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SLP Rx > Dysphagia Rx > Flashcards

Dysphagia Rx Flashcards

1
Q

Considerations and Rx for:
Parkinson’s - increasing difficulties with swallowing and speech
recurrent chest infections
VF - aspirating on all consistencies

A

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

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2
Q

Justifications for Videofluoroscopy

A
  • 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)
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3
Q

Outcome measures for dysphagia rx

A

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

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4
Q

LMN cortical stroke affects which part of face

A

same side upper and lower (ipsilateral)

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5
Q

Medullary Stroke swallowing impact

A
  • 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
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6
Q

Left side stroke swallowing impact

A

more oral phase difficulties

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7
Q

Right side stroke swallowing impact

A

more pharyngeal difficulties

higher incidence of aspiration

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8
Q

COPD impact on swallowing

A
  • 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
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9
Q

IDDSI levels

A
  1. Regular
  2. Soft and bite-sized
  3. Minced Moist
  4. Pureed/ extremely thick fluids
  5. Liquidised/ moderately thick
  6. Mildly Thick
  7. Slightly thick
  8. Thin
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10
Q

Limitations of VF

A
  • artificial environment
  • contrast tastes strange
  • not good for medically unstable patients
  • radiation exposure
  • limited access (SPA 2005)
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11
Q

Reference for VF advantages and limitations

A

SPA, 2005

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12
Q

Safe swallowing strategies:

A

oral care
sitting up straight
alertness and ability to follow instructions
encourage self feeding

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13
Q

Swallow respiratory cycle

A 
spoon approaches lips
small inhale
small exhale
apnoea as swallow happens
immediate exhale post swallow
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14
Q

Age related changes that impact on swallowing

A 
tooth loss
 tissue and muscluar changes
respiration changes
increased swallow durations ad delays in initiation
respiratory/swallow interactions
appetite changes
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15
Q

Best practice for oral care

A

2x day
clean before oral trials
special toothbrushes, biotene toothpaste
saliva substitutes and lip balms

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16
Q

Strategies to improve oral care compliance

A
  • make it part of a routine
  • encourage client to assist wherever possible
  • ensure comfy and relaxed
  • use simple language to explain what is happening
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17
Q

Why consider non-oral nutrition?

A

risk of aspiration due to dysphagia is high, and this may result in aspiration pneumonia

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18
Q

2 types of non oral nutrition

A

parenteral and enteral

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19
Q

What is enteral nutrition?

A

delivery of nutrition into GI tract e.g. NGT

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20
Q

What is parenteral nutrition?

A

delivery of nutrition into vein e.g. TPN

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21
Q

Types of parenteral nutrition

A

Total Parenteral nutrition (TPN) - central vein
Peripheral Parenteral nutrition (PPN) - peripheral
Intravenous hydration (IV) - hydration only

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22
Q

2 most common types of Enteral nutrition

A 
Nasogastric tube (NGT)
Percutaneous endoscopic gastrostomy (PEG)
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23
Q

Indications for Parenteral Nutrition

A
  • non functional GI tract
  • burns
  • severe malnutrition
  • Bowel resection
  • cancer
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24
Q

Contraindications for parenteral nutrition

A

functional GI tract

Enteral is always preferable

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25
Q

Indications for enteral nutrition (general)

A

1-2 weeks of no oral intake

patient wish

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26
Q

Contraindications for enteral nutrition

A

mechanical obstructions
Severe vomiting
upper GI bleeding
GI impairment

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27
Q

Indications for NGT

A

short term oral nutrition required for up to 30 days

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28
Q

contraindications for NGT

A

facial trauma, patient intolerance and embarrassment

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29
Q

Indications for PEG

A

oral feeding has not commenced within a month

and realistically can’t manage enough orally to meet nutritional needs

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30
Q

Contraindications for PEG

A

patient tolerance
risk of surgery
cost of surgery

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31
Q

2 types of feeding regimes for non oral nutrition

A

Bolus ( meal time feeds)

Continuous enteral feeding

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32
Q

Regime to progress from non-oral to oral nutrition

A
  • 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
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33
Q

Information to consider when recommending feeding options

A

amount and frequency of aspiration
diagnosis
history of pneumonia
ability to complete manoeuvres

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34
Q

Information to consider when recommending feeding options

A 
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
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35
Q

3 common reasons for tube feeding:

A
  1. The patient’s inability to sustain nutrition orally although the swallow response is safe
  2. The requirement for sufficient calories on a short-term basis to overcome an acute medical problem
  3. The risk of tracheal aspiration if the patient is allowed to eat orally
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36
Q

management of dysphagia is based on ..

A

client wishes, history and risk (aspiration, choking, malnutrition & dehydration)

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37
Q

goal setting considerations

A
  • 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
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38
Q

general therapy goals for dysphagia

A
  • Re-establishment of oral feeding
  • Maintaining adequate nutrition/hydration
  • Improving swallowing safety
  • Maintenance
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39
Q

example of dysphagia BS and F

A

tongue strength, bolus control

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40
Q

example of dysphagia activity

A

eating, drinking

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41
Q

example of dysphagia participation

A

returning to work (consider life roles)

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42
Q

Priorities for acute setting

A

medical status and impairment

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43
Q

Priorities for inpatient rehab

A

impairment and activity
restoration and compensation
intensive rx

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44
Q

Priorities for outpatient rehab

A

participation

less intensive rx

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45
Q

Priorities for long term community based clients

A

monitoring

wellbeing and adjustment

46
Q

How long before you should see some kind of progress in dysphagia rx

A

6 weeks
Quicker soon after stroke
Longer years post stroke

47
Q

Examples Goal targets for dysphagia

A
  • 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
48
Q

2 main treatment considerations for dysphagia

A

airway protection and adequate nutrition and hydration

49
Q

Examples of compensation for dysphagia

A

postures, manoeuvres, texture modification, bolus delivery modification

50
Q

Examples of rehabilitation for dysphagia

A

OMES, Rehab exercises, Therapeutic feeding

51
Q

Candidacy for swallowing rehabilitation

A

 Non-progressive disorders (however some slow progressive e.g. Parkinsons can be suitable)
 Cognitively able
 Communicatively able
 Motivated

52
Q

Example of substitution treatment for dysphagia

A

non-oral feeding

53
Q

Can you do compensatory and rehabilitative rx at same time ?

A

Yes - rehabilitative bw meals, compensatory during meals

54
Q

medical rx for dysphagia

A

dietary modifications (for underlying issues e.g. diabetes) and pharmacologic management (e.g. reflux meds, gastric motility drugs, salivary meds (to replace or thin)

55
Q

Surgical rx for dysphagia

A

improving glottal closure (e.g. medialisation thyroplasty, biomaterial injection),
tracheostomy
improving PES opening (stretching, dilating, cutting and paralysis (botox)

56
Q

behavioural rx for dysphagia

A

food modification
modifying feeding activity
patient modifications
mechanism modifications (e.g. motor exercises)

57
Q

Indirect intervention is conducted with a bolus

A

false

58
Q

Direct intervention is conducted with a bolus

A

true

59
Q

dysphagia rx for spasticity/hyperfunction

A

Headlift/Shaker or Mendelsohn’s depending on presentation

60
Q

Dysphagia rx for hypotonicity/ flaccidity

A

meldelsohn, masako, effortful swallow

oromotor for strengthening through increasing tone

61
Q

Dysphagia rx for dyscoordination

A

external cues to bring on swallow e.g. counting swallow in with ‘1, 2, 3 swallow’

62
Q

Name some rehabilitation techniques for swallowing

A
  • 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)
63
Q

Oromotor exercises used for

A

increasing strength

improving lip seal and in hemiglossectomy

64
Q

Valsalva / effortful swallow

  • with or without food?
  • rehab or compensatory?
  • what does it do?
A

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

65
Q

Masako manoeuvre

  • with or without food?
  • rehab or compensatory?
  • what does it do?
A 
anchor tongue with teeth and swallow
- without food
- rehab
- increases BOT to PPW contact
increases strength of phx swallow
66
Q

Mendelsohn manoeuvre

  • with or without food?
  • rehab or compensatory?
  • what does it do?
A

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
67
Q

Head lift / Shaker manoeuvre

  • with or without food?
  • rehab or compensatory?
  • what does it do?
A

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
68
Q

EMST

  • with or without food?
  • rehab or compensatory?
  • what does it do?
A

expiratory muscle strength training

  • without food
  • rehab
  • increases active expiratory pressure (cough function) and hyoid movement and subsequently PES opening
69
Q

biofeedback examples for dysphagia

A

surface electro myography, ultrasound, endoscopy, watching FEES or VF

70
Q

aim of compensatory techniques for dysphagia

A

'’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)

71
Q

compensation techniques for dysphagia include

A
  1. Postural strategies
  2. Bolus control techniques
  3. Volitional airway protection strategies (some crossover with rehab)
  4. Prosthetic devices
  5. Modifying food/fluid consistencies (biggest area)
72
Q

What is best body posture for dysphagia?

A

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

73
Q

Pharyngeal posturing examples

A

chin-tuck, head turn, head tilt, side lying and neck extension

74
Q

What is chin tuck used for

A

delays in swallow, poor tongue control, reduced posterior tongue mvt and reduced airway closure (Logemann, 1983)

75
Q

Effect of chin tuck

A

widens vallecular space, narrows airway entrance, pushes BOT back to PW, puts epiglottis in protective position, increases PES pressure
= reduced aspiration

76
Q

instructions for chin tuck

A

Have sip or mouthful and look down at the floor

77
Q

what is head rotation (head turn) for and what does it do?

A

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

78
Q

instructions for head turn

A

Look over shoulder and swallow

79
Q

what is head tilt for and what does it do?

A

unilateral weakness
reduces aspiration
by leaning whole body or head to stronger side, slowing bolus providing time to adjust and protect airway

80
Q

bolus control techniques (compensatory)

A 
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
81
Q

Volitional airway protection strategies

A 
supraglottic swallow
super- supraglottic swallow
effortful swallow
mendelsohn
Phx expectoration
Vocal quality checks
82
Q

Instructions for supraglottic swallow?

A

Hold breath
bear down
Swallow
gentle cough immediately after

83
Q

What is supra glottic swallow for?

A

aspiration preswallow as closes VF before the swallow
delay in swallow response
post swallow phx residue
increased lx excursion

84
Q

What is supersupraglottic swallow

A

Hold breath
bear down
Swallow
gentle cough immediately after

85
Q

What is super supraglottic swallow for

A

aspiration preswallow as closes VF before the swallow
delay in swallow response
post swallow phx residue
increased lx excursion

86
Q

compensatory prosthetic rx

A

palatal lifts

trache valves

87
Q

considerations for modifying textures

A
  • nutritional adequacy
  • dryness/moisture content
  • particle size
  • hardness/brittleness
  • adding gravy and sauces
  • how good is the chef
88
Q

environmental changes to help with modified diets

A
  • 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
89
Q

Cons of modified diets

A
  • 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
90
Q

Frazier water protocol

  • what is it?
  • pre reqs?
A

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

91
Q

Frazier water protocol results

A

few instances of dehydration or chest infection

92
Q

Why take outcome data?

A
  • Show change over time as a result of rx
  • To contribute to the knowledge base
  • For clinical accountability
93
Q

FOIS measures…

A

Functional Oral Intake Scale - diet as quick outcome measure
1-7 scale:
1: nothing my mouth
7: total oral diet with no restrictions

94
Q

EAT-10 measures..

A

quickly Measures dysphagia and QOL and symptoms (Belfasky et al 2008). Score >3 = dysphagia

95
Q

SWAL-QOL measures…

A

QOL over longer time, mental health, eating out , worry etc

96
Q

AUSTOMS measures…

A

outcome in terms of all areas of ICF on 0 (least severe) - 5 (most severe) scale

97
Q

MASA measures …

A

Mann Assessment of Swallowing ability (Carnaby-Mann 2002)

evaluation or orophx dysphagia post stroke
good for goals to show improvement or lack thereof

98
Q

What can be done for client who is minimally conscious/not ready for oral intake

A

Oral care, joint session with physio

99
Q

Ways to involve client in therapy?

A

get to pass items, hold toothbrush while assisted, self feed

100
Q

impairment of CNV - swallow issues

A
  • 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
101
Q

impairment of CNVII - swallow issues

A
  • 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
102
Q

Impairment of CNIX and X

A
  • 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
103
Q

Impairment of XII

A

deficits in tongue function e.g. manipulating and containing bolus, including posterior movement of bolus, and difficulty initiating swallow reflex

104
Q

Which manoeuvres reduce oral residue?

A 
Oromotor exercises (R)
Lingual sweep, bolus placement, cyclic ingestion, head tilt (C)
105
Q

Which manoeuvres assist with A->P transfer difficulties due to lingual weakness?

A 
oromotor exercises (R)
chin tuck, chin up, slurp and swallow, smaller bolus (C)
106
Q

Which manoeuvres reduce premature post spillage?

A

masako (R)

Chin tuck, 3 second prep (C)

107
Q

Which manoeuvres reduce delay in swallow response?

A

all compensatory: chin tuck, supraglottic and super supraglottic swallow, 3 second prep, multiple swallows, larger bolus

108
Q

Which manoeuvres increase PES opening due to reduced hyolx excursion?

A 
mendelsohn, Shaker/head lift (R)
Head rotation (C)
109
Q

Which manoeuvres reduce post swallow residue?

A

mendelsohn, valsalva, shaker, EMST (R)

phx expectoration, cyclic ingestion, multiple swallows, chin tuck, super supra/supra glottic swallows

110
Q

Which manoeuvres reduce penetration and aspiration

A

mendelsohn, vocal adduction exercises (R)

chin tuck, s-s & s-glottic swallows, phx expectoration, vocal quality check, diet modification (C)

111
Q

Which manoeuvres compensate unilateral orophx weakness?

A

head rotation, head tilt, side lying

SLP Rx (6 decks)

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