1. Copyright © 2008 Delmar. All rights reserved. Unit Ten Dysphagia

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

3. Copyright © 2008 Delmar. All rights reserved. 3 Dysphagia Difficulty swallowing that occurs when impairments affect any of the four phases of swallowing that puts a person at risk for aspiration

4. Copyright © 2008 Delmar. All rights reserved. 4 Dysphagia Team approach is required: –SLP –Dentist –Dietician, PT, RT, OT, ENT –Neurologist –Gastroenterologist –Pharmacist

5. Copyright © 2008 Delmar. All rights reserved. 5 Four Phases of the Normal Swallow Oral preparatory phase Oral phase Pharyngeal phase Esophageal phase

6. Copyright © 2008 Delmar. All rights reserved. 6 Oral Preparatory Phase Thinking about food/liquid and how to get it to the mouth Chewing the food in our mouth

7. Copyright © 2008 Delmar. All rights reserved. 7 Oral Phase Begins when chewing stops Tongue pulls the food to the back of the mouth Takes one second

8. Copyright © 2008 Delmar. All rights reserved. 8 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

9. Copyright © 2008 Delmar. All rights reserved. 9 Esophageal Phase Bolus carried to lower esophageal sphincter to enter stomach

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

11. Copyright © 2008 Delmar. All rights reserved. 11 Oral Phase Problems Anterior spillage Premature spillage into airway Difficulty moving bolus back towards pharynx

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

13. Copyright © 2008 Delmar. All rights reserved. 13 Esophageal Phase Problems Upper esophageal sphincter does not open Slow or absent esophageal peristalsis

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

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

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

17. Copyright © 2008 Delmar. All rights reserved. 17 Evaluation of Adults Review medical chart Screen patient –Behavioral observations –Interview –Check for protective cough

18. Copyright © 2008 Delmar. All rights reserved. 18 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

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

20. Copyright © 2008 Delmar. All rights reserved. 20 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

21. Copyright © 2008 Delmar. All rights reserved. 21 Ultrasound Imaging Noninvasive imaging that uses sound waves to view the oral and laryngeal structures

22. Copyright © 2008 Delmar. All rights reserved. 22 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

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

24. Copyright © 2008 Delmar. All rights reserved. 24 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

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

26. Copyright © 2008 Delmar. All rights reserved. 26 Postural Techniques Chin-tuck (down) Head rotation Head tilt

27. Copyright © 2008 Delmar. All rights reserved. 27 Oral-Motor Exercises Can help increase muscle tone and strength

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

29. Copyright © 2008 Delmar. All rights reserved. 29 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

30. Copyright © 2008 Delmar. All rights reserved. 30 Goals of Treating Infants and Children Promote adequate nutrition and hydration Develop age-appropriate feeding skills

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

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

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

34. Copyright © 2008 Delmar. All rights reserved. 34 Emotional and Social Effects Eating is a a social event Diet modifications can reduce enjoyment of eating and affect quality of life

35. Copyright © 2008 Delmar. All rights reserved. 35 Emotional and Social Effects Anxiety Depression Grief Embarrassment Sense of loss