Evaluation Flashcards
Evaluation
Implementation of dysphagia programs is accompanied by substantial reductions in pna rates
3 programs evaluated pre- and post- implementation of formal dysphagia eval programs = pna rate dropped from 8.2% to 1.3%- an average of an 87% decline across programs
Aspiration increases the relative risk of pna by 6.5%
A reduction in pna by as little as 1/3 could result in savings of more than $1 billion annually nationwide
Improved quality of life…
Limited published data on this,
SLPs are able to help avoid PEGs and / or overly restrictive diets
Measures of Swallowing (Objective)
Clinical Swallow Evaluation / Bedside Swallow
Modified Barium Swallow Study / Videofluoroscopic Swallow Study
Fiberoptic Endoscopic Evaluation of Swallowing
Measures of Swallowing (Subjective)
Clinical Swallow Eval
Requirements
MD order Chart Review Go see the patient Patient / caregiver report Brief speech, language, cognitive screen Oral Motor Eval Bolus Presentations Make appropriate recommendations
Physician’s Order
Will contain the patient’s basic info:
Name Age DOB MR Number Location Primary Diagnosis Reason for Request
Chart Review
- Past Medical History
- —Related medical history (CVA, COPD, pna, cancer)
- —Related psycho-social history - Current Medical Status /
- ——Reason for Admit
- —–List of meds
- —–POC - Other Physician Consultations (ENT, GI, Neurology, Neurosurg)
- Other Ancillary Services (OT/PT, Nursing, Social Work)
- Lab work / Diagnostic Testing Results
- –Head CT / MRI — GI work up
- –CXR — Bloodwork - Other
- –Current po status
- –Overall mental status
Go See the Patient: Formal and Informal Observations
Introduction
Explanation of why you are there Talk to the patient, talk to the caregiver Brief cognitive screen (A & O X 3) person, place, and date Speech, language, apraxia screen Decision making abilities
Speech Intelligibility
Impact of Dysarthria
Muscles as face aren’t moving as efficiently as they should
Is the Patient easily understood?
With / without careful listening and attention
Could this be correlated to a swallowing problem?
Weak speech muscles = weak swallowing muscles
Possible lingual strength and coordination deficits
Cough Production
Strength of Volitional Cough and Throat Clear
Is it productive enough to move material out of larynx?
Are there secretions that currently need to be cleared?
General pulmonary power / effort
Voicing
Normal Wet Breathy? Hoarse? Strained? Volume Aphonic Resonance Positioning
What position is the patient in?
Flexed: Flaccid Leaning to one side Leaning back Head position - up, down, rotated ----Reclined 45 degree ----Supporting apparatus (OT/PT aides)
Safety concerns
C-spine precautions, drain in place, lumbar puncture
Secretion Management
No overt secretion difficulties Wet breath sounds at baseline Coughing at baseline Suction set up at the bedside Anterior spillage of secretions Pooled secretions in mouth
Other Considerations
Respiratory Rate
Heart Rate
Oxygen Saturations
Patient Report
1.Do you have difficulty swallowing? In what way?
2.Is the swallowing difficulty greater for solids or liquids?
3.Do you have this sensation without swallowing food?
4.How long has swallowing difficulty been present?
5.Has heartburn been associated with your dysphagia?
6.Is swallowing painful?
7.Do you get chest pain?
8.Does food get stuck when you swallow? If so, where?
9.Do you choke or cough when you swallow?
10Is there temperature sensitivity to dysphagia (especially cold)?
11.Has there been weight loss?
12What types of foods or liquids are hardest for you to swallow
13Have you lost any weight?
14Do you have frequent respiratory issues, such as pna or bronchitis?
Facial
movement: VII
sensation: V
.Lips
Tongue
Buccal Cavity
Soft and Hard Palate
Gag
Lip movement
Closure
Strength of closure
Pucker / Smile
Droop
Eye brow lift
Symmetry in general
Unilateral, Bilateral?
Jaw movement and strength
Tongue
Protrusion Deviation noted Always deviates to the weak ROM (range of motion) Strength Coordination + ROM Diadochkinesis Dysarthria?
Soft Palate
Palate Movement Quick? Symmetry Deviation of uvula indicates palatial weakness Motion of PPW?
Interior sensation
Tongue Buccal Cavities Gag Anterior faucial pillars PPW?
Dentition
Number of teeth
Location
Status
Decaying? Clean?
Saliva
Wet / shiny mucosa in oral cavity and tongue Hypo salivation Tongue may be cracked Whitish-grey in color Dried secretions
Oral care (done before
feeding or swallow study) Supply as needed toothbrush sponge mouthwash
Laryngeal Palpation
Thyroid notch between the middle and ring fingers
Should move in a superior and anterior direction to clear or nearly clear the middle finger
Know the patient’s medical status. May re-consider moving forward if:
Pt is not alert enough to swallow Pt cannot cough Pt cannot manage own secretions Pt cannot volitionally swallow Trial of ice chip
Bolus Presentation
Mastication / Oral stage Swallow Initiation Laryngeal Elevation Cough, throat clear, other s/sx aspiration (change in vocal quality, eye watering, changes in breathing) Use of cervical auscultation?
Bolus Consistencies Typically Used
Ice chip
Water Nectar thick liquid (gross) Honey thick liquid (gross) Extra thick liquid – pudding Puree Soft solid Solid Mixed consistency (liquid and solid)
Bolus Presentations: Volumes Typically Used
Siphoned sip via straw ½ teaspoon Teaspoon Cup sip Straw sip Multiple sips Progression of bolus presentation
Start with an ice chip almost always
Then, small sip of water vs. teaspoon of puree
Progression of bolus presentation:
If no clinical s/sx aspiration noted, move on to the next “easiest” consistency
If started with water, may try puree next
If started with puree, may try water next
If difficulties noted with purees or water, may try thickened liquids
If the pt does well with water, likely do not need to try thickened liquids
If too many difficulties noted, consider discontinuing the eval
Continue this process throughout the consistencies, concluding with mixed consistencies and large, multiple sips of liquids
Have pt self administer pos as able
Progression of bolus presentation:
If no clinical s/sx aspiration noted, move on to the next “easiest” consistency
If started with water, may try puree next
If started with puree, may try water next
If difficulties noted with purees or water, may try thickened liquids
If the pt does well with water, likely do not need to try thickened liquids
If too many difficulties noted, consider discontinuing the eval
Continue this process throughout the consistencies, concluding with mixed consistencies and large, multiple sips of liquids
Have pt self administer pos as able
Stop eval at consistent aspirations
During each bolus presentation
Timing of each stage?
Feel for laryngeal elevation
After each bolus presentation
Listen to the pt’s voice
Recommend a type of liquid and type of solid
Other considerations:
Consistent / Inconsistent s/sx aspiration? Soft clinical s/sx aspiration? Effects of NGT on swallowing? When to terminate eval? Secretion management?
Posture
Upright positioning?, Limitations- Shunt? Fractures? Drains?
Need for objective swallow study?
Types of Diet Recommendations
If recommending pos, make recommendation on solid consistency and liquid consistency
Regular solids -- Thin Soft mechanical solids -- Nectar Chopped -- Honey Ground Purees
Types of Diet Recommendations
Dysphagia diets may be used in some institutions
Dysphagia 1: Pureed Dysphagia 2: Minced Dysphagia 3: Ground Dysphagia 4: Chopped Dysphagia 5: Modified Regular (Soft Mech)
Silent aspiration may be occurring if:
The pt exhibits a clear voice prior to presenting a bolus… and a wet voice after
There is a drop in the pt’s oxygenation
There is an increased work of breathing noted
The pt has a delayed cough (greater than 1 minute)
The Gag
30% of healthy younger adults and 44% of healthy older adults may have unilateral or bilateral absent gag reflexes
Absent gag reflex can be associated with dysphagia, but does not predict aspiration risk in insolation
Absence of gag alone is not statistically significant in predicting aspiration
Abnormal cough and abnormal gag predicts aspiration 85% of the time
Accuracy of the CSE
Presence of aspiration can be predicted 66% of the time by trained SLPs
Ability to detect aspiration
Absence of aspiration can be predicted 67% of the time by trained SLPs
Ability to detect no aspiration
Aspiration is more frequently silent in the neurogenic population
50% of patients who aspirated during the MBSS complained of difficulties swallowing to their medical team or SLP
Often complaints of swallow difficulty do not produce evidence of actual swallowing disorder when measured objectively
Up to 90% noted in one study
So… Is a CSE sufficient
How acceptable is an ~30% false negative rate when dealing with aspiration?
Conversely, how acceptable is a 30% over-identification rate?
Clinical consequences include oral feeding and medications incorrectly withheld in a large number of patients until an objective swallow study can be performed, or overly restrictive diets are recommended
Certain patients can tolerate a degree of aspiration
True, but a CSE is not sufficient in determining amounts of aspiration
Why not go straight to an objective?
Lose valuable information re: CN function and involvement, cognitive linguistic abilities, pulmonary status
Aspiration Prevalence
59% of acute care patients are silent aspirators with highest incidence in the youngest, oldest, and neurologically impaired age groups
58% of patients with dysphagia are silent aspirators
Further Considerations:
30 – 50% of CVA population aspirate
40% of patients with Unilateral CVA aspirate
56% of patients with Bilateral CVA aspirate
67% of patients with Brainstem CVA aspirate
How does the CSE direct treatment?
PROS
Generally effective for straight forward patients Relatively few supplies Patient directed and centered SLP can typically readily do Cost effective Non-invasive
CONS
Do not detect pharyngeal delay or pharyngeal residue
Sometimes need to know more than aspiration vs. no aspiration
Effectiveness of compensatory strategies?
Ability to clear aspiration materials Amount of aspiration Referrals to other specialists There are many benefits to the CSE However, when readily available, objective swallow evaluations are often significantly more useful than clinical evaluations alone in the assessment of patients with dysphagia
Types of Nutrition
Parenteral / Hyperalimentation
Via the veins
Bypasses the intestines Infusion, injection or implantation of medications or nutrition Pharmacological uses (to administer meds) IVs TPN Central Lines Enteral Nasogastric tube (NGT) Corpak, panda, dubhoff Gastrostomy feeding tube percutaneous endoscopic gastrostomy (PEG) Jejunostomy tube (J-tube)
Enteral
Absorption through the GI tract
NG Tubes
Not permanent, most temporary
NG Tubes
Can be used to administer liquid tube feeds/nutrition/medications
Or can be set to suction- meaning they are used to suction out gastric contents that the stomach or intestines may not be able to pass through (i.e. in patients diagnosed with a GI bleed) (take a look back at the last slide- this is pictured in the top right corner)
FOOD for THOUGHT: Can SLP’s perform a swallow eval on patients with an NGT in place?
YES
Corpak
Not permanent, but can remain in place longer than NGTs
Inserted similarly to NGTs
G Tubes
Permanent, but removable
Does not decrease the risk of pneumonia for patients with advanced dementia
J Tubes
Helpful for individuals with: Poor gastric motility Chronic vomiting At high risk for aspiration Patients in whom G-tubes are contraindicated
