1. Dysphagia & Aspiration Pneumonia
The Center for Life Enrichment
Resource: MTTP Student Manual
Dysphagia & Aspiration Pneumonia

2. What is Dysphagia?
Dysphagia is a condition of having difficulty swallowing
Dysphagia is due to problems or damage in nerve or muscle control in the throat
It is common after a stroke or in individuals with cerebral palsy

3. Why does dysphagia occur?
Dysphagia occurs when there is a problem with any part of the swallowing process
Weak tongue or cheek muscles may make it hard to move food around in the mouth for chewing. As a result, food pieces that are too large for swallowing may enter the throat and block the passage of air

4. How are people affected?
People with dysphagia have difficulty swallowing and may also experience pain while swallowing
Some people may be completely unable to swallow or may have trouble swallowing liquids, foods, or saliva
Eating may become a challenge
Often, dysphagia makes it difficult to take in enough calories and fluids to nourish the body

5. The Process of Swallowing
The process of swallowing involves the interaction of more than 20 muscles and several nerves
The entire process is completed in several seconds

6. The Normal Phases of Swallowing: Stage 1
Oral Phase- Food is placed in the mouth, chewed and turned into a bolus (lump of chewed food mixed with saliva)
The bolus is moved toward the throat by the tongue

7. The Normal Phases of Swallowing: Stage 2
Pharyngeal Phase- Food is moved by wave-like muscle action down the throat to the esophagus (tube to the stomach)
During this process, the epiglottis closes to protect the trachea (breathing tube)
Next the food enters the esophagus (tube to stomach)
If the epiglottis doesn’t close properly, the bolus may enter the trachea and go into the lungs causing aspiration
If there is abnormal muscle movement then the food bolus can become stuck causing a blockage/choking

8. The Normal Phases of Swallowing: Stage 3
Esophageal Phase- Food is moved by wave-like muscle movement through a muscle ring into the stomach
Normally, the food enters and stays in the stomach where the digestive process continues
If the muscle ring does not function properly, stomach contents may go back up (reflux) into the esophagus
This is associated with heartburn or indigestion and is called Gastro-Esophageal Reflux Disease (GERD)

9. What the individual might complain about/What to look for?
There are identified “red flag indicators” that should be watched for during meals. Some of these include, but are not limited to:
Pocketing food under the tongue, in cheeks or the roof of mouth
Food remaining on the roof of the mouth or on tongue after swallowing
Food spilling out of the mouth
Diagnosis of stroke, cerebral palsy, GERD
Taking fluids to drink to facilitate swallowing without chewing properly
Putting food in the mouth before swallowing the previous bite

10. More “Red Flag Indicators”
Not chewing food adequately
Tongue thrusting noted
Coughing noted while chewing, when swallowing or after swallowing
Regurgitating food or liquids from nose or mouth
Eating quickly
Eating very slowly
Spitting food out of mouth
Talking with food in mouth
Stealing food
Food stuffing
PICA behavior (persistent and compulsive cravings to eat nonfood items)
Excessive drooling
Choking
Throat clearing during meals or fluids
“Wet” vocal sounds (gurgling)
Multiple swallows of the same mouthful of food
Gagging/retching
Putting hands in mouth or forcing self to vomit
Weight loss
Complaining that food feels “stuck”
Refusing to eat

11. How is dysphagia diagnosed?
Individuals with dysphagia or choking issues may self identify their signs/symptoms or family or staff may identify signs/symptoms
A Choking Monitoring Tool has been developed by DDA and the following protocol should be followed in this order:
Staff notices a “red flag indicator” of choking as listed on the previous slides
Staff reports to the RN that a “red flag indicator” was observed
RN instructs the staff to complete the Choking Monitoring Tool
Staff completes the Tool as instructed by the RN and returns info to the RN or the RN completes the tool
RN evaluates the completed Tool and determines if further intervention is needed by the individual’s HCP

12. The Choking Monitoring Tool
Based on the information provided on the Choking Monitoring Tool, the HCP may recommend texture alterations in the diet or that the individual undergo a Swallowing Study where the mechanics of the swallowing process can be observed and aspiration determined
If aspiration is an issue, then a G or J tube may be recommended
In addition to the Choking Monitoring Tool, the RN may complete a “Choking Risk Screening Tool”

13. What is the treatment?
The HCP may order an alteration in diet consistency to address eating difficulties
Puree- Blended
Ground- Minced
Chopped- Mechanical Soft
Bite Size
Regular

14. Puree- Blended Description- smooth with no lumps, pudding like
Consistency- smooth and thick enough to mound on a plate
May need to add extra liquid when preparing

15. Ground- Minced Description- foods are moist and soft textures
Food processed to the size of rice or taco meat
May add some liquid or condiment to help mix

16. Chopped- Mechanical Soft
Description- meats chopped ½ inch in size, other foods soft
Meat cut into ½ inch pieces, fruits, and veggies chopped into fruit cocktail-size pieces
Sandwich cut into 8 pieces or more- use soft breads and fillings

17. Bite Size & Regular Bite Size
Description- all foods cut or broken into 1 inch pieces
Regular
No preparation needed

18. Liquids
Liquids can be very difficult for an individual with a swallowing disorder to handle safely
Liquids can be thickened to facilitate safe swallowing
The HCP may order thickened liquids in the following manner:
Nectar Consistency
Honey Consistency
Pudding Consistency
Thin Consistency

19. Nectar Consistency
Description- able to go through straw, glides off spoon
Examples- fruit nectars, shakes, eggnogs, smoothie

20. Honey Consistency
Description- will not go through a straw, flows slowly off a spoon
Examples- honey, karo syrup, molasses

21. Pudding Consistency Description- needs to be fed with a spoon
Examples- pudding, yogurt

22. Thin Consistency Description- no preparation needed
Examples- water, tea, coffee, thin juices, soda

23. Warning!
Individuals who have been ordered thickened liquids should not be given foods that become liquid at room temperature. For example, gelatin, ice cream, sherbet, water ices, smoothies, shakes
Follow directions on thickener packaging to achieve consistency as ordered
Liquids given with medication must also be thickened as ordered
The consistency of thickened liquids changes over time (continues to thicken)

24. Your Responsibility
Always be alert and observant while individuals are eating
Choking Monitoring Tool should be completed when “red flag indicators” are noted
Report any problems to the RN as soon as possible!

25. Check out: Normal vs. Abnormal Swallowing
Swallow: A Documentary - Dysphagia
Normal vs. Abnormal Swallowing

26. Part 2
Aspiration Pneumonia

27. Aspiration Pneumonia
Aspiration of foreign material into the lungs may develop into pneumonia
Aspiration occurs when the body’s normal defense against aspiration are breached
For example, when the muscles used in normal swallowing do not function properly, material from the mouth can enter the trachea and lungs rather than the esophagus and stomach

28. Individuals at Risk for Aspiration include, but are not limited to:
Those with…
Impairment of consciousness
Seizure Disorder
Impairment of esophageal function (including Hiatal Hernia, GERD)
Impairment of swallowing mechanism (including cerebral palsy)
Impairment of cough mechanism (including neuromuscular weakness, cerebral palsy)
Oral/dental/sinus infections

29. What the individual might complain about/What to look for?
The individual may have experienced a one-time episode of aspiration or may experience on-going subtle aspiration
These experiences may or may not be identified or witnessed
The individual may present with shortness of breath, low blood oxygen levels, low blood pressure, fever, and chest x-ray changes

30. How is it diagnosed?
Aspiration pneumonia is usually diagnosed by clinical presentation and x-ray findings
Failure of a swallowing study supports the diagnosis of aspiration pneumonia

31. What is the treatment?
The individual may be hospitalized for treatment of aspiration pneumonia
Treatment may include suctioning and intubation (the insertion of a tube into the patient's airway) to protect the airway from further aspiration
Supplemental oxygen may be needed
Antibiotic therapy is required

32. Your Responsibility
If you identify “red flag indicators” for choking as described in the previous slides, the RN should be notified immediately
Any symptoms of respiratory distress should be reported to the RN immediately

33. Questions?