SWALLOWING AND FEEDING STRATEGIES

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SWALLOWING AND FEEDING STRATEGIES
Presented by Alana MacIntyre, SLP Northeastern
Ontario Stroke Network www.neostrokestrategy.com
Adapted by Alana MacIntyre, SLP, from Jill
Riva-Pateys presentation Low-Risk Feeding
Strategies Post Stroke and Lisa Sacco and Holly
Sloans presentation Eating Well after a Stroke
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The Importance of G

• Dysphasia/Aphasia - is a language disorder in
  which there is an impairment of the comprehension
  and expression of language
• Dysphagia - is a medical term defined as
  "difficulty swallowing."

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Swallowing After Stroke

• Stroke can affect ability to eat or swallow when
• Muscles involved in feeding, swallowing, or
  breathing are affected
• Alertness and attention to eating are affected
• Independence for eating is taken away

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Dysphagia

• Inability to safely swallow specific
  consistencies of fluid and/or food
• Presentation is varied and difficulty can occur
  in one or more of the swallowing phases
• Risk increases with the elderly population

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Incidence of Dysphagia in Stroke

• 30-51 of stroke patients present with dysphagia
• 15-27 at 7 days
• 2-21 at 1 month
• 8 at 3 months
• 
  (Martino, 2000 Kidd,
  1995)

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Signs of Swallowing Problems?

• Drooling
• Slow eating, prolonged chewing
• Food left in mouth after eating

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More Signs of Swallowing Problems?

• Coughing or choking during and/or after
  swallowing
• Throat clearing after swallowing
• Voice changes (i.e. wet/gurgly voice)

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Complications

• Airway obstruction
• Aspiration pneumonia
• Malnutrition
• Dehydration
• Reduced quality of life

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Palate
Velum
Tongue
Lips
Teeth
Pharynx
Valleculae
Epiglottis
Mandible
Hyoid
Larynx
Sulcus Cheek Salivary Glands
Esophagus
Trachea
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Normal Swallow

• A semi-automatic motor action
• Movement of food from mouth to stomach
• Average adult swallows 1500 times per day
• Awake, we swallow once every 60-120 seconds

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Normal Swallow

• Swallow has three phases
• Oral Phase
• Pharyngeal Phase
• Esophageal Phase

(xo.typepad.com/blog/ images/swordswallowing.jpg)
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Oral Phase

• Initial Stage
• Food and drink are brought to the mouth
• Lips and jaw close to seal the mouth
• Saliva is produced to add moisture

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• Oral Stage
• Under voluntary control
• Food is chewed and mixed with saliva to form a
  bolus (ball of food)
• Bolus is delivered by voluntary tongue movement
  to the back of the mouth, into the pharynx

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Pharyngeal Phase

• Involuntary/reflexive lasts 800 milliseconds
• Triggered when food passes towards the oesophagus
  and the soft palate closes
• Pharynx and the larynx move up to protect the
  airway and direct the bolusto the oesophagus
  

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Oesophageal Phase

• Involuntary/reflexive
• Relaxation of the upper part of the oesophagus
• Peristalsis pushes the bolus down into the
  stomach
• Gravity also assists with bolus transportation

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Palate
Velum
Tongue
Lips
Teeth
Pharynx
Valleculae
Epiglottis
Mandible
Hyoid
Larynx
Sulcus Cheek Salivary Glands
Esophagus
Trachea
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A Few Words About Reflexes

• Absence of a gag reflex does not predict
  dysphagia
• Presence of a gag reflex does not protect against
  aspiration
• The cough reflex can be impaired or absent, so
  silent aspiration may occur

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What Is Aspiration?

• Aspiration Inhaling of bacteria in saliva, food,
  fluid or refluxed material into the airway
• It can lead to choking, breathing problems or
  aspiration pneumonia

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• Dysphagia management is the key to preventing
  aspiration!

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Goals of Dysphagia Management

• Maximize nutrition
• Protect airway from obstruction
• Protect airway from aspiration
• Reflux
• Oral bacteria
• Medication
• Food
• Fluid

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A Few Words About Feeding

• Stroke survivors should be encouraged and
  assisted to feed themselves - safer than being
  fed
• 20 of patients who are fed develop Dysphagia -
  movement of food from plate to mouth prepares for
  swallowing
• Use hand-over-hand support with Dysphagic
  patients who cannot self-feed

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Feeding Strategies

• Feeding is a skill that requires knowledge and
  experience!!

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Solid Textures

• Regular Any food
• Diced Food that is cut into bite-size pieces
• Minced Food that is the consistency of ground
  meat (incl. scrambled eggs, and
• salad sandwiches)
• Purée Food that has been blended

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Fluid Textures

• Thin Any fluid, includes anything that turns
  into a fluid once in the mouth (i.e.. ice cream,
  Jell-o, milkshakes, etc.)
• Nectar Thick This is the consistency of tomato
  juice or buttermilk.
• Honey Thick This is the thickest consistency,
  almost the consistency of liquid honey

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Diet Texture

• Solids
• Easiest-----------------------------------Hardest
• Puree Minced Diced Regular
• Fluids
• Easiest ----------------------------------Hardest
• Honey Nectar Thin

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How Should the Person Be Positioned?

• While Eating and Drinking
• Sit fully upright
• Slight chin tuck

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How Should the Feeder Be Positioned?

• Eye-level with the patient
• Across from the patient
• Feeder should be comfortable
• Do not feed from above the mouth

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Other Feeding Strategies

• Feed at a relaxed pace
• Watch/feel for the swallow before giving the next
  bite
• One teaspoon at a time
• Do not engage in conversation during feeding

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Other Feeding Strategies

• Remain upright for at least 30 minutes after meal
• Provide 1 pill at a time (crush if necessary)
• Complete mouth care after each meal

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Refer to SLP If Patient Continues to Present With

• Coughing
• Choking
• History of pneumonia
• Temperature spikes
• Wet vocal quality
• Decreased lung sounds
• Malnutrition
• Dehydration