Swallowing Disorders

Normal swallowing is necessary to control one’s secretions as well as to support adequate nutrition. People eat as much more for pleasure than to supply the body with fuel. Indeed, most of our social activities and holidays involve eating. “What’s for dinner?” is a common daily question in most households.

So when Dysphagia, or swallowing difficulty interferes with an individual ability to eat normally their daily life is significantly impacted.

Dysphagia Management

Dysphagia is defined as the presence of difficulty in swallowing. It is a common problem (10 million Americans being evaluated each year). Recent studies in Europe suggest that over half of older persons with dysphagia are inadequately evaluated and treated. MedSpeech has Medical Speech Language Pathologists with the background and training to accurately evaluate and treat individuals with swallowing difficulty.

MedSpeech uses the following evaluation tools to determine where along the dynamic swallow sequence an individual’s system has “broken down”:

Clinical/bedside evaluation – includes thorough review of medical/clinical history, assessment of oral motor structures and function, auscultation of swallow, speech and vocal quality assessment, neurological function/functional communication of patient including ability to respond to instructions, outward response to modified amounts of oral feeding, possible compensatory techniques, and possible endoscopic assessment of secretions if further testing is not indicated.

Videofluoroscopic Swallowing Study (VFSS) /MBS (Modified Barium Swallow) – considered the “gold standard” for diagnosing oropharyngeal dysphagia, is a dynamic test which includes oral presentation of barium mixed with modified bolus sizes and consistencies. A video fluoroscopic recording is made in both antero-posterior and lateral views. VFSS allows for observation of bolus progress throughout the different stages of the swallowing process. The dynamic nature of this study helps the SLP to identify breakdowns and to try appropriate compensatory strategies. Also, it provides an accurate observation of whether aspiration is occurring. It requires the cooperation of an alert patient, which is the most limiting factor to performing VFSS.

Fiberoptic Endoscopic Evaluation of Swallowing (FEES) – Allows direct visualization of the oropharynx in action with and without swallowing, using a fiberoptic scope inserted nasally. Includes oral presentation of dyed foods and reveals appropriateness of therapy techniques. This view shows patient’s ability to manage secretions. The location of the bolus residual is what helps to determine breakdown and appropriate intervention.

EMG Biofeedback – involves the use of surface electrodes that measure the micro-volt current output of an individual’s muscle contraction activity during swallow. People learn that all muscles produce micro-volts of activity when contracting. After a baseline level is established, one tries various swallowing maneuvers to increase the strength or number of micro-volt of the muscle contraction. The biofeedback helps one to know which maneuver created the greatest output. Further, the feedback reassures and encourages them to continue their efforts. There is significant efficacy date to support the benefit of biofeedback for enabling individuals to better understand the condition of their body.

Electrical Stimulation “E-stim” – “E-stim” is a new therapy technique which involves the use of surface electrodes which transmit a very small current to increase the contraction of the swallowing muscles. CLICK FOR HANDOUT

The goal of evaluation and treatment is to determine if patients may continue safe oral ingestion or if they are at risk for developing aspiration pneumonia. Note: Pneumonia contributes to approximately 34% of all stroke deaths and represents the 3rd cause of mortality in the first month following stroke.

MedSpeech SLP’s know the risk factors that help to accurately predict risk of pneumonia. Of note, recent research suggests that aspiration is not a statistically significant risk factor for predicting who will and or who won’t develop pneumonia. The more significant risk factors are: dependence for oral care and feeding, oral hygiene factor, multiple medications and/or diagnoses, tube feeding, still smoking, handling of secretions, and cognitive status.

Effective evaluation leads to effective treatment. As M.J. Feinberg, MD (1990) stated, “Radical dietary changes and artificial feeding are drastic measures by any standards”. MedSpeech appreciates this responsibility and wants to assure you that we will provide accurate data to help physicians and patients make careful dietary decisions. On a positive note, research suggests that “more than 15 million Americans have some degree of dysphagia, and with regular treatment 83% recover or significantly improve”. Bello, J. (1994).

What is a Swallowing Disorder?

You may hear your healthcare worker or speech language pathologist refer to your swallowing disorder as dysphagia (dis-FAY-juh). Dysphagia is the technical term for impaired ability to move food from the mouth to the stomach. During a normal swallow, food is put into the mouth, chewed thoroughly, then pushed to the back of the mouth by the tongue. The food then leaves the mouth and enters the pharynx (common pathway for food and air), where the brain triggers an involuntary swallow reflex (pharyngeal swallow). A series of muscle contractions push the food through the pharynx and close off the airway (trachea) so no food enters it. This part of the swallow lasts less than a second, so timing is very important. The food then enters the esophagus (food tube) and muscle contractions push the food down into the stomach. Breakdown anywhere along this pathway can result in swallowing difficulty. CLICK FOR POWER POINT

Predicting Pneumonia Risk With Swallowing Disorders

By Rebecca L. Gould, MSC, CCC-SLP

Dysphagia or swallowing difficulty impacts over 25% of older Americans a year, mostly secondary to stroke or head and neck cancer; however, it also occurs in patients with progressive neurogenic disorders such as Parkinson’s disease or ALS, and in airway disorders such us COPD.

Sometimes dysphagia is a complication for older individuals who are more sedentary while in the hospital for another condition. If aspiration (food or liquid ”going down the wrong pipe”), is discovered on a videoswallow (test to evaluate swallow function), individuals are often given an “alternate means of nutritional support” – They are not allowed to eat anything by mouth as it is felt to be unsafe.

Unfortunately, once discharged from the hospital, patients and practitioners forget to reassess swallow function quickly because of the order to eat nothing by mouth. During this time, swallow function may decline even more secondary to disuse. In addition, some practitioners do not realize that aspiration as and of itself does not predict who will and who will not get pneumonia in the presence of aspiration. CLICK FOR HAND OUT

It is important to have a swallowing evaluation performed by a knowledgeable clinician who is aware that the following risk factors help predict pneumonia risk:

1. Multiple disease factors – Patients with more than one diagnosis are “sicker” and therefore more at risk for complications.

2. Multiple medications – Again, more medications indicate more medical issues and more possibilities of interaction and side effects.

3. Motility status – Sedentary people don’t clear secretions as well as people who are upright and mobile, “moving air”.

4. Oral disease factor – Secretions/saliva contain more bacteria than water; good oral hygiene reduces the risk of infection from aspirating one’s own secretions. (As one ages, greater than 25% of individuals over 65 report difficulty with secretion management). CLICK FOR HANDOUT

5. Cognitive status – Individuals who are alert and aware may be instructed as to strategies they may use to reduce the impact of aspiration. Biofeedback provides them with immediate insights regarding what they might do.

6. Smoking status – Non-smokers fare better.

7. Secretion management – Individuals who have a strong reflexive cough that will clear their secretions do better than those who cannot clear.

8. Dependency for feeding – People who are depending on others to feed do not do as well as those who are independent and able to judge their bite size for themselves.

Suffice it to say, accurate evaluation of swallowing function requires sensitive observation of the strength, timing and control of all the mechanisms involved – i.e., coordination and timing of respiration along with voluntary and involuntary oral motor control is critical for an effective swallow.

The best management strategy evolves from careful and clear assessment.

The clinicians at MedSpeech have the knowledge and skill to make an accurate assessment and to work with swallowing. (Bibliography available)