Screening, instrumental and non-instrumental assessment of swallowing function Flashcards
Why is a bedside examination not useful with aspirating patients
A bedside examination is unable to identify the anatomic and physiologic causes of aspiration
(which, the information is needed for development of treatment plan)
What type of evaluation is used for a patient suspected of aspiration?
Radiographic evaluation
Why is a radiographic evaluation necessary?
- to identify the presence of aspiration
- define the etiology of the aspiration
- examine the immediate effects of selected treatment procedures and design appropriate therapy for the pt
- Determine the best method of nutritional intake
The MBS, FEES, and FEESST assessments are used to assess swallowing physiology for what purposes?
- identify aspiration, penetration, and/or residue patterns
- detect etiology (dysfunction structure)
- determine techniques, maneuvers, and consistencies that enhance swallowing safety and efficiency
Identify 5 implementations to enhance swallowing
- postural changes to change the dimensions of the pharynx and food flow (i.e., head turn)
- Increasing bolus sensory input (i.e., carbonation, ice)
- modify volume and speed of bolus presentation
- modify food consistency or viscosity
- use intraoral prosthetics
Identify 8 consistencies of bolus’ used?
- ice chips or lemon-ice
- thin liquids (water, mild, juice, formula)
- nectar (thick)
- honey (thick) or milkshake
- puree (pudding, apple sauce, yogurt)
- semisolid food (mashed potato, banana, pasta)
- Soft solid food that requires some chewing (bread and cheese, soft cookie, casserole, meat load, cooked veggies(
- Hard chewy crunchy food (meat, raw fruit, salad, soup with food bits, cereal with milk)
What are the 9 different bolus sizes used in swallowing examination
- <5cc (for medically fragile and poor pulmonary clearance pts)
- 5cc/1 teaspoon
- 10cc
- 15cc or 1 tablespoon
- 20cc or heaping table spoon
- single swallow from cup or straw-monitored
- single swallow from cup or straw self-monitored
- free consecutive swallows self-presented
- feed self food at own rate
8 recommendations following swallowing examination
- NPO
- swallowing therapy/biofeedback
- therapeutic feeding only with icechips with SLP
- feeding with liquid diet only
- feeding pudding consistency only
- continue with alternative feeding for nutritional and hydrational need: yes or no
- repeat examination
- consultation with ENT, GI, or Neurologist
Identify some dysphagia treatment techniques:
- sensory enhancement of food (taste, texture, temperature)
- range of oral motor exercises
- range of motion exercises for pharyngeal structures
- therapy with or without food
- thermal tactile stimulation
- shaker exercise
- jaw opening exercise
- chin tuck against resistance
- electrical stimulation
- mendelsohn
- head turn
- super-supraglottic swallow
- supraglottic swallow
- lee silverman voice treatment (LSVT)
- chin tuck
- swallow solutions
- IOP
- vital slim
- expiratory muscle strengthening therapy
What is the ultimate goal of evaluation? to answer what question/s
- Who, when, and how to treat?
- At what intensity to treat?
- How many repetitions in treatment?
- When should intervention be initiated in the course of a disease?
Three themes in treating dysphagia… what are they?
- Intensity: the amount of load, volume, and duration of exercise stimulus
- Specificity: how closely the exercise task corresponds to the targeted outcome
- Transference: implicated in the rationale for using cross-training and non-specific strength training to ultimately improve function
What factors should an SLP consider when choosing which evaluation procedure will be most appropriate for the pt?
-age
-language
-cognition
-medical diagnosis
Many evaluation techniques can be used concurrently… for example, MBS can be used with which two other instruments?
-MBS + manometer
-MBS + EMG
List the 5 imaging techniques for evaluation
- Ultrasound
- Videoendoscopy (FEES, FEESST)
- Videofluoroscopy (MBS, Pharyngogram)
- Barium Esophagram
- Scintigraphy
What information can be gathered when using imaging evaluation technique?
- Anatomy: structure presence/absence, symmetry
- Physiology: bolus flow characteristics, range/displacement and timing (biomechanics), residue patterns, airway protection (aspiration or penetration and pt reaction), sphincter valve function and timing, and displacement
- Identify aspiration or penetration
- Detect etiology
- Sensation
List 5 non-imaging techniques
- electromyography (EMG)
- Cervical auscultation
- Electroglottography (EGG)
- Pharyngeal and esophageal manometry
What information can be gathered when using non-imaging evaluation technique?
Function: identifies
-timing
-pressure
-neuromuscular patterns
-valve function
-sounds
What is Electromyography technique?
It includes what information?
Neuromuscular electrical activity recording
It includes…
1. detection
2. amplification
3. recording
4. processing and analysis
5. interpretation
There are three ways of recording the signals with electromyography, what is the most popular?
Surface electromyography (sEMG) is the most popular
Advantages of using electromyography (EMG)
-Sensitive to low amplitude muscular activity
-Non-invasive (surface electrode on FOM)
-Detects timing and amplitude of regional neuromuscular activity
Disadvantages of using electromyography (EMG)
-Non-specific (it records activity by region, not individual muscle)
-Invasive hook wire electrode-laryngeal UES
How does the manometry evaluation technique work?
-Uses a catheter that measures pressures at various intervals along the length of the esophagus
-Data on strength, timing, and sequencing of pressure events are obtained with each swallow
Using a manometer at evaluation can indicate?
- dysphagia
- non-cardiac chest pain in patients without evidence of mechanical obstruction, ulceration, or inflammation
Advantages of manometry
-tests pressure wave physiology
-sensitive to visually undetectable deficits (ex: like the failure of UES relaxation)
What is an actual test of pressure wave physiology
Manometry
How is high resolution manometry different from conventional manometry?
High resolution manometry 1. uses more pressure sensors
2. more accurate at assessing pressure changes
3. pressure sensors closer together (~1cm) compared to conventional manometry (~3 to 5cm)
4. Improves ability to diagnose esophageal motor disorders
5. Reduces movement artifact
6. Improves the detail of the acquired information
How is high-resolution manometry better at displaying and analyzing pressure change data?
Uses a esophageal pressure topography plot
What is an esophageal pressure topography plot?
- Seamless, dynamic representation of the entire pressure pattern, displaying pressure dynamics throughout the entire esophagus
-Obtains information regarding the anatomy, pressure gradients, and contractile activity
Disadvantages of manometry
- not widely available (but this is changing)
- can’t diagnose visible lesions
- unplesant
- technically demanding to perform
- Catheter movement
- no oral event
- few pharyngeal events
When may a manometry evaluation be indicated?
When patients need recurrent intraluminal pressure assessment for achalasia or diffuse esophageal spasm
What is Auscultation technique
Listening to the sounds of swallow and respiration using stethoscope
Advantages of auscultation technique?
- entirely non-invasive
- available
- portable
Disadvantages of auscultation technique?
- Lacks standardization
- lacks sensitivity and specificity
- subjective
- Somewhat controversial evaluation method
Advantages of using plain film imaging for evaluating dysphagia
Cheap and quick
Disadvantages of using plain film imaging for evaluating dysphagia
cannot detect mechanisms of the swallow
Advantages of using barium esophagram for evaluating dysphagia
widely available & provides better anatomic detail
Disadvantages of using barium esophagram for evaluating dysphagia
involves radiation exposure
Barium esophagram is indicated in patients who…
demonstrate suspected structural disorder (i.e., dysphagia of solid foods)
How does ultrasound imaging evaluation work?
Sound waves enter and reflect from structures, allowing view of tissue layers and movements
What can you see with ultrasound imaging?
-upper digestive tract
-assess mobility & bolus transit
-Identify vallecular stasis
Advantages of using ultrasound imaging when evaluating dysphagia
-No use of radiation
-portable
-normal food can be used
-completely non-invasive
Disadvantages of using ultrasound imaging in evaluating dysphagia
-not widely available
-study is segment in nature- Poor anatomic detail
-low resolution
What is the gold standard for evaluating dysphagia?
Modified Barium Swallow (MBS)
According to MBS, how is penetration different from aspiration?
-penetration is the entry of contrast/bolus into the larynx (above true VFs) DURING swallowing
-aspiration is the entry of contrast/bolus into the airways (below true VFs) DURING or AFTER swallowing
Advantages of using Modified barium swallow for evaluating
-comprehensive test evaluating all swallowing phases
-good anatomic detail
-relatively noninvasive
-relatively inexpensive
-assesses intervention effects
-reviewed later in a multidisciplinary setting
Disadvantages of using modified barium swallow for evaluation
-pt radiation exposure
-patient movement
-low resolution
-radiologist required for use
-pt transportation required to lab
-difficulty in coordinating schedules
-logistics involved with bedridden pts
-inability to directly assess sensation
-less than ideal rendering of the anatomy (because it relied on radiographic shadows)
The modified barium swallow impairment profile consists of 3 domains… what are they?
- oral impairment domain
- pharyngeal impairment domain
- esophageal impairment domain
What are the components of evaluation of oral impairment
- lip closure
- tongue control during bolus hold
- bolus preparation/mastication
- bolus transport/lingual motion
- oral residue
- initiation of pharyngeal swallow
What are the components of evaluation of pharyngeal impairment?
- soft palate elevation
- laryngeal elevation
- anterior hyoid excursion
- epiglottic movement
- laryngeal vestibular closure
- pharyngeal stripping wave
- pharyngeal contraction
- pharyngoesophageal segment opening
- tongue base retraction
- pharyngeal residue
What are the components of evaluation of esophageal impairment?
- esophageal clearance (in upright position)
Explain modified barium swallow scoring of impairment?
-3 swallow domains evaluated with components in each, totaling 17 MBSImP components
-components scored on a scale of 0-2 to 5 describing progressive levels of impairment
-includes scoring schema that provides valid profile of impairment
Is the MBSImP clinically efficient?
Yes
-It was developed and clinically used over 5yr research period to prove efficiency
-high inter-rater and intra-rater reliability
Advantages of Flexible Endoscopic Evaluation of Swallowing (FEES)
-simple equiptment
-widely available
-portable
-no pt exposure to radiation
-can be used to train pt in speech therapy with biofeedback
-good assessment of neurologic status
-assesses sensation
-increased detail of anatomy with direct visualization of larynx and pharynx
-pt head movement are less obtrusive to view
-relatively non-invasive
-good resolution
-repeatable without dosage risk
-allows for use of real food (no barium)
-accurate visualization of residue (better view than MBS)
-duration of exam can be as long as needed
-Assesses the effects of fatigue
-Pooling of saliva and aspiration of saliva can be easily determined
Disadvantages of Flexible Endoscopic Evaluation of Swallowing (FEES)
-blind spot DURING the swallow (esophagus lifts, blocking view)
-no direct visualization of aspiration and penetration
-cricopharyngeus and esophagus can’t be assessed
-pharyngeal phase activities are inferred
-can’t determine aspiration during swallow
-no oral phase information
-no information on hyoid bone movement
What are 6 additional evaluations of swallowing?
- GI
- Barium swallow of esophageal phase and stomach function
- neurological consult
- dietary consult
- surgery
- radiation treatment
6 questions to consider when selecting an evaluation test?
- what do you know, not know, expect, not expect?
- are you experienced?
- what do you want to find out?
- what do you plan to do with your findings?
- how will you communicate your findings and your plan?
- how will you implement your plan?
What does FEES stand for?
Flexible Endoscopic Evaluation of Swallowing
Bedside evaluation can miss silent aspiration ___% of the time
Up to 40% of the time
Flexible Endoscopic Evaluation of Swallowing has 2 main parts…
- Examination of structure and function of pharynx and larynx
- Determine the swallowing function
The Flexible Endoscopic Evaluation of Swallowing protocol has 2 components… what are they and what is the purpose?
-Vary consistency
-Vary volume
Bolus consistency and volume are varied because these two factors effect swallow timing and displacement
14 Swallowing Events evaluated when using the Flexible Endoscopic Evaluation of Swallowing (FEES)
- oral bolus containment
- bolus preparation and mastication
- lingual mobility
- initiation of pharyngeal swallow
- soft palate elevation and retraction
- tongue base retraction
- hyolaryngeal excursion
- laryngeal closure
- pharyngoesophageal segment opening
- esophageal function
- lower esophageal segment relaxation
- saliva management
- residue patterns
- sensation of tongue, pharynx, and larynx
3 purposes of a Flexible Endoscopic Evaluation of Swallowing (FEES)
- Define abnormalities: aspiration, penetration, detect etiology (sensory or motor deficits), saliva management, sensation, and residue patterns
- Determine what enhances swallowing safety and efficiency to continue oral diet (employment of real food, taste, temperature, texture, and extended period of time to see fatigue)
- Biofeedback tool during therapy
Non-silent aspiration will be evident how?
Presence of a reactive productive or non-productive cough
Flexible Endoscopic Evaluation of Swallowing (FEES) anatomic/physiologic assessment evaluates what structures/functions?
- Velopharyngeal Closure
- Appearance of hypopharynx and larynx at rest
- Base of tongue and pharyngeal muscles
- Laryngeal function
- Sensory testing
6, handling of secretions and swallowing function
How would you assess the velopharyngeal closure during FEES exam?
- Pt says oral sounds “ee” or “ss”
- Pt alternates oral and nasal sounds “duh-nuh”
- Pt demonstrates a dry swallow
How are the appearance of hypopharynx and larynx at rest evaluated during FEES exam?
Observation of
-symmetry-structural abnormality
2. tongue base
3. vellacula
4. epiglottis
5. posterior pharyngeal wall
6. pyriform sinuses
How would you assess the base of tongue and pharyngeal muscles during a FEES exam?
- Base of tongue: say post-vocalic /l/ words several times “earl, ball, call”
-pharyngeal contraction and shortening: produce /i/ with pitch glides, pt screech or squeal
How would you assess the laryngeal function during a FEES exam?
-Assess respiration (at rest, symmetry, adduction, abduction)- pt sniffs, pants, alternate ‘ee’ with light inhalation
-Assess Phonation (symmetry, adduction, abduction)- pt says ‘ee’ ‘he he’ 5 to 7x
-Assess Elevation- pt glides up in pitch until strained, hold pitch
-Assess Airway Protection- pt holds breath lightly, pt holds breath tightly, hold breath to count of 7, cough, clear throat
How would you assess handing of secretions and swallowing function during FEES exam?
-Assess the amount and location of secretions
-Assess frequency of dry swallows over 2 min period
How would you assess sensory testing during FEES exam?
-lightly touch tongue base, pharyngeal wall, epiglottis
-formal sensory testing with air pulse simulator
What is a functional oral intake score (FOIS)
Rating from 1 to 7 indicating the level of restriction for oral intake
5 Behavioral swallowing rehabilitation techniques for oral phase
- range of motion exercises (jaw and tongue)
- resistance and strengthening exercises (tongue)
- Masako exercise
- IOP
- Oral hygiene protocol
5 Behavioral swallowing rehabilitation techniques for pharyngeal phase
- pharyngeal squeeze exercises
- mendelsohn maneuver
- supraglottic and super-supraglottic maneuvers
- Effortful swallow maneuver
- Pharyngeal glides
2 Behavioral swallowing rehabilitation techniques for esophageal phase
- shaker exercise
- CTAR
6 predictors of aspiration pneumonia
- dependent for feeding
- dependent for oral care
- number of decayed teeth
- more then one medical dx
- number of medications
- smoking
Is dysphagia a risk factor of aspiration pneumonia?
It is an important risk factor, but is generally not sufficient to cause pneumonia unless other predictors/risk factors are present
Using the videofluoroscopic MBS instrumentation, what can we see in AP compared to lateral view?
AP view: symmetry of structure, whether pharynx is constricting, and accurate location of residue (unilateral or bilateral residue), gives information about UES function with followthrough
Lateral view: will tell presense of residue, but not the side residue is on, so not able to indicate paralysis
Define a esophagram
Series of x-ray pictures of esophagus taken after pt drinks barium liquid performed by radiologist
An esophagram can identify is there are structural problems where?
UES or LES or any interruption of esophageal peristaltic wave
A high resolution pharyngeal manometry pressure tube is delivered through what structures?
Goes through nose, through pharynx, UES, esophagus, LES, then stomach
When would you refer a pt for manometry?
If MBS indicates oral pharyngeal swallow is within normal limits, but pt has symptoms of food being stuck, causing diet changes
Who preforms a manometry evaluation?
GI
Who preforms a Esophagram?
Radiologist
Who preforms the MBS or FEES?
SLP
If Pt is diagnoses with laryngeal and pharyngeal paralysis, what is the most important position to assess using MBS?
AP view
WHY? it will let us see if the pharynx is contracting or not and if the residue is unilateral or bilateral
What is the gold standard that should be employed when using MBS study?
-AP view of swallowing mechanism
-Lateral view of swallowing mechanism
-Esophageal follow-through
ALL with varying consistencies and volumes of bolus
The MBS and FEES assessments both allow for ability to examine…
-nasopharynx
-oropharynx
-laryngeal elevation presence or absence
-pharyngeal constriction, residue in pharynx
-detect presence of aspiration
The MBS can evaluate 5 components that FEES cannot… what are they?
- Evaluation of upper esophageal sphincter function
- Evaluation function DURING swallow
- Examine hyoid bone functioning
- Evaluate oral containment
- Evaluate esophagus
The FEES can evaluate 5 components of swallowing that the MBS cannot… what are they?
- Evaluate the influence of real food on swallowing (information on food temperature, texture, and taste)
- Examine sensation of materials
- Saliva management information
- No exposure to radiation and can be done in pt’s home
- Longer duration of tool use
