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CD 663 > Bedside Swallow Eval > Flashcards

Bedside Swallow Eval Flashcards

1
Q

What are the Symptoms of Dysphagia?

A 
¥	Cannot get swallow started
¥	Coughing
¥	Choking
¥	Sticking
¥	Comes back up
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2
Q

Types of Evaluation Procedures

A

¥ Screening
¥ Bedside Swallow Exam
¥ Instrumental Swallow Exam

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3
Q

Screening

Purpose:

A

Identify the highest risk pts who require further assessment with a full bedside exam, as well as instrumentation to assess swallow physiology

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4
Q

Screening, Procedures:

A
  • Brief chart review
    ≫ Look for factors indicative of dysphagia
    ≫ If in-­‐pt setting, look for nursing daily report

−Brief pt observation

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5
Q

Screening: Signs suggesting the need for a referral

A

¥ Decreased alertness/cognitive dysfunction
¥ Inappropriate approach to food
¥ Manifestations of impaired oropharyngeal function
¥ Pt complaints or observations of…
- Difficulty initiation swallow
- Long oral transport time (holding/pocketing food in mouth)
- Sensation of obstruction of bolus in chest/throat

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6
Q

Screening: Water Test (?)

A

(Controversial) Not a standardized procedure for all clinic facilities

¥ 3 oz. (85mL ~ 1/3cup) water swallow test

  • pt is given 3 oz. of water in a cup, and told to drink it all without stopping
  • An abnormal response would be coughing during or aWer the exam, or a change in vocal quality, to wet or hoarse

¥ High false positive rate
- Pts who fail the test may not dysphagic

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7
Q

Bedside Swallow Exam, first….

A

FIRST, obtain physician’s approval/referral before proceeding to the exam

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8
Q

Bedside Swallow Exam: Purpose

A

1) Determine, as much as possible, the physiologic factors contributing to the dysphagia
≫ Focus of the pt’s dysphagia (oral, pharyngeal..)
2) Make recommendations for safest means of intake.
≫ Recommend diet
≫ Decision on best posture
This is usually a need from the referral

≫ Selection of optimal swallowing instruction (compensatory strategy of safe swallow)
3) Make determination for need for other tests
4) Management/Treatment decision
≫ Exercises
≫ Compensatory strategies

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9
Q

What do we want to find out? (4 Clinical questions)

A

¥ Is there a h/o aspiration pna?
¥ What is the anatomical/functional status of the oral mechanism?
¥ Is there a risk for aspiration given the current diet?
¥ Is the pt improving or maintaining nutritional status on current diet?

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10
Q

What do we want to find out? (4 more questions) (cont’d

A

¥ Should the pt be referred for an instrumental swallow eval?
¥ Is the pt cognitively able to participate in an instrumental eval or follow swallow recommendations/ participate in tx?
¥ What are the diet and/or therapy recommendations?
¥ PO or NPO?

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11
Q

Components of Bedside Exam

A

¥ History/Chart review

  • Medical report
  • Pt’s complaints
¥	Physical exam
-	Oral mechanism exam
≫ Structures: face, jaw, tongue, larynx, velum
≫ Ability to protect airway
≫ Quality of cough
-	Test swallows (Trials of Swallow)
≫ s/s of aspiration, oral, pharyngeal dysphagia?
≫ Further (instrumental) testing?
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12
Q

Components of Case Hx:

From Medical Chart

A 
Recent hospitalization – reasons
¥	Past medical history & medications
¥	History of PNA? causes?
¥	History of swallowing problem
−Onset/progression
¥	Respiratory status
¥	Current nutritional status
¥	Associated symptoms -­‐ e.g. voice changes, weakness
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13
Q

Components of Case Hx: PT

A

From Pt’s

¥	Identify complaints
¥	Define cognitive status
−Alert/oriented, follow direction, etc…
¥	Pt/caregiver’s descriptions of problem
−Onset of the problem
−Course of the problem
−Presence of coughing
−Difficulty with any types of food
» Management of various food consistencies
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14
Q

Components of Bedside Exam: Adults

A

¥ Physical exam

  • Oral mechanism exam
  • Test swallows (Trials of Swallow)
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15
Q

When should you NOT do a physical exam?

A

¥ Pt is not alert

¥ Pt refuses

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16
Q

Oral Mechanism Exam, FOCUS ON

A

¥ Focus on lips/face, tongue, jaw, larynx, velum

¥ Exam the sensory/motor functions of cranial nerves V, VII, IX, X, XI and XII.

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17
Q

Oral Mechanism Exam, Variables of interest

A

Variables of interest
−Size, position, strength, speech, ROM, steadiness, tone, accuracy
−Examine structures at rest during sustained postures, and during repetitive movements

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18
Q

OMEC 5 AREAS

A 
• 5 areas:
 −Oral structures/functions/
 sensation
 −VP mechanism
 −Laryngeal function
 −Respiration
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19
Q

Oral Mechanism Exam: The condition and hygiene of

A

¥ The condition and hygiene of the teeth, gums, and oral cavity is assessed as well as the presence/fit of dentures/partial plates if applicable.

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20
Q

Oral Structures/Functions

A 
¥	Cheeks
¥	Lips
¥	Jaw opening / closing /side
¥	Tongue
¥	Dentition
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21
Q

Oral Structures/Functions: Cheeks

¥ Dentition

A
  • Symmetry

- Strength

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22
Q

Oral Structure/ Functions: Lips

A

¥ Lips

  • Symmetry
  • Spread and pucker
  • Repeat /pa/
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23
Q

Oral Struct: Jaw

A

¥Jaw opening
/ closing
/side

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24
Q

Oral Struct: Tongue

­

A

Note presence of atrophy or fasciculations (LMN damage- ROM, symmetry
- Repeat /ta/, /ka/

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25
Q

Oral Struct: Dentition

A

¥ Dentition

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26
Q

Sensation

A

¥ Intra-­‐oral sensation of the anterior tongue/lips/cheeks/ gums/floor of mouth (CN V) and posterior tongue (CN
IX) is assessed by lightly touching these areas with a cotton swab.

¥ If delayed trigger noted in the later procedure:
¥ Search for optimal oral-­‐sensatory stimulus type
¥ Any place in the oral cavity is most sensitive or best to stimulate?

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27
Q

Sensation (Cont’d)
¥ Check for:
¥ Reduced:
¥ Dry mouth:

A

quality/quantity of secretions
¥ Reduced intra-­‐oral sensation or alertness may result in pooling or drooling

¥ Dry mouth may be due to meds, x-­‐ray tx, tube fed, pts on supplemental O2 or ventilation

28
Q

VP Mechanism

A

¥ Palate at rest
¥ Palatal elevation with phonation (motor)
¥ Resonance during nasal/non-­‐nasal sentences (motor)

¥ Palatal reflex: (elevation of the soW palate without pharyngeal wall contraction) is elicit by stroking the soW palate (sensatory)
¥ Gag reflex (sensory: CN IX)
- Look for asymmetrical sign

29
Q

Laryngeal Function

A 
¥	Strength of voluntary cough/throat clearing
¥	Listen for stridor
¥	Voice quality (vf closure)
-	Vowel prolongation
≫ Gurgly voice, hoarse voice	
≫ Shortness of breath (respiration)

¥ Laryngeal elevation

30
Q

Palpation of Laryngeal Elevation

A

¥ Dry swallow

  • Check ability to initiate; any delay (+2-­‐3 s)
  • Palpate for laryngeal elevation
31
Q

Palpation of Laryngeal Elevation

A

¥ Position the person sitting upright so that the pharynx is vertical
¥ Position your hand on the person’s neck with a light touch
¥ Index finger under the chin
¥ Middle finger on the hyoid bone
¥ Ring finger on the top of the thyroid cartilage
¥ Smallest finger on the bottom of the thyroid cartilage
¥ Ask pt to perform a dry swallow

32
Q

[8] Standards of Administering Oral Care

A
  1. Use clean gloves
  2. Assess mouth problems
  3. Brush teeth with toothbrush
  4. Brush for at least 2 minutes
  5. Brush tongue
  6. Rinse mouth with water
  7. Use mouthwash
  8. Floss
33
Q

Oral Hygiene / Oral Care

A

Oral hygiene/Care Program

  • Tooth brushing x 3 daily
  • Oral Swab Care x 2 daily with an anti-­‐ plaque or antiseptic solution
    i. e., (antiseptic) Peridex, Oral-­‐B Anti-­‐ Plaque Wash
34
Q

Oral Care:: Severe Dysphagics/NPO

A

¥ Denture

  • Brush denture with liquid soap or denture cream
  • Soak denture in chlorhexidine gluconate for 3 minutes
35
Q

Tests of Aspiration at Bedside

A

¥ Using when giving foods/liquids to pts during
- Assessment and Therapy

¥	Two common devices
-	Pulse oximetry
≫ SpO2 < 90%, stop feeding
-	Cervical auscultation
≫ Two burst during apnea; one single burst aaer swallow during exhalation
*Both unreliable but may be useful
36
Q

Oxygen Saturation Test

A

Oxygen Saturation Test
¥ Pulse Oximetry: commonly used in the clinic
¥ A drop in SpO2 was associated with events of aspiration
¥ If below 90%, should stop feeding
¥ However, the findings from some research disagree this association.
SpO2 ＝ Peripheral capillary oxygen saturation

Normal: 96% or higher
Mild respiratory distress: 90% or above

37
Q

Cervical Auscultation

A

¥ Cervical auscultation is relatively new low-­‐ tech technique to facilitate accurate bedside evaluation of the swallow

¥ Monitors the sounds of the swallow

  • Stethoscope
  • Microphone
  • Accelerometer
38
Q

Cervical Auscultation Procedures

A

¥ Place the stethoscope on the neck at the level of the vocal folds
¥ Listens/records to the sounds associated with swallowing
- Establish baseline
- Listen to breathing and dry swallow
- During swallow
- Within period of apnea, two low pitch bursts of sound are markers of the presence of a swallow
- Aaer swallow:
- A high pitch when pt exhales aaer swallow
- Sound of Wetness?

¥ Not foolproof but may be a useful addition to bedside eval

39
Q

Cervical Auscultation (cont’d)
Listen during swallow….
ABNORMAL SOUNDS

A 
¥	Changes in respiratory rate
¥	A muffling/melding of the distinct clumps of sound
¥	No apnea (No two bursts)
¥	Prolonged apnea (delayed two bursts)
¥	Prolonged swallow sounds
¥	No clearing exhalation
¥	Delayed clearing exhalation
¥	Turbulence in the air-­‐exchange (sounds of wetness)
−Stridor bubbling squeaks
−Wheeze gurgling crackling
40
Q 
Cervical Auscultation (cont’d)
Listen during swallow…. Normal sequence
A 
¥	Inhalation
¥	Apnea
− two clumps-­‐clicks
¥	Exhalation
−single, short burst
41
Q

Summary: Tests of Aspiration

A 
¥	Two common devices
-	Pulse oximetry
≫ SpO2 < 90%, stop feeding
-	Cervical auscultation
≫ Two burst during apnea; one single burst after swallow during exhalation

*Both unreliable but may be useful

42
Q

Reduce the chance of ge^ng aspiration PNA??

A

YES!

¥ Pneumonia is caused by pathogen colonized in the lungs…
- inhaled through nose or aspirated through mouth

¥ Hygiene anytime, everywhere!
-Medical devices, hands, & oral cavity

43
Q

Develop PNA after Aspiration?

A

¥ The precise mechanisms of how one develops an aspiration pneumonia are unknown.

¥ Aspiration pneumonia does NOT develop in ALL patients who aspirate
- The upper and lower airway defense systems are most active when the patient’s immune system is strong

44
Q

Aspiration PNA (cont’d)

A

¥ Groups predisposed to aspiration PNA:

  • Aging (elderly)
  • Congestive heart failure
  • COPD
  • Use of multiple medications (sedatives)
  • Feeding dependence
  • Smoking
  • Hx of aspiration pneumonia
  • Having a feeding tube in place
  • Bedbound state (may b/c inappropriate posture while eating)
  • Tube feeding (Poor oral hygiene)
45
Q

¥ Silent aspiration
¥ Patient is aspirated without cough reflex presence

¥ Physical signs for aspiration PNA (silent or overt aspiration):
¥ SOB w/ rapid heart rate
¥ Fever and an increase in sputum with cough
¥ Acute mental confusion (altered mental status)
¥ Infection
¥ Incontinence

A

Signs of Aspiration PNA

46
Q

Aspiration Pneumonia (cont’d)

A

¥ Differential diagnosis
- Dysphagia-­‐related aspiration pneumonia
≫ Patient has pneumonia
≫ Aspiration caused by gravity-­‐dependent substances via oral
≫ Patient has dysphagia
- Non-­‐dysphagia-­‐related aspiration pneumonia
≫ Patient has pneumonia
≫ Patient does not have oropharyngeal dysphagia
≫ Aspiration is conceivable due to GE reflux, emesis/
vomiting, etc…
Who should we treat??

47
Q

Aspiration and Pneumonia

A

¥ Pneumonia (PNA) does not entail aspiration or dysphagia.

¥ Pneumonia: Can be inhaled or aspirated sources

  • Lung infection by pathogen colonized in the lungs
  • Lung inflammation by irritant/traumatizing lungs

¥ Aspiration = entry of food/liquid into the airway below the level of the true vfs

  • Not airborne or inhaled pathogen
  • via swallow
48
Q

¥ Physical exam

A
  • Oral mechanism exam

- Test swallows (Trials of Swallow)

49
Q

Clinical Exam: Initial Test Swallows

A
  1. First must decide whether to proceed with food presentation.
    ¥ If pt already PO ,
    ¥ Feed:
     Determine appropriate diet (dysphagia management if needed)

¥ Not feed:
 Significant deficits on oral-­‐facial exam and poor mental status/alertness -­‐> High risk of aspiration (next slide)  Refer to MBSS (?)

50
Q

Following Signs may Indicate Patient is at risk for aspiration

A

Risk for Aspiration

¥ Reduced alertness (orientation)
¥ Reduced responsiveness to stimulation
¥ Absent swallow
¥ Absent protective cough
¥ Significant reduced in range and strength of oral motor and laryngeal movements
¥ Difficulty handling secretions as evidenced by excessive coughing and choking, wet gurgly voice
¥ Medical instability (e.g., respiratory distress)

51
Q

Clinical Exam: Initial Test Swallows

A
  1. First must decide whether to proceed with food presentation
    ¥ If pt already NPO
    ­ Not feed:
    ¥ NPO due to failing recent MBSS test
    ¥ Severe oral-­‐facial deficits or mental status/alertness issues, severe respiratory disorders (e.g., pna), high risk of aspiration (look for most recent eval )
    ­ Feed:
    ¥ NPO not d/t dysphagia-­‐related issues
    NPO in place a few months ago, and pt appears improved overall
52
Q

If not Proceed to Test Swallows…

A

¥ If you decide not to feed (proceed to Test Swallows), you will recommend: NPO and follow up
¥ If someone is acutely ill (e.g., 1-­‐2 days post CVA) and recommended NPO and no MBSS, you will probably want to follow daily.
¥ …decide if an instrumental exam is required for further examination

53
Q

Ultimate goal: Pt will safely

A

tolerate the least restrictive diet to maintain optimal nutrition and hydration, and quality of life.

54
Q

Clinical Exam: Initial Test Swallows

2. Then consider

A

food textures/consistencies, position changes, placement of food in mouth

 Begin Trials of Swallow (MBSS follows similar procedures)
¥ (Do not proceed: pts with high risk of aspiration)
¥ Have patient sit upright, facing forward

55
Q

ALWAYS Remember….

Perform Oral Hygiene :

A

before giving trials (liquids/ foods) to reduce chance of getting pneumonia if pt aspirated.

  • ­‐ before trials of swallow
  • ­‐ before treatment (feeding trials)
  • ­‐ aaer oral intake (be sure no oral residue)
56
Q

Trials of Swallow: Begin

¥ Prepare

A

substances with different textures and consistencies
¥ Volumes range
- 5 ~ 10 mL: starting with a smaller bolus (~ 20 mL)
¥ Methods of delivery
- Spoon
- Cup
- Straw (more challenging)
- requires longer and more coordinated airway closure mechanics
1 teaspoon = 5 mL

57
Q

Types of Consistencies

¥ Thin liquids & Solid Textures

A
  • Usually start with this
    ¥ (if not pass) Thickened liquids
  • Nectar > Honey-­‐thick > Pudding-­‐thick¥ Meals/Solid texture
    ¥ Puree
    ¥ (if pass) Mechanically altered solid food
  • Mechanical-­‐ground (cohesive bolus), chopped
    ¥ (if pass) Solid
  • Usually refers to normal food items
    Always begins with thin water  baseline
58
Q

Trials of Swallow (ice chips)??
¥ Pros:
¥ Most DO NOT

A 
Trials of Swallow (ice chips)??
¥	Pros: using ice chips
-	Observe ability to handle water
-	May elicit chewing and swallow reflex
 * Good for swallowing therapy.	
¥	Most DO NOT agree to use ice chips for test swallowing.
-	Ice chip may provide additional sensory input that facilitates swallow
 Avoid ice chips for swallow eval.
59
Q

Sequences of Swallows

A

¥ Observation + Palpation of larynx
¥ Ask pt to hold the liquids until your verbal command
¥ Let pts drink/swallow with their own pace

¥ Aaer each swallow have the pt phonate an ‘ah’

¥ Listen carefully. Look for any gurgly voice, throat clearing, coughing is/are present?
¥ If above signs present, second dry swallow -­‐> then, phonate again

¥ Try different postures followed by phonation (‘ah’)
¥ e.g., Head rotation, head tilt, chin tuck, etc.

60
Q

Sequence of Swallows Liquids:

A

¥ If going well with 2~3 sips  proceed to serial swallows.
¥ A straw (not with thickened consistencies)
¥ May require more coordination skills
¥ May be more difficult to tolerate if there is a delay

61
Q

Sequence of Swallows: Solids & other consistencies (thickened liquids, puree, solids)

¥ Solids & other consistencies (thickened liquids, puree, solids)

A

¥ Continue the above procedures
¥ Check for mastication, pocketing, oral residue
¥ Because puree/solids may block the airway, if any significant coughing/choking/throat clearing noted discontinue trial feed

62
Q

During Trial Swallow

Coughing/throat clearing

A

¥ Coughing/throat clearing during or immediately aaer the swallow and/or wet vocal quality probably represent penetration/aspiration but…
¥ their absence does not rule it out dysphagia  could be
silent aspiration or absent cough reflex

¥ Still may miss the 50 -­‐ 60 % of pts who are silent aspirators

  • Respiratory rates
  • Observation or using Pulse oximetry
  • Listen to sound of swallowing
  • Using cervical auscultation
  • More see Tests of Silent Aspiration Lecture Handout
63
Q

Trials of Swallow: Respiratory Rate

¥ Before and After

A

the swallow
- the examiner should be cognizant of the respiratory rate.

¥ Comparisons should be made between Pre-­‐trials and Post-­‐trials.

¥ Marked change in the respiratory rate or an increase in respiratory congestion may be a sign of airway compromise.

64
Q

Clinical Exam: Consistency Considerations

A

¥ (During eval.) Thinking ahead to manage
- Optimal “side” for bolus placement depending upon motor/sensory function
- Varying textures to increase swallowing safety, e.g.,
≫ Poor oral control: thicker liquids
≫ Reduced tongue coordination: thinner liquids
≫ Delayed trigger: thicker liquids
≫ Poor tongue base movement: thicker liquids
≫ Reduced vf closure/weak cough/grunt: thicker liquids
≫ Reduced laryngeal/airway closure: thick liquid, pudding

65
Q

Common Clinical Findings

A 
¥	Oral residue/pocketing of food
¥	Edentulous
¥	Drooling
Reduced pharyngeal or laryngeal function on bedside assessment
¥	Coughing/choking while eating/drinking
¥	Frequent throat clearing
¥	Multiple swallow pattern
¥	Wet vocal quality
¥	Increased time to complete meal
¥	Resistance to eating/ drinking
¥	SOB
¥	Odynophagia
¥	Significant weight loss
¥	Repeated pneumonia
66
Q

Weakness of Bedside Swallow Exam

A

¥ If the person does not cough, s/he may be silently aspirating
¥ Although gross estimates of transit times can be made, no real information on the pharyngeal stage of the swallow is collected
¥ Since the structures cannot be seen, the most appropriate therapy cannot be determined

¥ If silent aspiration is suspected, further exam (instrumental exam) is recommended.
¥ Modified barium swallow study (MBSS)
¥ Flexible Endoscopic Evaluation of Swallowing (FEES)

67
Q

Summary: Bedside Swallow Exam

A

¥ Oral hygiene
¥ Begin with a tsp of water (via spoon or small sip from a cup) and proceed to next level of consistency if no s/s aspiration
¥ During eval, note:
- lip closure, the presence of drooling
- any delay of initiation of the swallow
- any overt coughing or choking before/during/aaer the swallow and the strength of the cough, any throat clearing aaer the swallow
- the extent of laryngeal elevation during the swallow
- the presence of a wet-­‐gurgly voice quality aaer the swallow
- oral residue aaer the swallow (check the oral cavity)

CD 663 (4 decks)

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