wk3 speech-language therapy & Airway clearance

Question 1

4 key role of speech-language therapy in acute care

Answer 1

1. maximize person’s ability to communicate
2. assess and manage swallowing disorders, minimising risk of aspiration pneumonia
3. develop plan for communication and/or swallowing rehabilitation
4. education and support for family and health care team

Question 2

Who needs to be seen by an SLT?

Answer 2

1. Anyone with communication difficulties

2. Anyone with swallowing difficulties

Question 3

problems associated with dysphagia for both short term and long term

Answer 3

Short term
-coughing, chocking
Long term
- malnutrition, dehydration, aspiration pneumonia, lung damage, death

Question 4

xx % of stroke patients have dysphagia

Answer 4

44%

Question 5

The more severe the dysphagia, the more likely it is to be ?

Answer 5

silent - could become very serious problem

Question 6

assessment tools for dysphagia

Answer 6

• Cranial nerve test
• cough reflex testing - citric acid via nebuliser. 3x15 sec/trials. need > 2 coughs in > 2 trials
• Cervical auscultation - compare pre/post swallow pharyngeal sound
• Bronchial auscultation
• FEES - direct visualisation of pharynx

Question 7

What is role of PT in patient with dysphagia

Answer 7

support with positioning, use of affected arm in feeding, auscultation

Question 8

Risk of aspiration pneumonia is higher if

Answer 8

aspirated material is food or thick fluid

Question 9

management of dysphagia

Answer 9

diet modification
position changes - upright, support weak side
bolus change (small mouthful amount, salt / pepper to activate more sensation to help with swallowing)
supervision with oral intake

Question 10

5 golden rules of of communication with patient with aphagia

Answer 10

1. use gesture
2. speak simply, breaking instructions down
3. allow time for the person to respond
4. always have a pen and paper at hand
5. minimise distractions - noise, light, people, TV

Question 11

Airway clearance techniques (ACT)

Answer 11

• ACBT (combined GAD and/or manual technique)
• PEP + oscillating PEP
• HFCC (high-frequency chest-wall compression)
• autogenic drainage
• supported coughing
• assisted coughing

Question 12

What does ACBT consist of?

Answer 12

• BC
• TEE
• FET

Question 13

Rationale for PEP device

Answer 13

1. obtain temporary increase in FRC
2. allow collateral ventilation to recruit alveoli
3. Gets air behind secretions
4. use FET to mobilise and clear secretions

Question 14

PEP- evidence

Answer 14

many studies in chronic sputum production population
-reduced exacerbations
-reduced antibiotic use
-preserved lung function
-decreased morbidity
(Christensen et al, 1990; Mcllwaine et al, 1997)

Question 15

method of PEP

Answer 15

1. sit lean forward with elbow supported, holding device
2. 5-8 breaths slightly larger than TV
3. breath hold at the end of inspiration if possible
4. slightly active expiration against the device
5. Aim to increase FRC across the cycle i.e. pumping up
6. Huff through device
7. BC at the end of cycle

• aiming to leave airways as open as possible

Question 16

Evidence of using ACBT, PEP and autogenic drainage in patient with cyctic fibrosis

Answer 16

Consider the active cycle of breathing techniques when
recommending an airway clearance technique for adults
with cystic fibrosis. (Grade A)

Consider autogenic drainage when recommending an air-way clearance technique for adults with cystic fibrosis.
(Grade A)

Consider positive expiratory pressure when recommending an airway clearance technique for adults with cystic fibrosis.
(Grade A)
(Bott et al, 2009)

Question 17

Evidence of combined standard physio therapy, ACT and FET

Answer 17

It has been suggested that standard physio therapy with Active Cycling of breathing and Forced expiratory technique is more effective than Chest physiotherapy alone. (Fink, no date)

Question 18

Evidence of PEP therapy with FET in patient with COPD

Answer 18

4 week PEP therapy with FET significantly increased diffusing capacity and 6MWTD, and reduced coughing difficulty compared to FET only in COPD patient with mucus hypersecretion. (Su et al, 2007)

Question 19

Which sputum clearance technique can we use for patient without coughing ability due to neurological condition

Answer 19

Assisted cough -deep breathing (px) + passive push (PT)
- incr build up of intra-thoracic pressure
- incr forced expiration
Cough Assist Device (CAD)

Question 20

Who might get benefit from assisted cough / CAD

Answer 20

predominantly neuromuscular weakness population
e.g. spina bifida, muscular dystrophy, SCI, CP, patient who are drowsy/ hypoventilating post-op
over-narcosed patients with secretion retension

Question 21

evidence of CAD use

Answer 21

prevention or reversal of oxyhaemoglobin desaturation
reduces number of hospitalisation
reduces length of hospitalisation
Morrow et al, 2012

Question 22

Types of humidification / nebuliser

Answer 22

Humidified oxygen
nebulised bronchodilators
nebulised saline (normal saline 0.9%)
hypertonic saline
mucolytic agents

Question 23

evidence of using nebulised bronchodilators for sputum clearance

Answer 23

using nebulised beta 2 agonists prior to treatment enhances sputum clearance
Pasteur et al, 2010

Question 24

evidence of using ‘normal’ saline for airway clearance

Answer 24

-Sterile water inhalation may be used before airway clearance to facilitate clearance.
- use of nebulised normal saline prior to airway clearance could be considered to increase sputum yeild, reduce sputum viscosity, improve ease of expectoration
Pasteur et al, 2010

Question 25

evidence of using 'hypertonic saline' prior to airway clearance

Answer 25

increase sputum yield, reduce sputum viscosity, ease expectoration (Pasteur et al,, 2010) increase ciliary transport of sputum increased lung function (pryor and prasad 2008)

Question 26

Precautions of using hypertonic saline

Answer 26

- may induce bronchospasm | - when first dose, record PEFR or FEV1 pre and 5 mins post inhalation

Question 27

AIm of Mucolytic agents

Answer 27

change physical properties of sputum | reduce oxidative stress/lung damage

Question 28

evidence of using mucolytic agents

Answer 28

``` reduced number of exacerbations reduced number of hospitalisation improved lung function improved QoL Davies & Calverley, 2010) ```

Question 29

evidence of using mucolytic nebulizers in CF population

Answer 29

breaks down the DNA in sputum/ mucus reduces its viscosity promotes improved clearance of secretions Bott et al, 2009

Question 30

evidence of 'timing[ of using mucolytic nebulizer in CF population

Answer 30

30mins before airway clearance may be more beneficial than inhalation after the airway clearance. But lack of evidence. Dentice and Elkin, 2011

Question 31

evidence of physical activity in patient with CF

Answer 31

exercise alone should not be used as an airway clearance. | addition of physical activity to chest physiotherapy significantly improves lung function compared to PT alone