The practitioner's acquisition of advanced-level knowledge and skills as related to
intervention with people with feeding, eating, and swallowing difficulties is
_________________.
Individualized
Susceptibility to swallowing deficits:
CNS & PNS disorders (disease; trauma), such as:
-CVA
-TBI
-MD
-Alzheimer's and dementia
-CA of head, neck, esophageal
-Impaired oral cavity/dentition
-Polypharmacy
-Elderly
-15-50% of those > age 60
-40-50% of residents of SNF
Having a swallowing disorder
Increases risk of aspiration pneumonia
Feeding
Process of set up, arranging, and bringing food or fluids to mouth from plate or cup
Also known as self feeding sometimes
Getting food ready
Buttering rolls, adding sugar, cutting meat, etc
Eating
Keeping food in mouth, getting ready for swallowing. Manipulating the food.
Swallowing
Foods, fluids, medication and getting it to back of mouth and to the stomach
Dysphagia
Difficulty with any component of eating or swallowing
PO
By mouth
NPO
Nothing by mouth
Aspiration
Anything that is not air that enters the trachea below the larynx and vocal cords. (Food,
fluid, toys, anything)
5 Stages of feeding, eating, swallowing
Stage One: Pre-Oral /Anticipatory (feeding)
Stage Two: Oral Preparatory (eating)
Stage Three: Oral (swallow)
Stage Four: Pharyngeal (swallow)
Stage Five: Esophageal (swallow)
Stage one: Pre-oral/Anticipatory
Getting ready to eat
Smell the food
See it on the plate
Salvation
UE active ROM kicks in
(Voluntary)
Stage two: Oral preparatory
Lip closure around the food
Use tongue and cheek to move food around.
Start chewing and mastication
Turn food into a bolus
Need physical and muscular control as well as sensation to form a bolus.
Time frame various depending on type of food you're eating
(Voluntary)
Stage three: Oral
Bolus moves to middle of mouth to be forced to back of the throat for swallowing. Takes
about 1 second
Stage four: Pharyngeal
1 - soft palate elevates closing off nasopharynx
2 - larynx elevates & epiglottis tips to close off entrance to trachea
3 - pharyngeal peristalsis: pharynx constricts & pushes bolus down
through pharynx
4 - Upper Esopageal Sphincter relaxes -> food can pass down to esophagus
Swallowing apnea occurs during this stage (breathing stops)
Stage Five: Esophageal
Involuntary reflex
Upper esophageal closes
Contracting and relaxing of muscle occurs: esophageal peristalsis
Gravity helps move food down to stomach - 8-20 seconds
Types of Dysphagia (three types total)
Neurologic
-Paralytic
-Pseudobulbar
Structural
-Mechanical
Neurologic Dysphagia (2)
1.Paralytic - LMN impairment
- oral & pharyngeal anatomy is weakened
&/or sensory impairment
- weak or absent swallow reflex
2. Pseudobulbar - UMN impairment
-oral motor musculature with abnormal tone
- swallow reflex slow &/or poorly controlled
Structural Dysphagia (1)
Mechanical - loss of normal anatomical structures in the mouth, pharynx or esophagus
-weakness due to injury of above
-sensory loss of these anatomical structures
Clinical Assessment
History & OP: diagnosis, previous med. history, I&O, mealtime behavior, weight,
respiratory status, NPO status, individual food preferences (diet, culture, religion)
Cognition:
Alert
Follow directions
Memory
->WHY?
Safety
Actively participate
Perception: vision, neglect, anosognosia, somatagnosia, spatial relations, right/left
discrimination, perseveration
Physical: endurance, ROM, strength, dexterity, tone, & sensation -UB/UE and oral -
particularly for self-feeding, pre-oral and oral prep stages
If deemed appropriate based on all of above, proceed with feeding trial.
Signs & Symptoms of Aspiration
Change in color
Prolonged coughing
Breathiness
Loss of voice
Gurgling
Choking
Drop in o2 levels
No swallow response at all
Aren't able to keep mouth closed
Drooling excessively
*CAN BE SILENT
Clinical observations during feeding trial:
Look for: pocketing of food, collection of food on hard palate, loss of food from mouth,
slow oral transit time, excessive tongue movement, excessive oral secretions,
regurgitation of food from nose.
-Listen for: cough or choke, gurgling in voice of loss of voice, wetness heard with
stethoscope (auscultation)
-Feel : neck palpation during swallow
-Monitor oxygen levels: pulse oximeter (suspect if O2 < 92%)
Feeding trial:
Begin with thick fluids and soft foods. If client is safe with, proceed per food and fluid
progression.
Assess pre-oral and oral prep stages: ability to manipulate food and utensils, bring food
and liquids to mouth, oral-motor functions (open/close mouth, biting, chewing)
Assess oral stage: is bolus formed, contained, moved, chewed?
Assess pharyngeal stage: laryngeal elevation, voice quality after swallow, repetitive
swallows, cough reflex
Recommendations from clinical assessment
PO vs NPO
-Nutritional consult
-Specific textures of food/fluids
-Specific positioning techniques for mealtimes
-Supervision level
-Assistive equipment
-Instrumental assessment
INSTRUMENTAL ASSESSMENT (imaging diagnostics): Electromyography
Assess pertinent muscle function via electrodes
INSTRUMENTAL ASSESSMENT (imaging diagnostics): Fiber optic endoscopic swallow
study
View still anatomy (palate, pharynx, larynx) and when in motion during swallowing via
camera at end of tube inserted nasally
INSTRUMENTAL ASSESSMENT (imaging diagnostics): Manometry
Esophageal contractions measured via catheter
INSTRUMENTAL ASSESSMENT (imaging diagnostics): Scintigraphy
Camera tracks radioactive particles in food, assesses speed of bolus transit, aspiration
INSTRUMENTAL ASSESSMENT (imaging diagnostics): Ultrasound
View mobility of anatomy
INSTRUMENTAL ASSESSMENT (imaging diagnostics): Video Fluoroscopy
Most common
Modified barium swallow (MBS)
Swallowing therapist able to assist in implementation and interpretation; client swallows
various consistencies of food/fluid while video provides clinicians with real time viewing
of process of swallowing.
Standardized Assessment:
The Dysphagia Outcome and Severity Scale:
Provides standardized reporting mechanism to qualify and quantify clinical observations
of swallowing and the MBS
7-point scale to rate function
oral severity of dysphagia
Assists in formulating recommendations for diet, level of (I), and nutrition
Quick with excellent interrater and intra-rater reliability
Intervention: Indirect
Compensatory and remedial, w/out food ingestion) (For clients at risk for aspiration, all
intervention will be indirect at first.)
a) Restorative:
Increase ROM, strength, coordination, endurance at any deficient area (UB/UE, neck,
head, oral motor)
Strengthen pharyngeal and laryngeal anatomy
b) Compensatory:
Desensitize oral cavity (brush teeth etc)
Increase swallow response
Environmental modifications
Positioning
Presentation of food
Assistive feeding equipment
Appropriate verbal direction
Order of food presented, size of bites
Intervention: Direct
During ingestion of food
Chin tuck: down towards chest during swallow
Effortful swallow: conscious effort to squeeze throat muscles
Mendelsohn maneuver: push tongue up against roof of mouth
Neck rotation: turn head towards weaker side, or, stronger side ((D) upon specific
anatomical problem)
Supraglottic swallow: hold breath during swallow, cough after
Super-supraglottic swallow: as above, with increased effort/'bearing down'
New Dysphagia Standards
2012 -2015- International Dysphagia Diet Standards Initiative -
Effort to standardize terminology and categories:
-8 levels, 0 - 7.
-0 - 4: thin drinks (0) to extremely thick drinks (4)
-3 - 7: liquidised foods (3) to regular foods (7)
Diet progression (by texture) food:
Thick puree
Very soft moist chewable
Dry chewable
Firm chewable w/ biting
Diet progression (by texture) fluid:
No fluids
Honey thick
Nectar thick
Thin flavored
Water
Safety
Use universal / standard precautions at all times
Cease eating if signs and symptoms of aspiration present
Have patient cough, talk, in between bites to assess voice quality and ensure airway is
open
Manage secretions: cough, talk, suction as needed
Tracheostomy (safety)
Can cause, or worsen, existing dysphagia
Increased risk of aspiration:
delayed swallow reflex
pooling in pharynx
decreased vocal cord closure
decreased laryngeal movement
Ventilator (safety)
If air entry is via trach, patient may be able to eat by alternating breathing and
swallowing
-chance of developing dysphagia increases after 1 week
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