Swallowing Pills

G. Carnaby & M. CrarySwallowing Research Laboratory

SwallowingSwallowing is something that we do 2,000 to 3,000 times every day, yet it is a very complex act requiring many muscles coordinated by the brain and brainstem.

The swallow mechanism is innervated by 7 pairs of nerves and 26 muscle groups

Normal Swallowing

Three phases of swallowingOral phasePharyngeal phaseEsophageal phase

Phases of swallowingOral phase. Biting and chewing takes place in the mouth. During this stage, food is broken down into smaller pieces and mixes with saliva. This preparation stage is where the pleasure of eating is derived.

Oral phase

In this voluntary stage, the tongue pushes the food or liquid to the back of the mouth, where it is positioned to pass into the throat (pharynx). When this stage is completed, there should be no food or liquid remaining in the mouth.

Pharyngeal phase

During this phase, the palate, the soft structure that hangs in the back of the throat, elevates to prevent food or liquid from entering the nose. The voice box closes to prevent food from entering the windpipe, and a muscle at the low end of the pharynx relaxes to allow food to enter the esophagus.

Fluoroscopic Lateral View – OroPharyngeal Components

Video 1 – slow motion oropharyngeal swallow

Swallow Variants - Accommodation

Video 2 – Bolus Accommodation examples

Endoscopic View - Oropharyngeal

Video 3 – endoscopic view normal oropharyngeal swallow

Esophageal phase

A series of coordinated muscle contractions pushes the food down the esophagus (food tube) and into the stomach.

Esophageal Clearance - Fluoroscopy

Video 4 – example of fluoroscopic clearance

The whole sequence

http://srl.phhp.ufl.edu

University of FloridaSwallowing Research

Laboratory

Swallowing Research Laboratory

Research Foci Study of normal and abnormal swallowing physiologyDevelopment of innovative assessment and treatment ‘tool’s for adult dysphagia

Current Projects (examples)Prevention of dysphagia in head/cancerSwallow frequency to screen for dysphagia in strokeReflux and swallow frequency in acute strokeOral morbidities in head/neck cancerSwallow abilities in community dwelling elderly

Swallowing Research Laboratory

Measurement CapabilitiesVideofluoroscopyTransnasal endoscopyTransnasal esophagoscopyLingual-palatal pressure measurementPharyngeal and upper sphincter manometryHigh Resolution ManometryMRIsEMGRespiratory measuresAnd More!

Difficulty swallowing

“Dysphagia (dis-fag-ia)Defined as difficulty swallowing or the inability to swallow food or fluids”

Epidemiology of dysphagia

Estimated to affect 22% of the world’s population >50 years of age Swallowing disorders are becoming a major source of disability –estimated 17 million adults in the US alone

Up to 30% of patients in hospitals~60% of residents in nursing homesProbably 14% of people >65 years of age living in the community

Approximately 10 million children in the US

Disorders of swallowingCan occur in all age groups May be a result of many different medical conditionsCan be an acute problem or progress slowly over a long period of timeEarly identification and involvement of health professionals offers a good prognosis for swallowing disorders. Abnormalities of swallowing could be secondary to defects in any of the stages of swallowing enumerated above.

Many people with dysphagia can go unrecognized or undiagnosed until a major medical event occurs.

Additional DefinitionsAspiration: Passive entry of any food item into the trachea (eg, during inhalation), although the term often is used to denote any entry of material into the trachea in any manner Penetration: Active entry of any food item into the trachea (eg, during swallowing), although the term often is used to denote the entry of any material into the laryngeal vestibule

Diagnostic tools

Videofluoroscopic procedure (xray video)Most widely used determine physiology of swallow

Other evaluation toolsFiberoptic endoscopic examinationUltrasoundElectromyographyManometry

Videofluoroscopy

Videofluoroscopic procedureAlso known as modified barium swallowA radiographic study of a person’s swallowing mechanism that is recorded on videotape

Videos - dysphagia

Video 5 - Zenker’s Diverticulum

Dysphagia

Video 6 – Cricopharyngeal Bar

CP bar

Normal swallow

Dysphagia

Video 7 – Stricture in PES with NPR

Pills and More

Video 8 – Liquids pass but not the tablet!

Pills and More

Video 9 – Pills stick in throat and chest

Endoscopy - dysphagia

Video 10 – Endoscopic View Dysphagia in Elderly

Swallowing PillsEpidemiology Online National US survey 2003 [ n=679, 513 – 18-64yrs; 166 ≥65yrs]

40%- Report difficulty with swallowing pills 51% women /27% men18-64 (44%); ≥65yrs (26%)

Problem encountered % reported

Stuck in throat 80

Bad taste 48

Gagging 32

Impact of difficulty taking pills

14% delayed dosage 8% skipped a dose4% discontinued14% discussed issue with a health care provided

failure to follow dosing recommendations is associated with poorer health outcomes

Impact of difficulty taking pills

1/5 hesitate before taking pillsShape (84%)Size (29%)

1/10- choose based upon anticipated difficulty to swallow

Women (14%)Men (4%)

Strategies attempted to assist swallowing pills

Strategies to assist swallowing pills

% reported

Drink lots of water 55%

Gulping water 48%

Tilt head back 43%

Place on back of tongue 31%

Multiple swallows 30%

Split pills in half 17%

Deep breath before swallow 13%

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preparation ty

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taste

0%

10%

20%

30%

40%

50%

60%

70%

80%80% 78% 76%

65% 61%

Factors Influencing pill preference

Pill swallowing – Physiologic effects

Little data on the alterations in the swallow system that occurs with pillsSwallowing a learnt complex motor task…Shibamoto et al (2007)

fMRI to view cortical brain activation with pill swallowing (11mm X 2mm columnar capsule) n=21 healthy personsdifferent brain areas activated during capsule swallowing- i.e. cerebellum

swallow

Tongue movement

Finger tapping

Food Sticking in Throat Study

Review of outpatient with complaints of food/liquid sticking in throatEvaluation of fluoroscopic videos to identify

Any confirmation that something does stickWhere it sticksCause of ‘sticking’What material best identifies the problem

Methods

315 outpatients were reviewed

117 patients c/o solid “sticking” 24 patients c/o solid and liquid “sticking”

Total of 141 patients with the complaintPrevalence = 45%

Results

Mean Age (in years) : 61.46

Female:Male = 88:53

Positive fluoroscopic findings108 patients = 77%

Anatomic vs. Physiologic findings

15% of the positive cases = anatomic strictures, pouches etc.

85% of the positive cases = physiologicesophageal dysmotility, achalasia etc.

UES = Upper Esophageal Spincter

15% of positive cases had anatomic obstructions

UES = Upper Esophageal SphincterLES = Lower Esophageal Sphincter

85% of positive cases had physiologic obstructions

Marshmallow yielded highest positive result at 53%

Conclusions• 45% Prevalence of food sticking symptoms• 27% correctly localized obstruction in “throat”• Anatomic obstructions, primarily in UES

• Better localization for anatomic obstructions • 73% incorrectly localized obstruction upward in

throat• Primarily physiologic obstructions

SummarySwallowing is a complex process with interplay among major anatomical components

OralPharyngealLaryngeal

Dysphagia may be overt or covertMany patients with covert of mild dysphagia remain total oral feeders and take meds orallyFood sticking is a common complaint in overt/covertPills sticking is a common complaint

Pill swallowing is different from food/liquidPhysiology is differentNeurology is different