Dysphagia Rx Flashcards
Considerations and Rx for:
Parkinson’s - increasing difficulties with swallowing and speech
recurrent chest infections
VF - aspirating on all consistencies
DEpends on stage of illness
QOL vs medical health
consider PEG though will not stop aspiration
Oral hygiene especially if they want to keep having food
Discuss risks of continuing to eat
Frasier Water protocol
Monitor temp closely
Ask Physio for recommendations re lung health
Justifications for Videofluoroscopy
- most comprehensive assessment for dysphagia as allows observation of all swallow phases
- Allows for a dynamic view to identify presence, cause and occurrence of aspiration
- provides immediate feedback of strategy effectiveness, informing management
- provides a baseline to measure outcomes against
(SPA 2005)
Outcome measures for dysphagia rx
EAT-10: QOL and symptoms (Belfasky et al 2008)
Functional Oral INtake Scale (FOIS) - diet as outcome measure
AUSTOMS - all areas of ICF on 0 (least severe) - 5 (most severe) scale
LMN cortical stroke affects which part of face
same side upper and lower (ipsilateral)
Medullary Stroke swallowing impact
- severe dysphagia
- may have near normal oral phase
- difficulties in phx phase including:
absent or delayed phx response,
reduced hyolx excursion,
reduced orophx and phx constriction, and
reduced lx closure
brief swallow event - incoordination b/w respiration and swallow causing increased aspiration risk
Left side stroke swallowing impact
more oral phase difficulties
Right side stroke swallowing impact
more pharyngeal difficulties
higher incidence of aspiration
COPD impact on swallowing
- high chance of undiagnosed dysphagia
- increased risk of pre-swallow aspiration from bolus transit before swallow triggered
- altered airway protection mechanism (often inhale immediately after swallow)
- issues with swallowing efficiency (slow effortful bolus prep) which may residue in residue
IDDSI levels
- Regular
- Soft and bite-sized
- Minced Moist
- Pureed/ extremely thick fluids
- Liquidised/ moderately thick
- Mildly Thick
- Slightly thick
- Thin
Limitations of VF
- artificial environment
- contrast tastes strange
- not good for medically unstable patients
- radiation exposure
- limited access (SPA 2005)
Reference for VF advantages and limitations
SPA, 2005
Safe swallowing strategies:
oral care
sitting up straight
alertness and ability to follow instructions
encourage self feeding
Swallow respiratory cycle
spoon approaches lips small inhale small exhale apnoea as swallow happens immediate exhale post swallow
Age related changes that impact on swallowing
tooth loss tissue and muscluar changes respiration changes increased swallow durations ad delays in initiation respiratory/swallow interactions appetite changes
Best practice for oral care
2x day
clean before oral trials
special toothbrushes, biotene toothpaste
saliva substitutes and lip balms
Strategies to improve oral care compliance
- make it part of a routine
- encourage client to assist wherever possible
- ensure comfy and relaxed
- use simple language to explain what is happening
Why consider non-oral nutrition?
risk of aspiration due to dysphagia is high, and this may result in aspiration pneumonia
2 types of non oral nutrition
parenteral and enteral
What is enteral nutrition?
delivery of nutrition into GI tract e.g. NGT
What is parenteral nutrition?
delivery of nutrition into vein e.g. TPN
Types of parenteral nutrition
Total Parenteral nutrition (TPN) - central vein
Peripheral Parenteral nutrition (PPN) - peripheral
Intravenous hydration (IV) - hydration only
2 most common types of Enteral nutrition
Nasogastric tube (NGT) Percutaneous endoscopic gastrostomy (PEG)
Indications for Parenteral Nutrition
- non functional GI tract
- burns
- severe malnutrition
- Bowel resection
- cancer
Contraindications for parenteral nutrition
functional GI tract
Enteral is always preferable
Indications for enteral nutrition (general)
1-2 weeks of no oral intake
patient wish
Contraindications for enteral nutrition
mechanical obstructions
Severe vomiting
upper GI bleeding
GI impairment
Indications for NGT
short term oral nutrition required for up to 30 days
contraindications for NGT
facial trauma, patient intolerance and embarrassment
Indications for PEG
oral feeding has not commenced within a month
and realistically can’t manage enough orally to meet nutritional needs
Contraindications for PEG
patient tolerance
risk of surgery
cost of surgery
2 types of feeding regimes for non oral nutrition
Bolus ( meal time feeds)
Continuous enteral feeding
Regime to progress from non-oral to oral nutrition
- Bolus feeding continue for 3-5 days to re-stretch stomach and re-initiate the hunger cycle
- Introduce one oral meal daily for one week, with more meals added as tolerance increases
- Tube feeding is modified as oral intake increases
- Need a maintenance phase before tube is removed - need to maintain oral intake over time, use food diaries to determine
Information to consider when recommending feeding options
amount and frequency of aspiration
diagnosis
history of pneumonia
ability to complete manoeuvres
Information to consider when recommending feeding options
amount and frequency of aspiration diagnosis history of pneumonia ability to complete manoeuvres QOL impact of being NBM on swallowing function (consider mixed feeding) how much can client eat/drink by mouth informed consent of client
3 common reasons for tube feeding:
- The patient’s inability to sustain nutrition orally although the swallow response is safe
- The requirement for sufficient calories on a short-term basis to overcome an acute medical problem
- The risk of tracheal aspiration if the patient is allowed to eat orally
management of dysphagia is based on ..
client wishes, history and risk (aspiration, choking, malnutrition & dehydration)
goal setting considerations
- Diagnosis
- Prognosis
- Severity of dysphagia
- Cognition (can they implement strategies at home)
- Comprehension
- Respiratory function
- Caregiver support
- Motivation (big factor for outcomes)
- Medical and allied health teams’ goals
- Short and long term objectives
general therapy goals for dysphagia
- Re-establishment of oral feeding
- Maintaining adequate nutrition/hydration
- Improving swallowing safety
- Maintenance
example of dysphagia BS and F
tongue strength, bolus control
example of dysphagia activity
eating, drinking
example of dysphagia participation
returning to work (consider life roles)
Priorities for acute setting
medical status and impairment
Priorities for inpatient rehab
impairment and activity
restoration and compensation
intensive rx
Priorities for outpatient rehab
participation
less intensive rx
Priorities for long term community based clients
monitoring
wellbeing and adjustment
How long before you should see some kind of progress in dysphagia rx
6 weeks
Quicker soon after stroke
Longer years post stroke
Examples Goal targets for dysphagia
- use x strategy % of the time
- will not develop aspiration pneumonia using x strategy
- manage x diet without developing complications
- return to oral feeding
- limiting functional deterioration
2 main treatment considerations for dysphagia
airway protection and adequate nutrition and hydration
Examples of compensation for dysphagia
postures, manoeuvres, texture modification, bolus delivery modification
Examples of rehabilitation for dysphagia
OMES, Rehab exercises, Therapeutic feeding
Candidacy for swallowing rehabilitation
Non-progressive disorders (however some slow progressive e.g. Parkinsons can be suitable)
Cognitively able
Communicatively able
Motivated
Example of substitution treatment for dysphagia
non-oral feeding
Can you do compensatory and rehabilitative rx at same time ?
Yes - rehabilitative bw meals, compensatory during meals
medical rx for dysphagia
dietary modifications (for underlying issues e.g. diabetes) and pharmacologic management (e.g. reflux meds, gastric motility drugs, salivary meds (to replace or thin)
Surgical rx for dysphagia
improving glottal closure (e.g. medialisation thyroplasty, biomaterial injection),
tracheostomy
improving PES opening (stretching, dilating, cutting and paralysis (botox)
behavioural rx for dysphagia
food modification
modifying feeding activity
patient modifications
mechanism modifications (e.g. motor exercises)
Indirect intervention is conducted with a bolus
false
Direct intervention is conducted with a bolus
true
dysphagia rx for spasticity/hyperfunction
Headlift/Shaker or Mendelsohn’s depending on presentation
Dysphagia rx for hypotonicity/ flaccidity
meldelsohn, masako, effortful swallow
oromotor for strengthening through increasing tone
Dysphagia rx for dyscoordination
external cues to bring on swallow e.g. counting swallow in with ‘1, 2, 3 swallow’
Name some rehabilitation techniques for swallowing
- Oromotor therapy • Valsalva swallow
- Masako manoeuvre • Mendelson manoeuvre
- Head lifting manoeuvre • Expiratory muscle training
- Vocal adduction exercises
- Therapeutic feeding/neurosensory stimulation
- Biofeedback (SEG, other techniques)
Oromotor exercises used for
increasing strength
improving lip seal and in hemiglossectomy
Valsalva / effortful swallow
- with or without food?
- rehab or compensatory?
- what does it do?
used with or without food
can be rehabilitative or compensatory
may reduce depth of penetration and reduce residue through increased tongue/palate pressure, increased duration of swallow, increased tongue base movement
Masako manoeuvre
- with or without food?
- rehab or compensatory?
- what does it do?
anchor tongue with teeth and swallow - without food - rehab - increases BOT to PPW contact increases strength of phx swallow
Mendelsohn manoeuvre
- with or without food?
- rehab or compensatory?
- what does it do?
hold up lx for 5 secs during and after swallow
- with food
- rehab
- improves swallow coordination, reduces postswallow residue and aspiration by keeping PES open for longer to decrease pooling and sustains lx elevation and seals epiglottis for longer
Head lift / Shaker manoeuvre
- with or without food?
- rehab or compensatory?
- what does it do?
lay down, lift head 3 x for 10secs each keeping shoulders down
- no food
- rehab
- increases opening of cricopharyngeal sphincter, laryngeal elevation and increases pharyngeal contraction
EMST
- with or without food?
- rehab or compensatory?
- what does it do?
expiratory muscle strength training
- without food
- rehab
- increases active expiratory pressure (cough function) and hyoid movement and subsequently PES opening
biofeedback examples for dysphagia
surface electro myography, ultrasound, endoscopy, watching FEES or VF
aim of compensatory techniques for dysphagia
'’redirect/improve the flow of food and eliminate symptoms, such as aspiration, but do not necessarily change the physiology of the patient’s swallow” (Logemann, 1997)
compensation techniques for dysphagia include
- Postural strategies
- Bolus control techniques
- Volitional airway protection strategies (some crossover with rehab)
- Prosthetic devices
- Modifying food/fluid consistencies (biggest area)
What is best body posture for dysphagia?
upright with pelvis as far back in chair as possible
solid chair with arms
feet flat on floor, hips at 90 degrees
head aligned with trunk
Pharyngeal posturing examples
chin-tuck, head turn, head tilt, side lying and neck extension
What is chin tuck used for
delays in swallow, poor tongue control, reduced posterior tongue mvt and reduced airway closure (Logemann, 1983)
Effect of chin tuck
widens vallecular space, narrows airway entrance, pushes BOT back to PW, puts epiglottis in protective position, increases PES pressure
= reduced aspiration
instructions for chin tuck
Have sip or mouthful and look down at the floor
what is head rotation (head turn) for and what does it do?
for unilateral weakness
= reduces post swallow residue and aspiration
by directing bolus down stronger side of pharynx through rotation of head to weaker side, closing off weaker side of phx, resulting in increased amount swallowed, less residue and less aspirated
instructions for head turn
Look over shoulder and swallow
what is head tilt for and what does it do?
unilateral weakness
reduces aspiration
by leaning whole body or head to stronger side, slowing bolus providing time to adjust and protect airway
bolus control techniques (compensatory)
3 second prep, lingual sweep, cyclic ingestion, dry swallows, bolus placement (on stronger side) modification of bolus size and rate of intake slurp and swallow
Volitional airway protection strategies
supraglottic swallow super- supraglottic swallow effortful swallow mendelsohn Phx expectoration Vocal quality checks
Instructions for supraglottic swallow?
Hold breath
bear down
Swallow
gentle cough immediately after
What is supra glottic swallow for?
aspiration preswallow as closes VF before the swallow
delay in swallow response
post swallow phx residue
increased lx excursion
What is supersupraglottic swallow
Hold breath
bear down
Swallow
gentle cough immediately after
What is super supraglottic swallow for
aspiration preswallow as closes VF before the swallow
delay in swallow response
post swallow phx residue
increased lx excursion
compensatory prosthetic rx
palatal lifts
trache valves
considerations for modifying textures
- nutritional adequacy
- dryness/moisture content
- particle size
- hardness/brittleness
- adding gravy and sauces
- how good is the chef
environmental changes to help with modified diets
- Try different sized spoons
- Try finger food
- Cut food up into smaller pieces
- Train carer to prompt client
- Only give one mouthful at time
- Use ‘nosy’ cup (AKA dysphagia cup)
- Reduce distractions
Cons of modified diets
- Disliked by clients (the thicker the less liked)
- may impose other health risks e.g. dehydration
- thickening reduces aspiration for 5ml bolus but not 10ml
Frazier water protocol
- what is it?
- pre reqs?
allowing selected patients with dysphagia who aspirate thin fluids access to small amounts of clean water between meals to increase QOL and reduce dehydration
Need good mobility, , adequate cognition, sit up straight, and good oral hygiene
Frazier water protocol results
few instances of dehydration or chest infection
Why take outcome data?
- Show change over time as a result of rx
- To contribute to the knowledge base
- For clinical accountability
FOIS measures…
Functional Oral Intake Scale - diet as quick outcome measure
1-7 scale:
1: nothing my mouth
7: total oral diet with no restrictions
EAT-10 measures..
quickly Measures dysphagia and QOL and symptoms (Belfasky et al 2008). Score >3 = dysphagia
SWAL-QOL measures…
QOL over longer time, mental health, eating out , worry etc
AUSTOMS measures…
outcome in terms of all areas of ICF on 0 (least severe) - 5 (most severe) scale
MASA measures …
Mann Assessment of Swallowing ability (Carnaby-Mann 2002)
evaluation or orophx dysphagia post stroke
good for goals to show improvement or lack thereof
What can be done for client who is minimally conscious/not ready for oral intake
Oral care, joint session with physio
Ways to involve client in therapy?
get to pass items, hold toothbrush while assisted, self feed
impairment of CNV - swallow issues
- mastication difficulties
- tongue ant 2/3 sensation lost
- face sensation (possible lack of awareness of ant. spillage)
Also involved in combo with velum tension and elevation (tensor veli palatini) to contain bolus and close off nasophx, and hyoid and lx elevation
impairment of CNVII - swallow issues
- lip and cheek motor control -> inability to retain bolus is oral cavity, food pocketing
- Ant 2/3 tongue taste -> taste impacted
- salivary glands (submandibular and sublingual) - reduced saliva production -> inappropriate bolus consistency for swallowing, difficulty forming a bolus
Impairment of CNIX and X
- tongue general sensation and taste post 1/3
- impairments to soft palate, phx and lx:
issues with sealing nasophx and contain bolus (Palatopharyngeus)
True and false VF adduction issues -> poor airway protection
poor communication with brainstem and cortex
poor phx constriction
Impairment of XII
deficits in tongue function e.g. manipulating and containing bolus, including posterior movement of bolus, and difficulty initiating swallow reflex
Which manoeuvres reduce oral residue?
Oromotor exercises (R) Lingual sweep, bolus placement, cyclic ingestion, head tilt (C)
Which manoeuvres assist with A->P transfer difficulties due to lingual weakness?
oromotor exercises (R) chin tuck, chin up, slurp and swallow, smaller bolus (C)
Which manoeuvres reduce premature post spillage?
masako (R)
Chin tuck, 3 second prep (C)
Which manoeuvres reduce delay in swallow response?
all compensatory: chin tuck, supraglottic and super supraglottic swallow, 3 second prep, multiple swallows, larger bolus
Which manoeuvres increase PES opening due to reduced hyolx excursion?
mendelsohn, Shaker/head lift (R) Head rotation (C)
Which manoeuvres reduce post swallow residue?
mendelsohn, valsalva, shaker, EMST (R)
phx expectoration, cyclic ingestion, multiple swallows, chin tuck, super supra/supra glottic swallows
Which manoeuvres reduce penetration and aspiration
mendelsohn, vocal adduction exercises (R)
chin tuck, s-s & s-glottic swallows, phx expectoration, vocal quality check, diet modification (C)
Which manoeuvres compensate unilateral orophx weakness?
head rotation, head tilt, side lying
