[Dysphagia] bolus size and choking

[eripley at yahoo.com (Irene Campbell-Taylor)]

There is no safe bolus size or unsafe bolus size for that matter

. Posted by me on 24 May, 2001

?The articles by Ekberg and Feinberg that I have

> referred to on near -death )(and fatal) choking

> episodes on "dysphagia diets" included several

> patients who choked on mashed banana. The problem, as

> they identified it later, was not the diet, but the

> fact that the (dependent) patients had been fed too quickly.? The major article is:


Clinical and demographic data in 75 patients with near-fatal choking episodes.Dysphagia. 1992;7(4):205-8.

 
And, do I understand that some people are still recommending ingestion by teaspoons? Apart from being impossible (Have you ever tried getting through as day?s worth of food using only a teaspoon?) but the exact opposite of bolus volumes required for efficient swallowing as per Logemann, Kahrilas, Cook and a host of others e.g. Closure mechanisms of laryngeal vestibule during swallow
J. A. Logemann, P. J. Kahrilas, J. Cheng, B. R. Pauloski, P. J. Gibbons, A. W. Rademaker and S. Lin 

 

This study examined the temporal effects of bolus volume on closure of the laryngeal vestibule at the arytenoid to epiglottic base and the mobile portion of the epiglottis, the temporal relationships between these levels of airway closure and cricopharyngeal opening for various bolus volumes, and the mechanisms responsible for these two levels of airway protection during deglutition. Closure of the laryngeal vestibule progressed inferiorly to superiorly at all bolus volumes. Duration of closure of the airway at the arytenoid to epiglottic base increased systematically with bolus volume, as did the duration of descent of the epiglottis below horizontal. Closure at the arytenoid to epiglottic base occurred earlier in relation to maximal laryngeal elevation as bolus volume increased. (therefore indicating more efficient swallow and better airway protection with larger boluses. This has also been demonstrated by Cook, Brasseur, Shaker and others.)

AND

Gastroenterology. 1989 Dec;97(6):1469-78.

 


Upper esophageal sphincter opening and modulation during swallowing.

Jacob P, Kahrilas PJ, Logemann JA, Shah V, Ha T.

Department of Medicine, Northwestern University, Chicago, Illinois.

Studies were done on 8 normal subjects with synchronized videofluoroscopy and manometry to facilitate a biomechanical analysis of upper esophageal sphincter opening and volume-dependent modulation during swallowing. Movements of the hyoid and larynx, dimensions of sphincter opening, and intraluminal sphincter pressure were determined at 1/30th-s intervals during swallows of 1, 5, 10, and 20 ml of liquid barium. Our analysis subdivided upper esophageal sphincter activity during swallowing into five phases: (a) relaxation, (b) opening, (c) distention, (d) collapse, and (e) closure. Sphincter relaxation occurred during laryngeal elevation and preceded opening by a mean period of 0.1 s. Opening occurred as the sphincter was pulled apart via muscular attachments to the hyoid such that the hyoid coordinates at which sphincter opening and closing occurred were constant among bolus volumes. Sphincter distention after opening was modulated by intrabolus pressures rather than graded hyoid
 movement. The generation of intrabolus pressure coincided with the posterior thrust of the tongue that culminated in pharyngeal wall contact and the initiation of pharyngeal peristalsis. Larger volume swallows were associated with greater intrabolus pressure and increased bolus head velocity. The duration of sphincter opening increased in conjunction with a prolongation of the anterior-superior excursion of the hyoid and a delay in the onset of pharyngeal peristalsis (the event that determined the timing of sphincter closure). We conclude that transsphincteric transport of increasing swallow bolus volumes is accomplished by modulating sphincter diameter, opening interval, and flow rate (reflected by bolus head velocity). Furthermore, upper esophageal sphincter opening is an active mechanical event rather than simply a consequence of cricopharyngeal relaxation.

 

 

So ? why a teaspoon ? or less?


Marie Isbell <Marie.Isbell@state.tn.us> wrote:I work with this population also. We look at this in two ways. 1) size of the bite, which we assess through clinical observation and staff interview, and 2) diet textures, which would be the size of the piecesof food. #2 is dependent on the person's ability to adequate process the food. We use puree (smooth and creamy with no lumps), ground (1/8 to 1/4" sized pieces), diced (1/4 to ½" sized pieces), regular cut up (1/2 to 1" sized pieces) and regular (food is not processed for the person). #1 is assessed based on the person's ability to form a bolus and initiate the swallow. Since we primarily have direct care staff assisting at mealtime, we select a spoon by its bowl size. If we want the person to have a smaller bolus, we'll use a youth spoon. If no restrictions, a teaspoon. And we never use soup spoons or tablespoons as they can hold more than would be safe. Hope this helps. Marie

Marie M. Isbell, MA, CCC-SLP
West TN Regional PNM Team
West TN Regional Office
8383 Wolf Lake Drive
Bartlett, TN 38133
(901) 213-1847
Fax: (901) 372-3460
Marie.Isbell@state.tn.us

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>>> Sandi Lancaster 1/18/2005 6:20:52 AM >>>

Hello all,

Does anyone know of general recommendations for bolus
size for solids that will not obstruct the airway in
the average adult if a bolus were to be aspirated?

I evaluated a man who is profoundly MR and the
residential staff wanted recommendations from me on
bolus size. He does not have a history of choking or
pneumonia, but his oral stage is marked by lots of
mashing of boluses against his palate rather than
mastication, and holding of boluses before initiating
a swallow. He had no s/s of distress with any
consistency during my evaluation. Because this
patient presents with good tolerance of all
consistencies with his current swallowing pattern, and
doesn't have a history of choking when fed by staff, I
don't really want to recommend diet modification (why
fix what isn't broken, right?) But the current
"action plan" for this patient is for his food to be
cut into 1/2 tsp bites. (Which I don't think is being
done anyway.) I would like to have staff increase
their guideline for bite size as I think 1/2 tsp is
too tiny, but I really don't know of any general rules
for what bolus sizes will or will not obstruct the
airway during an aspiration event for an adult. 

I appreciate any feedback!

Thanks,

Sandi

=====
Sandi Lancaster, M.A. CCC-SLP
Speech-Language Pathologist



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