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Background Information: Sixty-one year old male. Married with two children. Factory employee. Interests included football and travelling.
Medical History: Traumatic subarachnoid haemorrhage post fall in August 2015. Moderate head injury which impacted considerably on his neurological status. He has been NPO and has PEG feeding in situ since his head injury. Weight stable. Occasional lower respiratory tract infections which have ben linked to PEG feed. No LRTI's in last 4 months.
Reason for Referral: Family querying if client might be suitable for swallow rehabilitation.
Clinical Swallow Evaluation: Client attended with wife. He was wheelchair bound. Limited volitional upper limb function. Occasional voicing observed (e.g., when anxious). Good eye contact and facial expression noted.
Client presented with right facial weakness and poor lip seal (CN VII motor). Some spontaneous saliva swallowing was observed. He was managing his secretions well although he had a Hyoscine patch positioned behind his left ear.From an airway protection perspective, he could produce strong vocalisations indicating that vocal cords were adducting to some degree. During swallow trials, client required hand over hand assistance for feeding. He presented with poor bolus acceptance of any bolus into the oral cavity/limited mouth opening at the oral preparatory stage of the swallow. Oral and pharyngeal phase of swallow could therefore not be evaluated.
Based on this initial assessment, exploratory dysphagia rehabilitation was recommended. The aim of intervention would be to return client to a partial PO intake both for quality of life and to rehabilitate his swallow from a neuroplasticity viewpoint. This was highlighted to family members as a full oral diet and PEG removal was highly unlikely given extent of dysphagia, fluctuating alertness levels, risk factors for aspiration pneumonia (immobility, inability to self feed, neurological status etc.) and and post-acute phase of recovery since traumatic subarachnoid haemorrhage. Family understood this and were very agreeable to the proposed plan. When asked, it was explained that client was not a candidate for Vitalstim (neuromuscular electrical stimulation or NMES) as he could not elicit a swallow on command. An instrumental evaluation (videofluoroscopy or FEES) was not deemed appropriate at this point as cleint was reluctant to accept a bolus into the oral cavity.
Client and wife attended for dysphagia rehabilitation twice weekly for a three month period. Client was adequately alert for all but two sessions, where sessions were discontinued due to drowsiness. He typically responded very well to auditory and tactile prompting to increase alertness for dysphagia rehabilitation. The nature of dysphagia intervention is described below.
1. Dysphagia intervention began with a Sensory (gustatory, thermal, olfactory) Stimulation programme. This included the presentation of multiple taste stimuli (e.g., sugar grains, salt, lemon juice, pepper, bitter) on client’s lips and observation of his response to these stimuli. Over the course of three to four sessions, he began to consistently respond to these taste stimuli by smacking and licking his lips and accepting material into the oral cavity.
2. Deep Pharyngeal Neuromuscular Stimulation (DPNS) was initiated during the fifth session to strengthen his pharyngeal swallow. It was highlighted to the clients wife and to the multidisciplinary team that this intervention currently has no published evidence base. However, DPNS manoeuvres were observed to initiate a pharyngeal swallow response within sessions which was promising from a "use it or lose it" and "use it and improve it" perspective. Using chilled lemon glycerine swabs, numerous DPNS techniques (e.g., lateral pharyngeal stimulation, lingual glide) were used (c. 20 per session). The client began producing a consistent strong pharyngeal swallow in response to each stimulation. Adequate hyo-laryngeal excursion was noted subjectively. The rationale behind this intervention was to increase the number of pharyngeal swallows she was eliciting and to strengthen his pharyngeal swallow from a neuroplasticity viewpoint.
3. After six weeks of rehabilitation during which his chest remained clear, the client was first trialed with oral trials of crushed ice using a cold metal spoon. He accepted the bolus into the oral cavity and initiated a prompt pharyngeal swallow in response to the crushed ice. He subjectively appeared to clear the bolus efficiently from his oral cavity and pharynx. He did not produce any overt signs of aspiration (i.e., wet voice, reflexive cough, respiratory changes). This was continued for several sessions.
4. Two weeks later, the client was initially trialed with five small teaspoons of vanilla ice-cream. He tolerated this small amount well at a slow rate and his enjoyment of this was very clearly evident (i.e., smiling facial expression). Since this date, the client has been given teaspoons of fruit sorbets (mango, raspberry, lemon sorbet) which his husband has brought into the sessions and he has tolerated 15-18 tspns sorbet per session without any overt signs of aspiration. This was an ideal bolus from a taste, temperature and consistency viewpoint. The rationale here was that swallowing small amounts orally will act as a rehabilitation to strengthen the clients swallow.
Instrumental Dysphagia Examination
The client attended for a videofluoroscopy ten weeks into his dysphagia rehabilitation. See report below. He swallowed eighteen teaspoons of sorbet ice-cream and puree consistency (Petit Filous) with efficient bolus clearance (Eisenhuber rating= 1). There was no evidence of aspiration (Penetrtion-Aspiration Scale scores=1). He presented with a moderate to severe dysphagia (DOSS level 2).
Impression: Moderate oral preparatory, oral and pharyngeal stage dysphagia. This was characterised by anterior spillage & weak labial tone), mild lingual and vallecular residue (weak lingual tone) and a swallow reflex delay (tongue base sensation). However, his swallow is relatively prompt, hyo-laryngeal excursion and UOS opening are adequate and pharyngeal sensation is good, with spontaneous swallows being elicited without cueing to clear oro-pharyngeal residue. There was no evidence of penetration or aspiration during procedure and bolus clearance through the pharynx is effective.
DOSS Severity Rating: 2 moderate severe- requires alt feeding & partial PO only
Advice and Recommendations
Compensatory: Ensure pt is sitting upright and alert and his chest status is clear/she is medically stable. Ensure cold bolus (sorbet or ice-cream) to maximise sensory stimulation. Use cold metal spoon. Slow rate and verbal encouragement.
Diet modification: 15 tspns sorbet/ice-cream (assorted flavour- raspberry, mango, lemon- as per Tx sessions) administered daily by SLT.
Rehabilitation: as per above. Limited PO diet should serve as swallow rehabilitation.
Please monitor for reduced chest or increased temperature, if occurs place NPO and request SLT r/v
The following oral diet recommendations were made when client is (i) medically well, (ii) her chest is clear and (iii) he is sitting upright in her chair and adequately alert:
- 15 tspns sorbet/ice-cream (assorted flavour- raspberry, mango, lemon- as per Tx sessions) administered at a slow rate daily by a dysphagia-trained SLT. The daily rate is important in order to promote long term change in swallow function. SLT to observe for any overt signs of aspiration and discontinue if evidence of same.
- In the longer term, it might be reasonable to consider trialling other foods of a similar consistency (e.g., mashed potato or carrot with butter; chocolate mousse; rice pudding) and training of staff from residential care setting to asist with feeding.
Nine months on, client continues on above oral diet which has benefit client and family members from quality of life point of view. It is also proposed that initiation of this oral diet has also benefited the swallow from a neuroplasticity perspective.
Take Home Message:
This case demonstrates that adults with chronic dysphagia may benefit from direct intervention.