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: 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.

View of Normal Swallow

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

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.

How does a Speech/Language Pathologist prepare for an assessment? Interview the patient Check the patient’s chart for the admitting diagnosis. Check nursing notes, look for indications of coughing or choking Check the patient’s level of alertness.

Assessment 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.

Assessment cont. Review the patient’s nutrition and hydration status Check the patient’s 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

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 ?

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 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.

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 Normal http://www.youtube.com/watch?v=PwVreNrTKBw Abnormal http://www.youtube.com/watch?v=huZ6ymeKFd4

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.

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 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.

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.

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.

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.

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 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.

Therapeutic Interventions continued Head / neck stretch Supraglottic 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.

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.

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

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.edu American Speech-Language Hearing Association, Preferred Practice Patterns for the Profession of Speech-Language Pathology