L9: Management- compensatory strategies

Question 1

what is the goal of intervention?

protective and supportive function?

Answer 1

to avoid/prevent morbidity associated w dysphagia

ensure swallowing is safe (protective function)

ensure pt has adequate hydration and nutrition (supportive function) = establish safe intake of…. and establish consistent intake of…

Question 2

how are intervention goals met? accomplished?

Answer 2

goals are met thru objectives = targeting specific aspects of swallow physiology (ex. HLE, UES opening duration)

objectives are accomplished thru action plans = specific techniques, freq of practice techniques, etc (ex. mendelshon maneuver (HLE), Shaker exercise (UES opening))

Question 3

what is the goal of management?

Answer 3

to establish/re-establish oral feeding while maintaining adequate hydration and nutrition, and safe swallowing

Question 4

how can the goal of management by accomplished? (3 ways)

Answer 4

compensation = meant to be used in short-term to maintain swallow safety; allowing for some oral intake

therapy = to improve swallow phys w lasting effects; chnage in phys expected to remain once therapy stops

preventative = to minimize or prevent dysphagia in high risk popns

Question 5

what are the 4 management considerations?

Answer 5

nature of swallowing deficit

pt characs

can oral intake be maintained?

prepare for change over time

Question 6

nature of swallowing deficit refers to

Answer 6

feeding vs swallowing
vol vs invol
phase of swallow

Question 7

pt characs refers to

Answer 7

etiology - prognosis
severity of dysphagia
anticipated medical course
psychological factors
caregiver support

Question 8

what does “can oral intake be maintained?” refer to?

Answer 8

if time to swallow bolus is >10 sec, oral intake will need to be supplemented

if amount asp >10% per trial, oral intake should not be reco

Question 9

what does “prepare for change over time” refer to?

Answer 9

re-assessment to advance diet, or reco further restrictions

Question 10

enteral nutritional support =

Answer 10

indicated when GI tract is functional

nasogastric/nasointestinal tube
gastrostomy tube
jejunostomy tube

Question 11

pareneral nutritonal support =

Answer 11

indicated when GI tract is not functional

TPN = total parenteral nutrition

PPN = periperhal parenteral nutrition

Question 12

what is the procedures for a nasogastric (nasointestinal) tube?

Answer 12

tube passed thru nostril into nasopharynx, eso, and stomach (nasointestinal = spon passae of tube into duodenum/jejunum)

placement verified radiographically

formula administered either continuously across day or intermittently for NG; cont for NI w gravity drip or feeding pump

vol of feed inc gradually

Question 13

what are the indications for a nasogastric (nasointestinal) tube?

Answer 13

short term use = max 4-6 weeks
cooperative/alert pt

Question 14

what are the risks for a nasogastric (nasointestinal) tube?

Answer 14

risk of asp of gastric contents w NG tube

Question 15

what is the procedures for a gastrostomy tube?

Answer 15

surgical = used in more complicated cases (tube inserted under general A)

PEG = Percutaneous endoscopic gastrostomy (inserted under local A and endoscopic guidance)

Question 16

what are the indications for a gastrostomy tube?

Answer 16

prolonged or indefinite use; PEG tubes are replaced every 6M

recurrent asp

Question 17

what are the complications for a gastrostomy tube?

Answer 17

gastric perforation, gastric bleeding, wound infection, stomal leak, tube dislodgement, asp, diarrhea

Question 18

what is the procedures for a jejunostomy tube?

Answer 18

directly into jejunum; or gastrostomy-jejunostomy (G-J) tube

feeding formula tailored to pt

Question 19

what are the indications for a jejunostomy tube?

Answer 19

direct access to small bowel needed bc of eso or gastric disease

recurrent asp of gastric contents

Question 20

what are the complications for a jejunostomy tube?

Answer 20

diarrhea, catheter displacement, abdominal pain, small bowel obstruction

Question 21

indications for parenteral nutritional support?

Answer 21

nonfunctional GI tract

feeding required for >1 week

Question 22

two types of parenteral nutritional support

Answer 22

total parenteral nutrition (TPN) = complete metabolic diet administered via a central vein (central vein necessary bc hypertonic soln irritates peripheral veins; sterile procedure performed at bedside)

periphral parenteral nutrition (PPN) = feeding required 7-10 days; nutrition administered via peripheral vein

Question 23

compensatory strategies are often under control of _____ and therefore…

Answer 23

clinician/caregiver

education is critical

Question 24

6 types of compensatory strategies

Answer 24

postural adjustments

oral sensory presentation

vol maneuvers

additional techniques

diet mods

Question 25

postural adjustments can...

Answer 25

effectively eliminate asp in a wide range of pts if postures are selected based on anatomic or physiologic swallowing deficits

Question 26

4 postural adjustments to redirect bolus flow and change pharyngeal dimensions =

Answer 26

head back/extension (tilt chip up) head down/chin down (rotate chin to chest) head rotated to the side (rotate chin over shoulder) head tilted to the side (ear to shoulder)

Question 27

"posterior head toss" ....head back/extension (tilt chin up) does what?

Answer 27

to assist in oral transport, ensure adequate airway protection designed to provide vol transport of the bolus from mouth to pharynx reduced oral transport ned to ensure have good airway protective measures - take material into mouth; hold - take a deep breath and hold it - toss head back, dumping material into throat - swallow 3/4/5 times, then cough

Question 28

"chin tuck" ....head down/chin down (rotate chin to chest) does what?

Answer 28

to facilitate airway protection during swallowing designed to maintain bolus in the anterior oral cavity imp retro-oral seal, delayed pharyngeal swallow (opens valleculae) - take material into mouth; hold - rotate your chin down to your chest - keep your chin tucked while you swallow

Question 29

head rotated to the side (rotate chin over shoulder) does what?

Answer 29

to close off weak side (in case of hemiparesis)

Question 30

head tilted to the side (ear to shoulder) does what?

Answer 30

to promote oral transport by engaging stronger side

Question 31

during postural adjustments we need to

Answer 31

evaluate change in amount of asp, residue, and/or transit times

Question 32

how can you manipulate oral sensory awareness?

Answer 32

provision of preliminary stimulus prior to oral phase of swallow inc downward pressure against tongue sour bolus cold bolus larger vol of bolus (>3ml) food requiring chewing thermal-tactile stimulation

Question 33

how can you measure effectiveness of oral sensory awareness on VFSS?

Answer 33

duration of time bw command to swallow and oral phase initiation oral transmit time pharyngeal delay time

Question 34

oral sensory awareness is useful for indvs presenting w ?

Answer 34

delayed onset of oral phase delayed pharyngeal swallow dec sensory awareness apraxia of swallowing tactile agnosia for food

Question 35

whats an example of oral sensory awareness? how does it work? evidence?

Answer 35

thermal-tactile application (TTA) use of a cold, mechanical stimulus to alert the CNS of bolus to be swallowed chilled laryngeal mirror (held in ice) is used to stroke each anterior faucial arch 2-3 times prior to the intro of a bolus - reduces pharyngeal delay time -reduces total transit time - effective for 2-3 swallows following app no evidence of lasting effect (not rehabilitative)

Question 36

what are the two reasons why modifying bolus presentation may help?

Answer 36

delay in triggering pharyngeal swallow = may benefit from a larger bolus (greater sensory stimulation properties) weak pharyngeal swallow = too much food, too rapidly results in severe residue in pharynx, and likley asp, therefore smaller boluses at a slower rate will be indv dependent

Question 37

vol maneuvers are designed to... require ability ...

Answer 37

place specific aspects of pharyngeal swallow physiology under vol control require ability to follow directions carefully; not feasible pts who have cog or sig lang impairment require inc muscular effort; not appropriate in pts who fatigue easily

Question 38

vol maneuvers allow for temporary ...

Answer 38

use as the swallow recovers (compensation or therapeutic use to encourage recovery) - as a compensatory strategy use w a food/liquid bolus - as an exercise, use w saliva (or small bolus as safe)

Question 39

to use vol maneuvers we want pt... try w ... attempt on...

Answer 39

to be alert, relatively relaxed, able to follow simple directions w/o becoming upset or confused try w saliva first until pt demonstrates mastery attempt on VFSS - have concrete evidence of success provide verbal cuing w each step

Question 40

supraglottic swallow (SGS): designed to... indication...

Answer 40

close the airway at the level of the TVFs before and during the swallow indication = someone w imp laryngeal closure

Question 41

4 steps of supraglottic swallow as an exercise...

Answer 41

1= take material into your mouth, hold it in your mouth 2= breathe in through ur nose, then hold your breath tightly 3= keeping your breath held tight, swallow 4= release your breath w a sharp cough or throat clear, then swallow again as an exercise repeat steps 2-4 10 times

Question 42

super supraglottic swallow (S-SGS) designed to...

Answer 42

close the entrance to the airway vol by tilting the arytenoud cart anteriorly to the base of the epi bf and during the swallow and close the vocal cords tightly

Question 43

super supraglottic swallow 5 steps as an exercise...

Answer 43

1 = take material into your mouth; hold it in your mouth 2= breathe in thru your nose, then hold your breath tightly 3= keeping your breath held tight; push your hands hard together/against table 4= keep pushing your hands as you swallow 5= release your breath w a sharp cough or throat clear, then swallow again as an exercise = repeat steps 2-5, 10 times

Question 44

what is important to know about the SGS/S-SGS vol manuveurs?

Answer 44

prolonged vol colsure of the glottis during SGS and S-SGS swallowing techniques may create the valsalva maneuver the valsalva maneurver has been associated w cardiac death and cardiac arrhythmias

Question 45

Chaundhuri et al (2002) who examined SGS and S-SGS on cardio sys groups: cardiac status status monitored for 4hrs during: results:

Answer 45

group 1= recent stroke/dysphagia/hx of coronary artery disease group 2 = recent stroke/dysphagia, no known CAD group 3= orthopedic diagnosis (no dys or CAD) monitored during: swallowing training, other therapy sessions, a meal results: - groups 1+2 = 87% had abnormal cardiac findings during swallow training but not during other activities - group 3 = did not show cardiac abnormalities during any of the 3 conditions

Question 46

effortful swallow is aimed at indication?

Answer 46

inc posterior motion of the base of the tongue and pharyngeal constrictors action indication =residue

Question 47

3 steps of effortful swallow as an exercise...

Answer 47

1= push as hard as you can w the tongue against the roof of your mouth 2= while holding your tongue in that position, swallow your saliva as hard as you can, squeezing all of the muscles in your throat 3= after your swallow, relax as an exercise repeat steps 1-3, x10

Question 48

mendelsohn maneuver is aimed at indication??????

Answer 48

inc the extent (amp) and duration of HLE indication???? ASK SOMEONE

Question 49

3 Steps of the mendelsohn maneurver as an exercise...

Answer 49

1 = place your fingers over your (My) voice box, this is sometimes called the adams apple 2= swallow as you do, feel the adams apple lift and lower 3= swallow again, and as you do squeeze the muscles under your child to hold the adams apple up for 3 sec as an exercise repeat steps 1-3, x10

Question 50

what are two additional techniques?

Answer 50

multiple swallows/dry swallow liquid wash

Question 51

why use multiple swallows/dry swallow? caveat?

Answer 51

designed to clear residue from mouth and pharynx (use w oral and pharyngeal weakness) prevents asp after swallow caveat = can dev swallowing efficiency (multiple, non-nutritive swallows inc feeding time), fatiguing effect

Question 52

liquid wash ... caveat?

Answer 52

clears residue from mouth and pharynx (prevents asp after swallow) same indications as multiple/dry swallows caveat = use thin liquids to remove residue, only if pt is able to manage thing liquids safely (i.e no asp)

Question 53

diet modificiations should be determined... no single..

Answer 53

determined based on specific swallowing disturbances no single modified diet appropriate for all pts

Question 54

what is the IDDSI? 2 objectives?

Answer 54

international dysphagia diet standardization to dev standardized way of naimg and describing texture modified foods and liquids or ppl w dysphagia practical and valid measurement techniques to facilitate use by persons w dysphagia, caregivers, clinicians, food service professionals

Question 55

thin liquids are most diff for pts w

Answer 55

reduced oral control delayed pharyngeal swallow reduced airway closure

Question 56

thin liquids should be used in cases of ... caveat?

Answer 56

reduced pharyngeal peristalsis (to wash residue) UES disorders (to inc flow thru UES) caveat = easily aspirated

Question 57

thickened liquids are appropriate for pts w... caveat?

Answer 57

asp mildly reduced oral control mild delay in pharyngeal phase, who would be at risk of asp w thin liquids caveat= can inc vallecular residue w large volumes

Question 58

there is some question whether pts restricted to thickened liquids...

Answer 58

get adequate hydration, hydration must be monitored

Question 59

puree is appropriate for pts w

Answer 59

moderate delay in pharyngeal phase and potential for asp reduced laryngeal closure reduced mastication

Question 60

puree may be diff for...

Answer 60

pts w oral control deficits bc some purees are not cohesive (material such as pudding may be easier to swallow) thicker puree (paste) diff for pts w oral and/or pharyngeal weakness (residue but less easily asp)

Question 61

eat high calorie items ...

Answer 61

early in meal if they can become fatigued

Question 62

helpful tips for pts

Answer 62

avoid dry breakable foods avoid sticky foods avoid mucous producers avoid mixing textures meds should be given in tolerable consistencies schedule meals appro w respect to fatigue level, med schedule

Question 63

4 prosthetic assistance measures

Answer 63

adaptive feeding devices synthetic saliva palatal prostheses jaw sling

Question 64

adaptive feeding devices includes

Answer 64

glossectomy feeding, spoons, synringes, straws specialized dishes, cutlery devices that facilitate/inhibit reflexes nosey cups

Question 65

palatal prostheses includes

Answer 65

palatal lift palatal obturator palatal reshaping prosthesis- to inc tongue to palate contact

Question 66

jaw sling inc...

Answer 66

jaw support of tongue in cases of mandibular weakness

Question 67

compensations on initial assessment: lingual stripping wave imp results in oral residue, so we could....

Answer 67

head/neck extension w pre-swallow airway closure, followed by head/neck flexion head tilt to alter bolus position and flow multiple swallows alter bolus placement bypass w syringe

Question 68

compensations on initial assessment: failure of linguapalatal valve results in premature spill, so we could....

Answer 68

head/neck flexion limit size of bolus to vol that valleculae and pyriform sinuses can accomodate vol pre-swallow airway closure

Question 69

compensations on initial assessment: imp closure of VP leads to leakage and diminished oropharyngeal pressure, so we could....

Answer 69

head/neck rotation if unilateral weakness smaller bolus, more viscous bolus may require prosthetic or behavioural approaches to improve VP closure

Question 70

compensations on initial assessment: imp closure of laryngeal valves leads to penetration +/- asp, so we could....

Answer 70

head/neck flexion head/neck rotation, if unilateral imp inc effort prolonging closure and/or elevation

Question 71

compensations on initial assessment: imp opening of pharyngoesophageal valve leads to pyriform sinus residue, so we could....

Answer 71

repeated swallows per bolus inc and extend duration of max HLE and closure head/neck rotation, flexion, extension reduce bolus size, viscosity

Question 72

compensations on initial assessment: imp closure of pharyngoesophageal valve following swallowing leads to retrograde flow, so we could....

Answer 72

utilize effects of gravity to aid in eso motility slow rate of bolus presentation post-prandial upright posture to reduce reflux

Question 73

compensations on initial assessment: imp opening of pharyngoesophageal valve leads to pyriform sinus residue, so we could....

Answer 73

repeated swallows per bolus inc and extend duration of max HLE and closure head/neck rotation, flexion, or extension reduce size, viscosity

Question 74

compensations on initial assessment: imp closure of pharyngoesophageal valve following swallowing leads to retorgrade flow, so we could....

Answer 74

utilize effects of gravity to aid in eso motility slow rate of bolus presentation post-prandial upright posture to reduce reflux

Question 75

compensations on initial assessment: imp obliteration of pharyngeal chamber results in residue (level depends on location of deficit), so we could....

Answer 75

inc effort of BOT retraction and/or pharyngeal constriction head/neck rotation or flexion inc and prolonged HLE repeated swallows post-swallow vol laryngeal clearing

Question 76

first priority =

Answer 76

establish some safe and efficient oral intake

Question 77

after establishing some safe and efficient oral intake, determine if...

Answer 77

accommodations are needed in the short-term or long-term if recovery anticipated = compensatory strategies may only be needed in the short-term if decline is expected = compensatory strategies may be required until oral intake can no longer maintain nutrition/hydration status