Aspiration
What are the two feedback loops of the lungs?
Negative: suppress
Positive: magnify
immigration and elimination of bacteria
Three types of behavioral dysphagia management
- Compensatory (adapt, indirect)
- Restorative (restore, direct)
- Preventative
What are the six categories of etiologies?
•Neurogenic/Neurologic
•Mechanical
•Iatrogenic
•Artificial airways/mechanical ventilation/pulmonary
•Psychogenic
•Esophageal
Palliative vs Hospice Care
Palliative: serious illness, managing symptoms and improving QOL, may receive carative care
Hospice: end of life, likely to die within 6 mo (recert), managing symptoms and improving QOL, no curative care provided
CNS / PNS
CNS: brain, spinal cord
- pyramidal
- extrapyramidal (intentional)
PNS: ganglia, nerves
Definition of Aspiration
Below the level of the vocal folds
Ideal candidate
•Impairment(s) identified for which a technique(s) is deemed effective
•Motivated
•Adequate cognitive status to participate
•Can employ/practice independently or has support from staff/caregiver(s)
•Physician clearance (if necessary)
Name 3 Neurogenic causes of dysphagia
•Stroke
•Traumatic brain injury
•Cerebral palsy
•Dementia
•Parkinson’s disease
•Progressive supranuclear palsy
•Huntington’s disease
•Dystonia
•Amyotrophic lateral sclerosis
•Multiple sclerosis
•Polio/post polio
•Guillain-Barre
•Myopathy
•Myasthenia gravis
Medical ethics
Autonomy, beneficence, nonmalfience, justice/equity, dignity, confidentiality
- include client/family in discussion, 1 team member as primary communicator, avoid irreversible decisions, withdraw vs withhold treatment, DOCUMENT
(1) medical and nonmedical risks/benefits of intervention (2) how did patient establish preferences (3) QOL (4) contextual factors
Function of relevant cranial nerves
- CNV: trigeminal: sensory: ant 2/3 of tongue, face/oral cavity; motor: TVP, tensor tympani, suprahyoid (hyolaryngeal movement), muscles of mastication (pterygoids, temporalis, masseter)
- CNVII: facial: (temporal, zygomatic, buccal, mandibular, cervical) sensory: external ear, taste for ant 2/3 of tongue; motor: facial exp, post belly of digastricus, stylohyoid, stapedius, mucosa of oral/nasal cavity, glands - lacrimal, submandibular, sublingual
- CNIX: glossopharyngeal: sensory: oropharynx, gen/taste for post 1/3 of tongue; motor: stylopharyngeus (laryngeal elevation/pharyngeal shortening), parotid gland
- CNX: vagus: (pharyngeal branch, RLN - subglottic sens, SLN - hypopharynx/larynx) sensory: pharynx/larynx, taste to epiglottis; motor: pharyngeal constrictors, palatal muscles (NOT tvp), palatoglossus, long pharyngeal muscles (NOT stylophar), intrinsic laryngeal muscles (RLN, SLN = CT), esophagus, glands of pharynx/larynx/trachea/esophagus; COUGH: irritation -> afferent signals to medulla (CN X) -> efferent impulses to muscles for cough (CNX, phrenic nerve, other spinal motor nerves)
- CNXI: (spinal) accessory: motor: trapezius, SCM (posture)
- CNXII: hypoglossal: motor: intrinsic lingual (size/shape), extrinsic lingual muscles (except palatoglossus) (location, genio protrudes, hyo/stylo retract base)
Risk Factors for Aspiration (name 5)
Age, artificial airways, bedbound/inactive, cognitive impairment, dysphagia, feeding tube, frailty, esophageal motility disorders, impaired cough reflex, poor oral health, post-surgery, neurologic disease, residue, suctioning, unintentional weight loss
Compensatory Strategies
1. Bolus (increased volume, increased viscosity)
2. Postural (upright - 70 to 90, reclined - 30 to 70, side-laying on stronger side)
3. Head positioning (chin tuck (head flexion), head turn/rotation to stronger side, head tilt to stronger side, head extension, head turn + chin tuck)
4. Swallow maneuvers ((super) supraglottic, effortful, Mendelsohn, hawking, sensory awareness (TTS))
Name 3 causes of mechanical dysphagia
•Cervical osteophytes
•Cricopharyngeal bars
•Pharyngeal webs
•Diverticulum
•Head and neck cancer
•Trauma to structures of the head and neck
Location of taste buds
tongue, soft palate, posterior pharyngeal wall, epiglottis
- no specific areas on tongue for one taste
Describe the central pattern generators
Nucleus tractus solitatious (NTS) - sensory information from perphery (V, VII, IX, X)
Nucleus ambiguous (NA) - initates pharyngeal swallow (V, VII, IX, X, XII)
Brainstem: CPG
Three pillars of pneumonia from aspiration
1. impaired health status (compromised immune system)
2. impaired airway protection (dysphagia)
3. impaired oropharyngeal environment - bacterial colonization (poor oral health)
Restorative strategies
Indirect
- Shaker (head lift), recline exercises (isometric, isotonic), CTAR (isometric, isotonic), labial/lingual strengthening (IOPI, tongueometer, swallowstrong), VF exercises, respiratory muscle strengthening (EMST), jaw strengthening (therabite)
- pull tongue back with gauze, yawn, gargle
- falsetto, effortful pitch glide (EPG)
Direct
- (super) supraglottic, Mendelsohn, effortful, masako (tongue hold)
Tech:
- surface electromyography (sEMG), High resolution manometry (HRM), Neuromuscular electrical stimulation (NMES), cortical stimulation, Continuous positive airway pressure (CPAP)
Programs:
- McNeil dysphagia therapy program (MDTP) - High intensity, repetitive swallowing of liquids/foods focusing on “hard and fast” swallows
- Respiratory-swallow training (RST) - HNC - ID, acq (swallow during expiratory phase at mid-to-low lung volume), mastery
- Lee Silverman voice treatment (LSVT) - hypokin dysarth / others - max phonation duration, glides, func sp loudness drills, carry-over activity
- intensive dysphagia rehabilitation (IDR) Program - neurogenic - 2 exercises selected and completed on alternating days, set of “challenging” swallows
- MD Anderson swallowing boot camp - HNC - short, intense (daily, 2-3 weeks) outpatient program
Name iatrogenic causes of dysphagia
•Medical procedures/surgery
•Medications
- ant cervical discectomy and fusion
- pill-induced esophagitis
What age do fetus' begin to swallow?
As early as 9 weeks gestation
Motor neurons
UMN: cortex to LMN (corticobulbar: head and neck) - damage: muscle weakness, spasticity, increased reflexes - contralateral for CNVII (lower), XI (SCM, bilat for trapezius), XII (genioglossus)
LMN: brainstem (CNs) or spinal cord (nerves) to muscle (corticospinal: trunk and limbs) - final common pathway - damage: muscle weakness, flaccidity, reduced reflexes, muscle atrophy, fasiculation
Cortex -> UMN -> brainstem -> LMN -> muscle
8 levels of penetration/aspiration
1. contrast doesn't enter
penetration (2-5)
2. contrast enters - above - no residue
3. contrast enters - above - residue
4. contrast enters - contacts - no residue
5. contrast enters - contacts - residue
aspiration (6-8)
6. contrast enters - below - no residue
7. contrast enters - below - residue (response)
8. contrast enters - below - residue (no response)
Non-behavioral approaches
- Medical: botox, radiotherapy
- Surgical: cricopharyngeal (CP) myotomy, PES dilation, VF medialization, laryngeal suspension/separation, laryngectomy, denervation/rerouting/excision of salivary glands
- prosthetic: dentures, palatal augmentation prosthesis, lingual
Name 3 esophageal causes of dysphagia
- pharyngoesophageal reflux, esophageal eosinophilia, hiatal hernia, scleroderma
IDDSI testing
Liquid: 0 (thin): less than 1mL, 1 (slightly thick): 1-4mL, 2 (mildly thick): 4-8mL, 3 (moderately thick): 8-10mL, 4 (extremely thick): 10mL - no drip
Solid: 3 (liquidized): dollops/strands through fork, 4 (pureed): mound/small flow tail on fork + spoon tilt shape and little left, 5 (minced and moist): fork test (4mm fork prongs, 2-8mm children, 4-15mm adults) + spoon tilt shape and little left with flick + thumb doesn't blanch, 6 (soft + bite sized): thumb blanches + shape doesn't return (8mm x 8mm children, 1.5cm x 1.5 cm adults), 7 ((1) easy to chew): breaks easily with fork + thumb blanch + no shape ((2) regular): no test
Spinal nerves
- cervical spinal nerve 1 (C1): motor: geniohyoid, thyrohyoid
- ansa cervicalis (C1-C3/4): motor: infrahyoids