Treatment


Supraglottic (SG) and Super Supraglottic (SSG) Swallow


COPD patients that have dysphagia are more likely to have increased risk of aspiration. People with a normal swallow prevent aspiration because their vocal folds close before and during swallowing (Hirst, 1998). In patients that are susceptible to aspiration the SG and SSG swallow are techniques that protect the airway from aspiration (Donzelli, 2004; Hirst, 1998).

The technique is based on voluntary closure of the true vocal folds followed by a cough to force expiration. This clears away any material that may remain in the airway (Donzelli, 2004).

The difference between the SG and SSG is the amount of effort used (Gohler, 2010; Donzelli, 2004). The increased effort of the breath hold is to ensure the vocal folds are fully adducted.

Table 1: Breath-holding instructions given to subjects (Donzelli, 2004, p. 209)
Breath Hold Instructions
Easy Breath Hold “Hold your breath while I count out loud to 5"
Inhale/ Easy Breath Hold “Take a deep breath, then hold your breath while I count out loud to 5"
Hard Breath Hold “Hold your breath very tightly, bearing down, while I count out loud to 5"

Above are instructions on what to say to elicit the appropriate breath for each technique. The easy breath hold is used in the SG swallow while the hard breath is used for the SSG swallow. The correct wording is important to make sure the appropriate swallow is elicited.

For the SSG swallow to be effective the true vocal folds must be completely adducted (Donzelli, 2004). Research shows that "Inhale/ Easy Breath Hold" was the least effective because while inhaling it was discovered that patients were not closing off their vocal folds so were holding their breath in the abducted position (Donzelli, 2004; Hirst, 1998). If the true vocal folds are not completely adducted then aspiration can still occur.


external image copd.jpg

Fig. 1 Optimal disease management entails redesigning standard medical care to integrate rehabilitative elements
into a system of patient self-management and regular exercise 17].
American Thoracic Society / European Respiratory Society Task Force. Standards for the Diagnosis and Management of Patients with COPD [Internet]. Version 1.2. New York: American Thoracic Society; 2004 [updated 2005 September 8]. Available from:http://www.thoracic.org/go/copd.


Tracheostomy Tubes

  • Remove the tube - Tubes are preferably a short term solution
  • Deflate the cuff during swallowing
    • increases subglottal air pressure
    • facilitates laryngeal adduction
    • strengthens the force of the cough


GERD

  • Lifestyle modifications - the first two are the most important
    • Weight reduction
    • Elevation of the head of the bed
    • Posture
    • Eliminate alcohol and smoking
    • Diet modifications
    • Avoidance of GERD aggravating medications
  • Antacids
    • rapid, short term relief
    • however, does not heal the oesophagus
    • does not prevent GERD
  • Proton Pump Inhibitors
    • Provides rapid relief
    • Heals oesophagus
  • Antireflux surgery
  • Antireflux endoscopic therapy
    • Risky side effects


Pursed lip breathing
- Technique where ehalation is performed through a resistance created by the constriction of the lips (8)
- Spontaneuosly performed by COPD patients to alleviate dypnea, but does not always appear to help.
- Half patients recived relief from Dyspnea, hald made it worse (8)
- PLB promotes slower and deeper breathing at rest or excercise (8)
- PLB’s ability to promote changes in breathing pattern does not depend on the prescence of expiratory flow obstruction, as healthy people can do it too (8)?
- Despite a reduced rate of breathing, the effort to do PBL can offset this change (8)
- The more the dyspnea, the greater the likelyhood of spontaneuous PLB (9)
- PLB rest patients had lower excercise tolerance, more hypercapnic, lower diffusion capacity, greater flow limitation, and hyper inflation (9

Management


When deciding a management strategy for a patient suffering from dysphagia it is important to determine the severity of their dysphagia. Below is a hierarchy of questions to determine their severity and to determine which is the best form of treatment.
  • Does the patient exhibit a swallowing disorder?
    • Yes, Are they at risk of aspiration?
      • Yes, Can an oral diet be considered with modifications?
        • No, is oral feeding precluded OR can a certain amount of aspiration be tolerated?

Aspiration

  • Elevate the head of the bed
  • More likely to occur if patient is; bed bound, reduced activity, dependent on others for feeding. Try to eliminate these factors or reduce their impact.
  • Patient needs good oral hygiene.
  • Aspiration of food is more likely to lead to pneumonia than aspiration of liquid. Look at diet modifications if necessary.
  • Experienced nursing staff will have the knowledge and experience of what patients need.
  • Postural changes will lessen aspiration, for example, sitting upright during and after a meal.
  • Swallowing maneuvers
  • Dietary modifications
  • "Safe Feeding" techniques
    • reduce quantity of food aspirated
    • improve nutritional status
    • maximize host resistance
  • Dental treatment
  • Eliminate non-oral forms of feeding
  • Increase patient's activity levels.

References: Wheeler (1995), Poh (2010), Langmore (1998)


References:
Donzelli, J., & Brady, S. (2004). The effects of breath-holding on vocal fold adduction: Implications for safe swallow. Archives of Otolaryngology - Head and Neck Surgery, 130, 208-210.
Grohler, M., & Crary, M. (2010). Dysphagia: Clinical Management in Adults and Children. Maryland Heights, MO: Mosby, Inc.
Hirst, L., Sama, A., Carding, P., & Wilson, J. (1998). Is a 'safe swallow' really safe? International Journal of Language and Communication Disorders, 33(s), 279-280.