Final Flashcards
What information should you supply about the patient?
Medical History- very thorough Code Status Tracheostomy Medications History of pneumonia or aspiration Present complaint Esophageal symptoms Onset Previous evaluations Current diet
When is an instrumental exam needed
If you suspect pharyngeal dysphagia
Pulmonary or nutritional status is compromised dysphagia related to cause
You cannot develop an appropriate treatment plan without IE
Patient continues to show signs of aspiration
Patient had a previous IE with diet and compensatory strategies
Videofluoroscopic swallow study
Define the abnormalities in anatomy and physiology causing the patient’s symptoms
Identify and evaluate treatment strategies that enable the patient to eat safely
Allows for visualization of all stages of the swallow
Performed by SLP and radiologist
Lateral and A-P views
MBS is gold standard bc you can see a lot more than w fees..but there is radiation exposure.
Able to determine physiological deficits.
Can determine if posture or maneuver will help them eat safely.
Oblique views too
Info about MBS
Placement of food
Types and amounts of food/liquid
Positioning for test- usually upright
Viscosity (thin liquid, nectar thick liquid, honey thick liquid and pudding thick)
Consistency (puree, soft solid, hard solid, mixed consistencies, barium tablets)
Bolus volumes (1, 3, 5, 10 mL, ½ tsp, 1 tsp)
Sequential cup sips, swallows, straw drinking
Instrumental Assessment for Swallowing
Ultrasound
Modified barium swallow study (videofluoroscopic swallow study)
Flexible endoscopic evaluation of swallowing
Manometry
Scintigraphy- to see amount (%) of aspiration happening. Radiology does the test
Selection Principles
Goal: Identify presence, characteristics, and severity of dysphagia Selection principles: Safest Most repeatable Most diagnostic information Least bioeffects (e.g. radiation) Least invasive Least health care costs
Ultrasound
Assesses movements of tongue, floor of mouth, hyoid bone and larynx.
High frequency sound waves are reflected off tissue, received by ultra and converted into a visual image.
Useful for biofeedback but limited ability to assessing pharyngeal stage as only soft tissue structures are well identified
Palatography
Assess tongue and palate contact
-used more for treatment
Electromyography
Assess contraction pattern of labial, lingual and buccal muscle movements using surface electrodes or needles
- surface EMG for treatment purposes
- good biofeedback tool
Advocacy
taking action to solve a problem.
Client gets most services he/she needs-child.
Adult-advocating for pt. to eat a certain diet consistency, strategies, positioning for safe feeding strategies.
Respect for Autonomy
pts. Have right to make independent choices about their care.
In order to do that they have to be free of any controlling influences.
Must have mental capacity to reach those decisions. Pt can write advanced directives.
Make sure treatment is ethical, appropriate, provide best possible treatment for pt. in consultation with pt. or involve family if they are not able to make a decision.
5 parts of clinical assessment
Screening (Signs and symptoms of dysphagia, Risk factors) Case history Oral-peripheral examination Food trials Blue Dye test
Screening
Review chart Id risk factors Id warning signs Dysarthria Drooling Unexplained weight loss Recurrent pnuemonia Id signs and symptoms of dysphagia Bedside Swallow Assessment (water by spoon/cup) Gugging SSA-Standardized Swallowing Assessment Kidd Water Test Massey Bedise (1 tsp., 1 glass water) EATS (semi-solid, liquid, solid) TOR-BSST – Toronto Bedside Swallowing Screening Test
Case History
Diagnosis Medical and surgical history Swallowing history Respiratory status Medications Reason for referral Patient’s complaints (e.g.duration, frequency) Observations (e.g. drooling, cognitive status, voice quality, fatigue)
Aspiration, health status and pneumonia
Dysphagia does not imply aspiration pneumonia
Examples of risk for inadequate nutrition and hydration
- Thickened liquids
- Thickened liquids provide same amount of free water as thin water
- BUT recall intake may be limited by
- Dislike of taste (few naturally occurring thick liquids)
- Limited availability
Amount of fluid needed is determined by:
Height Weight Age Gender Physiologic activity Medical diagnosis Medications- may make patient have dry mouth
Fluids
Fluid is anything that is in a liquid state at room temperature (includes jello, ice chips and ice cream)
Non-fluids can contain fluids (e.g. fruit)
Fraizer Free Water Protocol
Bedside and instrumental swallow study If impulsive require supervision No water if choking or strict NPO per MD Water allowed between meals Provide aggressive oral care At least 30 minutes after a meal if eat by mouth Any time if NPO Unrestricted quantity Use any recommended swallow strategies No medication with thin liquids -during meals drink thickened liquids but if thirsty throughout the day they can have water as well -monitor patient for aspiration -medications can't be given because they can choke
Purpose of Fraizer Free Water Protocol
- started it because they are not getting enough hydration
- not right for every patient
Water and aspiration pneumonia
- Aspiration of different materials presents different risks for developing aspiration pneumonia.
- Aspiration of thick liquids and solids results in a greater risk for aspiration pneumonia and death than aspiration of water.
- Aspiration pneumonia may result from aspiration if material is pathogenic to lungs and resistance to material is compromised
- Fluid is absorbed in lungs
Sources of pathogens remain:
Bacterial contamination in Tap water At least meet EPA standards Oral cavity Aggressive oral hygiene Dental treatment Increase saliva in xerostemia
Frazier Free Water Protocol Procedure
Experimental group received thin liquids btwn meals after rinsing their mouth, thick liquids with meals over 30 days
Control group received thick liquids between meals and with meals over 30days
All participants were monitored for development of aspiration pneumonia
Frazier Free Results
No participants developed aspiration pneumonia
Experimental group had significantly greater overall intake of fluids
Experimental group reported higher degree of satisfaction
Limitations of Frazier Free
Small sample size
Relatively healthy participants
Individualized Treatment Plan
Determined through consideration of:
Results of the clinical or instrumental examination
General selection principles
Treatment candidacy
General Selection Principles of Treatment
Least restrictive intervention Easiest to understand Easiest to execute Least tiring Thinking of preforming the mendelson-a lot more tiring than chin-tuck.
Treatment Candidacy
Arousal- someone who is sleeping all the time not good candidate
Alertness- participation, following directions
Endurance
Cognitive-linguistic status
Ability to follow commands (one-step? multi-step?)
Memory
Awareness of deficits
Ability to execute and control voluntary movements
Medical diagnosis
Prognosis (potential for recovery)
Comorbidities- other diseases
Motivation
Agreement with plan of care
Support network
Treatment Plan derived by
an understanding of anatomy, neurology, and physiology
Goal is for safe and efficient intake of least restrictive diet for adequate nutrition and hydration
Treatment Plan Goal
Reestablish partial or full intake of least restrictive diet
Maintain safe intake of least restrictive diet over a longer period of time
Intervention Techniques
Compensatory techniques* Postural Sensory input Modification of presentation of food/ liquid Modification of diet Swallow Maneuvers*,** mendelson-can perform it as therapeutic exercise or observe the pt use it w. meal Exercises** * Direct therapy: food is given ** Indirect therapy: no food is given
Compensatory Techniques
Under caregiver control
Does not require complex directives
Alter the direction and rate of bolus flow
Often do not change physiology of swallow, but helps w. bolus flow
Do not cause fatigue as much as maneuvers
Postural Techniques Candidates and Goals:
Candidates: Variety of disorders Minimal learning required: can be implemented by caregiver Goals: Redirect bolus flow Change pharyngeal dimensions
Chin Tuck/ Chin Down
- touch neck w. chin
- reduced bolus control: reduces premature spillage to pharynx
- delayed pharyngeal swallow: see below
- reduced airway protection: widens valleculae to protect airway and lowers epiglottis and narrows airway entrance.
- reduced base of tongue retraction: facilitates base of tongue contact w pharyngeal wall by pushing base of tongue towards pharyngeal wall
Head Turn to weak side
unilateral pharyngeal weakness-direct bolus down strong side by closing off the pyriform sinus on the weak side
unilateral vocal fold paresis/ paralysis-facilitate vocal fold closure by medializing the weak vocal fold
Head Tilt to strong side
unilateral oral weakness (residue on weak side)- use gravity to help redirect bolus on strong side
-unilateral pharyngeal weakness- use gravity to direct bolus down strong side
Tilt head back, chin up
- would not use this when pharyngeal swallow is not intact- pt could aspirate
- reduced anterior to posterior bolus transit- use gravity to propel bolus posteriorly
- when you tilt head back you are using gravity to help push it back would be most valuable with oral prep/transit issues
Sensory Input Candidates and Goals
Candidates: Reduced recognition of food Reduced oral sensation Delayed or absent swallow response Goals: Increase recognition of food Elicit pharyngeal swallow if absent Increase timeliness of pharyngeal swallow if present by ‘heightening sensitivity”
Types of Sensory Input
- Exert pressure on tongue (e.g. with the back of a spoon)
- Alter taste, temperature, or texture of food across a meal: cold, sour, textured, and carbonated thin liquids
- Thermal-tactile stimulation: stimulate anterior faucial pillars prior to swallow
Explain sequence of normal swallow
start with awareness of food
Presbyphagia
-increased oral transit time
time for trigger swallow
COPD at mealtime
smaller and more frequent meals because the patient fatigues often
- respiratory disease have trouble coordinating breathing and swallowing
- get fatigue, tired during meals, get bloated, dry mouth, chest pain, heartburn.
4 factors could affect severity of dysphagia for COPD
from midterm
Swallowing Maneuvers Goals and Candidates
Candidates:
Reduced airway protection
Demonstrate ability to follow multi-step commands
Demonstrate adequate strength and coordination
Demonstrate adequate respiratory support
Diagnosis: Cardiac or stroke patients may not be candidates as may some maneuvers induce cardiac arrhythmia.
Goals:
Increase range of motion
Control timing of swallow
Supraglottic Swallow
reduced or late vocal fold closure causing aspiration during the swallow
delayed pharyngeal swallow
***Close true vocal fold before and during swallow
protect airway by holding breath during swallow
protect vocal folds by holding breath before and during delay
Supraglottic Swallow Instructions
Inhale Hold your breath (Place food in mouth) Swallow while holding your breath Cough Swallow again
Super-Supraglottic Swallow
reduced or late vocal fold closure causing aspiration during the swallow
delayed pharyngeal swallow
***Close airway entrance, false and true vocal fold before and during swallow
protect airway: tilt arytenoids forward, close the false vocal folds and laryngeal vestibule
improve coordination of the swallow
Super-Supraglottic Swallow Instructions
Inhale Hold your breath Bear down (Place food in mouth) Swallow while holding your breath and bearing down Cough Swallow again
Effortful Swallow
reduced base of tongue retraction
increase base of tongue retraction during swallow clears vallecular residue
Effortful Swallow Instructions
swallow hard: squeeze all the muscles of your throat when you swallow
Mendelsohn maneuver
-use when they have difficulty with laryngeal elevation.
-reduced hyolaryngeal elevation-strengthens the muscles of elevation
-reduced cricopharyngeal opening-increase duration and extent of cricopharyngeal opening
discooridinated swallow-improve coordination and timing of swallowing
Mendelsohn maneuver instructions
Can be done with or without careful manual assistance
Raise larynx as you swallow
When you larynx is elevated hold it up for several seconds (with or without manual assistance)
if can’t do mendelsohn try shaker
Exercises Candidates and Goals
Candidates:
Oral motor weakness
Demonstrated ability to follow commands
Goals:
Improve precision of movement, strength and range of motion of musculature for improved e.g. lip seal, bolus formation and manipulation, chewing, bolus control
-lingual sweep is functional to clean up anything coming out of oral cavity. may not be helpful for neuromuscular disorders
Masako Exercise
aids in tongue based retraction.
not done with food but used as an exercise
-difficult with npo or dry mouth
Exercises Oral:
Improve lip seal to reduce anterior loss of bolus and drooling
range of motion: maintain a pucker, smile, alternate pucker-smile
strength: hold tongue depressor(s) tightly between lips, smile when angle of lip is held
Improve bolus formation and manipulation:
range of motion: tongue lateralization, protrusion, tongue tip elevation
strength: ‘popping’, push against tongue blade (side or front of tongue)
Improve bolus propulsion:
anterior to posterior tongue movements
squeeze liquid from gauze
tongue tip elevation
tongue lateralization, tongue protrusion, and retraction
Improve bolus control:
manipulate object (e.g. gauze, lollipop)
Improved chewing:
chew gauze
tongue lateralization
Exercises Pharyngeal and laryngeal
- Improve base of tongue retraction:
- pull tongue back and hold
- pretend to yawn and hold
- pretend to gargle (if adequate airway protection)
- Improve vocal fold closure:
- push-pull with production of /a/ with hard attack
- Improve hyolaryngeal elevation:
- pitch glides and sustained falsetto
- posterior tongue sweep
- tongue tip elevation with resistance
- Shaker exercise
Positioning of safe feeding strategies
Feet flat on support (or slight dorsoflexion) Hips flexed at 90˚ (HOB elevated to 90˚) Trunk at midline Head at midline Chin slightly retroflexed
Presentation of food
- Ensure patient is alert
- Minimize distractions
- Encourage self-feeding if appropriate
- Feeder at eye level
- Alternate textures, temperatures, and tastes
- Encourage slow rate of intake
- Encourage single sips, small bites
- -present food in certain way
- Encourage sip after each bite (‘alternate consistencies’)
- Encourage repeat swallow
- Encourage finger or tongue sweep
- Encourage throat clear and repeat swallow as need
- Remain upright for 30 to 45 minutes after the meal
Diet Consistency
Recall goal of treatment is safe and efficient intake of least restrictive diet
Typically alter diet if other compensatory strategies and swallowing maneuvers are
not adequate to prevent aspiration risk
not feasible as patient cannot follow commands
not feasible due to movement disorder, reduced postural control
Thin Liquid
- reduced tongue coordination-easier to propel posteriorly
- reduced tongue strength-easier to propel posteriorly
- reduced base of tongue retraction-transits through pharynx with gravity
- reduced pharyngeal wall contraction-transits through pharynx with gravity
- reduced UES opening
Parent Interview Record
Chief Complaint Patient’s Perception of the Problem Character of Complaint Course of Complaint Activities of Daily Living Previous Treatment
Nutrition
Oral intake 24-hour dietary recall Enteral Intake Parenteral Nutrition Weight change Lab values/blood parameters
Medical Record Review
Patient’s medical history Findings from physical exam by physician Reports of laboratory tests Findings of special examinations Findings from consultants Notes of treatment Medications Surgical options Progress notes by all disciplines
Advocacy
taking action to solve a problem. Client gets most services he/she needs-child. Adult-advocating for pt. to eat a certain diet consistency, strategies, positioning for safe feeding strategies.
respect for autonomy
pts. Have the right to make independent choices about their care. In order to do that they have to be free of any controlling influences. Must have mental capacity to reach those decisions. Pt can write advanced directives.
Make sure treatment is ethical, appropriate, provide best possible treatment for pt. in consultation with pt. or involve family if they are not able to make a decision.
5 steps of clinical assessment
-Screening: Signs and symptoms of dysphagia Risk factors -Case history -Oral-peripheral examination -Food trials -Blue Dye test
Screening
Review chart Identify risk factors Identify warning signs Dysarthria Drooling Unexplained weight loss Recurrent pnuemonia Identify signs and symptoms of dysphagia Bedside Swallow Assessment (water by spoon/cup) Gugging SSA-Standardized Swallowing Assessment Kidd Water Test Massey Bedise (1 tsp., 1 glass water) EATS (semi-solid, liquid, solid) TOR-BSST – Toronto Bedside Swallowing Screening Test
Case History
Diagnosis Medical and surgical history Swallowing history Respiratory status Medications Reason for referral Patient’s complaints (e.g.duration, frequency) Observations (e.g. drooling, cognitive status, voice quality, fatigue)
Clinical Examination
Assess structural and functional integrity
Assess airway protection
Assess safety of oral feeding
Determine need for additional diagnostic tests and/or referrals
Gather baseline data
Oral Peripheral Exam
Alertness Cognitive-linguistic skills Sustained attention Memory Following directions (1, 2, 3 step) Problem-solving Safety awareness Insight Respiratory status- breathing on own or do they have some sort of artificial airway? Can they communicate? How do they communicate? Are they impulsive? Aware of their actions, pragmatically aprop? Symmetry Range of motion (ROM) Strength Precision Coordination Sensation Dentition, dentures (condition) Xerostomia Secretions Oral mucosa Velopharyngeal structure and function- use a mirror to see if air is escaping through nostrils to see nasals vs. non-nasals Gag reflex – highly variable in people; 30% of people have minimal to no gag Physicians still think no gag = no swallow Laryngeal function Voice (quality, loudness, pitch) Strength of cough/ throat clear
3 Ounce Water Test
3 ounces of water without interruption
Coughing, choking, stopping wet-hoarse vocal quality during test or 1 minute later-fail screen
If fail water test get MBS?FEES- not bedside (Suiter/ Leder , 2008)
If pass- reg diet/thin liquids with dentures
If edentulous, puree diet/ thin liquids
If patient improves, retest
oral prep phase
1 swallowing -place food in mouth, manipulate/chew food Sensory recognition of food Labial closure, seal and stripping Buccal tension Soft palate is pulled down and forward Bolus manipulation Chewing Bolus formation
oral phase
(1-1.5 seconds) step 2 Propel bolus posteriorly Posterior movement of bolus Tongue tip and lateral margins of tongue held against alveolar ridge Central groove at midline of tongue Lingual stripping
pharyngeal phase
(1second) step 3 Transit bolus vertically through pharynx Velopharyngeal closure Hyolaryngeal elevation Laryngeal closure Base of tongue retraction Cricopharyngeal opening
esophageal phase
(8-20 seconds) step 4
Transit bolus vertically through esophagus
UES closes as soon as bolus passes into the esophagus
Bolus transits through esophagus via peristalsis
thick liquid
flow less quickly and easier to control
flow less quickly and easier to control
less likely to penetrate into larynx
less likely to pass through vocal fold
Solids
Types of solids (National dysphagia diet)
Puree (Level 1):
homogenous, very cohesive, pudding-like, requires very little chewing
Mechanical soft or Mechanically altered (Level 2):
cohesive, moist, semisolid foods, requiring some chewing
Soft solid (‘dysphagia-advanced’) (Level 3)
soft foods that require more chewing ability
Regular (no restricted consistencies) (Level 4)
puree
does not require chewing
flows less quickly and easier to control
mechanical soft
does not require chewing
more cohesive
soft solid
requires chewing more cohesive (avoid rice, nuts, coconut, dried fruit, hard bread items)
long-term functional goals
Patient will demonstrated safe and efficient intake of least restrictive po diet without clinical signs or symptoms of aspiration
Patient will consume a mechanical soft diet with thin liquids without complications such as aspiration pneumonia
Patient will demonstrate overt tolerance of pleasure feeding to supplement alternate means of nutrition and hydration
short-term functional goals
Patient will perform the supraglottic swallow maneuver on dry swallows with min cues with 90% accuracy to improve airway protection
Patient will perform the Masako technique accurately x10 in 3/3 sessions with mod cues to increase base of tongue retraction
Patient will demonstrate accurate use of chin tuck in 5/5 trials of thin liquid over 3/3 sessions with min cues to increase safety for po intake
