Swallowing Assessment Flashcards
Clinical Exam should include:
- Medical and psychosocial history
- Physical evaluation (inc mental status screening & exam head/neck muscles
- Test swallows of liquid, semi-solid and solids (if appropriate)
* If clinical exam does not reveal cause of symptoms, INSTRUMENTAL EXAM is required
Instrumental Exam:
Most common technique for visualizing all stages of swallowing:
MBS or VFSS
Instrumental Exam:
A standard barium swallow only assesses:
Esophagus
Instrumental Exam:
Endoscopy allows for direct visualization of:
Pharynx, larynx and esophagus through use of a scope
Instrumental Exam:
Manometry measures ____ and is done to evaluate the ________
Pressure during the swallow
Esophagus (rather than mouth or pharynx)
Goals of Care:
- Ensure patient can safely consume enough food/liquid to stay nourished
- Determine which tx options are most viable
4 Main areas of Tx
Behavioural (compensations, strategies, muscle strengthening)
Dietary (modify textures, tastes, volume)
Medical (change meds affecting mental status/swallow, placement of NG tube)
Surgical (placement of G tube or PEG tube, mobilization of a weak VF)
Three main components of the Bedside clinical exam:
Medical history
The physical exam (vs. oral mech)
Observations of swallowing competence (test swallows, meal and environmental ax)
Purposes of the Bedside exam:
- Screen for presence of swallowing impairment
- Determine nature (locus) of the problem
- Determine relative risks of selected foods and liquids
- Determine candidacy for instrumental eval
- Monitor progress, determine possibility of upgrading/downgrading
- Assess structure/function (motor/sensory)
Caveat of Bedside Exam:
Non invasive and easy to perform but poorly predicts presence of silent aspiration (aspiration and laryngeal penetration indistinguishable)
May over dx aspiration, unwarranted diet restrictions
Why some pts w/ dysphagia develop pneumonia and others do not?
Aspiration pneumonia is an “opportunistic” disease, developing in PTs who are already seriously ill.
(neurological/structural factors and immune system factors)
Clinical Exam Flowchart
- medical history
- rapport w/ pt
- interview pt/family/staff
- observe pt bevr
- screen cognitive communication
- perform OME
- perform swallowing ax
- make recommendations
- generate written report
When reviewing medical chart, look at:
- Dysphagia symptoms
- Respiratory conditions, disease and current status
- Weight loss, current diet textures, restrictions
- Other diseases
- Dr notes
- Medications
- Medical staff interview
- Surgical procedures (anesthesia can compromise airway protection)
Bedside Exam:
Clinical observation/patient interview to determine:
LOC Orientation/mental status Insight, motivation, family support Neurological status (motor speech, language, cognition, spatial perceptual fx) General health Hydration Assistive aids PT report of impairment
Environmental Ax:
When cognitive impairment, may need to ID envtal variables that influence problem behaviours at mealtime:
Physical - noise, lighting, tray set up, food presentation, traffic flow, # people
Psychosocial - seating arrangement, eating companions, attitudes of CGs, waiting periods, length of mealtimes
Bedside/Clinical
Other observations:
Speech sample - artic, intelligibility Voice - normal pitch, loudness, quality Resonance - normal/hyper nasal? Muscles of facial expression Lips - seal, strength Ability to manage secretions Oral mucosa - hydration, oral health Dentition Tongue Palate (gag reflex provides minimal info about swallowing) Neck exam Sensation Pathological reflexes Volitional cough (not predictive of protectional cough) Sustained phonation Volitional dry swallows (laryngeal elevation) Body position
Contra-indicators for trial swallows
- poor respiratory status
- unstable medical status
- poor cough reflex
- low level of arousal/responsiveness
- difficulty, inability to swallow secretions
- absent/delayed swallow
- bedridden
- very poor oral hygiene
Bedside exam if NPO:
Use innoculous stimuli to assess readiness for PO intake (ice water, maybe ice chip)
Progress to more challenging textures very slowly and cautiously
Bedside exam if PO:
3 ounce water test
- provide variety of textures to determine safest texture/volume
- trial adaptive aids to facilitate self-feeding
- trial compensatory strategies, postures and maneuvers
- manipulate environment as necessary
During test swallows/meal observation look for:
Recognition of food items/ability to focus on task
Fatigue over course of meal
Ability to judge appropriate bolus size and feeding rate
Use utensils
Lip seal
Throughout mastication
Timely transit of bolus from oral cavity
No coughing before swallow
Awareness and appropriate management oral residue
No coughing or through clearing or resp distress
No change in voice quality
Laryngeal elevation to palpation
Subjective complaints
Recommendations following assessment:
- need for VFSS
- NPO (pretty severe)
- appropriate food/fluid texture
- volume/frequency meals
- method of med administation
- positioning
- feeding techniques
- comp strategies
- environmental needs
- oral hygiene needs
- need for re-ax
- referrals
VFSS allows for _______ of anatomical structures and ________, _______, ________.
Evaluation of the efficacy of:
Direct visualization
How they move, timing of swallow events, observation of how efficiently the bolus moves
- Adjustments of bolus volume, consistency & rate of delivery (start w/ 5-10 ml bolus)
- Adjustments in positioning
- Implementation of maneuvers
Contra-indications for VFSS
- pt no longer has dysphagia complaints
- pt too medically compromised/uncooperative
- clinician’s judgement is the exam would not alter clinical course/management plan
During VFSS look for:
- Effectiveness of bolus preparation and transit
- Triggering of pharyngeal swallow in relation to bolus position
- movement of pharyngeal structures
- transit times
- efficiency of bolus movement
- evidence and timing of penetration/aspiration and patient reaction
Penetration Aspiration Scale is an 8 point scale to discretely quantify
- occurrence of airway penetration and aspiration
- depth of airway invasion and residue
- responsiveness - cough/clear airway
*sensitive to differences in airway protection across the age span in healthy adults (score of 2 “high penetration” w/ no clearance of residue is normal in older adults)
Dysphagia Severity Rating Scale
0-normal swallowing mechanism 1-minimal dysphagia 2-mild 3 -mild/mod 4-moderate 5-moderately severe (pt aspirates 5-10% w/ potential for aspiration on all consistencies, cough reflex absent, alternate mode of feeding needed)
Pulse Oximetry
Refers to:
Link to aspiration:
-monitoring of peripheral blood oxygenation through fingertip device (detects hemoglobin in blood - worrisome if
Types of instrumental exams:
MBS/VFSS
Standard barium swallow (esophagus only)
Endoscopy
Manometry (pressure during swallow in esophagus)
