MANAGEMENT DYSPHAGIA IN POST-STROKE PATIENTS RECOMMENDATIONS FOR INDONESIAN NURSING INTERVENTION STANDARDS: A LITERATURE REVIEW

Background: Dysphagia often occurs in post-stroke patients, causing aspiration that can result in disability or death. Nurses have an essential role to play in preventing these complications as they 24/7 care for patients. However, there is no written standard of nursing care regarding specific interventions of post-stroke dysphagia in reality. Objective: The purpose of this article is to conduct a literature review of interventions that can be made in patients with post-stroke dysphagia so that it can be a recommendation for Indonesian nursing standards. Design: Electronic literature searches PubMed, EBSCO (Medline), ProQuest, and ScienceDirect databases from January 2011 to October 2020. There was sixteen studies reviewed included in this systematic study were experimental, randomized controlled trials, or systematic reviews (which are also experimental designs, randomized controlled trials). The study focused on non-invasive interventions performed on post-stroke dysphagia patients. Results: Interventions in dysphagia found, namely: The use of food thickeners against the risk of aspiration resulted in the patient's swallowing ability significantly increased by 71.9% (p <0.01); Chin down intervention combined with thickening fluid provides a solution to improve the nutritional needs of patients dysphagia post-stroke; Tongue training interventions, swallowing training and speech therapy; Tongue stretching exercises that have a positive effect on tongue motility and oromotor function in post-stroke dysphagia patients; Intervention of Tongue resistance training that increases the strength of the tongue and reduces fluid residue in the vallecular; and early screening of dysphagia by nurses using formal guidelines to manage dysphagia patients thereby reducing chest infections and mortality. Conclusion: Nurses should not diagnose dysphagia, but can identify post-stroke dysphagia to determine the interventions necessary for nutrition management, hydration, and aspiration prevention. Interventions include early dysphagia screening within 24 hours after stroke, thickening nutrition according to nutritionist recommendations, laryngeal elevation exercises, peripheral stimulation, posture regulation, and education on eating and drinking.

Swallowing Dynamics and Breathing-Swallowing Coordination Are Altered in Patients with Mild Cognitive Impairment

<b><i>Introduction:</i></b> Postinspiratory activity, which is essential for laryngeal closure during swallowing to prevent aspiration of food into the airways, is reduced in a mouse model of tauopathy. Therefore, we hypothesized that patients at the stage of mild cognitive impairment (MCI) exhibit alterations in swallowing dynamics and coordination between swallowing and breathing. <b><i>Methods:</i></b> We examined breathing-swallowing coordination in patients with MCI. Patients who scored ≥24 on the Mini-Mental State Examination and &#x3c;26 on the Japanese version of the Montreal Cognitive Assessment were recruited at Sumoto Itsuki Hospital. Parameters associated with breathing-swallowing coordination were assessed using a combination of two sensors: a respiratory flow sensor and a piezoelectric sensor attached to the skin surface of the anterior neck. <b><i>Results:</i></b> Nineteen patients met the criteria for MCI; 16 of these patients (79.5 ± 9.1 years old) scored &#x3c;3 on the 10-item Eating Assessment Tool and were enrolled in the study. Their data were compared with those of an age-matched elderly cohort (79.9 ± 2.9 years old). The frequencies of swallowing during inspiration and swallowing immediately followed by inspiration in patients with MCI were 6.9% and 9.6%, respectively; these frequencies were not significantly different from those of the age-matched elderly cohort. However, the timing of swallowing in the respiratory cycle was significantly delayed in the MCI patients, and both time from the onset to the peak of laryngeal elevation and the duration between the onset of rapid laryngeal elevation and the time when the larynx returned to the resting position were significantly lengthened in this group. <b><i>Conclusion:</i></b> At the stage of MCI, breathing-swallowing coordination has already started to decline.

The effect of laryngeal elevation training on swallowing function in patients with dysphagia

Objective To investigate the effect of laryngeal elevation training without highly loaded head lifting on swallowing function in patients with dysphagia. Methods Fifty-seven patients with dysphagia (36 men; mean age, 78.5 ± 11.4 years) were included. All participants performed the swallowing forehead exercise and the chin push–pull manoeuvre for two months. Videoendoscopy to assess swallowing function, the peak expiratory flow test and the hand grip strength test were performed at the initial visit (time 1) and two months after the start of the intervention (time 2). We used the Hyodo score, a scoring method for videoendoscopic assessment, for evaluation of swallowing function. Results The linear mixed model showed a significant main effect of time (the Hyodo score at time 1 was greater than the score at time 2). The effects of the co-variates were not significant. Conclusion The present study demonstrated the significant effect of laryngeal elevation training without head lifting on the Hyodo score.

Assessment of Dysphagia as a Risk Factor of Chronic Cough

Background: The aim of the study was to determine the prevalence of dysphagia in patients with chronic cough and its relationship with the long-term persistence of these symptoms. Methods: Thirty consecutive patients. All patients underwent physical examination, ENT assessment, videolaryngoscopy, functional phoniatric assessment at rest and speech, Water-Swallow Test, and Fiberoptic Endoscopic Evaluation of Swallowing disorders with Reflux Finding Score. Reflux Symptom Index questionnaire was performed. The study was approved by the local Ethics Committee Review Board (KB/39/A/2016). Results: The results of the RFS and the RSI questionnaire showed the risk of reflux in participating patients. The patients presented episodes of spillage, double swallows, penetration, aspiration and residue of food at the hypopharynx. The results of functional assessment correlated with the Water-Swallow Test. The correlation between Fiberoptic Endoscopic Evaluation of Swallowing disorders and Water-Swallow Test results was found for aspiration risk, spillage, and retention of saliva. Conclusion: The results of the study showed prevalence of dysphagia in most patients with chronic chough. It seems that phoniatric assessment in those cases should be expanded and the following tests should be performed: assessment of the laryngeal elevation, Water-Swallow Test, and Fiberoptic Endoscopic Evaluation of Swallowing disorders.

Therapeutic Singing as a Swallowing Intervention in Head and Neck Cancer Patients With Dysphagia

Background: Head and neck cancer patients often suffer from dysphagia after surgery and radiotherapy. A singing-enhanced swallowing protocol was established to improve their swallowing function. This study aimed to evaluate the beneficial effects of therapeutic singing on dysphagia in head and neck cancer (HNC) patients. Methods: Patients who participated in this study were allocated to the intervention group (15 patients) and the control group (13 patients). Patients assigned to the intervention group received therapeutic singing 3 times per week for 4 weeks. Each group was divided into 2 subgroups, including the oral cavity cancer group and the pharyngeal cancer group. The patients’ vocal functions were evaluated in maximum phonation time, pitch, intensity, jitter, shimmer, harmonics to noise ratio, and laryngeal diadochokinesis (L-DDK). To evaluate swallowing function, videofluoroscopic swallowing study was done, and the results were analyzed by videofluoroscopic dysphagia scale (VDS) and dynamic imaging grade of swallowing toxicity (DIGEST). Results: Among the voice parameters, L-DDK of the intervention group significantly increased compared to that of the control group. Swallowing functions of the intervention group were significantly improved in VDS and DIGEST after the intervention. Detailed items of VDS and DIGEST showed improvements especially in the pharyngeal phase score of VDS, such as laryngeal elevation, pharyngeal transit time, and aspiration. In addition, the pharyngeal cancer group showed significant improvements in VDS and DIGEST scores after the intervention. Conclusions: Our outcomes highlight the beneficial effects of singing for HNC patients with dysphagia. The notable improvements in the pharyngeal phase suggest that therapeutic singing would be more appropriate for HNC patients who need to improve their intrinsic muscle movements of vocal fold and laryngeal elevation.

Dysphagia Precipitated by Cervical Lordosis in the Aged

A lordotic curve of the cervical spine in the aged is a physiological curvature of the cervical spine. The swallowing disorder precipitated by lordosis of the cervical spine in the aged, the swallowing function and intervention were reported on. An 86-year-old woman complained of swallowing difficulty for a few months. A lordotic curve (physiological curvature) of the cervical spine was observed. In the neutral neck position, the cervical lordotic angle was 29° using the Cobb C2-C7 method. When the lordotic curve of the cervical spine was intentionally straightened, the lordotic angle became 0°, the laryngeal elevation changed from 0.5 times the height of a cervical vertebra to 1.75 times, the laryngeal elevation delay time changed from 0.5 seconds to 0.23, the percent laryngeal elevation changed from 50% to 72% and pharyngeal transit time changed from 0.83 seconds to 0.75. Lordosis of the cervical spine inhibited laryngeal elevation and influenced the swallowing function. In cases in which lordotic curvature of the cervical spine adversely influences the swallowing function in the aged, rehabilitation to manage the lordosis of the cervical spine is useful. For the purpose of effective intervention, not only diagnostic but also therapeutic videofluorographic examination of swallowing is very important.