Transcript Chapter 10: Dysphagia

Chapter 10:
Dysphagia
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.1
Focus Questions
• What is dysphagia?
• How is dysphagia classified?
• What are the defining characteristics of
dysphagia?
• How is dysphagia identified?
• How is dysphagia treated?
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.2
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)
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.3
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.4
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?
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.5
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 gtube
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.6
Case Study #2 Questions
• Is Lee a candidate for dysphagia therapy
at this time? Why or why not?
• What education should be provided to Lee
regarding his situation?
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.7
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.8
Case Study #3 Questions
• 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?
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.9
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.10
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.11
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)
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.12
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.13
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.14
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.15
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.16
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.17
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.18
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.19
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)
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.20
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.21
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)
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.22
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.23
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)
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.24
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)
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.25
• Stroke
Dysphagia Causes:
Neurological Disease
– 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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.26
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.27
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.28
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.29
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.30
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.31
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.32
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”)
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
10.33
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
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.