Dysphagia – Follow The Swallow
Barbara Kamm Miller, M.A. CCCSLP, CBIS
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RESPECT
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What is Dysphagia?
Dysphagia is the term used to describe a
disorder of swallowing.
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What are some causes of
Dysphagia?
Dysphagia may be caused by Acquired or
Traumatic Brain Injury, neurological deficits,
cancer, MS, ALS, Parkinson’s Disease etc.
What else can cause Dysphagia?
In addition, secondary complications such as
anoxia, pneumonia, intra-cranial pressure,
seizures, lesions from intubation may all
contribute to Dysphagia.
What are the four stages of
swallowing?
The four stages of swallowing are:
1. Oral preparatory- the act of taking food, chewing it,
mixing it with saliva, and forming it into a bolus.
2. Oral- controlling the bolus and transporting it to the
back of the mouth.
3. Pharyngeal- initiating the swallow reflex in a timely
manner which is normally 1 second.
4. Esophageal- the food enters the esophagus, the
passageway to the stomach.
View of Normal Swallow
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What are the symptoms of
Dysphagia?
The following symptoms may be observed:
Coughing / choking while eating or drinking
Coughing after swallowing
Choking
Uncoordinated chewing or swallowing
Leakage of food or liquid from the mouth
Leakage of liquid from the nose
Reddening of the face
Symptoms continued
Pocketing of food in the cheek
Labored or effortful swallowing
Gurgling or wet vocal quality
Complaints of food sticking in the throat
Facial grimacing
Impulsive eating or drinking behavior is a red flag.
How does a Speech/Language
Pathologist prepare for an
assessment?
1. Interview the patient
2. Check the patient’s chart for the admitting
diagnosis.
3. Check nursing notes, look for indications of
coughing or choking
4. Check the patient’s level of alertness.
Assessment cont.
5. Check the chart for additional diagnoses which
may put the patient at risk for dysphagia.
6. Review previous treatments listed.
7. Obtain the patient’s pre-morbid status.
Assessment cont.
9. Review the patient’s nutrition and hydration
status
10. Check the patient’s current diet.
11. Note any dietary restrictions
12. Note any special diets the patient may be
following, such as an ADA diet for diabetes,
or an American Heart Association diet
Assessments continued
Is the patient on an alternate method of feeding,
such as an IV, NG tube, or a PEG tube?
Other factors to consider are:
What medications is the patient taking?
Do any of the medications enhance, or hamper
swallowing?
How are medications presented- are they by
mouth, and if so are they taken whole ?
Assessments continued
How is the patients respiratory status? Notes
from
Respiratory Therapy, or results of chest x-rays
must be reviewed.
Is the patient on oxygen?
Is the patient, or has the patient been recently
intubated?
Assessments continued
Check nursing notes to get information regarding
the patient’s usual living situation, cognitive status
etc.
Last, but certainly not least, check for other GI
examinations, such as a barium swallow, which
examines the esophagus, or a GI series.
Clinical Swallow Evaluations
Initially, an oro-motor examination of the jaw, lips
and tongue will be performed. Any deviations
or weaknesses will be noted.
This may be followed by a 3 oz. water swallow
test, whereby the patient is given 3 oz. of water
in a cup, and told to drink it all without
stopping. An abnormal response would be
coughing during or after the exam, or a change
in vocal quality, to wet or hoarse.
Blue Dye Test
If the patient is on a trach, and suctioned, then the
presence of the blue dye would indicate
aspiration (leakage into the airway or lungs).
This test would be appropriate in an acute hospital
setting.
Modified Barium Swallow - MBS
A Modified barium swallow is performed by a
Radiologist, a Speech-language Pathologist, and
a radiology technician.
Barium sulfate powder is mixed in liquid form.
Thickener is added to make liquids nectar, honey
or puree consistency.
MBS continued
Barium paste is used, and spread on cookies.
The test is done in 2 views, Lateral (side), and AP
Anterior-Posterior.
MBS continued
Thin liquids are first presented in small amounts, 3
cc, 5 cc, 10 cc, and then progressed to
uncontrolled amounts.
Liquids are presented from a cup, and through a
straw.
MBS continued
As soon as the patient exhibits difficulties,
compensatory techniques are attempted.
Techniques may be as simple as:
adjusting or changing posture,
changing texture,
a chin tuck for airway protection,
or a supraglottic swallow, which will be explained
shortly.
MBS continued
The MBS also allows screening for the esophageal
phase of the swallow. Any abnormalities will be
noted, and recommendations for follow up with
a specialist will be provided.
MBS continued
All testing is recorded on DVD, and available for
review at a later time.
By the time the patient is finished with the MBS,
he / she should know what the safest and least
restrictive diet is, and which compensatory
strategies should be used in order to avoid
aspiration.
Video of MBS
Normal
http://www.youtube.com/watch?v=PwVreNrTK
Bw
Abnormal
http://www.youtube.com/watch?v=huZ6ymeKFd
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Fiberoptic endoscopic Evaluation
of Swallowing FEES
The FEES was developed in 1991 by Dr. Susan
Langmore. There are two parts to the
examination. A flexible endoscope is passed
through the nasal passage, into the pharynx
The first part of the procedure involves examining
the structures, and function of the larynx and
pharynx. This also allows the examiner to
determine how secretions are being managed.
FEES continued
During the second part of the exam, swallowing
function with different sizes and consistency of
liquid and solid boluses is assessed.
When a problem is detected, boluses may be
thickened, or postures may be altered, in order
to see if the problem is minimized, or
eliminated.
Comparison of MBS and FEES
FEES is more often utilized in long term care
facilities, as it can be performed at the bedside,
MBS is performed in a hospital or outpatient
setting.
MBS exposes the patient to radiation, FEES
doesn’t.
FEES is more invasive, due to the endoscope.
What’s Next?
Once the results of the examinations are received,
the patient will be placed on the safest and least
restrictive diet.
Dietary Levels
The National Dysphagia Diet by the American
Dietetic Association has several levels that a
patient may progress through.
Level 1
Level 1 consists of pureed and cohesive foods
with smooth textures.
Examples include: pureed meats, pureed
vegetables, pureed / strained soups, mashed
potatoes, Cream of Wheat etc.
Level 2
Level 2 consists of mechanically altered foods,
which are soft and moistened.
Examples include: baked fish, cottage cheese,
macaroni and cheese, pureed meats, vegetable
soufflé, cheesecake without crust
Level 3
Level 3 consists of foods which are near normal in
texture, cut into bite sized pieces.
Recommended foods include: ground meat, tuna
salad, cottage cheese, sliced cheese, pancakes,
waffles, all types of potatoes, cream pies etc.
Level 4
Level 4 is a regular consistency diet, with most
foods included.
Liquids
Liquid recommendations may be :
Thin – no thickener needed. Thin liquids include
broth, water, tea, coffee, fruit juice, jello, ice
cream , milk, and popsicles.
Thickened Liquids
Nectar like- liquids naturally this consistency
would include;
V-8 juice, milkshakes, egg nog, fruit nectars etc.
Honey like
Honey like consistency will be achieved by adding
the appropriate amount of thickener to a liquid.
Instructions are printed on the label of the
thickener canister.
Spoon Thick
Spoon thick liquids will be pudding like. This will
be achieved, by adding the proper amount of
thickener to any liquid, hot or cold.
Thickeners
Thickeners are available commercially, in canisters
or packets. Thickeners may be obtained via
prescription, or over the counter.
There are some pre-thickened liquids available for
purchase.
Thickener alters the texture, but not the taste of
the liquid.
Compensatory Strategies
In addition to tailoring a diet to the patient’s
current needs, compensatory strategies may be
implemented to optimize safety.
Examples of compensatory
strategies
1. Head turn to the weaker side- to close it off,
and prevent a bolus from traveling down the
weaker side by twisting the pharynx.
Turn your head to the side as though you are
looking over your shoulder.
2. Chin tuck for airway protection, and to force
the bolus into the esophagus.
Strategies Continued
Bring your chin to your chest.
3. Head tilt to the stronger side, directs the bolus
to the stronger side of the oral / pharyngeal
cavities.
Tilt your head like you are trying to touch your
ear to your shoulder.
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Strategies continued
4. Head back will allow gravity to clear the oral
cavity for patients with an oral transit
dysfunction.
Tilt your head back like you are looking up.
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Develop a Swallow Guide
A Swallow Guide is an invaluable tool. It contains
written and pictorial instructions. Positioning,
diet level, rate and method of feeding, and all
specifics are clearly outlined. It also contains
reminders for use of any assistive devices such
as eyeglasses, hearing aids, and dentures, as well
as Reflux Precautions to be followed.
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Therapeutic Interventions
The Speech-language Pathologist may implement a
therapy program designed to strengthen the
swallowing mechanism.
Therapeutic interventions
continued
Therapy will focus on strengthening the weakest
areas. Recommended exercises may be:
Oro –motor exercises – to strengthen the tongue,
lips, cheeks and jaw.
Falsetto/pitch exercises- pitch glides for airway
protection.
Therpeutic Interventions
continued
3. Head lift maneuver- to improve forward
movement of the larynx.
4. Masako tongue hold- to strengthen the base of
the tongue
5. Mendelsohn maneuver- to keep the larynx at its
highest point to reduce food from falling into
the airway.
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Therapeutic Interventions
continued
6. Head / neck stretch
7. Supraglottic Swallow – to keep the voice box
closed to keep food or liquid from entering the
lungs.
8. Effortful Swallow – strengthens the base of
the tongue.
9. Gargle- also strengthens the base of the
tongue.
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Additional Techniques To
Stimulate The Swallow
1. Sour bolus- presenting a lemon swab for
sucking on, or lemon ice in small amounts.
2. Cold bolus – alternating very cold bites or sips
of food / liquid
3. Thermal stimulation- using a chilled 00 mirror
to stimulate various parts of the oral cavity.
Thermal Stimulation
http://www.youtube.com/watch?v=wRAPHIqL3
z0
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Patient and Caregiver Education
Patients and caregivers should be provided with
clear instructions regarding all precautions,
strategies and interventions utilized to keep the
patient safe from aspiration.
As previously mentioned, written Swallow Guides
are helpful for consistently adhering to the
recommended diet and strategies.
Conclusion
In conclusion, Dysphagia can be managed
effectively if you follow the swallow in all of it’s
stages, and utilize recommended strategies and
therapeutic techniques to minimize the risk of
aspiration.
Thank You
Thank you so much for attending today’s Webinar.
Please feel free to e mail me at
barbara.miller@bancroft.org should you have
any questions.
References
Source For Dysphagia, Nancy B. Swigert, third
edition 2007
Swallowing In TBI, calder.med.edu
American Speech-Language Hearing Association,
Preferred Practice Patterns for the Profession of
Speech-Language Pathology