Unit 4 Evaluation of Swallowing Disorders / Unit 5 Management Flashcards
Describe what Screening Procedures Provides and what it doesn’t:
Indirect evidence that the pt has a swallowing disorder, but does not provide info on the physiology of the disorder.
Once completed. clinician should indicate whether the pt is a normal swallower or whether the risk of dysphagia is high and further assessment is needed.
3 Things about Swallow Screenings
- Tend to ID signs and symptoms of dyspahgia (coughing, pneumonia Hx)
- Indicates whether the pt might need an in depth physiological assessment
- Quick, low cost, low risk (chart reviews or observation of pt eating)
Bedside or Clinical Evaluation
*Most frequent type of examination for swallowing
A. First step of Preparatory Exam
Obtain a doctor’s order before you begin
2nd Step of Preparatory Exam - Review Chart
In Chart look for 8 things:
- Hx of recurrent pneumonia
- Poor cognition / self awareness
- Reports of prior swallowing problems
- Respiratory status
- Tracheostomy, mechanical ventilation, etc.
- Current nutritional status and feeding method (allergies, diabetes?)
- General medical history – what brought pt to the hospital
* **Look at Dr’s and nurses notes for any information about swallowing
3rd step of Preparatory Exam - Discuss
Discuss the nature of the problem with the nursing staff.
4th step of Preparatory Exam
Observe the Patient’s 4 things:
- Alertness, ability to follow directions & answer questions
- Posture
* ***Neutral posture: upright, chin slightly tucked - Presence or absence of trach. tube and its status (cuffed, inflated, deflated, etc)
- Patient’s handling of secretions
5th Step: Interview the patient
- Start off by introducing yourself and ask how they are doing.
- Ask them if they notice any problem with their swallowing, if they have been coughing, have they been choking on their saliva, etc. – all of these can tell you a lot by their response.
- Check for their self-awareness of their problems through their conversation.
- Watch for: cognitive deficits, oral motor function, facial symmetry, memory abilities, etc.
B. Examine the Oral Cavity: 6 things
Oral Motor Exam “Plus”
- To see movement of tongue, jaw, lips and velum
- Keep you wording simple
- Get comfortable, maybe sit on the edge of the bed
- Make sure the pt is sitting up
- Look at strength, speed and accuracy of muscular movements of oral mechanism (open/close) ( range of motion)
- Look for abnormal oral reflexes, such as: bite reflex (clamping down), tongue thrust, gag reflex
* **Make sure to put railings back up
Steps of Oral Motor Exam
- Check jaw strength
- Check lip movements (strength, ROM & coordination)
- Check Tongue Movements
- Assess chewing using gauze
- Check velum - /a/, symmetry, velar elevation, arches come together laterally
/u/ velopharyngeal closure - Extrinsic Muscles of Larynx / Laryngeal Funciton
a. vocal quality (hoarse, gurgly)
b. saliva management?
c. see how well they can cough or clear throat
d. have them swallow & feel for laryngeal excursion
The Info collected during the oral exam should alert you to:
- Any facial paralysis
- Patient’s ability to maintain lip closure
- Limitations in tongue function that may affect ability to hold bolus or to propel food back
- Indicate area of oral cavity where food can be positioned for the best tongue control
- Help in selection of food consistencies you think the pt will be able to handle
Should trial swallows at bedside be attempted?
Consider risk/benefit ratio
a. NPO
b. barium swallow
Should trial swallows at bedside be attempted?
Negative Factors
- Pt is acutely ill
- Significant pulmonary complications
- Weak voluntary cough
- Over 80 years old
- Cannot follow simple directions
- Suspected pharyngeal swallow disorder
Should trial swallows at bedside be attempted?
Positive Factors
- Can follow directions
- Can cough on command
- Good pulmonary function
If a pt is already eating orally, observe a meal, noting:
- The pt’s reaction to food
- Oral movements and chewing (food manipulation)
- Any coughing or throat clearing or changes in breathing
- Changes in secretion levels
- Wet vocal quality
- Duration of meal, fatigue issues, total intake
- Coordination of breathing and swallowing
4 Levels of Bolus
- Thin liquid (water)
- Thick liquid (nectar)
- Puree - applesauce, pudding
- Chew - crackers, banana
Once you decide to do trial feeding / swallows:
- Decide on best posture for food presentation
2. Decide on best textures / foods to administer
4 Postures:
- Tilt head down then throw head back (dump & swallow)
- Tilt head down (chin tuck)
- Turn head toward the affected side.
- Tilting the head toward the strong side.
Postures:
1. Dump and Swallow
Tilt head down then throw head back
- **Only do in 1 scenerio:
1. Severe oral phase issue
2. Normal Pharyngeal Phase (for airway closure)
Postures:
2. Chin Tuck
Tilt head down
***Most common Helps with: 1. Premature entry - gravity 2. Poor airway closure 3. Increases tongue retraction
Postures:
3. Turn head towards affected side
- Turn toward weak side to pinch off food sending food to strong side
Postures:
4. Tilting head toward strong side
- Keeps bolus on strong side (gravity)
* Most extreme is patient on their side
Food Textures/Consitencies
On a continuum
Solids:
1. Regular, Normal Texture - no restrictions
2. Mechanical Soft- ground , but normal
3. Pureed- apple sauce, ***Start with first
Liquids:
1. Thickened - nectar, honey, extra thick
2. Naturally thick - nectars, milkshake, smoothie, Ensure
What is on Assessment Tray
- Puree
- Thin liquid
- Pack of “Thick-it” or thickened juice
- Mechanical soft - banana
* Possibly a regular - 1/4 size Lorna Doone cookie
Selection of food depends on
- Info collected from Hx
- Info on oral control
- Info on Pharyngeal-laryngeal
Steps to do for feeding eval:
- Is voice wet or gurgly - get voice clear
- Listen for cough
- Orally suction if need be
- Get into position to use hand
- Start with puree
- Start tiny (1/3 tsp)
- Put in mouth
- Start counting
- Note timing of swallow / tongue pumping
- Listen to voice /a/
- Do about 2-3 swallows, then move to bigger bolus size
12.Check for residue - If good - PASS on puree, move to 1/2 of mechanical soft
- Same procedure as above
- If 20-30 second delay - DO NOT PASS
- Check oral cavity
- Have them cough
- Have them dry swallow
- Push on tongue with spoon
- Move to Nectar thick - small sip
- Thin liquids
**If after 2 swallows of struggling - STOP
**Define highest level of solids and liquids
Can try postures - eliminates problems about 70% of time
Best Consistencies for Different Problems:
- Poor Oral Control - thickened liquids 1st, then move toward thin
- Delayed Pharyngeal Swallow - best with thicker consistency: puree
- Reduced Tongue Base or Pharyngeal Wall Contraction; liquids
- Reduced Laryngeal Elevation Or Reduced UES:
liquids - Reduced Airway Closure: thicker
- Combo of disorders - more difficult (puree)
Proper Hand Position for Swallow Eval
- Place hand under chin with fingers spread
- Index finger - immediately behind mandible, anteriorly
- Third finger - top of thyroid cartilage
- Fourth finger - bottom of thyroid cartilage
* **Submandibular, hyoid and laryngeal movement can be felt
Compose Report of Swallow Eval
Develop your recommendations and management plan
Include:
1. Solids
2. Liquids
Follow up after Swallow Eval
- Discuss plans with pt and family in terms they can understand
- Track down the pt’s nurses and share the results with them verbally
- Post precaution in pt’s room
- For doctor, place report in care and follow up with phone call when requested, or if you are making recommendations for new dietary orders, new therapy orders, MBSS or NPO
- Make any special requests to dietary / kitchen staff
Modified Barium Swallow Study: MBSS
Videofluroscopy Procedure
Purpose:
Examines details of oral, pharyngeal and cervical esophogeal physiology:
- Define abnormalities in anatomy and physiology that are causing pt problems
- Identify and evaluate Tx strategies for safer eating
- Identify or rule out aspiration, amount and cause
Who should be referred for MBSS?
- Anyone suspected of aspiration
2. If swallow disorder is expected to be of pharyngeal origin or have pharyngeal component
MBSS:
Placement of Food in Pt Mouth
- Explain what you are going to do, and show each food item before you present it
- Food - use spoon
Liquids - cup, straw, spoon, bottle for infants
MBSS:
Types / Amounts of Materials to be used
At least 3 consistencies:
- Thin liquid barium (as close to water as possible)
- Barium paste (can mix with applesauce or chocolate pudding
- Food needing mastication (cookie or cracker with barium paste)
At least 2 swallows of each consistency in the following order:
- 1 - 3 - 5 - 10 ml
- cup drink with thin liquid
- honey-thick or nectar thick- liquid, as needed
- 1/3 tsp of pudding consistency
- ¼ of cookie or cracker
- If OK on all above, try different food types and volumes
* have the pt self-feed, if possible
* * small amts are very important for pt safety
* ** liquids before solids = aspirated material will not block the airway, and liquids are easier to clear if they do enter the airway
MBSS:
Try Various Treatment Procedures
- Positioning
- Compensatory strategies
- Procedures to increase sensory input
- Swallow maneuvers
MBSS:
Positioning the Patient:
- Can be difficult and time consuming, but it is important for:
a) good test results
b) patient safety - The pt should be sitting upright, if possible
- Lateral View first, then A-P View if necessary
- Laying down position - reclined= gravity keeps food in pharynx, away from airway
MBSS:
Measurements and Observations = Lateral View
- Oral Transit Time - initiation of posterior bolus movement
- Pharyngeal Transit Time - pharyngeal swallow is triggered - start to count until bolus tail passes through the cricopharyngeal juncture (time in pharynx) ***Past 1 second is a delay
- Pharyngeal Delay Time - bolus crosses point where mandible crosses tongue base until the pharyngeal swallow is triggered as indicated by:
a. Hyo-laryngeal elevation
b. Posterior tongue base movement to meet posterior pharyngeal wall - Analyze lingual movement
- Gross estimate of residue in valleculae
- Estimate the amount of aspiration, per bolus and the timing of aspiration
- Note anatomic/physiologic reason for aspiration
MMBSS:
Measurements and Observations = A/P View
- Movement of bolus through the vallecula and pyraform sinuses (look for moment and symmetry, although 20% of normal swallowers swallow unilaterally)
- Examine residue in pharynx, vallecula, pyraforms, etc (lateral?)
- Have pt hold head back and say ah to view vocal folds (residue?)
Trial Therapies for Swallow: 3
- Different positions and compensatory strategies
- Sensory enhancement (sour, cold)
- Swallow Maneuvers
Postural Changes:
Redirect food or liquid:
- Dump and swallow
- Head down
- Head rotated to weak side
- Head tilt to strong side / lying on one side
Techniques for Increased Oral Sensory Awareness
- *Used with swallow apraxia, delayed onset or delayed trigger
1. Increase downward pressure with spoon
2. Sour bolus
3. Cold bolus
4. Bolus needing chewing
5. Increase size of bolus
6. Thermal -tactile stimulation **Only used with delayed or absent reflex
Swallowing Maneuvers and what they accomplish:
- Supraglottic Swallow - designed to close airway at the level of the true vocal folds before and during swallow
- Super-Supraglottic - closes airway at and above true VF, before and during swallow
- Effortful Swallow - increases tongue base posterior motion and bolus clearance from valleculae
- Mendelson Maneuver - increase extent and duration of laryngeal elevation
Supraglottic Swallow Steps:
- *Used for penetration before swallow, poor airway closure
1. Breathe in
2. Hold breath at VF level
3. Swallow hard
4. Cough in case of penetration/aspiration
5. Reswallow - Must cough right away so it is not breathed in
Super-supraglottic Swallow Steps:
Use effortful swallow with supraglottic swallow
Effortful Swallow Steps:
- *Increase tongue base retraction, clear residue from valleculae and pharynx
1. Bear down and squeeze hard while swallowing
Mendelsohn Maneuver Steps:
- **Increase amount and duration of hyolaryngeal elevation or excursion and cricopharyngeal opening
1. Feel, then hold larynx up and open
2. Hold until peek of swallow, then let go
If therapy strategies are not feasible or effective:
Change food consistencies
Eliminate food consitences
ID those that are safe
Protocols and Reports
- Review various protocols and precautionary forms
1. Oral
2. Pharyngeal
3. Recommendations
Oral Reports:
- Measure of oral transit time
- Describe neuromuscular/ anatomic problems in oral phase
- Note trigger delay
- Differences based on size/texture of bolus
- Aspiration? Before swallow?
Pharyngeal Reports:
- Measure pharyngeal transit time
- Describe neuromuscular/ anatomic problems in pharyngeal phase
- Amount of aspiration and when it occured
- Amount of residue in valleculae and/or pyraform sinuses
- Differences based on size/texture of bolus
Recommendations in Report:
- Management of nutritional intake (ie. non-oral feeding vs full oral feeding)
- Texture changes and management strategies during meals
- Precautions
- Results of intervention and therapy techniques
- Procedures for swallowing Tx
- Re-evaluation or consultations
* If the report does not contain the anatomic or physiologic reason for aspiration or residue (not just the symptoms) and the interventions attempted to reduce / eliminate symptoms and their effects, the study is incomplete!!
Unit 5: Management of Swallowing Disorders
- The continuous goal of any treatment program is the re-establishment of oral feeding while constantly maintaining adequate hydration, nutrition and safe swallowing.*
Levels of Oral vs. Non-oral Feeding:
- Swallow safety and efficiency is adequate for total oral feeding - not necessarily normal diet
- Partial oral feeding with supplementary tube feedings, as needed
- Primary tube feeder with “recreational” oral eating allowed
- NPO = no oral feeding allowed
Non-Oral Feed Procedures - 6
- NGT = nasogastric feeding tube
- G-tube = gastrostomy tube
- PEG = Percutaneous Endoscopic Gastrostomy
- J-tube = Jejunostomy tube
- Pharyngostomy
- Esophagostomy
NGT description
Nasogastric Feeding tube
Tube running through nose, then pharynx to esophogus
*Very temporary - not socially acceptable, irritating
G-tube description
Gastronomy tube
Opening placed in abdomen with tube going into stomach
Full operation - long-term or permanent
Only blended foods or liquides
PEG description
Percutaneous Endoscopic Gastrostomy
From abdomen to stomach
Done endoscopically, in office under less anethesia
Fairly long term
J-tube description
Jejunostomy tube
Not done so much for swallowing disorders
Placed through the stomach endoscopically into the small intestine
Bypasses the stomach, giving stomach time to heal (ulcers, cancer)
Pharyngostomy description
Put food through tube directly into pharynx
Esophagostomy
Goes directly into esophagus
Compensatory Strategies objective vs Theraputic Strategies objective
**Know
- Control the flow of food and eliminate pt symptoms (residue or aspiration), but do not necessarily change the physiology of the swallow
- Theraputic strategies are designed to change the swallow physiology by promoting better musculature or swallow using direct or indirect methods or excerciese
Compensatory Strategies
- Modified volume and/or speed of food presentation and/or manner in which food is presented (strong side, alternate solids and liquids, syringe, sippy cups, sour, cold, thermal stim)
- Food
