Midterm Flashcards
Phases of Swallowing
Oral preparation
Oral phase (oral transit)
Pharyngeal
Esophageal
Oral Prep Phase
1 swallowing -place food in mouth, manipulate/chew food Sensory recognition of food Labial closure, seal and stripping Buccal tension Soft palate is pulled down and forward Bolus manipulation Chewing Bolus formation
Oral Phase
(1-1.5 seconds) step 2 Propel bolus posteriorly Posterior movement of bolus Tongue tip and lateral margins of tongue held against alveolar ridge Central groove at midline of tongue Lingual stripping
Pharyngeal Phase
(1second) step 3 Transit bolus vertically through pharynx Velopharyngeal closure Hyolaryngeal elevation Laryngeal closure Base of tongue retraction Cricopharyngeal opening
Esophageal Phase
(8-20 seconds) step 4
Transit bolus vertically through esophagus
UES closes as soon as bolus passes into the esophagus
Bolus transits through esophagus via peristalsis
Swallowing vs. feeding disorder
Swallowing disorder as problems with one of four stages of swallowing.
Feeding disorder-may have difficulty bringing bolus to oral cavity
Definition of Dysphagia
Impairment in any of four phases of swallow may be symptom of underlying disease patient has.
Depending upon where damage was if had stroke.
Patient may lose weight, may have regurgitation.
May have reduced sensation.
Need saliva to help break down bolus in smaller pieces to help trigger swallow.
Consequences of Dysphagia
Could be result of stroke, head and neck cancer, certain medications.
-Medical consequences- depends on disease. Could develop aspiration pnemonia, poor nutrition and hydration.
-Psychosocial consequences- patient part of senior group see show and lunch once a week. Now life has changed impacts functioning because of emotions now. -Celebrations and occasions are involved around eating impacts psychosocial
-Clinical management- clinical swallow exam. Get case history, chart review, make determination of patient after swallow exam to see if requires instrumental exam to further assess, then determine treatment options and strategies (diff. postures? Or diet changes?)
Clinical Examination
Instrumental Examination
Treatment Options
Signs and Symptoms of Dysphagia
Difficulty recognizing food- cognitive function impacted
Difficulty controlling food/ liquid – do they regurgitate
Difficulty controlling saliva- constantly drooling? Open mouth no tight lip seal
Coughing
Recurrent pneumonia
Unexplained weight loss- important symptoms as well as tiredness
Gurgly voice – sound like gargling all the time. Wet vocal quality maybe food or liquid is going into airway. Not coughing to protect airway.
Any perceptual changes that they notice in their bodily functions. Leads patient to seek medical help, sometimes patients ignore symptoms until it gets too bad they seek help. Common complaint-food getting stuck.
-signs are objective measures of behavior that people elicit during examination.
Ex: lab findings to find out patient has pneumonia, or white blood cell count is really high. Sometimes symptoms overlap.
Diagnosis and Treatment of Dysphagia
Define feeding and swallowing problem Identify etiology Determine appropriate diagnostic tests Plan approach Implement treatment Monitory progress Evaluate progress Slp responsible for assessment and intervention of swallowing disorders. -chart review, patient interview to possibly identify etiology. Determine tests..
Who Manages Dysphagia
Speech-language pathologist- primary person
Otolaryngologist- important for upper digestive tract
Gastroenterologist- lower digestive issues. If give Modified barium swallow. Give patients different food consistencies. Notice reflux but don’t diagnose-ask radiologist. Refer to gastro.
Radiologist
Neurologist- neurological based disorder, stroke, tbi
Dentist- if require any prosthetic device for oral cavity
Nurse- important because they are with the patients all the time. Help feed patients
Dietition- responsible for establishing type of diet
Occupational Therapist- may need different feeding utensils
Pulmonologist-physician/respiratory therapist- if patient is on trach or ventilator dependent. Not regular members of the team. But could have a role depending on primary diagnosis
Settings for Dysphagia Patients
Acute Care Setting- hospital
Sub-acute Care Setting- more medical monitoring. Could be rehab within hospital or skilled nursing facility. Intensive speech but medically clear
Skilled Nursing Facility- more long-term care. Patient may have alzheimer’s . Care for patient and keep patient safe
Home Health Care- slp receives eval and conducts eval and treatment. May do more cognitive rehabilitation
Aging is determined by
Passage of years
Genetic make-up
Environmental factors
Swallowing Changes in normal aging
Changes in oral cavity
Loss of dentition and loss of bone mass
Reduced taste sensation
Changes in the pharynx/ larynx
Reduced maximal hyolaryngeal movement (reserve)
Ossification of thyroid and cricoid cartilages
Lowering of larynx to C7 (>70 y.o.)
Presbyphagia
Normal age related changes in swallow function in healthy individuals
Increased duration of oral transit
Slight increase in frequency and extent of oral residue reduced sensation
Uncoupling of oral and pharyngeal stages
Delay in triggering of pharyngeal swallow
Delayed hypolaryngeal elevation
Increase in frequency and amount of pharyngeal residue
Common complaints with COPD
Xerostomia- dry mouth Heartburn Chest pain Mouth breathing lightheadedness Restless leg syndrome Sleep apnea
Scleroderma
causes skin to thicken and harden. Lose energy and strength. Throw up food, lose weight. Difficult breathing, lose sense of balance. Respiration and swallowing needs to be coordinated.
What is affected if there is cortical damage?
Anterior L or R hemisphere:
Oral phase impairment
Apraxia: no tongue response or searching tongue movement
Delayed oral transit
Pharyngeal phase impairment
? Delayed pharyngeal swallow
Note: Bilateral damage ↑ prevalence and severity
What is affected if there is brainstem damage?
Lower brainstem (medulla)
Oral phase may or may not be intact (depending on CNXII involvement)
Pharyngeal phase impairment
Swallow reflex may be absent initially
Delayed pharyngeal swallow
Unilateral pharyngeal weakness
Reduced hyolaryngeal elevation → reduced UES opening
Complicating Factors
Medical history (previous strokes)
Concomitant diseases (comorbidities)- combo of COPD or respiratory diseases, heart disease, TBI in addition? Impacts prognosis
Post-stroke complications-
Cognitive impairments- able to follow directions, alert, oriented, aware and able to perceive their problems?
Age
What is affected with TBI
More diffuse damage
Coup, contrecoup
Shear
Swelling
Oral preparation, transit and/or pharyngeal phases may be imparied
Complications:
Physical damage to larynx, other structures
Cognitive deficits-follow directions, express verbally, answer questions, be oriented to person, place, time
Impulsiveness-severe risk for aspiration depending on what region is affected
? Compliance
depends on area affected
Alzheimer’s complications
Characteristics
Agnosia for food – lack of awareness. Don’t open mouth in response to food
slow acceptance
slow or absent initiation of oral phase (abnormal bolus hold)
Apraxia for feeding- difficulty motor initiation and initiating oral stage. Knowing to form bolus.
Apraxia for swallowing
difficulty initiating oral stage (abnormal bolus hold)
-progressive in nature. Lose memory skills, not aware of surroundings.
Delayed pharyngeal swallow
Reduced strength of pharyngeal wall contraction- moving bolus down the pharynx into the esophagus
Reduced hyolaryngeal elevation
Parkinson’s complications
Oral phase
Slow initiation of movement
Reduced jaw opening
Reduced lingual range of motion and strength
Slow oral transit due to ‘tongue pumping’ (i.e. repetitive anterior to posterior lingual movement with reduced lowering of the back of tongue)
Reduced base of tongue retraction
Reduced pharyngeal wall contraction
Reduced hyolaryngeal elevation (reduced airway protection and UES opening)
Amyotrophic Lateral Sclerosis
UMN and LMN damage
Oral phase:
Reduced lip closure
Reduced tongue mobility
Reduced bolus control
Reduced bolus propulsion (reduced tongue pressure)
Pharyngeal phase
Reduced base of tongue retraction
Reduced pharyngeal wall contraction
Reduced hyolaryngeal elevation (reduced airway protection and UES opening)
Earlier onset of dysphagia if UMN damage predominates
Huntington’s complications
Dysphagia Tachyphagia (‘bolt food’) Oral phase: Impaired bolus formation Impaired bolus propulsion Due to chorea Pharyngeal phase: Reduced base of tongue retraction Delayed pharyngeal swallow Reduced airway protection due to neck extension
MS complications
Dysphagia
Symptoms depend on site of lesion: spasticity vs. ataxia
Reduced coordination of the oropharyngeal muscles and respiratory muscles
Leading cause of morbidity and morality (dehydration, malnutrition, aspiration pneumonia)
Complications:
Cognitive impairments
Medications
Note: exacerbations and remittance!
Endotracheal intubation:
arytenoid dislocation desensitization of pharynx and larynx development of granulation, stenosis-narrowing of the pathway because of the tube keeping the airway open Tube can be placed orally or nasal More long term-endotracheal intubation.
Tracheotomy
reduced cough reflex reduced hyolaryngeal elevation development of granulation Inserted into the trachea, below the level of vocal folds. See handout
Esophagus problems
we don’t diagnose we make recommendations for esophagus
Eosinophilic Esophagitis
inflammartory condition where esophagus is stiffened. Going to be difficult swallowing solids because of inflammation. Can treat with meds. Structural problems may cause this
GERD
- reflux up to the lower esophageal sphinctor-burning sensation
LPRD
- reflux comes up to upper esophageal sphinctor- up into the esophagus into the pharynx
NERD
- has GERD symptoms, burning sensation. Harder to make diagnosis because you don’t have the esophageal injury
Types of Cancer
Oral
Oropharyngeal
Laryngeal
Treatment for Cancer
Surgery
Radiation
Chemotherapy
Combination of treatment
Cancer and Dysphagia
Occurs when cell growth is out of control
-sudden weight loss, severe fatigue even after you have slept, pain in unexplained areas, high fevers, lack of motivation to do anything, difficulty concentrating or wanting to participate in any type of activity.
T= how big the tumor is
N= if there is lymph node involvement and how extensive is the involvement
M=metastisis distant or surrounding
Difficult to predict type and severity of dysphagia based on diagnosis
Treatment can lead to dysphagia
Oral and oropharyngeal cancer Tumor Sites
Lips Lateral tongue margin Base of tongue Mandible Floor of mouth (anterior, lateral) Tonsils Hard palate Soft palate
Cancer and Lip Resection
Reduced labial seal
anterior bolus loss
drooling
Partial Glossectomy
Reduced bolus manipulation and formation Reduced bolus control Reduced propulsion Increased oral transit time Extent of tongue resected affects type and severity of symptoms
Suturing of Tongue: Glossectomy
Reduced bolus formation and manipulation
Reduced chewing
Reduced bolus propulsion
Reduced bolus control
Mandibulectomy with anterior floor of mouth resection:
Disrupt attachments for muscles of the floor of the mouth
Reduced oral preparation
Reduced oral transit
Reduced bolus formation
Lateral floor of mouth resection
Penetration- occurs to level of vfs Reduced oral preparation Reduced oral transit Reduced bolus formation Delayed pharyngeal swallow Reduced base of tongue retraction Reduced pharyngeal wall contraction
Partial Laryngectomy
Removal of hyoid bone and top of larynx May include removal of the epiglottis, false vocal folds, arytenoids, aryepiglottic folds Results in Delayed pharyngeal swallow Reduced airway protection Reduced hyolaryngeal elevation Reduced UES opening- pharyngeal phase
Total Laryngectomy results in
Reduced pharyngeal wall contraction
At risk for tracheo-esophageal fistula development
At risk for a pseudoepiglottis- false epiglottis forming
Radiation At Risk For:
Tracheo-esophageal fistula – forming opening
Xerostomia (first 3-6 months) very dry mouth
Edema (first 3-6 months)
Mucositis (first 3-6 months)
Fibrosis (years following treatment): depends on how long radiation/chemo was, what other diseases patient has had
reduced base of tongue retraction
reduced laryngeal elevation
reduced pharyngeal wall motion
Malnutrition,Dehydration and Xerostomia
Consequences of multiple issues related to dysphagia but are also related to cancers. Think of medications patient is on look up side effects of medication, when pt takes the medication. Could affect their swallowing as far as dry mouth.
Medical Record Contains Info:
Patient’s medical history
Findings from physical exam by physician
Reports of laboratory tests
Findings of special examinations
Findings from consultants PT, OT
Notes of treatment
Medications
Surgical options-procedures they had, hospitalizations
Progress notes by all disciplines- motivated? Cooperative? Cognitively aware? Follow directions? Express themselves well? Gives info on how pt performs in other types of therapy hoping it would be a carryover into your treatment. Lab results- weight, nourishment
What is patient’s medical diagnosis, what is the dysphagia a result of. Previous hospitalizations. Function previous to incident. Medications they are currently taking.
Perception of overall illness. Patient’s perception of their swallowing problem.
What does a Screening do
predicts the likelihood that a person has dysphagia
Disease Process in a Medical Record
The disease process or combination of contributing factors that are related to dysphagia
Course of recovery varies
Surgical procedures will vary
We discussed many diseases
Surgical procedures in a medical record
Procedures, date performed, and resolution
Piror to dysphagia how did it affect their swallowing disorder.
Airway Status
Artificial airways
Pulmonary Status
Pneumonia- are they at risk, have they previously had this
Radiographs- chest xrays, visualizing the lungs to see if pneumonia is present at the time. Aspiration pneumonia- symptoms cough, fever,
Nutrition
Oral intake
24-hour dietary recall-pt reporting amnt of food and intake to keep track of nutrition and dehydration
Enteral Intake-nutrition directly into GI tract from a tube
Parenteral Nutrition- nutrition directly into the bloodstream
Weight change- how much weight loss in what pd of time, look at hydration. What they should be (BMI) vs. what they actually are and create ratio.
Lab values/blood parameters- possible reasons why the pt is not getting enough nutrition.
NG Tube
short term feeding tube placed directly into nose and goes down into stomach. Not for a patient that needs a long term feeding tube. Physician does it bedside it is very quick. Negatives: very uncomfortable, patient who is not cognitively aware may pull it out.
Gastric G Tubes
more long term.
Tube directly into the stomach. Surgical procedure requires surgeon.
Negative- if pt has reflux
PEGS
percutanious endoscopic gastronomy tube- more common, surgical, requires local anesthesia
Hydration
Fluid in/urine out monitor
Serum Sodium
Osmolality
Interview
Questionnaires
Surrogate informants
Educate nursing aides about dysphagia. Different checklists that are available.
Parent Interview Record
Chief Complaint Patient’s Perception of the Problem Character of Complaint Course of Complaint Activities of Daily Living Previous Treatment
What is the definition of swallowing screening
used to refer to a minimally invasive evaluation
procedure that provides quick determination of
- likelihood dysphagia exists;
- whether pt requires referral for further swallowing assessment;
- whether safe to feed pt orally (for purposes of nutrition, hydration, and administration of medication);
- whether pt requires referral for nutritional or hydrational support.
What questions can a screening procedure answer with respect to swallowing
used to determine whether any of following represent a risk of dysphagia and/or a reason to maintain an NPO
- a known history of dysphagia;
- a medical diagnosis that frequently involves swallowing impairment (e.g., stroke);
- reduced level of consciousness;
- overt signs of aspiration;
- overt signs or complaints of difficulty swallowing.
MBS purposes:
- define abnormalities in anatomy and physiology causing symptoms
- i.d. and evaluate treatment strategies enabling pt to eat safely/efficiently
- why pt is aspirating
different strategies
exercises to strengthen muscles body positions diets different consistencies change in habits
Ask for MBS from physician at skilled nursing facility. Completed bedside on patient that showed clinical signs of aspiration including coughing immediately after thin and thick liquids. A wet vocal quality. Patient did not show clinical signs of aspiration with pudding. Doctor refuses to send the patient for an MBS. How do you make your request to the doctor?
It’s a cost issue, the patient has to be transported out. Educate the physician and tell the doctor they could be silently aspirating. Could be life threatening. Educate the family as well. Tell the family you don’t agree with the doctor and what you recommend. When you write it write what you recommend and what you have expressed to the physician and the family. Doctor may still decide not to. Happens often. Write specifically what you have educated to the family. Don’t be so brief.
I saw patient for CSE (bedside examination) and I recommended an MBS and patient remain NPO until study is complete. However, Dr. refuses MBS and says “slp to feed whatever diet seems safest.”
- Do you begin trial feeds?
- What do you tell the doctor?
No, it isn’t safe. Don’t start trial feeds because it is going against your license.
If you did trial feeds during clinical exam tell the doctor what happened, patient coughed, patient became out of breath. Show documentation. Educate the doctor on findings, what you did, signs and the literature. What you tried and each issue with each consistency.
My boss wants me to teach the OT how to treat dysphagia
- What do you tell your rehab director?
- How do you prepare for meeting with rehab director?
bring state licensure laws, your research, code of ethics, ashas national outcomes measurement systems- has aspects about measurements of efficacy of treatment of dysphagia.
Look on asha for guidelines. Be aware of all guidelines. If you are in doubt you can call asha. You don’t cross train.
Bedside Swallow Exam
Review of medical records Comprehensive interview with client Oral mechanism examination Trial feedings observation Feeding recommendations Referrals for either: Further instrumental assessment (need physician’s prescription to be covered by insurance) Specialized testing by other professionals
Instrumental Dysphagia Exam
More objective, quantifiable measure of swallowing function
Commonly used approaches:
Fiberoptic Endoscopic Examination of Swallowing: visualization of swallowing through flexible tube with recordable camera
Ultrasonography: uses sound waves to recreate a picture of structures (most beneficial in oral phase evaluation
Videofluorscopy: same as a modified barium swallow (most commonly used; “gold standard”)
How is Dysphagia treated?
SLP works to remediate oropharyngeal dysphagia
Compensatory approaches
Restorative approaches
To maintain nutrition, dietary modifications and/or alternative nutrition via a feeding tube
Nasogastric, gastrostomy, jejunostomy
Include ongoing assessment of client’s response to intervention, and adjust goals and approaches to fit evolving needs
What happens if the PES/UES malfunctions?
Can lead to residue in the piriform sinus and possible post swallow aspiration
What causes aspiration?
material falls into the larynx below the VF due to abnormal swallowing or altered level of consciousness
List the oral structures.
lips, teeth, cheeks, mandible, hard palate, tongue (tip, blade, back), anterior faucial arches
List pharyngeal structures.
velum, tongue base, pharyngeal walls, epiglottis, UES
valleculae, piriform sinuses
List laryngeal structures.
true VFs; false VFs; ariepiglottic folds
