Download Aspiration Precautions

Swallowing
Team
Speech
Safety
Department of Learning with Special thanks to Speech
Therapy & Rehabilitation Staff at Broward Health Coral
Springs for contributing to this learning module.
Note: 1 Contact Hour and 1 Stroke Hour
Q00501
Information
Purpose
• To provide information on the basics of dysphagia and
aspiration precautions and intervention to promote safety
among patients at Broward Health.
Contact Hours
• This course material is approved for 1 contact hour for:
Clinical Social Work, Marriage & Family Therapy & Mental
Health Counseling, Nursing, CNA’s, Occupational
Therapy, Respiratory Care, Dietetics and Nutrition
Outline
• Introduction to Dysphagia
• Anatomy
• Phases of the Swallow
• Signs and Symptoms of Dysphagia
• Aspiration Precautions
• Aspiration Pneumonia
• Swallowing Techniques
• Dysphagia Diets
• Tests and Recommendations
• Summary
Methodology
• This module contains didactic information and a post-test
and an evaluation tool
Objectives
• List the 3 parts of the esophagus
• Identify the 4 categories of dysphagia
• List types of dysphagia diets
• Identify 4 causes of aspiration
• Identify 3 swallowing techniques
Contact Person
• If you have questions, concerns or issues regarding this
module, please contact the Regional Clinical Education
Department at your facility.
Disclaimer
• This Self-learning Module is not intended to give the
reader details on the specific policies and procedures
(P&P) used at Broward Health facilities.
• Please refer to your facilities P & P on the Broward Health
intranet located in the document library.
Introduction to Dysphagia
Dysphagia
What is Dysphagia?
How Does it Happen?
• From the Greek word:
• The mouth, tongue, and epiglottis play
a vital role in the swallowing process.
• Dys: Loss of
• Phagia: Ability to eat (to swallow)
• Dysphagia refers to any disorder in the
swallowing process that does not allow
food or fluid to pass safely from the mouth
to the stomach.
• There are various causes that can lead to
different types of dysphagia.
• If the oral or pharyngeal areas become
weak or uncoordinated, there is a risk
that food or drink that is swallowed
may end up in the lungs rather than
the stomach.
• This can have serious health
consequences.
Dysphagia
• Oral dysphagia means it takes more time
and effort to move food or liquid from your
mouth to your stomach.
• Pharyngeal dysphagia means there is an
impairment in the movement of the
epiglottis, larynx, hyoid or posterior
pharyngeal wall.
• Dysphagia may also be associated with
pain (Odynophagia).
• In some cases, swallowing may be
impossible.
• But persistent dysphagia may indicate a
serious medical condition requiring
treatment.
• Occasional difficulty swallowing, which
may occur when you eat too fast or
don't chew your food well enough,
usually isn't cause for concern.
• Dysphagia can occur at any age, but it's
more common in older adults.
• The causes of swallowing problems vary,
and treatment depends on the cause.
Worldwide Prevalence
• Dysphagia is generally a sign of underlying diseases that can be associated with varied
diagnoses.
• Neurological disorders, cancer and age-related physiologic changes are the major primary
diagnosis associated with swallowing difficulties.
Prevalence Worldwide
35 - 50% Stroke Patients
5.6-8 mio patients
80% Alzheimer Patients
+/- 19.2 mio patients
50% Parkinson Patients
3.2 mio patients
33-40% Multiple Sclerosis Patients
0.8-1 mio patients
44 -51% Cancer: Head & Neck
+/- 0.25 mio patients
40-50% Elderly Population
Hospital
(12-49%)
• mio = minimally invasive oesophagestomy
Nursing Home
(32-51%)
Community
(15%)
Terminology
Mastication
• The process of chewing by which the teeth and tongue work together to break down
food to form a bolus.
Bolus
• The collected and shaped body of food which has been chewed and chemically
processed by enzymes prior to being swallowed
Pocketing
• Food sticks between the cheek and the teeth/gums after the swallow
Residue
• Some food or liquid remains in the mouth or the throat after the swallow
Terminology (Continued)
Penetration
• The Process in which food or liquids enters the larynx but does not become inhaled
into the lungs. These foreign substances are ejected from the laryngeal area
Aspiration
• The inhalation of food, liquid, or other foreign matter into the lungs
Silent Aspiration
• Patient does not cough when aspiration occurs
Peristalsis
• The wave like motion which conducts the bolus through the oral, pharyngeal, and
esophageal structures
Swallowing Trivia
• The swallow mechanism is innervated by 7 pairs of nerves and 26 muscle groups
• We swallow more than 600 times each day
• We swallow about once every minute while asleep
• Of the 2 palates, which is able to move, hard or soft?
•
The hard palate contains bone and cannot move. The soft palate, which contains the uvula, has no
bone and consists of muscle fibers. The levator of the soft palate elevates to seal off the nasal cavity
from the oral cavity, and is innervated by the pharyngeal plexus of the vagus (X) nerve. The tensor
muscle contracts to make the soft palate stiff, and is innervated by the mandibular branch of the
trigeminal nerve (V3).
• Is swallowing Voluntary or Involuntary?
•
While swallowing is very difficult to stop when started, thus appearing to be an autonomic action, it is
actually voluntary. All the muscles involved are striated voluntary muscle. Initiation of the swallow is
voluntary as you can swallow when there is not food in your mouth. However, the peristalsis
movement of the esophagus is involuntary as it is initiated when the bolus reaches the UES at the end
of the pharyngeal phase.
Anatomy
Introduction
Understanding the Anatomy
• The mouth and throat are made up of a many
different parts. The esophagus is a muscular
tube that carries food and liquids from the
throat into the stomach.
• It is located behind the breathing tube
(trachea, or windpipe).
• The esophagus is divided into three parts,
going from the top to the bottom: the
cervical/proximal esophagus, thoracic/medial
esophagus and abdominal/distal esophagus.
Anatomy of the Mouth
Anatomy of the Esophagus
3 Parts to the Esophagus
• Cervical/Proximal esophagus: This part of the esophagus
begins at the upper esophageal sphincter (UES). It lies
approximately at the level of the 6th cervical vertebra (C6)
and extends to the 5th thoracic vertebra (T5).
• Thoracic/Medial esophagus: This part of the esophagus
extends from the 5th thoracic vertebra (T5) to the 10th
thoracic vertebra (T10).
• Abdominal/Distal esophagus: This part of the esophagus
extends from the esophagus/gastric (GE) junction, which is
about the level of the xiphoid process.
Phases of the Swallow
Normal Swallowing
Lateral view of bolus propulsion during swallowing:
Phases of a Normal Swallow
• Swallowing is complex, and a number of conditions can interfere with this process.
• Sometimes the cause of dysphagia can't be identified. However, dysphagia generally
falls into one of the following phases:
Oral Preparatory
Food is broken down by chewing and mashing
with tongue and exposure to enzymes in saliva
which creates a bolus.
Oral
Bolus is propelled posteriorly by tongue to reach
anterior faucial pillars, which triggers the
swallow reflex
Pharyngeal
Vocal folds close, epiglottis inverts to cover air
way, and bolus travels over base of tongue to
vallecule and then the pyriform sinuses.
Esophageal
Food travels down esophagus through the
means of peristalsis and enters stomach
Difficulties that Can Occur During the
Swallow
Oropharyngeal
• Difficulties with the passage of the food
bolus from oral cavity to cervical
esophagus.
Possible causes of Oropharyngeal Dysphagia
include:
Neurological
Disorders
• Certain conditions can weaken your
throat muscles, making it difficult to
move food from your mouth into your
throat and esophagus when you start to
swallow.
Certain disorders, such as multiple
sclerosis, muscular dystrophy and
Parkinson Disease.
Neurological
Damage
• You may choke, gag or cough when you
try to swallow or have the sensation of
food or fluids going down your trachea
(windpipe) or up your nose.
Sudden neurological damage, such
as from a stroke, traumatic brain
injury (TBI), Amyotropic Lateral
Sclerosis (ALS) or spinal cord
injury.
Pharyngeal
Diverticula
A small pouch that forms and
collects food particles in the
throat, often in cervical/proximal
esophagus, leads to difficulty
swallowing, bad breath and
repeated throat clearing or
coughing.
Cancer
Certain cancers and some cancer
treatments, such as radiation.
• This may lead to pneumonia.
Difficulties that Can Occur During the
Swallow
Esophageal Dysphagia
• Esophageal dysphagia refers to the sensation of food sticking or getting stuck in the base of your
throat or in your chest after you've started to swallow.
• Some of the causes of esophageal dysphagia include:
Achalasia
• When the lower esophygeal muscle (sphincter) doesn’t relax properly to let
food enter the stomach, it may cause food to back up into the throat.
• Muscles in the wall of the esophagus may be weak, which worsens over time.
Diffuse Spasm
• This condition produces multiple high-pressure, poorly coordinated
contractions of the esophagus, usually after swallowing.
• Affects the involuntary muscles in the walls of the lower esophagus.
Esophageal
Stricture
• A narrowed esophagus (stricture) can trap large pieces of food.
Esophageal
Tumor
• Difficulty swallowing tends to get progressively worse when esophageal
tumors are present.
Esophageal Ring
• A thin area of narrowing in the lower esophagus can intermittently cause
difficulty swallowing solid foods.
• Tumors or scar tissue, often caused by gastroesophageal reflux disease
(GERD), can cause narrowing.
Difficulties that Can Occur During the
Swallow
Esophageal Dysphagia (cont.)
• Some of the causes of esophageal dysphagia include:
Eosinophilic
Esophagitis
• This condition, which may be related to a food allergy, is caused by an
overpopulation of cells; eosinophils in the esophagus
Foreign Bodies
• Food or other objects can partially or completely block your throat or
esophagus.
• Older adults with dentures and patients who have difficulty chewing their
food may be more likely to have a piece of food lodged in the throat or
esophagus
Gastroesophageal
Reflex Disease
(GERD)
• Damage to esophageal tissues from stomach acid backing up into the
esophagus can lead to spasm or scarring and narrowing of the lower
esophagus
Radiation Therapy
• This cancer treatment can lead to inflammation and scarring of the
esophagus.
Scleroderma
• Development of scar-like tissue, causing stiffening and hardening of
tissues, can weaken the lower esophageal sphincter, allowing acid to back
up into the esophagus and cause frequent heartburn.
Signs and Symptoms of Dysphagia
Signs and Symptoms of Dysphagia
Signs and symptoms associated with dysphagia may include:
• Hoarse vocal quality
• Difficulty swallow
Signs
• Bringing food back up (regurgitation)
• Coughing or gagging when swallowing
• Drooling
Symptoms
• Food or stomach acid back up into your throat
• Frequent heartburn
• Pain while swallowing (odynophagia)
• The sensation of food getting stuck in your throat or chest or behind your breastbone
(sternum)
• Cutting food into smaller pieces or avoiding certain foods because of trouble swallowing
• Unexpectedly losing weight
Risk Factors
The following are Risk Factors for Dysphagia:
• Aging
• Due to natural aging oral, pharyngeal and esophageal musculature become weakened.
• Elderly patients are at greater risk of certain conditions, such as stroke or Parkinson's
disease. Older adults are at higher risk of swallowing difficulties.
• Certain health conditions
• Patients at any age with certain neurological or nervous system disorders are more likely to
experience difficulty swallowing.
Complications
Difficulty Swallowing can Lead to:
• Malnutrition, weight loss and dehydration
• Dysphagia can lead to inadequate nourishment and hydration.
• Respiratory problems
• Food or liquid entering your airway when you try to swallow can cause respiratory problems,
such as aspiration pneumonia or upper respiratory infections.
• 25-30% of patients with dysphagia are “silent aspirators”
• Patients who silently aspirate are at greater risk for aspiration pneumonia
• In the elderly with dysphagia those who have silent aspiration have a higher mortality rate
Dysphagia Consequences
Many patients with dysphagia go
unrecognized or undiagnosed until a major
event such as aspiration pneumonia occurs.
Dysphagia Consequences
The Vicious Cycle
Aspiration Pneumonia
Aspiration Pneumonia
Aspiration pneumonia can occur when:
• Inhalation food, drink or vomit into your lungs.
• Poor oral hygiene resulting in bacteria in the saliva
• A patient has a weakened immune system in
combination with other risk factors
• Something disturbs your normal swallow function,
such as a brain injury, stroke, swallowing problem
• Excessive use of alcohol or drugs.
Aspiration Pneumonia
Causes
• Aging
• Anesthesia
• Coma
• Dental problems
• Esophageal disorders
• Ingesting large amounts of alcohol
• Reduced levels of alertness
• Sedatives
• Swallowing problems
Only air should enter the lungs. Inhaling food,
liquids, etc. may accidentally get into the
airway and then further into the lungs. It can
cause an irritation and swelling in the lungs
and bacteria may grow .
Who is at Risk?
• The highest risk of this condition is seen in
elderly individuals with a history of any of the
following:
• Stroke
• Neurologic diagnoses
• Seizures
• Dental problems/poor oral hygiene
• Lung disease
• Patients requiring feeding assistance.
Aspiration Pneumonia
Symptoms
Diagnosed by:
• Symptoms of this condition are similar to other
types of pneumonia. They include:
• Bad breath
• Blue discoloration of the skin
• Chest pain
• Cough, possibly with green sputum, blood,
pus or a foul odor
• Difficulty swallowing
• Excessive sweating
• Fatigue
• Shortness of breath
• Wheezing
• Prompt treatment can make a significant
difference in recovery.
• Swallowing evaluation/Modified Barium
Swallow
• Arterial blood gas
• Blood culture
• Bronchoscopy
• Chest x-ray
• Complete blood count (CBC)
• CT scan of chest
• Sputum culture
Aspiration Pneumonia
Treated
• Treatment depends on the severity of the
pneumonia
If treatment is acquired quickly, this condition rarely
causes complications.
• The overall prognosis depends on:
• Generally, the first line of treatment is
antibiotics
• How much of your lungs have been affected
• Choosing the right antibiotic can be
difficult. The bacteria that causes this
condition may be hard to identify
• The type of bacteria causing the infection
• Note: patients with trouble swallowing may
need alternate means of nutrition
• The severity of the pneumonia
Without correct treatment or late treatment,
pneumonia can cause long-term problems.
• Lung abscess and inflammatory problems
may occur.
• Some patients will develop acute respiratory
failure, which could be fatal.
Tests and Diagnosis
Tests & Diagnosis
Tests and Diagnosis:
Barium Swallow (X-ray of the
esophagus with contrast
material)
• A barium solution coats the esophagus, allowing a better view on x-ray, e.g. shape
and muscular activity
Video Swallow/Modified
Barium Swallow
• Swallow barium-coated foods of different consistencies.
• This provides an image as the food travels through the mouth and esophagus.
Endoscopy
• A thin, flexible lighted instrument (endoscope) is passed down your throat to view
the esophagus.
Esophageal Muscle Test
(Manometry)
• A small tube is inserted into the esophagus and connected to a pressure recorder
to measure the muscle contractions of the esophagus when swallowing.
Fiber-optic endoscopic
evaluation of swallowing
(FEES)
• Examination of the pharyngeal and esophageal areas with a special camera
(endoscope) and lighted tube when swallowing.
Imaging Scans
• These may include CT scan which combines a series of x-ray views and computer
processing to create cross-sectional images of the body's bones and soft tissues;
• MRI scan which uses a magnetic field and radio waves to create detailed
images or organs and tissues
• Positron Emission Tomography (PET) san which uses a radioactive drug
(tracer) to show how the tissue and organs are functioning.
Tests & Treatments
Tests & Treatments
• Treatment for dysphagia depends on the type or cause of the swallowing disorder
Oropharyngeal
Dysphagia
• May be referred to a speech-language pathologist
• Therapy may include:
• Exercises - certain exercises may help coordinate swallowing muscles to re-stimulate the nerves
that trigger the swallowing reflex.
• Learning Swallowing Techniques - Learn how to place food in your mouth or to position your
body and head to help you swallow
Esophageal
Dysphagia
• Treatment approaches for esophageal dysphagia may include:
• Esophageal Dilation - for a tight esophageal sphincter (achalasia) or an esophageal stricture an
endoscope with a special balloon attached to gently stretch and expand the width of the
esophagus or pass a flexible tube to stretch the esophagus (dilatation)
• Surgery - For an esophageal tumor, achalasia or pharyngeal diverticula surgery may be
necessary to clear the esophageal path.
• Medications - Difficulty swallowing associated with Gastroesophageal Reflux Disease (GERD)
can be treated with prescription oral medications to reduce stomach acid. These medications
may need to be taken for an extended period of time.
Severe
Dysphagia
• If difficulty swallowing prevents you from eating and drinking adequately the following may be
recommended:
• Feeding Tube - In severe cases a feeding tube inserted directly into the stomach will bypass the
part of your swallowing mechanism that isn’t working normally.
Tracheostomy
What is a Tracheostomy?
• A tracheostomy is a procedure to create an
opening through the neck into the trachea.
• This allows direct access to the windpipe and the
patient now breaths directly with the
tracheostomy tube rather than through their nose
or mouth.
• When a new tracheostomy is placed, a SLP will
often be ordered to evaluate the patient’s ability
to safely swallow.
• Patients with existing tracheostomies, where the
patient has been eating and shows no signs or
symptoms of aspiration, generally do not need to
be seen by a SLP.
Aspiration Precautions
Aspiration Precautions
General Guidelines to Prevent Dysphagia
General Guidelines to Prevent Aspiration
• Although swallowing difficulties can't be
prevented, you can reduce your risk of
dysphagia by eating slowly and chewing your
food well.
• Feed small amounts of food.
• Early detection and effective treatment of
GERD can lower your risk of developing
dysphagia.
• Provide oral care before and after meals.
• Seat patient fully upright
• Do not force feed.
• Never put food or fluids in the mouth of a
patient who is not fully alert.
• Crush pills and put them in soft food such as
pudding or applesauce.
• Some pills should not be crushed, check
with pharmacist or physician before
crushing any pills.
Prevention (cont.)
As a caregiver to someone who may aspirate, the following are some general guidelines:
Caring for someone
who can eat and drink
orally:
• Seat the patient in an upright position when eating or drinking, such as
Sitting up in a chair
• If the patient is unable to sit in a chair, position the patient in bed so they are
upright
• Keep the patient sitting upright for 30 - 45 minutes after eating to reduce the risk
of aspirating residue and/or reflux management
• Remind the patient to eat slowly and chew well
• Do Not distract the patient
• This is especially important for patients with cognitive problems.
• Check the patient’s mouth for leftover/pocketed food after eating
• Do Not serve food or drink for at least 2 hours before bedtime
Caring for someone
who has a feeding
tube; or cannot eat or
drink through their
mouth:
• Keep the patient in an upright position as much as possible
• Do Not lay the patient flat if they are getting continuous feedings
• Turn the feeding tube off if you need to lay the patient flat for any reason
• Check feeding tube residuals as directed by healthcare provider.
• If a large amount of tube feeding is aspirated, the healthcare provider should
be notified as soon as possible.
Sitting Upright
Remember what 90 degrees looks like!
Oral Care: What, When & How
What?
When?
How?
• Antiseptic oral rinse, e.g.
Scope
• Most importantly before
breakfast
• Upright or nearly upright
position
• Mouth Moistener
• Before and after every meal
• Pen Light
• Before water if patient is on
Free Water Protocol
• Visually inspect with pen
light (remove dentures)
• Suction toothbrushes &
sponges
• Toothbrushes
• Toothettes
• Toothpaste
• Every 2 - 4 hours for NPO
patients (including
intubated/ventilated patients)
• Soft toothbrush and
fluoride toothpaste
• Clean all surfaces (teeth,
gums, palate & tongue)
• Rinse with antiseptic
mouthwash (Scope)
• Mouth moistener, if needed
• Suction toothbrushes are
available for patients who
are NPO
Oral Care: Do’s
Special Considerations:
• Oral care is more important than ever!
• Dentures
• Brush with non-abrasive gel paste. At night
soak for 15 minutes in denture cleaning
product. Rinse and store overnight in water.
• Edentulous/Intubated/Ventilated patients
• If the patient has adequate oral control and
ability to spit…
• Proceed as usual with head positioned over
sink to avoid swallowing
• If a patient with inadequate oral control…
• Hang head over sink
• Toothette with alcohol free antibacterial
oral rinse. Brush tongue with toothbrush
• Suction toothbrush as necessary
• Use suction toothbrush/sponge and
antibacterial oral rinse (Scope)
• Rinse with dry toothette or gauze
• Small amount of toothpaste
• Optimize bacterial prevention with
mouthwash.
Oral Care: Don’ts
Oral Care “Don’ts”
• Don’t use toothettes to clean teeth, they don’t remove plaque
• Don’t use toothettes with water only, does not remove bacteria
• Don’t assume the mouth is clean without looking
Swallowing Techniques
Swallowing Techniques
Swallowing may seem like a simple
task, since it is typically automatic,
however, it is actually complex,
involving varied nerves and muscles.
Swallowing Techniques
• The appropriate swallow techniques will
be determined by the Speech Language
Pathologist (SLP) following the results of
the Swallow Evaluation.
• The following section describes some of
the most common swallow techniques
that you may see at the patient’s
bedside.
Common Swallow Techniques
• Multiple Swallows
• The patient is instructed to swallow 2 times
before taking the next bite or sip
• This technique helps clear any food or liquid
residue which may remain in the throat
• Alternate Liquids and Solids
•
Cue the patient to take a bite
•
When it has been completely swallowed,
next have them take a sip, and repeat
•
This technique clears food residues that
may be left in the oral cavity or throat.
Swallowing Techniques
Common Swallow Techniques (cont.)
• Effortful Swallow
• The patient is instructed to swallow “hard”
as if swallowing a pill or something dry
• This technique is helpful for patients who
have weakened pharyngeal musculature
• Swallow-Cough-Swallow
• The patient is cued to swallow the bite then
cough voluntarily then swallow again.
• This technique helps to prevent food or
liquids from going into the trachea “wrong
pipe”
• Chin Tuck
• The patient is instructed to tuck the chin
close to chest before the swallow and keeps
chin down until finished swallowing
• This technique reduces chance of aspiration
for some patients; however, Chin Tuck does
not help all patients
Seek Immediate Care
In assessing aspiration precautions in people outside
the hospital setting, seek immediate medical care if
any of the following occur.
If the patient has:
• Trouble breathing or starts to breathe rapidly
• Breathing very slow or stops breathing
• Significant coughing after eating or drinking
• Coughs up thick, yellow or tan sputum
• Fever or persistent symptoms for more than 72 hours
• Fever and their symptoms suddenly get worse
Dysphagia Diets
Dysphagia Diet
Diet
Indication
Description
Level I
Severe dysphagia
• Thick liquids
(Most Restricted)
• Patients just beginning to eat by
mouth
• Decreased fiber
• Unable to safely:
Level II
•
Swallow chewable foods
•
Safely drink thin liquids
Moderate dysphagia
•
•
Can tolerate minimal easily
chewed foods
Cannot swallow thin liquids safely
• No coarse textures, nuts, raw fruits or
vegetables
• Medications must be crushed and mixed
with pureed foods
• Thickened liquids with thickener as needed
• Nectar or honey thick liquids
• Decreased fiber. No bread products or rice
• No coarse textures, nuts, raw fruits or
vegetables
• Medications may need to be crushed in
puree foods or in liquid form
Dysphagia Diet
Diet
Level III
Rule of Thumb:
Should be soft
enough to mash
with a fork.
Level IV
(Least Restricted)
Indication
• Difficulty chewing,
manipulating or swallowing
foods
Description
•
Mechanically soft
•
Pasta or Soup
• No tough skins
• Patients beginning to chew
• No nuts, or dry, crispy, raw or stringy foods
• Meats need to be minced or cut into small
pieces
• patients chewing soft
textures, swallow liquids
safely
•
Liquids as tolerated, thicken liquids may still be
necessary
•
Medications may need to be crushed in pureed
foods or in liquid form
•
Soft textures that do not require grinding,
chopping
•
No nuts, no raw, crisp or deep fried foods
•
Medications and liquids as tolerated
Diet Restriction Options
No Mixed Consistency = Thin Liquid + Solid
• Any food that has both a thin liquid part and a
solid part (can be an exclusion on any
type/level diet), examples:
• Vegetable soup
• Broth = thin liquid; Vegetables = solid
• Cold cereal
• Milk = thin liquid; Cereal = solid
Note: It is more difficult to manage thin
liquids and solids at the same time.
Liquid Consistencies
Thickest to Thinnest
• Honey Thick Liquids
• Similar consistency to honey or thick syrup
• Nectar Thick Liquids
• Similar consistency to buttermilk or tomato juice
• Thin Liquids
• Regular liquids
• No modifications needed
Thickened Liquids
• Hydration is critical to overall good health of patients
with dysphagia
• Proper consistency and adequate consumption are key
factors in promoting safe hydration for your patients
Liquid Consistencies
Pre-thickened Liquids
• Includes:
• Fruit Juice
• Dairy item
• Advantages
Powered Thickeners
• Available to thicken
other liquids
Thin Liquids
• In addition to beverages, other
items are considered to be a
“Thin Liquid” because they
become liquid at body
temperature:
• No mixing required
• Ice chips
• They are exactly the correct
thickness and do not continue
to thicken as they sit
• Ice cream & Sherbet
• Jello
What’s Wrong with this Picture?
• On this tray there is a nectar thick
drink, as well as, a soup which
contains a thin liquid.
• Normally, these won’t occur on the
same tray.
• But, it’s always important to
double-check for diet
restrictions/modifications before
feeding any patient.
Always Check the Diet Order
• Always compare the items on the tray with information on the Swallowing
Precautions Sign.
• Look specifically for both liquid and diet texture
• Look for service instructions such as:
• No Straws
• Liquids by Spoon Only
• Feeding assistance
• 1:1 Feeding vs 1:1 Cueing (Prompting the Patient)
• If the tray and orders/precaution sign don’t match, do not feed the patient until tray
corrected, notify the RN/Speech therapist
Conclusion
• Dysphagia is a serious condition that requires clinical screening and treatment.
• Treatment involves speech therapy treatment and/or diet and liquid modifications.
• Swallowing techniques
• Team Communication is essential
• The National Dysphagia Diet provides specific dietary guidelines to reduce risk of
complications from dysphagia
Recommendations
Lifestyle Modifications
Lifestyle Modifications
If you have trouble swallowing, be sure to see a doctor and
follow their advice. Also, some things you can try to help
ease your symptoms include:
• Changing your eating habits. Try eating smaller, morefrequent meals. Be sure to cut your food into smaller
pieces and eat more slowly.
• Trying foods with different textures to see if some cause
you more trouble. Thin liquids, such as coffee and juice,
are a problem for some people, and sticky foods, such
as peanut butter or caramel, can make swallowing
difficult. Avoid foods that cause you trouble.
• Avoiding alcohol, tobacco and caffeine. These can make
heartburn worse.
Recommendations for Feeding Patients
Recommendations for feeding/assisting
patients to eat:
• Carefully observe the patient to make sure they
have swallowed before taking the next bite or
drink.
Note:
• An empty mouth does not mean the patient has
swallowed.
• It only means the food/drink is no longer in the
mouth
• The larynx (Adam’s apple ) should rise and fall
during a swallow, which you may be able to
feel or see.
Recommendations for Feeding Patients
STOP feeding the patient and inform the RN if:
• You aren’t sure if the patient is swallowing
• The patient can’t stay awake
• The patient shows signs and symptoms of
aspiration
When helping patients to eat or drink, be aware
of the following:
• Rate -
Go Slow!!!!
• Amount -
Small bites and sips
• Swallows -
Watch/Feel for the Larynx
(Adam’s apple) to go up & down
Recommendations for Feeding Patients cont.
Recommendations for feeding/assisting
patients to eat:
If the patient needs supervision and/or
assistance with oral intake:
• Know whether or not the patient wears full or
partial dentures and if they are in place
• Never leave food or drink within their reach or
sight
• Always have dentures/partials soaking in water
or cleaning solution in a labeled denture cup
• If left dry, dentures can change shape and
become unusable
Note:
• When not in use, remove partial dentures,
since they can be a choking risk!
Summary
• If you have any concerns regarding the
swallowing safety of any patients always
discuss with the RN and SLP.
• If a swallow evaluation is needed, an order
needs to be obtained from a physician.
• A SLP will evaluate the patient and provide
recommendations and treatment options.
• By understanding and following the SLP
recommendations regarding diet, swallow
techniques and precautions you are:
• Helping your patients remain:
• Comfortable
• Free of aspiration / pneumonia
• Hydrated
• Nourished
Bibliography/References/Websites
American Speech-Language-Hearing Association http://www.asha.org/
St. Johns Healthcare, Dysphagia Diets & How to Keep Patients Safe from Aspiration, 2012
Getting a Handle on Aspiration Pneumonia, 2013 www.healthline.com
The Mayo Clinic www.Mayoclinic.com
The website is owned by the Mayo Foundation for Medical Education and Research. The Mayo clinic mission is to empower
people to manage their health. The website offers useful and up-to-date information and tools on a wide variety of health topics.
Website includes information on difficulty swallowing.
MedLine Plus www.nlm.nih.gov/medlineplus
A service of the United States National Library of Medicine and the National Institutes of Health, MedlinePlus brings together
authoritative information from the National Institutes of Health (NIH), and other government agencies and health-related
organizations. Information about Swallowing difficulty is on the web site.
The Ohio State University Medical Center Patient Education Materials
http://medicalcenter.osu.edu/patientcare/patient_education
The patient education web site has information about dysphagia .
Dysphagia and Aspiration Precautions
Self-assessment - January, 2015
1. The esophagus is located behind which structure:
a. Trachea
b. Right bronchi
c. Left Bronchi
d. Aorta
2. Which of the following are components of the 3 parts of the esophagus:
a. Cervical/proximal
b. Thoracic/medial
c. Abdominal/distal
d. All of the above
3. Which of the following statements are correct relating to the anatomy of the esophagus:
a. In front of the cervical esophagus is the trachea
b. Beside the cervical are the structures in the carotid sheath
c. The thyroid gland curves around from the front of the neck and can sit beside the cervical
esophagus
d. All of the above
4. In this phase of a normal swallow Food is broken down by chewing and mashing with tongue and
exposure to enzymes in saliva which creates a bolus.
a. Oral Preparatory
b. Oral
c. Pharyngeal
d. Esophageal
5. Food reamins between the cheek and the teeth/gums after the swallowing process is called:
a. Silent Aspiration
b. Pocketing
c. Residue
d. Palates
6. Which of the following facts related to swallowing are correct:
a. The swallowing mechanism is innervated by 7 pairs of nerves and 28 muscle groups
b. The average person swallows more than 600 times each day and once every minute while
sleeping
c. While swallowing is very difficult o stop when started, thus appearing to be an autonomic action,
it is actually voluntary
d. All of the above
7. Dysphagia refers to any disorder in the swallowing process that does not allow food or liquid to pass
safely from which of the following:
a. Mouth to cervical esophagus
b. Mouth to thoracic esophagus
c. Mouth to abdominal esophagus
d. Mouth to stomach
8. According to worldwide prevalence, the major primary diagnosis associated with swallowing difficulties
include which of the following:
a. Neurological disorders
b. Cancer
c. Age-related physiologic changes
d. All of the above
9. Which of the following statements related to dysphagia are correct:
a. May be associated with pain and in some cases swallowing may be impossible
b. Occasional dysphagia usually isn’t cause for concern; but persistent dysphagia may indicate a
serious medical condition requiring treatment
c. Dysphagia can occur at any age; but usually in older adults; Treatment depends on the cause of
swallowing difficulty
d. All of the above
Self-assessment_Dysphagia & Aspiration Precautions_012115
10. Oropharyngeal dysphagia can be caused by many disorders including which of the following:
a. Neurological disorders, e.g. Parkinson’s, Muscular Sclerosis, Muscular Dystrophy
b. Neurological Damage, e.g. Stroke, Brain or Spinal Cord Injury
c. Esophageal Diverticula, e.g. Pouches that form and collect food in the esophagus; Cancer
d. All of the above
11. Which of the following are causes of esophageal dysphagia:
a. Diffuse spasms; GERD; Foreign body
b. Esophageal stricture; Esophageal ring
c. Esophageal tumor; Radiation therapy
d. All of the above
12. Which of the following are considered signs and symptoms of dysphagia:
a. Being hoarse; unable to swallow
b. Chronic coughing or gagging when swallowing; drooling
c. Frequent heartburn; Unexpected loss of weight
d. All of the above
13. Dysphagia may lead to which of the following complications:
a. Malnutrition
b. Dehydration
c. Weight loss
d. All of the above
14. Which of the following tests may be used to determine the diagnosis and degree of dysphagia:
a. Barium Swallow (X-ray with contrast material); Modified Barium Swallow Study
b. Endoscopy; Esophageal Muscle Test
c. Fiber-optic Endoscopic Evaluation of Swallowing (FEES); Imaging Scans
d. All of the above
15. Many people with dysphagia go unrecognized or undiagnosed until a major event such as aspiration
pneumonia occurs.
a. True
b. False
16. The “Rule of Thumb” in the Level III - Dysphagia Diet is which of the following:
a. Food should be soft enough to mash with a fork
b. Medications can be given normally, e.g. crushing, dissolving
c. May eat nuts, or dry, crispy, raw or stringy foods
d. Liquids are restricted
17. Which of the following diet restriction options are correct:
a. No straws
b. It is difficult to manage thin liquids and solid food at the same time, e.g. vegetable soup
c. No mix consistency can be an exclusion on any diet
d. All of the above
18. When caring for a patient with “Swallowing Precautions” you should:
a. Always check the diet order
b. Look for service instructions such as: No straws, feeding assistance and/or Liquids by spoon
only
c. 1:1 feeding versus 1:1 cueing
d. All the above
19. Which of the following are potential causes of aspiration:
a. A decreased level of consciousness, e.g., stroke, traumatic brain injury, neurological disease,
seizures
b. Aging; Dental problems
c. Drinking large amounts of alcohol; Taking medications that cause drowsiness
d. All of the above
Self-assessment_Dysphagia & Aspiration Precautions_012115
20. Which of the following symptoms can occur with aspiration:
a. A change in voice and skin color (cyanotic)
b. Coughing
c. Difficulty breathing; Fever
d. All of the above
21. Which of the following are general guidelines to prevent aspiration:
a. Feed small amounts; Do not force feed
b. Use as little water as possible; Crush pills if pharmacy approved
c. Never put food or liquids in the mouth of a person who is not fully alert
d. All of the above
22. When caring for someone who can sit upright, which of the following are general guidelines for aspiration
prevention:
a. Sit upright in bed or in a chair, up to 45 minutes after eating
b. Do not distract the person; remind them to eat slowly and chew well
c. Do not serve food for at least 2 hour before bedtime
d. All of the above
23. Which of the following are correct statements relating to oral care in the patient with dysphagia:
a. Most important before breakfast; before and after every meal
b. Before water, if patient is on a Free Water Protocol
c. Every 2-4 hours for NPO patients, including intubated/ventilated patients
d. All of the above
24. Which of the following are correct statements regarding recommendations for feeding patients
a. Know whether or not the patient wears a full or partial set of dentures
b. If dentures are left dry they can change shape and be unusable; When not in use dentures should
be removed as they are a choking risk
c. Never leave food or drink within the reach or sight of the patient.
d. All of the above
25. By understanding and following the Speech-Language Pathologist recommendations regarding diet,
swallow techniques and precautions, you are helping your patient with which of the following:
a. To be comfortable
b. Free of aspiration / pneumonia
c. Hydrated and Nourished
d. All of the above
Self-assessment_Dysphagia & Aspiration Precautions_012115
Dysphagia and Aspiration Precautions
Self-assessment - January, 2015
1. The esophagus is located behind which structure:
a. Trachea
b. Right bronchi
c. Left Bronchi
d. Aorta
2. Which of the following are components of the 3 parts of the esophagus:
a. Cervical/proximal
b. Thoracic/medial
c. Abdominal/distal
d. All of the above
3. Which of the following statements are correct relating to the anatomy of the esophagus:
a. In front of the cervical esophagus is the trachea
b. Beside the cervical are the structures in the carotid sheath
c. The thyroid gland curves around from the front of the neck and can sit beside the cervical
esophagus
d. All of the above
4. In this phase of a normal swallow Food is broken down by chewing and mashing with tongue and
exposure to enzymes in saliva which creates a bolus.
a. Oral Preparatory
b. Oral
c. Pharyngeal
d. Esophageal
5. Food reamins between the cheek and the teeth/gums after the swallowing process is called:
a. Silent Aspiration
b. Pocketing
c. Residue
d. Palates
6. Which of the following facts related to swallowing are correct:
a. The swallowing mechanism is innervated by 7 pairs of nerves and 28 muscle groups
b. The average person swallows more than 600 times each day and once every minute while
sleeping
c. While swallowing is very difficult o stop when started, thus appearing to be an autonomic action,
it is actually voluntary
d. All of the above
7. Dysphagia refers to any disorder in the swallowing process that does not allow food or liquid to pass
safely from which of the following:
a. Mouth to cervical esophagus
b. Mouth to thoracic esophagus
c. Mouth to abdominal esophagus
d. Mouth to stomach
8. According to worldwide prevalence, the major primary diagnosis associated with swallowing difficulties
include which of the following:
a. Neurological disorders
b. Cancer
c. Age-related physiologic changes
d. All of the above
9. Which of the following statements related to dysphagia are correct:
a. May be associated with pain and in some cases swallowing may be impossible
b. Occasional dysphagia usually isn’t cause for concern; but persistent dysphagia may indicate a
serious medical condition requiring treatment
c. Dysphagia can occur at any age; but usually in older adults; Treatment depends on the cause of
swallowing difficulty
d. All of the above
Self-assessment_Dysphagia & Aspiration Precautions_012115
10. Oropharyngeal dysphagia can be caused by many disorders including which of the following:
a. Neurological disorders, e.g. Parkinson’s, Muscular Sclerosis, Muscular Dystrophy
b. Neurological Damage, e.g. Stroke, Brain or Spinal Cord Injury
c. Esophageal Diverticula, e.g. Pouches that form and collect food in the esophagus; Cancer
d. All of the above
11. Which of the following are causes of esophageal dysphagia:
a. Diffuse spasms; GERD; Foreign body
b. Esophageal stricture; Esophageal ring
c. Esophageal tumor; Radiation therapy
d. All of the above
12. Which of the following are considered signs and symptoms of dysphagia:
a. Being hoarse; unable to swallow
b. Chronic coughing or gagging when swallowing; drooling
c. Frequent heartburn; Unexpected loss of weight
d. All of the above
13. Dysphagia may lead to which of the following complications:
a. Malnutrition
b. Dehydration
c. Weight loss
d. All of the above
14. Which of the following tests may be used to determine the diagnosis and degree of dysphagia:
a. Barium Swallow (X-ray with contrast material); Modified Barium Swallow Study
b. Endoscopy; Esophageal Muscle Test
c. Fiber-optic Endoscopic Evaluation of Swallowing (FEES); Imaging Scans
d. All of the above
15. Many people with dysphagia go unrecognized or undiagnosed until a major event such as aspiration
pneumonia occurs.
a. True
b. False
16. The “Rule of Thumb” in the Level III - Dysphagia Diet is which of the following:
a. Food should be soft enough to mash with a fork
b. Medications can be given normally, e.g. crushing, dissolving
c. May eat nuts, or dry, crispy, raw or stringy foods
d. Liquids are restricted
17. Which of the following diet restriction options are correct:
a. No straws
b. It is difficult to manage thin liquids and solid food at the same time, e.g. vegetable soup
c. No mix consistency can be an exclusion on any diet
d. All of the above
18. When caring for a patient with “Swallowing Precautions” you should:
a. Always check the diet order
b. Look for service instructions such as: No straws, feeding assistance and/or Liquids by spoon
only
c. 1:1 feeding versus 1:1 cueing
d. All the above
19. Which of the following are potential causes of aspiration:
a. A decreased level of consciousness, e.g., stroke, traumatic brain injury, neurological disease,
seizures
b. Aging; Dental problems
c. Drinking large amounts of alcohol; Taking medications that cause drowsiness
d. All of the above
Self-assessment_Dysphagia & Aspiration Precautions_012115
20. Which of the following symptoms can occur with aspiration:
a. A change in voice and skin color (cyanotic)
b. Coughing
c. Difficulty breathing; Fever
d. All of the above
21. Which of the following are general guidelines to prevent aspiration:
a. Feed small amounts; Do not force feed
b. Use as little water as possible; Crush pills if pharmacy approved
c. Never put food or liquids in the mouth of a person who is not fully alert
d. All of the above
22. When caring for someone who can sit upright, which of the following are general guidelines for aspiration
prevention:
a. Sit upright in bed or in a chair, up to 45 minutes after eating
b. Do not distract the person; remind them to eat slowly and chew well
c. Do not serve food for at least 2 hour before bedtime
d. All of the above
23. Which of the following are correct statements relating to oral care in the patient with dysphagia:
a. Most important before breakfast; before and after every meal
b. Before water, if patient is on a Free Water Protocol
c. Every 2-4 hours for NPO patients, including intubated/ventilated patients
d. All of the above
24. Which of the following are correct statements regarding recommendations for feeding patients
a. Know whether or not the patient wears a full or partial set of dentures
b. If dentures are left dry they can change shape and be unusable; When not in use dentures should
be removed as they are a choking risk
c. Never leave food or drink within the reach or sight of the patient.
d. All of the above
25. By understanding and following the Speech-Language Pathologist recommendations regarding diet,
swallow techniques and precautions, you are helping your patient with which of the following:
a. To be comfortable
b. Free of aspiration / pneumonia
c. Hydrated and Nourished
d. All of the above
Self-assessment_Dysphagia & Aspiration Precautions_012115
Broward Health Medical Center
Broward Health Coral Springs
Broward Health Imperial Point
Broward Health North
Broward Health Weston
Broward Health Physician Group
Broward Health Community Health Services
Awards this
Certificate of Compeletion
This certifies that
[StudentNameAtTimeOfCompletion]
[LicenseNumber]
Has successfully completed thefollowing course:
Dysphagia and Aspiration Precautions
CE Broker Num ber: 20-XXXXXXX
For 1.0 contact hour on [CompletionDate]
Florida State Board
CE Broker Provider Number 50-1443
Jean Seaver, RN, MSN
Do Not send this certificate to your designated Florida State Board
Retain for your personal records for 4-years