DYSPHAGIA MANAGEMENT A Collaborative Plan for Successful Interventions Joseph L. Garcia, MS-CCC/SLP

STAGE ONE – THE ORAL PREP STAGE Begins as soon as food or liquid reaches the lips. Labial and lingual structures, existing dentition, and intraoral musculature are all working in unison to have a bolus prepared for a safe and timely swallow. Timely oral preparation of solids and liquids maintains the oral bolus from leaking out of the oral structure and allows it to remain intraorally until it is ready for a safe esophageal transfer.

Signs and Symptoms of Oral Preparatory Dysfunction: Perseverative mastication Heightened or diminished pace of self feeding Expectoration of solids/liquids Coughing and choking Texture avoidance Protein malnutrition and failure to thrive Weight loss Drooling with or without meal items Xerostomia Oral stuffing or oral hoarding

WHAT CAN BE DONE FOR ORAL PREP DYSFUNCTION: Texture modifications and analysis of temperatures Environmental modifications: seating arrangements with talkative eaters Functional endurance lingual training throughout the day Labial, lingual, and oral musculature strengthening and resistance training Compensatory eating and feeding strategies: lingual or finger sweeps; chin tuck Alternate liquids with solids to improve bolus breakdown & residual clearance Energy conservation strategies: small frequent meals; positioning; O2; etc. Staff and family training for improved success Referrals: Speech and Occupational Therapies; Dentist; Dietitian/Nutritionist

STAGE TWO – THE PHARYNGEAL STAGE Occurs immediately after a bolus leaves the mouth by passing over the base of the tongue and through the pharynx. Multiple muscle groups must work strongly, succinctly and simultaneously for a safe pharyngeal phase. Weakened or untimely swallow triggers will significantly increase the potential for aspirants to enter the trachea and/or into the lungs. Pharyngeal dysfunction can occur with both solids and with liquids.

Signs and Symptoms of Pharyngeal Dysfunction: Coughing/choking can be immediate or delayed Gagging Excessive throat clearing during or after meals Nasal emission of meal items Laryngeal bobbing Absent swallow triggers Oral holding of meal items Dehydration and/or weight loss Grimacing and/or turning the head when swallowing Complaints of food or pills that stick in the throat Recurrent pneumonia; URIs; FUOs; tracheal congestion

WHAT CAN BE DONE FOR PHARYNGEAL DYSFUNCTION: Texture and consistency modifications and analysis Electro-Musculature Stimulation Pharyngeal strengthening exercises Palatal lift exercises or prosthetics Compensatory eating/feeding strategies: chin tuck; double or hard swallow; head turn Alternate liquids with solids for improved pharyngeal cleansing Energy conservation strategies via small frequent meals; O2 Staff and family training for improved success Videofluoroscopic Swallow Study Referrals: Speech and Occupational Therapies; Dietitian/Nutritionist

STAGE THREE – THE ESOPHAGEAL STAGE The final swallowing stage where a bolus is passed into the esophagus. Peristaltic action pushes food and liquids to the stomach. Upper and lower esophageal sphincters and peristaltic action must work in unison to be effective. UE and LE sphincters are chemically aggravated by highly acidic food and drink causing reflux. Newborns, preemies, diabetics, PEG/NG patients, and those with degenerative neurological disease are at high risk.

Signs and Symptoms of Esophageal Dysfunction: Belching Early satiety Weight loss/failure to thrive Dehydration Foul or sour breath despite good oral hygeine Upper GI bleeds Referred globus – the feeling of food getting stuck in the esophagus Odynophagia: pain with swallowing Regurgitation during or soon after meals Recurrent pneumonia; URIs; FUO’s; delayed tracheal congestion

WHAT CAN BE DONE FOR ESOPHAGEAL DYSFUNCTION: Physician referral for upper GI testing; gastric dumping; etc. Esophageal dilation Pharmaceutical management for lowering acid or for improved peristaltic control X-ray to determine possible obstruction Hiatal hernia surgery (not typical) Leaning away from an obstruction with each swallow Avoidance of tomato and citrus-based products Avoidance of carbonated drinks and of caffeine Losing weight Head elevation during slumber; never lay flat or on the belly Smaller, lighter meals Gelatin or applesauce chasers Referral to: Speech Therapy; PCP; Dietitian/Nutritionist

COLLABORATIVE DYSPHAGIA MODEL: Developing an Interdisciplinary Team (IDT) 1) First, develop the IDT Patient and Family (grandparents?) Speech and Occupational Therapies Physicians and Nursing Teachers/Aides Dietitian/Nutritionist 2) Then, develop a plan: Swallowing Eval with POT by the SLP Feeding Eval with POT by the OT Dietitian referral for options/replacements Referrals to specialists as needed Training resident and POA prior to discharge with dysphagia mgt; meal prep; weight monitoring and with F/U care.

ONGOING PATIENT DEVELOPMENT FOR EFFECTIVE CARRYOVER SLP and/or OT treat the patient with the development of goals and their proposed outcomes. Regular screens for ALL dysphagic patients. Increased frequency of weight monitoring and I&Os with all patients receiving modified textures or consistencies. Teachers/Aides/Nursing support feeding techniques and strategies for continuous, cross-contextual skills training. Dietitian/Nutritionist develops a focused plan specific to each dysphagic patient to avoid dehydration or nutritional deficiencies. Discharge education from all disciplines.

BARRIERS Things we can control: Siloed departments Territorial departments Time constraints Lack of patient advocacy Perception of food vs. nutrition Things out of our control: Cultural departures Degenerative disease and wasting Existing comorbidities Patient non-compliance Patient/family follow-through

QUESTIONS AND ANSWERS: Joseph L. Garcia, MS-CCC/SLP