Locked in syndrome

1. Think of a recent therapy session or event.

I assessed a patient who had locked in syndrome (quadriplegic, with bilateral vocal fold palsy. Some movement in his right index finger and thumb. All due to multiple brainstem and cerebellar infarcts). I called his previous hospital for a handover and contacted therapists at the specialist AAC centre in Putney for advice on his access to communication.

2. Describe the session/experience

The patient had been extensively assessed throughout his time in hospital, so I made sure to get a detailed handover. I have little experience using AAC so I contacted specialists in Putney. They advised that I look at the following: a) Consistent yes/no response, b) cognition, c) What movements can he do consistently, d) comprehension, e) cranial nerves. They also advised that I keep a diary for the patient so that his family and staff can record his behaviours and note down what he does in his day, for use in SLT e.g. did you… how was physio … It was advised that I create clear communication guidelines for the patient and assess for a baseline. The therapists recommended using an AEIOU alphabet chart.

During my session I 1) asked the patient 1-2 stage instructions, 2) explained my role and the information I had on him 3) Trialled use of the alphabet chart. The patient was consistent with head nodding/ shaking for a yes/ no response. It was effortful for both of us to use the alphabet chart. I followed advice from Putney and modelled spelling out items using the alphabet chart. The patient engaged with this.

3. What did this session make you feel?

I felt exhausted from concentrating on the patients communication attempts (mouthing, breathy speech, jerky body movements, head nodding/shaking, alphabet chart use). I felt that by keeping assessment functional e.g. giving instructions relating to an oro-motor exam and asking about pain/ comfort the patient stayed engaged in my session. It was reported that he quickly became disengaged in communication sessions due to the effort fullness of communication.

4. What would you want to change, and why?

I would ideally have talked to the patient’s family to ask them for some yes/no questions that are engaging for the patient. I would also have done a joint session with the OT around what movements may be harnessed for AAC use.

5. What has this session has taught you?

Look for a consistent yes/ no responses, think about low tech accessible forms of AAC, continue to empathise with patients and explain the goals of my assessments in order to motivate them for assessment.

6. What do you need to learn or find out before the next event?

More information about AAC and communication with locked- in patients.

Putney advice

·      Use errorless learning when teaching AAC use e.g. with the AEIOU alphabet chart. E.g. we are going to spell tree…

·      Patients normally pick up alphabet chart use if they have no cognitive impairments – it may be a sign of impairment if they have ++ difficulties.

·      Have joint sessions with OT’s re – big mac or switch use.

·      Start with a nurse call – big mac = good prep for Phigh tech AAC since switch use is a pre-requisite for eye gaze etc..

·      Make sure Yes/ no is reliable + staff consistently ask for the same response.

·      Using a diary is a good way to engage with family members/ find material for communication sessions.

·      What commands can they follow?

·      Establish a clear baseline.

A	B	C	D
E	F	G	H
I	J	K	L	M	N
O	P	Q	R	S	T
U	V	W	X	Y	Z

Guidelines for using the AEIOU alphabet board

Purpose

To help John communicate information that he is unable to convey using mouthing, body language, eye pointing and head nodding/ shaking. The alphabet is split into rows so that communication partners don’t need to read out the whole alphabet. The letters are in alphabetical order making communication quicker and thereby reducing the burden on Johns’ sight.

How to use the alphabet board

1.    Ask John to think of the first letter of the word he wishes to spell and to look at the row this letter is in.

2.    Confirm the row as either A, E, I, O or U, looking for a head nod on the correct row.

3.    Ask John to nod when you say the correct letter, and then proceed to read out the letters in the row.

4.    Write down the letters John chooses and confirm his responses.

Communication method	YES	NO
Head	Nod	Shake
Thumb/ finger	Moves up/out	Moves down/in
	Eyes looks up Eyes Look to one side  Look to a YES card	Eyes looks down Look to the other side Look to a NO card
Blinks	One long blink	Two short blinks
Eyebrows	Raised	Lowered
Switch	Pressed once	Pressed twice

Aim for the most natural method, the clearest and the easiest to perform. + that everyone uses the same method. If the patient is well supported and comfortable they are more likely to be able to make a consistent response.

Reflective log14.05.13: low arousal- oral desensitisation program

1. Think of a recent therapy session or event.

I had a 104 year old client with a large LMCA stroke who was very low arousal. Her family were keen for her to have oral trials/ a swallow assessment but she was unable to follow instructions or to functionally communicate and was not alert enough to be safe for a swallow assessment. I completed the WHIM with her while giving her mouthcare/ in joint OT sessions. Initially the patient did not like the oral sponges so I used a toothbrush instead and hand over hand facilitation.

2. Describe the session/experience

I developed an oral desensitisation program for the patient which her family could complete with her. My rationale was that she was refusing mouthcare (tuning her head and closing her lips). If she would engage with mouthcare perhaps she could then progress onto oral trials/ a swallow assessment. Furthermore her family would have a concrete task that they could use to interact with her.

3. What did this session make you feel?

I felt like I was able to handover a useful task for the patients family to do with her, which would make them feel more useful and feel like we were a team.

4. What would you want to change, and why?

I would have considered the oral desensitisation program earlier in her admission and considered how I could engage the patients family in her rehabilitation goals/ how to give them information.

5. What has this session has taught you?

I have learnt that I need to prepare information and tasks for patients’ families so that they can feel empowered and part of the therapeutic process.

6. What do you need to learn or find out before the next event?

- Research desensitisation.

Oral desensitisation program

• ·      Using a dry soft cloth gently massage the patients lower face, on both sides, starting with his nose and moving over his cheeks, jaw, chin and lips. Wipe the cloth around his lips gently. Be careful not to put your fingers in his mouth as he may bite you.
• ·      Repeat the massage using a cold wet cloth.
• ·      Using a mouthcare sponge moistened with room temperature water, wipe around the inside of the patients mouth and around their teeth (on both sides, top and bottom).
• ·      Wipe the sponge along his hard palate, being careful not to go too far back in his mouth.
• ·      Wipe the sponge along his tongue, from back to front and along the sides.
• ·      Repeat the last 3 steps with a sponge dipped in ice water and a sponge dipped in a flavoured liquid e.g. squash.
• ·      Make a note of how well the patient can tolerate each stage, whether she is biting on the sponge, whether she swallows any of her saliva and whether there is any coughing or shortness of breath.

Cervical Auscultation and pulse oximetry

Cervical Auscultation

Borr et al 2007: Reliability and validity of cervical auscultation

Conclusion

Cervical auscultation = an early warning system for identifying patients at risk of aspiration/penetration but is not a stand alone tool.

Study 1: CA parameters 2 parameters separated older adults from dysphagic adults on the study: The duration of the first swallow burst was shorter in dysphagic adults and dysphagic patients needed more than one gulp to swallow a bolus.

Study 2: CA reliability – experts at CA also take into account the quality of the swallow sound. SLT’s over detected dysphagia when using CA with a bias towards labelling older adults as dysphagic. SLT’s were able to listen for respiration, voice quality (both 100% correct), duration of swallow (66%) and number of swallows (55%). There was some disagreement between raters (reliability) and some were able to be more specific/ sensitive to sounds.

Pulse Oximetry

Sherman et al 1999, Assessment of dysphagia with the use of pulse oximetry

-        Pulse oximetry measures SPO2, is non-ivasive and gives a realtime output.

-        Aspiration has been shown to decrease oxygen saturation by interfering with alveolar gas exchange. Viscous liquids/ solids will have a greater adverse effect on O2 saturation.

-        Direct aspiration of material may cause reduced air flow to the affected lung tissue and stimulate a reflex bronchospasm, both of which may cause desaturation.

-        During the study modified barium swallow assessments were carried out with pulse oximatory at the same time. A baseline for SP02 was collected over one minute.

-        The study demonstrated a direct correlation between the degree of oxygen desaturation and the severity of swallowing abnormality.

-        Patients who aspirated had a significantly greater decline in SP02 than those who penetrated and cleared or did not aspirate.

-        Pulse oximatry may be useful to differentiate between patients who may be penetrating and clearing material and those who are aspirating.Exclusions: patients receiving O2.

Reflections on the use of Pulse Oximetry and cervical auscultation

Research

Literature reviews for both pulse oximetry and cervical auscultation have shown variable support for the use of these techniques to reliably and consistenly to identify aspiration/ dysphagia.  Although there have been contradicting studies it appears that cervical auscultation and pulse oximetry are useful additions to the clinical swallow exam when not used in isolation. Research suggests that they are useful at giving information on whether or not a swallow is abnormal or that aspiration may be present without being able to confirm why or what type of dysphagia may be present.

Reflection

I have found cervical auscultation useful with patients who are unable to vocalise after swallowing in order to listen to their breathing sounds for any changes in quality. I also find it useful to listen for any abnormal swallow sounds. I find that I am unable to identify clear physiologic swallow sounds e.g. the opening of the UES. I have also found CA useful for patients with COPD to identify their baseline breathing sounds and to help listen to the duration of the apnea period.

I find that pulse oximetry is useful for patient s with whom I would like an extra tool during their swallow examination to help me identify whether they are aspirating or not. I find it useful for patients who may be silently aspirating. The SP02 levels can vary with patients who are not aspirating so I find I look for the timing of any changes as well as the degree of desaturation when interpreting results.

Non-oral Feeding

Non-oral Nutrition

Definitions

Enteral feeding	Delivery of nutrients and hydration into the gastrointestinal tract.
Nasogastric feeding (NG)	Placement of a tube for nutrient ingestion in the nose.
Percutaneous endoscopic gastrostomy (PEG)	Endoscopic placement of a tube through the abdominal wall directly into the stomach.
Jejunostomy (J-tube)/ PEJ	Surgical/ endoscopic placement of a tube for nutrient ingestion through the abdominal wall directly into the jejunum.
Cervical esophagoscopy/pharyngoscopy	Surgical placement of a tube through the lateral pharyngeal wall directly into the upper oesophagus.
Total parenteral feeding (TPN)	Administration of nutrients through a central vein.
Intravenous hydration	Administration of fluids for hydration only.

Enteral Feeding

Indications	Contraindications
·   1 to 2 weeks of no nutrient intake (unable to orally ingest nutrients/ unsafe oral feeding). ·   Can be temporary/permanent. ·   Placing tubes into the stomach allows for digestion at a controlled rate (rather than into the small intestine).	·   Mechanical obstructions. ·   Severe vomiting/ upper GI bleeding ·   If the patient is not able to ingest nutrients via the GI tract.

Nasogastric Feeding (NG-tube)

Indications

·   Indicated when enteral feeding is required for a short period of time i.e. recovery of swallow function is expected.

·   Typically used for under 30 days.

Contra-indications

·   Nasal obstruction

·   Confused/agitated patients – may not cooperate/ tolerate the discomfort of tube insertion as placement can be quiet traumatic.

Placement of the NG-tube

·   Patients are asked to swallow the tube as it is pushed through the nose into the stomach.

Complications

·   GI and mechanical complications can occur.

·   Vomiting, cramping, diarrhea, risk of self-extubation

·   Risk of aspiration if the tube is inappropriately placed.

Gastrostomy Feeding (e.g. PEG)

Surgical opening into the stomach to allow the placement of a feeding tube. Gastrostomy is the most prevalent type of long term enteral feeding.

Indications

·   Patients who cannot/ will not orally eat.

·   If the resumption of oral feeding is likely to take longer than 30 days.

·   May be used for patirents with dysphagia.

·   PEG = non surgical (a fibreoptic endoscope is used).

Contra-indications

·   Overall medical condition of the patient i.e. are they medically stable.

·   Patients with severe irreversible illnesses, especially the elderly.

Jejunostomy

·   For patients who have a previous history of tube-feeding aspiration pneumonia, reflux esophagitis, or when there is a reason the stomach cannot be used.

·   Often used with patient swho have severe reflux.

·   Diarrhea is a common complication due to the patients difficulty in regulating absorption via the intestine.

Intravenous Nutrition

·   Used when patients have a non-functioning GI tract.

Complications of Enteral feeding

Aspiration	1.     Aspirtion of oral secretions – tube feeding may not eliminate the primary source of pulmonary aspiration in patients with severe dysphagia. 2.     Reflux aspiration – increased reflux may occur with NG feeding since the tube passes through the pharynx and may lead to transient relaxation of the LES. 3.     Body position aspiration – patients need to be at 45 degrees when tube fed if they are in a supine position they are at risk of tracheal aspiration.
Enteral feeding regimens	1.     Bolus feeding – administration of formula intermittently throughout the day using a syringe, pump or gravity. Syringe feeding = rapid + can be associated with GI reflux and vomiting. It  does however ‘normalise’ the digestive system. 2.     Continuous feeding – speed of feeding is controlled with a pump/ gravity. Roubenoff (1992) recommend slow continuous drip feeding to reduce the risk of aspiration regardless of placement. Feeding is slow. But nutrient absorption is enhanced. A gradual progression from continuous to bolus feeding is recommended to normalise the bodies consumption of nutrients.
Diarrhoea	·   Common complication of enteral feeding
Medications	·   Drug absorption and metabolism may be altered/ interrupted during tube feeding.

Deciding on non-oral feeding

1.     Comprehensive formal/ informal dysphagia assessment – gain information on the patients medical condition, physiology and personal attributes.

2.     Patient’s preferences/ capacity – does the patient have capacity to make a decision regarding feeding options.

3.     Prognosis for recovery

Legal/ Ethical issues

·   Quille (1992) tube feeding is not viewed as ‘basic, humane care that must always be provided’

·   If a patient pulls out a feeding tube, it is a non-verbal indicator that they do not give consent for the tube.

·   PEG tubes are less likely than NG-tubes to be pulled out.

How to progress form non-oral to oral nutrition

Groher and Mckaig (1995)

·   Suggest that bolus feeding continues for 3-5 days before oral trials are attempted, to allow the stomach time to ‘stretch’ and reinitiate the hunger cycle.

·   They recommend that one meal be introduced orally for 1 week, with more meals added as the patient is able to tolerate oral feeding.

·   Tube feedings are adjusted depending on the patients oral intake.

·   The introduction of oral food requires consultation with the medical team (nurse, physician, dietician, pharmacist) to monitor health, nutritional status and any significant changes.

·   Criteria necessary for increased oral nutrition= indicators of nutritional status (fluid+calorific intake), and overall health status, such as strength, endurance and respiratory condition.