Dysphagia Lecture 3

Reduced Lip Closure

Reduced Tongue Shaping/Coordination

Reduced Tongue Range of Motion (ROM) or Coordination

Reduced Labial Tone/Strength

Reduced Buccal Tension/Tone

Reduced Tongue Control, Tongue Thrust

Apraxia of swallow, reduced oral sensation

Apraxia of swallow

Tongue thrust

Reduced Labial Tension/Tone

Reduced Buccal Tension/Tone

Reduced Tongue Shaping

Reduced Tongue ROM or Strength

Reduced Tongue Elevation

Reduced Tongue Elevation/Strength

Reduced Lingual Coordination

Abnormal Tongue Movement/Coordination

Reduced Tongue Control/Linguavelar Seal

Piecemeal Deglutition

Reduced Velopharyngeal Closure

Unilateral Pharyngeal Wall Weakness

Reduced Bilateral Pharyngeal Contraction

Reduced Base of Tongue (BOT) Movement

Reduced Laryngeal Elevation

Residual material in the pharynx

Reduced Laryngeal Closure

Reduced Anterior Laryngeal Motion/Cricopharyngeal Dysfunction

Esophageal-Pharyngeal Backflow

Tracheoesophageal Fistula

Zenker's Diverticulum

Gastroesophageal Reflux Disease

Barrett's Esophagus

Achalasia

A tracheoesophageal fistula is a hole in the soft tissue of the common wall between the trachea and the esophagus.

A tracheoesophageal fistula can allow food to flow back into the trachea from the esophagus.

Zenker's diverticulum is a side pocket that forms when the pharyngeal or esophageal muscle herniates, typically in the cricopharyngeal region

Zenker's diverticulum may be caused by a hypertonic cricopharyngeus muscle, which leads to increased pressure during swallowing.

Zenker's diverticulum appears as a balloon-like structure on a modified barium swallow (MBS) study.

GERD stands for Gastroesophageal Reflux Disease. It is the backflow of food and stomach acid from the stomach to the esophagus due to the failure of the lower esophageal sphincter (LES) to keep food in the stomach.

GERD cannot be detected on an MBS study as the LES, which is responsible for the reflux, is not typically visualized during the procedure. If GERD is suspected, it is recommended to refer the patient to a gastroenterologist for further evaluation and management.

Screening procedures are used to identify signs and symptoms of dysphagia, such as coughing, a history of pneumonia, or food residue in the oral cavity. These screenings can be performed at the bedside, home, or school settings and may involve a combination of observation, patient history, and chart review. They are designed to be quick, low-cost, and low-risk assessments.

The advantages of screening procedures include their quick and accessible nature, as they can be performed in various settings without the need for specialized equipment or extensive resources. They are cost-effective and can provide initial insights into the presence of dysphagia, helping to identify individuals who may require further evaluation and intervention.

Screening procedures have some limitations. They are not comprehensive assessments and may not provide a detailed understanding of the underlying causes and severity of dysphagia. They primarily serve as initial screening tools and may not capture subtle or asymptomatic swallowing difficulties. If dysphagia is suspected based on the screening results, further evaluation by a qualified healthcare professional is recommended for a more comprehensive assessment.

Screening for swallowing disorders is a preliminary assessment that focuses on identifying individuals who may have dysphagia. It involves observing signs and symptoms of dysphagia, such as coughing, history of pneumonia, or food residue in the oral cavity. However, it does not examine the detailed anatomy or physiology of the oropharynx.

The primary purpose of screening is to identify individuals who may have swallowing difficulties and require further evaluation. Screening helps to flag potential cases of dysphagia, allowing for timely referral to diagnostic procedures, such as videofluoroscopic swallowing studies (MBS) or fiberoptic endoscopic evaluation of swallowing (FEES).

While screening can provide initial indications of swallowing difficulties, it does not provide a comprehensive understanding of the underlying causes or severity of dysphagia. Further assessment through diagnostic procedures, such as MBS or FEES, is required to evaluate the anatomy, physiology, and functional aspects of swallowing in more detail. These diagnostic procedures provide more specific information to guide treatment and management decisions for individuals with dysphagia.

Identifying etiologies during the screening process helps to understand the underlying causes of dysphagia. It allows healthcare professionals to determine the factors contributing to the swallowing difficulties, such as neurological conditions, structural abnormalities, or medical conditions. This information is crucial for selecting appropriate diagnostic tests and planning the most effective approach for assessment and treatment.

Determining appropriate diagnostic tests is essential to obtain a comprehensive evaluation of swallowing function. Different diagnostic tests, such as MBS or FEES, provide valuable information about specific aspects of swallowing, such as oral, pharyngeal, or esophageal function. By selecting the most appropriate tests based on the individual's symptoms and clinical presentation, healthcare professionals can obtain accurate and detailed information to guide diagnosis and treatment planning.

The screening process provides insights into the nature and severity of the swallowing problem, which helps in planning the most suitable approach for assessment and treatment. It allows healthcare professionals to consider various factors, such as the patient's age, medical history, and specific needs, in order to develop a personalized plan of care. This may involve recommendations for modified diets, compensatory strategies, or therapeutic interventions to improve swallowing function and ensure safe and efficient oral intake.

Teaching about feeding problems is an integral part of the screening process, especially when dysphagia is identified. It involves providing information and education to the patient and their family about the nature of the swallowing difficulties, potential risks associated with dysphagia, and strategies to manage and cope with feeding challenges. Teaching can include guidance on modified food textures, adaptive feeding techniques, and appropriate positioning during meals. This education helps promote safety, improve feeding outcomes, and empower the patient and their family to actively participate in the management of dysphagia.

Chart review provides valuable information about the patient's medical history, including past medical conditions, surgeries, and medications. It helps in identifying any pre-existing conditions or factors that may contribute to dysphagia. Additionally, it can provide insights into the patient's current nutritional status, previous treatment approaches, and any documented incidents of aspiration or pneumonia. Chart review helps in gathering a comprehensive background to inform the evaluation and management of swallowing disorders.

Assessing cognitive-communication status is crucial because cognitive abilities and communication skills can impact swallowing function. Cognitive impairments, such as dementia or stroke-related cognitive deficits, can affect the patient's ability to understand and follow instructions during swallowing evaluations and implement recommended strategies for safe swallowing. Communication difficulties, such as aphasia or dysarthria, may also influence the patient's ability to express their swallowing symptoms or understand the instructions provided by healthcare professionals. Evaluating cognitive-communication status helps in planning appropriate assessment and intervention strategies for individuals with swallowing disorders.

Assessing the respiratory status and checking the tracheostomy or ventilator function is important in the evaluation of swallowing disorders. Dysphagia can increase the risk of aspiration, which can lead to respiratory complications. Monitoring the patient's respiratory status helps in identifying any signs of respiratory distress or difficulties that may be related to swallowing dysfunction. For patients with tracheostomy or on a ventilator, ensuring proper functioning and management of the airway is crucial during swallowing evaluations to prevent aspiration or airway compromise.

The oral-mechanical exam assesses the structures and movements involved in the oral phase of swallowing. It involves evaluating the strength, range of motion, coordination, and sensation of the lips, tongue, jaw, and facial muscles. The exam helps in identifying any abnormalities or weaknesses in these structures that may affect the oral preparatory and oral transport stages of swallowing. It provides valuable information about the integrity and functionality of the oral mechanism and aids in determining appropriate treatment strategies or referrals for further assessment.

The cranial nerve exam is conducted to assess the function of the cranial nerves that are involved in swallowing. Cranial nerves, such as the trigeminal (V), facial (VII), glossopharyngeal (IX), vagus (X), and hypoglossal (XII) nerves, play a vital role in coordinating the movements and sensation required for effective swallowing. Assessing the integrity of these cranial nerves helps in identifying any deficits or abnormalities that may contribute to swallowing difficulties. It guides the evaluation and management of dysphagia and aids in determining appropriate treatment approaches or referrals to other healthcare professionals if necessary.

A laryngeal function exam assesses the function and coordination of the laryngeal structures involved in swallowing. It involves evaluating the movement and closure of the vocal folds, the effectiveness of laryngeal elevation, and the integrity of the laryngeal protective mechanisms during swallowing. The exam helps in identifying any laryngeal abnormalities, such as reduced vocal fold closure or penetration/aspiration, that may contribute to dysphagia. It provides valuable information for planning appropriate interventions and determining

Assessing optimal posture during a bedside exam helps determine the most suitable body positioning for the patient during swallowing. Proper posture plays a crucial role in facilitating safe and efficient swallowing by ensuring the correct alignment of the head, neck, and body. It can help reduce the risk of aspiration and improve bolus control and transit through the oral and pharyngeal phases of swallowing. Identifying the optimal posture for each individual can guide recommendations for positioning adjustments during meals and swallowing therapy.

Identifying the best position of food in the mouth is important to optimize oral preparation and bolus manipulation. Some individuals may have difficulty with specific food placements, such as holding the bolus too far forward or on one side of the mouth, which can affect oral control and coordination during swallowing. Assessing the optimal position of food in the mouth helps in determining strategies to improve bolus management and reduce the risk of oral residue or premature spillage into the pharynx.

Determining the best food consistency is crucial in managing swallowing disorders. Different individuals may have specific tolerances or difficulties with certain food consistencies, such as thin liquids, thick liquids, purees, or solids. Identifying the most appropriate food consistency for each patient helps in developing safe and effective diet modifications or texture modifications. It ensures that the bolus is manageable and can be safely swallowed without causing aspiration or choking.

Placing a hand lightly on the neck and phonating "ah" during trial swallows helps assess the coordination and movement of the laryngeal structures during swallowing. It allows for the detection of any laryngeal abnormalities, such as vocal fold movement asymmetry or laryngeal penetration, which may not be visible externally. The phonation of "ah" helps elicit laryngeal movement and provides valuable information about laryngeal function during swallowing. This information is important for understanding the presence of any laryngeal abnormalities that may contribute to dysphagia and guiding appropriate treatment approaches or referrals.

Tracheostomy tubes are inserted for the following reasons:

Upper airway obstruction at or above the level of the true vocal cords.

Potential upper airway obstruction, such as edema.

Respiratory care, including suctioning.

Tracheostomy tubes are inserted into the trachea via an incision made between the third and fourth tracheal rings. They are left in place until the factors causing the need for the tube are alleviated. In some cases, tracheostomy tubes may be left permanently.

- outer cannula

- inner cannula

- obturator

The purpose of downsizing tracheostomy tubes during the weaning process is to gradually reduce the size of the tube. This is typically done in a stepwise manner, starting from larger sizes (e.g., 8mm) and progressing to smaller sizes (e.g., 6mm, 4mm). By downsizing the tracheostomy tube, it helps to evaluate and assess the patient's ability to breathe through their oral and nasal passages.

After the tracheostomy tube has been downsized, the next step in the weaning process is to cap the tracheostomy tube for short periods of time. This involves covering the opening of the tracheostomy tube temporarily to encourage the patient to breathe through their mouth and nose. The purpose of this step is to assess if the patient is ready for decannulation, which is the removal of the tracheostomy tube.

The ultimate goal of the weaning process involving tracheostomy tubes is to encourage oral-nasal breathing. By downsizing the tracheostomy tube and gradually capping it, the aim is to assess the patient's ability to breathe independently through their natural airways without the need for the tracheostomy tube. If the patient demonstrates sustained oral-nasal breathing and is able to tolerate trach tube capping for extended periods, it indicates that they may be ready for decannulation, which involves the removal of the tracheostomy tube.

Voicing with a tracheostomy tube is achieved by utilizing the small amount of space between the tube and the trachea. During inhalation, when the finger is used to occlude the opening of the tracheostomy tube, air can pass around the tube and through the larynx, allowing for voicing. However, it is important to note that the voice produced with a tracheostomy tube is typically softer and more breathy compared to natural voicing.

When the finger occludes the tracheostomy tube during inhalation, it creates a temporary closure of the tube's opening. This allows air to be directed through the natural larynx, enabling the production of voice. By redirecting the airflow through the larynx, individuals with a tracheostomy tube can generate vocal sounds. However, the resulting voice quality is often softer and more breathy due to the altered airflow dynamics caused by the presence of the tracheostomy tube

When voicing with a tracheostomy tube, the voice quality is generally characterized as softer and more breathy compared to normal voicing. The presence of the tracheostomy tube disrupts the natural airflow patterns and vocal cord vibration, leading to a reduction in vocal loudness and clarity. The air passing through the larynx is diverted around the tube, resulting in a voice that may sound weak and lacking in projection.

Cuffed tracheostomy tubes are used for respiratory treatment and to reduce the risk of aspiration. The cuff, which surrounds the lower portion of the tube like a balloon, can be inflated to create a seal between the upper and lower airway. In contrast, uncuffed tracheostomy tubes do not have a cuff and allow for more unrestricted airflow.

Cuffed tracheostomy tubes are used for respiratory treatment and to address potential aspiration risks. The cuff, when inflated, acts as a seal between the upper and lower airway, preventing air from escaping and reducing the risk of aspiration.

Fenestrated tracheostomy tubes are used for patients who are experiencing difficulty producing voice while using a cuffed tracheostomy tube. They feature a small opening or fenestration above the cuff, allowing airflow through the vocal cords and enabling the patient to phonate and produce voice.

Fenestrated tracheostomy tubes have a small opening or fenestration above the cuff, enabling airflow through the vocal cords and facilitating voice production. Unfenestrated tracheostomy tubes, on the other hand, do not have this opening and direct all airflow through the tracheostomy tube, limiting the patient's ability to produce voice.

Fenestrated tracheostomy tubes have a fenestration or window present in the tube, which allows for greater airflow through the upper airway. They are used to facilitate improved airflow and support voice production in patients who may have difficulty speaking with a regular tracheostomy tube.

Yes, fenestrated tracheostomy tubes are often used during the weaning process. The presence of the fenestration allows for increased airflow through the upper airway, which can help patients transition from assisted breathing to breathing through their natural airway. This step is usually part of the gradual process of weaning a patient from tracheostomy tube dependence.

No, it is rare for cuffed tracheostomy tubes to be fenestrated. The majority of fenestrated tracheostomy tubes are uncuffed. Cuffed tracheostomy tubes are primarily used for respiratory treatment and protection against aspiration, and the presence of a fenestration may compromise their intended functions. Fenestrated tracheostomy tubes are more commonly used in situations where voice production and increased airflow are the primary goals.

Presence/Status of Cuff: Determine if the tracheostomy tube has a cuff and whether it is inflated or deflated.

Size of Tracheostomy Tube: Note the size of the tracheostomy tube, which can affect airflow and patient comfort.

Presence of Fenestration: Identify if the tracheostomy tube has a fenestration (a small opening), which can impact airflow and voice production.

Length of Time Tracheostomy Has Been in Place: Consider the duration the tracheostomy tube has been in place, especially if it exceeds six months. Prolonged placement can lead to scar tissue formation that may impede laryngeal elevation and function.

Deflating the Tracheostomy Cuff: If it is medically feasible, deflate the tracheostomy cuff during the evaluation process. This allows for the assessment of natural airflow and vocalization.

The Blue-Dye Test is used as a screening method to detect the presence of aspiration in patients. During the test, the patient is given measured amounts of food mixed with blue dye, and their swallowing is immediately followed by suctioning to check for the presence of the blue dye in the aspirate.

Does not reveal anatomical or physiological causes of aspiration: While the test can determine if aspiration has occurred, it does not provide information about the underlying anatomical or physiological reasons for the aspiration.

False negatives: The Blue-Dye Test can yield false negative results, meaning that it may not detect cases of aspiration even when it is present. False negatives can occur in up to 50% of cases, reducing the test's reliability in identifying aspiration.

Worsened swallowing while on the vent: Swallowing function may be compromised when a patient is on a ventilator. The mechanical support provided by the ventilator can impact the coordination and effectiveness of the swallowing process.

Slightly slower oral and pharyngeal phase of swallow: Ventilated patients may exhibit a slight delay in the oral and pharyngeal phases of swallowing. This delay can be attributed to factors such as reduced muscle strength and coordination due to their medical condition and the presence of the ventilator.

Inflated cuff may reduce laryngeal elevation: The inflated cuff of the tracheostomy tube can hinder the movement and elevation of the larynx during swallowing. This can result in reduced protection of the airway and an increased risk of aspiration.

There is a suspicion of aspiration.

A pharyngeal swallowing disorder is suspected.

There is any pharyngeal component to the swallowing disorder.

Define abnormalities of anatomy and physiology related to swallowing.

Identify and evaluate treatment strategies that can improve swallowing function.

Chart review: Review patient's records, including history, evaluations, conditions, medications.

Observations: Assess appearance, posture, alertness, respiratory distress signs.

Cognitive-communication status: Evaluate cognitive abilities, communication skills.

Respiratory status, trach/vent check: Assess respiratory function, tracheostomy/ventilator.

Swallowing history: Gather difficulties, treatments, feeding methods.

Oral-mechanical examination: Evaluate lip closure, tongue movement, residue, oral control.

Cranial nerve examination: Assess trigeminal, facial, glossopharyngeal, vagus, hypoglossal nerves.

Laryngeal function examination: Evaluate vocal folds, sensation, cough reflex.

Optimal posture: Position patient for swallowing.

Food placement: Determine mouth placement.

Food consistency: Select safe consistencies.

Trial swallows: Monitor laryngeal movement, vocal fold closure, coordination.

Regular Diet

Soft Diet

Mechanical Soft Diet

Chopped Diet

Puree Diet

Thin Liquid

Nectar Thick Liquid

Honey Thick Liquid

Pudding Thick Liquid

Regular Diet

Soft Diet(omit hard to chew meats/breads, raw veggies/fruits-apples, carrots)

Mechanical Soft Diet

Chopped Diet

Puree Diet

Thin Liquid

Nectar Thick Liquid

Honey Thick Liquid

Pudding Thick Liquid

test mockbedside from notes