B4L3 Adult Swallowing Intervention.pdf

Goals of Dysphagia Pulmonary safety Getting adequate nutrition Maximizing Quality of Life Make swallowing (close to) normal ○ Not always possible Treatment Approaches A. Surgical B. Medical C. Behavioral a. Bolus/food modification b. Compensatory T...

Goals of Dysphagia Pulmonary safety Getting adequate nutrition Maximizing Quality of Life Make swallowing (close to) normal ○ Not always possible Treatment Approaches A. Surgical B. Medical C. Behavioral a. Bolus/food modification b. Compensatory Techniques c. Rehabilitative Exercises D. Neurostimulation Surgical Management Usually done if therapy is unsuccessful Most procedures are on the larynx or UES Structure Surgical Procedure Intended Effect UES Cricopharyngeal Myotomy Remove UES outlet obstruction; improve bolus flow UES botox injection Remove UES outlet obstruction; improve bolus flow UES Dilatation Remove UES outlet obstruction (too small); improve bolus flow Velopharynx Pharyngeal Flap Surgery- Reduce velopharyngeal Get tissue from pharynx and insufficiency attach it to soft palate Larynx Total Laryngectomy- Preventing aspiration complete removal of larynx Tracheostomy- incision just Secure airway, reducing below vocal folds and a tube aspiration is inserted Vocal fold medialization Improve glottic closure; for VF to approximate better Medical Management Pharmacological ○ Capsaicin Found in hot peppers, increases release of substance P -> improves pharyngeal sensory functions ○ Cholinesterase inhibitor drugs Seen in most medications for Alzheimer’s, Myasthenia Gravis Decreases breakdown of acetylcholine which improves involuntary muscle function (from pharynx to larynx) Enteral feeding/ Tube feeding ○ Inability to get proper nutrition by mouth ○ Impaired airway protection when swallowing ○ Nasogastric Tube (NGT) vs Percutaneous Endoscopic Gastrostomy (PEG) ○ Other intervention is given to improve tolerance of different food and liquid consistencies, until tube feeding is no longer needed. Parameter NGT PEG Insertion Easy, Quick Invasive, Surgically placed Tube life 1 month Less than or equal to 9 months; made to last Replacement Often Infrequent Invasiveness to Patient High Low (discomfort) Common problems Mucosa scarring Infection encountered Arytenoid Swelling Tube obstruction Tube displacement Behavioral Management Modifies Diet (bolus modification) Patient (postural adjustment) Swallow (compensatory techniques) Structure (rehabilitative exercises) Bolus Modification Changing consistency, or texture of foods and/or liquids (Refer to IDDSI levels) Can also alter other properties (i.e. size, taste) Reduces aspiration events (e.g. coughing) but none much else (e.g. improving in fluid intake, decreasing odds of aspiration pneumonia, etc.) according to current research Compensatory Strategies Could be in the form of posture, maneuver, and/or sensory enhancements Considered “quick fixes” to dysphagia Does NOT rehabilitate structure or physiology of swallow Efficacy checked through instrumental evaluation Problem in Phases of Swallowing Compensatory Strategy Poor bolus awareness Verbal reminders (sir, ill be giving you one tablespoon of mashed potato, are you ready?), improve taste or aroma Anterior leakage Bolus placement (more medial), use of straw, syringe delivery Oral residue Finger sweep, lingual sweep Nasal regurgitation Decrease bolus size, effortful swallow, cued swallow (increase awareness towards swallowing movement) Vallecular residue Throat clearing, suctioning, effortful swallow, cued swallow Pyriform sinus residue (usually liquids) Volitional coughing, effortful swallow, cued swallow Penetration Supraglottic swallow, coughing, cued swallow Aspiration Supraglottic swallow, vocal quality check, cued swallow Pharyngeal regurgitation Decrease bolus size, cyclic ingestion (solid then liquid then solid) Compensatory Techniques Technique Function Addresses Cued Swallow Increases coordination of Vallecular residue swallow physiology through Pyriform sinus residue increasing awareness of the Aspiration/ Penetration task Premature spillage Effortful Swallow Increase BoT retraction Vallecular residue Reduced BoT-PPW approximation Mendelsohn Maneuver Increase duration of Impaired UES Opening hyolaryngeal excursion Impaired hyolaryngeal elevation Supraglottic Swallow Increased VF closure Penetration Aspiration Super-supraglottic swallow Increased closure in all Penetration laryngeal structures, BoT Aspiration retraction, earlier and Pharyngeal residue prolonged UES opening Thermal-tactile stimulation Increases oral and Penetration Aspiration pharyngeal perception Chin tuck- head flexion (head Push tongue base and Penetration movies backward) epiglottis backward, hyoid Aspiration and larynx are closer Pharyngeal residue Chin down- head is bowed Widens vallecula, increases Pre-swallow aspiration down lingual force, earlier and Delayed swallow reflex longer laryngeal closure Head rotation (rotate to the Narrows hypopharynx on the Pharyngeal or laryngeal weaker side)- narrows weak side of rotation hemiparesis side allowing bolus to travel Reduced laryngeal closure in the stronger side Head tilt- Directs bolus to the side of Pharyngeal or laryngeal tilting hemiparesis Reduced laryngeal closure Reclining( 60 or 45 degree Uses gravity to aid in bolus Delayed swallow reflex angle transport to pharynx; normally Impaired pharyngeal wall done with supraglottic contraction swallow Rehabilitation Exercises Improves neuromotor control Can be done with food (direct) or without food (indirect) Exercise principles should be applied ○ Intensive ○ Specific ○ Structured ○ Feedback Motivation plays a big part in success Technique Function Addresses OPM exercises (tongue, jaw, Increased strength, and ROM lips) of OPM Effortful swallow Increases BoT retraction Reduced pharyngeal contraction Reduced BoT-PPW approximation Masako Maneuver Strengthen PPW Reduced pharyngeal contraction Reduced BoT-PPW approximation Mendelsohn Maneuver Strengthens suprahyoid Impaired UES muscles and laryngeal opening closure Hyolaryngeal elevation Super supraglottic swallow Increases and prolongs Impaired laryngeal closure  laryngeal closure Shaker Strengthens anterior neck Impaired UES muscles assisting in UES opening opening Hyolaryngeal elevation Neurosensory stimulation Increasing cortical activation, Delayed swallow reflex and pharyngeal swallow Weak cough response Lee Silverman Voice Strengthens suprahyoid Impaired airway protection Treatment (LSVT) muscles Neurostimulation Neuromuscular Electrical Stimulation (NMES) - sends electrical impulses to nerves causing them to contract; to avoid atrophy and keep integrity of laryngeal muscles Intervention Team Physician - if in the hospital setting, is the primary of the team; in charge of the patient’s holistic care Neurologist - specializes in diagnosing and treating disorders of the brain Pulmonologist - determines safety and effectiveness of the patient’s breathing Otorhinolaryngologist - helps with instrumentation especially during swallow evaluations Dietician - provides a meal plan addressing nutritional needs of the patient Speech-Language Pathology - works with the patient in improving swallowing function and provides specific food and liquid consistencies tolerable for the patient Occupational therapy - helps with independent feeding and improving cognitive functions needed for safe feeding Physical Therapist - helps with facilitating adequate posture that promotes successful feeding and swallowing Pharmacist - helps in ascertaining dosage of pharmacological treatments if applicable to patient