Swallowing issues with paralysis

Swallowing issues with paralysis

Posted by AskNurseLinda on Nov 21, 2016 10:57 am

17c70a5cc926e0e39ca41d70a0e92c32-huge-isThe ability to swallow is an intricate process for all people. Food, fluid and saliva is removed from the mouth by swallowing into the esophagus so it can be used by the body for nutrition and hydration. Both food and fluid are essential to ensuring the function and even life of the human body. Swallowing can be a very delicate process as the tube from the mouth to the stomach, the esophagus, and the tube to supply air to the lungs, the trachea, are extremely close together in the throat.

When air is being breathed into and out of the lungs the trachea remains open but when swallowing, a little flap closes the top of the trachea so food and fluid cannot enter into the lungs. When food, fluid or even salvia, gets into the trachea, choking occurs. Everyone chokes at some point in time. It can be just a little choke, easily cleared by a cough or a large choke which is quite frightening.

Individuals with paralysis at any level can be more susceptible to choking. A problem with swallowing is called dysphagia. Those with higher level injuries, may have a dysfunction in the mechanism of swallowing which does not allow for proper closing of the trachea when swallowing. Anyone who has or has had a tracheostomy, a tube to allow easier breathing, can be at a higher risk for choking. If a tracheostomy is present, you might be advised not to eat and drink so food and fluid does not enter the trachea or you might learn special techniques to help ensure the food and fluid enter the body through the correct pathway. If you have had a tracheostomy for any reason, but it is now removed, scaring can increase your risk of choking as the trachea might not be as elastic as it once was.

For anyone with any type or any level of paralysis, even lower injuries, the ability to clear a choke might be affected. With paralysis, the muscles of the chest wall or abdomen might not be as strong as needed to be able to provide an adequate cough to clear the obstruction from the trachea or lungs. This can be the same for someone who has paralysis on one side of the body such as from stroke or just a general muscular weakness for neurological disease. Clearing an obstruction for the airway, takes a terrific amount of force from the muscles of the abdomen. The obstruction has to be overcome by an increased pressure from the abdomen to be able to clear the trachea. Since the obstruction might be completely blocking the airway, creating enough abdominal pressure comes from muscular contraction.

For others, the necessity of medical treatment can increase the risk of chocking. Risk of choking can be increased when stabilization of the neck is a priority. Neck collars, halo bracing, improper neck support when sitting can lead to over extension of the neck and thereby over extension or under alignment of the swallowing mechanism in your body. Coordination of swallowing with mechanical ventilation support can also lead to difficulty in safe swallowing. If surgery was performed on the neck to stabilize your injury, post-operative swelling can interrupt safe swallowing. This is only temporary as once the swelling has decreased, safe swallowing returns.

Not everyone will choke in a noticeable manner. Some people, especially with dysfunction or high risk for choking may have something called silent aspiration. If the swallowing mechanism is not working in unison, a small bit of fluid or food can slip into the trachea without the signs of choking being exhibited. Silent aspiration is noted by a test called a swallow study. In this case, a person sips some special fluid that can be detected on fluoroscopy. A trained healthcare provider administers the fluid and monitors the person being tested. The fluoroscopy will detect if an undetermined amount of the substance enters the trachea either with or without signs of choking. Prevention techniques will be initiated if this occurs.

An old nursing adage is to look at the individual to determine ability to swallow effectively. What you see on the outside is what is going on inside. If you see the risks for choking as listed above or if there is any facial droop, unevenness in the sides of the face, drooling or inability to control salvia, or skin sagging in the face or neck, there is probably some mechanical problem with the swallowing process. This is certainly not a definitive test but it can guide you to seek assistance or testing to ensure your swallowing mechanism is safe and effective.

A person can choke, clear their own airway and there is no consequence. This has probably happened to everyone. However, sometimes choking can lead to a range of complications. These can include temporary hypoxia or lack of oxygen in the blood, pneumonia, a collapsed lung, a spasm in the trachea or a physical obstruction to breathing.

Choking is a horrible situation as the person cannot get the oxygen they need, or rid themselves of carbon dioxide. Unlike holding your breath, choking comes on suddenly when you are unprepared. The feeling of not being able to take in or release air from the lungs is horrifying. You have an overwhelming desire to clear the obstruction but might not have enough power to force out the obstruction on your own. The breathing emergency will require immediate action such as suctioning, if that equipment is available. This is especially useful for choking on fluid as the substance is too thin to force out. Suctioning can also be used for more substantial plugs such as from mucous or even food.

The Heimlich maneuver is done with choking to remove an obstruction.  In this procedure, a helper assists the person choking by applying a quick pressure just below the rib gage on the abdomen. The pressure is applied in a quick thrust in and up. This provides external pressure to clear the obstruction. Before doing this procedure, you must have trained in the proper application with hand positioning and understanding the amount of pressure to apply so you do not break the recipient’s rib or cause other injury. There are classes available in the healthcare setting as well as in the community to learn this procedure. Instruction for adults, children and infants is available as the techniques are different depending on the size of the person.

Unrelated to choking, but a helpful technique to clear the airway is assisted coughing. This is another manual maneuver performed by a helper person if an individual has difficulty coughing. In this procedure the hands are placed in a certain way on the rib cage and pressure is applied as the individual attempts to cough on their own. This, also, provides additional pressure when there is a high level injury, chest muscle or diaphragm weakness. This procedure requires training by a professional who is familiar with the procedure to protect the individual from harm. It is dangerous for some individuals to use assisted coughing so it should not be attempted without training and without specific indication from your healthcare provider to use this technique.

There are treatments that can improve your respiratory status. These include secretion management by suctioning and medication to reduce secretions if they are excessive. Chest physical therapy, intermittent positive pressure breathing and strength and endurance training. Do you recall the incentive spirometer that you were given in the hospital? It is a device that can help build your respiratory muscles to improve your ability to cough.

There are techniques that will help you avoid choking if you are having difficulty. The first step is to review your positioning. Sitting bolt upright is the best position for swallowing. If you cannot do this due to your condition, attempt to sit as upright as possible. Be sure you have trunk and head support that is adequate for your frame. If you do not have a restriction, tucking your chin to your chest provides a mechanical help to your swallowing mechanism.

Check your teeth to make sure you can properly chew. A dental exam will help ensure your teeth are in good health for eating. Clean food particles out of your mouth after eating by rinsing if necessary.

Take bites that you can handle, not gulping your food. Chew carefully. Do not talk with food or fluid in your mouth. Be sure enough time is allowed that you can chew your food and swallow it before taking more. If you are eating with assistance from a caretaker, be sure you are ready for the next bite before being served. Take time to eat and chew. Don’t rush through a meal. This is helpful for swallowing as well as enjoying the flavors of your food.

If you cannot handle thin fluids such as water, thickeners can be added that will change the texture but not the taste. Instead of cutting food in to coin type slices, cut the food into small pieces so that it is thinner rather that rounder. Some foods such as bread and doughy desserts can thicken with water, creating a plug if swallowed incorrectly. Avoid sticky foods such as peanut butter. Avoid foods that can act as plugs in the windpipe if accidently swallowed such as peanuts, anything with seeds, hard candies, sticky or runny foods.

 As always, avoid alcohol which can hamper the effectiveness of your swallowing mechanism.

If you have even the slightest suspicion that something might be amiss with your swallowing, notify your health professional. Ask for training to perform the Heimlich maneuver or if assistive coughing will help. Request an incentive spirometer if you have misplaced yours to build your respiratory strength.

The consequences of choking can be quite devastating. If you feel your swallowing is alright but you are having multiple chest infections, especially pneumonia, it is time to ask for an evaluation. You could have silent aspiration. Should there be any change in your physical condition, be sure to ask about swallowing. This is one area where it is better to be safe than sorry.

Nurse LindaI'm online in this community every Wednesday from 8-9 PM ET to answer your SCI and paralysis related questions.

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