dysphagia – Flashcard
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1. what type of nutritional management is necessary 2. should therapy initiated? (what type) 3. specific strategies for therapy?
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what are the questions to ask following the evaluation?
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Therapy= designed to change swallow physiology Compensatory strategies= eliminate symptoms
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What is the difference b/w therapy vs compensatory strategies?
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Direct=presenting food or liquid to patient Indirect therapy= exercise programs or saliva swallow (no food/liquid)
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Difference b/w direct vs indirect therapy?
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-prognosis -diagnosis -caregiver support -patient motivation -severity -respiratory function -cognition -reaction to compensatory strategies
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How do you determine if therapy is needed?
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-no absolute guidelines ---SAFETY ---TIMING of swallow ----Aspiration ALERtness
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How do we know when it is safe to use oral feeding vs non-oral?
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in the diagnostic stages
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compensatory treatment procedures are introduced when?
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control the flow of food and eliminate aspiration
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what do compensatory treatment procedures do?
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-postural changes -increase in sensory input -modification of the volume and speed of food presentation -changing food consistency/viscocity -prosthetics
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examples of compensatory treatment procedures?
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1. behavioral 2. surgical 3. medical
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What are the three types of treatment options?
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when the strength, endurance or mobility of structures is diminished, or when evaluations have shown that the swallow would improve w/ compensatory strategies.
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When are behavioral therapies recommended?
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to strengthen, imrpove ROM, and coordinate movement.
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what are oral motor exercises used for?
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5-10 times, and should be completed 5-10 times per day
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how often should oral motor exercises be used?
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strengthen slow twitch muscles, which are more susceptible to atrophy
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how do oral motor exercises work?
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3%
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A muscle that loses it's neurological signal to fire begins to atrophy at a rate of ___ a day.
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fast twitch- fast fatigue
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which muscles are more susceptible to fatigue?
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mcneill dysphagia therapy program chewing and swallowing program which is exercise based. begins after VSS results--- 5 ml of nectar thick liquid, keep lips closed and swallow hard and fast
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MDTP
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-two fold for speech therapy -good homework for clients -maybe the only choice for some patients
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advantages of oral motor exercises
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tongue elevation and lateralization tasks- helps clear the lateral sulcus... ex: elevate tongue tip, move tongue back
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Range of motion exercises
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pushing tongue against an object (tongue blade, finger, sucker)... move tongue up, to the side, forward
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Resistance exercises
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Iowa Oral Performance Instrument- uses a "bulb" for tongue exercises and the goal is to compress the bulb as much as possible
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IOPI
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give the patient something like gauze/licorice, and have them move it around. gradually move to smaller objects (lifesaver, gum)
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Exercises to improve manipulation of material
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laterally
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exercises to hold a cohesive bolus should be used after the client can manipulate material____
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first start w/ a paste consistency and have them move it around the tongue, then vary size of the bolus and move on to liquids
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what kinds of exercises help the client hold a cohesive bolus?
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practicing posterior propulsion of the bolus
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bolus propulsion exercises are used for what?
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use a long roll of gauze soaked in juice, and have them push upward and backward against the gauze to squeeze out the liquid
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examples of bolus propulsion exercises
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to improve airway entrance closure
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ROM exercises for the pharyngeal structures are used for what?
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-bearing down exercises -vocal fold adduction exercises -/ah/ on a hard glottal attack 5 times -supraglottic or supra-supraglottic maneuvers -repat 5-10 times daily for 5 mins at a time
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examples of ROM exercises for the pharyngeal structures
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shaker exercises help increase UES opening and help with VF closure. It involves sustained head elevation while the patient is lying on their back. do 3 times a day for 6 weeks.
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What is the shaker exercise?
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pull tongue straight back and hold pretend to yawn pretend to gargle practice the effortful swallow
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what are some base of tongue exercises?
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swallow with your tongue between your teeth. helps w/ tongue base contact to PPW.
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What is the Masako maneuver?
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"falsetto" exercises- slide your pitch and hold the high note for several seconds
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How do you do laryngeal elevation exercise?
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Lee silverman voice therapy (LSVT)
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what are some respiratory strengthening exercises?
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transcutaneous electrical stimulation- enhances contraction of muscles. low levels of electrical current to the brain.
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external stimulation- NMES
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uses NMES electrical stimulation. Small electrical currents stimulate muscles. must use exercise w/ muscle contractions and must have 3 yrs dysphagia experience/complete training.
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vital stim
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medications, GERD, xerostomia
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Medical therapies
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used to improve anatomic or physiologic swallowing disorders . can provide nutrition and hydration- non oral feeding tubes
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surgical therapies
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not performed by SLPs. Ex: botox injections, dilation, surgical reduction of osteophytes
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surgical procedures
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epiglottic pull down suturing the vocal folds together suturing the false folds together tracheostomy laryngectomy (total)
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procedures to control constant aspiration
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can be temporary or permanent slp role- DETERMINE IF THE PATIENT'S SWALLOW FUNCTION IS SAFE AND FUNCTIONAL TO SUSTAIN NUTRITIONAL SUPPORT non oral increases risk of reflux as compared to oral feeding
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non-oral feeding
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nasogastric tube-into the nostril and to the stomach PEG tube - directly in the abdominal wall to stomach (more long term)
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non oral feeding methods
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to the jejunum
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jejunostomy
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keep separate from meal times can use meal times to re-evaluate. group therapy can be effective
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When to do swallow therapy?
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acute CVA, head trauma, head and neck cancer, degenerative diseases
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which patients are at risk for dysphagia?
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dementia, elderly patients, malnourished, in recovery. altered levels of consciousness, weakness, poor oral care
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which patients are harder to identify for dysphagia?
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nursing/intake assessments, dietery assessments, screening by SLP, hospital protocols, aspiration precautions
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how is multidisciplinary care involved?
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indicated in many settings for all patients will be modified for each individual patient identified w/ dysphagia precautions may vary w/ setting: -inpatient -outpatient
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aspiration precautions
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do not allow patient to eat unattended position patient in 90 degree uptake for all intake observe for coughing, throat clearing, or struggle during oral intake minimize distractions assess pulmonary status
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Inpatient precautions
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caregiver education ensure family is familiar w/ hemlich, CPR, and aspiration signs. train them on food preparation make referrals to dietician if necessary
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outpatient precautions
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communicate w/ dietician, nursing, cafeteria attention should be paid to the overall nutritional intake daily input (I) and output (O) weight loss/gain change in blood chemistry
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nutritional assessment
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1: dysphagia pureed (blended smooth w/o lumps to masticate) 2: mechanically altered (minimal mastication- ground meats, no breads or cold solid) 3: advanced normal food
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National dysphagia diet levels 1-3
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some include a wet/slippery puree vs regular puree authors add dysphagia puree w/ ground meat
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variability within the diets
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45
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the aging swallow may begin as early as --- year old
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presbyglutition
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the aging swallow is called
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comorbidities
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what will impact the aging swallow?
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nervous system muscular system
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what factors affect the aging swallow decline?
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-oral health status (xerostomia, tooth decay..) -cognitive status
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Other factors affecting the aging swallow
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aspiration- at high risk for aspiration pneumonia malnutrition- decreases resistance to infection dehydration- UTIs, falls, constipation. thin liquids cause difficulties
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considerations w/ the elderly patient w/ dysphagia
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EDUCATE screenings at nursing homes, etc ask geriatric patient about swallowing abilities educate nurses to ask specific questions/probe
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how to prevent decline?
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education ROM exercises annual MBS
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preventative measures?
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use of non-oral feeding method? discontinue use? final decision lies w/ patient or power of attorney SLP role: EDUCATE, safe diet, strategy recommendations
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ethical dilemmas
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uncertainty, lack of clarity, different value systems, conflict regarding goals of treatment
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ethical dilemmas occur why?
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-medical indications -patient preferences -quality of life -contextual features
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what to consider ethically?
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consider the patient values, beliefs and treatment goals advance directives: formal documentation of preferences in writing (living will and durable power of attorney)
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patient preferences
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difficult to define. patient must dermine...
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quality of life
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social factors, cultural, financial differences, family preferences...
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contextual features
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patient self determination act of 1990 and federal right to privacy allow refusal of decisions. paitients are presumed competent until proven otherwise.
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legal rights
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do not resuscitate
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Legal definitions.... DNR
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the patient's right to self-determination and maximization of independence in medical decision making
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autonomy
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patients ability to make decisions regarding her own current or future medical care
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decision making capacity
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someone else acts on behalf of the patient
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surrogate decision maker
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-tongue fills the oral cavity -newborn has buccal (sucking) pads in the cheeks for stability soft palate and epiglottis are in contact at rest larynx and hyoid are higher in the neck for extra protection eustacian tube runs from middle ear to nasopharynx face grows until age 21
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proportional differences in child anatomy
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greatest elongation of pharynx occurs during Puberty Nasopharynx: eustachian tubes, adenoid Oropharynx: no true oral pharynx, tonsils intact hypopharynx: tip of epiglottis to CP sphincter muscle
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pharynx- child
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close to base of tongue mass is large length of VF small (3 mm) larynx decends over time
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Infant larynx
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age 5: c6 age 15-20: c7
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larynx at age 5 vs age 15-20
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nasal breathing facilitated by small oral cavity and close proximity of tongue/pharynx
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infant breathing?
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after the first 3-4 months; sucking pads disappear and neck elongates
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when is mouth breathing more consistent in an infant?
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-limited neck stability -primitive reflexes -rhythmic sucking pattern -1:1 suck/swallow ratio 2:1 non-nutritive ratio
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Developmental stages- birth- 4 months
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stroke cheek-disappears 3-5 mos.
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rooting reflex
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disappears 6 months (finger)
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suck reflex
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disappears 3-5 months (pressure to gums)
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bite reflex
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should not disappear (tongue blade)
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gag reflex
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disappears at 4 months (push out solid food)
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tongue protrusion relfex
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palpate, listen for wet cry/voicing
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swallow reflex
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increased neck stability lip closure around spoon munching and smacking lean toward spoon lateral tongue starts using both hands-begins
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developmental stages 5-7 months
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primitive reflexes DISAPPEAR! food manipulation skills self-feeding skills develop teeth erupt upper lip more mobile rotary chewing begins drinks from a cup eats finger foods and soft foods
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dev. stages 8-12 months
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13-18 months: long sequence with drinking 19-24 months: meats, chopped foods, sucks with a straw 25-36 months: regular table foods
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dev stages 13-36 months
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GERD strucutral anomalies neurological deficits sociobehavioral maladaptation snesory deprivation
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common etiologies in pediatric feeding
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inadequate nutritonal support associated w/ cognitive, developmental and behavioral impairments
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importance of nutrition and growth
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data collection, nutritional screening, feeding history, dev. milestones, physical assessment, oral mech, psychosocial interaction assessment
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pediatric assessment
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medical history growth chart current clinical nutritional status
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data collection
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collect info from parent/caregiver compile complete picture (posture, food types, behavior, etc)
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nutritional screening and developmental milestones
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alert? active? development normal? physical appearance
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physical assessment
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primitive reflex assessment compare age to abilities progress from least threatening (outside mouth) to most (inside mouth)
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oral motor skills assessment
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swallowing begins as early as 15-18 weeks GESTATION w/ sucking birth- tongue uses pumpkin action swallow triggers once bolus is formed laryngeal elevation reduced
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swallowing
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oral cavity forms a closed chamber and then draws liquid from the nipple oral cavity increases in size as tongue and jaw drop during sucking tongue pumps 2-7 times to express milk which is collected at farcical arches positive pressure occurs when baby compresses the nipple between the tongue and maxilla which expels fluid from the nipple
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mechanics of sucking
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to obtain nourishment 1:1 suck/swallow ratio 1 suck per second (older infant 2 or 3:1)
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nutritive sucking
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pacifier and fingers, calming 2 sucks per second very high ratio (6:1 or 8:1)
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non nutritive sucking
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newborn: 1:1 eventually: 3:2 breathes nasally and will suppress eating to maintain breathing
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suck-swallow ratio
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gums- hyperplasia? palate- cleft? dentition- present? airway tongue reflexes (gag, bit, tongue, rooting, suck, swallow)
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pediatric oral mech
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increase difficulties w/ suck coordination continue 1:1 swallow ratio neurologic problems respiratory problems hearing impairment neurologic problems higher risk for SIDS GERD cardio issues anemia increased risk for aspiration bc of poor coordination of swallowing, sucking and breathing prolonged feeding time oral aversions
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preterm infants and swallow complications
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from prolonged periods of restricted eating and drinking experience discomfort associated w/ feeding or medical intervention
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oral aversions
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CP kids are at increased risk in ALL phases. they demonstrate: silent aspiration, poor nutrition, recurrent infections, weak cough, and decreased mobility
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neurological disorders
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tongue thrust, poor lingual function prolonged bite and gag reflex delayed swallow residue aspiration exaggerated bite and gag reflex food refusal and behavioral problems during feeding
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CP swallow characteristics
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vary temperature and texture thicker texture improve jaw, lip and cheek control signals for wiping mouth or wristbands to keep the face dry stretching, brushing, vibrating, icing and stroking areas of the face (spastic) reduce rate of feeding
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CP interventions
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shaken baby falls under TBI or CP impaired attention, awareness, cognition altered behavior to feeding tonal and postural deficits oromotor, respiratory, and laryngeal impairments oral sensitivity and control issues
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TBI
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behavior control issues- delayed initiation of feeding, panic reactions w/ sequence cup drinking in general: distractable, unaware of deficits
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cognitive considerations with TBI
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hypertonicity of the muscles of the lips and chewing muscles smaller jaw decreased volume of the oral cavity weak suck/rooting reflexes underdevelopment of frontal sinus leads to mouth breathing and tongue protrusion respiratory, cardiac, and GI problems
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down syndrome
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simultaneous presentation of liked and disliked foods gradually change the type of food or utensils progressive muscle relaxation systemic desensitization
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down syndrome interventions
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chewy tubes massagers toothettes tooth brushing food shaped toys kazoos/whistles teething toys oral play- bubbles, cotton balsl
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materials to elicit oral strengthening/ sensory awareness
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abnormal suction and compression due to structural malformations infant with only lip involvement is able to achieve suction palate usually cannot breastfeed habermann feeder allows for compression without suck- use this (but may cause nasal regurgitation)
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infants w/ cleft palate
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restricted diet to promote healing some discourage bottle; recommend spoon or cup position semi-upright w/ head higher than stomach use slow flow nipple nasal regurg pace intake
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post surgery cleft palate
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will adapt treatment w/ each stage of surgery modified nipples on bottles breast feeding tube feeding- ng or PEG tube
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cleft palate intervention
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small/absent mandible suck-swallow-breathe pattern frequently has a trach posterior position of tongue/ respiratory difficulties
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pierre robin sequence
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tube feed if necessary position for tongue movement sidling position w/ special bottle
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pierre robin sequence intervention
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weakness in the lips; inability to suck. no seal, excessive drooling
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moebius syndrome
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feeder assisted squeezing w/ special bottle
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moebius syndrome intervention
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limitation of ROM in jaw, lips or tongue unilaterally. Intervention: use stronger side of mouth, provide stabilization to waker side, special bottle/nipple
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hemifacial microsomia
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inefficient sucking. Intervention- special bottle
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treacher collins syndrome
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fatigue due to cardiac involvement. intervention- tube feeding, sensorimotor stimulation, special bottles
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velocardiofacial syndrome
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poor suck and swallow, sensory deficits, ROM in jaw reduced, CNS problems (seizure, palate), motor coordination, esophageal issues
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FAS
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consult w/ nurse and family. Adaptive equipment- nipples with sucking pattern, thickened liquids/formula multiple feedings (minimum 10 times a day) non-nutritive sucking (chewing, pacifiers)
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FAS intervention
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recurrent vomiting recurrent chest infection poor growth and nutrition choking attacks hoarse cry arches back during feeding irritable sleep problems eats small amounts frequently
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GERD
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medication, change formula, breast feeders watch mom diet, thicken formula, burp constantly, frequent small meals. position- sit 30 degrees after meals. Should end between 8-12 months.
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GERD treatment
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diagnosis, sudden weight loss, sudden change in feeding, bottle feeding lasting 30 minutes or more, frequent spitting up, choking during feeding, weak suck
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General symptoms requiring clinical assessment
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facial or dental trauma nasal, oral, or pharyngeal tissue soft injury laryngeal or tracheal trauma laryngospasm pulmonary aspiration spinal cord injuries elevation of intracranial pressure- can be used with or without mechanical ventilation
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artificial airway is used why?
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a surgical incision
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what is a tracheotomy?
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the OPENING in the trachea
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what is a tracheoSTomy?
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tube placed into the tracheal opening to maintain airway and provide means for mechanical ventilation.
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what is a TracheoSTomy tube?
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hemmorrhage thyroid injruy trach too high or too low (should be between 2nd and 3rd tracheal cartilages) fistula cardiac arrest air leaks nerve injury
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complications of tracheostomy
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inserted into trachea through a surgical incision between 2nd and 3rd tracheal rings well below true vocal cords- avoids damage to the larynx during emergent situations, they may be placed higher and may cause scarring tubes are usually left in place until airway obstruction is completed. they can also be permanent.
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placement
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stoma- open hole. trach- small slit
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stoma vs. trach
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outer cannula inner cannula flnage outer diameter cuff air inlet valve air inlet line pilot cuff fenestration speaking valve
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parts of the trach
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bigger, smaller
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male sizes are ___ and females are ____
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tube inserted into the tracheal incision until neck plate is flush against neck
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what is the outer cannula?
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slides into the outer cannula, helps keep tube from having too many secretions
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what is the inner cannula?
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provides a smooth tip for insertion of the tube but is immediately removed
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what is the obturator?
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may cause damage and rub the trachea, will not allow air around the trach to use a speaking valve
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what happens if the trach is too tight?
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should not occupy more than 2/3 of the inner diameter of the trachea
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how bug should the trach be?
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decrease the size of the diameter
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how do you wean from a trach?
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should properly fit to maximize oxygen delivery and decrease pressure on the trachea.
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why is the diameter of the trach tube importabt?
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bivona, lanz, portex, shiley
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manufacturers of tubes
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the balloon-shaped extension on the end of the tube primary function is to SEAL the trachea reduces aspiration
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what are cuffs?
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a precise measurement too much causes damage to trachea too little inefficient they can pop! MUST be suctioned before deflated; they will often cough after. air taken in must be the same as air taken out
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how is the cuff inflated?
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high-volume low pressure- common in acute setting foam- no air injected, passively inflates
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What are the two cuff designs?
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used to provide an airway when patient can still breathe on their own but needs assistance with secretion removal and airway maintenance
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cuffless tracheostomy tubes
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can increase the risk of aspiration 2 functions: 1. to aid in the removal process 2. to faciliate verbal communication- air can pass through the VFs
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fenestrated tracheostomy tubes
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pulse oximetry- to monitor patient's oxygen saturation, want 90% or above humidifier- keeps secretions moist suction- yankauer suction tip use for oral or tracheal suctioning- do NOT mix the two!
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Other items used with a trach patient
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physiological changes attributed to tracheostomy and placement of trach tube
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what are swallowing considerations?
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-decreased laryngeal elevation -decreased laryngeal sensitivity decreased subglottic pressure
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Know for quiz the swallowing considerations:
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-anchors larynx, epiglottis cannot provide protection.
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how does trach tube cause decreased laryngeal elevation?
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reduced reliance of cough- silent aspiration
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how does the trach tube cause decreased laryngeal sensitivity?
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material can easily enter lower airway during swallow because vocal folds have no pressure below... risk for aspiration
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how does the trach tube cause decreased subglottic pressure?
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cuffs do not protect against aspiration- incomplete sealing of trachea; secretions and food above cuff mechanical ventilation- increased risk of aspiration due to patient breathing asynchronously with the ventilator
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swallow limitations:
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aspiration will void out of the trach tube site and we will SEE the aspiration- it will come out of the tube!
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swallow benefits with trach:
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blue dye, bedside swallow, MBS, FEES
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methods of swallow eval w/ trach:
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controversial. colors food to determine aspiration
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blue dye test
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suction above cuff orally before deflation continue as a usual eval watch contents for aspiration out of trach site
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clinical swallow
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same as clinical but with radiation
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modified barium swallow assessment
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passed through the nose as usual
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FEES
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stimulate swallow supraglottic strategy- hold breath mendehlson- elevate larynx finger occlusion or speaking valve cough/throat clearing alternate textures, volume, positioning, etc
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strategies with pharyngeal dysphagia and trachs
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special tubes for means of verbal communication for patients requiring mechanical ventilation gas travels from an external source through an airflow line, exits through fenestrations located above the cuff and passes through the glottis to support vocalization
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talking tracheostomy tubes
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-portex trach talk -single fenestration biovona trach talk- single fenestration, foam cuff communi-trach- gas travels between the inner and outer cannula, 8 fenestrations
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3 types of talking tracheostomy tubes
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requires long term ventilation unable to tolerate cuff deflation s/p 5 days placement free of vocal pathology adequate alertness
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patient selection for talking trach
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lack of upper airway potency inadequate articulation dysfunctional laryngeal mechanism large amount of secretions
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contraindications
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used in final stage of decantation process designed to keep the stoma open and allow direct access to trachea if necessary small hollow tube in trach tube, can use speaking valve or cap
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tracheostomy button
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directs exhaled air past the vocal folds to support speech exhaled air is forced to exit through the folds and mouth- must have clear upper airway cuff must be deflated- suction before deflation orally
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one way speaking valves
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does not require mechanical ventilation s/p 48 hours placement has cuffless trach or deflated cuff no significant tracheal or laryngeal abnormality adequate alertness able to produce phonation around deflated cuff
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one way speaking valves- patient selection
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upper airway obstruction inflated cuff patient with a foam cuff is NOT a candidate
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one way speaking valve- not for these patients
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speech eliminates need for finger occlusion improved taste and smell enhanced swallowing function
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advantages to one way speaking valve
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can speak with it in unique no leak design only speaking valve approved for use with a ventilator can speak and eat
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parry muir speaking valve
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must have doctors order can practice with the client using finger occlusion always consult respiratory therapist- suctioning, vent settings, problem solving
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speaking valve
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will want to gradually increase timing- 5 min to most of awake time use during meals remove when sleeping clean with warm soapy water train client to put on and off
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speaking valves- how to use
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monitor changes with treatment, discontinue if vital signs become outside normal ranges perform suctioning before onset of treatment/during treatment
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treatments of patients with artificial airways
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amount consistency color
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secretions what are we looking for?
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endotracheal suctioning- closed suction system oral and pharyngeal suctioning- yankauer suction wand
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types of suctioning
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cardiac arrhythmias mucosal trauma infection bronchospasm respiratory arrest
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complications of suctioning
