Spth 465 Dysphagia and Related Disorders: Management

1
Spth 465 Dysphagia and Related Disorders
Management

• Lecture Four
• Compensatory Management

2
More definitions

• Rehabilitation Interventions that when
  provided over the course of time and are thought
  to result in permanent changes in the substrates
  underlying deglutition ie...changing the
  physiology of swallowing mechanisms. May
  include, but not limited to oral/facial
  exercises, vocal adduction exercises, breathing
  exercises, pharyngeal strengthening exercises.
• Compensation Strategies that provide an
  immediate but typically transient effect on the
  efficiency or safety of swallowing. As a rule,
  if the strategy is not consistently executed,
  swallowing will return to the prior dysfunctional
  status. May include but are not necessarily
  limited to posturing, adaptations in rate, route
  or nature of oral intake.

3
Compensatory Techniques

• Postural Strategies
• Bolus Control Techniques
• Volitional Airway Protection Techniques
• Diet Modifications
• Prosthetic Devices

4
Compensatory Techniques

• Postural Strategies
• Chin tuck
• Head rotation
• Head tilt
• Side lying
• Neck extension
• Diet Modification
• Liquid modifications
• Solid modifications

• Bolus Control technique
• 3-second prep
• Lingual sweep
• Cyclic ingestion
• Dry swallows
• Thermal stimulation
• Bolus placement
• Slurp and swallow
• Modifying rate of intake and size of bolus

5
Compensatory Techniques, cont...

• Airway Protection
• Supraglottic swallow
• Super-supraglottic swallow
• Pharyngeal expectoration
• Vocal quality checks

• Prosthetic Devices
• Palatal lifts
• Tracheostomy valves
• Dentures

6
Compensatory Techniques Worksheet
7
Postural Strategies Chin tuck

• PHYSIOLOGIC ABNORMALITY
• Primarily used for delayed onset of pharyngeal
  swallow where protection of airway is latent.
• Secondarily may have applications in management
  of pharyngeal weakness or decreased laryngeal
  elevation resulting in post swallow vallecular or
  pyriform sinus residual (clinical impression).
• Although research has shown that pharyngeal
  pressures are not altered, the repositioning of
  structures may facilitate pharyngeal clearance.
• SYMPTOMS
• pre-swallow pharyngeal pooling secondary to
  delayed pharyngeal swallow post swallow
  vallecular residual

8
Postural Strategies Chin tuck

• Logemann (1983) Chin tuck posturing widens the
  vallecular space leading to improved airway
  protection 2o protective reservoir
• Ekberg (1986) Radiographic eval of head position
• 9/18 patients with defective closure of laryngeal
  vestibule improved with neck flexion
• 1/18 neck flexion exacerbated aspiration
• Welch, et al (1993) Videoprint analysis of chin
  tuck
• Chin tuck leads to posterior shift of anterior
  pharyngeal structures (including tongue),
  narrowing of laryngeal entrance and decreased
  distance from epiglottis to pharyngeal wall and
  laryngeal entrance.
• No effect on pharyngeal pressures, UES
  relaxation, or coordination between pharyngeal
  contraction and UES relaxation.

9
Postural Strategies Chin tuck, cont

• Shanahan et al. (1993)
• Elders with decreased benefit from chin tuck.
  Hypothesized that chin tuck was not as
  successful in eliminating aspiration with the
  older group because they did not exert as much
  direct posterior pressure on the thyroid notch
  into the anterior tracheal wall when they
  performed a chin tuck.
• Bülow, et al. (1999) Videomanometry
• Significantly reduced laryngohyoid distance
• Significantly reduced hyo-mandibular distance
• Significantly weaker pharyngeal contraction
• May impair airway protection in patients with
  impaired pharyngeal function

10
Postural Strategies Chin tuck, cont

• Bülow (2001)
• In Patients with moderate to severe pharyngeal
  phase dysphagia, chin tuck results in
• No change in aspiration/penetration, although
  depth of penetrated material higher
• No change in pharyngeal retention
• Decreased hyomandibular and thyro-hyoid distance
• Does not improve weak pharyngeal contraction
• Martin-harris and Cherney (1996)
• Increased aspiration risk in patients with poor
  laryngeal excursion and closure

11
Postural Strategies Chin tuck

• INSTRUCTION
• Patient is instructed to tilt the neck forward
  with the cervical spine erect during ingestion of
  the bolus. Care should be taken to avoid
  bird-necking with the head and neck forward as
  a combined unit.
• POTENTIAL GOALS
• Patient will recall and implement chin tuck
  posturing throughout 90 of meals at home with
  environmental cues to aid recall.
• Patient will tolerate 90 of liquid trials using
  chin tuck posturing with no environmental cues
  and without clinical signs or symptoms of
  aspiration during the treatment session.
• Patient will require 2 or less swallows per puree
  bolus with chin tuck posturing to subjectively
  clear the pharynx on 90 of trials during the
  treatment session.
• ENVIRONMENTAL CUING
• Place food tray in a position that is low and
  close to the patient
• Utilize a straw for ingestion of liquid, with the
  cup maintained close to the chest, even with the
  sternum Pillow or towel roll behind the head for
  tactile support
• Verbally cue the patient to look at his knees
• Adapted soft cervical collar

12
Compensatory Techniques

• Postural Strategies
• Chin tuck
• Head rotation
• Head tilt
• Side lying
• Neck extension
• Diet Modification
• Liquid modifications
• Solid modifications

• Bolus Control technique
• 3-second prep
• Lingual sweep
• Cyclic ingestion
• Dry swallows
• Thermal stimulation
• Bolus placement
• Slurp and swallow
• Modifying rate of intake and size of bolus

13
Postural Strategies Head Rotation

• PHYSIOLOGIC ABNORMALITY
• Utilized when the patient demonstrates unilateral
  weakness or structural reconstruction of the
  pharynx, resulting in post swallow residual on
  the weaker or reconstructed side.

14
Postural Strategies Head Rotation

• Logemann, et al. (1989)
• Videofluoroscopy on 6 healthy volunteers and five
  patients with lateral medullary syndrome three 1
  cc swallows of liquid barium in three postures
  neutral, 90 deg right, 90 deg left.
• In normals, head rotation to either side
  increased UES opening diameter by an average of 2
  mm without affecting the period of UES opening or
  oropharyngeal transit time. Maximal rotation
  caused the bolus to lateralise away from
  direction of rotation and caused significant fall
  in UES pressure.
• In patient group, head rotation increased
  percentage of bolus swallowing and increased EUS
  opening diameter significant with head turned
  toward paretic side.
• Two effects functional exclusion of the
  relatively flaccid, weakened pharyngeal wall, and
  reduced UES tone (likely not decreased tone but
  increased suprahyoid pull on existing tone.

15
Postural Strategies Head Rotation

• Rasley and colleagues (1993)
• Chin down and head rotation positioning were both
  found to be effective in eliminating aspiration
  in a group of 165 patients with increasing liquid
  bolus size.
• Able to eliminate aspiration for all bolus
  volumes in 25 of patients, and had some
  beneficial effect on 77 of patients. Head
  rotation was as effective as chin tuck posturing.
  
• The prevailing belief is that rotation of the
  head toward the weakened/reconstructed side will,
  in effect, reduce the size of pharyngeal cavities
  on that side thus, the bolus will be redirected
  toward the stronger/intact side of the pharynx,
  promoting a more efficient swallow.
• There appear to be infrequent cases when rotation
  toward the stronger side is more beneficial,
  presumably effecting increased cricopharyngeal
  sphincter opening on the weakened side therefore
  the strategy should be confirmed diagnostically.

16
Postural Strategies Head Rotation

• CONTRAINDICATION none documented
• INSTRUCTION
• Patient is instructed to turn head toward
  designated shoulder to the full extent
  comfortable the torso should remain forward.
  Strategy may be enhanced when paired with chin
  tuck posturing.
• POTENTIAL GOALS
• Patient will recall and implement head rotation
  posturing to the right throughout 90 of meals at
  home with environmental cues to aid recall.
• Patient will tolerate 90 of puree trials using
  head rotation posturing with no environmental
  cues and without clinical signs or symptoms of
  aspiration during the treatment session.
• Patient will require 2 or less swallows per puree
  bolus with head rotation posturing to
  subjectively clear the pharynx on 90 of trials
  during the treatment session.
• ENVIRONMENTAL CUING
• Place patients tray to the side of head rotation
• Seat patient during meals with areas of
  stimulation on side of head rotation i.e.
  family/friends/television toward the side of head
  rotation.
• Adapted soft cervical collar

17
Postural Strategies Head Tilt

• PHYSIOLOGIC ABNORMALITY
• Impaired oral motor control, unilateral
  pharyngeal weakness, asymmetric altered anatomy
• SYMPTOMS
• Post swallow oral or pharyngeal residual
• EFFECT
• Tilting the head to the stronger, undamaged side
  of a neurologically impaired patient may also
  direct the bolus to the stronger, potentially
  more sensate oral and pharyngeal side (Logemann,
  1983).
• Increased sensation and motor strength/coordinatio
  n experienced on the undamaged side may provide
  immediate positive benefits to the patient. These
  benefits may include improved oral control, bolus
  formation and propulsion with a stronger
  pharyngeal swallow response

18
Postural Strategies Head Tilt

• CONTRAINDICATION
• None documented
• INSTRUCTION
• The patient is instructed to tilt the head toward
  the stronger, nonimpaired side during PO
  ingestion.
• POTENTIAL GOALS
• The patient will recall and implement head tilt
  positioning with no verbal cues on 90 of liquid
  swallows.
• ENVIRONMENTAL CUING
• Adapted soft cervical collar

19
Postural Strategies Head Tilt

• STRATEGY Side Lying
• PHYSIOLOGIC ABNORMALITY
• reduced pharygneal contraction hemiparetic
  pharyx
• SYMPTOMS
• Post-swallow pharyngeal residual
• EFFECT
• The rationale for this posture is that a lateral
  head/trunk position will reduce the gravitational
  force on any residue that is left in the pharynx
  after a swallow. Repeated swallows while on one
  side may effectively clear residue, thus
  decreasing aspiration risk. No documented
  research.

20
Postural Strategies Head Tilt

• CONTRAINDICATION
• None documented.
• Although this posture may be beneficial for
  selected patients, it may not be readily accepted
  by patients or caregivers. It is very difficult
  to self-feed a meal from a lateral position.
  Excellent eye-hand coordination, flexibility and
  patience must be present to attain this feat
  without spilling most of the food off a utensil.
  Care should always be taken when patients are not
  fed in upright posture.
• INSTRUCTION
• Patient is comfortably positioned in a the
  lateral position in bed or in semi-reclined or
  fully reclined chair. The meal tray is positioned
  in front of the patient, which in this position
  would likely be at the side of the chair or bed.
  Small pillow may provide additional head support
  and comfort.
• POTENTIAL GOALS
• Side-lying positioning will be implemented for
  all PO intake with no evidence of aspiration or
  porr oral control.

21
Postural Strategies Neck Extension

• PHYSIOLOGIC ABNORMALITY
• Primarily suggested for use in patients with
  profound oral phase impairment with concomittent
  rapid airway protection.
• SYMPTOMS
• post swallow oral residual, ineffective bolus
  transfer
• EFFECT
• Employs the effects of gravity to aid bolus
  transfer bolus falls off of base of tongue into
  the pharyngeal cavity. Gravity pulls the bolus
  into pharynx

22
Postural Strategies Neck Extension

• Ekberg, (1986)
• Radiographic analysis of postural strategies
• Impaired airway protection and increased
  aspiration risk with neck extension.
• Castell, et al (1993)
• UES relaxation begins after the onset of
  pharyneal contraction and that terminiation of
  relaxation occurred prior to completion of
  pharyngeal contraction when neck extension
  utilised.

23
Postural Strategies Neck Extension

• INSTRUCTION
• Patient is instructed to extend neck with back
  erect when he/she is prepared to transfer the
  bolus for the execution of the swallow.
• POTENTIAL GOALS
• Patient will recall and implement neck extension
  posturing during PO intake at home 90 of trials
  with minimal verbal cues.
• Using neck extension posturing, patient will
  clear gt90 of each puree bolus from the oral
  cavity on the first trial during the treatment
  session.
• ENVIRONMENTAL CUING
• Verbal Cueing
• Slightly reclined positioning may be assistive

24
Compensatory Techniques

• Postural Strategies
• Chin tuck
• Head rotation
• Head tilt
• Side lying
• Neck extension
• Diet Modification
• Liquid modifications
• Solid modifications

• Bolus Control technique
• 3-second prep
• Lingual sweep
• Cyclic ingestion
• Dry swallows
• Thermal stimulation
• Bolus placement
• Slurp and swallow
• Modifying rate of intake and size of bolus

25
Thickened Liquids

• Thickened liquids no standardization!
• Mills (1996) commercial thickeners react
  differently with each beverage.
• Liquids with low pH value are more acidic and
  will thicken faster and thicker than water,
  although thickness will lessen over time.
• Hot liquid does not thicken as well as cold
  liquids
• Liquids thickened with commercial thickeners can
  continue to absorb liquid and thicken for up to
  30 minutes
• Pre-thickened liquids approximately 75 more
  expensive than using artificial thickeners

26
Diet Modifications

• Use of a modified diet as a compensation for
  dysphagia is between 29-46 in long term care
  facilities.
• Incidence of malnutrition in long term care
  12-70
• Recommendation for thickened liquids increases
  risk of dehydration
• Groher and McKaig (1995) Reviewed 2 nursing
  homes with 212 residents with dysphagia.
• 31 of residents were found on altered diet.
• 4 at a higher dietary level than was considered
  safe, 5 were at an appropriate diet level
• 91 were found to be at a diet level more
  restrictive than needed for safety.
• OGara (1990) patient will typically refuse a
  food consistency when it takes gt10 seconds to
  complete the oral pharyngeal swallow

27
Compensatory Techniques

• Postural Strategies
• Chin tuck
• Head rotation
• Head tilt
• Side lying
• Neck extension
• Diet Modification
• Liquid modifications
• Solid modifications

• Bolus Control technique
• 3-second prep
• Lingual sweep
• Cyclic ingestion
• Dry swallows
• Thermal stimulation
• Bolus placement
• Slurp and swallow
• Modifying rate of intake and size of bolus

28
Bolus Control Technique 3 sec prep

• PHYSIOLOGIC ABNORMALITY
• For use with patients demonstrating
  characteristics of tachyphagia (uncontrolled,
  rapid ingestion pattern), in patients with
  premature transfer of the bolus into the pharynx
  and in patients with delayed initiation of the
  swallow.
• EFFECT
• Volitional, conscious pause prior to transfer of
  the bolus may allow the patient a greater
  opportunity to organize execution of bolus
  transfer and elicitation of the swallow, will
  insert a purposeful break in the rapid ingestion
  pattern of a tachyphagic patient, and allows
  greater time in the patient with delayed onset of
  swallow to elicit volitional airway protection.
  This strategy alters the swallow from a reflexive
  response to a more volitionally controlled action.

29
Bolus Control Technique 3 sec prep

• CONTRAINDICATION
• Some patient's with poor oral motor control,
  particularly base of tongue to palate
  approximation, may experience premature spillage
  of bolus into the pharynx and thus increase
  preswallow aspiration risk.
• INSTRUCTION
• After placement of the bolus in the oral cavity,
  the patient is instructed to mentally count to
  three prior to transfer of the bolus into the
  pharynx.
• POTENTIAL GOALS
• Patient will recall and implement 3 second prep
  during intake of all diet textures in the
  treatment session on 90 of trials with moderate
  verbal cueing.
• Using 3 second prep strategy, patient will
  decrease rate of intake of puree in the treatment
  session, to a ingestion rate of 4 cups of puree
  in 15 minutes.

30
Bolus Control Tech Lingual sweep

• PHYSIOLOGIC ABNORMALITY
• Oral motor impairment of any etiology that
  restricts the ability to form a cohesive bolus,
  resulting in buccal, sublingual and intra-oral
  residual post swallow.
• EFFECT
• Clears residual from oral cavities and redirects
  to tongue blade for development of a bolus.
• CONTRAINDICATION
• none documented
• INSTRUCTION
• Patient cued to purposefully use tongue to sweep
  the entire oral cavity, particularly areas of
  weakness or reconstruction, to collect residual
  bolus. Patient should repeat technique throughout
  meal as indicated to inhibit development of
  residual. In cases where lingual movement
  restricts search of certain regions, finger sweep
  may be substituted.

31
Bolus Control Tech Lingual sweep

• POTENTIAL GOALS
• Patient will independently use lingual sweep
  strategy after every third bolus trials 90 of
  the time in all mealtime environments.
• During intake of ground diet, patient will
  demonstrate minimal left sided buccal or
  sublingual residual following lingual and/or
  finger sweep 90 of trials during treatment
  session.
• Patient will independently recognize the need to
  clear oral residual with lingual sweep after
  intake regular diet during the treatment session
  90 of the time.
• ENVIRONMENTAL CUING
• Use of a mirror during meals may cue patient to
  residual.

32
Bolus Control Tech Cyclic Ingestion

• PHYSIOLOGIC ABNORMALITY
• Utilized when patient demonstrates pharyngeal
  weakness/dyscoordination or hypertonicity of the
  UES resulting in post swallow pharyngeal residual
  in valleculae and/or pyriform sinuses.
• EFFECT
• Liquid after a solid bolus facilitates clearance
  of the pharyngeal cavities by serving as a liquid
  wash.
• CONTRAINDICATION
• Cannot be used with patients on liquid restricted
  diet.
• In a limited number of patients, the subsequent
  liquid bolus will bypass the residual in the
  valleculae as opposed to washing out and will
  then present potential for aspiration, thus the
  strategy should be evaluated diagnostically.

33
Bolus Control Tech Cyclic Ingestion

• INSTRUCTION
• Patient given liquids with all meals and
  instructed to alternate liquid and solid intake
  throughout the meal, either in 11 ratio or as
  indicated by diagnostic examination.
• POTENTIAL GOALS
• Patient will recall and implement strategy of two
  bolus swallows followed by one liquid swallow 90
  of the trials of PO intake at home with no verbal
  cues from family.
• ENVIRONMENTAL CUING
• Have liquids available during all meals

34
Bolus Control Tech Dry Swallow

• PHYSIOLOGIC ABNORMALITY
• Utilized when patient demonstrates pharyngeal
  weakness/dyscoordination or hypertonicity of the
  cricopharyngeal sphincter (UES) resulting in post
  swallow pharyngeal residual in valleculae and/or
  pyriform sinuses.
• May also be used in cases of intact pharyngeal
  phase swallowing when oral residual falls post
  swallow into the pharynx in inadequate quantity
  to elicit a pharyngeal swallow.
• EFFECT
• Repetition of the swallow without a new bolus
  serves to aid in clearing post swallow residual.

35
Bolus Control Tech Dry Swallow

• CONTRAINDICATION
• none documented
• INSTRUCTION
• Patient instructed to dry swallow after every
  bolus swallow or to swallow each bolus 2, 3 or 4
  times as indicated by diagnostic examination.
• POTENTIAL GOALS
• Patient will recall and implement compensation of
  dry swallow after bolus swallow on 90 of PO
  trials during the treatment session with minimal
  verbal cues.
• Patient will demonstrate no increase in signs and
  symptoms of aspiration late in meal at home as a
  result of progressively increased pharyngeal
  residual.
• ENVIRONMENTAL CUING
• Decreasing rate of intake may facilitate this
  strategy. This can be promoted by requiring
  patient to put down the spoon, fork or cup
  between bites.

36
Bolus Control Technique Thermal StimulationFact
or Fiction!

• PHYSIOLOGIC ABNORMALITY
• Primarily used when initiation of the pharyngeal
  swallow is delayed in onset thus allowing for an
  unprotected airway in the presence of the bolus
  in the pharynx.
• May also be used when decreased oral sensitivity
  hinders awareness and manipulation of the bolus.
• EFFECT
• Generally thought to heighten sensitivity of the
  oral cavity and pharynx, thus preparing the
  system for the introduction and management of a
  bolus.
• The presumed result is a more timely initiation
  of the pharyngeal swallow in the case of delayed
  onset of swallow. In cases of decreased
  sensitivity of the oral cavity and pharynx the
  result is a more responsive system with greater
  efficiency of the swallow.

37
Bolus Control Technique Thermal Stimulation

• EFFECT
• Generally thought to heighten sensitivity of the
  oral cavity and pharynx, thus preparing the
  system for the introduction and management of a
  bolus. The presumed result is a more timely
  initiation of the pharyngeal swallow in the case
  of delayed onset of swallow. In cases of
  decreased sensitivity of the oral cavity and
  pharynx the result is a more responsive system
  with greater efficiency of the swallow
• CONTRAINDICATION
• Not suggested for patients with a hyperactive gag
  response.
• Lemon glycerine swabs may exacerbate dryness of
  the oral mucosa in patients with xerostomia.
• Sugar content of lemon italian water ice should
  be considered in the care of the diabetic patient.

38
Bolus Control Technique Thermal Stimulation

• INSTRUCTION There are several methods of
  applying Thermal (gustatory) stimulation.
  Introduced initially as only thermal stimulation,
  the patient was instructed to use a chilled
  laryngeal mirror to vertically stroke the
  anterior faucial arches 5-6 times each side prior
  to and intermittently during meals.
• Clinical practice indicates similar, if not
  improved results, through the addition of strong
  taste, particularly a tart lemon, applied more
  globally to the entire oral cavity. The use of
  frozen lemon glycerine swabs is one option.
• Another effective and less obtrusive option is
  the ingestion of limited amounts of lemon Italian
  water ice throughout the meal to facilitate oral
  pharyngeal awareness. This technique does not
  limit the thermal-gustatory stimulation to the
  anterior faucial arches but includes the entire
  oral cavity and is comfortably incorporated into
  the patients diet.

39
Bolus Control Technique Thermal Stimulation

• POTENTIAL GOALS
• Following application of thermal stimulation with
  frozen lemon glycerine swabs by the clinician
  during the treatment session, patient will elicit
  a volitional swallow within 3 seconds on 90 of
  trials.
• Patient will ingest 1/2 teaspoon lemon Italian
  water ice (also known as Italian ice) at the rate
  of one teaspoon after every 4 food/liquid
  swallows during mealtime at home.
• Patient will tolerate 90 of 1 tsp sips of thin
  liquid trials at home with supervision following
  thermal stimulation with no clinical
  signs/symptoms of aspiration.
• ENVIRONMENTAL CUING
• Use of a mirror before and during meals may
  facilitate correct application of thermal
  stimulation when using a chilled mirror or lemon
  swab.
• Italian ice available during meals.

40
Rosenbek.

• Done with kind-hearted rigour

41
Bolus Control Technique Thermal Stimulation

• Mansson and Sandberg (1975)
• Evaluated dry swallowing in normal subjects, half
  of whom received anaesthesia to the posterior
  oral cavity and half without. Anaesthesia
  increased the latency of the pharyngeal response,
  or produced a delay in onset of the pharyngeal
  swallow. Thus, support for the importance of
  mucosal receptors in swallowing onset.
• Lazarra et al. (1985)
• Evaluated short term effects.
• 25 subjects with MBS pre and post stimulation
• 23/25 demonstrated improved triggering of the
  swallow after stimulation

42
Bolus Control Technique Thermal Stimulation

• Rosenbek, et al. (1991)
• Long term effects
• ABAB treatment design 15 to 25 trials of stim
  each session with an average of five sessions per
  day for one week duration prior to switching to
  control condition
• 2 of 7 patients demonstrated improvement in
  transit time (decreased stage transition)
• But subjects were 5 weeks post onset.
• Author states that this provides weak support
  for this therapeutic modality.

43
Bolus Control Technique Thermal Stimulation

• Ali, Lundl, Wallace, deCarle, and Cook (1996)
• 14 normal volunteers evaluated radiographically
  subsequent to thermal stimulation and local
  mucosal receptor anesthesia.
• No influence on the temporal relationships of
  motor events secondary to thermal stimulation or
  anaesthesia. Concluded no support for thermal
  stimulation.

44
Bolus Control Technique Thermal Stimulation

• Kaatze-McDonald, Post and Davis (1996)
• Evaluated 20 normals using a laryngograph to
  document timing issues of swallowing. Applied
  warmed and cooled laryngeal mirror and solutions
  of saline, glucose and distilled water. Cold
  stimulation facilitated more prompt swallow.
• Rosenbek, et al (1996)
• Short term compensatory effects.
• 22 neurologically impaired patients
• 15/22 patients demonstrated decreased latency of
  onset of swallowing after thermal stimulation.

45
Bolus Control Technique Thermal Stimulation

• Rosenbek et al. (1998)
• Long term effects
• 2 weeks therapy trial 4 groups (150, 300, 450,
  660 trials of thermal stim per week)
• No single intensity emerged as most therapeutic
  no significant effects
• Trend that 660 trials might begin to be
  efficacious.very difficult to execute.
• Weak support for technique may reflect lack of
  diagnostic precision.

46
Bolus Control Tech Bolus size/rate of intake

• PHYSIOLOGIC ABNORMALITY
• May be beneficial for patients with poor oral
  control or pharyngeal weakness in which a large
  bolus is too difficult to manage, or a small
  bolus provide too little sensory input.
• SYMPTOMS
• Post swallow oral or pharyngeal residual,
  pre-swallowing pooling secondary to delayed
  pharyngeal swallow impaired oral-pharyngeal
  response to bolus.
• EFFECT
• Highly variable
• Smaller boluses may allow for greater control and
  less scatter to oral recesses with more efficient
  manipulation and a more cohesive bolus.
• With a heavier bolus and more variable texture,
  the patients sensory system is better stimulated,
  thus facilitating greater oral-pharyngeal
  awareness and more efficient bolus control. Rate
  of intake is likewise variable among patients.
• In general slowing the rate of intake may allow
  for greater oral pharyngeal efficiency by giving
  the patient more time to manage the bolus.
• Additionally, patients with neurodegenerative
  disease or chronic obstructive pulmonary disease
  may demonstrate significant fatigue during oral
  intake, thus requiring control of the length of
  the meal or rate of intake.
• No specific published research.

47
Bolus Control Tech Bolus size/rate of intake

• CONTRAINDICATION
• Alternations in rate of intake or bolus size
  should be carefully validated during diagnostic
  exam to assure that strategy does not increase
  aspiration risk.
• INSTRUCTION
• If the patient has adequate cognition to control
  the rate and quantify of intake independently,
  instructions are provided for the size of bolus
  and rate of ingestion that has been determined to
  maximize swallowing efficiency. Otherwise
  environmental cueing may be required.
• POTENTIAL GOALS
• The patient will demonstrate decreased rate of
  puree intake as measured by 4 ounces ingested in
  no less than 5 minutes.
• ENVIRONMENTAL CUING
• Slow rate of liquids with lidded travel mug
  decrease hole by taping with duct tape if needed.
• Straw sips particularly with straw of narrow
  diameter or one with air lead in straw
• Cue patient to put spoon or fork down between
  bites to slow rate of solid intake
• Wrist weight may provide extra tactile cues to
  slow rate of intake.
• Remove centre of spoon
• Portion control

48
Bolus Control Tech Slurp Swallow

• PHYSIOLOGIC ABNORMALITY
• For use with patients demonstrating limited oral
  control that are unable to transfer the bolus
  anterior to posterior.
• EFFECT
• Circumvents the oral phase of the swallow and
  rapidly transfers bolus into the pharynx.
• CONTRAINDICATION
• Will increase aspiration risk in patients with
  inadequate airway protection or pharyngeal phase
  impairment.
• INSTRUCTION
• Patient is instructed to place bolus centrally in
  oral cavity, then "suck" or "slurp" the bolus
  posteriorly into the pharynx, followed promptly
  by elicitation of a swallow.

49
Bolus Control Tech Slurp Swallow

• POTENTIAL GOALS
• Patient will maintain adequate PO nutrition of
  puree diet for 6 months with no pulmonary
  compromise using slurp-swallow strategy to
  transfer bolus to the pharynx.
• On 90 of trials of puree diet in the treatment
  session, patient will clear 90 of the bolus
  from the oral cavity on the first trial with a
  slurp-swallow strategy.
• Patient will demonstrate no indication of
  pre-swallow aspiration using slurp-swallow
  strategy.
• ENVIRONMENTAL CUING
• Technique may be facilitated by intake with a
  thick straw (may be found in some Radiology
  departments or MacDonalds Restaurants) or a
  catheter tip syringe.

50
Airway protection tech Supraglottic Swallow

• PHYSIOLOGIC ABNORMALITY
• Utilized in cases of inadequate airway protection
  mechanisms when aspiration is documented or at
  high risk. Indicated particularly when patient is
  known to be a silent aspirator.
• EFFECT
• The supraglottic swallow provides volitional, in
  the absence of reflexive, airway protection. The
  lungs are filled and the vocal folds firmly
  sealed through conscious effort prior to the
  swallow, with a volitional cough/forced
  expiration immediately following to clear
  laryngeal coating/potential aspiration.
• CONTRAINDICATION
• none documented
• INSTRUCTION
• Patient is instructed to take a deep breath and
  hold it firmly while swallowing the bolus. Upon
  completion of the swallow, patient is instructed
  to forcefully expel the air in the lungs with a
  volitional cough, prior to inhalation. The
  patient then swallows and coughs a second time.

51
Airway protection tech Supraglottic Swallow

• POTENTIAL GOALS
• Patient will recall and implement the sequence of
  supraglottic swallowing strategy during mealtime
  at home with 90 accuracy and no verbal cueing.
• Following 90 of trials of PO liquid with
  supraglottic swallow strategy during the
  treatment session, patient will demonstrate no
  evidence of wet dysphonia or blatant indication
  of aspiration.
• ENVIRONMENTAL CUING
• Patient may require written instruction to recall
  sequence of events as this can be a difficult
  task for many patients to coordinate.
• A technique to facilitate learning of this
  strategy is to break the task, upon first
  presentation, into discrete steps with mastery at
  each level prior to moving ahead.
• a. Hold your breath (3, 5, 10 sec progressively)
  then relax
• b. Hold your breath (3, 5, 10 sec progressively)
  then exhale forcefully or with a cough.
• c. Hold your breath, swallow, then exhale
  forcefully or with a cough.

52
Airway protection tech Super Supraglottic
Swallow

• Same as above but with effort

53
Airway Protection Tech pharyngeal expectoration

• PHYSIOLOGIC ABNORMALITY
• Clinically useful technique for clearing
  pharyngeal residual post-swallow in the presence
  of the physiologic abnormality of decreased
  pharyngeal contraction and laryngeal excursion or
  impaired UES opening.
• By inhibiting the buildup of post-swallow
  residual, there is decreased likelihood for
  post-swallow aspiration of residual.
• As patients progress in swallowing
  rehabilitation, they should be encouraged to
  swallow, rather than expectorate, oral pharygneal
  secretions. No one has methodically, empirically
  studied spitting (wonder why?)
• EFFECT It clears pharyngeal goo!!

54
Airway Protection Tech pharyngeal expectoration

• PATIENT INSTRUCTIONS
• Patient is instructed to bring up secretions from
  the back of the throat.
• CONTRAINDICATIONS
• Social implicationsnot so polite to spit in
  public.
• ENVIRONMENTAL CUING
• Colloquialisms such as truck drivers spit or
  hawking up a clam may communicate more
  effectively the intent of the instruction.

55

• The art of managing the dysphagic patient may
  consist of amusing the patient until nature takes
  its course.