Dysphagia Final

true

T/F Good cough efficiency does not effect aspiration risk—Cough efficiency is only about clearing what has already been aspirated!

head turn

Turn towards weak side to compensate for decreased pharyngeal propulsion → causes stasis in pyriform sinuses

mendelsohn

a. Increases hyolaryngeal elevation and tongue base strength b. When "voicebox" is touching the chin at top of the swallow, hold it there for 3 sec c. Don't hold with hands! Use muscles! d. Can make any of these more difficult by combining with other resistance based exercises

showa

a. Increases tongue strength and blade elevation b. Hold base of tongue to top of mouth and hold for 10-20 sec c. Could use ora-light to feel if they're pushing d. Could use sucker, lifesaver with string tied to it, sponge, etc. for them to feel the pushing against the palate

shaker

a. Lay on floor/table and tuck chin to look at toes b. Can help with hyolaryngeal elevation—use when you see decreased epiglottic retroflexion, decreased airway protection, and stasis c. Can't do with pts who are pregnant or have had neck surgery

mcneill dysphagia therapy program (MDTP)

a. Resistance based exercises in hierarchy b. Have to be trained c. Incorporates exercise physiology principles in the mouth d. Integrates what they can already do

push/pull exercises

a. Use to strengthen vf approximation b. Can't do if pregnant or have heart problems c. Pull down on chair (i.e.) and phonate

• Pt complaint • Diagnosis • Cognition • Current PO intake • Mobility concerns • Surgical hx • Medications • Recent imaging • Referral • Had radiation? • History of pneumonia • Living environment • Occupation • Recent hospitalizations • Family support • Food preferences • How do they take medications? • Pt goals

before swallow eval need to know...

postural

change anatomy; change from using one anatomical structure to another

behavioral

changing physiology; change the dynamics of the bolus flow

effortful swallow

contract muscles really hard to push food down - Use when you need more pressure and have stasis

yes but inefficient

does open trach valve allow for voicing?

yes

does passy muir speaking valve allow voicing?

PEG (percutaneous endoscopic gastrosomy tube)

goes in stomach o MicKey button—flush button on stomach • For babies so they can't pull it out • Adults that are really thin can get them

J-tube (jejunum duodenum tube)

goes in the gut, bypasses the stomach

super supraglottic swallow

hold breath, bear down, swallow, cough/clear throat, then swallow again - Combines effortful and supraglottic swallow - Do this during every swallow

supraglottic swallow

hold breath, swallow, cough/clear throat, then swallow again - Will get rid of stasis in the laryngeal vestibule on the surface of the vfs

conservative consistency (low aspiration risk)

i. Liquids, honey consistency ii. Thin liquids iii. Thin liquids in serial swallows iv. Thin liquids from straw (easier than cup, bolus is already formed)

solids

i. Puree ii. Pudding iii. Soft solids iv. Firm solids (bread, fruit bar) v. Crunchy solids

masako

increases tongue base approximation with the posterior pharyngeal wall - 9 sets of 10 a day (can modify) - Stick out tongue, swallow—this increases tongue base strength - The farther the tongue sticks out, the harder it is—tongue fights against resistance - Use if there is stasis in the valleculae—means bad pharyngeal propulsion - Can compensate for decreased hyolaryngeal elevation by increasing tongue base strength - If a pt has no larynx, this can build up tongue base strength to help protect and close off airway

gustatory stimulation

increasing the sensory input of bolus - Can add flavor additives, herbs, sour things, lemon to water, etc. - Enhance sensory decoding of food to increase appetite and swallowing safety—will trigger harder, faster swallow - "Put a party in their mouth and spice up the bolus" - Good for someone with an absent or delayed swallow onset

CN IX, glossopharyngeal

innervates oral/base of tongue

CN XII, hypoglossal

innervates pharyngeal tongue

24

it takes muscles ____ hours to atrophy if not used

PEG, J-tube, Parenteral nutrition

long term non-oral feeding

resistance based swallowing exercises

masako, showa, mendelsohn, shaker, push/pull exercises, mcneill dysphagia therapy program

compensatory; rehabilitation

most of the postures are ____, and most of the exercises are for ____

20-30 min

normal adult average meal time

10-15 min

normal baby average meal time

2-3cc

normal bolus size

decreases

open trach valve ____ cough efficiency

increases

open trach valve ____ secretions because of a lack of warming, humidifying, and filtering by the nasal cavity

decreases

open trach valve ____ subglottic pressure causing inefficient bolus flow through the proximal esophagus (stasis, aspiration)

decreases

open trach valve ____ taste/smell because the air bypasses the nasal cavity

increases

open trach valve ____ work of breathing leading to decreased PEEP

tethering

open trach valve there will be decreased hyolaryngeal elevation and excursion because of ____ (also causes decreased UES opening, arytenoid/epiglottic approximation, epiglottic retroflexion, airway protection, and increased aspiration)

ora-light

oral motor exercises - Research shows that using normal oral pattern is better - Provide correct repetitions of a muscle movement (takes 10,000 repetitions to master it!) - Tracy uses these exercises for swallowing and articulation therapies - Inexpensive; comes in child and adult sizes

increases

passy muir speaking valve ____ cough efficiency

decreases

passy muir speaking valve ____ secretions by increasing heat/moisture

increases

passy muir speaking valve ____ subglottic pressure (restores PEEP to normal 5 mg/cm2)

increases

passy muir speaking valve ____ taste/smell by increasing airflow through the nose

decreases

passy muir speaking valve ____ work of breathing (leading to increased PEEP)

IOPI, MOSST, Dworkin, Ora-light

resistance based lingual strengthening devices

IOPI (Iowa Oral Performance Instrument)

resistance based strength trainer that gives feedback on pressure reader i. Set at how much pressure you want and have to sustain it ii. Objectively measures tongue and lip strength iii. Set exercises, logs performances; can see improvement

nasoenteric feeding tube

short term non-oral feeding

thermal tactile stimulation

take a double O laryngeal mirror, put it in ice and get it cold, stroke in and down at the base of the faucial arches, put in the bolus and tell pt to swallow - Have to do between every swallow - Controversial - Tracy believes that changing the bolus is better than stroking between each swallow - Gives a strong input; priming and reminding the system how to swallow

progressive; 2

use long term non-oral feeding tube if they have a ____ dysphagia or they need to be tube fed longer than ____ weeks.

non-traditional therapies

vital stimulation NMES (Neuromuscular Electrical Stimulation), DPNS (Deep Pharyngeal Nerve Stimulation),

1. Lingual (Presence, ROM, strength, coordination) 2. Labial (ROM, strength, symmetry, coordination) 3. Oral hygiene 4. Dentition 5. Palate 6. Mandibular movement 7. Salivary management 8. Vocal quality 9. Cough efficiency 10. Pitch (only ask if you think it's neurological) 11. Buccal tone/symmetry 12. Swallow onset for volitional swallow 13. Artic/intelligibility 14. Trunk control 15. Hyolaryngeal elevation and excursion

what to look at in an oral mech exam...

oral prep, oral, pharyngeal

which phases are visible in FEES?

oral prep, oral, pharyngeal, esophageal (ALL OF THEM)

which phases are visible in a modified barium swallow study/videofluoroscopy?

oral prep, oral, pharyngeal

which phases are visible in an ultrasound?

oral prep and oral

which phases are visible in the CA? (cervical auscultation)

oral prep and oral

which phases are visible in the CSE? (clinical swallow evaluation)

oral prep and oral

which phases are visible in the evan's blue dye test?

oral prep and oral

which phases are visible in the modified evans blue dye test (MEBDT)?

tethering

with the passy muir speaking valve, there will be decreased hyolaryngeal elevation and excursion, but the restored subglottic pressure will counteract ____ to bring the larynx up higher and cause the epiglottis to retroflex

gavage feeding

• Bypass the oral preparatory phase and deliver bolus to mid tongue with catheter or syringe • Use if something is wrong with the lips, partial glossectomy, mandibulotomy—something that decreases the ability to organize the bolus

recommendations

• Changes to diet for the time being • Home exercise programs • Referrals to another doctor, PT, OT, etc. • Reeval if deglutition should decrease from current level

head back

• Hyoid elevates • Airway protection is decreased • Use for decreased oral transit

mandibular retraction

• Moves tongue base back to posterior pharyngeal wall • Used tongue base to protect airway, bringing arytenoids to tongue base • Could use for a pt with a tongue base glossectomy

head tilt

• Tilt towards opposite side • Bolus is pulled down by unaffected side

Frazier water protocol

• Water aspirated is not harmful—it is pH neutral so is reabsorbed into the bloodstream upon aspiration • Hydration is important to the health and quality of life of our pts • Encourages pts to drink water all day, but 30 min after eating to ensure they won't aspirate food

chin tuck

• Widens the vallecular space • The epiglottis drops down and the valleculae widens and the bolus slides off • Hyolaryngeal complex is elevated, tongue base is tightened, better laryngeal contraction • Use for stasis in the valleculae

long term goal

"Mrs. Smith will increase PO intake of soft consistency solids to meet 75% of daily hydrational and nutritional needs without signs of aspiration."

short term goal

"Mrs. Smith will perform Masako exercises in 9 sets of 10 daily to improve tongue base strength."

CN X, vagus

(includes recurrent and superior laryngeal nerves), innervates everything else

Wet vfs (indicate penetration), coughing (aspiration or penetration), delayed coughing (stasis), throat clear, watery eyes, runny nose, change in respiratory status, change in heart rate, loud swallow (borbophagia), aphonia (can't talk), effortful swallow, multiple swallows, food coming back up

In a CSE, after swallow listen for...

ultrasound, fiberoptic endoscopic evaluation of swallowing (FEES), modified barium swallow study

Instrumental tests

clinical swallow evaluation, evan's blue dye swallow test, modified evan's blue dye test, cervical auscultation

Non-instrumental tests

2

If they can go ____ weeks eating PO and don't lose weight they can take the tube out

modified barium swallow study

- Can see entire swallow - Videofluoroscopy: moving X-ray - Leaks more radiation than other X-rays - Takes about 3-5 minutes (after 3 minutes alarms go off) - View: 2D, black and white, can look anterior to posterior and laterally (Can see bones, diverticulum, etc.) - Can use real food but add in barium - Stand AP, watch approximation of vfs while pt says /i/ - AP, lateral, back to AP → need to see all of these views! - Can do for babies—can scope them but can't use the anesthesia! - Need to be able to see: oral cavity (don't need to see lips bc you are watching them eat!), bolus formation, AP transit, pharynx, larynx, proximal esophagus Disadvantages: i. Have to transport the pt to radiology ii. Many parties involved in the process (radiologist, radiographers, SLP, nurse, pt, family, health care providers, transporter, insurance companies iii. Radiation exposure (instrumental)

evans blue dye test

- Drop of blue dye on back of tongue - For pts who can't have food PO - Monitor secretions management - Only for pts with a trachestomy—have to be suctioned - Requires coordination of personnel over 24 hours; put a dot on the back of pt's tongue. For pts with no PO at oral prep, bolus is saliva - Can tell lip closure, anterior bolus hold, swallow onset - Not real food (non-instrumental)

nasoenteric feeding tube

- Enteric = stomach - Goes from the nose to the stomach - Stays in for a max of 2 weeks • Why 2 weeks? Can cause atrophy, tissue irritation, decreased epiglottic retroflexion, keeps the UES open, interferes with palate approximation, decreases pharyngeal propulsion, desensitizes oro-pharynx and can lose swallow onset

cervical auscultation

- Idea that you can hear the aspiration - Put stethoscope on thyroid cartilage—can hear a "clunk" if they aspirate - No validity or studies that this is a definitive test for aspiration - Can't do treatment plan based on this—don't know the etiology just the effect - Can't make recommendations (non-instrumental)

MOSST

- Looks like a retainer, forms to mouth; push on with tongue and sensors pick up which part of tongue is weakest - Expensive - Press against palate with tongue - Made by same lady that made IOPI - Good for tracking homework—data goes into computer so SLP can track pts work

DPNS (Deep Pharyngeal Nerve Stimulation)

- Not many SLPs trained in this - Stick hands or lemon swabs into pharynx to stimulate muscles and nerves - No follow up research, NOT evidence based - Have to be trained to use it

modified evans blue swallow test

- Only for pts with a tracheostomy—have to be suctioned - They get to eat actual food - If the clinician retrieves blue aspirant, you know they aspirated. If you don't get blue stuff back, maybe they haven't had time to aspirate it (you can't say anything!) - Need one person to feed and one person to suction (bc it needs to be sterile). Single use only! - Allows you to formulate a treatment plan, but it is limited (non-instrumental)

Dworkin crossbar apparatus

- Protrusion, lateralization, depression, elevation - Inexpensive - Tape 2 tongue depressors together, slide 3rd depressor in between them. The pt has to make the tongue depressors approximate using different exercises. Can increase depressors up to 5

vital stimulation

- Put on neck to trigger movement and contract muscles - Use for pt with problems of hyolaryngeal elevation - NOT evidence based—all data is biased - Have to be trained by their company and buy their equipment; can only be used by a clinician—pt can't take it home - Use with limited pts 1. Don't use on someone with recent dx of head/neck cancer—this could increase metathesis 2. Think of the cause of their dysphagia—what is wrong with their swallow?

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

- Requires flexible nasoendiscope (camera) - Pass through nare to just above the epiglottis - Give pt what food you would in CSE - Good to use anesthesia - View: superior, color, 3D Advantages: i. Can bring to pt ii. Inexpensive iii. No radiation exposure iv. Use real food v. 3D view—can see amount of stasis vi. Can use results to do treatment plan vii. Can recommend diet changes Disadvantages: i. Can't see actual aspiration because the epiglottis retroflexes and covers the larynx—"White out" ii. Hurts without anesthesia iii. Camera may alter swallow iv. Anesthesia may slow the swallow onset v. Can't assess esophageal swallow (instrumental)

NMES (Neuromuscular Electrical Stimulation)

- Same as vital stem - Tracy only uses for tongue, lips, and face, not throat - Electrical impulses for contraction - Tracy uses as a starting place for contractions, then moves to resistance based treatments - Won't work if the nerve has been cut

ultrasound

- ____ them while they swallow—if clinician can read it, can see everything happening in the swallow - Very rare - Can make treatment plans if trained to read it (instrumental)

parenteral nutrition

- long term non-oral feeding - Protein is already broken down and goes straight to the bloodstream - Very expensive - Pre-digested food - Don't recommend this!

clinical swallow evaluation

1. Start with 3oz water test to prime their system and check for silent aspiration 2. Go through all the steps and consistencies—can only suspect aspiration (can't see for sure)—can say "suspected pharyngeal dysphagia" - Start with conservative consistency (low aspiration risk) - Solids - Mixed consistency 3. Often diet recommendations are made from ____ —able to check to see which liquids don't give soft signs of aspiration - Can suspect stasis if multiple swallows per bolus 4. Screener—can't base treatment plan on it or change consistencies - But can make plans if problem is in oral prep or oral phases—has to be supported by what you find - Can use to refer to instrumental evaluation (non-instrumental)

mixed consistency

Different bolus manipulation ii. Ex: cereal & milk, stew