Evaluation of Swallowing Flashcards

1
Q

Dysphagia Bedisde Screening is:

A

– 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?

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2
Q

Bedside Screening Includes (3):

A

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

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3
Q

What is a false positive?

A

Id’ed as aspirating but they are not

better than false negative

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4
Q

What is a false negative?

A

Id’ed as not aspirating but are actually aspirating

NOT good. DO NOT want this to happen

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5
Q

Is a screening sufficient or is more assessment needed?

A

more dx assessment is needed

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6
Q

Symptomatology: (look for)

A

1) Valleculae hesitation/pooling
2) Pyriforms pooling
3) UES dysfunction
4) Aspiration

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7
Q

Symptom: If patient says they feel something is “stuck” high in throat

A

Valleculae hesitation/pooling (location and symptom)

Location: Base of tongue/ epiglottic area

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8
Q

Symptom: Patient complains something is “stuck” in middle of throat

A

Pyriforms pooling

Just below larynx

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9
Q

Symptom: Patient complains they feel something is “stuck” lower in throat or high in chest, pain in upper chest

A

UES dysfunction

Feels pain in upper chest or inches below larynx, about the level of vertebrate C6

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10
Q

Symptom: Patient complains of:

  • Coughing
  • Choking
A

Aspiration

***50%+ aspirate without cough (silent)

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11
Q

Bedside Clinical Exam Provides (8)

A

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

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12
Q

Bedside Clinical Exam

Materials (11)

A

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)

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13
Q

Bedside Clinical Exam

PREP (6)

A

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?

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14
Q

Respiratory status /hx (taken during PREP part of bedside evaluation) (6):

A

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?

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15
Q
Bedside Clinical Exam
PHYSICAL EXAM (5)
A

1) Posture

2) Oral exam
- Anatomy
- Physiology

3) Laryngeal Function Exam
4) Pulmonary Function Testing (if warranted)
5) Pneumotachometry (if warranted)

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16
Q

What to look for in Anatomy during the PHYSICAL EXAM:

A

LOOK AT:
lips, hard palate, soft palate, uvula, faucial arches, tongue, sulci, teeth, secretions

LOOK FOR:

  • Scarring
  • Asymmetry
17
Q

What to look for in Physiology during the PHYSICAL EXAM -ORAL EXAM (6):

A

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)

18
Q

PHYSICAL EXAM

Laryngeal function exam (10)

A

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)

19
Q

Bedside Clinical Exam

TRIAL SWALLOWS: DO NOT attempt if (6):

A

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

20
Q

Bedside Clinical Exam

TRIAL SWALLOWS: What do to (3)

A

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.)

21
Q

Bedside Clinical Exam

TRIAL SWALLOWS: What to note (8)

A

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

22
Q

What cc / ml should you use with pts when doing trial swallows?

A

Cc = ml (the same thing)

3cc with pts generally

23
Q

What does new evidence say about how many cc’s should be used with CVA pts?

A

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.

24
Q

Bedside / Clinical Exam RESULTS

What is the Posture resulting in best/safest swallow?

A

Usually 90% of hip flexion

25
Q

Bedside / Clinical Exam RESULTS (5)

A

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)

26
Q

How often do we re-evaluate swallow for pts with dysphagia?

A

4-6 is typical

do not do MBS too often bc of radiation exposure so 4-6 week is more appropriate

27
Q

DX INSTRUMENTATION - Imaging (4)

A

1) MBS / Videofluoroscopy* (xray view)
2) FEES/FEESST/ Videoendoscopy (“raw” view)
3) Ultrasound/fMRI/PET
4) Scintigraphy

28
Q

DX INSTRUMENTATION - Nonimaging (4)

A

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)

29
Q

Imaging:
VIDEOFLUOROSCOPY - MBS
Indications – reason why to do MBS (6):

A

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.

30
Q

Imaging:
VIDEOFLUOROSCOPY - MBS
Contraindications – reasons not to do an MBS (5):

A

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)

31
Q

Imaging:
VIDEOFLUOROSCOPY - MBS
Limitations (5):

A

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

32
Q

Imaging:

FEES (positives (4) and negatives (2)):

A
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
33
Q

Imaging:

Ultrasound (positives (3) and negatives (2)):

A

Positives:
+Tongue function
+Oral transit time
+Hyoid motion

Negatives:

  • Can’t image pharynx
  • Oral stage only
34
Q

What consistencies do we use for FEES?

A

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.

35
Q

Imaging:

fMRI (Functional Magnetic Resonance Imaging)

A

Neural basis/mechanisms

Neural mapping – cortical control

36
Q

Imaging:

PET (Positron Emission Tomography)

A

Neural activity assoc. w/ motion

Radiation exposure

37
Q

Imaging:
Scintigraphy:

A

) Radioactive

2) Gamma camera
3) Amount of aspiration & residue
4) Mouth & pharynx not well-visualized – can’t id dysfunction
5) Can dx esophageal (GERD)