Choking and Coughing - not the only Signs of Dysphagia

What is Dysphagia?

Dysphagia is defined as a difficulty in swallowing and can be a symptom of some neurological impairment or illness such as a stroke, muscular sclerosis, Parkinson's, a mechanical or structural dysfunction or behavioural disorder. It can affect any one phase of the swallow.

Phases of the Normal Swallow:

1. Oral Preparatory phase: food is chewed or manipulated in the mouth in preparation for bolus formation and swallow
2. Oral Phase: the tongue pushes the food back until the pharyngeal swallow is initiated
3. Pharyngeal Phase: the swallow is triggered and the food moves through the pharynx and the UES (upper esophageal sphincter) opens to allow the food to enter the esophagus
4. Esophageal phase: Food moves through the esophagus into the stomach by peristalsis

Signs and Symptoms of dysphagia:

Coughing or choking, pocketing of food, difficulty chewing, poor saliva formation or excessive thick saliva, breathing problems, dehydration, malnutrition and weight loss are all signs and symptoms of dysphagia.

A cough reflex can occur when the food or fluid passes down below the level of the vocal cords and into the trachea. However, aspiration can be silent. In some cases chronic spitting up or vomiting of sputum can indicate silent aspiration.

A proper swallowing assessment is required to determine what the underlying problem or condition is. The signs and symptoms being observed will help determine which foods and fluids are best tolerated and how to manipulate the diet to reduce the risk of aspiration and choking.

Nutrition Therapy:

Alteration of food texture:

• Pureed diet: cream of wheat, pureed scrambled eggs, pureed cooked fruit and veg, soups, yogurt, custard
• Minced diet: cooked oatmeal, cooked eggs, yogurt, mashed cooked fruit and veg (no skins), ground meats and pasta, no nuts or seeds
• Soft diet: all soft textures, no toast, nuts, crisp or deep fried foods

Alteration of fluid consistency/viscosity:

• Thin: no change to consistency
• Nectar-like: can be sipped through a straw or cup, slowly falls off a spoon that is tipped (buttermilk, tomato juice, eggnog
• Honey-like: can be eaten with a spoon, too thick for a straw (thick yogurt, tomato sauce and honey)
• Pudding-like: very thick fluids, eaten with a spoon, hold shape on spoon (thickened apple sauce, milk pudding)

Incorporation of high protein and high calorie foods:

• Custards, puddings, skim milk powder added to milk and soup, fats and oils,
• Use of alternative feeding routes (enteral feeding tubes or parenteral (IV))

Feeding Environment

It is important to ensure the appropriate feeding environment such as positioning upright, hips at a 90 degree angle and shoulders slightly forward. After eating it is a good idea to stay sitting upright for at least 30 minutes. Sometimes assistance with feeding may be required. The eating environment should be calm, pleasant and social to stimulate the appetite. Eating small bites can be easier to manage and ensuring the food has cleared the mouth before eating the next bite is important. Checking for voice quality asking the person to say "Ah" can help determine if food has cleared. If the voice is wet and gurgly the food may be resting on the vocal cords.

The Bottom Line:

If you suspect a swallowing problem with your loved one, get a proper swallowing assessment from a swallowing expert such as a dietitian, occupational therapist or nurse with experience in this area.