Dysphagia Midterm Flashcards
(112 cards)
1
Q
what is dysphagia?
A
swallowing disorder involving the oral cavity, pharynx, esophagus, or gastroesophageal junction
difficulty moving food and liquid from the mouth to stomach
2
Q
consequences of dysphagia
A
malnutrition and dehydration
aspiration pneumonia
compromised general health
chronic lung disease
choking
death
adults may also experience disinterest, reduced enjoyment, embarrassment, and/or isolation related to eating or drinking
may increase caregiver
3
Q
feeding
A
the placement of food in the mouth; the manipulation of food in the oral cavity prior to initiation of swallow
4
Q
swallowing
A
entire act of deglutition, from the placement of food in the mouth through the entrance into the esophagus
5
Q
deglutition
A
act of swallowing
6
Q
what is the importantance of swallowing? why does it matter?
A
nutrition
enjoyment and quality of life
in acute medical care, method of taking medication
pneumonia; death
7
Q
how much of medical SLP’s caseload is dysphagia?
A
70-80%
8
Q
other etiologies of dysphagia
A
amyotrophic lateral sclerosis (ALS)
critical illness
dementia
endotracheal intubation
gastroesophageal reflux disease (GERD)
head and neck cancer
intellectual disabilities (adult)
multiple sclerosis
neurologic conditions requiring intubation
Sjogren’s syndrome
systemic lupus erythematosus
tbi
vf immobility (unilateral)
whiplash injuries/ injuries to neck
9
Q
general sensation receptors are for:
A
pressure/touch
temperature
pain
10
Q
anterior 2/3 of tongue
A
cn v (trigeminal)- general sensation via lingual nerve
cn vii (facial)- taste via chorda tympani
11
Q
posterior 2/3 of tongue
A
cn ix (glossopharyngeal) taste and general sensation
12
Q
cranial nerves that innervate the pharynx?
A
cn ix (glossopharyngeal) and cn x (vagus)
13
Q
UES (upper esophageal spincter)/ PES (pharynesophageal segment)
A
4cm tract connecting pharynx and esophagus
attached to cricoid cartilage
14
Q
what are the 3 areas swallowing takes place?
A
peripheral
subcortical- learned motor activity
cortical-changes motor behavior to modify swallow behaviors
15
Q
SENSORY mucosa of valleculae is innervated by:
A
internal branch of superior laryngeal nerve (vagus nerve; cn (x)
16
Q
SENSORY secondary afferent
A
glossopharyngeal (ix)
17
Q
SENSORY tonsils, pharynx and soft palate is innervated by:
A
pharyngeal branch of vagus (x)
18
Q
SENSORY pharynx, larynx, and viscera is innervated by:
A
glossopharyngeal (ix) and vagus (x)
19
Q
efferent/motor innervation of masticatory, buccinators, floor of mouth:
A
trigeminal v
20
Q
efferent/motor innervation of lip sphincter
A
facial (vii)
21
Q
efferent/motor innervation of tongue:
A
hypoglossal (xii)
22
Q
efferent/motor innervation of constrictors and stylopharyngeus
A
glossopharyngeal (ix)
23
Q
efferent/motor innervation of palate, pharynx and larynx
A
vagus (x)
24
Q
efferent/motor innervation of tongue
A
hypoglossal (xii)
25
efferent/motor innervation of esophagus
vagus (x)
26
central pattern generator
swallowing center in the medulla in the brainstem housed by the nucleus ambiguus (NA) and nucleus tractus solitarius (nts)
network of neurons in brainstem hardwired to create the same set of events for swallowing all of the time
swallowing cn send sensory info to the NTS (nucleus tractus solitarius)
motor components are in the na
tumor and/or stroke in the central pattern generator= cannot swallow at all when they appear fine
27
cranial nerves involved in swallowing
accessory nerve (xi)
hypoglossal (xii)
vagus (x)
glossopharyngeal (ix)
facial (vii)
trigeminal (v)
28
trigeminal nerve for swallowing
responsible for all sensation for the face. from lateral sides of pons. innervates temporalis and masseter
damage can affect mastication, significant oral phase deficits, skin sensory loss in the area affected, impact hyolaryngeal motion)
branches: opthalmic, maxillary, mandibular
29
exam for trigeminal nerve (v)
sensation of face- use cotton or hard item response to face
clench teeth - feel masseter
swallow- palpate hyoid
close eyes- test three diff division
open mouth with and without resistance
30
facial nerve (vii)
motor innervation contralateral lower part of face; bilateral upper part of face
salivation; sensory/taste of anterior 2/3 of tongue
motor function of face, hyolaryngeal excursion, base of tonge to posterior pharyngeal wall
31
exam for facial nerve (vii)
close eyes
raise eyebrows
smile, puff out cheeks
close lips and keep closed with resistance
pucker lips
make a smile
frown
taste items from tongue
32
glossopharyngeal nerve (ix)
sensory to mucosa of posterior tongue and pharynx; some salivary glands; taste posterior 1/3 of tongue
damage is more rare- sensory limbs of swallowing reflex arc
sense arrival of bolus at palate
gag reflex and palate elevation
pharyngeal constriction and shortening motor movement
33
exam for glossopharyngeal (ix)
hot/cold to posterior 1/3 tongue, faucial pillar, palatine tonsils
symmetry and movement of velum
34
vagus nerve (x)
usually impaired w cn 9,10,11,12
innervates palatoglossus, intrinsic pharyngeal and laryngeal muscles
efferent arm of gag and swallow reflex
-- recurrent laryngeal nerves (responsible for larynx, voice, vfs) innervated most laryngeal muscles for GLOTTIC CLOSURE during swallow
- superior laryngeal nerve- hypopharynx, laryngeal vestibule, surface of true vfs
vp closure motor, vf approximation
middle/inferior pharyngeal constriction
PES relaxation
esophageal peristalsis --> sending food back up esophagus
90% sensory for oropharynx, residue pharynx and larynx for knowing that you're choking
*** cardiac surgery common and can affect vagus nerve
35
exam for vagus nerve
use a light-observe a velar elevation during phonation- symmetry
phonate for vocal quality
36
hypoglossal nerve (xii)
hypoglossal nerve (often brain tumor or brainstem stroke) innervates tongue muscles
MOTOR- power source for tongue
anterior hyoid movement --> closure of vfs, etc.
*** only nerve with contralateral innervation
37
exam for hypoglossal (xii)
protrude tongue
tongue in cheek with outside cheek resistance
muscular atrophy?
paralysis and weakness observation
tongue deviation
resistive assessment
38
accessory nerve (xi)
motor nerve for 2 muscles in neck. head turn/support
assists with vp closure
*note: diff positions change swallow/changing shape of pharynx, etc.
39
exam for accessory nerve (xi)
shrug shoulders and move head side-side/up-down
move shoulder against resistance
40
factors impacting neurosensory system
medications
anti-seizure meds
change in labs ex)dehydration
dementia
oral care
41
stages of swallowing
1. oral preparatory stage
2. oral transit stage
3. pharyngeal stage
4. esophageal stage
42
oral prep stage
anticipatory preparation as food/drink approach mouth- hand and visual cues
labial seal
buccal/facial muscle tension
spoon stripping- lips close around utensil, creating tension
tongue cupping of liquids- bowl shape
mastication - rotary vs. munching
lingual pulls the bolus centrally on tongue in prep for transit
sensation- during this whole process, a lot of sensory info (tongue) is being integrated in preparation for swallow and how the muscle with respond and adapt
43
oral stage (1-1.5 sec)
begins when tongue begins the anterior to posterior transit of the bolus
stripping of bolus between tongue and palate - pressure system
1-1.5 seconds to transit typically
proprioceptive receptors send info to cortex, brainstem, medulla
44
pharyngeal stage (1 sec or less)
starts with the leading edge of bolus passes between anterior faucial arches and the rim of the mandible crosses the tongue base/middle of the tongue base. as aging occurs tends to become lower
elevation and retraction of velum to close vp port-PPW may move in a little bit to meet also
elevation/excursion(moving forward) of hyoid and larynx
laryngeal closure at 3 levels- TVF, laryngeal entrance (FVF, anterior tilting of arytenoids, and thickening of epiglottic base), and epiglottic deflection
swallowing apnea- cessation of respiration at beginning of an exhalation cycle
opening/relaxing of UES
ramping of tongue base, then retration, then contact bulging of PPW to start pushing bolus
progressive top-bottom contraction of pharyngeal constrictor muscles - shorten and narrow as contract
45
vacuum effect
negative pressure system to draw bolus down esophagus
push bolus down
no airway from mouth, nose, lungs
UES opens
sucks bolus down to esophagus
46
esophageal stage
as bolus tail passes thru PES, exhalation continues
begins entering the cricopharyngeal juncture/UES/PES until passes the gastroesophageal juncture/LES. peristaltic wave sequentially moves room top to bottom
lumen is collapsed at rest
primary and secondary peristaltic waves
also adjusts to the the type of bolus/viscosity
esophageal function can impact swallowing w aspiration and pharyngeal involvement
slp domain: cervical/upper esophagus
47
neuromuscular system creates zones of
high pressure and negative pressure (by contracting muscles)
48
valving and pressure
1. lips (closure)
2. oral tongue- palate
3. vp port
4. tongue base- PPW
5. larynx
- epiglottis
- artytenoid
- vf closure
6. cricopharyngeal sphincter (opening)
** all creating vacuum system
49
bolus
masticated food/food mixed with saliva that's ready to be swallowed
50
rheology
science that studies the deformation and flow of material
51
volume
texture/viscosity, taste, delivery method
52
viscosity
has more impact on swallow generated pressures than volume (thicker the textures, the greater the tongue-palate contact and pressure)
53
taste
studies of sweet, salty, sour, bitter
sour bolus increases activation of suprahyoid musculature
54
delivery method
cup, spoon, straw
decides rate, volume, etc
55
connection between breathing and swallowing can cause:
impaired coordination of respiration and apnea
insufficient respiration/volumes for breath hold (lung damage)
insufficient glottic closure during the swallow; vf paralysis
aspiration can cause pneumonia
56
respiratory/pulmonary intervention can impair swallowing for example:
intubation- rigid tube through mouth in middle of airway
tracheotomy- throws off pressure and weighs down swallow
surgical resections
57
laryngeal penetration
entry of material into the airway above the true vocal folds
58
aspiration
entry of material into the airway below the true vocal folds
59
aspiration can occur
before the swallow (loss of bolus control in oral phase- premature spillage)
during the swallow- often due to vf closure deficits/pharyngeal phase
after the swallow- aspiration of residue or refluxed material
60
pneumonia
an inflammation of lungs caused by bacteria, virus, or other organisms. occurs w a weakened immune system
- community acquired pneumonia
-nosocomial pneumonia/hospital-acquired pneumonia (weakened state/supergerms)
- ventilator associated pneumonia
- aspiration pneumonia
61
pneumonitis
an acute lung injury from aspiration of gastric contents. onset is usually within hours of an aspiration even
vomiting during seizure and aspirating that vomit
62
aspiration pneumonia
nocturnal aspiration is normal in 50%n of adults
traditional right lower lobe, but this is position dependent
treated with antibiotics and ideally aggressive oral hygiene and dysphagia tx
- leading cause of death in patients with dysphagia secondary to neurological conditions
- 4th most common cause of death in the elderly
- mortality rates up to 50% in hospitalized patients w pneumonia;
- aspiration present in 43%-54% of stroke patients w dysphagia
63
prandial aspiration
aspiration of food/liquid during the swallow
64
non prandial/post prandial aspiration
aspiration of contents from esophagus or stomach after the swallow
65
which lobe of lung is more susceptible to aspiration?
RLL because gravity and right bronchi is more straight
66
atelectasis
after long term aspiration; collapsing of alveoli where oxygenation/gas exchange happens
can occur from anything; smoking, etc.
67
immediate aspiration response
cough response with material moving into vestibule and/or below glottis. attempt to expel material from trachea w force
mucociliary clearance (MCC) primary innate defense mechanism of lung
airway obstruction
68
developing aspiration response
pneumonia/pulmonary infection
temperature spiking, fatigue/lethargy
malnutrition
WBC (rise in white blood cell count)/infection on lab data
69
signs and symptoms of aspiration
cough
throat clear
wet/gurgly voice
watery eyes and runny nose
difficulty breathing
choking
70
transient penetration
only see it during the swallow but gets sucked back out
71
predictors for aspiration/concomitant
poor posture
pharyngeal stasis--> residue
severe dysphonia--> impaired glottic protection
wet gurgly voice
reduced volitional cough
poor hyolaryngeal excursion
poor health status and oral hygeine
age
prior h/o aspiration pna
feeding tubes
trach tubes
location in hospital
feeding dependent
immobility/ ambulatory status
72
oral hygeine
aspiration or oral bacteria/flora
poor dentition/infection of gums
impaired saliva flow and clearance "xerostomia"
oral hygeine is a leading factor in deciding on initiating a po diet, allowing water, risk for respiratory failure
73
what do we do about oral hygeine?
slp is part of team for oral care
oral care is also an effective therapy technique -->simulation in mouth
teach pt, family, staff
74
oral hygeine tools
sponge swabs
toothbrush/toothpaste
mouthwas
suction catheter
lip moisturizer
oral moisturizer
oral mist spray
branded kits
medical tools to remove secretions
75
what are the three pillars of pneumonia?
- impaired immunity/health (you ability to ambulate (walk) and lung health affects ability to attain pneumonia)
- aspiration
- poor oral health
76
etiologies of dysphagia
aging and presbyphagia
any disorder that impacts the neurological motor/sensory swallow
disorders of respiration (swallow apnea)
neurodegenerative disease
presence of cancer/surgical intervention
developmental/traumatic structural anatomical differences
temporary causes
- intubation
- lethargy/fatigue
- delirium
- abnormal metabolics
77
typical aging includes:
general decrease in muscle strength and speed
loss of dentition
changes in smell and taste
reduced appetite- sweet taste sensation stay
xerostomia (medication side effect-dry mouth)
ossofication of laryngeal cartilage
78
presbyphagia
normal, age-related change to the aerodigestive tract that may be associated with fraility
79
sarcopenia
reduction in muscle mass with loss of strength and speed
80
apraxia
motor planning for initiating and executing the swallow (programming is off)
81
pharyngeal recesses
pyriform sinuses AND vallecula
82
intubation and NGT use
traumatic intubation- can cause more damage
prolonged intubation- > 1-2 days
prolonged NGT use
traumatic NGT placement and replacement
83
medication-related dysphagia
medications in isolation or when combined can cause
- cognitive changes
- xerostomia (dry mouth)
- motor dysfunction
- GI function (side effects)
- loss of appetite
antipsychotics can affect motor function, cause dyskinesia
84
what is assessment?
screening
- designed to be ~10 mins
- meant to identify the risk of dysphagia, NOT to evaluate swallowiing
- often required in medical settings
- often performed by other non-SLP staff
evaluation
- clinical swallowing eval
- bedside swallowing eval
- done by SLP
tx
- ongoing assessment of skills at any time during tx to assess for progress, regression and goal setting
85
dysphagia screen
rationale
development hx
JCAHO/DNV- make sure hospitals are following policies, etc.
stroke population
EBP studies for various screens
86
dysphagia screen examples
3 oz water test
Barnes-Jewish Hospital Stroke Dysphagia Screen
Toronto Bedside Swallowing Screening Tests
SSA
Mini MASA
GUSS
87
clinical swallowing eval components
I. hx and interview
ii. baseline medical assessment
iii. cranial nerve and oral exam
iv. clinical PO trials and assessment
v. formulation of impression
vi. clinical recommendations
88
in the medical record (EMR):
admission date and length of stay if in facility
referring physician and MD, reason for referral
history of present illness including all current med. diagnoses
radiologic exams (CXR, MRI, CT, US)
laboratory test results (kidney function, COVID, flu, etc.)
multidisciplinary notes
specialty consult notes
current diet orders
food and drug allergies
medical precautions (PPE change)
oxygen needs and respiratory status
89
I. patient interview/ medical history questionnaire
age
med hx
hx of dysphagia or weight loss
prior swallowing assessments
medications that may impact swallowing
presenting complaint, reason for referral, and onset of cc
social history
90
ii. baseline medical assessment
mental status and orientaion
vocal quality and speech assessment
respiratory status (o2 needs, resp. rate, presence of trach/vent support)
heart rate/blood pressure
physical positioning
alternative feeding support
91
cranial nerve and oral exam
cn exam
dentition assessment
oral exam
- xerostomia
- fasiculations or tremors
- thrush
volitional cough and phonation
baseline cervical auscultation
92
clinical PO trials
feeding capabilities and equipment
- independent, partial assistance, total/full assistance, hand over hand
- spoon, cup, straw
PO trials determined by the patient's case
- ice, thin water, purees, soft solids, hard solids, thickened liquids
- 5 mL, 10 mL, 20 mL
- controlled vs. independent/spontaneous
post-prandial observations and signs
assessment of efficiency for po intake
modifications and compensatory techniques
93
oral prep assessment
anticipatory preparation as food/drink approach the mouth- starts with the hands and visual cues "sensory recognition of approaching food"
labial seal w cup and spoon; during mastication
buccal/facial muscle tension
spoon stripping
tongue cupping of liquids
mastication- rotary vs muching
lingual pull the bolus centrally on tongue in prep for transit
sensation during this whole process a lot of sensory info is being integrated in prep for swallow and how the muscle will respond and adapt
94
oral transit assessment
begins when tongue begins the anterior to posterior transit of the bolus
stripping of bolus between tongue and palate pressure system
1-1.5 secs to transit typically
proprioceptive receptors send info to cortex, brainstem, medulla
95
pharyngeal assessment
initiation w leading edge of bolus passes between anterior facial arches and the rim of the mandible crosses the tongue base/ middle of the tongue base. as aging occurs, tends to become lower
elevation and retraction of velum to close VP port-PPW may move in a little bit to meet also
elevation/excursion of hyoid and larynx
laryngeal closure at 3 levels - TVF, laryngeal entrance (FVF, anterior tilting arytenoids, and thickening of epiglottis base), and epiglottic deflection (epiglottis helps direct food around the airway to the sides)
swallowing apnea
opening/relaxing of cricopharyngeal sphincter
ramping of tongue base--> followed by retraction --> contracting bulging PPW
progressive top-bottom contraction of pharyngeal constrictor muscles- shorten and narrow as contract
96
hyolaryngeal palpation
is a swallow present?
what is the timing? (prompt or delayed?)
how many times does Pt swallow?
feel laryngeal vibrations/throat clearing (could be clear secretions)
assess subjective "strength" of movement
97
hx and research of cervical auscultation
2 bursts of sound- bolus entering and leaving the pharynx
fair at best inter and intra rater reliability
**NOT EBP
NO STRONG CORRELATION
98
current stethoscope use
baseline respiratory congestion, patterns, rate
post po trial changes
throat clearing and coughing
wetness/ wet gurgly voice
congestion
brand impacts sensitivity
**good, extra tool to help w clinical exam
subjective
99
what are the elements that evidence supports their importance in stroke patients?
dysphonia- harshness and breathiness
wet-sounding voice
dysarthria
poor secretion management
cough on trial swallows
decreased laryngeal elevation
100
how many features are needed to be found to be predictive of dysphagia and an unsafe swallow?
2 or more features
101
post po trial questions
is there a deficit? dysphagia?
safe po diet recommendation?
po diet that's efficient for nutritional needs?
concomitant factors considered? (radiation, etc.)
risk for pulmonary sequelae considered? likeliness of pneumonia
physician input?
pt/family input?
therapy recommended?
instrumental exam necessary and or feasible?
102
key components of clinical impressions
related medical diagnosis and pertinent hx
severity of oral phase and cause/likely cause of deficits
severity of pharyngeal deficits and cause/likely cause of deficits
s/s of laryngeal penetration/aspiration present/ judged risk for aspiration
additional concerns (esphogeal, further consult, testing, etc.)
recommendations
**NO DATA
103
recommendations
po diet vs. npo
alternate means of nutrition (NGT, peg tube)
positioning and aspiration precautions
solid and liq recommendations
method of presenting PO
medication administration
adaptive equipment
compensatory strategies
instrumental exam
therapy and goals (LTG + STG)
104
formal swallowing assessments/rating scales
MASA
EAT-10
FIOS
MDADI
DHI
SWAL-QOL/SWAL-CARE
105
Odynophagia
pain associated with swallowing
106
pharyngeal swallow initiation
faucial pillars and jaw
107
pros of MBS
less invasive
no need for consent
see anatomy/whole swallow
can see before, during, and after swallow
108
cons of MBS
radiation
complicated to schedule
can't see inside: secretions, tumor, edema, vf movement
109
pros of FEES
- can see vf movement
- administered at bedside/you are in control and don't need a MD in NYS
- can see secretions
110
cons of FEES
- discomfort
- invasive
- need consent
- cannot see entire swallow/ cannot see oral stage (only clinically)
- bad visualization/white out period
111
effects of intubation
edema/swelling that impacts airway closure
112
silent aspiration
absent patient response (no noticeable symptoms of) to the entry of material into the airway below the true vocal folds
