Swallowing & Dysphagia Flashcards
2 functions of swallowing
- nutrition
- protects from aspiration
Swallowing is a _ reflex
primitive
When does the human fetes start swallowing
12 weeks
What do you swallow (3)?
- saliva
- food
- fluids
What is saliva composed of?
What is its function?
- water, electrolytes, proteins
- moistens food, digestion, antibacterial protection, enhances taste, oral hygiene
_ muscles involved in swallowing
25 (mouth, pharynx, larynx, oesophagus)
What coordinates swallowing and breathing?
cranial nerves
# of cranial nerves in body? # of cranial nerves involved in swallowing ?
12 cranial nerves
5 affect swallowing
What are the 5 cranial nerves involved in swallowing?
V: Trigeminal VI: Facial nerve IX: Glossopharyngeal X: Vagus XII: Hypoglossal
4 phases of swallowing
Oral Preparatory phase
Oral transit phase
Pharyngeal phase
Esophageal phase
Oral Preparatory phase:
- cranial nerve involved
- voluntary/involuntary
- main function
- V (trigeminal, VII (facial), XII (hypoglossal)
- voluntary
- food prepared into bolus
Oral transit phase:
- cranial nerve involved
- voluntary/involuntary
- main function
- V (trigeminal), VII (facial), XII (hypoglossal)
- voluntary
- bolus propelled towards pharynx
Pharyngeal phase:
- cranial nerve involved
- voluntary/involuntary
- main function
- IX (glossopharyngeal), X (vagus), XII (hypoglossal)
- involuntary
- airways are protected as bolus moves through oropharyngeal cavity towards the esophagus
Esophageal phase:
- cranial nerve involved
- voluntary/involuntary
- main function
- IX (glossopharyngeal), X (vagus), XII (hypoglossal)
- involuntary
- bolus propelled through esophagus into stomach
Trigeminal nerve (V) involved in which phase?
Is it motor or sensory?
oral preparatory and oral transit phases
Motor : mastication
Sensory : taste and touch
Facial nerve (VII) involved in which phase?
Is it motor or sensory?
oral preparatory and oral transit phases
Sensory: taste on anterior 2/3 of tongue
Glossopharyngeal nerve (IX) involved in which phase?
Is it motor or sensory?
oral preparatory and oral transit phases
motor: swallowing, gag reflex
sensory: palatal, glossal, oral sensations
Vagus nerve (X) involved in which phase?
Is it motor or sensory?
pharyngeal and oesophageal phases
motor: Gi activity
sensory: cough reflex, taste on posterior 2/3 of tongue
Hypoglossal (XII) nerve involved in which phase?
Is it motor or sensory?
all phases
motor: tongue movement
Considerations of the oral preparatory phase
- sight
- ability to self feed
- hand mouth coordination
- lip seal
- tongue control/strength
- oral sensation
- dentition/chewing difficulty
- cognition
- positioning
Oral preparatory phase
- food and drink enter mouth
- saliva secreted
- lips seal mouth
- soft palate drop to base of the tongue (protects airway)
- tongue moves food around mouth
- bolus formed and between tongue and soft palate
Oral transit phase
- soft palate raises to seal nasal cavity from oropharynx
- prepared bolus propelled to the oropharynx
Considerations of the oral transit phase
- foods that don’t from cohesive bolus can get stuck (honey, peanut butter, crackers)
- pocketing (food is stuck between cheek and teeth or gum)
- tongue strength
- oral hygiene
- oral sensation
- energy level of individual
Shortest phase
Pharyngeal phase (1 second)
Most complex phase of swallowing
Pharyngeal phase
Pharyngeal phase
- nasal passages sealed
- laryngeal muscles involved in vocal fold closure
- epiglottis drops and covers larynx
- respiration stopped
- bolus propelled towards esophagus
When does respiration stop during swallowing?
in pharyngeal phase reparation stopes to protect airway
When does breathing resume during swallowing?
After pharyngeal phase
Considerations of pharyngeal phase
- faucial pillars
- pharynx
- larynx
- epiglottis
Signs and symptoms that there is a problem in the pharyngeal phase
- gagging
- chocking, coughing
- watery eyes
- nasopharyngeal regurgitation
- “wet” vocal quality
Esophagus:
- sphincters
- # of tissue layers
- chief function
- when does peristalsis begin
- 2 sphincters:
UES = upper oesophageal sphincter
LES = lower oesophageal sphincter - 4tissue layers
- chief function = motility
- peristalsis begins after swallow
Which sphincter is the main barrier in preventing laryngopharyngeal reflux?
UES (= pharyngoesophageal junction)
Esophageal phase
- cricopharyngeal muscles relax and help open UES
- bolus passes through UES to oesophagus
- UES seals
- peristalsis propels bolus towards LES
- LES relaxes and food enters stomach
- secondary peristaltic waves if remnants in esophagus
What are difficulties in the esophageal phase due to?
Are they age related?
- mechanical obstruction/ cancer/ GERD
- not age related
GERD =
Gastroesophageal Reflux Disease
What is GERD
Reflux of gastric contents into esophagus
What are inner signs and symptoms of GERD
Gastric acid and pepsin found in esophagus
What triggers GERD
- increased secretion of gastrin, estrogen, progesterone
- medical conditions
- smoking
- medications
- foods
Which foods trigger GERD
high fat, chocolate, spearmint, peppermint, alcohol, caffeine
Which medication trigger GERD
dopamine, morphine, theophylline
Which medical conditions trigger GERD
hiatal hernia, scleroderma (=hardening of connective tissue), obesity
Normally what keeps the LES sealed?
Pressure esophagus > pressure stomach
GERD symptoms
- dysphagia
- heartburn
- increased salivation
- belching
- radiating pain in back, neck, jaw
- throat clearing/hoarseness
- abdominal pain
- ulceration
- Barrett’s esophagus
GERD symptoms in children
-refusal to eat
Treatment goals for GERD
- increasing LES competence
- decreasing gastric acidity, decreasing symptoms
- improving clearance of the esophagus
What treatments can be done for GERD
- medical management
- nutrition therapy
- lifestyle intervention
- surgery
Lifestyle interventions for GERD
- weight loss if necessary
- avoid: alcohol, eating within 3-4hours before sleep, lying down after meals, tight fitting clothing, smoking
- elevate head of bed while sleeping
When would surgery take place for GERD?
As a last resort, if very severe complications
2 possible surgeries for GERD
- Laparoscopic Nissen fundoplication
=> wrap the fundus around the lower esophagus giving it more strength - Stretta Procedure
=> balloon inflated with electrolytes and radio frequency
What is Barrett’s esophagus?
What are the symptoms?
A change in the oesophageal mucosa’s epithelial cells
- squamous cells –> metaplastic columnar cells (pre-cancerous)
- no specific symptoms
In which patients is Barrett’s esophagus found?
in 10% of patients undergoing endoscopy
Nutrition therapy for GERD
- excludes food groups that may lead to nutritional deficiencies
- long term medication use may impair B12, calcium and iron absorption
- decrease exposure to gastric contents : small frequent meals, low fat foods, chocolate, mint, alcohol avoided
- reduce gastric acidity : avoid coffee, fermented alcoholic beverages
- prevent pain and irritation
What is dysphasia
= disordered eating, any difficulty in swallowing or inability to swallow (solids/liquids)
T/F
Dysphagia is a diseased caused by a variety of disorders
F
Dysphagia is a symptom caused by a variety of disorders
Causes of dysphagia
Result from diseases:
- stroke
- neurological
- physical barriers
- FAS
- injury
- developmental disabilities
Dysphagia is more prevalent in men or women
women
What does the extent of recovery depend on
Depends on the ethology, can be permanent or transient
T/F
Dysphagia occurs in older age people who have a stroke
F
Dysphagia occurs all throughout the lifespan
Common neurological conditions associated with dysphagia
- Stroke
- MS
- Alzheimer’s disease, Huntington’s disease, Parkinson’s disease
- Cerebral palsy
- ALS
Transient dysphagia caused by:
- chronic anemia (-> esophageal webs)
- Bell’s palsy (cranial nerve pressure, infection)
- GERD
- cancer (esophageal, tumors, treatment side effects, chemotherapy)
- intubation
2 locations of dysphagia
- oropharyngeal dysphagia
- esophageal dysphagia
Oropharyngeal dysphagia divided into 2 subclasses:
- oral (preparatory and transit)
- pharyngeal
Symptoms of oral dysphagia
- weak tongue and lip muscles
- difficulty propelling food to throat
- difficulty initiating a swallow
- weakness
- decreased oral sensation
Signs of oral dysphagia
- reduced lip seal
- food pocketing
- drooling
- food/liquid spillage
- repetitive rocking of tongue from front to back (lingual pumping)
- reduced range of tongue motions have and coordination
Symptoms pharyngeal dysphagia
- delayed swallowing reflex
- swallow doesn’t clear bolus from throat
- bolus may penetrate into larynx
Signs of pharyngeal dysphagia
- repeated swallowing
- frequent throat clearing
- wet vocal quality
- complaints of food stuck in throat (globes sensation)
- repeated pneumonia
- fever
- chest/lung congestion
Esophageal dysphagia
- structural blockages
- stenosis
- strictures due to GERD or oesophageal dysmotility
- pressure or discomfort in the chest
- chronic heartburn
Complications of dysphagia
- inadequate oral intake (fear)
- weight loss
- malnutrition
- chocking
- aspiration pneumonia
- dehydration
- decreased rehab potential
- depression
- decreased quality of life
- increased length of hospital stay
- increased costs
Aspiration =
Accidental inhalation of food or particles or fluids into lungs
2 different aspirations
-silent aspiration
= no signs of aspiration, no coughing or chocking but food is entering the lungs
-aspiration pneumonia
= results form aspirated contents causing inflammation in the lungs
Techniques to prevent aspiration
- upright positioning for feeding
- chin down when swallowing liquids
- small quantities
- dry swallow to clear pharyngeal cavity
Special considerations with aspiration
- dental care/oral hygiene
- aspiration of saliva from poor oral hygiene increases risk of aspiration pneumonia
- special tools (suction, curve toothbrushes, non-foam toothpaste)
Who screens ad diagnoses dysphagia?
- physician, nurse, speech therapist (SLP), RD, OT, psychologist, PT
- the individual, and/or family members
Initial dysphagia screening can be done using
- patient’s history and physical
- bedside screening
- observing patient while eating
Who is at risk of dysphagia?
- stroke
- alzheimer’s
- parkinsons
- multiple sclerosis
- head and neck cancers
- enteral nutrition
Symptom screening for dysphagia
- drooling
- pocketing of food
- poor tongue control
- facial weakness
- difficulty chewing
- throat clearing
- weight loss
The bedside swallow:
- performed by?
- monitors : _
- assesses: _
- performed by OT, SLP, Rd
ask a series of questions - monitor eating
- assess: tongue strength and mobility, lip seal, coughing, chocking, voice changes, repeated swallowing, oral lesions,…
Modified barium swallow:
- what is the patient given
- what do you see
- who monitors
- what does it determine
- patient given a barium sulfate milkshake
- drinking is visualised by fluoroscopy or x-ray
- physician or SLP can monitor swallow
- determines degree of aspiration, bolus transit time, integrity of swallow, presence of dysphagia, motility problems, ulcers, tutors, inflammation
What is fiberoptic endoscopic evaluation of swallowing (FEES)
- long flexible tube with a lens and a light passed through the nose to assess swallowing function while patient eats
Dietitian’s assessment of a patient with dysphagia
- weight, weight changes
- height
- BMI
- swallowing pb history
- recurrent pneumonia
- slurred speech
- presence of GI bleeds
- diet history
- blood pressure
- dental care
- positioning
- results of swallowing tests
What is the purpose of nutrition are for dysphagia?
- provide appropriate nutritional and fluids to patient
- support independent eating
- improve nutritional deficiencies
- reduce risk of aspiration
- teach
- improve quality of life
What are the general diet descriptions?
- They are individualised based on swallowing assessment and patient preference/tolerance
- Have varied textures
Foods to omit when have dysphagia
- stringy fruits/vegetables
- nuts, seeds, coconuts
- foods that crumble easily
- popcorn, potato chips, muffins, cakes, cookies, biscuits
_ agents may help with swallowing
Moistening agents
According to the National Dysphagia Diet:
- 4 textures are
- 3 consistencies are
4 textures = regular, soft, minced, puree
3 consistencies = nectar, honey, pudding
What what founded in 2013 to standardise dysphasia care across the world?
IDDSI : international dysphagia diet standardisation initiative
What are the OPDQ Guidelines on modifying food textures and fluid consistencies are based on __
Based on APNED (not IDDSI)
What are the textures according to APNED
Tender, soft, minced, puree
What are the liquids according to APNED
Clear, nectar, honey, pudding
What is allowed in a TENDER menu
- a regular menu
- no hard or raw veg, no nuts
- most veg are cooked
What is allowed in a SOFT menu
- all soups
- chewing is difficult
- no melted cheese
What is allowed in a MINCED menu
- can eat with spoon or fork
- minimal chewing
- finally cut (5mm or less
What is allowed in a PUREED menu
- foods must be pureed, no lumps, no textures, no skin
- smooth desserts
How is viscosity measured
- Bostwick consistometer
- @ 8°C
- measured distance a material flows in 30 seconds
Units of viscosity
cP (centiposes or milliPAscal seconds)
Clear liquids are :
- regular liquids with no adjustments needed
- Botswick 24
Nectar liquids:
- falls slowly from spoon
- can be sipped from a straw or a cup
- Botswick 14
Nectar liquids:
- falls slowly from spoon
- can be sipped from a straw or a cup
- Bostwick 14
Honey liquids:
- drops from a spoon
- too thick for a straw
- Bostwick 8
Pudding liquids:
- maintains shape
- too thick to use a start or cup
- use a spoon
- Bostwick 4
Nectar liquids examples
buttermilk, tomato juice, Yoplait drink
Exemple de prescription nutritionnelle: régime diabétique à 2500mg Na, texture en purée avec liquides épaissis Bostwick _
8
Problem between IDDSI and APNED
They are the inverse
What is the IDDSI flow test to classify liquid thickness
Filling a syringe and release nozzle for 10 seconds
Thickening products are
- thicken up by Nestlé
- mashed potatoes
- skim milk powder
- whey powder
- corn starch
- graded cheeses
- powdered beverages
What can be an issue for certain dysphagia and should be considered when preparing food?
- delay between food prep and eating
- some foods melt in mouth
- consistency is not always stable
Why is it important to inform the caregiver
They are the primary source of care for the patient
Information to give to caregiver
- diet is designed to decrease chocking risk
- follow CFG for servings
- small frequent meals (help tolerance, fatigue, frustration)
- small meals before resting
- clean mouth after eating
- proper position of head and body
- small mouthfuls
- avoid liquids
What is important to consider when someone has dysphagia?
- try to indivualize diet, give recipes and recommendations
- understand the frustration
What is important to consider when someone has dysphagia?
- try to individualize diet, give recipes and recommendations
- understand the frustration
- try to enhance patients enjoyment of food
- adapt to what the client wants
Impact of dysphagia on individuals and society
- afraid to eat
- loss of independence
- financial cost
- malnutrition risk
- loss of social life
