Dysphagia Flashcards
any disruption in the swallowing process which results to either physiological or anatomical changes in the mouth, pharynx, larynx, or esophagus
dysphagia (solids/liquids/both)
t/f dysphagia is often a symptom of a medical problem
true
patients more likely to develop dysphagia
- > 65 yo
- dementia
- institutionalized elderly
- radiotherapy for head and neck cancer
- stroke
- learning disabilities
what is neurogenic dysphagia
- neurological disorder that can induce weakness of specific muscles and muscle groups
- diminished laryngeal closure = silent aspiration
one of the neurogenic causes of dysphagia
stroke (ischemic or hemorrhagic)
average duration of swallowing rehab for patients who are dependent on tube feeding
two months, only 55% return to an oral diet
in anatomical dysphagia, the severity depends on the ___
location of the tumor and extent of the surgery
t/f dysphagia will be negatively influenced by postoperative radiation due to fibrotic changes
true, radiation = reduced sensitivity
effective management for anatomical dysphagia
swallowing rehabilitation
dysphagia in healthy older adults due to normal aging process
presbyphagia
age-related changes in presbyphagia
- difficulty in forming and propelling a bolus
- a decrease in the pressure of the tongue
- obstruction of the passage of the bolus
- stoppage of the bolus when swallowing
- a decrease in the sensation of smell and taste
- loss of teeth
management for prebysphagia
- meal texture modification
- compensatory postures
- food administraton techniques
- direct therapeutic procedures
what is sarcopenic dysphagia
- sarcopenia of masticatory muscles and other groups of skeletal musculature
- loss of muscle mass and strength of the swallowing muscle
sarcopenic dysphagia is higher among
- elderly patients
- malnourished
- disuse of swallowing musculature
s/sx of dysphagia
read
complications of dysphagia
- weight loss, dehydration, malnutrition
- reduced quality of life, depression, respiratory problems
- immunocompromised
- increased risk of infection
- poor wound healing
- decreased functional status
- muscle breakdown
- worsening of swallowing activity
most serious problem of patients with dysphagia
aspiration pneumonia
symptoms of structural dysphagia
- regular
- short duration, rapid progression
- solid, may progress to liquid
history of structural dysphagia
alarm features
- onset >50 yo
- bleeding
- odynophagia
- weight loss
- vomiting
symptoms of motility dysphagia
- intermittent
- long duration
- solid and liquid
history of motility dysphagia
- connective tissue diseases
- dm
- non-cardiac chest
- pain
what is the 3 oz swallow test
tests voice hoarseness
- patient is asked to drink 90 ml water
- positive: patient coughs during or after swallowing or develop a wet or hoarse voice
- vocal cord is coated with saliva
what is the gugging swallowing screen test
- graded assessment that considers pathophysiology of voluntary swallowing
- uses multiple consistencies
- important for pts with acute stroke related dysphagia
purpose of gugging swallowing screen test
- assess severity of aspiration risk
- determine recommendation for dietary revisions when necessary
- can detect slight signs of aspirations
parts of guss test
preliminary assessment (indirect swallowing)
direct swallowing test
- semisolid: pudding
- liquid: thin liquids of 3, 5, 10, 20 ml
- solid: dry bread 5x every 10s
point system of guss test
- max 5 points per subtest, maximum must be obtained to continue to the next subtest
- highest score: 20 pts
- <10 = severe dysphagia with high risk of aspiration
recommendations from guss test
<5 in subtest: stop exam, special oral diet and further investigation
<10: severe dysphagia with high risk for aspiration, npo + further assessment (fees/vfes) + rehab for speech and language
bedside test for clinical screening of impaired safety and efficacy of swallowing
volume viscosity swallow test
procedure for volume viscosity swallow test
- clinical swallowing examination after stroke is performed with different consistencies and volumes of food
- 5-20 ml nectar liquid and then pooling boluses are administered during the video fluoroscopy
signs of impaired safety from volume viscosity swallow test
- cough
- fall in oxygen saturation of more/= 3%
- voice changes
signs of impaired efficacy
- piecemeal deglutition
- oropharyngeal residue
what is swallowing endoscopy
fiberoptic endoscopic esophageal swallowing test
purpose of fees
- to determine and visually see any structural change that can contribute to dysphagia
- to assess how well a patient swallows
procedure for fees
- the ent passes a thin, flexible instrument through nose
- offer food to pt to swallow
- view the throat while swallowing different consistencies
what is videofluoroscopy / videoendoscopy
- allows assessment of upper airway during swallowing attempts
- gives useful information on true feeding dependence
- also shows aspiration
if the patient has difficulty initiating swallowing, including coughing, choking, and nasal regurgitation, they have __
oropharyngeal dysphagia
if the patient has food stopping or sticking after they swallow, they have ___
esophageal dysphagia
esophageal dysphagia for solid food or solid/liquid food
solid food only: mechanical obstruction
solid or liquid food: neuromuscular disorder
intermittent mechanical obstruction vs progressive mechanical obstruction
intermittent for bread/steak: les problem
progressive, chronic heartburn, no weightloss: peptic stricture
progressive, >50 yo, weight loss: carcinoma
intermittent vs progressive neuromuscular disorder
intermittent with chest pain: diffuse esophageal spasm
progressive, chronic heartburn: scleroderma
progressive, bland regurgitation, weight loss: achalasia
evaluation for mechanical and neuromuscular obstruction
esophagoscopy or barium esophagogram
neuromuscular disorders: also manometry
clues and possible causes of dysphagia
difficulty initiating swallowing, repetitive swallowing: oropharyngeal dysfunction
retrosternal “hanging up” sensation: esophageal dysfunction
difficulty with solids but not liquids: mechanical obs
difficulty with both solids and liquids: esophageal dysmotility
regurgitation of undigested food, halitosis: zenker diverticulum
treatment considerations
read
what is swallowing rehabilitation
- targeted to train tongue muscles to make better bolus in the mouth
- improve laryngeal excursion and pharyngeal contraction
what is the shaker exercise
- lie flat on back and raise head for 60s, with 60s rest
- do 3-6 times per day for at least 6 wks
what is the hyoid lift maneuver
- small pieces of papter
- use straw to suck one of the paper
- keep sucking and bring to another cup
- do until 5-10 pieces are transferred
what is the mendelsohn maneuver
- keep adams apple elevated for about 2-5 s each time
- repeat several times per day until you can control swallowing without resistance from hands
types of respiratory physiotherapy
- sputum discharge maneuver
- huffing
- forced expiratory maneuver (breathe + huff)
- squeezing (for peripheral lungs)
compensatory mechanisms: positioning head and neck
- entrance of respiratory tract narrows
- pharyngeal cavity narrows
- anterior neck muscles relax
- decreases risk for aspiration
compensatory mechanisms: breath hold and cough
- learn to hold his breath prior to swallowing and taught to close both true and false vocal folds when swallowing
- after swallowing, patient deliberately coughs to clear residue
feeding strategies
- sit upright during and 30 mins after meal
- head tilted forward/ chin down
- support impaired side of body
- sit at or below patient’s eye level
- put food in stronger side
- sit on side to maximize careful feeding
types of texture modified diets
mild: soft and easily chewed, liquids in syrup consistency
moderate: thick puree to finely mashed, liquids in honey texture
severe dysphagia: thin puree, liquids that are jelly in consistency
high risk foods
- dry stringy meats
- mixed textures (soups with bits)
- hard foods (boiled sweets)
- fibrous foods (coarse vegetables and stalks)
diet level 1: puree
- i: severe dysphagia
- thick and smooth semiliquid food
- non irritating and low in fiber
- all thin liquids are omitted or thickened
diet level 2: mechanically altered
- i: moderate dysphagia
- can tolerate minimally easily chewed foods or cannot swallow thin liquids safely
- thickened liquids with commercial thickeners
- transition food
diet level 3: dysphagia advanced
- i: difficulty chewing, manipulating or swallowing foods
- meats are soft and bite sized pieces
- regular liquids can be tolerated
what is small frequent feeding
6-8 times per day, beneficial for pts with neuromuscular disorders
how can nutritional content be improved
table 4
populations that would benefit from oral nutrition supplementation
- pts with bmi <20
- weight losing individuals with bmi >/= 20
- patient able to tolerate liquids but not solids
indications for enteral feeding
- unsafe to take oral diet
- pt is unable to meet nutrient needs from oral diet
- malnourished pts with dysphagia
- malnourished pts on oral supplements but unable to maintain nutritional status
- non malnourished patients with failed textured diet
if enteral feeding is >1 mo, needs __
percutaneous gastrotomy
