Saliva management in MND

Saliva Management

• How do saliva problems relate to swallowing and breathing?

  ✓Supports this

  “Saliva that is not cleared can go towards the airway rather than being swallowed.”

  Says a build up of saliva raises the risk of choking, and the review of sialorrhoea it reproduces further down the same page describes saliva held in the mouth leading to aspiration and then to pneumonia.

  A build up of saliva and thick tenacious mucus can disrupt sleep and increase the risk of choking.

  Management

• How do saliva problems relate to swallowing and breathing?

  ✓Supports this

  “When swallowing weakens, saliva is no longer cleared and pools in the mouth or at the back of the throat.”

  States the mechanism directly: drooling is not caused by producing more saliva, but by losing the ability to manage the normal amount as the tongue, lip and swallowing muscles weaken.

  Sialorrhoea or drooling does not occur due to excess saliva production but rather a decreased ability to manage normal saliva production due to weakness of the tongue, lip and swallowing muscles.

  Management

• What can help with thick or sticky saliva?

  ✓Supports this

  “Keeping fluids up is part of the standard management of thick, sticky saliva.”

  Puts checking fluid intake first among the non drug measures it lists for thick, tenacious saliva in MND.

• What can help with too much saliva or drooling?

  !Qualifies this

  “There are recognised treatments for drooling in ALS/MND, so it does not have to be put up with in silence.”

  Agrees that saliva should be actively treated, but is more cautious about how well it works. It calls excess saliva one of the hardest symptoms in MND to address, and says the medicines used rest largely on good clinical practice rather than trials, so having recognised treatments is not the same as reliable relief.

  There are few randomised controlled trials to confirm the efficacy of drugs and interventions to manage this disabling and troubling symptom.

  Pharmacological management:

• What can help with too much saliva or drooling?

  ✓Supports this

  “Radiotherapy to the saliva glands is one of the less common treatments used for drooling.”

  Lists low dose, one sided radiotherapy to the saliva glands among the treatments used for drooling in MND, alongside anticholinergic medicines, amitriptyline and botulinum toxin injections.

  Sialorrhoea treatments include suction, drug treatments and more invasive approaches, such as injection of botulinum toxin or irradiating the salivary glands, which may improve sialorrhoea and QoL.

  Pharmacological management:

• What can help with too much saliva or drooling?

  !Qualifies this

  “Medicines used to reduce saliva have side effects that have to be weighed against the benefit, and they differ in how much they affect the central nervous system, which is why NICE NG42 suggests a medicine with fewer such effects for people with cognitive impairment.”

  Says the drugs used for saliva may be only partly beneficial and that their side effects have to be considered, with treatment tailored to how much the symptom affects the person and balanced against those side effects.

  Currently, there are a number of drugs that may be, at least partially, beneficial, but side effects need to be considered.

  Pharmacological management:

• When should I raise saliva problems with my team?

  ✓Supports this

  “Saliva and the airway are connected, so coughing on saliva involves breathing as well as swallowing.”

  Says a build up of saliva and thick mucus raises the risk of choking, and the review of sialorrhoea it reproduces further down the same page describes saliva held in the mouth leading to aspiration and then to pneumonia.

  A build up of saliva and thick tenacious mucus can disrupt sleep and increase the risk of choking.

  Management

• When should I raise saliva problems with my team?

  ✓Supports this

  “Saliva that is not cleared from the mouth can be breathed in, and that aspiration can lead to pneumonia.”

  The review of sialorrhoea reproduced on this page lists the serious complications of saliva held in the mouth in ALS: choking, and aspiration followed by pneumonia.

  Moreover, the excess mouth-retained saliva in ALS patients may lead to serious complications, such as choking, which causes anxiety, and aspiration with the consequent pneumonia.

  Pharmacological management:

• Why can saliva and drooling become a problem in ALS/MND?

  ✓Supports this

  “Drooling in ALS/MND usually comes from weakened swallowing leaving normal saliva to pool, rather than from making more saliva.”

  States the mechanism directly: drooling is not caused by producing more saliva, but by losing the ability to manage the normal amount as the tongue, lip and swallowing muscles weaken.

  Sialorrhoea or drooling does not occur due to excess saliva production but rather a decreased ability to manage normal saliva production due to weakness of the tongue, lip and swallowing muscles.

  Management

• Why can saliva and drooling become a problem in ALS/MND?

  !Qualifies this

  “There is a recognised set of ways to manage saliva problems in ALS/MND, although how well they work varies.”

  Agrees that saliva should be actively managed, but is cautious about results. It calls excess saliva one of the hardest symptoms in MND to address, so having recognised options is not the same as reliable relief.

  Management of excess saliva in people living with MND is one of the most difficult symptoms to address.

  Saliva management