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DYSPHAGIADYSPHAGIA
Lisa Granville, M.D.Lisa Granville, M.D.Associate Chair & Professor of MedicineAssociate Chair & Professor of Medicine
Department of GeriatricsDepartment of GeriatricsFlorida State UniversityFlorida State University
Copyright 2008, Florida State University College of Medicine. This work was supported by a grant from Copyright 2008, Florida State University College of Medicine. This work was supported by a grant from the Donald W. Reynolds Foundation. All rights reserved. the Donald W. Reynolds Foundation. All rights reserved.
Today’s Learning Objectives:Today’s Learning Objectives:• Develop an understanding of the five stages of Develop an understanding of the five stages of
swallowing functionswallowing function• Relate at least five of the common signs and Relate at least five of the common signs and
symptoms of swallowing abnormalities to symptoms of swallowing abnormalities to etiologic conditionsetiologic conditions
• Describe the swallow evaluation process Describe the swallow evaluation process including use of radiological assessmentincluding use of radiological assessment
• Compare and contrast the benefits and limitations Compare and contrast the benefits and limitations of artificial feeding for dysphagic patientsof artificial feeding for dysphagic patients
Importance of EatingImportance of Eating
• PleasurePleasure
• SocializationSocialization
• Maintenance of healthMaintenance of health
Mr. D, a 72 year old man living in a Mr. D, a 72 year old man living in a nursing home, has had a right sided nursing home, has had a right sided stroke. He has impulsive behavior stroke. He has impulsive behavior with poor judgment consistent with with poor judgment consistent with right sided brain damage. right sided brain damage.
• What feeding and/or swallowing What feeding and/or swallowing concerns might exist for this patient?concerns might exist for this patient?
DYSPHAGIA - from the GreekDYSPHAGIA - from the Greek
dys = difficulty dys = difficulty phagia = swallowingphagia = swallowing
Five Stages of EatingFive Stages of Eating
• FeedingFeeding
• Oral PreparatoryOral Preparatory
• Oral TransportOral Transport
• PharyngealPharyngeal
• EsophagealEsophageal
Definition:Definition:FeedingFeeding
Voluntary movement of food from Voluntary movement of food from the environment into the oral cavity the environment into the oral cavity for the purpose of ingestionfor the purpose of ingestion
Patient/Caregiver Reported Patient/Caregiver Reported Symptoms of Eating Symptoms of Eating
AbnormalitiesAbnormalitiesSelf-Feeding:Self-Feeding:•Easy distractibility, disinterest, drowsinessEasy distractibility, disinterest, drowsiness•Rearranging, playing with foodRearranging, playing with food•Attempts to ingest nonfood itemsAttempts to ingest nonfood items•Incorrect utensil selection or useIncorrect utensil selection or use•Inability to open containers or grasp utensilsInability to open containers or grasp utensils•Dropping food enroute to oral cavityDropping food enroute to oral cavity
Definition:Definition:Oral Preparatory StageOral Preparatory Stage
Voluntary mastication and Voluntary mastication and preparation of food into a boluspreparation of food into a bolus
Definition:Definition:Oral Transport StageOral Transport Stage
Voluntary posterior movement of a Voluntary posterior movement of a bolus from the tip of the tongue to bolus from the tip of the tongue to the anterior tonsillar pillarsthe anterior tonsillar pillars
Patient/Caregiver Reported Patient/Caregiver Reported Symptoms of Eating Symptoms of Eating
AbnormalitiesAbnormalities
Oral Preparatory and Oral Transport Stages:Oral Preparatory and Oral Transport Stages:•Drooling or oral spillageDrooling or oral spillage•Impaired chewing, munchingImpaired chewing, munching•Pocketing, holding of food in oral cavityPocketing, holding of food in oral cavity•Delayed or difficult initiation of swallowDelayed or difficult initiation of swallow•Coughing and chokingCoughing and choking
Definition:Definition:Pharyngeal StagePharyngeal Stage
Reflexive passage of a bolus from Reflexive passage of a bolus from the oral cavity into the upper the oral cavity into the upper esophagusesophagus
Patient/Caregiver Reported Patient/Caregiver Reported Symptoms of Eating Symptoms of Eating
AbnormalitiesAbnormalitiesPharyngeal Stage:Pharyngeal Stage:•Nasal regurgitationNasal regurgitation•AspirationAspiration•Wet or gurgly voice qualityWet or gurgly voice quality•Coughing and chokingCoughing and choking
Definition:Definition:Esophageal StageEsophageal Stage
Reflexive passage of a bolus from Reflexive passage of a bolus from the cricopharyngeal sphincter past the cricopharyngeal sphincter past the lower esophageal sphincter into the lower esophageal sphincter into the stomachthe stomach
Patient/Caregiver Reported Patient/Caregiver Reported Symptoms of Eating Symptoms of Eating
AbnormalitiesAbnormalities
Esophageal Stage:Esophageal Stage:•Neck or chest painNeck or chest pain•Heart burnHeart burn•Food stickingFood sticking•Difficulty swallowing solids > liquidsDifficulty swallowing solids > liquids•RegurgitationRegurgitation
Etiology of Feeding Etiology of Feeding & Swallowing Problems& Swallowing Problems
NeurologicalNeurological
MechanicalMechanical
PsychologicalPsychological
CombinationCombination
Medication Related Medication Related Swallowing ImpairmentsSwallowing Impairments
Mechanism Drug/Class
Xerostomia Anticholinergics,antidepressants, antiemetics,antihistamines, diuretics,opiates
ExtrapyramidalEffects
Antipsychotics,metoclopromide,prochlorperazine
Esophageal Injury Antibiotics, ASA, Iron, KCl,prednisone, theophylline
Reduced LESpressure
Anticholinergics, calciumchannel blockers, diazepam,morphine, nitrates,theophylline
Identification/Evaluation of Feeding Identification/Evaluation of Feeding & Swallowing Problems& Swallowing Problems
• Patient / caregiver observationsPatient / caregiver observations
• Clinical examinationClinical examination
• Instrumental evaluationInstrumental evaluation
Clinical Examination of SwallowClinical Examination of Swallow• Background informationBackground information
– Active medical problems, therapies, nutrition/hydration status, Active medical problems, therapies, nutrition/hydration status, overall health status, life expectancyoverall health status, life expectancy
• Description of the problemDescription of the problem– Onset, duration, frequency, progression, speechOnset, duration, frequency, progression, speech
• Clinical observation/mental status examClinical observation/mental status exam– Speech, language, voice status, cognitive statusSpeech, language, voice status, cognitive status
• Oral mucosa and dentitionOral mucosa and dentition• Sensory motor exam of oro-facial structuresSensory motor exam of oro-facial structures• Test swallow observationsTest swallow observations
– Duration of oral stages, oral residue, cough, self feeding ability Duration of oral stages, oral residue, cough, self feeding ability
Instrumental Examination of Instrumental Examination of Swallow FunctionSwallow Function
• Videoflurographic swallowing study (VSS)Videoflurographic swallowing study (VSS)– AKA: modified barium swallow, cookie swallow testAKA: modified barium swallow, cookie swallow test– Considered to be the “gold standard”Considered to be the “gold standard”– Allows observation of outline of structures from oral cavity to Allows observation of outline of structures from oral cavity to
stomach, this is a dynamic assessment stomach, this is a dynamic assessment
• Fiberoptic endoscopic evaluation of swallow Fiberoptic endoscopic evaluation of swallow (FEES)(FEES)– Allows direct observation of structures: nasal cavity, Allows direct observation of structures: nasal cavity,
nasopharynx, oropharynx, larynx, hypopharynxnasopharynx, oropharynx, larynx, hypopharynx
Three Major Goals of Three Major Goals of Dysphagia InterventionDysphagia Intervention
• 1. To maintain or improve nutrition 1. To maintain or improve nutrition and hydration.and hydration.
• 2. To prevent or reduce the risk of 2. To prevent or reduce the risk of aspiration.aspiration.
• 3. To maintain or restore the highest 3. To maintain or restore the highest level of functional ability and level of functional ability and maximize quality of life. maximize quality of life.
Nutritional SupportNutritional Support
Enteral vs. parenteral routes of administrationEnteral vs. parenteral routes of administration
Long-term vs. short-term useLong-term vs. short-term use
Complete nutritional replacement vs. partial Complete nutritional replacement vs. partial supportsupport
Possible Benefits of Artificial Possible Benefits of Artificial FeedingFeeding
Promotion of healingPromotion of healing
Improved resistance to infectionImproved resistance to infection
Decreased skin breakdownDecreased skin breakdown
Decreased aspirationDecreased aspiration
Prolonged lifeProlonged life
Artificial feeding does not reverse or cure Artificial feeding does not reverse or cure dysphagiadysphagia
Possible Burdens of Artificial Possible Burdens of Artificial FeedingFeeding
Tube placementTube placement
InfectionInfection
Need for restraints or immobilityNeed for restraints or immobility
Increased aspirationIncreased aspiration
Prolonged lifeProlonged life
At lunchtime Mr. D is served a hotdog, At lunchtime Mr. D is served a hotdog, bites off too large a piece, begins bites off too large a piece, begins choking and subsequently dies of choking and subsequently dies of asphyxiation. asphyxiation.
• Could this outcome have been avoided?Could this outcome have been avoided?
• How would you inform the family of his death?How would you inform the family of his death?
• What reaction from his family is anticipated?What reaction from his family is anticipated?