Dysphagia Flashcards
What is dysphagia?
Any dysfunction in the way a person anticipates, accepts, manages or swallows foods and/or liquids
We distinguish 4 phases of swallowing
Preparatory stage
Oral stage
Pharyngeal stage
Esophageal stage
Can range from a normal variant to profoundly impaired
What are risk factors for dysphagia?
Age 70 + Neck Hyperextension/ kyphosis Altered Mentation Suboptimal Positioning Dysphonia/ Aphonia Pulmonary Disease Neurological Disorder/ Disease Xerostomia Poor Dentition Deconditioning History Dysphagia (pharyngeal or esophageal) GERD History XRT to chest/ neck/ face History fibrosis in chest/ neck (from prior surgeries/ treatments/ disease) Prolonged Intubation/ Proximity to extubation Thoracic Surgery Tracheostomy
What are some age related changes to swallowing
Age Related changes- lowering of larynx, degenerative arthritic changes (osteophytes), timing differences
What are swallowing assessment options?
Screenings vs Evaluations
One asks a question, the other answers it
UPHS Nurse Screening- the Aspiration Risk Tool
Formal Swallow Evaluation/ Assessment by an SLP
Bedside
Instrumental Swallow Assessment w/ SLP
MBS/VFSS
FEES
Instrumental Assessment of GI tract
What are diet consistency options?
Food consistencies: Regular Chopped Ground Pureed Liquid consistencies: Thin Nectar-thick Honey thick
What does a speech pathologist evaluation look like?
Bedside
Assesses oral and pharyngeal stages
May reveal symptoms indicative of esophageal dysphagia
Will generally result in one or all of the following:
a diet order
a recommendation for alternate source of nutrition
a request for FEES or VFSS
A recommendation for referral to another service (GI, ENT)
What is the oral phase of swallowing?
Anticipation of bolus/ preparedness Acceptance of bolus Containment/ Oral control Rotary Mastication Lingual transfer to base of tongue
Predicated upon desire to eat, appetite, interest
Mastication- how’s the dentition?
Bolus clearance vs retention/ pocketing
Can be impacted by altered mentation, lack of awareness/ inattention
What is the pharyngeal phase of swallowing?
Initiation of swallow reflex
Tongue base retraction, velar elevation for nasopharyngeal closure, hyoid and laryngeal elevation/ excursion for closure of the laryngeal vestibule in conjunction with vocal fold adduction, arytenoids move forward, epiglottic inversion and pharyngeal contraction with cricopharyngeus relaxation
Occurs in < 1 second during a period of apnea lasting 0.3-2.5 seconds
Expiratory resistance provided by vocal folds with resistance of 8-10cm/H2O/liter/minute to maintain lung inflation during expiratory phase. Similar pressure exists in subglottis during swallow under normal conditions
What is the MBS/VFSS?
Modified Barium Swallow/ Videoflouroscopic Swallow Study Performed in the radiology department Performed by SLP & radiologist Recorded Reviewed Limitations & Advantages
Limitations: Pt must be able to travel, takes RN off unit, pt must drink Barium, minimal info regarding soft tissue injury and larynx (may be able to identify vocal fold dysfunction to a degree), either fully upright or supine on table
Advantages: Information about all three phases of swallowing, less likely to miss silent aspiration during the swallow
What is aspiration?
Penetration vs Aspiration Symptoms Coughing, throat clearing Silent Aspiration Wet, gurgly vocal quality Change in respiration (rhonchi, wheezing) Eyes tearing, nasal flaring
Aspiration can occur at any point during swallow or afterwards from regurg/reflux
What is FEES?
Fiberoptic Endoscopic Evaluation of Swallowing
SLP utilizes a nasopharyngeal laryngoscope
Recorded
Reviewed
Requires consent
Limitations: can be somewhat uncomfortable, we do not use topical anesthetics, can not be done on patients with certain anatomical changes, can cause nosebleed, can cause laryngospasm, cannot see the moment of swallow due to whiteout
Advantages: can be done bedside, utilizes food and liquids rather than Barium, can see soft tissue changes/ anomalies
What are signs/symptoms of esophageal dysphagia and possible etiologies?
Signs & Symptoms of esophageal dysphagia Globus/ stasis Pain Belching Regurgitation of undigested material Possible Etiologies Zenker’s UES dysfunction Stricture Dysmotility Esophagitis
How long does therapy last and what does it consist of?
Until goals met or Until discharge Individualized Diets Strategies/Precautions Treatment plans
Diets: liquid levels, food consistencies
Strategies/ Precautions: one size does NOT fit all
Expectation for recovery: Heart-Vascular Surgery pts usually with more rapid recovery vs neurological/ neurosurgical or head & neck, generally a temporary condition resulting from prolonged intubation, delirium. Sometimes a longer course or permanent deficit due to RLN damage. Can be 6 weeks to 6 months depending on degree of damage. May require long term enteral source.
What are you considering in a an evaluation to add a PEG?
SLP frequently involved in these conversations
May depend on the patient’s GOC
Live as Long as possible?
Live as Well as possible?
May depend on whether it’s a reversible process
Ideally a bridge to recovery
Gradually increased use for long term/ permanent use
Many contraindications/ risks
