SWALLOW AWARENESS TRAINING
‘Hard to Swallow’
SPEECH & LANGUAGE THERAPY
Sally Bradford, June 2006.
THE NORMAL SWALLOW
WHAT CAN GO WRONG?
HOW TO HELP
SWALLOWING A SIMPLE TASK?
We all swallow about 1000 times a day
clearing over a litre of saliva.
Complex process involving multiple cerebral
It involves 5 cranial nerves and 31 pairs of
muscles of the mouth and throat.
FOUR STAGES OF THE NORMAL
Pre-oral , preparatory stage.
Transfer of food or fluid from the plate/cup into the
Saliva begins to flow, sight and smell of food is
Chewing the food and mixing with saliva to form a
Tongue very mobile, tip, sides & middle collects all
Holding the bolus in the centre of the tongue
awaiting oral stage to begin.
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.
PRE-and ORAL SWALLOW
Diffculty getting food/ drink to mouth,e.g. visual difficuties, head not in
mid-line,or using weak or non-dominant hand.
Decreased lip closuredrooling, spillage, pooling or residue, change
in oral pressure.
Facial weaknessresidue in cheek, biting cheek wall.
Reduced sensation residue „pocketing‟ difficulty forming bolus,
premature spillage of material into pharynx, biting tongue.
Reduced tongue functionimpaired movement of bolus, residue on
tongue, lateral sulci or palate.
10 Poor soft palate closure food/ drink back down nose.
Food/ liquid is forced over the back of tongue
Larynx moves up and forward and the airway
Cricopharyngeal sphincter opens so food/
drink passes into oesophagus.
Larynx opens, breathing re-starts.
PHARYNGEAL STAGE DISTURBANCE
Delayed/ absent triggering of pharyngeal swallowpooling in
pharynx and possible aspiration.
Reduced tongue base retractionresidue in valleculae.
Reduced contraction of wall of pharynxresidue.
Larynx may not rise or close eficiently airway not protected,
Cricopharyngeus may not openoverspill when breathing re-
Duration approximately 5 seconds.
Reflex (involuntary) action.
The bolus is transferred down the
oesophagus to the stomach.
Reflux can occur and can be aspirated.
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
High incidence of dysphagia and pneumonia for stroke-
prominent in brain stem stroke. (Martino, Foley et.al. 2005)
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.
SIGNS OF DYSPHAGIA TO WATCH
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
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‟
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
Excessive salivation causes skin irritation, infection risk.
POOR ORAL HEALTH = INCREASED RISK OF PNEUMONIA
Assessment of the mouth.
Regular mouth care (hourly).
Water and soft toothbrush, lubricant for lips.
Royal college of Nursing , or Royal Marsden advice.
WHAT MIGHT BE RECOMMEDED?
Exercises for the tongue, lips, palate, pharynx or larynx
Postural changes „SIT STROKE UP‟, chin tuck, head turn.
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
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.
There are five types of diet that may be
– 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.
STAGE 1……..NIL BY MOUTH
NG TUBE IV OR SUB CUT REGULAR
PEG TUBE FLUIDS ORAL CARE
• no food or fluid orally
• regular mouthcare needed
STAGE 2……..THICK SMOOTH DIET
PUREED BISCUITS SOAKED ROAST DINNER FRUIT SMOOTHIE
PORRIDGE IN SOLUTION OR MILKSHAKE
• 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
24 or piped
STAGE 3……..MASHED DIET
PORRIDGE SPONGE PUDDING SHEPHERD‟S PIE VEG CURRY
• 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
25 • Mashed with fork by nurse / carer
STAGE 4……..SOFT DIET
COOKED APPLE PIE AND MEAT PIE AND MEAT CURRY WITH
BREAKFAST CUSTARD VEG WITH GRAVY ROTI
• 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
STAGE 5……..NORMAL DIET
PEAS CORNFLAKES WITH CRUSTY BREAD SALAD
• 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
27 • Husks
HOW TO HELP
Be aware of those patients at risk of aspiration. Follow
recommendations that are documented, read before each time pt.
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
If difficulties are noted document this and get advice as soon as
28 Ensure good mouth care, dentures fit.
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.
How to refer to Speech and
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
St. Lukes Hospital Tel. ext.5220 Fax 5443.
Bradford Royal Inf. Tel. ext 6517 Fax 6946.