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6-Clinical Nutrition 1 > Dysphagia > Flashcards

Dysphagia Flashcards

1
Q

What are the functions of swallowing?

A
  1. Nutrition

2. Protects from aspiration

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2
Q

What is saliva made out of and what is its purpose?

A
  • 1-2L produced each day
  • moistens food
  • digestion
  • antibacterial protection
  • enhances taste
  • oral hygiene
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3
Q

How many muscles are involved in swallowing?

A

25

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4
Q

What are the cranial nerves involved in swallowing?

A
  • V - Trigeminal
  • VII - Facial
  • IX - Glossopharyngeal
  • X: Vagus
  • XII: Hypoglossal
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5
Q

What is the function of CN V-Trigeminal in swallowing

A

• Oral preparatory & oral transit phases
¬ Motor: mastication
¬ Sensory: taste & touch

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6
Q

What is the function of CN VII-Facial in swallowing

A

• Oral preparatory & oral transit phases

¬ Sensory: Taste on anterior 2/3 of tongue

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7
Q

What is the function of CN IX-Glossopharyngeal in swallowing

A

• Pharyngeal & esophageal phases
¬ Motor: swallowing, gag reflex
¬ Sensory: palatal, glossal & oral sensations

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8
Q

What is the function of CN X-Vagus in swallowing

A

• Pharyngeal and esophageal phases
¬ Motor: GI activity
¬ Sensory: Cough reflex, taste on posterior 2/3 of tongue

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9
Q

What is the function of CN XII-Hypoglossal in swallowing

A

• All phases

¬ Motor: Tongue movement

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10
Q

What are the 4 phases of swallowing?

A
  1. Oral preparatory phase
  2. Oral transit phase
  3. Pharyngeal phase
    Esophageal phase
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11
Q

Which cranial nerves are involved in the oral preparatory phase?

A

• CN: V, VII, XII

¬ Trigeminal, facial and hypoglossal

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12
Q

What happens in the oral preparatory phase?

A

• 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

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13
Q

What is mastication?

A
  • 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
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14
Q

What are some considerations in the oral preparatory phase?

A
  • Sight
  • Ability to self feed
  • Hand mouth coordination
  • Lip seal
  • Tongue control / strength
  • Oral sensation
  • Dentition / chewing difficulty
  • Cognition
  • Positioning
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15
Q

Which nerves are involved in the oral transport phase?

A

• CN: V, VII, XII

¬ Trigeminal, facial & hypoglossal

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16
Q

What happens in the oral transport phase?

A

• 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

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17
Q

What are some considerations in the oral transit phase?

A 
•	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
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18
Q

Which nerves are involved in the pharyngeal phase?

A

• CN: IX, X, XII

¬ Glossopharyngeal, vagus & hypoglossal

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19
Q

What happens in the pharyngeal phase?

A
  1. Nasal passages sealed
  2. Laryngeal muscles are involved in vocal fold closure
  3. Epiglottis drops and covers larynx
  4. Respiration stopped
  5. Bolus propelled towards esophagus
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20
Q

What are some considerations for the Pharyngeal phase?

A
  • Faucial pillars
  • Pharynx
  • Larynx
  • Epiglottis
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21
Q

What are some signs and symptoms that indicate some kind of disfunction in the pharyngeal phase?

A
  • Gagging
  • Choking, coughing
  • Watery eyes
  • Nasopharyngeal regurgitation
  • “Wet” vocal quality
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22
Q

What are the sphincters of the esophagus?

A

¬ UES: Upper esophageal sphincter

¬ LES: Lower esophageal sphincter

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23
Q

What is the function of esophagus?

A
  • Chief function is motility

* Peristalsis begins after swallow

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24
Q

What is the function of UES?

A

¬ Mainly cricopharyngeal muscle
¬ AKA Pharyngoesophageal junction
¬ Main barrier in preventing laryngopharyngeal reflux

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25
Q

Which nerves are involved in esophageal phase?

A

• CN: IX, X, XII

¬ Glossopharyngeal, vagus, hypoglossal

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26
Q

What happens in the esophageal phase?

A

• 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

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27
Q

Some difficulties during the esophageal phase might be due to___

A

¬ mechanical obstruction / cancer / GERD

¬ Not necessarily age related

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28
Q

What is GERD?

A
  • 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
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29
Q

What are some causes of GERD?

A
  • 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
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30
Q

What are some symptoms of GERD?

A
  • 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
31
Q

What are the 3 major treatment goals for GERD?

A
  1. Increasing LES competence
  2. Decreasing gastric acidity, decreasing symptoms
  3. Improving clearance of the esophagus
32
Q

What are the lifestyle interventions suggested for GERD?

A 
¬	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
33
Q

What are the 2 types of surgeries that can be done to treat GERD?

A
  • 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
34
Q

What is Barrett’s esophagus?

A

• 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

35
Q

What is a possible treatment for Barrett’s esophagus?

A

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
36
Q

What are nutrition implications for GERD?

A

¬ Excluding food groups may lead to nutritional deficiencies

¬ Long-term medication use may impair B12, Ca2+, and Fe absorption

37
Q

What is the nutrition intervention for GERD?

A

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

38
Q

What is dysphagia?

A

• 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

39
Q

What is the etiology of Dysphagia?

A 
•	Highly variable
•	Results from diseases: 
- Neurological 
- Physical barriers
- Less common:
∇	Developmental disabilities
∇	FAS 
∇	Injury
•	Extent of recovery depends on the etiology 
- Permanent / transient
40
Q

What are the common causes of dysphagia?

A 
¬	Stroke
¬	MS
¬	Alzheimer's disease, Huntington’s Disease, Parkinson’s Disease 
¬	Cerebral palsy
¬	ALS
41
Q

When does transient dysphagia happen?

A 
•	Chronic Anemia
- Esophageal webs
•	Bell’s palsy
- Cranial nerve pressure, infection
•	GERD
•	Cancer
- Esophageal
- Tumors (Head & Neck) 
- Treatment side effects 
- Chemo/radiation
•	Intubation
42
Q

What are the 2 types of dysphagia?

A
  1. Oropharyngeal Dysphagia

2. Esophageal Dysphagia

43
Q

What are the two types of oropharyngeal dysphagia?

A

oral

pharyngeal

44
Q

What are the two types of oral dysphagia?

A

preparatory

transit

45
Q

What are the symptoms of oral dysphagia?

A 
¬	Weak tongue and lip muscles,
¬	Difficulty propelling food to throat 
¬	Difficulty initiating a swallow
¬	Weakness
¬	Decreased oral sensation
46
Q

What are the signs of oral dysphagia?

A

¬ 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

47
Q

What are the symptoms of pharyngeal dysphagia?

A

¬ Delayed swallowing reflex
¬ Swallow does not clear bolus from the throat
¬ Bolus may penetrate into the larynx

48
Q

What are the signs of pharyngeal dysphagia?

A 
¬	Repeated swallowing
¬	Frequent throat clearing
¬	Wet vocal quality
¬	Complaints of food stuck in throat (globus sensation) 
¬	Repeated pneumonia
¬	Fever
¬	Chest/lung congestion
49
Q

What is pharyngeal dysphagia?

A 
•	Structural blockages
•	Stenosis
•	Strictures due to: 
- GERD
- Esophageal dysmotility
•	Pressure or discomfort in the chest 
•	Chronic heartburn
50
Q

What are the complications of dysphagia?

A
  • 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
51
Q

What is aspiration?

A

• The accidental inhalation of food or particles or fluids into lungs

52
Q

What is silent aspiration?

A

¬ No signs of aspiration present, no coughing or choking, but food or liquids are entering the lungs

53
Q

What is aspiration pneumonia?

A

¬ Results from aspirated contents causing inflammation in the lungs

54
Q

What are the techniques to prevent aspiration?

A
  • Upright positioning for feeding
  • Chin down when swallowing liquids
  • Small quantities
  • Dry swallow to clear pharyngeal cavity
55
Q

What are special considerations in aspiration?

A 
•	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
56
Q

How is the screening and diagnosis done in aspiration?

A

• 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

57
Q

Who is at risk of dysphagia?

A
  • 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
58
Q

What are symptoms of dysphagia?

A
  • 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
59
Q

What are the diagnostic tests that can be done for dysphagia?

A
  • bedside swallow
  • modified barium swallow
  • fiberoptic endoscopic evaluation of swallowing
60
Q

What is the bedside swallow test?

A
  • 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
61
Q

What is the modified barium swallow?

A
  • 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
62
Q

What is the fiberoptic endoscopic evaluation of swallowing?

A

¬ 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

63
Q

What do dietitians assess in dysphagia patients?

A 
•	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
64
Q

What is the Propose of Nutrition Case for Dysphagia (ADA)?

A

• 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

65
Q

What are general diet descriptions of a patient with dysphagia?

A

• 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

66
Q

What are the nutritional treatments recommended for dysphagia patients?

A 
•	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
67
Q

What are some foods to omit in dysphagia?

A

∇ Stringy fruits/ vegetables
∇ Nuts, seeds, coconuts
∇ Foods that crumble easily
∇ Popcorn, potato chips, muffins, cakes, cookies and biscuits

68
Q

What are dietary modifications in dysphagia?

A

• 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

69
Q

What is NDD: Level 1: Pureed?

A
  • 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
70
Q

What is NDD: Level 2: Mechanically Altered / Minced?

A
  • 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
71
Q

What is NDD: Level 3: Advanced / Soft?

A
  • 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
72
Q

What are the categories of thickened liquids?

A

• 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

73
Q

What are some thickening products?

A
  • Mashed potatoes
  • Skim milk powder
  • Whey powder
  • Corn starch
  • Grated cheeses
  • Powdered beverages
  • Gelatin mixes
  • Mashed cottage cheese
  • Pureed vegetables/ fruits
  • Infant cereals
74
Q

What are some important informations for caregiver?

A
  1. Diet is designed to decrease choking risk
  2. Follow CFG for servings, or other guide for separate disease (QMP for diabetes)
  3. Small frequent meals: helps with tolerance/ fatigue/ frustration
  4. Small meals prior to resting; to help minimize reflux and aspiration risk
  5. Clean mouth after eating
  6. Proper positioning of head and body
  7. Sit up for 15-30 minutes prior to rest
  8. Use best side/ coordinated side of mouth
  9. Small mouthfuls
  10. Avoid liquids to wash down food
  11. Follow “thickened” guidelines
  12. Medications consistent with swallowing ability

6-Clinical Nutrition 1 (21 decks)

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