By Anita Wiese, M.A., CCC-SLP and

Audra A. Amreihn, M.A., CCC-SLP

}  SLP’s are trained to: ◦  assess and treat a variety of diagnoses that cause

communication and swallowing disorders

◦  work with families and staff to improve communication skills and decrease the risk of aspiration caused by the swallowing disorder

}  Dysphagia means the difficulty or inability to swallow

}  There are 3 phases: oral, pharyngeal and esophageal

}  The Speech-Language Pathologist’s main focus is the first two phases

}  If there is a malfunction with any of these 3 phases the person will have a swallowing disorder or dysphagia

}  Oral Phase ◦  Lips ◦  Teeth ◦  Tongue ◦  Cheeks ◦  Hard and Soft palate ◦  Velum

}  Pharyngeal Phase ◦  Pharyngeal muscles ◦  Valleculae ◦  Epiglottis ◦  Pyriform Sinuses ◦  Upper Esophageal

Sphincter

}  Lip seal to keep food in the oral cavity }  Adequate dentition for mastication }  Tongue mobility and coordination for bolus

control and transportation posteriorly }  Adequate jaw mobility to assist in

mastication, bolus manipulation and transport

}  Cheek tone to reduce pocketing }  Soft palate moves superiorly to close off the

nasal cavity

}  The bolus passes into the pharynx where the pharyngeal constrictor muscles squeeze to propel the bolus as the posterior tongue elevates to invert the epiglottis to close off the airway

}  Simultaneously the vocal folds close and the larynx raises up and tilts forward providing extra closure of the airway

}  The upward and forward movement of the larynx is what helps to open the cricopharyngeal muscle (UES) in order for the bolus to pass into the esophagus.

}  Intellectual and Developmental Disabilities in conjunction with neurological and psychological disorders

}  Down’s Syndrome }  Cerebral Palsy }  Spina Bifida }  Stroke }  Dementia }  Deconditioning and Debility }  Prolonged intubations }  Lung/respiratory disorders }  Cancer with radiation to the surrounding swallowing

mechanism }  Neurological disorders }  And many more…

}  Open mouth while swallowing }  Head thrown back for swallowing }  Pocketing of food }  GERD }  Tongue thrust }  Prolonged chewing }  Abnormal length of time to complete meals }  Coughing or choking on their own saliva }  Excessive drooling }  Pneumonia }  Repeated swallowing }  Delay in swallowing }  Holding food in mouth for too long

}  Aspiration is food and liquid that enters the airway below the vocal folds from either an impaired swallow or refluxing contents from the esophagus or stomach.

}  Silent aspiration is the same as above, however, the individual does NOT cough or choke when contents enter the airway… silent

}  Coughing }  Choking }  Elevated temperature }  Increased WBC }  Lung sound changes typically in the right

lower lobe. }  Chest x-ray may not show aspiration for up

to 72 hours after the aspiration event. }  Aspiration can occur in the left lower lobe if a

person typically leans to the left.

}  Enlarged tongue }  Short frenulum (tongue tied) }  Cleft palate }  Vaulted palate }  Lack of tone in the lips, tongue and cheeks }  Poor dentition }  Sensory issues for texture }  Lack of sensory awareness of the bolus

}  Bedside/Clinical Swallow Evaluation

}  Modified Barium Swallow Study

}  Dysphagia Therapy/Swallow Strategies/Diet Modifications

}  Traditional dysphagia therapy }  Diet modification analysis to food textures

and liquids }  Swallowing strategies or techniques }  NMES (Neuromuscular Electrical Stimulation)

Vital Stimulation }  DPNS (Deep Pharyngeal Neural Stimulation)

}  Oral care is important to: ◦  Keep the mouth moist and clean ◦  Keep bacteria in saliva from being aspirated ◦  Keep food particles from being aspirated after

meals }  A client who is on thickened liquids is at risk

for dehydration and dry mouth, therefore, oral care is especially important.

}  Optimal body positioning is having a client sitting up at 90 degrees and head in neutral position.

◦  If in bed, boost or pull the client up toward the

head of the bed, then raise the head of the bed. ◦  If in chair, reposition the client so that the hips are

flexed at 90 degrees.

}  This position maximizes: ◦  Bolus control in the oral cavity ◦  Anterior to posterior movement of the bolus ◦  Cricopharyngeal opening ◦  Bolus propulsion into the esophagus

}  Meals at the table }  Tilt the wheel chair }  Recline bed for a person with kyphosis }  Place pillow behind the head }  Straws versus no straws }  Chin tuck versus head in neutral position }  Soft cervical collar or neck brace

}  If head is not in proper position the risk of aspiration may increase.

◦  When airway is lengthened the muscles used to

close off the airway are less effective. ◦  Individuals with Cerebral Palsy, Tardive Dyskinesia,

etc. have a tendency to be in constant motion and traditional head placement may be too difficult… in that case texture modifications may need to be considered.

}  If the person is reclined, reflux symptoms may increase. ◦  Be aware if medications are working properly ◦  Stay upright for at least 60 min after meals ◦  Smaller more frequent meals may need to be provided

}  Other conditions that may cause or increase reflux: ◦  hiatal hernia ◦  Medications ◦  Poor esophageal motility.

�  These can also be affected by poor positioning.

}  5-6 small meals }  One bite/sip at a time }  Alternate solid then

liquid }  Minimize distractions }  Small bite/sip size }  Reduce rate of intake }  Large handled utensils

}  Chin tuck }  Swallow hard }  Hold then swallow }  Swallow twice }  Clear the throat or

cough and re-swallow

}  Provale Cup ◦  5cc and 10 cc bolus size ◦  Works with thin and nectar ◦  Increases independences ◦  Decreases cues ◦  One, two or no handles

}  Nosey Cup ◦  Helps maintain head in neutral position ◦  User has control of flow rate unless being fed

}  Novo Cup ◦  User is in control of flow

rate when cap plug is in place ◦  Ideal for clients with

restricted head and neck movements ◦  Must be able to suck

through a straw

}  Maroon spoon }  Baby spoon with long handle }  Cocktail fork }  Weighted spoons }  Foam handles for utensils }  Weights on wrists

}  Puree Diet: ◦  Smooth in texture ◦  No chewing required. ◦  Easy to form and swallow bolus. ◦  Examples: custard, blended yogurt, oatmeal, cream

of wheat and pureed foods.

}  Ground Diet: ◦  All food is ground into tiny pieces and should be

moist. Chopped Diet: ◦  All food is chopped/cut into small pieces.

}  Mechanically Altered Diet: Ground Meats Diet: ◦  Moist ◦  Soft-textured foods ◦  Easily formed into a bolus. ◦  Some chewing is required. ◦  Examples: fruit with yogurt, soft veggies, canned

fruit, lasagna, macaroni and cheese, moist ground meats, soft flaky fish.

}  Regular Diet: ◦  No food texture restrictions. Example: raw

vegetables, meat, crunchy foods, nuts etc.

}  Thin Liquid: ◦  It will not coat the spoon. ◦  It moves very quickly. ◦  It is anything that will liquefy in the mouth within a few

seconds. Examples: water, tea, hot chocolate, coffee, milk, juice, milkshakes, ice cream, sherbet, gelatin etc.

}  Nectar Thick Liquid: ◦  Liquid will coat the spoon or sides of cup/glass. ◦  It will pour freely in small rapid drops. ◦  If spilled, it will splash. Examples: tomato juice, plain

nectars, creamed soups, smoothies made with yogurt, any liquid with the correct amount of thickener added.

}  Honey Thick Liquids: ◦  Will pour more slowly like honey from a honeycomb. ◦  A straw will stand up. ◦  If spilled, it will spread rather than splash. Examples:

any beverage correctly thickened to honey-thick consistency

}  Pudding Thick Liquid: ◦  It will fall off the spoon in a glob. ◦  If the cup is turned upside down, the beverage should

still move. If it doesn’t it is too thick! Examples: any beverage correctly thickened to pudding-thick consistency.

}  If too little or too much powder is used it will not be accurate.

}  Stir and pour the thickener at the same time

to avoid getting lumps. }  Stir briskly for 30 to 45 seconds. ◦  Let set for 3 minutes for water, coffee, tea, juice. ◦  10 minutes for milk, creamed soups, Ensure, Boost.

◦  Use the correct amount of thickener. ◦  Pour and stir at the same time. ◦  Let set for the allotted time. ◦  Have all the required thickener ready before you

start adding it to the beverage. (lumps) ◦  Liquid medications need to be thickened. ◦  When thickening soda only add a small amount of

thickener to dissipate some of the carbonation. ◦  Place thickener in cup before adding supplement.

(lumps) ◦  Stir beverages one more time before serving.

}  Chill the beverage ahead of time. }  Add ice to the beverage to chill, remove

before thickening. }  Add lemon or lime juice flavoring to water. }  Do not over thicken. }  Add ginger ale to juices. }  For a tasty treat make Kool-Aid, add

thickener and then freeze into popsicles.

}  Beverages have been known to loose their thickness over time for no known reason. ◦  Soda pop ◦  Warm liquids ◦  Water �  Irrespective of type of thickener

}  Supplements require extra time to thicken. }  Enzymes in saliva can break down thickeners

and some foods. (wipe spoon)

}  Thickened liquids allow for normal hydration }  Digestible }  Doesn’t bind fluid }  98% of free water is released after consumption }  Offer beverages through out the day }  Offer foods with high water content such as: ◦  carrots, broccoli, cantaloupe, watermelon, peaches,

strawberries, oranges, grapes, apples, blueberries, kiwi, pears, pineapple, plums, cabbage, cooked pasta, kidney beans. �  These items need to be pureed and thickened.

*made w/Xanthan gum More natural flavor

}  Thick-It }  Thick-It 2 concentrated }  ThickenUp }  ThickenUP Clear* }  Simply Thick (gel) }  Thick & Easy }  Thick & Easy Clear* }  Thik & Clear (Cellulose

gum, more natural flavor) }  Hydra-aid (gel) }  AquaCare H2O* }  Aqua Thick

}  Baby cereal }  Instant pudding }  Jell-O }  Pureed fruit in juice }  Dehydrated potato

flakes }  Bread crumbs }  Prethickened liquids ◦  Novartis, Sysco,

Walgreens, CVS, WalMart

}  The following recipe is good for clients with esophageal scarring, hiatal hernia and dysmotility issues. ◦  Box of Jell-O according to package directions ◦  Refrigerate until it begins to gel ◦  Remove from fridge - add a ¼ cup of cold liquid for

every cup of Jell-o the recipe makes ◦  Mix and refrigerate ◦  Client eats bite of their food, swallow, then bite of

slick diet }  May add thickener during first step

}  There are many medications that may affect the swallow function from the oropharyngeal to the esophageal phase.

◦  Anti anxiety/Benzodiazepines drugs ◦  Antipsychotic/Neuroleptic drugs ◦  Antiepileptic drugs ◦  Narcotics ◦  Muscle relaxants

}  Multiple medications can cause dry mouth ◦  give sips of water before giving medications or

meal. �  ACE inhibitors, anti-nausea, antihistamines and

decongestants, calcium channel blockers, diuretics, antidepressants

}  Medications not given with enough water can lay in the esophagus and cause damage

�  antibiotics, aspirin, iron pills, bronchodilators, NSAID’s, potassium supplements, vitamin C

◦  Dry mouth – food sticks at base of tongue, throat and possibly the esophagus. ◦  Muscle impairments in the face and tongue leading

to discoordinated swallows such as Tardive Dyskinesia ◦  Reflux that can cause damage to the peristaltic

movement of the esophagus ◦  Lethargy (increases risk for aspiration, dehydration

and poor nutrition)

}  Client is always awake and alert for all meals and medication passes

}  Oral hygiene }  Proper body and head positioning for the

individual client }  Provide proper diet texture and liquid

consistency }  Follow any swallow strategies }  Plenty of water to wash medications into the

stomach }  Conduct a quarterly review of medications

}  Radionz. (2010, August 9). The Intra-Swallow Aspiration [Video file]. Retrieved from http://youtu.be/1sFNMk87558

}  Northern Speech. (2012, March 29). MBSImP Sample Animation: Penetration & Aspiration [Video file]. Retrieved from http://youtu.be/sowo87vxxxM

}  Killphil08. (2012, January 26). Dysphagie [Video file]. Retrieved from http://youtu.be/BevsLki9IU8

}  Griffin, Maggie. (2012, November 19). Swallow Inservice: If You Could See What I See. [Video file]. Retrieved from http://youtu.be/3XkkBvJ_cYo

}  Alanswatches. (2013, January 2). Aspiration. [Video file]. Retrieved from http://youtu.be/huZ6ymeKFd4

}  Ferguson, Neina. (2011, May 25). Normal Swallow. [Video file]. Retrieved from http://youtu.be/Cwy5Wfdf8nY

}  Cork, Alejandra. (2012, July 17). Swallowing. [Video file]. Retrieved from http://youtu.be/pNcV6yAfq-g

}  Logemann, J. A. (1997) Evaluation and Treatment of Swallowing Disorders. Austin, TX: Pro-Ed.

}  Balzer, KM, PharmD, “Drug-Induced Dysphagia”, International Journal of MS Care, page 6, Volume 2 Issue1, March 2000. (http://www.mscare.com/a003/page_06.htm)

}  http://www.ct.gov/dds/lib/health/attacha_med_dysphagia_swallowing_risks.pdf.

}  http://www.speechmedconsults.com/medications---affecting-swallowing.html

}  Slick Jell-O recipe http://dysphagia.com/maillist/2009-May/msg00013.html

}  Dysphagia Resource Center www.dysphagia.com