Dysphagia

Question 1

What are the indications for a PEG or an RIG tube insertion?

Answer 1

“1. aspiration pneumonia

2. loss of >10% body weight
3. impaired QoL due to time required to maintain nutrition orally

Note: RIG = radiologically inserted gastrostomy.
Ref: DeLisa, pg 731.”

Question 2

What are the benefits of feeding tube placement in motor neuron disease?

Answer 2

“1. stabilizes weight
2. prolongs survival

Ref: DeLisa, pg 731.”

Question 3

What are the 3 phases of swallowing?

Answer 3

“OOOPPPPEEEE!!!

1. ORAL (a. Preparatory b. Propulsion)
   - food manipulation and mastication
   - voluntary phase, when tongue propels food posteriorly until swallowing reflex triggered
2. PHARYNGEAL: reflexive swallow carries bolus through pharynx
3. ESOPHAGEAL: peristalsis carries bolus through cervical and thoracic esophagus into stomach

Ref: Review notes 2012”

Question 4

Which phase is aspiration most likely to occur in?

Answer 4

“Aspiration most likely to occur in pharyngeal phase.

“

Question 5

What are some symptoms/signs of aspiration for each phase of swallowing?

Answer 5

“1. ORAL: drooling, pocketing food

2. PHARYNGEAL: food sticking, choking/coughing, wet/gurgling voice
3. ESOPHAGEAL: heartburn, food sticking”

Question 6

What is the innervation of salivation?

Answer 6

“Salivary secretion mediated by PSNS.
1. CN 9: Parotid gland
2. CN 7: the rest of the glands (submandibular, sublingual)
Ref: wikipedia.”

Question 7

What is the definition of aspiration?

Answer 7

“Entry of material into airway, below the level of the true vocal cords.
Ref: EBRSR Module 15 pg 4.”

Question 8

What are risk factors for dysphagia and aspiration?

Answer 8

“PAST MEDICAL

1. tooth decay (in ABIEBR, more risk for pneumonia)
2. smoker (in ABIEBR, more risk for pneumonia)
3. immunocompromised

INJURY CHARACTERISTICS:

1. TBI severity (extent, duration of coma, lower GCS, severity of CT scan findings)
2. brainstem involvement
3. physical damage to oral, pharyngeal, laryngeal and esophageal structures (ABIEBR)

CURRENT INTERVENTIONS:

1. NG tube
2. tracheostomy
3. prolonged mechanical ventilation
4. endotracheal intubation

CURRENT CLINICAL STATUS:

1. unable to feed self/distraction while eating
2. difficulty swallowing secretions, wet voice, weak voice, weak cough, etc.
3. poor cognition/decreased LOC.
4. ascultatory evidence of lower lobe conslidation
5. improper food consistency.
6. improper positioning (eg. Unable to sit upright).
7. coughing/throat clearing or wet, gurgly voice quality after swallowing water
8. choking more than once while drinking 50mL water
9. weak voice and cough
10. wet-hoarse voice quality
11. recurrent lower resp infections
12. low-grade fever or leukocytosis
13. severe cognitive and cognition disorders

Ref: EBRSR module 15 pg 5, ABIEBR Module 5 p15”

Question 9

What are independent predictors of pneumonia following stroke?

Answer 9

“1. Age > 65 years

2. Dysarthria or no speech due to aphasia
3. Modified Rankin Scale score ≥ 4
4. Abbreviated Mental Test score <8
5. Failure on water swallow test

Presence of ≥2 these risk factors = 90.9% sensitivity and 75.6% specificity for development of pneumonia.

Ref: EBRSR module 15 pg 10.
"

Question 10

What are the factors more likely to be associated with aspiration pneumonia following stroke?

Answer 10

“1. Brainstem stroke

2. Aspiration on VMBS (greater risk if aspirates >10% of barium laced test material)
3. Aspiration of thick fluids or solids
4. Slower pharyngeal transit time on VMBS

Ref: EBRSR (Table 15.6)”

Question 11

What is the most common location of aspiration pneumonia?

Answer 11

Right lower lobe, due to angle of the bronchus.

Question 12

List 5 compensatory strategies during swallowing for management of dysphagia.

Answer 12

“1. Chin tuck: Delayed initiation of pharyngeal swallow.

2. lateral Head tilt: towards strong side.
3. Head turn: towards side of weakness.
4. Supraglottic swallow: breath holding before and after swallow.
5. Super supraglottic swallow: valsalva plus breath holding.
6. Mendolsohn Maneuver: hold larynx up with muscles or hand.
7. Double swallow
8. Masako maneuver (pt protrudes tongue and then swallows).
9. Effortful / hard swallow: Reduced tongue base retraction, pharyngeal weakness (Improve bolus flow through pharynx)

EBRSR module 15 pg 36; Stroke rehab textbook pg 194-195.”

Question 13

What types of fluids can a patient have, and how would you define them?

Answer 13

“1. THIN: regular fluids, no modifications.

2. NECTAR: thin enough to be sipped through a straw or cup, but thick enough to fall off tip of spoon slowly (eggnog).
3. HONEY: too thick for straw, eaten with a spoon, but does not hold its own shape (tomato sauce)..
4. PUDDING/SPOON THICK: thick fluids that must be eaten with a spoon, hold their shape on a spoon (applesauce).
   Ref: Dr. Cleary’s notes, SLP”

Question 14

What are the contraindications to using an NG feeding tube?

Answer 14

"1. Basal skull fractures.
2. Facial fractures.
3. Esophageal strictures
4. esophageal varices
5. bleeding diatheses
Ref:uptodate article – NG and nasoenteric tubes."

Question 15

List 4 pathologies that can be seen on video fluoroscopy.

Answer 15

“1. Pocketing of food (oral preparatory phase).
2. Inability to move bolus with tongue (oral propulsion phase).
3. Inability to move bolus past pharynx (pharyngeal phase).
4. Aspiration (pharyngeal phase).
5. Inability to move bolus down esophagus (esophageal phase).
Ref:”

Question 16

List 5 strategies to help a patient with dysphagia.

Answer 16

“1. FOOD: change food consistency, cold food, carbonated drinks for sensory feedback, etc.

2. ENVIRONMENT: feed self, sit upright, quiet environment, no straws.
3. MANEUVERS: Mendolsohn maneuver. Double swallow. Supraglottic swallow. Head tilt. Rotate to weaker side, chin tuck, super supraglottic swallow.
4. DEVICES: special spoons, etc.
5. INVASIVE: NG tube, PEG tube, TPN.
6. assess fluid and nutrition status regularly.”

Question 17

“List 2 complications of severe dysphagia in stroke patient.
2 potential treatments?”

Answer 17

"COMPLICATIONS:
1. Aspiration pneumonitis.
2. Aspiration pneumonia.
3. Dehydration.
4. Malnourishment.
Braddom pg 592.

TREATMENTS:
1. NPO until properly assessed.
2. Changes in posture and head position.
3. Elevation of head in bed.
4. Feeding in upright position.
5. Chin tuck with swallowing.
6. head rotation (Turn head to paretic side with swallowing).
7. Diet modifications (e.g. thickened fluids, pureed, soft foods in small boluses).
8. electrical stimulation (conflicting evidence).
9. tMS (1a).
10. nifedipine (1b).
11. black pepper oil (1b).
Ref: EBRSR module 15; ABC."

Question 18

4 signs or symptoms of dysphagia.

Answer 18

"1. choking on food.
2. coughing during meals.
3. drooling.
4. loss of food from mouth.
5. pocketing of food in cheeks.
6. slow, effortful eating.
7. difficulty swallowing pills.
8. avoiding food or fluids.
9. complaining of food stuck in throat.
10. problems swallowing.
11. reflux.
12. heartburn.
13. nasal regurgitation
14. wet voice
15. abnormal gag reflex (Cuccurullo – debatable).
Ref: EBRSR – module 15, pg 4; Cuccurullo pg 35-36."

Question 19

“1. Definition of Dysphagia.

2.Definition of Odynophagia.”

Answer 19

“1. Dysphagia: Difficulties with swallowing (Impaired swallowing).
- any abnormality in oral, pharyngeal or esophageal phases of swallowing that lead to impairment in swallowing safety or efficiency (Review Notes)

2. Odynophagia: Painful swallowing.

Ref: Braddom pg 581.”

Question 20

What differentiates penetration from aspiration?

Answer 20

“Aspiration - below vocal cords / supraglottic space

Ref: Review Notes 2012”

Question 21

Which cranial nerves are important for eating and swallowing?

Answer 21

“CN V, VII, IX, X, XI, XII

Ref: Review Notes 2012”

Question 22

What are the best predictors of pneumonia in severe TBI patients?

Answer 22

“1. Dependence in self-feeding and oral-care

2. Amount of tooth decay
3. Need for tube feeding
4. More than one medical diagnosis
5. Smoking
6. Total number of medications

Ref: ABIEBR Module 5 p12”