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Case 5: Ms. LawCase 5: Ms. Law

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TerminologyTerminology

Myasthenia gravis (MG) Autoimmune & neuromuscular junction

disease, Characterized by rapid weakness of

muscle with use + improvement withrest Antibodies form against acetylcholine

(ACh) receptors less functioningreceptors at motor end plate weaker

muscle contraction Improvement with rest nerves can

replenish supply of ACh Signs - ptosis (drooping of eyelid),

flaccid dysarthria, dysphagia

(Duffy, 2005)

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TerminologyTerminology

MG crisis MG deterioration that necessitate

mechanical ventilation

Bulbar symptoms Bulbar muscles: oropharyngeal and

laryngeal muscles

Impairment difficulties withspeech, swallowing or both

(Bershad, Feen, & Suarez, 2008)

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TerminologyTerminology

Consolidation White shadowed areas reflected in

chest x-ray

Can be caused by bronchial infection

Yentis, Hirsch, & Smith (2009)

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Background informationBackground information

F / 60Diagnosis of myasthenia gravis in

2003

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Medical historyMedical history

20th Nov 2006 admitted ICUbecause of: Fever

Respiratory failureExaminations:

Physical examinationWorsening of bulbar symptoms

(dysphagia, dysarthria & ptosis) CXRBilateral lower zone patchy consolidation

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Medical historyMedical history

Diagnosis Influenza

Pneumonia

Acute MG crisisFeeding at ICU

R/T tube

28th Nov 2006 discharged togeneral ward

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History of treatmentHistory of treatment

Swallowing training since 23rdNov 2006

Re-assessment done on 10th Dec

2006

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Assessment resultsAssessment results

Satisfactory dental condition

Pre-requisite for mastication

Fair tongue strength and adequaterange of movement

food bolus formation

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Assessment resultsAssessment results

Reduced MPT

Fair cough effort

Weak vocal fold adduction

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Assessment resultsAssessment results

Diminished gag reflex

NOT indicative of swallowing reflex

Moderate degree of hypernasality Functional swallowing is possible withou

VP closure (Logemann, 1998)

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Assessment resultsAssessment results

Mild delay in swallowing

High consistency: rest at vallecula

Low consistency: splash into the airway

Moderately reduced laryngeal

elevation Reduced closure of airway by epiglottis

CP sphincter NOT opened adequately

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Assessment resultsAssessment results Multiple swallow per intake

Food remaining at valleculae andpyriform sinuses

Throat clearing with thin liquid, mildly

thick liquid, puree and biscuits Aspiration

Delay in swallowing increases withamount of food

Implication for tx planning

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Management planManagement plan

Compensatory strategies Postural modification

Diet modification

Improve oral sensory awarenessSwallowing therapies

Deep pharyngeal neuromuscular

stimulation

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Postural modificationPostural modification

Chin tuck (Logemann, 1998) Instructions: Bring your chin to chest

Rationale:

Push the base of tongue towardspharyngeal wall

Expands valleculae recesses

Narrows the entrance to laryngeal

vestibule by moving the epiglottisposteriorly

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Diet modificationDiet modification

10cc thin liquid Rationale: Scores 1 in 8-point Penetration/

aspiration Scale (Rosenbak et al., 1996)

No solid food Rationale: Scores 5 in 8-point

penetration/aspiration scale (Rosenbak etal., 1996) : penetration occurs!

Meal: pureed meat congee ( )

to Lydia: what is the rationale? Thevegetable and meat is a must to bepureed la, but how about the choicebetween congee/ soft rice/ pureed for

the

?

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Improve oral sensoryImprove oral sensory

awarenessawarenessSensory enhancement

techniques

Present a cold/ sour bolus

Rationale: to trigger the pharyngeal stageof swallowing more rapidly (Logemann,1998)

D h lD h l

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Deep pharyngealDeep pharyngeal

neuromuscular stimulationneuromuscular stimulation

(DPNS)(DPNS)Provide stimulations with icedlemon glycerin swabs to oral andpharyngeal areas

Rationale:To stimulate the contraction of

pharyngeal and lingual muscles

To stimulate the cranial nerve bytouching specific areas within themouth and tongue

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Swallowing maneuver?Swallowing maneuver?

Would not be implementedRationale:The patient is diagnosed to have MG

in which she would show muscleweakness on sustained effort (Webb& Adler, 2008)

these maneuvers require increasedmuscular effort and are notappropriate in patients who fatigueeasily (Logemann, 1998, pg. 215)

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ReferencesReferences

Bershad, E. M., Feen, E. S., & Suarez, J. I.(2008). Myasthenia gravis crisis. SouthernMedical Journal, 101 (1), 63-69

Duffy, J. R. (2005). Motor speech disorders:Substrates, differential diagnosis, and

management(2nd ed.). St. Louis: ElsevierMosby.Love, R. J., & Webb, W. G. (2008). Neurology

for the speech-language pathologist. St.Louis, MO: Mosby/Elsevier.

Yentis, S. M., Hirsch, N. P., & Smith, G. B.(2009). Anaesthensia and intensive care A-Z: An encyclopedia of principles andpractice (4th ed.). New York: ElsevierLimited.