Swallowing disorders secondary to cerebrovascular disease have received increasing attention because they have a significant impact on the maintenance of nutrition, disease recovery, and quality of life of patients. Although more than 85% of swallowing disorders in acute cerebrovascular disease can be recovered or reduced with treatment, untimely treatment and loss of the best time for recovery can lead to lifelong nasal feeding. Therefore, patients with swallowing disorders in acute cerebrovascular disease should be evacuated from nasal feeding and trained for swallowing function as early as possible. Oral phase disorders include voluntary and passive movements around the oral cavity, tongue muscle movements, ice press.
Skin massage, ice massage of the throat, etc. or moist heat stimulation vocal training; pharyngeal phase paralysis has side-lying swallowing, swallowing while lowering the head, air or saliva swallowing training, small mouth breathing, coughing, humming, etc. Whether indirect or direct swallowing disorder training, patient position is particularly important. This is because the forward-flexed neck position tends to cause the swallowing reflex, while the backward tilt of the trunk can prevent mis-swallowing and also promote the recovery of swallowing function.
Training methods
There are basic training and feeding training. Basic training is the functional training of the organs related to feeding and swallowing activities; feeding training is the training of actual eating.
1.Basic training
It is used as a preparatory training before feeding in the acute phase of brain injury and before feeding training for patients with moderate to severe ingestion-swallowing disorders.
1.1 Pharyngeal cold stimulation and empty swallowing
Cold stimulation of the pharynx involves using a frozen cotton swab with a little water to gently stimulate the soft palate, tongue root and posterior pharyngeal wall, and then asking the patient to do empty swallowing. Cold stimulation can effectively strengthen the swallowing reflex, and repeated training can make it easy to induce and powerful swallowing.
l.2 Breath-holding-vocal exercise.
The patient sits in a chair and does pushing exerciscs with both hands supporting the chair surface and holds his breath. At this time, the thorax is fixed and the vocal chambers are tightly closed; then, suddenly release the hands, the vocal chambers open wide, and exhale and vocalize. This exercise not only trains the latching function of the vocal chambers, strengthens the muscle strength of the soft hires and helps to remove the food left in the smoke.
1.3 Lip, tongue and progressive muscle training.
1.3.1 Pronunciation exercise
Firstly, the patient should start with “you, me, him”, and each word should be sung twice each time to make it easy to learn. The first part of “Dongfang Hong” was sung to encourage them to sing out loud naturally, and to promote lip movement and vocal atresia through the opening and closing of the mouth. Generally, after the morning care and the afternoon basic care, the vocalization and pronunciation are gradually required to be accurate and coordinated with the movement and strength of the language muscles.
1.3.2 Tongue muscle and masticatory muscle movement
In the absence of swallowing reflex in the patient, massage of the tongue muscle and masticatory muscle was performed first. Then ask the patient to open the mouth, extend the tongue outward as far as possible, first lick the lower lip and the left and right corners of the mouth, turn to lick the upper lip and the hard palate, then retract the tongue, close the mouth for the upper and lower teeth to tap each other and chew 10 times, if the patient can not tongue movement on their own, the nurse can use gauze to gently hold the tongue for up and down, left and right movement, return the tongue to its original place, lightly support the lower jaw to close the mouth, to grind the teeth and bite 10 times, respectively in the morning, lunch and dinner before and 5 min each time.
1.3.3 Buccal muscle and internal laryngeal muscle movement
Ask the patient to lightly open the mouth and then close it, so that the cheeks are filled with gas, bulging cheeks, and then gently exhale with exhalation, or wash the patient’s hands and make finger-sucking movements to contract the cheeks and the muscles of the rotator cavernosus.
1.3.4 Swallowing action
Cold stimulation of the pharynx, using a frozen cotton swab dipped in a little water, gently stimulate the soft palate, tongue root and posterior pharyngeal wall, and then ask the patient to do empty swallowing action, cold stimulation, can effectively strengthen the swallowing reflex and promote swallowing strength, 3 times a day. Only after the basic training is carried out effectively can the oral ingestion method be performed.
1.3.4 Indirect swallowing training.
The following training can be started when the patient is conscious and can sit still. Training to improve the pharyngeal reflex can be performed by repeatedly stimulating the soft palate and posterior pharyngeal wall with frozen wet cotton swabs. Vocal closure exercises allow the patient to pronounce “ah” out loud. This exercise trains the patient to close the vocal cords at will and is effective in preventing aspiration. Supraglottic swallowing This is a set of training actions that allows the patient to inhale fully, hold it, then slowly swallow saliva, then exhale, and finally cough. This is trained by using the principle of vocal fold closure when stopping breathing, and the final cough is to remove the remaining food around the larynx. It is suitable for patients whose swallowing process causes misopharynx.
1.2 Feeding training
After the basic training, the feeding assistance training is started. First of all, attention should be paid to the selection of a suitable position for the patient to eat, the form of food and the amount of bites to be eaten. The mouth should be carefully cleaned before and after the feeding training.
1.2.l Position.
The position suitable for the patient is not entirely consistent, and should be adjusted according to the individual in actual operation. For bedridden patients, generally take the trunk supine position with the head flexed forward and the shoulder of the hemiplegic side padded with a pillow, the nurse is located on the patient’s healthy side, so that food is not easily leaked out of the mouth, which facilitates the transportation of food to the tongue and reduces reflux and misopharynx. For those who are still able to get out of bed, sit straight with the head slightly flexed forward, and the body can also be inclined to the healthy side by 30°, so that food can enter the esophagus from the healthy side of the pharynx, and if the head can be turned to the paralyzed side by 80°, the healthy side of the pharynx is enlarged at this time, which facilitates the entry of food to prevent misopharynx. Forward flexion of the neck is also a method to prevent misopharynx. Because the neck tends to be posteriorly flexed when lying on the back, the anterior cervical muscles related to smoke swallowing activities are tense and it is difficult to lift the larynx up, thus making it easy for micturition to occur.
1.2.2 Morphology of food.
The shape of food should be selected according to the degree and stage of swallowing disorder, based on the principle of easy before difficult. Foods that are easy to swallow are characterized by uniform density, appropriate viscosity, not easy to loosen, easy to deform when passing through the pharynx and esophagus, and do not remain on the mucosa. In addition, the color, aroma, taste and temperature of the food should be taken into account. For those who are drowsy or drowsy with less than moderate swallowing ability, they should be given a liquid diet that is easy to swallow, and the dietitian should prepare the main food with fresh milk, vegetable juice and fruit juice, etc. With the improvement of swallowing function and recovery of physical ability, the food should be made into jelly or porridge, which is characterized by uniform density, sticky and not easy to be loosened, easy to be deformed when passing through the pharynx and esophagus, fresh color, strong aroma and taste, and easy to eat and digest.
1.2.3 One-bite quantity.
When training patients to swallow, if one mouthful is too much, it may leak out of the mouth or cause residue in the pharynx and lead to mis-swallowing; if it is too little, it will be difficult to induce the swallowing reflex due to insufficient stimulation intensity. Generally, a small amount is tried first (3 – 4m1), and then increased as appropriate. In addition, attention should be paid to the choice of utensils. A thin and small spoon is appropriate at first. The following points should also be noted when swallowing.
① Empty swallowing and reciprocal swallowing, when there is already food residue in the pharynx, if you continue to eat, the residue accumulation will increase, which will easily cause mis-swallowing. Therefore, after swallowing each time you eat, you should make several empty swallows repeatedly to swallow all the food pieces and then eat again. You can also drink a very small amount of water (1 – 2ml) after swallowing each time you eat, which is good for stimulating the swallowing reflex and removing residual food from the pharynx, called “cross-swallowing”.
②Side swallowing, the “dyed crypt” on both sides of the pharynx is the place where food is most likely to remain.
③Nod-like swallowing, the epiglottis is another area where food is easily left behind. When the neck is flexed backward, the epiglottis becomes narrow and the residual food can be squeezed out, then, the neck is flexed forward as much as possible, resembling a nodding head, while making empty swallowing movements, and the residual food can be removed.
1.3 Cultivate habituation
1.4 Direct feeding training.
Practice eating when the patient is clear, stable, has gag reflex and can cough at will. Position: The patient in the half* position has less misopharynx and is light, so when you start to practice feeding, it is better to feed with the head slightly tilted forward in the half* position. For hemiplegic patients, a lateral position with the healthy side underneath can be adopted, with the neck slightly flexed forward, which is easy to cause the gag reflex and can reduce misophagy. In addition, rotation of the patient’s neck to the affected side can reduce the residual food in the pharynx. The food used for feeding training should be homogeneous jelly or paste food, such as egg custard, batter, etc., which can be easily moved in the mouth and not easily swallowed, taking into account the patient’s preference and nutritional composition. Because liquid food is easy to move in the oral cavity, but it is weak to stimulate the pharynx and prone to mispharynx. Solid food is easy to stimulate the pharyngeal reflex and less misopharyngeal, but requires full chewing and does not easily move to the pharynx. Therefore, patients can use foods such as egg custard and batter for initial training, and gradually transition to eating a normal diet and water. When training, a bite of food should be 1 small tablespoon, the speed of eating should not be too fast, and after each bite, the patient should be allowed to swallow several times repeatedly. It should be especially noted that acidic and fatty foods are prone to pneumonia by inhalation. According to the different needs, the appropriate daily distribution, to breakfast eat well, Chinese food full, dinner eat less principle. For lethargic and drowsy patients, they should be encouraged while eating and given some stimulation to be able to keep eating in the awake state. For patients with psychiatric symptoms, we should grasp the amount of food they eat on weekdays. Patients often cover their mouths and do not eat, so we should patiently enlighten and inspire them, and try to assist them to take in all the scheduled amount. Some patients do not open their mouths when they eat, then they should pour a spoonful of water from their teeth to stimulate them to open their mouths, and once they start, they should give one mouthful after another, without interruptions, and the patients do not open their mouths after interruptions. For patients with lingual muscle paralysis, who cannot push food to the pharynx but whose swallowing reflex is still preserved, send the food ball to the root of the patient’s tongue and then gently press the tongue with a spoon to cause the swallowing reflex to swallow the food. For patients with facial palsy, food tends to fall out from the corner of the affected side of the mouth or be retained in the affected cheek, so the patient should be allowed to hold the spoon on the healthy side of the mouth and place the food mass on the healthy side of the mouth, and the nurse or the patient can hold the lower jaw with her own hands to bring the lips together and pull them to both sides, and the tongue is slightly retracted and attached to the palate before the swallowing movement can be performed. To prevent misophagy, the patient is instructed to inhale enough air during feeding, hold the breath before and during swallowing so that the vocal cords close to close the larynx before swallowing, and cough a little after swallowing to expel the gas from the lungs to spray out the food residue remaining in the back of the throat. For patients with pharyngeal motility disorders, if sufficient water and calories cannot be maintained by mouth intake, nasal feeding can be used
In addition, oral care should be performed regularly to prevent food residues from remaining in the mouth. To prevent esophageal reflux from causing aspiration by mistake, patients should remain seated for more than half an hour after meals.
2.Comprehensive training for ingestion-swallowing disorder
Only oral function training is not enough for brain injury patients with ingestion-swallowing disorder, and comprehensive training should be advocated, including muscle strength training, guidance of sputum removal method, functional training of upper limbs to aid food, selection and use of aids, food preparation, maintenance of oral hygiene before and after eating, assistance of assistants and supervision methods, etc. All details related to ingestion should be taken into consideration. Therefore, only under the guidance of physicians, speech therapists, physical therapists, occupational therapists, nurses and dieticians can achieve satisfactory results through close cooperation and collaboration.