HC 6 Medical treatment & team approach Flashcards
What do medical therapies rely on?
On the etiology of the dysphagia (treat the underlying medical condition)
- neuromuscular disease
- GER (gastroesophageal reflux)
- xerostomia
What’s the medical therapy for a person with neuromuscular disease?
- Determine any medication that may contribute to dysphagia, as many drugs affect the cholinergic nervous system (e.g. production of saliva)
- ask list of prescribed medications
=> find a blance between therapeutic benefit and side effects of the medication
Which patient populations are more at risk to GER contributing to swallowing difficulties?
- asthma,
- cricopharyngeal bar on DSS
- glottic incompetence (risk for aspiration)
Which treatment do we provide to patients with GER?
- behavior modifications
- if behavior modification is not adequate to control reflux symptoms: add specific medication
Which anti-reflux recommendations do we give?
- At least 3 to 4 hours before supine position (bed time): no eating
- No bedtime snacks
- Sit upright and use gravity to minimize risk
- Elevate head of the bed by 10-15 cm (blocks are more effective than pillows)
- Antacid medication before going to bed
- Avoid certain foods -> increase gastric acid, lower resting tone, dehydratation (Coffee, tea, pepermint, chocolate, citrus fruits, alcohol)
- Avoid tobacco
What medication may help with GER?
- H2-blockers = standard therapy: specific dose and schedule
- proton-pump inhibitors (2-3 months) = more powerful to decreasing gastric acid production but increased risk of side effects
- symptoms controlled -> replace proton-pump inhibitors by H2-blockers -> can be used long term
What’s the consequence of xerostomia?
Problems with
−Bolus lubrication
−Bolus flow. Poor flow => bolus residue (tongue, palate, pharyngeal wall), risk for aspiration
−Oral mucosal health
−Dental health
−Esophageal GER defense
−Increased viscosity => bolus residue => at risk for aspiration of obstructive bolus
Which factors predispose patients to xerostomia?
- autoimmune conditions
- radiation effects
- medication (dry mucosa, decrease saliva)
- iron or vit. B12 deficiency
How will we treat xerostomia?
−Maximizing general hydration
−Limiting mouth-breathing
−Minimizing products that would contribute to xerostomia (certain medications, mouthwashes or toothpaste with alcohol)
−Minimizing products that favor increased oral bacterial growth
−Maximizing oral hygiene: artificial saliva, pilocarpine
−Avoid potentially irritating foods because of oral sensitivity
−Wet the bolus during oral preparation
When would we consider surgical therapy?
- when structural or anatomic abnormalities results in incompetence
- occasionally when muscular weakness is the etiology
How would surgery benefit lips and oral muscles?
- release contractures that prevent oral closure
- recreate an intact orbicularis oris muscle
How would surgery benefit the soft palate?
- soft palate tissue defects and soft palate muscular weakness may be surgically repaired with local flaps (pharyngeal flap)
- palatal obturators
How would surgery benefit the tongue?
- reconstruction after a floor of the mouth cancer resection to minimize tethering and improve tongue mobility
- when loss of tongue bulk: tissue flaps or fill with body fat
How would surgery beneft the vocal folds?
- vocal fold medialization to correct de vocal fold paralyses -> not always successful in eliminating aspiration
How would surgery benefit the UES opening?
1) relaxation of cricopharyngeus:
- CP myotomy: incisision or cut CP muscle (only if driving forces are still good enough!)
- CP dilatation = enlarged pharynx at rest (catheter with inflatable balloon and stretch muscle -> greater opening)
- botox injection in UES sphincter
2) elevation hyoid & larynx:
- further research needed
What is a Zenker’s diverticulum. How can it be treated surgically?
- result of long-term failure of PES to relax
- out-pouching of the pharyngeal mucosa (above CP muscle and between the inferior pharyngeal constrictor fibers) => food and liquids collect => regurgitation, aspiration
- complete myotomy of the CP muscle
If nothing works, there are some last options to protect the airway. Which ones?
- laryngeal stent: plug into the larynx (tracheostomy needed)
- laryngotracheal separation (tracheostomy needed)
- total laryngectomy
- feeding tubes:
- nasogastric tube
- gastrostomy: PEG or PEJ
What do we do after the treatment plan has been finalized?
Communicate the plan to the patient and all relevant caregivers and family members:
−Summarise medical and feeding history
−Summarise clinical and radiographic evaluations
−Additional observations?
−Current capabilities and impairments
−Impact on nutrition and respiratory health
−Prognosis
−recommendations for follow-up (few generalisations possible)
Explain: it is imperative that we have good, reliable and valid assessment tools to diagnose dyshpagia, but also to track change.
Possible tools:
−Biomechanical measures, standardized manner: DSS
−Imaging studies: e.g. endoscopy
−Laboratory studies: e.g. blood to check for inflammation
−Special studies: e.g. pH testing to monitor medication GER
−Clinical evidence: e.g. weight gain, less feeding restrictions needed
−Self-assessment tool: e.g. SWAL-QUOL, EAT-10
What does the nurse play an important role in?
- Nurse is often the first person to recognize the signs and symptoms of dysphagia
- Major role in
−Alternative feeding methods (nurse knows how it works)
−Monitoring dietary recommendations and restrictions
−Monitoring psychosocial factors
•Communication with other team members
What do we have to educate the nurse in to do so?
−Risk factors for aspiration
−How to observe during meals
−Aspiration and feeding precautions e.g. upright position
−Observation of patients from tube to oral feeding
−Observation & care of patients with artificial airways
