SLIDE #15 - dysphagia Flashcards
what is another word for swallowing ?
deglutition
what is “normal swallowing” ?
Neuromuscular act of moving substances from the mouth into the throat and stomach
what are the 3 reasons we swallow ?
1) Maintenance
2) Ingestion
3) Protection
what does “maintenance” mean in regards to swallowing ?
Remove natural buildup of saliva in oral cavity
what does “maintenance” mean in regards to swallowing ?
- Consume liquids and food
- produce bolus for swallowing
what does “Ingestion” mean in regards to swallowing ?
Protect respiratory system from entry of foreign material (In adults, upper respiratory and digestive paths are crossed)
what are the main structures involved in swallowing ?
- oral cavity
- pharynx
- trachea
- esophagus
- nasal cavity
define the “oral cavity” in regards to being a structure involved in swallowing ?
- lips (prepare to go backwards)
- tongue ( helps create bolus)
- teeth (chew)
- saliva (enzymes that help break down)
define the “nasal cavity” in regards to being a structure involved in swallowing ?
- velum
- lifts up so thigs don’t go up nasal cavity
define the “pharynx” in regards to being a structure involved in swallowing ?
- muscles (contract to move bolus to esophagus)
- epiglottis (fold)
- valleculae (pooling area that collects before swallowing)
- upper esophageal sphincter (helps move bolus to esophagus)
define the “trachea” in regards to being a structure involved in swallowing ?
- cartilage
- doesn’t really affect
define the “esophagus” in regards to being a structure involved in swallowing ?
- Muscle (peristalsis)
- long tube that moves food down
- rhythmic muscle contraction
how many stages of swallowing are there ?
3
what are the 3 stages of swallowing ?
- Oral (transfer)
- Pharyngeal (transport)
- Esophageal (entrance)
describe the purpose of stage #1 (Oral (transfer)) :
To prepare substance to be swallowed and move
bolus to rear of oral cavity until swallow reflex is triggered (in
pharyngeal phase)
how does stage #1 (Oral (transfer)) occur ?
– Begins when food/liquid enters mouth (lips sealed)
– Tongue and cheek muscles move material for mastication
– Saliva softens food to help create a bolus
– Posterior tongue action that moves the bolus back
– Ends when bolus passes through anterior faucial arches and swallowing reflex is initiated
describe the purpose of stage #2 (Pharyngeal phase (transport)) :
To propel bolus through pharynx to entrance to esophagus
how does stage #2 (Pharyngeal phase (transport)) occur ?
Starts when swallow reflex (involuntary) is triggered
- Velum raises (velopharyngeal closure)
- Pharynx contracts and squeezes
- Larynx moves up and closes (vocal folds close, epiglottis lowers)
- Reflexive contractions of pharyngeal muscles moves bolus towards the esophagus
- Upper esophageal sphincter opens
how does stage #3 (Esophageal phase) occur ?
- Muscles of esophagus move bolus down to stomach in peristaltic contractions
- Food propelled through esophagus by peristatic action (and gravity) towards the stomach
- Not under voluntary control
- After bolus enters esophagus, breathing returns to normal
FILL IN THE BLANK
once the swallowing reflex is triggered, everything else is pretty __________
automatic
what is dysphagia ?
A condition in which an individual exhibits unsafe or inefficient swallowing pattern
what can dysphagia include ?
difficulty with any step of feeding process
what is dysphagia due to ?
Due to developmental, neurological, or structural problems that alter normal swallowing process
within what age group is dysphagia most common within ?
very common in people who have had a stroke (50-75%)
how common is dysphagia within common adults ?
15-30%
FILL IN THE BLACK
dysphagia is very common with those who have had a _____
stroke
what are some negative outcomes of dysphagia ?
- Malnutrition, weight loss, growth delay (in children), dehydration, fatigue, ill health
- Frustration, depression, reduced independence, social isolation
- Dependence on feeding tubes
what does Penetration mean ?
Food or liquid enters trachea, which can cause choking
what is the aspiration negative outcomes of dysphagia ?
– Food/liquid passes through larynx and into lungs, which can cause aspiration pneumonia
– Silent aspiration occurs without any signseath
can dysphagia lead to death ?
yes
how many types of dysphagia are there ?
3
what are the 3 types of dysphagia are there ?
1) Oropharyngeal dysphagia
2) Esophageal dysphagia
3) Functional dysphagia
which type of dysphagia is the most common ?
Oropharyngeal dysphagia
what does “Oropharyngeal dysphagia” affect :
- Affects transfer of bolus from pharynx to esophagus
- some kind of issues with getting pharynx to esophagus
what does “Esophageal dysphagia” affect:
Affects transfer of bolus from esophagus to the
stomach
what is the cause of “functional dysphagia” :
No clear cause or difficulty
types of dysphagia can be split into what two main phases ?
oral and pharygeal part
what are the problems of the oral phase (Oropharyngeal Dysphagia) :
- Poor lip seal
- Difficulty chewing
- Reduced tongue range and function (or tongue thrust)
- Premature swallow and aspiration before swallow
what are the consequences of the oral phase (Oropharyngeal Dysphagia) :
- Loss of food/drink from mouth
- Poor bolus formation and flow
- Food residue in various places
what are the problems of the oral phase (Pharyngeal Dysphagia) :
- Incomplete elevation of velum
- Reduced tongue force (movement of blous towards esophagus) of moving bolus through pharynx
- Delayed or absent swallow reflex
- Nasal and airway penetration
what are the consequences of the oral phase (Pharyngeal Dysphagia) :
- Food/liquid residue in nasal cavity and on pharyngeal wall
- Residue in pharynx after swallow
- Aspiration before or after the swallow
what are the problems of the oral phase (Esophageal Dysphagia) :
- Delayed or absent opening of upper esophageal sphincter
- Reduced esophageal contractions
- Incomplete bolus movement through the cricopharyngeal muscle
what are the consequences of the oral phase (Esophageal Dysphagia) :
- Residue in laryngeal area
- Backflow of food from esophagus to pharynx
- Sensation of food being stuck
what are the problems of the oral phase (Functional Dysphagia) :
Globus
what are the consequences of the oral phase (Functional Dysphagia) :
Feeling of food getting stuck or moving slowly through the
esophagus (e.g., when swallowing pills) (when swallowing pills without enough liquid)
which type of dysphagia is the least common ?
Functional Dysphagia
what are the different levels of severity ?
- mild
- moderate
- severe
- profound
describe “mild” severity :
some difficulties with oral preparation and pharyngeal functioning
describe “moderate” severity :
some danger of aspiration and penetration
describe “severe” severity :
serious risk of aspiration and penetration
describe “profound” severity :
unable to swallow safely
what are some causes of dysphagia ?
- Stroke
- Cancer of mouth, throat, larynx
- HIV/AIDS
- Neuromuscular disorders (e.g., MS, ALS, Parkinson’s)
- TBI, Spinal cord injury
- Medications
- Dementia
- Intellectual impairment
- Prematurity/low birth weight
- Cleft lip and palate
- Stress (functional dysphagia)
what are the MOST common causes of dysphagia ?
- Stroke
- Cancer of mouth, throat, larynx
- HIV/AIDS
- Neuromuscular disorders (e.g., MS, ALS, Parkinson’s)
what are some dysphagia warning signs ?
- coughing
- drooling
- choking
- food or fluid coming out of the nose
- gurgly voice quality
- wet-sounding breathing
- spillage of food or liquid from the mouth
- frequent throat clearing
- low grade fever
- progressively slower rate of food intake
- difficulty initiating a swallow
- pain upon swallowing
- food or liquid left in the mouth after a swallow
dofficulty manipulating food orliquid in the mouth - weight loss
what are the 3 assessments of dysphagia ?
- Screening
- Clinical assessment
- Instrumental assessment
discribe the “screening” phase of assessment of dysphagia :
- “mini assessment”
- Is patient at risk for aspiration?
- Can patient take food/liquid by mouth safely?
- Is alternate nutritional support needed?
- Is further assessment needed?
discribe the “clinical assessmemt” phase of assessment of dysphagia :
(aka bedside swallow examination)
- Includes
- Review medical records and client/caregiver interview
- Oral mechanism examination
- Attempt trial feedings to observe:
- Naturalness and automaticity of swallow
- Drooling during swallow
- Coughing during swallow
- Voice pre- and post-swallow
what might Clinical Assessments also include as a tool to assessment ?
a cervical auscultation
what is a “cervical auscultation “ ?
a clinical procedure that uses a stethoscope to amplify swallowing sounds to assess the pharyngeal phase of swallowing and its interaction with breathing.
how do clinicians use cervical auscultation ?
- Stethoscope to listen to the neck area during a swallow
- SLP makes perceptual judgement about swallowing function
- Compare sound of normal swallow to sound of
disordered swallow
which phase of Assessment of Dysphagia can be considered contreversial ?
Clinical Assessment
what do Clinical Assessment provide information about ?
− The possible nature/severity of disorder
− Consistencies that are easiest/hardest to swallow
− Head and body posture
− Laryngeal functioning
− Caregiver and environmental factors
− Cognitive and communicative functioning
what are the areas of concern of clinical assessment ?
- Observed difficulties during eating or drinking
- Appears to be at risk for aspiration
- Appears to not be receiving adequate nourishment
if we see difficulty or are concerned in a clinical assessment, what do we refer to ?
refer for instrumental assessment
what are some instruments used for assessments ?
- Videofluoroscopic Swallowing
Study - Fiberoptic Endoscopic Evaluation
of Swallow (FEES) - Ultrasound
- Electromyography
what is the Videofluoroscopic Swallowing study, assessment of dysphagia ?
AKA Modified Barium Swallow Study
- Barium on food or in liquid
- X-ray recorded for later analysis
- Used for determining
- readiation exposure
» Oral vs non-oral feeding
» Safest food textures (thin liquid could be worse than thick)
» Appropriate therapies
what is the Fiberoptic Endoscopic Evaluation of Swallow (FEES), assessment of dysphagia ?
- Flexible laryngoscope through nose into pharynx
- Swallow dyed food (blue or green)
- May reveal premature spillage,
airway closure
what is the ultrasound assessment of dysphagia ?
Ultrasound is a non-invasive imaging technique that uses sound waves to create images of structures inside the body. In the context of dysphagia, ultrasound is primarily used to assess oral and pharyngeal swallowing mechanics.
what is the Electromyography assessment of dysphagia ?
Electromyography (EMG) is a diagnostic tool used to measure the electrical activity of muscles. It can be applied to assess the function of muscles involved in swallowing, specifically those in the pharyngeal and laryngeal areas.
in simplest way, what is Fiberoptic Endoscopic Evaluation of Swallow (FEES) ?
alternative to x-ray barrium swallowing
in the Fiberoptic Endoscopic Evaluation of Swallow (FEES) instrumental assessment, why do we dye the food blue or green
dye good to see the residue post swallowing
what does the Fiberoptic Endoscopic Evaluation
of Swallow (FEES) provide information about ?
Provides information about. :
– Desirable posture
– Preferred food types
– Aspiration
what is one reason that Fiberoptic Endoscopic Evaluation of Swallow (FEES) could be considered better than a Videofluoroscopic Swallowing Study ?
because it is less risky cause there is no radiation
what is a tradeoff about doing a Fiberoptic Endoscopic Evaluation of Swallow (FEES) rather than a Videofluoroscopic Swallowing Study ?
you cannot see to confirm aspirating (we cannot see like we can on x-ray
how does Ultrasound Assessment of Dysphagia work ?
High-frequency sound waves are directed at the throat and mouth during swallowing. The ultrasound waves are reflected off the tissues, creating real-time images (or videos) of the structures involved in swallowing.
how does Electromyography (EMG) for Dysphagia work ?
Small electrodes are placed on the skin (surface EMG) or inserted into muscles (intramuscular EMG) to detect electrical signals produced by muscle activity. These signals are recorded and analyzed to assess the timing, strength, and coordination of muscle contractions during swallowing.
what are some advantages of ultrasound Assessment of Dysphagia ?
- Non-invasive and safe, with no radiation.
- Can be used at the bedside, making it accessible for patients who may have difficulty going to a radiology department.
- Allows for real-time imaging of swallowing.
what are some limitations of ultrasound Assessment of Dysphagia ?
- Limited ability to view deeper structures such as the esophagus.
- May not provide detailed information about the larynx or vocal cords.
what are some advantages of Electromyography (EMG) assessment of dysphagia ?
- Provides valuable information about muscle function and the neurological control of swallowing.
- Can help in diagnosing neuromuscular disorders that affect swallowing, such as stroke, Parkinson’s disease, or amyotrophic lateral sclerosis (ALS).
what are some limitations of Electromyography (EMG) assessment of dysphagia ?
- Invasive when using intramuscular electrodes.
- Provides limited information on the anatomical structures involved in swallowing (unlike ultrasound or video fluoroscopy).
what does ultrasound Assessment of Dysphagia assess?
- Oral phase duration
- Structure/movement of hyoid bone and tongue
(put it under tongue to see)
what does Electromyography (EMG) assessment of dysphagia assess ?
- Assesses muscle functioning during swallow
- Invasive
- More typical in research settings
(procedure that allows us to access muscle functioning during swallowing but it is more invasive
what are the 4 main treatments of dysphagia ?
- Indirect treatment
- Direct treatment
- Medical treatment
- Lifestyle changes
what are the Goals of Treatment of Dysphagia ?
- Maintain a safe swallow or reduce aspiration risk
- Increase per oral intake
what do we mean by “team approach” ?
use of many people together : SLP, dietician, OT, physician, physio, etc. all working together
describe “indirect treatment” of dysphagia
- Does not involve food
- Exercises to improve muscle strength
- Range of motion
- Increase tension
- Increase range of movement
- Strengthen lip closure
^ all of the following improving mobility of bolus - Exercises to stimulate swallow reflex
- Exercises to improve airway adductio
describe “swallowing therapy” of dysphagia restorative techniques :
Oral and pharyngeal exercises
– Effortful swallow
– Masako maneuver
– Supraglottic swallow
– Mendelsohn maneuver
Biofeedback (e.g., ultrasound)
the following is for what kind of dysphagia therapy ?
- exercises to stimulate swallowing reflexes
- to strengthen oral and pharyngeal muscles during actual swallowing
- swallowing normally but trying to have more conscious contractions
swallowing therapy
what are some compensatory strategies of swallowing therapy ?
- Body and head positioning (turning head in one direction may be stronger in some individuals than others)
- Positioning of food
- Modification of foods/liquids (textures (thin food may be safe while thick may not), quantities (multiple small meals may be smarter than one big mea), and temperatures (hot vs cold food)
as a compensatory strategy swallowing therapy, why might patients change the way people are positioned during swallowing ?
to reduce the risk of aspiration
what are the 3 main categories of Medical and Pharmacological Approaches ?
Drug Treatments & Surgical Procedures & Non-oral Feeding (NPO)
describe “Drug Treatments” as a Medical and Pharmacological Approache :
- Medications can either help or cause/ contribute to swallowing disorders
what is an example of Drug Treatments as a form of Medical and Pharmacological Approache ?
ex. some medications can help with aspects such as reflex
describe “Surgical Procedures” as a Medical and Pharmacological Approache :
- Release muscular tension or stretch/dilate narrow stricture
- might need surgery
- feeding tube placement
what are the two types of Feeding tube placements ?
Enteral (nasogastric, gastrostomy) & Parenteral
what are Enteral Feeding Tubes ?
These are tubes used to deliver food directly into the digestive system when a person can’t eat by mouth.
what are the two kinds of Enteral Feeding Tubes?
Nasogastric Tube (NG Tube) & Gastrostomy Tube (G Tube)
what is a Nasogastric Tube (NG Tube) ?
- Inserted through the nose and down the throat into the stomach.
- Used for short-term feeding (days to weeks)
- Suitable for people who can swallow but need help with food intake.
what is a Gastrostomy Tube (G Tube) ?
- Inserted directly into the stomach through the skin (surgically or with a small incision).
- Used for long-term feeding (months to years).
- Suitable for people who cannot swallow or have long term swallowing issues.
what are parenteral Feeding Tubes ?
These tubes deliver nutrition directly into the bloodstream, bypassing the digestive system.
describe “Non-oral Feeding (NPO)” as a Medical and Pharmacological Approache :
means that a person is not allowed to eat or drink anything by mouth. This can happen for medical reasons, like before surgery or when someone is too sick to swallow safely.
what type of Non-oral Feeding (NPO) is “administering liquid nutrition into the vein” ?
parenteral tube
what type of Non-oral Feeding (NPO) is “tube going into nose through pharynx into esophagus” ?
Nasogastric tube
what type of Non-oral Feeding (NPO) is “directly into the stomach” ?
Gastrostomy tube (PEG)
what term is used when we do NOT want patients eating anything from the mouth /no food by mouth ?
Non-oral Feeding (NPO)
describe “Lifestyle changes (for GERD)” as a treatment of dysphagia :
- Increased exercise, diet modifications
- Common recommendations:
- Balanced diet
- Avoid alcohol and caffeine
- Seat smaller, frequent meals (not before bed)
- Reduce stress
- Elevate head while sleeping
what are some main cultural considerations we should be aware of ?
- Language Barriers
- Physical Space
- Food & Nutrition
- Ageism
how to go about “Language Barriers” in regards to a cultural consideration ?
Ensure patients and families understand terms and
concepts (e.g., dysphagia, aspiration, NPO)
how to go about “physical space” in regards to a cultural consideration ?
Physical proximity and touching required for assessment
how to go about “Food & Nutrition” in regards to a cultural consideration ?
- Recommendations must consider cultural preferences
- Consult dietician
- Ultimately patient choice (QOL)
how to go about “Ageism” in regards to a cultural consideration ?
Integrate needs and perspectives of older patients
what is Pediatric Feeding Disorder ?
is when a child has trouble eating or drinking enough to grow and develop properly
TRUE OR FALSE
Pediatric dysphagia = Adult dysphagia
FALSE
Pediatric dysphagia ≠ Adult dysphagia
what is the criteria for a pediatric feeding disorder ?
– oral intake that is not appropriate
– lasting at least 2 weeks
– dysfunction of 1+ domains given their age (i.e., medical, nutritional, feeding skill psychosocial)
how many people do Pediatric Feeding Disorders affect ?
~1% of children
what might Pediatric Feeding Disorders involve ?
- Refusing certain foods or only eating very limited types.
- Struggling to chew or swallow.
- Eating too little or not gaining weight.
what are the 4 assessments of pediatric feeding disorders ?
- Medical
- Nutritional
- Feeding skill
- Psychosocial
describe “medical” aspect of pediatric feeding disorders :
- Compromised airway during feeding
- Aspiration or recurrent pneumonia
describe “Feeding skill” aspect of pediatric feeding disorders :
- Malnutrition
- Significantly reduced oral intake or reliance on enteral feeding
describe “medical” aspect of pediatric feeding disorders :
- Use of modified feeding strategies, positions, or equipment
- Need for texture modifications
describe “Psychosocial” aspect of pediatric feeding disorders :
- Avoidance behaviours during feeding
- Inappropriate management of feeding behaviours\
- Disrupted social functioning during feeding
what do treatments of pediatric feeding disorder target ?
Treatment targets the four domains of pediatric feeding disorders
TRUE OR FALSE
Care coordination with feeding team and family is essentially for improvement of pediatric feeding disorder ?
TRUE
