Compensatory- Management of Dysphagia

MANAGEMENT OF DYSPHAGIA

SECTION OBJECTIVES

The student will be able to:

  • Describe factors that contribute to treatment decisions

  • Describe and demonstrate dysphagia compensatory treatments

  • Select appropriate compensatory treatments to reduce dysphagia symptoms in case studies

  • Identify IDDSI textures from numbers & colors

Goals of Dysphagia Management

Primary Goals

  1. Safe and adequate oral intake

    • Prevention of aspiration (safe)

    • Prevention of malnutrition/dehydration (adequate)

Secondary Goals

  1. As early as possible, re-establish oral feeding

  2. Meeting the patient’s psychological needs

Bottom Line

  • Improve the patient’s Quality of Life!!

Fundamental Decisions in Dysphagia Management

  1. Primary means of nutrition (oral or not)

  2. Behavioral management

    • Compensatory or rehabilitative

  3. Medical and/or surgical management

Factors that Assist in Management Decisions

  • Current medical diagnosis, coexisting medical problems, and current medical treatment

  • Respiratory status

  • Patient’s current nutritional, dietary, or hydration status

  • Type & severity of physiological problems at each stage of swallowing

Factors that Assist in Management Decisions (contd.)

  • Patient’s physical abilities

  • Patient's speech, language, and cognitive abilities

  • Orientation & attention

  • Emotional status (depression, anxiety etc.)

  • Patient’s living arrangements

  • Motivation

  • Ethnicity & culture!

Dysphagia Team

  1. Pediatrics

  2. Speech-Language Pathologist (SLP)

  3. Radiology

  4. ENT/GE

  5. Pulmonary specialists

  6. Patient

  7. Neurology/Oncology

  8. Nursing

  9. Nutrition

  10. Physical Therapy/Occupational Therapy (PT/OT)

How do I select Treatments?

  • Management of dysphagia begins during Case History

    • Gather as much information as possible from medical records, patients, family members, and the rest of the team

  • Complete a comprehensive assessment to understand physiology & pathology

  • During instrumental evaluation, include carefully selected treatment strategies to assess improvements in the safety & efficiency of swallowing

    • A problem well stated is a problem half solved

How do I select Treatments? (contd.)

  • Select strategies based on:

    • Anatomic or physiologic impairment

    • Mental & cognitive status

    • Social support & environment

    • Evidence-based practice!!

CURRENT EVIDENCE IN DYSPHAGIA MANAGEMENT

Treatment Principles

  • Dysphagia treatments should target the anatomic/physiologic deficits, not just the symptoms

    • Note: Symptomatic therapy may be the stepping stone

Treatment Approaches

A. Behavioral (SLPs)

  1. Compensatory (Symptomatic)

  2. Rehabilitative
    B. Medical/Surgical (medical team)

  • Ideal dysphagia treatments must combine compensatory and rehabilitative treatment methods

SYMPTOMATIC - COMPENSATORY TREATMENTS

Overview

  • These treatments address symptoms and are performed during mealtime

  • Types of treatments include:

    • Postural changes

    • Swallowing maneuvers

    • Diet modification

    • Changes in eating habits

    • Assistive devices

    • Environmental changes

    • Oral hygiene

Postural Changes

  • Modify the speed and direction of bolus flow through the mouth and pharynx

Types of Postural Changes

  1. Head Tilt

    • Tilt to the Back: Used when there is poor anterior-posterior bolus propulsion. Rationale: Uses gravity to assist in clearing the oral cavity. Requires intact pharyngeal stage.

    • Tilt to the Strong Side: Used when there is unilateral pharyngeal weakness. Rationale: Directs bolus down the stronger side, avoiding residue on the weaker side.

    • Note: Not recommended if there are laryngeal problems.

  2. Head Rotation

    • Turn head towards the weak side. Used for unilateral pharyngeal weakness (residue on one side). Rationale: Eliminates that side from the bolus path.

    • Important to have intact spinal accessory for this posture.

  3. Chin Tuck

    • Tuck chin to chest. Used for delayed or incomplete vocal fold closure (risk for aspiration). Rationale: Narrows airway to prevent pre-swallow spill.

    • Tuck chin immediately after chewing or sipping until the entire bolus clears the pharynx.

  4. Reclining Position

    • Used when there is reduced pharyngeal contraction and resultant residue. Rationale: Eliminates gravitational effect, prevents residue from entering the airway.

    • Common recline angles: 60 and 45 degrees.

Example Postures and Their Indications

Posture

Indication

Rationale

Head tilt (back)

Poor anterior-posterior bolus propulsion

Uses gravity for clearing the oral cavity

Head tilt (strong side)

Unilateral pharyngeal weakness

Directs bolus down the stronger side

Head rotation

Unilateral pharyngeal weakness

Decreases anatomical space in valleculae and pyriform sinus

Chin tuck

Delayed/incomplete vocal fold closure

Narrows airway to prevent spill

Reclining position

Reduced pharyngeal contraction

Eliminates gravitational effect on pharyngeal residue

Quick Review

  • If a client displays left pharyngeal weakness, they can attempt head tilt to the strong side.

  • If a client has unilateral pharyngeal residue and aspiration, they can attempt head rotation posture.

SYMPTOMATIC - COMPENSATORY TREATMENTS

  • Postural changes

  • Swallowing maneuvers

  • Diet modification

  • Changes in eating habits

  • Assistive devices

  • Environmental changes

  • Oral hygiene

Swallowing Maneuvers

Overview

  • These are compensatory maneuvers/actions performed during the swallow

  • Must be practiced with saliva before trialing with food to ensure understanding and correct performance

  • Primarily for airway protection

Common Swallowing Maneuvers

  1. Mendelsohn Maneuver

    • Used for inadequate hyolaryngeal elevation. Rationale: Keeps larynx lifted for longer protection.

  2. Safe Swallow (Supraglottic Swallow)

    • Used for glottal incompetence. Rationale: Closes vocal folds during swallow.

  3. Super-Safe Swallow

    • Similar to Safe Swallow but involves coughing after swallowing to ensure clearing.

Instructions for Common Maneuvers

  • Mendelsohn Maneuver:

    • Place fingers on the larynx while swallowing. Hold the larynx at its highest point for 2-3 seconds.

  • Safe Swallow:

    • Hold food in the mouth, take a deep breath, hold breath, then swallow while maintaining tightness in the throat.

  • Super-Safe Swallow:

    • Same initial steps as Safe Swallow; however, immediately cough post swallow and swallow again.

Dietary Terms to Know

  • PO (Per Os) - by mouth

  • NPO (Nil per os) - never by mouth

  • PPO (Pars per os) - partially by mouth

Dietary Modifications

Texture-modified Diet Options (IDDSI)

  • Liquid

  • Thick (categories: slightly < mildly < moderately < extremely)

  • Thin

  • Solids

    • Pureed: homogenous and cohesive, requiring very little chewing

    • Minced & moist: cohesive, mixed with sauces, requires some chewing (e.g., ground meat with gravy)

    • Soft: soft-cooked solid foods (e.g., vegetables, chopped meat)

    • Regular: all other foods

IDDSI - Global Effort!

  • The International Dysphagia Diet Standardization Initiative (IDDSI) started in 2013 to replace the National Dysphagia Diet.

  • Goals include standardizing levels of food and liquid textures across 9 nations, including ASHA from the US.

IDDSI Assessment Methods

  • Testing drinks: IDDSI flow test using a 10ml syringe

  • Testing foods: Fork-drip test, spoon-tilt test, pressure tests

  • These tests ensure that foods and liquids meet IDDSI standards when thickening liquids or modifying food textures.

Dietary Modifications - Liquid Thickeners

Possible liquid thickeners include:

  • Commercial thickening products

  • Instant cream of wheat or oatmeal

  • Instant mashed potatoes

  • Baby rice cereal

  • Pureed vegetables or fruits

  • Corn starch

Summary of Thickening Research

  • Pros: Thickening liquid reduces aspiration rates, as observed in immediate effects on VFSS.

  • Cons: Increased incidence of pneumonia over a 3-month period, with more residue in the valleculae with thicker liquids.

  • Current clinical notion: The thicker the liquid, the safer the swallow, but not always true.

    • The greatest factor in cough clearability is the adhesiveness of materials in the airway.

Changes in Eating Habits

  • Modifications include:

    • Smaller bites/sips

    • Reduced rate of presentation to ensure residue clearance

    • Following solids with liquids (if applicable)

    • Monitored by caregivers

    • Implementing reflux precautions

Reflux Precautions

  1. Eat in a relaxed setting.

  2. Small meals rather than one large meal.

  3. Separate solids and liquids; do not drink during meals.

  4. Include protein in each meal.

  5. Lower fat content.

  6. Avoid irritating foods (caffeine, mint, alcohol, chocolate, etc.).

  7. Wait 30-45 minutes after eating before reclining.

  8. Elevate the head of the bed six inches.

Assistive Feeding Devices

  • Include:

    • Syringes or squirt bottles

    • Feeding spoons

    • Sculptured cups (nosey cups)

    • One-way valve straws

    • Wide straws

Environmental Changes

  • Eliminate distractions during mealtime (e.g., turn off TV, fewer company at the table).

  • Follow a consistent routine.

  • Offer 6 smaller meals per day.

  • Provide encouragements and prompts.

Oral Hygiene

Importance

  • Regular rinsing and brushing are critical.

  • Dry mouth often occurs in NPO, PPO, or patients on thickened liquids, leading to higher pneumonia risk.

  • A rigorous oral care routine improves awareness of food and desire to eat.

Protocols

  • Frazier or Free Water Protocol: for NPO or modified diets.

    • Ensures access to water and emphasizes clean mouth hygiene.

    • Aggressive oral care twice a day, unrestricted water intake between meals, and specific guidelines for post-meal water consumption to reduce aspiration risk.

Conclusion

  • Oral hygiene impacts risk for pneumonia in dysphagic individuals. Patients with better oral care and hygiene have lower risks associated with aspiration.

Quick Review

  • Fill in the blanks based on learned materials from the course.

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