Unit Ten Dysphagia Copyright 2008 Delmar All rights

Chapter 40 Normal Swallow Function and Dysphagia Copyright © 2008 Delmar. All rights reserved.

Dysphagia • Difficulty swallowing that occurs when impairments affect any of the four phases

Dysphagia • Team approach is required: – – – SLP Dentist Dietician, PT, RT,

Four Phases of the Normal Swallow • • Oral preparatory phase Oral phase Pharyngeal

Oral Preparatory Phase • Thinking about food/liquid and how to get it to the

Oral Phase • Begins when chewing stops • Tongue pulls the food to the

Pharyngeal Phase • Bolus contacts anterior faucial pillars and initiates the swallow response •

Esophageal Phase • Bolus carried to lower esophageal sphincter to enter stomach 9 Copyright

Oral Preparatory Phase Problems • • Decreased awareness of food Difficulty holding food in

Oral Phase Problems • Anterior spillage • Premature spillage into airway • Difficulty moving

Pharyngeal Phase Problems • Delayed swallow response • Impaired coordination of oral and pharyngeal

Esophageal Phase Problems • Upper esophageal sphincter does not open • Slow or absent

Penetration and Aspiration • Penetration – Material enters larynx and remains above the vocal

Aspiration Pneumonia • Acute inflammation caused by material entering the lungs through the airway

Chapter 41 Diagnosis of Dysphagia Copyright © 2008 Delmar. All rights reserved.

Evaluation of Adults • Review medical chart • Screen patient – Behavioral observations –

Bedside Evaluation • Evaluate all speech systems • Patient drinks and eats selected consistencies

Modified Barium Swallow Study • “Gold standard” of instrumental assessment • A dynamic imagining

Fiberoptic Endoscopic Evaluation of Swallowing (FEES) • Provides information about pharyngeal phase • Endoscope

Ultrasound Imaging • Noninvasive imaging that uses sound waves to view the oral and

Evaluating Infants and Children • • • Review medical chart Assess postural control and

Chapter 42 Treatment of Dysphagia Copyright © 2008 Delmar. All rights reserved.

Feeding Environment • Environment for eating will affect the experience with meals • SLPs

Textures and Consistencies of Food and Liquid • Foods • Regular • Dysphagia advanced

Postural Techniques • Chin-tuck (down) • Head rotation • Head tilt 26 Copyright ©

Oral-Motor Exercises • Can help increase muscle tone and strength 27 Copyright © 2008

Swallow Maneuvers • Used for the pharyngeal phase: – Double or dry swallow –

NPO – Nothing by Mouth • Patients who cannot eat orally receive nutrition through

Goals of Treating Infants and Children • Promote adequate nutrition and hydration • Develop

General Areas of Management for Children • • • Establish optimal feeding readiness Organize

General Areas of Management for Children • • • Develop oral stimulation program Reduce

Chapter 43 Emotional and Social Effects of Dysphagia Copyright © 2008 Delmar. All rights

Emotional and Social Effects • Eating is a a social event • Diet modifications

Emotional and Social Effects • • • Anxiety Depression Grief Embarrassment Sense of loss

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Pharyngeal Phase • Bolus contacts anterior faucial pillars and initiates the swallow response • Soft palate rises • Peristalsis moves the bolus down • Vocal folds close tightly • Esophageal sphincter pulled open 8 Copyright © 2008 Delmar. All rights reserved.

Oral Preparatory Phase Problems • • Decreased awareness of food Difficulty holding food in mouth Pocketing food in cheeks Premature spillage of food into airway 10 Copyright © 2008 Delmar. All rights reserved.

Pharyngeal Phase Problems • Delayed swallow response • Impaired coordination of oral and pharyngeal structures • Weak elevation of velum • Inadequate closure of vocal folds 12 Copyright © 2008 Delmar. All rights reserved.

Penetration and Aspiration • Penetration – Material enters larynx and remains above the vocal folds • Aspiration – Material goes below level of the vocal folds 14 Copyright © 2008 Delmar. All rights reserved.

Aspiration Pneumonia • Acute inflammation caused by material entering the lungs through the airway • Symptoms include spiked temperatures, myalgia, and productive cough 15 Copyright © 2008 Delmar. All rights reserved.

Bedside Evaluation • Evaluate all speech systems • Patient drinks and eats selected consistencies of liquids and food • Monitor for signs of aspiration – Coughing, wet voice quality 18 Copyright © 2008 Delmar. All rights reserved.

Modified Barium Swallow Study • “Gold standard” of instrumental assessment • A dynamic imagining of the bolus from entering the mouth to entering the stomach 19 Copyright © 2008 Delmar. All rights reserved.

Fiberoptic Endoscopic Evaluation of Swallowing (FEES) • Provides information about pharyngeal phase • Endoscope is passed through nose into nasopharynx • Laryngopharynx can be viewed while patient eats 20 Copyright © 2008 Delmar. All rights reserved.

Evaluating Infants and Children • • • Review medical chart Assess postural control and muscle tone Note respiratory function/endurance Evaluate oral structures Complete feeding/swallowing evaluation Instrumental assessment 22 Copyright © 2008 Delmar. All rights reserved.

Feeding Environment • Environment for eating will affect the experience with meals • SLPs can be limited in modifying many aspects of the hospital environment and its distractions 24 Copyright © 2008 Delmar. All rights reserved.

Textures and Consistencies of Food and Liquid • Foods • Regular • Dysphagia advanced • Dysphagia mechanical soft • Dysphagia pureed • • • Liquid Thin Nectar-like Honey-like Spoon-thick 25 Copyright © 2008 Delmar. All rights reserved.

Swallow Maneuvers • Used for the pharyngeal phase: – Double or dry swallow – Effortful or hard swallow – Supraglottic swallow – Mendelsohn maneuver – Thermal/tactile stimulation 28 Copyright © 2008 Delmar. All rights reserved.

NPO – Nothing by Mouth • Patients who cannot eat orally receive nutrition through entereal feeding: – Nasogastric (NG) tube – Gastrostomy tube (G-tube) – Percutaneous endoscopic gastrostomy (PEG) tube 29 Copyright © 2008 Delmar. All rights reserved.

General Areas of Management for Children • • • Establish optimal feeding readiness Organize oral feeding Establish nonnutritive suck Establish external pacing Establish optimal position 31 Copyright © 2008 Delmar. All rights reserved.

General Areas of Management for Children • • • Develop oral stimulation program Reduce oral aversion Alter consistency, taste, temperature Develop chewing skills Choose feeding utensils 32 Copyright © 2008 Delmar. All rights reserved.