Dysphagia

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Dysphagia Follow The Swallow Barbara Kamm
Miller, M.A. CCC-SLP, CBIS
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Our Mission
Bancroft provides opportunities to children and
adults with diverse challenges to maximize their
potential.
A community where every individual has a voice, a
purpose and a rightful place in society. 
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What is Dysphagia? Dysphagia is the term used to
describe a disorder of swallowing.
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What are some causes of Dysphagia?

• Dysphagia may be caused by Acquired or Traumatic
  Brain Injury, neurological deficits, cancer, MS,
  ALS, Parkinsons Disease etc.

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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.

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What are the four stages of swallowing?

• The four stages of swallowing are
• Oral preparatory- the act of taking food, chewing
  it, mixing it with saliva, and forming it into a
  bolus.
• Oral- controlling the bolus and transporting it
  to the back of the mouth.
• Pharyngeal- initiating the swallow reflex in a
  timely manner which is normally 1 second.
• Esophageal- the food enters the esophagus, the
  passageway to the stomach.

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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 drinking
• Coughing after swallowing
• Choking
• Uncoordinated chewing or swallowing
• Leakage of food or liquid from the mouth
• Leakage of liquid from the nose
• Reddening of the face

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Symptoms continued

• Pocketing of food in the cheek
• Labored or effortful swallowing
• Gurgling or wet vocal quality
• Complaints of food sticking in the throat
• Facial grimacing
• Impulsive eating or drinking behavior is a red
  flag.

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How does a Speech/Language Pathologist prepare
for an assessment?

1. Interview the patient
2. Check the patients chart for the admitting
   diagnosis.
3. Check nursing notes, look for indications of
   coughing or choking
4. Check the patients level of alertness.

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Assessment cont.

1. Check the chart for additional diagnoses which
   may put the patient at risk for dysphagia.
2. Review previous treatments listed.
3. Obtain the patients pre-morbid status.

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Assessment cont.

• Review the patients nutrition and hydration
  status
• Check the patients current diet.
• Note any dietary restrictions
• Note any special diets the patient may be
  following, such as an ADA diet for diabetes, or
  an American Heart Association diet

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Assessments continued

• Is 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 ?

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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?

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Assessments continued

• Check nursing notes to get information regarding
• the patients 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.

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Clinical Swallow Evaluations

• Initially, 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.

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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.

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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.

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MBS continued

• Barium paste is used, and spread on cookies.
• The test is done in 2 views, Lateral (side), and
  AP
• Anterior-Posterior.

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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.

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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.

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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.

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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.

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Video of MBS

• Normal
• http//www.youtube.com/watch?vPwVreNrTKBw
• Abnormal
• http//www.youtube.com/watch?vhuZ6ymeKFd4

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Fiberoptic endoscopic Evaluation of Swallowing
FEES

• The 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 pharynx
• The 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.

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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.

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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
  doesnt.
• FEES is more invasive, due to the endoscope.

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Whats Next?

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

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Dietary Levels

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

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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.

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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

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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.

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Level 4

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

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Liquids

• Liquid recommendations may be
• Thin no thickener needed. Thin liquids include
  broth, water, tea, coffee, fruit juice, jello,
  ice cream , milk, and popsicles.

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Thickened Liquids

• Nectar like- liquids naturally this consistency
  would include
• V-8 juice, milkshakes, egg nog, fruit nectars etc.

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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.

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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.

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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.

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Compensatory Strategies

• In addition to tailoring a diet to the patients
  current needs, compensatory strategies may be
  implemented to optimize safety.

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Examples of compensatory strategies

• 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.

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Strategies Continued

• Bring your chin to your chest.
• 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

• 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 Guide

• A 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.

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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.

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Therpeutic Interventions continued

• Head lift maneuver- to improve forward movement
  of the larynx.
• Masako tongue hold- to strengthen the base of the
  tongue
• Mendelsohn maneuver- to keep the larynx at its
  highest point to reduce food from falling into
  the airway.

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Therapeutic Interventions continued

1. Head / neck stretch
2. Supraglottic Swallow to keep the voice box
   closed to keep food or liquid from entering the
   lungs.
3. Effortful Swallow strengthens the base of the
   tongue.
4. Gargle- also strengthens the base of the tongue.

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Additional Techniques To Stimulate The Swallow

• Sour bolus- presenting a lemon swab for sucking
  on, or lemon ice in small amounts.
• Cold bolus alternating very cold bites or sips
  of food / liquid
• Thermal stimulation- using a chilled 00 mirror to
  stimulate various parts of the oral cavity.

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Thermal Stimulation

• http//www.youtube.com/watch?vwRAPHIqL3z0

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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.

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Conclusion

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

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Thank You

• Thank you so much for attending todays Webinar.
• Please feel free to e mail me at
  barbara.miller_at_bancroft.org should you have any
  questions.

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References

• Source For Dysphagia, Nancy B. Swigert, third
  edition 2007
• Swallowing In TBI, calder.med.edu
• American Speech-Language Hearing Association,
  Preferred Practice Patterns for the Profession of
  Speech-Language Pathology