Dysphagia – swallowing disorders

If food or drink enters your airway (trachea) rather than travelling down towards your stomach (via the oesophagus) you may observe:

• coughing or choking before, during or after eating or drinking
• changes in breathing, eg: wheezing or shortness of breath
• wet or ‘gurgly’ voice quality after eating or drinking
• changes in facial colour, turning red, grey or blue
• eyes watering.

Other acute signs of eating and drinking difficulties can include:

• fatigue during a meal
• increased length of mealtime
• significant changes in eating or swallowing foods/liquids
• complaints of discomfort or food getting stuck
• difficulty clearing the mouth, food spilling out of the mouth, reduced chewing
• change in the amount/consistency of saliva
• chronic signs (become evident over a period of time)
• repeated chest infections (particularly of the right lung)
• weight loss
• general ill health – urinary tract infections, dehydration, pressure sores
• reduced appetite, food avoidance or refusal
• behavioural changes associated with mealtimes
• requires support to maintain oral health
• requires support for feeding
• changes in positioning for eating and drinking (slouching, head tipped back, leaning to one side).

Please inform or refer to the Speech and Language Therapy team if these signs are observed

If you are supporting someone who is waiting for a swallowing assessment, please follow these routines for feeding safely:

• Consciousness – no-one should be given food or drink if they are unconscious or semiconscious. Alternative nutritional and hydration options should be discussed with the responsible clinician.
• Distraction – reduce distractions at mealtimes to facilitate concentration and awareness.
• Time – allow adequate time to support the individual to eat and drink.
• Positioning – people should sit upright for all snacks, meals and drinks. People should remain sitting upright for at least 30 minutes after a meal to avoid reflux.
• Oral hygiene – ensure the mouth is clean and free from residue at the end of the meal. Encourage a ‘clearing swallow’ or ‘saliva swallow’ to assist in clearing residue from the mouth. Cleaning teeth and the mouth at intervals during the day is recommended.
• Position yourself – at eye level so that you may observe signs of food and drink going down the wrong way (aspiration) as well as being able to provide verbal prompts and encouragement. Positioning yourself above eye level or sitting at the side of individuals to assist with eating and drinking may have a negative impact on the individual’s ability to swallow safely as they may change their posture.
• Utensils – ensure you have the correct utensils identified for the individual.
• Dentures – if dentures are worn, ensure they fit well. Be aware that some individuals prefer to eat without their dentures and softening the diet may help.
• Glasses – swallowing requires multisensory stimulation. Food should be visually appetising in its presentation and smell appealing to stimulate the appetite.
• Hearing aids – ensure that the individual can hear the guidance and advice being given eg: when prompted to slow down.
• Modifying diet – ensure the correct consistencies of food and drink are prescribed for the individual with dysphagia.
• Independence – individuals should be encouraged to feed and drink themselves to encourage and maintain functional independence.
• Portion size – people who are frail or lack stamina should be given small portions which require less energy to eat (e.g. softer and/or more moist foods). These small portions of food or drink should be given at more frequent intervals in the day. The Dietician should be asked to advise if a patient/client is losing weight.
• Size of mouthful – It should be sufficient to stimulate chewing and swallowing but it is important to avoid overlarge mouthfuls.

Many of the muscles used in swallowing are also involved in breathing, so problems with breathing may lead to difficulties with swallowing. It is common for people with breathing difficulties to have problems eating and drinking

How is swallowing linked to breathing?

The swallow temporarily interrupts breathing. The moment you swallow, you must momentarily hold your breath to close the airway. This prevents any food or drink from getting into the lungs.

For this process to occur well, the body must co-ordinate the breathing cycle with the swallow.

Breathe out -> hold breath to protect airway (around one to one and a half  seconds) -> swallow -> continue to breath out a little -> breathe in -> repeat.

People who have a breathing difficulty may breathe in after swallowing rather than breathe out. This increases the risk of food and drink going down the windpipe (the wrong way). If you have difficulties doing a strong cough, this can make it harder to cough something out if it went down the wrong way.

How could this affect you?

If you have a breathing difficulty, your muscles might feel tired and weak during mealtimes and you might breathe faster and get more breathless during eating and drinking. This can increase the risk of food and drink going down the wrong way. If food and drink goes down the wrong way a lot, it can cause a chest infection.

Breathing difficulties have also been linked to a higher chance of having acid reflux and indigestion where food and drink can come back up from the stomach. This can cause irritation and dryness in the throat and make you cough more.

Difficulty and extra effort with breathing will make your muscles tired. If you are exhausted or feel weak you may find that it takes longer to have your meals and you may eat and drink less. This may mean you miss out on important nutrients which can lead to losing weight.

If you are on oxygen

If you wear an oxygen mask it may make eating and drinking more difficult. If you  wear an oxygen mask or you have to breathe through your mouth, it can  you can cause your mouth to feel dry, which makes chewing and clearing food from your mouth more difficult as things can stick

Signs that you may have difficulty swallowing because of a breathing problem

If you have a breathing problem, these are common signs to watch out for that indicate you may have difficulty swallowing:

• getting more breathless during mealtimes
• finding breathing harder or more effort when eating or drinking
• getting tired during and after eating and drinking
• difficulty chewing and avoiding difficult textures eg: chewy/crunchy foods
• wet or gurgly voice during and/or after swallowing
• taking much longer to complete a meals
• sensation of food sticking in the throat
• anxious when eating or drinking
• experiencing a sensation of feeling ‘full-up’ even though you have only eaten very small amounts
• experiencing more acid indigestion (reflux)
• coughing during or just after eating and drinking
• chestiness or recurrent chest infections
• difficulties taking tablets.

Getting ready to eat and drink

These tips may help you to avoid problems when you are eating and drinking:

• if you have saliva or phlegm stuck in your throat or back of mouth, try to cough to clear these first
• if you wear dentures make sure these fit well and are comfortable, if they are loose or ill-fitting they may cause more of a problem
• it’s helpful to have a relaxed and comfortable environment during mealtimes and to try to relax your whole body as much as possible
• make sure you are well rested before eating and drinking – be aware that food preparation may be tiring
• if your mouth is feeling dry, take a sip of drink when you need to but be aware that alternating drinks with mouthfuls of food may be difficult.

Tips for drinking

• Avoid taking lots of mouthfuls of drink in a row, try to take one sip at a time.
• Do not use spouted cups or straws unless they have been specifically recommended as these shoot the drink further back in your mouth and can make it harder to control the drink.

Tips for eating

• It may help to have softer foods which need less chewing – if you find some foods are hard for you to chew and swallow, avoid them if they are very hard to manage, or consider making simple swaps such as dunking biscuits in tea to soften them; swapping baked beans for spaghetti hoops; avoiding hard sweets and having smooth chocolate instead.
• Eat slowly and take smaller mouthfuls.
• Try an extra swallow to clear any food residue in your mouth and throat before taking another mouthful.
• Remain upright for at least 30 minutes after a meal.

Managing breathlessness when eating and drinking

If you feel breathless when eating and drinking, try to breathe out immediately after a swallow. Then get your breath back after swallowing – take your time and make sure your breathing is settled before having more.

You may find eating little and often easier. Select high calorie options if you are struggling to eat enough If you are extremely breathless, please contact your GP for advice as eating and drinking may become very difficult.

Saliva plays an important role in swallowing and speech. It lubricates your tongue, lips and throat. Saliva is also involved in digestive actions and is responsible for dental protection, inhibiting the growth of bacteria and maintaining ph levels.

A variety of conditions can impact upon saliva and swallowing including:

• neurological conditions such as stroke, motor neurone disease or cerebral palsy
• dementia, learning disability and other conditions that may result in cognitive impairment
• head and neck cancer.

Reflux, poorly fitting dentures, medications which cause dry mouth, dehydration and a need for oxygen/suction can also impact on saliva and swallowing.

Effects from too little saliva

• dry mouth
• difficulty chewing, swallowing and speaking
• thickened/ stringy mucus
• irritated/inflamed tissue in the mouth
• higher risk of tooth decay, gum disease and tooth erosion
• pain/burning in the mouth or tongue
• inflammation of the salivary gland
• altered taste
• bad breath
• ulcers/sores in the mouth.

Effects from too much saliva (salorrhea)

• thin saliva
• risk of breathing saliva, fluids or food into the lungs (aspiration)
• skin cracking around the mouth/chin
• bad odour
• dehydration
• saliva coming out of the front of the mouth (especially if the individual has poor lip seal)
• embarrassment.

Managing difficulties with saliva

Your speech and language therapist will be able to advise you of on how best to manage your difficulties, according to your needs. They may give advice on medication, positioning, hydration and/or oral care. They may also refer to you a physiotherapist for suction or cough assist support.

Remember to follow any eating or drinking guidelines you have been given to help manage your saliva.