copyright © 2008 delmar. all rights reserved. unit ten dysphagia
TRANSCRIPT
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Dysphagia
• Difficulty swallowing that occurs when impairments affect any of the four phases of swallowing that puts a person at risk for aspiration
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Dysphagia
• Team approach is required: – SLP– Dentist– Dietician, PT, RT, OT, ENT– Neurologist– Gastroenterologist– Pharmacist
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Four Phases of the Normal Swallow
• Oral preparatory phase
• Oral phase
• Pharyngeal phase
• Esophageal phase
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Oral Preparatory Phase
• Thinking about food/liquid and how to get it to the mouth
• Chewing the food in our mouth
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Oral Phase
• Begins when chewing stops
• Tongue pulls the food to the back of the mouth
• Takes one second
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Pharyngeal Phase
• Bolus contacts anterior faucial pillars and initiates the swallow response
• Soft palate rises
• Peristalsis moves the bolus down
• Vocal folds close tightly
• Esophageal sphincter pulled open
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Esophageal Phase
• Bolus carried to lower esophageal sphincter to enter stomach
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Oral Preparatory Phase Problems
• Decreased awareness of food
• Difficulty holding food in mouth
• Pocketing food in cheeks
• Premature spillage of food into airway
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Oral Phase Problems
• Anterior spillage
• Premature spillage into airway
• Difficulty moving bolus back towards pharynx
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Pharyngeal Phase Problems
• Delayed swallow response
• Impaired coordination of oral and pharyngeal structures
• Weak elevation of velum
• Inadequate closure of vocal folds
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Esophageal Phase Problems
• Upper esophageal sphincter does not open
• Slow or absent esophageal peristalsis
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Penetration and Aspiration
• Penetration – Material enters larynx and remains above
the vocal folds
• Aspiration – Material goes below level of the vocal folds
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Aspiration Pneumonia
• Acute inflammation caused by material entering the lungs through the airway
• Symptoms include spiked temperatures, myalgia, and productive cough
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Evaluation of Adults
• Review medical chart
• Screen patient– Behavioral observations– Interview– Check for protective cough
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Bedside Evaluation
• Evaluate all speech systems
• Patient drinks and eats selected consistencies of liquids and food
• Monitor for signs of aspiration– Coughing, wet voice quality
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Modified Barium Swallow Study
• “Gold standard” of instrumental assessment
• A dynamic imagining of the bolus from entering the mouth to entering the stomach
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Fiberoptic Endoscopic Evaluation of Swallowing (FEES)• Provides information about pharyngeal
phase
• Endoscope is passed through nose into nasopharynx
• Laryngopharynx can be viewed while patient eats
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Ultrasound Imaging
• Noninvasive imaging that uses sound waves to view the oral and laryngeal structures
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Evaluating Infants and Children
• Review medical chart
• Assess postural control and muscle tone
• Note respiratory function/endurance
• Evaluate oral structures
• Complete feeding/swallowing evaluation
• Instrumental assessment
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Feeding Environment
• Environment for eating will affect the experience with meals
• SLPs can be limited in modifying many aspects of the hospital environment and its distractions
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Textures and Consistencies of Food and Liquid
• Foods• Regular• Dysphagia -
advanced• Dysphagia -
mechanical soft• Dysphagia pureed
• Liquid• Thin• Nectar-like• Honey-like• Spoon-thick
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Postural Techniques
• Chin-tuck (down)
• Head rotation
• Head tilt
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Oral-Motor Exercises
• Can help increase muscle tone and strength
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Swallow Maneuvers
• Used for the pharyngeal phase:– Double or dry swallow– Effortful or hard swallow– Supraglottic swallow– Mendelsohn maneuver– Thermal/tactile stimulation
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NPO – Nothing by Mouth• Patients who cannot eat orally receive
nutrition through entereal feeding:– Nasogastric (NG) tube – Gastrostomy tube (G-tube)– Percutaneous endoscopic gastrostomy
(PEG) tube
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Goals of Treating Infants and Children
• Promote adequate nutrition and hydration
• Develop age-appropriate feeding skills
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General Areas of Management for Children
• Establish optimal feeding readiness
• Organize oral feeding
• Establish nonnutritive suck
• Establish external pacing
• Establish optimal position
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General Areas of Management for Children
• Develop oral stimulation program
• Reduce oral aversion
• Alter consistency, taste, temperature
• Develop chewing skills
• Choose feeding utensils
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Emotional and Social Effects
• Eating is a a social event
• Diet modifications can reduce enjoyment of eating and affect quality of life