Worried about difficulty swallowing . . . (dysphagia)

If you've come to this blog entry, perhaps it's because you may have concerns about the swallowing ability of yourself or a loved one. Difficulty swallowing is frightening and it can obviously be dangerous.  Many of the underlying factors that make a person vulnerable for difficulty swallowing are related to muscle weakness from a variety of causes:  stroke, multiple sclerosis, and generalized developmental difficulties, etc.

Asphyxiation and Aspiration

Weakness of the muscles that allow food to pass from the mouth, down the esophagus, and into the stomach can cause  choking.  If the choking doesn't dislodge the food from the windpipe, it can become lodged there and result in asphyxiation when air can't pass into the lungs.

Choking can result in some food or liquid actually entering the lungs.  The medical term for inhaling food or liquid is aspiration.  Aspiration can hurt the lungs in various ways, often a severe case of aspiration pneumonia results..

Swallow Screening for Stroke Patients--Always Necessary

When a stroke is suspected, hospitals require that a "swallowing screen" be performed before a patient is allowed to have anything by mouth.  In addition, among the questions patients are asked when they are admitted to the hospital for any reason is, "Do you experience any difficulty swallowing?"  If they answer, "yes," or give any other clues that make the admitting RN suspicious, the swallowing screening test is easily performed.

RN Swallow Screening Guidelines

Each hospital will have their own particular screening procedure.  This is an example taken from my personal experience in a facility where I was employed, and I'm presenting it to give you an idea about the factors that help define swallowing difficulty.  The RN performing the screening needs applesauce (or if patient is allergic something of the same consistency, like pudding), a graham cracker, and a spoon.  The patient cannot be lying down for this exam.  They need to be sitting almost at a right angle, and suction needs to be readily available in case the patient needs quick intervention.

Positioning

• Elevate the head of the bed at least 70 degrees
• Support the weak side of the body with a pillow if appropriate.  (This keeps the patient from slouching to the weak side.)
• Perform each step of the screening  (bites or sips) in this order and STOP if any item would cause a check on the documentation checklist at any point in the screening.

Procedure

1.  Give 1 teaspoon of applesauce. Watch for any signs and symptoms of dsyphagia (see checklist below.) STOP if any item is checked. If no signs or symptoms Repeat with a second teaspoon. If no signs and symptoms after the second spoonful, proceed to step 2.

Checklist:
__Holds food in mouth without initiating swallow or spits food out
__Significant facial droop with food or liquid coming out of mouth (Facial droop:  one side of the face droops from muscle weakness)
__Pocketing of food/drink in mouth or cheeks (Pocketing:  instead of swallowing, the food/fluid is kept in the mouth, usually held in the "pocket" between the bottom cheek and gums--like a chipmunk holds nuts.)
__Suctioning required during assessment
__Food or liquid coming out of nares (the nose "holes")
__Choking or persistent coughing during any stage of the swallowing screen
__Eyes reddening or tearing
__Wet, gurgly voice
__Patient reports painful swallow or food lodged in throat
__Labored breathing or moist breathing sounds (known medically as "rales")


2.  Give patient one teaspoon size of thin liquid (nurse is to control the amount of liquid placed on the spoon for patient to sip.)  If successfully swallowed, allow the patient to give self a second sip independently. STOP if any sign or symptom occurs.
 
Checklist:
__Holds food in mouth without initiating swallow or spits food out
__Significant facial droop with food or liquid coming out of mouth
__Pocketing of food/drink in mouth or cheeks
__Suctioning required during assessment
__Food or liquid coming out of nares (the nose "holes")
__Choking or persistent coughing during any stage of the swallowing screen
__Eyes reddening or tearing
__Wet, gurgly voice
__Patient reports painful swallow or food lodged in throat
__Labored breathing or moist breathing sounds (known medically as "rales")


3.  Give the patient a graham cracker and ask him or her to take a bite, chew it up, and then swallow.  If successful, offer the rest of the cracker. STOP if any sign or symptom occurs.
 
Checklist:
__Holds food in mouth without initiating swallow or spits food out
__Significant facial droop with food or liquid coming out of mouth
__Pocketing of food/drink in mouth or cheeks
__Suctioning required during assessment
__Food or liquid coming out of nares (the nose "holes")
__Choking or persistent coughing during any stage of the swallowing screen
__Eyes reddening or tearing
__Wet, gurgly voice
__Patient reports painful swallow or food lodged in throat
__Labored breathing or moist breathing sounds (known medically as "rales")


4.  Document results on the sticker and place it in the physician's progress notes.
5.  Obtain an order for a Speech Therapy consult if patient fails screening.
If one or more items are checked in any phase of the screening, the swallowing screen is FAILED.  The patient is to be kept NPO or "nothing by mouth."  Speech pathology consult is ordered.

• If NO items are checked, then the screening is PASSED.
• If the patient passes only on the applesauce (step 1), check with the physician to see if medications may be given crushed and mixed in applesauce while wating for the speech consult.

What can you do?

If you live with someone who is at risk for aspiration because of difficulty swallowing, make sure that their physician is aware of this and follow his or her advice and recommendations.  If they haven't suggested it already, ask for a Speech Pathology evaluation for your loved one.  In some cases, thickened liquids and specific consistency of foods will be recommended.  There are other important tips that a Speech Pathologist will teach you to help you or your loved one prevent aspiration and asphyxiation because of dysphagia.

Also, if you haven't already done so,  learn CPR and the Heimlich Maneuver so that you will be able to quickly intervene on behalf of your loved one. 

• Find a CPR class via the American Heart Association or the American Red Cross

Read more about dysphagia, check out the hyperlinks in this article for additional reading.


. . .

Lacunar Stroke or Lacunar Infarction

My mom started off the year with some troubling health issues. She's usually quite healthy, except for high blood pressure that has plagued her for years, sometimes rising high enough to cause a hypertensive crisis that required hospital treatment. It was a hard winter and Mom was occasionally experience "funny feelings" that I call the "feeling of impending doom." The day that those uneasy feelings wouldn't resolve, Mom went to the ER at St. Mary's hospital in Galesburg, IL. Another hypertensive emergency was discovered, and the excellent staff at St. Mary's initiated further diagnostic testing. A CT of the brain came back showing "something" that needed further investigation by MRI. All of that uncertainty and unfolding drama did not help Mom's blood pressure issues resolve at that point--and in fact, probably spiked the blood pressure of Dad, me, my brother and sister! (I'm quite certain that it did.)

The MRI revealed evidence of "several" old areas of Lacunar strokes. These are also known as Lacunar infarcts (infarctions). Mom had no classic symptoms of stroke that she can recall, so it's difficult to know when those tiny clots formed. Lacunar strokes can also be described as "subcortical strokes." High blood pressure is definitely a risk factor, along with diabetes, and atherosclerosis.

Lacunar strokes are a type of ischemic stroke. They occur deep in the brain in the smallest of the brain's blood vessels. When thinking of the circulatory system as a tree with roots and branches, the large vessels taper to smaller ones that branch out all over the body. Lacunar infarcts occur in blood vessels that would be like the tiny twigs on the branch of a tree.

A few years ago there was a push to change the term "stroke" to "brain attack." The new term never really caught on in places that I've lived and worked. But I have seen an increase in the number of hospitals that have become certified stroke centers.. The American Stroke Association cautions that "time lost is brain lost." Recognizing the signs of stroke and seeking care immediately are essential to ensure the best possible outcome.

Fortunately, Mom is doing much better and has no lingering effects from her recent health emergency. Her medications were tweaked to give her better control over her blood pressure and her daily aspirin dosage was increased. She’s recently started attending the Sunday auctions again, and that’s kind of how we gauge wellness in our family.

For good information about Lacunar strokes, these reputable sites are recommended:

Johns Hopkins

Harvard Medical School

National Stroke Association

National Institute of Neurological Disorders and Stroke (NINDS)

Know symptoms of a Stroke and act Face Arms SpeechTime

Face--weakness on one side of the face can be noted by a smile that "droops" on one side.
Arms--the inability to hold both arms straight out to the side (level with the shoulders) without one of them drifting downward is a sign of concern.
Speech--slurred speech or the inability to accurately repeat a sentence are symptoms of concern
Time--Make a note of the time when symptoms begin & provide that information to your healthcare professionals at the hospital. Strokes caused by clots can be treated with a strong clot-busting drug--but only if the symptoms started less than 3 hours before.

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