Eating and Swallowing

Feeding – Process of setting up, arranging, and bringing food (fluid) from the plate or cup to the mouth
Swallowing/Eating – Keeping and manipulating food or fluid in the mouth and swallowing it.
Dysphagia – difficulty with swallowing. Can occur at any stage (oral, pharyngeal or esophageal). NOT a primary
medical diagnosis

4 stages of eating and swallowing

Anticipatory phase: Psychological, emotional and social aspect surrounding meal time
1. Oral preparatory phase:
 Clinical pictures: a cva client brought food to his mouth, did not have symmetric lip closure,
food/fluid dribble from the left side of his mouth. Frequently foods remain in the check
after swallowing
 Problems in this phase can disrupt the normal swallow sequence. Decreased sensory
awareness compromises his ability to notice food/fluids and use a napkin to wipe food from
the face.
2. Oral phase:
 Clinical pictures: the same CVA client is alert but had hard time maneuvering food in his
mouth during the oral phase. His ability to chew textured food is compromised, and
requires additional time to chew foods.
 Problems: this contributes to the decreased oral intake.
3. Pharyngeal phase: Voluntary and involuntary components are necessary for a normal swallow.
 Marks the involuntary portion of the swallowing process
 Clinical pictures: the same CVA coughs, indicating difficulties with the timing and
coordination of the pharyngeal phase.
 Problems: swallowing water may indicate diminished laryngeal elevation and decreased
airway protection during the swallow.

4. Esophageal phase: This phase starts with a bonus enter the esophagus through the crio-pharyngeal
juncture
 Clinical pictures: the same CVA complains of frequently coughing and choking on food and
fluid.
 Problems: may be due to problems with the preoral, oral, pharyngeal, or esophageal phase
of eating
 Think of which assessment results you would look for to identify which phase is producing
the episodes of coughing and choking
Aspiration
• Acute symptoms of aspiration can occur before, during, or after the swallow.
1. Any change in the client’s color, particularly if the airway is obstructed
2. Prolonged coughing or choking
3. Gurgling voice and extreme breathiness or lose of voice
4. Excessive secretions
Precaution
• Many clients with dysphasia silently aspirate, which means they show no clinical symptoms of
aspiration during swallowing. For these clients, aspiration and the etiology of aspiration can only be
determined through an instrumental assessment. During the 24 hours immediately after the swallow,
the therapist and medical staff must observe the client for additional signs of aspiration.
• Aspiration pneumonia: Is a lung infection requiring medical intervention that may result from
aspiration during swallowing.
 • Clinical signs of aspiration pneumonia:
• fever, shortness of breath with a rapid heart rate,
• mental confusion,
• incontinence, although not all of the symptoms are always present, especially in older clients.
• If aspiration pneumonia develops, the client must be reevaluated for a change diet levels or
taken off the feeding program.
Instrumental assessment
 VFSS (video fluoroscopy swallow study): Most commonly used instrumental assessment tool to
examine oropharyngeal swallowing disorders.
o Uses fluoroscopy to capture the clients swallow with a variety of food and textures
o Conducted in hospital radiology department. Radiologist, radiology tech, swallowing therapist
present
 FEES (fiberoptic endoscopy): Allows for direct assessment of the motor and sensory aspect.
o Can be repeated as often as necessary without exposure to radiation
o Useful in detecting aspiration and critical features of pharyngeal dysphasia

- Puree food
o Decreased oral motor control & chewing difficulties apraxia
o Poor endurance, breathing difficulties
o Difficulty attending to the task of eating
- Soft food: More easily formed into bolus & require less chewing
o Impaired oral motor control
o Easier to keep in cohesive bolus as they are moved through oral cavity
- Ground food: Good for assessing
o Therapist can assess client’s ability to chew, form bolus and move it in mouth
- Thick liquid: Move more slowly from front to the back of mouth  Delayed swallow
o Gives impaired oral motor skill more time to control the liquid until the swallow response is
triggered
- Thin liquid: Hardest to swallow
o Need intact oral motor strength & coordination
o Need intact swallow to prevent aspiration
INTERVENTION
• It involves trunk and head positioning techniques to facilitate oral performance
• improve pharyngeal swallow and reduce the risk of aspiration.
Rehabilitation Technique Compensatory Strategies
1) the use of exercise to improve strength and function. 1. Increase swallow safety and decrease
Oral motor exercises are specifically designed to improve the clients symptoms, such as
the strength and coordination of facial musculature, the aspiration, but do not change the
tongue, and Jaw. physiology of the swallow.
2) “an effortful swallow”, the client is instructed to 2. Postural techniques have been found
swallow with maximal effort either with or without food to redirect bolus flow and reduce
has been shown to increase tongue base retraction and aspiration risk.
oral and pharyngeal pressure to improve the swallow.
Techniques
“The Mendelssohn maneuver”
“the Masako maneuver”
“the Shaker head lift”
OT GOAL: remediation of eating and swallowing dysfunction at as follows
1. facilitation of appropriate positioning during eating
2. improvement of motor control at each stage of the swallow, through normalization of tone,
facilitation of quality movement, and strengthening of oral musculature
3. maintenance of an adequate hydration and nutritional intake
4. prevention or reduction of aspiration risk
5. reestablishment of oral eating to the safest, optimum level and the least restrictive diet
TEAM MANAGEMENT
• The dysphagia team: attending physician, OT, PT, the dietitian, the nurse, the speech-language
pathologist, the radiologist and the client’s family.
• Interdepartmental in-service education is frequently required.
• OT’s role: (AOTA) “ to select, administer, and interpret assessment measure; develop specific
intervention plans, and provide therapeutic interventions.
• PT’s role: muscle reeducation and tone normalization; increasing client’s pulmonary status for breath
support, chest expansion, and cough
• Speech-Language Pathologist (SLP): reeducating the oral and laryngeal musculature used in speaking,
voice production, and swallowing. The SLP is a key member of the team.
• Nurse: monitor the client’s medical and nutritional status. They can perform dysphagia screening.
• Family members: education
POSITIONING
• The client is seated on a firm surface, such as a chair
• The client’s feet are flat on the floor
• The client’s knees are at 90 degree flexion
• There is equal weight bearing on both ischial tuberosities of the hips
• The client’s trunk is flexed slightly forward (100 degree hip flexion) with the back straight
• Both the arms are placed forward on the table
• The head is erect, in midline, and the chin is slight tucked
• For the client who is bed bound, needs to sit in a semi reclined position
• For the client who has to be in supine, oral feeding is usually contraindicated.
• Side-lying in bed, with head and neck alignment. Knees and hips flexed and trunk aligned
• Problems: poor positioning, hypertonicity, hypotonicity, weakness, etc.
ORAL HYGIENE
• Prevents gum disease, the accumulation of secretions, the development of the plaque, and the
aspiration of food particles that remain after eating, decreased oral sensitivity
• Poor Oral hygiene link with pneumonia, respiratory track infections, and influenza in elderly people.
NONORAL FEEDING: NG VS PEG
• A client who aspirates more than 10% of food or liquid or whose combined oral and pharyngeal transit
time is more than 10 seconds, is not a good candidate for oral eating.
• Or a client who lack the endurance to take in sufficient calories
• NG tube: passed through the nostril, through the nasopharynx, and down through the pharynx and
esophagus to rest in the stomach.
• Temporary: should not be used for longer than 1 month
• PEG: a minor surgical procedure. The Client receives a local anesthetic, and a small skin incision is
made to create an external opening in the abdominal wall. A tube is passed through the opening into
the stomach.
• Less risk of reflux and aspiration; Does not irritate the swallowing mechanisms
• Ideal for longer than 1 month