Swallowing Pills
G. Carnaby & M. CrarySwallowing Research Laboratory
SwallowingSwallowing is something that we do 2,000 to 3,000 times every day, yet it is a very complex act requiring many muscles coordinated by the brain and brainstem.
The swallow mechanism is innervated by 7 pairs of nerves and 26 muscle groups
Normal Swallowing
Three phases of swallowingOral phasePharyngeal phaseEsophageal phase
Phases of swallowingOral phase. Biting and chewing takes place in the mouth. During this stage, food is broken down into smaller pieces and mixes with saliva. This preparation stage is where the pleasure of eating is derived.
Oral phase
In this voluntary stage, the tongue pushes the food or liquid to the back of the mouth, where it is positioned to pass into the throat (pharynx). When this stage is completed, there should be no food or liquid remaining in the mouth.
Pharyngeal phase
During this phase, the palate, the soft structure that hangs in the back of the throat, elevates to prevent food or liquid from entering the nose. The voice box closes to prevent food from entering the windpipe, and a muscle at the low end of the pharynx relaxes to allow food to enter the esophagus.
Fluoroscopic Lateral View – OroPharyngeal Components
Video 1 – slow motion oropharyngeal swallow
Swallow Variants - Accommodation
Video 2 – Bolus Accommodation examples
Endoscopic View - Oropharyngeal
Video 3 – endoscopic view normal oropharyngeal swallow
Esophageal phase
A series of coordinated muscle contractions pushes the food down the esophagus (food tube) and into the stomach.
Esophageal Clearance - Fluoroscopy
Video 4 – example of fluoroscopic clearance
The whole sequence
http://srl.phhp.ufl.edu
University of FloridaSwallowing Research
Laboratory
Swallowing Research Laboratory
Research Foci Study of normal and abnormal swallowing physiologyDevelopment of innovative assessment and treatment ‘tool’s for adult dysphagia
Current Projects (examples)Prevention of dysphagia in head/cancerSwallow frequency to screen for dysphagia in strokeReflux and swallow frequency in acute strokeOral morbidities in head/neck cancerSwallow abilities in community dwelling elderly
Swallowing Research Laboratory
Measurement CapabilitiesVideofluoroscopyTransnasal endoscopyTransnasal esophagoscopyLingual-palatal pressure measurementPharyngeal and upper sphincter manometryHigh Resolution ManometryMRIsEMGRespiratory measuresAnd More!
Difficulty swallowing
“Dysphagia (dis-fag-ia)Defined as difficulty swallowing or the inability to swallow food or fluids”
Epidemiology of dysphagia
Estimated to affect 22% of the world’s population >50 years of age Swallowing disorders are becoming a major source of disability –estimated 17 million adults in the US alone
Up to 30% of patients in hospitals~60% of residents in nursing homesProbably 14% of people >65 years of age living in the community
Approximately 10 million children in the US
Disorders of swallowingCan occur in all age groups May be a result of many different medical conditionsCan be an acute problem or progress slowly over a long period of timeEarly identification and involvement of health professionals offers a good prognosis for swallowing disorders. Abnormalities of swallowing could be secondary to defects in any of the stages of swallowing enumerated above.
Many people with dysphagia can go unrecognized or undiagnosed until a major medical event occurs.
Additional DefinitionsAspiration: Passive entry of any food item into the trachea (eg, during inhalation), although the term often is used to denote any entry of material into the trachea in any manner Penetration: Active entry of any food item into the trachea (eg, during swallowing), although the term often is used to denote the entry of any material into the laryngeal vestibule
Diagnostic tools
Videofluoroscopic procedure (xray video)Most widely used determine physiology of swallow
Other evaluation toolsFiberoptic endoscopic examinationUltrasoundElectromyographyManometry
Videofluoroscopy
Videofluoroscopic procedureAlso known as modified barium swallowA radiographic study of a person’s swallowing mechanism that is recorded on videotape
Videos - dysphagia
Video 5 - Zenker’s Diverticulum
Dysphagia
Video 6 – Cricopharyngeal Bar
CP bar
Normal swallow
Dysphagia
Video 7 – Stricture in PES with NPR
Pills and More
Video 8 – Liquids pass but not the tablet!
Pills and More
Video 9 – Pills stick in throat and chest
Endoscopy - dysphagia
Video 10 – Endoscopic View Dysphagia in Elderly
Swallowing PillsEpidemiology Online National US survey 2003 [ n=679, 513 – 18-64yrs; 166 ≥65yrs]
40%- Report difficulty with swallowing pills 51% women /27% men18-64 (44%); ≥65yrs (26%)
Problem encountered % reported
Stuck in throat 80
Bad taste 48
Gagging 32
Impact of difficulty taking pills
14% delayed dosage 8% skipped a dose4% discontinued14% discussed issue with a health care provided
failure to follow dosing recommendations is associated with poorer health outcomes
Impact of difficulty taking pills
1/5 hesitate before taking pillsShape (84%)Size (29%)
1/10- choose based upon anticipated difficulty to swallow
Women (14%)Men (4%)
Strategies attempted to assist swallowing pills
Strategies to assist swallowing pills
% reported
Drink lots of water 55%
Gulping water 48%
Tilt head back 43%
Place on back of tongue 31%
Multiple swallows 30%
Split pills in half 17%
Deep breath before swallow 13%
ease of tr
ansp
ort
administ
ration
preparation ty
pe
need for w
ater
taste
0%
10%
20%
30%
40%
50%
60%
70%
80%80% 78% 76%
65% 61%
Factors Influencing pill preference
Pill swallowing – Physiologic effects
Little data on the alterations in the swallow system that occurs with pillsSwallowing a learnt complex motor task…Shibamoto et al (2007)
fMRI to view cortical brain activation with pill swallowing (11mm X 2mm columnar capsule) n=21 healthy personsdifferent brain areas activated during capsule swallowing- i.e. cerebellum
swallow
Tongue movement
Finger tapping
Food Sticking in Throat Study
Review of outpatient with complaints of food/liquid sticking in throatEvaluation of fluoroscopic videos to identify
Any confirmation that something does stickWhere it sticksCause of ‘sticking’What material best identifies the problem
Methods
315 outpatients were reviewed
117 patients c/o solid “sticking” 24 patients c/o solid and liquid “sticking”
Total of 141 patients with the complaintPrevalence = 45%
Results
Mean Age (in years) : 61.46
Female:Male = 88:53
Positive fluoroscopic findings108 patients = 77%
Anatomic vs. Physiologic findings
15% of the positive cases = anatomic strictures, pouches etc.
85% of the positive cases = physiologicesophageal dysmotility, achalasia etc.
UES = Upper Esophageal Spincter
15% of positive cases had anatomic obstructions
UES = Upper Esophageal SphincterLES = Lower Esophageal Sphincter
85% of positive cases had physiologic obstructions
Marshmallow yielded highest positive result at 53%
Conclusions• 45% Prevalence of food sticking symptoms• 27% correctly localized obstruction in “throat”• Anatomic obstructions, primarily in UES
• Better localization for anatomic obstructions • 73% incorrectly localized obstruction upward in
throat• Primarily physiologic obstructions
SummarySwallowing is a complex process with interplay among major anatomical components
OralPharyngealLaryngeal
Dysphagia may be overt or covertMany patients with covert of mild dysphagia remain total oral feeders and take meds orallyFood sticking is a common complaint in overt/covertPills sticking is a common complaint
Pill swallowing is different from food/liquidPhysiology is differentNeurology is different