Mealtime Partners, Inc.

Specializing in Assistive Dining and Drinking Equipment

February 2013 Independent Eating and Drinking Newsletter

	February Topics: Pulmonary Aspiration Face Care for Individuals with Disabilities

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Pulmonary Aspiration

Many disabilities can be caused by neurological disorders which are disorders of the nervous system. They can be manifested by paralysis, muscle weakness, poor coordination, loss of feeling, seizures, altered levels of consciousness, pain, etc. Common neurological conditions and disorders include Alzheimer’s disease, amyotrophic lateral scoliosis, cerebral palsy, dementia, essential tremor, muscular dystrophy, and Parkinson’s disease. Many individuals affected by neurological conditions have difficulties with eating and drinking and are at greater risk of choking or aspirating than the average individual and therefore it is helpful to understand the mechanics of swallowing to lessen the risk of aspiration.

Throughout Mealtime Partners Newsletters there are references to aspiration without any qualification of the type of aspiration. What should have been said is pulmonary aspiration. However, in documents referring to eating, drinking and swallowing it is easier to abbreviate the name, understanding that pulmonary aspiration is being referred to when the word “aspiration” is used.

The Merriam Webster dictionary defines aspiration as follows:

1. audible breath that accompanies or comprises a speech sound

2. the pronunciation or addition of an aspiration; also: the symbol of an aspiration

3. a drawing of something in, out, up, or through by or as if by suction: as

4. the act of breathing and especially of breathing in

5. the withdrawal of fluid or tissue from the body

6. the taking of foreign matter into the lungs with the respiratory current

7. a strong desire to achieve something high or great

8. an object of such desire

It should be noted that the type of aspiration referred to in our Newsletters is number 6 on the above list: the taking of foreign matter into the lungs with the respiratory current. What does that really mean? Pulmonary aspiration is when matter (saliva, mucus, food, drink, stomach contents, including stomach acid) is sucked into the pulmonary system by breath.

Respirtory Tract

The respiratory system is composed of two sections, the upper and lower tracts, as illustrated above. The upper tract includes the nasal cavity. When breathing and swallowing become uncoordinated during the first stage of eating or drinking, food, and more commonly liquid, can be forced into the nasal cavity (and sometimes actually comes out of the nose). After food has been chewed and saliva mixed with it in the mouth, the back of the tongue elevates until it touches the roof of the mouth. The muscles at the back of the tongue form a trough through which the ball of food, or bolus, is forced, to project it into the esophagus. Before anything can be swallowed there are several changes that must happen at the back of the mouth and throat to allow a safe swallow.

The pharynx sits just above the larynx or vocal folds (commonly called vocal cords, but this name is not accurate). The pharynx divides into two tubes just above the vocal folds: the trachea (or windpipe), and the esophagus (the tube that carries food and liquid from the mouth to the stomach). A flap of cartilage (the epiglottis) is attached to the top of the larynx. When breathing is executed the epiglottis is relatively vertical or open. However, when a swallow is going to take place the epiglottis folds down over the opening to the vocal folds prohibiting material that is being swallowed from entering the trachea. When the epiglottis covers the vocal folds, respiration is stopped. During a swallow, no breathing takes place for the duration of the swallow. Most people inhale prior to swallowing and exhale after the swallow. It is believed that the process of exhaling after a swallow clears away any remaining particles from the trachea. However, some people exhale prior to the swallow and inhale after its completion, thus negating the hypothesis described above for those individuals.

Eating, drinking and breathing coordinate easily when the process just described functions well. When they do not synchronize properly, choking or pulmonary aspiration can occur. Choking occurs when something partially or completely blocks the passage of air from the environment into the lungs, getting stuck in the throat or windpipe. In most cases of choking, coughing will dislodge whatever is stuck in the throat. If coughing doesn’t work, abdominal thrusts, known as the Heimlich-Maneuver, has been recommended for many years. Today the American Red Cross and the American Heart Association have evolved into recommending a series of steps to alleviate choking sometimes referred to as 5 and 5:

1. Encourage coughing

2. Back slapping using the heal of the hand on the back of the person choking (repeat 5 times)

3. Abdominal compressions, i.e., Heimlich-Maneuver (repeat 5 times)

Once the person loses consciousness due to lack of oxygen caused by the obstruction in the windpipe, treatment should be changed to CPR (cardiopulmonary resuscitation) to try and provide oxygen to the unconscious person. Urgent medical help should be sought if the material that has caused the choking cannot be removed quickly. Choking quickly resolves or escalates to an emergency condition that can result in death.

Pulmonary aspiration can be similar to choking and its impact can range from none to death. Material can be inhaled into the trachea, bronchial tubes or lungs. The resulting impact depends upon what is aspirated, its size and the level it is inhaled into the pulmonary system. If pure water is inhaled in a small amount, it may have no impact. However, if something acidic is drawn into the pulmonary system, such as materials regurgitated from the stomach, containing stomach acid, the lining of the trachea, bronchial tubes or lungs could be damaged and become inflamed. Should bacteria be inhaled into the lungs (from the gut or respiratory system), bacterial pneumonia can result.

The average person is protected from aspiration by their body’s natural reactions – swallowing and coughing. For significant aspiration to occur these natural reactions must be suppressed due to an altered level of consciousness including unconsciousness. The presence of neurological disease or a head injury may cause a changed neurological state. An altered level of consciousness is seen in people who are drunk or have had a drug overdose, those in a comma or are under general anesthetic, and those suffering from dementia and other neurologically impacting diseases including strokes. Many disabling diseases, both congenital and acquired, can cause neurological damage resulting in altered cognitive function that may be permanent or temporary. This change in function can impact the ability to eat and drink safely.

For those who have chronic neurological disorders the texture and viscosity of the food and drink that they consume should be modified to accommodate their increased risk of aspiration. The intake of thickened liquids can reduce the likelihood of aspirating liquids. Those who suffer from some level of chronic pulmonary aspiration frequently have a “rattle” in their lungs when they breathe. For those who must consume thickened liquids to avoid aspiration, the Thickened Liquid Cup is available from Mealtime Partners.

For those who are at risk of aspirating thin liquids, Mealtime Partners sells two other cups that may provide a safer method of drinking: the Provale Cup that dispenses 5-ccs of liquid for each drink taken from the cup; and the Rije Cup that dispenses an adjustable volume of liquids from 3-ccs to 15-ccs.

Hands Free Eating The Mealtime Partner Dining System provides eating independence and reduces the risk of choking or aspiration
	The Mealtime Partner Dining System is able to serve foods from puree texture to normal bite sized pieces of food. For those who are unable to feed themselves and, therefore, must be fed by another person, the Mealtime Partner Dining System provides an alternate to being fed. It is not only a way of becoming independent at mealtimes but also is a safer way to eat than being fed by another person, because the person eating can choose when they take each bite of food and can chew as long as they wish. This reduces the risk of choking or aspiration that occurs when people eat hurriedly.
More information about the Mealtime Partner Dining System is available at our website under Dining. If you are not sure which system to choose when considering purchasing a dining system, call 1-800-996-8607, or email our staff for assistance at Assisted Dining Questions. We will be happy to assist you.

Face Care for Individuals with Disabilities

In last month’s Newsletter there was a discussion about the impact of cold weather on skin. This month that theme is continued with an emphasis on the skin tissue of the face and lips.

During the winter months our lips are particularly vulnerable to the weather. They are not only exposed to the weather when we are outside but they are often moist because they are frequently licked or due to drooling. The combination of moist skin and cold weather can lead to chapping. Individuals with disabilities often drink through a straw and chapped lips can make it more difficult to drink through a straw. To create suction to enable drinking through a straw, a seal must be created around the top of the straw. If lips are chapped and cracking it is more difficult to make a complete seal around the straw due to both uneven skin on the lips, and discomfort from chapped lips. Using a generous application of lip balm prior to drinking can help make a seal when lips are chapped.

Prevention is the best way to deal with this problem and chapped lips can be avoided for most people by the regular use of lip balm or petroleum jelly. However, for those who have to deal with excess saliva that escapes from their lips, lip balm is easily removed as saliva is wiped up. In this situation, not only do the lips become dry, but the skin around the mouth and on the chin can become dry and cracked. This is a very common problem for babies who are cutting teeth. There are several steps that can lessen the impact of the saliva on skin. First, the skin should never be wiped. Instead a dabbing motion should be used. Gently place a clean, soft, absorbent towel (old towels work well), on the moist areas of skin and apply a small amount of pressure. A rolling motion, side to side or up and down is acceptable, but a wiping motion, where the cloth is moved across the skin should be avoided. Once dry, the lips and skin should have a thin coat of petroleum jelly applied to them creating a barrier that protects the tissue. This process should be repeated frequently. Another treatment for chapped skin on the lips and face is to use Lanolin, which commonly is used by breastfeeding mothers to soothe sore nipples. It not only creates a moisture barrier but will contribute to healing the skin.

Additionally, if drooling is excessive, it is not uncommon for the neck of shirts to become wet. Having wet clothing touching the skin during cold weather can cause further skin damage and should be avoided. This can be achieved by covering up clothing with an absorbent cloth like a bandana. For infants, a bib that is changed frequently, or by changing clothing frequently, will help to avoid additional skin damage.

Skin can also dry out even if the individual does not go outside in cold weather. This is due to low humidity inside the home caused by heating systems. If the problem of dry skin persists, a humidifier may help during the winter months.

Regardless of the level of dry skin, it should always be remembered that the problem may not be able to be solved but can be improved by proper hydration. If someone is dehydrated because they have not consumed enough fluids their skin will be impacted. For information on the Mealtime Partners Drinking products, click here.

Did You Know? Did you know that a completely new strain of Norovirus, or stomach bug, was identified in Australia last year? This virus has spread throughout the United States and many other countries. Noroviruses are often referred to as “stomach flu” or “food poisoning”, but they are not related to the influenza virus. They are a group of viruses that cause stomach and intestinal illnesses, or gastroenteritis. Anyone can become infected. Symptoms develop quickly and include stomach ache, vomiting and/or diarrhea. The Centers for Disease Control and Prevention (CDC) estimates that more than 20 million cases of acute gastroenteritis are caused by Noroviruses each year.

This particular strain of Norovirus is highly virulent and as few as 17 virus particles can infect someone. Unlike many viruses, this strain can live for as long as two weeks outside the human body on door handles and other surfaces. Hand sanitizers are not recommended as a way of avoiding becoming infected with the virus as they do not physically remove the virus. Thorough, frequent, hand washing with soap and warm water is recommended. Washing should continue for at least twenty seconds to remove the “bug” (for more information about hand washing, refer to the Mealtime Partners May 2011 Newsletter topic "An Update on Hand Cleaning"). Surfaces should be washed often with a chlorine based product. Illness typically lasts for 2 to 3 days but people can still be contagious for an additional 3 days. Children, the elderly, or individuals who have a compromised immune system can become very ill from this virus and it is extremely important that they remain hydrated. Dehydration can easily occur when vomiting and diarrhea are ongoing and can be very serious.

More information about Noroviruses can be found at the CDC website.

Mealtime Partners, Inc.

Specializing in Assistive Dining and Drinking Equipment

February 2013 Independent Eating and Drinking Newsletter

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