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PassPMR - 02 Acquired Brain Injury > 6- Dysphagia > Flashcards

6- Dysphagia Flashcards

1
Q

What is the innervation of salivation? 🔑🔑

Which cranial nerves are important for eating and swallowing?🔑

A

Parasympathetic Innervation:

CN 9: Parotid gland

CN 7: Submandibular, sublingual

Ref: Wikipedia.

CN for swallowing

CN V, VII, IX, X, XI, XII (All except eyes)

Ref: Review Notes 2012

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2
Q

Definition of Dysphagia vs Odynophagia

A

Dysphagia

Difficulties with swallowing

Odynophagia

Painful swallowing

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3
Q

Define aspirations vs silent aspiration. 🔑🔑

A

Aspiration

Entry of material into the airway below the level of the true vocal cords.

Silent Aspiration

Entry of material into the airway below the level of the true vocal cords, without cough or any outward sign of difficulty. Such cases may be missed in the absence of a videofluoroscopic swallow study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) assessment

ERABI Module 3 pg8

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4
Q

What are the signs of silent aspirations. 🔑🔑

A
  1. Recurrent lower respiratory infections
  2. Low-grade fever
  3. Leukocytosis
  4. Chronic congestion

ERABI Module 3 pg8

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5
Q

Define Dysphaigia - Penetration - Aspiration 🔑🔑

A

Dysphagia = difficulty with swallowing.

Penetration = entry of material into the larynx but not below the true vocal cords.

Aspiration = entry of material into airway below level of true vocal cords.

Stroke Rehabilitation Clinician Handbook 2020 Model 6 pg2

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6
Q

Phases of swallowing & problem seen with each phase 🔑🔑

Mention which phase is the most critical and list its complications 🔑🔑 EXAM 2021

A

1- Oral Preparatory Phase

Drooling and pocketing

2- Oral Propulsive Phase

Drooling and pocketing, Slow, effortful eating, difficulty swallowing pills

3- Pharyngeal Phase

Aspiration, food sticking, choking and coughing, wet/gurgling voice, nasal regurgitation

4- Esophageal Phase

GERD and food sticking

Cuccurollo 4th Edition Chapter 1 Stroke pg38

Stroke Rehabilitation Clinician Handbook 2020 Model 6 pg3

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7
Q

List 8 Medical Conditions That Can Cause or Associated with Dysphagia

A

💡 Cognition - Brain - Corticobulbar Tract - Brainstem - NMJ - Connective Tissue

  1. Alzheimer Disease and Other Dementias
  2. Cerebrovascular Accident (Stroke)
  3. Traumatic Brain Injury
  4. Amyotrophic Lateral Sclerosis
  5. Multiple Sclerosis
  6. Parkinson Disease and Parkinson-like Syndromes
  7. Cerebral Palsy
  8. Lateral Medullary Syndrome
  9. Myasthenia Gravis
  10. Muscular Dystrophy and Myotonic Dystrophy (Myopathies)
  11. Dermatomyositis and Polymyositis
  12. Rheumatoid Arthritis
  13. Systemic Lupus Erythematosus

https://pubs.rsna.org/doi/10.1148/rg.e22

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8
Q

Dysphagia. 3 structural & 3 peripheral nervous system causes?🔑🔑

A

CNS: Stroke, TBI, Dementia, Parkinson

PNS: MS, GBS, ALS, Polio

Myopathic: Dermatomyositis, Polymyositis, Myasthesia Gravis

Structural: Tumor, Diverticulum, Cervical Web

UpToDate

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9
Q

Risk factors for development of pneumonia secondary to aspiration include🔑

A
  1. Decreased level of consciousness
  2. Tracheostomy
  3. Nasogastric tube (NGT) feeding
  4. Reflux
  5. Dysphagia
  6. Emesis
  7. Prolonged pharyngeal transit time

Cuccurollo 4th Edition Chapter 1 Stroke pg39

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10
Q

What are independent predictors of pneumonia following stroke?

A

💡 Presence of ≥2 these risk factors = 90.9% sensitivity and 75.6% specificity for development of pneumonia.

ORIGINAL ANSWER

  1. Age > 65 years
  2. Dysarthria or aphasia
  3. Modified Rankin Scale score ≥ 4
  4. Abbreviated Mental Test score <8
  5. Failure on water swallow test

MODIFIER ANSWER “EASY”

  1. Older age
  2. Dysarthria/no speech due to aphasia
  3. Severity of post-stroke disability
  4. Cognitive impairment
  5. Abnormal water swallow test result

Ref: EBRSR module 15 pg 10.

https://www.ahajournals.org/doi/10.1161/strokeaha.106.478156

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11
Q

Risk Factors Associated with Aspiration Difficulties Post-Stroke 🔑🔑

What are the factors more likely to be associated with aspiration pneumonia following stroke?

A
  1. Brainstem stroke.
  2. Poor oral hygiene.
  3. Difficulty swallowing oral secretions.
  4. Coughing/throat clearing, choking or wet gurgly voice quality after swallowing water.
  5. Weak voice and cough.
  6. Immunologically compromised or chronic lung disease.
  7. Recurrent lower respiratory infections.
  8. Aspiration or pharyngeal delay on videofluoroscopic modified barium swallowing (VMBS).

Stroke Rehabilitation Clinician Handbook 2020 Model 6 pg3

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12
Q

Strongest predictor of dysphagia following TBI? 🔑🔑

A

Initial severity of brain injury appears to be the strongest predictor of dysphagia related aspiration.

ERABI Module 3 pg8

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13
Q

What are the risk factors for dysphagia post-ABI? 🔑🔑

A

Phase 1: Beginning of injury

Head Injury: Severe TBI (GCS, coma), CT

  1. Severity of brain injury
  2. Lower Glasgow Coma Score on admission (GCS 3-5)
  3. Duration of coma
  4. Severity on CT Scan findings
  5. Severe cognitive and cognition disorders

Structural Injury: Intervention, Fracture

  1. Translaryngeal (endotracheal) intubation
  2. Duration of mechanical ventilation
  3. Tracheostomy
  4. Physical damage to oral, pharyngeal, laryngeal, and esophageal structures
  5. Oral and pharyngeal sensory difficulties

ERABI Model 3 pg7

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14
Q

What are the risk factors for aspiration following an ABI? 🔑🔑

A

Phase 2: TBI Man doing fiberoptic endoscopic evaluation

Head Injury

  1. Lower Glasgow Coma Score (3-5)
  2. Poor cognitive functioning
  3. Brainstem involvement

Structure Injury

  1. Presence of a tracheostomy
  2. Prolonged period of mechanical ventilation

Assessment

  1. Difficulty swallowing oral secretions
  2. Hypoactive gag reflex
  3. Reduced pharyngeal sensation
  4. Coughing/throat clearing or wet, gurgly voice quality after swallowing water
  5. Choking more than once while drinking 50 ml of water
  6. Recurrent lower respiratory infections
  7. Dependence on feeding assistance

ERABI Model 2

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15
Q

What are the risk factors for aspiration pneumonia post-ABI? 🔑🔑

A

Phase 3: TBI man, feeding with chest infection and polypharmacy.

  1. Dependence in self-feeding and oral care
  2. Amount of tooth decay
  3. Need for tube-feeding
  4. Smoking
  5. Greater than one medical diagnosis
  6. Total number of medications

ERABI Module 3 pg9

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16
Q

Feeding dysfunction in PD

List 4 adaptive equipment to improve feeding in PD patient 🔑🔑

A

Gastrointestinal Problems in PD

  1. Swallowing Dysfunction
    • Dysphagia due to loss of lingual control and inability to propel the bolus due to delay in the contraction of pharyngeal muscles.
    • Assessment → Modified barium swallows
    • Treatment → oral-motor exercises and providing compensatory strategies
    • Malnutrition → gastrostomy feeding tube
  2. Delayed Gastric Emptying
    • Nausea and vomiting, GERD, “heartburn” or indigestion
    • Metoclopramide may worsen dyskinesias (extrapyramidal s/e)
  3. Constipation
    • Causes: autonomic dysfunction, medications, limited mobility, impaired hydration
    • Tx: Hydration, increased physical activity, and high-fiber diets.

Feeding Equipment

  1. Plate-guards
  2. Swivel fork and spoons
  3. Weighted utensils
  4. Large-handled cups with straw

Cuccurollo 4th Edition Chapter 12

Movement Disorder pg872 Table 12-3

DeLisa 5th Edition Chapter 26 Movement Disorder pg650-651

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17
Q

List 2 Complications of Dysphagia 🔑🔑

Another Twist: Goals of Dysphagia Management

A

Complications

  1. Dehydration
  2. Malnutrition

Cuccurollo 4th Edition Chapter 1 Stroke pg41

Goals

  1. Meet the nutritional and hydration needs of the stroke survivor.
  2. Prevent aspiration-related complications.
  3. Maintain and promote swallowing function as much as possible.

Stroke Rehabilitation Clinician Handbook 2020 Model 6 pg6

18
Q

Complications of Malnutrition Post-Stroke 🔑

A

“Common to see patient who is cachectic, not adhering to therapy, developing bed sore and contractures, not functional gains .. just prolonged hospital stay.” Dr. Maitham.

  1. Decreased response to physiotherapy.
  2. Increased length of stay.
  3. Greater risk of bedsores and UTIs.
  4. Lower Barthel Index scores at 1-4 months.

Stroke Rehabilitation Clinician Handbook 2020 Model 6 pg25

19
Q

List 4 Indication for videofluoroscopic modified barium swallowing (VMBS) Studies 🔑

A

Indication for VMBS Studies

  1. Brainstem stroke.
  2. Obvious signs of choking or wet, hoarse voice after drinking.
  3. Problems maintaining adequate nutrition and hydration. (malnutrition)
  4. Recurrent respiratory infections.
  5. Follow-up of previous positive VMBS study

Stroke Rehabilitation Clinician Handbook 2020 Model 6 pg10

Clinical Risk Factors (at least one) → VBMS

  1. Brainstem Stroke.
  2. Choking more than once while drinking 50cc of water.
  3. Difficulty swallowing oral secretions.
  4. Coughing/throat clearing or wet, gurgly voice quality after swallowing water.
  5. Weak voice and cough.
  6. Recurrent lower respiratory infections.

Stroke Rehabilitation Clinician Handbook 2020 Model 6 pg21

20
Q

List 4 ways to assess for dysphagia 🔑🔑

A

1- Bedside Clinical Examination by SLP

Testing

  • General observation
  • Cough Strength
  • Oral motor examination
  • Evaluates gag reflex or pharyngeal sensation
  • Receptive & Expressive Language
  • Ability to understand directions
  • Trail of different food and fluid consistencies
  • Swallow palpation

Goal

  • Looking for signs of cough or other difficulty during swallowing
  • It’s safe to feed a patient orally (nutrition, hydration, and medications)
  • Requires further swallowing assessments

2- Water Swallowing Test

  • During bedside examination, 30oz - 90ml

3- Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

  • Pharyngeal stage of swallowing
  • Evaluation for presence of residue, penetration, and/or aspiration
  • Decide the safest position and food texture

4- Videofluoroscopic Swallow Study (VFSS) or modified barium swallow study (MBSS)

  • “Gold standard” for evaluation and treatment of dysphagia
  • Different amounts and consistencies of solids and liquids mixed with barium are swallowed while visualizing the anatomy of swallowing

ERABI Module 3 pg11 Table 3.2

Cuccurollo 4th Edition Chapter 1 Stroke pg38

21
Q

What are some components of a bedside swallowing examination?🔑🔑

A

COGNITION & COMMAND

  1. General observation
  2. Ability to understand directions (Cognition - Apraxia)

CRANIAL NERVES

  1. Oral motor examination (CN 5-7-12)
  2. Receptive & Expressive Language (Dysarthria)

PROTECTIVE REFLEX

  1. Cough Strength
  2. Evaluates gag reflex or pharyngeal sensation

WATER TEST

  1. Trail of different food and fluid consistencies
  2. Swallow palpation

ERABI Module 3 pg35 & pg11 Table 3.2

22
Q

Predictors of aspiration on “bedside swallowing exam” 🔑🔑

Another Q: What are the positive signs in bedside swallowing exam.

A

CRANIAL NERVES - OROMOTOR POWER

  1. Dysphonia
  2. Dysarthria

PROTECTIVE REFLEXS

  1. Abnormal gag reflex
  2. Abnormal cough

WATER TEST

  1. Cough after swallow
  2. Voice change after swallow

Cuccurollo 4th Edition Chapter 1 Stroke pg39

23
Q

Gold standard tool for diagnosis of aspiration and its clinical correlation 🔑🔑

A

Videofluoroscopic swallow studies (VFSS)

considered to be the “gold standard” in the diagnosis of aspiration.

Phases examined

Oral and pharyngeal phases of swallowing

High risk of pneumonia

  • Patients who aspirate over 10% of the test bolus
  • Severe oral and/or pharyngeal motility problems

ERABI Module 3 pg13

24
Q

How to tell patient is underweight? 🔑

List 2 Biochemical Markers of Nutritional Status

A

Underweight

Body Mass Index (BMI) < 18.5

Labs

  1. Serum Albumin (Protein)
  2. Serum Trasferrin (Aneima)
25
Q

How to manage any patient with dysphagia? General approach.

A

Feeding is made up from two parts:

  1. Food:
    1. Type → IDDSI level
    2. Route → cup > straw > NGT
  2. Patient
    1. Before eating → low risk feeding strategy
    2. During eating → compensatory techniques and manuvers
    3. After eating → clerance technique

Dr. Maitham Note

26
Q

Assessment of Swallowing Post Stroke at Time of Admission. 🔑🔑

A

Clinical Risk Factors (at least one):

  1. Brainstem Stroke.
  2. Dysphonia or Dysarthria
  3. Dysphagia (Malnutrition & Aspiration)
    1. Difficulty swallowing oral secretions.
    2. Choking more than once while drinking 50cc of water.
    3. Coughing/throat clearing or wet, gurgly voice quality after swallowing water.
    4. Recurrent lower respiratory infections.

Stroke Rehabilitation Clinician Handbook 2020 Model 6 pg21

27
Q

75 F stroke pt with severe dysphagic symptoms.

List 2 complications of importance

What are 2 potential treatments for pt?

A
  1. Aspiration
  2. Malnutrition and dehydration
28
Q

What are the different type of liquid textures? 🔑

A
  1. THIN: regular fluids (water), no modifications.
  2. NECTAR: thin enough to be sipped through a straw or cup, but thick enough to fall off tip of spoon slowly
  3. HONEY: too thick for straw, eaten with a spoon, but does not hold its own shape
  4. PUDDING/SPOON THICK: thick fluids that must be eaten with a spoon, hold their shape on a spoon

Ref: Dr. Cleary’s notes, SLP

29
Q

What are some common diet modifications that can aid swallowing? 🔑🔑

Think about how can you “modify” the food of the patient.

A
  1. For solid textures, food may be diced, minced, or pureed.
  2. For fluids, they may be thickened to nectar, honey, or pudding consistencies.
  3. Limit mixed consistency food.
  4. Limit the amount of food they attempt to swallow (e.g. taking smaller bites, slower pacing)

ERABI Module 3 pg19

30
Q

What are the contraindications to using an NG feeding tube? 🔑🔑 MOCK 2021

A

UpToDate article – NG and nasoenteric tubes.

  1. Basal skull fractures.
  2. Facial fractures.
  3. Esophageal strictures
  4. Esophageal varices
  5. Bleeding diatheses

Extra

  1. Recent nasal surgery
  2. Esophageal fistula or perforation
  3. Alkaline ingestion
31
Q

List 3 indications for a PEG or an RIG tube insertion? 🔑🔑

What are the benefits of feeding tube placement in motor neuron disease?

A

💡 Twisted question about dysphagia complication thus needs intervention

Indications of PEG

  1. Aspiration pneumonia
  2. Loss of >10% body weight (malnutrition)
  3. Impaired QoL due to time required to maintain nutrition orally

Benefits

  1. Stabilizes weight
  2. Prolongs survival

DeLisa 5th Edition Chapter 28 MND pg731

32
Q

List 2 Risks of parenteral feeding 🔑🔑

A
  1. Central/peripheral line complications (infection, clot formation, edema)
  2. Risk of pneumothorax
  3. Electrolyte and metabolic abnormalities

Cuccurollo 4th Edition Chapter 2 TBI pg89

33
Q

Direct gastrostomy & jejunostomy. When it’s time to start? main advantage? 🔑🔑

A

Guidelines for enteral feeding in adult hospital patients

  • Long term NG and NJ tubes should usually be changed every 4–6 weeks swapping them to the other nostril (grade C).
  • Gastrostomy or jejunostomy feeding should be considered whenever patients are likely to require enteral tube feeding for more than 4–6 weeks (grade C) and there is some evidence that these routes should be considered at 14 days (grade B).

https://gut.bmj.com/content/52/suppl_7/vii1

Advantage

  • Decreased risk of aspiration and GERD

Cuccurollo 4th Edition Chapter 2 TBI pg 89

34
Q

List 4 Compensatory Strategies. 🔑🔑

A
  1. POSTURAL TECHNIQUES
    • Chin Tuck: Facilitating forward motion of the larynx and facilitating bolus movement through the pharyngeal region
    • Chin Up: Drive the food or liquid out of the mouth and into the pharynx. Helpful for those who have oral tongue propulsion problems
    • Head Rotation: Head turn to weaker side to redirect bolus flow to stronger side of pharynx
    • Head Tilt: Uses gravity to guide bolus into stronger pharynx.
  2. SWALLOWING MANEUVERS
  3. THERMAL STIMULATION
  4. OROMOTOR EXERCISES

Cuccurollo 4th Edition Chapter 1 Stroke pg41

35
Q

Describe some low-risk feeding strategies 🔑🔑

A

From Heart and Stroke Foundation, 2016

  1. Calm eating environment, with minimal distractions.
  2. Patient is in an upright position with the neck slightly flexed facing midline.
  3. Self-feeding.
  4. Proper oral care.
  5. Feed at eye level.
  6. Feed slowly.
  7. Feed using metal teaspoons (no tablespoons or plastic).
  8. Ensure bolus has been swallowed before offering more.
  9. Drink from wide mouth cup or a straw to reduce the neck extending back.
  10. Properly position the patient and monitor for 30 minutes after each meal.

ERABI Module 3 pg

  1. Check the food tray to ensure the correct diet type has been provided.
  2. Ensure the environment is calm during meals and minimize distractions.
  3. Position the stroke survivor with the torso at a 90° angle to the seating plane, aligned in mid-position with the neck slightly flexed.
  4. Support the stroke survivors with pillows if necessary.
  5. Perform mouth care before each meal to remove bacteria that have accumulated on the oral mucosa.
  6. Feed from a seated position, so that you are at eye level with the stroke survivor.
  7. Do not use tablespoons. Use metal teaspoons, never plastic for feeding individuals with bite reflexes.
  8. Use a slow rate of feeding and offer a level teaspoon each time.
  9. Encourage safe swallowing of liquids by providing them with wide-mouth cup or glass or in a cut-down nosey cup, which helps prevent the head from flexing backward and reduces the risk of aspiration.
  10. Ensure that swallowing has taken place before offering any additional food or liquid.
  11. Observe the stroke survivor for any signs or symptoms of swallowing problems during and for 30 minutes after the meal.
  12. Perform mouth care after each meal to ensure that all food debris is cleared from the mouth.
  13. Position the patient comfortably upright for at least 30 minutes after each meal to promote esophageal clearance and gastric emptying and to reduce reflux.
  14. Monitor the oral intake of the stroke survivor with dysphagia: note any food items that are not consumed and ensure that intake is adequate, especially important in individuals receiving a thickened-liquid diet.
  15. Document the patient’s intake, any changes in swallowing status and any self-feeding problems.

Stroke Rehabilitation Clinician Handbook 2020 Model 6 pg15

36
Q

When is the best time to initiate oral care with a patient who has dysphagia? 🔑🔑

A

Mouth care should be thorough and performed before eating or drinking

Research suggests that the introduction of oral bacteria to the lungs via aspiration is more problematic than the food or liquid that is aspirated

ERABI Module 3 pg25

37
Q

Mouth care is more challenging in patients with TBI given the frequent presentation of significant cognitive-communication issues including:

A
  1. Fatigue
  2. Lack of physical recovery necessary to complete the task of brushing independently
  3. Reduced level of alertness
  4. Cooperation and comprehension

ERABI Module 3 pg25

38
Q

List 4 Clearance Technique. 🔑🔑

A
  1. Brushing before and after feeding
  2. Liquid wash
  3. Coughing after each bolus swallow
  4. Digital manual clerance
  5. Dry Swallow
  6. Double Swallow

Braddom 6th Edition Chapter 3 Table 3.2

Cuccurollo 4th Edition Chapter 1 Stroke pg41

39
Q

What are therapeutic treatment techniques in dysphagia to reduce the risk of aspiration? 🔑🔑

A

💡 Best treatment for dysphagia is swallowing and stimulation. Compensation may not necessarily treat dysphagia.

Remember what they do in SLP:

  1. Oral and motor exercises
    1. Range of motion
    2. Vocal fold adduction
    3. Shaker exercises.
  2. Swallowing maneuvers.
  3. Thermal-tactile stimulation.
  4. Passy-Muir Speaking Valve (PMV).

ERABI Module 3 pg21

40
Q

The use of antiemetic medication (metoclopramide) for TBI patient?

A

Should be avoided because of sedation and extrapyramidal side effects

Cuccurollo 4th Edition Chapter 2 TBI pg 89

PassPMR - 02 Acquired Brain Injury (6 decks)

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