“Reference Values for Healthy Swallowing Across the Range From Thin to Extremely Thick Liquids”
“Thickened liquids are frequently used as an intervention for dysphagia, but gaps persist in our understanding of variations in swallowing behaviour based on incremental thickening of liquids.”
“Dysphagia Prevalence, Attitudes, and Related Quality of Life in Patients with Multiple Sclerosis” by Printza et al.
"Dysphagia in patients with multiple sclerosis (MS) is associated with significant morbidity and has profound impact on the quality of life (QoL)….one out of four patients reported difficulties or choking while drinking fluids and eating food,… need for food and drink segmentation…"
"Facing COVID-19: Impact on swallowing in patients following intubation and tracheostomy"
"...When considering the potential for dysphagia in patients following intubation, tracheostomies, and mechanical ventilation, a speech-language pathologist (SLP) must have a strong understanding of what these interventions are and how they may impact anatomy and physiology..."
"Evidence supporting dysphagia telepractice and Practical advice for telepractice dysphagia intervention"
“… early literature suggests that telepractice swallowing interventions can be feasible, yield high patient and clinician satisfaction, and provide reliable assessment results when using a standardized technological setup…”
Thicker isn’t always better!
“Sometimes liquids are thickened to make swallowing them safer for people with dysphagia. However, there is a lot of variability in liquid consistencies across products and labels.”
Dysphagia & Special Populations: Managing Dysphagia in Adults with Intellectual Disability
“…Adults with intellectual disability are at risk for dysphagia. The unique swallowing, feeding, and behavioral challenges experienced in this population are vital considerations in the assessment and treatment of these patients…”
Are we ready for post-extubation dysphagia
“Post-extubation dysphagia is an under-recognized and potentially costly form of impairment in survivors of critical illness…
SLPs are worried about the increased risks for COVID patients to acquire an additional aspiration pneumonia, become re-intubated, and have prolonged hospitalizations (Leder & colleagues, 2019). Dr. Madison Macht, a critical care/pulmonary/neuro-critical care physician, who frequently writes about evaluating and treating dysphagia in the ICU, already noted in 2013 that…
“Brodsky, et al. (2018) found the following post-extubation symptoms:
- Dysphonia: 76% (Note: along with hoarseness and vocal cord impairment/hypomobility, we suspect reduced sensation of airway invasion, as well as a weak cough to eject the material.)
- Pain (odynophagia means pain with swallow): 76%
- Dysphagia: 49%
- Laryngeal dyspnea: 23%
- Stridor: 7%”
Guidance for SLPs During COVID-19 Pandemic.
The Infection Prevention and Control (IPAC) at the University Health Network have been working with our Speech Language Pathologists (SLPs) to provide guidance for SLP specific tasks during this COVID-19 pandemic, including the use of Personal Protective Equipment (PPE).
The guidance we are following to determine urgent priorities for VFSS across ALL our corporate facilities (acute and rehab) is below:
· Symptoms of aspiration (i.e., coughing & choking with p.o. intake across ALL textures at bedside, unable to identify a “best” texture in non-instrumental exam)
· Dysphagia management is discharge-limiting (i.e., feeding tube removal needed for discharge to next level of care/home)
· Patient has documented signs of aspiration on imaging (i.e., CXR/CT shows aspiration)
· Patient is currently diagnosed with aspiration pneumonia and there is a reason to suspect oropharyngeal dysphagia as the cause
· For outpatients, significant weight loss (>10% in 6 months) or significantly decreased p.o. intake related to current diet texture
· On a clinical trial (e.g. cancer trial) with oral targeted therapy
How You Swallow
How You Swallow
People normally swallow hundreds of times a day to eat solids, drink liquids, and swallow the normal saliva and mucus that the body produces. The process of swallowing has four stages:
1.The first is oral preparation, where food or liquid is manipulated and chewed in preparation for swallowing.
2.During the oral stage, the tongue propels the food or liquid to the back of the mouth, starting the swallowing response.
3.The pharyngeal stage begins as food or liquid is quickly passed through the pharynx, the canal that connects the mouth with the esophagus, into the esophagus or swallowing tube.
4.In the final, esophageal stage, the food or liquid passes through the esophagus into the stomach.
Although the first and second stages have some voluntary control, stages three and four occur by themselves, without conscious input.
What Causes Swallowing Disorders?
Any interruption in the swallowing process can cause difficulties. It may be due to simple causes such as poor teeth, ill fitting dentures, or a common cold. One of the most common causes of dysphagia is gastroesophageal reflux. This occurs when stomach acid moves up the esophagus to the pharynx, causing discomfort. Other causes may include: stroke; progressive neurologic disorder; the presence of a tracheostomy tube; a paralyzed or unmoving vocal cord; a tumor in the mouth, throat, or esophagus; or surgery in the head, neck, or esophageal areas.
Symptoms of swallowing disorders may include:
- drooling;
- a feeling that food or liquid is sticking in the throat;
- discomfort in the throat or chest (when gastroesophageal reflux is present);
- a sensation of a foreign body or “lump” in the throat;
- weight loss and inadequate nutrition due to prolonged or more significant problems with swallowing; and
- coughing or choking caused by bits of food, liquid, or saliva not passing easily during swallowing, and being sucked into the lungs.
Who Evaluates and Treats Swallowing Disorders?
When dysphagia is persistent and the cause is not apparent, the otolaryngologist–head and neck surgeon will discuss the history of your problem and examine your mouth and throat…If necessary, an examination of the esophagus, stomach, and upper small intestine (duodenum) may be carried out by the otolaryngologist or a gastroenterologist. These specialists may recommend X-rays of the swallowing mechanism, called a barium swallow or upper G-I, which is done by a radiologist.
If special problems exist, a speech pathologist may consult with the radiologist regarding a modified barium swallow or videofluroscopy. These help to identify all four stages of the swallowing process. Using different consistencies of food and liquid, and having the patient swallow in various positions, a speech pathologist will test the ability to swallow. An exam by a neurologist may be necessary if the swallowing disorder stems from the nervous system, perhaps due to stroke or other neurologic disorders.
Possible Treatments
Many of these disorders can be treated with medication. Drugs that slow stomach acid production, muscle relaxants, and antacids are a few of the many medicines available. Treatment is tailored to the particular cause of the swallowing disorder.
Gastroesophageal reflux can often be treated by changing eating and living habits, for example:
- eat a bland diet with smaller, more frequent meals:
- eliminate alcohol and caffeine;
- reduce weight and stress;
- avoid food within three hours of bedtime; and
- elevate the head of the bed at night.
- If these don’t help, antacids between meals and at bedtime may provide relief.
Many swallowing disorders may be helped by direct swallowing therapy. A speech pathologist can provide special exercises for coordinating the swallowing muscles or restimulating the nerves that trigger the swallow reflex. Patients may also be taught simple ways to place food in the mouth or position the body and head to help the swallow occur successfully.
Some patients with swallowing disorders have difficulty feeding themselves. An occupational therapist can aid the patient and family in feeding techniques. These techniques make the patient as independent as possible. A dietician or nutritional expert can determine the amount of food or liquid necessary to sustain an individual and whether supplements are necessary.
Once the cause is determined, swallowing disorders may be treated with:
medication
swallowing therapy
surgery
UNDERSTANDING DYSPHAGIA
Dysphagia is a medical condition which describes the difficulty in swallowing solids or liquids. A person suffering from dysphagia may either have problems forming a bolus (the mass of food to be swallowed) in the mouth or have difficulty moving the bolus from the mouth to the stomach.
Swallowing is a complex process involving various muscles, glands and nerves. The swallowing process consists of three distinct phases, each controlled differently.
Dysphagia can originate from a disorder in any one or more of these swallowing phases.
Swallowing difficulty can occur at any age but is more common in older adults. Almost 14% of the population over the age 50 have clinical signs of dysphagia. As dysphagia can cause other health problems, early diagnosis and the right treatment are the best recommendations for good quality of life.
...In fact, people over 65 years of age have seven times higher risk for choking on food than children aged 1–4 years of age. Texture modified foods are provided clinically to reduce choking risk and manage dysphagia. Although certain food textures offer greater swallowing safety, they significantly restrict food choice. This commentary paper will highlight age-related changes to the eating and swallowing system, noting especially those that are relevant for frail elders. Swallowing impairments also affect the ability to manage liquids, and aspiration risk in healthy and frail elders is also discussed.