swallowing/feeding Flashcards
dysphagia causes
stroke, head trauma, MS, CP, dementia, brain/SC tumor, cervical spine injury, motor neuron disease, myopathy
dysphagia symptoms
- choking
- coughing during/after swallow
- coughing/vomiting up food
- weak, soft, gurgly voice
- aspiration
- excessive saliva/drooling
- difficulty chewing
- trouble moving food to back of mouth
- food stuck in throat
pharynx
throat; funnels food into esophagus
- shared by food & air
larynx
voice box
- closes during swallowing (valve to trachea) to protect from aspiration
- vocal folds, pitch, volume of voice
trachea
allows air into lungs
- closed by larynx during swallowing
cranial nerve V: trigeminal nerve damage
no sensation, unable to move mandible
cranial nerve VII: facial nerve damage
no taste to front of tongue, no jaw opening/closing, poor lip strength, dry mouth, paralyzed face muscles
cranial nerve IX: glossopharyngeal nerve damage
decreased taste/salivation, inhibited gag reflex, weak cough reflex
cranial nerve X: vagus nerve damage
no gag, no pitch, difficulty swallowing, nasal regurgitation, hoarse/breathy/wet voice
cranial nerve XII: hypoglossal nerve damage
unable to position food for chewing = food pocketing
phases of swallowing
- oral preparatory phase
- oral phase
- pharyngeal phase
- esophageal phase
oral preparatory phase
VOLUNTARY, TIME DEPENDS ON FOOD CONSISTENCY
oral manipulation: chewing to form bolus
oral phase
VOLUNTARY: 1-3 SECONDS
tongue moves bolus to back of mouth, ends with beginning of pharyngeal swallow
pharyngeal phase
INVOLUNTARY: 1-3 SECONDS
swallowing, epiglottis retroflexes to protect airway
esophageal phase
INVOLUNTARY: 8-10 SECONDS
bolus pushed towards & into stomach
esophageal dysphagia
FEELING OF FOOD STUCK IN THROAT WHILE SWALLOWING
- symptoms: pain when swallowing, sensation of food stuck in throat, regurgitation, heartburn, back-up of food or stomach acid into the mouth or throat, hoarseness, sudden weight loss
- Cause: GERD, radiation for cancer, scleroderma, esophageal tumors or spasms
oropharyngeal dysphagia
WEAK MOUTH/THROAT MUSCLES, FOOD & LIQUID CAN’T BE MOVED TO STOMACH OR ESOPHAGUS
- symptoms: coughing/gagging when swallowing, drooling, sudden weight loss, can’t swallow, need food cut into small pieces or avoid some foods
- Cause: neurological disease/damage, pharyngoesophageal diverticulum, cancer or cancer tx
pharyngoesophageal diverticulum/Zenker’s
a small pouch just above the esophagus that collects food particles
Achalasia
esophagus muscle spasms or strictures/restriction
esophagitis
esophagus inflammation
Videofluoroscopy
moving x-ray (fluoroscopy) to observe food and liquid as it travels down the GI tract
how do OTs support SLPs?
- carryover of feeding/swallowing techniques during ADLs
what replaced the national dysphagia diet?
International Dysphagia Diet Standardization Initiative (IDDSI) Framework
levels 0-1 liquids
THIN-SLIGHTLY THICK
0 = nothing remaining after 10 second flow
1 = 1-4 mL remaining after 10 second flow
- normal consistency
EX: water, milk, juice, broth, foods that melt such as popsicles, coffee, tea
level 2 liquids
MILDLY THICK, NECTAR THICK
2 = 4-8 mL remaining after 10 second flow
LEVEL 150 FLUID
- liquid slightly thickened, slowing flow
EX: Tomato juice, fruit nectar, smoothies, cream soup
level 3 liquids
MOD THICK, LIQUIDIZED, HONEY THICK
3 =. 8-10 mL remaining after 10 second flow
LEVEL 400 FLUID
- thickened until it drips/flows slowly off spoon
EX: honey, syrup
level 4 liquids
PUDDING, EXTREMELY THICK/PUREED
4 = IDDSI fork drip test & spoon tilt test
LEVEL 900 FLUID
- does not flow/drip off spoon
EX: pudding, ice cream
IDDSI levels of food consistency
3: liquidized/mod thick
4: pureed/extremely thick
5: minced & moist
6: soft & bite sized
7: regular
(levels 5-7 = transitional levels)
level 4 foods
PUREED
- pudding consistency, add liquid to dry foods
EX: mashed potatoes/bananas/squash, cooked cereals applesauce
level 5 foods
MECHANICAL SOFT, MIN CHEWING
- 4 MM PARTICLE SIZES (2MM FOR KIDS)
- Soft, cohesive foods are allowed unaltered
- Chunkier foods or harder foods are cooked and fork-mashed, ground or softened
- NO BREADS
EX: ground meat, mashed vegetables, meat loaf, baked beans, casseroles
level 6 foods
SOFT: no choking/asphyxiation risk
- 1.5 CM OR 15 MM (NO LARGER THAN 8 MM FOR KIDS)
- Soft solid foods, chewy foods
- Meat cooked well and cut into small pieces
- Fruits and vegetables peeled and/or cooked
- Soft breads
EX: Diced beef or chicken, canned meat such as tuna, canned vegetables, soft fruits like bananas, strawberries, pizza, cheese, bagels
level 7 foods
REGULAR
- foods that fall apart (bread, rice, muffins) then mixed textures
piriform sinus
pear shaped fossa at entrance to laryngeal space
- channels swallowed material before it enters esophagus
vocal folds
vocal cords (vagus nerve controls)
- open when breathing/vibrating (speaking, singing)
- produce sounds for speech
- protect airway from choking, regulate airflow into lungs
bronchioles/bronchi
major air passage of lungs coming from windpipe
if someone aspirates food, they are at risk for
pneumonia
esophagus
food/liquid normally enters while swallowing
upper esophageal sphincter
bundle of muscles at top of esophagus
- consciously controlled, used when breathing, eating, belching, vomiting
oral sensory problem
- food pocketing
- lack of awareness of food on side of mouth with decreased sensation
- spilling food into airway when vocal cords are open
- swallow sequence timing is off
cricopharyngeal junction
junction of pharynx & esophagus
when there is weakness of the elevation of the pharynx during swallowing, what happens?
incomplete trigger of pharyngeal phase of swallowing
vocal cord paralysis leads to
aspiration (vocal cords dont close during swallow)
clinical aspiration
food enters airway, person clears by coughing (reflex intact)
- aspirates when food comes up & patient can’t swallow it
silent aspiration
food enters lung, person does not react, respiratory distress without cough, too weak of cough to get bolus out of lungs
no esophageal motility
bolus sits in esophagus, can slowly either move down towards stomach or up towards pharynx
when does swallowing dysfunction come into question?
- coughing during/after drinking water/thin liquid
- changes in face color during/after eating (flushed, ashed, blanches = pale)
- gasps for breath
immediate action for aspiration
- heimlich maneuver
- basic life support if they lose consciousness (abdominal thrusts, back blows, periodically looking in oral canal to try to see object)
heimlich maneuver
clear obstruction & raise bolus that has been aspirated
- HAVE TO BE AWAKE/RESPONSIVE
bedside swallowing eval
- assess alertness, direction following, anosognosia, orientation
- assess sensory & motor components of swallowing
- assess ability to manage secretions via auscultation & clin obs
- assess swallowing via trial bolus (suggest diet modification, recommend further testing)
ascultation
listening to heart, lungs with stethoscope
modified barium swallow (MBS)
- swallowing team + radiologist
- person upright at edge of table (must have good sitting balance, must be supervised at all times)
- trial bolus of mixed food consistencies laced with barium which coats GI tract & can see problem areas on x ray
- test ceases if they aspire (xray shots still taken)
- dx swallowing disorders, GI dysfunction
FEES
- bedside or office
- foods laced with green food coloring
- variety of consistencies to swallow
- see whether swallow is intact/impaired using flexible endoscopic catheter with mini camera
- tests for LIGHT TOUCH sensation in pharyngeal cavity by forcing air through endoscopic tube
- can dx swallowing disorder, GI dysfunction
psychosocial effects of tube feeding
- change in roles
- uncomfortable with dining in public
- infantilizing
- sex appeal & self image
- how others see them
pre oral phase
- salivating
- smell & visual appreciation of food
chin tuck
- for delayed swallow initiation
- Moving CHIN TOWARDS CHEST while swallowing
- Protects airway
- Reduces aspiration risk
Mendelsohn maneuver
- Prolong opening of upper esophageal sphincter during swallow
- pushing tongue into upper palate while manually elevating Adam’s apple
supraglottic swallow
Close vocal cords before/during swallow
- Cough at the end of the swallow to clear food
- Take deep breath
- Hold breath while swallowing
- COUGH to clear saliva or food that may have passed beyond vocal cords
super supraglottic swallow
Close airway entrance ABOVE vocal cords
- Take deep breath
- Hold breath and BEAR DOWN (as in bowel movement) while swallowing
- COUGH to clear saliva, food that may have passed beyond vocal cords
For mealtime FATIGUE: (ALS)
eat frequent small meals rather than 1 big meal
For correct JAW control while feeding child from the SIDE
Jaw opening/closing controlled by index & middle fingers
- thumb on child’s neck (fulcrum of jaw movement)
For correct JAW control while feeding child from the FRONT
- thumb on child
- middle finger under chin to control opening/closing of jaw
- index finger on side of child’s face
sequence of swallowing
food into mouth –> forms bolus –> bolus pushed to back of mouth with tongue –> larynx elevates/protracts –> bolus into pharynx –> into esophagus
