Transcription:
Dysphagia: What to Do When It’s Hard to Swallow

Caitlin Whyte (Host): Welcome to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We put knowledge and care within reach, so you have everything you need to live your life to the fullest. This podcast is sponsored by the University of Maryland Joint Network. Dysphasia can affect anyone because people can have a variety of minor problems ranging from trouble with chewing related to dental problems to undiagnosed self-management of symptoms. Natural aging causes loss of muscle mass, including tongue and throat muscles, which can cause trouble with chewing and swallowing. Jillian DeLuca joins us today to answer some common questions about dysphasia and what can be done. She is a level four Speech Language Pathologist at the University of Maryland Shock Trauma Rehabilitation Team.

So Jillian to start off our conversation today, tell us a bit about what dysphasia is and who does it affect?

Jillian De Luca, MS, CC-SLP (Guest): Sure. So dysphagia is the medical term to describe trouble swallowing in general. But it can include any of what we call the three phases of swallowing, which include the oral phase, which is the part in the mouth where you prepare food, hold food or liquid, or put maybe a pill on your tongue. Or it could be in phase two, what we call pharyngeal dysphagia, which is what you think of down your throat. So that starts kind of at the back of your tongue and travels in what we think of as a one-way space. So the pharynx or your throat is a space where you either are only breathing and only want air or you're swallowing something. So you would only want the food or liquid.

So you may have trouble in that second phase, the pharyngeal phase, if the food or liquid is having trouble getting squeezed through that area. Could be where the food or liquid is sticking in the throat, or it could be that the food or liquid is actually entering or nearly entering the airway, which is not an area obviously we want food or liquid while swallowing, but is very, very close to the pharynx and the opening of the esophagus, which actually is what makes swallowing so complicated and is kind of a specialty area that we know and understand and diagnose and treat with dysphagia as speech language pathologists.

The third area where people can have trouble swallowing is in the third phase, the esophageal phase, which is your esophagus, which is your food tube. That takes food from the throat to the stomach. When we think of these three phases, only part of them, part of the first phase in your mouth is the part we can actually see, you know, by opening your mouth and seeing what's left behind. Phase two and three are the complicated ones because we can't see them, obviously when we're just looking at someone, or even when you're thinking about swallowing, you can't see in your throat or in your esophagus. So that's where it comes into play when we try to diagnose dysphagia or trouble swallowing, we usually need some sort of imaging to understand the problem, what's causing the problem and then figure out how to fix it. Otherwise we go by what we call behavioral or clinical symptoms, which are the things maybe that you may feel or describe. Like, I feel like food's stuck in my throat or I'm coughing, I'm clearing my throat. It takes a long time. Those would be symptoms that relate to behaviors and feelings about swallowing.

Host: So with all of these different phases and symptoms, who is the most at risk?

Jillian: Yeah. I think that the groups that people most commonly think of are stroke survivors because the statistic, I think is about 40 to 50% of stroke patients at some point will have trouble swallowing. That could be right away after the stroke, or it could become what we call chronic where it's a lifelong problem or disorder that is attempted to be managed. The next group is, you know, we kind of think in general, any person who is working through a neurologic disorder.

So some of those may be those more commonly known, like Parkinson's disease. Sometimes we have flare-ups in neurologically based auto immune diseases, such as myasthenia gravis, or there are other diseases, ALS, Lou Gehrig's disease, where that unfortunately is one where people, they're swallowing just gets worse and worse and worse over time.

Other diseases such as Alzheimer's disease kind of people think of the dementias that's common and they kind of have their own pattern of trouble swallowing or dysphagia. So those are sort of some of the neurologic groups, but other groups, people don't really think of as much are people who have chronic breathing problems, such as COPD, people who need oxygen and other groups such as just the general aging population.

Fun fact, that your brain kind of is at its peak of its, you know, operation, its peak of life around age 35. After that, the brain kind of slowly starts to age a bit. As our muscles get older, you know, in our sixties, seventies, that's a term called sarcopenia where you start to lose some muscle mass. Because a lot of swallowing function is related to muscle function that sarcopenia or normal loss of muscle bulk is commonly relates to the dysphagia symptoms as well. So, you know, there are, so from that, there are a few groups that we normally wouldn't think of, but even recently up to about 25% of people in their aging lifespan will experience some sort of dysphagia, even if they've never had a stroke and other kind of neurologic disorders.

Host: You mentioned that, you know, two of the three kind of phases are not possible to see right? They're just kind of feelings that the patient has. So what can be done to help dysphasia patients?

Jillian: Sure. So the first step is having someone like myself, talk with the patient. We usually do a clinical swallow evaluation. That's where we get our interview. We look for the pattern of dysphagia symptoms. We are commonly referred by a primary care doctor. Or if there's any other specialists being followed by the patient or the person. After we kind of gather all of the clinical symptoms, then we will commonly do what I refer to as an imaging study, there are two types that we do.

Both allow very similar information for that phase two, that pharyngeal phase of swallow, the two types of tests are called what we described as F-E-E-S like F like fish. It's a flexible endoscopy of swallowing where we use a tiny camera, go down one of the nostrils, and then we, the, the camera sits high. So that we can actually feed people normal food, liquid, and then watch where it's sticking in the throat. Can evaluate for either if there's weakness of the muscles, or if it's something related to timing of closing the airway. The other type of evaluation we do is called a modified barium swallow, sometimes referred to video fluoroscopic swallow study, and this is done in the x-ray department. So it would be done in a hospital setting and the person would sit down in front of an x-ray and we would actually watch them eat or drink barium based material because the barium we see on x-ray and we create little snippets of what you think of a little x-ray in motion, like a little movie, so we can actually evaluate the muscle function.

And again, those similar things that we see on the flexible endoscopic swallow evaluation, the barium swallow is helpful in if we're suspecting trouble in the esophagus or the top of the esophagus, that's where it kind of transitions from phase two to three. The other study, the flexible endoscopic swallow, we do not see contents going through the esophagus, but we're able to see if things are maybe coming up, back up from the esophagus into the throat. So depending on what the pattern of symptoms is, you know, if there are other problems that would avoid or not, to do one of those two studies, we would do one of them so that we can actually then say, these are your symptoms.

The reason you're having your symptoms is because of whatever we find on that study. So as again, again, is it because there's weakness of a muscle? Is it because there's timing issues of closing the airway or opening the esophagus? Depending on what those reasons for the trouble swallowing or dysphagia.

Then we can formulate treatment plans of if we need to help establish a exercise program to try to strengthen the muscles. Or sometimes if it's again, timing or maybe sometimes a little a structural problem, we might be able to do what we call a behavioral strategy where you might put your head down a little bit to open the space in your throat, turn your head a certain way so that it opens up the esophagus a little bit better.

So depending on what we find, that's how we then end up treating the dysphagia and hopefully alleviating some of the symptoms. If we cannot figure it out, then at that point we may hand off to maybe a pulmonologist, a gastroenterologist who might be able to look a little bit more into maybe coughing symptoms if it's maybe pulmonology related. Or if it looks like there's something abnormal going on in the esophagus, the gastroenterology team may be helpful. If we see something abnormal in the throat or in the larynx, the airway space, then of course we would refer to the otolaryngologist or commonly known as an ENT to then help figure out the medical problem as well.

Host: Well, what about prevention? What can people do to avoid this in general?

Jillian: That's a really good question. That's something in our field we're actually doing research on. There are some theories and some studies going on to see if actually doing swallowing exercises, even as a healthy individual will somehow ward off what we're thinking of is trying to prevent any dysphagia. So if we're thinking about it, in terms of that natural aging population, it seems to be that there may be promise in this area where we do things just called really effortful swallows, where you're doing a little bit of extra muscle force into swallowing and, and some other different equipment based swallow therapy, which you would learn those if you went to a speech language pathologist. So there, there are some exercises that we could do in early aging, or as you kind of reach that transition of, of the older aging population, that we have seen work actually.

So exercise-based therapy the way you think of physical therapy or doing physical based activities to prevent other aging in the body. There are some things we can do there. And then the best thing, you know, I would say in general to try to prevent the other diseases is try to live that moderate lifestyle, eat healthy, you know, stay active, even in terms of what we didn't really talk about was part of swallowing is coordinating breathing and swallowing. So while you do the act of swallowing, you briefly hold your breath, so that, that one way, the one way channel, your throat can get food down and around the top of the airway entrance. So there's, again, some research going on with pulmonary based exercise and medicine in that, which then relates to physical activity and staying active.

If you are keeping up your kind of pulmonary exercise, you're, you know, going for long walks, have good lung expansion, there is a relationship between being able to take a deep breath and have healthy lungs. And actually it makes your swallowing a little bit stronger. So that is something else indirectly you can do is just stay physically active. We know it's good for your heart and lungs and everything else, but who knew that it was also good for swallowing. So I'd say that those are some of the best tips and tricks for people to try to avoid this sometimes disabling problems.

Host: Oh, those are some great suggestions. And if we do end up with dysphasia, how does rehab help the process?

Jillian: Sure. So some of the things that we would do is look at each person as an individual person. Everyone's different. Everyone has different habits, different likes, preferences, dislikes. So we would take the person into consideration what kind of their normal food intake is like, what their preferences are. You know, even though like when they're most alert, you know, the best times of day, so we would create an individualized plan for them where we would say, I'll take myself as an example. Like if I love my water and my coffee, but I'm having trouble swallowing those, the speech language pathologist in rehab services would take my preferences if they are at all safe and try to incorporate those things into my quality of life and my safety of being able to still take those things, but maybe in a modified way. So maybe instead of taking really large drinks, I'm paying close attention to taking really small sips using other strategies to do that. We kind of think of those as compensatory strategies where it's not fixing the problem. But we're allowing people to continue on with the things that really we know as humans, we enjoy and create a quality of life safely. So that would be one piece.

And then the other piece again, would be that individualized exercise or what we think of as a curative or rehabilitative plan. So going back to why we do that study with the person, figure out if it's weakness, if it's timing related, if there's a structure involved that we need to try, if we can, not all quote unquote fix that, we will help to create that plan.

And then the third thing that we do is, you know, just incorporate everything else into, all those tips I just gave, you know, if let's take someone who has maybe had a stroke and they're working on their physical activity and normally they were before the stroke able to walk and they love walking and they, you know, physical activity was something that they're working towards maybe with also going to physical therapy. That's going to, you know, kind of spill over into what we try to do for swallowing. So the more physically active someone can be, the more their swallowing is going to get better. So those are some examples of how we would take an individual person, their individual needs, wants, desires for their quality of life and try to rehabilitate their function because with rehab services, our primary goal is function. And so that's what we always try to do is improve function to therefore improve safety, health and quality of life.

Host: Beautiful. Well, wrapping up here, I've heard of something called a dysphasia diet. Can you tell us about that?

Jillian: Yeah. So that is something that if someone is in the hospital, that is one way we try to safely deliver foods to the person who has gone through all of the testing and everything that we've just spoke about. So in a hospital setting, or maybe in a nursing home setting, in some sort of, kind of facility that you would think of, it's a way to describe foods in their preparation and their texture, maybe in the size of the bite or the, the texture of the food. So that we're trying to optimize that safety and efficiency.

So how quickly, but safely someone can eat and drink who's having these trouble, getting it through the mouth, through the throat and down into the. In the United States, we have been using what we call a the National Dysphagia Diet. It's a system to kind of describe foods. The problem is it hasn't really described liquids very well.

So right now, actually for the last, probably about four years internationally and the entire, in the world, we've recognized that this is a gap. As our world's getting smaller, we're traveling more, people are using you know, Tele-health or using computers, all these different things where you could literally be in India, and then part of the time you're in the United States to be with your family. Internationally, there's been a group of dysphagia experts who have come together to actually create what we call the now the International Dysphagia Diet. And so they have been standardizing or coming up with terminology that is one, understandable from a language point of view. So anyone who speaks a different language, it translates into concepts. Whether, whether they're culinary terms of food preparation, or just by texture, something that people can understand. And they've created this system to describe everything from a liquid through all types of foods. So that also is and liquids can be kind of categorized into different textures. And we can use the system all the way from birth and babies when they're bottle fed and then transitioning to use, you know, really kind of liquidy, spooning foods, you know, the very, very soft kind of like crispy things that they practice chewing with, all the way through the lifespan where, you know, the circle of life kind of comes back together towards the end of life, or maybe we're going back to drinking a lot of liquids, taking really soft foods, kind of spoonable foods. And we can actually track and communicate through the world someone's dysphagia diet needs experience, and, and literally speak the same language no matter where the person lives or resides or gets care.

So that the safety of the patient or the person can be consistent all throughout the country or excuse me, excuse me, world and country too. And so it's a pretty neat system and it's out there right now for the public to look at. So if anyone listening to this is experiencing dysphagia, it's a wonderful resource. It's the International Dysphagia Diet Standardization Initiative or iddsi.org. And they have, you know, a tab for consumers, patients, general people that describes dysphagia. So it's a really good resource out there right now. It's in different hospitals use this just to print out straight from a wonderful resource.

Host: Beautiful Jillian. We covered so much about dysphasia today. Do you have any last takeaways our listeners should know?

Jillian: I would just say that if there's something that you are experiencing, that doesn't seem right, or it doesn't seem to go away, it's definitely worth just mentioning it to a doctor. So the doctor can get you hooked up with a speech language pathologist, sometimes occupational therapists get involved if it's with younger children.

So don't be afraid. Don't think there's anything wrong with you. Or that it's something strange that you should ignore. It's very, you know, the younger you are that we catch these things, it can help you to try to figure out what the problem is. We're here to help. So sometimes there's a stigma that we try to kind of keep people from eating, but that's really not the case. If you've ever had a loved one in the hospital, sometimes that setting is the most restrictive, but really, I think the beauty of rehab and rehabilitation is that it's a growing field in that we really try to focus on the function and keep person-centered care at heart to improve your quality of life. So you're not alone if you are experiencing this or know someone who has, there's help out there. So I hope that's just the biggest takeaway from anyone listening to this today.

Host: Well, thank you so much, Jillian, for joining us and for this episode chock full of information, we appreciate your time. This episode is sponsored by the University of Maryland Rehabilitation Network. Offering a range of physical rehabilitation services, the UM Rehab Network brings together a committed team of experts from across Maryland to help patients recover from illness or injury, such as stroke, joint replacement, or traumatic injury. The University of Maryland Rehabilitation Network, bringing world-class comprehensive rehabilitation services directly to your neighborhood.

Find more shows just like this one at umms.org/podcast. And thank you for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again.