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COMPREHENSIVE DYSPHAGIA MANAGEMENT

COMPREHENSIVE DYSPHAGIA MANAGEMENT. INDIANA OUTREACH SERVICES Jamie Bailey MCD-CCC-SLP james.bailey@fssa.in.gov. FOUNDATIONS. ASPIRATION SILENT ASPIRATION DYSPHAGIA TRIGGERS COUGHING CHOKING GASTROESOPHAGEAL DISEASE(GERD). ASPIRATION AND SILENT ASPIRATION.

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COMPREHENSIVE DYSPHAGIA MANAGEMENT

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  1. COMPREHENSIVE DYSPHAGIA MANAGEMENT INDIANA OUTREACH SERVICES Jamie Bailey MCD-CCC-SLP james.bailey@fssa.in.gov

  2. FOUNDATIONS • ASPIRATION • SILENTASPIRATION • DYSPHAGIA • TRIGGERS • COUGHING • CHOKING • GASTROESOPHAGEAL DISEASE(GERD)

  3. ASPIRATION AND SILENT ASPIRATION • ASPIRATION - passage of food or liquid through the vocal folds and into the lungs • SILENTASPIRATION - Aspiration occurring with no signs/symptoms (aka triggers)

  4. LONG TERM CONSEQUENCES OF ASPIRATION • Pneumonia • Lung Damage • Death

  5. Cause of Death (MR/DD) in Indiana

  6. ASPIRATION MAY OCCUR ANY TIME DAY OR NIGHT This includes: • Meals • Oral Care • Medication Administration • Bathing • Dressing • Sleeping

  7. DYSPHAGIA DYSPHAGIA-Difficulty feeding or swallowing • 3 types of Dysphagia • Oral • Pharyngeal • Esophageal

  8. Oral Prep Oral Phase DYSPHAGIASwallowing Phases

  9. DYSPHAGIASwallowing Phases Pharyngeal Phase

  10. DYSPHAGIASwallowing Phases Esophageal Phase

  11. Dysphagia • TRIGGERS- Signs or symptoms associated with possible aspiration

  12. Coughing w/ signs of struggle Wheezing Wet Vocal Quality or Respirations Excessive Drooling Pocketing of food in the mouth Sudden change of color around the lips and face Fever (24-48 hours post suspected incident) Refusal of foods or liquids Watering eyes Gagging Facial Grimacing Smell of formula on breath Increased Residuals EXAMPLES OF DYSPHAGIA WARNING SIGNS OR TRIGGERS

  13. Dysphagia Triggers TRIGGERS SHOULD BE INDIVIDUALIZED Examples: • Vocalizing in a low wet sounding moan • Residue in the mouth after liquid intake • Fatigues before meal is completed • Increased vocalizations during oral intake • Leaning to the left in chair

  14. COUGHING Airway is not blocked Keeps your throat and airway clear May be dry or productive If Coughing: Encourage coughing and clear airway CHOKING Airway is blocked Medical emergency Lack of oxygen to the brain If Choking: Follow the provider’s emergency protocol Coughing or ChokingWhat’s the difference?

  15. Dysphagia Triggers What to do if you notice a Dysphagia trigger Check all Plans: • Diet Texture • Fluid Consistency • Positioning • Eating Instructions • Adaptive Equipment • Pace of Eating • Bite or Drink Size • Other Dysphagia Interventions • INTERVENE AND SELF CORRECT IF ANY OF THE PLANS OR INSTRUCTIONS WERE NOT FOLLOWED CORRECTLY

  16. Dysphagia Triggers What to do (cont) IF INDIVIDUAL HAS STOPPED EXHIBITING THE TRIGGER AND IS SAFE FROM HARM: • Resume meal or activity IF INDIVIDUAL DEMONSTRATES THE TRIGGER AGAIN: • Stop meal or activity • Call for an evaluation • Document who was called and the time of the call • Document occurrence of trigger on the flow record • Wait for further instructions

  17. GASTROESOPHAGEAL DISEASE (GERD) • GERD - Acidic stomach contents that move backward into the esophagus or mouth

  18. Hiatal Hernia Lower Esophageal Sphincter Incompetence (LES) CAUSES OF GERD

  19. GERDWho’s at risk? • People with skeletal deformities • People who smoke, drink coffee, or alcohol • People who take relaxants • People with delayed stomach emptying • People who eat high fat diets • People who take medications that relax muscles • People with seizure disorders that take medication that affects muscle tone

  20. DYSPHAGIA IMPLICATIONS OF GERD • Inhalation of stomach contents into the lungs (aspiration) resulting in possible pneumonia • Esophagitis • Strictures • Ulcerations

  21. GERD SIGNS AND SYMPTOMS • Hoarseness • Drooling • Coughing • Hand in mouth • Repeated swallowing • Frequent respiratory problems (i.e., coughing, wheezing, bronchitis, pneumonia) • PICA • “Sour” smelling or “Formula” burps

  22. TREATMENT FOR GERD • PROTON PUMP INHIBITORS (Nexium, Prilosec, Prevacid are examples) • Elevation – from top of head to at least hips, if not able to be totally upright • Supported so not curving sideways or slumping forward • Elevated right sidelying or prone positioning may assist with stomach emptying and decrease reflux

  23. TREATMENT FOR GERD (cont) • Slow down eating • Encourage thorough chewing • Frequent small meals • No meals 2-3 hours before lying down

  24. MINIMIZING THE RISK OF ASPIRATION AND MANAGING DYSPHAGIA I. GENERAL INFORMATION • Evaluation • Preventive Measures • Diet Texture • Mealtime • Oral Care • Medication • ADLs ( personal care, dressing, bathing, toileting, and bedtime) • Positioning • Training • Monitoring and Tracking II. Program Implementation

  25. Physician and Nursing >>> Speech Pathologist>>>>>> Occupational Therapist>>> Physical Therapist>>>>>>> Dietary>>>>>>>>>>>>>>>> Behavior Clinician>>>>>>> Overall Health and Risk Assessment Diet Texture and Swallow Evaluation Adaptive Equipment, Positioning Positioning, Transfers Meal and Nutritional Planning Behavioral Food Issues EVALUATION

  26. EVALUATION TEAM APPROACH • Identify factors that increase the risk of aspiration • Discuss: • Mealtime problems • Positioning issues • Oral care • Medication administration • Risk issues

  27. PREVENTITIVE MEASURESDIET TEXTURE • Our job is not to take variety away from individual but to ensure that people can safely eat a variety of foods. • Diet Textures are typically described as: • Regular • Mechanical #1-Whole Sandwich Meat • Mechanical #1-Chopped • Mechanical #2 Soft-Ground • Pureed

  28. PREVENTITIVE MEASURES DIET TEXTURE REGULAR • This diet includes all foods with no texture restrictions. • Peanut butter may be thinned with Syrup, Honey, or Jelly

  29. PREVENTITIVE MEASURESDIET TEXTURERegular

  30. PREVENTITIVE MEASURES DIET TEXTURE MECHANICAL #1-Whole Sandwich Meat • For individuals who have mild chewing and swallowing deficits. They have increased difficulty tolerating certain types of meats, fresh fruit, and raw vegetables, however they are able to tolerate specific sandwich items.

  31. PREVENTITIVE MEASURES DIET TEXTUREMech #1 – Whole Sandwich Meat

  32. PREVENTITIVE MEASURES DIET TEXTURE MECHANICAL (#1)-chopped meat • For individuals who have mild chewing and swallowing deficits. They have increased difficulty tolerating certain types of meats, fresh fruit, and raw vegetables. These individuals are unable to tolerate whole sandwich items.

  33. PREVENTITIVE MEASURES DIET TEXTUREMech #1 (Chopped meat)

  34. PREVENTITIVE MEASURES DIET TEXTURE MECHANICAL (#2) SOFT-ground meat • For individuals who have limited chewing or swallowing mobility but are able to tolerate a greater variety and texture of foods than the pureed diet offers.

  35. PREVENTITIVE MEASURES DIET TEXTUREMech #2 Soft (Ground Meat)

  36. PREVENTITIVE MEASURES DIET TEXTURE PUREED • For individuals who have severe difficulty chewing or swallowing. All foods are pureed/blended.

  37. PREVENTITIVE MEASURES DIET TEXTUREPureed

  38. PREVENTITIVE MEASURES DIET TEXTURE • Drink (Fluid) textures are generally described as: • Thin-any fluid texture is allowed • Nectar-tomato juice, prune juice, buttermilk • Honey-honey, milkshake • Pudding-spoon thick

  39. PREVENTITIVE MEASURES DIET TEXTURE (Nectar)

  40. PREVENTITIVE MEASURES DIET TEXTURE RESTAURANT FOODS CONSISTENCY CHART • All foods whether at the individual’s home or away on trips must be modified to fit their specific diet texture. • How to modify foods outside of the home • Portable Chopper • Fork mashing • Cutting with knife

  41. Restaurant Foods Consistency Chart • Please refer to your handout.

  42. PREVENTITIVE MEASURES DIET TEXTURE Things to Consider: • The risk for malnutrition and dehydration increases when diet is altered. • Formal Nutritional Assessment should be completed by a Dietician • Alternative Nutritional Considerations • Airway is repeatedly assaulted regardless of supportive interventions • Nutritionally compromised • Impairments consistently interfere with food/fluid intake • Respiratory Status is compromised

  43. GENERAL FACTORS Dining room should be quiet Minimal distractions Conversations should not be encouraged when individual has food in their mouth Encourage individual to focus on swallowing Positioned appropriately Monitor food textures PREVENTITIVE MEASURESMEALTIME

  44. PREVENTITIVE MEASURESMEALTIME GENERAL FACTORS cont… • Straw decreases the level of oral sensation • Small amounts per bite and sip is easier to manipulate and tolerate • Alternating sips and bites helps clear the oral cavity • If wearing dentures, they should be well-fitted • Remain upright for at least 30-60 minutes after oral intake

  45. PREVENTITIVE MEASURESMEALTIME Things to Consider: • The person may not be able to tolerate 3 large meals • Liquids that are thickened may change in consistency over time • Repositioning may be needed during the course of a meal • Person may fatigue through the meal and have more trouble swallowing safely • The type of Adaptive equipment needed changes over time • Swallow strategies change over time

  46. PREVENTITIVE MEASURESMEALTIME Positioning • Make sure the person is properly elevated, aligned and supported. • Head is maintained in midline with chin tucked unless otherwise specified Tools • Adaptive mealtime equipment (coated spoon, divided plate, small bowled spoon, measured cups etc.) • Adapted positioning equipment • Compensatory strategies • Diet texture modifications • Environmental modifications

  47. PREVENTITIVE MEASURESMEALTIME Common Errors Bites that are TOO BIG and sips that are TOO MUCH What is too big? Any bite or sip that is unable to be safely handled in 1 swallow How to Correct • Follow the dining plan • Watch the neck for signs of a swallow • Use the correct utensils • Do not overload the eating utensil • Spread food out over entire plate

  48. PREVENTITIVE MEASURESMEALTIME Common Errors (cont) Giving bites and sips TOO FAST!!! What is too fast? When the person does not have time to swallow and breathe between bites or sips. How to Correct • Follow the dining plan for the number of swallows needed for each bite or sip • Know how to identify the person’s swallow • WATCH for the swallow—DO NOT GUESS! • Watch for distress signals that tell you the person needs to swallow again

  49. PREVENTITIVE MEASURESMEALTIME Poor head alignment What is Poor Head Alignment? When the head is not in midline with a chin tuck (Not only when giving food/fluid but during the swallow). How to Correct • Follow the dining plan for instructions on supporting or cueing the person for midline with a chin tuck or as specified. • Asafe practice is maintaining the head in midline with a chin tuck from presentation until after the swallow.

  50. PREVENTITIVE MEASURESMEALTIME Poor placement of the food/fluid What is poor placement? When the food or fluid is placed where the person is unable to safely swallow or handle it. How to Correct • Follow the Dining Plan • Place food/fluid on the center of the tongue or an alternate place in the mouth as noted on the dining plan • Use the correct utensil as specified on the dining plan.

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