Decisions about goals and treatment options are made in partnership with the person, their family/caregiver, and other caregiving professionals. As part of a multidisciplinary team (see the Assessment section above), the speech-language pathologist (SLP) may be involved in assessing the individual’s response to medical treatment and in implementing both indirect and direct strategies during or following medical treatment. See ASHA’s resources on
interprofessional education/interprofessional practice [IPE/IPP] and
person- and family-centered care.
Comprehensive multidisciplinary treatment of aerodigestive disorders may include
- medical management (including pharmacotherapy and/or surgery) of underlying causes;
- indirect or compensatory treatment via environmental, dietary, and lifestyle modification; and
- direct or restorative intervention via voice, swallowing, and/or laryngeal airway treatment by an SLP.
Medical management decisions in aerodigestive disorders balance airway needs for breathing with optimal preservation of vocal quality and swallowing integrity (Dinwiddie, 2004). Approaches vary from “wait and watch” to complex surgical interventions.
Examples of medical approaches by appropriate medical professionals include, but are not limited to, the following:
- endoscopic treatment of structural abnormalities (e.g., dilation)
- medical or surgical management of the underlying disease/condition leading to the aerodigestive disorder
- surgical repair of structural abnormalities affecting aerodigestive function (e.g., arytenoidopexy, fundoplication, laryngeal cleft repair, supraglottoplasty, arytenoidectomy)
Dietary, compensatory, and environmental management may include the following:
- Dietary changes, such as
- implementing elimination diets,
- conducting food challenges (systematic introduction of new foods or textures),
- reducing acid-producing foods, and
- increasing water intake to hydrate the vocal folds and to support healthy phonation.
- Compensatory changes, such as
- using positional strategies while eating or drinking (e.g., elevating the head of the bed, turning the head) and
- implementing maneuver-based strategies when eating and drinking (e.g., supraglottic swallow).
- Environmental management, such as
- avoiding triggers (e.g., environmental pollutants, strenuous exercise).
SLPs provide direct or restorative treatment to address functional voice problems (including respiratory support for voicing) and feeding and swallowing problems. SLPs also provide direct treatment for laryngeal airway problems, including paradoxical vocal fold movement (PVFM), and chronic cough.
The nature, scope, and duration of SLP management depend on
- the underlying aerodigestive disorder, structures and functions affected, severity, and relevant history;
- the type and course of medications to treat underlying and co-occurring diseases; and
- the type and extent of surgical management required (e.g., surgical intervention and healing time, need for a temporary feeding tube).
See ASHA’s Practice Portal pages on
Dysphagia (Adult), and
Dysphagia (Pediatric) – Feeding and Swallowing for specific treatment options and techniques related to these disorders.
See ASHA’s resources titled
Person-Centered Focus on Function: Voice [PDF],
Person-Centered Focus on Function: Adult Swallowing [PDF], and
Person-Centered Focus on Function: Pediatric Feeding and Swallowing [PDF] for examples of handouts featuring assessment data consistent with the International Classification of Functioning, Disability and Health framework.
Treatment selection depends on the child’s age, cognitive and physical abilities, and specific swallowing and feeding problems. Treatment options—including postural and positioning techniques, maneuvers, and feeding strategies—are discussed in detail in the
Dysphagia (Pediatrics) – Feeding and Swallowing Practice Portal page.
Infants and young children with aerodigestive disorders may benefit from alterations of liquid viscosity to improve airway protection during swallowing and/or to reduce the impact of reflux when tube feeding. This may include the use of natural foods or commercial dietary thickening agents to increase liquid viscosity. When making such recommendations, SLPs should consult with the medical team and be aware of the possible impact of thickening agents on nutritional status and overall health. For example, the addition of a thickener may alter the nutritional composition of the formula or breast milk. This may require the child to ingest more volume in order to obtain the necessary nutrients, or it may provide more than the recommended calories or the amount of certain nutrients (e.g., more than the recommended iron, if rice cereal is the thickening agent).
In addition, children with a history of necrotizing enterocolitis are advised to avoid gel-based thickeners containing the agent xanthan gum. Food allergies must also be considered when thickening agents are being considered.
The U.S. Food and Drug Administration (FDA) has cautioned consumers about using commercial, gum-based thickeners for infants from birth to 1 year of age, especially when using the product to thicken breast milk. SLPs should be aware of these cautions and consult, as appropriate, with their facility to develop guidelines for using thickened liquids with infants. See FDA consumer cautions (FDA, 2017).
See also the
Treatment section of ASHA’s Evidence Map on Dysphagia (Pediatrics) – Feeding and Swallowing. Use keywords “Diet Modifications” and “Early Intervention.”
The goal of treatment is to establish consistent vocal fold abduction during the breathing cycle to maintain a patent airway. This reduces anxiety and affirms that breathing is consistently achievable, even in the presence of environmental or activity-related triggers.
Behavioral management by an SLP is the preferred treatment approach to PVFM (Reitz et al., 2014). Other disciplines may also be involved in treatment (e.g., medical intervention to treat reflux or allergy triggers, when present).
SLPs may implement the following procedures with most individuals with PVFM. Procedures are individualized based on triggers or other factors (Mathers-Schmidt, 2001; Sandage & Zelazny, 2004) and include the following:
- Relaxed throat breathing—trains the vocal folds to abduct and remain abducted throughout the breathing cycle. Techniques include
- sniffing in through the nose with the tongue relaxed on the floor of the mouth and the lips gently touching, followed by exhalation through pursed lips or the production of a strident sound such as /s/, an
- sipping air in through pursed lips, followed by an exhalation through pursed lips or the production of a strident sound such as /s/.
- Diaphragmatic/abdominal breathing—trains attention to expansion of the lower rib cage and abdomen during inhalation to avoid clavicular breathing patterns and shoulder/neck tension.
Once the individual has identified their most effective breathing technique, the SLP may introduce challenges (triggers) while using the technique. These include the following:
- Sports or exercise-specific training—implementing breathing techniques during a routine exercise activity or competitive sports training
- Training in the presence of environmental triggers (if applicable)—implementing breathing techniques during exposure to odors or other environmental triggers, beginning with non-noxious stimuli and progressing through noxious stimuli
See Reitz et al. (2014), Blager (2006), and Murry et al. (2006) for intervention details.
The goal of treatment is to help the individual manage their cough by identifying triggers, using strategies to suppress the cough, reducing laryngeal irritation, and using healthy vocal hygiene behaviors (Vertigan, Theodoros et al., 2007). Speech-language services should be coordinated with medical management of the underlying cause; services should be implemented after ruling out or addressing other contributing factors (Murry et al., 2006).
Treatment activities include the following:
- Educating the individual about chronic cough and its treatment, including
- discussing the difference between acute cough and chronic cough, emphasizing that chronic cough does not have physiological benefits;
- establishing cough suppression as a safe and achievable goal;
- defining the cough trigger threshold and desensitization of the cough response; and
- emphasizing the importance of adhering to medications prescribed by physicians to manage cough.
- Implementing healthy vocal hygiene practices to maximize hydration and reduce irritation of the vocal folds, including helping the individual
- identify behaviors that are contributing to the cough (e.g., poor hydration, mouth breathing) and
- practice healthy vocal hygiene behaviors (e.g., drinking plenty of water and talking at moderate volume).
- Teaching cough suppression strategies (as appropriate), including
- monitoring the cough precursor or trigger;
- using relaxed throat breathing or prolonged, slow exhalation (see PVFM above);
- using pursed-lip breathing; and
- substituting coughing with other behaviors or distractions such as
- sucking on ice or non-medicated candy and
- swallowing dry or with sips of water.
The SLP typically introduces strategies without the presence of triggers to establish functional behaviors and to determine the person’s most consistent response. The SLP may then introduce stimulants such as strong odors, increased activity levels, or other identified triggers to help the individual use the strategies before the “need” to cough. Treatment ends when the person can manage cough across a variety of contexts and in the presence of triggers.
See Blager et al. (1988), Petty and Dailey (2009), Soni et al. (2017), Vertigan (2017), and Vertigan, Theodoros et al. (2007).
Providing appropriate procedure codes for evaluation and treatment is an important aspect of successfully billing for services. Payer policies often outline specific coverage guidelines and list relevant Current Procedural Terminology (CPT; American Medical Association, 2018) codes from the International Classification of Diseases and Related Health Problems (10th Revision, Clinical Modification; World Health Organization, 2015).
Although individuals with PFVM or chronic cough may not present with dysphonia, respiratory and laryngeal function are substrates of the speech system. SLPs use diagnostic and procedure codes for assessment and treatment of voice to represent these services. Payer policies regarding the coverage of PVFM and chronic cough vary. SLPs working with private insurance should verify coverage on the basis of each individual.
For more information about coding, see the following ASHA resources:
New CPT Evaluation Codes for SLPs
Medicare CPT Coding Rules for Speech-Language Pathology Services
Coding for Reimbursement Frequently Asked Questions: Speech-Language Pathology
In addition to determining the type of treatment that is optimal for individuals with feeding, swallowing, voice, and laryngeal airway problems related to aerodigestive disorders, SLPs consider other service delivery variables—including format, provider, dosage, timing, and setting—that may affect treatment outcomes.
- Format—whether a person is seen for treatment one-on-one (i.e., individual) or as part of a group. The format of service delivery for this population can include in-person and telepractice models.
- Provider—the person administering the treatment (e.g., SLP, trained volunteer, caregiver).
- Dosage—the frequency, intensity, and duration of service.
- Timing—when intervention occurs relative to the diagnosis. This includes the timing of behavioral intervention in relation to surgical/physical management.
- Setting—the location of treatment (e.g., inpatient, outpatient, home, community based, sports venue).