Group Study Guide Flashcards
What is best practice?
Evidence
Experience
Empathy
What associations/entities define our scope of practice and the rules SLPs should adhere to when diagnosing and treating swallowing patients?
the entities are:
- ASHA
- state boards
- insurance companies like medicare and managed health care companies
- whoever you receive reimbursements from also defines what you can and cannot do
the rules SLPs should adhere to are:
- physician must be present when we are conducting a MBS
- we do not have exclusive rights to be the only providers of dysphagia
- OT’s can be the primary providers as well if they are adequately trained (evaluation and intervention are within their scope of practice)
- we cannot dictate what other professionals do
- we cannot control other professionals
Explain the four stages of swallowing, the normal physiology and the cranial nerves that innervate each of the stages.
Oral prep: the purpose is to break down food to a consistency appropriate for swallowing and mix it with saliva. Neuromuscular actions include labial seal, rotary chew, lateral motion of tongue and jaw. The larynx and pharynx are at rest. It is a sensory feast. For larger volumes the tongue subdivides and splits up the bolus in your mouth. Cranial nerves include V: trigeminal, VII:facial, X;vagus, and XII;hypoglossal. The stage ends when the tongue starts to propel the bolus to the back of the throat. The amount of time this stage lasts depends on what you are eating. chewing steak is very diferent than chewing ice cream. This stage is voluntary.
Oral: This stage is initiated when the tongue moves back. The main componanent is propulstion (stripping action). This stage ends with the pharyngeal swallow. Canial nerve XII, hypoglossal, is the primary nerve in this stage. The oral stage lasts for 1 second. It is hypothesizsed that the trigger for the pharyngeal swallow comes froms the lower brainstem. This stage is voluntary.
Pharyngeal: look at midterm
Esophageal: starts when the UES opens until the passing into the stomach. It is involuntary. It is controlled by vagus nerve. There are striated annd smoth muscles in the esophagus. Striatedmuscles are striped and found in the hear. The esophogus goes through the diagphragm. It is an ivoluntary stage that lasts for 2-6 seconds.
What are the 5 key activities that occur during the pharyngeal stage (in your notes).
- closure of the velopharyngeal port
- tongue base retraction (contacts an hits pharyngeal wal)
- elevation of hyoid and larynx
closure of larynx
relaxation.opening of the UES
What is the UES?
It is the upper esophageal sphincter. It is know as the cricopharyngeal opening or the pharyngeal esophageal segment. It is located inat the lower end of the parhynx and guards the entrance into the esophagus.
What is the UES’ role in swallowing?
- pressure drives the UES to open (this is caused by the larynx elevating)
- the cricopharyngeus muscle opens to permit entry o bolus into esophagus
- it prevents reflux contents into the pharynx to guard airway aspiration
- this stage is involuntary and lasts 1 second
What role does the floor of the mouth muscles play in swallowing?
the muscles of the floor of the mouth elevate the hyoid and larynx
What are the methods we utilize to evaluate swallowing (clincal and instrumental)?
besides swallow evaluation we give MS, FEES, manometry (mostly for research), and ultrasound.
What are the 4 categories of swallowing treatment that Groher and Crary discuss. Give an example of each one.
Behavioral: changing behavior to adapt to the swallowing disorder (i.e look left, no straws, slow down)
Dietary: changing the diet to adapt to the swallowing disorder, chopped meats, blended food
Medical: medication changes adapt to the swallowing disorder, N-G tube, botox
Surgical: surgical procedure to fix the swallowing disorder, Thyroplasty, G-tube
What is the main medical consequence of pharyngeal dysphagia?
aspiration pneumonia
Name a few normal changes of swallowing that occur in the elderly as it relates to each of the stages.
Oral stage: hold bolus more anteriorly, increased/prolonged masticationm reduction of tongue mobility, sensory changes
Pharyngeal stage: larger volumes to trigger the swalow, slower time for UES/PE segment to relax, triggering of pharyngeal swallow below ramus. coupling of swallowing seperates
Esophageal: transmit may be delayed, higher incidence of reflux and mobility issues
Why are the normal healthy elderly at risk for swallowing problems?
there is an overall reduction in reserve
anotomical and physiological changes take place
the uncoupling of oral and pharyngeal events occur
Where is the main neural control center located? Define the NTS.
It is called the nucleus tractus solitariIt is located in the medulla oblangata where clusters of cell bodies (nuclei) regulate sensory and taste; it is a junction box that coordinates a large amount of input/output sensory.mortor information.
The Vagus nerve in the medulla controls motor information. The NTS controls sensory information (including taste)
What is the difference between penetration and aspiration?
Penetration: some of the bolus enters the area above the glottis. The larynx and the hypod move up and the trace amount of bolus is removed from the glottis. Penration is normal for older aults as long as it clears. It is caused by problems with the back of the tongue, reduced laryngeal elevation, reduced hyoid movement forward
Aspiration: when the bolus enters the area above the glottis and it is not removed. It passes through the vocal folds and into the lungs. Aspiration can be normal as long as it is trace (we all aspirate once in a while).
What is the difference between nutritive and non-nutritive sucking?
Nutritive sucking: sucking for nutrition, 1 suck per second, apnea occurs, airway not always open
Non-nutrtive: 2 sucks per second, airway is open, apnea does not occur
What are the differences in the anatomy of swallowing in an infant vs. an adult?
The nose in infants:
- smaller nares
-sinuses are not completely formed
Oral cavity in infants:
-tongue fills the mouth
-edentulous (no teeth)
-tongue rests between lips, sits against palate
-sucking pads in cheeks
-smaller mandible
-sulci (space between gum and inside of cheek) important in sucking for an infant
Pharynx in infants
- no definite oropharynx so they have less risk of aspiration
- obtuse angle at skull base in nasopharynx
-single line of breathing allowing infants to suck and swallwo at the same time
larynx in infants
- 1/3 the size of an adults size
-1/2 true vocal folds are cartilage
-very narrow vertical epiglottis
- more forward and higher
-thyroid cartilage is round
Esophagus in infants
-1.5 cm in length
-LES is still immature, LES keeps acid from coming back up into esophagus -LES is still developing
-Usually matures by 6 months - may take 9-12 monnths
-delayed gastric emptying
-reflux is normal in infants
-40% regergitate at least once a day
*swallowing is voluntary and involuntary in adults,, but it is only involuntary in newborns
How is the infant’s anatomy customized to prevent aspiration?
there is no definite orpharynx, the soft palate and epiglottis are squished together, allowing the child to suck and breath simultaneously
What is RDS and how would it affect infant’s swallowing?
Respiratory Distress Syndrome
- affects lungs of preterm neonates due to lack of “surfactant” or (fluis decreed by lungs to stabilize and prevent them from collapsing upon exhalation)
- due to lack of flusid, premies have difficulty inflating and deflaing lungs
RDS affects the infannt’s swallow because they choose to protect thier repiratory systemm throuugh a volntary refusal to swallow
What are the most important reflexes for the infant?
rooting
suck/swallow
tongue thrust
gag reflex
What is the suck/swallow reflex and why is it important?
- infants/mouth area are touched, mouth opens and – - sucking/suckling begins
- its important because it facilitates transition from breast to bottle
When is the right time to introduce an infant to food?
around 4-6 mos when reflexive responses have diminisehd aling with motor development of body and upper extremeties - so they can hold a cup
From your textbook, what are some of the clinical signs of reflux in infants? How does this affect thier ability to feed?
gaggins choking apnea halitosis (bad breath) burping, frequent swallowing
What is failure to thrive and why is it so important?
failure to grow based on esablished growth for age and gender
- important because children who do not get adequate nutrition MAY NEVER RCOVER fron the effects because the CNS is still developing
- Children may also not be receiving poper nutrition due to poor dentition, medical complications, poor communciation, and genetic growth failure.
What are the different methods utilized to feed infants who may not be eating by mouth?
nasogastric (n-g)
orogastic (O-G)
gastrostomy - directly to stomach
paraenteral - into bloodstream
How does Pierre Robin Sequence affect swallowing?
respiratory distress when feeding in infancy coughing, grunting, sputtering glossotosis micrognathia retrognathia
What is eosinophilic esophagitis?
allergic inflmation of the esophagus
caused food impaction, poor appetite, an reflux
What factors affect preemies swallowing?
posture - may be hyperextended whcih results in higher risk for aspiration and reflux
immature structural alignemtn
Can SLPs be feeding therapists too? Defend your answer.
Yes but we split the job with OTs. Oral motor skills: SLP mealtime behaviors: SLP reaction to food types/textures -SLP self feeding and posturing - OTS
Know the differences between swallowing and feeding disorders in infancts.
feeding disorders
-often behaviorally motivated
-results in aversion or refusal of foods/liquids
Swallowing disorders:
reduced function of oral, pharyngeal, and esophageal structures
Criteria for referral for a probable swallowing disorder.
sucking and swallowing incoordination
weak suck
breathing disruptions or apnea during feedins
excessive gaggin or recurrent coughing during feeds
new onset of feeding difficulty
diagnosis of disorders associated with dysphagia or undernutrition
a. cleft palate, cerebral palsy, canofacial disorders
- weight loss or lack of weight
- severe irritability or behavior problems
- histroy of recurrent pnumonia
-concern for possible aspiration
Criteria for a probable feeding disorder.
- food aversion or refusal
- failure to advance to age appropriate foods
- excessive vommiting
- negative mealtime behaviors
- failure to thrive
- gagging or choking
How do you know if they infant is having sensory issue?
- unable to sort solids and liquids
- holds food under tongue and cheek
- demonstrates nipple confusion with breast feedling and bottle feeding
-hyperreactive-extreme response to tates/temp
hypoactive - diminished response to taste/temp-need strong flavors
Why is posture so important?
oral phase: then tongue would be retracted, poor lip seal, and reduced lingual movement and higher risk for aspiration
pharyngeal phase:???
esophageal phase: higher incidence of reflux because of gravity helping reflux so if child is hyperexended you want them to be more forward
How do you know that a premie is ready to eat?
cardiac, respiratory status
bowel sounds adequate
feedings can be done with minimal respiratory distress
tolerance of bolus feedings
infants need to be OFF the ventilator to even consider oral feeding
suck/swallow/breathe needs to be regulated
What is OST?
Oral sensorimotor treatment__> using snsory stimulation to improve eating and drinking
you are trying to desentitize patient from different componant (lips, tongue, jaw, wc)
not giving them anything else edibale just stimulating the sences
Why are there differences in bottles and nipples for infants?
infants have different needs
Dr. Brown’s–> reduces air, makes sucking easier
syringe bottle–> controls volume
chu chu –> for cleft palates
wide neck nipples –> improves lips closure
What are the goals of behavior treatment?
basically counseling - least intrisuve treatment
addressing importanct/impact of lighting and family dynamics
educating reducing stress, create best environment possible, providing resources
operant conditions to let child know they can revieve arewards whan they eat
operant conditioning: rewards throughout when child reaches good foals
when they reach a vertain food goal, increase complexity of food
Systematic desentiziation: playing games and activities with child with food and increasing complexity
Upper motor neurong and lower motor neurons control which systems?
UMN: central nervouse system
LMN: peripheral system
The degree of cortical impairment depends on a variety of factors….name at least 3.
location of damage
extent of damage
type of damage (trauma vs. blunt force)
unilateral vs. bilateral
What swallowing deficits (be specific) would a lower brainstem stroke exhibit?
difficulty triggering the pharyngeal swallow
absebt pharyngeal swallow
delayed pharyngeal swallow
reduced laryngeal elevation
reduced UES opening
information regarding taste, cough, and gag reflux
can GROSSLY aspirate, can have absent cough reflex
What is oral apraxia?
Happens in LH strok.. Voluntary movement isorder of sequencing (inability to sequence motor movements)
As swallowing therapists, the goal is 2 fold. What is it.
to achieve the patient swallow safely but also maintain or maximize nutrition.
Many dementia and alzheimer patients exhibit oral agnosia. What is it? Give an example.
inability to recognize food- tactile stimulit from the face, lips, oral muscles are not funcitong so they may not be able to tell that a non-f00d tem is something theyr;re not suppose to eat
may try to eat silverware becuase they think it is food since they are putting it inti thei mouth
Why can patients with TBI be difficult to treat for dysphaisa.
Behavioral issues, imulsive, poor awareness, no awareness of deficits or what has happened to them, attention issues
What are some of the specific clinical features of Parkinsons?
resting tremor
bradykinsia-slow movement
mask exression
cogwheeling - muscles jerk when force is applied to them
pill rolling, moving fingers like rolling a pill
dysarthira
Name a few of the swallowing deficits associate with Parkinsons.
poor oropharyngeal contorl (bolus control)
tongue pumoing
weak swallow refluz
incoordination of swallow and respiration
drooling incresased rsik of silent apiration
Name the generalized treatment for Parkinsons all ages.
dietaryL thicken liquids chop up meatns behavioral small poritions small and frequence meakexercises adaptive equipment early PD: exercises moderate parkinsons sensory changes.input sever parkingsoneL internal nutrition =-nutirents directly into the GI tract.maximizing nutrition
What affect does antipsychotic medication have on the stages of swallowing? Why?
causes idiopathic.iatrogenic dysphagiae-these drugs are meant to slow down the CNS and over ie it will slow down the swallow
This is imopratn beacue choking and psychomatic dyspahgiae ancan resutls form being on these meds for an extended period of time
NAme a LMN disease and the effects on swallowing.
amyotropich lateral sclerosis effects on swallowwing: -reduced tongue base mvoeme treudeuced pharyngeal wall canstictions reduced pharyngeal wall caonstircution reduced laryngeal eevation decreased labual closure
What are the side eefffects of radiation and how does it affect swallowing?
side efffects (inflmatiion of mucoud membranes_ edema trismus odynophaga (painful swallowing) xerostomia dental changes fibrisis (scarring of tissue) how does it affect swallowing? becomes extremely difficulty to xerostomia, odynophaiga, and potential fibrosis (radiation is like getting an extremem sunburn inside your body_
Why is dy motuuh (xerostomia) a problem in head and neck cancer paients?
because salivary glands are radiated
When should swallwoing treatment being for a hea and nack cancer patient?
need to build up muslcse stregnth before the event to they come out where they were pre-treatment
f
Why is it important to keep a head and neck cancer patient swallowing EVEN if they are aspirating>
if they don’t keep sallowing they will devop fibrosis
do not le the muscles atrophy and turn fibrotic, keep them swallowing
so not make them NPPO
if they don’t swallow thoise muscles will turn to scare (fibrososi) the mre tey don’t usie it the more the musclesl wil turnurn to stone
What is trismsu?
inability to open mouth a very much
muscle spasm ins the jaw that keep the mouth clenched shut
What is a total laryngectomy how does this affect swallowing?
physcal seaparation of GI tract from the repisratory tract or removal of larynx OR separeration of the airway from the esophogus - affects swallowing becaucse of reduced laryngeal clearnace afdddiitaionl probelms related to swallowing include: -pseudoepiglottis backflow of material into pharynx poor pharyngeal pressure casal regurgitation fistual puch formaiton reduced hypolaryngeal excusrion reduced UE or PES popening redueced pharyngeak stripping wave complaints of food sticking
what specific swallow chagnes woudl you see in a n oral cancer patients?
reduced tongue/bolus controal reduced tongue elevation slwoed oral transits with disrorgancieed tongue movement dealyed pharyngeal swallow reduced tongue base tretrationg reduced pharyngeal wall cotnraction reduced laryngeal elvation reduced UES/PES oeoeinging reduced veloparygneal closure redudeuced epiglottic invesion
What speccifc swallow chagnes woudl you see in a larygneal patient?
redueced larugenal elvation reduced gltoottal and larygneal clisure reduced UE aor PES clisure redcued EUS or PES opengi reduced phatynael wall crontraiations
