Dysphagia

Question 1

What are the three phases of swallowing?

Answer 1

1. Oral phase - chewing and propelling food to back of mouth, voluntary
2. Pharyngeal phase - involuntary swallow reflex into laryngeal vestibule into esophagus
3. Esophageal phase - skeletal muscle propel proximal and smooth muscle distal

Question 2

Changes to taste and swallow with age

Answer 2

1. Taste sensation decreases (can still discriminate)
2. Olfactory function declines
3. Loss of teeth and sarcopenia = reduced chewing efficiency
4. Esophageal phase decreases in advanced age
5. Prolonged duration of swallow

Question 3

What is the most common cause of oral phase dysphagia?

Answer 3

Dementia

Question 4

What is the most common cause of pharyngeal dysphagia?

Answer 4

Inability to protect airway = choking, nasal regurgitation

Stroke
Brainstem (Parkinson’s, CNS tumor, ALS, MG)

Question 5

What are causes of esophageal dysphagia?

Answer 5

Sense of food being stuck

Solid and liquid = motility disorder (achalasia, scleroderma)

Progressive solid = mechanical obstruction (cancer, ring, stricture)

Question 6

What are causes of medication induced esophagitis?

Answer 6

Potassium
NSAID
PO Bisphosphonates
Tetracycline
Candida promoters (prednisone, immunosuppressants)

Question 7

What is the definition of aspiration?

Answer 7

Misdirection of oral or gastric contents into airway

Question 8

Aspiration pneumonia vs. chemical pneumonitis

Answer 8

Aspiration PNA = bacteria enters lungs from pharynx, overcoming host defences
Chemical pneumonitis = aspiration of gastric contents, can have fever, tachypnea, hypoxemia and rales <24 hr before host defines mechanisms clear

Question 9

What effect do feeding tubes have on aspiration risk?

Answer 9

NG does not prevent aspiration and is actually a risk for it
J tube does not reduce risk of pneumonia compared to G tube
Choosing wisely supports hand feeding safer

Question 10

How do you assess for dysphagia?

Answer 10

Full bedside evaluation
Videofluoroscopic examination
Modified barium swallow
NP Laryngoscopy

Question 11

How to manage dysphagia?

Answer 11

1. Evaluate for depression/metabolic disorders
2. Eliminate unduly restricted diet
3. Consider individual food preferences
4. Environment - socialization, reduce disruptions
5. Determine need for assistance with feeding
6. Eliminate meds that cause inattention, xerostomia, movement disorders or anorexia

Question 12

What are recommendations regarding PEG tubes?

Answer 12

1. Does not prolong life
2. Does not help with weight gain or strength
3. Increase risk of aspiration and PNA
4. Increase risk of pressure sores
5. Discomfort or bothersome for patient
6. Bleeding, infection, skin irritation
7. N/V/D

Question 13

List 8 non-invasive strategies to help a patient with oropharyngeal dysphagia.

Answer 13

a. SLP assessment for dietary texture and patient specific recommendations
b. Oral care prior to eating or drinking
c. Upright as close ot 90’ as possible
d. Head in a neutral or slightly downward position
e. Supervised careful hand feeding, ensure swallow complete before preceding
f. Provide prompts to swallow, multiple swallows if needed
g. Avoid rushed or forced feeding
h. Inspect oral cavity after swallow
i. Elevate HOB at least 30’ for at least 1 hr post eating