Bedside Swallow Eval Flashcards
What are the Symptoms of Dysphagia?
¥ Cannot get swallow started ¥ Coughing ¥ Choking ¥ Sticking ¥ Comes back up
Types of Evaluation Procedures
¥ Screening
¥ Bedside Swallow Exam
¥ Instrumental Swallow Exam
Screening
Purpose:
Identify the highest risk pts who require further assessment with a full bedside exam, as well as instrumentation to assess swallow physiology
Screening, Procedures:
- Brief chart review
≫ Look for factors indicative of dysphagia
≫ If in-‐pt setting, look for nursing daily report
−Brief pt observation
Screening: Signs suggesting the need for a referral
¥ 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
Screening: Water Test (?)
(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
Bedside Swallow Exam, first….
FIRST, obtain physician’s approval/referral before proceeding to the exam
Bedside Swallow Exam: Purpose
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
What do we want to find out? (4 Clinical questions)
¥ 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?
What do we want to find out? (4 more questions) (cont’d
¥ 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?
Components of Bedside Exam
¥ 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?
Components of Case Hx:
From Medical Chart
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
Components of Case Hx: PT
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
Components of Bedside Exam: Adults
¥ Physical exam
- Oral mechanism exam
- Test swallows (Trials of Swallow)
When should you NOT do a physical exam?
¥ Pt is not alert
¥ Pt refuses
Oral Mechanism Exam, FOCUS ON
¥ Focus on lips/face, tongue, jaw, larynx, velum
¥ Exam the sensory/motor functions of cranial nerves V, VII, IX, X, XI and XII.
Oral Mechanism Exam, Variables of interest
Variables of interest
−Size, position, strength, speech, ROM, steadiness, tone, accuracy
−Examine structures at rest during sustained postures, and during repetitive movements
OMEC 5 AREAS
• 5 areas: −Oral structures/functions/ sensation −VP mechanism −Laryngeal function −Respiration
Oral Mechanism Exam: The condition and hygiene of
¥ 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.
Oral Structures/Functions
¥ Cheeks ¥ Lips ¥ Jaw opening / closing /side ¥ Tongue ¥ Dentition
Oral Structures/Functions: Cheeks
¥ Dentition
- Symmetry
- Strength
Oral Structure/ Functions: Lips
¥ Lips
- Symmetry
- Spread and pucker
- Repeat /pa/
Oral Struct: Jaw
¥Jaw opening
/ closing
/side
Oral Struct: Tongue
Note presence of atrophy or fasciculations (LMN damage- ROM, symmetry
- Repeat /ta/, /ka/
Oral Struct: Dentition
¥ Dentition
Sensation
¥ 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?
Sensation (Cont’d)
¥ Check for:
¥ Reduced:
¥ Dry mouth:
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
VP Mechanism
¥ 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
Laryngeal Function
¥ 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
Palpation of Laryngeal Elevation
¥ Dry swallow
- Check ability to initiate; any delay (+2-‐3 s)
- Palpate for laryngeal elevation
Palpation of Laryngeal Elevation
¥ 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
[8] Standards of Administering Oral Care
- Use clean gloves
- Assess mouth problems
- Brush teeth with toothbrush
- Brush for at least 2 minutes
- Brush tongue
- Rinse mouth with water
- Use mouthwash
- Floss
Oral Hygiene / Oral Care
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
Oral Care:: Severe Dysphagics/NPO
¥ Denture
- Brush denture with liquid soap or denture cream
- Soak denture in chlorhexidine gluconate for 3 minutes
Tests of Aspiration at Bedside
¥ 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
Oxygen Saturation Test
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
Cervical Auscultation
¥ 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
Cervical Auscultation Procedures
¥ 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
Cervical Auscultation (cont’d)
Listen during swallow….
ABNORMAL SOUNDS
¥ 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
Cervical Auscultation (cont’d) Listen during swallow…. Normal sequence
¥ Inhalation ¥ Apnea − two clumps-‐clicks ¥ Exhalation −single, short burst
Summary: Tests of Aspiration
¥ 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
Reduce the chance of ge^ng aspiration PNA??
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
Develop PNA after Aspiration?
¥ 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
Aspiration PNA (cont’d)
¥ 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)
¥ 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
Signs of Aspiration PNA
Aspiration Pneumonia (cont’d)
¥ 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??
Aspiration and Pneumonia
¥ 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
¥ Physical exam
- Oral mechanism exam
- Test swallows (Trials of Swallow)
Clinical Exam: Initial Test Swallows
- 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 (?)
Following Signs may Indicate Patient is at risk for aspiration
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)
Clinical Exam: Initial Test Swallows
- 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
If not Proceed to Test Swallows…
¥ 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
Ultimate goal: Pt will safely
tolerate the least restrictive diet to maintain optimal nutrition and hydration, and quality of life.
Clinical Exam: Initial Test Swallows
2. Then consider
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
ALWAYS Remember….
Perform Oral Hygiene :
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)
Trials of Swallow: Begin
¥ Prepare
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
Types of Consistencies
¥ Thin liquids & Solid Textures
- 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
Trials of Swallow (ice chips)??
¥ Pros:
¥ Most DO NOT
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.
Sequences of Swallows
¥ 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.
Sequence of Swallows Liquids:
¥ 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
Sequence of Swallows: Solids & other consistencies (thickened liquids, puree, solids)
¥ Solids & other consistencies (thickened liquids, puree, solids)
¥ 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
During Trial Swallow
Coughing/throat clearing
¥ 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
Trials of Swallow: Respiratory Rate
¥ Before and After
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.
Clinical Exam: Consistency Considerations
¥ (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
Common Clinical Findings
¥ 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
Weakness of Bedside Swallow Exam
¥ 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)
Summary: Bedside Swallow Exam
¥ 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)
