STROKE: Swallowing and the Impact of Stroke Module V

1. STROKE: Swallowing and the Impact of StrokeModule V K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

2. OBJECTIVES: • Discuss the clinical signs and symptoms of dysphagia • Review problems that may exist as a result of dysphagia • Identify components included in a screen for dysphagia • Identify resources for management of dysphagia K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

3. DYSPHAGIA • Becomes an increasingly common problem with age • 6-10 million Americans currently report some degree of swallowing difficulty • Despite advances in the assessment and treatment of dysphagia, it is often underappreciated by the general public and by health care providers K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

4. KNOW THE BASICS:PHASES OF SWALLOWING • Oral Phase • Pharyngeal Phase • Esophageal Phase • Important to know this level of detail: • This information is crucial to the development of a treatment plan • Swallowing problems can occur in any or all of the phases of the swallowing K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

5. ORAL PHASE (1) • Two parts to the oral phase • Oral Preparatory • Oral Transit • Oral Prep • Chewing / mixing food with saliva, forming a “bolus” • Completely voluntary K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

6. ORAL PHASE (1) • Oral Transit • Ready to swallow the bolus • Stop chewing and gather the bolus along the tongue dorsum • Tongue moves up against the hard palate and sequentially moves the bolus posteriorly toward the oropharynx K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

7. PHARYNGEAL PHASE (2) • Once the bolus passes by the faucial arches, the swallow reflex is triggered • The following occurs as part of the reflex: • Velum elevates and occludes nasopharynx • Larynx elevates • Pharyngeal constrictor muscles contract K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

8. PHARYNGEAL PHASE (2) • Closure of the larynx bottom-top (3 level airway protection) • True vocal cords • False vocal cords • Epiglottis deflects • Stop breathing • Cricopharyngeus (upper esophageal sphincter) relaxes K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

9. ESOPHAGEAL PHASE (3) • Bolus passes through the upper esophageal sphincter • Esophagus contracts, sequentially moving the bolus toward the lower esophageal sphincter K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

10. IMPACT OF DYSPHAGIA: • Aspiration pneumonia • Malnutrition • Dehydration • Debilitation, fatigue • Diminished quality of life • Increased length of stay K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

11. STROKE – The Bad News: • The most common cause of dysphagia in the elderly • The literature suggests that swallowing difficulties can affect 22%-64% of the acute stroke population • Nearly half of all stroke patients aspirate early after the event • As many as 35% of the deaths that occur after an acute stroke are caused by pneumonia K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

12. STROKE – The Good News: • Studies of the natural history of dysphagia in the stroke population suggest that nearly half of the patients recover to their pre-morbid swallowing status within a week of the event • Up to 87% resume normal oral intake by 6 months after the event K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

13. STROKE AND DYSPHAGIA • Given the high number of cases annually, and associated mortality, it is critical to identify the stroke patients that are at greatest risk for developing pulmonary complications • Prompt identification and treatment of dysphagia can have a positive impact on morbidity and mortality in the stroke population • As a result, it is critical to address dysphagia in the acute care setting K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

14. STROKE PATIENTS MOST AT RISK for dysphagia: • Anterior hemispheric lesions (associated with decreased tongue control and facial weakness) • Brainstem lesions • Cortical lesions (particularly on the right) can cause cognitive impairments that compromise swallowing function • Large area strokes and those with other comorbid conditions that can effect swallow • Dysfunction of cranial nerves V, VII, IX, X, or XII K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

15. Chronic Obstructive Pulmonary Disease Alzheimer’s disease Prolonged mechanical ventilation History of previous strokes Prior decreased functional status Prior malnutrition OTHER POPULATIONS & COMORBIDITIES that impact swallow function: • Parkinson’s Disease • Muscular Dystrophy • Myasthenia Gravis • Multiple Sclerosis • Head and Neck Cancer • Medication effects • Polypharmacy • Amyotrophic Lateral Sclerosis K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

16. SIGNS AND SYMPTOMS OF DYSPHAGIA: Oral Phase (1) • Drooling • Facial asymmetry • Pocketing food in the cheek • Poor tongue movement • Inability to close lips tightly, with resulting leakage of food or fluid from the mouth K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

17. SIGNS AND SYMPTOMS OF DYSPHAGIA: Pharyngeal Phase (2) • Nasal regurgitation • Inability to swallow • Coughing when eating or drinking • Wet sounding voice or cough • Complaints of food catching in the throat K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

18. SIGNS AND SYMPTOMS OF DYSPHAGIA: Esophageal Phase (3) • Burping or indigestion • Globus sensation: “lump in the throat” • Complaints about a bad taste in the mouth on awakening K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

19. *DYSPHAGIA SCREENING* • Dysphagia screening is one of JCAHO’s core performance measures for Primary Stroke Centers • Must show evidence that every stroke and transient ischemic attack (TIA) patient is screened for dysphagia prior to being given anything by mouth (including meds) • Screening can be done by physician or speech pathologist • There are 6 order sets that address this requirement: ED Stroke, Stroke Post Thrombolysis, Stroke Ischemic Adult, Stroke-Hemorrhagic ICH / SAH, Stroke mini –Order, and TIA K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

20. SWALLOWING SCREENING • To date, no swallowing screening tool has been universally accepted or recommended • Most of the swallowing screening tools have been developed for the stroke population • All however evaluate: *Level of alertness *Presence of a communication deficit (dysarthria / aphasia) *Symmetry of face, tongue and lips *Presence of voluntary cough *Ability to swallow own secretions (no drooling) K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

21. SWALLOWING SCREENING: All Include PO trial • Assessment for: • Presence of a swallow • Coughing • Gurgly vocal quality • Water dribbling out of mouth K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

22. SWALLOWING SCREENING:Maine Medical Center • Swallowing screening is included in the physician admission order sets for ischemic and hemorrhagic stroke and TIA • Stipulates the following for initiation of diet: • Alert • Cranial nerves VII-XII intact • Cough present • Managing oral secretions • Able to swallow 1 teaspoon of water • Documentation that the patient has no evidence of swallowing difficulties and is cleared to have oral intake K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

23. MANAGEMENT OPTIONS: • Diet / liquid consistency modifications • Environmental modification to reduce noise and distractions • Aspiration precautions • Oral hygiene • Positioning / postural strategies • Chin tuck • Head turn / head tilt • Swallowing strategies • Hard swallow • Double swallow • Supraglottic swallow • Super-Supraglottic swallow • Mendlesohn maneuver • Alternative modes of nutrition K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

24. KNOW WHO TO CONSULT • Speech-Language Pathologist • Bedside assessment • Modified Barium Swallow • Development of a management plan • Dietician • Other Physicians for possible surgical or other medical management interventions K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

25. KNOW HOW TO ADVOCATE • Be aware of the dysphagia management plan – collaborate with the Speech Pathologist and other staff • Monitor for compliance with positional guidelines and swallowing strategies at meal time • Be supportive of the diet consistency • Involve the patient and family • Contact the Speech Pathologist with any questions or concerns K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

26. Test question(s): • Behaviors that would indicate a need for swallowing evaluation include which of the following: • Drooling, coughing, choking, poor tongue movement • Clear voice quality • Prompt initiation of swallow • Symmetric palate elevation K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

27. Test question(s): • Which of the following is not in compliance with the JCAHO quality measure for dysphagia screening: • Screening should be completed on all stroke and TIA patients • Oral intake of medications is initiated prior to screening • Screening prior to oral intake is documented • NPO ordered until swallow evaluation is completed by physician or speech pathologist K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

28. Test question(s): • Resources that are available to guide evaluation and management of dysphagia include: • Speech language pathology • Nutrition services • Adult admission order sets for stroke and TIA • All of the above K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)

29. Test question(s): 4. The most serious complication associated with a swallowing deficit is: • a. Gastric tube infection • b. Pulmonary complications due to aspiration • c. Anorexia • d. Weight loss K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD5 (rev. 01.18.08)