Management of Dysphagia Flashcards
Besides aspiration, what are two reasons for getting a chest infection?
Poor oral hygiene and being fed by someone else
What is the likelihood of an error in medication if you have Dysphagia?
21%
What do compensatory strategies for swallowing work on?
Symptoms
What do swallowing exercises work on?
Physiology/underlying disorder
Who is a ‘head back’ postural technique good for?
postural change (compensatory strategy) that’s good for someone who has a good pharyngeal swallow but very little oral movement. Ideal candidate would be someone who has had a glossectomy but NEVER trial without an instrumental assessment
Extra precaution - hold breathe
What is the first decision to make after completing a detailed assessment?
Whether to treat or not
Name 2 examples of patient perception protocols for swallowing
EAT-10
Sydney Swallow Questionnaire
Name 5 factors to consider when deciding whether to treat for swallowing or not
Medical diagnosis (e.g. prognosis, cognitive abilities etc.)
Motivation
Home support
Respiratory function/Cardiac function (some interventions are not appropriate if a person has difficulties here)
Response to trial therapy
What are the Dysphagia treatment goals?
Ensure swallow safety
Increase swallow efficiency
Enhance quality of life
Why is adequate nutritional support vital for successful rehabilitation?
Allows maximal recovery and helps to avoid confusion, fatigue, pressure sores and can make wounds breakdown (if not getting)
Name 4 means of non-oral support
Intravenous line (IV) Nasogastric Tube (NG) Gastrostomy tube (PEG or RIG) Jejunostomy tube (inserted further down in the bowel)
When would a person be given an NG tube?
If they haven’t eaten or are unlikely to eat for 5 days or more OR have inadequate intake (e.g. less than half normal intake for 10 days)
How long can a NG tube stay in place?
Up to 3 months
When is a PEG recommended ?
When swallowing problems are likely to persist for 6 weeks or more
What are the 3 options for management of swallowing disorders?
Surgical (e.g. vocal fold medicalisation, laryngectomy)
Pharmacological (e.g. anti-reflux, saliva management)
SLT rehabilitation (most common)
What are the 3 types of SLT management for swallowing disorders?
- Compensatory
- Exercises
- Combined Techniques
Name 5 types of compensatory management approaches
- Postural changes
- Altering sensory input
- Modifying volume of bolus presented
- Modifying viscosity of bolus
- Intravenous-oral prosthetics
Who is compensatory management most beneficial for?
People with poor cognition. Compensatory management does not require good cognitive awareness and can be ‘delivered’ by a carer
Head Turn - how? why?
How - turn head toward weak side, closing off the weak side of the pharynx and changing the pressure in the UOS
Why - unilateral pharyngeal weakness
Head Tip - how? why?
Why - for both oral and pharyngeal weakness on one side (e.g. Brainstem stroke - likely to have weakness of palate on one side)
How - tip to the stronger side so food will go that way and down the stronger side of the pharynx
Chin Down/Tuck - how? why?
Why - delay in swallowing trigger, reduced laryngeal elevation and difficulty swallowing liquids
How - much chin toward chest - hold for 5 seconds, repeat x10
Head back/ Chin Up - how? why?
Why - good for someone with very little oral movements but a good pharyngeal swallow (e.g. HNC - glossectomy)
How - head and neck are extended backward and the chin is lifted before initiation of the swallow
Give an example of how to alter sensory input?
Who might this be useful for?
Changing bolus characteristics (e.g. temperature, taste - lemon barley water)
Use downward pressure of spoon
Suck/swallow
For apraxic person - want them to be feeding themselves/hand-over-hand
When does the pharyngeal swallow start?
At the point at which the bolus is just coming past the point where the base of tongue and the mandible intersect with each other (if bolus goes past this point without the pharyngeal swallow being initiated - delay)
How do you know if someone has a pharyngeal delay?
At bedside give them a bolus and ask them to swallow while you palpate the larynx.
You know they have tried to move the bolus when you feel the floor of mouth muscles moving. If the pharyngeal swallow doesn’t happen for a while after this - delay.
Only way to be sure = VF
What is ‘dump and swallow’ and who is it for?
If you know the pharyngeal swallow is safe but you know a person has reduced oral control.
Get them to take a large volumes, head back and swallow. Using a large volume as you want them to get as much down as is possible.
When would you suggest a decrease in bolus volume?
If there is a delay in the pharyngeal swallow - a smaller bolus will be contained within the vallecula until the pharyngeal swallow is initiated.
(But you would try increasing bolus first - that is a more natural way to eat/drink)
Give 3 examples of intra-oral prosthetics:
Palatal lowering appliance (bring hard palate down so the tongue can reach it) Palatal obturator (fill a hole where palate is split - HNC) Palatal lift (plate with extension at the back to keep soft palate in semi-elevated position)
Name 3 types of Oro-motor exercises:
- Tongue strengthening (e.g. depressor)
- Range of movement (same as assessment)
- Bolus control (e.g.polo on string)
Note: these can be very good but might not translate easily to swallowing (need lots of coordination for that)
Masoko Maneuver/Tongue Hold Maneuver
Aim? How?
Aim: increase BOT and PPW contact - this pressure generator is really important
How: Tongue is held between the teeth to anchor it in an anterior position - the further out the tongue the harder it is.
This encourages the PPW to increase movement and forces the BOT to work harder
NB: never with food/drink
Vocal Fold Adduction Exercises
For who? How?
For someone with vocal fold palsy
How - bearing down (e.g. pushing/pulling up on a chair) and brining the vocal folds together
Falsetto - why?
Encourages laryngeal elevation - e.g. arpeggios/glides
Shaker Exercise Aim? How?
Aim - increase hyoid elevation. As the hyoid is attached by the hyolaryngeal muscles, this will also increase laryngeal elevation
How - lie on your back, elevate your head to look at your toes, hold for 5. Repeat 3-5 times
Note: might need to make adaptions for people with find it difficult to get on/off bed
Neuromuscular Electrical Stimulation
How does it work?
What is the issue with it?
How: by applying surface electrodes to muscles of swallowing to stimulate them and get them to contract (used by physios for foot drop)
Issue: so many pharyngeal muscles - don’t necessarily know what you re stimulating (some for elevating, some for lowering)
Note: NICe guidelines being developed
Name the 5 types of combined management techniques for swallowing
- Thermo-tactile
- Supra-glottic swallow (SGS)
- Super supra- glottic swallow
- Mendelssohn Manoeuver
- Effortful swallow
Thermo-Tactile Stimulation
Aim:
How:
Aim: stimulating nerve ending in the mouth with tactile and temperature
How: dip laryngeal mirror in ice-water for 10 seconds. Stroke lightly vertically up/down on each anterior faucial arch for 3-4 times toward the bottom
Note: conflicting evidence
Supraglottic Swallow: Aim? How?
Aim: Designed to close the vocal folds to protect the airway
How: patient is instructed to hold his/her breathe just before swallowing to close the vocal folds. The swallow is followed immediately by a volitional cough
Super-Supraglottic swallow: Aim? How?
Aim: designed to voluntarily move the arytenoids anteriorly, closing the entrance to the laryngeal vestibule before and during the swallow. Initially designed for people with supra glottic laryngectomy. How: Similar to to SGS. But with increased effort - hold breath and bear down. Continue to hold breath and swallow. Immediately after swallow, forceful exhalation
Mendelssohn Maneuver: Aim? How?
Aim: prolong elevation of the larynx and therefore prolong UOS opening
How: Swallow normally. When you feel the voice box go up, grab it with the throat muscles and don’t let it go down. Hold for the count of 3, let go. Repeat x5
Effortful Swallow: Aim? How?
Aim - increases posterior tongue base movement to facilitate bolus clearance
How - patient is instructed to swallow and push hard with the tongue against the hard palate ((Huckabee & Steele, 2006)
What is the suggested order of compensatory/exercises/both for long term dysphagia management (acknowledging this will vary depending on the individual)?
- Postural Changes
- Alter sensory input
- Swallow manoeuvres
- Exercises
- Volume changes
- Food consistency modification (last for long term problem)
