final Flashcards
treatment, therapy, exercises, diets
purpose of instrumental exams
image structures in oral cavity, pharynx, larynx, PES, esophagus
assess swallowing movements and functioning
identify airway invasion
evaluate effectiveness of compensatory maneuvers
formulate clinical recommendations for: route of nutrition/hydration, diet, feeding modifications, therapeutic intervention
considerations when choosing instrumental exam
safe po/nutritional plan?
concern for aspiration?
nature, volume, incidence of aspiration?
why is there dysphagia?
pt radiation exposure?
transportation to exam?
tolerance for a scope?
pt agreement/desire?
medically stable?
what to look for in oral stages of MBS
labial seal
lingual bolus hold
mastication
bolus transport
oral residue
what to look for in pharyngeal stage of MBS
initiation of phase
velar movement/seal
laryngeal excursion
epiglottic deflection
laryngeal vestibule closure
pharyngeal stripping
PES opening
tongue base retraction
pharyngeal residue
what to look for in esophageal stage of MBS
esophageal clearance - retrograde flow/abnormal motility
pros of MBS
non-invasive
can see all phases of swallowing
cons of MBS
radiation
radiographic image - may not always be clear
requires radiology appt and radiologist
cannot see edema or erythema
cannot see secretions or secretion management
pros of FEES
view structures on camera
view edema/erythema
view secretions and secretion management
bedside mobile unit - no transport of pt
SLP owned equipment
cons of FEES
invasive procedure
white-out period - cannot see all phases of swallowing
limited subglottic view
FEES prodcedure
BEFORE BOLUS:
assess velar function/symmetry
observe pharynx/larynx at rest, dry swallow, cough, phonation, breath hold
observe secretions and characteristics
WITH BOLUS:
assess oral containment
white-out
residue location and amount
airway compromise
pt reaction to residue/compromise
effect of maneuvers and compensations
3 concepts of dysphagia management
compensation
rehabilitation
prevention
considerations for selecting pt treatment
etiology of dysphagia
severity of dysphagia
psychosocial factors
anticipated medical course (incline or decline)
caregiver factors
4 types of dysphagia intervention
surgical interventions
pharmacological interventions
diet modifications
compensatory techniques, therapy, exercises
surgical interventions
vocal fold intervention for glottic closure (medializations, injections, laryngectomy)
feeding tubes
PES opening intervention (myotomy, dilation, toxin injections)
pharmacological intervention
anti-reflux meds
gastric motility
salivary management
Free Water Protocol
pts with clean mouths and normal lung functions will not have harm if water is aspirated
complete oral care 2x/day and always before 1st meal
only thickened liquids with meals
no water with meds
wait 30min after meals for water
water may be requested and allowed in small volumes
enterally-fed pts may have water during/after meals
research found pts did not develop pneumonia and were more hydrated
compensatory techniques
chin tuck
chin up
head turn
2sec bolus hold
alternate solids/liquids
multiple swallows
tongue/finger sweep
postural adjustments
techniques & exercises
effortful swallow
supraglottic swallow
super-supraglottic swallow
effortful breath hold
bolus stimulation
Kinesiotape
thermal-tactile stimulation
exercises only
Mendelsohn maneuver
oral motor exercises
Shaker exercises
CTAR
Masak maneuver
I-PRO
IOPI
MOST
MDTP
RMT
JOAR
IDR
chin tuck
compensatory technique to combat premature spillage
lengthens oral transit route from anterior to posterior, slowing rate of premature spillage and prolonging transit time
requires pt to manually initiate a swallow
may also change anatomy of pharynx - can be good or bad
pairs well with 2-sec bolus hold
chin up
compensatory technique for pts with severe oral transit deficits, usually glossectomy pts
bolus and gravity work together for oral transit to be possible by shortening route and time
may change anatomy of pharynx
can move airway forward projecting bolus directly back to UES
head turn
compensatory technique for pts with unilateral weakness
have pt turn head towards side of weakness
opens wide lateral channel down “strong” side, allowing bolus to go over tongue base to side of vallecula and to pyriform sinuses
directs bolus down side of intact muscles
can also try turning head the other way
alternate solids and liquids
compensatory technique for pts with bolus residue
taking a sip of a liquid will help clear bolus residue
not suitable for pts who struggle with thin liquids
multiple swallows
compensatory technique for pts who struggle with residue, mainly of liquids
tell pt to dry swallow after each bolus swallow to clear oral cavity and pharynx from residue
2-second bolus hold
compensatory technique used to help with premature spillage
tell pt to hold the bolus in the front of the mouth for 2 seconds before swallowing
pt manually initiates swallow and allows for structures to prep for swallow
commonly paired with chin tuck
tongue/finger sweep
compensatory technique for pts with reduced sensation/lingual strength or oral pocketing
tell pt to use tongue or finger to clear the food from mouth
effortful swallow
technique and exercise for pts with weakness and vallecular residue
tell pt to imagine swallowing a golf ball or an egg, and “swallow really hard”
will see more muscle movement
improves base of tongue retraction, tongue propulsion, oral pressure, VF closure, and duration/extend of hyoid movement, causing better PES opening
supraglottic swallow
technique and exercise for pts with reduced or shortened VF closure or airway invasion
tell pt to take a deep breath, hold it, swallow, cough, and exhale
causes prolonged airway closure, increases anterior laryngeal movement which increases PES opening, and increases BOT retraction
super-supraglottic swallow
technique and exercise for pts with airway invasion
tell pt to take deep breath, bear down, hold breath, swallow, cough, exhale
prolonged airway closure
increases anterior laryngeal movement, causing better PES opening
bearing down increases ventricular fold closure and assists in closing posterior glottis
breath hold/effortful breath hold
technique and exercise for preventing airway invasion
tell pt to hold breath really hard while swallowing
closes larynx harder and more efficiently
oral care
technique and exercise for pts with reduced stimulation
increases stimulation and promotes clearing of oral cavity
increases initiation timing for swallow
bolus stimulation
technique and exercise for pts with reduced stimulation
carbonation and temp create more stimulation for pts
feeding the pt the same food will create less stimulation
thermal-tactile stimulation
technique and exercise for pts with no swallow
apply cold laryngeal mirrors to faucial arches to try and stimulate a swallow
can also use pipette droplets of water
kinesiotape
technique and exercise used for CN V weakness or pts with reduced oral tone
apply strips above and below lips
increases subcutaneous blood flow, facilitates weak muscles, relaxes tense ones
straws
technique and exercise meant to increase labial seal, tension, and sucking movement
may be used with pts doing chin tuck by holding cup with straw down at chest
Mendelsohn maneuver
exercise only for pts with reduced laryngeal movement and poor coordination
tell pt to swallow and hold the middle part of the swallow
might also help to tell them to press their tongue to hard palate
dont do without SEMG biofeedback - might look like they’re doing it when they are not
oral motor exercises
exercise only for pts with muscle weakness
must have specific target
approach must be “load-based,” as in high intensity and frequency
may be therapeutic to strengthen muscles
Shaker exercise
exercise only for pts with reduced UES opening
flat on a plinth, hold head up and look at toes for 60 sec, rest 60 sec
helps strengthen muscles that move the hyoid anteriorly to pull UES open
if pts cannot do this motorically, do the CTAR
chin tuck against resistance (CTAR)
exercise only for pts with reduced UES opening
use device to push chin against, like towel or partially deflated ball
less strenuous than Shaker, greater submental activity
can also use a neck-slimmer
ISO swallowing device - open jaw against it
tongue hold/Masako maneuver
exercise only for pts with limited pharyngeal clearance and reduced BOT retraction
stick out tongue, bite down gently, swallow
10 reps 10x/day
provides resistance by making tongue pull back harder to swallow
give assistance to pts by holding tongue for them with gauze
Isometric Progressive Resistive Oropharyngeal Therapy (I-PRO)
exercise program only for lingual weakness
“Swallow Strong” device
can also use tongue depressors
Iowa Oral Performance Instrument (IOPI)
exercise program only for reduced lingual strength
comes with feedback meter to attach to laptop
put bulb in pts mouth and have them complete oral strengthening exercises
Madison Oral Strengthening Therapeutic (MOST)
exercise only for reduced lingual strength
same thing as I-PRO, different bulb
McNeill Dysphagia Therapy Program (MDTP)
exercise program for pts with poor coordination
swallowed materials are introduced sequentially to facilitate progressive resistance or speed and coordination of swallowing
SLPs must be trained and follow specific rules to advance pts
Respiratory Muscle Training (RMT)
exercises only for pts with dysphagia cased by weakened respiratory muscles
handheld trainer device providing resistance against inspiration/expiration
EMT: targets abdominal and upper airway muscles
improves cough for airway protection, improved afferent stimulation, velar closure, increased hyoid elevation, increased activation of submental muscles
Jaw Opening Against Resistance (JOAR)
exercises for pts with reduced hyoid/UES opening
increases hyoid excursion which improves UES opening
hold jaw open for 10sec, rest 10sec, x5 for 2x/day for 4 weeks
can do with or without resistance
can also use a neck slimmer
Intensive Dysphagia Rehabilitation (IDR)
exercise program for pts with severe neurogenic dysphagia
pt seen 2x/week for 60 mins with daily home program
electrical stimulation (Estim)
still being experimented
applies electrical current to cause sensory and motor nerves to activate
surface Estim has been debunked
intrinsic Estim is still being researched
biofeedback tools
FEES: biofeedback during therpapy, po trials, strategies, techniques
sEMG: sticker electrodes stuck the pt connected to a screen; measures muscle strength and amplitude of movement
very helpful for cognitively intact pt to see objective feedback –> motivates pt
pt culture features
time concept, social organization, communication patterns, generation, spirituality, health practices, food preferences
informed consent
decision-making process between a pt and healthcare provider aimed at making an educated and informed medical/healthcare decision
SLPs do not have waivers for dysphagia in acute care, just informed consent
components of informed consent
providing clear and adequate information
capacity to consent
voluntariness
agreement
palliative care
focused on comfort, pain management, decision making, and QOL - but does not need to be for terminal illness
hospice care
palliative measures but requirement of 6mo or fewer to live relating to a terminal illness
presbyphagia
age-related swallowing disorder
sarcopenia
loss of skeletal muscle mass, strength, and speed of movement
contributes to presbyphagia
4 stages of swallowing
oral prep
oral transit
pharyngeal
esophageal
oral prep
from food approaching mouth to preparation of transit
hands as visual cues for sensory recognition
labial seal, facial tension, spoon stripping, tongue cupping of liquids, mastication
lingual pull of bolus centrally onto tongue for prep for transit
oral transit
beginning of bolus transit to bolus head passing anterior faucial arches
stripping of bolus between tongue and palate
takes about 1-1.5 seconds
pharyngeal stage
leading edge of bolus passing anterior faucial arches to passing through UES
rim of mandible crosses BOT
elevation and closure of velum
elevation and excursion of hyoid and larynx
3 levels of laryngeal closure
swallowing apnea
opening/relaxing of UES sphincter
ramping of BOT, retraction, contact with PPW
top to bottom contraction of pharyngeal constrictors
3 levels of laryngeal closure during pharyngeal stage
TVF close
laryngeal vestibule closes - 3 levels: FVF close, arytenoids tilt anteriorly, thickening of epiglottis base
epiglottis deflects/inverts
esophageal stage
bolus tail passing through UES
bolus travels until it passes gastroesophageal juncture
primary and secondary peristaltic waves squeeze bolus down
