Bedside Swallow Eval Flashcards

Question

Oral Struct: Dentition

Answer 1

¥ Dentition

Answer 2

¥ Intra-‐oral sensation of the anterior tongue/lips/cheeks/ gums/ﬂoor of mouth (CN V) and posterior tongue (CN IX) is assessed by lightly touching these areas with a cotton swab. ¥ If delayed trigger noted in the later procedure: ¥ Search for optimal oral-‐sensatory stimulus type ¥ Any place in the oral cavity is most sensitive or best to stimulate?

Answer 3

quality/quantity of secretions ¥ Reduced intra-‐oral sensation or alertness may result in pooling or drooling ¥ Dry mouth may be due to meds, x-‐ray tx, tube fed, pts on supplemental O2 or ventilation

Answer 4

¥ Palate at rest ¥ Palatal elevation with phonation (motor) ¥ Resonance during nasal/non-‐nasal sentences (motor) ¥ Palatal reﬂex: (elevation of the soW palate without pharyngeal wall contraction) is elicit by stroking the soW palate (sensatory) ¥ Gag reﬂex (sensory: CN IX) - Look for asymmetrical sign

Answer 5

``` ¥ Strength of voluntary cough/throat clearing ¥ Listen for stridor ¥ Voice quality (vf closure) - Vowel prolongation ≫ Gurgly voice, hoarse voice ≫ Shortness of breath (respiration) ``` ¥ Laryngeal elevation

Answer 6

¥ Dry swallow - Check ability to initiate; any delay (+2-‐3 s) - Palpate for laryngeal elevation

Answer 7

¥ Position the person sitting upright so that the pharynx is vertical ¥ Position your hand on the person's neck with a light touch ¥ Index ﬁnger under the chin ¥ Middle ﬁnger on the hyoid bone ¥ Ring ﬁnger on the top of the thyroid cartilage ¥ Smallest ﬁnger on the bottom of the thyroid cartilage ¥ Ask pt to perform a dry swallow

Answer 8

1. Use clean gloves 2. Assess mouth problems 3. Brush teeth with toothbrush 4. Brush for at least 2 minutes 5. Brush tongue 6. Rinse mouth with water 7. Use mouthwash 8. Floss

Answer 9

Oral hygiene/Care Program - Tooth brushing x 3 daily - Oral Swab Care x 2 daily with an anti-‐ plaque or antiseptic solution i. e., (antiseptic) Peridex, Oral-‐B Anti-‐ Plaque Wash

Answer 10

¥ Denture - Brush denture with liquid soap or denture cream - Soak denture in chlorhexidine gluconate for 3 minutes

Answer 11

¥ Using when giving foods/liquids to pts during - Assessment and Therapy ``` ¥ Two common devices - Pulse oximetry ≫ SpO2 < 90%, stop feeding - Cervical auscultation ≫ Two burst during apnea; one single burst aaer swallow during exhalation *Both unreliable but may be useful ```

Answer 12

Oxygen Saturation Test ¥ Pulse Oximetry: commonly used in the clinic ¥ A drop in SpO2 was associated with events of aspiration ¥ If below 90%, should stop feeding ¥ However, the ﬁndings from some research disagree this association. SpO2 ＝ Peripheral capillary oxygen saturation Normal: 96% or higher Mild respiratory distress: 90% or above

Answer 13

¥ Cervical auscultation is relatively new low-‐ tech technique to facilitate accurate bedside evaluation of the swallow ¥ Monitors the sounds of the swallow - Stethoscope - Microphone - Accelerometer

Answer 14

¥ Place the stethoscope on the neck at the level of the vocal folds ¥ Listens/records to the sounds associated with swallowing - Establish baseline - Listen to breathing and dry swallow - During swallow - Within period of apnea, two low pitch bursts of sound are markers of the presence of a swallow - Aaer swallow: - A high pitch when pt exhales aaer swallow - Sound of Wetness? ¥ Not foolproof but may be a useful addition to bedside eval

Answer 15

``` ¥ Changes in respiratory rate ¥ A muﬄing/melding of the distinct clumps of sound ¥ No apnea (No two bursts) ¥ Prolonged apnea (delayed two bursts) ¥ Prolonged swallow sounds ¥ No clearing exhalation ¥ Delayed clearing exhalation ¥ Turbulence in the air-‐exchange (sounds of wetness) −Stridor bubbling squeaks −Wheeze gurgling crackling ```

Answer 16

``` ¥ Inhalation ¥ Apnea − two clumps-‐clicks ¥ Exhalation −single, short burst ```

Answer 17

``` ¥ Two common devices - Pulse oximetry ≫ SpO2 < 90%, stop feeding - Cervical auscultation ≫ Two burst during apnea; one single burst after swallow during exhalation ``` *Both unreliable but may be useful

Answer 18

YES! ¥ Pneumonia is caused by pathogen colonized in the lungs… - inhaled through nose or aspirated through mouth ¥ Hygiene anytime, everywhere! -Medical devices, hands, & oral cavity

Answer 19

¥ The precise mechanisms of how one develops an aspiration pneumonia are unknown. ¥ Aspiration pneumonia does NOT develop in ALL patients who aspirate - The upper and lower airway defense systems are most active when the patient's immune system is strong

Answer 20

¥ Groups predisposed to aspiration PNA: - Aging (elderly) - Congestive heart failure - COPD - Use of multiple medications (sedatives) - Feeding dependence - Smoking - Hx of aspiration pneumonia - Having a feeding tube in place - Bedbound state (may b/c inappropriate posture while eating) - Tube feeding (Poor oral hygiene)

Answer 21

Signs of Aspiration PNA

Answer 22

¥ Diﬀerential diagnosis - Dysphagia-‐related aspiration pneumonia ≫ Patient has pneumonia ≫ Aspiration caused by gravity-‐dependent substances via oral ≫ Patient has dysphagia - Non-‐dysphagia-‐related aspiration pneumonia ≫ Patient has pneumonia ≫ Patient does not have oropharyngeal dysphagia ≫ Aspiration is conceivable due to GE reﬂux, emesis/ vomiting, etc… Who should we treat??

Answer 23

¥ Pneumonia (PNA) does not entail aspiration or dysphagia. ¥ Pneumonia: Can be inhaled or aspirated sources - Lung infection by pathogen colonized in the lungs - Lung inﬂammation by irritant/traumatizing lungs ¥ Aspiration = entry of food/liquid into the airway below the level of the true vfs - Not airborne or inhaled pathogen - via swallow

Answer 24

- Oral mechanism exam | - Test swallows (Trials of Swallow)

Answer 25

1. First must decide whether to proceed with food presentation. ¥ If pt already PO , ¥ Feed:  Determine appropriate diet (dysphagia management if needed) ¥ Not feed:  Signiﬁcant deﬁcits on oral-‐facial exam and poor mental status/alertness -‐> High risk of aspiration (next slide)  Refer to MBSS (?)

Answer 26

Risk for Aspiration ¥ Reduced alertness (orientation) ¥ Reduced responsiveness to stimulation ¥ Absent swallow ¥ Absent protective cough ¥ Signiﬁcant reduced in range and strength of oral motor and laryngeal movements ¥ Diﬃculty handling secretions as evidenced by excessive coughing and choking, wet gurgly voice ¥ Medical instability (e.g., respiratory distress)

Answer 27

1. First must decide whether to proceed with food presentation ¥ If pt already NPO Not feed: ¥ NPO due to failing recent MBSS test ¥ Severe oral-‐facial deﬁcits or mental status/alertness issues, severe respiratory disorders (e.g., pna), high risk of aspiration (look for most recent eval ) Feed: ¥ NPO not d/t dysphagia-‐related issues NPO in place a few months ago, and pt appears improved overall

Answer 28

¥ If you decide not to feed (proceed to Test Swallows), you will recommend: NPO and follow up ¥ If someone is acutely ill (e.g., 1-‐2 days post CVA) and recommended NPO and no MBSS, you will probably want to follow daily. ¥ …decide if an instrumental exam is required for further examination

Answer 29

tolerate the least restrictive diet to maintain optimal nutrition and hydration, and quality of life.

Answer 30

food textures/consistencies, position changes, placement of food in mouth  Begin Trials of Swallow (MBSS follows similar procedures) ¥ (Do not proceed: pts with high risk of aspiration) ¥ Have patient sit upright, facing forward

Answer 31

before giving trials (liquids/ foods) to reduce chance of getting pneumonia if pt aspirated. - ‐ before trials of swallow - ‐ before treatment (feeding trials) - ‐ aaer oral intake (be sure no oral residue)

Answer 32

substances with diﬀerent textures and consistencies ¥ Volumes range - 5 ~ 10 mL: starting with a smaller bolus (~ 20 mL) ¥ Methods of delivery - Spoon - Cup - Straw (more challenging) - requires longer and more coordinated airway closure mechanics 1 teaspoon = 5 mL

Answer 33

- Usually start with this ¥ (if not pass) Thickened liquids - Nectar > Honey-‐thick > Pudding-‐thick¥ Meals/Solid texture ¥ Puree ¥ (if pass) Mechanically altered solid food - Mechanical-‐ground (cohesive bolus), chopped ¥ (if pass) Solid - Usually refers to normal food items Always begins with thin water  baseline

Answer 34

``` Trials of Swallow (ice chips)?? ¥ Pros: using ice chips - Observe ability to handle water - May elicit chewing and swallow reﬂex * Good for swallowing therapy. ¥ Most DO NOT agree to use ice chips for test swallowing. - Ice chip may provide additional sensory input that facilitates swallow Avoid ice chips for swallow eval. ```

Answer 35

¥ Observation + Palpation of larynx ¥ Ask pt to hold the liquids until your verbal command ¥ Let pts drink/swallow with their own pace ¥ Aaer each swallow have the pt phonate an 'ah’ ¥ Listen carefully. Look for any gurgly voice, throat clearing, coughing is/are present? ¥ If above signs present, second dry swallow -‐> then, phonate again ¥ Try diﬀerent postures followed by phonation (‘ah’) ¥ e.g., Head rotation, head tilt, chin tuck, etc.

Answer 36

¥ If going well with 2~3 sips  proceed to serial swallows. ¥ A straw (not with thickened consistencies) ¥ May require more coordination skills ¥ May be more diﬃcult to tolerate if there is a delay

Answer 37

¥ Continue the above procedures ¥ Check for mastication, pocketing, oral residue ¥ Because puree/solids may block the airway, if any signiﬁcant coughing/choking/throat clearing noted discontinue trial feed

Answer 38

¥ Coughing/throat clearing during or immediately aaer the swallow and/or wet vocal quality probably represent penetration/aspiration but… ¥ their absence does not rule it out dysphagia  could be silent aspiration or absent cough reﬂex ¥ Still may miss the 50 -‐ 60 % of pts who are silent aspirators - Respiratory rates - Observation or using Pulse oximetry - Listen to sound of swallowing - Using cervical auscultation * More see Tests of Silent Aspiration Lecture Handout

Answer 39

the swallow - the examiner should be cognizant of the respiratory rate. ¥ Comparisons should be made between Pre-‐trials and Post-‐trials. ¥ Marked change in the respiratory rate or an increase in respiratory congestion may be a sign of airway compromise.

Answer 40

¥ (During eval.) Thinking ahead to manage - Optimal “side” for bolus placement depending upon motor/sensory function - Varying textures to increase swallowing safety, e.g., ≫ Poor oral control: thicker liquids ≫ Reduced tongue coordination: thinner liquids ≫ Delayed trigger: thicker liquids ≫ Poor tongue base movement: thicker liquids ≫ Reduced vf closure/weak cough/grunt: thicker liquids ≫ Reduced laryngeal/airway closure: thick liquid, pudding

Answer 41

``` ¥ Oral residue/pocketing of food ¥ Edentulous ¥ Drooling Reduced pharyngeal or laryngeal function on bedside assessment ¥ Coughing/choking while eating/drinking ¥ Frequent throat clearing ¥ Multiple swallow pattern ¥ Wet vocal quality ¥ Increased time to complete meal ¥ Resistance to eating/ drinking ¥ SOB ¥ Odynophagia ¥ Signiﬁcant weight loss ¥ Repeated pneumonia ```

Answer 42

¥ If the person does not cough, s/he may be silently aspirating ¥ Although gross estimates of transit times can be made, no real information on the pharyngeal stage of the swallow is collected ¥ Since the structures cannot be seen, the most appropriate therapy cannot be determined ¥ If silent aspiration is suspected, further exam (instrumental exam) is recommended. ¥ Modiﬁed barium swallow study (MBSS) ¥ Flexible Endoscopic Evaluation of Swallowing (FEES)

Answer 43

¥ Oral hygiene ¥ Begin with a tsp of water (via spoon or small sip from a cup) and proceed to next level of consistency if no s/s aspiration ¥ During eval, note: - lip closure, the presence of drooling - any delay of initiation of the swallow - any overt coughing or choking before/during/aaer the swallow and the strength of the cough, any throat clearing aaer the swallow - the extent of laryngeal elevation during the swallow - the presence of a wet-‐gurgly voice quality aaer the swallow - oral residue aaer the swallow (check the oral cavity)

Bedside Swallow Eval Flashcards

(67 cards)