DYSPHAGIA Lisa Granville, M.D. Associate Chair & Professor of Medicine Department of Geriatrics Florida State University Copyright 2008, Florida State.

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?