midterm Flashcards
What are the NEUROLOGICAL red flags for dysphagia?
-stroke
-TBI
-infectious disease
What are PROGRESSIVE neuro red flags for dysphagia?
-dementia
-Guillain barre syndrome
-myasthenia Gravis
-Muscular Dystrophy
-Parkinsons disease
-amyotrophic Laterals sclerosis (ALS)
What STRUCTURAL dx’s are red flags for dysphagia?
-Cancer in
oral cavity
nasopharynx
pharynx
hypopharynx
esophagus
-trauma
-surgical anatomical changes
-edentulous
What LATROGENIC dx’s are red flags for dysphagia?
-radiation therapy
-chemotherpay
-intubation
-tracheostomy
-ACDF
-post sx coronary artery bypass
-medication related
What are the RESPIRATORY red flags for dysphagia?
-COPD
-PNA
-acute respiratory failure
-COVID-19
what are other red flags for dysphagia?
-GERD
-Advanced Age
-decomposition /fraility
-altered mentation
what are the consequences of dysphagia?
-aspiration
-dehydration
-malnutrition
-psychosocial limitations
who manages dysphagia?
-slp
-otolaryngologist (tracheo)
-gastroenterologist (GERD)
-radiologist (MBSS)
-Neurologist (manage progressive dx)
-dentist
-nurse (oral hygeine/ tube feeding)
-dietition (diet intake/ amount)
-OT (adaptive feeding)
-Neurodevelopmental specialist(NICU)
-pulmonologist/respiratory therapist (ventilation)
What are the cranial nerves involved in swallowing?
-Trigeminal (V)*
-Facial (VII)*
-Vagus (X) & accessory (XI)
-Hypoglossal (XII)
-glossopharyngeal (IX)
How is Trigeminal (V) involved in swallowing?
-innervates muscles of mastication,
-elevator and depressor of the mandible permitting side-to-side movement of tongue
-elevates tongue & floor of mouth
What muscles are innervated by trigeminal (V)?
-temporalis
-masseter
-medial pterygoid
-lateral pterygoid
-tensor veli palitini
-mylohyoid
-digastic
How is the Facial (VII) nerve involved in swallowing?
-innervates muscles of the face
-closes, opens, protrudes, inverts, and twists lips
-in charge of facial expressions
-elevated hyoid & tongue base
What muscles are innervated by facial (VII) nerve?
-obicularis oris
-zygomaticus minor
-zygomaticus major
-levator labii superior
-levator labii alaque nasi
-levator anguli oris
-depressor anguli oris
-depressor labii inferior
-mentalis
-risorius
-buccinator
-stylohyoid
How are the Vagus (X) & Accessory (XI) nerves involved in swallowing?
-raises & stretched soft palate
-raises tongue back
-closes nasopharynx
-shorten & raises uvula
-intrinsic muscles of larynx
-pharyngeal constrictor muscles
What muscles does the Vagus (X) and Accessory (XI) nerve innervate?
-Levator Veli Palitini
-Palatoglossus
-palatopharyngeus
-uvulae
How is the Hypoglossus (XII) nerve involved in swallowing?
-it depresses the tongue & protrudes and elevates up and back
-draws hyoid bone forward
-depresses mandible when hyoid bone is fixed
What muscles does the hypoglossal (XII) nerve inervate?
-hypoglossus
-genioglossus
-styloglossus
-geniohyoid
How is the glossopharyngeal (IX) nerve involved in swallowing?
& what muscle does it innervate?
-narrows fauces and elevated posterior tongue
-palatoglossus
What are the stages of swallowing?
- ORAL PREPATORY
-mastication and preparation into bolus
-cortical/ voluntary movement - ORAL STAGE
-the movement of the bolus from the anterior oral cavity to oropharynx
-voluntary
3.PHARYNGEAL STAGE
-bolus passage from the oropharynx into the esophagus
-mostly reflexive w/ some voluntary control (if cognition is intact)
4.ESOPHAGEAL STAGE
-bolus passage through the esophagus into the stomach
-reflexive
What is the Cortical function of FRONTAL Lobe?
-responsible for motor control
-intent & initiation
-coordination movement in time & space
-executing the movement in and organized and timely fashion
what is the cortical function of PARIETAL Lobe?
-recognizing & interpreting sensory functions
-identification of presence and interpretation of sensory stimulus
what is the cortical function of the SUPERIOR TEMPORAL lobe?
communication & cognition
what is the cortical function fo the OCCIPITAL lobe?
Responsible for visual perception (color, form, motion)
What is the hemispheric control of swallow function (motor control)
- swallowing motor functions are bilaterally represented in the hemisphere
- if the dominant hemisphere is impaired, a contralateral “backup” may be available for recovery
- cortical plasticity may occur over time, increasing utility of the intact, non dominant hemisphere to control swallowing motor functions
- bilateral strokes often demonstrate the MOST sever & persistent dysphagia characteristics as well as cognitive
-2million brain cells die every minute during acute stroke
What about ACUTE strokes?
-PNA noted in 10% of acute stroke pt
~contributed by dysphagis
~aspiratation of foods / liquids/ oropharyngeal secretions
~dependence on nonoral feeding (PEG) = HIGHER respiratory infection
- nutrition / hydration deficits
~prevalence of nutritional deficits from hosptial to rehab =50%
~dehydration = 53% (increase w/ dysphagia)
-NIHSS national institute of health stroke scal
~determines stroke severity
How do Basal Ganglia defects affect dysphagia in patients?
- poor bolus control: involuntary movements
~oral
~oropharyngeal - residue from inefficient swallow
~oral
~oropharyngeal
~pharyngeal - difference among swallow types
~automatic vs. intentional movement
What is Parkinson’s disease? (subcortical)
-slow progressive disease of the basal ganglia
-key problem in execution of voluntary movements
-resisting tremor, bradykinesia (slow progressive hesitations or halts in movement/speed), rigidity (stiffness)
what is the swallowing impairment in the ORAL stage of Parkinson’s disease?
-lingual tremor
-repetitive tongue
-prolonged ramplike posture
-piecemeal deglutition
-velartremor
-buccal retention
What is the swallowing impairment in the PHARYNGEAL stage of Parkinson’s disease?
-vallecular retention
-piriform sinus retention
-impaired laryngeal elevation
-airway (supraglottic) penetration
-aspiration
What is Sialorrhea in Parkinson’s disease?
-drooling
-excess and reduced secretion management
-sensory impairment
-reduced frequency of spontaneous swallowing
What is GASTROPARESIS in Parkinson’s disease?
-delayed emptying of the stomach
-vagus nerve damage
-sx: heartburn, nausea, vomiting, & feeling full quickly
What does the brainstem do? (subcortical)
- HOME of SWALLOWING center
- major ascending sensory tracts receive input from the head & neck region by way of cranial nerves
-coordinates swallowing mechanism & breath swallow coordination
damage to BS:
-sensory deficits to head/neck
-motor deficits w/ upper & lower motor neurons
medulla oblongata: swallowing
What is lower motor neuron & muscle disease?
-LMN connect w/ muscles at the myoneural junction
-Damage can cause:
~flaccid weakness (reduced muscle tone)
~WORESNING MOTOR FUNCTION W/ USE
~RECOVERY OF MOTOR FUNCTION W/ EXTENDED REST
~ sensory loss
What are TX consideration for LMN & muscle disease?
-disease that affects LMN and peripheral muscle groups are progressive
-diet modification
-behavior modification
-establish oral vs. nonoral nutrition
-exercise can fatigue muscle groups
-med Tx: Intravenous Immunoglobulin Therapy
What is esophageal stenosis (structural disorder)?
-structural disorders cause obstruction of bolus passage
-ES: narrowing of the lumen or channel of the esophagus
-difficulty w/ tough, dry, fibrous solids & soft absorbent solids that swell when mixed w/ saliva (bread pasta)
-difficulty w/ liquids after esophageal impact of solids
-1/3 pt w/ obstruction near distal esophagus point to their neck as the site obstruction (innacurate sensation)
-esophagus size in pt w/ luminal –> less than 12mm
-can be caused by rings, web, benign structure, or malignant structures
What is an esophageal ring?
-band of tissue made of mucosa and submucosa –> located in esophagogastic junction
-Schatzki’s ring: MOST COMMON; bandlike, symmetric , ring tissue that forms inside esophagus/ causes: esophageal narrowing
-tx: dilation
what is an esophageal web?
-ban of tissue made of mucosa and submucosa located in esophagus or hypopharynx
-not associate w/ anemia
-frequently asymetric
-dysphagia w/ solids
-tx: dilation
What is diverticulum?
-zenker’s diverticulum occurs when pouch of tissue forms above where the pharynx meets esophagus
-Cause: increased pressure inside esophagus, resulting in tightening and bulging above point of pressure
-SX: bad breath, weight loss, globus sensation, chronic cough, dysphagia, delayed regurgitation
-esophageal diverticulum is rare and usually asymptomatic
-SX: dysphagia of solids/ liquids w/ delay regurg.
what is esophageal motility?
-peristaltic, wave like movement of food through esophagus
-normal esophageal transit: 8-20 seconds
what is GASTROESOPHAGEAL REFLUX DISEASE (GERD)?
-common cause of esophageal dysmotility
-can coexist w/ esophagitis
-further aggravated by hiatal hernia in place due to compromised LES (lower esophageal sphincter) protective barrier by pushing LES into chest cavity
-Eval: 24hr monitoring (nasogastric catheter placement)
-fluorosocopy
What is physiological reflux of GERD?
-GERD is a common physiological event due to constantly changing pressure relation between stomach and esophagus
-LES briefly relaxes, stomach content enter the distal esophagus, and immediately clear back into the stoma
What is the pathological reflux of GERD?
when sx such as heartburn, chest pain, regurgitation, and dysphagia, become overt
What is laryngopharyngeal reflux? (GERD)
-when gastric content reaches the laryngeal/ pharyngeal level
-Globus sensation, odynophagia, chronic cough, hoarseness, chronic throat clearing, sore throat
-Endoscopy findings: mucosal abnormalities on the PPW, edema on arytenoids cartilages, and generalized erythema in the laryngeal vestibule
What are the tx options for GERD?
-alternation of lifestyle
-pharmaceutical involement
-surgery
what are the alteration of lifestyle options for GERD tx?
-Avoid acid-triggering food/liquids
-Upright during meals and at least -45 minutes after
-No smoking
-Don’t bend over after eating. Wait two hours after eating, before going to bed
-Sleep with HOB (head of bead) elevated at 30+ degrees (bed wedge)
-6 small meals, instead of three large meals
What are the pharmaceuticals tx options for GERD?
-antacids (symptomatic relief of intermittent, infrequent heartburn)
-Proton-pump inhibitors (PPIs)E.g., lansoprazole, pantoprazole, omeprazole) – severe GERD or esophagitis
What are the surgery tx options for GERD?
-Hiatal hernia repair
-Lasparascopic approaches
-Suturing of the LES
-Electrical stimulation
-Radiofrequency ablation (reduced frequency of tSLERs
what is cricopharyngeus BAR?
-Appearance of a bar within the pharngoesophageal segment (at the level of the cripharyngeal muscle, near C6-C7)
-Failure of cricopharyngeus muscle to full distend versus the development due to increased tone (higher PES pressures) in the cervical esophagus as a result of the failure for LES to relax
-Can cause obstruction of bolus flow within the pharyngoesophageal segment, noting retention and retrograde flow
-Can coexist with Zenker’s diverticulum
-Tx: Dilation and/ or cricopharyngeal myotomy
What is the larynx composed of?
1 hyoid bone
11 cartilages (single thyroid, cricoid, & eplogottic cartilgaes & paired arytenoid, corniculate, cuneiform and triticeal cartilages
What are the two functions of arytenoid cartilages?
-adducting vocal folds / closing rima glottidis
rima glottidis: narrowest part of the cavity of larynx
glottis: interval between the vocal folds
What are the sensory input?
internal laryngeal nerve branch of superior laryngeal nerve supplies the level above the vocal cords and the level below the vocal cords is supplied by recurrent laryngeal nerve. The lining of vocal cords and the who larynx is supplied by sensory fibers
(there is a picture in slide)
What are endotracheal tubes (ETTs)?
-long, plastic, flexible tubes, connected to a ventilator
-oral or nasal
-cuff attached to the end of tube
~located –> below vocal cords
~seals tracheal lumen prevents orals secretions from aspirating & prevents air from escaping past the tube
-7-12 days
-prolong intubation: risk for laryngeal & lung injury
prolong use of ETT develop/ cause what?
Develop:
~granuloma
~hematoma
~edema
~risk for ventilator
-trauma can cause:
~arytenoid displacement
~vocal fold paralysis
What are the indications for tracheostomy tubes?
-Emergent or elective
-Difficulty weaning from ETTs
-Airway obstruction above the level of the trachea (present or anticipated)
-Allows possibility for voicing (PMV) & swallowing
-Less trauma to the vocal cords (because of cut below the vocal cords
What are the complications for tracheostomy tubes?
-Tracheal edema/ erythema of the tracheal lumen
-Increased secretions from bodys response to foreign object
-Tracheomalacia: cartilage of trachea becomes weak –> cause tracheal wall to collapse –> block the airway (tx:medical → dilate the trachea)
-Tracheoesophageal fistula: abnormal connection between trachea and esophagus due to tissue breakdown from constant irritation
What is PNA (pneumonia)?
-Inflammation of the lungs caused by infection w/ bacteria, viruses and other organism
-SX:Chest pain, fever, shaking, chills, SOB, increased RR and HR, cough, mental status change
What is Community acquired PNA
&
Hospital acuired PNA or nosocomial PNA
-CA-PNA
~contracted by individuals outside the hospital environment –> cause viral resp infeciton
-HA-PNA
~contracted at hospital
What is Ventilator acquired PNA
&
Aspiration PNA?
-VA-PNA
~develops 48hrs or longer after mechanical ventilation is given by means of an endotracheal tube or traschectomy
-A-PNA
~development in PTs at risk aspiration of oropharyngeal content
What are the avenues of aspiration pneumonia?
-Aspiration of food and liquids during the swallow
-Aspiration of oropharyngeal secretions
-Aspiration of emesis
risk for aspiration PNA increases if pt has..
-dysphagia
-Poor oral care (bacteria colonization)
-Reduced respiratory drive for adequate cough
-Reduced spontaneous swallowing frequency
-Reflex
-Anatomical deviations in the upper aerodigestive tract
-Various health conditions, increase risk for generalized weakness and deconditioning
-Age (65+)
What influences the risk for the development of PNA
-frequency, type & amount of aspiration
-excessive bacteria increases risk for resp. infection
-leading cause of death in pt’s w/ dysphagia 2ndary to neuro diseases/ conditions
What are the TX options for aspiration PNA?
-Antibiotics
-Dysphagia evaluation / tx for prevention of recurrence
-Collaboration with RD (registered dietitian) to facilitate improved nutritional status and subsequent stronger immune function
-Physical therapy for pulmonary toileting
What is COPD?
-Chronic Obstructive Pulmonary Disease
-group of resp diseases that causes airflow blockage & breathing related problems
~Emphysema (airsacks are damaged)
~Chronic bronchitis
~Asthma
~Cystic fibrosis
-3rd leading cause of death and 5th leading cause of disability worldwide
-Complicated by Chronic Heart Failure (CHF) in 20-30% of patients
What are the swallow impairments for dysphagia & COPD?
-Reduced hyoid excursion
-Earlier and longer airway closure durations (reduced breath swallow coordination)
-Earlier airway closure time relative to PES relaxtion onset (increasing risk for mistiming of swallow)
-Oropharyngeal and pharyngeal swallow delay due to muscular weakness
-Ineffective cough reflux
What are the GERD and COPD complications?
-GERD can increase risk for acute exacerbation of COPD
-COPD meds cause relaxation of LES pressures, thus patients with COPD are at greater risk for GERD
-Pathological Reflux scores is 62% of patients w/ COPD
Half reported NO GERD symptomology
postsurgical dysphagia results in…
-Edema
-Interference to the peripheral nerve supply to the muscles of swallowing (e.g, endarterectomy, throidectomy, and cervical spinal fusion)
-Loss of central nervous system (brainstem) innervation (posterior fossa and skull base sx), affecting peripheral CNs (V, VII, IX, & XII)
-Replacement of swallowing structures that also interfere w/ peripheral cranial nerves
What are cardiovascular SX?
-reconstruction of cardiac valves
-damage/ trauma to CN X (vagus)
-causing vocal fold paralysis w/ dysphagia
-Additional complications
~Prolonged intubation
~Tracheotomy
What are the cervical spinal cord injury complications?
-sustained brain injury
-intubation
-tracheotomy
What is ACDF and Cervical Halo?
-anterior cervical diseconomy & fusion
-Surgery is approached through the anterior neck to get to the cervical spine.The target spinal disc is removed from between two vertebral bones. Afusion involves placing bone graft and/or implants where the disc originally was in order to provide stability and strength to the area.
-Leaves patients with cervical spinal hardware
-hyperextended cervical posture, increase risk for tracheal aspiration
what is anterior cervical osteophytes?
-Bone spurs of the cervical spine, ranging from C1 vertebra to C7 vertebra
Primary cause: degeneration, trauma
-Obstruction of bolus flow, oropharyngeal and esophageal depending on location of osteophytes
~Can impact airway protection and bolus flow
At C3 level – aspiration usually occurs during the swallow
At C6 level – aspiration usually occurs after the swallow
-Tx options: diet modifications, aspiration precautions, compensatory strategies, postural changes, surgery (ACDF)
What is the postural change of cervical lordosis and kyphosis ?
-Narrows pharyngeal space
-Reduces laryngeal elevation
-Subsequent risk for penetration / aspiration
Severe trauma injuries in the …
-spinal
-Cortical
-Bones
laryngeal skeleton (comprises airway, vocal fold injury)
mandibular fracture (affecting oral acceptance/oral phase)
-Proximal esophageal injury from blunt trauma to the neck
-Dental Trauma (affecting oral preparation and delivery)
-Thermal Burn Trauma
-Respiratory supports
~Intubation
~Tracheostomy
Medications
-Side effects:
~Cognition
~State of arousal
~Motor performance
~Xerostomia (dry mouth)
~Gastrointestinal function (GERD)
-Antipsychotics, anticonvulsants, opioids (e.g., morphine), and antianxiety (e.g., diazepam and clonazepam) meds:
~May affect state of arousal and motor performance
-Long-term use of antipsychotic drugs may result in tardive dyskinesia (uncontrollable, repetitive, regular movements of the tongue and lips)
~Interferes with oral preparatory and oral initiation stages of swallowing
how to determien Symptoms of dysphagia ?
-any change in bodily function that the patient notices
-Patient interview
-Reliable/ standardized questionaires
~EAT-10 (QoL & swallowing Sx)
~Burke Dysphagia Screening Test (stroke)
~ SWAL-CARE questionnaire
What to ask in patient interview of dysphagia sx:
-quetioning disorder beyond localization to imporve accuracy
-obstruction
-liquid vs. solid food
-avoidance of certain foods
-GERD
-eating habits
What is respiratory rate? (vital signs/ lab ranges)
-# of breaths per minute
-normal RR: 12 - 20 breaths per min
-RR under 12 or over 25 while resting = abnormal
-impacted by: asthma, anxiety, PNA, CHF, lung disease, use of drugs
What is oxygen Saturation ?
-% of O2 bound to hemoglobin
-96-100% = NORMAL
- less than 90% = hypoxemia
What is WBC?
-white blood cells
-help fight infection
-4300-10800/ mm3 normal range
What to check for during Oral Cavity Inspection…
-Oral candidiasis (milk white appearance)
-Xerostomia: dry mouth
-Oral mucositis
~Edema/erythema
~Mouth sores
-Secretions
-Dentition
~Edentulous?
~Missing dentition?
~Decaying dentition?
~Dentures? (full or partial)
-Clean, moist mucosa? Is oral care indicated?
What is Biofilm in the oral cavity and how to care for it?
-Groups of bacteria that rapidly reproduce on wet surfaces and fight together against host defense mechanisms
-Large amounts of bacteria found are in dental Biofilm-due to ideal surfaces and environment
-BRUSHING is very important as it breaks down biofilm barrier
-Swabs or mouth wash/rinse alone
may not be effective in breaking biofilm barrier down.
How to perform an Oral Exam?
-LIPS & MOUTH
~Cracking, lesions, ulcers, swelling, discoloration, redness
-BUCCAL MUCOSA
~abrasions, moisture, discoloration, hygiene
-TONGUE/FLOOR OF MOUTH
~Color, size, symmetry, coating, lesions, deviation, tremor
-PALATE
~Symmetry, lesions, coloration
-GINGIVA (gums)
~Color, bleeding, swelling, food impaction
-TEETH
~Visible decay, loose teeth
Bedside observation / assessment
-Anterior spillage of the bolus
-Bolus acceptance (ataxic oral motor movements?)
-Bolus manipulation (oral holding?)
-Bolus formation/a-p propulsion (any oral residue post initial swallow?)
-Timing of swallow initiation
-Hyolaryngeal excursion on palpation
-Overt s/s of laryngeal penetration/aspiration
-Respiratory drive (adequate cough strength, if present?)
-Audible belching (wet/dry?)
-Any patient c/o oropharyngeal or esophageal dysphagia symptoms during PO trials?
-Feeding behaviors
What are the s/s of laryngeal penetration/ aspiration ?
Coughing
Choking
Throat clearing
Sneezing
Watery eyes
Runny nose
Wet vocal quality
SOB or respiratory distress (e.g., wheezing)
Increased respiratory rate
Drop in oxygen saturation
What to look for in pt behaviors during feeding eval?
-Easily distracted?
~Is the patient talking while eating?
~Is the patient patient attention to the television, affecting cervical posture and increasing risk for mistiming due to inattention?
-Self-feeding?
~Are they impulsive?
~Can the patient use utensils to transport food to mouth?
~Do they need 1:1 assistance?
-Able to maintain upright positioning during meals and after meals? (aspiration and reflux precautions)
~Do they need external support
-Eating/drinking?
~Are they on the safest diet?
~Do they demonstrate fatigue while eating/drinking?
~Are they maintaining adequate nutrition/hydration?
What is the purpose of instrumental assessments?
-Imaging of the upper aerodigestive tract, oral cavity, velopharynx, pharynx, larynx, pharyngoesophageal segment, and esophagus
-Assess movement patterns of swallowing-related structures
-Identify and describing any airway compromise (aspiration, penetration) and the circumstances under which these events occur
-Evaluate of the effectiveness of compensatory strategies
-Identify and describe secretion management
-Complete a cursory eval of esophageal A&P.
-Assist in forming clinical recommendations
-Referrals to medical specialist, other medical tests/procedures or further
-speech pathology services as appropriate
What are the objectives for MBSS?
-Obtain a video image of the upper aerodigestive tract and esophagus during swallowing
-Evaluate anatomy and physiology of the dynamic swallow function
-Identify structural abnormalities and impaired physiological components of the dynamic swallow function
-Evaluate the effectiveness of compensatory strategies
-Confirm pt symptoms
-Assist with development of POC
-Referrals to medical specialist, other medical tests/procedures
What observations to look for during MBSS?
a. Labial closure
b. Mandibular motion and mastication efficiency
c. Lingual ROM and coordination for lingual hold, onset of bolus propulsion, elevation and seal, lateral control and anterior to posterior bolus propulsion.
d. Tongue base retraction (apposition of the tongue base to the pharyngeal wall)
e. Velopharyngeal closure
f. Timing of pharyngeal complex response relative to bolus location
g. Pharyngeal muscle contraction
h. Timing, excursion and duration of laryngeal elevation
i. Airway protection at supraglottic and glottic levels
j. Epiglottic movement for vestibular closure
k. Pharyngeal stripping wave
l. Pharyngoesophageal segment opening
m. Presence of upper esophageal clearance or retention; only the proximal 1/3 of
the esophagus should be viewed.
What are the indications for FEES
-Transport to radiology is risky; a medically fragile patient
-Fluoroscopy is not available
-Patient is obese
-Positioning patient in fluoroscopy chair is too difficult
-There is a concern for radiation exposure.
-Patient has severe dysphagia and needs a conservative exam, i.e.; brainstem CVA or NPO for prolonged period
-There is compromised pulmonary clearance and need for a conservative exam
-There is a question of aspiration of secretions
-The larynx needs to be visualized (i.e. the voice suggests laryngeal involvement or if there are anatomical changes/laryngeal trauma/ post intubation etc.)
-Need to visualize velopharyngeal competence
-Sensation in the laryngopharynx needs direct assessment
-Biofeedback is needed in therapy
-The Modified Barium Swallow does not answer all the clinical questions (need increased sensitivity to microaspiration)
-There is an allergy to barium
Patients who may not be appropriate for a FEES include..
-anxious pt
-Pt’s post surgery to the nose
-Nasopharyngeal trauma/obstruction, significant edema, significant erythema/irritation
What are potential complication & risks w/ FEES?
Discomfort
Gagging
Nosebleed
Allergic reaction to topical anesthetic, if used
Laryngospasm
Vasovagal response
What are Surgical Treatment options?
-Improved glottal closure, enhancing airway protection
Medialization thyroplasty
Injection of biomaterials
Stents
Laryngotracheal separation
Total laryngectomy (extreme approach) (would need to add a stoma)
Pharyngeal Esophageal Segment Opening
Dilatation
Myotomy
Botulinum toxic injection to relax and open the PES
List therapy techniques…
-Supraglottic swallow (compensatory strategy or rehab exercise)
-Super-supraglottic swallow (compensatory strategy or rehab exercise)
-Mendelsohn maneuver (compensatory strategy or rehab exercise)
-Effortful swallow (compensatory strategy or rehab exercise)
ral motor exercises
-Tongue-hold maneuver
-Head-lift exercise (Shaker exercise)
-Chin tuck against resistance (CTAR)
What are compensations / compensatory strategies?
-short term
-adjustments to posture, food, & feeding behaviors for safe oral intake
-no rehab impact & no lasting effect on functional swallowing
What are body posture adjustments?
-No single posture improves swallowing function in all patients
-Lying down : increases hypophayrngeal pressure on bolus
-side-lying: on stronger side
What is extension?
-head posture adjustment
-raises chin
-Widens oropharynx
-Assists with passage of bolus from oral cavity to pharynx
-Must have adequate pharyngeal function and airway protection
-Increases intraluminal pressure (less relaxation), decreasing duration of PES relaxation
What is flexion?
-head posture adjustment
-chin tuck
-Oropharyngeal narrowing
-Helps patients with a delayed swallow, increases airway protection, and reduced base of tongue movement.
What is rotation?
-head posture adjustment
-head turn
-Unilateral pharyngeal deficit
-Narrows and closes the swallowing tract on the side toward which the head is turned.
-Facilitates an increase in amount swallowed with less residue, reducing risk of airway compromise
What is head tilt?
-head posture adjustment
-Tilted towards the healthy side (~45 degree angle)
Widely used with patients with unilateral oral or pharyngeal weakness
When the head is tilted, food flows toward the direction of head tilt or towards the stronger side
How to modify volume & speed of food/liquids presentation?
-Smaller bolus size
~Teaspoon size bolus (5 ml)
-Slower rate of swallowing
~Encourage frequent breaks if experiencing increased WOB (work of breathing) and fatigue during meals.
How to modify diets/ thicken liquids
0- Thin Liquids –>fast
1- Slightly Thick –> thicker than waater/ more effort
2- Mildly Thick (nectar thick liquids) –>flow off spoon/ effortful
3- Moderately Thick (honey thick)–> consumed via cup/spoon
IDDSI 4- Pureed Solids–>not chewing/ no lumps
IDDSI 5- Minced & Moist Solids–> small lumps/ fork smash
IDDSI 6- Soft, bite sized –>bite sized pieces/ no liquid leak from food
IDDSI 7- Regular Diet –>normal food age approrpriate
What can dehydration cause?
Change in drug effects
Lethargy Constipation
Infections
Poor wound healing
Pressure sores
UTI’s
Altered cardiac function
Acute renal failure
Weakness
Declining nutritional intake
Confusion
What is free water protocol?
-Pt allowed ice chips or regular water w/ supervision, and with strict aspiration precautions
-Pt & caregivers express concern that long-term orders for thickened liquids or tube feedings without an option for water or ice chips denies basic drive to refresh the senses.
-Water is a clear neutral ph and is compatible with other body fluids.
-If water is aspirated, it will be absorbed by the lung mucosal tissues without harm.
-Per SLP clinical judgement
What is swallow rehab?
-exercise
-Can improve bolus acceptance/containment as well as bolus formation, control, and propulsion
-Can improve tongue base retraction, pharyngeal constriction, hyolaryngeal elevation and excursion, vocal fold adduction, PES opening
-Can improve overall airway protection and oropharyngeal and pharyngoesophageal bolus passage / clearance
range of motion and strengthening exercise to what areas?
Labial
Mandibular
Lingual/tongue base
Larynx
Vocal cords
What is thermal tactile stimulation?
-Short-term effect on swallow timing (does not equate to therapy outcomes)
-May stimulate swallow initiation. Reported benefit in patients with dysphagia from neurologic deficit
What is surface electromyography biofeedback?
-Non-invasive method to objectively measure muscular patterns and activity during swallowing. Multiple muscle groups can be assessed at the same time.
-provides immediate information about the timing and intensity of muscle activity
What is neuromuscular electrical stimulation ?
imulates motor and sensory nerve fibers via small electrical currents, enhancing the strength of the muscles associated with swallowing and facilitating reflexive swallowing
Tracheostomy is at high risk of…
-aspiration due to:
Loss of subglottic air pressure
Loss of upper airway sensitivity because of airway bypass
Loss of normal laryngeal closure reflex
Muscle weakness
Extent of respiratory illness (breath-swallow incoordination)
Mental status fluctuations
What are the benefits of PMV?
-Improvement in voicing/speech production
-Restoration of smell, taste
-Improves subglottic pressure, sensation, and pt ability to cough/clear secretions, improving swallow function and secretion management
-Improved normal pattern oxygenation
-Step towards tracheostomy weaning and decannulation
-Improved quality of life
What are side effects for chemoradiation tx?
-fatigue
-nausea/vomit
-mouth sores/mucositis
-odynophagia
-xerostomia
-loss of appetite
-weak immune system
-redness /irritation of skin
-tissue necrosis
-hair loss
-altered taste & smell
-dental problems
-edema errythema
-dysphagia
-fibrosis
-neuropathy
What are 4 common swallowing issues post surgery?
partial glossectomy
total glossectomy
palatal resection
total laryngectomy
What to do during H&N cancer eval/tx?
-Pre-treatment evaluation strongly recommended
-Ongoing evaluation during/after treatment to assess for side effects and adjustment tx methods accordingly
-Identify underlying cause of swallowing difficulty
-Monitor weight/oral intake to ensure adequate nutrition/hydration – work with RD (registered dietitian)
-Engage in swallow-related exercises before, during, and after radiation treatment to reduce risk of fibrosis and disuse dysfunction.
-Provide education on oral care
what to use during xerostomia
Biotene, Salivart, Xero-Lube, Oralbalance, Magic Mouthwash/ humidifier
NOT use:
-vaseline
-glycerin swab
every liter of exygen supplied, FiO2 increases by…
-4%
-room air =21%
-Nasal Cannula:
1 L/min flow rate can increase FiO2 to 24%,
2 L/min to 28%
3 L/min to 32%
4 L/min to 36%
5 L/min to 40%
6 L/min to 44%.
supplemental oxygen
Nasal Cannula
-1-6 L/min
Moderate Flow Nasal Cannula
-7-15 L/min
High Flow Nasal Cannula
-Up to 60L/min, 100% FiO2
-Facilitates improved communication, compared to BiPAP
-Increased risk for breath-swallow coordination and aspiration/microaspiration
What is a BiPAP?
Reduces the patient’s work of breathing and increases the functional residual capacity (FRC) of the lungs (FRC is the volume of air left in the lungs at the end of exhalation)
A mask or nasal plugs are connected to the ventilator. The machine supplies pressurized air into your airways
2 PRESSURE SETTINGS: - inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP)
What is COVID 19?
-infectious disease /virus
-Mild to moderate illness - recover without requiring special treatment.
-Severe illness - respiratory failure, lasting lung and heart muscle damage, nervous system problems, kidney failure or death.
-Older individuals and those with underlying medical conditions, such as cardiovascular disease, diabetes, chronic respiratory disease, or cancer are more likely to develop serious illness.
-Medication is prescribed to reduce inflammation, with antiviral activity for hospitalized patients on mechanical ventilators or who require supplemental oxygen
What are the COVID-19 symptoms?
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
Hypoxia
Hypoxemia
