Clinical Decision Making & Management of Swallowing Flashcards
1
Q
What are the five ways we can “treat” dysphagia?
A
positioning
strategies
diet
exercises
Stimulation
2
Q
In terms of positioning, what are some things we can teach?
A
head turns
head tilt
recline (rare-but used sometimes)
list to left or right (tilt with your trunk)
most of the time, upright 90 degrees is best
3
Q
If someone had a glossectomy, what positioning might you teach?
A
recline
4
Q
If someone has lack of tongue movement to propel the bolus into the pharyngeal area, what positioning might you use?
A
recline
5
Q
If someone has unilateral oral weakness with pooling, what positioning might you teach?
A
head tilt to the opposite side during chewing, so they are chewing on the strong side
6
Q
If someone has premature spillage while chewing, what positioning might we teach?
A
chin tuck
7
Q
If someone has unilateral pharyngeal weakness, what might we teach?
A
head turn: turn head during swallow–have them turn it toward the weak side to close off the weak side.
IF you want to clear away the reside, you turn it toward the strong side, opening up the weak side to clear it away.
8
Q
What are some strategies we might teach?
A
small bites/sips
chin tuck
hard effortful swallow (squeeze it down)
repeat/extra swallows (w/ or w/out head turns)
alternate solids with liquids
super supra-glottis swallow
Mendelsohn maneuver
9
Q
when might you teach a chin tuck?
A
used for swallow delay
10
Q
`when might you teach a hard effortful swallow?
A
if you have residue on the posterior tongue base or residue on the posterior pharyngeal wall
11
Q
When might you teach repeat/extra swallows?
A
if you have residue
12
Q
when might you teach super supra-glottiC swallow?
A
for someone who has a paralyzed vocal fold
13
Q
describe the super-supraglottic swallow
A
take a deep breath, take food/liquid in, then clear your throat.
14
Q
Describe the Mendelsohn maneuver
A
can be used as a strategy or as an exercise–Scott has found this helpful as an exercise, not really helpful as a strategy
you try and hold your larynx in the upright position when you swallow–swallow only halfway, hold it, then release–good exercise!!
-difficult to teach–difficult to do it
helps with laryngeal elevation–epiglottic inversion, it also helps with CP opening. Good for patients who have a tight CP and need more time to clear materials.
15
Q
If a patient is supposed to be performing a chin tuck, drinking from a cup can be dangerous since he/she has to tilt his/her head back to take a drink from the cup. Straw can be dangerous because it is difficult for some patients to control the amount they get.. so what is some equipment that aids patients with their strategies?
A
- Nosey Cup: Allows the drinker to keep chin down while tilting the cup back for taking a drink. $16 for 5pk of large green cups on amazon.
- Bionic Reusable Safe Straw: This system works with any time of drinking cup. the straw limits the amount of liquid that can be sucked through the straw at a controlled pace. Delivers about 1 teaspoon of liquid. $57 for one straw!
- Small teaspoon or toddler spoons: This may be helpful for those individuals who ned to take small bites. Very helpful for impulsive patients. Price: $6
16
Q
What are some things we can give patients as visual reminders for swallow safety strategies
A
scott always gives a written list of the patient’s strategies
most patient’s need that visual reminder
he makes several copies so they can keep at the table, couch, bed, etc…
17
Q
What is an example of what would be on a visual reminder?
A
Sit upright 90 degrees for all oral intake
Small bites/sips (1 drink at a time)
Chin tuck downward with liquids (may use a straw)
Hard-Effortful Swallow
Repeat-extra swallows with head turned to the left
Alternate solids with liquids
Periodic throat clears
18
Q
What strategy would you use for a swallow delay?
A
chin tuck
19
Q
what strategy would you use for decreased posterior tongue retraction?
A
hard-effortful swallow (while your swallowing)
repeat extra swallows or alternate solids with liquids after the initial swallow to remove residue
20
Q
What strategy would you use for decreased pharyngeal wall contraction?
A
hard effortful swallow
repeat extra swallows or alternate solids with liquids after initial swallow to remove residue
21
Q
What strategy would you use for decreased laryngeal elevation?
A
Mendelsohn Maneuver
Head turn w/ a repeat extra swallow (to remove from valleculae and pyriform sinuses due to the effect of decreased laryngeal elevation)
alternate solids with liquids (to remove from valleculae & pyriform sinuses due to the effect of decreased laryngeal elevation)
22
Q
What strategy would you use if you had residue in the valleculae?
A
Head turn with a repeat extra swallow
alternate solids with liquids
23
Q
ON EXAM
what strategy would you use if you had a paralyzed vocal fold?
A
super supra glottic technique
head turn could potentially work–but doesn’t always work (perfect time to try is during a FEES)
Periodic throat clears–b/c most likely are at risk to aspirate thin liquids
24
Q
What strategy would you use if your patient has residue in the pyriform sinuses?
A
head turn with a repeat extra swallow
Alternate solids with liquids
25
In the Groher et. al. study what are some facts they found about residents and their diets?
31% of residents in two facilities were prescribed a mechanically altered diet
91% were at dietary levels below that which they could tolerate safely
4% were at dietary levels higher than they could tolerate
5% were considered to be a at the appropriate diet level.
26
If a patient is NPO what are some ways for them to receive enteral nutrition?
Orogastric (OG)
Nasogastric (NG)
Percutaneous Endoscopic Gastrostomy (PEG)
Gastrostomy (G-tube)
Jejunostomy (J-tube)
Total Parenteral Nutrition (TPN)
27
Why is an OG tube not ideal?
they're rare b/c you don't want something going through the mouth b/c it's not comfortable and a breeding ground for bacteria.
It's used rarely in the ICU
28
Is an NG common or not?
very common
29
What are the "Solid' textures of a mechanical diet?
pureed
mechanical soft
regular w/ chopped meats/veggies/fruits
regular
30
What are the liquid textures of a mechanical diet?
thin
nectar
honey
pudding
31
What does Dharmarajan T.S. et al say about the data in the literature with dementia patients who had PEGs?
To further support their findings, what did Feinberg find?
Much of the data in the literature do not suggest that outcomes in dementia are favorably improved after PEG.
Artificial (enteral) feeding does not seem to be a satisfactory solution for preventing pneumonia in prandial aspirators.
32
What did Chouinard 2000 say influence the risk of pneumonia?
Mobility, nutritional status, & host immune response (not just dysphagia & aspiration) influence risk of pneumonia.
“prevention of pneumonia through appropriate management of dysphagia is not supported by empirical evidence.”
33
What did Gomes Et al say about NG tubes being associated with?
NG tubes are associated w/ colonization & aspiration of pharyngeal secretions & gastric contents leading to a high incidence of Gram(-) pneumonia. Mechanisms responsible for aspiration in patients bearing an NG tube are:
Loss of anatomical integrity of the upper & lower esophageal sphincters
Increase in the frequency of transient lower esophageal sphincter relaxations
Desensitization of the pharyngoglottal adduction reflex
34
What did prolonged PTN with bowel rest result in according to Ono, H. et.al.
prolonged TPN with bowel rest induces physiological dysfunction of gastric mobility
35
What did Lien, H.C., et al. (2001) say about PEJ feeding?
PEJ feeding reduced but did not eliminate GER
36
A retrospective study done by Taylor H.M. over a 24 month period with 25 people being fed via G-tube found what?
they experienced 40 cases of pneumonia during 508 months of observation. Only 5 individuals fed via J-tube experienced pneumonia.
37
According to Li, I (2002) studies show feeding tubes are not effective in what?
-preventing malnutrition
preventing the occurrence or increase healing of pressure sores
preventing aspiration pneumonia
providing comfort
improving functional life
extending life
38
What is the objective when transitioning from enteral to oral nutrition?
to eliminate a resident's dependence upon enteral nutrition support without jeopardizing his/her general health or safety.
oral foods/fluids are introduced in sequential phases, one meal at a time, w/ concurrent reduction in enteral nutrition support.
39
What is the theory behind the Frazier Water Protocol?
allowing oral water safely to patients with dysphagia or chronic dehydration--this revolutionized how we treat patients
40
What are some facts about aspiration pneumonia?
it is the second most common nosocomial infection in hospitals
aspiration pneumonia costs $30k-$40k per episode
41
Just read this freaking study:
...
Prospective study of 189 elderly subjects recruited from Ann Arbor VA
Patients were from acute care, outpatient, and Extended Care Facilities (ECF’s)
Followed for 4 years for an outcome of aspiration
```
Results: Of the 189 subjects:
o41 developed aspiration pneumonia (21.7%)
oOf those subjects:
o44% were ECF patients
o19% were inpatients
o9% were outpatients
```
Incidence by Medical Diagnosis
o27% were strokes
o33% were other Neuro diseases
o 32% had COPD, CHF, GI disease
•COPD they have significant coordination difficulty so they can’t coordinate in time for swallow and are at major risk for aspiration.
oNote: subjects with COPD & GI disease had a 50% incidence of pneumonia
oNote: 32% of the subjects who developed aspiration pneumonia were SMOKERS! and averaged at least 10 medications
42
ON EXAM:
What are the dominate risk factors for placing someone at risk for aspiration pneumonia?
#1. dependent on others for feeding
#2. dependent on others for oral care
#3. number of missing teeth
#2 & 3 are connected!
43
Why does aspiration occur when dysphagia and aspiration were not risk factors in and of themselves and patients without these factors did develop aspiration pneumonia?
The role of dysphagia/aspiration in the development of pneumonia may be better understood by considering the colonization of pathogenic bacteria and the host resistance to the prices
but the aspiration will only lead to pneumonia IF THE MATERIAL ASPIRATED IS PATHOGENIC TO THE LUNGS AND FI THE HOST RESISTANCE TO THE INOCULUM IS COMPROMISED
44
What about water, if you aspirate water without bacteria, is this a problem?
no, you're body reabsorbs water
this is where the frazier water protocol comes in
45
In 1984, at the Frazier Rehabilitation Hospital, what was happening?
SLPs were becoming concerned by the lack of compliance with patients who were on thickened liquids
patients were either "sneaking" liquids that weren't thickened and ending up with aspiration pneumonia...or...they were becoming dehydrated!
46
How much does dehydration cost medicare?
$450 million dollars monthly (1994)
Hospitalizations cost from dehydration in 1996 were $1.36 billion
47
What percentage of hospitalization from nursing homes are for dehydration?
13%
more than 18% of those hospitalized will die within 30 days
48
Facts about dehydration...
just read this shit.
Persons age 85-99 are 6x more likely to be hospitalized for dehydration than persons 65-69.
Dehydration is the most common fluid and electrolyte disturbance in the geriatric population, with high rates of morbidity and mortality. (Chernoff, 1994; Sansevero, 1997)
Staff does not recognize dehydration or its causes, and does not offer enough water outside of medication administration times. (Copeman, 2000; Vogelzang, 1999; Chidester and Spangler, 1997)
Only 8 subjects of 99 SNF residents met their standard water requirements. (Gaspar, 1999).
“Fluid intake declined over the 21 day period…pts. On thickened liquids failed to meet their fluid requirements.”
8 glasses of water a day is recommended for most people…imagine drinking that if you’re on ‘honey’ thick or ‘pudding’ thick liquids.
WATER CONTRIBUTES TO A PATIENT’S HYDRATION!!!!
What if patients could have regular water? Would they be less likely to drink other thin liquids if successfully hydrated with water?
49
What is the research behind the Frazier Water Protocol?
"frequency of pneumonia was not significantly different among patients who aspirated thin liquids and those who did not."
"Significantly higher risk of aspiration pneumonia if thickened liquids are aspirated"
50
What did Dr. Judah Skolnick recommend?
a pulmonologist who first recommended "free water"
51
What are some facts about water and it's association with aspiration?
The body is approximately 60% water.
Tap water is a near neutral ph and so is compatible with other body fluids.
It will not cause a chemical injury as might be expected with other liquids such as coffee, tea, or soda.
Clear liquids do not pose an aspiration pneumonia risk unless the pH is very high or very low or if the quantity is great enough to cause asphyxiation.
If a drink of water is aspirated, it will be absorbed by the lung mucosal tissues without harm.
.....and unlike an aspirated bite of carrot or bite of hamburger, water does not obstruct the airway!!!!
…..aspiration of water is a benign event! Feinberg et al. (1990)
52
What are Aquaporins?
they permit water aspirated during swimming or drinking to be rapidly absorbed from the airspaces
53
ON EXAM
Who can benefit from the Frazier water protocol/free water program?
patients who have thickened liquids as part of their diet
patients who are NPO (b/c the best way to target dysphagia/do therapy to improve swallow is to SWALLOW!!!)
Patients with chronic dehydration problems
54
ON EXAM
Who may not be appropriate for the frazier water program?
"Super Coughers"
55
ON EXAM
What are the RULES of the Frazier Water Protocol/Free water program?
Oral water is permitted until the first bite of a meal.
No water unless it is thickened as prescribed, is allowed during the meal or until the mouth is cleaned/disinfected again.
The PRESCRIBED thickened liquid is used during meals.
Use of all other “swallow strategies” determined by the SLP are encouraged.
Ice chips can also be offered.
Pills can be crushed and given with any from their prescribed diet texture…just not water
Water is not only allowed between meals (if oral cavity is cleaned/disinfected), it is encouraged by everyone (nursing, PT/OT, dietary, etc…)
Hopefully, patients will be less likely to “sneak” other thin liquids if hydrated with water!
Remember…the best way to improve a swallow is to swallow!
56
What is needed for the free water program/frazier water protocol?
hospitals should consider creating a protocol so orders can be written for "frazier water protocol" or "free water program" (if you say "Frazier Water Protocol" you need to use their cups and this costs more money)
all staff must be trained in the protocol including nursing, respiratory therapy, rehab, dietary staff, MD, etc..
ALL STAFF MUST BECOME FAMILIAR WITH THE PROTOCOL!!!!
57
What are some ideas on how the FWP would work?
Following a bedside swallow evaluation or MBS, the SLP would recommend the FWP to the MD and obtain an order.
For patients with dehydration problems, the MD may order the FWP at any time.
Special wrist bands and a labeled water pitcher?
Some notification that they are on the FWP placed over the bed.
Intervention placed in the care plan.
I & O should be recorded per your hospital procedures.
If a patient is on fluid restrictions, their allotted amount of water should be set out q-shift.
All caregivers can offer water and even encourage water intake.
Oral care is provided after eating/drinking (prior to allowing water).
58
What does I & O stand for?
intake and output
59
What is the oral care impact to aspiration pneumonia?
according to a 2-year study of 366 residents @ 11 nursing homes, the risk of pneumonia was significantly reduced in patients receiving oral care--whether they had teeth or not. In fact, for oral care patients, mortality due to pneumonia was about half of that in patients not receiving oral care.
60
How big is the problem with oral care relating to aspiration pneumonia?
a study of 52 Maryland hospitals found that "for all surgical patients, except those undergoing tracheostomy, aspiration pneumonia was independently associated with a 4.0-fold increased risk for ICU admission, 7.6 fold increased risk for in-hospital mortality, a 9 day mean increase in hospital LOS, and a $22k increase in total hospital charges
61
Who are the patients at risk for aspiration pneumonia?
those suffering from :neurologic dysphagia, stroke, COPD, malignancy, renal disease, dementia, liver disease, enteral feeding, suppressed immune systems, emergency room admission and more.
62
What is aspiration-risk pneumonia?
considered a hospital acquired pneumonia
caused by the inhalation of oropharyngeal secretions colonized by pathogenic bacteria
63
What is ventilator-associated pneumonia?
defined as pneumonia that arises more than 48-72 hours after endotracheal intubation
64
What is the definition of hospital acquired pneumonia?
caused by the inhalation of oropharyngeal secretions colonized by pathogenic bacteria
not on vent and positive respiratory culture after 2 days from admission
3 risk factors...
65
What are the 3 risk factors for hospital acquired pneumonia?
1. colonization of dental plaque with respiratory pathogens
2. bacterial colonization of oropharyngeal area
3. aspiration of subglottic secretions
66
OMG JUST READ THIS! GAHHH
Frazier Water Protocol--research
Frazier Rehab Center studied 234 patients on thickened liquids or tube feedings.
All were permitted oral water between meals.
Only 2 patients developed aspiration pneumonia…these were known food aspiration not from the water!
Only 4 of the 234 patients required IV fluids for dehydration.
Bethesda Hospital and Rehab Center studied (for one year) 20 known thin liquid aspirators on thickened liquids during their hospital stay and for 30 days following. They were on the FWP.
No patient developed pneumonia, dehydration, or complications during the course of the study or during a 30 day follow-up period.
Conclusion: When used within FWP, water is safe and effective for patients on tube feedings or dysphagia diets.
67
What are the different thickening substances for food?
powder
gel
prepared thickened products
68
what are the pros to using powder thickener?
corn starch based
Pro: Cheap, add it to whatever food, fairly easy to thicken
69
What are the cons to using powder thickener?
can't add to soda, varies if it's hot (hot tea vs. iced tea)
changes in consistency the longer it sits
70
What are the pros to gel thickener?
xantham gum based
can make up a whole gallon of it--once it's thickened the texture won't change whereas with the powder it can't sit as long.
you can refrigerate it
you can add it to soups
once it's thick it won't change regardless of changes in temperature
71
What are the cons to using gel thickener?
can't get it in drugstores (more difficult to find)
comes in a packet or a pump
doesn't stir real well--but use a lid and just shake it up
72
What are the pros to prepared thickened products
it's prepared, absolutely no prep
73
What are the cons to prepared thickened products?
have to order it
comes in so many flavors
can get expensive
74
What are exercises we can do with our patients to help with dysphagia?
oral motor exercises
laryngeal elevation exercises
vocal fold closure exercises
shaker exercise
masako maneuver
Therabyte jaw motion rehab system
75
Who are oral motor exercises typically appropriate for?
typically for people who have oral-prep phase problems
76
What are some oral motor exercises you can do for the lips?
open/close
pucker/smile
puff cheeks out with air
purse lips then relax
blow cotton swab with a straw
sucking thick liquid or puree through a straw
77
What are some oral motor exercises you can do for your tongue?
in/out
up/down (nose to chin)
side to side (ear to ear)
around lips with mouth open in both directions
around outside of teeth in both directions
78
What are some laryngeal elevation exercises
Mendelsohn maneuver
may be used as a strategy while eating or as an exercise to build strength
idea is to hold the larynx in the upright position (swallow half-way)
79
What are some vocal fold closure exercises?
may be used as a strategy while eating or as an exercise to build strength
idea is to hold the larynx in the upright position (swallow half-way)
lee silverman type exercises: shouting, ah-ah-ah, holding your breath, bear down onto chair w/ voicing
80
Describe the shaker exercise
Developed for people who have a tight CP sphincter
Stretch out on floor on back, raise head up w/ arms at your side. Keep feet, back, & shoulders down. Look at toes x 30. Then hold head up for 1 minute.
Good for people with CP Bar. Not good for people with cervical spinal problems or someone with carotid artery problems.
81
Describe the Masako Maneuver
Developed in Japan by Fuiju Masako
Originally was developed in hopes of increasing posterior tongue retraction
Studies show that this isn’t really true. However, posterior pharyngeal wall contraction was found to increase while performing the Masako during the swallow.
Should not be used as a technique/strategy but used as an exercise for posterior tongue retraction & posterior pharyngeal wall contraction.
Patient or therapist anchors tongue tip (between teeth or held with gauze/cloth) and perform a dry swallow.
82
Describe the Therabite Jaw Motion Rehab System
The TheraBite Rehab System is a hand operated device that provides a simple option for jaw hypomobility and dysfunction.
The TheraBite device successfully alleviates trismus from cancer, trauma, TMJD, facial burns, and stroke.
Available in Standard, Pediatric (
83
What are the stimulation techniques for dysphagia?
thermal tactile stimulation
deep pharyngeal neuromuscular stimulation (DPNS)
Myofascial Release
Neuromuscular Electrical Stimulation (NMES)
84
Describe Thermal-Tactile stimulation
developed by jeri logeman
designed to heighten oral awareness & provide an alerting sensory stimulus to the cortex and brainstem such that, when the pt. initiates the oral stage of swallow, the pharyngeal swallow will trigger more rapidly. It has been shown to reduce the delay for several swallows thereafter.
Involves vertically rubbing the anterior faucial arch firmly, 4-5 times, w/ a size 00 laryngeal mirror (which has been held in crushed ice for several seconds) in advance of the presentation of a bolus and the patient’s attempt to swallow.
Most therapists have de-bunked this… Not really effective.
85
What does DPNS stand for?
Deep Pharyngeal Neuromuscular stimulation
86
Describe Deep pharyngeal neuromuscular stimulation (DPNS)
Developed by Karlene H. Stefanakos, MA, CCC-SLP
It uses thermal stimulation to elicit reflexes which in turn activates muscle group contractions which then strengthens the pharyngeal & lingual musculature.
Concentrates on 3 reflex sites:
Tongue base & bitter taste buds for improving the tongue base retraction reflex
Soft palate musculature for improving the palatal reflex & velopharyngeal closure
Superior & medial pharyngeal constrictor musculature to improve the pharyngeal constrictor reflex
Theoretically it’s good, but because it was developed by a therapist in the hospital it was kinda bashed…
87
Describe Myofascial Release
OTs and PTs have been using it for decades.
It is just now beginning to be taught as a treatment for dysphagia.
There is not a lot of data out for or against it in regards to dysphagia treatment.
There is data from other muscle groups.
It’s a manual therapy technique to correct restrictions in muscle and connective tissue and improve a patient’s ability to develop muscular tension for functional pressure generation and success in swallowing.
88
What is the Treatment Rationale for Myofascial release
there is an expectation for functional success in: Fascial mobility, muscular range, muscular strength
89
Describe Myofascial Function
Much of the body is connective tissue, making up fascial sheaths of nerves, organs and muscle.
This connective tissue (fascia) supports structure, provides protection, allows effective circulation and lymphatic flow, and helps support cellular metabolic activity (waste and nutrition).
Restrictions result in pain and dysfunction.
90
What does NMES stand for?
Neuromuscular Electrical Stimulation
91
Describe NMES
Brand name: Vital Stim
Place electrodes onto the skin in the “neck” area. Electrical stimulation is presented causing involuntary contraction of the muscles.
More studies are needed, but promising.
FDA cleared method to promote swallowing through the application of NMES to the swallowing muscles with goals to strengthen and reeducate the muscles and improve motor control of the swallow mechanism.
Requires significant (24 hours) of CEUs
Intensive therapy (frequent) done for a short duration.
Electrical currents provided while swallowing (functional use of muscles)
Different placement of electrodes depending on findings of MBS
92
What are Contraindications to NMES
Placement over carotid sinus
Placement over active neoplasm/cancer/tumor
Placement over active infection
93
What are precautions to NMES
Dementia w/ non-stop verbalization
Significant reflux
Drug toxicity
Demand pacemaker
Deep brain stimulator
Implantable Cardioverter Defibrillators
Seizures
94
What is the reimbursement for NMES?
Medicare covers under typical “swallow therapy” (92526) code. It does not have its own code.
Medicare will not cover cost of the electrodes…yet.
All other insurance companies vary in their reimbursements
