Chapter 3 Flashcards
A screening is a
quick, non-invasive, low risk and low cost
How long does a dysphagia screening last?
10-30 minutes
What is a false positive?
ID’d as aspirating but aren’t
What is a false negative?
ID’d as not aspirating but are
Is a screening always 100% accurate?
no
further diagnostic assessment needed
Symtomatology of Dysphagia
Valleculae hesitation/pooling
Pyriform pooling
UES dysfunction
Aspiration
How does a patient describe valleculae hesitation/pooling
Patient says they have something “stuck” high in throat
How does a patient describe pyriform pooling
patient says they have something “stuck” in middle of throat
Hoe does a patient describe UES dysfunction
- pain in upper chest or inches below larynx
- patient says they have something “stuck” lower in throat or high in chest
Describe aspiraiton
coughing, choking, 50%+ aspirate without cough (silent)
The bedside clinical swallowing exam provides
- medical diagnostic, history, patient’s perception
- patient’s medical status: nutritional (tube?), respiratory (trach tube? ventilator?)
- Patient’s oral anatomy (coordination and strength)
- Patient’s respiratory function
- Control/function: labial, lingual, palatal, pharyngeal, laryngeal
- Cognitive status: comprehension, awareness
- Sensory: taste, temperature and texture
- Signs and symptoms during swallow attempts
What materials do you need for a bedside clinical exam for swallowing?
laryngeal mirror, tongue blades, cup, spoon, straw, syringe, towel/drape cloth, gloves, gown, eyewear/mask, stethoscope
Why do you need to bring a cup, syringe, spoon and a straw to a bedside evaluation?
to accommodate to whatever method the patient will be able to swallow
What is below sternal notch?
esophagus
What is above the sternal notch?
larynx
Where are the valleculae?
the base of tongue/epiglottic area, these are the swimming pools right below chin
Where are the pyriforms?
Its just below the larynx, by the thyroid cartilage area
Where is the UES?
its by C-6, right at the sternal notch
What do you need to prepare for a bedside exam?
chart review
What is included in the chart review?
- respiratory status
- dysphagia history
- history of pneumonia
- nutritional status
- medications
What does a fever indicate?
infection
When you are doing a chart review for a patient, what must you explore about their respiratory status?
- Do they have a trach, vent or are they intubated?
- What is their respiratory rate at rest?
- Time their saliva swallows and phase of respiration
- Time/gauge strength of cough (volitional and reflexive)
- Time of apneic period
- Do they breathe through their mouth or nose?
What is a normal respiration rate?
6-12 cycles per minute
Pneumonia, COPD and other respiratory diseases cause __ respiration
higher
What is a normal time for saliva swallows and phase of respiration?
2 min/swallow
When you are doing a chart review for a patient, what must you explore about their dysphagia history?
onset, symptoms, patient awareness and localization
When you are doing a chart review for a patient, what must you explore about their history of pneumonia?
check if they have a fever
*get their most recent vitals
When you are doing a chart review for a patient, what must you explore about their nutritional status?
diet type, its duration and adequacy
Were they ever tubed?
complications from food
When you are doing a chart review for a patient, why must you explore the medications they are on?
A lot of medications can cause xerostomia, decreased alertness or delayed reaction time
What does a bedside exam entail?
prep, physical exam and trial swallows
What needs to be explored during the physical part of bedside exam?
Posture, oral exam, laryngeal function, pulmonary function testing and pneumotachometry
When doing the physical exam portion of a bedside, what do you look for in the oral exam?
Anatomy and physiology
Bedside swallow
Physical exam
What do you look for in patient’s anatomy?
- observe patient’s lips, hard palate, soft palate, uvula, faucial arches, tongue, sulci, teeth, secretions
- look for scarring or asymmetry
- observe if there is any leftover food or if the mouth is dry
Bedside swallow
Physical exam
What do you do to examine patient’s oral physiology?
open mouth, stimuli (texture/taste/temperature)
examine chewing and sensitivity
look at labial, lingual, soft palate functions
Bedside swallow
Physical exam
Physiology/labial function
/i/, /u/, ddk, /pa/, bilabilal stops and check labial closure by having lips around object
Bedside swallow
Physical exam
Physiology/ anterior lingual function
- extension/retraction
- corners of mouth
- clear sulcus
- tip to alveolar ridge and behind bottom teeth with open mouth
- ddk, /ta/, alveolar stops
- rub along palate
Bedside swallow
Physical exam
Physiology/ posterior lingual function
- back elevated
- /k/, ddk, /ka/, velar stops
Bedside swallow
Physical exam
Physiology/ soft palate
sustain /a/, palatal reflex, gag reflex
Bedside swallow
Physical exam
Physiology/ apraxia
look for groping
Bedside swallow
Physical exam
Physiology/ abnormal oral reflexes
increased gag reflex, tongue thrust, tonic bite
Bedside swallow
Physical exam
How do you asses laryngeal function?
- listen to gurgly voice
- listen for hoarseness/breathiness
- DDKs, /ha/ for neurological impairments
- Strong cough and throat clear (reflexive/volitional)
- Vocal scaling
- phonation time with /s/ or /z/
Bedside swallow
Physical exam
Laryngeal function
What does a wet, grugly voice indicate?
definite penetration and possible aspiration because there is something sitting on the vocal folds
Bedside swallow
Physical exam
Laryngeal function
What does a hoarse or breathy voice indicate?
incomplete glottic closure
Bedside swallow
Physical exam
Laryngeal function
What does can vocal scaling indicate?
problems with CT muscle or SLN, intrinsics
decreased laryngeal sensitivity?
Apparent in PD and other neurological impairments
Most patients with neurological impairments won’t
cough volitionally but will throat clear instead
Bedside swallow
Physical exam
Laryngeal function
What does phonation time with /s/ or /z/ indicate?
decreased laryngeal control or decreased respiratory function
What is the longest part of a bedside?
pulmonary function testing
What parts of a bedside are used only if warranted?
Pulmonary function testing and pneumotachometry
How do you test pulmonary function as part the physical exam of the bedside?
Spirometry and manometry
What does spirometry measure?
capacities
FVC, FEV1
What does manometry measure?
strength
MIP, MEP
What does pneumotachometry assess?
inspiration, LCT, peak
What is the last part of a bedside?
trial swallows
You should not attempt trial swallows if
patient is acutely ill, has weak pulmonary functions, very weak cough, 90+ years old, decreased cognition or is suspected of silent aspiration
With trial swallows, use material that is
easiest for the patient to swallow
What quantity is recommended for a bedside trial swallow?
3 cc/ml
If you cannot attempt trial swallows, then send patient directly to
MBS or FEES to avoid risk
What quantity is recommended for a bedside trial swallow if patient has CVA?
9 OZ of water because they do better with bigger gulps
Why do CVA patients do better with larger quantity of water?
because it increases pharyngeal pressure and requires more muscle activity
What is another part of the trial swallow in a bedside?
cervical auscultation with 3-finger position on neck
What are you listening for with the cervical auscultation?
a hard gulp or clunk
If you hear dripping or shower sound, not good
Where do you place your fingers in the 3-finger position on neck?
index finger- suprahyoid, under chin to feel for pressure
middle finger- hyoid bone/thyroid cartilage to feel laryngeal movement
ring finger- cricoid
Where do you place the stethoscope for cervical ausculation?
on the side of the neck
What are some things to note when doing the trial swallow part of a bedside eval?
- Patient’s reaction to food
- Oral movements (chewing, manipulation, propulsion)
- Coughing, throat clearing before/after/during
- Secretion levels
- Meal duration (if observed) and what percentage was eaten
- Respiration/swallow coordination
- Hypolaryngeal excursion
- Sound of swallow
How do you assess hypolaryngeal excursion?
3 finger test
How do you assess sound of swallow?
cervical ausculation
What recommendation can an SLP give after a bedside or clinical exam?
posture resulting in best/safest swallow best positioning for food in mouth best food consistency hypothesis as to nature or swallowing disorder recommendations for treatment
What is the best posture resulting in safest/best swallow?
90 degree hip flexion
If best positioning for food in mouth applies, what is the best position?
depends on their problem
Can you do a diet modification (food consistency) with only a bedside eval?
no, you need a diagnostic
What is the proper way to hypothesize a patient’s problem in an official report?
“Patient showed symptoms __ which is indicative of __
Where can you order a FEES or MBS?
in recommendations
What are some imaging diagnostic instrumentations?
Videofluoroscopy (xray), VFSS, MBS, MBSS
FEES/FEESST/Videoendoscopy (raw view)
Ultrasound/fMRI/PET
Scintigraphy
What two imaging diagnostic instruments are not widely used for swallowing?
ultrasound and scintigraphy
Why isn’t scintigraphy used?
because of the large amounts of radiation
Why isn’t ultrasound used?
because the machine has a hard time picking up all the different muscles and bones in that area
What are some non-imaging diagnostic instrumentations?
EMG
EGG
Acoustics
Manometry
What does the EMG do?
measures muscle activity
What does EGG do?
measures vf vibration at the thyrohyoid level
How do you go about listening to acoustics?
accelerometer or stethoscope to listen
What does manometry measure?
pressure
Videofluoroscopy/MBS
Indications
- To identify normal and abnormal A&P of the swallow
- To evaluate airway protection before/during/after swallowing
- To evaluate the effectiveness of postures, maneuvers, bolus modifications and sensory enhancements in improving swallowing safety and efficiency
- To provide recommendations regarding the optimum delivery of nutrition and hydration
- To determine appropriate therapeutic techniques
- To obtain information in order to collaborate with and educate other team members, referral sources, caregivers, and patients regarding recommendations for optimum swallow safety and efficiency
Videofluoroscopy/MBS
Contraindications
- Medically unstable, lethargic, un-oriented, agitated, uncooperative, cognitive deficits
- When the information obtained from the study is unlikely to change the patient’s management (advanced care prefernces, chronic disease or end-of-life situations)
- Patient is unable to be adequately positioned
- Size of patient prevent adequate imaging or exceeds limit of positioning devices
- Allergy to barium (rare)
Videofluoroscopy/MBS
Limitations
- Time constraints due to radiation exposure
- As the procedure only samples swallow function, it does not fully represent mealtime function
- Contrast materials such as barium slightly increase viscosity and alter liquid and solid food composition and are not natural foods-may result in discordance between the results of VFSS and real meals
- Limited ability to evaluate a fatigue effect on swallowing, unless specifically evaluated
- Barium in an unnatural food bolus with potential for refusal
What does the FEES examine?
A&P before and after the swallow
What’s an advantage of FEES?
no barium and no radiation exposure
The FEES gives an excellent view of
vocal folds and larynx
What stage is visible?
pharyngeal only
What’s a disadvantage of the FEES?
The “white out” period
The Ultrasound displays what stage of the swallow?
oral stage only
What does the Ultrasound display?
tongue function, oral transit time and hyoid motion
What two diagnostic instrumentations are mostly used in studies?
fMRI (Functional Magnetic Resonance Imaging)
PET (Positron Emission Tomography)
What does fMRI (Functional Magnetic Resonance Imaging) display?
neural basis/mechanisms
neural mapping-cortical control
What does PET (Positron Emission Tomography) display?
neural activity associated with motion
What is a huge disadvantage of PET?
larger radiation exposure than MBS
What can the scintigraphy diagnose?
esophageal issues
What does scintigraphy display?
amount of aspiration and residue
What does scintigraphy use?
its radioactive and uses a gamma camera
The __ and __ are not well visualized in scintigraphy
mouth, pharynx
Can scintigraphy identify dysfunction?
No
What is thin puree?
Food consistency
applesauce
What is thick puree?
Food consistency
pudding
What is mechanical soft?
Food consistency
scrambled eggs
What is chopped?
Food consistency
corn beef hash
What is regular?
Food consistency
cookie, cracker
What are the 3 consistencies of liquids?
thin, nectar and honey
Why is cervical ausculation limiting?
because many sounds of deglutition appear to be silent
Whats diagnostic tool shows presence of aspiration?
FEES
What diagnostic tool shows presence of aspiration and etiology?
videofluoroscopy
What diagnostic tool shows pharyngeal anatomy?
rigid videoendoscopy
What diagnostic tool shows pressures?
pharyngeal manometry with videofluoroscopy
What non-imaging tools are good for biofeedback?
EMG and EGG
