What are the goals of dysphagia therapy?
MAXIMISE SAFETY (reduce the risk of aspiration/choking) MAXIMISE NUTRITION
Restore/rehabilitate swallowing function
Increase comfort and satisfaction at mealtimes
Improve quality of life
Prevent recurrence of dysphagia related comorbidities
What categories of treatments are available?
- Medical
- Surgical
- Behavioural *** MOST IMPORTANT
What two types of behavioural treatments are available?
- Compensatory
2. Rehabilitative
There are three types of compensatory treatments. What are they?
Modifying diet and fluid
Modifying feeding activity
Modifying posture (e.g. chin tuck)
Compensatory strategies are appropriate for which population?
Sever dysphagia Progressive disease Non-compliance Lacking motivation Resources not available for treatment
What rehabilitative treatment options are available?
Oromotor exercises
Treatment that alters swallowing physiology (require intensive, active participation)
Rehabilitative strategies are appropriate for which population?
Good prognosis for recovery or improvement, compliance, motivation, resources available for treatment
What is the rationale for recommending modified diet and fluids?
- Thickened fluids move through the oral cavity more slowly. They form a “clump” or more cohesive bolus that is easier to swallow.
- Modified diets require less chewing, and, given smaller pieces, are less likely to obstruct the airway if penetration/aspiration occurs.
Are there any limitations or reasons for concern?
- Thick fluids may be more dangerous for some people as, if aspirated, they are more difficult to cough up.
- Modified food and drinks are not palatable and therefore may not be consumed by the patient - therefore patient may become malnourished/dehydrated
What is the Frazier free water protocol? What is critical for the free water protocol to be successful?
Allows a patient with dysphagia to consume water BETWEEN meals. During meals, patient must still have thickened fluids.
Water is pH neutral, and, if aspirated, is least likely to cause harm to the respiratory system.
Good ORAL HYGIENE is critical - if water is aspirated, reduces risk of aspiration pneumonia.
What are some safe swallow strategies?
Ensure FULLY UPRIGHT AND ALERT for all oral intake
SMALL mouthfuls
Check that the mouth is CLEAR before taking the next mouthful
Maintain optimum ORAL HYGIENE
Cease oral intake if COUGHING is observed
Note the level of SUPERVISION required
What are the three most common reasons for tube feeding?
- The patient is unable to sustain nutrition orally, despite normal swallow function
- The requirement for sufficient calories on a short term basis to overcome a medical problem
- To reduce the risk of aspiration
What non-oral feeding options are available?
- IV: Intravenous fluid administed through a vein
- NGT (nasogastric tube): short term solution
- PEG (percutaneous endoscopic gastronomy): long term solution
What are some potential complications of any type of tube feeding?
- Feeding tube blockage
- Mechanical: not appropriate if there are obstructions in the nasal passage
- Potential for aspiration pneumonia (gastric refluc and aspiration of stomach contents)
- Dislocation of tube
What are some benefits of NGT?
Easy insertion (no anaesthetic) Only small hole required
What are some risks/disadvantages of NGT?
Uncomfortable
Easily removed
Nasal and pharyngeal irritation
May distend (swell) the UES
What are some benefits of PEG?
Generally well tolerated
What are some risks/disadvantages of PEG?
Potential for reflux
Infection at tube site
Expensive and requires surgery and anaesthesia for insertion
What are some nonmedical benefits of tube feeding?
May reduce the burden of trying to maintain adequate nutrition orally
Lost functions may “improve” becuase nutrition and hydration are back to normal
May provide physical and psychological relief from dysphagia
What are some nonmedical risks/disadvantages of tube feeding?
QoL may be impacted (taking away one of life pleasures)
Physical harm if patient tries to remote NGT
What is transitional feeding?
Transitioning from oral –> tube OR tube –> oral
Tube –> oral must be done GRADUALLY
When is it appropriate to transition from oral feeding to tube feeding?
- Irreversible swallowing dysfunction e.g. neurodegenerative disease
- No longer safe for oral intake
- Inability to maintain adequate nutrition and hydration through oral means
When is it appropriate to transition from tube feeding to oral feeding?
- Medical condition stabilising
- Protective reflexes e.g. cough improving - airway protection is adequate
- Recovery from dysphagia
- Increasing sensory, cognitive, and communication abilities
- To increase QoL in end of life patients
How can the mealtime activity be modified to meet the needs of the individual patients?
- Mealtime schedules
- Smaller meals, more frequently
- Reduce environmental distractions
