Day 4 PM Flashcards
7 purposes of the ISE
1.Image important anatomic swallowing structures 2.Ax movement patterns of these structures 3.Identify & describe any airway compromise (asp / pen) 4.Evaluate impact compensatory maneuvers 5.Identify & describe any pooled secretions & ability to clear 6.Complete cursory evaluation of esophageal A & P 7.Assist in forming clinical recommendations
2 most important characteristics of swallowing to consider during an ISE. Implications?
safety and efficiency. Safety prevents aspiration. Efficiency prevents excess residue that leads to malnutrition
When is the ISE indicated?
With some patients due to radiation exposure (also expensive, time, realism)
6 types of ISE’s
• Modified Barium Swallow (MBS) • Upper gastrointestinal series with hypopharynx • Videofluoroscopic swallow study (VFSS) • Videofluoroscopic swallow examination (VFSE) • Videofluoroscopic barium examination (VFBE) • Rehabilitation swallow study
7 objectives of VFSE
1.Evaluate anatomy & physiology of the swallowing mechanism 2.Evaluate swallow physiology 3.I.D. patterns of impaired swallow physiology 4.I.D. consequences of impaired swallow physiology 5.Evaluate the impact of compensations 6.Confirm pt symptoms 7.Make predictions
4 VFSE procedures
• Rec. to use standardized protocols • Position pt upright w adequate support • Typically begin in lateral position, then turned for A-P view • Esophageal Sweep
Why is A-P view important? Clinical implications for certain demographic?
Anterior-posterior view tells us so you can see both sides of everything- important for stroke patients. Can turn head to weak side (helps with efficiency of swallow)
Importance of Obamacare
Demand to increase productivity
One way to do this is to standardize practice for repeated procedures (dysphagia screening, MBS)
Across different SLP’s and within your own practice
Ways to standardize your practice
Equipment kept in same place
Disinfected in exact same way and steps
Same form and steps followed for screens
MBS tray set up the same every time
Benefits of standardizing your practice
Reduces costs, eliminates wastes, improves efficiency (SWIGERT)
Name of ISE done standing up
C-ARM
When evaluating the image, it is important to remember that the view is _____.
mirrored/inverted
2 types of common contrasts used in ISE
• Barium Sulfate Suspension (radiopaque) • Varibar - standardized barium line specific for swallow studies
3 things to vary (have a range of)
textures, volumes, viscosities
Volumes typical range
1 mL to 90 mL
3 viscosity categories of liquids
thin, nectar thick, honey thick
3 viscosity categories of solids
puree, mechanical soft, hard, mixed (like cereal)
6 structures seen in a MBS
lingua-velar seal, bolus, pharynx, hyoid, larynx, true vocal folds
3 non-contrasted tasks, their function
Simple speech task to evaluate structures in movement (lips,
tongue, velum, pharyngeal wall)
• Vowel Prolongation & repetition to evaluate laryngeal
excursion & VF adduction
• Falsetto |i| in A-P view affords good visualization of pharyngeal
wall constriction
_______ Can be different across settings & clinicians opinions vary
sequence of events
3 Martin-Harris suggestions for sequence of events
1) . Start with Thins: 5ml; 10ml; 20ml* •
2) . Then: Pudding; Soft; Regular; Mixed •
3) . If signs aspiration immediately downgrade to thicker viscosity
_________ beneficial but practice flexibility to maximize ________.
Standard protocol, diagnostic outcomes
8 steps in the general sequence of events of an ISE
1.Pt seated in lateral view
2.Simple speech tasks to Ax movement of structures
3.Liquid bolus presentations
4.Solid bolus presentations *
5.Pt turned to A-P view, vowel & falsetto tasks
6.Further swallow trials. Ax symmetry & effects of head turn
7.*Ax impact of compensatory maneuvers either before /
after AP view
8.When feasible, pt stands & cursory esophageal phase Ax eval
4 things to look for in an ISE
1) . Anatomy of All Structures
2) . Non-Swallow Movement: Lips, tongue, mandible, Larynx, Pharynx
3) . Kinematics, Timing, Airway Protection, Swallow Efficiency
4) . Impact of Strategies and Swallow Maneuvers
Bailout/study abortion criteria
usually 3rd episode of aspiration
Structural abnormalities
1) . No bar
2) . Non-obstructing CP bar, normal PES opening >0.60 cm
3) . Moderately obstructing CP bar, PES opening 0.3-0.6 cm
4) . Severely obstructing CP bar- PES opening
4 strengths of ISE
• Dynamic study of swallow biomechanics • Unlimited review capabilities • Comprehensive perspective from lips - esophagus • Readily accessible (inpt)
4 weaknesses of ISE
Time restraints due to radiation exposure • Sampled in artificial eating environment • Pooled secretions not captured • Limited access outside hosp
2 terms: endoscopic evaluation of swallowing
Fiberoptic Endoscopic Evaluation of Swallowing (FEES) & Fiberoptic Endoscopic Evaluation of Swallowing w Sensory Testing
(FEESST)
MBS vs. FEES: Similarities
• Purpose • Process of Evaluation
MBS vs. FEES: Differences
• Technique • Image Perspective • Portability • Repeatability • Duration of Exam • Sensory Assessment
5 FEES components
- Ax of pharyngeal & laryngeal anatomy 2.Eval of movement & sensation of pharyngeal structures
- Ax of secretions
- Direct Eval of swallowing Fn w oral trials 5.Eval of impact of compensatory maneuvers
4 parts of the FEES equipment
• Fiberoptic Endoscope • Light Source • Camera • Video Recorder
6 general procedures oFEES
1.Scope Passed
2.View Velopharyngeal Mechanism (hum, V, C, saliva swallow)
3.Advance to Oropharynx to visualize laryngeal & pharyngeal sts
4.Ask pt to perform non-swallow tasks to Ax anatomic
movement & function of laryngeal & pharyngeal structures
5.Perform Oral trials
6.If impaired swallow ID: Ax effect of compensatory techniques
6 things to look for during FEES
Anatomic integrity at each “level” of swallowing mechanism Movement characteristics Secretions Ax of swallow attempts Airway compromise Impact of maneuvers & compensations
5 strengths of FEES
• Objective study of swallow
physiology w unlimited review capabilities
• Superior inspection of pharyngeal
anatomy, sensations, secretions & laryngeal closure patterns then MBS
• Accessibility • No radiation exposure • No time constraints
5 weaknesses of FEES
No view of the oral cavity & esophagus • Assessment restricted to pharyngeal phase of swallow • ‘Whiteout’ during swallow • Potential med complications • Reqs further SLP training
High level of agreement between MBS and FEES for detecting what 4 things? percent of agreement?
• Aspiration (86-90%) • Pharyngeal Residue (80-89%) • Laryngeal penetration (85-86%) • Premature spillage (61-66%)*
Penetration aspiration scale
Score of 1-8. 1 = normal; 2-5 = penetration. 6-8 = aspiration
Define: penetration
residue at or above the level of the true vocal fold
Define: aspiration
residue below the level of the true vocal folds
Purpose of oral mechanism exam
Determine the structural and functional adequacy of the oral mechanism for speech and swallow.
OME Should be routine part of every evaluation, regardless of _________.
patient population/disorder
3 things that OME findings may help shape
theory of etiology, diagnosis and prognosis for change, direction for treatment.
Can an OME save someone’s life?
YES!
Parts of the OME
Gag Bite Cough Oral secretions Oral cavity Face: rest & movement Lips: rest & movement Tongue: rest & movement Mandible: rest & movement Palate: rest & movement Airway Phonation respiration Volitional swallow
CN-I - name and function
olfactory- smell
CN-II - name and function
optic- vision
CN-III - name and function
oculomotor- eye movement, pupil constriction
CN-IV - name and function
Trochlear- eye movement
CN-V- name and function
Trigeminal, jaw movement
CN-VI - name and function
Abducens, eye movement
CN-VII - name and function
Facial- facial movement
CN-VIII - name and function
Cochleovstibular- pharyngeal movement
CN-IX - name and function
Glossopharyngeal- pharyngeal palate
CN-X - name and function
Vagus- pharyngeal palatal and lingual movement
CN-XI - name and function
Accessory- shoulder and neck movement
CN-XII - name and function
Hypoglossal- tongue movement
Cranial Nerves mnemonic device
On occasion our trusty truck acts funny, very good vehicle any how
Cranial nerve sensory/motor mnemonic
Some say marry money, but my brother says big brains matter more
6 cranial nerves pertinent to SLP
V, VII, IX, X, XI, XII
3 sensory nerve branches
VI: Ophthalmic: forehead, eyes, nose
V2: Maxillary: upper lip, maxilla, maxillary sinus, upper teeth, cheeks, palate
V3: Mandibular: mandible, lower lip, a portion of the external ear, the first 2/3 of the tongue, the bottom set of teeth
5 ways to assess CN-V
Sweep 4 quadrants of face: forehead, cheeks, jaw Touch front and back of tongue Ask about taste Bite: feel masseters Wiggle Jaw back and forth
Sensory and motor innervations by CN VII
Sensory:
taste anterior 2/3 tongue, preauricular skin
Motor:
facial muscles: frontalis, obicularis oris, obicularis oculi, stapedius
4 ways to assess CN-VII
Ask to smile or repeat “eee”
Ask to pucker or repeat “ewwww”
Touch skin in front of ear
Ask about taste
Reasons for non-patent airway
Tumor
Subglottic Stenosis or web
Tracheomalacia
Vocal cord paralysis
Congenital abnormalities of the airway
Large tongue or small jaw that blocks airway
Inhalation or chemical burns to upper pharynx, laryngeal area
Foreign body obstruction
Wired jaws
Laryngectomy (however, I will not address the H&N cancer population in this lecture)
2 ) lung protection from potential obstructions or aspiration; Need for prolonged respiratory support, Chest wall injury and Diaphragm paraylsis, injury or dysfunction
Sensory and motor innervations by CN-IX
Sensory
Taste posterior 1/3 tongue
Motor
Pharyngeal constriction
How to assess CN-IX
How to assess- say aah. House-Beckman- used to classify degree of severity 0-5 scale (disfiguring droop, gold weight in eyelid), 1 would be normal
Sensory and motor innervations of CN-X
Sensory: Posterior 1/3 tongue Gag? NO 13-37% normals have absent reflex Unless asymmetric Motor: Cricothyroid Levator veli palatini Salpingopharyngeus Palatopharyngeus Pharyngeal constrictors Intrinsic laryngeal muscles
How to assess CN-X
Phonation; dysphonia or hypophonia could be indicative of unilateral RLN damage
Velar elevation (say aaaah) also listen to resonance (hypenasality could indicate disordered velar movement)
Cough
Volitional swallow (multiple swallows/bolus=CP dysfunction)
Motor innervations of and how at assess CN-XI
Motor Trapezius SCM How to assess: Shoulder shrug Head tilt against resistance
Motor innervations of CN-XII
Motor: (extrinsic and intrinsic tongue)
genioglossus
styloglossus
hyoglossus
How to assess CN-XII
Tongue protrusion, lateralization (both volitional and against resistance); UMN deviates
8 pathological resposes
Adiadochokinesis- inability to perform rapid alternating muscular movements
Babinski- big toe extends or remains extended when sole of foot is simulated
Suck/snout
Diplopia- seeing double
Echolalia- repeat
Nystagmus- rapid involuntary eye movement in different directions
Perseveration- unable to shift tasks
Ptosis- eyelid drooping or looking sleepy
Define: DDK (diadochokinetic)
how quickly an individual can accurately produce a series of rapid, alternating sounds. Have patient repeat them for as long and as quickly as possible
For UF/Shands clinics, we use _____ as our electronic
medical record platform
EPIC
Many outside clinics (do/don’t) use this software
don’t
EPIC live- timing consideration
Many of our Outpatient SLP clinics did not go live
onto EPIC until approximately Spring 2014- LOTS of archived paper charts, some of which are/are not
scanned into EPIC for review
EPIC access must be granted through the _____
UF privacy office
Authorized personnel receive a _______ and _______
username and password
Your access is renewed by ______ each _____.
supervisors, semester
Clinician differences- EPIC consideration
Every clinician is different
about how they like you to document notes in EPIC
Scanned documents older than 2014 appear in the ____ tab
Media
____ make EPIC documentation more efficicent
smart phrases
4 things in EPIC notes we are possibly concerned with
What did H&P and neurology notes say? What did we say? What was the last safest diet? Has this patient been seen in the past
With inpatients, start with ______ when documenting in EPIC
H&P
For outpatients, start with _______ when documenting in EPIC.
start with most recent office note from referring provider
Always check for _______ hidden in the _____.
old SLP notes, media tab
______ are your friend to sort notes
filters
2 ways to not labor over every single note
We need you to be quick but efficient because there is more than one
person to see in a day!
¡ Look for key things: why are they there, what
treatments/interventions have they gotten, what do they want from us, do they already have a diet ordered, do they have nutritional access (e.g. feeding tube), do they have a trach/vent
4 things to do when going to see the patient
1). Have your Pt list for the day printed/written out
2). Make a quick summary about each Pt to remind you at a quick glance
3). Ask your supervisor if they are ok with you taking notes
in the room or waiting until you leave the patient
4). Have all of your tools ready to take into the room
4 things to look for before entering a patient room
- Check the front
doors for precaution signs- FOLLOW them for your safety and the patient’s - Speak to the RN before going in if possible
- Take essentials only
- Gel/Hand WASH
3 important considerations in interacting with patients. Why?
1). ALWAYS introduce yourself to the patient and
family/caregivers
¡ Patients have the right to know who is in their room and why
¡ You’re not “just a student,” you are an important member of the
team who needs to be introduced
÷ “Hi my name is Julie, I am speech therapy graduate student/clinician”
2). If you are not sure who someone is, it’s ok to ask
¡ Don’t assume, you’ll get into trouble ÷ “Who do you have with you today” or “Are you family, friends,
caretaker?”
3). Show the patient’s respect when speaking to them
¡ Call them Mr. or Ms., shake their hand if possible, make sure you
look at them when you speak to them, thank them for their time, put them back how you found them
3 more considerations when interacting with patients
1). Be confident with your voice and your demeanor 2). Let us know if you are uncomfortable with a patient
or patient situation
¡ Politely step out or ask to speak to us in private
3). Listen to your body!
¡ If you are getting dizzy in a room, sit down or leave
¡ If you are sick that day, don’t come to clinic to get us and the
patient sick….take care of yourself so you can care for others
3 considerations in interacting with supervisors
1). Please don’t be scared of us!
2). Make sure to communicate your needs
¡ What type of feedback you like ¡ Family/work conflicts, disabilities, time commitments, etc.
3). We like questions…
¡ Make them constructive, try to relate something you do know about
the topic, show us that you took the initiative to already find the
answer before asking us
÷ PET PEEVE ALERT: asking us what an acronym means when you are
sitting at a computer and are capable of looking it up!
¡ Sometimes we can’t answer the questions right away, but we will get
back to you!
¡ Secret: we also have to look things up too!
