Dysphagia

When you can’t swallow.

Dysphagia Facts
Approximately 300,000 to 600,000 people with
neurogenic disorders are diagnosed with dysphagia.
Swallowing involves the use of 6 cranial nerves.
Approximately 40% of patients with dysphagia silently
aspirate.
Swallowing is one of the most complex body reflexes,
yet in the normal adult, this process is automatic,
effortless and efficiently performed an average of 600
times a day.
Dysphagia Facts
Evidence of dysphagia in 51% of patients with acute
stroke.
Parkinson’s dysphagia develops in approximately 50%
of patients.
With patients with multiple sclerosis, 34% with
dysphagia.
Phases of the Swallow
Oral Phase
Involves the lips, tongue, teeth and cheeks.
The swallow begins when food is presented at the level
of the lips.
 Patients must have good labial seal to hold the bolus within
the oral cavity and to create appropriate pressures to propel
the bolus and initiate the swallow.
 Patients with stroke may have labial weakness which allows

the food to spill out of the mouth.

Tongue
The tongue contains the taste buds allowing us to
taste foods.
The tongue is made up of muscles.
The tongue is used to
Move the bolus within the oral cavity for proper
mastication of the bolus
Propel the bolus posteriorly to initiate the pharyngeal
stage of the swallow
Teeth
Dentition is important for swallowing and it is
important to assess dentition for appropriate diet
recommendations.
The SLP will need to know if the patient wears dentures,
is missing teeth, etc.
Teeth are important for appropriate mastication of
foods.
Cheeks
Buccal tension:
Assists in creating appropriate pressures for initiating
the pharyngeal swallow
Assists in maintaining the bolus
Helps to prevent lateral pocketing of the bolus.
Pharyngeal Phase
Once the food is masticated and reaches the anterior faucial
arches, the pharyngeal stage of the swallow is initiated.
Within 1-3 seconds the following occurs:
Tongue Base Retraction
Velopharyngeal closure
Pharyngeal constriction
Pharyngeal contraction
Hyoid Elevation
Hyoid Protraction
Hyothyroid approximation
Vocal fold closure
Upper esophageal sphincter opening.
Oral Care
Microorganisms found in the lungs of elderly patients with
pneumonia originate in the mouth and gingival, making a
link between poor oral hygiene and aspiration pneumonia.
 Three categories that add to the risk factors that lead to
aspiration pneumonia: o Any factor that increases the
bacterial load or colonization in the oral-pharyngeal cavity
(lack of tooth brushing, xerostomia).
 Any factor that decreases the patient’s resistance to the
inoculums (i.e. malnutrition or ventilator dependency).
 Any factor that increases the risk of aspiration (i.e. paralysis
from stroke or chronic neurological disease affecting the
muscles and nerves involved in swallowing.
Oral Care
Those at risk:
Patients who are dependent for oral care.
Have large numbers of missing teeth.
Dentures
Have limited hand dexterity
Decreased mental capacity
Multiple medical co-morbidities
Immunosuppressed
Ventilator dependent
Receive non-prandial feedings
Have had a stroke
Neurologically impaired
Have xerostomia
Known Dysphagia
Poor access to professional dental care.
Dependence on caregivers for oral care.
Active smoking
Depression.
Use of sedative medication
Use of gastric acid-reducing medication.
Use of ACE inhibitor
Poor feeding position.
Frazier Water Protocol
Patients who are on thickened liquids are often placed
on a Frazier Water Protocol to increase hydration.
Thickened liquids are given with meals and
medications.
Wait for 30 minutes after meal, complete thorough oral
care, then patient can have all the water they want until
their next meal.
Thickened Liquids
There are four consistencies of liquids
Thin or regular
 Normal drinks with no thickening agents added.
Nectar thick liquids
 Should be the consistency of maple syrup and run off the spoon
like syrup does.
Honey thick liquids
 Consistency of honey and should run off the spoon as honey
does.
Pudding thick liquids
 Should be the consistency of pudding and “plops” off the spoon.
Medications
When patients have dysphagia, they are often ordered
to have their pills crushed or given in
applesauce/pudding.
When passing pills, remember people that have
difficulty swallowing and try to give them one pill at a
time.
Check at the end of the med pass to make sure all pills
were swallowed and were not pocketed.
Food Consistencies
Pureed
Baby food consistency, should have no lumps and be
easy to swallow.
Mechanical Soft/Ground Meat
Should only require minimal chewing, no hard/crunchy
foods
Regular
No restrictions
Assessment Techniques by SLP
Bedside assessment
Cervical Auscultation
Laryngeal elevation
Monitor s/s aspiration
Trial consistencies
Pulse Oximetry
Heart Rate
Blue Dye Assessment
3Ounce water test
Bolus Manipulation Task
Instrumental Assessment
MBSS
FEES
Manometry
Ultrasound
Treatment Techniques by the SLP
VitalStim-NMES for dysphagia
DPNS/FMEP
Thermal/tactile stimulation
Myofascial release and manual techniques
Oral/Pharyngeal Exercises
Exercises with resistance
TheraSip Swallowing Trainer
IOPI
OraLight
Ice Finger
Laryngeal Mirrors/ThermoStim Probe
Things to Remember

Patients that self-feed have a lower incidence of aspiration.

Feed patients as you would like to be fed, don’t shovel food into their
mouth or stick the food into their mouth before they’re ready.
Aspiration pneumonia in nursing home residents occurs 10 times more
frequently than in elderly community dwellers.
 Pneumonia is the most common cause of death from nosocomial
infections in the elderly.
 Pneumonia results in functional declines and increased health care
expenditures.
One study suggests that 70% of patients with a history of pneumonia
aspirated during their sleep.
One study suggests that effective oral care can decrease mortality due to
pneumonia by half.
Bolus Propulsion
Select Medications that Affect Swallowing
Oropharyngeal function Esophageal function
Sedation, pharyngeal weakness, dystonia
Benzodiazepines
Inflammation (resulting from irritation by
Neuroleptics pill)
Anticonvulsants* Tetracycline
Myopathy
Doxycycline (Vibramycin)
Corticosteroids
Iron preparations
Lipid-lowering drugs
Xerostomia Quinidine
Anticholinergics Nonsteroidal anti-inflammatory drugs
Antihypertensives* Potassium
Antihistamines* Impaired motility or exacerbated
Antipsychotics
Narcotics gastroesophageal reflux
Anticonvulsants* Anticholinergics
Antiparkinsonian agents*
Antineoplastics*
Calcium channel blockers
Antidepressants* Theophylline
Anxiolytics* Esophagitis (related to immunosuppression)
Muscle relaxants*
Diuretics Corticosteroids
Inflammation/swelling *--Various agents in the class.
Antibiotics*
Sources
American Speech-Language Hearing Association Division 13
(2006). Perspectives on Swallowing and Swallowing Disorders,
15(3), 1-28.
American Speech-Language-Hearing Association (1990). Skills
needed by speech-language pathologists providing services to
dysphagic patients/clients, ASHA, 32 (suppl 5), 7.
DPNS Manual. Available through the Speech Team Inc. Author:
Karlene Stefanokos.
The Source for Dysphagia. LinguiSystems. Author: Nancy
Swigert.
Logemann, J. A. (1998). Evaluation and treatment of swallowing
disorders. Austin, TX: Pro-Ed.
Sources
Carl, L., & Johnson, P. (2005). Drugs and dysphagia: How
medications can affect eating and swallowing. Austin, TX:
Pro-Ed.
Palmer, J.B., Drennan, J.C., and Baba, M. (2000).
Evaluation and Treatment of Swallowing Impairments.
www.aafp.org/afp/20000415/2453.html
Panther, K. Frazier Water Protocol: Safety, Hydration and
Quality of Life. (2008). ASHA
www.asha.org
Wijting, Yorick. VitalStim Manual. (2003).
www.vitalstim.com