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CD 663 Midterm- Tori > CD 663 Midterm-Tori > Flashcards

CD 663 Midterm-Tori Flashcards

1
Q

What are the three different types of instrumental assessments?

A

FEES, FEAST and MBS

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2
Q

FEES stands for what?

A

Flexible Endoscopic Evaluation of Swallowing

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3
Q

How is a FEES assessment done?

A

Done transnally through the nareys up and over the soft palate such that the light and thevcamera in the endoscope are hanging down and can view structures of laryngeal vestibule, including VF
View the VF immediately after before and after swallow (BUT NOT DURING)

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4
Q

Benefits of a FEES assessment/ Useful methodology for swallowing

A 
. Observe structure 
. Able to see patients at bedside
. No radiation
. Biofeedback (visual form)
. Portable
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5
Q

What is a whiteout?

A 
A moment that is caused by the action of the
epiglottis which plops down over the
vocal folds and obscures our view all we
can see is sort of the white light from
the endoscope reflected off of the
epiglottis.
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6
Q

Process of FEES Assessment

A

Clinician tells pt. what to do/ not to do, and while narrating at the same time so when she goes back later to view the film she’ll have an auditory log of what they were doing at the time the film had taken place.

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7
Q

Landmarks in a FEES view

A
  • Arytenoid Cartilages in (posterior aspect)
  • VF (if open can see rings of trachea)
  • Pads of tissue (projections of the FVF)
    Located above the true VF
    -Epiglottis
    -Pyriform sinus
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8
Q

Is blue a normal color in the laryngeal vestibule?

A

No, things are blue during an abnormal swallow due to (blue dye with the substance the pt. is swallowing)
Done to identify aspiration/ penetration

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9
Q

What is FEESST stand for?

A

Flexible Endoscopic Evaluation of Swallowing with Sensory testing

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10
Q

What is the duct in the FEEST assessment used for?

A

It puts a spurt of air into the larynx to spark the sensory stimulation to see if there is any damage to the VF. It gives a good view of what happens in terms of reaction to sensory stimulus. Ex. Pts. with cranial nerve or sensory damage. Its useful to see if those patients can swallow safely.

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11
Q

Are the substances in the FEES and FEEST assessments the same?

A

Yes. Only difference is the blue dye that is administered.

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12
Q

What does MBSS/ VDSW stand for?

A

Modified Barium Swallow Study or Video swallow

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13
Q

In what order is the substances in the MBSS given in?

A

Liquid and Puree first (in abnormally sm. amts.)
Start with persons own secretions
Next move to 1/2 to 1 tsp. of substance (which it can be water, but it will be water with barium)
Then slowly advancing to amounts that are more typical.
Eg. advancing to sips, serial sips, gulps, , allowing pt. to feed self
(Start with a small amount of liquid (easiest to clear from the airway and the amt. of aspiration will be less.

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14
Q

What happens during the MBSS Oral stage?

A

Look out for drooling, can pt. contain and form bolus.
After barium is administered you will look out for:
-Bolus transit/propulsion (Is it smooth?)
-Tongue movement (pumping?)
-Soft palate
-Hard palate
After swallow, check for oral residue (in the sulci, anterior aspect, on the palate)
Look out next for premature spillage/ or any unexpected characteristic to the transit of the bolus from the end of the oral stage into the beginning of the pharyngeal stage.
Ability of pt. to chew/ masticate (fxn)

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15
Q

What happens during the MBSS Pharyngeal stage?

A

Position of bolus before the swallow is triggered (Is there a delay?)
Adequacy/timing:
- of VP closure, BOT retraction
-epiglottic inversion/retroflexion
-hyoid movement/ laryngeal elevation
-contraction of the pharyngeal constrictors
-PES relaxation/opening

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16
Q

Pharygeal Stage continued.. (what else happens)

A

Look out for abnormalities such as:
Is there penetration?
If so, what are the characteristics.
Is there aspiration?
If so, does the pt. react? Or is it silent aspiration?
If you see aspiration during the MBSS you can ask pt. to clear it with a voluntary cough.
If you see pharyngeal residue, you will see how much is left if you have pt. do a dry swallow/second swallow.

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17
Q

What is another name for a dry swallow?

A

Double swallowing or second swallow

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18
Q

What happens during the Esophageal Stage?

A

This stage can only be seen in a MBSS.
Look out for :
-Opening/ Closing of sphincters
(In typical view look for backflow of liquid back up into the pharynx.
-Top of esophagus is wide enough to allow food/liquid to pass through.

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19
Q

What do we need to know about the Anterior/ Posterior view done in an MBSS?

A

Typically this is not done at the very beginning of an MBSS.
Its done toward the end of study.
You may try thin, thick or puree on pts. which you suspect any asymmetry (ex. Stroke pts. who might have unilateral impairment of action of the VF, and the pharynx, and the oral structures.
Look to see:
-how symmetrical the bolus is when it goes down.
-any anatomical variations/ abnormalities

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20
Q

When is the esophagus screened on a MBSS?

A

During the Anterior/Posterior view
(Done to find any significant abnormalities of structure)
Is there any issues with P/O flow of substance?

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21
Q

Indicators/ Benefits for the MBSS

A
  • Unknown medical etiology
  • vague symptoms, (need a a comprehensive view)
  • Visualize submucosal anatomy (eg. cervical osteophytes)
  • Assess oral stage/ BOT mvmt
  • UES stricture/ hypertonicity?
  • Examine the movement of multiple structures at height of swallow
  • Globus complaints
  • Esophageal symptoms
  • Fistula after surgery
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22
Q

Indicators for FEES: logistics reasons

A
  • Fluroscopy not available
  • Transportation to radiology is risky, (medically fragile patient)
  • Transportation to hospital problematic
  • Family input desired during exam
  • Positioning problematic (contractures, quadripelgic, neck, halo, obese, on a ventilator)
  • concern about radiation
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23
Q

Indicators for FEES: clinical reasons

A

-visualize surface anatomy, mucosal abnormalities, resection etc.
-VP incompetence
-Visualize laryngeal mvmt/ VF mobility
-Severe dysphagia; need conservative exam, compromised pulmonary clearance
-Clinical question of secretions management
-Extended therapeutic exam/needed or desired
-Biofeedback is desired: therapy session
Ex. (need to teach patient to turn their head when they swallow to see if it improves airway safety)

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24
Q

Types of Interventions

A
  • Free water protocol
  • Diet management
  • Oral motor exercises
  • Shaker exercise
  • Tactile thermal stimulation
  • Electrical stim of muscles
  • Swallowing maneuvers
  • Postures and positions for protection of the airway.
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25
Q

Recommendations and diet

A

Use the results from a bedside evaluation, medical history, and objective results from the MBSS to make a final decision about:

  • NPO vs. PO
  • If you recommend PO, what kind of diet? Is thickened etc..
  • Aspirations precautions? What kind?
  • Any compensatory swallowing postures/ maneuvers?
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26
Q

Deciding NPO vs. PO

A

The decision making process is similar to what happens after a clinical bedside evaluation. However, we also have the following info:

  • Did aspiration occur? How much was there? Was it silent or not? How effective was the pt.’s cough?
  • What postures/procedures /maneuvers help reduce aspiration and/or promote improved swallowing.
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27
Q

More recommendations in deciding NPO vs. PO

A

Make decisions about:

  • level of supervision during meals (does the person need to be fed, or can they feed themselves?
  • Will the SLP continue to follow the pt. and if so how often or will pt. be discontinued.
  • Is a repeat MBSS warranted? When?
  • Is pt. candidate for dysphagia tx?
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28
Q

Dysphagia Recommendations continued..

A
  • Decision making in pts. with acute vs. chronic dysphagia
  • Recommending NGT vs. PEG
  • Frazier free water protocol (SLP usually doesn’t make an recommendation on this unless your facility is using that for individuals with dysphagia)
  • Quality of life issues
  • Dietary waivers
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29
Q

True or False Dypshagia affects quality of life?

A

True

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30
Q

Will someone with severe dysphagia who needs alternative means of hydration be able to handle tiny feedings?

A

Yes, small tiny feedings for pleasure. (even though there is a risk of aspiration, there may be some foods that are allowed because they will maintain or improve the pts. quality of life.

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31
Q

What is considered a Non-surgical tx for dysphagia

A
  • Interventions that either make the swallowing mechanism get better and help restore normal swallowing fxn
  • Accommodations/ changes that can make swallowing safer (Ex. postural, or improving specific muscle tone)
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32
Q

Is there evidence that supports that oral motor exercises will improve muscle tone / help improve articulation?

A

No

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33
Q

Oral motor exercises considerations when it comes to swallowing

A

-Does the pt. show weakness or incoordination in muscles / structures that might benefit from strengthening or practicing patterns of movement.
If so, we should institute a program or exercise that will strengthen the muscle/s.

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34
Q

Is there evidence that supports that the tongue benefits from a regime of strengthening exercises in pts. with dysarthria?

A

Yes

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35
Q

Does every muscle need to be strengthened when it comes to doing oral motor exams?

A

No, it is up to the SLP to make that decisions on which need strengthening.

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36
Q

Robbins stated out of all the structures in the swallowing mechanism, which structure benefits from strengthening the most?

A

The tongue, but exercises must continue

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37
Q

What is the Lee silverman voice treament?

A

Technique used to facilitate stronger VF closure.

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38
Q

What is the basic premise of the LSVT?

A

Increasing vocal intensity and effort in order to close the VF

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39
Q

What is the exercise called that is specific to strengthening the suprahyodal muscles?

A

Shaker exercise

40
Q

What does the shaker exercise do?

A

-Strengthens the suprahyoidal muscles around the larynx to lift the larynx up and stretch the larynx

41
Q

Does the shaker exercise increase the opening of the pharyngeal esophageal segment?

A

Emerging evidence supports that it could facilitate laryngeal elevation.
(Thought to increase the opening of the PES)
*Easy to teach

42
Q

What should you consider doing when performing the shaker exercise?

A

-Document a baseline before the shaker exercise and performance afterwards.

43
Q

Is massed practice required to improve motor skills?

A

Yes, in order to change a motor skill you have to build that into tx or exercise so that your pts. understand this.

44
Q

What is the app called for helping swallowing?

A

iSwallow

45
Q

Why are postural changes and compensatory maneuvers done?

A
  • to improve airway protection

- improve oral or pharyngeal transit of food/liquid.

46
Q

Why is a chin tuck done?

A
  • to reduce premature spillage by letting gravity help keep bolus in oral cavity.
  • Widens the vallecular space in order to hold more food/liquid before the swallow.
47
Q

Do postures take away the enjoyment from eating?

A

Yes, and maneuvers do to some degree.

48
Q

True or False

If a pt. has clear overt symptoms of dysphagia, and presents with frequent coughing during meals will a posture or maneuver reduce the symptoms?

A

True

49
Q

How is a chin tuck done?

A

You simply tuck your chin down to your chest with an upright position still.

50
Q

Will doing a chin tuck narrow the distance between the posterior pharyngeal wall and the base of tongue?

A

Yes

51
Q

Benefits of the chin tuck

A

-Promotes better BOT to posture
Pharyngeal wall contact
-Decreases the opening to the Laryngeal vestibule.

52
Q

Head turning benefits

A

Used for unilateral laryngeal weakness
or Pt.’s with Head/ neck cancers
-Increased TVC closure via extrinsic pressure
-Promotes passage of bolus through the stronger side of the pharynx

53
Q

Will turning the head promote reduced resting pressure of the CP segment/aka UES/ esophageal sphincter?

A

Yes, by pulling the cricoid cartilage away from the posterior pharyngeal wall.

54
Q

For individuals with profound swallowing problems is it possible to combine a chin tuck and a head turn?

A

Yes, can be done to increase clearance and improve airway.

55
Q

When is a headturn most often used?

A

-when the pyriform sinus or pharygneal residue or asymmetry in residue is collected.

56
Q

Does an effortful swallow promote a stronger tongue palate?

A

Yes, it also strengthens BOT to post. pharyngeal wall contact.
It also is not as invasive as a BOT posture.

57
Q

MANEUVER

What is a supraglottic swallow?

A

Voluntarily holding ones breath prior to and during swallowing, then coughing immediately after the swallow, then followed by a dry swallow.
This helps prevent aspiration before the swallow happens.
*Done with cancer pts.

58
Q

What does swallowing hard do?

A

Promotes stronger tongue to palate contact to improve oral transit of the bolus and stronger BOT to post. pharyngeal wall contact to improve transit of the bolus.

59
Q

What is the super supraglottic swallow?

A

-bearing down plus supraglottic swallow

60
Q

What is the Mendelsohn maneuver?

A

-individual voluntarily prolongs the duration of laryngeal elevation resulting in increased duration/ extent of laryngeal elevation and therefore, increased duration /extent of CP opening.

61
Q

What is the Tongue hold or Masako maneuver?

A

Taking hold of the interior tip of the tongue between the front upper and lower teeth while we swallow.

62
Q

What should be done in a bedside or chairside evaluation?

A

Determine physiologic factors for difficulties with swallowing food or liquid.
Make a determination for need for other tests/assessments methodologies.
Make a recommendation for the safest means of intake.
Recommend a diet that their mechanism can handle.

63
Q

What does the Glasglow Coma Scale measure?

A

It is a screening that measures overall level of alertness, ability to move, and understand language.
Ex. >13 is not a good score
You would then check NO, not good candidate for PO.
Look for asyemmtry and weakness.
You would then check No, and No and proceed to administer 3 oz. water to pt. and instruct them to take several drinks.

64
Q

Does a screening device like the Glasglow Scale have 100% accuracy in regards to identifying all individuals with dysphagia.

A

No, some pts. will pass the screening but will have some form of dysphagia that was not identified.

65
Q

What do you look for in a medical/case history?

A

o Any neurological conditions and their onset?
o Any relevant surgical procedures/dates (glossectomy, cervical surgery, laryngectomy, thyroid surgery)
o Recent endotracheal intubation or tracheostomy?
o History of recurrent pneumonias, respiratory infections, heart conditions, or frequent high temperatures?
o Signs of gastroesophageal reflux (including history of hiatal hernia)?
o Any recent weight loss history?
• Most often the case those seen for dysphagia have lost a large amount of weight with no explanation

66
Q

What do you look for in a medical/case history contd.

A 
o	Medications that may contribute to dysphagia?
o	Other medical factors?
o	Patient report of dysphagia
•	Describe their symptoms
•	Where does it stick?
•	Onset date
•	Stayed the same? Progressive?
•	Frequency?
•	Consistency of foods?
•	Pain when swallowing? (Odynophagia)
•	More often than not they DO NOT complain of pain
67
Q

What are general/ bx observations?

A

o Alertness/readiness
o Mental status (confusion, attention/memory)
o Aphasia, apraxia, dysarthria present
o Overall physical status
• Stable
• Oxygen stats?
o Data suggest that patients with decreased alertness or AMS (sleepy) and poor cough reflex are at more risk of aspiration pneumonia even if tube fed

68
Q

What do you look for in an oral facial examination?

A

o In general, what is the general visual impression looking at the patient?
• Symmetrical structures?
• Muscle wasting?
o Determine the structural integrity of the lips, jaw, tongue, hard palate, and velum
o 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
o Exam the sensory/motor functions

69
Q

What cranial nerves are involved with the oral facial examination?

A

Cranial nerves
• V (trigeminal): jaw, lip, hyolaryngeal excursion
o damage associated with poor function of these structures
o seems to correlate with reduced saliva production and reduced taste sensation
• IX (glossopharyngeal)
• X (vagus)
• XI (spinal accessory)
o IX, X, XI damage associated with impaired pharyngeal stage
o May also affect velar function
• VII (facial)
o Lip closure
o Buccal strength
o Any kind of VII resection (example corodid tumor) will be affected in these aspects of the swallow)
• XII (hypoglossal):
o Tongue strength
o ROM

70
Q

Do you check the strength/presences of voluntary cough in an oral motor exam?

A

Yes.

71
Q

Should you check for quantity/quality of secretions in an oral motor exam?

A

Yes, • Reduced intra-oral sensation or alertness may result in pooling in mouth or overt drooling
• Dry mouth or insufficient saliva may be due to meds, xrt (xerostomia), tube fed patients in supplemental oxygen or ventilation.

72
Q

In an oral motor exam is it common to make note of any speech or voice problems or problems with breathing?

A

Yes…
o Make note of any speech or voice problems
• Apraxia, dysarthria, hoarseness/hyophonia
o Make a note about their breathing rate
• Adults breathe about 12 times/minute
• Note shortness of breath
• Any complaints about shortness of breath?
o Heart rate and oxygen saturation may be important in respiratory compromised patients as the former measure may increase and/or the latter decrease (SpO2 levels below 92%-94% are generally considered pathologic) during feeding/swallowing, or fatigue/stress associated with the breath holding required when swallowing

73
Q

Why are heart rate and respiration important to evaluate in compromised pts?

A

o Heart rate and oxygen saturation may be important in respiratory compromised patients as the former measure may increase and/or the latter decrease (SpO2 levels below 92%-94% are generally considered pathologic) during feeding/swallowing, or fatigue/stress associated with the breath holding required when swallowing

74
Q

Is swallowing an apneic event?

A

Pulse Oximetry and aspiration are equivocal
• Recall that swallowing is an apneic event – involves breath holding. So oxygen saturation (or sats in hospital setting) should be at least 92-94%
• Some places do not like us evaluating swallowing even if sats are below 95%
• If they’re already having difficulty getting enough oxygen they may not be a good candidate for assessment!

75
Q

How do you evaluate a dry swallow?

A

• Check ability to initiate
• Any delay (+2-3 seconds)
• Using your GLOVED hand, palpate for laryngeal elevation
o Robust? Weakened?

76
Q

What is involved in a clinical feeding?

A

o If all of your assessments are good up to this point then you’re going to begin clinical feeding
o Going to determine whether they are safe for PO (feed)
• If patient is already eating something (already PO) then you will feed them without too much concern unless you notice something on oral-facial exam or mental state or alertness that is not safe and they should not be taking nourishment or hydration via PO

77
Q

If your patient is NPO will you not feed bedside or chairside if there was severe oral-facial deficits or mental status/alertness issues, OR severe respiratory dz (ie pna)?

A

No, If your pt. is NPO, before you see them then you will most likely only offer them their own secretions or a very small amount of water. They may have deficits overall or severe respiratory disease that would prevent them from being a good candidate for this part of the assessment, the feeding.
• IF you decide NOT to feed you will recommend (remember, CLINICAL feeding only!):
• NPO or (nothing by mouth)
• MBSS (VFSS) – instrumental assessment

78
Q

If someone is acutely ill (for example, 1-2 days post CVA) and you recommend NPO and no MBSS do you want to follow the pt. daily?

A

Yes, see if they are not consistently awake/alert, 1-2 days post CVA.

79
Q

True or False?

If a voluntary cough is present/noted previously this DOES NOT ensure that a reflexive cough is present.

A

True.
• Daniels et al (1998) showed that an abnormal voluntary cough and coughing during feeding predicted aspiration (MBSS) in only 78% of persons. Changes in voice correlated even less.
• There’s no 1:1 correlation between voluntary cough and whether or not someone is aspirating
• People can silently aspirate, where they are aspirating material into respiratory system without overt symptoms

80
Q

If pt. is well enough for PO, what do we begin with and what do we look for?

A

o If all is well, begin feeding with about 5cc of water (about ½ plastic tsp. of water) and note:
• Lip closure (presence of drooling)
• Any delay of initiation of the swallow
• Any overt coughing or choking before/during/after the swallow and the strength of the cough, any throat clearing after the swallow
• The extent of laryngeal elevation during the swallow? How robust?
• Presence of a wet-gurgly voice quality after the swallow

81
Q

When checking the oral cavity, what do we look for after the swallowing has occurred?

A

Checking the oral cavity for oral residue, note:

. some will use ice chips first instead of water – Jackson’s concern is that they start solid but turn into liquid so if they have trouble, what is the issue? Solids? Liquids?
• Some residue is normal but most cases when given a liquid those with healthy swallow can clear the residue.

82
Q

Does coughing/throat clearing during or immediately after the swallow and/or having a wet vocal quality (new) probably represent penetration/aspiration?

A

Their absence does not rule it out. However, with silent aspiration you would indicate that you cannot be sure.

83
Q

Is a reflexive cough in a neurologically impaired population mean it may be diminished rather than absent?

A

• It may take a greater amount of penetration/aspiration to elicit the cough than the very small amount it takes to elicit such a response in a normal population.

84
Q

What is the next step if PO goes well in the first trial?

A

o If all goes well then we proceed with another trial of liquid
• After 2 – 3 tsps/sips, try serial swallows
• Serial swallows: give the client/patient a cup and you say to please take sips of water and please take them continuously

85
Q

What can help with poor motor control?

A

o A straw which places the bolus more posteriorly and may bypass certain oral control/initiation issues but because it enters the hypopharynx sooner (so it may be more difficult to tolerate if there is a delay).
• The Idea is that straws are “neater”

86
Q

What is the bobsled idea of swallowing?

A

Allowing the substance to enter the hyopharnyx sooner. However, • For some individuals this may be dangerous because it does not give them time to initiate airway protection.

87
Q

How do you check for solids in terms of mastication?

A
  • For solids check for mastication, and pocketing material in buccal sulci or anywhere else in the mouth
  • If you see pocketing or mastication is ineffective, give some liquids to see if that helps to clear
  • Because thick liquids, puree and solids may block the airway, if any coughing/choking/throat clearing noted, DISCONTINUE TRIAL FEED
88
Q

Do most healthy adults have a lot of thick liquids as part of their regular diets (exception smoothies/milkshake)?

A

No.
We (SLP’s) are primarily interested in thin liquids, purees, and solids when trying to plan what the patient’s intake will be and what is safe.

89
Q

Are pts. with tracheostomy more complicated to evaluate due to their change in their airway?

A

Yes, Evaluation is MORE COMPLICATED by the change in their airway
• May also have scarring from surgery
• May be unable to elevate the larynx
• Do not have voicing ability
o Protocol changes: these cases discussed separately

90
Q

What is listed on the left side of the clinical swallow assessment form?

A

Background info such as:
Dentures, Primary language, Dx, etc.
Then SLP is asked to evaluate pt. overall cognitive status.
If someone has very limited movement of oral structures, if they immediately have aspiration symptoms upon swallowing own saliva then you’re not continuing much with a formal assessment using many substances.
Next part of the form asks you to state some info about the preadmission diet or current diet of the patient (we don’t always have this info).
Under the history, write a very few succinct things that will relay the relevant medical conditions!
-specific functions of the oral motor mechanism, of speech production of the oral phase, and other pieces of info.
- clinical judgement of how you think they’re functioning on the LEFT side of the form

91
Q

What is listed on the right side of the clinical swallow assessment form?

A

oral pharyngeal and esophageal function.

You won’t say much at clinical phase about esophageal fxn unless pt. complains of reflux.

92
Q

What are the common assessment form ratings?

A
  • WFL (within functional limits)
  • mild
  • moderate
  • severe impairment
  • could not assess fxn/ did not assess
93
Q

What do you want the reader of the swallow assessment form to take away from the form they read?

A
  • Recommendations
  • Whether or not the person needs to be in swallowing therapy
  • Have specific behaviors remedaited or not
94
Q

Characteristics of food that are important

A

• Sticky: peanut butter
• Mixed consistency: soup, salad
• Crumbly/noncohesive: rice, peas
o Difficult in terms of keeping bolus together because individual pieces do not stick together.
• Temperature
o Contradictory evidence that cold (icing) affects timing of pharyngeal swallow response
o Typically applied to the anterior faucial pillars; it may quicken response of subsequent swallows.
• Sourness
o Some evidence that a sour bolus (lemon) might enhance the oral phase in patients that have dysphagia.
• Carbonation
o Some people are believers of stimulation that carbonation provides to oral structures.
• Bolus size (volume)
o Larger bolus can affect swallowing-typically initiate a more robust swallow with a wider opening of the PES
• Consistency/viscosity
o Thicker liquids

95
Q

National Dysphagia Diet

A

Posted in 2002, put together by American dietetic association, slps and food scientist. They were looking to put out standard terminology and reference points in regards to texture and viscosity in substances used in dysphagia management. It clearly refers to foods (solids) and not liquids.

96
Q

How do you decide what foods to administer?

A

o If you know this patient, you already have an idea about what is difficult, what their home environment is like, their needs
o If patient is new, you may have more concerns and you may want to stick to a more classic profile. Starting with secretions, liquids…ect. You probably wont try manipulation of unusual textures of consistencies.

CD 663 Midterm- Tori (1 decks)

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