Swallowing maneuvers, which encourage voluntary control over certain parts of the pharyngeal swallow, can be visualized during VFSS. of the doctors, and will just straight-up tell them I think the patient has hit a Dysphagia. Acta Radiol. Arend: It helps to have family watch my session with the patient. Neurogenic dysphagia: frequency, progression and outcome in adults following head injury. Saatman KE, Duhaime A-C, Bullock R, Maas AIR, Valadka A, et al. Involvement of the patient, family and caregivers, is also critical to ensuring that management strategies generalize to functional settings, such as the home . Learn more about the causes, symptoms, diagnosis, and treatment of dysphagia for people with swallowing disorders. The Speech Pathology Association of Australia Limited; 2004. p. 9–11. Determine area of weakness/deficits 3. Crit Care Med. The program uses swallowing of different consistencies and volumes as the exercise [94•]. Would it be warranted to document an eval/note stating This includes taking into account their neuromuscular, cognitive-communicative and behavioral presentation. Pelletier CA, Lawless HT. and really thinking about what the patient would want, makes it easier. A systematic review of randomised controlled trials in the field of dysphagia rehabilitation. NMES applies an electrical current to stimulate motor and/or sensory nerves or nerve endings . However, dysphagia following TBI has a multifactorial presentation, with causative and contributory factors including cognitive-communication, behavioral, neurological, and mechanical issues. In this way, physical injury may add complexity to the management of neurological dysphagia. Leder SB, Ross DA. Normal swallowing physiology as viewed by videofluoroscopy and videoendoscopy. 2008;51(1):S276–300. Reducing food/fluid intake volume and speed can help prevent pharyngeal pooling and aspiration in patients with delayed or weak pharyngeal swallows . the nurse in to verify and/or informed the nurse, and name the nurse. Krival: And a really good evaluation or POC (plan of care) process that supports the concerns 2008;51(5):1072–87. Participant: What one article best illustrates the benefits of careful hand feeding over tube feeding? policies and procedures that are broader than just SLP roles or nursing roles. Folia Phoniatr Logop. how you would document this in your chart note. Dysphagia. Terk AR, Leder SB, Burrell MI. NPO, or nil per os, is also known as ‘nothing by mouth’, and is a medical instruction meaning to withhold fluids and food. Logemann JA, Gensler G, Robbins J, Lindblad AS, Brandt D, Hind JA, et al. Modifying bolus temperature alone will not alter swallowing physiology; [76, 85] however, application of cold and pressure to the faucial arches can increase the speed of the onset of tongue movement and the pharyngeal phase of the swallow in the short-term . Post-TBI dysphagia is caused and influenced by a number of factors. De Vita M, Spierer-Rundback L, Eisen H, Rudy T. Effects of tracheostomy tube on swallowing function in patients following critical illness. are if the patient can’t swallow. Current Physical Medicine and Rehabilitation Reports If The absence of an automatically triggered swallow risks choking or aspirating if they start to speak . Studies into the effects of carbonated boluses have been criticized , and further, better designed studies are required before conclusions can be drawn . 2010;25:35–9. Stauffer J, Olson D, Pelta T. Complications and consequences for endotracheal intubation and tracheostomy: a prospective study of 150 critically ill adult patients. for pulmonary issues, so they’ll begin to see that perspective as well.  In some patients with TBI, the cognitive-communication and behavioral impairments may dictate dysphagia management, rather than the physiological deficits . Treatment … If the address matches an existing account you will receive an email with instructions to reset your password. Field LH, Weiss CJ. 1989;3(1):19–26. For example, there is very little, if any, data on what constitutes normal tone in the swallowing musculature , and abnormal oropharyngeal muscle tone is difficult to identify. challenged by the idea of laying out options for our patients. Dysphagia. 1995;38:556–63. Studies suggested that even in the absence of neurological conditions, patients with tracheostomies risked dysphagia . As a Home Health SLP, I am often asked the same questions. Lan Y, Ohkubo M, Berretin-Felix G, Sia I, Carnaby-Mann GD, Crary MA. Ian J. Baguley. I have to have a conversation with the doc. Such dysphagia in trauma patients with prolonged ETT intubation is often multifactorial , resulting from prolonged contact of the ETT with chemo- and/or mechanoreceptors in the pharyngeal and laryngeal mucosae, critical for triggering the swallowing reflex .Physical injury including vocal fold ulceration and laryngeal edema  and impaired laryngeal elevation and/or closure may impede swallowing function . Dane TEB, King EG. QOL and safety of diet with cases concerning end-stage dementia and even patients 1998;13:69–81. The cognitive-communication/behavioral issues that influence the ability to safely eat and drink occur across multiple domains, creating challenges for patients attempting to swallow safely and influencing how dysphagia is assessed and managed [9, 40]. will still be at risk of aspiration of secretions and on tube feeding due to positioning. Kate Krival: Mine would be that we manage our patients best by applying terrific evaluations and Dysphagia is a common morbidity and cause of mortality following traumatic brain injury (TBI). J Head Trauma Rehabil. It is also known as nil per os ( npo or NPO ), a Latin phrase that translates literally to English as "nothing through the mouth". Establishing a dysphagia family intervention program for head-injured patients. The multifactorial nature of dysphagia following TBI, and its far-reaching effects on quality of life, necessitates multidisciplinary management involving the patient, family or caregivers wherever possible. that we are really Dysphagia. 1991;100:678–81. The effects of lingual exercise in stroke patients with dysphagia. 2002;17:197–201. In most cases, ice chips were viewed as a … doctor about it. Other less frequently observed deficits include decreased laryngeal elevation [6, 11, 32, 42], reduced base of tongue retraction [11, 42], decreased pharyngeal peristalsis [11, 32], prolonged pharyngeal transit time , prolonged oral transit time [11, 41], unilateral pharyngeal paralysis , absent or weak reflexive or voluntary cough , cricopharyngeal dysfunction [11, 32] and primitive oral reflexes (biting, pursing and rooting) . and things you are learning at conferences like this would be the best way to proceed. Heterogeneous subject groups, small subject numbers, lack of specificity of transcutaneous NMES at a tissue level  and differences in electrode placement and stimulation parameters are just a few of the reasons why better designed studies are required [94•] before the efficacy of this treatment option will be known. Studies of ‘neurogenic dysphagia’ typically include heterogeneous subject groups, including subjects with cerebrovascular accident (CVA), progressive neurological diseases, brain tumors as well as TBI [19, 20]. There is also evidence that these maneuvers may work differently, depending on individual technique . Curr Phys Med Rehabil Rep. 2013;1:197–215. Reddened, irritated oropharyngeal cavity (stomatitis) 5. Dysphagia. Presence of a tracheotomy tube and aspiration status in early, postsurgical head and neck cancer patients. the cases in which we as the SLP might be the ones recommending a transition toward Recent research into the effects of dysphagia therapy for patients undergoing head and neck cancer treatment have provided new insights into the importance of proactive swallowing therapy. a clinician, in my view. Patients can also be at risk of aspiration if they are so distracted they forget to swallow . For example, increased intracranial pressure is associated with moderate to severe dysphagia and a coma duration of >24 h associated with more severe dysphagia . Langmore SE, Schatz K, Olsen N. Fiberoptic endoscopic examination of swallowing safety: a new procedure. 1993;8:160. conversation about goals of care. Veis SL, Logemann JA. Best Pract Res Clin Gastroenterol. Epilepsia. Current Dysphagia Therapy Techniques 1. Schindler A, Vincon E, Grosso E, Miletto AM, Di Rosa R, Schindler O. Rehabilitative management of oropharyngeal dysphagia in acute care settings: data from a large Italian teaching hospital. 2008;13(3):8–11. Do you have any approaches or suggestions for educating Effect of citric acid and citric acid-sucrose mixtures on swallowing in neurogenic oropharyngeal dysphagia. Arend: It will depend on how the patient does with milk-based products, just like with anything May 16, 2019 - This handout is designed for Speech-Language Pathologist working with people who are on relatively long-term NPO status while recovering from other health impairments. Surg Gynecol Obstet. Arend is an affiliate of ASHA Special Interest Groups That meeting helped a lot. Logemann JA. Ludlow CL. Am J Med. Evaluate with use of instrumental swallow testing: Typically Modified Barium Swallow Study (MBSS) or FEES 2. Increased frequency of obstructive airway abnormalities with long-term tracheostomy. If you are talking about patient who is truly at end of 1999;14:93–109. Clark HM. • Crary MA, Carnaby GD. Bulow M, Olsson R, Ekberg O. Videoradiographic analysis of how carbonated thin liquids and thickened liquids affect the physiology of swallowing in subjects with aspiration on thin liquids. In a recent online chat, John R. Ashford emphasized the importance of good oral hygiene to the overall health of dysphagia patients and infection control. Leder SB, Ross DA. team (family, patient, doctor, etc.). The management of dysphagia following TBI requires a multifaceted, individualized approach that incorporates the contributory and causative cognitive-communication, behavioral, physiological, and pharmacological factors, any concomitant injuries and the pathoanatomic features of the TBI. Typically, NPO status due to dysphagia is an attempt to prevent aspiration, choking and other potential negative consequences of dysphagia (weight loss, dehydration, recurrent UTIs, skin breakdown, fatigue, malnutrition). 2008;23:230–6. 1971;174:29–33. Aspiration is very common, present in 38–63 % of patients [11, 32, 41, 42]. Arch Otolaryngol Head Neck Surg. 1990;5:147–51. Careful and detailed assessment of the impact of these factors on the dysphagia should guide treatment and management plans. Initially, we may have been guessing: you aspirate, you may or may not be able to Late mortality after severe traumatic brain injury in NSW: a multi-centre study. Combativeness and refusal to be fed by a caregiver can also cause safe feeding problems when complicated by impulsivity . Post-discharge from rehabilitation, patients with TBI can be 79 times more likely to die from aspiration pneumonia compared to the general population . patient who is truly at end of life, I provide education to staff and family about Delayed or disorganized oral preparatory or oral phases of the swallow and premature spillage of the bolus into the pharynx can indicate poor tongue control . J Speech Lang Hear Res. Krival: Yes. Taken together, these studies support the contention that the presentation of post-TBI dysphagia differs to that following CVA. AHSA Lead. This is particularly important when the patient also has impaired swallowing physiology [8, 9, 40]. More frequent, smaller meals may be recommended if alertness fluctuates during the day .  found that isometric tongue exercises improved tongue strength and swallowing function in patients post-CVA. Tolep K, Getch CL, Criner GJ. Krival: And as far as the team, to some extent the same concept works pretty well for me, Research into the treatment and management of dysphagia in TBI-specific populations tends to be limited and often lack scientific rigor. VFSS can assess other management approaches where appropriate.  found that duration to the first swallowing assessment (DFSA) was a predictor for achieving normal oral feeding. Burkhead LM, Sapienza CM, Rosenbek JC. Sometimes I just ask them myself and will let the doctor know. a VFSS (videofluoroscopic swallow study)? Krival: I will say that what helped me most in the SNF setting was to have collaborated with Groher ME, Crary MA. For example, a person with head and neck cancer with chronic dysphagia from late-radiation induced dysphagia may tolerate some aspiration and want to stay on a least restrictive diet. with the now quick-turnover rate, how do you take that into account and help the NPO J Speech Lang Hear Res. These postures aim to improve airway protection or redirect food toward the stronger side of the pharynx . the same attention to careful diagnosis and treatment possibilities as our rehab patients. Traditional treatments for ‘neurogenic dysphagia’ such as postural adjustments, swallowing maneuvers and oral motor exercises are not necessarily appropriate or effective for TBI patients. PubMed Central Arend: First, I look to see if there is documentation about patient/family wishes about tube-feeding. A study by Robbins et al. 1995;23:486–90. Ekberg O, Hamdy S, Woisard V, Wuttge-Hannig A, Ortega P. Social and psychological burden of dysphagia: its impact on diagnosis and treatment. 1989;96:877–84. Altman KW, Yu G, Schaefer SD. They reported that feeding mode at discharge correlated with RLA level on admission and discharge and Disability Rating Scale (DRS) score on discharge . Arch Phys Med Rehabil. As with the postural adjustments, these maneuvers provide an ‘immediate but only transient approach to the underlying physiologic deficit.’  The supraglottic swallow functions to close the vocal folds before and during the swallow  and clear bolus residue from the airway post-swallow . However, it was unclear whether these results were due to improvements at the ‘muscle level alone or neuroplastic modifications as well’ . Simultaneous videofluoroscopic swallow study and modified Evans blue dye procedure: an evaluation of blue dye visualization in cases of known aspiration. Bulow M, Olsson R, Ekberg O. Videomanometric analysis of supraglottic swallow, effortful swallow, and chin tuck in healthy volunteers. the concern for a patient who has an increase in mucus with milk products, but I wouldn’t Additionally, patients with more severe injury (on GCS) took longer to initiate oral feeding. Furuta M, Yamashita Y. Am J Speech Lang Pathol. Barium contrast is not required, improving patient compliance with food and fluid trials [67, 68], particularly if they are orally or tactilely defensive , combative or agitated. 2008;51(1):173–83. 2005;40(1):1–6. Laryngoscope. “If the patient was speaking for themselves 20 years ago, what would they have to in place, like, “Call us back if things change.”. The effortful swallow increases oral pressure during swallowing, the amplitude of submental muscle activation , tongue base retraction, duration of pharyngeal pressure, among other changes . Dysphagia. 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In an anterior position while swallowing [ 77 ] Murray JT, Lopatin D Millham... And videofluoroscopic evaluations of swallowing ] to see if there are strategies to,. A recent literature review of exercise-based therapy for swallowing disorders and Wales post-stroke dysphagia what. With each other the things we are excited about causes, symptoms diagnosis! Peter hospital in Olympia, Washington of life [ 17 ] including the nature and severity of the pharyngeal,. Establishing a dysphagia family intervention Program for head-injured patients exposure can lead to uncertainty about they. With agitation and combativeness post-injury, with CVA more common in older patients nursing! As far as the muscles are small and overlapping [ 105 ] X, XII ).... Multifactorial, team-based and involve the patients ’ families and carers are common in way. The address matches an existing account you will receive an email with instructions to reset your.... Food toward the stronger side of the patient ’ s not really something that I feel I can in. Rehabilitation in chronic brainstem dysphagia: what we are really challenged by the idea laying! Issues [ 10, 44, 45 ] never think about how to manage these complex.... 30, 31 ] can produce hypertonicity, hypotonicity, reduced contraction oppositional..., Lindblad as, Brandt D, Hind JA, et al etc. OO, Clave oral! Plan in place, like, “ Call us back if things change. ” days! Manifests and is assessed and managed important when the patient to initiate oral feeding is reported frequently, hypotonicity reduced. A bedside assessment, it has been suggested that post-stroke oromotor features of dysphagia in populations... Reddened, irritated oropharyngeal cavity ( stomatitis ) 5 to swallow secondary to unresponsiveness to oral stimuli,.... Pretty good conversation, I discontinue the order if there are strategies help.