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Clinical Nutrition 1 > Swallowing & Dysphagia > Flashcards

Swallowing & Dysphagia Flashcards

1
Q

2 functions of swallowing

A
  • nutrition

- protects from aspiration

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2
Q

Swallowing is a _ reflex

A

primitive

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3
Q

When does the human fetes start swallowing

A

12 weeks

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4
Q

What do you swallow (3)?

A
  • saliva
  • food
  • fluids
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5
Q

What is saliva composed of?

What is its function?

A
  • water, electrolytes, proteins

- moistens food, digestion, antibacterial protection, enhances taste, oral hygiene

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6
Q

_ muscles involved in swallowing

A

25 (mouth, pharynx, larynx, oesophagus)

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7
Q

What coordinates swallowing and breathing?

A

cranial nerves

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8
Q 
# of cranial nerves in body? 
# of cranial nerves involved in swallowing ?
A

12 cranial nerves

5 affect swallowing

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9
Q

What are the 5 cranial nerves involved in swallowing?

A 
V: Trigeminal
VI: Facial nerve 
IX: Glossopharyngeal
X: Vagus
XII: Hypoglossal
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10
Q

4 phases of swallowing

A

Oral Preparatory phase
Oral transit phase
Pharyngeal phase
Esophageal phase

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11
Q

Oral Preparatory phase:

  • cranial nerve involved
  • voluntary/involuntary
  • main function
A
  • V (trigeminal, VII (facial), XII (hypoglossal)
  • voluntary
  • food prepared into bolus
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12
Q

Oral transit phase:

  • cranial nerve involved
  • voluntary/involuntary
  • main function
A
  • V (trigeminal), VII (facial), XII (hypoglossal)
  • voluntary
  • bolus propelled towards pharynx
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13
Q

Pharyngeal phase:

  • cranial nerve involved
  • voluntary/involuntary
  • main function
A
  • IX (glossopharyngeal), X (vagus), XII (hypoglossal)
  • involuntary
  • airways are protected as bolus moves through oropharyngeal cavity towards the esophagus
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14
Q

Esophageal phase:

  • cranial nerve involved
  • voluntary/involuntary
  • main function
A
  • IX (glossopharyngeal), X (vagus), XII (hypoglossal)
  • involuntary
  • bolus propelled through esophagus into stomach
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15
Q

Trigeminal nerve (V) involved in which phase?

Is it motor or sensory?

A

oral preparatory and oral transit phases

Motor : mastication
Sensory : taste and touch

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16
Q

Facial nerve (VII) involved in which phase?

Is it motor or sensory?

A

oral preparatory and oral transit phases

Sensory: taste on anterior 2/3 of tongue

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17
Q

Glossopharyngeal nerve (IX) involved in which phase?

Is it motor or sensory?

A

oral preparatory and oral transit phases

motor: swallowing, gag reflex
sensory: palatal, glossal, oral sensations

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18
Q

Vagus nerve (X) involved in which phase?

Is it motor or sensory?

A

pharyngeal and oesophageal phases

motor: Gi activity
sensory: cough reflex, taste on posterior 2/3 of tongue

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19
Q

Hypoglossal (XII) nerve involved in which phase?

Is it motor or sensory?

A

all phases

motor: tongue movement

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20
Q

Considerations of the oral preparatory phase

A
  • sight
  • ability to self feed
  • hand mouth coordination
  • lip seal
  • tongue control/strength
  • oral sensation
  • dentition/chewing difficulty
  • cognition
  • positioning
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21
Q

Oral preparatory phase

A
  • 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
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22
Q

Oral transit phase

A
  • soft palate raises to seal nasal cavity from oropharynx

- prepared bolus propelled to the oropharynx

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23
Q

Considerations of the oral transit phase

A
  • 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
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24
Q

Shortest phase

A

Pharyngeal phase (1 second)

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25
Q

Most complex phase of swallowing

A

Pharyngeal phase

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26
Q

Pharyngeal phase

A
  • nasal passages sealed
  • laryngeal muscles involved in vocal fold closure
  • epiglottis drops and covers larynx
  • respiration stopped
  • bolus propelled towards esophagus
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27
Q

When does respiration stop during swallowing?

A

in pharyngeal phase reparation stopes to protect airway

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28
Q

When does breathing resume during swallowing?

A

After pharyngeal phase

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29
Q

Considerations of pharyngeal phase

A
  • faucial pillars
  • pharynx
  • larynx
  • epiglottis
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30
Q

Signs and symptoms that there is a problem in the pharyngeal phase

A
  • gagging
  • chocking, coughing
  • watery eyes
  • nasopharyngeal regurgitation
  • “wet” vocal quality
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31
Q

Esophagus:

  • sphincters
  • # of tissue layers
  • chief function
  • when does peristalsis begin
A
  • 2 sphincters:
    UES = upper oesophageal sphincter
    LES = lower oesophageal sphincter
  • 4tissue layers
  • chief function = motility
  • peristalsis begins after swallow
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32
Q

Which sphincter is the main barrier in preventing laryngopharyngeal reflux?

A

UES (= pharyngoesophageal junction)

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33
Q

Esophageal phase

A
  • 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
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34
Q

What are difficulties in the esophageal phase due to?

Are they age related?

A
  • mechanical obstruction/ cancer/ GERD

- not age related

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35
Q

GERD =

A

Gastroesophageal Reflux Disease

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36
Q

What is GERD

A

Reflux of gastric contents into esophagus

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37
Q

What are inner signs and symptoms of GERD

A

Gastric acid and pepsin found in esophagus

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38
Q

What triggers GERD

A
  • increased secretion of gastrin, estrogen, progesterone
  • medical conditions
  • smoking
  • medications
  • foods
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39
Q

Which foods trigger GERD

A

high fat, chocolate, spearmint, peppermint, alcohol, caffeine

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40
Q

Which medication trigger GERD

A

dopamine, morphine, theophylline

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41
Q

Which medical conditions trigger GERD

A

hiatal hernia, scleroderma (=hardening of connective tissue), obesity

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42
Q

Normally what keeps the LES sealed?

A

Pressure esophagus > pressure stomach

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43
Q

GERD symptoms

A
  • dysphagia
  • heartburn
  • increased salivation
  • belching
  • radiating pain in back, neck, jaw
  • throat clearing/hoarseness
  • abdominal pain
  • ulceration
  • Barrett’s esophagus
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44
Q

GERD symptoms in children

A

-refusal to eat

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45
Q

Treatment goals for GERD

A
  • increasing LES competence
  • decreasing gastric acidity, decreasing symptoms
  • improving clearance of the esophagus
46
Q

What treatments can be done for GERD

A
  • medical management
  • nutrition therapy
  • lifestyle intervention
  • surgery
47
Q

Lifestyle interventions for GERD

A
  • 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
48
Q

When would surgery take place for GERD?

A

As a last resort, if very severe complications

49
Q

2 possible surgeries for GERD

A
  • Laparoscopic Nissen fundoplication
    => wrap the fundus around the lower esophagus giving it more strength
  • Stretta Procedure
    => balloon inflated with electrolytes and radio frequency
50
Q

What is Barrett’s esophagus?

What are the symptoms?

A

A change in the oesophageal mucosa’s epithelial cells

  • squamous cells –> metaplastic columnar cells (pre-cancerous)
  • no specific symptoms
51
Q

In which patients is Barrett’s esophagus found?

A

in 10% of patients undergoing endoscopy

52
Q

Nutrition therapy for GERD

A
  • 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
53
Q

What is dysphasia

A

= disordered eating, any difficulty in swallowing or inability to swallow (solids/liquids)

54
Q

T/F

Dysphagia is a diseased caused by a variety of disorders

A

F

Dysphagia is a symptom caused by a variety of disorders

55
Q

Causes of dysphagia

A

Result from diseases:

  • stroke
  • neurological
  • physical barriers
  • FAS
  • injury
  • developmental disabilities
56
Q

Dysphagia is more prevalent in men or women

A

women

57
Q

What does the extent of recovery depend on

A

Depends on the ethology, can be permanent or transient

58
Q

T/F

Dysphagia occurs in older age people who have a stroke

A

F

Dysphagia occurs all throughout the lifespan

59
Q

Common neurological conditions associated with dysphagia

A
  • Stroke
  • MS
  • Alzheimer’s disease, Huntington’s disease, Parkinson’s disease
  • Cerebral palsy
  • ALS
60
Q

Transient dysphagia caused by:

A
  • chronic anemia (-> esophageal webs)
  • Bell’s palsy (cranial nerve pressure, infection)
  • GERD
  • cancer (esophageal, tumors, treatment side effects, chemotherapy)
  • intubation
61
Q

2 locations of dysphagia

A
  • oropharyngeal dysphagia

- esophageal dysphagia

62
Q

Oropharyngeal dysphagia divided into 2 subclasses:

A
  • oral (preparatory and transit)

- pharyngeal

63
Q

Symptoms of oral dysphagia

A
  • weak tongue and lip muscles
  • difficulty propelling food to throat
  • difficulty initiating a swallow
  • weakness
  • decreased oral sensation
64
Q

Signs of oral dysphagia

A
  • 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
65
Q

Symptoms pharyngeal dysphagia

A
  • delayed swallowing reflex
  • swallow doesn’t clear bolus from throat
  • bolus may penetrate into larynx
66
Q

Signs of pharyngeal dysphagia

A
  • repeated swallowing
  • frequent throat clearing
  • wet vocal quality
  • complaints of food stuck in throat (globes sensation)
  • repeated pneumonia
  • fever
  • chest/lung congestion
67
Q

Esophageal dysphagia

A
  • structural blockages
  • stenosis
  • strictures due to GERD or oesophageal dysmotility
  • pressure or discomfort in the chest
  • chronic heartburn
68
Q

Complications of dysphagia

A
  • 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
69
Q

Aspiration =

A

Accidental inhalation of food or particles or fluids into lungs

70
Q

2 different aspirations

A

-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

71
Q

Techniques to prevent aspiration

A
  • upright positioning for feeding
  • chin down when swallowing liquids
  • small quantities
  • dry swallow to clear pharyngeal cavity
72
Q

Special considerations with aspiration

A
  • dental care/oral hygiene
  • aspiration of saliva from poor oral hygiene increases risk of aspiration pneumonia
  • special tools (suction, curve toothbrushes, non-foam toothpaste)
73
Q

Who screens ad diagnoses dysphagia?

A
  • physician, nurse, speech therapist (SLP), RD, OT, psychologist, PT
  • the individual, and/or family members
74
Q

Initial dysphagia screening can be done using

A
  • patient’s history and physical
  • bedside screening
  • observing patient while eating
75
Q

Who is at risk of dysphagia?

A
  • stroke
  • alzheimer’s
  • parkinsons
  • multiple sclerosis
  • head and neck cancers
  • enteral nutrition
76
Q

Symptom screening for dysphagia

A
  • drooling
  • pocketing of food
  • poor tongue control
  • facial weakness
  • difficulty chewing
  • throat clearing
  • weight loss
77
Q

The bedside swallow:

  • performed by?
  • monitors : _
  • assesses: _
A
  • 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,…
78
Q

Modified barium swallow:

  • what is the patient given
  • what do you see
  • who monitors
  • what does it determine
A
  • 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
79
Q

What is fiberoptic endoscopic evaluation of swallowing (FEES)

A
  • long flexible tube with a lens and a light passed through the nose to assess swallowing function while patient eats
80
Q

Dietitian’s assessment of a patient with dysphagia

A
  • 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
81
Q

What is the purpose of nutrition are for dysphagia?

A
  • provide appropriate nutritional and fluids to patient
  • support independent eating
  • improve nutritional deficiencies
  • reduce risk of aspiration
  • teach
  • improve quality of life
82
Q

What are the general diet descriptions?

A
  • They are individualised based on swallowing assessment and patient preference/tolerance
  • Have varied textures
83
Q

Foods to omit when have dysphagia

A
  • stringy fruits/vegetables
  • nuts, seeds, coconuts
  • foods that crumble easily
  • popcorn, potato chips, muffins, cakes, cookies, biscuits
84
Q

_ agents may help with swallowing

A

Moistening agents

85
Q

According to the National Dysphagia Diet:

  • 4 textures are
  • 3 consistencies are
A

4 textures = regular, soft, minced, puree

3 consistencies = nectar, honey, pudding

86
Q

What what founded in 2013 to standardise dysphasia care across the world?

A

IDDSI : international dysphagia diet standardisation initiative

87
Q

What are the OPDQ Guidelines on modifying food textures and fluid consistencies are based on __

A

Based on APNED (not IDDSI)

88
Q

What are the textures according to APNED

A

Tender, soft, minced, puree

89
Q

What are the liquids according to APNED

A

Clear, nectar, honey, pudding

90
Q

What is allowed in a TENDER menu

A
  • a regular menu
  • no hard or raw veg, no nuts
  • most veg are cooked
91
Q

What is allowed in a SOFT menu

A
  • all soups
  • chewing is difficult
  • no melted cheese
92
Q

What is allowed in a MINCED menu

A
  • can eat with spoon or fork
  • minimal chewing
  • finally cut (5mm or less
93
Q

What is allowed in a PUREED menu

A
  • foods must be pureed, no lumps, no textures, no skin

- smooth desserts

94
Q

How is viscosity measured

A
  • Bostwick consistometer
  • @ 8°C
  • measured distance a material flows in 30 seconds
95
Q

Units of viscosity

A

cP (centiposes or milliPAscal seconds)

96
Q

Clear liquids are :

A
  • regular liquids with no adjustments needed

- Botswick 24

97
Q

Nectar liquids:

A
  • falls slowly from spoon
  • can be sipped from a straw or a cup
  • Botswick 14
98
Q

Nectar liquids:

A
  • falls slowly from spoon
  • can be sipped from a straw or a cup
  • Bostwick 14
99
Q

Honey liquids:

A
  • drops from a spoon
  • too thick for a straw
  • Bostwick 8
100
Q

Pudding liquids:

A
  • maintains shape
  • too thick to use a start or cup
  • use a spoon
  • Bostwick 4
101
Q

Nectar liquids examples

A

buttermilk, tomato juice, Yoplait drink

102
Q

Exemple de prescription nutritionnelle: régime diabétique à 2500mg Na, texture en purée avec liquides épaissis Bostwick _

A

8

103
Q

Problem between IDDSI and APNED

A

They are the inverse

104
Q

What is the IDDSI flow test to classify liquid thickness

A

Filling a syringe and release nozzle for 10 seconds

105
Q

Thickening products are

A
  • thicken up by Nestlé
  • mashed potatoes
  • skim milk powder
  • whey powder
  • corn starch
  • graded cheeses
  • powdered beverages
106
Q

What can be an issue for certain dysphagia and should be considered when preparing food?

A
  • delay between food prep and eating
  • some foods melt in mouth
  • consistency is not always stable
107
Q

Why is it important to inform the caregiver

A

They are the primary source of care for the patient

108
Q

Information to give to caregiver

A
  • 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
109
Q

What is important to consider when someone has dysphagia?

A
  • try to indivualize diet, give recipes and recommendations

- understand the frustration

110
Q

What is important to consider when someone has dysphagia?

A
  • try to individualize diet, give recipes and recommendations
  • understand the frustration
  • try to enhance patients enjoyment of food
  • adapt to what the client wants
111
Q

Impact of dysphagia on individuals and society

A
  • afraid to eat
  • loss of independence
  • financial cost
  • malnutrition risk
  • loss of social life

Clinical Nutrition 1 (13 decks)

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