Mealtime Partners, Inc.

Specializing in Assistive Dining and Drinking Equipment

May 2016 Independent Eating and Drinking Newsletter

Independent Eating...   is a Wonderful Thing

May Topics:

  • Why We Choke

  • Piecemeal Deglutination

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Why We Choke

In many of the articles in the Mealtime Partners Newsletters, caregivers who feed other people are encouraged to provide small bites of food and sips of liquid, rather than large bites and gulps of liquid. This article will try to shed some light on the “technical” reasons for these recommendations.

The processes of eating and drinking are two of the most basic human functions and almost everybody eats and drinks by mouth. The process of eating and swallowing, or deglutination, involves the interaction and coordination of many muscles and nerves to permit food to be transported from the mouth to the stomach, safely. Yet the vast majority of us eats and drinks without difficulty, almost automatically. We might choke on a very rare occasion, especially when we hurry or are distracted, but as a whole, meals, drinks, and snacks are given little attention beyond what is being consumed. And, when we do choke, we cough vigorously and dislodge whatever went down “the wrong way”, and are back to normal in just a few minutes.

Choking and aspiration occurs when the interplay between the respiratory system and the digestive system does not coordinate properly. The definition of choking is an object is in the airway. Partial or complete obstruction of the airway can be due to a foreign body (e.g., food, a bead, toy, etc.) entering it. When an object blocks the airway there is a sudden onset of respiratory distress with coughing. If the object is not removed the person will be unable to breathe. Uncorrected choking can be very serious and result in death (www.medterms.com). Aspiration1 is when solids or liquids that should be swallowed into the stomach are instead breathed into the respiratory system and penetrates below the true vocal cords, or when substances from the outside environment are accidentally breathed into the lungs1. Aspiration can result in aspiration pneumonia (an infection in the lungs) and is also very serious.

Obviously, all of us breathe ongoingly. Breathing continues while we chew a mouthful of food, just as we do when we are not eating or drinking. However, when we swallow, whether it is a “dry swallow” (only saliva), or a swallow to process food or liquid, our breathing must stop while we swallow. This is known as an apneic event2. The period that breathing stops (the apneic period) varies in length considerably depending upon both the individual and the texture of the food or liquid being swallowed. We all follow a respiratory pattern even though the pattern differs from person to person. The majority of people chew and form a bolus; when the bolus is moved to the back of the mouth, they exhale (breathe out), stop breathing (apneic event), swallow, and then inhale. Some people inhale prior to the apneic event and exhale once it is over. The volume of the bolus being swallowed will impact the organization of this respiratory pattern.

Eating starts before food reaches the mouth when saliva is produced in anticipation of eating. The body position that the person is in while they eat greatly impacts their function when food is received. Previous Newsletters (July 2009 and March 2010) have addressed issues relating to position while eating. Once food enters the mouth, its texture affects how it is handled. For example, a cracker will need to be broken into very small particles by the teeth and the particles will be mixed with a significant amount of saliva as they are moved around the mouth by movement of the tongue and jaw to form a ball, or bolus, before it is swallowed. Yet a bite of soft food, like pudding, needs little or no chewing but only needs to be formed into an appropriate sized bolus and swallowed.

Lazareck and Moussavi3 describe normal swallowing as: “involving intricate control and coordination of three swallowing phases, commonly referred to as oral, pharyngeal, and esophageal”. The oral phase is when food is in the mouth and being chewed and mixed with saliva; the pharyngeal phase is when a bolus is formed in the mouth and is passed to the back of the mouth to the epiglottis (the flap of cartilage that is attached to the root of the tongue and keeps food/liquid from going down the windpipe4); and the esophageal phase which is when the bolus enters the esophagus (the tube that connects the throat with the stomach).

Many studies have been conducted over the past several decades to gain a greater understanding of the swallow function and its interaction with respiratory function. Also, studies have evaluated changes in swallow function that occur when both different volumes of food or liquid are consumed, and when they are swallowed at a different pace5&6. However, for those who feed individuals who are unable to self-feed, there is little in the literature to guide them as to when to provide each bite of food or a drink. It is difficult for even a very observant feeding partner to see each time the person being fed, swallows. Even more difficult, is to know whether they will require additional swallows to clear their mouth after a single bite of food. Compounding this problem is the fact that meals are time consuming and most people who feed someone else have other people to feed, or other chores to attend to. This time constraint encourages feeding someone quickly. If the person has not cleared their mouth of food prior to receiving the next spoonful of food, they tend to hurry to clear their mouth, and in doing so they reduce the number of chews per bite of food. As a result, the size of the particles of food that make up the bolus are larger than those making up a bolus of well chewed bites. This process creates an environment that can promote choking or aspiration.

The same risk occurs when liquid is provided if the person is required to drink quickly. When drinking, if swallow after swallow occurs without a break for a breathe, the risk of choking or aspiration increases proportionally with the number of consecutive swallows, as the respiratory pattern becomes less organized with each swallow. To provide the safest environment, adequate time should be provided between each swallow to allow for the appropriate breathe/swallow pattern to occur, whether eating or drinking.

When swallowing difficulties are suspected, the best method of evaluating an individual’s swallowing is through videofluoroscopic examination (VFE). However, VFE must be limited because of the exposure to radiation necessary to conduct the examination. Therefore, only a relatively short record of swallowing is possible. When a VFE is conducted, the patient eats or drinks (or both) food or liquid that has been mixed with barium and the movement of the barium-laced product is graphically recorded as it moves from the mouth into the throat and is swallowed. This allows clinicians to visualize the biomechanical movements of the swallow but does not necessarily expose the underlying causes for abnormal movement patterns. It should be noted that some people have “silent aspiration”. They aspirate without any outward signs such as coughing. If someone is suspected of any type of aspiration, medical advice should be sought as quickly as possible. Currently, VFE is the gold standard for identifying swallowing difficulties.

In conclusion, being able to control the quantity and pace of drinking or eating greatly reduces the risk of choking or aspiration. Adaptive equipment is now available for almost everyone to eat and drink independently, regardless of their disability. For eating, a full range of equipment is available ranging from simple adapted eating utensils to fully powered dining devices (like the Mealtime Partner Dining System). For independent drinking, a variety of drinking products are available from Mealtime Partners, Inc., that suit the needs of most individuals.

 

The Mealtime Partner Dining System
For individuals who are unable to feed themselves because of limited or no hand and/or arm function, the Mealtime Partner provides them a way to eat independently. This lets them experience an enjoyable mealtime that is totally under their control. They can choose what they eat for each bite and pace their eating to suit their own needs and desires.
Boy using the Mealtime Partner
The Mealtime Partner Dining System can be positioned to meet the specific needs of each user. The user does not have to adjust their position to eat using the device because the Partner’s flexible mounting systems permit positioning to fit the user's needs, making mealtimes a comfortable, relaxed experience, with the user positioned safely for eating.

The Mealtime Partner empowers its user to eat what they want, when they want it.

The Mealtime Partner Dining System is quick and easy to learn and has no complicated programming requirements. Each Dining System comes with a complete training video on DVD so new users and caregivers can learn to use it in just a few minutes.

There are no other assistive dining systems that meet the needs of the users, like the Mealtime Partner.
For more information about this device, click on this link.

To talk to a representative call: 800-996-8607, or email us at: info@mealtimepartners.com and we will be happy to assist you in selecting the best system to meet your needs.

Piecemeal Deglutination

The first article in this month’s Newsletter discussed some of the causes of choking and aspiration. This article will shed some light on one of the common causes of choking and aspiration: piecemeal deglutination.

Piecemeal deglutination is a long name for something that we all do at times while eating or drinking but are most probably not aware that we are doing it. The danger of choking or aspiration increases for those at risk when piecemeal deglutination occurs. To understand what piecemeal deglutination is in a practical sense, imagine you have just been outside on a very hot day without having water available to you. You go inside and grab a drink and take a great big mouthful of water. You then swallow the mouthful of water in several successive swallows until your mouth is empty. Because you took such a large gulp, instead of all of the liquid in your mouth being swallowed at one time, the automatic reflexes controlling the muscles of your mouth and swallowing, break the liquid down into several segments that are manageable to swallow and are swallowed one after the other.

Deglutination is defined as the act of swallowing. Liquid or food is formed into a bolus (or ball) in the mouth and is then moved from the mouth to the pharynx and esophagus to the stomach. Piecemeal deglutination is a physiological phenomenon that occurs when a bolus is too big to swallow and is broken into two or more pieces that are swallowed successively. Ertekin, et ak7, defined 20 ml as the smallest volume of a bolus that will cause normal subjects to swallow in this way. There is risk associated with piecemeal deglutination because when we swallow several times in rapid succession the coordination of the act of swallowing becomes less and less organized, with each successive swallow. When someone swallows a single small bolus of food or liquid they are unlikely to choke, but if they rapidly swallow bolus after bolus, the risk of choking increases exponentially.

Therapists and caregivers need to understand piecemeal deglutination so that they can help reduce the likelihood of it occurring, and, therefore, reduce the risk of choking or aspiration for their clients who need aid with eating and drinking.

Did You Know? Did you know that many care providers, both family members and paid caregivers, make the mistake of positioning a person who need assistance at mealtimes with their back against a wall? It is common for those who are fed, or receive help during a meal, to be put “out of the way” of the active part of the dining area. This is a practical decision that allows others to move around the dining area during a meal without having to negotiate around a wheelchair, or other type of chair. However, positioning someone in a corner or against a wall has a significant drawback: if they choke during a meal it is difficult or impossible to rapidly get behind them to assist them or to perform the Heimlich  maneuver on them, should it be needed.



References and Notes:
1. Aspiration Definition: Gale Encyclopedia of Medicine, 2008.
2. Apneic event: Related to apnea. Temporary absence or cessation of breathing. American Heritage Dictionary of the English Language, Fourth Edition.
3. Lazareck, L., Moussavi, Z. M. K. Classification of Normal and Dysphagic Swallows by Acoustic Means. IEEE Transactions on Biomedical Engineering, Vol. 51, No. 12, December 2004.
4. The epiglottis functions as a lid or flap that allows air to pass through the larynx into the lungs. When swallowing occurs the epiglottis covers the entrance to the larynx (voice box) to stop food or liquid from entering the windpipe.
5. Rempel, G., Moussavi, Z. The Effect of Viscosity on the Breath-Swallow Pattern of Young People with Cerebral Palsy. Dysphagia 20:108-112 (2005).
6. Steele, C.M., Pascal H.H.M., & Lieshout, V. Influence of Bolus Consistency on Lingual Behaviors in Sequential Swallowing. Dysphagia 19:192-206 (2004)..
7. C. Ertekin, I Aydogdu, & N. Yuceyar. Piecemeal deglutination and dysphagia limit in normal subjects and in patients with swallowing disorders. Journal of Neurology, Neurosurgery & Psychiatry. November 1996; 61(5): 491-496.




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