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Eating, Feeding, Swallowing
| Term | Definition |
|---|---|
| feeding vs. swallowing | Process of setting up, arranging, & bringing food from plate to mouth vs. Complex act of food/fluid moved from mouth through pharynx & esophagus to stomach |
| dysphagia | Condition resulting from interruption in eating pleasure or maintenance of nutrition/ hydration Any difficulties in any stage Impairs the person from swallowing independently/ safely A symptom of another condition |
| 1. penetration 2. aspiration 3. silent aspiration | 1. Food/ fluid enters laryngeal vestibule but not below level of true vocal cords 2. Food/ fluid enters airway below level of true vocal cords 3. Aspiration without cough response |
| 1. bolus 2. NPO 3. residue | 1. Collection of food or liquid 2. Nothing by mouth 3. Food/ fluid left in oral/ pharyngeal spaces |
| 1. oral cavity 2. pharyngeal space 3. esophagus | 1. From lips to tongue base 2. Tongue base to upper esophageal sphincter 3. From upper esophageal sphincter to lower esophageal sphincter |
| 1. alveolar ridge 2. salivary glands 3. mucosa | 1. Fancy words for gums 2. Maintains oral moisture, reduces tooth decay, aids in digestion 3. Covers oral cavity & helps transports the bolus |
| 1. dentition 2. hard palate 3. soft palate | 1. Helps with bolus formation 2. Tongue pushes against it to help transport the bolus 3. Includes uvula, closes to protect the nasal cavity |
| tongue 1. Tip, blade, back 2. Base | 1. Controlled voluntarily for bolus formation & propulsion 2. Controlled involuntarily by brainstem |
| pharynx | Funnel shaped tube running from base of skull to C6 3 areas: nasal, oral, laryngeal |
| valleculae vs. piriform sinuses | Wedge shapes space that forms between base of tongue & epiglottis vs. 2 mucosal pouches that form at lower end of hypopharynx |
| hyoid bone | Linked to attachments for many muscle groups Affects oral, pharyngeal, laryngeal functions Overall influences esophageal opening How it moves lets us know how strong swallowing is |
| larynx | Valve that separates trachea from upper digestive tract Made up of cartilage, membrane, ligaments & moved by many muscles Functions: voice, regulate respiration, make effective cough, airway protection from aspiration |
| arytenoids vs. aryepiglottic folds | Small, pyramid shaped. Contracts & contacts the epiglottis for airway closure vs. Tissue joining the arytenoids to tissue of epiglottis |
| thyroid cartilage vs. cricoid cartilage | Attachment for muscles and ligaments of the larynx vs. Attachment for muscles below the thyroid cartilage |
| 3 levels of closure | Aryepiglottic folds (first layer and last one to close) False vocal folds True vocal cords (3rd level and first one to close) |
| laryngeal reflexes | Sensory receptors in mucosal tissues respond to stimuli (vibration, touch, air pressure change, liquid stimuli) Helps protect from aspiration Laryngospasm indicates abnormal response |
| muscle types in esophagus 1. upper 3rd 2. middle 3rd 3. lower 3rd | 1. striated muscle 2. smooth/ striated 3. smooth muscle |
| infant anatomy differences | Full fat pads Oral cavity doesn't have that much room Tongue tip goes between alveolar ridges Hyoid bone is still cartilage Tongue movement is anterior- posterior |
| cervical nerves 1-2 | Controls infrahyoid muscles Lesions will decreases airway protection, decrease control of laryngeal elevation & depression |
| neurological control of swallowing | Sensory receptors of tongue base, soft palate, faucial arches, tonsils, & posterior pharyngeal wall will send messages to medulla oblongata Info from swallowing center is conveyed back to muscles to swallow |
| 4 stages of swallowing | Oral preparatory phase Oral phase Pharyngeal phase Esophageal phase |
| oral preparatory phase | Lips maintain bolus in mouth Cheeks keep bolus in teeth Tongue is cupped, moved bolus around for chewing & mixing with spit Teeth bite & masticate food Velum rests anteriorly to prevent food into pharynx Pharynx rests, airway open, nasal breathing |
| oral phase pt 1 | Voluntary Bolus propelled post into mouth, tongue ant to post on hard palate Thicker stuff needs more pressure to propel End when bolus is btwn anterior faucial arches & mandible crosses base of tongue Some food can go into valleculae during chewing |
| premature spillage vs. oral transit time | Loss of control of bolus prior to tongue propulsion vs. Time where tongue mvmnt initiated to time where bolus passes anterior faucial arches (1-1.5 seconds) |
| tipper pattern vs. dipper pattern | Bolus held between tongue & anterior portion of hard palate vs. Bolus held on floor of mouth in front of tongue |
| pharyngeal phase pt 1 | Reflex 1. Soft palate elevates to close nasal passage 2. Tongue retracts to prevent food from re-entering mouth- driving pressure 3. Post pharyngeal wall pulls fwd to contact tongue base |
| pharyngeal phase pt 2 | 4. Laryngeal entrance closes by hyoid mvmnt & laryngeal elevation 5. Hyolaryngeal mvmnt makes pharynx larger, makes a vacuum, helps relax cricopharyngeus muscle 6. Larynx closes in 3 locations, bolus moves over the epiglottis |
| hyoid & laryngeal movement during pharyngeal phase | Hyoid: Anterior & superiorly, 0.9cm anteriorly & 1.1 cm superiorly Laryngeal: superior, 2.5 cm |
| airway is well sealed by | Hypolaryngeal elevation Inversion of epiglottis Vocal cord adduction |
| 3 factors driving bolus movement | Tongue base retraction/ propulsion Positive pressure in pharynx- combination of tongue & post pharyngeal wall wave Negative pressure in hypopharynx |
| pharyngeal transit time | When bolus passes base of tongue until it enters UES segment 0.85- 1.5 seconds Increases with thicker liquid and solids |
| pharyngeal delay time | When bolus passes tongue base and laryngeal elevation begins Between 0.11 & 1.58 seconds Location of delay is important Some is common with liquids & expected solids, abnormal delay is more than 2 seconds w/ aspiration |
| esophageal phase | Reflex 1. Bolus passes UES 2. Peristaltic wave moves bolus through LES & into tummy 3. Wave makes positive pressure |
| normal times with esophageal phase | 1-3 seconds for liquids & very soft foods 4-10 seconds for soft & solid foods Elderly can take up to 20 seconds |
| oral phase in infants | Fluid extraction from nipple Tongue grooving, seal to nipple, intra-oral pressure 1 suck, 1 swallow, 1 breath is the most ideal |
| general normal changes w/ aging | Overall loss of muscle mass, strength, contractility Loss of elasticity in lung tissue, reduced respiratory capacity Ossification of tissues |
| oral changes with age | Smell/ taste Reduced saliva production Gum atrophy & denture fit Deteriorating dentition More chewing & residue in mouth Reduced tongue strength & suction pressure on straw |
| pharyngeal changes with age | Delayed initiating of swallow trigger Increased transit time More residue after swallow Reduced hyoid & laryngeal excursion Reduced pharyngeal & laryngeal sensation Cervical vertebrae change Penetration |
| esophageal changes with age | Increased transit time Reduced clearance efficacy Increased non-peristaltic contractions (spasm) Weakening of LES- more GERD symptoms |
| key causes of dysphagia | Neurological NM Mechanical/ structural Surgical Cardiac/ pulmonary Head/ neck cancer Metabolic Esophageal Autoimmune Infection Psych Iatrogenic Aging/ illness |
| red flags of dysphagia | Prolonged chewing Food avoidance, refusal, spitting out Anxiety w/ eating Pocketing food in mouth Drooling saliva Regurgitation of food Slowed oral transit Throat clearing/ choking Stuff sticking in throat |
| red flags of dysphasia pt 2 | Change in breathing/ voice quality Altered baseline voice Chest congestion Recurrent fever, pneumonia Pain associated w/ swallowing Globus sensation Diff initiating swallowing Weight loss |
| predictive risk factors for aspiration pneumonia pt 1 | Dependency for feeding & oral care Multiple medical diagnosis & meds Poor oral care Dysphagia with aspiration Tube feeding Weak cough Impaired mucociliary clearance |
| predictive risk factors for aspiration pneumonia pt 2 | Impaired immune response Delirium UTI/ dehydration Modified texture diet Weight loss Reduced mobility Neurological & gastrointestinal disease |
| oral mech exam | 1. Oral structures 2. Oral mucosa & secretion management 3. Lip movement 4. Jaw movement 5. Tongue movement 6. Palate & pharynx 7. Laryngeal function |
| oral structures | Structures- symmetrical, droopy Sensation Tone Dentition Pathological reflexes (suck, bite) |
| oral mucosa vs. lip movement | Suctioning, health, lesions vs. Closure at rest, protraction/ retraction, resistance, rapid alt movement |
| jaw movement vs. tongue movement | Open/ close, strength, hypolaryngeal elevation vs. Spasticity, protrusion ROM/ strength, tip elevation, lateralization ROM/ strength, rapid alt mvmnt |
| palate & pharynx vs. laryngeal function | Symmetry/ atrophy/ elevation, palatal reflex, gag reflex vs. Volitional cough & throat clear, voice quality, dry swallow on command, 4 finger palpation of laryngeal elevation |
| CMOP-E & feeding | Self-care Leisurely social interactions Spirituality- rituals, ceremony, beliefs Person- for those w/ physical involvement, risk for developing oral aversion Environment- dyad w/ parent, caregiver stress |
| OT role | Address... Positioning Oral & pharyngeal phases Self-feeding Environment Sensory processing perspective |
| entry level vs. advanced level OT | Provide basic feeding ax & interventions. Use functional analysis & sensory processing vs. Support medically fragile, instrumental eval, develop new approaches |
| screening tools | Toronto bedside swallow screening test Burke dysphagia screening test Yale swallow protocol Timed water swallow test |
| limitations to screens | Misidentify or underestimate impairment Screening risk must not be unacceptable |
| history | Reason for referral Informal client interview Collateral signs & symptoms reported (what is concern? how long? where are meals? who feeding? red flags? food record) Medical hx Allergies, psychosocial, mobility, cog, height & weight |
| specific history | Neurological conditions Congenital issues Cardiac, COPD GERD Prematurity Developmental delay |
| physical/ cognitive ax | Positioning/ posture Alertness & attention Communication Visuoperception function Physical health, strength, tone, fine motor, mobility Resp Oral mech |
| bolus trials/ meal observations client considerations | Resp & mental status Medical acuity Not managing own secretions (saliva pouring out of mouth) Poor cough Presence of tracheostomy |
| decisions on where to start bolus trials | Ensure adequate oral care/ hygiene before starting Generally trial fluids before solids If pt is NPO vs. receiving diet already |
| purpose of bolus trials | Observe & collect data on how client is managing different textures Completed in home, clinic, hospital Provides baseline & trialing intervention |
| range of fluids | Ice chips- dab of ice or liquid on lips Thin Mildly thick (nectar) Moderately thick (honey) Extremely thick (pudding) |
| range of solids | Pureed Minced Diced Regular |
| bolus trials delivery method vs. pt factors | Teaspoons, sips, straws vs. Self feeding vs. feeder, rate & volume being fed, fine motor & coordination |
| in bolus trials, watch for | Ability to maintain bolus in mouth Oral preparation & organization Oral residue/ pocketing Time to manage bolus Nasal regurgitation Effortful swallow Grimace Fatigue RR |
| bolus trials: palpation of larynx vs. listening after | Determine initiation of swallow, 4 finger method, feel for multiple swallows vs. Wet/ gurgly voice, throat clearing, coughing |
| questions that instrumental evaluation answers | Anatomy & physiology Ability to swallow various materials Assess secretions & reactions to them Adequacy of airway protection & coordination of resp & swallow Eval impact of compensatory therapy maneuvers |
| reasons to do instrumental evaluation | Clinical exam fails to address questions Dysphagia is vague & need more info Nutritional/ resp issues indicate dysphagia Safe swallowing is concerning Rehab is needed Identify underlying medical problem |
| reasons to maybe vs. not to do instrumental eval | Medical condition has high dysphagia risk, swallowing has overt change, unable to cooperate for exam vs. No longer has dysphagia, too medically compromised/ uncooperative, ax wouldn't alter clinical course or management plan |
| VFSS | Add barium to view swallow mechanism Looks at anatomy & physiology Impairments in physiology & consequences Eval potential for compensation strategies May screen for esophageal issues |
| limitations of VFSS | Exposure to radiation Limited view of pooling secretions Eval over short period of time in controlled environment- not functional (snapshot in time) Clinical interpretations |
| FEES | Use small tube w/ camera in nose to see pharyngeal space Nasal spray opens airway & topical anesthetic used prior May cause gagging, discomfort, nosebleeds Clinic or bedside by SLP Ax secretion management & vocal cord structure/ function |
| why FEES | Pharyngeal dysphagia & eval sensory awareness Secretion eval Pain in swallow Abnormal voice quality Nasal regurgitation Limited radiation exposure/ barium Can't travel |
| why not FEES | Need to see bony anatomy Screen oral/ esophageal function Agitated Mvmnt disorders of head/ neck Vasovagal/ fainting hx Severe nosebleeds Cardiac disorder Facial trauma |
| recommendations | Goals of care Acuity Resp status Consider values, env factors, social situation, goals Develop hypothesis of ability to take food in & hypothesis around pathophysiology of swallow function |
| in recommendation, include | Mode of nutrition (oral or non-oral) Fluids & solids consistency Variations Medication delivery Delivery method/ volume Env factors Consults needed Compensations Tx F/U |
| foundation to interventions | Client goals- improve function, new skills, social eating/ QoL Prevention of dysphagia illness Consider underlying disease Motivation & participation SAFETY (prefeed, consistencies, education) Adequate nutrition/ hydration Development of skills |
| adequate nutrition & hydration vs. development of skills | Consideration to feeds, volume, schedule, duration, different types of feed vs. Texture progressions, self feeding skills |
| family centered care vs. TUS | Provide ongoing education, dynamic feedback loop vs. Establish trust, don't trick, remain neutral to avoid need for constant reinforcement |
| basic considerations for interventions | Overall health & reconditioning Consider developmental stage & progression in peds Oral care/ dentition, moisture, & hygiene |
| environment & intervention | create focus to feeding Sensory aspects (visual, auditory, olfactory, tactile, movement) Schedule |
| positioning 1. infant 2. child 3. adult | 1. Flexion, midline, swaddling, head elevated, side lying 2. Dynamic, 90/90 is start, feet supported, safety 3. As with children |
| spoons considerations vs. plates/ bowls | Bowl size & shape, materials (coated, metal, plastic), grip/ handle, design vs. Create stability, lip on bowl, diff weighted items, ability to corral foods |
| techniques | Hand over hand Bwd chaining Placement of food Provide a tool Mess management (encourage messes) Food shape |
| key components of feeding someone | Client is alert Present food at eye level Talking at appropriate times Neutral head position Smaller bites Give time btwn food Monitor for fatigue Label food |
| fluids are thickened to | Slow rate of transit Support skill development |
| oral stimulation | Predictable pattern of sensory input Start at cheek, lips, tongue, own hands to mouth Use when feeding development disrupted Encourage autonomy |
| oral motor support techniques | Lip closure, seal, retract Jaw strengthen (hard toddler cookies) Jaw support Tongue thrust Manage tone |
| adaptive positions for feeding | Chin tuck- narrows airway & widens vallecular space Head turn- twd weaker side Side lying Neck extension- oral propulsion Whole body positioning |
| swallowing exercises | Masakos- tongue hold to improve base retraction Showa- tongue against hard palate Effortful swallow- swallow hard McNeill protocol- hard swallow w/ specific hierarchy of tasks Mendelsohn- hold larynx at height |
| swallowing exercises pt 2 | Supraglottic swallow- swallow then cough Super-supraglottic swallow- close airway & clears after swallow 3 second hold Dry swallows Thermal stimulation Biofeedback & NM stim |
| non-swallowing exercises | IOPO-tongue push Hawk- any word ending w/ K Shakers- lay flat, do chin tuck CTAR- similar as chin tuck but w/ resistance Jaw opening exercise Lee Silverman Expiratory muscle strength training- use 1 way valve |
| medical vs. surgical interventions | Non-oral feeding routes, saliva management, reflux medications vs. Vocal cord issues, UES opening, fistula management |
| parent vs. child responsibility | What food offered, when is offered, how food offered vs. How much eats, when child eats |
| get permission approach | By Marsha Klein Redefine try- as long as they interacted w/ food in some wat, they tried Kiss & hug- Give the food a kiss and put it down |
| sequential oral sensory approach | By Dr. Kay Twomey Breaks eating down into many more elements Encourage OT to slow down & look at all aspects |
| food chaining | Fraker, Fishbein, Cox, Walbert Analyze food that child accepts w/ attention to properties like taste, texture, color Start w/ anchor food then change 1 sensory property of food |
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