time from when the bolus enters the UES until is passes into the stomach at the LES (8-20sec)
- Peristalic wave begins at the top of the esophagus and pushes the bolus ahead of it until LES opens and the bolus enters the stomach.
- Pts with esophageal disorders are referred to a gastroenterologist
For swallowers to clear food from oral cavity and larynx with NO RESIDUE and good airway protection the following things need to occur:
- oral prolusion of bolus into pharynx
- Airway closure
- UES opening with laryngeal elevation
- tongue base retraction with pharyngeal wall squeezing and propelling to carry the bolus through the pharynx and into the esophagus
aspiration
-food and liquid has gone below the level of the true folds
silent aspiration
aspiration without coughing or any auditory signs
penetration
food and liquid gets into the additus and vestibule
residue
what is left over after the swallow, location shows the point of weakness
Disorders of oral preparatory phase
- Reduced lip closure
- Reduced tongue coordination
- Reduced Lip strength or tone
- Reduced buccal/cheek strength or tone
- Abnormal Hold position
Disorders of Oral Phase
- Delayed initiation of oral phase
- Tongue thrust
- Residue in mouth after an oral swallow
- Uncoordinated Tongue
- Reduced tongue elevation
- Lingual Rock n Roll
- Premature over spill of liquid into pharynx
- Piecemeal Deglutition
- Delayed initiation of of pharyngeal swallow (trigger)
Disorders of Pharyngeal Phase
- Cervical Osteophytes
- Unilateral/bilateral residue on pharyngeal wall or pyraform sinuses
- Food residue in valleculae
- Reduced laryngeal elevation
- Reduced closure of airway opening
- Nasal penetration during swallow
- Pseudoepiglottis
Disorders of esophageal Phase
- Laryngopharyngeal Reflux (LPR)
- Gastroesphageal Reflux (GERD)
- Esphageal Fistula
- Zenkers Diverticulum (pocket in the esophagus)
Swallowing Disorders after Stroke
Most severe (1) Brainstem stroke because its controlled by brainstem which impacts the nerves essential for swallowing.
- (2)Right CVA: Everything will be delayed
- (3) LCVA: Frequently don’t have that many swallowing issues or at least long lasting issues
- Subcortical Stroke (least common): stroke occurring in thalamus or basal ganglia, generally recovers over time.
Outline of Assessment
- Chart Review: Doctors orders
- Screening
- Bedside evaluation: modified oral motor exam and presentation of food or liquid
- Modified Barium Swallow Study or FEES
Screening Procedures
- Provides indirect evidence that the patient has a swallowing disorder, but does not provide information on physiology of the disorder.
- Screenings tend to ID the signs and symptoms of dysphagia and indicate that the patient might need an in depth physiological assessment.
- Quick, low cost and low risk
Bedside Or Clinical Evaluation: A.Preparatory Exam
- Doctors order
- Review Chart
- Discuss nature of the problem with the nursing staff
- As you enter the patients room, observe their alertness, ability to follow directions and answer questions, look for presence of trach, and how patient handles secretions
- Interview the patient
- Examine Oral cavity
- check jaw strength
- cheek lip movement
- check tongue movements (strength, ROM, & coordination)
- Assess chewing
- check velum
* *Extrinsic muscles of the Larynx/laryngeal function
- check vocal quality (hoarse, gurgly, etc)
- see how they do with their own saliva management
- see how well they can cough for you or clear their throat
- have them swallow and feel for laryngeal excursion
B. Examine Oral Cavity
- check jaw strength
- cheek lip movement
- check tongue movements (strength, ROM, & coordination)
- Assess chewing
- check velum
- *Extrinsic muscles of the Larynx/laryngeal function
- check vocal quality (hoarse, gurgly, etc)
- see how they do with their own saliva management
- see how well they can cough for you or clear their throat
- have them swallow and feel for laryngeal excursion
Information gathered during oral exam should alert you to:
- any facial paralysis
- patients ability to maintain lip closure
- limitation in tongue function that may affect ability to hold bolus or to propel food back
- indicate area of oral cavity where food can be positioned for the best tongue control
- help in selection of food consistencies you think the patient will best be able to handle
C. Trial Swallows: should they always be attempted?
Negative factors
- patient is acutely ill
- significant pulmonary complications
- weak voluntary cough (means they cant protect the airway)
- Over 80 years old
- cannot follow simple directions (cognitive problems)
- suspected pharyngeal swallow
Positive Factors
- can follow directions
- can cough on command
- good pulmonary function
Decide on Best posture
- Dump and Swallow: tilt head down then throw head back (used for severe oral problems, but good pharyngeal phase)
- Chin tuck: tild head down tightly. (helps to pinch off airway, gravity helps control bolus, and they must have a good oral seal, helps promote increase tongue movements which empties valleculae.
- Head Turn: turn head toward affected side (used for unilateral pharyngeal weakness, closes off and patient can squeeze down the stronger side of pharynx
- Head tilt: tilting head toward strong side, because gravity keeps bolus on strong side (severe version of head tilt is lying down)
Food textures and consistencies
Solids
- Regular normal texture
- Mechanical soft: normal diet, but no large solid pieces of food. Sometimes called dental soft, chopped, or ground. Doesn’t require a lot of chewing
- Puree: solid food that has been blended or pureed into pudding-like texture
Liquids
4. Thickened liquids: nectar-thick (lowest), honey-thick, extra thick. Adding thickener to it any type of liquid
- Naturally Thick Liquids: nectars, buttermilk, milkshakes, ensure, protein drinks, V8 juice
- Thin Liquids: water, juice, tea, coffee
Selection for patients
- Poor oral control = do best with thickened liquids first, then move towards material of thin consistencies
- Delayed pharyngeal swallow= do best with thicker consistency, such as pureed foods, applesauce, mashed potatoes
- Reduced tongue base or pharyngeal wall contraction= do best with liquids
- Reduced Laryngeal Elevation or Reduced upper esophageal sphincter opening= do better with liquids
- Reduced airway closure= do better with thicker consistencies
Initiate Swallow Evaluation
A. Proper hand position
B. Check patients vocal quality
C. Steps
1. Present food
2. Feel swallow with hand position
3. After swallow, immediately check vocal quality by having patient say “ah”
-If vocal quality is wet, ask patient to cough and reswallow (repeat until clear)
4. Look in mouth for residue
5. Have patient pant and later head position to make sure bolus isn’t in valleculae or pyraforms.
6. If vocal quality remains clear, you can assume the bolus went down the right way.
7. Do the sequence listen above several times, gradually increasing the amount of food you are giving them.
8. If ok with puree, go with mechanical soft, then regular texture, then liquids
9. If patient coughs during any part of sequence or gurgly vocal quality is hear, aspiration is suspected.
Compose your report, and do follow up.
Tracheostomy tubes are normally placed for:
- upper airway obstruction at or above the level of the TVF
- potential upper airway obstruction
- provision of respiratory care
Variations of trach
- cuffed/uncuffed
- UNCUFFED: air can usually pass between the outer cannula and walls of trachea when tube is occluded
- CUFFED: unable to push air around tube when cuff is inflated. cuff can be deflated - Fenestrated/unfenestrated
- FENESTRATED: a window is cut into the tube to facilitate the passage of air into the larynx. This may assist with voice production. Often used as patients are being weaned from the trach.
Blue Dye Test
- Review chart
- Examine trach, cuff, ect (check for voice)
- Suction the pt
- deflate the cuff (if its cuffed)
- suction again once cuff is deflated (check voice again for baseline)
- present food or liquid in same steps as bedside swallow (gently occlude trach during swallow)
- suction upon completion of eval and ask nurse to suction every 1/2 hour or so
- If blue material is coughed out or suctioned out this would be evidence of aspiration
Modified barium swallowing study: Purpose
A procedure designed to examine the details of oral, pharyngeal, and cervical esophageal physiology during swallow
Purpose:
1. to define abnormalities in anatomy and physiology that are causing patients symptoms
2. to identify and evaluate treatment strategies that may immediately enable the patient to eat safely and/or efficiently (great opportunity to check if treatment works)
3. to identify/rule out aspiration, amount of aspiration, and cause of aspiration
who should be referred for MBSS?
- any patient suspected of aspiration
2. if swallow disorder is suspected to be pharyngeal origin or have a pharyngeal component
Placement of food in patients mouth & amounts of materials to be used
Placement
1. explain what you are going to do
2. Food= use a spoon
Liquid= cup, straw, spoon
Types/ amounts (at least 3 consistencies)
- thin liquid barium
- barium paste
- food needing mastication
At least two swallows of each consistency in the following order: 1ml 3ml 5ml 10ml cup drink with thin liquid honey-thick or nectar thick liquid 1/3 tsp pudding consistency 1/4 of cookie or cracker If OK in all above, try different food types and volumes
Measurements and observations to be made
Lateral View
- Oral Transit Time
- Pharyngeal Transit Time
- Pharyngeal Delay Time
- Analyze the patterns of lingual movement
- gross estimate of the amount of vallecular residue after swallow
- estimate the amount of material aspirated, per bolus; the timing of aspiration, and the anatomic/physiologic reason for aspiration
AP VIEW (done on request only)
- movement of bolus through the valleculae and pyraform sinuses (movement & symmetry) 20% of normal swallowers, swallow unilaterally
- Examine residue in pharynx, valleculae, pyraforms, ect
- have the patient hold head back and say “ah” to view vocal folds
Trial Therapy: Postural techniques
- re-direct food/liquid flow and change pharyngeal dimensions
1. head back (dump & swallow)
2. chin tuck (promotes tongue base contractions)
3. head rotated to damaged or weak side
4. Lying down on one side
Trial Therapy: techniques to increase oral sensory awareness
- *used with swallow apraxia, delayed onset of swallow or delayed trigger
1. Increase downward pressure with spoon
2. sour bolus
3. cold bolus
4. bolus needing chewing
5. increase size of bolus
6. thermal tactile stimulation (only used with patients that have delayed or absent swallow reflex)
Trial Therapy MBSS: Swallowing maneuvers: Supraglottic Swallow
- designed to close the airway at the level of the TVF during swallow
- have patient take deep breath, then have them hold their breath (so you know TVF are closed), instruct them to swallow, cough, and then re-swallow.
- *If aspiration occurs during swallow, means there’s poor airway closure.
Trial Therapy MBSS: Super-supraglottic Swallow
- closes airway at and above the level of the TVF, before and during swallow (supraglottic & effortful swallow)
- when you use effort your TVF, FVF, and epiglottis squeeze down tightly, forcing closure of all 3 valves. Increases muscle activity and pharynx activity.
Trial Therapy MBSS: Effortful Swallow
- increases tongue base posterior motion and bolus clearance from valleculae
- swallowing as hard as possible and bear down during swallow.. helps to increase muscle activity in general
Trial Therapy MBSS: Mendelsohn Maneuver
*increase extent and duration of laryngeal elevation. Helps for hyolaryngeal elevation
Protocols and Reports of MBSS
- Oral
- measure of OTT
- describe neuromuscular/anatomic problems in oral phase
- note any delay in triggering the pharyngeal swallow
- differences based on size/texture of bolus
- did aspiration occur during this phase - Pharyngeal
- Measure PTT
- describe neuromuscular/anatomic problems in pharyngeal phase
- amount of aspiration and when it occurred
- amount of residue in vallecular and/or pyraform sinus
- difference based on size/texture of bolus - Recommendations
- management of nutritional intake, texture changes, and management strategies to be used during meals, precautions
- results of interventions and therapy techniques
- procedures for swallowing TX
- Re-evaluations or consultations
***If the report does not contain the anatomic or physiologic reason for aspiration or residue (not just symptoms) AND the interventions attempted to reduce/eliminate symptoms and their effects, the study is not complete!
Management: Oral VS. non-oral feeding
- Swallow safety and efficiency is adequate for total oral feeding (may still be on special diet or use techniques but are safe to get what they need orally)
- Partial oral feeding with supplementary tube feedings, as needed (may have efficiency issues so they have tube to get nutritional intake, counting calories)
- Primary tube feeder with “recreational” oral eating allowed (may have some foods they can tolerate on thanksgiving or other special days: puree foods)
- NPO-no oral feeding allowed.
NGT= nasogastric feeding tube (in nose, down pharynx, dumps into stomach. generally used for short term option)
G-tube= gastrostomy tube (opening in abdomen that leads directly to stomach. Surgically placed for long term use.
PEG= percutaneous endoscopic gastrostomy (hole in abdomen leading to stomach, its inserted differently. done endoscopically, not by surgery. Meant for patient if oral feeding isn’t expected in first month.
J-tube= jejunostomy tube (hole in abdomen that leads to intestine. done if patient has severe stomach condition (not swallowing issue)
Pharyngostomy (food direction into pharynx. usually in cancer patients where structures had to be removed. rare.)
Esophagostomy ( food directly into esophagus. usually in cancer patients where structures had to be removed. rare.)
Management: compensatory strategies
**strategies that control the flow of food and eliminate patients symptoms such as aspiration, but do not necessarily change the physiology of swallow
- Modifying volume and/or speed of food
- food consistency and diet changes
- Postural changes
Management: Therapeutic strategies and Swallowing maneuvers: Oral Motor Exercises
**designed to change the swallow physiology. can be direct (with food) or indirect (without food)
- Oral motor exercises. Lots of repetition, 3 sets of 20.
- strengthening lips (puckering and smiling, sustaining intraoral pressure, pulling lips apart, button in mouth
- tongue (resistance against tongue blade, up & down, in cheek)
- tongue base contraction movement (anterior tongue hold procedure, bite on tongue while out, then swallow OR yawning OR pretending to gargle)
- weak pharyngeal contraction (effortful swallow & super-supraglottic swallow)
Management: Therapeutic strategies and Swallowing maneuvers: Adduction and/or falsetto exercises
used for patients with poor VF closure.
- compressing folds with thoracic fixation
- pushing/pulling exercises
Management: Therapeutic strategies and Swallowing maneuvers: Suck & swallow
sucking back, biting down, and swallowing.
-good to increase coordination and bolus transport
Management: Therapeutic strategies and Swallowing maneuvers: Mendelsohn Meneuvre
helps coordination of swallow
-indirect exercise for suprahyoid
Management: Therapeutic strategies and Swallowing maneuvers: Thermal-tactile Stimulation
- only purpose is to increase speed and strength of the swallowing trigger
- only used if patient has weak/delayed/absent trigger
- research showed that 95% of patients improved their swallow
Management: Therapeutic strategies and Swallowing maneuvers: other techniques already talked about
- supraglottic swallow
- super-supraglottic swallow
- effortful swallow
- dump and swallow
Management: Medical Treatment
- surgical reduction of osteophytes
- Teflon injection to improve vocal fold closure
- Laryngeal suspension for reduced laryngeal elevation
- Dilation of scar tissue in cricopharyngeal region or esophagus
- Cricopharyngeal myotomy
- Botulinium toxin injection
- Surgical techniques to control unremitting aspiration
