Management of the Patient with Dysphagia Flashcards
Clinical Questions To Think Of Prior to Therapy
- What type of nutritional management is necessary?
- Should Tx be initiate and what type?: Compensatory, Exercises, Direct, Indirect
Clinical Questions to Think of During Therapy
Does the patient require a maintenance program to maintain the gains in therapy or slow deterioration?
Main Goal for any dysphagia treatment plan
Re-establishment of oral feeding while constantly maintaining proper hydration, nutrition, and safe swallowing
Diagnosis- Primary factor in deciding whether to initiate therapy
Knowledge of the speed and potential of the patient’s swallowing disorder
Diagnosis- Therapy Considerations
- Compensatory strategies may only be necessary if a patient is likely to recover quickly (i.e., stroke without other medical complications – recovery may be within 1-2 weeks)
- Effortful swallows and active exercise may be inappropriate for patients that have motor neuron disease secondary to fatigue (i.e., Myasthenia Gravis- clients fatigue over time because of constant muscle activity)
- Dementia patients may not be a candidate for therapy as they are unable to follow directions
Prognosis- Sudden onset neurological damage
- stroke
- head injury
- spinal cord injury
- structural damage (surgical, radiation therapy from head and neck cancer, gun shot wound, other trauma)
Tx is appropriate as there is potential for partial or full recovery of PO intake
Prognosis- Progressive degenerative disease
- Parkinson’s
- Motor neuron disease
- Myasthenia Gravis
- Multiple sclerosis
- Various types of muscular dystrophy
- Alzheimer’s disease
Tx may not be appropriate because of eventual loss of motor control or cognitive abilities to ensure safe swallowing via compensatory strategies or active treatment
Compensatory Strategies
If compensatory strategies alone are successful in eliminating the symptoms of dysphagia (aspiration, residual material): swallowing therapy may not be warranted
Severity of Dysphagia
If compensatory strategies alone are unsuccessful: swallowing therapy may warrant a variety of exercises to improve the range and coordination of the oral and oropharyngeal movements necessary without giving solid/liquid (pre-feeding therapy)
Following directions
- Determine if Pt can follow simple and complex directions
- Swallowing maneuvers are complex
- Compensatory strategies rely more on caregiver
Respiratory function
-Normal swallowing requirements:
0.3 to 0.6 seconds for sip of liquids
3 to 5 seconds for continuous cup drinking
- Supraglottic and Super-Supraglottic swallows require modification of airway closure duration
- Effortful swallow and Mendelsohn maneuver affect duration of airway closure
- If respiratory function is severely affected Tx may be postponed until proper functioning is restored
Caregiver Support
Necessary for some to ensure:
- regular Tx practice
- compensatory strategy reminders
- proper feeding
Compensatory Treatment Procedures
Usually introduced during Dx procedure
- Control the flow of food and eliminate the patient’s symptoms (aspiration)
- Don’t always change the swallow physiology
- Largely under the control of the caregiver or clinician and can be used with patients of all ages and cognitive levels
- Less muscle effort or work for the patient
- Do not fatigue the patient as quickly as swallowing exercises
Compensatory Treatment- Postural Techniques
- Chin-Down (chin tuck)
- Chin-Up
- Chin-Down and head rotation
- Head Tilt
- Lying Down
- To improve sensory awareness: thermal-tactile, exaggerated suck-swallow,
- Modifying volume and speed of food presentation
- Diet changes (food consistencies)
- Intra-oral prosthetics
Chin-Down (chin-tuck)
- Touch chin to neck
- Pushes anterior pharyngeal wall posteriorly
- Tongue base and epiglottis pushed close to pharyngeal wall
- Narrows airway entrance
Used for:
- Delayed triggering of pharyngeal swallow
- Reduced tongue base retraction
- Reduced airway closure
Chin-Up
- Drains food from oral cavity via gravity
Used for:
- Pt with reduced lingual control (weakening, amputated, paresis)
- If concerned with airway closure: supraglottic swallow maneuver is used to close the vocal folds
Chin-Down and head rotation
- Good for airway protection
Used for:
- Pt with weakness on one side
Head Tilt
- Tilt head to better/stronger side
- Gravity drains food to side with better control
Used for:
- Unilateral oral impairment and unilateral pharyngeal impairment on same side
Lying Down
- Use gravity to drain residual food on pharyngeal wall as opposed to sitting up where it would go to airway
- Only can use straw to drink with sucking rather than inhalation
- Should NOT be used with successive swallows if there is food buildup in pharynx
- More elevation (15-30degrees) for those with GERD
- Clear residue before sitting up
Used for:
- Pt without oral movement
To Improve Sensory Awareness
Used for:
- Pt with swallow apraxia
- Tactile agnosia (can’t feel food)
- Delayed onset of oral swallow
- Reduced oral sensation
- Delayed trigger of pharyngeal swallow
Includes:
- Increasing downward pressure of the spoon against the tongue when presenting food
- Sour bolus
- Cold bolus
- Bolus that requires chewing
- Larger volume bolus
- Thermal stimulation
To Improve Sensory Awareness
Both therapeutic and compensatory:
- Compensatory because they are under the control of the caregiver/clinician and do not change the motor control of the swallow
- Therapeutic because they change the timing of the swallow by reducing both the oral onset time and pharyngeal delay time
Sensory Awareness- Thermal-tactile stimulation
- Vertically rub anterior faucial arches firmly 4-5x
- Use 00 laryngeal mirror
- Heightens oral awareness and alerts brainstem and cortex- will trigger pharyngeal swallow when oral stage begins
Sensory Awareness- Exaggerated Suck-Swallow
- Increase vertical tongue-jaw sucking with lips closed
- Facilitates pharyngeal swallow triggering
- Draws saliva to back of the mouth
Used for:
- Pt with poor saliva control
Modifying Volume and Speed of Food Presentation
- Build-up of food can result in collection and potential for penetration/aspiration
- Take smaller boluses as slower rate to eliminate risk for aspiration
Used for:
- Pt with weak pharyngeal swallow
- Requiring 2-3 swallows per bolus
Diet Changes (Consistency changes)
- The last compensatory strategy
- Should only be done with other strategies or therapies are unsuccessful
- Can be difficult for Pt to accept
Used for:
- Pt with constant postural changes or movement disorders
- Pts who cannot follow directions and use maneuvers
- Pts where oral-sensory procedures are inappropriate
Intraoral Prosthetics
Can assist oral cancer Pts with:
- 25% or more oral tongue tissue removed
- Poor tongue movement
- Neurological Pts with bilateral hypoglossus paralysis
- Pts with velopharyngeal difficulties
- Cleft palates
Types of Intraoral Posthetics
Palatal Lift: lifts soft palate to closed position
used for patients with velar paralysis
Palatal Obturator: closes a hole in the palate
used for patients with cleft palate and significant soft palate resections (cut outs)
Palatal Augmentation or Reshaping Prosthesis: recontours hard palate to meet tongue to make A-P bolus transport more efficient
used for patients with tongue resections or bilateral tongue paralysis
