Swallowing Guide PDF

**Swallowing** **Dysphasia:** the difficulty moving food from mouth to stomach, or any problem happing in normal swallowing phase. **Feeding disorders:** it is the avoidance to eat different types of food. **[-Phrases ]** - **Oral preparatory phrase:** the food and liquids are manipulated,...

**Swallowing** **Dysphasia:** the difficulty moving food from mouth to stomach, or any problem happing in normal swallowing phase. **Feeding disorders:** it is the avoidance to eat different types of food. **[-Phrases ]** - **Oral preparatory phrase:** the food and liquids are manipulated, chewed, and made into the bolus, voluntary - **Oral phrase:** the tongue moves the food or liquid toward the back of the mouth. voluntary - **Pharyngeal phrase:** involuntary \\disorder: aspiration or penetration or delayed swallow - **Esophageal phase:** the food is transported from esophagus to stomach. **Aspiration:** when the food and liquid goes through the trachea and below the level of vocal folds. **Penetration:** when the food and liquid goes through the trachea and stay above the vocal folds. **Residue:** the food is left behind the mouth or pharynx after swallow. **Regurgitation:** backflow of food from pharynx into nasal cavity. **Oral phase:** - **Poor oral control:** weak or uncoordinated lip, tongue or jaw or poor oral sensitivity. - **Spill the food out of the mouth**: poor labial and lingual seal, inability to maintain lip closure, leading to food and/or liquids leaking from the oral cavity - **Premature spillage:** the bolus falls over the base of tongue and may be aspirated because of reduced tongue strength or range of motion. - **Chewing difficulty:** reduced mandibular and lingual strengths, or poor oral sensitivity. **Food or liquid remaining in the oral cavity after the swallow:** - **Residual food between cheeks and tongue**: reduced buccal tension. - **Residual food under the tongue after swallow:** : reduced lingual strength. - **Residual food on hard palate after swallow**: reduced lingual elevation. - Time taken to move the bolus is abnormal slow **Pharyngeal phase:** - **Coughing or chocking or wet voice quality when the food enters the airway:** delayed or absent swallow reflex, reduced laryngeal elevation or closure. - **Nasal regurgitation** occur due to inadequate velopharyngeal closure. (food and/or liquids leaking from the nasal cavity) - **Excessive saliva and mucus:** due to aspiration and body's attempt to clear away the foreign material. **Signs of dysphagia may include** 1. **Drooling and poor control of food in mouth** 2. **Chest infection\\ pneumonia** 3. **Food sticking on throat.** 4. globus sensation or complaints of a \"fullness\" in the neck; 5. **Complaints of pain when swallowing;** 6. Frequent throat clearing and wet or gurgly sounding voice during or after eating or drinking, 7. **Coughing during or right after eating or drinking;** 8. **Difficulty coordinating breathing and swallowing;** 9. **Extra effort or time needed to chew or swallow;** 10. malnutrition or dehydration 11. keep food in mouth (pocketing). **Dysphagia cause form:** **stroke; traumatic brain injury; spinal cord injury; dementia; Parkinson\'s disease; multiple sclerosis**; ALS (or Lou Gehrig\'s disease); muscular dystrophy; developmental disabilities in an adult population (i.e., cerebral palsy); myasthenia gravis **Assessment:** 1. The interview/case history)medical/clinical records including the potential impact of medications(. 2. Seating 3. Screening+ Bedside assessment 4. **FEES**: Fiberoptic endoscopic evaluation of swallowing it is a flexible scope passes through nose to the level of soft palate, give a view of pharyngeal and laryngeal structure. Adequate airway protection, timing of swallow, spillage before swallow, residue after swallow, clear residue, presence of reflux, aspiration. Strategies for improving swallowing as such postural changes, diet modification, swallowing mauves can be identified. 5. **MBS**: mix barium with four consistencies and see through the x-ray, The **videofluroscopic swallowing study** (VFSS), also known as the **modified barium swallow study** (MBSS), is a radiographic procedure that provides a direct, dynamic view of oral, pharyngeal, and upper esophageal function. It helps to identify the specific site of asp and pent, its causes, and strategies that increase safety swallowing as changing head position, or modifying bolus size. It provides clinically useful information on the influence of compensatory strategies and diet changes. **Look at in assessment:** 1. lip seal and see if any spillage of food ( indication of weakness). 2. Swallowing onsets (delayed swallowing onset or premature spillage ). 3. Aspiration and penetration scale 1-8 4. 4-any residue and where it is **Intervention** 1. **Seating position** 2. **Dietary modification (thicken up):** modifications to the texture, taste or temperature of the food. This may include changing the viscosity of liquids and/or softening, chopping, or pureeing solid foods. Work with dietician. 3. **Postural\\ position technique** (chin tuck, rotating the head if he has unilateral vocal paralysis). **It redirects the movement of the bolus in the oral cavity and pharynx. Postural techniques may be appropriate to use with patients with [neurological impairments], head and neck cancer resections, and other structure damage.** Postural techniques may be used in patients of all ages. - **Chin-tuck**: the chin is tucked down toward the neck during the swallow, which may bring the tongue base closer to the posterior pharyngeal wall, narrow the opening to the airway. Before swallowing. (reduced posterior motion of tongue base), delay in triggering the pharyngeal swallow. - **Chin-up posture**: the chin is tilted up, which may facilitate movement of the bolus from the oral cavity. Before swallowing. Inefficient oral transit (reduced posterior push of bolus by the tongue). - **Head rotation (turn to the side)**: the head is turned toward the damaged or weak side to direct the bolus to the stronger of the lateral channels of the pharynx. (unilateral vocal folds paralysis, aspiration during swallow).(unilateral pharyngeal paresis, residue on one side of pharynx). - **Head tilt** : the head is tilted toward the strong side to keep the food on the chewing surface.(unilateral oral and pharyngeal weakness on the same side, residue in mouth and pharynx on same). Postures and maneuvers may be combined in an appropriate manner, taking care to minimize patient effort/burden, where possible 4. **Swallowing maneuvers** ( supraglottic swallow: holding breathing before). **Maneuvers are strategies that clinicians use to change the timing or strength of particular movements of swallowing.** Some maneuvers require following directions and may not be appropriate for patients with cognitive impairments. Examples of maneuvers include the following: - **Effortful swallow:** increases posterior tongue base movement to facilitate bolus clearance. The patient is instructed to swallow his saliva and squeeze all his mouth and neck's muscles and then push hard with the tongue against the hard palate while he sallow. (reduced posterior movement of the tongue base). - **Mendelsohn maneuver:** designed to elevate the larynx and open the esophagus during the swallow to prevent food/liquid from falling into the airway. The patient holds (reduced range of laryngeal movement or discoordinated swallow) - **Supraglottic swallow:** designed to close the vocal folds by voluntarily holding one\'s breath before and during swallow in order to protect the airway. (reduced or late VF closure or delayed pharyngeal swallow). 5. **Oral-Motor Therapy/Exercises:** include stimulation to or actions of the lips, jaw, tongue, soft palate, pharynx, larynx, and respiratory muscles that are intended to influence the physiologic underpinnings of the oropharyngeal mechanism in order to improve its functions**.** Some of these interventions can also incorporate sensory stimulation. Oral-motor treatments range from passive to the more active (e.g., range-of-motion activities, resistance exercises, or chewing and swallowing exercises). Examples of exercises include the following: - **Masako or tongue hold:** the patient holds the tongue forward between the teeth while swallowing; this is performed without food or liquid in the mouth, to prevent coughing or choking. Although sometimes referred to as the Masako \"maneuver,\" the Masako (tongue hold) is considered an exercise (not a maneuver), **and its intent is to improve movement and strength of the posterior pharyngeal wall during the swallow.** - **Shaker exercise, head-lifting exercises:** the patient rests in a supine position and lifts his or her head to look at the toes to facilitate an increased opening of the upper esophageal sphincter through increased hyoid and laryngeal anterior and superior excursion. 6. **Oral hygiene** 7. **Nasogastric tube (NG-tube)***:* inserted through the patient\'s nose and passed through the esophagus to the stomach to provide non-oral nutrition. NG-tubes are often the preferred option for short-term use (over G-tubes or J-tubes). Tube size may vary and may influence swallow function 8. **Gastrostomy tube (PEG, G-tube)***:* inserted through the abdomen to provide non-oral nutrition. A **percutaneous endoscopic gastrostomy tube**, or **PEG tube***,* is a common type of G-tube. 9. counseling **If they have aspiration on all consistencies, use NGT or pig tube.** **Children** **Feeding disorder:** avoiding eating or limit what he or she eats, disordered are characterized by extreme food selectivity by type, texture brand, shape or color. **Feeding disorders:** it is the avoidance to eat different types of food. **Pediatric swallowing** **Assessment** - **Case history** : medical status (illness, surgery, medication, breathing), feeding status (fed-breast or given a bottle, position during feeding, using adaptive equipment, refuse eating), if the child has food allergies, nutritional intake, let you know when he is hungry or full, ask about behavior during or after meal (vomiting crying, chocking, gurgly voice). - **Altering**: (infant), provide info about the infant's ability to prepare for or attend to feeding. - Deep sleep: respiratory pattern are regular, eyes are closed, and body are relaxed - Active sleep: respiratory pattern are regular and irregular, eyes are closed, random movement of limbs occur. - Drowsy: respiratory pattern are regular, eyes are full or partially open, smooth movement of limbs occur, quickly to stimulation. - Awake\\alert: eyes are alert, response to auditory and visual stimulation - Alert agitated: eyes are alert, body is active, movement are disorganized - Crying: intense crying with difficulty comforting. - **Physiologic status (infant)** - Heart rate: 120\\140, preterm: 160\\180 beats\\min - Respiratory rate: 30\\60 breaths\\ minute, for both - Oxygen saturation: \ - **Non-nutritive sucking**: six to eight sucks in 3-4 seconds, swallow, pause for 6-7 seconds to breath, and rest before repeating. To assess suck strength, placed the gloved figure in the mouth, and not how well the tongue cups the figure, weather lip closure is obtained. - Burst cycle - Labial seal on finger or nipple - Lingual cupping - Suck strength - Respiration - **The nutritive sucking** pattern is slower than the NNS pattern. NNS is two per sec, while NS is one per sec. the infant will suck once, swallow once and then breath once per burst. - Burst cycle - Labial seal, fluid loss at seal - Lingual cupping - Suck strength - Suckle\\sallow ratio - Fluid expression - Respiration - swallow reflex: normal, delayed, absent, multiple swallow - pharyngeal response: none, cough, gag, wet voice, wet breathing. - **Primitive reflex** - Babkin, hand move to mouth - **Rooting**, move the head toward the stimulation (nipple) - Phasic bite: up-down movement of the jaw - **Tongue thrust**, protrusion of the tongue, protect against chocking - **Suckle,** suck on anything that touches the roof of the mouth. (tongue forward and backward, jaw up and down). - **Suck,** (tongue moves up and down). - **Swallow reflex:** the reflex protect the airway and push the bolus into the esophagus. - **Abnormal reflex:** - **Tonic bite reflex**, jaw clamps down when teeth or gums are stimulated, and the child have difficulty to release it. Indicate inappropriate oral feeding and manipulation of nipple, cup. - **Tongue retraction,** tongue is pulled back while the tip of the tongue may be held against the hard palate, face difficulty to remove the food from spoon or using the tongue for chewing and swallowing - **Jaw thrust,** lower jaw is extended down and appear to be stuck open, difficulty in receiving and keeping the food into mouth. - **Strength, stability and posture:** - Muscle tone: normal, tense, flaccid - Head control - Head/ neck alignment: good, hyperextension of neck - Shoulder alignment: good, elevated, retracted, adducted. - **Oral structure:** - Jaw: size, at rest, movement (reduced to left or right, restricted, thrust), strength (normal, weak), teeth - Cheeks: at rest, tone, strength - Lip: at rest, tone, strength, movement (reduced on right or left), structural deviation (cleft, scar), drooling. - Tongue: size, at rest, tone, movement at rest, strength, protrusion, lateralization, elevation. - Palate: at rest, cleft( none, hard, soft) - Pharynx\\larynx: vocal quality, gag (normal, hyperactive, absent) - Facial sensitivity: face, mouth. - **Oral facial structure, infant at rest, while older children may imitate oral movement.** - Structure abnormalities, cleft palate= poor labial seal, interfere with sucking ability. - Oral motor weakness= poor sucking ability or oral control of the bolus. - Abnormal muscle tone= impair sucking ability, manipulation of bolus, (flaccid=inadequate stability of head or body, tension=difficulty bringing hand to mouth). - Abnormal movement of oral structure= impair chewing and swallowing ability, (restricted range of jaw movement may cause difficulty biting into solid food). - Facial and oral sensitivity = reduced sensitivity may reduce awareness and control of food on face or oral cavity, child who is hypersensitivity may refuse to eat. - Cough, chocking or wet vocal quality= penetration of food into airway. **Formal assessment:** MBS, modified strategies during the assessment **Treatment for infant and children:** - **Modify posture:** have the child positioned fully upright, reduce jaw and tongue retraction and thrusting, improve lip sealing and motion. - **Manually support jaw, tongue, lips:** improve weak suck assist with lip seal , reduce jaw and tongue retraction and thrusting, reduce pooling. - **Provide adaptive equipment:** modify the nipple, child with poor oral facial strength can drink from straw. - **Alert food:** thicken up the liquid, modify the temperature of food **Feeding team:** Physician, dietitian , Behavioral specialist, Occupational therapist , SLP **Feeding Approaches:** **Food chaining:** Pre-Chaining and Food Chaining, expands the child's food repertoire by introducing new foods that have the same features as the foods the child currently eats. - **Flavor Mapping** involves analyzing the child's preferences and looking for patterns between the child's favorite foods including flavor, texture, and color. - **Transitional Foods** involves using favorite foods in between bites of new food to encourage the child to eat while also helping to mask after taste of the newly introduced food. - **Flavor Masking** involves finding flavors accepted by the child that can be used on a variety of newer food items. (Example: Ranch Dressing, Mrs. Dash seasoning, cinnamon).