Week 8 Flashcards
What is the difference between treatment, compensation, and management?
Treatment requires actively changing the swallow. Target is changing the strength, timing, and/or coordination of the swallow to make it safer/more efficient.
Compensation is a “Band-aid” approach. No change in the physiology, but manipulation of a feature to make swallowing safer and more efficient
Management reduced the impact of dysphagia and the manifestation of its sequelae (aspiration and pneumonia)
What are the specific risk factors for developing aspiration pneumonia?
Dependent for feeding Dependent for oral care Number of decayed teeth Tube feeding More than one medical Dx Number of medications Smoking
Aspiration of what liquids most likely does less damage than what other liquids?
Thin liquids probably do less damage than thick
What is better to aspirate? neutral or acidic and fat based items?
Neutral
In what condition are oral bacteria worse?
Dry mouth/xerostomia
When might stomach contents be aspirated?
Reflux
Vomiting in the medically compromised
What are the different types of oral care tools and their effectiveness?
Lemon glycerine swabs - not effective! has a drying agent that promotes xerostomia
Toothette - not very effective
Toothbrush - yes! even better with suction, most expensive
Chlorhexidine mouthwash - effective! MD prescribed manages bacteria. More powerful than Listerine. NOT GOOD FOR PTS WITH ASPIRATION. ALSO, DO NOT USE WITH IMPULSIVE PTS
What is the free water protocol?
Allowing pts who are on thickened-liquids to have water between meals AFTER oral care
Why have a free water protocol?
- Not all who aspirate thin liquids will develop pneumonia and prescribed modified diets can be unnecessarily restrictive.
- Pts do no like drinking thickened liquids and are noncompliant
- Potential for increased aspiration risk of thickened liquids post swallow due to pharyngeal residue
- Increased risk for AP or death when aspirating thickened liquids
- Limited empirical evidence of medical effectiveness of fluid viscosity modification
The greatest concern is those on thickened do not consume enough fluids
What are factors to consider for free water protocols?
Supplies/staff/support for oral care Cognition Compliance Impulsiveness Health status Ambulatory status
When should 1-to-1 feeding assistance/observation be performed?
Reduced alertness or attention
Difficulty following directions
Impulsive
What are the types of assistive devices for dysphagia?
Cups (provale, nosey)
Spoons
Non-slip pads
Straws (regular vs. diameter adjusted)
What are different bolus delivery compensation?
Multiple swallows per bolus Alternate liquids and solids (clear pharyngeal residue) Feed only when alert Reduce distractions Needs verbal cues to use recommended strategies Small sips and bites when eating Slow rate; pacing Clearing swallow b/t sips/bites No straw (controversial) Sips by straw only (controversial)
What is the positioning for all pts with dysphagia?
Upright during all PO
What is the positioning for all patients with confirmed (or even suspected) residue?
Remain upright for 30 minutes post-PO
Other than PO, when is it also important to take heed to position?
Oral care
Bacteria being dislodged has the potential to be aspiration
How does positioning increase bolus flow?
Used to redirect the bolus to improve safety or efficiency
What are the types of bolus flow positioning techniques?
Lateral tilting
Anterior tilting (chin tuck)
Posterior tilting
Head/neck rotation
Lateral tilting of the head
Bolus flow will be directed through the oral chamber biased to the downhill side; enter the pharynx on the downhill side, BUT will travel through the pharynx unaltered
Physiological targets - Unilateral impairment of lingual movement, sensation or anatomy
Anterior tilting of the head (chin tuck)
Keeps the bolus in the mouth until actively compressed by the tongue; compresses the airway closed
Physiological targets - Premature spill, poor airway closure, penetration/aspiration before and/or after the swallow
What are precautions for chin tuck?
If there is a lot of post-swallow residue, chin tuck may push more residue into pharynx.
Must test with instrumentation
Posterior tilting of the head
Facilitated oral transit of thicker consistencies using gravity; pt must have adequate airway protection (puts into a vulnerable position
Physiological targets - impaired anterior-posterior bolus transport but with good airway protection
Head rotation
Maximal rotation to the weak side will compress the weak side and divert the bolus to the more functional side; it will also decrease or eliminate weaker piriform sinus
Physiological targets - unilateral impairment in pharyngeal constriction and/or UES opening; unilateral post-swallow residue.
EX. Impairment on left, look maximally to the left
What are types of bolus manipulation?
Temperature Taste Size Carbonation Viscosity
What is the most common compensatory strategy used in clinical practice?
Bolus viscosity
Rationale: Thin moves quickly, thicker allows more time to swallow safely. Less agility and control needed than thin liquids
What are the caveats of bolus viscosity?
Thicker liquids are more likely to cause residue
Thicker liquids have more potential for airway obstruction
Thicker liquids have SERIOUS consequences for QoL and patient compliance
What is enteral feeding?
Delivery of food directly to the GI tract
AKA ‘tube feeding’
Does enteral feeding prevent aspiration?
No.
- Saliva
- Reflux
What are the types of feeding tubes?
Nasogastric Nasoduodenal Nasojejunal Gastrostomy (G-tube) Jejunostomy Total parenteral nutrition
All nasal-enteral feeding must…
be confirmed w/ x-ray for placement
can cause sinusitis
