Third Year SP-DYS 336: Swallowing PDF

#separator:tab #html:true #deck column:1 #tags column:5 3 THIRD YEAR::1 SP-DYS 336::0 Everything Doc DYS "PRELIMS1 OUTLINE Anatomy, Physiology and Neural Control of SwallowingLearning Objectives Determine relevant anatomical structures to the process of swallowing Describe the stages of swallowing and the corresponding neurological structures that are involved in the process Differentiate the infant and adult human structures of deglutitionSwallowing Deglutition transitive verb ""To take through the mouth and esophagus into the stomach"" (Merriam Webster, 2021) Activity 1 Grab any food or drink that you have Take a few bites from your food or a few sips from your drink Answer the following questions: What parts are involved when you are eafing/drinking? How did the strudures move when you were chewing and/or swallowing?Physiology of Normal DeglutitionHuman Swallow: 3 Stage Model Oral Phase Pharyngeal Phase Esophageal Phase4 Stage Model (What we use as basis)(ORAL PHASE HAS 2 PARTS) Oral Preparatory Phase Stage 1: Transport Food is brought into the mouth Tongue places and holds the food on the oclusal surface of lower teeth for food processing- Cheeks push food between upper and lower teeth- Tongue pushing food between the upper and lower teeth Food Processing Immediate follows stage 1 transport Mastication and salivation Tongue and soft palate movement coordinated with jaw movement Hyoid bone movement- lips closed so food/liquid won't fall out- Chewing will continue until the bolus is well enough to pass through the pharynx and esophagus Oral Propulsive Phase Stage 2 Transport Tongue tip rises Expands the tongue-palate contact to squeeze the bolus along the palate and into the pharynx Pharyngeal Phase2 crucial biological features:1. Food passage, i.e., propelling bolus through the pharynx and the UES to the esophagus2. Airway protection, isolating the larynx and trachea from the pharynx during food passage to prevent the food from entering the airway Esophageal Phase  Upper esophageal sphincter opening and closing- It opens during swallowing to allow food and liquids to pass into the esophagus, and it can also reduce the backflow of food and liquids from the esophagus into the pharynx. - It is usually closed when a person is not eating, preventing air from entering the esophagus. Or after dumaan bolus, it closes Peristaltic wave and gravity moves the bolus  Lower esophageal sphincter prevents regurgitation, it's always closed to prevent esophageal reflux; and will only open if bolus will be directed to stomachActivity 2 Grab any food or drink that you have Take a few bites from your food or a few sips from your drink Describe the four phases of swallowingSummaryAnatomy and Neuroanatomy of Normal DeglutitionSectionsOral Cavity: VestibuleOral Cavity: TeethAdults have a total of 28 adult teeth. A full set of baby teeth is 20 teeth: 10 on top and 10 on botto. Baby teeth are gradually replaced with (28+4molars=) 32 permanent adult teeth.  Upper teeth Lower teeth TypesOral Cavity: Tongue and Salivary GlandsTip of tongue is most active when chewingBase of tongue is most active when swallowing and it remembers how it will seal the oral cavity behindSalivary GlandsSaliva maintains moisture to prevent teeth decay and neutralize stomach acidvisid viscous salivaserous thinner watery salivaOral CavityPharyngeal CavityHypopharynx or laryngopharynxPharyngeal Cavity: PharynxSuperior and medial pharyngeal constrictorPyriform sinus- space after epiglottis- space btw thyroid cartilageCricopharyngeus- always closed and perpetually contracted and opens when bolus comes inside in upward movement of hyoid bone (opens) which is part of the UESPharyngeal Cavity: Larynx- keeps food from entering the airway- Epiglottis will close and act as a trapdoor and VF are tightly closed or contracted to move into medial position- Epiglottis is also in valecular space (important since naiiwan food here sometimes)Pharyngeal Cavity: Vocal Folds- protects our larynx and trachea to prevent food from getting into lungsEsophagusRMR:UES and LESUES - perpetually closed and relax if hyoid bone moves forward and relax the pharyngeus muscles; graviy pulls downLES - perpetually closed so acid won't regurgitateNerves Involved in Swallowing CN V: Trigeminal CN VII: Facial CN IX: Glossopharyngeal CN X: VagusCN XI: Abducens CN XII: HypoglossalCranial Nerve V TrigeminalMandibular branch helps in production of bolus. Jaw moves in sync w tongue to create bolus.It innervates masseter for chewingTemporalis depress retract and protrude mandible, it contractsPterygoid (medial lateral) Medial pterygoid - elevates mandible and assists in lateral movementLaterl pterygoid - protrude and grinds mandibleLateral and rotary movt of mouth and jawCranial Nerve VII FacialInnervates lower facial muscles like maxilla and madibleMandibular and MaxillaryBuccinator & Risorius- helps compress  cheek and lips respectively Orbicularis Oris- oral sealMentalis- elevates the lower lipCranial Nerve XII Hypoglossal nerve Two groups of lingual muscles Intrinsic – originate and insert within the tongue- superiror, inferior transverse and vertical muscles Extrinsic – originate outside the tongue and insert within the substance of the tongue- genio, hyo, stylo, palato glossusShapes contours and provide diff tongue functions and other mandible functionsGeniohyoid- elevates hyoid bone and depresses mandibleDigastric muscles- elevate hyoid and depress mandibleLongitudinal- elevate tip and deviateVertical- cup and groove tonguegenioglossus- move tongue body, cupsstyloglossus- palatoglossus- tongue fibers and attachments review!Cranial nerves IX, X, XIGlossopharyngealVagusAccessoryhelps in movt of soft palate, eustachian tube, VF musclesMusculus Uvulae- shorten soft palateEustachian tube- keep pressure in earConstrictor muscles- helps direct food downwards pharyngeal and esophageal cavityPhysiologically, the UES is influenced by the swallowing reflex, which initiates a series of coordinated muscle contractions in the pharynx and esophagus. When swallowing occurs, signals are sent via the vagus nerve, leading to relaxation of the sphincter, thus permitting food to enter the esophagus. Upon completion of swallowing, the sphincter tightens again to prevent aspiration and protect the airway.Possible problems in oral preparatory stage?Breakdown in structures firstOral StagePossible deficits in theoral prep stage?TongueteethSoft palate movt issuesmandiblecheeksoral propulsive phasedifficulty initiating reflex of swallow (w soft palate and back of tongue moves downwards)Sensory motor functions of musclesPharyngeal StageRespiration stops when swallowingPossible deficits in pharyngeal stage?aspirationairway protection not completeEsophageal Phase Upper esophageal sphincter Lower esophageal sphincterDamage sa Vagus nerve may affect pharyngeal constrictors like ma-paralyzeNerves and Muscles they InnervateCentral Pattern Generator (CPG)Types of movements (Hooper, 2000) Reflexes - involuntary, stereotyped, and graded without threshold (e.g. knee jerk) Fixed action patterns - involuntary and sterotyped but typically have a stimulus threshold (e.g. sneezing) Directed movements - voluntary and complex, but neither stereotyped nor repetitive (e.g. reaching) Rhythmic motor patterns - stereotyped, complex, and subjected to voluntary control (e.g. breathing, walking, swallowing) governed by CPGsSwallowing CPG Composed of interneuronal network with both afferent and efferent control over swallowing Located in two main brainstem areas: Dorsal Swallowing Group (DSG) around the NTS DSG - sensory, found in nucleus tractus solitarius (NTS); Involved in triggering, shaping, and timing of the sequential or rhythmic swallow pattern- receives sensory input- Supramedullary inputs All afferent fibers involved in initiation or facilitation of swallowing converge and terminate in the NTS Provides inhibition-excitation inputs which result in sequential activation and inhibition of swallowing muscles Proximal parts of the swallowing tract are activated, while more distal parts are inhibited- Peripheral afferent inputs  From oropharyngeal sensory receptors Important in initiation of swallowing Provides continuous sensory feedback to modify and modulate the swallowing CPGs Ventral Swallowing Group (VSG) in the ventrolateral medulla above the nucleus ambiguous (NA) VSG - Composed of premotor neurons that excite motor neuron pools bilaterally- distribute swallowing drive or actions to inititate swallow movement accdg to sensory input Consists of two hemi-CPGs located on each side of the medulla Synchronizes and organizes the bilateral contraction of muscles during swallowing to improve shaping and timing of swallows  Nerve fibers crossing the midline serve as connections for the hemi-CPGs  Motor sequence is generated in the ipsilateral CPG then transfers signals to the contralateral CPGMedullary Infarctreceive info from ipsi side (NTS, DSG) direct info ipsilaterally and then execution movts. on contralateral side (NA, VSG)e.g. left sided weakness, cant receive left side info so no info will be directed sa right, no action- drooping on left side, tongue muscles cant be directed on certain sides Peripheral afferent inputs From oropharyngeal sensory receptors Important in initiation of swallowing Provides continuous sensory feedback to modify and modulate the swallowing CPGsSUPER USEFUL FLOW CHART OF SENSORY TO MOTOR INFOFigure 1. Key Structures/Areas of Neural Control for Somatosensation and Their Ascending Pathways. Supramedullary inputs All afferent fibers involved in initiation or facilitation of swallowing converge and terminate in the NTS (main afferent structure in swallowing) Provides inhibition-excitation inputs which result in sequential activation and inhibition of swallowing muscles Proximal parts of the swallowing tract are activated, while more distal parts are inhibited Motor outputs Controls both reflexive and voluntary swallowing Cortical areas control the pharyngeal phase through the swallowing CPGs Involved in protective reflexes such as coughing  Structures in the swallowing CPG are also involved in respiration, mastication, and phonationCerebral Cortex Involved in voluntary swallowing which activates CPGs Represented in the lateral precentral and premotor cortices Primary motor cortex (BA 4) Premotor cortex (BA 6), supplementary motor areas, anterior cingulate cortex, insula, motor planning n sequencing- attentional, mediate digestive functioninsula - sensory motor integreation, swallowing sequences  Somatosensory cortex (BA 3,1,2), temporal lobe, basal ganglia, thalamus, cerebellum Appears to have an asymmetrical representation of swallowing muscles in the two hemispheres  Damage to the dominant hemisphere predisposes and individual to develop dysphagia  Recovery is associated with an enlargement cortical representation in the undamaged hemisphereCoordination among eating, swallowing and breathing Swallowing is dominant to respiration Physical closure of airway Neural suppression of respiration (brainstem)Importance of Sensation in Swallowing Appropriate preparation of food = continuous feedback of sensory information from receptors Detects size and texture of the bolus Determines the chewing action required from the muscles of mastication  Pharyngeal phase = sensory input from the posterior oral regions and pharynx = intensity of pharyngeal muscle activity and overall duration of the pharyngeal phase of swallowing varies in response to sensory information relayed from afferent receptors about the unique characteristics of the bolusDifference Between Child and Adult SwallowInfant, small soft palate and uvula bigger to accomodate food. tongue is filling up the oral cavity.Hyoid bone n larynx are highSuck swallow and breathing reflex automaticSummary: Oral Preparatory and Oral Phase – volitional transfer of ingested material – controlled by the discrete areas of the cerebral cortex; CN V, VII, IX, XII Pharyngeal Phase: swallowing center in the medulla; CN IX, X, XI Esophageal Phase: begins following closure of the upper esophageal sphincter; reflexive component serves the primary function of transporting food to the stomach by a sequential peristaltic contraction of muscles initiated in the pharynx and relaxation of the lower esophageal sphincter; CN X2 OUTLINE Food types, Consistencies, and Feeding DevelopmentLearning Objectives Describe the WHO prescribed feeding and complementary feeding guidelines Differentiate the kinds food types and consistencies that are available or can be prepared for your clients Determine what are the changes expected in feeding and swallowing of a normal aging adultDefinition of Concepts Feeding vs swallowing vs eating ""Feeding disorders are defined as problems with eating activities, such as sucking during breastfeeding or bottle-feeding, eating with a spoon, chewing, or drinking from a cup.   Swallowing disorders, or dysphagia, are  defined as abnormalities in one of the four phases of the normal swallowing mechanism, namely, the oral preparatory, oral transport, pharyngeal, and esophageal phases (van den Engel-Hoek et al., 2015).Feeding and Swallowing in Infancy Breastfeeding and/or bottle feeding Mothers are encouraged to breastfeed RA No. 10028: Expanded Breastfeeding Promotion Act of 2009- maternal leaves, breastfeeding areas- giving incentives to companies to encourage these Essential Intrapartum and Newborn Care (EINC) or ""Unang Yakap"" Initiation of breastfeeding within the first hour of birth Immediate skin-to-skin contact with mothers        Benefits of Breastfeeding Breastmilk provides the necessary nutrients and antibodies for protection of infants (World Health Organization) Studies found that breastfeeding was associated with significant cognitive development among children. Meta-analysis (Anderson, Johnstone & Remley, 1999) Prospective cohort study (Kim & Choi, 2020)Major Causes of Death in Neonates and Children under Five in the World, 2004Recommended infant and young child feeding practices1. Early initiation of breastfeeding within 1 hour of birth (UNANG YAKAP/Breast crawl)2. Exclusive breastfeeding for 6 months (180 days)3. Nutritionally adequate and safe complementary feeding starting from the age of 6 months with continued breastfeeding up to 2 years of age or beyondPromoting Appropriate Feeding For Infants and Young Children Unequalled way of providing ideal food An integral part of the reproductive process with important implications for the health of mothers. Even though it is a natural act, breastfeeding is also a learned behavior Considerations for women in paid employment- - breastfeeding breaks Complementary Feeding - timely, adequate, safe, properly fed Providing sound and culture-specific nutrition counselling to mothers of young children and recommending the widest possible use of indigenous foodstuff will help ensure that local foods are prepared and fed safely in the home. In addition, low-cost complementary foods Industrially processed complementary foods For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative- pwede breastfeed from a healthy wet nurse or human wet bank donations- or feeding w a cup, bottle For infants who do not receive breast milk, feeding with a suitable breast-milk substitute — Infant formula prepared in accordance with applicable Codex Alimentarius standards (READ THRU THIS) our main goal is to promote safe feeding and swallowing for all patients Home-prepared formula with micronutrient supplements — demonstrated by HW only to the mothers and family members Information given should include adequate instructions for appropriate preparation and the health hazards of inappropriate preparation and use.Breastmilk (BM) Production Colostrum (first few days)- more proteins and immunoglobulins Mature milk (4 weeks onwards)- more carbs than colostrum- bluish gray  Hind milk - towards end of feed, rich in fatimportant to consider how long the child is feeding and their endurance to take in breastmilk.Mother's maternal health, diet, envi exposure, gestational age, infancy age can affect the breastmilk. 87% water 3-5% fat 3.9% lactose 0.8% proteins60-75 kCal / 100 mLMilk line has the mammary glandsNote how the ducts are placed, and location of where the infant should place their mouth to pump out the milk (it should be efficient).Ducts are towards the end, circular, and goes through a narrower channel; there's a small chance na hindi lahat mappump ng infant.Reflexes and BreastfeedingSuckling is the up and down movement of the jawSucking is when cheeks move forward to extract milkReflexes and Breastfeeding (BF) their level of maturation will guide whether an infant can breastfeed directly or temporarily requires another feeding methodNormal Feeding and Swallowing Physiology for BFGood Attachment ‒ breast not nipple3-4 sucks to contain the milk then swallow reflex will activateSuck and swallow reflex won't generate like thisAnatomy of an InfantSucking vs Suckling Suckling - front to back wave like movement of the tongue3 months of age v Sucking - straight up and down movement of the tongue and jawNewborn's Stomach CapacityDay 1 5-7 mlDay 3 22-27 mlDay 7 45-60 mlDay 30 80-150 mlRead thru the pre-feeding checklistRemember what a 6mon old child looks like when feedingFood quantity, liquid etc, Complementary feeding is 6mos to 2yoStart at chronological child's age then go down to checklist and describe the skills present (jaw, lip, tongue, sucking swallowing breathing,) try to look at it at what age the skills presented.what food types per month and movements of swallowingBottle vs Breast Feeding Increased use of masseter and temporalis in breastfeeding vs increased use of orbicularis oris and buccinator muscles in bottle feedingSwallow Study w Posterior Tongue Tietongue accepts the teat, it bunches up and it slightly pushes the teat out when swallowing. There's premature spillage, frequent choking.Neural Control of Sucking and SwallowingReflexes and their Cranial NervesAdaptive Rs are expected to be gone at a specific point in time. If these persist, there is a problem.0-3 months feedingCorrect Latchareolas are hidden, chin is on breast and not nose.Complementary Feeding Complementary feeding is defined as the process starting when breast milk is no longer sufficient to meet the nutritional requirements of infants, and therefore other foods and liquids are needed, along with breast milk. The target range for complementary feeding is generally taken to be 6 to 23 months of age, 1 even though breastfeeding may continue beyond two years (13).- can anticipate food, can hold head up when sitting, shows interest in others, opens mouth, moves food from spoon to throat4-6 months feedingCup Feedingblankets to swaddle babycloths15 cc of formulaUse the Pre-Feeding Checklist to describe the child's feeding skills- sitting position at 90 degrees- able to attend to the food- able to use pincher grasp to observe food and put it to the mouth and chew- keeps the food in the cheeks and mouth while chewing- initiated swallow? w no issues with gagging or choking- pauses were frequent, kind of distracted while chewingMonth of child given: 6 monthsAnother age: 3 months- food is like pureed food or baby food- first time semi-solid eating thru spoon, accepts it with drooling and spillage, but no gagging or choking- uncoordinated tongue movt and jaw, lips movement patterns are young mostly sucking and suckling patterns parin-  tongue is cupping kahit spoon siya, not nipple.- medyo mabilis yung pagbigay nung food and the baby keeps the bolus in the mouth pa, parang tuloy tuloy siya and yun stated sa  3 monthd ns no discernabke pasusses- the spoon is being tilted to support the spillage- supported semi-sitting reclining at a 90 degree angleNote: how the food is being taken sa mouth and cheeks9-12 mos- eating two cookies - uses pincher grasp both hands and tries to eat the cookie whole then it drops, then he tries again- biting is not sustained, uncontrolled- no drooling and there is rotary movtDysphagia and Aging Expected in aged 65 but be evident in those as young as 45 involved in swallowing that may show changes in mass and contractility include the following: Loss of elasticity in lung tissue + decreased respiratory capacity andcontrol ORAL PHASE Tongue hypertrophy Sensory changes Dentition Jaw Pharyngeal Stage Decrease in the connective tissue in the suprahyoid musculature t More instances of airway penetration after 50 years old Duration of airway closure time (humahaba) Slower oropharyngeal transit times Decreased sensitivity in the protective reflexes Esophagus Aging alone does not explain decrease in esophageal motor activityActivity: Preparing and swallowing differenttypes of consistencies Solids Puree - baby food, apple sauce Mechanical soft - has more form than puree but no lumps (think KFC mashed potato) Mashed - mashed but with some lumps (mashed potato you made at home with a fork) Mixed - liquid and solid in one food (e.g., sabaw at kanin) Regular - regular table food Hard — biscuits or cookies Chewy — tough meats, steak well done   Jelly/GelatinOUTLINE Definition, Etiologies, and Classification Systems of DysphagiaLearning Outcomes Describe dysphagia, its etiology, symptoms and classifications Categorize common conditions afflicted with dysphagia Determine use and limitations of oral, enteral and parenteral sources of nutritionDysphagia Characterized by the abnormality in the transfer of bolus from the mouth to the stomach. Functional definition is that dysphagia is a condition resulting from an interruption in either eating pleasure or the maintenance of nutrition and hydration. (Groher, 1997)Feeding vs Swallowing (Logemann, 1998)  Feeding Placement of food in the mouth Manipulation of food in the oralcavity prior to the initiation of the swallow, including mastication if necessary  Oral stage of the swallow when the food is propelled backward from the tongue Swallowing Entire act of deglutition fromplacement of food in the mouthtnrough the oral, pharyngeal andesophageal stages of swallow until the material enters the stomach through the gastro esophageal junction Swallowing therapy — include techniques for reducing any delay in the triggering the pharyngeal swallow and improving the pharyngeal transit time and individual neuromotor actions comprising the pharyngeal and oral stage of swallowYES or NO?Signs and Symptoms of Dysphagia Difficulty in placing food in the mouth Inability to control food or saliva in the mouth Coughing before a swallow Coughing during a swallow Coughing after a swallow Frequent coughing in the end or immediately after a meal Recurring pneumonia Weight loss (due to no other apparent reason) Wet or gurgly voice Increase in secretions in the pharynx or chest after a swallow or towards the end of the meal Complains of swallowing difficulty Restricted volume of oral intake Limited range of food in the diet Limited range of textures in the diet Prolonged mealtime durations (30 minutes ideal) Problems/battles during mealtime Family stress due to eating problemsDefinition of Symptoms of Oropharyngeal Dysphagia in an Assessment ProcedureSymptomDefinitionAspirationEntry of food or liquid into the airway below the true vocal folds (SUBGLOTTIC)PenetrationEntry of food or liquid into the larynx at some level down to but not below the true vocal cords Entry in the LARYNGEAL VESTIBULEResidueFood that is left behind in the mouth or pharynx after the swallowBackflow / RegurgitationBolus moves from the esophagus into the pharynx and or from the pharynx into the nasal cavityProlonged swallow apneaThe airway closes over and fails to reopen in time for regular breathing to continue after swallow; in infants, this may occur in response to the presence of a material near or the center of the larynx (laryngeal chemoreflexChokingSolid bolus physically blocks the airwayDysphagia can be classified as: Oral, Pharyngeal, Esophageal- oral prep etc- pharyngeal transit time Mechanical or Neurogenic- structural vs brain probMyogenic - can process signals but motor signals cant be executedWe dont diagnose the esophageal parts, so whatever we receive, we js relate it to the structuresAdvisable to do videofluoroscopy, x-rays.Limitations: ExpensiveCommon Conditions with DysphagiaPrematurityLow gestational age at birthLow birth weightComorbidities associated with prematurityRespiratory and Cardiac disordersApnea of the newbornRespiratory distress syndromeHeart defects (co-occur)Gastrointestinal DisordersTracheoesophageal fistula and esophageal atresia Gastroesophageal reflux EsophagitisFood allergies and intolerances Neurologic DisordersMicrocephaly, hydrocephalusBirth asphyxia and cerebral palsyAcquired brain injuries (stroke and TBI)Congenital AbnormalitiesCleft lip and palateDown syndromeMaternal and Perinatal IssuesJaundiceDiabetesFetal alcohol syndromeIatrogenic Complications (tracheostomy, intubation, tube feeding)Nutritional Sources Oral - food intake in mouth Enteral - use of tube Parenteral - use of injectionOral Nutrition Eating through the mouth NPO - nil per os in Latin ""nothing by mouth"" Withhold food and fluids from a person for various reasonsReasons for Tube Feeding Patient’s inability to sustain nutrition orally although swallow response is safe Requirement for sufficient calories on a short-term basis to overcome an acute medical problem Risk for tracheal aspiration if the patient is allowed to feed orallyEnteral Nutrition Method of supplying nutrients directly into the gastrointestinal tract NASOGASTRIC TUBE (NGT) – inserted through the nose and into the stomach Percutaneous Endoscopic GASTROSTOMY (PEG) and JEJUNOSTOMY TUBES – placed directly into the stomach with the assumption that digestive processes are intact; if stomach is not functioning, it is placed directly into the jejunum of the small intestineCOMPARISONParenteral Nutrition Used when gastrointestinal tract cannot be used due to medical complications Parenteral nutrition bypasses the normal digestion in the stomach and bowel. It is a special liquid food mixture given into the blood through an intravenous (IV) catheter (needle in the vein). The mixture contains proteins, carbohydrates (sugars), fats, vitamins and minerals (such as calcium). This special mixture may be called parenteral nutrition and was once called total parenteral nutrition (TPN), or hyperalimentation Hypodermal clysis: The introduction of fluid into the body by subcutaneous injection to replace fluids that have been lost through vomiting, sweating, or diarrhea. Peripheral Parenteral Nutrition (PPN) Form of nutritional support delivered through the vein  Used up to 7-10 days  Total Parenteral Nutrition (TPN) be used up to 4-6 weeks as neccessary  A special intravenous (IV) catheter is placed in a large vein in the chest or arm. It can stay in place for as long as needed.Enteral and Parenteral NutritionManagement Perspectives Logemann (1998) Swallowing therapy is superimposed on continuously adequate nutrition and hydration Goal is to outline the best program to maintain nutrition and increasingly improve the patient’s swallowing function- we look into diff procedures and exercisesManagement Perspectives 3 Questions That Needs to Be Answered What type of nutritional management is necessary? Should therapy be initiated and what type (compensatory or exercises, direct or indirect?) What specific therapy strategies should be used?DECISIONS IN DYSPHAGIA ORAL/PO VS NON-ORAL/NPO FEEDING WILL THE PATIENT BE FED ORALLY OR THROUGH NASOGASTRIC TUBE?  Ensure SAFE and EFFICIENT oral intake  COMPENSATION VS REHABILITATION Compensatory strategies – aims to improve safety (short-term, quick fix) or 'pag lumakas na ulit Rehabilitation exercises – aims to improve efficiency (long-term)  DIRECT VS INDIRECT Do you introduce food in mouth and reinforce good swallowing behavior and motor control during swallow? (direct)  Do you use exercises to improve neuromotor controls that are prerequisites to swallowing and practice on dry swallow of saliva only? (indirect)PATIENT SAFETY Second to maintaining nutrition is to ensure SAFETY OF PATIENT DURING ORAL FEEDINGS WHEN ORAL FEEDING IS APPROPRIATE ASPRIRATION MUST BE KEPT TO A MINIMUM Introduce small amount of material (1ml) and increase volume as tolerated If patient aspirates shows clinical signs of aspiration, restrict swallowing of that consistency by mouth  VIDEOENDOSCOPIC OR VIDEOFLUOROSCOPIC ASSESSMENT will ensure that there are no silent aspirations  Ensure proper oral careFor the speech-language pathologist, there are a few decisions that we need to make: PO/NPO If PO – patient must demonstrate the necessary physiologic function of the oral, oropharyngeal, pharyngoesophageal, and esophageal phases to safely swallow with or without modifications in food texture, liquid consistency, and posture/compensatory strategies. If NPO, Enteral vs Parenteral Enteral – NGT vs PEG Factors to consider: Clinical and instrumental examinations of swallowing  Medical status (diagnosis, acute vs. chronic, progressive vs. reversible)  Nutritional status (current and previous nutritional status and intake, projected needs as determined by dietitian)  Behavioral/cognitive status (ability to attend and participate in the meal process)  For patients with mild-moderate dysphagia, the objective is to wean from enteral nutritiReinstituting Oral Feeding Readiness for oral feeding Assessment of safety and efficiency of swallow (clinical swallowing exam and instrumental evaluation) Massachusetts General Hospital-Swallow Screening Tool (Cohen, 2009)Massachusetts General Hospital-Swallow Screening Tool (MGH-SST; Cohen 2009) Part 1 Adequate level of alertness  Stable breathing status  Ability to sit upright  Acceptable oral hygiene  Screening only progresses to Part 2 if all parameters are present. Otherwise, NPO Part 2 Tongue movement (1 point) Volitional cough (1 point)  Vocal quality (1 point) Pharyngeal sensation (1 point) Water swallowing (2 points) Pass = 5 or 6 pointsCase Analyses Answer the following questions for all cases: What is the type of dysphagia? What source/s of nutrition will you recommend? If NPO, enteral or parenteral? Why? If enteral, NGT or PEG? Why? If both oral and enteral, why? If oral only, why?Case 1 Jose, 52/M, was diagnosed with laryngeal cancer. Partial laryngectomy (left side) was conducted. After the surgery, he complained of difficulty swallowing both solids and liquids. He presented with normal CN functions except for CN X. He was noted to have a breathy voice and short MPT. He coughs frequently, even when he is not doing anything. Upon presentation of thin liquid (water), he coughed excessively to the point of fatigue and shortness of breath. This response prompted the clinician to defer the clinical swallow examination.Structural (laryngectomy) and Neurogenic (cranial nerve affectation) Score: 3 pts in MGH-SSTso NPO, bc of thin liquids, compromised respiratory not NGT due to CN affectationprefereably PEGhe tolerated most consistencies present w hoarseness, kaya niya mag-PO but u have t identify which consistenciestarget  Andres, 78/M, had his third stroke recently. He demonstrated adequate alertness and sustained attention to participate in an evaluation. Although he appeared to have adequate vocal functioning, his speech was slurred. Cranial nerve testing showed reduced functioning for CN V and VII. He tolerated most consistencies presented, but coughing and wet hoarseness were noted with thin and thickened liquids.Neurogenic - d/t stroke, affectations in CN V n VIIYou target cranial nerve exercise to avoid discouraging them, so possible PO w strict monitoringNote yung specific na kaya niya. Recom NGT for short time to address liquid tolerance until it improves Melchora, 2/F, has Down’s syndrome. She was reported to cough frequently when drinking milk and when eating rice. She was noted to have macroglossia, hypotonic facial muscles, and open mouth posture. Nonetheless, she showed stable head and neck posture, as well as adequate trunk control. When fed with various consistencies, frequent coughing was observed. However, when the amount of presentation of liquids and solids was reduced to half, she tolerated most consistencies with significant reduction in coughing.- Structural (manifestations like macroglossia)- PO w strict monitoring; take note of duration of feeding- given her age, try not to suggest invasive proceduresDO ON UR OWN Juan, 37/M, underwent surgical removal of metastasized malignant tumors in his small and large intestines. While recovering, he had a hemorrhagic stroke which put him in a comatose state for 7 days. Upon waking up from coma, he underwent initial evaluation. He demonstrated lethargic consciousness, with intermittent wakefulness. He had difficulty following all types of commands. He showed limited limb movements, as well as generalized body weakness. He opens his eyes but shows limited regard towards the examiner.Case 5 Antonio, 85/M, was diagnosed with Parkinson’s disease ten years ago. He appeared to have reduced functioning for all cranial nerves. Although he was alert during the evaluation, he was frequently distracted. He followed simple commands when given adequate prompting and redirection. He was reported to eat meals with his family, but it would take him 2 hours to finish. Coughing and wet hoarseness were noted for all types of consistencies. He expressed his desire to continue eating together with his family during mealsReferences Cohen, A. K. (2009). Creating a swallow screening program at Mass General Hospital: a model for development and implementation. Perspectives on Swallowing and Swallowing Disorders. Dec 2009:123-128. Groher, M. E. (2016) Dysphagia: Clinical Management in Adults and Children,. St. Louis, Missouri: Elsevier Logemann, J. A.. (1998) Evaluation and Treatment of Swallowing Disorders, Austin, Texas: PRO-ED Scottish Intercollegiate Guidelines Network. (2010). Management of patients with stroke: Identification and management of dysphagia. NHS Quality Improvement Scotland (NHS QIS).dripspoon tiltfork liftOUTLINE Multidisciplinary Dysphagia Team and Ethical ConsiderationsSession Learning Outcomes Determine the roles of dysphagia team members in patient care Explain different management perspectives in dysphagiamanagement Apply clinical precautions in dysphagia evaluation and management Incorporate religious and ethical considerations in dysphagiaevaluation and managementThe Dysphagia Team Fidelity Broadly requires that we act in ways that are loyal. This includes keeping our promises. Role Fidelity Entails the specific loyalties associated with a particular professional designation Purtillo (2005) lists five expectations of patients: That you treat them with basic respect. That you, the caregiver or other health care professional, are competentand capable of performing the duties required of your professional role. That you adhere to a professional code of ethics. That you follow the policies and procedures of your organization andapplicable laws. That you will honor agreements made with the patient.Speech-Language Pathologist SLPs have taken a leading role in the management of patients withdysphagia related to poor oral and pharyngeal swallowingmechanisms Frequently the first professional to perform a history and physicalexamination that is specific to oropharyngeal dysphagia Coordinates and consults with other team members Obtain clearance from the attending physician for other additionaltesting or referrals Integrate the rehabilitative components of the dysphagia treatmentprogramOtolaryngologist Provide significant information in the assessment of upper digestive tract Facilitates use of endoscopy for direct visualization (videoendoscopy or flexible endoscopic evaluation of swallowing) Provides medical and surgical intervention for patients as needed May provide referral for clinical assessment of swallowingGastroenterologist Has special interest in problems in the esophagus Leads management of gastroesophageal reflux disease Does esophageal endoscopy to rule out stricture or cancer as a cause for dysphagia Involved with placement of Percutaneous Endoscopic Gastrostomy (PEG) tubeRadiologist Provide dynamic (videoflouroscopic) and static (plain films) imaging of the aerodigestive tract and lung fields Works together with SLP in the videofluoroscopic swallowing study (VFSS) or the Modified Barium Swallow (MBS) procedureNeurologist Provides initial identification and subsequent management of swallowing problems Information from their evaluation provides an explanation of the dysphagia and prognosis for future complications Differentiate neurogenic vs structural vs psychogenic symptoms May provide referral for assessment of swallowingPhysiatrist/Rehab Doctor Acts as an attending physician to patients requiring one or more rehabilitation services May act as team leader in a rehabilitation facility May provide referral for assessment of swallowingDentist Interested in oral stage manifestations of swallowing disorders particularly dental disorders, tongue tie or lip tie Prosthodontist is skillful at making prostheses for the oral cavityNurse 24 hour responsibility for monitoring the patient’s swallowing problems Can guide patient to do swallowing strategies Administering tube feeding and maintaining oral hygiene Can be trained to administer a swallowing screening tool Dysphagia screening Brief assessment that is easy to administer and minimally invasive No diagnosis is made in the screening Purpose if to determine who is AT HIGH RISK for dysphagia oraspiration If negative result -> can proceed to oral intake without specific modifications If positive result -> ideally -> recommendation made for NPO includingmedication and then referred to SLP No diet modifications or swallowing strategies must be made basedon a screening procedureDietician-Nutritionist Assesses the nutritional and hydration needs and monitors thepatient’s response to those needs Communicates with food service to ensure special diet is preparedproperly Provides guidelines for the amount and rate of tube feeding Works together with SLP during transition to oral feeding inmonitoring intake and makes needed adjustmentsOccupational Therapist Retraining or training the patient to self feed Works closely with SLP in the NICU At times also serves as the swallowing therapist Addresses sensory processing issues associated with feeding andswallowingPhysical Therapist Improve sitting balance and ensure trunk and head stability Design optimal seating for the patientPulmonologist and Respiratory Therapist Patients of pulmonologists frequently have problems that requiremanagement by the swallowing team Special interest in patients with tracheostomy and ventilatorysupport Work toward decannulation Improvement of respiration is a prerequisite to better swallowingresponseSchool Teacher / SPED tr- for recess, they help monitor child in school settingsAdvance Directive (AD) Legal document Statement made by a person with decision-making capacityindicating his or her preferences for receiving medical treatment ornot receiving medical treatment under certain circumstances Specific end of life decisions or circumstances when an individual’smedical condition is futile Need for surrogate to act on patient’s behalf on end of life orirreversible conditions when the patient is not competent to make aninformed decision. Especially needed for patients with terminal and progressivediseasesEnteral Feeding Ethical Considerations SIMPLE for patients who cannot sufficiently feed through oralmeans DIFFICULT for patients who can feed minimally but needs tube feeding to sustain nutrition. EXTREMELY DIFFICULT for patients with AD not to use tube feeding COMPROMISE between oral and non-oral feeding Preference to avoid certain types of food due to religious beliefs Muslim Jehovah’s Witness 7th Day Adventist Hindu, Buddhist JewishSummary- team, mds and specializations, allied health professionals- ethical considerations (religion, culture)References Daniels, S. and Huckabee, M (2014) Dysphagia Following Stroke, 2nd Edition,Plural Publishing, San Diego, California Groher M. and Crary M (2016) Dysphagia: Clinical Management in Adults andChildren 2nd Edition, Elsevier, St. Louis, Missouri Logemann, Jeri (1998) Evaluation and Treatment of Swallowing Disorders 2ndEdition, Pro-Ed, Austin, TexasMIDTERMSOUTLINE Sensory and Behavioral issues in FeedingSENSORY AND BEHAVIORAL ISSUES IN FEEDING OVERVIEW OF OCCUPATIONAL THERAPY PRACTICE FRAMEWORK2. THE FEEDING PROCESSg. SENSORY PROCESSING4. FEEDING ASSESSMENT5. FEEDING INTERVENTIONS/ STRATEGIESOccupational TherapyOccupational therapy (OT) is defined as the therapeutic use of everyday life activities (occupations) with individuals or groups for the purpose of enhancing or enabling participation in roles, habits, and routines in home, school, workplace, community, and other settings.They look atPerson - optimizing gunctionTask - graading and adapting tasksEnvironment - modifying itOCCUPATIONSrefer to the everyday activities that people do as individuals, in families, with communities to occupy time and bring meaning and purpose to life. Occupations include things people need to, want to and are expected to doFedera60n of Occupatiotvi Therapists, 2012)- they enhance and enable participationInstrumentals - meals and money etcADLs - feedingSensory integration of feeding - kulang natin as SLPs- integration- processingThe FEEDING PROCESSSWALLOWING/ EATING- Keeping and manipulating food orfluid in the mouth and swallowing it;- swallowing is moving food from themouth to the stomachFEEDING- Setting up, arranging, andbringing food [or fluid) from the —plate or cup to the mouth; some-times called self-feeding- table to mouthFeeding- A MULTI-DIMENSIONAL ACTIVITY- SEQUENTIAL COORDINATION OF CROSS AND FINE MOTOR TRUNK. ARMS, HANDS AND MOUTH- EATING AND SWALLOWING ARE COMPLEX BEHAVIORS INCLUDING BOTH VOLITIONAL OR REFLEXIVE ACTIVITIES INVOLVING MORE THAN go NERVES AND MUSCLES. (MATSUO AND PALMER,  2008)Feeding Process- complex interaction of many components1. INTEGRITY OF THE CHILD- a spectrum- kids can be physically disabled- adult na paralyzed- medically stable ba2. SWALLOWING AND RESPIRATION- px in a trach- to swallow, the respiration stops- if prob w respi, he will breathe first than swallowg. ENVIRONMENT- mahirap if maguloq. CHILD-FEEDER INTERACTION- sometimes it's the feeder- madalas, we orient a caregiver5. FEEDING TECHNIQUES- not the food, but it's the techniqueG. POSITIONING7. UTENSILS8. FOODFactors to Consider Pertinent to Therapy1. Developmental Level (developmental age)2. Prematurity3. Medical (status, medically stable?)- get a clearance from doc if safe to feed- if not, baka prep muna4. Chronic Health Problems5. Digestive- GERD6. Appetite regulation- no drive to eat, maybe d/t medication7. EnvironmentAnalyzing Feeding ProblemCommon Pediatric Feeding Concerns:- Prolonged mealtime (1-2 hrs) when it should be 30 mins less (affected by attention span, food changes after 30 mins, appetite regulation closes after 30 mins, motoric fatigue)- Response / Behavior - feeding in disruptive or stressful- Weight gain - child not gaining weight in past 2-3 mos- Limited food repertoire - only eats specific foods repetitively, lacks variety- Food refusal - refuses to eat certain or unfamiliar food- Food choices - type of food not appropriate for age Primary Areas to Consider1. Motor2. Behavior3. SensoryMotor- postural control and stability- muscle tone- oral motor skills- developmental level- bcos a lot of times, ppl do compensatory actions when they have motoric problems- as a caregiver, we compensate, so if tumutulo, the head tilts backward nalang (pero if hyperextension, the airway is compromisedd)our position for follow is semi-flexion- - Pre-feeding skills- 2 BEHAVIOR- THE WAY IN WHICH SOMEONE CONDUCTS ONESELF- ANYTHING THAT AN ORGANISM DOES INVOLVING ACTION AND RESPONSE TO STIMULATIONBehavior is a learned responseCauses:- child temperament (response in that situation) could be easy, slow-to-warm-up, or difficult- pain and discomfort (commonly missed, yung humahagod yung spoon sa chin)- negative experiences with feeding (force feeding, scare feeding)- negative experience related to mouth (painful teeth, medically eventful hx like intubations or medications, force brushing, dental trauma)- feeder / parent-child interaction - anxiety3 SENSORY- behavioral vs sensory reaction?- SensesBASIC 5+ THREE OTHER for OTInteroception - recognizing internal input (pain, hunger, tired)Three Powerful Systems:Tactile, Vestibular, Proprioception for FeedingTactile:- Location: Skin receptors- Functional Concepts - protective/defensive - kids w feeding probs have this very actively or very sensitive - discriminative- Why do kids like fast food more than regular food?- bcos home cooked meals are not consistent yung pag-cook. compared to fast food na consistent na the same ang pag-luto all throughout.Vestibular:- Location: Inner ears- movement sensation, kung gumagalaw with eyes closed- balance, muscle tone, arousal level, oculomotor (vision-movement), auditory-languageProprioception:- Location: joint receptors- function:- body in space- body image- control of effort (tapping vs pushing) - proprioception + vestibular + visual = balance- connection? the jaw sometimes gets affected, so may teeth grinding when chewing. so it's too much, uncontrollable.Sensory Thresholdyou can be a low threshold or high thresholdLow - a bit input, registered naHigh - more input, then registeredpwede high-threshold tactile (trichotollomania), high-threshold in proprio (accidentally breaking things), and low-threshold vestibular (mahiluhin)in feeding, we need to understand the threshold of our clients.- they're low-threshold in feeding (not liking rice, coz they feel each butil due to low-threshold tactile)- high-threshold orally, kids fill up their mouths super; they don't even feel some tingaIn practice:Presentations of sensory issues or processing are not the same all the time (for the same kid) (it only becomes an issue if it affects nutrition)- they can be in optimal range - but in sessions, they can be sensory dysregulated state (galaw nang galaw, we might want them to relax to optimal state first before feeding; we cn move first before intervention)- some come in sensory overload (try managing, if wala, do home instruction)FEEDING ASSESSMENTGoals when doing Feeding1. Safe feeding, no choking no aspiration2. Adequate nutrition3. Pleasant MealtimesComprehensive AxA REVIEW OF CHILD'S- MEDICAL HISTORY- DEVELOPMENTAL HISTORY- FEEDING HISTORY- FAMILY & SOCIAL INTERACTIONPre-Feeding Evaluation- before evaluating feeding, ano mga itatanong?- asking behavioral patterns during feeding, feeding routine (saan kumakain, may toys ba tv?)- asking for what type of food kinakain niya- ano po yung pinaka-concern natin (it should revolve around that)- Explore any food aversions, sensitivities, or preferences.- Assess the patient's ability to chew and swallow different food and liquid consistencies- environmentPhysical Examination- OPM- Oral Mechanism Examination:Observe the structure and appearance of the lips, tongue, palate, and teeth.Assess the range of motion, strength, and coordination of the lips, tongue, and jaw.Evaluate the patient's ability to perform various oral-motor tasks, such as puckering, smacking, and lateralizing the tongue.Sensory Evaluation:Assess the patient's sensitivity and response to touch, temperature, and taste within the oral cavity.Observe the patient's gag reflex and cough response to determine the integrity of the pharyngeal mechanism.Swallowing Evaluation:Observe the patient's ability to initiate the swallow, including the timing and coordination of the oral and pharyngeal phases.Assess the patient's ability to manage different food and liquid textures, noting any signs of difficulty, such as coughing, choking, or nasal regurgitation.Evaluate the patient's ability to clear the bolus from the oral cavity and pharynx effectively.Respiratory Function:Observe the patient's breathing patterns and coordination during feeding and swallowing.Assess the patient's ability to manage their airway and maintain adequate respiratory support during the swallow.Posture and Positioning:Evaluate the patient's head, neck, and trunk posture during feeding and swallowing.Observe the impact of different positioning and support on the patient's feeding and swallowing abilities.Feeding EvaluationIs the child safe to feed orally?NO:can swallow:Instrumental Assessment- FEES (cons: invasive, for adults mostly, sees swallow only; pros: videofluoroscopy, clear visuals in ax)- Modified Barium Swallow- radiographic test- dye on food, swallow n xrays monitor where it goes- pros: you can assess after swallow- cons: unclear closurecannot swallow:Non-oral feeding- NGT- PEGBe at eye level of kidSOS ApproachMyths about Feeding1. Systematic - gradually expose to child to eventually manage sensory issuesSteps to Feeding1. Tolerate the physical presence / sight of the food2. Interact with the food (not touching it, just involve the child in cooking or baking, playing w utensils)3. Tolerate the smell/odor4. Touch the food5. Taste the food6. Chew and Swallow the food10 Myths to FeedingSOS is for the sensory experienceHANDOUT SENSORY & BEHAVIORAL ISSUES IN FEEDINGLady M. Suarez, OTRPOccupational Therapist3 October 2024The Feeding ProcessSWALLOWING / EATING- Keeping and manipulating food or fluid in the mouth and swallowing it.- swallowing is moving food from the mouth to the stomach- Act of manipulating and swallowing the foodFEEDING- Setting up, arranging, and bringing food [or fluid] from the plate or cup to the mouth; some- times called self-feeding- act of bringing food to the mouthSource: Occupational Therapy Practice Framework: Domains & Process. 3rd Edition. 2014. American Journal of Occupational TherapyWhat is feeding?- It is a multi-dimensional activity- Sequential coordination of gross and fine motor → trunk, arms, hands and mouth- Eating and swallowing are complex behaviors including both volitional or reflexive activities involvingmore than 30 nerves and muscles. (Matsuo and Palmer, 2008)- It is a complex interaction of many components:o Integrity of the childo Swallowing and respirationo Environmento Child-Feeder interactiono Feeding techniqueso Positioningo Utensilso Food- Factors pertinent to feeding therapyo Developmental levelo Prematurityo Medicalo Chronic health problemso Digestiveo Appetite regulationo EnvironmentAnalyzing a Feeding ConcernCommon Pediatric Feeding Concern- Prolonged mealtime- Response/ behavior (disruptive and stressful)- Poor weight gain – child has not gained weight in the past 2-3 months- Limited food repertoire (eats only specific food repetitively)- Food refusal (refuses to eat certain or unfamiliar food)- Food choices (types of food are not age appropriate)Primary Factors to Consider (pertinent to therapy interventions)1. Motor2. Behavior3. Sensory(1) MOTOR- postural control and stability- muscle tone- oral motor skillso sucklingo suckingo swallowingo bitingo chewing- developmental levels- feeding skillso spoon feedingo cup feeding(2) BEHAVIORBehavioral Theories- Classical Conditioningo Pavlovo stimulus acquires a capacity to evoke a response that was originally evoked by another (unconditioned/conditioned stimulus)- Operant Conditioningo Skinnero a process that attempts to modify behavior through the use of positive and negative reinforcementPossible factors affecting behavior- Child temperament- Pain and discomfort- Negative experiences with feeding- Negative experiences related to mouth- Feeder/ parent-child interaction- Anxiety(3) SENSORYSensory Integration- It is the process by which people register, modulate, and discriminate sensations received through the sensory systems to produce purposeful, adaptive behaviors in response to the environment (Ayres, 1976/2005)- It is the ability to synthesize, organize and process incoming sensory information coming from the body and environment to produce purposeful goal-directed responses.Three Powerful Systems1. Tactileo Location: skin receptorso Functional Concepts:§ Protective/ defensive§ Discriminative2. Vestibularo Location: inner earso Functions:§ Balance§ Muscle tone§ Arousal level§ Oculomotor (vision-movement)§ Auditory- language3. Proprioceptiveo Location: joint receptorso Functions:§ Body in space§ Body Image§ Control of effortProprioceptive + Vestibular + Visual = BalanceFeeding AssessmentAside from assessing the following areas,1. Motor2. Behavior3. SensoryWe also need to review the medical aspect.GOALS IN FEEDING THERAPY1. Safe feeding2. Adequate nutrition3. Pleasant mealtimeComprehensive assessment includes- A review of child’so Medical historyo Developmental historyo Feeding historyo Family and social interaction- Pre-feeding Evaluation- Physical Examination- Feeding EvaluationIs the child safe to feed?o NO- Instrumental Assessment FEES Modified Barium Swallow- Non-oral feedingo YES- Feeding therapyFeeding InterventionPositioning Basics- How we hold the child- How we place the child in a chair- Seat- On the floorFactors- Age of the child- General developmental skills- Individual needs- Caregiver abilities- Resources available in the environmentThe Mealtime “Dance”- Ability to communicate effectively- CHILD leads, the FEEDER followsRoles- Feeder - what to present & the manner (preparation & presentation)- Child - how much or even whether they want to eatSOS Approach to Feeding- Sequential Oral Sensory (SOS)- Dr. Kay Toomey- A transdisciplinary program for assessing & treating children with feeding difficulties- Eating is a learned behavior (Toomey, 2019)- Tenets:o Myths about Feedingo Systematic Desensitizationo Normal Developmento Food Hierarchy and Choices10 Myths about Feeding1. Eating is number 1 priority of the bodyFACT: Top 3 Priorities(1) Breathing(2) Postural Stability(3) Eating2. Eating is instinctive.FACT:1st month of life – Eating is instinctiveAfter 6 months → eating is learned motor behavior3. Eating is easy.FACT: Eating is most complex physical task. It requires coordination of muscles, cranial nerves, sensorysystems4. Eating is 2-step process (sit and eat)FACT: Eating is multiple steps.5. It is inappropriate to touch or play foodFACT: Wearing food, playing with purpose or being messy is ok.6. If the child is hungry, he or she will eat.FACT:If it hurts, the child won’t eatAppetite can be suppressed for children with medical needs7. Children only eat 3x a dayFACT: Most children eat 5-6x a day.8. If the child won’t eat, he or she has behavioral or organic problemFACT: If the child won’t eat, it could be a combination of behavioral or organic problems.9. Certain foods are only to be eaten at certain times of the dayFACT: Food is food.10. Mealtimes are proper social occasion.FACT:o Eating comes first, manners come secondo Mealtimes are teaching opportunities.Steps to Eating1. Tolerate the physical presence or sight of the food2. Interact with the food3. Tolerate the smell/ odor4. Touch the food5. Taste the food6. Chew and swallow the foodOUTLINE Clinical Evaluation of Pediatric DysphagiaLearning Outcomes Differentiate between screening and diagnostic tools for swallowing Develop key questions to ask caregivers to obtain data for a comprehensive swallowing evaluation Determine positioning options for clients to be able to promote best swallowing options Correctly execute and document a swallowing assessment on a typical pediatric client who presents with dysphagia Understand special considerations made for neonate populationScreening Indirect evidence that a person has a swallowing disorder Can identify the following information: If the patient shows signs of aspiration (usually performed bedside) Signs and symptoms of dysphagia If patient needs further assessment Pediatric patients (Logemann, 1988) Rejection of food  Food selectivity Gagging - hypersensitive, abnormal oral sensation, low threshold tactility Open-mouth postureAssessment- are they at risk for aspiration? do they need further ax? Process to identify the nature and extent of the problem High risk → poor nutrition, impaired health status due to long term cognitive, communication and sensorimotor outcomes Good assessment will yield increase in QoL  Multidisciplinary assessment Treatment options will vary per patient ICF Model (WHO, 2001)- ax of dysphagia is also looking at ICF Levels of impairment of body structure and function Activities of the child during mealtime Information on social and physical mealtime environments Goal is to promote meaningful, safe, and functional mealtime experience for children and familiesCriteria for Referral (Arvedson, 1998)Problems you might encounter or look out for: Sucking and swallowing incoordination (delayed devt. milestones) Weak suck  Breathing disruptions or apnea during feeding Excessive gagging or recurrent coughing during feeds New onset of feeding difficulty Diagnosis of disorders associated with dysphagia or undernutrition Weight loss or lack of weight gain for 2-3 months Severe irritability or behavior problems during feeding History of recurrent pneumonia and feeding difficulty Concern for possible aspiration during feeding Lethargy or decreased arousal during feeding Feeding periods longer than 30-40 mins Unexplained food refusal and undernutrition Drooling persisting 5 years old Nasopharyngeal reflux with feeding Delay in developmental milestones Children with craniofacial anomalies or other muscular concerns (DS problems with muscle tone)Comprehensive Clinical Evaluation (Arvedson & Lefton-Greif, 1998)a. Review of family, medical, developmental and feeding historyb. Physical examination c. Observation of typical meal- You would want to see how they feed at home, then you do ax of skills there- after all of these, you also see if they need instrumental or video eval- do your chart reviews or ask for reports from other professionals, what doctorEvaluation of Dysphagia Early promotion of optimal oral sensorimotor function Oral sensorimotor and feeding assessment (which phase) Behavior concerns, need psychotherapeutic intv? Understanding of physical, social and cultural mealtime environment (how long kumakain? what environment influences this, sinong mga kasabay niya, kumusta school or what type and time siya kumakain sa school, how about sa social gatherings or resto, how do u prep meals at home, what goals) Knowledge of normal developmental patterns and sequential advancement of oral sensorimotor skillsClinical Dysphagia Evaluation Case History Taking Examination of oral, pharyngeal, facial and thoracic anatomy Examination of oral and pharyngeal reflexes Observation of swallowing function Examination of oral anatomy Testing of oral reflexes Observation of oral sensory processing Observation of oral motor skills in feeding tasks Observation of swallowing skills and airway protection duringswallowing Observation of physiological stability during feeding Trials of modified food and liquids Trials of feeding equipment Observation of child behavior and parent child interactionHow to Elicit  https://www.youtube.com/watch?v=rHYk1sYsge0  https://www.youtube.com/watch?v=b0CLcNtOOEQCase History Taking What pertinent questions should we ask regarding family and social history? What pertinent questions should we ask regarding medical and developmental, prenatal, birth and perinatal history What pertinent questions should we ask regarding medical and developmental history specific to neonates? Feeding history Sources: Chart Review, Doctor’s Referral and Interview  https://www.asha.org/uploadedFiles/Pediatric-Feeding-Template-Liquids.pdf Important to ask: Family arrangement and primary caregiver for mealtimes Daycare/schooling arrangements and ability of educational staff to manage child during mealtimes Cultural issues that need to be considered in relation to feeding Family access to safe food and storage, necessary feeding equipment and modify food and fluids to meet child’s needs5 year old, difficulty swallowingKelan niyo po unang napansin yung problem?- 2 yoPaano po yung setup ni [px] tuwing kumakain siya?Pwede niyo po ba i-describe yung mga details (time ng meal, how long) sa mealtimes niya- 2 hrs, sinusubuanAno po yung mga pinaka-favorite niyang pagkain na halos wala po siyang problema kainin?Paano niyo po na-ssustain yung nutrition niya?Other therapy servicespositioningbehavior or development milestoneskumusta po pangangakhow siya magccommunicate and behavior niya  Apgar Score Chartdapat 7-10 yung scoreCase History taking: Feeding History What pertinent questions should we ask regarding feeding history?positionduration and when ang mealtimessettingpaano kakain pag nasa school sa bahaycheck voice qualities, sleep patterns if may, snoring, mouth breathing etcfiberoptic endoscopic evaluation of swallowing (FEES)Oral Assessment in Dysphagia Physical examination Pre-feeding examination Hypoactive responses? towards sensations  Hyperreactive responses? (ayaw magpahawak) Oral sensory defensiveness? (ayaw niya hinahawakan in general)Trial Feeding Swallow SafetyBest to ask parent to bring actual food and utensils.Check for Coordination of Suck, Swallow and Breathing and other Adverse SignsModification of ConsistenciesLimiting Variations of Feeding Skills JAW Jaw instability, exaggerated jaw movements, jaw thrust, phasic bite, tonic bite, jaw retractionLimiting Patterns of the JawFacilitate 3 Ppoint Jaw Technique TONGUE Tongue retraction, exaggerated tongue protrusion, tongue thrustLimiting Patterns of the TongueCheck video:https://www.youtube.com/watch?v=DBxhwXc0I3k LIP AND CHEEKS Low tone lips, lip retraction, lip pursingLimiting Patterns of the Lip PALATE Cleft palateStress CuesHeart Rate and Respiratory RateSensory or Motor-Based Problems Sensorimotor dysfunction Abnormal response to sensory input Postural control Muscle tone, postural control, overall fine and gross motor skill levelsCranial Nerve AssessmentNonnutritive Suckingto practice good latch and facilitate sucking reflexuse gloved finger, stsroke lips and tongue paharap 4-6x then stop, then try x4-6 or 1 stroke per second, repeat 10-12 timesif hindi working sa tongue, try sa hard palateobserve pressure sa cheeks ng babyNutritive Sucking and SwallowingBad Suckingshallow quick sucksboth side of jaw dont moveGooddeep rhythmic movts (around 1 suck sec, 10-3 suck-swallow sequence, or x4-6 suck)pauses to swallowPre-feeding Observation Infant Nutritive sucking Ensure respiratory, cardiac status, bowel sounds, and feeding can be done Observe for 15-20 minutes Signs to look out for: Gagging  Spitting Tongue thrusting  Squirming, withdrawing  Arching of back or neck  Falling asleep before or during process- cardiac and respi rate and if problematic yung rhythms Nonoral feeding Remove OG and NG tube before testing (request assistance) Feeding observation Observe primary caregiver giving food to the infant  Watch actions and interactions (may communication cues ba) Suggest changes during assessment  Recommendation for additional consultation or testingPremature Infants in Neonatal Intensive Care Unit (NICU) Understand genetic, neurologic, pulmonary, cardiac and gastrointestinal disorders; knowledge on embryology Premature infants: immature postural tone, respiratory function (should be less than 70 breaths per min before feeding) and structural alignment (referral)stop oral feeding if respi rate goes higher then 80-85bpm during oral feeding Swallowing (11-12 weeks) sucking (18-24 weeks) 37 weeks not observed full oral feeding yet Feeding specialists Bedside assessment observation State, posture, and position  Sensitivity to stimuli  Respiratory status  Heart rate  OPMOptimal Feeding Posture (Alexander, 1987; Glass & Wolf, 1998)1. Neutral head position with balance flexion and extension2. Neck elongation3. Symmetrical shoulder girdle stability and depression4. Symmetrical trunk elongation5. Pelvis stability, with child’s hips symmetrical and neutral position6. Hips, knees, ankles at 90° degrees with neutral base of abduction and rotation7. Symmetrical and stable positioning of feet in neutral with slight dorsiflexion supported by firm surfaceReflexes to Observenote which cranial nerve and what type of stimulus is presented and age of disappearancePre-feeding Observations of Older Children Posture – central alignment and positioning during sitting Head and trunk control Presence of primitive reflexes, level of physical activity and type of oral stimulation Look into the following Level of alertness  Head and mouth position  Presence of drooling  Verbal and nonverbal communication  Eye contact, head turning, touch and avoidanceAssessment of Older Children Developmental Level Food Preferences MotivationAssessment of Transitional Feeders (when transitioning to solid foods) or Older (usually 7 up)Feeding Evaluation for Older Children Posture and positioning evaluation Present small amounts at a time of varied textures and consistencies Use familiar spoons or other utensils Look into the following: Tonic bite  Tongue thrust  Lip retractionAdjuncts to Clinical Swallowing Examination Pulse oximetry Cervical auscultation - use a steth to listen to (2) swallow clicks inside the pharyngeal cavity, these are the opening of upper esophageal sphincter and cricopharyngeal sphincter and swoowsh of air after (but not super accurate in Cough reflex or ask px to coughTools Used to Assess Feeding (Feeding Kit) Pacifiers Nipples Bottles Cups Straw Spoon Orofacial Stimulation materialswith rationalizationSummary Screening - identify if px has risk for aspi or may feeding concerns Assessment Determine actual feeding concerns  What phase of swallowing is the problem Results of the OPM, CN testing and observation Identify patterns and movements needed for feeding and swallowing Purpose of assessment - identify what the problem is and how to manage and ifne ed ng further testing like video or instrumental Specific tools for feeding na ipapadalaFeeding and Swallowing Evaluation (VFSS) Videofluoroscopic Study of Swallow  Same thickness that would be used for child’s actual diet 3 teaspoons of any solid consistencies 3 sips of any drink in the cup 10-20 second sample of sucking from a bottle Fatigue testing – feed for 5 to 10 minutes with machine turned offthen record 10-20 second sample with machine turned onReferences Arvedson J. Brodsky L. (2002). Pediatric Swallowing and Feeding Assessment and Management Morris, SE. Klein, MD. (2002) Pre-feeding Skills. 2ndEd Texas: PRO-ED Logemann, J. (1988). Evaluation and treatment of swallowing disorders (2nd ed). Austin, Mankekar, G. (2015). Swallowing – physiology, disorders, diagnosis and therapy. Mumbai India: Springer IndiaSources Groher M and Crary M (2016) Dysphagia Clinical Management inAdults and Children 2nd edition Morris S and Klein M (1987) Pre-feeding Skills A ComprehensiveResource for Feeding DevelopmentOUTLINE Interventions for Pediatric DysphagiaSession Learning Outcomes Identify the primary goals of feeding and swallowing intervention Understand the relationship between causes of specific feeding/swallowingpatterns and the necessary interventions to address these problems Identify the available intervention strategies that are most suitable to facilitatebetter feeding patterns among children with dysphagiaPrimary Goals of Intervention (ASHA) “support safe and adequate nutrition and hydration; determine the optimum feeding methods and techniques to maximize swallowing safety and feeding efficiency; collaborate with family to incorporate dietary preferences; attain age-appropriate eating skills in the most normal setting and manner possible (i.e., eating meals with peers in the preschool, mealtime with family); minimize the risk of pulmonary complications; maximize the quality of life; and prevent future feeding issues with positive feeding-related experiences to the extent possible, given the child's medical situation.”Management Approaches (ASHA) Medical (pharmacologic and/or surgical) Behavioral Postural and positioning techniques Diet modifications Equipment and utensils Swallowing maneuvers Oral-motor treatments Feeding strategies Prosthesis and appliances Tube (enteral feeding)Source: https://www.asha.org/practice-portal/clinical-topics/pediatric-dysphagia/Posture and Positioning (ASHA) Chin down/chin tuck Chin up Head rotation Upright positioning Head stabilization Cheek and jaw assist (3-point jaw control) Reclining position Side-lying positioning for infants.Diet Modifications (ASHA) Altering viscosity, texture temperature, portion size, taste, or appearance of food and liquids Thickening of liquids  Precaution on the use of thickeners for infants (may lead to infections) Softening Cutting or chopping PureeingEquipment and Utensils (ASHA) Modified nipples- how big is the hole Cut out cups- can help na pag buo yung cup, they will overcompensate yung pagdrink motorically so they might drown. the cut makes it easier to manipulate motor Weighted forks and spoons- heavier, increasing na threshold to feel na may hawak siya Angled forks and spoons Sectioned plates- different type of consistencies can be presented at the same time for the child to xplore Non-tip bowls- w suction or balance so that it wont spill all over (for children w hand movt. problems)Swallowing Maneuvers (ASHA)- involve the specific muscles for swallowing instead of just specific structures of tongue. we faciliate the reflex kahit papaano- help strengthen structures for swallowing- try not to do with food, only dry swallows or small amts of liquid- check first if ur px can do this, note cognitive and language skills, teach family to emsure safety of facilitationEffortful swallow- ask px push the tongue more backward and against the palate then swallow nang madiin- helps clear the bolus from post base of tongue- extends effort to initiate swallow reflex- helping post pharyngeal wall and airway protection mech to do movts during effortful swallowMasako maneuver- hold tongue against teeth then swallow- helps in providing movt in post base of tongue and have post walls patalikod- promote initiation of swallow and strength is practice- NO foodMendelsohn maneuver- Larynx elevated atlonger period of time- you hold the larynx by hyoid bone,thyroid cartilage, iaangat then tell them to swallow *akyat* then baba pagka-swallow- swallow tayo, hawakan kasabay ng swallow then ibababa after swallow- adds another protection to airway- NO foodSupraglottic swallow- voluntarily close vocal folds- inhale, hold breath, then swallow- pwede w food or liquids (careful)Super-supraglottic swallow- inhale, hold breath then push swallow- combined w effortful swallow(will be discussed in detail)Oral-Motor Treatments and Sensory Stimulation (ASHA)Passive Tapping or Vibration Stroking or stretchingActive Range-of-motion exercises Resistance exercises Chewing or swallowing exercisesSensory StimulationThermal-tactile (laryngeal mirror dipped in ice para cold, stroke anterior faucial pillars then swallow)Tactile - NUK brush, finger brushNuk and finger brush to stimulate gums, tongue, hard palate. Used to prime before presenting food, if kulang sa sensation yung child.If we dont have these items, we can use gloved or clean fingers. Tap the inside of cheeks of the child to stimulate buccal cavity and stroke up and down 10x or pull. Careful, always wash hands when moving next cheek.Feeding Strategies (ASHA)- for nonverbal newborns/infants Pacing - try to manage the rate and amt of intake of food via bites or swallows. alternate the foods and liquids. (e.g. food 2-3x like pureed oatmeal then sip of water)- give time in between giving food, or more fast during active feeding or if fully awake siya.- depends on case of child- stay within 30-40 mins feeding time- pwede rin sa bottle-feeding, pacing the mL and time Cue-based feeding - observe how much the rate of sucks the child has- too slow, too fast? you can check if she slows down, then that might mean child needs a break (tired, full, etc.)- look at cues (turning head, pushing nipple away)- ask caregiver to be aware of these cues- quality of feeding is okay during all that time. the good suck, effort, and strength.- instead of volume as goal, establish identifying appropriate cues at a certain amount of time- once you see the cues, you do your responsive feeding Responsive feeding - caregiver n child dynamic.- lessen difficulties during feeding timeProsthesis and Appliances (ASHA) Palatal obturator Palatal lift Feeding plateBefore you feed, check the following: (ASHA) Alertness, Demand for feeding Cues that signal stress Neurodevelopmental level General health status- schedule of childSpecific Behavioral StrategiesFacilitating Normal Sucking Pattern- check for initiation of movements- elevates base of tongue then bababa during swallow- try removing finger then put back then check if kaya independently- check tone, excessive biting, breathing patternsSucking at the Breast Goal: Maintain breastmilk supply. Pump every 2-3 hours. Use of supplemental nursing system- use expressed pumped milk, if not enough milk, we can use donor milk or formula- DIY breastfeeding- in order to help child do the natural swallow-suck reflex (still latched on breast)Facilitating Safe Swallows Facilitate normal sucking pattern with proper latching and positioning Thickening of liquids may cause harm to babies/infants which may lead to necrotizing enterocolitis Use breastmilk or prescribed formula milk Avoid adding thickeners unless prescribedFacilitating Mature Oral Movements During Spoon Feeding of Soft Foods- ARK- head tilts upward sa pagsubo- try to approximate a 90 degree oral position- establish a more natural and more mature oral movement- teach EXPECTED oral movt.Improving Jaw Stability- sit up straight- work with opening n closing mouth, slowly, gently mga x5- chewy-chubes, targets each side, prolonging biting, then with resistance- to help us manage the bolus and speech sounds that need the opening of jawTargeting Food Aversion- making it more sensory- may behavioral theory applied, reinforcement- Elena speech therapist, picky eaters- note certain characteristics at a certain age are needed to provide modifcations to elicit proper feeding/swallowing behaviorQuestions to Assist Decision Making Regarding Nutritional Supplement Weaning Programs Is the patient being treated in the in-patient or out-patient setting? How long is the program? How many sessions are needed and how frequent? Are there criteria that preclude eligibility from the program? How will skill-based issues (motor & sensory) be managed? How will fear and anxiety (behavioral) issues be managed? How do you drop the volume of supplement feeds to increase appetite for oral feed? Does the clinic use appetite stimulants and how are they used? What will happen when supplemental feeds are stopped, and child does not eat? How long can the child not eat before you supplement?- dont immediately remove bfeeding, js wean What techniques are used to prompt the child to feed? What will you use to reward desirable/undesirable behavior? What are the role of the parents? Are parents trained to implement program at home? How long will be the follow up after intervention? What happens if gains are not maintained after intervention? Is any outcome data available? How much does the program cost? Where does the program run? What will happen when the child returns to their province? How will the child’s management data be shared with other members of the team?How is Success Measured?  Nutritional Outcomes No supplemental feeds or less supplemental feeds? Are oral supplements acceptable? Or do we need to get all nutrition from food? Is it okay if the child only eats a few types of food? Or is goal to eat a wide variety of food?  Growth Outcomes Is the goal to maintain weight or gain weight? Or reach appropriate height, weight and BMI?  Developmental Outcomes If eating pureed food is that ok? Or need for developmentally appropriate textures? Is self feeding a goal? Is the length of time to feed part of the goal?Interventions for Problems with Individual StructuresJaw Thrust Rule out medical, dental or orthopedic concerns Work on posture Reduce sensory input Position on prone Reduce hypersensitivity 3-point jaw Introduce toothbrushing Biting tasksVideo on decreasing sensitivity and focus on biting. Consistency is also managed.- focusing on stimulating muscles first, chewing first, biting- you can start desensitizing my massaging sa distal area first then moving centerJaw – Clenching/Teeth Grinding/Retraction Posture Hypersensitivity Brushing teeth Deep massage on the masseter See reaction to environmentJaw – Instability Posture Tapping, patting, stroking the cheeks 3-point jaw control Biting tasksTonic Bite Posture Sensory input triggering tonic bite Introduce food at the lower lip, so lips move not the teeth Reduce hypersensitivity If you are comfortable start with putting your moist finger in the child’s mouth Use index/little finger: Slide along the outer surface of the upper and lower gums, use firm sustained pressure; stop and stay inside the mouth if there is slight tension vs pulling outcompletely Use both hands for graded stimulation If already comfortable move to the biting surface of gums or teeth IF CHILD BITES; do not pull it will just increase the strength of bite; calm the child first to relaxand release by rocking allowing other body movementsTongueTongue - Retraction Posture Stimulate lips with food Tap upward under the chin at the base of the tongue Do gum desensitization move towards tongue: Downward vibration of tongue to flatten on surface of oral cavity You can also do lateral movement massages for it to extend and rest Stroke forward to draw tongue outTongue - Protrusion Posture Change consistencies – move towards chewing laterally and centrally Jaw stability Promote lip movement vs tongue movement in sucking – put cup on lipsTongue - Low Tone/Limited Tongue Movement/Asymmetry Posture Tap base of tongue INCREASE sensory input: explore sour, ice, textured toys/teethers, z-vibe or nuk brush Rapid or fine vibration or shaking on the tongue on the tongue For asymmetry, place focus on less active side but still provide input on activesideLipsLips - Retraction Posture, decrease sensory input Hold the cheek scissor fashion between index and middle finger and do rapid vibration; hold cheek and draw it forward Wipe or rub cheek or jaw towards non retracted (OPPOSITE) directionLip – Limited Upper Movement Posture Increase sensory input to lips and cheeks; lip tapping/massage Place fingers on side of nose and vibrate downward toward the bottom of theupper lip slowly and evenly; sustained aspect of stretch and vibration Introduce straw drinkingCheeksCheek – Low Tone Posture Increase sensory input Put liquid on the side of the cheek to encourage SLURPING, hide food at cheek sulci to push Teach straw drinking to control intraoral pressurePalatePalate - Reflux Posture Improve cheek and tongue function for effective bolus manipulation Thicken food/liquids- sensitive gag reflexCheck this video: What do you think are the main concerns in this video?- nutrition, posture What would you recommend given the situation?- enteral or parenteral feeding- conduct full assessment: f&s, language, cog, aac ax, CN testing, recurring pnemonia- counselling and referrals and assistance from othe professionals, px educationDysphagia Telepractice During COVID-19 Malandraki, et al. (2021). Available from:http://pubs.asha.org/doi/10.1044/2020_AJSLP-20-00252 Rapid systematized review 11 articles on telehealth for dysphagia 8 recommended the use of clinical swallowing assessment 7 articles recommended swallowing therapy 6 articles described telehealth as a second-tier service delivery option Highlighted the need for practice guidelines to ensure safe and reliable dysphagia managementReferences American Speech-Language-Hearing Association. Pediatric Dysphagia. Available from https://www.asha.org/practice-portal/clinical-topics/pediatric-dysphagia/ Groher M and Crary M (2016) Dysphagia Clinical Management in Adults and Children 2nd edition Morris S and Klein M (1987) Pre-feeding Skills A Comprehensive Resource for Feeding Development Malandraki GA, Arkenberg RH, Mitchell SS, Malandraki JB. Telehealth forDysphagia Across the Life Span: Using Contemporary Evidence and Expertise toGuide Clinical Practice During and After COVID-19. American Journal of Speech- Language Pathology [Internet]. 2021 Mar 26;30(2):532–50. Available from: http://pubs.asha.org/doi/10.1044/2020_AJSLP-20-00252FINALSOUTLINE Clinical Evaluation of Acquired DysphagiaLearning Objectives Identify the clinical swallowing assessment and evaluation procedures for patients with acquired dysphagia Determine assessment tools that can be used for evaluation Understand special considerations made for population with dysphagia secondary to degenerative conditionsScreening vs Diagnostic ToolsScreening- chart reviews Screening  Quick and minimally-invasive  Provides indirect evidence on the physiology of the disorder  Identifies signs and symptoms of dysphagia  Allows the clinician to decide whether the patient needs further and in-depth physiological assessmentDysphagia Screening Checklist (Logemann, 1998)- pooling of swallowBedside Swallow Screen1. Cognitive Screen2. Assess to Follow One-Step Commands3. Oral-Motor ExamAfter, if they fail (coughing, wet gurgly voice after few mins) THEN do a clinical evaluationClinical Examination of Dysphagia (Logemann, 1997)- (we refer to logemann's) try to rationalize why important each item1. Information on the current medical diagnosis 2. Medical, nutritional, respiratory status 3. Oral anatomy 4. Respiratory function and relationship to swallow 5. Labial control 6. Lingual control 7. Palatal function 8. Pharyngeal wall contraction 9. Laryngeal control 10. General ability to follow direction, monitor and control behavior 11. Reaction to oral sensory stimulation, taste, temperature and textureClinical Evaluation of Dysphagia (CED) (Cherney, Pannelli, & Cantiere, 1994)what wasnt mentioned in logemann:hx of aspirationtype n size of trachlevel of responsivenessin Case Hx, direct some of questions towards the px parin (include them)current feeding methodsvoluntary swallowother observations (how they are in-px rooms, outside, reflexes, drooling, mouth odors)response to stiulation (e.g. tongue depressor on the structures)recomms and goalsgag reflex (not necessarily gag, js the movt of the arches n base of tongue, reactions)Clinical Dysphagia ExaminationPreparatory Exam Patient chart review and case history   Observations when entering the room   Respiratory status   Examination of oral anatomy   Laryngeal function examination   Pulmonary function testingInitial Swallowing Exam Observations during trial swallowsPatient Chart Review and Case Hx Read through medical charts  Respiratory status  Pneumonia (recent? recurrent?); pulmonary examination (chest x-ray)  Tracheostomy or endotracheal tube; ventilator  History of swallowing diagnosis Person’s awareness and nature of disorder  Interview family member, caregiver, or nurseObservations Posture Alertness and reaction to clinician/environment Presence/absence of tracheostomy or endotracheal tube Feeding tube managementManaging of secretions (saliva, mucous), ask them what they do when their saliva pools etcCan follow instructions?Respiratory Status- Observe respiratory rate  Any signs of respiratory distress Regularly check pulse oximeter  SpO2 = should be equal or greater 95%   Observe the following:  Timing of saliva swallows to phases of respiratory cycle Timing of coughing  Patient’s comfortable breath hold –1 sec, 3 sec, 5 sec  Rest breathing pattern –oral vs nasalExamination of Oral Anatomy   Motor-Sensory Evaluation   Motor examination   Labial function   Lingual function   Chewing function   Swallowing function  Sensory examinationLaryngeal Function Examination   Perceptual voice assessment   What skills should we assess?Perceptual Voice Assessment- Loudness- Qualitygurgly? why?- Pitchhow structures move, intensitys/z ratio (respi and laryngeal fx)What skills should we assess?- Decisions on the Following Information  Best posture?  Optimal food position in the mouth?  Possible best food consistency?  Optimum swallowing instructions?  Utensils for initial evaluation?Trial Swallows  3-oz swallow  150mL test Other thin liquids  Thick liquid  Pudding  Puree  Ice chipsPalpation Index behind mandible anteriorly  Middle finger at hyoid bone  Ring finger at the top of thyroid cartilage  Small finger at the bottom of thyroid cartilage- Laryngeal Palpation (4 fingers) then px will do a dry swallow, it should move in sequence Palpate at the level of the thyroid notch to feel for laryngeal excursion as a sign that a swallow response has been elicited.Test Swallows - palpationPositionCorresponds to:Index behind mandible anteriorlyInitiation of tongue movement for initiation of swallowMiddle finger at hyoid boneElevation for pharyngeal swallowRing finger at the top of thyroid cartilageElevation for pharyngeal swallowSmall finger at the bottom of thyroid cartilageElevation for pharyngeal swallowComparing the time elapsed from between initiation of tongue movement and initiation of hyoid and laryngeal movement can provide the clinician with a VERY ROUGH ESTIMATE of oral transit time and pharyngeal delay time.; or initiation of swallow time until pharyngeal swallow is triggered. (No less than 1 second). You have NO IDEA WHAT IS HAPPENING INSIDE PHYSIOLOGICALLY.Acoustic- cervical auscultation Place stethoscope at the level of the vocal folds  Listen for sounds  Pre-swallow  Larger bolus would make bigger sound  Period of apnea (no sound) during swallow followed by two burst sounds  Followed by a burst of exhalatory burst or glottal release sign is present after swallow.Dry Swallownumber of swallow per 30 second is 3+- then laryngeal palpation during this Humans repeat swallowing at certain intervals in order todispose of saliva in the mouth, even when not eating. This dry swallowing is the basic movement used to dispose of saliva. It is therefore necessary to check if the patient can swallow well before conducting any other screening tests.Repetitive Saliva Swallowing Test (RSST) This test is intended to check the patient’s ability to voluntarily swallow repeatedly, which is highly correlated with aspiration.  Place the patient in a resting position and wet the inside of the patient’s mouth with cold water. Instruct him/her to repeatedly swallow air and monitor the number of swallows achieved. Three or more dry swallows within 30 seconds is considered normal. The number of swallows is counted by the movement of laryngeal elevation, either visually or by palpating.Water Swallow Test- we use modified swallow test Is a screening tool to determine if the patient is suspect to have the presence of dysphagia  Has three goals 1. Determine likelihood that aspiration present 2. Need for formal swallow evaluation 3. When it is safe to resume oral alimentationModified1-4 give 2 more attempts 3 ml water5 ok na, js do 4 2 times3oz Water Swallow Test  Each patient is required to drink 3 ounces (90cc) of water (cup or straw) without interruption Criteria for referral or for further testing:  Inability to complete task   Coughing or choking   Wet or hoarse vocal quality   Either during or within 1 minute of test completion True Positive: + asp. FEES / Failed 3oz test True Negative: -asp. FEES / Passed 3oz test False Positive: -asp. FEES / Failed 3oz test False Negative: + asp. FEES / Passed 3oz testtrue negative (no problem)Interpreting Results (Suiter and Leder, 2008) Sensitive for identifying aspiration of thin liquids: 96% who aspirated on FEES also failed 3oz test Also, 3oz test had high negative predictive value (98%), i.e., if passed also no aspiration on FEES Therefore, passing 3oz test = good predictor to safely tolerate thin liquids Specificity for determining liquid aspiration during FEES = low, 50%, and false positive rate high (50%), i.e., half of patients who failed the 3oz test did not aspirate during FEESTrial Swallows Grossly assess the swallow response with real food items Test trials provide the coordinated integration of all the swallowing muscles. Usually range from thin to thick liquids, pudding to soft items and items that require mastication Use an item that is relatively safe if partially aspirated and to be certain that the patient can cough to protect the airway from aspiration. You can start with a spoonful of crushed ice (elicit chewing reflex, alerting due to temperature, melts to water so it does little harm)After the swallow Ask the patient to say /ah/ for several seconds if there are any signs of gargling -> check sign of wet gurglyvoice Ask the patient to pant or cough to expel and then phonate /ah/ again (to expel food from valecullaeand pyriform sinuses, false vocal chords) If still gurgly Move head from side to side (puts pressure on pyriform sinuses)  Tilt head up (pushes on the vallecular space)  If they cough or expel any bolus then suspect foraspiration but absence does not rule out silent aspirationAssessment of Oral Intake 5mL amount Change volume before you change consistency, e.g., 5, 10, and 15 ml When drinking symptoms may change based on how you introduce food (through spoon, cup or straw)Assessment of Oral Intake: Transitioning ConsistenciesBedside Swallow EvaluationTracheostomy  Placed to bypass upper airway obstruction  Upper airway obstruction above true VF  Potential upper airway obstruction from edema following surgery  Provision of respiratory careTracheostomy TubesManagement of Tracheostomized Patient During Assessment of Swallowing Examine the following: Presence and status of cuff  Fenestrated? Or not?  When did the patient start having tracheostomy tube?Degenerative Diseases Progressively changing Would need shifting strategies Evaluate swallowing regularly to monitor: Patient’s progressively worsening function and how to compensate Patient’s risk of serious aspiration and pulmonary problems Optimal nutrition and hydration status maintenance  Counseling Goals and general progress  Risks and benefits of recommendations Concerns with clients with degenerative diseases Agnosia or oral tactile agnosia  Reduced physiological capacities  Increased feeding times  Control of voluntary and involuntary swallow  Upper and lower motor degenerationSample eval flow Chart Review (when possible)  Case History  Assess posture and respiration  OPM/Cranial Nerve Evaluation + Voice  Dry Swallow Palpation  Water Swallow Screening/Test  Trial Feeds (you can change the consistency, volume or provide facilitating techniques)References Haynes, W. O., & Pindzola, R. H. (2004).Diagnosis and evaluation in speech pathology. Boston: Allyn and Bacon. GroherM. and CraryM. (2016) Dysphagia Clinical Management in Adults and Children 2ndEdition, Elsevier, St. Louis, Missourri HoriguchiS and Suzuki Y (2011) Screening Tests in Evaluating Swallowing Function, Japan Medical Association –Journal 54 page 31-34 LederSD and Suiter DM (2008) Clinical Utility and Efficacy of the 3 Ounce Water Swallow Challenge, Presented at the 2008 Annual Convention of the American Speech-Language-Hearing Association, Chicago, IL Logemann, Jeri (1998) Evaluation and Treatment of Swallowing Disorders, ProEd, Austin, TexasOUTLINE INTERVENTIONS FOR ACQUIRED DYSPHAGIALearning Outcomes Determine the possible intervention options for acquired dysphagia Demonstrate compensatory techniques and exercise maneuvers for adult patients with dysphagiaMAP FOR ACQUIRED DYSPHAGIA INTERVENTIONPossible Management Options Medical Biofeedback Diet Modifications Electrical Stimulation Equipment and Utensils Maneuvers Oral Motor Exercises Pacing Posture Appliances/Prosthesis Sensory Stimulation Compensatory vs Rehabilitative Compensatory Improve safety of swallows. ""quick-fix"" Immediate effects on swallowing Rehabilitative Improve efficiency of swallows Has long-term effects Uses the principles of neuroplasticity, exercise, and motor learning MedicalCommon Medical Options for Dysphagia  Pharmacologic Management Anti-reflux medications Prokinetic agents Salivary managementCommon Surgical Options for Dysphagia  Improved Glottal Closure Medialization thyroplasty Injection of biomaterials Protection of the Airway Stents Laryngotracheal separation Laryngectomy Tracheostomy tubes Feeding tubes Improved Pharyngoesophageal Segment Opening  Dilation Myotomy  Botulinum toxin injection BiofeedbackVideoMay visual representation ng strength of swallow using VR.- Some exercises we can do in future: gauze can be dipped in orange juice or like wine, then put in inside mouth, then hawak mo other end, you have to feel the elevaiton of the tongue push against the tongue and you pull and you shouldnt be able to take the gauze from their mouth. Diet ModificationsPossible Management Options Changing the viscosity of liquids and/or softening, chopping, or pureeing solid foods.  Modifications of the taste or temperature to change the sensory input of the bolus  Clinicians consult with the patients and caregivers to identify patient preference and values for food when discussing modifications to oral intake (even fatigue) Consulting with the team, including a dietician, to ensure that the patient's nutritional needs continue to be met.- VIDEO: Screenshot the Good to Know Electrical Stimulation Electrical stimulation is promoted as a treatment technique for speech and/or swallowing disorders that uses an electrical current to stimulate the nerves either superficially via the skin or directly into the muscle in order to stimulate the peripheral nerve. Electrical stimulation for swallowing is intended to strengthen the muscles that move the larynx up and forward during swallow function.Current to muscles to help them contract, strengthens the muscles, esp larynx.Video:  Equipment and UtensilsNose cup- helps in tilting the cup without having to tilt a lot furtherSmart Utensil Video- for parkinson's- stabilizes the spoon so the food is kept in Pacing Clinicians modify the bolus size (i.e., bigger/smaller bolus amounts), particularly for patients that require a greater volume to adequately stimulate a swallow response or for patients that require multiple swallows per bolus. Patients may also require cuing and assistance to maintain an appropriate rate during meals.- ask px to eat slowly- change bolus size (bigger → might help in providing sensation)- take note when mo iaadjust in terms of taste and temperature given OPM Ax- some px require bigger volume due to high threshold sensation- remind abt residue in mouth, do double swallows- they might get frustrated, write reminders to eat slowly, how many times to chew,  Appliances / Prosthesis Sensory Stimulation Sensory stimulation techniques vary and may include thermal-tactile stimulation (e.g., using iced lemon glycerin swab, cold laryngeal mirror) or thermal tactile stimulation applied to the tongue, around the mouth, and/or in the oropharynx (pwede rin chilled end of spoon). then ask px to swallowVideo:- you can also try palpating yung changes ng pag-elevate ng base of tongue and elevate ng larynx- 3-5 times to stroking and swallows before providing food and liquids Posture Chin-down or chin-tuck posture —the chin is tucked down toward the neck during the swallow, which may bring the tongue base closer to the posterior pharyngeal wall, narrow the opening to the airway, and widen the vallecular space. Chin-up posture —the chin is tilted up, which may facilitate movement of the bolus from the oral cavity. ONLY if there is tongue weakness but GOOD AIRWAY PROTECTION during swallow  Head rotation (turn to the side) —the head is turned to either the left or the right side, typically toward the damaged or weak side (although the opposite side may be attempted if there is limited success with the first side) to direct the bolus to the stronger of the lateral channels of the pharynx.- turn head away towards weak side Head tilt —the head is tilted toward the strong side to keep the food on the chewing surface.- tilt toward stronger sideLet’s Try: What posture can you ask patient to try? Drooling noted on right side of lips, asymmetry and drooping on right side. Weakness on tongue lateralization to right and patient complains of food getting “stuck” on right side of larynx when asked to point. - so their tongue is deviated probably at the left, the stronger side- upright posture- head rotation to Right- head tilt towards Left side to help food be directedLimited sensation on left side of the face. Good SE  (sensory evaluation) of lips, fair strength and endurance for tongue. He points that he feels something behind mandible above thyroid notch after swallow so we will cough. Cough noted 3-5 seconds after swallowing then patient says he is already ok after.- chin tuck bc abbove thyroid notch, or valleculae area we  want t

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