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Swallowing
Difficulty
In-service Training Guide
Four Phases of
Normal Swallow
1)
2)
3)
4)
Oral Preparatory
Oral / Voluntary
Pharyngeal / Involuntary
Esophageal / Involuntary
Oral Preparatory Phase
 “Anticipatory stage”
 Occurs prior to the food entering the mouth
 Your mouth begins watering and your stomach
may start to growl
 Your body’s reaction to the anticipation of eating
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Oral Phase / Voluntary
 The tongue moves the food around in the
mouth for chewing. Chewing makes the food
the right size to swallow and helps mix the food
with saliva. Saliva softens and moistens the
food to make swallowing easier. The tongue
collects the prepared food or liquid, making it
ready for swallowing.
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Pharyngeal Phase /
Involuntary
 This stage begins when the tongue pushes the
food or liquid to the back of the mouth, which
triggers a swallowing reflex that passes the food
through the pharynx (the canal that connects the
mouth with the esophagus).
 During this stage, the larynx (voice box) closes
tightly and breathing stops to prevent food or
liquid from entering the lungs.
• Aspiration is most likely to occur
during this phase.
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Esophageal Phase /
Involuntary
 The food is propelled downward from the upper
esophagus to the stomach by a peristaltic
movement.
 Impaired esophageal functioning can result in
retention of food & liquid in esophagus after
swallowing
 An interval of 8-20 seconds may be required to
drive food into the stomach.
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Abnormal Swallow
 53 – 74% of Nursing Home Residents Affected
 Aspiration Pneumonia
• 5th Leading Cause of Death = over
60 year of age
• 3rd Leading Cause of Death = over
80 years of age
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Swallowing Difficulties
Actually symptoms of other
underlying conditions.
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Two Broad Types of
Swallowing Difficulties
-Oropharyngeal Dysphagia
Affects the mouth & upper throat
-Esophageal Dysphagia
Affects the esophagus
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Oropharyngeal Dysphagia
 Characterized by difficulty moving food or
liquid to the back of the throat, and initiating
a swallow.
 Food accumulates in the mouth - spills out
the corners or from the back of the mouth
into the nasal passages
 Will actually pass the vocal cords and enter
the trachea causing respiratory distress.
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Esophageal Dysphagia
Characterized by a sensation that
swallowed food or liquid is sticking
in the esophagus somewhere near
the neck or chest.
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Causes of
Oropharyngeal Dysphagia
 Stroke
 Parkinson's Disease
 Muscular dystrophy
 Tumors of the mouth
 Radiation-induced dry
mouth
 Drug-induced dry
mouth
 Chemotherapyinduced inflammation
of the mouth
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Causes of Esophageal Dysphagia
 Inability to produce involuntary, wave-like
contractions of the esophagus
 Esophageal spasms that block food and liquid
instead of propelling them downward toward
the stomach.
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Causes of Esophageal Dysphagia
(continued)
 Age related changes of motor function of
esophagus
 Tumors of the esophagus
 Functional dysphagia with no physical reason stress
 Esophagitis induced by reflux disease
(GERD)
Symptoms of Dysphagia
 Difficulty chewing
 Difficulty initiating
swallowing
 Persistent sensation of
a "lump" in the throat
 Frequent need to clear
throat
 Drooling
 Pain during swallow
 Bad breath
 Change in voice
(Nasal voice or
hoarseness)
 Hiccups
 Weight Loss
 Heartburn
 Chest Pain
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Warning Signs of
Swallowing Difficulty
 Taking a long time to
begin a swallow
 Needing to swallow 34 times for each bite
 Coughing
 Frequent throat
clearing
 Difficulty swallowing
liquids in mouth
 Wet / gurgly voice
 Extremely slow eater > 45 minutes
 Rocking tongue back
& forth
 Spitting food out
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Swallowing Difficulty
Complications
 Malnutrition
 Weight Loss
 Dehydration
 Choking
 Aspiration
 Pneumonia
 Depression
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Swallowing Assessment
 Watch the resident while he or she drinks a few
ounces of water – delayed swallowing initiation,
coughing, a wet or hoarse voice quality may
indicate a problem. After the swallow, observe
resident for 1 minute or more to see if delayed
cough response is present.
 Document observations in medical record.
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Signs to Report
 Oral leaking
 Choking
 Pocketing food
 Taking longer than 2-10 seconds to swallow
 Choking on pieces of food
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Positioning for
Swallowing Difficulty
 90 degree angle / swallowing is easier & safer
 If paralyzed on one side, turn head slightly to
the weak side & slightly down
• (may increase ability to swallow – positioning
this way may help reduce the passageway on
the paralyzed side of the esophagus)
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Reducing Swallowing Problems
Solutions/Interventions/Techniques
 Tilt the head down
slightly
 Place food in the back
of the mouth
 If paralyzed on one
side, place food on
strong side of mouth
 For tongue thrusting –
try placing food on the
back of the tongue
 Small management
sips or bites
 Keep upright for 30
minutes after eating to
prevent risk of
aspiration
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Meal Time Interventions
 Remove distractions
 Use special swallowing maneuvers
recommended by SLP
 Eat more slowly
 Smaller mouthfuls of food
 Special utensils & prosthetics
 Adjust temperature, taste & texture of food
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Solutions/Interventions/Techniques
 Avoid dry foods –
moisten with gravy,
sauce or broth
 Wait for resident to
swallow prior to
placing any more food
in mouth
 Check mouth very
carefully after meals
 Clear all food from
back of mouth,
between cheek &
gums & under
dentures
 NEVER RUSH
 BE VERY ATTENTIVE
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Making Swallowing
Easier
 Soft, chopped, ground
or pureed foods
 Thickened liquids
 Cohesive foods
 Serve food cold or hot,
(not warm).
 Cold, sour foods or
liquids can improve
the oral stage of the
swallow by the
triggering of a swallow.
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What if Choking Occurs?
 Stop feeding
immediately
 Call for assistance
 Utilize Heimlich
maneuver if needed
 Sit the individual
forward
 (If unable to sit, turn
head to side)
 Do not give water or
fluids until symptoms
subside
 Trained personnel
may need to use
suctioning techniques
 Do not give water or
fluids until symptoms
subside
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Always follow the
recommendations of the Speech
Language Pathologist (SLP),
in addition to your facility’s policy
and procedures.
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Questions?
Thank you for all that you do
for our residents!
Arkansas Innovative Performance Program (AIPP)
1020 W 4th Street, Suite 430 • Little Rock, AR 72201
877-375-5700 • (Fax) 501-375-5926
[email protected] • aipp.afmc.org  arkansasculturechange.com
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THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC) UNDER CONTRACT WITH THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE CONTENTS PRESENTED DO
NOT NECESSARILY REFLECT ARKANSAS DHS POLICY. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT.
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