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So after what was supposed to be a lone post about compensatory strategies, everyone got all up in arms about what to do with their cognitively impaired patient, and I totally get it. So here we are with part 2, which actually turned in to the longest post of verbal diarrhea ever, so this is now a 3-part series. Part 3 is all about thickened liquids, you’re welcome.

Did I mention that I passed my exam last week and I’m officially a Board Certified Specialist in Swallowing and Swallowing Disorders (BCS-S) now? Well you do now, and I’m still feeling the effects of celebrating for several days (read: weeks) consecutively, but now the secret’s out as to why I’ve been buried in text books and creating cheat sheets lately. Although it sounds cool to say I sit and sip champagne with my pinky in the air while reading Dysphagia textbooks in my spare time (NOT), there was in fact a reason for this nonsense after all! But you guys made it apparent that you actually dig what I have to say, and for that I’m grateful, so the knowledge vomit shall continue!

Anyways, where was I? Ok, so Gertrude gets admitted to your facility, and being the stellar clinician that you are, you’ve been working tirelessly during your treatment session on those compensatory strategies. But Gertrude has some co-morbidities going on that don’t make you feel completely confident that those strategies will have any sort of carryover. Well what in the heck am I supposed to do now? I’ll just slap her on some puree and honey thick liquids and discharge her from caseload since I can’t really do jack squat about that swallow right? WRONG! Just like compensatory strategies should be used for specific pathophysiological deficits, the same goes for diet changes. I really don’t want you going all Oprah and handing out thickened liquids to the masses. We have a few more tools in our toolbox that we can explore first before we resort to the Oprah thickened liquids method and you discharge everyone on your caseload so that you can get to happy hour on time.

(Disclaimer: For ease of read and to lessen the confusion, I’m sticking with the generic nectar and honey thick liquids for this post. I know IDDSI is all the rage and we should be doing our due diligence of making that conversion, but I’ll leave that to the amazing Karen Shefflers and Dr. Steeles of the world to teach. I’m just trying to spread the good word that honey thick liquid is not the magic potion that cures all dysphagia.)

I briefly mentioned the awesome Logemann (1993) paper in my last post, but I want to expand on that here and now. She suggests introducing treatment methods in the following order:

1. Postural techniques
2. Techniques to enhance oral sensation
3. Swallowing maneuvers
and last but certainly not least: Diet changes!

So like I said, you’re a stellar clinician and you’ve totally conquered #1, so now lets review #2: Techniques to enhance oral sensation. (And again back to the whole stellar clinician thing where you did your extensive cranial nerve exam, so now you’re well aware that Gertrude has some sensory deficits.) There are a whole crap ton of things that can cause a sensory impairment including but not limited to oral surgery, cancer, or any type of CN V, VII, or IX interruption caused by a CVA or disease. Providing increased sensory info can help fine tune the swallowing mechanism ahead of time which may assist those who have difficulty recognizing the bolus in the oral cavity or present with a delayed swallow response. Pretty cool right?

This post is very similar to the last one, only this time we’re going to play a game called, “What else can I try, how do I do it, and WHY?”

Again if this is all new to you, or you’re feeling extra ballsy and want to send these to your colleague, the thickened liquids worshiper, please click the green box at the top and print out the “cheat sheet” to carry with you,

Techniques to enhance oral sensation:

Strategy: Temperature
How do I do it? Present ice chips or a cold bolus
Who’s it for? Anyone with a swallow delay
Why? This is slightly controversial in that several studies have found no change in the swallow with temperature changes, however it is hypothesized that presenting a cold bolus (ice chips or cold liquid) reduces the swallow response delay through increased sensory input.

Strategy: Carbonation
How do I do it? Present carbonated water, soda
Who’s it for? Anyone with a delayed swallow, post swallow residue, or needing to minimize airway invasion.
Why? This is where the one-size-fits-all wizards of the world really grind my gears. I can’t tell you how many times I’ve heard “Oh she’s on nectar thick, but you can just give them soda and it does the same thing..” Wait wuuuuut?!? No. But, carbonation does do some pretty rad things to the swallow. Note: Carbonation is pretty difficult to assess on MBSS due to the fact that barium may neutralize the carbonation, so if this is a technique you’re wanting to try, FEES may be your top choice here.

Strategy: Taste – sour bolus
How do I do it? Present real lemon juice
Who’s it for? Anyone with discoordinated oral transit, delayed pharyngeal swallow
Why? Lemon juice has been shown to increase the peripheral stem of CN V in the oral cavity which, after exciting some neurons in the brainstem, can lead to increased tongue pressure generation which can increase swallow timing in both phases. The caveat with this strategy is that straight lemon juice may just send your patient through the roof. Remember we want consistency with these strategies people, not straight torture. So if Gertrude is A-OK with naked lemons, this could be a winner.

Strategy: Thermal-tactile stimulation (TTS)
How do I do it? Stroke the anterior faucial pillars with a cold laryngeal mirror or frozen stick
Who’s it for? Anyone with a swallow delay
Why? TTS has been shown to increase bilateral cortical activation which can improve the oral and pharyngeal phases of the swallow. However, an improvement in the swallow trigger response immediately following TTS has only been demonstrated as a short term benefit and the long term benefits have yet to be studied. So this may improve Gertrude’s swallow temporarily, but if she’s gagging all over your laryngeal mirror, she may slap it out of your hand anyways. If not, keep on strokin’!

So to sum up the sensory goodness, decreased sensation may affect the patient’s ability to hold, manipulate, and propel the bolus. According to Logemann, once the patient is able to safely attempt trials of food and liquid, the bolus can be manipulated to increase the sensation by presenting a sour bolus, a cold bolus, a bolus requiring chewing, and/or a larger bolus.

Now on to #3 of Logemann’s wish list (as in she wishes you would do things in this order instead of going all Oprah!):

Swallowing Maneuvers:

Strategy: 3-second prep
How do I do it? Tell the patient to silently count to 3 then provide a verbal cue to swallow
Who’s it for? Anyone with discoordinated oral transit, delayed pharyngeal swallow
Why? By silently counting to 3 after placing the bolus in the posterior oral cavity, and following with a verbal cue to swallow, the swallow can improve due to central volitional control. The research is dicey about this one as well, but anecdotally, the strategy has revealed shorter oral transit time and stage transit duration.

Strategy: Breath holding – Supraglottic and Super-supraglottic
How do I do it? For the supraglottic maneuver, instruct the patient to hold their breath, swallow during the breath hold, then cough immediately before inhalation. For the super-spraglottic, have the patient bear down during the swallow in addition to the above instructions.
Who’s it for? Anyone with reduced laryngeal closure
Why? The supraglottic maneuver improves true vocal fold closure. The super-supraglottic improves total closure of the laryngeal vestibule. (Please note: this strategy is contraindicated for anyone with cardiac issues. Please do a thorough medical hx review or consult the MD before directing this strategy.)

There are a few more strategies that I do want to discuss here that I always thought were no brainers to try, but recently I’ve had a few clinicians look at me like I had 3 heads when I suggested them.

Note: These strategies may involve some cooperation from nursing and/or family members, but they may also keep Gertrude off thickened liquids, which may make her a much happier camper, and the family and facility may prefer that as well, and then you look like the hero, and you know you want to be the hero!

Strategy: Volume Regulation
How do I do it? Provide a maroon spoon (small, baby spoon), or flow restricting cup or straw
Who’s it for? Anyone with a swallow delay, compulsive behaviors, or inconsistent staff feeding
Why? There are a bajillion cool products on the market that can be used to keep Gertrude from chugging down that entire glass of OJ beer bong style. The Provale cup and Therasip straw are 2 of the most common products that I see. They limit the bolus to either 5mL or 10mL, whichever is deemed most appropriate via instrumental. There are many pros and cons to these products as they can be greatly beneficial if used properly, but they can be costly, can grow legs and walk away from dietary, and some patients realize they are being tricked and refuse to use them. Gertrude isn’t stupid people, so if you’re going to go this route, please discuss it at length with her, her family, and the nurses, so they all understand that it does in fact have a purpose, and it’s not just a pretty color.

Strategy: Alternate bites and sips
How do I do it? Present sip of liquid following each bite
Who’s it for? Anyone with oral or pharyngeal residue
Why? Again I thought this was a no brainer, but Gertrude uses the liquid to wash away the residue and clear her oral or pharyngeal cavity. So let’s really think about this one.. Gertrude has a crap ton of residue in her mouth. We ask her to wash it down with water. Make sense? I think so. “Well Gertrude has tons of food left in her mouth and is having trouble swallowing so we should downgrade her to honey thick liquids.” Make sense? Are you serious? Hell NO! Adding a thicker liquid to an already thick residue lining the mouth does not always equal a beautiful, timely swallow. For some it certainly might, but again lets not assume that it will.

Strategy: Dry (double) swallow
How do I do it? Cue patient to swallow again following each bite
Who’s it for? Anyone with oral or pharyngeal residue
Why? Again I thought this was a no brainer as well, but same as above, if we can cue Gertrude to take a double swallow and clear the residue after each bite, she may be much more willing to play your tongue games in therapy rather than just consider you the rotten human that put her on that thickened shit.

Now before you jump down my throat and say that Gertrude really does do best on nectar thick liquids, that very well may be the case, but please, PLEASE, PLEASE don’t just leave her on nectar thick, discharge her, and never try anything else in your toolbox. Some patients truly do need thickened liquids or an altered diet, and I’ll discuss that it in the next post, but please know that there are other strategies that you can try to improve your patient’s swallow that don’t require lengthy directions to follow. You NEVER know which strategies they can carry out independently or with a little cueing from nursing if you don’t try! The longer I’ve been in this field the more I’ve learned that nurses, family members, or caregivers often have NO problem giving Gertrude little reminders of a strategy IF they understand what it does for her!

It’s easy to say that nursing doesn’t give a rat’s ass about our strategies, but sometimes taking 5 minutes out of your day to educate them about WHY it helps and not just using the Mom line of “Because I said so” can do wonders for teamwork. Bring an ipad, bring a diagram, print out a picture from the MBSS or FEES and SHOW them exactly what it does to improve Gertrude’s swallow and I PROMISE you they will be a little more willing to help a sister (or brother) out!

(Side note: Click that green box at the top to print out a PDF of these strategies in a pocket-sized chart that you can carry with you … just remember… your patients deserve better than the Oprah thickened liquids method!)

Resources:
Corbin-Lewis, K, Liss, J. M., & Sciortino, K. L., (2005). Clinical Anatomy & Physiology of the Swallow Mechanism. Thomson Delmar Learning, Clifton Park, NY

Daniels, S. K., & Huckabee, M. L. (2008). Dysphagia following stroke. San Diego: Plural Pub.

Logemann, J. A. (1993). The dysphagia diagnostic procedure as a treatment efficacy trial. Clinics in Communication Disorders, 3(4), 1-10.

 

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