To Tuck or Not to Tuck

chin tuck

The chin tuck.  I’m not talking about Chin Tuck Against Resistance (CTAR), I’m talking about the compensatory strategy.  That strategy that we’ve taught so well that nurses, respiratory therapists and doctors all tell patients, if you’re having trouble swallowing, just tuck your chin.  Somewhere down the road, we’ve made the chin tuck the end-all be-all in therapy, just after thickening liquids and diet modification.

We use the chin tuck with patients for a variety of reasons.  We have patients use a chin tuck to widen the valleculae, push the tongue base back placing the epiglottis more posterior and to narrow the airway, according to the research.

We often have patient tuck their chin to eliminate vallecular residue and to help in the prevention of laryngeal penetration or aspiration.

One study (Robbins and Hind 2008) compared using a chin tuck with thin liquids vs. nectar thick liquids and honey thick liquids.  The study found more aspiration with the chin tuck group than with the thickened liquid group, however there were more adverse effects with the group on thickened liquids (dehydration, UTI, fever).

Studies (Robbins et al 2005, Shaker et al 2002) found the chin tuck to be effective in 72% of the patients studied.  They found it may be contraindicated in patients with weak pharyngeal contraction pressure as it decreased pharyngeal contraction pressure and duration.

In my own practice, I have seen the chin tuck as both effective and ineffective.  It has been effective at times in prevention of laryngeal penetration or aspiration.  I have also seen exactly the opposite where patients tried the chin tuck to eliminate vallecular residue.  The patients had no penetration or aspiration until a chin tuck was introduced, which was when the patient aspirated.

The moral to the story:  Don’t assume the chin tuck will always work because it won’t.  Make sure to observe multiple trials of the chin tuck under fluoro to ensure that it is effective in your patient.  Not all patients will benefit from a chin tuck.  Just because Tom does well with the chin tuck and it is very effective for him, does not mean it will be the same for Rick.

Books to Read-The Source for Pediatric Dysphagia

source pediatric dysphagia

If you saw my last Books to Read post and LOVE The Source for Dysphagia, this is another must-have for pediatric SLPs.

This is another great book discussing dysphagia in the pediatric population along with assessment and treatment ideas for various dysfunctions.  This book not only offers great advice, but forms that you can utilize in your practice.

The Source for Pediatric Dysphagia by Nancy Swigert

Variations in Tongue-Palate Pressures with Xantham Gum Thickened Liquids-Research Overview

Steele, CM, Molfenter, SM, Peladeau-Pigeon, M, Polacco, RC, Yee, C.  Variations in Tongue-Palate Swallowing Pressures When Swallowing Xantham Gum-Thickened Liquids.  Dysphagia (2014) 29:678-684.

“Thickened liquids are frequently recommended to reduce the risk of aspiration in patients with oropharyngeal dysphagia.”  We know that tongue-palate pressures increase with thicker liquids, however little is known about the differences in swallowing pressures with nectar and honey thick liquids.

“Liquid boluses are initially held in a chamber along the midline groove of the tongue.  The tongue moves upwards and forwards, compressing a bolus against the palate and squeezing it backwards in a conveyer-belt like fashion.  As the bolus reaches the pharynx, the tongue withdraws from the palate, and sweeps downwards and backwards.” 

Participants:  78 healthy adults.  40 (19 men and 21 women) with a mean age of 27 and 38 (22 women and 16 men) with a mean age of 70.  No participants had a history of swallow, motor speech, gastro-esophageal or neurological difficulties.  

Equipment:  Lingual pressures were measured using the lingual manometry module of the KayPentax Swallowing Signals Lab.  Using a soft silicone strip with three pressure bulbs were placed in the palate and measurements were registered at the anterior, mid and posterior hard palate.  Participants took blocks of 4 repeated sips using flavored (lime, raspberry, diet raspberry or cranberry) water, nectar thick and honey thick liquids.  Sip size was not controlled and cups contained 60 ml of liquid.  The cup was instructed to be removed from the lips following each sip.  The xantham thickener was supplied by Flavour Creations, Inc.  

Results:  Healthy adults do recruit higher tongue-palate pressure amplitudes with nectar and honey thick liquids using xantham gum as compared to water.  The authors warn that “although thicker liquids elicit higher amplitudes of tongue-palate pressure compared to water, the observed values should still be easily achieved by most adults, falling below 40% of maximum isometric pressure values.”  It is also important to remember that although thickened liquids require higher tongue pressures to propel, caution is needed when selecting thickened liquids for patients with reduced tongue strength and that viscosity may become too thick to be effective for oral processing.

The authors also warn that there are limitations to the findings including:

  1. That the sweetness of the flavoring may have contributed to the observed pressure differences compared to the water.
  2. Sip volume was not controlled and the influence of the sip size on tongue pressures is unknown.
  3. Participants with dentures had to remove their top plates to avoid damage from glue from the sensors.
  4. Different thickening agents may encourage different results.

Tongue

I think this area will take an interesting turn with the amount of people getting their tongues pierced.  What are your thoughts?

Course Alert-Cranial Nerves and Sensory Treatment

cranial nerves

I have always loved SpeechPathology.com.  I love the fact that it costs me very little for UNLIMITED CEUs!!!  What could be better?

I was extremely excited when they asked me to do not 1 but 2 webinars!!  The first is on Cranial Nerves and the second is Sensory Treatment options.

I’d love if you would check these out!

Cranial Nerves and Dysphagia:  Making the Connection

A Sensory Approach to Dysphagia Treatment:  After the Cranial Nerve Exam

Oral Care

Aspiration is defined as the inhalation of either oropharyngeal or gastric contents into the lower airways, that is, the act of taking foreign material into the lungs.  (http://emedicine.medscape.com/article/296198-overview)

lungs

At one time, we thought the food/liquid that was aspirated was the most important factor in those who end up with aspiration pneumonia.  I remember being told early in my career to avoid foods/drinks with high sugar content because they will cause the person to develop pneumonia.

There are many factors in developing aspiration pneumonia.  There are people walking around that aspirate on a daily basis that never develop pneumonia.  Others simply look at a  piece of pizza and bam, pneumonia.  Health status, respiratory status, activity level, medications can all play a factor in the development of aspiration pneumonia.  A major factor is oral care.

Bacteria from the oral cavity and nares are the main culprits in causing aspiration pneumonia including:  Streptococus pneumoniae,Haemophilus influenza, Staphlococcus aureus, and gram-negative bacteria (Bacteroides, Prevotella, Fusobacterium).

Oral colonization of bacteria worsens with (Gomes et al 2003, Wan et al 2003):

  • Antibiotic use
  • Oral disease
  • Xerostomia
  • Malnutrition
  • Presence of teeth
Patients at Risk for Aspiration Pneumonia
 
  • Patients who are dependent for oral care
  • Have large numbers of missing teeth
  • Dentures
  • Have limited hand dexterity Decreased mental capacity Multiple medical co-morbidities Immunosuppressed
  • Ventilator dependant
  • Receive non-prandial feedings Have had a stroke
  • Neurologically impaired Xerostomia
  • Known dysphagia
  • Poor access to professional dental care
  • Active smoking
  • Depression
  • Use of sedative medicine
  • Use of gastric acid-reducing medication
  • Use of ACE inhibitor
  • Poor feeding position

 Aspiration pneumonia is a 3 phase process:

  • Colonizes pathogenic bacteria in the oropharynx
  • Aspirates the bacteria into the airway
  • Unable to clear the material and then develops a bacterial infection in the respiratory system

 (Langmore S, Terpenning M., Schork A., Chen Y., Murray J., Lopatin D., Loesche W.  Predictors of aspiration pneumonia:  How important is dysphagia? Dysphagia 1998; 13: 69-81)

 

Proper oral care is essential in the elimination/reduction in this harmful bacteria.  Oral care consists of brushing with a toothbrush and a toothpaste containing fluoride.  Rinsing with a non-alcohol based mouthwash may also help with oral care.

Lemon glycerine swabs are not made for oral care and can, in fact, be very drying to the oral mucosa.

lemon glycerin swabs

toothettes

Toothette swabs do not create adequate friction to clean the oral cavity.

Improper oral care can be linked to increased risk of stroke.

Oral Care Assessment:

oral cavity

The Sage Oral Cavity Assessment is a tool that allows you to rate the oral cavity and assign a severity to oral care or lack of.  

The Oral Health Assessment Tool (OHAT) is a tool that is great for use in the SNF setting.  It is much like the Sage in that you rate the oral cavity condition and assign severity to oral care or lack of.  It also prompts for an admission rating and quarterly ratings.  There are even educational slides to use in facility training.

Oral care is an absolute necessity during a bedside evaluation.  Have you ever tried to chew and swallow a cracker with a severely dry mouth or after you have not brushed your teeth for days?  It’s not easy.  While helping the patient or performing oral care, you have a great opportunity to educate the patient/family member/caregivers on oral care and its importance.  Oral care is a great tool for patients that refuse an NPO status or for patients that are not compliant with diet recommendations.  It’s an absolute essential for everyone.

In the News-Seen around the Web

Find out why it’s harder to swallow after the age of 50!

coffee

Nearly 40 percent of older Americans are living with a swallowing disorder known as dysphagia.

Although it is a major health problem associated with aging, it is unknown whether the condition is a natural part of healthy aging or if it is caused by an age-related disease that has yet to be diagnosed, such as Parkinson’s disease or amyotrophic lateral sclerosis (ALS).

Following a recent study, researchers at the University of Missouri have established a model that identifies aging as a key factor in the development of dysphagia, which may lead to new therapeutic treatments.

“As people age, and especially once they’re 50 and older, their ability to swallow quickly and safely deteriorates with each advancing decade,” says Teresa Lever, assistant professor of otolaryngology at the School of Medicine and lead author of the study.

“For years, we haven’t known why. Through our research with mice, we now know this disorder can occur naturally and independent of another disease.

“Our next step is to study this model to determine why age-related dysphagia, also called presbyphagia, occurs and identify ways to prevent it.”

Pneumonia Risk

Individuals with presbyphagia generally experience slow, delayed, and uncoordinated swallowing that compromises airway function. This puts older individuals at risk for developing life-threatening malnutrition and aspiration pneumonia, which is caused when food or saliva is breathed into the lungs or airways.

These risks are increased when an individual has an existing health condition, such as a neurodegenerative disease, head and neck cancer, or a major surgery.

Videofluoroscopy has long been the gold standard for diagnosing swallowing disorders in humans. A video fluoroscopic swallow study is a radiologic examination of an individual’s swallowing function that uses a special X-ray device called a fluoroscope.

The patient is observed swallowing various foods and liquids mixed with a contrast agent that can be seen by fluoroscopy in order to evaluate his or her ability to swallow safely and effectively.

Same Symptons in Mice

However, because a long-term study of the swallowing ability of an individual as he or she ages is unfeasible, Lever and her research team studied the swallowing function of healthy mice throughout their approximate two-year lifespan.

“We have a miniaturized fluoroscope and swallow test protocol that are unique to our lab that we can use to determine if a mouse has dysphagia,” Lever says. “By studying the swallowing function of healthy mice over their lifespan, we found they exhibit many of the same symptoms of dysphagia as healthy aging adults.”

15 Signs and Metrics

The researchers established 15 metrics that could be compared to human swallowing function. These metrics include functions such as swallow rate, pharyngeal transit time—the time it takes liquid to be swallowed through the pharynx , or throat, and into the esophagus, or food tube—and the number of ineffective swallows through the esophagus.

The researchers found that healthy aging mice develop symptoms of swallowing impairment that closely resemble the impairments seen in older adults: generally slowed swallowing function, impaired tongue function, larger size of the amount swallowed, and an increase in the time it takes liquid to travel through the throat to the stomach.

“We’re about to change the landscape of dysphagia intervention,” Lever says. “For years, we’ve only been able to treat the symptoms and have been unable to address the root causes of dysphagia.

“Though more research is needed, this knowledge sets the stage for us to study ways to prevent, delay or potentially reverse swallowing disorders using new therapies.”

The study was published online by the journal Dysphagia. Funding from the University of Missouri and the National Institutes of Health helped support the project.

Source: University of Missouri Republished from Futurity.org under Creative Commons License 4.0.

*Image of “coffee” via CIAT/Flickr

Source:  http://www.theepochtimes.com/n3/1315567-why-its-harder-to-swallow-after-age-50/