Class 12- Dysphagia Part IV Flashcards
Evidence: “Information that has been …
Treatment decisions based upon:
- Best available_____from published literature
- Patient’s ____
- Clinician’s _____with ______
Literature -
Effectiveness/efficacy
filtered systematically through scientific processes and meets minimum standards of rigor.”
- Evidence
- wishes
- Experience; similar problems
Efficacy: gone through a rigorous set of trials
Effectiveness: it does seem to help
Example: use of OME may be effective for your particular patient, but it is not efficacious (meaning it is not always supported by the literature)
Evidence-based?
1998 Dutch Neurological Society Guidelines
(Note 12-1, pg. 232)
____ of water
______
After _____, PEG tube
No ________
No _______
50 ml of water
NG Tube
After 21 weeks, PEG tube
No Videofluoroscopy
No swallowing therapy
Questions to ask yourself:
Are the patients in the study ______to my patient?
Is the technique described in ________that I may use it in the same way?
Is the technique ________ similar to the one where I practice?
Does the technique require technology that is _________?
Are the ______ obtained in the study the same as those I want to obtain for my patient?
Are _____ and ______for failure described in the study?
What are the ____to my patient?
Do I have the ______to apply this technique as it is described in the study or is specific training required?
Is the technique ______for my patient and environment?
Does it have time or intensity demands that __________or my patient’s endurance of compliance?
Are the patients in the study similar to my patient?
Is the technique described in sufficient detail that I may use it in the same way?
Is the technique applied in an environment similar to the one where I practice?
Does the technique require technology that is available to me?
Are the outcomes obtained in the study the same as those I want to obtain for my patient?
Are failures and reasons for failure described in the study?
What are the risk to my patient?
Do I have the clinical skills to apply this technique as it is described in the study or is specific training required?
Is the technique practical for my patient and environment?
Does it have time or intensity demands that exceed the reality of my workload or my patient’s endurance of compliance?
General Treatment Considerations
Are they _____?
Airway _____
_____ & ______
_____vs. _____Treatment
Are they aspirating?
Airway protection
Nutrition & hydration
Indirect vs. Direct Treatment
Indirect:
Direct:
Indirect: Does not introduce foods but rather uses exercises, stimulation, environmental adaptations.
Direct: Involves presenting food or liquid to the client and asking him/her to swallow
Indirect Management
TEXT:
______management
Structuring the ______
Modifying _____
Specifying the degree of supervision for _______
_____Therapy Techniques
THE SOURCE: Includes all of the above PLUS……
____Modification
_________
_________
Indirect Management TEXT: Secretion management Structuring the eating environment Modifying utensils Specifying the degree of supervision for safe oral intake Indirect Therapy Techniques
THE SOURCE: Includes all of the above PLUS……
Diet Modification
Frazier Water Protocol: can have an unlimited amount of water; must brush their teeth before drinking; specific limitations; good reliability
Positioning
Direct Management
1. 2. 3. 4. 5.
- Sensory stimulation
- Oral-motor/physiotherapeutic exercises therapy
- Compensatory postures or positioning
- Compensatory maneuvers
- Assistive devices
Sensory Stimulation
- Modifying…
- Modifying…
- Direct…
Modifying food placement
Modifying bolus characteristics (texture, volume, temperature, taste)
Direct sensory treatment (Thermal stimulation)
Oral-motor/physiotherapeutic exercises therapy
- Range of motion
2. Strengthening
Compensatory postures or positioning:
chin down, head back, head tilt, head rotation, etc.
Compensatory maneuvers-
double swallow, hard swallow, supraglottic swallow, super-supraglottic swallow, Mendelsohn maneuver (tighten hyoid and laryngeal structures and elevate larynx)
*** Look these up in book/ handouts
Assistive devices-
palatal augmentation
Considerations for choosing a specific treatment technique 1. 2. 3. 4. 5.
Options
Clinical indicators
Anticipated risks and benefits
Functional outcomes
Patient empowerment
Medical Options
1.
2.
- Dietary Modifications
2. Pharmacologic Management
Dietary Modifications
Special diets
Regulation of nutrition and hydration
Possible interaction with feeding route
Pharmacologic Management
Anti-reflux medications
Prokinetic agents
Salivary management
Surgical options
1.
2.
- Improved glottal closure
2. Improved pharyngo-esophageal segment opening
Improved glottal closure
Medialization thyroplasty (teflon/collegen injections)
Injection of biomaterials (fat or collagen)
Improved pharyngo-esophageal segment opening
Dilation
Cricopharyngeal/UES Myotomy or dilation
Botulinum Toxin injections
Extreme Cases
Logemann….only in ”unremitting cases of aspiration…” Protection of the airway is paramount:
Stents
Laryngotracheal separation
Tracheostomy tubes
Feeding tubes
Laryngeal suspension
Epiglottic Pull-down
Suturing vocal folds
Suturing False Vocal Folds
Laryngeal Bypass
Tracheostomy:
With a cuff
Without a cuff
Total Laryngectomy
Behavioral Options
1. 2. 3. 4. 5.
Food modification
Modifying feeding activity
Patient modifications
Swallow modification
Mechanism modifications
National Dysphagia Diets
Level 1:
Level 2:
Level 3:
Level 4:
Level 1: Dysphagia Pureed
Level 2: Dysphagia Mechanically altered
Level 3: Dysphagia advanced
Level 4: Regular Diet
Making Treatment Decisions
Steps in developing a _____
_______Dysphagia
Pre-treatment _____level
_______that contribute to functional level
Desired functional level at the of treatment: Goal
Specify ______targets objectives
Select treatment techniques, action plans, _____
Evaluate ______of specific treatments
Develop a ______plan
Steps in developing a treatment plan
Pharyngeal Dysphagia
Pre-treatment functional level
Factors that contribute to functional level
Desired functional level at the of treatment: Goal
Specify treatment targets objectives
Select treatment techniques, action plans, monitors
Evaluate risks of specific treatments
Develop a treatment plan
Which technique to use?
Table 14-2 Page 293
Hand-out from Cherney
