12. Dysphagia.pdf

Dysphagia DR. DALAL ALALI  Normal Swallowing The action of transferring food and/or liquid from the mouth to the pharynx and into the stomach. Necessary to maintain nutrition & hydration Involves more than 50 pairs of muscles  Norma...

Dysphagia DR. DALAL ALALI  Normal Swallowing The action of transferring food and/or liquid from the mouth to the pharynx and into the stomach. Necessary to maintain nutrition & hydration Involves more than 50 pairs of muscles  Normal Swallowing Norms We swallow 500-700 times a day As little as 2-3/hr. while sleeping (Sato et al, 2011) On average 1/min while awake and more frequently while eating (Ertekin 2011)  Skills needed for a good swallow Motor skills – Ability to move muscles in face, mouth and throat. Sensory skills – Ability to detect food/fluid in your mouth and throat. Cognitive skills – Ability to recognise food and open your mouth to it. Voluntary mechanism Involuntary/reflexive mechanism  Cranial Nerves Needed for a Good Swallow Function Cranial Nerve Bite Chew Close lips Manipulate and retrieve bolus Initial push of bolus  Normal swallow Fast- liquid passes the pharynx in 2 secs Easy Nothing left behind Nothing enters the airway  Abnormal swallowing (Dysphagia) The name dysphagia is taken from the Greek root ◦ Dys= difficulty ◦ phagia = to eat Dysphagia is the medical term for difficulty, or inability to eat  Definitions of dysphagia Dysphagia has varying definitions and meanings: “Any difficulty or discomfort when eating and drinking” “Difficulty moving food from the mouth to the stomach” “Difficulty with sucking, swallowing, drinking, chewing, eating, controlling saliva, taking medication, or protecting the airway”  Prevalence of dysphagia 1 in 17 people will develop some form of dysphagia in their lifetime 50-75% of stroke patients 60-70% of patients with head and neck cancer. Up to 90% of patient withs neurological diseases Dysphagia increases with age Dysphagia is most prevalent in acute care settings and aged care facilities.  Causes of dysphagia Dysphagia is a symptom of many medical conditions including: Neurologic conditions: ◦ Stroke ◦ Traumatic brain injury ◦ Damage to the CNS ◦ Brain tumours Congenital and developmental conditions Cerebral Palsy Cleft lip/palate  Causes of dysphagia Obstruction (throat & oesophagus) Mouth, throat, laryngeal or oesophageal cancer Radiotherapy treatment Gastro-oesophageal reflux disease Infections can lead to inflammation of the oesophagus  Causes of dysphagia Muscular conditions Scleroderma Achalasia Other causes Post surgical procedures Medications Aging Cancer of head, neck or esophagus Spinal cord injury Psychological  Symptoms of Dysphagia Patient’s complaints Most common complaint presented by patient is that “food/fluid gets stuck in the throat”. Food is left behind in the mouth Spillage from corners of the mouth Lump in the throat known as globus or globus sensation Coughing (prior, during or after a swallow) Eating and drinking has become a slow and troublesome process In aged patients: Lowered appetite Decreased food intake Decreased in taste sensation  Symptoms of Dysphagia in Patients with Dementia Physical problems: Inability to use utensils properly Inability to maintain proper posture during meals Sensory problems: Inability to recognize food or drinks Inability to estimate food temperature Reduced awareness of hunger and thirst Changes in smell and taste Agnosia: Holding the bolus in the oral cavity for long periods without attempts to swallow  Symptoms of Dysphagia in Patients with Dementia Poor oral hygiene: Eating may be unpleasant due to dry mouth, mouth ulcers, poor oral hygiene, poor or missing dentition Medication side effects: Medications may affect appetite Communication and cognitive problems: Inability to express needs and food preferences Difficulty following instructions to participate in meals Difficulty remembering to eat Increased confusion leading to unwanted behaviours during meals  Medical Consequences of dysphagia Malnutrition Reduced oral intake Reduced nutrients Dehydration Reduced fluids intake  Medical Consequences of dysphagia Increased risk of aspiration Food/fluid/saliva enter the airway into the lungs These substances may carry bacteria that affect the lungs. Aspiration pneumonia can develop as a complication Our body is protected against small amounts of aspirated materials  Medical Consequences of dysphagia Aspiration Pneumonia 25-30% Of patients with dysphagia are silent aspirators Silent aspiration creates higher risk for developing aspiration pneumonia In the elderly, those who have silent aspiration have a higher death rate Aspiration can only be diagnosed through an instrumental assessment Many people with dysphagia are undiagnosed until a major event such as aspiration pneumonia occurs.  Social & Pyschological Consequences of dysphagia Reduced quality of life Changes in eating routines & food choices. Eating & drinking becomes less enjoyable Reduced personal independence Challenge to participating in community activities.  Phases of swallowing The act of swallowing is described in 4 phases: 1. Oral prep phase: Food is manipulated in mouth & masticated to reduce the consistency for easy swallowing 2. Oral phase: When tongue pushes food posteriorly until pharyngeal swallow is triggered 3. Pharyngeal phase: When pharyngeal swallow is triggered, and bolus moved through the pharynx 4. Esophageal phase: When is the bolus is carried through the oesophagus and into the stomach  1. Oral Prep Phase Voluntary Food is brought to the mouth Food is chewed and mixed with saliva Phase ends when bolus is placed on top of the tongue  2. Oral Phase Voluntary Requires good dentition The bolus is held against the hard palate The tongue moves the food to the pharynx  3. Pharyngeal phase Involuntary Begins when the bolus touches the tonsils This is when the swallow is triggered Trachea is closed to prevent food/liquid from entering the airway Bolus is squeezed down the throat Bolus travels through the pharynx in 1-2 seconds  4. Esophageal phase Food leaves the pharynx and enters the oesophagus The oesophagus has 2 important muscles that open and close reflexively (upper & lower sphincter) Sphincters allow the food bolus to flow in a forward direction Sphincters prevent food from going in the wrong direction (regurgitation) Ends as the bolus enters the stomach Bolus travels through the oesophagus in 5-6 seconds  Phases of swallowing The time and characteristics of each phase depends on 2 factors: 1. Consistency of food 2. Amount of food Red flags Too long to chew & swallow Multiple swallows  Protective mechanism Soft palate: Elevates to prevent food from entering the nasopharynx Epiglottis: Covers the larynx to prevent food from entering the airway Cough: If material enters the airway, reflexive cough occurs to expel it  Penetration & Aspiration Once food enters the airway 2 things happen: Penetration: When food/fluid enters the airway above the level of vocal fold Aspiration: When the food/fluid enter the airway below the level of the vocal folds Abnormalities/symptoms of the oral prep & oral phase Reduced lip seal Patient description: Unable to keep food in mouth Clinical Symptom: drooling, spillage of food or liquids from the mouth Weakness of the buccal muscles Patient description: Food sticking in the mouth Clinical Symptom: Food can be trapped in the buccal area Reduced oral sensation Patient Description: Material goes all over mouth Clinical Symptom: Material spreads around oral cavity Abnormalities/symptoms of the oral prep & oral phase Reduced tongue movement Impaired mastication/chewing Impaired bolus formation Impaired bolus transport Extra effort needed to chew/swallow Inability to eat specific food types Abnormalities/symptoms of the pharyngeal phase Delayed pharyngeal swallow: Occurs when the bolus enters the pharynx & the swallow is not triggered within 0.5 secs. If the pharyngeal swallow is not initiated as the liquid passes the tongue, there is an increased risk of penetration/aspiration Patient Description Coughing, choking Abnormalities/symptoms of the pharyngeal phase Absent pharyngeal swallow: Characterized by 1) Absence of anterior movement of the hyoid bone. 2) Incomplete laryngeal elevation. Patient Description: Food does not go down Clinical Symptoms: No hyoid/thyroid elevation Slow oral transit times Foods and liquids do not move through the pharynx well and may be left behind after the swallow. Coughing, choking or gagging after a meal  Abnormalities of the oesophageal phase Oesophageal phase dysphagia is often characterized by: Reflux (heartburn): Movement of foods, liquids and stomach acids back up the oesophagus Complaints of dysphagia without coughing, choking Frequent respiratory problems or infections  Who Manages Dysphagia? Multidisciplinary team involved at all times: ENT SLP Gastroenterologists Radiologist Neurologist Nurse Dietitian  Role of the SLP SLPs are the professionals most appropriately trained to assess and treat dysphagia in the oral and pharyngeal stages of dysphagia.  Purpose of Assessment To determine the presence or absence of dysphagia To evaluate the nature and severity of dysphagia. To determine the suitability of eating/ drinking safely To recommend intervention To provide prognosis for improvement and identification of relevant factors To refer for other services or professionals To counsel, educate, and train the patient, health care providers, and caregivers  Hierarchy of Assessments Screening Swallowing clinical assessment Insrumental Assessment: Videofluoroscopy- Modified Barium Swallow Endoscopy- Flexible Endoscopic Evaluation Swallowing (FEES)  Screening of Dysphagia The purpose of the screening is to determine (ASHA, 2009) The likelihood that dysphagia exists The need for further swallowing assessment  Screening of Dysphagia Screening is a pass/fail procedure to identify individuals with dysphagia. Once dysphagia is suspected a comprehensive clinical assessment should be administered. Screening protocols may include: o A questionnaire that addresses the patient's perception of and/or concern with swallowing o Observation of mealtime o Observation of the presence of the signs & symptoms of dysphagia  Screening of Dysphagia Early detection is important because complications from dysphagia can: Increase patient’s illness Lengthen hospitalisation Increase patient risk of death  Screening of Dysphagia Screening Assessment Who conducts it? Who conducts it? Nurses SLPs Doctors SLPs Outcome: Outcome: “Is it safe to eat? Yes/No” Why does this patient have swallowing problems? “Do we need an SLP for further assessment?” Is the patient aspirating? What can we do? What treatment can we recommend?  Components of a Clinical Assessment The main components of a clinical assessment include: 1. Medical/clinical records 2. Case history 3. Oral motor examination (OME) 4. General observation 5. Clinical observation 6. Swallowing trial 7. Feeding recommendations 8. Referrals for further instrumental assessment or other specialists  Sources of Information Medical File (current and previous file notes) Discussion with doctors & nursing staff/carers. Patient/client and family/carer interview  Medical File (1 of 3) Obtain the following information from the file: Diagnosis: Date and medical diagnosis Secondary diseases ◦ Gastroesophageal reflux disease (GERD) ◦ History of aspiration pneumonia ◦ Lung/breathing disorders ◦ Head/Neck Cancer ◦ Chemotherapy/Radiation  Medical File (2 of 3) Identify clinical signs of aspiration from the medical file Temperature: Fever indicates infection Chest status Respiratory status Colour of sputum  Medical File (3 of 3) Clinical Signs of Pneumonia Chest Clear OR patient exhibits: Productive cough Coloured/thick sputum Increased chest sounds Chest x-ray indicative of consolidation  Case History (1 of 3) 1. Referral details ◦ General information about patient/client 2. Hx of presenting condition ◦ Current medical diagnosis 3. Background medical Hx ◦ Other relevant medical Hx ◦ Previous Hx of dysphagia ◦ Previous SP intervention  Case History (2 of 3) 4. Diet status o Allergies, intolerances, preferences, nutritional supplements o Typical feeding status o Weight level o Diet currently tolerated o Texture of food/fluids o Quantity of food/fluids  Case History (3 of 3) 5. Client/Patient and carer perspective of eating/drinking difficulties ◦ Level of patient/caregiver distress ◦ Consider factors of fatigue, motivation  Oral Motor Assessment Observe the following: Oral condition – mucosa, dentition, oral hygiene Saliva management Protective reflexes Conduct Cranial Nerve Assessment  General Observations 1. Level of alertness 2. Ability to participate in assessment 3. Cognitive status 4. Head and body positioning 5. Presence of breathing and/or feeding/hydration tubes  Clinical Observation Oropharynx Observations of velum at rest & during phonation. o Is it symmetrical? o Does it move up & down? Assess gag reflex o Use tongue depressor to stimulate o Complete absence is not a good sign  Clinical Observation Larynx Ask patient to sustain vowel /a/ and make note of: Quality of voice (breathy, wet) Hyper/hypo nasal quality “Dry swallow” while palpating: Larynx should move forward and elevate Normal elevation= 2-4 cm Movement shouldn’t be weak Movement should be fast  Swallowing Trial It is important to try different consistencies of fluid & food Begin with fluids: o Thin (regular): Milk, water, juices, coffee, tea, etc. o Nectar thick: Thick as milkshakes, apricot or guava juice. o Honey thick: Thicken to be like honey consistency using a thickening agent. o Spoon thick (pudding): Thicken to pudding consistency using a thickening agent. Foods (Always start with a very small amount, ½ - 1 teaspoon) ◦ Regular food ◦ Dysphagia advanced: Thin-sliced, tender meats ◦ Dysphagia mechanically altered: Moist ground meat served with gravy or sauce. ◦ Dysphagia pureed: Puddings, custards, yogurt  Observations During Swallowing Trial Observe: Avoidance of certain food and liquids Any leakage or spillage Tongue movement Mastication Feeding respiratory pattern Listen: Cough Gurgly, wet voice Feel: Swallowing movements Delayed pharyngeal swallow  Signs of Penetration/Aspiration Change of voice quality o “Wet voice”: Presence of saliva or fluids in the larynx or even on the vocal cords Wheezing without asthma Gagging or excessive throat clearing during or after meals  Penetration/Aspiration Penetration/Aspiration before the swallowing: When fluid/ food in the mouth spills down into the larynx and beyond before the swallow is initiated. This is seen most in stroke patients. Penetration/ Aspiration during swallowing: When fluid/food during swallowing drops into the larynx and enters the airway. This could happen when vocal cords don’t close properly, due to paralysis, paresis, or tissue loss. Penetration/ Aspiration after swallowing: When some fluid/food remains in the lower throat and the patient takes a post-swallow breath  How serious is it to aspirate? Several factors can contribute to the effects of aspiration: 1. Quantity 2. Depth 3. Properties of the aspirated substance 4. Ability to clear aspirated material  Indications for instrumental assessment Continuing coughing Transport problems / food is getting stuck Recurrent aspiration pneumonias  Assessment of dysphagia/ Instrumental tools Types of instrumental tools: Endoscopy (Flexible Endoscopic Evaluation Swallowing) ◦ Most commonly used ◦ Conducted by a trained SLP ◦ Involves inserting an endoscope through the nose into the soft palate Videofluoroscopy (Modified Barium Swallow): ◦ A radiographic procedure ◦ The radiologist conducts the procedure ◦ Allows us to view the oral, pharyngeal and esophageal function during swallowing ◦ Allows us to visually observe if material is travelling into the airway  Management of dysphagia Individualised dysphagia management is based on: Patient’s history Findings of the clinical and instrumental assessment Prognosis  Management of dysphagia The purpose of dysphagia management: To protect the airway from obstruction Reduce the chance of food or fluids entering the lungs Ensure adequate nutrition and hydration Maintain quality of life  Management of dysphagia There are 3 main options for managing dysphagia: 1. Compensatory strategies 2. Swallowing rehabilitation 3. Changes in diet  Compensatory strategies These are strategies that are used to maintain swallowing safety and ensure adequate oral intake. They are compensatory and do not result in a lasting functional change. When using these strategies, a patient learns how to avoid symptoms of dysphagia Compensatory techniques are based on redirecting the bolus to the unaffected side / the stronger side How to determine ‘stronger’ side? o OMA o Medical diagnosis  Compensatory strategies: Chin Tuck Used for patients with delayed swallow initiation & reduced laryngeal elevation The patient is taught to drop their chin toward their chest & uphold this posture throughout swallowing. It results in narrowing the entrance to the larynx to prevent laryngeal penetration or aspiration.  Compensatory strategies: Head Turn Used for patients with unilateral pharyngeal, laryngeal weakness and reduced UES opening. The patient is instructed to turn their head toward the weaker side This strategy ensures the bolus is directed to the stronger side This strategy narrows the laryngeal entrance and increases vocal fold closure which is useful for patients with unilateral laryngeal weakness. It also drops the UES on the side opposite to the head turn resulting in increased expansion and duration of UES opening  Compensation: Head Tilt Used for patients with unilateral oral weakness Patients are instructed to tilt their head to their shoulders. This technique results in directing the bolus to the stronger side of the oral cavity  Swallowing Rehabilitation These are exercises designed to create lasting change in an individual’s swallowing by improving underlying physiologic function. These exercises improve function in the future rather than compensate for a deficit momentarily.  Swallowing Rehabilitation: Supraglottic swallow For patients who have reduced airway closure during swallowing. Patients are instructed to hold their breath, swallow, & then cough voluntarily before they inhale. This exercise increases the airway protection by increasing the vocal folds closure. Swallowing Rehabilitation: Effortful Swallow For patients with residue in the valleculae and/ or pyriform sinuses. Increases posterior tongue base movement to facilitate bolus clearance. The patient swallows and pushes hard with the tongue against the hard palate.  Swallowing Rehabilitation: Mendelsohn Designed for patients with reduced laryngeal elevation and/or reduced UES opening. Patients swallow and hold the larynx in an elevated position for several seconds before finishing the swallow. This exercise elevates the larynx and opens the oesophagus during the swallow to prevent penetration/aspiration  Diet Modification Modifying the texture of food and fluids will allow safe oral intake. Instrumental assessments are used to determine the food texture/fluid thickness safest for patients  Diet modification/Liquid Modifying liquids: The fast transit of thin liquids such as water creates risks for patients with: Poor motor skills who are unable to keep fluids in their mouths Patients at risk of aspiration Patients with reduced cognitive awareness  Diet Modification/Liquid Purpose of thickening fluids: To create a consistency that matches the patient’s capacity for swallowing To slow the time it takes for the liquid to move through the mouth into the oesophagus Allow better control of the swallow Decrease the risk of aspiration pneumonia  Diet Modification- Liquids The National Dysphagia Diet by the American Dietetic Association recommend four levels of thickened fluids: Thin: No thickener needed (water, tea, fruit juice, milk) Nectar-like: Thick juice, milkshake Honey-like: Consistency will be achieved by adding the appropriate amount of thickener to a liquid Spoon-like: This will be achieved by adding the proper amount of thickener to any liquid (pudding like)  Diet Modification- Food The National Dysphagia Diet by the American Dietetic Association recommend four levels of food textures: Dysphagia Pureed diet: Pureed foods with smooth textures (Hummus) Dysphagia mechanically altered diet: Soft and moistened foods (scrambled eggs, cooked soft fruits) Dysphagia advanced diet: Near normal foods cut into bite sized pieces (pasta, fish) Regular: Regular diet with most foods included  General Suggestions for a Safe and Efficient Swallow Be sure that dentures fit well Sit upright when eating, drinking and taking medication Have a quiet and relaxed atmosphere at mealtime Keep foods soft and moist if needed Chew well Chew and swallow food before talking Swallow before taking another bite When drinking, swallow each sip before taking another one Sit upright for at least an hour after eating to allow food to be digested Brush your teeth after each meal  General Suggestions for a Safe and Efficient Swallow If you need to be fed let the person feeding you know if They are going too fast They are giving large amount of food Not putting food in your mouth correctly