Chapter 10: Dysphagia Justice Communication Sciences and Disorders: An Introduction Copyright ©2006...

Chapter 10:

Dysphagia

JusticeCommunication Sciences and Disorders: An Introduction

Copyright ©2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458

All rights reserved.

Focus Questions

• What is dysphagia?

• How is dysphagia classified?

• What are the defining characteristics of dysphagia?

• How is dysphagia identified?

• How is dysphagia treated?

10.1




Introduction

• Dysphagia: impairment in the ability to swallow because of neurological or structural problems that alter the normal swallowing process

• ASHA expanded the Scope of Practice for speech-language pathologists to include swallowing disorders in late 1980s

• Dysphagia intervention now makes up about 50% of a SLP’s caseload in medical settings (e.g., hospital, nursing homes)

10.2




Case Study #1: Sylvia Anderson• 78-year old with Alzheimer’s dementia

living in a nursing home – needs minimal to moderate assistance while eating

• Lately, hasn’t been finishing meals, has gurgly voice quality during mealtime, and has recently had severe coughing episodes while eating

• SLP suspects a pharyngeal stage swallowing problem and wants a further instrumental assessment at local hospital

10.3




Case Study #1 Questions

• Transporting Sylvia to the local hospital for an instrumental examination is costly. How can the costs be justified?

• How might reliance on others for assistance with feeding influence nutritional status and hydration?

10.4




Case Study #2: Lee Chin• 43-year old bilingual man who has

persistent dysphagia following cancer of the right buccal space

• To treat the cancer, Lee had radiation therapy and neck dissection

• Currently exhibits pharyngeal dysphagia, aspiration, hoarse vocal quality, and right lower facial weakness

• Currently receives nutrition through a g-tube

10.5





• Is Lee a candidate for dysphagia therapy at this time? Why or why not?

• What education should be provided to Lee regarding his situation?

10.6




Case Study #3: Martin Coleman• 45-year old man diagnosed with ALS 18 months

ago• Unable to work, on a puree diet with thin liquids,

has lost 15 pounds in past two months, just recovered from severe aspiration pneumonia

• MBS shows severe oral and pharyngeal dysphagia with aspiration

• Martin and his family now need to decide whether or not to resort to feeding tube, and want to consult their priest to make sure decision is in keeping with their religious beliefs

10.7





• As the speech-language pathologist, what are your responsibilities to this client and his family in making their decision?

• What support systems should be provided to this family during their decision-making process?

10.8




I. What is Dysphagia?

• Disorder of swallowing rendering person unable to safely and/or efficiently eat or drink

• To understand disorder swallowing, must first understand the normal swallowing process

10.9




The Normal Swallow• Innate ability which is present in the

developing fetus• Necessary to maintain nutrition and

hydration• Adults swallow approximately 580 times

daily unconsciously • Swallowing is a four-phase process:

– Oral preparatory phase– Oral phase– Pharyngeal phase– Esophageal phase

10.10




Oral Preparatory Phase• Begins as food or liquid enters the mouth• Containing, manipulating, and preparing

the food or liquid into a bolus• Chewing (mastication) occurs to grind

solid bolus into manageable texture– Requires coordination of lips, tongue, teeth,

mandible, and cheeks

• Duration: variable depending on substance

• Respiration: normal through the nose (mouth closed)

10.11




Oral Phase

• Bolus is propelled to the back of the mouth– “stripping action” by the tongue– Tension in the cheeks (buccal muscles)

• Duration: 1-1.5 seconds

• Respiration: normal through the nose

10.12




Pharyngeal Phase• Begins as the bolus reaches the tonsils (faucial

pillars)• Pharygeal swallow reflex is triggered:

– Pharyngeal wall and back of tongue move together and pharyngeal muscles squeeze to move bolus down through the pharynx

• Upper esophageal sphincter opens to allow passage of bolus into esophagus

• Time: 1 second• Respiration: briefly halted (apneic moment)• During bolus transit, risk of food or liquid

entering the airway

10.13




Pharyngeal Phase – Protective Mechanisms

• Soft palate elevates to stop bolus from flowing upward into nasal area

• Larynx moves forward and higher in the neck to reduce risk of entrance into airway

• Epiglottis forms a cover over the larynx

• Vocal folds come together to close the entrance into the larynx

• If material does enter the larynx, reflexive cough to expel it will occur

10.14




Esophageal Phase• Bolus is propelled through the esophagus

by an involuntary wave or contraction• Moves from the upper esophageal

sphincter through the lower esophageal sphincter and into the stomach

• Time: 8-20 seconds, can be influenced by age (often increase in duration in elderly population)

• Respiration: normal through nose and mouth

10.15




Disordered Swallow: Dysphagia• Impairment can occur in one, some, or all of the

four phases of swallowing

• Some persons have impairments that result in aspiration (food or liquid moves below the level of vocal folds into the airway)

• Some persons have to alter their diet to control the consistencies, but this can cause difficulty maintaining hydration and nutrition

• Some persons require an enteral feeding tube for nutritional maintenance

10.16




Additional Considerations• Dysphagia should not be confused with a

disruption in feeding, but it is one subgroup of feeding disorders

• Dysphagia is not a disease but a symptom of several etiologies (e.g., neurological injuries, progressive brain diseases)

• Social and psychological impacts of dysphagia: changes in eating routines and food choices, decreased personal independence, and challenge to participating in community activities

10.17




Prevalence and Incidence

• Statistics on who experiences dysphagia:– 14% of acutely hospitalized patients– 30-35% of patients in rehabilitation facilities– 50% of residents in nursing home

environments

10.18




II. How is Dysphagia Classified?• No universally accepted system, but usually

based on etiology, manifestation, and severity

• Some available instruments:– Penetration-Aspiration Scale: 8-point scale to

describe degree of airway protection during the swallow (1 = no material enters airway, 8 = aspiration)

– New Zealand Index for Multidisciplinary Evaluation of Swallowing: rates swallowing performance on a scale from 0 to 4 (0 = no significant impairment, 4 = profound impairment)

10.19




III. Defining Characteristics of Dysphagia

• Structural abnormalities or physiological deficits for each of the phases of swallowing:– Oral preparatory– Oral– Pharyngeal– Esophageal

• SLP manages oral preparatory, oral, and pharyngeal dysphagias (i.e., oropharyngeal dysphagia); gastroenterologist manages esophageal dysphagia

10.20




Oral Preparatory Phase Dysphagia

• Likely causes: head and neck cancers, stroke, Parkinson’s disease

• Characteristics:– Decreased lip closure– Problems controlling ingested materials– Problems biting or chewing– Inefficient oral preparation (long duration)

10.21




Oral Phase Dysphagia

• Likely causes: stroke, progressive neurological diseases

• Characteristics:– Difficulty moving bolus to the back of mouth– Inability to control bolus flow– Delayed initiation of bolus movement

10.22




Pharyngeal Phase Dysphagia• Likely causes: head and neck cancers,

neurological disorders• Characteristics:

– Incomplete palatal elevation (nasal reflux)– Delayed initiation of pharyngeal swallow reflex– Weak tongue and pharyngeal muscle forces– Reduced laryngeal elevation (more prone to

aspiration)– Inadequate opening of the upper esophageal

sphincter (bolus cannot move into the esophagus)

10.23




Esophageal Phase Dysphagia• Likely causes: reflux, certain cancers

• Characteristics:– Structural abnormalities in esophagus– Decreased esophageal motility or contraction– Inadequate opening of lower esophageal

sphincter (bolus cannot move into stomach)– Excessive opening of the lower esophageal

sphincter, allowing backward flow of contents from stomach to esophagus (reflux)

10.24




Dysphagia Causes: Neurological Disease

• Stroke– Interruption in blood supply to brain, resulting in

brain damage

– Frequency of dysphagia is about 50%

– Increases risk for malnutrition, aspiration, and pneumonia

• Traumatic brain injury– Dysphagia is common complication of

neurological damage (from 26 – 71%)

– Delay in pharyngeal swallow reflex, decreased pharyngeal constriction, and oral motor problems

10.25




Dysphagia Causes:Progressive Neurological Disease• Parkinson’s disease:

– Incidence of dysphagia from 50% to 92%– Drooling, problems in bolus preparation and

transport, delayed swallowing reflex, aspiration, residual materials in pharynx

• Amyotrophic lateral sclerosis:– Also known as Lou Gehrig’s disease, patients will

experience oropharyngeal dysphagia at some point in their disease process

• Dementia: – Dysphagia is common feature in moderate and

severe impairment levels

10.26




Dysphagia Causes:Head and Neck Cancers

• Many patients with cancers of the mouth, pharynx, and larynx experience dysphagia prior to medical management of the cancer, but treatments can cause dysphagia or make the already existing case more severe

• The extent of the medical intervention to combat the cancer influences the swallowing profile

10.27




Dysphagia Causes:Medical Interventions

• Surgical management: full or partial removal of components of swallowing

• Radiation therapy: reduced saliva production, edema, tooth decay, and pain

• Chemotherapy treatment: nausea, vomiting, and fatigue

• Tracheotomy: tube alters normal air exchange, interfering with swallowing performance

10.28




IV. How is Dysphagia Identified?

• SLP is responsible for these tasks:– Determine presence or absence of dysphagia– Determine underlying causes– Assess severity– Make recommendations– Design and implement rehabilitation plan– Share information with other professionals

• Need to achieve a balance between concern for safety issues and quality of life

10.29




Consultation with the SLP

• Referral from physician or nurse who suspects swallowing impairment

• Interdisciplinary approach to screening at hospitals, rehabilitation centers, and clinics:– Health care staff members should be trained

to recognize possible signs of dysphagia, and then make referral to SLP for further evaluation

10.30




Clinical Swallowing Examination• Also called Bedside Swallow Examination:

– Review of medical records– Comprehensive interview with client– Oral mechanism examination– Trial feedings observation– Feeding recommendations– Referrals for either:

• Further instrumental assessment (need physician’s prescription to be covered by insurance)

• Specialized testing by other professionals

10.31




Instrumental Dysphagia Exam• More objective, quantifiable measure of

swallowing function• Commonly used approaches:

– Fiberoptic Endoscopic Examination of Swallowing: visualization of swallowing through flexible tube with recordable camera

– Ultrasonography: uses sound waves to recreate a picture of structures (most beneficial in oral phase evaluation

– Videofluorscopy: same as a modified barium swallow (most commonly used; “gold standard”)

10.32




V. How is Dysphagia Treated?• SLP works to remediate oropharyngeal

dysphagia– Compensatory approaches– Restorative approaches

• To maintain nutrition, dietary modifications and/or alternative nutrition via a feeding tube– Nasogastric, gastrostomy, jejunostomy

• Include ongoing assessment of client’s response to intervention, and adjust goals and approaches to fit evolving needs

10.33




Chapter 10: Dysphagia Justice Communication Sciences and Disorders: An Introduction Copyright ©2006...

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