Class 8

Question 1

According to the Power Point discussion, a decrease in oxygen saturation levels below _____ indicates a risk for swallowing impairment.

Answer 1

90%

Question 2

An examination technique whereby the examiner tests laryngeal elevation by feeling the thryoid notch during the swallowing process is called______.

Answer 2

Digital Manipulation/laryngeal palpitation

Question 3

The _________test is specific to patients with tracheostomy tubes and involves evaluation of suctioned tinted boluses to assess aspiration.

Answer 3

Modified Evans Blue Dye Test

Question 4

What is the purpose of using a thickening agent like “Thick-It” or “Simply Thick” in liquids?

Answer 4

To alter the consistency of liquids for increased swallow safety.

Question 5

According to the Functional Oral Intake Scale, a client who has been evaluated and is recommended for an oral diet but with pureed consistency only (puree solids and pudding thick liquids) would be a level______.

Answer 5

4

Question 6

The ______is an example of a questionnaire for dysphagia performed to determine the need for further evaluation.

Answer 6

The Baker, Fraser & Baker Test

Question 7

The pharyngeal stage of the swallow makes two distinct “click” sounds. It is possible to assess pharyngeal stage dysphagia using a technique called __________________.

Answer 7

Cervical Auscultation

Question 8

According to Logemann in the classic article by Langmore and Logemann (1991), approximately _____of the cases of silent aspiration go undetected during a clinical/bedside evaluation.

Answer 8

38-40%

Question 9

In the article by Tohara, Seitoh, Mays, et al. (2003) the combination of which three tests listed below provided the best predictors of aspiration when an MBS or FEES was not available (e.g. nursing home setting)?

Answer 9

3 oz., water test, 4 grams of pudding swallow, and a still X-ray of the lungs.

Question 10

In the article by Suiter & Leder (2008) the research question is asked, “Does the 3 oz. water swallow test identify individuals who aspirate thin liquids?” What were their conclusions?

Answer 10

Yes, it had good sensitivity for identifying aspiration of thin liquids.

Question 11

 Clinical/Bedside Evaluation

Answer 11

 More of a screening to get an idea of what we are working with
 According to Logemann in the classic article by Langmore and Logemann (1991), approximately 38-40% of the cases of silent aspiration go undetected during a clinical/bedside evaluation (due to silent aspiration)

Question 12

 (Just the) Instrumental Evaluation

Answer 12

 NEED TO DO BOTH. Logemann says to ALWAYS do one.
 Some long-term care facilities do not have an MBS or FEES machine available.
 Use as a screening for instrumental tests
 Use as an outcome measurement
 McCullough, Wertz, & Rosenbek (2000) only 50% reliable on clinical exams. Need to standardize the clinical exam.

Question 13

 Langmore & Logemann Article

Answer 13

 Discussion:
 Pros and Cons of a bedside evaluation
 Pros: Questionnaire, patient concerns, problems, functional issues
 Cons: However, it takes more time and it is not that reliable for detecting what is really going on
 Why does Logemann feel that you should always include a clinical exam?
 Clinical questions to be answered
 Percentage of silent aspiration missed
 Langmore recommends FEES, why?

Question 14

 Logemann’s 5 Reasons to Pursue a Clinical Exam

Answer 14

 1) To define a potential cause of a swallowing disorder
 2) To establish a working hypothesis
 3) To establish a tentative treatment plan
 4) To develop a potential list of questions that may require further study
 5) To establish the readiness of the patient to cooperate with further testing

Question 15

 Clinical Evaluation:

Answer 15

3 Main Components of a Clinical Evaluation
1.) Medical History-
 Chart Review
 Questionnaire
2.) Physical inspection of swallow mechanism
 Cranial Nerve Exam
 Oral-Mech. Exam
3.) Observation of swallow with test swallows
 3-oz. water test- The Source, Tohara, et al., DiPippo, Holas, & Reding (1992); Garon, Eagle, & Ormistrin (1995)
 Prediction of Aspiration with screening tests
 Various consistencies attempted

Question 16

 Dysphagia Questionnaire

Answer 16

 Ask client to describe their problems and symptoms
 Helps you find out what to evaluate more closely/discover patient concerns
 May not be able to describe problems
 Unreliable or responses may not fit objective findings
 Groher & Crary (textbook) found this is easier when problems are severe vs. milder dysphagic symptoms

Question 17

 Samples of Questionnaire

Answer 17

 Baker, Fraser & Baker (1991) (in text Box 9-1)
 Burke Dysphagia Screening Test (DiPippo, 1994)
 Wallace Dysphagia Screening Test (Wallace, et al., 2000)–Designed specifically for Parkinson’s Disease

Question 18

 General Categories of Interview/Questionnaire Findings

Answer 18

	Obstruction
	Liquids vs. Solids
	Gastroesophogeal Reflux 
	Eating Habits
	Medical History

Question 19

 Physical Examination

Box 9-2, Page 173

Answer 19

 Feeding Tubes
 Tracheostomy Tubes
 Respiration- Oxygen Saturation, Rate
 Oxygen levels below 90% indicates at risk for swallowing impairments: Practice O2 sensor
 Mental Status
 May be unable to cooperate.
 Cranial Nerve Examination: Which ones?
 Sonies assessment or screen
 Facial Muscles
 Lips at rest and at work—upper vs. lower motor neuron damage
 Muscles of Mastication
 Tongue Muscles
 Look for fasciculations, atrophy, deviation
 Oral Cavity
 Lesions, thrush infection, saliva, dentition
 Oropharynx
 Velum at rest and at work, gag reflex (NOTE: presence or absence not indication that they have normal swallow or are at risk. Absence might suggest other problems if other findings are noted
 Pharynx
 No clinical tests of pharyngeal function: listen for vocal fold function.

Question 20

Pharyngeal Function- Clinical Evaluation

Answer 20

Vocal Fold function test
Digital Manipulation/ Laryngeal palpation test
Cervical Auscultation
	Three audible sounds
	Stethoscopes:
	-Littman Cardiology II (3M Corp.)
	-Rappaport-Sprague  Pediatric Size (H-P)
	-Bell surface vs. Flat Surface

Question 21

 Testing Aspiration Clinically-

Is it Reliable? Is it Safe?

Answer 21

	Mann & Hankey (2001)
	Stroke patients N=71)
	Regression Analysis of 23 Clinical features
	6 variables predictive of aspiration:
	Impaired pharyngeal response
	Male
	Disabling stroke
	Incomplete oral clearance
	Palatal weakness
	>70 years old
	Leder & Espinoza (2002)
	Stroke patients  (N=49)
	Clinical exam = underestimated those who aspirate and overestimated those who did not aspirate

Question 22

 Swallow Tests

Answer 22

Tohara, et al. Article Review
 Three measures recommended for an effective alternative to instrumental examination
 3 oz. purified water
 4 grams of pudding (safest, next safest is nectar)
 Plain X-ray of the pharynx

Groher & Crary:
 Crushed ice first
 5- 10 ml of water then 20-ml bolus of water
 Cup versus straw
 Cup is safer
 Clinician presentation versus client presentation
 Clinician can control amount
 Solids in sequence of difficulty
 Puree and pudding is safest, next safest is honey and nectar consistency

 Modified Evans Blue Dye Test- MEBD
 For individuals with tracheostomies
 Test bolus’ with blue dye
 Deep suctioning every 15 minutes for one hour
 Poor reliability
 MEBD: Thompson-Heney & Braddock, 5 patients, MEBD found no aspiration but MBS/FEES found that all 5 aspirated.

Question 23

 Feeding Evaluation

Answer 23

Consistencies: Simplest to most difficult
 Purees
 Thickened liquids:
 Pudding thick (easiest to swallow)
 Honey thick
 Nectar thick
 Chopped/ground/diced
 Mixed consistencies (soup thin and chunks, or fruits (solid and juice)
 Regular solids: mechanical soft (potatoes, bananas, beans) to crumbly (crackers, biscuits, nuts, corn bread, popcorn, chips)
 Thin liquids

Tools
 Spoon (simplest, safest)
 Cup
 Straw

Question 24

 A Clinical Exam Tray (The Source, pg. 37-38)

Answer 24

 ¼ cup thickening agent: Thick-it, Simply Thick (looks better, tastes better, but more expensive), etc.
 ¼ cup puree fruit or pudding
 ¼ cup ground meat
 ¼ cup regular meat
 ¼ cup diced mixed vegetables or chopped peaches
 ¼ cup rice or noodles (soft solid)
 1 slice white bread (mechanical soft)
 1 pineapple ring (mixed consistency b/c of juice in it)
 1 sugar cookie (mechanical soft or crumbly)
 1 /2 cup Cheerios (with milk, mixed consistency)
 ½ cup milk (thin)
 ½ cup apple juice, tea, or water (thin)
 Cup, straw, spoon, knife, fork
 Work with dietician at facility to arrange for a standard tray to be developed for this test.

Question 25

 Results: The Functional Oral Intake Scale

Answer 25

1. NPO
2. Tube dependent with minimal attempts at food or liquid
3. Dependent with consistent intake of liquid or food
4. Total oral diet of a single consistency
5. Total oral diet with multiple consistencies but requiring special preparation or compensations
6. Total oral diet with multiple consistencies without special preparation but with specific food limitations
7. Total oral diet with no restriction

Question 26

 Non-standardized Forms

Answer 26

	ASHA Template
	The Source Clinical Evaluation
	Logemann’s Evaluation
	Site Specific Forms/Samples:  
	 SMC
	 St. Francis

Question 27

 Available Clinical Evaluation Instruments- Standardized

Answer 27

 Mann Assessment of Swallowing Function (MASA): First with Psychometric Integrity
 Normed on 128 first-stroke patients
 Rating scale utilized
 24 areas of assessment
• Review MASA Forms
• Open MASA booklet on D2L
• Practice giving MASA
 McGill Ingestive Skills Assessment (MISA)
 Standardized test, offers a predictive code
 Clinically assesses in natural environment
 Examiner prepares various food items, patient attempts to eat them.
 Designed for clinicians working with older adults in a skilled nursing facility.
 Five areas of performance, 43 test items, 3-point scale for each.