- tip lick - lick around lips - tip pushes to sides/up against fingers/blades - tip push to inner left/right sides against fingers - push up to flatten tongue - tongue click - back of tongue: /ka/

- lip resistance: pucker lips against blade, place straw btw lips - upper lip resistance: place straw on lower lip - smile ex. - lip stretch and pucker (i-u) - kissing ex.

Management of Dysphagia (2) Flashcards by Jasmin Rojas

Level 1: Puree

no chewing, has potato like consistency

i.e., pureed meats, soups, mashed potatoes

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Level 2: Mechanical Soft

semi solids texture consistency

i.e., baked fish, cottage cheese, fine ground meats

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Level 3

Near normal texture, cut into small bits

i.e., tuna, pancakes

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Level 4

Regular consistency diet; most foods included

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Thickener alters the ______, but not the ______ of the liquid.

texture

taste

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Target populations for thinner liquids

pt w/ good airway protection
overall tongue dysfunction
reduced UES opening
reduced pharyngeal constriction

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Target populations for thicker liquids

pt w/ tongue base weakness
delayed trigger (thicker liquids help trigger pharyngeal swallow/airway protection)
reduced laryngeal closure

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Thickening liquids does not reduce aspiration rates in groups of patients (particularly, during evaluation). T or F?

False; it does

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The effects of thickening liquids on dysphagic intervention is still unclear for long term benefit. T or F?

True

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Who are candidates for Free Water Protocol?

Pts are NPO or currently taking honey thick or nectar thick liquids
Pts are able to swallow water without demonstrating excessive coughing and discomfort
Pts are able to maintain alertness and arousal
Pts are able to maintain upright posture

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Who are NOT candidates for Free Water Protocol?

Pts are not alert
Fragile Pts w/ acute pulmonary disorders or a hx of recurrent aspiration pneumonia
Pts w/ a fever of unknown origin
Pts demonstrating excessive coughin and discomfort after drinking water
Pts are not able to maintain upright posture

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Pills can be given w/ thin water. T or F?

FALSE

Pills should always be crushed and mixed w/ one of the following: appleasuce, yogurt, thickened liquids or pudding

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Pills w/ thin liquids may be allowed for pt w/ only ________ such as mastication difficulty.

mild oral dysphagia

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Minimizes pt with airway protection issue

Cut-out cup

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For Pt without good motor control

Universal ADL cuff or Good grips utensils

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Therapetic/rehab techniques

oral moto exercises
swallow maneuver exercises
thermal tactile stimulation
e-stim therapy or NMES

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Focusing on improving strength/ROM or more general control/manipulation (tongue, lips, face/cheeks, jaw/mandible, VF adduction)

Oral Motor Exercises

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Improving strength, ROM of tongue may…

increase bolus retention and transit time

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Tongue OME

tip lick
lick around lips
tip pushes to sides/up against fingers/blades
tip push to inner left/right sides against fingers
push up to flatten tongue
tongue click
back of tongue: /ka/

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Improving strength, ROM of lips may…

increase lip closure

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Lip OME

lip resistance: pucker lips against blade, place straw btw lips
upper lip resistance: place straw on lower lip
smile ex.
lip stretch and pucker (i-u)
kissing ex.

Improving strength of face/cheeks may…

improve bolus retention

Face/Cheeks OME

cheek puff
lip and cheek toner: suck in inner cheeks
massage

Mandible OME

jaw rotation (slide jaw from side to side)
jaw resistance (open and close)
massage jaw and chin

VF Closure OME

- falsetto voicing - sit on chair - hand push ex - neck ex

Direct Treatment Strategies

Supraglottic Mendelsohn Shaker Masako

Direct treatment strategies/manuevers are designed to...

give the pt more info to faciliate swallowing, improve swallow function/safety, performed w/out food [except supraglottic]

individual voluntarily prolongs the duration of laryngeal elevation resulting in increased duration of CP opening and laryngeal elevation

Mendelsohn

"Swallow and feel the larynx lift but do not let it drop. Hold it w/ your muscles for ___ sec. Release and repate ___ times."

Mendelsohn

Mendelsohn is best for what pts?

Pts w/ reduced laryngeal elevation, reduced CP opening and discoordinated swallow

Presumably improves suprahyoid function, improves PES opening, anterior laryngeal excursion and reduce backflow aspiration, strengthens mylohyoid, geniohyoid, and ant. belly of digastric

Shaker

"Lay on your back and raise your head to look at your shoes, do not raise your shoulders."

Shaker

Shaker is best for what pts?

Pts w/ weak pharyngeal muscular strength and reduced laryngeal elevation, resulting in UES dysfunction

Tongue hold/bite exercise; improves movement of PPW

Masako

"hold tongue btw teeth/lips while swallowing"

Masako

Masako is best for what pts?

Pts w/ incomplete tongue base contact with PPW and reduced laryngeal elevation

Thermal Tactile Stimulation

- Use cold object (laryngeal mirror, ice sticks, lemon glycerin swab) - Rub pillars and sides of tongue vigorously - Have pt swallow hard after 1 trial

Improve trigger swallowing by heigtening sensitivity

Thermal tactile stimulation

Thermal tactile stimulation is best for what pts?

Pts w/ delayed initiation of pharyngeal swallowing (delayed greater than 2 sec.), aspiration or no swallow response.

After swallowing eval, SLP's need to make?

Recommendations why? to ensure safety of oral feeding

The common reasons for placing a feeding tube are? (4)

1. Pt fails the swallow test; unable to swallow safely 2. pts unable to sustain nutrition orally 3. the requirement for sufficient calories on a short term basis to overcome an acute medical problem 4. high risk of aspiration

Catheter/tube placed transnasally to the stomach

Nasogastric Tube (NG Tube)

Nutritional solution administered through GI tract

Percutaneous endoscopic gastronomy (PEG)

Feeding tube inserted directly into the stomach

G-TUBE/PEG

Feeding tube inserted directly into the jejunum

J-Tube/PEG

Nutritional solution adminstered directly into vien

Total parenteral nutrition (TPN) *does not eliminate aspiration

What is the SLP's role when pt is NPO w/ feeding tube?

- secretion management, oral care - trials of swallow (often using water, ice chip, puree) if pt has potential to resume oral intake - if pt has reflux issues, recommend proper posture when feeding (via tube) - may have small PO feeds for oral gratification or trials

What is the SLP's role when pt is PO w/ feeding tube?

- unable to consume adequate nutrition via oral intake | - intervention usually framed in terms of increasing activities and participation and not restoration of function

What are 3 other considerations in RE to management for NPO pt?

1. Frazier Free Water Protocol: find out if it acceptable yes --> SLP and trained nurse can do no --> SLP can incorporate into tx 2. Quality of Life Issue: is oral gratification safe?; min amount of ice chips ok?; daily oral hygiene a must 3. Dietary Waivers: when NPO is not an option for pt

What must candidates to return to oral feeding demonstrate?

a safe and efficient swallow on a consistant basis, able to consume adequate amounts of food or liquid to support nutritional requirements, follow single stage commands and remain alert long enough to finish meal, respiratory stability, ability to self feed or cooperate fully w/ feeding assitance.

Once NPO pt w/ feeding tube passes instrument swallow exam -->

- work closely w/ a dietician - when pt is able to consume 75% or more of nutritional requirements consitantly for 3 to 5 days - document progress and inform nursing or dietician to place order for removing the tube