Evaluation of Swallowing Disorders

Question 1

screenings identify signs and symptoms of dysphagia such as:

Answer 1

• Coughing behaviors
• History of pneumonia
• Diagnosis at greatest risk
• Material expectorated from tracheostomy (indicating aspiration; material goes below the level of the vocal folds, can stay in the trachea (can be coughed up) or go into the lungs (can lead to aspiration pneumonia))
• Penetration (material enters laryngeal vestibule but never goes below the level of the vocal folds; you would cough)
• Presence of residual food in the mouth

Question 2

Screenings are usually performed at:

Answer 2

• patient’s bedside
• home
• school

Question 3

purpose of screening

Answer 3

to identify the highest risk patients who require further assessment

Question 4

bedside or clinical exam provides clinician with the following info:

Answer 4

• info on current medical dx and hx of swallowing disorder
• medical statues including nutritional and respiratory status
• oral anatomy
• labial control
• lingual control
• palatal function
• pharyngeal wall contraction
• laryngeal control
• ability to follow directions
• reaction to oral sensory stimulation (taste, texture, temperature)
• reactions and symptoms during swallow

Question 5

chart review should be used to ID:

Answer 5

Current and past medical problems that may cause dysphagia
Current and immediate past medications that may have an effect on dry mouth (xerostomia) and swallowingHistory of swallowing disorder
Including time and nature of onset
Symptoms such as coughing on food that is caught in throat (pharynx)
Difficult and easy solids/liquid
Patient’s general awareness or perception of swallowing problem
Presence, type, duration and method of placement (emergency or planned) of any airway device
Presence, type, duration of placement, adequacy and complication of oral and nonoral nutrition

Question 6

trach tube usually placed due to

Answer 6

• upper airway obstruction at or above level of true VFs
• potential upper airway obstruction (after oral, pharyngeal, laryngeal surgery)
• provision of respiratory care

Question 7

where is the tracy tube inserted?

Answer 7

Generally inserted into the trachea through a surgical incision made between the third and fourth tracheal ring.

Question 8

patients with trach tube for more than 6 months

Answer 8

may be at greater risk for scar tissue and reduced closure of the vocal folds due to the reduced stimulation of the sensory receptors under the vocal folds

Question 9

cuffed trach is placed when

Answer 9

Need for respiratory treatment

Potential for the patient to aspirate material

Question 10

how does cuffed teach tube work?

Answer 10

The cuff surrounds the lower portion of the tracheostomy tube like a balloon
Deflated - the tracheostomy tube is the same as if it had no cuff allowing air to pass upward
Inflated - the cuff contacts the tracheal wall and prevents air from passing upward and seals the airway from secretions from above

The cuff must be inflated if patient is on a mechanical ventilator that operates on positive pressure principles
The cuff is usually inflated for those patients who are believed to be aspirating their secretions
Saliva and other secretions collect above the cuff
When the cuff is to be deflated – thorough suctioning is required

Question 11

fully inflated cuffed trachs are not left in place for a long time bc..

Answer 11

Pressure of cuff contacting the tracheal wall can create an irritation causing ischemia (decrease in blood supply) in the tracheal wall and lead to tracheal stenosis.
Can inhibit a patient’s relearning to swallow by restricting laryngeal elevation

Question 12

when is a fenestrated trach used

Answer 12

Used when patients are having a difficult time producing voice
A small window is cut into the outer cannula to allow for greater airflow
Used in patients who are close to being weaned from the tracheostomy tube

Cuffed tracheostomy tube are generally not fenestrated, however if the patient no longer needs the cuff inflated such may be used

Question 13

why do patients report swallow being worse on a ventilator?

Answer 13

• Ventilator controls the respiratory cycle and does not allow for extended exhalation for the swallow
• Patients often have inflated cuffs which also reduces laryngeal elevation
• Reduced closure of the entrance of the airway
• May allow food to enter or penetrate the entrance of the airway and be aspirated after swallow

Question 14

what is a blue dye study?

Answer 14

• The patient is suctioned prior to the evaluation
• The patient is then given measured amounts of blue-dyed foods of varying consistencies
• The patient is then suctioned immediately following
• If blue dye is detected – aspiration has occurred
• If blue-tinged secretions are later suctioned from the tracheostomy
• It doesn’t necessarily mean the patient is aspirating
• Normal secretion flow is down from the mouth and pharynx and is quite normal for the blue dye to mix with secretions and gradually coat the trachea

Question 15

what is intubation?

Answer 15

Usually involves placing a tube through the mouth or nose, through the pharynx to the lower trachea
Often used in an emergency situation
May be maintained for hours, days or weeks

Question 16

what happens if intubation is maintained for days or weeks?

Answer 16

-Laryngeal tissue damage that may affect laryngeal closure during the swallow may result
-Including:
Redness
Edema
Nodule or polyp formation
Unilateral adductor paresis or paralysis
-Bottom edge may rub and irritate the soft tissue causing tissue breakdown and the formation of a tracheoesophageal fistula

Question 17

what is a tracheoesophageal fistula (TEF)

Answer 17

A tracheoesophageal fistula (TEF) is a congenital or acquired communication between the trachea and esophagus. TEFs often lead to severe and fatal pulmonary complications.