Evaluation of Swallowing Flashcards
Dysphagia Bedisde Screening is:
– quick, non-invasive, low risk, low cost
- 10-30min
- look inside mouth
- eat and drink something small
Trying to answer: DOES THE PATIENT HAVE DYSPHAGIA?
Bedside Screening Includes (3):
1) Signs & symptoms
2) Chart review
3) Observation
- 3 oz water test
- Timed swallow test
* False positive = id’d as aspirating but aren’t
* False negative = id’d as not aspirating but are
* NOT 100% accurate!
* Further dx assessment needed
If there is any inclination that there is aspiration, follow up with a FEES and/or MBSS
What is a false positive?
Id’ed as aspirating but they are not
better than false negative
What is a false negative?
Id’ed as not aspirating but are actually aspirating
NOT good. DO NOT want this to happen
Is a screening sufficient or is more assessment needed?
more dx assessment is needed
Symptomatology: (look for)
1) Valleculae hesitation/pooling
2) Pyriforms pooling
3) UES dysfunction
4) Aspiration
Symptom: If patient says they feel something is “stuck” high in throat
Valleculae hesitation/pooling (location and symptom)
Location: Base of tongue/ epiglottic area
Symptom: Patient complains something is “stuck” in middle of throat
Pyriforms pooling
Just below larynx
Symptom: Patient complains they feel something is “stuck” lower in throat or high in chest, pain in upper chest
UES dysfunction
Feels pain in upper chest or inches below larynx, about the level of vertebrate C6
Symptom: Patient complains of:
- Coughing
- Choking
Aspiration
***50%+ aspirate without cough (silent)
Bedside Clinical Exam Provides (8)
1) Medical dx, hx, pt’s perception
2) Pt’s medical status: nutritional (tube?), respiratory (trach tube? ventilator?)
3) Pt’s oral anatomy
4) Pt’s respiratory function
5) Control/fxn: labial, lingual, palatal, pharyngeal, laryngeal
6) Cognitive status: comprehension, awareness
7) Sensory: taste, temperature, texture
8) S/s during swallow attempts
Bedside Clinical Exam
Materials (11)
1) Laryngeal mirror
2) Tongue blades (for oral mech)
3) Cup
4) Spoon
5) Straw
6) Syringe
7) Towel/ drape cloth
8) Gloves
9) Gown
10) Eyewear/ mask
11) Stethoscope
(never sit directly in front of the patient)
Bedside Clinical Exam
PREP (6)
1) Chart review
2) Respiratory status /hx: trach? vent? intubated?
- Resp rate at rest (should me 6-12 cylces per min)
- Time saliva swallows (should be~every 2 min) & phase of respiration
- Time/gauge strength of cough (volitional and reflexive cough if it happens)
- Time apneic period– 1 sec, 3 secs, 5 secs?
- Breathing pattern: mouth or nose?
3) Dysphagia hx: onset? symptoms? pt awareness? localization?
4) Hx of pneumonia? Do they have a fever?
5) Nutritional status: diet type? duration? tubed? adequacy? complications?
6) Medications: xerostomia? ↓alertness?
delayed rxn time?
Respiratory status /hx (taken during PREP part of bedside evaluation) (6):
1) trach? vent? intubated?
2) Resp rate at rest (should me 6-12 cylces per min)
3) Time saliva swallows (should be~every 2 min) & phase of respiration
4) Time/gauge strength of cough (volitional and reflexive cough if it happens)
5) Time apneic period– 1 sec, 3 secs, 5 secs?
6) Breathing pattern: mouth or nose?
Bedside Clinical Exam PHYSICAL EXAM (5)
1) Posture
2) Oral exam
- Anatomy
- Physiology
3) Laryngeal Function Exam
4) Pulmonary Function Testing (if warranted)
5) Pneumotachometry (if warranted)
What to look for in Anatomy during the PHYSICAL EXAM:
LOOK AT:
lips, hard palate, soft palate, uvula, faucial arches, tongue, sulci, teeth, secretions
LOOK FOR:
- Scarring
- Asymmetry
What to look for in Physiology during the PHYSICAL EXAM -ORAL EXAM (6):
1) Open mouth, stimuli (taste/texture/temp), chewing, sensitivity
2) Labial fxn: /i/, /u/, ddk /pa/, bilabial stops (p), lips around object)
3) Lingual fxn:
- anterior: extension/retraction, corners of mouth, clear sulcus, tip to alveolar ridge & behind bottom teeth w/open mouth, ddk /ta/, alveolar stops (t), rub along palate
- posterior: back elevated /k/, ddk /ka/, velar stops (k)
4) Soft palate: sustain /a/, palatal reflex, gag reflex
5) Apraxia (groping behaviors?)
6) Abnormal oral reflexes (↑ gag, tongue thrust, tonic bite)
PHYSICAL EXAM
Laryngeal function exam (10)
1) Gurgly voice > definite penetration, aspiration?
2) Hoarseness/breathiness > incomplete gc?
3) Ddk’s, /ha/ > neuro impairment?
4) Hard cough/strong throat clear > reflexive? strong enough to clear?
5) Vocal scaling > CT m., SLN, intrinsics, ↓ laryngeal sensitivity?
6) Phonation time (/s/ or /z/) > ↓ laryngeal control? ↓ respiratory fxn?
7) Pulmonary function testing (PFT) if warranted
8) Spirometry: capacity (FVC, FEV1)
9) Manometry: strength (MIP, MEP)
10) Pneumotachometry if warranted (Insp, LCT, peak)
Bedside Clinical Exam
TRIAL SWALLOWS: DO NOT attempt if (6):
1) acutely ill
2) ↓pulmonary
3) very weak cough
4) 90+ yrs old
5) ↓cognition
6) suspect silent aspiration
What should you go instead? go straight to MBSS or FEES for these pts
Bedside Clinical Exam
TRIAL SWALLOWS: What do to (3)
1) Use material that is easiest for pt to swallow (small quantity of 3cc/ml recommended)
2) 3-finger position on neck lightly (1 figure on suprahyoids, 1 on thyroid cartilage, 1 on cricoid), other hand is used to put stethoscope on neck.
3) Cervical auscultation (Should sound like this in the stethoscope, want to hear a nice hard clunk. NOT a running shower. NOT dripping.)
Bedside Clinical Exam
TRIAL SWALLOWS: What to note (8)
1) Pt’s reaction to food
2) Oral mvmts (chewing, manipulation, propulsion)
3) Coughing, throat clearing before/during/after
4) Secretion levels (don’t want to see drooling)
5) Meal duration (how long it takes) & amt (doc % they ate at each meal)
6) Resp/swallow coordination
7) Hyolaryngeal excursion (measured with the figure test)
8) Sound of swallow
What cc / ml should you use with pts when doing trial swallows?
Cc = ml (the same thing)
3cc with pts generally
What does new evidence say about how many cc’s should be used with CVA pts?
Current Evidence that shows the 9oz water test (higher volumes of water) is a better bolus size for pts with CVA
Probably because it creates more pharyngeal pressure and more muscle activity, so they are less likely aspirate on this amount.
Bedside / Clinical Exam RESULTS
What is the Posture resulting in best/safest swallow?
Usually 90% of hip flexion
Bedside / Clinical Exam RESULTS (5)
1) Position
2) Best positioning for food in mouth
(If missing parts of mouth, may need to adjust)
3) Best food consistency
(Never modify a diet and not send them for further evaluation. Always follow up so they are not stuck on that diet forever)
4) Hypothesis as to nature of swallowing disorder (e.g. pts show symptoms of __ which is indicative of ___)
5) Recommendations for dx (direct) (e.g. furthur testing is warranted. Recommended FEES and/or MBS)
How often do we re-evaluate swallow for pts with dysphagia?
4-6 is typical
do not do MBS too often bc of radiation exposure so 4-6 week is more appropriate
DX INSTRUMENTATION - Imaging (4)
1) MBS / Videofluoroscopy* (xray view)
2) FEES/FEESST/ Videoendoscopy (“raw” view)
3) Ultrasound/fMRI/PET
4) Scintigraphy
DX INSTRUMENTATION - Nonimaging (4)
1) EMG (measures m. activity)
2) EGG (measures vf vibration at TH level)
3) Acoustics (accelerometer (mic on throat) or stethoscope to listen)
4) Manometry (measures pressure) (we don’t usually do this, can measure pharyngeal pressure)
Imaging:
VIDEOFLUOROSCOPY - MBS
Indications – reason why to do MBS (6):
1) To identify normal and abnormal A & P of the swallow
2) To evaluate airway protection before/during/after swallowing
3) To evaluate the effectiveness of postures, maneuvers, bolus modifications, and sensory enhancements in improving swallowing safety and efficiency
4) To provide recommendations regarding the optimum delivery of nutrition and hydration (e.g., oral versus nonoral)
5) To determine appropriate therapeutic techniques
6) 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.
Imaging:
VIDEOFLUOROSCOPY - MBS
Contraindications – reasons not to do an MBS (5):
1) Medically unstable, lethargic, unoriented, agitated, uncooperative, cognitive deficits
2) When the information obtained from the study is unlikely to change the patient’s management (advanced care preferences-DNR, chronic disease, or end-of-life situations)
3) Patient is unable to be adequately positioned (e.g. spinal cord injuries, spasticity)
4) Size of patient prevents adequate imaging or exceeds limit of positioning devices
5) Allergy to barium (though this is quite rare)
Imaging:
VIDEOFLUOROSCOPY - MBS
Limitations (5):
1) Time constraints due to radiation exposure
2) As the procedure only samples swallow function, it does not fully represent mealtime function
3) 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
4) Limited ability to evaluate a fatigue effect on swallowing, unless specifically evaluated
5) Barium is an unnatural food bolus with potential for refusal. and Barium may constipate you
Imaging:
FEES (positives (4) and negatives (2)):
Positives \+Examines A & P before and after (pharyngeal) swallow \+No radiation exposure \+No barium \+Excellent view of vf’s & larynx
Negatives
- No oral or esophageal stages visible
- “White out” period
- cannot see esophageal phase. When UES opens our view is “whited out” while the tongue base is retracting
Imaging:
Ultrasound (positives (3) and negatives (2)):
Positives:
+Tongue function
+Oral transit time
+Hyoid motion
Negatives:
- Can’t image pharynx
- Oral stage only
What consistencies do we use for FEES?
1) Thin liquid: water, juice, shakes
2) Nectar Thick liquid: V8
3) Honey Thick liquid
1) Puree (thin and thick): villina pudding
2) Mechanical soft / chopped: corned beef hash (corned beef), scrambled eggs (mechanical)
3) Regular Diet: cookies, crackers, chicken (needs to be masticated and bolus needs to be formed)
***Check dietary restrictions, food allergies, etc.
Imaging:
fMRI (Functional Magnetic Resonance Imaging)
Neural basis/mechanisms
Neural mapping – cortical control
Imaging:
PET (Positron Emission Tomography)
Neural activity assoc. w/ motion
Radiation exposure
Imaging:
Scintigraphy:
) Radioactive
2) Gamma camera
3) Amount of aspiration & residue
4) Mouth & pharynx not well-visualized – can’t id dysfunction
5) Can dx esophageal (GERD)
