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339 Cards in this Set

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What do screening procedures give you?
Indirect information abou thte presence of a swallowing disorder but NOT about physiology. They tend to identify some signs/symptoms (coughing, history of pneumonia, food coming back out trach)
What is the purpose of a screening?
To identify patients at high risk for aphasia who are in need of an in-depth physiological assessment
What is the 3-Oz water test and the Timed Swallowing Test?
They are screening procedures that require the patient to swallow larger amounts of water. Beware of these because the patient may be aspirating!?
What are some statistical characteristics of screenings?
Sensitivity - the procedure identifies those individuals who are aspirating or have residue (true positives) Specificity - the procedure identifies patients with none of the symptoms (true negatives) * The procedure should NOT have a lot of false negatives or positives. Unfortunately at this point the ones with more true positives also give more false positives - they overidentify.
What are some red flags for individuals you can't interview? For example, if you are screening those with developmental delays…
1. Rejection of food - the body protecting itself 2. Food selectivity - we cut out difficult foods 3. Gagging - oral hypersensitivity / abnormal sensation
What are the twelve categories of information you can get from a Bedside/Clinical evaluation?
1. Medical Information 2. Patient's Medical Status 3. Oral Anatomy 4. Respiratory Function 5. Labial Control 6. Lingual Control 7. Palatal Function 8. Pharyngeal Wall Contraction 9. Laryngeal Control 10. Ability to Follow Directions / Self-Monitor 11. Reaction to Oral Sensory Information 12. Reaction to Symptoms During the Swallow
What types of information do you get from the clinical evaluation regarding MEDICAL HISTORY?
The patient's current medical diagnosis, History of swallowing disorders.
What types of information do you get from the clinical evaluation regarding the patient's MEDICAL STATUS?
The patient's nutritional intake (oral? Feeding tube?), and respiratory status (trach?)
What are the two parts of the bedside/clinical evaluation?
The preparatory exam (no swallowing) and the initial swallowing examination
What do you do during the preparatory exam in the bedside evaluation?
Conduct a chart review to determine: respiratory status, history of swallowing problems, current and past medical problems, current and recent medications, history of the swallowing disorder, airway devices, nutritional intake
What are you looking for when you check which medications your patient is on?
Whether any of them cause dry mouth, reduced alertness, or delayed reaction time (and therefore likely to cause swallowing problems)
What do you need to know about the history of the swallowing disorder?
1) Time and nature of onset 2) Coughing, food "catching" 3) Difficult and Easy foods 4) Patient's general awareness / perception of problem
What do you need to know about airway devices during the chart review?
Presence, type, duration, and method of placement
What do you need to find out about nutrition intake during the patient chart review?
Is it oral or non-oral? If is it non-oral: type, duration, adequacy, and complications of feeding tube. If oral: any complications?
What observations should you make when you enter the patient's room?
1) Patient's posture in bed 2) Alertness/reaction to your presence 3) Is there a trach? (Is patient aware of it? How does the patient handle the tube/secretions?) 4) Does the patient follow directions well?
What should you find out about the patient's respiration during the bedside/clinical eval?
Is the patient in respiratory distress? Respiratory rate at rest? Timing of saliva swallows Timing of coughing in relation to swallowing/respiration Duration of comfortable breath hold Patients resting breathing pattern (oral or nasal?) If oral - CAN the patient breath nasally?
What is the normal timing of swallowing in relation to respiration?
Usually, 60-80% of people inhale, swallow, exhale. The swallow should NOT interrupt inhalation because if you inhale immediately after the swallow you may aspirate.
What are the reasons for placement of a tracheostomy tube?
1) Upper airway obstruction above or at VF 2) Potential airway obstruction due to edema following surgery 3) Provision of respiratory care
Where is a trach usually placed?
Between 3rd-4th tracheal rings. In emergencies it may be placed as high as the 2nd - can scar the larynx!
What are the three parts of a tracheostomy tube?
1) Outer canula - holds the airway open 2) Inner canula - taken out for cleaning 3) Obturator - only for initial insertion (surgeon)
What are two options for weaning a patient off a trach?
1) Place a smaller tube. From an 8 to a 4 or 6 which encorages a combination of oral/nasal breathing and breathing through the trach. 2) Then, once patient is tolerating smaller tube, plug entrance with obturator or cap for longer and longer periods of time so that patient has to breath through mouth/nose.
Can you talk with a trach in place?
Yes, if you plug the outer end it will force air around the trach and up through VF. It will be less air than normal so the patient's voice will likely be softer and more breathy.
When is a cuffed trach placed?
1) When there is a need for respiratory treatment 2) When there is potential for aspiration of secretions.
What are the dynamics with an inflated cuff?
1) The cuff contacts the tracheal walls 2) It keeps material from entering larynx from about the cuff 3) This is necessary for mechanical ventilation operating on positive pressure
What can happen if the cuff is overinflated on the trach?
1) If can irritate the tracheal wall and cause tracheal stenosis 2) Can prevent re-learning to swallow because it restricts laryngeal elevation, reduces laryngeal sensitivity, places pressure on the front wall of the esophagus.
How can you ensure that the cuff of the trach is not overinflated?
MINIMAL LEAK TECHNIQUE: 1) Inflate the cuff fully until no air comes out, the take 1-2 cc of air out, allows a minimal leak. 2) This will prevent tracheal stenosis but may allow some aspiration!
If a cuffed trach is present for more than 6 months, what complications may result?
1) Greater scar tissue 2) Reduced VF closure because of restricted sensory input to the underside of the VF. 3) Cuff may not protect against all aspiration due to a misfit.
What are some reasons you may use a fenestrated trach?
1) If patient has trouble voicing, it will allow for greater airflow. 2) May be used in patients who are close to weaning off the trach. 3) Not generally used in patients with cuffed trach but maybe if patient no longer need the cuff inflated.
What are the things you need to find out about the patient's tracheostomy?
1. Is it cuffed - if so, is the cuff inflated? 2. What is the size of the tube? 3. Is the tube fenestrated or not? 4. How long has the trach been in place? 5. Is it medically feasible to deflate the cuff - best to do this for MBS or bedside because it restricts laryngeal elevation.
When a patient has a trach, what steps need to happen during swallowing?
1. DEFLATE THE CUFF if medically feasible 2. Teach the patient to cover trach with gauze or gloved finger during swallow and a few seconds after. Can also use a one-way valve if the patient tolerates it.
Why do you have the patient cover the outside end of the trach during a swallow?
It is found to improve the swallow by redirecting air through the larynx - creates more normal level of subglottic pressure, stimulates underside of the larynx, patient exhaling through VF after swallow will help clear residue. SOME STUDIES have should that this reduces or eliminates aspiration - check it radiographically.
IN ventilator-dependent patients, what considerations do you need to make?
1) If OTT and PTT are slow, they may not fit into the exhalation time allowed by the ventilator 2) Be sure to present food at the start of exhalation 3) Vent. patients usually have cuffed trach - possibly reduces laryngeal elevation and reduced closure of airway entrance.
What is the Blue-Dye Test?
A screening test for the presence of aspiration in trach patients
What are the steps of the blue-dye test?
Give the patient food dyed blue, suction trach immediately to check for the presence of blue material. If so, then the patient has aspirated. Then you know to do an MBS!!
Why are patients intubated? What things do you need to consider?
Placed in an emergency situation to set up a more stable airway. If it is left in place for days or weeks, laryngeal pathologies may develop (edema, redness, nodules/polyps, unilateral adductor paresis or paralysis). TE fistula may develop around the bottom edge. You do NOT conduct swallowing therapy while a patient is intubated. Following removal, there may be reduced ROM for up to a week.
What are some things you need to find out about the history of the swallowing disorder?
1) Was the onset gradual or sudden? 2) Do difficulties vary with food consistency? 3) What happens when the patient tries to swallow? Does material catch? Coughing? Can patient indicate where the food is collecting? 4) Notes on patient reliability - does the patient know about he swallowing disorder? Patients who are aware are usually reliable in identification and description (oropharyngeal SD only) 5) Ask the patient to demonstrate swallowing
When you watch the patient eat (assuming he or she is already eating…) what should you do?
1) Look for signs/symptoms 2) Does the patient take too much food? 3) Does the patient position food correctly in the mouth?
During the examination of oral anatomy, what do you examine?
You observe: lip and hard palate configuration; soft palate and uvular dimensions (relative to posterior pharyngeal wall); anterior and posterior faucial pillars; lingual configuration; adequacy of anterior and lateral sulci; scarring/assymetry; status of dentition and oral secretions; whether mouth is moist or dry
Following the anatomical examination, you conduct what?
An Oral-Motor Examination
What three things do you look at in the oral-motor examination? For what structures? What functions?
RANGE, RATE, and ACCURACY of movement For the lips, tongue, soft palate, pharyngeal walls. You do this during speech, reflexive activity, and swallowing.
What are the specific tasks you check during the oral motor examination?
1) Ability to open mouth voluntarily 2) Bite reflex 3) Identification of optimal oral-sensory stimuli and bolus 4) Identification of and compensation for swallowing apraxia 5) Identification of and compensation for abnormal oral reflexes 6) Labial function 7) Lingual function (anterior and posterior tongue motion) 8) Chewing function 9) Soft palate function and oral reflexes 10) Oral sensitivity examination
What can you do if the patient has trouble opening mouth?
The patient may need oral massage - give a rotary massage of the cheek on one side and give firm downward pressure on the chin. Give continuous verbal reinforcement.
How do you check the bite reflex? What should you do if it is present?
Touch a gauze roll to the teeth and alveolar ridge. If needed, make sure to select utensils that will not break easily. Also avoid touching the spoon to teeth or alveolar ridge.
In patients with cognitive impairments, oral activity may be in response to _________________
Particular sensroy combinations - taste, temp., texture
What is the purpose of checking oral-sensory stimuli?
TO identify the combination of taste, temperature, and texture that elicits the most swallowing-like oral movements. Use this to compare with regular MBS materials in radiographic study.
How can you check different oral sensory combinations?
Use different textures - gauze, satin, burlap. Dip these in different tastes/temps.
How do you identify and compensate for swallowing apraxia?
1) The patient will perform best with no verbal instructions. 2) Patient may do better when not told what to do 3) You'll see severe difficulties on MBS 4) If patient shows ONLY apraxia and symptoms of no other swallowing disorder you don't have to do an MBS.
How do you identify/compensate for abnormal oral reflexes?
1) Hyperactive gag, tongue thrusting, tonic bite 2) Identify locations in the mouth where these are triggered as well as nature of stimuli that triggers it. Then avoid these during MBS.
How do you test labial function during the oral motor exam?
1) /i/ and /u/ - then rapid alternation 10x 2) Get a DDK rate using /pa/ 3) Repeat a sentence with many bilabial stops - put the papers by the back door. 4) Make sure the patient can maintain lip closure during chewing (make sure to check nasal breathing)
How do you test ANTERIOR lingual function during the oral motor exam?
1) Extend and retract tongue as much as possible 2) Tongue tip to either corner, then rapidly alternate 3) Show motion needed to clear lateral sulcus 4) Open mouth wide - elevate and depress tongue as much as possible. Then rapidly alternate. 5) DDK using /ta/ 6) Repeat sentence with tip-alveolar stops - take time to talk to Tom.
How do you test POSTERIOR lingual function during the oral motor exam?
1) Assume position for /k/ and hold it for a few sec. 2) DDK with /ka/ 3) Repeat a sentence with velar stops - Can you keep the kitchen clean?
How do you assess chewing function during the oral motor exam?
1) This is safer with GAUZE than food 2) Roll gauze in tastant and wring it out -ask the patient to simulate chewing with the gauze.
How do you assess soft palate function in the oral motor assessment?
Do a prolonged /a/ and rapid repetition of /a/ - should see it elevate. The muscles are: Levator muscle (elevation) and the Palatopharyngeus muscle (retraction)
How do you test the palatal reflex in the oral motor exam?
1) Touch a cold instrument to the juncture between the hard and soft palate. (Or inferior edge of soft palate and uvula). 2) The reflex consists of an upward, backward movement of the soft palate but NO reaction in the pharyngeal walls. 3) The muscles are: afferent - glossopharyngeal (and maybe Vagus). Efferent - Vagus (and maybe glossopharyngeal). Trigeminal may be involved as well. 4) May require two strokes - the least stable of the oral reflexes.
How do you test the gag reflex in the oral motor exam?
1) Contact the tongue blade against the base of tongue or posterior pharyngeal wall. 2) The reflex consists of a strong, symmetrical contraction of the entire pharyngeal wall and soft palate. 3) Don't forget that the gag reflex is often absent in normal individuals! 4) Afferent is mainly X (IX may be involved)
What do you suspect if the gag reflex is assymmetrical?
Possible unilateral pharyngeal weakness (likely to affect swallowing)
The gag is triggered by ________________ while the swallow is triggered by ____________________.
(noxious stimuli - vomit, reflux, etc.) surface tactile receptors / deep proprioceptive receptors
What is the gag reflex designed to do?
Get foreign material out of the pharynx - designed to squeeze materials up and out of the pharynx.
How do you assess oral sensitivity during the oral motor exam?
Test light touch using a cotton swab - assess different areas of the tongue. Check patient awareness. If no gag is elicited - check posterior pharyngeal wall. All food should then be positioned in the area of maximum sensitivity. If the patient is not aware of touch, it suggests they may also be unaware of residue.
Helpful information obtained during the oral motor examination…
1) Labial assessment - facial paralysis or problems maintaining lip closure?? 2) Lingual function - limitation in functions needed to organize bolus or propel it backward? 3) Particular consistencies the patient can manage
What things do you check during the laryngeal function examination?
1) Voice quality 2) Laryngeal DDK - hahahah 3) Coughing and throat clearing 4) Sliding up and down vocal scale 5) Prolonged phonation, s/z
What do you check regarding voice quality during the laryngeal function examination?
1) Is the voice gurgly? RED FLAG!! Do an MBS 2) Is the voice hoarse? You should suspect reduced laryngeal closure during the swallow - careful laryngeal examination needed. Refer to an otolaryngologist!
What will you see when you try to do a laryngeal DDK task with patients with neurologic impairment?
Generally a continuous breathy /ha/
What does inability to change pitch suggest?
Reduced laryngeal sensation - these are served by the same nerve - Superior laryngeal nerve.
If you suspect that the larynx is borderline/impaired, what should you do prior to initiating any swallows?
Teach the supraglottic or super-supraglottic swallow!!
What are you looking at for the pulmonary function portion of the bedside eval?
Determining if the patient can tolerate any amount of aspiration - done by physician. Oral feeding regimens involve SOME aspiration!!
Patients who aspirate on MBS are at higher risk for…
Developing aspiration pneumonia in the next six months
What information is collected form the preparatory exam?
1) The posture that MAY result in the best swallow 2) The best position for food in the mouth 3) The potentially best food consistency 4) Some indication of the nature of the patient's swallowing disorder
When considering whether swallows should be attempted at bedside, what should you think about?
The risk:benefit ratio
IF the patient is ALREADY eating, what should you watch for?
1) Patient's reaction to food 2) Oral movements in food manipulation/chewing 3) Coughing, throat clearing, struggling behaviors, or changes in breathing (and TIMING) 4) Changes in secretion levesl throughout the meal 5) Duration of the meal and total intake 6) Coordination of breathing and swallowing
Posture: When is tilting head down and then throwing it back the best posture?
1) Poor tongue control - difficulty maneuvering bolus in mouth, premature spillage
When is tilting head back a safe posture?
When the patient has normal pharyngeal and laryngeal control - because you know the airway will be protected
Posture: When is Chin-Tuck a good choice - what does it do?
1) Patients with slightly inadequate laryngeal closure, pharyngeal delay, hemi-laryngectomy, reduced tongue-base retraction. 2) The epiglottis is positioned more posteriorly, the airway entrance is narrowed, the valleculae will be widened. This means more food can rest there during the delay.
Posture: When is head rotation a good choice? What does it do?
1) Patients with unilateral pharyngeal paralysis such as in medullary stroke. 2) When you turn toward the affected side, it closes the pyriform sinus on that side, directing food to the functional side.
Posture: When is head tilt a good choice? What does it do?
1) Patients with oral and pharyngeal weakness on the same side. 2) When you tilt the functional side, it allows gravity to pull material to the side that works. NOTE: you should have the patient tilt before placing food in the mouth.
When should you make decisions regarding posture?
Based on chart and preliminary information - BEFORE INITIATING SWALLOWS
How do you determine optimal food position in the mouth?
1) Depends on oral sensitivity - position it on the side with best sensitivity and best function. 2) You can use a pipette, syringe, or tongue blade to place liquid or food in different places
How do you select the best possible food consistency?
1) Information from history 2) Oral control 3) Pharyngeal / laryngeal control NOTE: it is good to start with the easiest one to make the patient more comfortable
In general, what consistency works well for patients with poor oral control?
Thickened liquid and then transitioning to thinner
In general, what consistency works well for patients with delayed pharyngeal swallow?
Thicker material because thin liquids tend to splash in the airway during the delay
In general, what consistency works well for patients with reduced tongue base or pharyngeal wall contraction?
Best with liquids - easier to clear from the pharyx
In general, what consistency works well for patients with reduced laryngeal elevation/reduced UES opening?
Liquids - more likely to flow through a narrow UES. Thicker material is more likely to sit on top of it and fall into airway.
In general, what consistency works well for patients with reduced closure of airway entrance?
Thicker consistency - less likely to penetrate.
In general, what consistency would work best for a patients with BOTH disturbed oral function AND delayed pharyngeal swallow?
Something between a liquid and paste - gravity will help with bolus propulsion (easier than thick) but the material will still cling to the valleculae (instead of splashing into airway as thin liquid would)
List six materials you need to use in the initial swallowing evaluation
Size 0 or 00 laryngeal mirror; tongue blade; cup; spoon to present liquids/pastes; straw (as pipette); syringe
During the initial swallowing evaluation, what do you need to do to manage the trach?
1) Deflate the cuff - get clearance from doc 2) SUCTION WELL orally and via trach 3) Tell pt. to occlude trach tube during each swallow
What are some advantages to initiating swallowing therapy while patient has a trach?
1) Can observe aspiration more directly - expectoration through tube 2) Elimination of aspirated material is easier - coughing or suction
What are some possible problems initiating swallowing therapy with a patient who has a trach?
1) Restriction of upward laryngeal movement - trachea is anchored to the strap muscles and neck 2) Compression of esophagus by tube pushing posteriorly on common wall 3) Change in intratrachial pressure because of the tube
A trach becomes more of a problem, if…
It is in place for 6 months or more
Prior to a trial swallow at bedside, what should you do…?
1) Review and write down instructions 2) Give the patients several dry swallows to practice sequence of instructions 3) Coach the patient through them 4) When patient is successful with instructions - assure them the amount of liquid will be very small. Encourage the patient to COUGH when needed. 5) Use 1/4 teaspoon of material - not sufficient to block airway and should cause minimal difficulty.
Where do you palpate during a trial swallow at bedside (finger placement)?
1) Index finger - Directly behind mandible 2) Middle finger - hyoid bone 3) Third finger - top of thyroid cartilage 4) Fourth finger - bottom of thyroid cartilage
What do you feel with your fingers in place during the trial swallow?
1) Index finger - submandibular movement 2) Middle finger - hyoid movement 3) 3rd and 4th fingers - laryngeal movement Notes - looking for the strength of movement and you can get a rough estimate of OTT and PTT. You can also follow a normal swallow with one preceded by TT stim - to see the difference in timing. BUT, no information on the pharyngeal stage is obtained.
After the trial swallow in the clinical exam - how can you assess aspiration?
1) Prolong /a/ - is it gurgly? Indicates material on VF 2) Panting - will loosen material in valleculae and pyriform sinus. Then ask patient to voice - gurgly? 3) Turn head to each side and vocalize - will squeeze any residue from pyriform sinus again making voice gurgly. 4) If voice is clear, ask patient to tilt head back - clears residue from valleculae. 5) If any task makes voice gurgly, aspiration can be expected.
What percentage of patients are silent aspirators?
Clinicians don't identify aspiration at bedside in ________ of patients who are actually aspirating
Conduct a radiographic study to assess…
1) Pharyngeal physiology 2) Presence of aspiration 3) Cause and amount of aspiration
Pros and Cons of cinefluoroscopy…
1) Pros - permits a frame by frame analysis 2) Cons - radiation exposure greater, can't make voice recordings
Pros and Cons of videofluoroscopy…
1) Pros - less radiation exposure, can patch VCR easily to fluoroscopy monitor 2) Cons - more difficult to frame - need to use a video counter timer. These numbers are placed at a rate or 30 or 60 per second.
How does a MBS differ from a traditional upper GI barium swallow?
1) Purposes - info on structural competence of the esophagus. Especially lower 2/3. Little attn. paid to oral/pharyngeal physiology. 2) Type and amount of material used - much more 3) Procedures used - don't introduce rehabs strategies as you do in MBS
Purposes of the MBS
1) Define abnormalities in anatomy and physiology causing the patient's symptoms. 2) Identify/evaluate treatment strategies that may enable patient to eat safely/effectively 3) Measure OTT and PTT 4) Assess valve function - VP, laryngeal, UES 5) Observe cervical esophagus peristalsis 6) Not only if but WHY patient is aspirating
During MBS, how is food placed in patient's mouth?
Generally a disposible spoon is used - unless patient has a bite reflex…then use something more sturdy. *For infants - Bottle or nipple - hold bottle with lead gloved hand.
What did Weathers, Becker, and Genieser (1974) create to help place material in the patient's mouth?
1) A tube with the nipple on one end and a 50cc syringe or a 450cc plastic bag on the other end. This way your hand doesn't enter the field of exposure.
What are the three consistencies used for the MBS?
1) Thin liquid barium 2) Barium paste = pudding + Esophatrast 3) Material required mastication = Lorna Doone cookie coated with pudding + Esophatrast
In addition to the three typical materials used during the MBS, how else do you select material?
Based on: patient complaints of what is difficult; food consistencies regularly given to patient; if the patient responded well at bedside to particular consistencies, tastes, temps
If the patient does well with all volumes and consistencies during MBS, what do you do next?
Allow the patient to self-feed and observe normal feeding
How do you alter volume in the MBS?
1) Increase it until the patient aspirates. Then determine cause and introduce intervention strategies. 2) You don't increase the volumes of pudding or cookie because it is natural for the amount to decrease as viscosity increases.
We introduce intervention strategies in what order?
Postures then sensory heightening then voluntary maneuvers then LAST - viscosity
Why do we start MBS with a very small volume?
1) Patients in MBS are ill - using more than 1 teaspoon of barium, if patient aspirates they could go into respiratory arrest. This is different from traditional barium swallows because the goal for that is to fill up esophagus and look for structural abnormalities.
Why do we start with liquids in MBS?
1) It ensures the material won't block the airway if aspirated 2) There is evidence the pneumonia is less likely from liquid than thicker foods 3) Lungs may be better able to clear thinner material back out of aspiration does occur
Following the evaluation, what four questions should be answered?
1) What type of nutritional management is needed? 2) Should therapy be initated and what type? -Direct or indirect? -Compensatory or therapeutic? 3) What specific therapy strategies should be used? 4) And as therapy progresses, does the patient require maintenance program to keep gains or slow deterioration?
What is the continuous goal of managing swallowing disorders?
To reestablish oral feeding while maintaining adequate nutrition, hydration, and safe swallowing
Treatment planning involves ___________ or ______________ activities to improve oropharyngeal swallow.
Progressive exercise / sensory stimulation
The decision to provide therapy is largely based on what two things?
1) Potential for improvement/recovery of swallow 2) Prolonged maintenance of oral intake because of therapy
What 8 patient characteristics are considered when determining if and what type of therapy to provide?
1) Diagnosis 2) Prognosis 3) Reactions to compensatory strategies 4) Severity of patient's dysphagia 5) Ability to follow directions 6) Respiratory function 7) Availability of caregiver support 8) Patient motivation and interest
When considering the patient's medical diagnosis in the decision to provide treatment, what are you trying to decide?
1) If the patient is likely to recover swallowing in a few weeks (e.g., a healthy patient with first stroke) - then maybe only compensatory strategies are needed. 2) Patients who will NOT be recovering shortly may need compensatory strategies and therapy 3) Patients with neuromotor disease - ROM exercises or effortful swallow may not be appropriate because they will fatigue the patient.
Prognosis for swallowing disorder: which patients are likely to have recovery of full/partial oral intake?
Those with sudden onset neurologic damage - stroke, TBI, spinal cord injury, structural damage (due to surgery, radiation, etc.)
Prognosis for swallowing disorder: for which patients may therapy be inappropriate?
Those with degenerative diseases (PD, MND, MG, MS, Alzheimers) because at some point it will no longer be effective. May be appropriate earlier in the course of the disease depending on the goals.
What about the patient's reaction to compensatory strategies may make therapy inappropriate?
If the compensatory strategy fully eliminates aspiration/residue and swallowing is safe to maintain oral nutrition/hydration. ESPECIALLY if spontaneous recovery is likely.
If compensatory strategies are enough to make swallowing safe, and you do not recommend therapy, what do you do with that patient?
Instruct the patient to use those compensatory strategies and then re-evaluate after 3-4 weeks
If the severity of the swallowing disorder is enough that compensatory strategies do NOT eliminate aspiration in MBS, what do you do?
Use INDIRECT THERAPY - improve oral and pharyngeal ROM and coordination.
How does the patient's ability to follow directions affect your treatment decisions?
1) Patient needs to follow several steps - ESPECIALLY for voluntary maneuvers. 2) Compensatory strategies are easier to do and also under the control of caregivers to some extent.
How long is the airway closed for liquids? Sequential cup-drinking?
0.3-0.6 seconds / 3-5 seconds
How does the patient's respiratory status affect treatment decisions?
1) If the patient cannot tolerate brief airway closure - you may need to postpone therapy 2) Some therapy procedures require longer closure so are more taxing to the respiratory system 3) Some prolong airway closure as side-effect
Which therapy procedures require longer airway closure during the swallow?
Supraglottic swallow, super supraglottic swallow
Which therapy procedures prolong airway closure as a side effect?
Effortful swallow, Mendelsohn Maneuver
Why is caregiver support considered when making treatment decisions?
It is required to ensure regular practice. Especially important in patients with memory deficits. Also, remember that some compensatory strategies are under caregiver control.
Logemann, Sisson, & Wheeler (1980) found that patients will exclude a food from their diet unless…
OTT and PTT combined take less than 10 seconds
When there is no aspiration/residue but oral and pharyngeal transit are slow, what is the problem?
Patients will exclude foods from their diet if it is too much work. At this point getting adequate nutrition becomes the concern.
If the patient's OTT + PTT are more than 10 seconds for EVERY consistency of food (but no aspiration), what is usually a solution?
The patient can continue to eat orally, but will need non-oral feeding to supplement it and ensure adequate nutrition and hydration.
Usually, it is not a good idea to keep a nasogastric tube in longer than…
3-4 weeks
Patients who are aware of their aspiration are found to eliminate foods when…
They are aspirating 10% or more of the total bolus
Patients who are unaware of their aspiration WILL or WILL NOT eliminate foods from their diet
Often they will NOT - this means they are at serious risk for developing aspiration pneumonia
In terms of aspiration, when do you recommend that a patient not be fed orally?
When the patient is aspirating 10% or more of EVERY consistency DESPITE therapy attempts.
What are factors in the selection of non-oral feeding type?
(Not our decision, but encourage use of smaller, more flexible tubes), patient's GI history, cost of feedings and insurance coverage, patient's behavior, patient's preference, patient's medical diagnosis
When are compensatory strategies first introduced?
During the eval - usually in MBS
Compensatory treatment procedures are those that ____________________ and ____________________ but do not necessarily ________________.
control the flow of food / eliminate the patient's symptoms such as aspiration / change the physiology of the pharyngeal swallow
What are some pros of compensatory strategies?
They involve less muscle effort/work for the patient. They do not cause as much fatigue. They are relatively simple to use.
What are the four types of compensatory strategies?
1) Postural changes 2) Sensory heightening 3) Modifying volume and speed of presentation 4) Introducing oral prosthetics
In general, what are the effects of postural techniques?
1) Alter the dimensions of the pharynx 2) Change the flow of food 3) Do so without increasing work/effort
What do you need to do before selecting a posture?
Correctly diagnose the anatomic and physiologic characteristics of your patient's swallow and then select the posture based on that.
Postural techniques are effective in eliminating aspiration in _______ of dysphagic patients (including _____________________)
75-80% (infants and those with cognitive impairments)
In MBS, how do you select/implement a posture?
1) Diagnose anatomic/physiologic disorder 2) Use the technique with the same type of swallow in which aspiration occurred
Are postural techniques meant to be permanent?
1) They are usually used temporarily until the patient's swallow recovers or until direct therapy procedures take effect. 2) Some patients will need to use them permanently
Describe the effects of the chin down posture
Patient touches the chin to the neck - tongue base and epiglottis rest closer to posterior pharyngeal wall. Airway entrace is narrowed. Valleculae is widened.
Chin Down posture is useful for which types of clients?
1) Delayed pharyngeal swallow 2) Reduced tongue base retraction 3) Reduced airway entrance closure
Chin Up posture is useful for which types of clients?
1) Reduced tongue control
What are the effects of the Head Rotation?
The head is rotated to the damaged side - this closes off that side of the larynx and food goes down the normal side. Also, in the case of unilateral VF paralysis, the damaged side is pushed toward midline which helps with adduction.
The Head Rotation is useful for which types of clients?
1) Unilateral pharyngeal wall impairment 2) Unilateral VF weakness
What provides the BEST airway protection (postures)?
Combination of Chin Down + Head Rotation
Head Tilt is useful for which types of patients?
Those with unilateral oral and pharyngeal impairment (on the same side)
What are the effects of the lying down posture?
It may eliminate aspiration after the swallow because gravity will pull residue to the side of the pharynx instead of it falling into the airway. PATIENT NEEDS TO COUGH BEFORE SITTING UP.
The lying down posture is useful for which types of clients?
1) Bilateral pharyngeal wall disorder 2) Reduced laryngeal elevation
What do you need to check with a patient before implementing the lying down posture?
1) Straw drinking - necessary for this posture 2) If residue continues to build up on pharyngeal wall with successive swallows, the patient is NOT a good candidate. 3) Patient with GERD - may need to elevate body 15-30 degrees. THis will prevent reflux while still eliminating aspiration.
____________ is the best exercise for swallowing
If a patient is successfully using a posture and returns for a reeval after 3-4 weeks, what do you do in MBS?
Try the patient swallowing without the posture first - then if the patient aspirates go back to the posture to see what is happening.
In general, patients will no longer need to use a posture after _________ but some will need it permanently
1-2 months
When a patient is going to use a posture without any therapy, what do you need to remind them??
That if swallowing becomes easier with the posture, they should NOT change back to normal swallowing without consulting with you
Techniques to improve oral sensory awareness are generally used for what disorders?
1) Swallow apraxia 2) Tactile agnosia for food 3) Delayed onset of oral swallow 4) Reduced oral sensation 5) Delayed triggering of pharyngeal swallow
Techniques to improve oral sensory awareness are both _________ and ____________ in nature
Compensatory / therapeutic
Why are oral sensory techniques considered compensatory? Why are they considered therapeutic?
1) Because they are largely under the control of the caregiver 2) Because they change the physiology of the swallow (change timing for reduced oral onset and pharyngeal delay)
All oral sensory techniques involve _________________________ and serve to _________________________.
Providing a preliminary sensory stimuli BEFORE initiating swallow attempt / alert the CNS and lower the threshold of the swallowing centers.
What are 6 oral sensory heightening techniques?
1) Increasing downward pressure w/ spoon on tongue when presenting food 2) Presenting sour bolus (50% lemon, 50% barium) 3) Presenting cold bolus 4) Presenting bolus requiring chewing 5) Presenting larger volume volus (3 ml +) 6) Thermal-tactile stimulation
For swallowing apraxia, what sensory techniques are useful?
Downward pressure with spoon, increased volume, taste, temp; thermal-tactile stim. Some patients may be facilitated for oral onset and OTT.
What sensory techniques are especially useful for triggering the pharyngeal swallow?
Thermal-tactile stim; suck-swallow
Describe Thermal-Tactile Stimulation
1) Vertically rub the anterior faucial arch (on each side) 4-5 times using a COLD size 00 laryngeal mirror. 2) Then follow with the swallow 3) Heightens oral awareness and alters the CNS to help trigger the pharyngeal swallow 4) Reduces delay for several swallows following the stimulation.
Describe the Suck-Swallow
1) Exaggerated vertical tongue-jaw sucking movements with lips closed. 2) Draws saliva to the back of the mouth - helpful for patients with poor saliva control 3) Helps trigger the pharyngeal swallow
In what ways do we measure the effectiveness of oral-sensory enhancement techniques?
1) Duration of time between command and swallow 2) OTT 3) PTT 4) Can measure by palpating (rough) but easier to measure in videofluoroscopy (easier than videoendoscopy because in that case you can't see the oral stage, so hard to determine swallow vs. premature spillage)
A patient with a weakened pharyngeal swallow may take ________ swallows per bolus. What do you need to watch for?
2-3 / taking too much food too quickly may result in severe collection of food in the pharynx and aspiration. These patients should take smaller boluses and allow plenty of time between swallows.
Generally, limiting diet to certain consistencies should be the _____________ because…
The last compensatory strategy attempted / this can be very difficult for the patient
When other things are not feasible, you may need to restrict your patient's diet to certain consitencies. What are some types of patients in which this may be the case?
1) Patient with movement disorders who can't control their posture 2) Patients who cannot follow directions to use swallowing maneuvers. 3) Patients for whom oral sensory procedures are not appropriate.
Thin liquids are the most appropriate for which (5) disorders?
1) Oral tongue dysfunction 2) Reduced tongue base retraction 3) Reduced pharyngeal wall contraction 4) Reduced pharyngeal elevation 5) Reduced cricopharyngeal opening
Thickened liquids are most appropriate for which (2) disorders?
1) Oral tongue dysfunction 2) Delayed pharyngeal swallow
Purees and thick foods are most appropriate for which (3) disorders?
1) Delayed pharyngeal swallow 2) Reduced laryngeal closure at entrance 3) Reduced laryngeal closure throughout
When a patient loses 25% or more of tongue tissue (ie. Cancer patients) what may be necessary?
Intraoral Prosthetics
What types of patients may require intraoral prosthetics?
1) Patients who have lost 25% or more of their tongue tissue 2) Tongue movement problems 3) Those with velopharyngeal deficits
What are the three types of intraoral prosthesis?
1) Palatal Lift 2) Palatal Obturator 3) Palatal Augmentation
What does a Palatal lift do?
Lifts the soft palate to a closed position in patients with velar paralysis
What does a Palatal Obturator do?
Can be used in those with a resection of the soft palate due to cancer
What does a Palatal Augmentation do?
AKA - Reshaping Prosthesis Used for those with significant tongue resections or bilateral tongue paralysis. It recontours hard palate to interact with remaining tongue so patient can propel bolus more efficiently.
Who makes the intraoral prosthesis?
The Maxillofacial Prosthodontist (The swallowing therapy consults)
Placement of intraoral prosthesis should be within ___________ in order to…
4-6 weeks post-operatively / avoid formation of maladaptive behaviors.
Therapy procedures are designed to ________________ while compensatory strategies are designed to _________________.
Change swallow physiology / simply eliminate symptoms
Three goals of therapy procedures are…
1) To improve ROM for oral/pharyngeal structures 2) Improve sensory input 3) Take voluntary control over the timing / coordination of selected motions.
What is the difference between direct and indirect therapy?
Direct therpay involves introducing food into the mouth and reinforcing behaviors during actual swallows. Indirect therapy involves working on exercises to improve neuromotor controls that are prerequisites to normal swallowing - NO FOOD GIVEN.
When deciding whether to use direct or indirect therapy procedures, on what do you base your decision?
The decision is based on aspiration information from MBS
When would you provide INDIRECT therapy?
When patients aspirate on all volumes/viscosities and are unsafe with oral intake
Can swallow maneuvers be practiced during indirect therapy?
Yes - they can be practiced using just saliva
What does direct therapy involve?
1) Presenting food or liquid to swallow while following specified instructions 2) Always give written instructions 3) Discuss the rationale for procedures and allow several dry practices before presenting food. 4) Give the patient small amounts - assure the patient it is not enough to bloch the airway. 5) ENCOURAGE THE PATIENT TO COUGH AS NEEDED!
Major oral control and oral/pharyngeal ROM exercises include…
1) ROM - to improve extent of movement for lips, jaw, oral tongue, tongue base, larynx, VF 2) Bolus control and chewing exercises 3) Oral-motor control exercises
What are the most frequent problems for which oral motor exercises are used?
1) Lateralization of the tongue during chewing 2) Elevation of the tongue to the hard palate 3) Cupping of the tongue to collect bolus 4) Anterior-posterior movement of the midline of the tongue
What is the purpose of tongue ROM exercises?
To increase elevation and lateralization of the tongue to improve oral transit
Describe tongue ROM exercises
1) Open mouth as wide as possible - do the following positions and hold for 1 second each. 2) Elevate tongue as high as possible in the front 3) Elevate tongue back as high as possible 4) Stretch tongue to clean out L/R lateral sulcus 5) Protrude and retract tongue as far as possible Do each 5-10 times each session (lasting about 4-5 minutes) - do this 5-10 times per day.
Tongue ROM exercises are shown to improve __________________ - especially in ________ patients.
Speech understandability and oropharyngeal swallow / Oral cancer
Describe tongue resistance exercises
1) Push tongue against tongue blade 2) Do this to the front and to each side, holding for 1 second each
Bolus Control Exercises include ___________, ______________, and ______________
1) Exercises to improve gross manipulation of material 2) Exercises to hold cohesive bolus 3) Bolus propulsion exercises
Describe exercises to improve gross manipulation of material?
1) Using rolled gauze, licorice whip, etc. 2) Grasp gauze between tongue and palate - roll side to side or slide front to back. 3) Progress to moving it in a circular fashion - middle of the mouth onto the teeth back to the middle and then back to the teeth again (on the same side) 4) This simulates chewing.
Once the patient can grossly manipulate a gauze roll, how can you increase the difficulty?
1) When patient can move the gauze three directions in one second, move to smaller items (ie. Lifesaver on a string) 2) Then thin cloth tape soaked in cranberry or orange juice - introduces small amount to swallow 3) Chewing gum - which the clinician cannot control
Describe exercises to hold a cohesive bolus - when do you start these?
1) You start them after the patient can manipulate material grossly 2) Begin with 1/3 teaspoon of paste - place it in the middle of the patient's mouth. The patient practices moving it around without letting it spread out. 3) Then you expectorate it- look for any residue 4) Increase difficulty by varying bolus size and then move to liquid
Describe bolus propulsion exercises
1) Use 4" gauze roll - soaked in juice 2) Patient is asked to push up and back against the gauze - this squeezes liquid out of the gauze and back while you hold the it so the gauze won't be swallowed. 3) Also includes a small amount of liquid to swallow
For bolus propulsion exercises - if your patient has reduced tongue elevation what can you do?
1) Start with a thicker gauze roll 2) Then reduce it as the patient gets more skilled
The four general types of ROM exercises for pharyngeal structures are…
1) Airway entrance exercises 2) Vocal fold adduction exercises 3) Tongue base exercises 4) Laryngeal elevation exercises
When would you begin using airway entrance exercises?
If the patient cannot get airway closure using postures or voluntary maneuvers
Describe ROM exercises for the airway entrance
1) Hold breath, bear down for 1 sec. and let go 2) Do this 5-10x /day for 5 minutes each
You should not use traditional ROM exercises for patients with ____________ so instead you should use…
1) High blood pressure - bearing down may make BP spike 2) Use repeated glottal attacks instead
Describe vocal adduction exercises
Set One: Bear down against chair while producing clear voice. Repeat 5x. Then do hard glottal attack on /a/ 5x. Repeat 3 times 5-10 times per day. Can use voice therapy to monitor improvement in laryngeal function. Set Two: Lifting or pushing with simultaneous voicing. Sit on a chair while pulling up while prolonging vowel. Then make repeated glottal attacks harder by making patient prolong it. Then practice the pseudo supraglottic swallow - take a breath, hold it, cough strongly.
Generally, you will see the effects of vocal adduction exercises in __________ but some patients will need ________ to attain adequate airway protection (give an example)
2-3 weeks / 6-8 months / Ex: patient with supraglottic laryngectomy or extensive laryngeal damage
Describe the three tongue base exercises
1) Retract the tongue as far as possible - hold 1 sec. 2) Pretend to gargle as hard as possible 3) False yawn 4) Effortful swallow also improves retraction
How do you decide WHICH tongue base exercise is the best for your patient?
1) Try all three in MBS 2) Select the one that gives the best retraction.
Describe the laryngeal elevation exercises
1) The Falsetto Exercise - the patient is asked to slide up the scale as far as possible. Hold that pitch for a few seconds. 2) Shaker exercises - lay on ground and lift your head to look at your toes. Hold this - strengthens the suprahyoid muscles.
Are sensory procedures compensatory or therapeutic in nature?
1) Compensatory - may need to be used as part of a maintenance program (Alzheimer's, MND, etc.) 2) Therapeutic - designed to regularly improve onset or oral swallow and triggering PS. (Stoke, TBI, head and neck cancer - recovery is expected)
You only use Thermal Tactile Stim for delayed pharyngeal swallow if…
You see the delay on TWO CONSECUTIVE swallows on MBS - some patients just need a warm up.
If you are trying to do Thermal Tactile Stim on a patient with a bite reflex, what do you need to do?
Coat the mirror with Teflon so that it won't break
Thermal Tactile Stim has been shown radiographically to improve the swallow of _____% of patients with delayed triggering of pharyngeal swallow when the swallow…
95% / immediately followed the stimulation
What are the long term effects of using Thermal Tactile Stim on patients with delayed triggering of pharyngeal swallow?
We don't know yet
If you are palpating a swallow, it is considered abnormal if the oral transit + pharyngeal delay takes more than ____ seconds.
You may need to do Thermal Tactile Stim for several weeks to a month before you see improvement, one the pharyngeal swallow begins to trigger, what can you do…
1) Increase the amount of material in small steps 2) Change to thicker material 3) Remember that the patient may need to continue non-oral feeding for some time while therapy progresses.
Swallow manuevers involve placing _____________________
Some aspect of the pharyngeal swallow under voluntary control
What are three problems for which you might use a supraglottic swallow?
1) Premature spillage 2) Reduced or late vocal fold closure 3) Delayed pharyngeal swallow
What is the goal of the supraglottic swallow?
Close the vocal folds to protect the trachea from aspiration
What are the instructions for the supraglottic swallow?
1) Take a deep breath and hold your breath 2) Keep holding your breath and lightly cover your trach (if applicable) 3) Keep holding you breath while you swallow 4) IMMEDIATELY after you swallow, cough
What is one problem you may have while you try to teach the supraglottic swallow - how can you troubleshoot this?
1) The patient may hold their breath by stopping chest movement - you will see the airway is still open during the MBS 2) Modify instructions: "Inhale, exhale slightly, then stop the exhalation and hold your breath" OR "Inhale, prolong /a/, then stop and hold your breath"
What is the extended supraglottic swallow? When would you use it?
1) AKA the "Dump and Swallow" technique - the patient holds breath, takes a large volume, and tosses head back, swallowing a few times to clear it. 2) Need to first make sure airway protection is adequate and also if the PS triggers on time. 3) Do this with patients with severely reduced tongue mobility, severely reduced tongue bulk, severe problems with oral transit - HELPS ENSURE ADEQUATE NUTRITION
What are some problems for which you would use a super supraglottic swallow?
1) Reduced closure of airway (entrance, too) 2) Patinets with supraglottic laryngectomies
What is the goal of the super supraglottic swallow?
To close the airway entrance voluntarily by tilting the arytenoid cartilage anteriorly to the base of the epiglottis before and during the swallow (The normal way of closing the airway but this technique gets it done earlier)
What are the instructions for the super supraglottic swallow?
1) Inhale & hold your breath tightly, BEARING DOWN 2) Keep holding breath bearing down as you swallow 3) Cough when you are finished
Why is the super supraglottic swallow useful for patients with supraglottic laryngectomies?
Because in these patients the epiglottis is removed so the airway entrance = the tongue base + the arytenoid cartilage. The patient needs to push hard so that the arytenoids contact the base of tongue
The effortful swallow is particularly useful for patients with…
Reduced tongue base retraction
What is the goal of the effortful swallow?
To increase posterior motion of the tongue base during the pharyngeal swallow (as well as improving bolus clearance from the valleculae)
What are the instructions for the effortful swallow?
As you swallow, squeeze hard with all your muscles
The Mendelsohn Maneuver is particularly useful for what two problems?
1) Reduced laryngeal movement 2) Discoordinated swallow
What is the goal of the Mendelsohn Maneuver?
TO increase the extent and duration of laryngeal elevation and thereby increase the duration and width of cricopharyngeal opening. Also improves the overall coordination of the swallow.
What are the instructions for the Mendelsohn Maneuver?
1) Swallow (saliva only) and pay attn. to your neck 2) Tell me if you can feel something (voice box, adam's apple, etc) lifting and falling as you swallow 3) Now, this time when you swallow, when you feel something lift, don't let it drop. Hold it up with your muscles for several seconds. (Alternative - everything squeezes together - HOLD THE SQUEEZE)
What are some key points about the voluntary maneuvers?
1) They require the ability to follow directions 2) Require increased musculatory effort - not appropriate for patients who fatigue easily 3) Each maneuver has a specific rational with different disorders.
What are the two major tasks in the oral preparatory phase?
1) Manipulate food in the mouth while maintaining lip closure (check nasal breathing) 2) Control the bolus to avoid premature spillage
Describe ROM exercises for the lips
1) Stretch to /i/ and hold 1 sec. 2) Pucker as tight as possible and hold 1 sec. 3) Bring lips together and hold 1 sec. 4) If the patient cannot close lips, use a stack of tongue blades or other item and then reduce it. 5) Increase the amount of time patient maintains lip closure. (Up to about 10 minutes/day)
Describe strengthening exercises against resistance
1) Use a tongue blade and have the patient hold it with their lips. They need to hold tight as the clinician tries to extract it. 2) Hold the lips closed while someone tries to manually part them
List therapy/compensatory options for patients with reduced tongue motion (laterally) during mastication
1) Therapy - ROM exercises to manage bolus 2) Compensation - Position food on the side with better motility. OR…tilt head to the intact side. Patient may also be asked to mash food vertically up against hard palate in the meantime.
List therapy/compensatory options for patients with Reduced buccal tension or buccal scarring
1) Therapy - facial ROM exercises. Rounding lips for "oh", stretch to /i/, rapidly alternate. Smile broadly and then tighten lips across cheeks. Pull lips as far as possible to one side and then hold 1 sec. 2) Compensation - Patient can put pressure on that cheek to seal lateral sulcus. Place food on unaffected side and tilt that way.
List therapy/compensatory options for patients with reduced range of lateral mandibular motion
1) Therapy - ROM exercises for jaw 2) Compensation - teach patient to mash food vertically to expand diet options. Also, "Guide-plane" prosthesis.
ROM exercises for the jaw are MOST important for which types of patients?
1) Post-operative oral cancer patients 2) Patients undergoing radiotherapy - potential scarring/fibrosis of muscles of mastication
What are some potential effects of radiotherapy?
1) Fibrosis of muscles of mastication 2) Narrowed mouth opening 3) Restriction of mandibular movement
List therapy/compensatory options for patients with reduced range of tongue movement vertically
1) Therapy - Vertical ROM exercises, strengthening 2) Compensation - If the tongue-palate contact is still incomplete after several months, you may consider a Reshaping Prosthesis
What does a palatal reshaping prosthesis do?
1) Lowers the palatal vault to complement tongue function - it will contain more material where the tongue is more restricted.
A Mandibular Tongue Prosthesis may be used to…
Improve oral manipulation of food and speed of oral transit
List therapy/compensatory options for patients with reduced tongue movement to form bolus
1) Therapy - exercises to control bolus 2) Compensation - tilt head forward to present spillage into pharynx or sulci. (Patient will lift head with the start of the swallow)
List therapy/compensatory options for patients with reduced ability to hold the bolus in normal position
1) Therapy - Patient given thick bolus and asked to hold against anterior to middle palate. This requires the tongue tip and lateral margins of the tongue contact the alveolar ridge. As patient gets better, you can make the bolus thinner.
List therapy/compensatory options for patients with tongue thrust
1) Therapy - Heighten patient's awareness of tongue thrust pattern. Ask patient to conciously position tongue on alveolar ridge and begin swallow with upward, backward push. 2) Compensation - position food more posteriorly on the tongue to avoid the pattern. Tilt head or body back (if food is pushed from mouth)
The ____________ is an instrument that can help the patient gage the amount of pressure applied between tongue and hard palate
IOPI (Iowa Oral Pressure Instrument)
List therapy/compensatory options for patients with Swallowing Apraxia
1) Therapy - SENSORY HEIGHTENING - thermal-tactile stim, changing bolus characteristics
Can a scarred tongue be improved with exercises?
NO! It must be released surgically (refer to head and neck surgeon). COMPENSATION - teach the patient to position food posterior to the scarring. Also, tilt head back to assist with oral transit.
List therapy/compensatory options for patients with delayed or absent pharyngeal swallow
1) Therapy - Thermal-Tactile stimulation!! Suck-swallow technique. Changing bolus characteristics. 2) Compensation - Chin tuck posture. Teach patient to pace swallows to avoid accumulation of too much material in pharyngeal recesses.
List therapy/compensatory options for patients with Reduced tongue elevation
1) Therapy - ROM exercises!! 2) Compensation - position food posteriorly in the tongue (may use straw). Tilt head backward (as long as pharyngeal swallow and laryngeal control are okay)
Often, in a patient with reduced tongue elevation, you will also see…
Reduced anterior-posterior tongue movement
What do you do with a patient who has disorganized tongue movement patterns (ie. Parkinson's disease)?
1) Alert the patient to the pattern 2) Instruct the patient to hold the bolus consciously against the hard palate with the tongue 3) And initiate the swallow with a single, strong, backward movement (This will be helpful as long as patient can remain aware of their swallow)
1) If can irritate the tracheal wall and cause tracheal stenosis 2) Can prevent re-learning to swallow because it restricts laryngeal elevation, reduces laryngeal sensitivity, places pressure on the front wall of the esophagus.
Involved clinician sucking on finger and then swallowing, then patient does the same but
List therapy/compensatory options for patients with Bilateral Reduction in Pharyngeal Contraction
1) No direct therapy improves this at all levels 2) Masako Exercises 3) Compensation - Alternate liquids and semisolids to wash residue down. Limit diets to foods requiring less pressure. Follow each swallow with repetitive dry swallows.
Describe the Masako Exercise
1) Hold tip of tongue between the teeth 2) Extended 3/4 of an inch 3) This stabilizes the anterior portion of the tongue and exercises the posterior tongue - GLOSSOPHARYNGEUS
List therapy/compensatory options for patients with Unilateral Reduction in Pharyngeal Contraction
1) Therapy - no exercises to improve this 2) Compensation - ROTATE head to damaged side. Closes that side. (If patient has lingual issues on the same side, the patient should instead TILT to the normal side)
List therapy/compensatory options for patients with Scarred Pharyngeal Wall
1) No exercises 2) Compensation - Head rotation can close damaged side and redirect bolus. Can also use supraglottic swallow to try to eliminate residue that collects near the scar.
List therapy/compensatory options for patients with Cervical Osteophyte
1) Surgical removal may be needed 2) May need to thin out consistency 3) May also compensate by having the patient Rotate Head either way - see if it improves the swallow
List therapy/compensatory options for patients with Pseudoepiglottis at the Base of the Tongue after Total Laryngectomy
1) Therapy - May need to be removed surgically 2) Compensation - Thin liquids, head rotation
Three possible causes of cricopharyngeal dysfunction are…
1) Failure of the CP to relax (Tx - myotomy) 2) Reduced laryngeal motion up/fwd (Try Mendelsohn maneuver) 3) Poor pressure to drive bolus (improve tongue base action)
List therapy/compensatory options for patients with Reduced Laryngeal Elevation
1) Mendelsohn Maneuver 2) Clear throat / Supraglottic swallow 3) Super-supraglottic / Falsetto exercise
List therapy/compensatory options for patients with Reduced Laryngeal Closure at the Vocal Folds
1) Therapy - improve adduction using VF exercises 2) Compensation - supraglottic swallow. May use chin tuck to help protect airway (as well as head rotation to bring damaged VF closer to midline)
Usually disorders affecting the esophageal phase of the swallow are handled with…
Medication or surgery
When you are going to use a combination of posture + voluntary maneuver - what do you need to do in MBS?
Check the effectiveness of each one separately and then the combination on MBS
What combination of posture + voluntary maneuver is useful for patients with poor airway entrance closure?
Head Rotation + Super-Supraglottic Swallow
What combination of posture + voluntary maneuver is useful for patients with poor tongue base motion?
Chin Down + Effortful Swallow
What combination of posture + voluntary maneuver is useful for patients with Poor Cricopharyngeal Opening?
Head Rotation + Mendelsohn Maneuver
If you use surface EMG for biofeedback what type of information can the patient pet?
Information on amount of effort for lip closure (electrodes on lips); muscle effort during swallow (electrodes under chin); electrical activity in laryngeal elevators (on larynx during Mendelsohn maneuver)
If you use Ultrasound for biofeedback, what type of information does the patient get?
Information about tongue movement patterns during swallowing so that the patient can watch changes
What are the different types of non-oral feeding?
1) IV 2) Nasogastric tube 3) Gastrostomy (including PEG) 4) Jejunostomy (including PEJ) 5) Pharyngostomy 6) Esophagostomy
What does IV feeding entail? How long would this be done?
The patient is fed through sugar water in the vein. This is done no more than a few days because you don't get much nutrition.
IN non-oral feeding, the width of the tube determines ___________________. For example, with a 1/8 inch tube…
1) The type of food the patient can get 2) The patient will need prepared feedings - table food will clog it up. This is more expensive.
Will you do swallowing therapy with an NG tube in place? How about a G-tube?
1) NO - the NG tube will disrupt the swallow. 2) You can do it with a G-tube in place
Why would you use a Jejunostomy or Nasal-jejunum tube? What is one added expense?
It helps prevent reflux because the food is introduced in the system below the level of the stomach. It is more expensive because the patient HAS to have prepared feedings, not table food (because it does not pass through the stomach to be digested)
What are some red flags for refux?
1) Mild hoarseness 2) Waking up gagging / coughing 3) Gagging within a few minutes after a meal 4) If the patient has had non-oral feeding
Are X-ray studies good for observing reflux? What is the best test?
1) NO - you are not looking that low in MBS & even regular Barium studies miss it 60-80% of the time 2) REFLUX MONITORING - tube inserted through nose and into esophagus. This tube has acid-sensitive sensors which will be set off by reflux.
What is a pharyngostomy? Any specific problems with this?
1) A type of non-oral feeding in which there is a hole from the outside of the neck into the pharynx for the feeding tube. 2) Problem - it may move migrate opening up the sutures and creating a fistula from the skin into the pharynx.
What is an esophagostomy? Any specific problems with this?
1) A non-oral feeding type in which there is a hole lower in the neck for the tube to enter and go down into the esophagus. 2) Problem - there are major blood vessels in the neck which can get disrupted (ie. the tube may irritate/degrade the carotid)
What is a gastrostomy? Any specific problems with this?
1) A non-oral feeding type in which there is a hole directly into the stomach for the feeding tube 2) This requires general surgery and many older people cannot undergo anesthesia.
What is a Jejunostomy? Any problems with this?
1) A non-oral feeding type in which there is a hold into the digestive system just below the stomach 2) Requires prepared feedings because the food is no longer passing through the stomach.
What are PEG and PEJ?
1) Percutaneous Endoscopic Gastrostomy OR Jejunostomy. Only LOCAL anesthetic is needed because an endoscope is placed down into the structure to determine where to enter for the feeding tube. The benefit is that now more people can have this instead of an NG or NJ tube. Unfortunately, it means some patients are given this too hastily.
What are the general problems with non-oral feeding?
1) It is more expensive than oral feeding 2) Puts people at risk for reflux - across ALL the types
While you may wait 2-3 days to put a patient on a feeding tube, you should not wait more than…
4-5 days - it is our job to help ensure the patient gets adequate nutrition
Why is non-oral feeding trickier in those under six years of age?
1) They have an underdeveloped LES so you need to do a surgery to reinforce it (to avoid reflux). The surgery involves twisting the entrance of the stomach around the LES. (Fundoplication)
If you patient has been recently intubated…
1) You will generally wait at least 24 hours (but preferably 3 days) before initiating swallowing eval/therapy. The intubation will likely cause some reduced ROM.
If your patient is tracheostomized, there will always be a ___________ in the room. You need to find out whether the trach is clean or _______ for that patient.
Trach kit / sterile
How do you clean out the trach?
Remove the inner canula, rinse it out. Then use a bottle brush to clean it. Rinse again, shake it, and stick it back in (this is the clean procedure)
When you start working somewhere, what do you need to do to figure out about handling trachs there?
1) Ask for an inservice with the respiratory staff to show you how to clean them (if you are allowed) 2) Find out if you are allowed to suction 3) Ask about cuff procedures - Minimal leak vs. fully inflated?
What is deep suctioning? Who does it?
1) A procedure in which a long flexible catheter is inserted in past the bifurcation of the bronchi to suction. 2) Selected Nurses can do it
Most ventilators work on ____________ which means…
1) Positive pressure 2) The ventilator applies pressure to inject air into the lungs. 3) Then the air is allowed to flow passively out of the lungs. 4) Cuff must be INFLATED!!!
What is auscultation? What are the clinical uses of it?
1) Listening to the sounds of the swallow. 2) Data is poor and you cannot tell if the patient is aspirating or not using this technique. What you CAN tell is the coordination of breathing and swallowing - remember that the swallow should NOT interrupt the inhalation.
For 75-80% of patients, what is the pattern of the swallow in relation to respiration? How is this controlled?
The patient inhales, stops breathing, swallows, and then exhales / Controlled by the medulla
How long does it take children to stabilize the pattern of swallowing in relation to respiration?
About three months
What are some respiratory issues that might prevent you from working on swallowing?
1) Rapid respiration 2) If the patient is ventilator dependent
How can you test different tastes, textures, etc. without putting the patient at risk?
Wrap fabrics of different textures around flexible straws - dip these in different tastes in order to see what elicits the best swallow.
Which taste seems to evoke the best swallow?
Besides increasing fibrosity of tissues, patients with radiation will also often experience…
Loss of sensitivity in places
______ of women and _______ of men have NO gag reflex
10% / 40%
What is the goal of therapy (RSTSC)?
To improve the oropharygneal swallow by changing the physiology: Range of motion, strength, timing, coordination, sensory input
Therapy is designed to be _________ and _________
Functional / Measurable
Reduced Mandibular Movement: Populations, Procedures, Measurement
1) Population: Oral Cancer (radiation, surgery) 2) Procedures: Open/Close mouth; lateral movement; circular movement; combine above with resistance 3) Measurement: Distance of opening; ability to put the bolus in the mouth
Reduced Labial Seal: Populations, Procedures, Measurement
1) Population: CVA, Oral cancer 2) Procedures: Protrusion/retraction; form seal around a cup (then hold the cup up that way); maintain air puffed cheeks; resistance against tongue blade. 3) Measurement: Distance, resistance, improved saliva/bolus control.
Reduced lingual movement for mastication, bolus formation, bolus control, and oral transit: Populations, Procedures, Measurement
1) Population: Oral cancer, CVA, TBI 2) Procedures: WORK IN ALL PLACES OF MOTION, MARGINS of STRENGTH: protrusion/retraction; lateralization; elevation (tip and back); resistance against tongue blade. 3) Measurement: distance, resistance.
What are the procedures and measurement options for chewing and tongue control?
These allow patients to manipulate something moving from gross to more skilled movement: 1) Procedures: manipulating item L to R / R to L in 2-3 lingual sweeps, rotary motion (midline to teeth again and again), tongue cupping bolus, A/P movement. 2) Measurement: number of lingual movements needed. (Materials = gauze, swab, licorice whip, lollipop, lifesaver on a string)
Reduced Tongue Base Retraction: Population, Procedure, Measurement
1. Population: CVA (subcortical), Pharyngeal cancer, SCI (cervical fusion), Respiratory failure (intubation), generalized dysfunction. 2. Procedures: pull back, yawn, gargle (use VFG to pick one), effortful swallow, Masako 3) Measurement: increased movement, reduced residue in valleculae.
Reduced Laryngeal Elevation: Populations and three procedures
1) Population: CVA (brainstem), SCI (cervical fusion), H/N cancer (surgery / XRT), generalized deconditioning. 2) Procedures: Falsetto voice, Mendelsohn maneuver, Shaker exercises
Describe Falsetto Voice procedure and how you would measure progress
1) Pitch glide up on /i/ and then hold for 2-3 seconds 2) Measurement: Palpate for laryngeal movement, improvement in pitch glide.
Describe how you would measure progress from using the Mendelsohn maneuver?
Increased movement, reduced pyriform sinus residue visualized in VFG
Describe the Shaker exercise and how you would measure progress. Also, what type of clients would you NOT use this for?
Part A: Lie down, elevate head for 1 minute, rest head for one minute, repeat process 3x. Part B: Repetitive head elevations X 30. 2) Measurement: Reduced pyriform sinus residue on VFG, observing duration of head lift. 3) DO NOT USE on patients with SCI or trach
Reduced glottic closure: Populations, Procedures, Measurement
1) Populations: Intubation trauma, VC paralysis 2) Procedures: Bearing down or lifting against hard surface with one hand; sustained phonation with hard onset, effortful breathhold, combine techniques to make it more difficult. 3) Measurement: Improvement in Voice Quality
What are the two functions of voluntary maneuvers?
1) To use as a compensatory strategy to make the swallow safer NOW 2) To use in therapy as an exercise to change the physiology of the swallow over time
Two disorders for which a supraglottic swallow is helpful; Rationale; populations
1) Reduced laryngeal closure at the vocal folds 2) Delayed pahryngeal swallow 3) RATIONALE: closes vocal cords before and during the swallow 4) Populations: VC paralysis, intubation trauma
How can you measure the effectiveness of the supraglottic swallow in VFG? At bedside?
1) VFG - presence/amount of aspiration on repeat 2) At bedside: Monitor for sequencing, duration of breath hold.
What disorder is most helped by super supraglottic swallow? Rationale? Typical Populations?
1) Reduced laryngeal closure at the airway entrance 2) Rationale: the arytenoids tilt forward, closing airway entrance before/during swallow 3) Partial laryngectomy, intubation trauma
How can you measure the effectiveness of the super supraglottic swallow on VFG? At bedside?
1) Presence/absence of aspiration on repeat VFG 2) At bedside: monitor for sequencing , duration of breath hold, effort of breath hold
What disorder is most helped by effortful swallow? Rationale? Populations?
1) Reduced tongue base retraction 2) Rationale: Effort improves movement 3) Populations: H/N cancer, SCI, CVS, generalized deconditioning
How can you measure improvement from using effortful swallow at VFG? At bedside?
1) VFG - movemetn seen on VFG, amount of vallecular residue seen on repeat VFG 2) Palpate for tension at bedside
Which disorder is most helped by the Masako exercise? Populations?
Reduced tongue base retraction / H/N cancer, SCI, CVA
How can you measure progress from using the Masako exercise on VFG? At bedside?
1) On VFG - Movement observed, amount of residue in the valleculae. 2) At bedside - monitor protrusion of the tongue, signs of fatigue
Should you use food when doing the Masako exercises?
Not if the patient is shown to have dysphagia in VFG
Name the two disorders most helped by the Mendelsohn maneuver. Rationale? Populations?
1) Reduced Laryngeal elevation 2) Reduced coordination of the swallow 3) Larygneal movement opens the UES so by prolonging laryngeal elevation we can increase the extent and width of UES opening. It also normalizes timing of the pharyngeal swallow. 4) Populations: SCI, H/N cancer (surgery,XRT), CVA
How can you measure progress from using the Mendelsohn Maneuver on VFG? At bedside?
1) On VFG - increased movement, reduced pyriform sinus residue on VFG. 2) At bedside - palpate the swallow
Which disorder is most helped by Thermal Tactile Stim? Rationale? Populations?
1) Delayed pharyngeal swallow 2) Rationale - technique heightens sensory awareness and alerts the cortex/brainstem that a swallow is coming. 3) CVA / TBI
How can you measure progress of patients using TTS? How can you increase the difficulty?
1) Improved timing of trigger seen on VFG, palpate the swallow at bedside. 2) Increase difficulty by withdrawing the frequency of TTS, increase bolus amount or viscosity)
What disorder is most helped by Suck-Swallow? Rationale?
1) Delayed pharyngeal swallow 2) Exaggerated movement provides sensory stimulus.
Other sensory enhancing procedures include…(besides suck-swallow, TTS)
1) Downward pressure with spoon 2) Changing bolus characteristics: volume, sour bolus, carbonated bolus
Intraoral prosthetics are used as a _________ procedure
List some populations that may benefit from intraoral prosthetics
1) Oral cancer patients loss of ROM or TISSUE itself 2) Neurologic disorders resulting in reduced lingual movement/strength.
Intraoral prosthetics are usually initiated _______
4-6 weeks post-surgery
The prosthetic device used for patients who have intact anatomy but reduced velopharyngeal competency. What does it do?
1) Palatal Lift 2) It elevates the natural tissue to close off the nasopharynx and reduce nasal regurgitation, increase pharyngeal pressure generation
The prosthetic device used for patients who have had resections of the soft palate. What does it do?
1) Palatal obturator 2) Designed to replace missing tissue
The prosthetic device used for those with limited lingual ROM or tongue bulk. What does it do?
1) Palatal Augmentation / Reshaping prosthesis 2) Lowers the palatal vault to improve lingual-palatal contact for bolus transit and speech.
Every therapy plan needs…
1) Long Term Goals 2) Short term goals (specific techniques, conditions) 3) Daily practice schedule (therapy and individual) 4) Explanation of rationales 5) WRITTEN INSTRUCTIONS 6) Timeline for reevalation or revision of goals
List the five disorders for which you should use THIN LIQUIDS
1) Oral Tongue dysfunction 2) Reduced Tongue Base retraction 3) Reduced Pharyngeal Wall Contraction 4) Reduced laryngeal elevation 5) Cricopharyngeal dysfunction
List the two disorders for which you should use THICKENED LIQUIDS
1) Oral Tongue Dysfunction 2) Delayed pharyngeal swallow
List the three disorders for which you should use PUREES/THICK FOODS
1) Delayed Pharyngeal Swallow 2) Reduced laryngeal closure @ entrance 3) Reduced laryngeal closure throughout