---To make treatment most effective the clinician must:
 --Understand the patient’s medical problems
  causing the dysphagia, as well as the patient’s
  swallowing physiology.
 --The treatment plan must be tailored to the
  specific diagnosis.

Planning Treatment
---Respiratory function should be considered.
 --Normal swallowing requires airway closure for a  brief period of time-3-5 seconds or more  during continuous cup drinking.
 --If a patient’s respiratory function is poor, they  may be unable to tolerate even the normal  brief duration of airway closure duration.
---Some swallowing therapy procedures require modifying airway closure duration, such as super-supraglottic swallowing.
---If respiratory function is severely affected, some types of swallowing therapy may need to be postponed until respiration improves.
--Diet should also be considered:

• Oral Feeding: If a patient can tolerate a  consistency without aspiration they can be fed orally.
• Nutritional supplements may be needed in addition to food.
• Nonoral:  If a patient aspirates more then 10% of every bolus, regardless of food consistency they should not be fed orally.

Gastroesophageal Reflux: Therapy Procedures:
---Laparoscopic Antireflux Surgery (LARS)
 --These procedure has been shown to be safe  and effective for the control of  gastroesophageal reflux disease.
 --This is a surgical procedure that involves twisting the top of the stomach around the lower esophageal sphincter to reduce reflux.
 --This procedure can be performed safely in an ambulatory surgery center.
 ---The outpatient setting is a safe, cost-effective, and patient friendly location for the performance of Laparoscopic Antireflux Procedures.
---Some complications with LARS include:

•  --Acute Paraesophageal Hiatus Herniation
•  --Severe Dysphagia
•  --Pneumothorax
•  --Vascualar Injury
•  --Perforation of the Gastrointestinal Tract

Reduced Airway Closure, Reduced Laryngeal Elevation, & Aspiration
--Compensatory Strategies work best because other types of exercises may put further stress and work on the respiratory system and may be unproductive.
---Compensatory changes usually do not increase muscular effort or the duration of airflow closure, which tends to be a problem with patients who have a respiratory disease.
---They do not fatigue the patient as much as some swallowing exercises.
---These treatment procedures are those that control the flow of food and eliminate the patient’s symptoms, such as aspiration.
---They do not change the physiology of the patient’s swallow.

---Postural Techniques

• These techniques are usually used temporarily:
• Until the patient’s swallow recovers or Direct therapy procedures take effect
• For Reduced Laryngeal Closure-Aspiration During the Swallow the following postural technique is recommended:
• Chin Down-Head Rotated to the Damaged Side
• This position puts the epiglottis in a more protective position.
• It narrows the laryngeal entrance.
• It increases the vocal fold closure by applying extrinsic pressure.
• The Chin Down Posture
• ---Involves touching the chin to the neck.
• ---This pushes the anterior pharyngeal wall posteriorly.
• ---The tongue base and epiglottis are pushed closer to the posterior pharyngeal wall.
• ---The airway entrance is narrowed.
• The Head Rotation Posture
• ---Head rotation to the damaged side twists the pharynx so that food flows down the more normal side.
• ---Head rotation pushes the damaged side toward the midline, therefore improving adduction.

• This should only be done if other compensatory or therapy strategies are not  feasible.
• For reduced laryngeal closure at the airway entrance it is recommended that the food consistencies consist of purees and thick foods including thickened liquids
• For reduced laryngeal elevation causing reduced cricopharygneal opening, thin liquids may be used

• ---Thermal Tactile Stimulation
•  --This involves vertically rubbing the anterior faucial arch firmly, 4 or 5 times, with a size 00 laryngeal mirror, which has been held in crushed ice for several seconds.
•  -- This occurs before the presentation of a bolus  and the patient’s attempt to swallow.
• ---The Suck-Swallow
• ---This involves using increased vertical tongue-jaw movements with the lips closed.
• ---This technique also draws saliva to the back of the mouth.

• Laryngeal Elevation Exercise-The Falsetto  Exercise:
• The patient is asked to slide up the pitch scale as high as possible to a high squeaky voice.
• When the patient reaches the top of the scale, they should hold the high note for several seconds with as much effort as possible.
• During the production of the falsetto, the larynx elevates almost as much as it does during the swallow.
• The patient may take a hand and gently pull up on the larynx to assist laryngeal elevation during the procedure.
• The manual assist should not be done during the swallow because the hand may get in the way of the swallow.
• Airway Entrance Range of Motion Exercises:
• If laryngeal incompetence during swallowing cannot be managed quickly by postural assists or by teaching the patient to voluntarily close the airway, a sequence of range of motion exercises should be initiated.
• The patient is asked to complete the series 5 to 10 times daily for 5 minutes each time.
• The patient should be seated and instructed to hold their breath and to bear down for a second, then to let go.
• The patient may do this while pushing down or pulling up on a chair with both hands for several seconds.
• ---The Supraglottic Swallow
•  --Goal: To close the vocal folds before and during the swallow, therefore protecting the trachea from aspiration.
•  --Can be attempted at first during a videofluoroscopic study at the bedside.
•  --Patient must be alert, relaxed, and able to follow directions.
•  --The patient is given material to swallow and told to keep it in their mouth while the followingdirections are given:
•   1.  Take a deep breath and hold your breath.
•   2.  Keep holding your breath and lightly cover your tracheostomy tube (if present).
•  3.  Keep holding your breath while you swallow.
•  4.  Immediately after you swallow, cough.
• ---These steps should first be practiced with the patient on saliva swallows.
• The Super Supraglottic Swallow
• --This maneuver is recommended for reduced airway entrance
• --Goal:  To close the entrance to the airway voluntarily.
• --It tilts the arytenoid cartilage anteriorly to the base of the epiglottis before and during the swallow and closes the false cords tightly.
• --This is the normal mechanism for the closure of the entrance to the airway, and is facilitated during normal swallow by the elevation of the larynx.
• --The effort involved in the swallow increases the anterior tilt of the arytenoid and the false vocal cord closure to close the airway entrance.
• --This takes place before and during the swallow.
• --The patient is given the following instructions:

•   1.  Inhale and hold your breath very tightly, bearing down.
•  2.  Keep holding your breath and bearing down as you swallow.
•  3.  Cough when you are finished.
• ---The bearing down helps to tilt the arytenoid forward, close the false vocal folds, and close the entrance to the airway.
• ---This swallow improves the rate of laryngeal elevation at the beginning of the swallow.