Presentation on theme: "Dysphagia – Follow The Swallow"— Presentation transcript:
1Dysphagia – Follow The Swallow Barbara Kamm Miller, M.A. CCC-SLP, CBIS
2Our MissionBancroft provides opportunities to children and adults with diverse challenges to maximize their potential.Our VisionA community where every individual has a voice, a purpose and a rightful place in society. Our Core ValuesResponsible Empathetic Supportive Passionate Empowered Committed TrustworthyR E S P E C T
3What is Dysphagia?Dysphagia is the term used to describe a disorder of swallowing.
4What are some causes of Dysphagia? Dysphagia may be caused by Acquired or Traumatic Brain Injury, neurological deficits, cancer, MS, ALS, Parkinson’s Disease etc.
5What else can cause Dysphagia? In addition, secondary complications such as anoxia, pneumonia, intra-cranial pressure, seizures, lesions from intubation may all contribute to Dysphagia.
6What 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.
8What 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
9Symptoms continued Pocketing of food in the cheek Labored or effortful swallowingGurgling or wet vocal qualityComplaints of food sticking in the throatFacial grimacingImpulsive eating or drinking behavior is a red flag.
10How does a Speech/Language Pathologist prepare for an assessment? Interview the patientCheck the patient’s chart for the admitting diagnosis.Check nursing notes, look for indications of coughing or chokingCheck the patient’s level of alertness.
11Assessment cont.Check the chart for additional diagnoses which may put the patient at risk for dysphagia.Review previous treatments listed.Obtain the patient’s pre-morbid status.
12Assessment cont. Review the patient’s nutrition and hydration status Check the patient’s current diet.Note any dietary restrictionsNote any special diets the patient may be following, such as an ADA diet for diabetes, or an American Heart Association diet
13Assessments 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 ?
14Assessments continued How is the patients respiratory status? Notes fromRespiratory 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?
15Assessments continued Check nursing notes to get information regardingthe 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.
16Clinical 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.
17Blue Dye TestIf 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.
18Modified 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.
19MBS continued Barium paste is used, and spread on cookies. The test is done in 2 views, Lateral (side), and APAnterior-Posterior.
20MBS continuedThin 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.
21MBS continuedAs 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.
22MBS 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.
23MBS continuedAll 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.
25Fiberoptic 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 passedthrough 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.
26FEES continuedDuring 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.
27Comparison 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.
28What’s Next?Once the results of the examinations are received, the patient will be placed on the safest and least restrictive diet.
29Dietary LevelsThe National Dysphagia Diet by the American Dietetic Association has several levels that a patient may progress through.
30Level 1Level 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.
31Level 2Level 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
32Level 3Level 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.
33Level 4Level 4 is a regular consistency diet, with most foods included.
34Liquids Liquid recommendations may be : Thin – no thickener needed. Thin liquids include broth, water, tea, coffee, fruit juice, jello, ice cream , milk, and popsicles.
35Thickened LiquidsNectar like- liquids naturally this consistency would include;V-8 juice, milkshakes, egg nog, fruit nectars etc.
36Honey likeHoney 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.
37Spoon ThickSpoon thick liquids will be pudding like. This will be achieved, by adding the proper amount of thickener to any liquid, hot or cold.
38ThickenersThickeners 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.
39Compensatory Strategies In addition to tailoring a diet to the patient’s current needs, compensatory strategies may be implemented to optimize safety.
40Examples 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.
41Strategies 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.
42Strategies continuedHead 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.
43Develop 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.
45Therapeutic Interventions The Speech-language Pathologist may implement a therapy program designed to strengthen the swallowing mechanism.
46Therapeutic 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.
47Therpeutic Interventions continued Head lift maneuver- to improve forward movement of the larynx.Masako tongue hold- to strengthen the base of the tongueMendelsohn maneuver- to keep the larynx at its highest point to reduce food from falling into the airway.
48Therapeutic Interventions continued Head / neck stretchSupraglottic Swallow – to keep the voice box closed to keep food or liquid from entering the lungs.Effortful Swallow – strengthens the base of the tongue.Gargle- also strengthens the base of the tongue.
49Additional 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 / liquidThermal stimulation- using a chilled 00 mirror to stimulate various parts of the oral cavity.
51Patient 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.
52ConclusionIn 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.
53Thank You Thank you so much for attending today’s Webinar. Please feel free to e mail me at should you have any questions.
54References 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