final exam review Flashcards
Management/Compensation/Treatment Example 1 – what would antibiotics for PNA fall under?
management
Management/Compensation/Treatment Example 2 – what would 2 swallows per bite/sip fall under?
compensation
What would Masako to strengthen BOT/PPW fall under?
treatment
Why is oral care the best predictor of aspiration PNA?
oral bateria increases the risk of aspiration PNA. dysphagia is an important risk factor for developing aspiration PNA but is not sufficent to cause it without other risk factors present
T/F Oral bacteria flourishes in a dry mouth
T
What is the name for aspiration of stomach contents?
Aspiration pneumonitis
What factors do you need to consider when deciding whether to implement free water protocol?
Management technique; QoL; patient is on thickened liquids but can have free access to water after oral care; factors to consider: support of oral care, cognition, ambulatory status, etc.
T/F Lateral tilting is a strategy that targets pharyngeal weakness.
False; lateral tilting of head physioligcal target is unilateral impairment of lingual movement, sensation or anatomy; ex: right side impairment –> tilt head laterally to left (tilt head to strong side)
T/F Chin tuck is a potentially good strategy for someone who aspirates before or during swallow
True; keeps bolus in mouth until actviely compressed by the tongue; compresses airway closed; physioligcal target is premature spill, poor airway closure, penetration/aspiration before/during swallow
Who might benefit from posterior head tilt?
impaired anterior-posterior bolus transport but with good airway protection
Who might benefit from a larger bolus or carbonated liquids?
patients with impaired sensory awareness; large bolus size may trigger mechanical receptors in mucosa (central pattern generator in NTS); carbonated water improves esophageal cleanrane and shortens pharyngeal transit time
T/F – TPN is a method of providing nutrients intravenously
True; TPN = total parenteral nutrition; nutrional formula containing ciritcal nutrients in high concentration delvered through large vein; very thick takes 10-16 hrs/day
What is the typical duration of an NG tube?
Nasogastric Tube; short duration < 6-8 weeks because nasal passage has low tolerance for edema, infecion, etc.; used with no evidence of GERD; most common
Why is TPN short term?
Invasive, infection risk; the liquid is very thick and can only be adminstered through larger vein
Define treatment
activitly changin swallow. targets changing the strength, timing and coordination of swallow to make it safer/efficeint
Define compensation
strategies representing band-aid approach. we manipulate a feature to make swallowing safer/efficient hwoever we DO NOT change the underlying swallowing physiology
define management
Update this slide to include examples
methods of reducing the impact of dysphagia and/or manifestation of its sequelae (def of sequela: A pathological condition resulting from a prior disease, injury, or attack)
name a few bolus delivery compensatory strategies
positioning, multiple swallows per bolus, alternate liquids and solids, reduce distractions, verbal reminders of strategies, slow rate, no straw, small sips/bites
4 positioning compensatory stratgeies
- lateral tilting
- anterior tilting (chin tuck)
- Posterior tilting
- Head/neck rotation
True/False Chin tuck is effective for patient with lots of post-swallow residue;
False, not effective b/c may push more residue into pharynx; must test with instrumentation
What is head rotation compenstaory strategy
compressed weak muscles against pharyngeal wall making all strong muscles do the work; physiologic target –> unilateral impairment in pharyngeal constriction and/or UES opening; unilateral post-swallow residue; must confirm with instrumentation
Tucking chin
compresses the airway closed
Tilting the head laterally
targets impaired unilateral lingual deficits
Tilting head back
targets poor anterior to posterior bolus manipoulation within the oral cavity
Turning the head maximally to one side
pushes the bolus to the unimpaired (strong) side to improve pharyngeal constriction and/or bolus flow through UES
T/F – The VFSS radiation exposure is about as much as someone might get on a transatlantic flight
T
How many frames per second is best for VFSS studies?
30 pulses per second
What are some ways you as a clinician limit your radiation exposure while completing these exams?
wear lead! stand behind wall, wear dosimeters
Why is it important to use a controlled density of barium in the study?
the higher the density the more residue; controlled consistency is important because it standardizes the consistency across all studies/patients; mixing substance by eye does not work
What does lateral view show that AP view doesn’t show as well?
best to view aspiration penetration; bolus flow; lateral views shows oral prep, oral, and pharyngeal phases of swallow; high as nasal cavity and as low as cervical esophagus
What does AP view show that lateral view doesn’t?
best for observing asymmetries in physiology and post-swallow residue; esophageal clearance; pharyngeal contraction
What term will you see in clinical practice to describe a 2 on the PAS?
PAS is a method for quanitfying swallowing safety; it an 8 point oridnal rating scale that quanitifies the depth of airway invastion and the body response;
important to comment on timing in relation to the swallow;
1-2 normal –> 3-4 penetration –> 6-8 aspiration;
2 = flash or transient penetration
Which PAS score is quite rare and why?
Penetration #5 - material enters the airway, contract the vocal folds and is not ejected from the airway –> rare b/c materail just can’t sit there
What score is silent aspiration?
Aspiration #8 - material enters airway, passes below the vocal folds and no efforts is made to eject
What are two reasons for aspiration before swallow?
- spill of material from the mouth
- delayed swallow initiation
T/F - the VFSS does not diagnose the etilogy of the swallowing disorder; instead it determines the detials of oropharyngeal swallow dysfunction and helps guides dicision sregarding behavioral swalllow theray based on those findings
True; what is the underlying phyisology and what can we do about it
Oral impairment MBSI components 1 - 6
true
Pharyngeal impairments mbsi components 7 - 16
true
Esophageal impairment component 17
true
What are the benefits of FEES and/or some reasons you might choose it over VFSS?
FEES and VFSS are complimentary exams
one might choose FEEs over VFSS because FEES:
- can be done bedside,
- can be used with more food/liquid variety,
- allow you to observe post-swallow residue for long periods to assess aspiration risk,
- fees home view allows us to see left and right,
- value of ‘online’ biofeedbacksensory integration of larynx/pharynx
Explain the debate about use of anesthetic in FEES exams and current research findings.
may lead to sensory changes of pharynx and swallow initiation due to post nasal drip f numbing agent; current resarch suggests lidocaine does not worsen PAS or residue bt does increase patient comfort level
T/F – ASHA’s position on FEES includes that FEES should only be done in a setting where medical personnel are available
true
What tasks would you complete while the scope is still in the nasal cavity?
scope b/w inferior and middle turbinates observe the velar elevation and constriction of the lateral and posterior pharyngeal walls during the following tasks:
- sustained vowel
- sustained /s/
- non-nasal senstence ‘is Sassy sick’ (tests tighter/maintaining closure of VFs)
What might you test if the pt has pooled secretions? How can you tell if the pooled secretions are a result of sensory impairment or motor impairment?
touch area of pharynx here pooling is occuring to assess senation and then ask patient to swallow –>
- if cleared after swallow sensnation may be impaired b/c patient didn’t feel pools - if not cleared after swallow the motor function may be impaired
What are you looking for when examining the larynx prior to PO trials?
have patient phonate /i/ to observe glottis closure, laryngeal elevation and vocal quaility;
observe true and false VF closure during breath holding task and coughing
What can you assess with liquid boluses?
bolus containment, premature spill, post-swallow residue in pharynx,
What does Shaker exercise target?
head raising exercise done supine to target improved UES function; targets poor UES opening resulting in post-swallow residue typicaly in pyriform sinuses
What is the name of the device to target tongue strengthening?
Iowa Oral Performance Instrument (IOPI) tongue resistance exercises - can be placed anterioroly or posteriorly - posterior tarets BOT, bolus control preventing premature oral seal in back of tongue
Who would benefit from using the IOPI?
target popuation includes poor bolus formation, premautre spill, oral residue, poor base of tongue to posterior pharyngeal wall, pharyngeal residue
Why should you not do the Masako with a bolus?
removing tongue movement from swallow decreases safety and effcieiny of swallow
Why would pairing NMES (e-stim) with a swallow possibly increase hyolaryngeal elevation?
pairing e-stim with a swallow because e-stim stabilizes hylolargeanl complex and the swallow must overcome the resistance as a strenthening task
T/F – neural stimulation has been utilized in some areas of speech/language treatment
True - neural stimulation can be ysed for swallowing and aphasia treatment
Discuss why effortful swallow can be considered a facilitative technique or a behavioral treatment
target population includes signitificant post-swallow residue, poor pharyngeal constriction, poor BOT to PPW;
can be used on initial swallow or 2nd clearing swallow ;
it is facilitative b/c it immediately increases swallowing pressures and residue clearance; it is behavioral b/c it increases tongue strength after 4 weeks of training
What could be helpful in teaching the Mendelsohn maneuver?
Verbal cueing due to the multi step direction
-Sit or stand comfortably.
-Start to swallow normally.
-When your Adam’s apple is at its highest point, squeeze your throat muscles to hold it in that position for 3 counts, and then relax. …
-Repeat these steps as many times as directed.
targets early UES closure, incomplete UES opening, poor pharyngeal constriction both resulting in post-swallow residue
BREAK IT DOWN - practice step by step before moving on
Breath hold - big breath in, bear down like you are lifting, close VFs and lifts larynx
Who might benefit from the super supraglottic as opposed to the supraglottic swallow and why?
super supraglottic swallow adds increased effort of airway closure by bearing down when swallowing; closes both true and false VFs –> extra recruitment for VF closure; super supraglottic targets difficulty with VF closure whereas supraglottic targets delayed VF closure
Supraglottic swallow —> holding breath closes VFs preventing bolus from entering laryngeal vestibule; task - bolus enters mouth, hold breath, swallow while holding breath, let go of breath and cough to clear VFs
What can cause CP Bar?
failure of cricopharyngeus muscle (vagus X -RLN) to relax during swallowing as a result of fibrosis, GERD, neuromusclar disease;
What textures do pts with CP Bar have difficulty with?
cuases increasing difficulty with increasing texture viscosity and signficant post-swallow residue
Why do we often see Zenker’s Diverticulum with CP bar?
Zenkers is a ballooning out ofhte pharyngeall wall due to high pressure cuasing a diverticulum (pouch); CP bar may cause Zenkers because there’s a problem of the insertion of the CP muscle not the lower pharyngeal constircotr causing potentail for high pressure enviroment to cause out-pouching
What are two examples of health markers that could be used as dysphagia outcome measures?
nurtrition, hydration, lung status
Which measure combines safety and efficiency into one rating?
DIGST - Dynamic Imaging Grade of Swallowing Toxicity - breaks down pharyngeal phase into safety and efficiency
Name two diet-based outcome measures
functional oral intake scale (FOIS) –> level 1 NPO through level 8 no restrictions on oral diet;
ASHA-NOMs scale –> level 1 –> not able to swallow anything by mouth use non-oral means for nutrition, level 7 able to eat independently, no limitations ot swallow function
Name some etiology specific scales
MD Anderson Dysphagia Inventory for HNC;
DYMUS Questionnaire for MS;
NIH SSS for stroke severity
what is behavioral therapy
done as therapy technique to change function;
the same techinque can be facilitative or behavioral depending on context and in the moment or overtime
what is facilitative technique
utilized as a band-aid in the moment
ex: - effortful swallow done under VFSS to clear pharynx -mendhelson manuever
- postures like chin down or head turn are always faciliative
what is the goal of behaviorial therapy and name 6 treatments
goal is to improve strength/mobility/endurance for components of swallowing
1. shaker exercise
2. tongue strengthening
3. masaka maneuver
4. EMST
5. transcutaneous e-stim
6. effortful pitch glide
what is the masako manuever
swallow intitiated ith the tongue held firmly between the teeth to improve PPW constriction not BOT;
target pop includes poor tongue to posterior pharyngeal wall contact, poor pharyngeal constriction, pharyngeal residue
T/F effortful pitch glide is a behavioral treatment targeting poor pharyngeal constirction and poor laryngeal elevation
true - low to high gliding pitch causes elevation of arytenoids/larynx and constirction of the pharynx
what is supraglottic swallow
goal is to close the airway prior to bolus entry into the pharynx and to keep the airway closed for the duration of bolus transport;
holding breath closes VFs preventing bolus from entering laryngeal vestibule;
task - bolus enters mouth, hold breath, swallow while holding breath, let go of breath and cough to clear VFs
Why do we refer to “feeding and swallowing” when discussing the pediatric population as opposed to adults?
feeding and swallowing for infants is one process;
swallowing disorder is impaired oral, pharygneal and/or esophageal phases of swallowing
feeding disorders include disrupted or disordered ability to gather food and prepare for sucking, masitcation or swallowing
Why might the prevalence of pediatric dysphagia be on the rise?
on the rise due to improved survival rates of children born prematurely, low birth weight or complex medical conditions
Why might SLPs work closely with OT for a pediatric client?
OTs evaluate and treat problems related to posture, tone and sensory issues
T/F The hyoid of a baby is in a more posterior position than that of an adult
false; infant hyoid is elevated and more anterior than adults (adults are more inferior)
List the other differences between adult/child anatomy
infant’s oral cavity is smaller, tongue fills oral cavity, larynx is elevated descending over the first 4 years
Why is it safe to lay a baby flat while feeding?
the velum and epiglottis can touch creating their own vestibule allowing the infant to breath through nose while sucking
What is the typical ratio of suck to swallow for infants?
suck–swallow–respiration is attained with a consistent suck–swallow ratio (1:1)
Why is instrumental Ax not indicated if a child’s symptoms indicate sensory preference issues?
a child with sensory preference issues may not comply with diagnositic testing
When does the rooting reflex disappear?
3-5 months
When does the bite reflex disappear?
3-5 months
When does rotary mastication start to develop?
5-7 months
Why is the tongue thrust reflex protective at a young age? Discuss what swallowing might look like in an older child who still (abnormally) displays the tongue thrust reflex.
seen as protective from birth to ~ 4 months to prevent unwanted material in the oral cavity; tongue thrust in older kids may look like mouth breathing, open mouth posture at rest, dentalizing /s z/
What is a self-pacing system for an infant and why might you recommend that technique?
Slow flow vs high flow
self-pacing allows child to take in the amount they want rather than a prescribed amount
promotes efficiency safety and comfort; slow flow = better for dysphagia;
high flow = helps if baby fatigues easily
Who might you refer someone to if they need a palatal prosthesis?
prosthodontist
Who might you refer someone to if you suspect esophageal dysphagia?
Gastroenterologist
What the name for the medical specialty focused on rehabilitation?
physiatrist coordinates rehab team during recovery from acute illenss or follow those with chronic diseases on an ongoing basis
What is a challenge that was mentioned about being a clinician treating dysphagia in the school setting?
lack of medical staff
What is a challenge that was mentioned about being a clinician treating dysphagia in acute care?
fast paced; need to be a generalist
What are pill delivery options for people with dysphagia?
taking pills with applesauce/puree or suggest asking pharmacy about liquid ofrm of Rx
What class of medications might cause someone to become a silent aspirator?
meds that worsen swallow function include depressants or other meds affecting central nervous system; NSAIDS
Discuss the choice of using barium vs water with a barium pill in VFSS.
use water with barium pill to assess pill getting stuck; use barium pill with barium liquid if concerned swallowing pill alters safety/efficiency
What is the name for reduced jaw opening and what device works to improve ROM?
trismus –> Current methods used to increase mouth opening include unassisted jaw ROM exercises, finger-assisted stretching exercises, stacked tongue depressors, and mechanical assistance with a device such as Therabite
What is our role in dealing with patients who are end-of-life?
comfort, consult,
What would you do if a patient or family is non-compliant with your recommendations?
inform patient about current condition and inform them of treatment options and how those treatments will aid their condition; it is the patients choice to follow recommendations
What would you do if your assessment methods were culturally insensitive to a specific client/patient?
Our role as SLPs need to be understood from the perspective of the patient.; use ethnographic interviewing. This is a method for asking questions in a way that can facilitate an effective interview and build rapport between you and your client.; learn how my culture and biases create my personal cultural lens
What are some components to ethnographic interviewing?
Tell me about a typical mealtime; Give me an example of what you are forgetting; Use open-ended questions; Restate what the client says by repeating the client’s exact words; do not paraphrase or interpret; Summarize the client’s or parent’s statements and give them the opportunity to correct you if you have misinterpreted something they have said; avoid multiple questions
what is the compensation for this deficit?
inefficient oral transit (reduced posterior propulsion of bolus by tongue)
head tilted back
what is the compensation for this deficit?
delay in triggering the pharyngeal swallow (bolus past ramus of mandible before pharyngeal swallow is triggered)
chin tuck aka chin down
what is the compensation for this deficit?
unilateral oropharyngeal weakness on the same side (residue in mouth and pharynx on same side)
Head tilt to strong side
what is the compensation for this deficit?
unilateral laryngeal dysfunction and reduced laryngeal closure
head turn to weak side + chin tuck
what is the compensation for this deficit?
unilateral pharyngeal paresis (residue on one side of pharynx)
head rotation/turned to weak side
