Exam Preparation Flashcards
(127 cards)
1
Q
What is the incidence of Dysphagia?
A
41-60% in stroke units
2
Q
Describe Dysphagia
A
Dysphagia is a disorder or difficulty swallowing. It involves disruption of any one or more of swallowing stages; oral, pharyngeal and/or oesophageal
3
Q
What are the 3 oral stage phases?
A
Oral anticipatory, oral preparation & oral transit
4
Q
What is the primary role of the oral anticipatory stage?
A
Sensory acknowledgement that food is present leads to an appropriate response (e.g. mouth opening, using smell, judging amount to place in mouth etc.)
5
Q
How many cranial nerves are there involved in swallowing?
A
There are 6 cranial nerves
6
Q
How many pairs of muscles are involved in a normal swallow?
A
There are 26 pairs of muscles involved in a normal swallow
7
Q
What is the Buccinator Press?
A
The Buccinator Press is where the cheek tension flattens cheeks down, causing the bolus to be kept within the ‘dental vault’ (i.e. between cheek and lateral teeth)
8
Q
What is the primary role of the oral preparation stage?
A
The preparation of food and fluid for oral transit and the initiation of the pharyngeal swallow
9
Q
Describe step-by-step what occurs in the oral preparation stage
A
- Mouth and lips open to accept bolus
- The tongue forms a groove to accept the bolus
- The lips seal around bolus to prevent any anterior spillage
- Tension in lips and cheeks keeps bolus in the correct place
- Food and liquid in the mouth stimulates taste/temperature and touch receptors
- Saliva is produced as the salivary glands are activated
FOR SOLIDS –> Coordinated movement of the tongue and jaw moves the bolus onto teeth for mastication. **Held at base of tongue
FOR LIQUIDS –> Glossopalatal seal contains to bolus within mouth ** Held anteriorly
10
Q
What is the Glossopalatal Seal?
A
The tongue and soft palate contact seals the oral cavity containing the bolus to prevent posterior spillage
11
Q
What is the primary role of the oral transit phase?
A
Posterior propulsion of the bolus from the oral cavity into the pharynx following bolus preparation
12
Q
Describe step-by-step what happens in the oral transit stage
A
- Tongue tip elevates and presses against the hard palate occluding the oral cavity
- Tongue dorsum & cheek tension hold bolus laterally
- Posterior tongue drops to open the back of the oral cavity
- Tongue-Palate contact expands from front to back- squeezing the bolus back along the palate & into the oropharynx, through the faucial arches
13
Q
How is a swallow triggered?
A
The swallow is triggered by sensory stimulation of the superficial mucosal receptors in the soft palate/pharynx & deep tissue receptors in the base of the tongue
14
Q
What are the two main roles of the pharyngeal stage?
A
- Food Passage: Propels the bolus through the pharynx, UES towards the oesophagus
- Airway Protection: Ensuring food/ drink don’t enter the airways
15
Q
What stage(s) of a normal swallow are involuntary?
A
The Pharyngeal and Oesophageal Phases are both involuntary
16
Q
What stage(s) of a normal swallow are voluntary?
A
All three oral phases are voluntary
17
Q
What prevents nasal regurgitation in the pharyngeal stage?
A
The velopharyngeal seal; sphincter-like action involving the velum, lateral and posterior pharyngeal wall
18
Q
What is ‘Hyolaryngeal Excursion’?
A
This is where the larynx is drawn upwards and forwards; assisting in airway protection and helping to create a negative pressure below bolus during the pharyngeal stage
19
Q
Describe step-by-step what happens in the Pharyngeal Stage
A
- The BOT retracts and the posterior pharyngeal wall moves forwards (BOT TO PPW APPROXIMATION) This creates pos. pressure on the bolus
- Hyolaryngeal excursion creates negative pressure below the bolus
- When the bolus enters the pharynx the pharyngeal constrictor muscles sequentially shorten and narrow the pharynx (PHARYNGEAL CONSTRICTION) squeezing the bolus through peristaltic movements to the oesophagus.
- The bolus then passes the the UES into the oesophagus
20
Q
How does the body protect the airways?
A
Through EPIGLOTTIC DEFLECTION (the epiglottis tilts backwards to deflect the bolus away) and GLOTTAL CLOSURE (closing/ adduction of the true vocal folds and false vocal folds)
21
Q
What is the main role of the oesophageal stage?
A
The primary role is to move the bolus from the UES to the stomach for digestion
22
Q
What structures are involved in the oral preparation phase?
A
The lips, cheeks, tongue, hard palate, soft palate, jaw, teeth, tastebuds & salivary glands
23
Q
What structures are involved in the oral transit phase?
A
Tongue, hard palate, soft palate, lips & cheeks
24
Q
What structures are involved in the pharyngeal stage?
A
Pharynx, pharyngeal constrictor muscles, BOT, vocal folds & laryngeal muscles
25
What structures are involved in the oesophageal stage?
UES, LES, Oesophageal muscle
26
When a swallow is triggered through sensory stimulation, where is this information then sent in the brain?
1. The sensory information first travels to the medulla (specifically the NTS: NUCLEUS TRACTUS SOLITARIUS) **This is where sensory information about the bolus is integrated with the programming to initiate a swallow
2. The NTS then triggers the VENTRAL SWALLOWING GROUP (VSG). This is essentially the 'motor swallowing centre' that enables the execution of the programmed swallow
27
How is the Cortical region of the brain relevant to swallowing?
MOTOR: intent, initiation, programming, execution.
SENSORY: recognition, awareness, motor tuning
28
How is the Sub-cortical (i.e. Basal Ganglia) relevant to swallowing?
MOTOR: initiation, refinement, inhibition
SENSORY: motor tuning, awareness, conveys sensory information
29
How is the Cerebellum relevant to swallowing?
MOTOR: refinement, inhibition
SENSORY: conveys sensory information
30
How is the Brainstem (i.e. Pons & Medulla) relevant to swallowing?
MOTOR: junction between the UMN and LMN, motor & sensory centres (heart, respiration & swallow)
SENSORY: conveys sensory information
31
How are the peripheral nerves relevant to swallowing?
MOTOR: LMN, drive movement
SENSORY: conveys sensory information
32
How are muscles and sensory receptors relevant to swallowing?
MOTOR: effect- movement
SENSORY: sensation reception
33
How do you identify an UMN lesion?
An UMN lesion results in weak or absent voluntary movements of the muscles; which leads to an increase in muscle tone and SPASTICITY. Reflexes can become jerky and exaggerated
CAN STILL RAISE EYEBROWS ON REQUEST
34
How do you identify a LMN lesion?
A LMN lesion can result in complete paralysis of the affected muscle(s); with ATROPHY, wasting and fasciculations of the muscle due to absence on use.
CAN NOT RAISE EYEBROWS ON REQUEST
35
What are the sensory functions of Cranial Nerve V (TRIGEMINAL) & why are they important?
- Anterior 2/3 of the tongue
- Hard palate
- Cheeks
- General sensation of the face
IMPORTANT FOR DETECTING ORAL RESIDUE & ANTERIOR ORAL ESCAPE
36
LIST the 6 Cranial Nerves involved in swallowing
```
V = Trigeminal
VII = Facial
IX = Glossopharyngeal
X = Vagus
XI = Accessory
XII = Hypoglossal
```
37
What are the motor functions of Cranial Nerve V (TRIGEMINAL) & why are they important?
- Controls muscles of mastication (inc. MASSETER, TEMPORALIS, MEDIAL & LATERAL PTERYGOIDS)
- Controls some muscles involved in hyolaryngeal excursion (inc. MYLOHYOID, ANTERIOR BELLY OF DIGASTRIC)
- Controls some muscles involved in tensing soft palate to assist velopharyngeal seal ( inc. TENSOR VELI PALATINI)
IMPORTANT FOR PREVENTING NASAL REGURGITATION, SWALLOWING BOLUS, AIRWAY PROTECTION & CREATING NEGATIVE PRESSURE
38
What are the sensory functions of Cranial Nerve VII (FACIAL) & why are they important?
- Anterior 2/3 of tongue
- Special taste sensation
IMPORTANT FOR PROVIDING SENSORY INFO FOR THE SWALLOW, CONTRIBUTES TO FLAVOUR
39
What are the motor functions of Cranial Nerve VII (FACIAL) & why are they important?
- Muscles of facial expression (inc. ORBICULARIS ORIS = Lip seal & BUCCINATOR = Buccinator Press)
- Secretomotor (Submandibular & sublingual salivary glands)
- Stylohyoid posterior belly of the digastric (HYOLARYNGEAL EXCURSION)
IMPORTANT FOR LIP SEAL, CONTAINING THE BOLUS & FOOR PREPARATION
40
What are the sensory functions of Cranial Nerve IX (GLOSSOPHARYNGEAL) & why are they important?
- Special taste sensation
- Posterior 1/3 of the tongue
- Gag reflex
- general sensation of the posterior 1/3 of tongue, soft palate, faucial arches
IMPORTANT FOR SWALLOW INITIATION
41
What are the motor functions of Cranial Nerve IX (GLOSSOPHARYNGEAL) & why are they important?
- Stylopharyngeus (elevates pharynx & larynx)
- Pharyngeal plexus (travels with X to help innervate the pharyngeal constrictors)
- Secretomotor - Parotid salivary gland
IMPORTANT FOR ORAL PREPARATION/ HYGIENE & BOLUS TRANSITION
42
What are the sensory functions of Cranial Nerve X (VAGUS) & why are they important?
- General sensation of the epiglottis, pharynx, valleculae, pyriform sinuses, larynx & vocal folds
- Special taste sensation of the epiglottis
IMPORTANT FOR SWALLOW INITIATION, DETECTING PHARYNGEAL RESIDUE, DETECTING ASPIRATION/ PENETRATION
43
What are the motor functions of Cranial Nerve X (VAGUS) & why are they important?
- Muscles of the soft palate (LEVATOR VELI PALATINI = velopharyngeal seal, PALATOGLOSSUS = glossopalatal seal & PALATOPHARYNGEUS UVULAE MUSCLE
- Pharyngeal constrictors
- Intrinsic muscles of the larynx
- Cricopharyngeus/ UES
- Oesophagus
IMPORTANT FOR AIRWAY PROTECTION, SEALS, UES OPENING & PREVENTING NASAL REGURGITATION
44
What are the motor functions of Cranial Nerve XI (ACCESSORY) & why are they important?
- Muscles of the head and neck
- Pharyngeal plexus
IMPORTANT FOR PHARYNGEAL CONSTRICTION & HEAD/NECK STABILITY
45
What are the motor functions of Cranial Nerve XII (HYPOGLOSSAL) & why are they important?
- Intrinsic muscles of the tongue
- Extrinsic muscles of the tongue (inc. HYOGLOSSUS, GENIOGLOSSUS, STYLOGLOSSUS)
- Geniohyoid (involved in hyoid elevation)
IMPORTANT FOR BOT TO PPW APPROXIMATION & THE FORMATION OF BOLUS
46
What are the 5 potential causes of Dysphagia?
1. Genetic (e.g. cleft palate)
2. Developmental/ congenital (e.g. CP)
3. Acquired (e.g stroke)
4. Functional (unable to determine a cause)
5. Iatrogenic (e.g. consequence of surgery, radiation etc.)
47
What are the symptoms of Dysphagia?
- Drooling/ anterior spillage
- Pocketing in the cheek/oral residue
- Prolonged oral phase or preparation
- Nasal regurgitation
- Effortful/ multiple swallows to clear throat
- Delayed/ difficulty swallowing
- Coughing on saliva
- Absent or weak cough
- Choking/ coughing while eating/ drinking
- Wet voice after swallowing
- Changes in posture during meals (e.g tilting head to swallow)
- Unexplained weight loss
- Recurrent chest infections
48
What are the consequences of Dysphagia?
MEDICAL CONSEQUENCES
- Aspiration/ coughing/ asphyxiation/ choking
- Respiratory difficulties (e.g. pneumonia, death)
NUTRITIONAL CONSEQUENCES
- Ability to meet nutritional/ hydration needs
- Vitamin/ mineral deficiencies
- Unexplained weight loss/ anorexia
- Skin breakdown/ reduced immunity
- FTT
- Developmental delay
- Fatigue
PSYCHOSOCIAL CONSEQUENCES
- Financial costs
- Psychological problems/ isolation/ depression
- Reduced QOL
49
What is aspiration?
Entry of secretions/ food or any foreign material into the airway that passes below the level of the true vocal folds.
50
When can someone aspirate?
Before, during and/or after swallowing
51
What are the risk factors for aspiration pneumonia?
Medical/ health status, multiple medications, poor oral hygiene, dependency for oral care, bed bound state, smoking, prior history of aspiration pneumonia, dysphagia, neck hypertension when eating/ drinking, feeding dependence, use of suctioning.
52
What are the clinical signs of aspiration pneumonia?
temperature spike, coughing, wet voice, change in lung status, increased temperature, difficulties breathing.
53
List some non-physiological factors that can compromise swallow safety and function
Cognitive/ alertness difficulties, motivation, environment, fatigue, postural control, behavioural problems, upper limb mobility, available support.
54
What changes that affect swallowing typically happen to patients with Dementia?
1. Reduced hyolaryngeal excursion & inefficient pharyngeal clearance.
2. Significant delays in oral preparation.
3. Delays between swallows may be encountered - long and slow meal times.
55
What impaired oral stage functioning is often seen in PD clients?
1. Drooling and pooling of saliva in the oral cavity.
2. Bradykinesia reduces tongue movement & oral mobility (tongue pumping, premature spillage into pharynx, poor bolus control, oral residue & overall slowness)
56
What impaired pharyngeal stage function is often seen in PD clients?
1. Delay in swallowing reflex/ initiation.
2. Reduced pharyngeal motility could cause pharyngeal residue.
3. Silent aspiration is a concern.
57
What are the typical characteristics of a Lateral Medulla Stroke?
1. Dysphagia
2. Dysphonia
3. Constant hiccups
58
What is Myasthenia Gravis (MG)?
MG is a neuromuscular and autoimmune disorder that affects how nerve impulses are transmitted to a muscle at the neuromuscular junction.
59
What are symptoms of 'Myasthenia Gravis'?
- Weakness & fatigue of voluntary muscles
- Fluctuating ocular, bulbar and limb weakness that becomes progressively fatigued with use, but improves after rest
- sudden inability to swallow/ breathe may occur at any time
60
What is Motor Neurone Disease?
Progressive neurological disease of unknown aetiology that attacks the brain and spinal cord nerve cells.
61
What are the four main effects that medications can have on swallowing function?
1. Those that depress the CNS
2. Those that impact oesophageal functions
3. Those that affect salivary flow
4. Tardive Dyskinesia - involuntary orofacial movements
62
What are the changes in swallowing as an effect of ageing?
- Reduced taste and smell
- Longer oral phase
- Decreased muscle strength and speed
- Reduced respiratory capacity and elasticity of lungs
- Difficulties with harder textures
- Delayed swallow initiation
- Increased swallow duration
- Slower oesophageal phase
- Slower pharyngeal transit time
- Penetrate occasional, but ASPIRATION IS NOT NORMAL
- Reduced/ delayed hyolaryngeal excursion
- Reduced/ delayed opening of UES
63
What are the 9 steps of a clinical swallowing assessment?
1. Background information
2. General observations
3. Communication/ cognition/ behaviour
4. Case history
5. Oropharyngeal Assessment (OME)
6. Oral trial/ feeding assessment
7. Overall impression/ diagnosis
8. Recommendations & management plan
9. Referral for any other assessments
64
What background/ medical information should you collect from a client prior to assessment?
- Age/ gender
- Relevant medical history/ diagnosis
- Current medical status/ recent illness?
- Current chest status
- Recent changes in medications?
- Previous SP management/ assessments
- Current nutritional status/ needs
- Any other relevant information (i.e. cultural)
65
What should the SP look for during general observation?
Ability to manage oral secretions, Alertness, Head positioning, Awareness, Respiratory status, Ability to participate, support system, Presence of tubes, Endurance/ fatigue, Ability to self feed, Current state, Posture
66
What is involved in determining cognition/ behaviour?
Observe client's :
- Ability to follow instructions
- Need for a communication device?
- Need to involve staff/ family members
- Visual & auditory skills
- Insight, awareness, compliance?
67
What should be discussed when collecting case information?
- Onset of the swallowing problem
- Pain associated with swallowing
- Diet/ fluid modifications
- Food preferences
- Duration of meals
- Characteristics of dysphagia
- Consistencies they find easier/ more difficult to swallow
68
Detail the steps involved in an OME and the cranial nerves each observation is assessing.
1. Raise eyebrows (VII)
2. Squeeze eyes closed (VII)
3. Big smile - Purse lips - 5 times each (VII)
4. Puff cheeks out (VII)
5. Open & close mouth (V)
6. Move jaw from side to side (V)
7. Bite down on back teeth - SP FEEL MUSCLES (V)
8. Test face sensation (V)
9. Open mouth - say "ahh" (XII - observation, X - "ahh")
10. Push tongue down and observe inside of mouth (XII)
11. Poke out tongue (XII)
12. Touch tongue to nose/ chin & side-to-side (XII)
13. Push tongue against finger placed on cheek (XII)
14. Pa-ta-ka (X)
15. Place hand on throat & ask patient to swallow saliva (IX/X = triggering of swallow & pharyngeal constriction, V/VII,XII = range, timing, coordination of hyolaryngeal excursion).
69
What liquid is best to begin with when doing an oral trial?
Water
70
What should your four fingers be placed on when palpating a swallow?
1. & 2. Larynx
3. Hyoid
4. Submandibular region
71
What is the checklist when doing an oral trial?
- Ability to open mouth/ accept bolus
- Ability to close mouth/ contain bolus
- Ability to chew bolus
- Evidence of primitive reflexes (e.g. bite reflex)
- Ability to control the bolus orally using lips, cheeks & tongue
- Evidence of prompt, delayed or effortful swallow initiation
- Presence or absence of hyolaryngeal excursion
- Note whether the oral/ pharyngeal stages are coordinated
- Are there any reports of pain or discomfort
- Check for oral residue after the swallow
- Observe the overall timing of the swallow
- Note whether respiration and swallowing appear coordinated
- Evidence of phonatory changes following swallowing
- Note any instances of reflexive coughing or throat clearing following the swallow
- Note the need for multiple swallows
72
What information should be included in the recommendations/ plan?
- Is it safe for the client to continue/ commence oral intake?
- Is it safe for the person to take medications orally?
- Are there any oral hygiene issues?
- Are any other assessments/ referrals required?
- What is the frequency of SP review?
- Are there any special instructions for staff?
73
Why would you refer a patient for an instrumental examination?
- Dysphagia characteristics are vague and require confirmation
- Safety or efficiency of swallowing is a concern
- Direction for swallowing rehabilitation is needed
- Help is needed to assist in identifying underlying medical problems that contribute to dysphagia symptoms
74
What are the limitations of a videofluoroscopy?
- Distance needed to travel for it
| - Is only a snapshot in time & is not always representative
75
What are critical areas to look at when observing a videofluoroscopy?
- Ability to protect airway
- UES
- Is there pharyngeal or oral residue?
- Pharyngeal region abnormalities (transport)
- Oral region abnormalities (transport - tongue function)
- Where was the swallow triggered from?
76
What are the advantages of doing a videofluoroscopy?
- Provides a view of the oral and pharyngeal structures
- Can assess the duration of each phase
- Can quantify aspiration
- Can view images in slow motion
- Gives information about the safety of different foods/ fluids
- Very useful for providing education and tracking progress
77
What is Fibreoptic Endoscopy Evaluation of Swallowing (FEES)?
FEES involves an endoscope being passed transnasally to provide direct visualisation of the swallowing anatomy and provide a more direct view of the structures than a videofluoroscopy.
78
What are the advantages of FEES?
- Portable/ bedside
- Reduced cost
- Uses real food/ drink
- Ease of repeating measure
- Can use in an extended therapy session
- Direct assessment of the larynx & secretion management
79
What are the disadvantages of FEES?
- Can't quantify aspiration - therefore only 'assumed'
- The view is interrupted at the height of the swallow
- Can't view the oral or oesophageal stage
- Quite uncomfortable
- Client needs to be cooperative
80
What is Pulse Oximetry?
It is a method that measures the amount of oxygen being carried in the bloodstream; given as a percentage. This is important, as a drop in oxygen levels can indicate aspiration.
81
What is Cervical Auscultation (CA)?
It is the assessment of swallowing sounds and swallowing related respiration.
82
Is feeding instinctive?
It is only instinctive for the first month of life, from then until the age of 6 months it is reflexive before eventually becoming a learned behaviour.
83
What are an infants first 3 priorities in life?
1. Breathing
2. Not falling on their heads
3. Eating
84
What are an infant's 7 oral reflexes?
1. Swallow
2. Phasic Bite
3. Gag
4. Suckle
5. Rooting
6. Tongue Protrusion
7. Cough
85
What are some indicators that solid food should be introduced to a child?
- Steady head control
- Beginning hand-to-mouth play
- Increased oral exploration
- Interested in food
- Early babbling/ sounds (not essential)
- Don't need to be competent in taking liquids
86
What are some tips when feeding babies solids?
- Let the stay dirty until the end of the meal
- Spitting is a part of the normal developmental process
- Increase food exposure to foods 15+ times
- Encourage self- feeding
- Bring more than 1 spoon to a mealtime
87
List the ages & corresponding foods we would be expecting a child to be introduced to.
```
0-18months = liquid
4-6months = watery puree
7months = thick, smooth puree
8months = soft mash, mouthing foods
9months = bite & dissolve foods
10months = soft cubes
11-12months = soft mechanicals
12-14months = soft cut up table foods
14-18months = hard mechanicals
```
88
What components can impact an infant's feeding?
- Oro-motor
- Communication
- Motivation
- Relationship/ attachment
- Nutritional intake
- Gross motor
- Sensory processing
- Postural support & positioning
- Anatomy & physiology
- Gastric responses
- Learned experiences
- Fine motor control
- Respiration
89
What are common airway issues that infants present with in a hospital setting?
- Laryngomalacia (floppy larynx)
- Choanal Atresia (blockage of nasal passage)
- Vocal fold paralysis/ paresis
- Laryngeal cleft
- Midface & mandibular hypoplasia
90
What extra assessment considerations are there for infants compared to adults?
It is recommended before observing the child during mealtime, that the SP watches the child play to observe where they are at with regards to milestones.
91
What is involved in an infant OME?
- Use a wisp of cotton wool to test for airflow
- Difficulties with NG insertion
- Reports of vomiting out nose
- Weak cry
- Oral defensiveness
92
What should you note when observing a child drink/ eat during assessment?
- Positioning
- Equipment used
- Tongue control of bolus
- Swallow
- Jaw control
- Rate & amount taken
- Fluid consistency
- Lip control
- Level of independence
- Reason for finishing
- Chewing pattern
- Anticipation
93
What are the different stethoscope placements for infants & children when listening to their swallow?
Older children = sternal notch
| Infants = cheek or lateral aspect of larynx
94
What is a nasogastric tube?
A tube is placed through the nose, throat, oesophagus and into the stomach for feeding. This is a short-term solution that generally lasts about 2 weeks.
95
What is a nasojejunal tube?
A tube is placed through the nose, throat, oesophagus, stomach and into the jejunum for feeding. This is used for children that aspirate reflux and have slow gastric emptying.
96
What is a Percutaneous Endoscopic Gastrostomy (PEG)?
A PEG is a surgically created fistula through the abdominal wall into the stomach; it is a reversible procedure that is used for longer term use.
97
What are some assistive devices to help children improve oral hygiene?
- Toothettes
- Suction toothbrush
- Clean, deride & moisturise
98
What is an important consideration when prescribing a child NBM?
ORAL STIMULATION
| - Toys, toothbrushes, theratubing, dummies, tastes, teething toys.
99
What compensatory options do we have for a 0-6 month old that is having difficulty feeding?
- Teats
- Positioning
- Pacing
- Viscosity
100
When would short teats be recommended to an infant?
It would be appropriate for a perm baby or an infant with a hypersensitive gag reflex.
101
When would long teats be recommended for an infant?
It would be appropriate for infants with poor tongue cupping as it provides a greater surface area for teat to be placed on the tongue).
102
When would a fast flow teat be recommended to an infant?
It would be appropriate for infants who fatigue quickly, with a weak suck but good SSB coordination or infants with a thickened formula.
103
When would a slow flow teat be recommended to an infant?
It would be appropriate for very strong or fast suckers or infants with poorly coordinated SSB.
104
What are appropriate thickening levels for an infant?
Levels 80, 150 and 400 (NOT 900)
105
What are treatment options for children with GOR?
- Medication
- Thickening fluids
- Positioning
- Surgery
106
What are red flags indicating hypersensitivity in children?
- Overly sensitive gag reflex
- Orally aversive to particular textures/ temperatures/ tastes
- Aversion to touch around the face/ mouth
- Easily overwhelmed by environmental stimuli
107
How do we manage hypersensitivity in children?
1. Desensitisation Therapy
2. Encourage the use of a dummy/ mouth toys
3. Toothbrush trainer kits
4. Messy play
5. Role play
108
What are red flags indicating hyposensitivity in children?
- Drooling excessively
- Needs revving up to get going
- Over stuffing of mouth
- Oral escape
- Poor chewing/ holding food in mouth
- Gagging/ choking
109
How do we manage hyposensitivity in children?
1. Supervised feeding
2. Smaller portions
3. Cueing for chewing
110
What are some therapeutic methods to use in the clinic to teach a child to bite and chew appropriately?
- Demonstrate
- Tongue tip lateralisation (Placing food off to the side, stick shaped food, hard mouthing foods, silly faces in the mirror, holding food in cheek with tongue)
- Bite size (bit and spit, mouse bites vs. kid bites vs. dinosaur bites, compare bite sizes)
- Bite strength (Theratubing, foods that make noise, bunny teeth into carrots)
- Chewing (use a mirror, teeth brushing, puppets with teeth, noisy foods, chew with mouth open, talk about front & back teeth)
111
What are not normal signs in infants?
- Cough/ scream/ cry at sight of feed
- Cough after feeds or during sleep
- Refusal to feed/ suck
- Continual detachment
- General fussing
- Gagging prior to or during a milk feed
- Poor growth
- Feeds taking more than 40 minutes
- Small/ snack feeds
- Difficulty sucking/ establishing SSB rhythm
112
What are not normal signs in toddlers?
- Choking/ gagging on food
- Refusal of solids
- Vomiting after meals
- Overstuffing mouth
- Limited range of food acceptance
- Spitting out food
113
What are assessment considerations during a paediatric feeding assessment?
- Referral information
- Environment
- Assessment tools
- Pre- assessment case history (e.g. food diary)
114
What is involved in a paediatric clinical examination?
Case history, OME, Observations, Oral trials
115
What is classed as FTT?
A FTT diagnosis comes when a child crosses over 2 percentiles from their normal development on a growth chart.
116
What are the 3 treatment approaches to Dysphagia?
1. Surgical
2. Medical
3. Behavioural
117
What behavioural treatments can a SP implement for Dysphagia management?
- Modifying diet & fluid
- Modifying feeding activity
- Modifying posture
- Actively treating the swallowing
118
What fluid levels can a SP use to modify a patient's fluids?
- Unmodified (regular fluid)
- Level 150 (mildly thick)
- Level 400 (moderately thick)
- Level 900 (extremely thick)
119
What diet levels can a SP use to modify a patient's diet?
- Unmodified (regular food)
- Texture A (soft)
- Texture B (minced moist)
- Texture C (smooth puree)
120
What is the rationale for recommending modified diets/ fluids?
Thickened fluids stick together and move slower. Pureed food involves less chewing and if accidentally swallowed it is less likely to be choked on.
121
What is the Frazier Free Water Protocol & what are the conditions of implementing it?
This protocol allows patients with Dysphagia (including those that aspirate thin fluids) to have access to water between meals. During mealtimes they are still expected to have thickened fluids. The condition of participating in this is that the patient has good oral hygiene & healthy lungs/ chest.
122
What are positive indicators that a patient can begin transitioning from an alternative feeding method back to oral intake?
- Adequate protection of airway
- Reasonable stability in conscious state
- Stability in medical and nutritional status
- Oral and pharyngeal phases adequate for swallowing
- Established management support system
123
What are the phases of weaning a client back on to oral intake?
1. Preparatory Phase = Physiologic readiness for oral nutrition.
2. Weaning Phase = Graduated increase in oral feeding with corresponding decrease in tube feed.
124
What are some ways that we can modify feeding activity/ environment ?
1. Bolus control techniques (e.g. bolus placement, modification of bolus size, lingual sweep etc.)
2. Equipment/ environmental supports
3. Environmental management
125
What are some methods to modify posture as a Dysphagia treatment?
1. Chin Tuck = widens the valleculae & narrows the airway entrance.
2. Head Rotation/ Turn to weaker side = redirects the bolus to the stronger side. Closes off the swallowing tract on the side which the head is turned.
3. Head Tilt = Tilted to the stronger side - gravity pulls bolus to stronger side.
4. Supraglottic Swallow = take a breath and hold it while you swallow, then cough air out immediately after swallowing.
5. Effortful Swallow (swallow harder) = increases BOT & PPW motion, increases pharyngeal clearance.
126
When is a chin tuck not an appropriate method of modifying posture in a client?
- For patients with a delayed swallow
- Patients with post-swallow residue in the pyriform recesses
- Patients with poor lip closure/ oral control
127
List 5 rehabilitation exercises that can be given to Dysphagia clients, where actively treating the swallow is appropriate.
1. Shaker - Head lift (lie flat & raise your head so you can see your toes without moving your shoulders).
2. Oral motor exercises
3. Masako
4. Mendelsohn
5. Effortful Swallow
