87 Questions
What 4 groups are at higher risk of malnutrition and dehydration?
Stroke Head and neck cancer Dementia Progressive neurodegenerative diseases (MS, PD, ALS)
Provide 3 examples of structural deficits that can impact the esophageal stage of swallowing
Cervical osteophytes Strictures Stenosis Webs Rings
When making diet recommendations and developing a treatment plan, the safety of the swallow is a priority. What is the other priority?
Receive adequate nourishment
This protocol allows patients who are NPO or on thickened liquids to have ice chips/water between meals when following specific guidelines.
Fraizer free water protocol
Dehydration may cause temporary cognitive impairments
True
What is iatrogenic dysphagia?
Dysphagia due to medications, surgery, radiation or other medical reason
Esophagitis is most commonly caused by reflex and may result in forming of esophageal strictures.
True
Infections and toxins can result in systemic disorders and dysphagia. Provide one example
Infections, toxins sepsis (infection in blood) toxic encephalopathy: (disease of brain) digoxin or lithium toxicity (produces reduced arousal/alertness)
This condition results in impaired LES relaxation and impaired/absent esophageal peristalsis
Achalasia
Malnutrition affects overall medical status, strength, resistance to infection, and the healing process
True
Describe GERD and provide an example of what can happen in patients with chronic GERD/Reflux
GERD occurs through one of three mechanisms: Inappropriate or transient lower esophageal sphincter relaxation Increased abdominal pressure or stress-induced reflux Incompetent or reduced lower esophageal sphincter pressures or spontaneous free reflux Chronic reflux is associated with Barrett’s esophagus (pre-cancerous): associated with chronic reflux causing changes in epithelium of esophagus due to damage of mucosa; considered premalignant lesion that can lead to adenocarcinoma Is a compensatory change in the esophageal mucosa from squamous to specialized intestinal epithelium, and it occurs in up to 15% of patients with atypical presentations of GERD.
Who is the trained professional who selects the proper calories and nutrition content of. the diet and monitors the nutritional status and continuing needs of the patient?
Dietician
What is rheology?
Study of the deformation and flow of matters
A dysphagia diet may need to be adjusted based on several factors, including the viscosity of liquids. What are some other factors to be considered?
Amount Viscosity Consistency Timing Of meals
Those who are on thickened liquids are at risk of dehydration. Provide 3 reasons to support this statement.
Limited access to thickened liquids Change in taste and texture Inability to quench thirst.
Briefly describe the Fraizer Free Water Protocol Guidelines
Patient is allowed to drink water between meals (beginning a minimum of 30 minutes after meals). Oral care must be done prior to consuming water. Patient should sit upright and use appropriate swallowing strategies.
Evidence supports the use of thickened liquids in patients with dysphagia to reduce the incidence of pneumonia.
False
This is an international movement to promote the use of standardized terminologies across countries that consists of 8 levels of foods and drinks numbered 0-7. What is it?
International Dysphagia Diet Standardization Initiative (IDDSI)
Why do thickened liquids result in decreased overall PO intake?
Thickened liquids are less palatable so patients drink less. They also increase intrabolus pressure leading to increased effort and strength to swallow which can lead to overall fatigue during the meal with a decrease in overall intake.
What are the 2 categories of non-oral nutrition? What is the difference?
Parenteral (intravenous) and Enteral (Feeding Tubes)
This is a temporary feeding tube that is minimally invasive, but not meant to stay longer than 2 weeks. The stomach must be functioning properly and uninvolved with primary disease.
Nasogastric (NG) Tube
These feeding tubes are temporary and placed lower in the GI tract. They are useful in conditions of gastroparesis or impaired stomach emptying and if the esophageal reflux present.
Nasoduodenal;/Nasojejunal
These tubes are placed through a small opening called a stoma that is made in the wall of the abdomen. The procedure to create the opening ins called an ostomy.
G tubes, J tubes, and GJ Tubes
What are the three main ways a feeding tube ostomy may be done?
Image-guided, surgical, endoscopic
This surgical feeding tube is a good alternative feeding route if the stomach is impaired
Jejunostomy (J-Tube)
What is the primary goal of a treatment plan for dysphagia?
To restore function
What is the term for the condition in which food, liquids, or pills pass into the airway below the true vocal folds?
Aspiration
Which of the following groups is at a higher risk of malnutrition and dehydration due to dysphagia?
All of the above
What is the term for the systemic infection that can occur due to feeding lines into the venous system or due to aspiration?
Sepsis
What is the term for the continuous and degenerative changes in swallowing functions that occur in healthy aging?
Presbyphagia
What is the term for the pulmonary infection that results from acute or chronic aspiration of fluids, foods, or oral secretions from the mouth or from fluids arising in the stomach?
Aspiration pneumonia
What is the primary cause of esophagitis?
Reflux
What is the primary characteristic of achalasia?
Impaired LES relaxation and esophageal peristalsis
What is the role of a dietitian in dysphagia management?
To select the proper calorie and nutrition content of the diet
What is the result of the failure of the LES to relax during swallowing?
The bolus is unable to move through into the stomach
What is the term for the protrusion of part of the stomach through the diaphragm into the thorax?
Hiatal hernia
What is the priority of diet treatment in dysphagia management?
To ensure swallow safety and receive adequate nourishment
Which type of aspiration syndrome is caused by chemical injury due to inhalation of sterile gastric contents?
Chemical pneumonitis
What is the most common type of PNA (Pneumonia)?
RLL PNA
What is the term for the narrowing of the passageway in the pharynx and esophagus?
Stenosis
Which of the following is a neurogenic degenerative etiology of dysphagia?
Muscular dystrophy
What is the term for the outpouches of one or more layers of the esophageal wall that can cause food to be retained in the pouch?
Diverticulum
Which of the following is a structural etiology of dysphagia?
Cervical osteophyte
What is the term for the inflammation or swelling of the lining of the esophagus?
Esophagitis
Which of the following is a type of PNA that is acquired in the hospital?
Nosocomial PNA
What is the term for the thin layers of cells that grow inside the esophagus and can cause food to be retained in the pouch?
Webs
Which of the following is a risk factor for aspiration?
Oral weakness
What is the main cause of dysphagia due to esophageal dysmotility?
Abnormal motility of the esophagus
Which type of feeding is used in patients who are unable to take adequate nutrition by mouth but have a functioning gastrointestinal tract?
Enteral feeding
What is a common side effect of antipsychotic drugs that can contribute to dysphagia?
All of the above
What is the term used to describe the retrograde movement of gastric contents from the stomach through the lower esophageal sphincter and into the esophagus?
GERD
What is the name of the premalignant lesion that can occur in patients with chronic GERD/Reflux?
Barrett's esophagus
What is the term used to describe the compensatory change in the esophageal mucosa from squamous to specialized intestinal epithelium?
Barrett's esophagus
Which type of medication can cause xerostomia, leading to dysphagia?
All of the above
What is the term used to describe the group of medical conditions in which the esophagus does not work properly?
Esophageal dysmotility
What is the term used to describe the umbrella term used to describe a group of medical conditions in which the esophagus does not work properly?
Esophageal dysmotility
Which type of feeding is used in patients who require long-term nutritional support?
Enteral feeding
What is the main objective of the International Dysphagia Diet Standardization (IDDSI)?
To standardize the terminology of food and liquid textures across countries
What is the purpose of the IDDSI flow test?
To determine the viscosity level of a liquid
Why are patients on thickened liquids at risk of dehydration?
Because of limited access to thickened liquids, change in taste and texture, and inability to quench thirst
What is the main concern when modifying liquids for patients with dysphagia?
Finding a consistency that allows maximal protection from penetration and aspiration, but minimal post-swallow residue
What type of thickening agent is xanthan-based?
Gel-based
What is the purpose of providing clear and simple written guidelines on food and drink preparation to family members or healthcare providers?
To ensure family members or healthcare providers can prepare food and drinks correctly
What is the main benefit of the Fraizer Free Water Protocol?
It allows patients who are NPO or on thickened liquids to have ice chips/water between meals
What is the term for the study of the deformation and flow of matters?
Rheology
What is the term for the resistance to flow or alteration of shape?
Viscosity
What is the term for the compactness of a substance?
Density
What is the primary reason for using water in the Free Water Protocol?
Because it is the least toxic to lungs and most absorbable
What is the purpose of oral care in the Free Water Protocol?
To prevent aspiration by removing residue
What is the minimum amount of time a patient should wait after a meal before consuming water in the Free Water Protocol?
30 minutes
What is the term for the decision to use alternative routes for medication administration?
Critical decision
What is the term for the condition where a patient is unable to take adequate nutrition orally?
Non-oral diet
What is the purpose of a feeding tube ostomy procedure?
To create an opening in the abdomen for a feeding tube
What is the term for the feeding tube that is placed lower in the GI tract and is useful in conditions of gastroparesis or impaired stomach emptying?
Nasoduodenal tube
What is the term for the risk of developing pneumonia in patients who are on honey-thick liquids?
PNA risk
What is the term for the condition where a patient's wishes for medical care are documented in writing?
Advance directive
What is the primary goal of instrumental testing in dysphagia diagnosis?
To assess the efficiency of swallowing
What is the primary advantage of a percutaneous radiologic gastrostomy (PRG) procedure?
It is a non-surgical procedure
What is the main difference between a gastrostomy (G-Tube) and a jejunostomy (J-Tube) feeding tube?
The location of the tube in the small intestine
Why was a temporary NG tube used in the case study of T.L.?
To give the patient time to recover neurologically and regain function
What is the primary benefit of using an endoscope in a percutaneous endoscopic gastrostomy (PEG) procedure?
It provides a video image of the inside of the stomach for accurate placement
What is the main complication of a jejunostomy (J-Tube) feeding tube?
Loss of controlled emptying of the stomach
What is the primary advantage of a surgical feeding tube placement?
It can be performed under general anesthesia
What is the primary characteristic of a gastrostomy (G-Tube) feeding tube?
It is suitable for long-term feeding
Why is insertion site care needed for a gastrostomy (G-Tube) feeding tube?
To prevent infection and skin irritation
What is the primary benefit of a percutaneous endoscopic gastrostomy (PEG) procedure?
It is a minimally invasive procedure
What is the main complication of a gastrostomy (G-Tube) feeding tube?
Risk of infection and skin irritation
Study Notes
Esophagitis and Esophagospasm
- Esophagitis: most commonly caused by reflux, may result in forming of esophageal strictures
- Esophagospasm: phasic, nonpropulsive contractions or abnormal LES function, painful
Achalasia
- Unknown etiology
- Impaired LES relaxation and esophageal peristalsis
- Esophagus is dilated
- Characterized by degeneration of neural elements in the wall of the esophagus, particularly at the LES
- Many medications and bulimic patients can cause achalasia
Diet and Nutrition
- Diet treatment priorities:
- Ensure swallow safety
- Receive adequate nourishment
- Amount of calories
- Content of calories
- Degree of satisfaction
- Dietitian: a trained professional who selects the proper calorie and nutrition content of the diet and monitors the nutritional status and continuing needs of the patient
Feeding Tubes
- Types of feeding tubes:
- G tube (gastric tube)
- GJ tube (gastric-jejunal tube)
- J tube (jejunal tube)
- Placement methods:
- Surgical feeding tube placement (in the operating room)
- Percutaneous radiologic gastrostomy (PRG)
- Endoscopic percutaneous gastrostomy (PEG)
- Characteristics:
- Suitable for long-term feeding
- Concurrent oral intake is possible in certain cases
- Cosmesis: feeding tube can be hidden under clothing
- Easy tube replacement
- Insertion site care needed
- Lowers risk of tube migration and aspiration
- Possible complications: insertion may require surgery, risk of infection, excoriation, and skin irritation at gastrostomy site, potential fistula at insertion site after tube removal, potential risk of pulmonary aspiration and reflux
Case Study: T.L
- History: 28-year-old female with Guillain-Barré Syndrome (GBS)
- Diagnosis: dysphagia and dysphonia
- Initial MBS: silent aspiration
- Recommendations: puree diet and nectar thick fluids
- Results of MBS: upgraded to full diet and thin fluids
Dysphagia and Associated Conditions
- Consequences of dysphagia:
- Aspiration: respiratory distress, pneumonia, death
- Choking: airway compromise
- Tracheostomy
- Malnutrition/dehydration
- Weight loss
- Chronic respiratory illness
- Principles of rehabilitation:
- Plan of biological plausibility
- Restoring function
- Managing/reducing symptoms
- Protecting the airway
- Optimizing nutrition
Aspiration and PEG/NG/J Tube Placement
- Aspiration: condition in which food, liquids, or pills, or oropharyngeal secretions pass into the airway below the true VFs
- PEG, NG, OG, or G Tube/J Tube placement: consideration for patients at risk of aspiration
Malnutrition and Dehydration
- Groups at risk of malnutrition and dehydration:
- Stroke
- Head and neck cancer
- Dementia
- Progressive neurodegenerative diseases (MS, PD, ALS)
- Dehydration:
- ↓ fluid intake due to discomfort of aspiration
- Lab values: BUN (blood-urine-nitrate) – if elevated from baseline; Na (sodium) – if > 145
- May cause temporary cognitive impairments (toxic metabolic encephalopathy TME)
Aging Population
- Presbyphagia: continuous and degenerative changes in swallowing functions in healthy aging
- Up to 84% of elderly may develop changes in swallowing functions
- Up to 68% of nursing home residents have signs of swallowing disorders
Sepsis
- Definition: systemic infection from feeding lines into venous system or due to aspiration
- Pulmonary complication/aspiration PNA: when pulmonary infection results from acute or chronic aspiration of fluids, foods, or oral secretions
Medication Induced Dysphagia
- Definition: dysphagia due to medications, surgery, radiation, or other medical reasons
- Examples:
- Medications that reduce spasticity (Baclofen)
- Medications that cause xerostomia
- Antipsychotic drugs
- Denture powders containing anesthetic
- Parenteral feeding
Esophageal Dysmotility
- Umbrella term to describe a group of medical conditions in which the esophagus does not work properly
- Leading to changes in the strength and condition of the muscles
- Remember: the esophagus is made of sphincters (proximal and distal)
GERDS and Esophageal Dysmotility
- GERDS: caused by incompetent LES; defined as the retrograde movement of gastric contents from the stomach through the lower esophageal sphincter and into the esophagus
- Esophageal dysmotility: group of medical conditions in which the esophagus does not work properly
- GERD: associated with chronic reflux, causing changes in epithelium of esophagus due to damage of mucosa; considered premalignant lesion that can lead to adenocarcinoma
RHEOLOGY
-
Study of the deformation and flow of matters
-
Key terms:
- Density: compactness of a substance
- Viscosity: resistance to flow or alteration of shape### Aspiration Syndromes
-
Aspiration syndromes occur in 3 ways based on pathophysiology: Chemical pneumonitis, Bacterial infection, and Acute airway obstruction.
-
Chemical pneumonitis occurs due to chemical injury caused by inhalation of sterile gastric contents from the stomach or esophagus.
-
Bacterial infection occurs due to increased volume of oropharyngeal secretions coupled with impaired defense mechanisms.
-
Acute airway obstruction depends on multiple factors, including amount, nature, acidity of the aspirate, consistency, cough reflex, and host immune defense.
Conditions and Factors Associated with Aspiration
- Oral, pharyngeal, or vocal fold weakness increase the risk of aspiration.
- Conditions that increase the risk of aspiration include recent stroke, paralysis to one or both vocal folds, and neurological disorders.
Pulmonary Complications
- Aspiration pneumonia (PNA) is a common complication, often occurring in the right lower lobe (RLL PNA).
- Other pulmonary complications include bronchitis, COPD exacerbation, pulmonary infiltrates, and atelectasis.
- Atelectasis is a shrunken, infected, airless state of lungs due to various factors, including foreign bodies.
- Infiltrates refer to infections passing into the lungs, denser than air, which lingers in the lungs.
Types of PNA
- Bacterial PNA is treated with antibiotics.
- Viral PNA occurs 48h or more after admission and not incubating at the time of admission.
- Nosocomial PNA is PNA acquired in the hospital.
Etiology and Conditions of Dysphagia
- Neurogenic dysphagia etiologies include Alzheimer's, Parkinson's disease, Amyotrophic lateral sclerosis (ALS/Lou Gehrig's Disease), Post-polio syndrome, Muscular dystrophy (MD), Dermatomyositis, Multiple sclerosis (MS), Myasthenia gravis (MG), Huntington's disease, and Dystonia.
- Structural etiologies of dysphagia include stenosis, rings, webs, and strictures throughout the pharynx and esophagus.
Structural Abnormalities
- Cervical osteophyte is a bony outgrowth or protrusion from cervical vertebrae, which can impinge on pharynx and/or esophagus, causing stenosis.
- Strictures typically occur in adulthood after esophagitis, causing edema, inflammation, and fibrosis, resulting in narrowing.
- Esophageal rings occur anywhere in the esophagus or hypopharynx, partially or completely blocking the esophagus.
- Webs are thin layers of cells that grow inside the esophagus, characterized by one or more thin horizontal membranes of squamous epithelial cells.
- Diverticulum is an outpouching of one or more layers of the esophageal wall, causing food retention in the pouch and subsequent aspiration after swallowing.
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