Kristi Roya and Allison Latiolais
COPD: Treatment and Maintenance of Dysphagia
---To make treatment most effective the clinician must:
--Understand the patientís medical problems
causing the dysphagia, as well as the patientís
--The treatment plan must be tailored to the
---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 patientís respiratory function is poor, they may
be unable to tolerate even the normal brief duration of airway closure
---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:
Gastroesophageal Reflux: Compensatory Procedures
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.
---Cigarette smoking may influence reflux, therefore, smokers
with complaints and disorders caused by reflux should strongly be
advised to STOP smoking.
---Rehabilitative measures may also be helpful, including dietary
modification and training in specific swallowing techniques.
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
---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
--Perforation of the Gastrointestinal Tract
---This treatment is used in the elderly, as well as adult patients
---The indication of LARS usually depends on the age of the patient.
---Maintenance: Quality of life after LARS is evaluated by performing
a 24 hour PH monitoring and esophageal manometry.
---Reflux decreases significantly after surgery and is comparable to
that of healthy individuals.
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 patientís symptoms, such as aspiration.
---They do not change the physiology of the patientís swallow.
Food Consistency Changes
These techniques are usually used temporarily:
Until the patientís swallow recovers or Direct therapy procedures take
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
---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
This should only be done if other compensatory or therapy strategies are
For reduced laryngeal closure at the airway entrance it is recommended
that the food consistencies consist of purees and thick foods including
For reduced laryngeal elevation causing reduced cricopharygneal opening,
thin liquids may be used
Reduced Airway Closure, Reduced Laryngeal Elevation, and Aspiration:
---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 patientís
attempt to swallow.
---This involves using increased vertical tongue-jaw movements with the
---This technique also draws saliva to the back of the mouth.
--Are designed to change swallowing physiology.
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
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
--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.