Dysphagia Unit 1 Flashcards
scope of practice
feeding and swallowing:
- oral phase
- pharyngeal phase
- esophageal phase
- atypical eating (food selectivity/refusal, negative physiologic response)
dysphagia
a swallowing disorder which it’s signs and symptoms may involve the mouth, pharynx, larynx, and/or esophagus
SLPs play a central role in the ___ and ___ of individuals with swallowing disorders
assessment, management
SLP’s role: identifying ___ and ___ of dysphagia
signs, symptoms
SLP’s role: identifying normal and abnormal…
swallowing anatomy and physiology supported by imaging
SLP’s role: identifying indications and contraindications…
specific to each patient for various assessment procedures
SLP’s role: identifying signs of potential disorders in the…
upper aerodigestive and/or digestive tracts and making referrals to appropriate medical personnel
SLP’s role: assessing…
swallow function as well as analyzing and integrating information from such assessments collaboratively with medical professionals, as appropriate
SLP’s role: providing treatment for…
swallowing disorders, documenting progress, adapting and adjusting treatment plans based on patient performance, and determining appropriate discharge criteria
SLP’s role: identifying and using…
appropriate functional outcomes measures
SLP’s role: understanding a variety of…
medical diagnoses and their potential impacts on swallowing
SLP’s role: recognizing possible contraindications to…
clinical decisions and/or treatment
SLP’s role: being aware of…
typical age-related changes in swallow function
SLP’s role: providing education…
counseling to individuals and caregivers
SLP’s role: incorporating the client’s/patient’s…
dietary preferences and person/cultural practices as they relate to food choices during evaluation and treatment services
SLP’s role: respecting issues related to…
quality of life for individuals and/or caregivers
SLP’s role: educating and consulting with…
other professionals on the needs with swallowing and feeding disorders and the SLP’s role in the diagnosis and management of swallowing and feeding disorders
SLP’s role: advocating for…
services for individuals with swallowing and feeding disorders
SLP’s role: performing…
research to advance the clinical knowledge base
SLP’s role: determining the effectiveness and possible impact of…
diet on overall health (positioning, feeding dependency, environment, diet modification, compensations)
as indicated in the ASHA Code of Ethics
- SLPs who serve this population should be specifically educated and appropriately trained to do so
- SLPs should maintain competency of skills through reading current research and engaging in continuing education
1920’s/30’s
- SLPs were involved with children with CP and other neuromotor disorders
- main focus: oromotor control and feeding
1950’s/60’s
- research in swallow began to increase
- main researchers: Dr.’s: Ardan and Kemp, Davenport, Donner, Siegle, Silbiger
1960’s/70’s
- expanded into medical settings (clinics, OP, IP, and rehab)
- published wor on evaluation treatments (Groher and Logeman)
1990’s
more children in schools were presenting with dysphagia and school based SLP were more involved
2020
current standards state that graduate students completing a graduate degree from an accredited program must be competent in dysphagia
oral cavity
refers to the mouth
mandible (jaw)
- jaw bone
- provides lateral, ortary movement for chewing
cheeks
keeps food on tongue
gums
cheeks push up against the gums to keep food on the tongue
labial function (lips)
- function of the lips
- includes pressure during closure to remove food from the utensil
- maintaining closure to keep food in the mouth during chewing
- “pucker power” and retraction
teeth
bits and masticates food
mastication
chewing process
lingual functions (tongue)
- tongue movement that forms food into a bolus, propels, the same backward, and assists in triggering the pharyngeal swallow reflex (or pharyngeal response)
- swallow reflex is still used, but you will also hear response
hard palate
bony part of the roof of the mouth
soft palate
soft portion of the roof of the mouth
faucial arches
visualized as arches in the back of the oral cavity
uvula
“hangy down” structure at lower margin of the soft palate
nasal emesis
when food or liquid comes out of the nose
pharynx
throat
valleculae
- spaces located between the base (not back) of the tongue and epiglottis where food may collect
- if there’s no feeling in that area, food/pills can get stuck here and eventually can fall into the airway
- medication can damage the tissue within this space
epiglottis
flap that covers the opening of the airway during the swallow
___ ___ and ___ ___ come together and squeeze upward as the ___ covers during the swallow
aryepiglottic folds, arytenoid cartilage, epiglottis
pyriform sinuses
base of the pharynx
larynx
- voice box, sits on top of the airway (trachea) to protect the airway from foreign objects
- vocal folds are housed there
laryngeal vestibule
- area in the larynx above the true vocal folds
- supraglottic area
trachea
airway/windpipe
phases of the swallow
- oral preparatory stage
- oral stage
- oropharyngeal stage
- pharyngeal stage
- esophageal stage
oral preparatory stage
- involves formation of food/liquid into a cohesive bolus
- may include oral anticipatory stage including seeing, smelling, and getting ready to taste food items
oral stage
stage in the swallowing process which involves the transport of the bolus from the front to the back of the oral cavity to the point of entry into the pharynx and initiating the swallowing response
oropharyngeal phase
overlap of oral and pharyngeal phases
pharyngeal phase
- stage of swallowing process which involves the movement of the bolus through the pharynx into the esophagus
- includes the swallow reflex, which is the squeezing motion of the pharyngeal constrictors, airway protection, and relaxation of the esophagus to permit entry of the bolus
oral phase: lips
- pull food off of utensil
- close to keep food in the mouth during mastication
oral phase: sulci
- anterior (top and bottom) spaces between lips and gums where food may collect
- lateral (top and bottom) spaces between cheeks (buccal cavity) and gums where food may collect
oral phase: teeth
- bite off/regulate size of food item entering oral cavity
- molars critical for crushing and grinding food items to form bolus
oral phase: mandible (jaw)
provides lateral, rotary motion for grinding food item to form bolus
bolus
cohesive mass or ball of food/liquid
oral phase: salivary glands
- provide moisture/saliva for formation of bolus
- medications can affect this
oral phase: floor of the mouth
- made up of the mylohyoid, geniohyoid, and anterior belly of the digastric muscles
- all attach to the body of the mandible anteriorly and the body of the hyoid anteriorly
oral phase: hard palate
keeps food from entering the nasal cavity during mastication
oral phase: tongue and bolus formation
- picks up food item and mixes with saliva
- places on teeth for crushing and grinding
- continues alternating same to form bolus, moves in lateral rotary motion similar to mandible
oral phase: tongue, oral transport
tongue tip anchors and dorsum of tongue carries bolus to back of oral cavity to initiate pharyngeal swallow
oral phase: soft palate
- relaxed and hanging down during oral stage
- at times coming in contact with back of tongue to help keep food in the oral cavity during oral preparation
- tenses and lifts up during swallow reflex to close off nasal pharynx to keep food from entering the nasal cavity
oral phase: uvula
- “hangy down” structure at lower margin of the soft palate
- helps to serve as marker to locate soft palate during oral examination
- no specific function in either speech or swallowing
oral phase: faucial arches
- visualized as arches in the back of the oral cavity
- swallow reflex in young adults triggered as the bolus reaches the anterior faucial pillar/arch
- in older adults, swallow may be triggered as bolus head reaches the region where lower edge of mandible crosses tongue base
oral phase: velopharyngeal closure
soft palate movement up and back to close off the nasopharynx to keep material from entering the nose
oropharyngeal phase
- overlap of oral and pharyngeal phase
- back of tongue (different from the base of tongue)
- soft palate
- velopharyngeal closure
- once the swallow is initiated, the pharyngeal phase takes 1 second
pharyngeal phase: soft palate
lifts up and back to close off nasal cavity to keep food out of the house
pharyngeal phase: base of tongue
- referred to as the pharyngeal portion of the tongue
- begins at the circumvallate papillae and extends to the hyoid bone: moves backward to contact posterior pharyngeal wall, to increase pressure to push bolus downward
pharyngeal phase: larynx
- voice box
- primary function is to protect the airway from foreign materials
- voice and speech are secondary functions
- structure located at the top of the trachea/windpipe/airway
pharyngeal phase: laryngeal closure
- occurs from the bottom up
- true folds, false folds, and aryepiglottic folds with final flap covering of the epiglottis
pharyngeal phase: laryngeal elevation
- begins as the hyoid and larynx are moved up and forward more directly under the base of the tongue
- aides in protecting airway and in allowing bolus to enter esophagus
- both the hyoid bone and the larynx are lifted up and forward
pharyngeal phase: epiglottis
- is tilted downward towards entrance of esophagus as bolus comes in contact with epiglottis
- same motion provides final protection of the airway as the epiglottis closes over the entrance to the airway
pharyngeal phase: upper esophageal sphincter (UES)
- cricopharyngeus muscles
- part of inferior pharyngeal constrictors
- also referred to as the cricopharyngeal sphincter, or the pharyngesophageal sphincter
pharyngeal phase: trachea
- wind pipe
- tube made up of cartilage rings with flexible material between rings allowing for some stretching and movement to occur
- leads to the bronchi and the lungs
- want to keep food, liquids, and foreign objects out of the trachea and out of the lungs
esophageal phase: upper esophageal sphincter (UES)
- cricopharyngeal muscle relaxes
- also called cricopharyngeal juncture
- pharyngeoesophageal juncture
esophageal phase: bolus exerts from within the…
sphincter as bolus enters sphincter
esophageal phase: lower esophageal sphincter (LES)
- permits entry into stomach and closes to keep material in the stomach
- also called the gastroesophageal juncture
esophageal phase: esophagus
- the food tube
- collapsed muscular tube
- opens to permit entry of food
- closes to keep food from re-entering the pharynx
- closure also keeps air out of the digestive tract
- shares a common wall with the trachea
- anterior wall of the esophagus is the posterior wall of the trachea
the general goal of dysphagia treatment is to…
reduce and/or eliminate “aspiration”
aspiration
- entry of material into the airway below the level of the vfs
- generally aspirated material makes its way to the lungs
- over time results in loss of motility of the lungs, infection, and pneumonia
acute aspiration
- generally single episode
- material becomes lodged in the airway occluding or partially blocking the airway and altering respiration
- Heimlich Maneuver to remove material so that respiration can resume
respiration and the swallow: these functions share some of the same pathway, upper aerodigestive tract
- respiration and swallowing are reciprocal functions, and cannot occur simultaneously, either breathe or swallow
- swallow generally occurs during the expiratory cycle (on exhalation)
- hypolaryngeal exertion
- continue to breathe through the nose during oral preparation
- interruption of respiration occurs during the pharyngeal swallow reflex as the vocal folds close, larynx is elevated up and forward, and esophagus opens
hypolaryngeal exertion
pulling up and forward during swallowing
cough
- brainstem reflex protecting the entrance of the airway from foreign material
- don’t say “drink water”, let them cough
laryngeal penetration
entry of food or liquid into the airway above the level of the vocal folds
hydration
intake of adequate liquids to maintain body fluids
deglutition
- acts associated with bolus transfer and transport of food the mouth to the stomach
- oral stage, pharyngeal stage, and esophageal stage of the swallow, but excludes oral anticipatory and oral preparatory components
oral intake
this sometimes also refers to the amount of food or liquid the individual is able to take in by mouth
pharyngeal pocketing
food lodging/remaining in the pharynx after the swallow reflex is completed
swallow response
- a 1 second coordinated action that momentarily stops respiration
- closes off airway and permits opening of the esophagus for the entry of the bolus
- may be referred to as the pharyngeal swallow
typical swallow across the lifespan: aged individual
- may lose some efficiency in the swallow but not to the point where aspiration becomes an issue
- some loss of tone and elasticity of muscles, and may take longer to eat and both oral and pharyngeal transport times may increase somewhat
- may take longer for oral preparation
- may have decreased appetite due to metabolic changes and/or effects of medications
- may avoid certain foods because of texture
- may experience some reduction in esophageal motility
- however, safety in oral intake, hydration, and nutrition are not seriously compromised
aged individuals: some loss of tone and elasticity of muscles, and may take longer to eat and both oral and pharyngeal transport times may increase somewhat
concern when they can’t feel it
aged individuals: may take longer for oral preparation
condition of teeth/dentures often an additional factor here
aged individuals: may have decreased appetite due to metabolic changes and/or effects of medications
may also eat less because it takes longer to eat
aged individuals: may avoid certain foods because of texture
- ex: meat that’s “too tough”, grainy textures such as “bran” because it doesn’t go down smoothly
- but overall nutrition is within acceptable limits
oral health
- dysphagia was a risk for aspiration pneumonia
- not typically sufficient to cause pneumonia unless other risk factors were present
oral health: other risk factors
- dependent for feeding
- dependent for oral care
- number of decayed teeth
- tube feeding
oral health risk factors: dependent for feeding
anticipatory stage can be off when you are not the one feeding yourself
oral health risk factors: dependent for oral care
getting rid of bacteria
oral health risk factors: tube feeding
- not solving aspiration issues
- when going a long time without swallowing food/liquid, the muscles are not adjusted to swallowing
- laying flat, possible GERD problems
saliva
- important role in keeping mouth healthy
- clears out pathogens
- maintains a healthy balance of good/bad bacteria
proper oral care
- reduces risk of aspiration pneumonia
- higher dental plaque scores predict risk of pneumonia
cultural influence
- how we look at food and oral intake is culturally based
- reflected in the types of foods we eat
- reflected in the textures of foods we eat
- related to feelings/emotions (comforting, health nurturing)
- related to communication and socialization
- related to “self image”
- denial of food is considered negative or punishing action for most of us
- how we eat, when we eat, what we eat, is associated with independence or freedom of choice
- *eating is a basic human drive, refusal to eat is not typical
risk factors in assessing and treating swallowing disorders: for the patient
- aspiration, dehydration, malnutrition
- any medical conditions arising from these
risk factors in assessing and treating swallowing disorders: for the agency/facility
- litigation for negligence
- failure to obtain informed consent
- absorbing unpaid costs of treatment
risk factors in assessing and treating swallowing disorders: for the professional
- litigation for negligence
- malpractice
- failure to obtain informed consent
considerations for the SLP
- we are ethically bound to do what is best for the patient and “to do no harm”
- we need to follow standard practice guidelines within our profession in all assessment, treatment, education, and documentation actions
- we can NOT ignore a patient who is at risk because of their swallowing problems; we MUST act
- we MUST seek informed consent to treat
- we should follow routine medical precautions such as hand washing, wearing gloves, owning, loving, and wearing masks as indicated for communicable disease/isolation situations
- we need to become certified in CPR for Healthcare Providers if working in medical settings
we are ethically bound to do what is best for the patient and “to do no harm”
- we do not want to cause aspiration, dehydration, or malnutrition which become serious considerations as we adjust food and liquid textures and/or complete texture “trials” for diet upgrades
- our treatment(s)/actions can not compromise patient hydration or nutrition
we MUST seek informed consent to treat
- patient/significant other must understand what we are saying
- must provide risks and benefits of treatment as well as risks and benefits of failure to treat
we need to become certified in CPR for Healthcare Providers if working in medical settings
not a bad idea for the school setting as well
protection for the professional
- document, document, document
- know and follow standard practice guidelines of the profession
- provide evidence-based assessment and treatment
- when in doubt get a second opinion and talk with colleagues
- continuing education
- know and follow routine medical safety precautions
- become certified in CPR
continuum of care in swallow disorders
- Clinical Swallow Exam (CSE)
- referral/screening
- bedside assessment
- instrumental assessment
- identify and implement elements of treatment both habilitative/rehabilitative techniques and compensatory strategies
- monitor progress via periodic reassessment
- train others in safe oral intake procedures: patient, caregivers
- discharge from active treatment
- continue to monitor progress and safety in PO intake
bedside assessment
- identify components of problem
- if oral stage problem set treatment/if the pharyngeal involvement suspected do instrumental assessment
instrumental assessment
- identify components of problem
- try compensatory strategies as part of assessment
locations for assessment and treatment in dysphagia
- all have different processes for the screening referral
- acute care
- initial rehabilitation
- long term care
- pediatric
acute care
generally hospital settings
sub acute care
generally hospitals and may include some specialty rehabilitation facilities
initial rehabilitation
- may include specialty units in hospitals
- rehabilitation facilities and nursing homes
- home health services (only for those who are house bound)
long term care
generally nursing homes
pediatric
- school setting
- may also have outpatient and home health services
hospital setting: screenings/evaluations
- generally do not screenings per se, but do receive referrals usually directly from the physician
- complete bedside assessment and instrumental assessments
hospital setting: treatment
seldom have the opportunity to follow treatment to its completion
hospital setting: typical insurance
Medicare Part A
hospital setting: case management
involve patient, family, and staff education specific to the patient as well as related to swallowing disorders in general
hospital setting: discharge
- involve reassessment of patient’s swallowing status prior to discharge and daily monitoring regardless of length of stay
- on discharge will generally be referring for additional services and/or follow up in next environment
rehab centers: screenings/evaluations
- screenings as well as rely on referrals
- complete bedside assessments and set and initiate treatment plans
- some facilities have the equipment to do instrumental assessment as well
rehab centers: treatment
- will provide treatment over weeks vs. days and may see significant progress in some patients
- may actually see return to almost normal oral intake
rehab centers: typical insurance
Medicare Part A
rehab centers: case management
patient and caregiver training specific to the patient as well as general training in swallowing disorders for caregivers, staff, and other professionals
rehab centers: discharge
may refer for ongoing services elsewhere, discharge from active treatment and/or set up monitoring program for follow up
rehab centers: screenings/evaluations
- screenings and receive referrals
- a screening followed by a formal bedside assessment
rehab centers: treatment
set up and initiate plans of treatment and follow through in most cases to completion
rehab centers: typical insurance
Medicare Part A, Medicare Part B, private insurance, and Medicaid
rehab centers: case management
continual reassessment of and monitoring of patient’s status (daily notes, summary every 10 days, every 30 days), educating of patient and caregivers (family and staff) specific to the patient, as well as general education concerning swallowing disorders to staff and other professionals
rehab centers: discharge
- may discharge patient to home and refer for continued services
- may discharge to home with goals achieved
- may discharge from speech services but continue in long term care
- in latter cases may establish restorative care program for ongoing monitoring of patient’s swallow status
- in most facilities will do quarterly checks of all patients to note any changes in swallowing and/or communicative behaviors
home health: screenings/evaluations
- generally following referrals of previous treatment setting
- may receive referrals from other professionals seeing the patient
- complete bedside assessments
- generally refer for instrumental assessments as needed
home health: treatment
will be setting and initiating treatment programs
home health: typical insurance
Part A and B
home health: case management
- will be doing lots of patient and family education since patient and/or their family members will be primarily responsible for oral intake when the SLP is not there
- will be doing reassessment of patient’s swallowing status and monitoring progress each visit
home health: discharge
- generally upon discharge patient has achieved their goals
- monitoring programs set up via other professionals still seeing the patient in their home
team functioning: multidisciplinary
- a group of professionals who share assessment results, treatment plans, and treatment results about a patient to provide optimal patient care
- the patient and their significant others are considered an integral part of the team
team functioning: interdisciplinary
- a group of individuals who share assessment results about a patient to develop an overall treatment plan for the patient and to incorporate overall patient concerns into their individual treatment plans for the patient
- the patient and their significant others are considered an integral part of the team
team functioning: transdisciplinary
- a group of individuals who share assessment responsibilities, treatment planning, and at times the implementation of treatments in part or in whole with other professionals to provide optimal patient care
- the patient and their significant others are considered an integral part of the team
team members
- speech-language pathologist (SLP)
- physical therapist (PT)
- occupational therapist (OT)
- respiratory therapist (RT)
- nursing: registered nurse (RN), licensed practical nurse (LPN), certified nursing aides (CAN)
- nutritionist/dietician
- physician: otolaryngologist, gastroenterologist, physiatrist, neurologist, radiologist, pulmonologist
- patient
- significant others: parents, spouses, companions
- educator/neurodevelopmental specialist
