A Collaborative Plan for Successful Interventions Joseph L Garcia MSCCCSLP STAGE ONE THE ORAL PREP STAGE Begins as soon as food or liquid reaches the lips Labial and lingual structures existing dentition and intraoral musculature are ID: 464849
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DYSPHAGIA MANAGEMENT
A Collaborative Plan for Successful Interventions
Joseph L. Garcia, MS-CCC/SLPSlide2
STAGE ONE
–
THE ORAL PREP STAGE
Begins as soon as food or liquid reaches the lips.Labial and lingual structures, existing dentition, and intraoral musculature are all working in unison to have a bolus prepared for a safe and timely swallow.Timely oral preparation of solids and liquids maintains the oral bolus from leaking out of the oral structure and allows it to remain intraorally until it is ready for a safe esophageal transfer.Slide3
Signs and Symptoms of Oral Preparatory Dysfunction:
Perseverative mastication
Heightened or diminished pace of self feeding
Expectoration of solids/liquidsCoughing and chokingTexture avoidance
Protein malnutrition and failure to thrive
Weight lossDrooling with or without meal itemsXerostomiaOral stuffing or oral hoardingSlide4
WHAT CAN BE DONE FOR ORAL PREP DYSFUNCTION:
Texture modifications and analysis of temperatures
Environmental modifications: seating arrangements with talkative eaters
Functional endurance lingual training throughout the dayLabial, lingual, and oral musculature strengthening and resistance trainingCompensatory eating and feeding strategies: lingual or finger sweeps; chin tuck
Alternate liquids with solids to improve bolus breakdown & residual clearance
Energy conservation strategies: small frequent meals; positioning; O2; etc.Staff and family training for improved successReferrals: Speech and Occupational Therapies; Dentist; Dietitian/NutritionistSlide5
STAGE
TWO
–THE PHARYNGEAL STAGE
Occurs immediately after a bolus leaves the mouth by passing over the base of the tongue and through the pharynx. Multiple muscle groups must work strongly, succinctly and simultaneously for a safe pharyngeal phase.Weakened or untimely swallow triggers will significantly increase the potential for aspirants to enter the trachea and/or into the lungs. Pharyngeal dysfunction can occur with both solids and with liquids.Slide6
Signs and Symptoms of
Pharyngeal Dysfunction:
Coughing/choking can be immediate or delayed
GaggingExcessive throat clearing during or after mealsNasal emission of meal itemsLaryngeal bobbing
Absent swallow triggers
Oral holding of meal itemsDehydration and/or weight lossGrimacing and/or turning the head when swallowingComplaints of food or pills that stick in the throatRecurrent pneumonia; URIs; FUOs; tracheal congestionSlide7
WHAT CAN BE DONE FOR
PHARYNGEAL DYSFUNCTION:
Texture
and consistency modifications and analysisElectro-Musculature StimulationPharyngeal strengthening exercises
Palatal lift exercises or prosthetics
Compensatory eating/feeding strategies: chin tuck; double or hard swallow; head turnAlternate liquids with solids for improved pharyngeal cleansingEnergy conservation strategies via small frequent meals; O2Staff and family training for improved successVideofluoroscopic Swallow Study
Referrals: Speech and Occupational Therapies; Dietitian/NutritionistSlide8
STAGE
THREE
–THE ESOPHAGEAL STAGE
The final swallowing stage where a bolus is passed into the esophagus. Peristaltic action pushes food and liquids to the stomach.Upper and lower esophageal sphincters and peristaltic action must work in unison to be effective.UE and LE sphincters are chemically aggravated by highly acidic food and drink causing reflux.Newborns, preemies, diabetics, PEG/NG patients, and those with degenerative neurological disease are at high risk.Slide9
Signs and Symptoms of
Esophageal
Dysfunction
:BelchingEarly satietyWeight loss/failure to thriveDehydrationFoul or sour breath despite good oral
hygeine
Upper GI bleedsReferred globus – the feeling of food getting stuck in the esophagusOdynophagia: pain with swallowingRegurgitation during or soon after mealsRecurrent pneumonia; URIs; FUO’s; delayed tracheal congestionSlide10
WHAT CAN BE DONE FOR
ESOPHAGEAL
DYSFUNCTION
:Physician referral for upper GI testing; gastric dumping; etc.Esophageal dilationPharmaceutical management for lowering acid or for improved peristaltic controlX-ray to determine possible obstruction
Hiatal hernia surgery (not typical)
Leaning away from an obstruction with each swallowAvoidance of tomato and citrus-based productsAvoidance of carbonated drinks and of caffeineLosing weightHead elevation during slumber; never lay flat or on the bellySmaller, lighter mealsGelatin or applesauce chasersReferral to: Speech Therapy; PCP; Dietitian/NutritionistSlide11
COLLABORATIVE DYSPHAGIA MODEL: Developing an Interdisciplinary Team (IDT)
1) First, develop the IDT
Patient and Family (grandparents?)
Speech and Occupational TherapiesPhysicians and NursingTeachers/AidesDietitian/Nutritionist2) Then, develop a plan:Swallowing Eval with POT by the SLPFeeding Eval
with POT by the OT
Dietitian referral for options/replacementsReferrals to specialists as neededTraining resident and POA prior to discharge with dysphagia mgt; meal prep; weight monitoring and with F/U care.Slide12
ONGOING PATIENT DEVELOPMENT FOR EFFECTIVE CARRYOVER
SLP and/or OT treat the patient with the development of goals and their proposed outcomes. Regular screens for ALL
dysphagic
patients.Increased frequency of weight monitoring and I&Os with all patients receiving modified textures or consistencies.Teachers/Aides/Nursing support feeding techniques and strategies for continuous, cross-contextual skills training.Dietitian/Nutritionist develops a focused plan specific to each dysphagic patient to avoid dehydration or nutritional deficiencies.Discharge education from all disciplines.Slide13
BARRIERS
Things we can control:
Siloed
departmentsTerritorial departmentsTime constraintsLack of patient advocacyPerception of food vs. nutritionThings out of our control:Cultural departuresDegenerative disease and wastingExisting comorbidities
Patient non-compliance
Patient/family follow-throughSlide14
QUESTIONS AND ANSWERS:
Joseph L. Garcia, MS-CCC/SLP
joegee_1@yahoo.com
garciaj@mennohaven.org