Dysphagia Assessment Flashcards
What are the steps in dysphagia assessment?
History —- > observation —- > OME —-> Trial swallow
What information is recorded regarding a patient’s history?
presenting problem, associated sx, ancillary sx, social, environmental, and family history, medical history
Who is on the dysphagia assessment team?
Radiologist (especially if VFSS is used), respiratory therapist (for tracheostomy tube management), nurse, dietitian, ENT (especially if FEES is used and head/neck assessment), physician, neurologist (for a comprehensive assessment)
What are the contraindications for a trial swallow?
Pt has particular medical conditions (e.g., VF paralysis); severe dysarthria, so you are concerned with the airway closing; severe dysphonia; little to no laryngeal movement during a dry swallow; severe cognitive issues (e.g., unable to follow directions)
What instructions does an SLP give a patient during a trial swallow?
They will swallow different types of foods/liquids; chew solids well before swallowing; spit out food before coughing
What is the standard protocol for a trial swallow?
phonation, swallow, phonation
What are the goals of a screening?
to identify individuals with signs and symptoms of dysphagia or who are at risk of developing dysphagia
What are the obvious goals of dysphagia assessment?
to define the presenting problem, to figure the possible etiologies and start referring to the appropriate professional, observe the oral/pharyngeal/laryngeal sensorimotor and swallow function, determine if additional tests are needed, gather pertinent medical and health hx, guess the likelihood of aspiration
What are the less obvious goals of dysphagia assessment?
to determine if alternative nutritional support is needed while the patient waits for additional testing; consider patient’s posture; choose optimum swallowing strategies; assess risk of malnutrition, dehydration, and aspiration pneumonia
What are ancillary symptoms that a pt with dysphagia may show?
weight loss/gain; changes in sleep, energy, speech/voice, eating habits, and feelings about food; dry mouth; fear of eating; compensations made by the patient; avoids eating in public
What are associated symptoms that a pt with dysphagia may show?
coughing/choking while swallowing; mouth odor or food left in the mouth; GER, feeling something stuck in the back of the throat or mouth; chest pain; nasal regurgitation; general pain; feel a lump in the throat
When determing the present problem of a pt with signs of dysphagia, the following information is considered
their typical daily menu; the impact of the consistency, volume, and temperature of the bolus; duration; severity; family’s perception of the problem; circumstances that worsen or lessen the problem
What medical history would you note when assessing a pt for dysphagia?
current medical status; previous medical conditions; family history; previous smoker; airway status; previous problems with swallowing, breathing, their brain, or GI; dental status; previous surgeries; any history of fever
What is the IDDSI (International Dysphagia Diet Standardization Initiative?
An initiative that aims to standardize the naming and describing texture-modified foods and liquids for trial swallows and people with dysphagia.
What is the purpose of palpation?
To assess the laryngeal mechanism during a swallow
When palpating, the index finger should be
behind the mandible towards the front of it
When palpating, the middle finger should be
pressed against the hyoid bone
When palpating, the ring finger should be
placed on top of the thyroid cartilage
What are the best predictors for an airway that’s been compromised?
fail to swallow thins and/or thicks; cough or have a wet voice after swallow; cannot feed themselves
What are clinical predictors of dysphagia/aspiration risk?
abnormal volitional cough; abnormal gag reflux; coughing or voice change after swallowing; dysphonia; dysarthria
What are the aims of imaging procedures?
evaluate the person’s anatomy and physiology; see if they have enough airway protection; evaluate respiraotion/swallowing coordination; assess impact of compensatory maneuvers; evaluate swallowing while swallowing different materials; assess secretions
When would imaging be necessary?
features of dysphagia are unclear; issues with respiration and nutrition make you suspect dysphagia; clinical exam does not answer all your clinical questions; direction for swallow rehab is needed; to determine precipitating medical issues contributing to dysphagia
What are the purposes of a VFSS (videofluoroscopic swallow study)?
To confirm the patient’s symptoms; to assess the consequences of the impaired swallow on safety and efficiency; to examine the patient’s anatomy and physiology; to make recommendations on what the patient should eat or drink as well as their oral diet; to identify the effects compensations have on swallowing; to see how the patient swallows
What are the purposes of FEES (fiberoptic endoscopic evaluation of swallowing)?
to confirm patient symptoms; to identify patterns of the issues the patient has with regards to swallowing; to recommend what the patient should eat and drink as well as suggest interventions or modifications; to see the patient’s anatomy and physiology; to identify the effects of compensations on the patient’s safety and efficiency.
What are the clinical indications for FEES?
VPI; to visualize the surface anatomy and mucosal abnormalities; questions about secretion management; visualize laryngeal movement and vocal fold mobility; you want biofeedback; severe dysphagia
What are the logical indications for FEES?
fluroscopy not available; transportation to fluoroscopy is too risky; family’s input is desired; concerned about using radiation on the patient; positioning the patient is an issue
When is imaging possibly indicated?
Patient has a medical condition that places them at a high risk for dysphagia; there’s an obvious change seen in how the person swallows; patient cannot cooperate with a full clinical exam
When is imaging not indicated?
No longer complains of dysphagia; patient’s condition is too medically involved or compromised; exam would not change clinical management or course of clinical actions
What are indicates for using MBS?
you don’t know the medical etiiology or the symptoms are vague; UES structture/ hypertonicity; to evaluate the oral stage and/or base of tongue movement; to see the mucosal anatony (E.g., cervical osteophytes); laryngetocomy complains
What supplemental assessment would be used if a patient is experiencing GERD?
reflux disease questionnaire
What supplemental assessment would be used to learn about a patient’s current dietary level?
functional oral intake scale
What supplemental assessment would be used to learn about a patient’s nutritional status
mini nutritional assessment
What assessment can be used as a screening tool for oropharyngeal dysphagia in community-dwelling elders as well as to learn about dysphagia’s impact on the person?
EAT-10
What are the indications that MBS should be used?
unknown medical etiology or vague symptoms; see the oral stage/movement of the base of the tongue; visualize UES structure and hypertonicity; laryngectomy complaints, see submucosal anatomy to see if there are any abnormalities such as cervical osteophytes
Regarding VFSS, two tools for evaluation are
MBS (a standardized swallowing assessment and Logemann; Catriona Steele
Weaknesses of FEES include
safety issues (nosebleed or allergic reaction in the patient); limited view of oral cavity, UES, and esophagus; patient may be aggressive and/or uncooperative or have movement disorders or bleeding disorders
What are features of SWAL-QOL assessment?
comprehensive (assesses swallowing specific symptoms and swallowing related symptoms); validated for many etiologies of dysphagia (Stroke, HNC), has 10 subsets (e.g., sleep, fatigue, communication, eating duration, eating desire, burden, mental health, food selection, social functioning, and fear)
How does VFSS differ from FEES?
More comprehensive; radiation is involved; uninterrupted (i.e., is not impacted much by patient behavior)
Other methods that can be used during an assessment are
cervical auscultation (i.e., using a stethoscope to listen to sounds made by the larynx during swallowing) and observation of a meal (i.e., watch them eat, their behaviors, what they use to eat, duration; ideally watch them during three meals)
During a trial swallow, the order of administering liquids is
dry swallow —> thin liquid —-> thick liquid —-> chopped/minced —-> puree or pudding —-> solids
What is pharyngeal manometry?
an instrumental techniques performed in conjunction with VFSS to determine the etiology of pressure changes; it reacts to pressure in the pharynx during pharyngeal swallow. A catheter is placed transnally so that pressure sensors capture information at the tongue base, UES, and cervical esophagus
What is electromyography?
an instrumental technique in which timing and relative amplitude of muscle contractions during swallowing; popularly used as a biofeedback tool during therapy; surface EMG (sEMG) most commonly used. Electrodes are placed on the surface of skin under the chin or above the thyroid cartilage
