Case Studies



Fig. 9.1
(a) Axial CT scan of the brain at the time of hemorrhage onset. The large area of increased density (white) represents acute bleeding in the right thalamic area, and the low density surrounding the blood indicates adjacent cerebral edema. (b) Axial fluid-attenuated inversion recovery magnetic resonance image at the time of admission to the rehabilitation ward shows hypointensity involving the right thalamic area



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Fig. 9.2
Chest CT at the time of admission to the rehabilitation ward shows bilateral opacities in both lower lungs (more severe on right side), suggesting chronic inflammation secondary to saliva aspiration . The patient had not yet begun oral intake before admission. This sign is crucial to the presence of severe dysphagia


The patient was totally dependent with respect to ADL . His motor Functional Independence Measure (FIM ) score, cognitive FIM score, and total FIM score were 16/91, 16/35, and 32/126, respectively.

Initial swallowing assessment revealed the following abnormalities associated with the cranial nerves : positive left curtain sign , left tongue deviation, reduced tongue movement in all directions, and weakened oromotor function. Swallowing screening by the repetitive saliva swallowing test (RSST ) revealed a score of 2 at admission. Further instrumental examination was recommended to diagnose the dysphagia , clarify the physiological abnormalities, and establish the treatment plan.


9.1.1 Instrumental Swallowing Assessment


VE was performed 1 day after admission. No aspiration occurred during swallowing, and no post-swallow residue using honey-thickened liquid and jelly was observed. However, post-swallow oral residue mixed with saliva was delayed moving downward to the hypopharynx , leading to aspiration. The dysphagia severity scale (DSS ) score was 2.

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Fig. 9.3
VF using 4 ml of a liquid with honey consistency . (a) Impaired bolus formation and inability to propel the bolus from the oral cavity to the pharynx in one swallow. (b) Oral barium stasis after swallowing

During the next 2 days, the patient was investigated by VF . The VF findings are shown in Table 9.1 and Fig. 9.3).


Table 9.1
VF findings at the initial evaluation





































































Posture

Bolus type

Amount of bolus

Findings

View

Degree

Head

Lat

45

N

Honey

4 ml

Oral residue

– Impaired bolus formation and propulsion

– No penetration /aspiration

– No pharyngeal residue

Nectar

4 ml

Thin LQ

4 ml

Lat

45

N

Rice porridge

½ spoon

Oral residue

– Prolonged oral stage with slow bolus manipulation and slow mastication

– No penetration /aspiration

– No pharyngeal residue

During the change of the position to reclining 60°, bolus residue from oral cavity falls late into vallecula and pyriform sinuses before starting the next bolus trial

Lat

60

N

Honey

4 ml

Oral residue

– Impaired bolus formation and propulsion

– No penetration /aspiration

– No pharyngeal residue

Nectar

4 ml

Thin LQ

4 ml

Lat

60

N

Rice porridge

½ spoon

Oral residue

– Shortening the duration of oral stage but still be slow bolus manipulation and slow mastication

– No penetration /aspiration

– No pharyngeal residue

AP

60

N

Honey

4 ml

– Mild delayed esophageal transition


Degree refers to the angle of the reclining posture

AP anteroposterior, Lat lateral, LQ liquid, N neutral position

The first VF study (Table 9.1) showed that the change in the reclining angle had a beneficial effect on bolus control in the oral cavity. The 60° reclining posture contributed to the improvement in oral function by minimizing the duration of bolus manipulation when compared with the 45° reclining posture. All bolus consistencies and textures , including the honey-thickened liquid , nectar-thickened liquid , thin liquid , jelly , and rice porridge , showed the same trend: no penetration , aspiration, or pharyngeal residue in either the pyriform sinus or vallecula . Mild dysfunction of esophageal transition was noted.

The main problems found in the first VF study were the presence of oral residue after swallowing and poor bolus manipulation . Upon returning to the ward, a large amount of sputum mixed with a barium bolus was suctioned from the tracheostomy tube. This indicated the presence of food aspiration , most likely from oral food stasis after the VF study. Although there was no clear evidence of penetration or aspiration during the VF study, the 10 ml thin liquid , cup drinking , and eating a two-phase food were not tested to ensure safety. Thus, the DSS score was 2 (food aspiration ).


Table 9.2
Physiologic abnormalities and other findings at initial evaluation




















Stages

Findings

Physiological abnormality

Oral

Oral residue

Oromotor weakness including tongue and poor coordination

Pharyngeal

– No penetration /aspiration seen during VF test

– No pharyngeal residue

– Within normal limit


NOTE: Cognitive dysfunction may affect the results of VF

Based on the outcomes of VF and VE , the main physical finding was oral residue , and the physiological abnormality was poor bolus control (both bolus formation and propulsion) secondary to orolingual weakness and dysfunction. This resulted in delayed post-swallow aspiration, as mentioned earlier (Table 9.2).


9.1.2 Course of Treatment and Recovery


Initial treatment involved nutritional support, mainly via an NG tube. A SLHT started target-oriented swallowing exercises once a day (lunch time) with nectar-thickened liquid , jelly -type rice porridge , and chopped softened food with thickened liquid at a 60° reclining position. Oromotor exercises including lip exercises, tongue movement exercises (forward-protrusion, left-right side, tongue tip elevation), and tongue strengthening exercises using the Pecopanda tool (JMS, Hiroshima, Japan) were performed as element-based exercises . Additionally, chewing exercises were recommended simultaneously with intensive pulmonary rehabilitation by a physical therapist . Table 9.3 summarizes the treatments performed based on the physiological abnormalities found.


Table 9.3
Treatments based on initial evaluation



















Findings

Physiological abnormality

Functional approacha

Postural and diet modification

Oral residue

Oromotor weakness and poor coordination

– Tongue muscle weakness

Orolingual exercise

• Tongue movement exercise

• Tongue strengthening exercise

• Lip exercise

Chewing exercise

Postural techniques

Reclining 60°

Diet modification

– Modified food

Thickened liquid


aFrequency of rehabilitation: 40 min/time, 1 time/day, 6 times/week

A speech-type valve with a deflated tracheostomy tube cuff was periodically used to control saliva aspiration and perform phonation training. Two days after starting target-oriented training with modified food, the patient developed a low-grade fever without other symptoms, and eating training was temporarily discontinued. Meanwhile, the element-based exercises were continued. The patient’s medical condition was generally stable. No increased amount of secretion or leukocytosis was found. The C-reactive protein concentration was slightly rising, however, and a chest radiograph showed mild consolidation in the right lower lobe. The most likely diagnosis was aspiration of saliva , not food. Therefore, the eating training performed by the SLHT was carefully resumed, and the tracheostomy tube cuff was inflated during training. The ward nurse also collaborated with the SLHT to closely observe the patient after meals.

After a 9-day course of swallowing rehabilitation, the antiepileptic drug was stopped; this improved the patient’s level of arousal. The patient was able to incrementally increase his cooperate with the swallowing training. His fever gradually resolved along with his improved clinical status, and his blood test results were within normal limits during the following 10 days. In addition, amantadine was started to further promote his swallowing ability (initial dosage, 50 mg/day with a subsequent increase to 100 mg/day in the next week).

The patient’s swallowing ability progressively improved, and the NG tube was removed when he was able to ingest three adequately sized meals a day 1 month post-training. Additionally, his secretion status was greatly improved, and the tracheostomy was eventually removed. The RSST score, MWST score, and tongue pressure were 4, 5, and 22.2 ± 2.1 kPa, respectively.

Follow-up VF was performed on day 37 after the first VF study to observe the changes in the patient’s abnormal physiology and his response to the rehabilitation treatment (Table 9.4).


Table 9.4
Findings of the second VF study (37 days after the first VF study)
























































Posture

Bolus type

Amount of bolus

Findings

View

Degree

Head

Lat

90

N

Honey

4 ml

– Reduced oral residue and able to clear by the second swallow

– Improved bolus formation and propulsion

– No penetration /aspiration

– No pharyngeal residue

Thin LQ

4 ml

Thin LQ

10 ml

Premature spillage

– Shallow penetration (PAS 2)

CB

8 g

– Slightly oral residue

– Prolonged mastication , faired bolus formation

CB + thin LQ

4 g + 3 ml

Oral residue

– Shallow penetration (PAS 2)

Cup LQ

30 g

Oral residue

– Deep penetration contacting with VFs (PAS 5)

Straw LQ

30 g

AP

90

N

Honey

4 ml

– Delayed esophageal transition with slightly esophageal residue


90° refers to the usual sitting-upright position

AP anteroposterior, CB corned beef hash , Lat lateral, LQ liquid, N neutral position, PAS penetration -aspiration scale VFs vocal folds

Various types of boluses were used during the repeated VF studies to clarify the patient’s swallowing ability and clinical improvement. The results showed improvement in his oral function (either bolus formation or propulsion) and decreased oral residue after swallowing. His chewing ability seemed improved compared with the first VF study. However, when chewing food such as corned beef and two-phase food and when drinking a large amount of liquid, orolingual weakness with coordination dysfunction was still observed. Continuation of all exercises was thus recommended with a gradual increase in intensity.

The DSS score was 4 (occasional aspiration ). Diet modification was slowly performed in a stepwise manner until ordinary porridge and soft food could be ingested while continuing the nectar-thickened liquid because the risk of thin liquid aspiration still remained. The RSST , MWST , and tongue pressure measurement were repeated, and the results indicated improvements in the swallow ability (4, 5, and 24.8 ± 1.7 kPa, respectively). After 2 months of continuous swallowing training, VF study was repeated.

The results of the third VF study (Table 9.5) demonstrated improved swallowing ability, particularly in bolus manipulation , chewing ability, and orolingual control. The oral residue was still present, although it was decreased. Liquid cup drinking resulted in no deep penetration as detected at the second VF study. The DSS score had changed to 6 (minimum problem).


Table 9.5
Findings of third VF study (59 days after the first VF study )





















































Posture

Bolus type

Amount of bolus

Findings

View

Degree

Head

Lat

90

N

Honey

4 ml

– Slightly oral residue

– No penetration /aspiration

– No pharyngeal residue

Thin LQ

4 ml

Thin LQ

10 ml

– No premature spillage

– Slightly oral residue

– Shallow penetration (PAS 2)

CB

8 g

– Shortened the duration of mastication compared with the second VF

– Slightly oral residue

– Improved bolus formation and propulsion

CB + thin LQ

4 g + 5 ml

Oral residue

– Shallow penetration (PAS 2)

Cup LQ

30 g

Oral residue

– Shallow penetration (PAS 3)

AP

90

N

Honey

4 ml

– Delayed esophageal transition with slightly esophageal residue


90° refers to the usual sitting-upright position

CB corned beef hash , Lat lateral, LQ liquid, N neutral position, PAS penetration-aspiration scale

The patient’s diet was altered in a stepwise manner to soft food, soft rice, and liquid without the use of a thickener . Finally, the patient was able to swallow regular food independently. Therefore, his physiological abnormalities had definitely improved by either spontaneous recovery or the improvement in his consciousness in addition to the effectiveness of swallowing rehabilitation. The progression of the DSS score, eating status scale (E SS) score, and treatment is summarized in Table 9.6.


Table 9.6
Progression of treatment and advancements in treatment results
























































Timea

Test

DSS

ESS

Exercises

Recommended diet modification

Recommended posture

Before admission
 
1

1
 
No oral feeding
 

0

VF

2

2

Orolingual exercise

– Tongue movement exerciseb

– Tongue strengthening exercise using Pecopan da

– Lip exercise

Chewing exercise

Paste with small particle

Jelly rice porridge

– Nectar-thickened

– liquid

Reclining 60°

37

VF

4

5

(Day 37)

Paste with small particle

Rice porridge

– Nectar-thickened liquid

Sitting upright

(Day 44)

– Soft food

Rice porridge

– Nectar-thickened liquid

59

VF

6

5

(Day 59)

– Soft food

– Soft rice

– Nectar-thickened liquid

Sitting upright

(Day 64)

– Soft food

– Soft rice

Thin liquid

(Day 78)

– Regular food

– Soft rice

Thin liquid


NOTE: All exercises were gradually increase intensity based on patient condition

aDuration (days) after the onset of intensive swallow rehabilitation therapy before admission

bTongue movement exercises consisted of three sets of ten repetitions of each of the following: tongue forward-protrusion-backward, left-right side, and tongue tip exercise

Eleven months after the onset of hemorrhage , the patient developed recurrent aspiration pneumonia every time he initiated direct exercise ; therefore, oral intake could not be started. However, he achieved the goal of a regular diet 59 days after admission to FHUH. The success of this case illustrates the importance of detailed evaluations of all swallowing components and performance of a systematic intervention. The patient’s abnormalities can be summarized as follows:


  1. 1.


    Reduced level of alertness (arousal level), manifesting as low activity due to the use of an anticonvulsant drug

     

  2. 2.


    Aspiration


    1. (a)


      Saliva aspiration due to tracheostomy

       

    2. (b)


      Oromotor dysfunction, especially diminished tongue movement

       

     

A transdisciplinary approach is important in swallowing treatment. Symptoms of aspiration pneumonia should be considered as an indication to proceed with treatment. Clinicians must engage in discussions with SLHTs and nurses regarding the patient’s symptoms (e.g., fever, amount of expectoration ) and whether these are early signs of severe pneumonia or if the patient can continue their exercises, as well as how to adjust the exercise prescription. SLHTs and nurses should regularly evaluate the effects of the swallowing exercises , particularly at the time of step-up. Finally, SLHTs and nurses must always observe the patient for symptoms of aspiration pneumonia and report any remarkable findings to the doctors.

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Mar 15, 2018 | Posted by in NURSING | Comments Off on Case Studies
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