Medical fair dysphagia talk 2011

Swallowing

Rehabilitation Parit Wongphaet, MD.

“The catalogue” • Baic Positioning

• Stretching Exercises

• Massage

• Strenghtening Exercise

• Facilitation Technic

• Compensatory Swallowing Technic

• Neck Positioning

• Food Adaptation

• Special Utensils

“The catalogue” • Baic Positioning

• Stretching Exercises

• Massage

• Strenghtening Exercise

• Facilitation Technic

• Compensatory Swallowing Technic

• Neck Positioning

• Food Adaptation

• Special Utensils

Comprehensive

Assessment

Rational

Mangagement

“The catalogue” • Baic Positioning

• Stretching Exercises

• Massage

• Strenghtening Exercise

• Facilitation Technic

• Compensatory Swallowing Technic

• Neck Positioning

• Food Adaptation

• Special Utensils

So much

options….

The Normal

Swallowing

(brief review)

Normal sequence of actions

Bolus control : glossopalatal seal

Begin of oral transition : tongue tip elevation to alveolar ridge

Tongue propulsion : food bolus move toward tongue base

Nasopharyngeal seal : velum elevation

Pharynx constricts & Tongue base move backwards

Laryngeal elevation

Epiglottis inverts

Larynx closes

Upper Esophageal Spincter open

Less than one second !

“The catalogue” • Baic Positioning

• Stretching Exercises

• Massage

• Strenghtening Exercise

• Facilitation Technic

• Compensatory Swallowing Technic

• Neck Positioning

• Food Adaptation

• Special Utensils

Prerequisits

to Swallowing Rehab.

• Consciousness : Awake ,Oriented

• Attention , Memory, Learning

Ability

• Sitting Balance & Endurance

• Medical conditions

Ramathibodi Bedside Swallowing

Assessment (Rama-BSAF)

• Consciousness

• Oro-pharyngeal sensory

• Oro-facial & neck motor

• Respiratory control

• Reflexes test

• Swallowing test

Ramathibodi Bedside Swallowing

Assessment (Rama-BSAF)

• Functional Outcome

• History of pneumonia

• Clinical Impression on type of dysphagia

• Choice of treatment compontents

Basic Positioning

Stretching Exercises

&Massage

Strenghtening

& Co-ordination Exercises

Breathing

Control Protective

Reflex

Speech Swallowing

Pattern

Generator

Facilitation Technic

Compensatory Swallowing

Technic

Mendelsohn

Technique Goal Indication Instruction

Forceful swallow

(Popderoux

1995)

Increase force of

tongue base

posterior

movement

Weak tongue

retraction

Swallow

forcefully

Supraglottic

Swallow

(Larsen 1973)

Closure of

airway during

swallow

Delayed

triggering of

swallowing reflex

Impair laryngeal

protection

In hale & hold

breath

Swallowing

Voluntary

cough& swallow

Super

supraglottic

Swallow

(Martin 1993)

Tight closure of

airway during

swalow

Same as above As above , but

also pressing

during

swallowing

Mendelsohn

(Mc connel 1989)

Prolonged

elevation of

larynx : inprove

CP opening

Limited Upper E-

spinctor opening

Limited laryngeal

elevation

Keep larynx

elevated until

swallowing is

finished

Neck Positioning

positioning goal Indication Anteflexion of neck

(welch 1993)

Use gravity

Expand valleculae

space

Facilitate posterior

tongue movement

Impaired oral bolus

control

Delayed swallowing

reflex

Impaired tongue

retraction

Neck extension

(Logemann 1989)

Use gravity Same as above

Neck rotation to weak

side (kirchner 1967)

Facilitate food bolus

transport to healthy

side

Tighten vocal cord ?

Hemiparesis of

pharynx

Unilateral vocal cord

paralysisImpaired

Combined anteflexion

and rotation (

Logemann 1989)

Reduce tone in upper

esophageal spincter

opening of CP

Lateral bending to

healthy side

(Logemann 1983)

Use gravity Combined unilat

tongue and

pharyngeal muscle

weakness or resection

Supine position (

Logemann 1994)

Prevent overflow in to

air way

Bilat pharyngeal

paresis or resection

Food Adaptation

Special Utensils

Screening for dysphagia in stroke

• 50 cc water test (likelihood ratio = 5.7)

• Impaired pharyngeal sensation (liklihood

ratio = 2.5)

• Screening seems to reduce incidence of

pneumonia ( RRR ~ 80-40%)

Martino R, Dysphagia 2000

Citric Acid Cough Test

Videofluoroscopic

Swallowing Examination

(VFSS)

Assistant Prof. Parit

Wongphaet,M.D.

19 April 2007

Overview of Lecture

• Normal Swallowing (brief

review)

• Instrumentation for VFSS

• Indications & Contraindications

• VFSS versus FESS & Clinical

Assessment

• Principles & Protocol

• Normal VFSS

• Pathological VFSS & reporting

Indications

• Find safe eating condition

• Identify aspiration risk

Contraindications

• Medically unstable

• Cannot position

• Poor cooperation

VFSS versus FESS &

Clinical Assessment

Fiberoptic Endoscopic Evaluation of Swallowing

VFSS FESS clinical

Intra

deglutative problems

yes no no

Radiation exposure yes no No

Voluntary laryngeal

control

+/- yes +/-

Laryngeal sensory

testing

no yes +/-

(cough

reflex

testing)

Instrumentation for

VFSS

• Same as Fluoroscopic

Examinaitons

• Additional Items

• Video Recorder

• Bare minimum 10 fps

• VHS & DVD(25-29fps)

• Freeze-Frame playback

• Timer (milliseconds)

Principles & Protocol

• Instrument check

• Patient instruction & consent

• Baseline anatomy review

• Lateral

• 3 ml liquid x2

• 5 ml liquid

• Cup drink

• 5 ml nectar

• 5 ml pureed

• Cookie

• Addition repeated swallowing as needed

• Special maneuvers as appropriate

Normal Video

Fluoroscope study

• No penetration

• No aspiration

• Fast and complete laryngeal

movement

• No retention

What to look for

Abnormal Video

Fluoroscope study

• penetration

• Aspiration

• Nasal regurgitation

• Delayed triggering or decreased

laryngeal excursion

• Decreased or ineffective cough

when aspirate

• retention

Common positive findings

in patients with

neurogenic dysphagia

• Delayed swallowing reflex

triggering 88%

• Dysfunction CP 75%

• Decreased tongue movement

74%

• Drooling related problems 60%

• Abnormal (hypo/hyper) gag

reflex 42/10% Posiegel M. Nervenarzt 2002

Pre-deglutative

Intra deglutative with CP spasm

Before & after

Cp not open

Post deglutative

Additional Swallowing

Try

• Neck Positioning

• Rotation,flexion,extension,lateral

bending

• Special Maneuvers

• Mendelson

• Supraglottic

• Super-supraglottic

• Forceful swallowing

positioning goal Indication Anteflexion of neck

(welch 1993)

Use gravity

Expand valleculae

space

Facilitate posterior

tongue movement

Impaired oral bolus

control

Delayed swallowing

reflex

Impaired tongue

retraction

Neck extension

(Logemann 1989)

Use gravity Same as above

Neck rotation to weak

side (kirchner 1967)

Facilitate food bolus

transport to healthy

side

Tighten vocal cord ?

Hemiparesis of

pharynx

Unilateral vocal cord

paralysisImpaired

Combined anteflexion

and rotation (

Logemann 1989)

Reduce tone in upper

esophageal spincter

opening of CP

Lateral bending to

healthy side

(Logemann 1983)

Use gravity Combined unilat

tongue and

pharyngeal muscle

weakness or resection

Supine position (

Logemann 1994)

Prevent overflow in to

air way

Bilat pharyngeal

paresis or resection

Mendelsohn

Technique Goal Indication Instruction

Forceful swallow

(Popderoux

1995)

Increase force of

tongue base

posterior

movement

Weak tongue

retraction

Swallow

forcefully

Supraglottic

Swallow

(Larsen 1973)

Closure of

airway during

swallow

Delayed

triggering of

swallowing reflex

Impair laryngeal

protection

In hale & hold

breath

Swallowing

Voluntary

cough& swallow

Super

supraglottic

Swallow

(Martin 1993)

Tight closure of

airway during

swalow

Same as above As above , but

also pressing

during

swallowing

Mendelsohn

(Mc connel 1989)

Prolonged

elevation of

larynx : inprove

CP opening

Limited Upper E-

spinctor opening

Limited laryngeal

elevation

Keep larynx

elevated until

swallowing is

finished

Outcome of IPD

swallowing rehab

Level of feeding Befor

e

Afte

r

Fully normal 14 52

With adaptation 5 42

Limited food texture 24 8

With adaptation and limited

food texture

8 35

Partial oral feed 26 25

Enteral feed only 131 36

Posiegel M. Nervenarzt 2002

Screening for dysphagia

in stroke

• 50 cc water test (likelihood

ratio = 5.7)

• Impaired pharyngeal sensation

(liklihood ratio = 2.5)

• Screening seems to reduce

incidence of pneumonia ( RRR ~

80-40%) Martino R, Dysphagia 2000

Screening for dysphagia

in stroke

• 100 cc water test

• Speed

• Sensitivity 85%

• Specificity 50 %

• Choking or Wet voice

• Sensitivity 45 %

• Specificity 91 %

Meng-Chun Wu,et al. Dysphagia 2004

Videofluoroscopy

Swallowing Study

(VFSS) Course &

Workshop

• 13 September 2007

• Queen Sirikit National Conference Center

• Key Note Lectruer

– Professor Christian Hannig

– Technical University Munich, Germany

• Course Objective

• “Enable Participants to Confidently Perform and

Interprets VFSS”

[email protected]

A 63 year-old male, DM,HT,DLP

- Lt MCA infarction 10 years ago, presented with loss of

consciousness and fully recovery

- Rt MCA infarction 8 months ago, presented with loss of

consciousness and mild weakness of Lt side

Now clinical was improved, but still has swallowing problem

Clinical assessment at first time(Jan 2011) showed drooling,

impaired lip and tongue movement and cannot trigger his

larynx and cannot clear his secretion. NG tube was inserted.

He also developed aspiration pneumonia 3 times and wt

loss.

Now showed normal lip and tongue movement, mildly apraxia,

normal laryngeal triggering, 2 FB-excurtion, can clear secretion

usually.

Currently he can eat banana via oral tract.

: Can he progress to more “advanced” feeding?

Banana กล้วยสุก

Soup-like

Water-like