SWALLOW AWARENESS TRAINING

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SWALLOW AWARENESS TRAINING

• Hard to Swallow
• SPEECH LANGUAGE THERAPY
• Sally Bradford, June 2006.

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SESSION PLAN

• THE NORMAL SWALLOW
• WHAT CAN GO WRONG?
• THICKENER
• FOOD TEXTURES
• FEEDING SESSION
• HOW TO HELP

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SWALLOWING A SIMPLE TASK?

• We all swallow about 1000 times a day clearing
  over a litre of saliva.
• Complex process involving multiple cerebral
  regions.
• It involves 5 cranial nerves and 31 pairs of
  muscles of the mouth and throat.

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FOUR STAGES OF THE NORMAL SWALLOW

• Pre-oral , preparatory stage.
• Oral stage.
• Pharyngeal stage.
• Oesophageal stage.

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PRE-ORAL STAGE

• Transfer of food or fluid from the plate/cup into
  the mouth.
• Saliva begins to flow, sight and smell of food is
  important.
• Chewing the food and mixing with saliva to form a
  bolus.
• Tongue very mobile, tip, sides middle collects
  all bits.
• Holding the bolus in the centre of the tongue
  awaiting oral stage to begin.

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ORAL STAGE

• Voluntary action. Breathing can continue.
• The tongue moves back transferring the bolus
  towards the pharynx.
• The lips and jaw close to form a partial vacuum
  which helps to move the food up and back towards
  the pharynx.
• The soft palate raises.

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PRE-and ORAL SWALLOW DISTURBANCE

• Diffculty getting food/ drink to mouth,e.g.
  visual difficuties, head not in mid-line,or using
  weak or non-dominant hand.
• Decreased lip closure?drooling, spillage, pooling
  or residue, change in oral pressure.
• Facial weakness?residue in cheek, biting cheek
  wall.
• Reduced sensation? residue pocketing difficulty
  forming bolus, premature spillage of material
  into pharynx, biting tongue.
• Reduced tongue function?impaired movement of
  bolus, residue on tongue, lateral sulci or
  palate.
• Poor soft palate closure? food/ drink back down
  nose.

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PHARYNGEAL STAGE

• Food/ liquid is forced over the back of tongue
  into pharynx.
• Larynx moves up and forward and the airway closes
  off.
• Cricopharyngeal sphincter opens so food/ drink
  passes into oesophagus.
• Larynx opens, breathing re-starts.

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PHARYNGEAL STAGE DISTURBANCE

• Delayed/ absent triggering of pharyngeal
  swallow?pooling in pharynx and possible
  aspiration.
• Reduced tongue base retraction?residue in
  valleculae.
• Reduced contraction of wall of pharynx?residue.
• Larynx may not rise or close eficiently? airway
  not protected, aspiration.
• Cricopharyngeus may not open?overspill when
  breathing re-starts.

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OESOPHAGEAL STAGE

• Duration approximately 5 seconds.
• Reflex (involuntary) action.
• The bolus is transferred down the oesophagus to
  the stomach.
• Reflux can occur and can be aspirated.

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WHAT IS DYSPHAGIA?

• Dysphagia is a breakdown in swallowing at any of
  the 4 stages.
• Occurrence in acute stroke 50-60.
• Associated with aspiration, asphyxiation, chest
  infections (pneumonia), weight loss,
  malnutrition, dehydration, depression, poor wound
  healing, increased length of hospital stay.
• High incidence of dysphagia and pneumonia for
  stroke- prominent in brain stem stroke. (Martino,
  Foley et.al. 2005)

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WHAT IS ASPIRATION?

• Aspiration is when all or part of the bolus goes
  down the wrong way ie towards the lungs where it
  can cause chest infections such as aspiration
  pneumonia.
• Among the elderly caseload ,weakened by their
  condition and stroke, aspiration can be fatal.
• About 52 of stroke patients are aspirators.
• Most stroke patients recover swallow by 3 weeks.

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SIGNS OF DYSPHAGIA TO WATCH FOR!

• Coughing while / shortly after eating or drinking
• Wet, gurgly voice or change in voice
• Shortness of breath whilst eating / drinking
• Difficulty initiating the swallow
• Food sticking in the throat
• Frequent repetitive swallows
• Effortful swallowing

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More signs of dysphagia

• Recurrent chest infections
• Weight loss, malnourishment
• Loss of appetite, meals/drinks not finished
• Food left in the mouth
• Fear of eating or drinking.
• Drooling or dribbling.
• Difficulty swallowing tablets.
• Patients complaining of difficulty.
• N.B. silent aspiration

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Dysphagia and oral health

• Saliva normally lubricates, glues, digests,
  buffers, dilutes, protects. Human mouth has over
  700 types of bacteria.
• Dry mouth affects chewing, swallow , speech,
  increase in bacteria -mucositis, glossitis,
  halitosis, caries, denture tolerance, gum
  disease.
• Lack of oromuscular movement or NBM encourages
  build up of debris, increase in bacteria e.g
  staphylococcus, pseudomonas, or yeasts in plaque
  and mucosa.
• Candida can build up hidden in pharynx/
  oesophagus-dry, coated tongue, painful.
• Excessive salivation causes skin irritation,
  infection risk.
• N.B.
• POOR ORAL HEALTH INCREASED RISK OF PNEUMONIA

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ORAL HYGIENE

• Assessment of the mouth.
• Suctioning secretions.
• Regular mouth care (hourly).
• Water and soft toothbrush, lubricant for lips.
• Treat disorders.
• Royal college of Nursing , or Royal Marsden
  advice.

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WHAT MIGHT BE RECOMMEDED?

• Exercises for the tongue, lips, palate, pharynx
  or larynx
• Postural changes SIT STROKE UP, chin tuck, head
  turn.
• Manoeuvres
• Use of equipment
• Valved straws, valved cups, Cups with cut away,
  large handled utensils, rimmed plates, Anti-slip
  mats, Aprons (to protect clothing)
• N.B. NO SPOUTED FEEDER BEAKERS!
• Modified diet and fluids

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THICKEN UP!

• Thickener makes fluids more cohesive and slows
  them down thus making them a safer consistency
  for many dysphagic people.
• There are three groups of thickened fluid
• Syrup consistency. 1scoop per 100 mls. fluid
• Custard consistency.11/2 scoops per 100mls.
• Pudding consistency.2 scoops per 100 mls.
• N.B. Whisk with fork. Leave for 1 minute.

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MODIFIED DIETS

• There are five types of diet that may be
  recommended
• Stage 1 Nil by Mouth
• Stage 2 thick smooth diet
• Stage 3 mashed diet
• Stage 4 soft diet
• Stage 5 normal diet
• All modified diets facilitate the oral stage and
  are less prone to block the airway if aspirated.

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STAGE 1..NIL BY MOUTH
IV OR SUB CUT FLUIDS
REGULAR ORAL CARE
NG TUBE
PEG TUBE

• no food or fluid orally
• regular mouthcare needed

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STAGE 2..THICK SMOOTH DIET
ROAST DINNER
FRUIT SMOOTHIE OR MILKSHAKE
BISCUITS SOAKED IN SOLUTION
PUREED PORRIDGE

• No chewing required
• Thick, smooth with no lumps. A uniform
  consistency
• Food has been pureed and sieved to remove
  particles
• A thickener may be added to maintain stability
• Can be eaten with a fork or spoon
• Will hold its own shape on a plate and can be
  moulded, layerd or piped

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STAGE 3..MASHED DIET
SHEPHERDS PIE
VEG CURRY
SPONGE PUDDING AND CUSTARD
PORRIDGE

• Only requires very little chewing.
• Foods can be easily mashed with a fork
• Food is moist, with some variation in texture
• Has not been pureed or sieved
• Tough meat should be pureed.
• May be served or coated in a thick sauce/gravy
• Mashed with fork by nurse / carer

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STAGE 4..SOFT DIET
MEAT PIE AND VEG WITH GRAVY
MEAT CURRY WITH ROTI
APPLE PIE AND CUSTARD
COOKED BREAKFAST

• Dishes consisting of soft, moist food.
• Foods can be broken into pieces with a fork.
• Avoid foods which cause a choking hazard
• (see list of high risk foods).
• Dishes can be made up of solids and thick
  sauces or gravies

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STAGE 5..NORMAL DIET
CRUSTY BREAD
SALAD
CORNFLAKES WITH COLD MILK
PEAS

• Requires unimpaired ability to bite and chew.
• Includes all foods from high risk foods
  list.
• Stringy, fibrous, textures.
• Vegetable and fruit skins including beans
• Mixed consistency foods
• Crunchy foods
• Crumbly items
• Hard foods
• Husks

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HOW TO HELP

• Be aware of those patients at risk of aspiration.
  Follow recommendations that are documented, read
  before each time pt. has food/drink.
• Make sure patient is staying alert for all
  feeding session.
• Get best seating and positioning of patient.
• Sit yourself in front of patient, below eyeline.
• Monitor closely for signs of difficulty. Watch
  for worsening symptoms.
• If difficulties are noted document this and get
  advice as soon as possible.
• Ensure good mouth care, dentures fit.

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SITTING POSITION
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HOW YOU CAN HELP-cont.

• Atmosphere -calm, reduce distractions.
• Ensure mealtime is appropriate- little, often.
• Encourage and support -give plenty of time.
• Psychological aspects. Be aware patient may be
  embarrassed anxious or depressed. Being fed by
  someone can cause lack of self-respect. Be
  positive.
• Make sure medication is modified.
• REMEMBER anticipation, vigilance and prevention
  are more effective than post-aspiration therapy.

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How to refer to Speech and Language Therapy

• At present we need a written referral from the
  doctor to see patients with dysphagia.
• Sip Test trained nurses can screen for
  dysphagia.
• All acute stroke patients should be screened
  within 24hrs.
• St. Lukes Hospital Tel. ext.5220 Fax 5443.
• Bradford Royal Inf. Tel. ext 6517 Fax 6946.