Chapter 3 Flashcards
(112 cards)
1
Q
A screening is a
A
quick, non-invasive, low risk and low cost
2
Q
How long does a dysphagia screening last?
A
10-30 minutes
3
Q
What is a false positive?
A
ID’d as aspirating but aren’t
4
Q
What is a false negative?
A
ID’d as not aspirating but are
5
Q
Is a screening always 100% accurate?
A
no
further diagnostic assessment needed
6
Q
Symtomatology of Dysphagia
A
Valleculae hesitation/pooling
Pyriform pooling
UES dysfunction
Aspiration
7
Q
How does a patient describe valleculae hesitation/pooling
A
Patient says they have something “stuck” high in throat
8
Q
How does a patient describe pyriform pooling
A
patient says they have something “stuck” in middle of throat
9
Q
Hoe does a patient describe UES dysfunction
A
- pain in upper chest or inches below larynx
- patient says they have something “stuck” lower in throat or high in chest
10
Q
Describe aspiraiton
A
coughing, choking, 50%+ aspirate without cough (silent)
11
Q
The bedside clinical swallowing exam provides
A
- medical diagnostic, history, patient’s perception
- patient’s medical status: nutritional (tube?), respiratory (trach tube? ventilator?)
- Patient’s oral anatomy (coordination and strength)
- Patient’s respiratory function
- Control/function: labial, lingual, palatal, pharyngeal, laryngeal
- Cognitive status: comprehension, awareness
- Sensory: taste, temperature and texture
- Signs and symptoms during swallow attempts
12
Q
What materials do you need for a bedside clinical exam for swallowing?
A
laryngeal mirror, tongue blades, cup, spoon, straw, syringe, towel/drape cloth, gloves, gown, eyewear/mask, stethoscope
13
Q
Why do you need to bring a cup, syringe, spoon and a straw to a bedside evaluation?
A
to accommodate to whatever method the patient will be able to swallow
14
Q
What is below sternal notch?
A
esophagus
15
Q
What is above the sternal notch?
A
larynx
16
Q
Where are the valleculae?
A
the base of tongue/epiglottic area, these are the swimming pools right below chin
17
Q
Where are the pyriforms?
A
Its just below the larynx, by the thyroid cartilage area
18
Q
Where is the UES?
A
its by C-6, right at the sternal notch
19
Q
What do you need to prepare for a bedside exam?
A
chart review
20
Q
What is included in the chart review?
A
- respiratory status
- dysphagia history
- history of pneumonia
- nutritional status
- medications
21
Q
What does a fever indicate?
A
infection
22
Q
When you are doing a chart review for a patient, what must you explore about their respiratory status?
A
- Do they have a trach, vent or are they intubated?
- What is their respiratory rate at rest?
- Time their saliva swallows and phase of respiration
- Time/gauge strength of cough (volitional and reflexive)
- Time of apneic period
- Do they breathe through their mouth or nose?
23
Q
What is a normal respiration rate?
A
6-12 cycles per minute
24
Q
Pneumonia, COPD and other respiratory diseases cause __ respiration
A
higher
25
What is a normal time for saliva swallows and phase of respiration?
2 min/swallow
26
When you are doing a chart review for a patient, what must you explore about their dysphagia history?
onset, symptoms, patient awareness and localization
27
When you are doing a chart review for a patient, what must you explore about their history of pneumonia?
check if they have a fever
| *get their most recent vitals
28
When you are doing a chart review for a patient, what must you explore about their nutritional status?
diet type, its duration and adequacy
Were they ever tubed?
complications from food
29
When you are doing a chart review for a patient, why must you explore the medications they are on?
A lot of medications can cause xerostomia, decreased alertness or delayed reaction time
30
What does a bedside exam entail?
prep, physical exam and trial swallows
31
What needs to be explored during the physical part of bedside exam?
Posture, oral exam, laryngeal function, pulmonary function testing and pneumotachometry
32
When doing the physical exam portion of a bedside, what do you look for in the oral exam?
Anatomy and physiology
33
Bedside swallow
Physical exam
What do you look for in patient's anatomy?
- observe patient's lips, hard palate, soft palate, uvula, faucial arches, tongue, sulci, teeth, secretions
- look for scarring or asymmetry
- observe if there is any leftover food or if the mouth is dry
34
Bedside swallow
Physical exam
What do you do to examine patient's oral physiology?
open mouth, stimuli (texture/taste/temperature)
examine chewing and sensitivity
look at labial, lingual, soft palate functions
35
Bedside swallow
Physical exam
Physiology/labial function
/i/, /u/, ddk, /pa/, bilabilal stops and check labial closure by having lips around object
36
Bedside swallow
Physical exam
Physiology/ anterior lingual function
- extension/retraction
- corners of mouth
- clear sulcus
- tip to alveolar ridge and behind bottom teeth with open mouth
- ddk, /ta/, alveolar stops
- rub along palate
37
Bedside swallow
Physical exam
Physiology/ posterior lingual function
- back elevated
| - /k/, ddk, /ka/, velar stops
38
Bedside swallow
Physical exam
Physiology/ soft palate
sustain /a/, palatal reflex, gag reflex
39
Bedside swallow
Physical exam
Physiology/ apraxia
look for groping
40
Bedside swallow
Physical exam
Physiology/ abnormal oral reflexes
increased gag reflex, tongue thrust, tonic bite
41
Bedside swallow
Physical exam
How do you asses laryngeal function?
- listen to gurgly voice
- listen for hoarseness/breathiness
- DDKs, /ha/ for neurological impairments
- Strong cough and throat clear (reflexive/volitional)
- Vocal scaling
- phonation time with /s/ or /z/
42
Bedside swallow
Physical exam
Laryngeal function
What does a wet, grugly voice indicate?
definite penetration and possible aspiration because there is something sitting on the vocal folds
43
Bedside swallow
Physical exam
Laryngeal function
What does a hoarse or breathy voice indicate?
incomplete glottic closure
44
Bedside swallow
Physical exam
Laryngeal function
What does can vocal scaling indicate?
problems with CT muscle or SLN, intrinsics
decreased laryngeal sensitivity?
Apparent in PD and other neurological impairments
45
Most patients with neurological impairments won't
cough volitionally but will throat clear instead
46
Bedside swallow
Physical exam
Laryngeal function
What does phonation time with /s/ or /z/ indicate?
decreased laryngeal control or decreased respiratory function
47
What is the longest part of a bedside?
pulmonary function testing
48
What parts of a bedside are used only if warranted?
Pulmonary function testing and pneumotachometry
49
How do you test pulmonary function as part the physical exam of the bedside?
Spirometry and manometry
50
What does spirometry measure?
capacities
| FVC, FEV1
51
What does manometry measure?
strength
| MIP, MEP
52
What does pneumotachometry assess?
inspiration, LCT, peak
53
What is the last part of a bedside?
trial swallows
54
You should not attempt trial swallows if
patient is acutely ill, has weak pulmonary functions, very weak cough, 90+ years old, decreased cognition or is suspected of silent aspiration
55
With trial swallows, use material that is
easiest for the patient to swallow
56
What quantity is recommended for a bedside trial swallow?
3 cc/ml
57
If you cannot attempt trial swallows, then send patient directly to
MBS or FEES to avoid risk
58
What quantity is recommended for a bedside trial swallow if patient has CVA?
9 OZ of water because they do better with bigger gulps
59
Why do CVA patients do better with larger quantity of water?
because it increases pharyngeal pressure and requires more muscle activity
60
What is another part of the trial swallow in a bedside?
cervical auscultation with 3-finger position on neck
61
What are you listening for with the cervical auscultation?
a hard gulp or clunk
| If you hear dripping or shower sound, not good
62
Where do you place your fingers in the 3-finger position on neck?
index finger- suprahyoid, under chin to feel for pressure
middle finger- hyoid bone/thyroid cartilage to feel laryngeal movement
ring finger- cricoid
63
Where do you place the stethoscope for cervical ausculation?
on the side of the neck
64
What are some things to note when doing the trial swallow part of a bedside eval?
- Patient's reaction to food
- Oral movements (chewing, manipulation, propulsion)
- Coughing, throat clearing before/after/during
- Secretion levels
- Meal duration (if observed) and what percentage was eaten
- Respiration/swallow coordination
- Hypolaryngeal excursion
- Sound of swallow
65
How do you assess hypolaryngeal excursion?
3 finger test
66
How do you assess sound of swallow?
cervical ausculation
67
What recommendation can an SLP give after a bedside or clinical exam?
```
posture resulting in best/safest swallow
best positioning for food in mouth
best food consistency
hypothesis as to nature or swallowing disorder
recommendations for treatment
```
68
What is the best posture resulting in safest/best swallow?
90 degree hip flexion
69
If best positioning for food in mouth applies, what is the best position?
depends on their problem
70
Can you do a diet modification (food consistency) with only a bedside eval?
no, you need a diagnostic
71
What is the proper way to hypothesize a patient's problem in an official report?
"Patient showed symptoms __ which is indicative of __
72
Where can you order a FEES or MBS?
in recommendations
73
What are some imaging diagnostic instrumentations?
Videofluoroscopy (xray), VFSS, MBS, MBSS
FEES/FEESST/Videoendoscopy (raw view)
Ultrasound/fMRI/PET
Scintigraphy
74
What two imaging diagnostic instruments are not widely used for swallowing?
ultrasound and scintigraphy
75
Why isn't scintigraphy used?
because of the large amounts of radiation
76
Why isn't ultrasound used?
because the machine has a hard time picking up all the different muscles and bones in that area
77
What are some non-imaging diagnostic instrumentations?
EMG
EGG
Acoustics
Manometry
78
What does the EMG do?
measures muscle activity
79
What does EGG do?
measures vf vibration at the thyrohyoid level
80
How do you go about listening to acoustics?
accelerometer or stethoscope to listen
81
What does manometry measure?
pressure
82
Videofluoroscopy/MBS
| Indications
- To identify normal and abnormal A&P of the swallow
- To evaluate airway protection before/during/after swallowing
- To evaluate the effectiveness of postures, maneuvers, bolus modifications and sensory enhancements in improving swallowing safety and efficiency
- To provide recommendations regarding the optimum delivery of nutrition and hydration
- To determine appropriate therapeutic techniques
- To obtain information in order to collaborate with and educate other team members, referral sources, caregivers, and patients regarding recommendations for optimum swallow safety and efficiency
83
Videofluoroscopy/MBS
| Contraindications
- Medically unstable, lethargic, un-oriented, agitated, uncooperative, cognitive deficits
- When the information obtained from the study is unlikely to change the patient's management (advanced care prefernces, chronic disease or end-of-life situations)
- Patient is unable to be adequately positioned
- Size of patient prevent adequate imaging or exceeds limit of positioning devices
- Allergy to barium (rare)
84
Videofluoroscopy/MBS
| Limitations
- Time constraints due to radiation exposure
- As the procedure only samples swallow function, it does not fully represent mealtime function
- Contrast materials such as barium slightly increase viscosity and alter liquid and solid food composition and are not natural foods-may result in discordance between the results of VFSS and real meals
- Limited ability to evaluate a fatigue effect on swallowing, unless specifically evaluated
- Barium in an unnatural food bolus with potential for refusal
85
What does the FEES examine?
A&P before and after the swallow
86
What's an advantage of FEES?
no barium and no radiation exposure
87
The FEES gives an excellent view of
vocal folds and larynx
88
What stage is visible?
pharyngeal only
89
What's a disadvantage of the FEES?
The "white out" period
90
The Ultrasound displays what stage of the swallow?
oral stage only
91
What does the Ultrasound display?
tongue function, oral transit time and hyoid motion
92
What two diagnostic instrumentations are mostly used in studies?
fMRI (Functional Magnetic Resonance Imaging)
| PET (Positron Emission Tomography)
93
What does fMRI (Functional Magnetic Resonance Imaging) display?
neural basis/mechanisms
| neural mapping-cortical control
94
What does PET (Positron Emission Tomography) display?
neural activity associated with motion
95
What is a huge disadvantage of PET?
larger radiation exposure than MBS
96
What can the scintigraphy diagnose?
esophageal issues
97
What does scintigraphy display?
amount of aspiration and residue
98
What does scintigraphy use?
its radioactive and uses a gamma camera
99
The __ and __ are not well visualized in scintigraphy
mouth, pharynx
100
Can scintigraphy identify dysfunction?
No
101
What is thin puree?
| Food consistency
applesauce
102
What is thick puree?
| Food consistency
pudding
103
What is mechanical soft?
| Food consistency
scrambled eggs
104
What is chopped?
| Food consistency
corn beef hash
105
What is regular?
| Food consistency
cookie, cracker
106
What are the 3 consistencies of liquids?
thin, nectar and honey
107
Why is cervical ausculation limiting?
because many sounds of deglutition appear to be silent
108
Whats diagnostic tool shows presence of aspiration?
FEES
109
What diagnostic tool shows presence of aspiration and etiology?
videofluoroscopy
110
What diagnostic tool shows pharyngeal anatomy?
rigid videoendoscopy
111
What diagnostic tool shows pressures?
pharyngeal manometry with videofluoroscopy
112
What non-imaging tools are good for biofeedback?
EMG and EGG
