Dysphagia – Follow The Swallow

Barbara Kamm Miller, M.A. CCC-SLP, CBIS

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What is Dysphagia?

Dysphagia is the term used to describe a disorder of swallowing.

What are some causes of Dysphagia?

Dysphagia may be caused by Acquired or Traumatic Brain Injury, neurological deficits, cancer, MS, ALS, Parkinson’s Disease etc.

What else can cause Dysphagia?In addition, secondary complications

such as anoxia, pneumonia, intra-cranial pressure, seizures, lesions from intubation may all contribute to Dysphagia.

What are the four stages of swallowing?

The four stages of swallowing are:1. Oral preparatory- the act of taking food,

chewing it, mixing it with saliva, and forming it into a bolus.

2. Oral- controlling the bolus and transporting it to the back of the mouth.

3. Pharyngeal- initiating the swallow reflex in a timely manner which is normally 1 second.

4. Esophageal- the food enters the esophagus, the passageway to the stomach.

View of Normal Swallow

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What are the symptoms of Dysphagia?

The following symptoms may be observed:Coughing / choking while eating or drinkingCoughing after swallowingChokingUncoordinated chewing or swallowingLeakage of food or liquid from the mouthLeakage of liquid from the noseReddening of the face

Symptoms continued

Pocketing of food in the cheekLabored or effortful swallowingGurgling or wet vocal qualityComplaints of food sticking in the throatFacial grimacing

Impulsive eating or drinking behavior is a red flag.

How does a Speech/Language Pathologist prepare for an assessment?1. Interview the patient2. Check the patient’s chart for the

admitting diagnosis.3. Check nursing notes, look for

indications of coughing or choking4. Check the patient’s level of

alertness.

Assessment cont.

5. Check the chart for additional diagnoses which may put the patient at risk for dysphagia.

6. Review previous treatments listed.7. Obtain the patient’s pre-morbid

status.

Assessment cont.

9. Review the patient’s nutrition and hydration status

10. Check the patient’s current diet.11. Note any dietary restrictions12. Note any special diets the patient

may be following, such as an ADA diet for diabetes, or an American Heart Association diet

Assessments continuedIs the patient on an alternate method of

feeding, such as an IV, NG tube, or a PEG tube?

Other factors to consider are:What medications is the patient taking?Do any of the medications enhance, or

hamper swallowing?How are medications presented- are they

by mouth, and if so are they taken whole ?

Assessments continued

How is the patients respiratory status? Notes from

Respiratory Therapy, or results of chest x-rays must be reviewed.

Is the patient on oxygen?Is the patient, or has the patient been

recently intubated?

Assessments continued

Check nursing notes to get information regarding

the patient’s usual living situation, cognitive status etc.

Last, but certainly not least, check for other GI examinations, such as a barium swallow, which examines the esophagus, or a GI series.

Clinical Swallow EvaluationsInitially, an oro-motor examination of the

jaw, lips and tongue will be performed. Any deviations or weaknesses will be noted.

This may be followed by a 3 oz. water swallow test, whereby the patient is given 3 oz. of water in a cup, and told to drink it all without stopping. An abnormal response would be coughing during or after the exam, or a change in vocal quality, to wet or hoarse.

Blue Dye Test

If the patient is on a trach, and suctioned, then the presence of the blue dye would indicate aspiration (leakage into the airway or lungs).

This test would be appropriate in an acute hospital setting.

Modified Barium Swallow - MBS

A Modified barium swallow is performed by a Radiologist, a Speech-language Pathologist, and a radiology technician.

Barium sulfate powder is mixed in liquid form.

Thickener is added to make liquids nectar, honey or puree consistency.

MBS continued

Barium paste is used, and spread on cookies.

The test is done in 2 views, Lateral (side), and AP

Anterior-Posterior.

MBS continued

Thin liquids are first presented in small amounts, 3 cc, 5 cc, 10 cc, and then progressed to uncontrolled amounts.

Liquids are presented from a cup, and through a straw.

MBS continued

As soon as the patient exhibits difficulties, compensatory techniques are attempted.

Techniques may be as simple as:adjusting or changing posture, changing texture, a chin tuck for airway protection, or a supraglottic swallow, which will be

explained shortly.

MBS continued

The MBS also allows screening for the esophageal

phase of the swallow. Any abnormalities will be noted, and recommendations for follow up with a specialist will be provided.

MBS continued

All testing is recorded on DVD, and available for review at a later time.

By the time the patient is finished with the MBS, he / she should know what the safest and least restrictive diet is, and which compensatory strategies should be used in order to avoid aspiration.

Video of MBS

Normalhttp://www.youtube.com/watch?v=PwVreNrTKBwAbnormalhttp://www.youtube.com/watch?v=huZ6ymeKFd4

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Fiberoptic endoscopic Evaluation of Swallowing FEESThe FEES was developed in 1991 by Dr.

Susan Langmore. There are two parts to the examination. A flexible endoscope is passed

through the nasal passage, into the pharynxThe first part of the procedure involves

examining the structures, and function of the larynx and pharynx. This also allows the examiner to determine how secretions are being managed.

FEES continued

During the second part of the exam, swallowing function with different sizes and consistency of liquid and solid boluses is assessed.

When a problem is detected, boluses may be thickened, or postures may be altered, in order to see if the problem is minimized, or eliminated.

Comparison of MBS and FEES

FEES is more often utilized in long term care facilities, as it can be performed at the bedside,

MBS is performed in a hospital or outpatient setting.

MBS exposes the patient to radiation, FEES doesn’t.

FEES is more invasive, due to the endoscope.

What’s Next?

Once the results of the examinations are received, the patient will be placed on the safest and least restrictive diet.

Dietary Levels

The National Dysphagia Diet by the American Dietetic Association has several levels that a patient may progress through.

Level 1

Level 1 consists of pureed and cohesive foods with smooth textures.

Examples include: pureed meats, pureed vegetables, pureed / strained soups, mashed potatoes, Cream of Wheat etc.

Level 2

Level 2 consists of mechanically altered foods, which are soft and moistened.

Examples include: baked fish, cottage cheese, macaroni and cheese, pureed meats, vegetable soufflé, cheesecake without crust

Level 3

Level 3 consists of foods which are near normal in texture, cut into bite sized pieces.

Recommended foods include: ground meat, tuna salad, cottage cheese, sliced cheese, pancakes, waffles, all types of potatoes, cream pies etc.

Level 4

Level 4 is a regular consistency diet, with most foods included.

Liquids

Liquid recommendations may be :Thin – no thickener needed. Thin

liquids include broth, water, tea, coffee, fruit juice, jello, ice cream , milk, and popsicles.

Thickened Liquids

Nectar like- liquids naturally this consistency would include;

V-8 juice, milkshakes, egg nog, fruit nectars etc.

Honey like

Honey like consistency will be achieved by adding the appropriate amount of thickener to a liquid.

Instructions are printed on the label of the thickener canister.

Spoon Thick

Spoon thick liquids will be pudding like. This will be achieved, by adding the proper amount of thickener to any liquid, hot or cold.

Thickeners

Thickeners are available commercially, in canisters or packets. Thickeners may be obtained via prescription, or over the counter.

There are some pre-thickened liquids available for purchase.

Thickener alters the texture, but not the taste of the liquid.

Compensatory Strategies

In addition to tailoring a diet to the patient’s current needs, compensatory strategies may be implemented to optimize safety.

Examples of compensatory strategies1. Head turn to the weaker side- to close

it off, and prevent a bolus from traveling down the weaker side by twisting the pharynx.

Turn your head to the side as though you are looking over your shoulder.

2. Chin tuck for airway protection, and to force the bolus into the esophagus.

Strategies Continued

Bring your chin to your chest.

3.Head tilt to the stronger side, directs the bolus to the stronger side of the oral / pharyngeal cavities.

Tilt your head like you are trying to touch your ear to your shoulder.

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Strategies continued

4. Head back will allow gravity to clear the oral cavity for patients with an oral transit dysfunction.

Tilt your head back like you are looking up.

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Develop a Swallow GuideA Swallow Guide is an invaluable tool.

It contains written and pictorial instructions. Positioning, diet level, rate and method of feeding, and all specifics are clearly outlined. It also contains reminders for use of any assistive devices such as eyeglasses, hearing aids, and dentures, as well as Reflux Precautions to be followed.

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Therapeutic Interventions

The Speech-language Pathologist may implement a therapy program designed to strengthen the swallowing mechanism.

Therapeutic interventions continued

Therapy will focus on strengthening the weakest areas. Recommended exercises may be:

Oro –motor exercises – to strengthen the tongue, lips, cheeks and jaw.

Falsetto/pitch exercises- pitch glides for airway protection.

Therpeutic Interventions continued

3.Head lift maneuver- to improve forward movement of the larynx.

4.Masako tongue hold- to strengthen the base of the tongue

5.Mendelsohn maneuver- to keep the larynx at its highest point to reduce food from falling into the airway.

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Therapeutic Interventions continued6. Head / neck stretch7. Supraglottic Swallow – to keep the

voice box closed to keep food or liquid from entering the lungs.

8. Effortful Swallow – strengthens the base of the tongue.

9. Gargle- also strengthens the base of the tongue.

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1.Sour bolus- presenting a lemon swab for sucking on, or lemon ice in small amounts.

2.Cold bolus – alternating very cold bites or sips of food / liquid

3.Thermal stimulation- using a chilled 00 mirror to stimulate various parts of the oral cavity.

Additional Techniques To Stimulate The Swallow

Thermal Stimulation

http://www.youtube.com/watch?v=wRAPHIqL3z0

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Patient and Caregiver Education

Patients and caregivers should be provided with clear instructions regarding all precautions, strategies and interventions utilized to keep the patient safe from aspiration.

As previously mentioned, written Swallow Guides are helpful for consistently adhering to the recommended diet and strategies.

Conclusion

In conclusion, Dysphagia can be managed effectively if you follow the swallow in all of it’s stages, and utilize recommended strategies and therapeutic techniques to minimize the risk of aspiration.

Thank You

Thank you so much for attending today’s Webinar.

Please feel free to e mail me at barbara.miller@bancroft.org should you have any questions.

References

Source For Dysphagia, Nancy B. Swigert, third edition 2007

Swallowing In TBI, calder.med.eduAmerican Speech-Language Hearing

Association, Preferred Practice Patterns for the Profession of Speech-Language Pathology