The Supraglottic Swallow – Timing is everything…
Did you know that adult humans only have a tenth of a second to get the airway closed prior to a bolus of liquid entering the upper part of the esophagus or food and liquid will go down the “wrong pipe” (aka trachea)?
Not a lot of room for error. Most of us have personally experienced the mis-timed swallow either privately or witnessed by others, often when we are talking or otherwise distracted. This hazard is not often experienced by babies, small children or animals because of what I would call “nature’s anatomical protection”, with the hyoid and larynx more closely approximated and in an elevated position and tucked under the base of the tongue, as compared to older individuals. In humans, due to the dual function of the larynx for communication and swallowing, the larynx and hyoid descend as we mature, making the airway more precarious for aspiration but allowing for complex communication and differentiating us from the animals.
Individuals with a variety of conditions can have alterations in the timing of the swallowing mechanism. These conditions include, but are not limited to, stroke, neuromuscular diseases, neurodegenerative disease (such as Parkinson’s), brain injury, head and neck cancer and developmental disorders. Problems with timing are more likely to happen with liquids, which flow quickly, but they can occur with solid food as well.
One swallowing maneuver that is often used to compensate for timing delays is called the Supraglottic Swallow. This technique was first introduced by Dr. Jerilyn Logemann in the 1980’s and is described in her book, “Evaluation and Treatment Swallowing Disorders.” When we swallow, there are a series of valves that need to open and close at the proper time to allow for safe and efficient swallowing. Two anatomical valves important for protecting the larynx (voice box) are the 1) epiglottis and 2) vocal folds. The Supraglottic Swallow aims to close the vocal folds and the supraglottic structures (the petiole of the epiglottis approximating the arytenoids) to protect the upper airway well in advance of the bolus arriving.
This swallow consists of 4 steps:
1) Take a sip of liquid into the mouth and hold it on your tongue
2) With your mouth closed, take a short breath in though your nose and BEAR DOWN—like you are picking up a heavy weight, or having a bowel movement
3) While holding your breath, swallow all at once
4) Cough when you let go of the air to clear residual liquid/food from the airway
A modification of this is called simply the “Early Breath hold maneuver” and includes steps 1-3 and omits the post swallow cough.
Are there contraindications for using this maneuver? A study conducted by Chudhuri and colleagues in 2002 at MarionjoyRehabHospital evaluated the use of the Supraglottic Swallow in stroke patients with known coronary artery disease. These folks underwent cardiac monitoring via Holter monitors while performing swallowing training sessions, regular therapy and during a meal. After 4 hours, 86% of patients experienced abnormal cardiac findings during the swallowing session (findings included supraventricular tachycardia, premature atrial contractions and premature ventricular contractions). The authors suggested that these maneuvers may be contraindicated with patients with a history of stroke or coronary artery disease.
Patients with underlying breathing difficulties or shortness of breath, COPD and emphysema may not find this maneuver effective. Why? Because these patients already have trouble with breathing; imposing another respiratory challenge on their system while eating or drinking may prove to stressing or added fatigue using this technique.
Byline: Jan Pryor (MA CCC-SLP, BRS-S)
Leonard R, Kendall K, & McKenzie S. Airway protection: Evaluation with Videofluoroscopy. Dysphagia 2004, 19: 65-70.
Logemann, Jerilyn. Evaluation and Treatment of Swallowing Disorders. San Diego: College Hill Press, 1983
Chaudhuri G, Hildner C, Brady S, Hutching B, Aliga A, Abadilla E. Cardiovascular Effects of the Supraglottic and Super-Supraglottic Swallowing Maneuvers in Stroke Patients with Dysphagia. Dysphagia 2002; 17: 19-23.