What can be done to prevent and treat Aspiration Pneumonia?
Feed with hand-over-hand or as independently as possible
Have people eat at 90 degree angle (as upright as possible)
Oral hygiene measures after every meal, make sure nothing is left in the oral cavity
Know their medications, avoid those with sedative effects when possible
Exercises to strengthen the swallowing muscles
New techniques like electrostimulation to shorten the length of a patient’s dysphagia symptoms
Treat their dysphagia symptoms to the best of your ability
McNeill Dysphagia Therapy
The McNeill Dysphagia Therapy Program (MDTP) is an exercise-based therapy framework for the treatment of swallowing issues in adults with dysphagia. It focuses on progressive strengthening and coordination of the act of swallowing, by using functional swallow activities and refining the muscles that influence movement patterns involved in swallowing. This therapy uses a “hard swallow” technique with feeding tasks to challenge the patient’s swallow system. The MDTP sessions systematically contain more swallow attempts than traditional swallowing therapy to allow for greater intensity and eliminating maladaptive or avoidance behaviors. The program is 15 sessions, originally intended to be once daily for 15 consecutive days.
Frazier Free Water Protocol
Due to concerns about aspiration and aspiration pneumonia, patients with dysphagia are typically prescribed a thickened liquid diet. However, when fluid intake of patients who suffered a stroke and were prescribed a thickened liquid diet are quantified, they do not consume the recommended amount of fluid intake unless additionally receiving intravenous fluids. Further, many patients with cognitive and language impairments have difficulty expressing their need for liquids. Some of recommendations can leave our patients at risk for complications. Those on thickened liquids may experience dehydration, urinary tract infection, and/or fever. Water, however, contains less pathogenic bacteria than other fluids, and
small amounts of aspirated water can be absorbed into the bloodstream without causing an infection. If it is safe, it may be possible to follow the Frazier Free Water Protocol if the patient is stable, doesn’t have a compromised respiratory system, is mobile and can sit fully upright, can drink water without coughing, has intact cognition, and no oral or dental infection.
Lee Silverman Voice Treatment
Dysphagia can occur at all Parkinson’s Disease stages due to some common characteristics including, increased oral transit time, poor bolus formation, oral residue, and/or tongue pumping. Further, aspiration pneumonia becomes a risk because of delayed swallow initiation, piecemeal deglutition or premature spillage of the bolus into the pharynx, gastroesophageal reflux, impaired vocal fold closure, residue in pharynx, and lower esophageal sphincter dysfunction. The Lee Silverman Voice Treatment is a treatment often used with individuals with Parkinson’s Disease. It is an intensive program requiring meeting four hours per week plus homework. Although it is primarily for helping with voice, initial research has indicated promising results for swallowing as well. After LSVT, fewer patients presented with reduced tongue coordination and lateralization during oral preparatory phase. Fewer patients also presented with reduced tongue movement, strength in the tongue, or tongue base retraction.
Respiratory Trainers: IMST and EMST
Respiratory muscle strength measures inspiratory and expiratory pressure. If a patient is breathless, demonstrates a weak cough, or has a known neuromuscular or neurodegenerative disease respiratory pressure generating tool may be helpful. There are two classes, inspiratory muscle strength trainers (IMST) and expiratory muscle strength trainers (EMST). IMST devices are typically used for persons with COPD, ALS, Myasthenia Gravis, Cystic Fibrosis, Asthma, Spinal Cord Injury, Diaphragmatic Paralysis, and some athletes (like rowers and swimmers). There are several IMST devices: Isocapnic Hyperpnea Trainers, Incentive Spirometers, Resistive Trainers, Pressure Threshold Trainers, Computer-controlled biofeedback, and The Breather. For EMST, there are only two devices, The Breather and ESMT150. Both devices can be used for Dysphagia, Stroke, Parkinson’s Disease, COPD, and Spinal cord injury. However, The Breather is better suited for Congestive Heart Failure, Asthma, Vocal Fold Pathologies, Ventilator/Trach Weaning, Sleep Apnea, and Hypertension and ESMT150 can be used with Pompe’s Disease, ALS, Athletes, Vocalists & musicians, and Navy divers & military personnel.
Deep Pharyngeal Neuromuscular Stimulation (DPNS)
DPNS was developed as a result of poor patient compliance with “traditional” dysphagia compensatory techniques using physical therapy techniques and medical research as the inspiration. It evaluates the swallow mechanism from an etiological basis rather than a symptom perspective. It is used for oral and pharyngeal dysphagia by clinicians certified in DPNS. There are no published studies with regards to treatment efficacy. DPNS restores muscle strength and reflexes within the pharynx for improved, efficient swallow function. It concentrates on the tongue base and bitter taste buds for improving the tongue base retraction reflex, the soft palate musculature for improving the palatal reflex and velopharyngeal closure, and the superior and medial pharyngeal constrictor musculature to improve the pharyngeal constrictor reflex. It is often used for stroke patients, individuals with mild to moderate Multiple Sclerosis, mild to moderate stages of Parkinson’s Disease, neuromuscular insufficiency that is age-related, dysphagia with esophageal reflux, Alzheimer’s disease through stage 6 (if the patient is non-combative), and individuals with closed head injury.
Thermal-Tactile Stimulation is a technique designed to stimulate the area of the oral cavity where the swallow reflex is triggered. It consists of stroking the anterior faucial pillars with a cold stimulus. It is suitable for patients who demonstrate delayed initiation of the pharyngeal aspect of swallowing, but there is no effect on other impaired stages of the swallow. It reduces swallow problems and assists in secretion management when it is unsafe to eat orally and also reduces aspiration risk. Thermal stimulation may be applicable for patients demonstrating delays in swallowing activity, but not for patients who show airway compromise. There is a general consensus that short-term therapy effects are not maintained or as powerful as therapy outcomes.
Neuromuscular Electrical Stimulation
NMES produces muscle contractions by stimulating the nerve endings in muscles or the nerves innervating the muscles. Blood, muscle, and tissue are good electrical conductors, whereas skin and fat are not. Research indicates that NMES strengthens deprived muscles, maintains or regain range of motion and motor control, helps with microcirculation, metabolic exchange, lymphatic or venous drainage and pulmonary oxygen uptake. NMES should not be used alone, but instead used as a supplement to other types of therapy.
VitalStim is also an additional modality that can be added to traditional exercise that use electrical stimulation to help with swallowing exercises. Preliminary research indicates combining VitalStim and traditional therapy will allow clinicians to accelerate the strengthening, restoration of function, and the remap of the parts of the brain related to the swallow. As is the case with NMES, research supports using this in combination with other therapies to improve treatment outcomes.
Oral Strengthening Exercise
Oral Strengthening Exercises improve tongue range of motion, tongue resistance, and bolus control activities to strengthen the structures needed for swallowing. Though these exercises you are working on oral motor control, the stimulation of swallow reflex, and the adduction of tissues for airway closure. Oral strengthening exercises can be appropriate for individuals with traumatic brain injury, a stroke, cerebral palsy, head and neck cancer, down syndrome, multiple sclerosis, and/or Parkinson's Disease, but these exercises are not appropriate for patients with neurodegenerative diseases, such as ALS.
Pharyngeal Strengthening Exercises
Pharyngeal Strengthening Exercises are appropriate for patients with Pharyngeal Phase Dysphagia. These exercises increase the trigger of the pharyngeal phase of the swallow, reducing the residue in the valleculae and pharynx, increase laryngeal closure of the airway and laryngeal elevation. These exercises are done by using an effortful swallow, the mendelsohn maneuver, the masako exercise or the shaker exercise.
Different strategies are recommended based on different symptoms. For instance, the effortful swallow reduces residue in the valleculae and improve tongue base control. The mendelsohn maneuver improves tongue base control, reduces residue in the valleculae, increases laryngeal elevation, and prolongs UES opening. The masako exercise, which is also known as the tongue hold exercise or the modified tongue anchor exercise, decrease residue in the valleculae and decreases residue in the pharynx. The shaker exercise, also known as the head-lifting exercise, facilitates an increased opening of the upper esophageal sphincter through increased hyoid and laryngeal anterior and superior excursion.
Diet modifications are common for people at risk for aspiration pneumonia. Diet modifications can be to the type of food served, but can also describe the manner in which the food is presented. Some common terms you see to describe the texture of food are soft, mechanical soft, chopped, ground, and blended. Terms to describe liquid are nectar thick, honey thick, and pudding thick. However, these terms are mostly used in the US. As a result, a new, international naming structure is being rolled out. In this framework, nectar, honey and pudding thick are being replaced by mildly thick (nectar), moderately thick (honey), and extremely thick (pudding).
Trismus is limited jaw mobility as a result of trauma, surgery, radiation treatment, TMJ, muscle damage, joint damage, connective tissue, central nervous system disorders or as a result of dental work. If you have trismus, you have difficulty opening your mouth. An SLP will work with you to find a device that will help increase your flexibility. Two such devices are the Therabite System and Oropress.