Dysphagia Flashcards
What are the functions of swallowing?
- Nutrition
2. Protects from aspiration
What is saliva made out of and what is its purpose?
- 1-2L produced each day
- moistens food
- digestion
- antibacterial protection
- enhances taste
- oral hygiene
How many muscles are involved in swallowing?
25
What are the cranial nerves involved in swallowing?
- V - Trigeminal
- VII - Facial
- IX - Glossopharyngeal
- X: Vagus
- XII: Hypoglossal
What is the function of CN V-Trigeminal in swallowing
• Oral preparatory & oral transit phases
¬ Motor: mastication
¬ Sensory: taste & touch
What is the function of CN VII-Facial in swallowing
• Oral preparatory & oral transit phases
¬ Sensory: Taste on anterior 2/3 of tongue
What is the function of CN IX-Glossopharyngeal in swallowing
• Pharyngeal & esophageal phases
¬ Motor: swallowing, gag reflex
¬ Sensory: palatal, glossal & oral sensations
What is the function of CN X-Vagus in swallowing
• Pharyngeal and esophageal phases
¬ Motor: GI activity
¬ Sensory: Cough reflex, taste on posterior 2/3 of tongue
What is the function of CN XII-Hypoglossal in swallowing
• All phases
¬ Motor: Tongue movement
What are the 4 phases of swallowing?
- Oral preparatory phase
- Oral transit phase
- Pharyngeal phase
Esophageal phase
Which cranial nerves are involved in the oral preparatory phase?
• CN: V, VII, XII
¬ Trigeminal, facial and hypoglossal
What happens in the oral preparatory phase?
• Food & drink enter mouth
• Saliva secreted;
- Response to food entering mouth
- Visual response to food “mouth waters”
• Lips seal mouth
• Soft palate drops to base of the tongue
- Protects the airways from food spillage
• Tongue moves food around the mouth, mixes with saliva
- Mastication, physical breakdown of food
• Bolus formed and between tongue and soft palate
What is mastication?
- Breaks food down into smaller pieces
- Mix foods with saliva
- Stimulates taste
- Tongue assists by moving food around in mouth
- Tongue is the largest muscle involved in mastication
What are some considerations in the oral preparatory phase?
- Sight
- Ability to self feed
- Hand mouth coordination
- Lip seal
- Tongue control / strength
- Oral sensation
- Dentition / chewing difficulty
- Cognition
- Positioning
Which nerves are involved in the oral transport phase?
• CN: V, VII, XII
¬ Trigeminal, facial & hypoglossal
What happens in the oral transport phase?
• Soft palate raises to seal nasal cavity from oropharynx
- Important for pressure to help propel bolus to pharynx
• Prepared bolus propelled to the oropharynx
- Anterior and lateral edges of tongue are raised and contact alveolar ridge
- Blade of tongue is pressed against hard palate and moves in a wave like motion (front to back)
- Posterior tongue is depressed and velum is elevated propelling bolus into oropharynx
What are some considerations in the oral transit phase?
• Foods that don’t form cohesive bolus, might get stuck - Honey, peanut butter - Saltine crackers • Pocketing • Tongue strength • Oral hygiene • Oral sensation • Energy level of individual
Which nerves are involved in the pharyngeal phase?
• CN: IX, X, XII
¬ Glossopharyngeal, vagus & hypoglossal
What happens in the pharyngeal phase?
- Nasal passages sealed
- Laryngeal muscles are involved in vocal fold closure
- Epiglottis drops and covers larynx
- Respiration stopped
- Bolus propelled towards esophagus
What are some considerations for the Pharyngeal phase?
- Faucial pillars
- Pharynx
- Larynx
- Epiglottis
What are some signs and symptoms that indicate some kind of disfunction in the pharyngeal phase?
- Gagging
- Choking, coughing
- Watery eyes
- Nasopharyngeal regurgitation
- “Wet” vocal quality
What are the sphincters of the esophagus?
¬ UES: Upper esophageal sphincter
¬ LES: Lower esophageal sphincter
What is the function of esophagus?
- Chief function is motility
* Peristalsis begins after swallow
What is the function of UES?
¬ Mainly cricopharyngeal muscle
¬ AKA Pharyngoesophageal junction
¬ Main barrier in preventing laryngopharyngeal reflux
Which nerves are involved in esophageal phase?
• CN: IX, X, XII
¬ Glossopharyngeal, vagus, hypoglossal
What happens in the esophageal phase?
• Relaxation of cricopharyngeal muscles helps open UES
• Bolus passes through the UES into esophagus
• UES is sealed
- Prevents regurgitation
• Peristalsis propels bolus towards the lower esophageal sphincter (LES)
• LES relaxes & food enters the stomach
• Secondary peristaltic waves if remnants in esophagus
Some difficulties during the esophageal phase might be due to___
¬ mechanical obstruction / cancer / GERD
¬ Not necessarily age related
What is GERD?
- Reflux of gastric contents into esophagus
- Normally; pressure in esophagus > pressure in stomach; keeps LES sealed.
- When LES pressure is lowered, gastric contents can flow backwards into esophagus
What are some causes of GERD?
- Increased secretion of gastrin, estrogen, and progesterone
- Medical conditions: hiatal hernia, scleroderma, obesity
- Smoking
- Medications: dopamine, morphine, theophylline
- Foods: high fat, chocolate, spearmint, peppermint, alcohol, caffeine
What are some symptoms of GERD?
- Dysphagia
- Heartburn
- Increased salivation
- Belching
- Radiating pain: back, neck or jaw
- Throat clearing / Hoarseness (bc of acid burn on vocal cords)
- Refusal to eat (children)
- Abdominal pain
- Aspiration
- Ulceration
- Barrett’s Esophagus
What are the 3 major treatment goals for GERD?
- Increasing LES competence
- Decreasing gastric acidity, decreasing symptoms
- Improving clearance of the esophagus
What are the lifestyle interventions suggested for GERD?
¬ Weight loss if necessary ¬ Avoid: ∇ Eating within 3-4 hours of going to sleep ∇ Lying down after meals ∇ Tight fitting clothing ∇ Smoking ∇ Elevate head of bed while sleeping
What are the 2 types of surgeries that can be done to treat GERD?
- Laparoscopic Nissen fundoplication:
∇ Fundus of the stomach is wrapped around the lower esophagus, giving the LES more strength and helps to avoid reflux - Stretta Procedure
What is Barrett’s esophagus?
• Found in 10% of patients undergoing endoscopy
• Persistent abnormal pH in esophagus despite medical management
• Change in the esophageal mucosa’s epithelial cells
- Squamous cells metaplastic columnar cells
- Precursor for esophageal cancer
• No specific symptoms
• No specific nutrition concerns unless diagnosed with cancer
• Treatment is relieving GERD symptoms
- Chronic disease prevention
- Reduce long term health care costs
What is a possible treatment for Barrett’s esophagus?
HALO for Barrett’s Esophagus – New possible treatment
- Radiofrequency which causes ablation to precancerous or dysfunctional tissue
- Used in Barrett’s esophagus
- High temperature
- Burns off the cells and is repaired with genetically normal neosquamous epithelium
What are nutrition implications for GERD?
¬ Excluding food groups may lead to nutritional deficiencies
¬ Long-term medication use may impair B12, Ca2+, and Fe absorption
What is the nutrition intervention for GERD?
Decrease exposure to gastric contents
∇ Small frequent meals
∇ Low fat foods, chocolate, mint
∇ Avoid alcohol
Reducing gastric acidity:
∇ Avoid: coffee, (decaf and regular)
∇ Fermented alcoholic beverages
Prevent pain and irritation
∇ Avoid any foods causing pain
What is dysphagia?
• Any difficulty in swallowing or inability to swallow
- 4 swallowing phases
- Solids / liquids
• Not a disease, rather a symptom caused by a variety of disorders
What is the etiology of Dysphagia?
• Highly variable • Results from diseases: - Neurological - Physical barriers - Less common: ∇ Developmental disabilities ∇ FAS ∇ Injury • Extent of recovery depends on the etiology - Permanent / transient
What are the common causes of dysphagia?
¬ Stroke ¬ MS ¬ Alzheimer's disease, Huntington’s Disease, Parkinson’s Disease ¬ Cerebral palsy ¬ ALS
When does transient dysphagia happen?
• Chronic Anemia - Esophageal webs • Bell’s palsy - Cranial nerve pressure, infection • GERD • Cancer - Esophageal - Tumors (Head & Neck) - Treatment side effects - Chemo/radiation • Intubation
What are the 2 types of dysphagia?
- Oropharyngeal Dysphagia
2. Esophageal Dysphagia
What are the two types of oropharyngeal dysphagia?
oral
pharyngeal
What are the two types of oral dysphagia?
preparatory
transit
What are the symptoms of oral dysphagia?
¬ Weak tongue and lip muscles, ¬ Difficulty propelling food to throat ¬ Difficulty initiating a swallow ¬ Weakness ¬ Decreased oral sensation
What are the signs of oral dysphagia?
¬ Reduced lip seal
¬ Food pocketing
¬ Drooling
¬ Food/ liquid spillage (anterior loss)
¬ Repetitive rocking of tongue from front to back (lingual pumping)
Reduced range of tongue motion, shape and coordination
What are the symptoms of pharyngeal dysphagia?
¬ Delayed swallowing reflex
¬ Swallow does not clear bolus from the throat
¬ Bolus may penetrate into the larynx
What are the signs of pharyngeal dysphagia?
¬ Repeated swallowing ¬ Frequent throat clearing ¬ Wet vocal quality ¬ Complaints of food stuck in throat (globus sensation) ¬ Repeated pneumonia ¬ Fever ¬ Chest/lung congestion
What is pharyngeal dysphagia?
• Structural blockages • Stenosis • Strictures due to: - GERD - Esophageal dysmotility • Pressure or discomfort in the chest • Chronic heartburn
What are the complications of dysphagia?
- Inadequate oral intake
- Weight loss
- Malnutrition
- Choking
- Aspiration Pneumonia
- Dehydration
- Decreased rehab potential
- Depression
- Decreased QOL – quality of life
- Increased length of hospital stay
- Increased costs
What is aspiration?
• The accidental inhalation of food or particles or fluids into lungs
What is silent aspiration?
¬ No signs of aspiration present, no coughing or choking, but food or liquids are entering the lungs
What is aspiration pneumonia?
¬ Results from aspirated contents causing inflammation in the lungs
What are the techniques to prevent aspiration?
- Upright positioning for feeding
- Chin down when swallowing liquids
- Small quantities
- Dry swallow to clear pharyngeal cavity
What are special considerations in aspiration?
• Dental Care / Oral Hygiene - Often overlooked • Aspiration of saliva from poor oral hygiene increases risk of aspiration pneumonia • Special tools - Suction tooth brushes - Curve tooth brushes - non-foaming toothpaste • OT has dental hygiene resources
How is the screening and diagnosis done in aspiration?
• Multidisciplinary approach:
- Physician, nurse, SLP, RD, OT, Psychologist, PT
- THE INDIVIDUAL, and/or family members
• Initial screening for dysphagia can be done using:
- Pts history & physical
- Bedside screening
- Observing patient while eating
Who is at risk of dysphagia?
- Stroke (CVA)
- Alzheimer’s
- Parkinson’s
- Multiple Sclerosis
- Sjogren’s syndrome
- Head & Neck cancers
- Radiation to head, neck or thoracic regions
- EN
- Esophageal Strictures
- Achalasia
- Scleroderma
- Amyloidosis
- Diabetic neuropathy
- Xerostomia
- Mucositis
- Post-extubation
- Tracheostomy
What are symptoms of dysphagia?
- Drooling
- Excessive secretions
- Pocketing of food
- Poor tongue control/ movements
- Facial weakness
- Difficulty chewing
- Slurred speech
- Frequent throat clearing
- Complaints of food getting “stuck”
- Mucositis or xerostomia
- Coughing before, after or during swallowing
- Delayed swallow reflex
- Poor control of head or body
- Bad positioning
- Nasal regurgitation
- Presence of oral lesions
- Wet or “gurgly” voice
- Absent swallow reflex
- Pneumonia
What are the diagnostic tests that can be done for dysphagia?
- bedside swallow
- modified barium swallow
- fiberoptic endoscopic evaluation of swallowing
What is the bedside swallow test?
- Preformed by OT, SLP or RD
- Ask a series of questions
- Monitor eating
- Assess:
∇ Tongue strength & mobility
∇ Lip seal, food pocketing
∇ Coughing or choking
∇ Voice changes post swallow
∇ Repeated swallowing
∇ Mechanical factors that impair swallowing
∇ Symmetry of jaw and facial muscles
Presence of oral lesions
What is the modified barium swallow?
- Patient given a barium sulfate “milkshake” to drink
- Drinking is visualized by fluoroscopy or x-ray
- Used for video fluoroscopic swallow study (VFSS)
- Physician or SLP can monitor swallow, from mouth through the stomach into duodenum
∇ Degree of aspiration, bolus transit time, integrity of swallow, presence of dysphagia, motility problems - Can determine other abnormalities:
Ulcers, tumors, inflammation
What is the fiberoptic endoscopic evaluation of swallowing?
¬ Long flexible tube with a lens, and a light
¬ Passed through the nose until the hypopharynx
¬ Clinician has a view of larynx, epiglottis, vocal folds
¬ Swallowing function is assessed while patient eats foods of different consistencies, each with a different food dye color
¬ White out period prevents from seeing the actual swallow
¬ Looks for different color residue on the vocal folds after swallow
¬ Can be done at bedside, or in a clinic
What do dietitians assess in dysphagia patients?
• Weight, weight changes • Height • BMI • Swallowing problem history • Recurrent pneumonia • Slurred speech • Presence of GI bleeds • Diet history • Blood pressure • Dental Care • Positioning • Results of swallowing tests • Cause of dysphagia • Determine consistency of food able to swallow - Bedside evaluation or MBS • Tolerance to foods • Food intake (supplements?) • Fatigue with eating • Medications • Lab results/ biochemistry
What is the Propose of Nutrition Case for Dysphagia (ADA)?
• Provide appropriate nutritional and fluids to patient
- Maintain/gain weight (PRN)
- Maintain adequate hydration status
• Progress meal plan to a greater variety of foods as swallow function improves • Provide foods that stimulate the swallow reflex
• Support independent eating
• Improve nutritional deficiencies
• Reduce risk of aspiration/choking
What are general diet descriptions of a patient with dysphagia?
• Individualized based on swallowing assessment & patient preference / tolerance
• Varied textures
• Fluid balance (hydration status) is difficult
• Monitor electrolytes & urine output
• If inadequate oral intake:
- Supplements
- EN as a last resort
What are the nutritional treatments recommended for dysphagia patients?
• National Dysphagia Diet • Foods with altered texture - Level 1: Dysphagia Pureed - Level 2: Dysphagia Mechanically Altered AKA Minced - Level 3: Dysphagia Advanced AKA Soft • Liquids with altered consistency / viscosity - Nectar Thick - Honey Thick - Pudding Thick
What are some foods to omit in dysphagia?
∇ Stringy fruits/ vegetables
∇ Nuts, seeds, coconuts
∇ Foods that crumble easily
∇ Popcorn, potato chips, muffins, cakes, cookies and biscuits
What are dietary modifications in dysphagia?
• Textures to swallow are not based on chewing only
• Moistening agents may help with swallowing
- Gravies, sauces, butter, margarine, mayonnaise, sour cream
• Liquids
• Hot or cold foods stimulate swallowing best
• High protein or high energy diet to ensure adequate intake
• Mixed consistencies
What is NDD: Level 1: Pureed?
- Foods are totally pureed, no lumps or coarse textures are allowed
- Fruits must be pureed, no seeds, pulp, or skins, juices may need to be thickened
- Desserts must be smooth, like custard or yogurt, no lumps
- Cereals have to be homogeneous and “pudding” like, no oatmeal
- Meats and substitutes must be very smooth in consistency and pureed, no peanut butter (unless in recipe and easy to swallow)
- Soups should be strained to avoid lumps, or pureed, if thickened fluids need, should be thickened to right consistency
- Texture is very homogeneous at this phase, gravies and sauces are added for eye appeal, palatability, and enjoyment
What is NDD: Level 2: Mechanically Altered / Minced?
- Foods are soft textured, easily form a bolus
- Beverages may have some pulp, depends also on fluid consistency
- Breads have to be pre-slurried or gelled, but soft pancakes are ok
- Cooked cereals can have a little bit of texture, dry cereal or nuts and seeds are to be avoided
- Soft canned fruits are allowed
- Moist ground or tender cooked meat with pieces no bigger than 1⁄4 inch, pasta, cottage cheese, tofu are ok
- Soft cooked vegetables that are easily mashable are ok
- Salsa, sauces, jelly and jam are allowed without seeds
- Peanut butter should be avoided
What is NDD: Level 3: Advanced / Soft?
- Foods are nearly normal texture, but exclude; crunchy, sticky or very hard foods. • Foods should be bite-sized and moist
- All moist breads are allowed, no crusty or tough bread
- All cereals are allowed, only very hard or course grains should be avoided
- Fruits should be soft and peeled
- All soups are allowed without course/tough pieces of meat
- Only foods to be avoided are nuts, seeds, coconuts and chewy candies
What are the categories of thickened liquids?
• Thin:
- Regular liquids with no adjustments needed
• Nectar:
- Falls slowly from spoon, can be sipped from a straw or from a cup
- Buttermilk, tomato juice
• Honey:
- Drops from a spoon, but to thick for a straw
- Tomato sauce
• Pudding:
- Maintains shape, to thick to use a straw or cup, need to use a spoon
- Pudding
What are some thickening products?
- Mashed potatoes
- Skim milk powder
- Whey powder
- Corn starch
- Grated cheeses
- Powdered beverages
- Gelatin mixes
- Mashed cottage cheese
- Pureed vegetables/ fruits
- Infant cereals
What are some important informations for caregiver?
- Diet is designed to decrease choking risk
- Follow CFG for servings, or other guide for separate disease (QMP for diabetes)
- Small frequent meals: helps with tolerance/ fatigue/ frustration
- Small meals prior to resting; to help minimize reflux and aspiration risk
- Clean mouth after eating
- Proper positioning of head and body
- Sit up for 15-30 minutes prior to rest
- Use best side/ coordinated side of mouth
- Small mouthfuls
- Avoid liquids to wash down food
- Follow “thickened” guidelines
- Medications consistent with swallowing ability
