Day 4 PM

Question 1

7 purposes of the ISE

Answer 1

1.Image important anatomic swallowing structures 2.Ax movement patterns of these structures 3.Identify & describe any airway compromise (asp / pen) 4.Evaluate impact compensatory maneuvers 5.Identify & describe any pooled secretions & ability to clear 6.Complete cursory evaluation of esophageal A & P 7.Assist in forming clinical recommendations

Question 2

2 most important characteristics of swallowing to consider during an ISE. Implications?

Answer 2

safety and efficiency. Safety prevents aspiration. Efficiency prevents excess residue that leads to malnutrition

Question 3

When is the ISE indicated?

Answer 3

With some patients due to radiation exposure (also expensive, time, realism)

Question 4

6 types of ISE’s

Answer 4

• Modified Barium Swallow (MBS) • Upper gastrointestinal series with hypopharynx • Videofluoroscopic swallow study (VFSS) • Videofluoroscopic swallow examination (VFSE) • Videofluoroscopic barium examination (VFBE) • Rehabilitation swallow study

Question 5

7 objectives of VFSE

Answer 5

1.Evaluate anatomy & physiology of the swallowing mechanism 2.Evaluate swallow physiology 3.I.D. patterns of impaired swallow physiology 4.I.D. consequences of impaired swallow physiology 5.Evaluate the impact of compensations 6.Confirm pt symptoms 7.Make predictions

Question 6

4 VFSE procedures

Answer 6

• Rec. to use standardized protocols • Position pt upright w adequate support • Typically begin in lateral position, then turned for A-P view • Esophageal Sweep

Question 7

Why is A-P view important? Clinical implications for certain demographic?

Answer 7

Anterior-posterior view tells us so you can see both sides of everything- important for stroke patients. Can turn head to weak side (helps with efficiency of swallow)

Question 8

Importance of Obamacare

Answer 8

Demand to increase productivity
One way to do this is to standardize practice for repeated procedures (dysphagia screening, MBS)
Across different SLP’s and within your own practice

Question 9

Ways to standardize your practice

Answer 9

Equipment kept in same place
Disinfected in exact same way and steps
Same form and steps followed for screens
MBS tray set up the same every time

Question 10

Benefits of standardizing your practice

Answer 10

Reduces costs, eliminates wastes, improves efficiency (SWIGERT)

Question 11

Name of ISE done standing up

Answer 11

C-ARM

Question 12

When evaluating the image, it is important to remember that the view is _____.

Answer 12

mirrored/inverted

Question 13

2 types of common contrasts used in ISE

Answer 13

• Barium Sulfate Suspension (radiopaque) • Varibar - standardized barium line specific for swallow studies

Question 14

3 things to vary (have a range of)

Answer 14

textures, volumes, viscosities

Question 15

Volumes typical range

Answer 15

1 mL to 90 mL

Question 16

3 viscosity categories of liquids

Answer 16

thin, nectar thick, honey thick

Question 17

3 viscosity categories of solids

Answer 17

puree, mechanical soft, hard, mixed (like cereal)

Question 18

6 structures seen in a MBS

Answer 18

lingua-velar seal, bolus, pharynx, hyoid, larynx, true vocal folds

Question 19

3 non-contrasted tasks, their function

Answer 19

Simple speech task to evaluate structures in movement (lips,
tongue, velum, pharyngeal wall)
• Vowel Prolongation & repetition to evaluate laryngeal
excursion & VF adduction
• Falsetto |i| in A-P view affords good visualization of pharyngeal
wall constriction

Question 20

_______ Can be different across settings & clinicians opinions vary

Answer 20

sequence of events

Question 21

3 Martin-Harris suggestions for sequence of events

Answer 21

1) . Start with Thins: 5ml; 10ml; 20ml* •
2) . Then: Pudding; Soft; Regular; Mixed •
3) . If signs aspiration immediately downgrade to thicker viscosity

Question 22

_________ beneficial but practice flexibility to maximize ________.

Answer 22

Standard protocol, diagnostic outcomes

Question 23

8 steps in the general sequence of events of an ISE

Answer 23

1.Pt seated in lateral view
2.Simple speech tasks to Ax movement of structures
3.Liquid bolus presentations
4.Solid bolus presentations *
5.Pt turned to A-P view, vowel & falsetto tasks
6.Further swallow trials. Ax symmetry & effects of head turn
7.*Ax impact of compensatory maneuvers either before /
after AP view
8.When feasible, pt stands & cursory esophageal phase Ax eval

Question 24

4 things to look for in an ISE

Answer 24

1) . Anatomy of All Structures
2) . Non-Swallow Movement: Lips, tongue, mandible, Larynx, Pharynx
3) . Kinematics, Timing, Airway Protection, Swallow Efficiency
4) . Impact of Strategies and Swallow Maneuvers

Question 25

Bailout/study abortion criteria

Answer 25

usually 3rd episode of aspiration

Question 26

Structural abnormalities

Answer 26

1) . No bar 2) . Non-obstructing CP bar, normal PES opening >0.60 cm 3) . Moderately obstructing CP bar, PES opening 0.3-0.6 cm 4) . Severely obstructing CP bar- PES opening

Question 27

4 strengths of ISE

Answer 27

``` • Dynamic study of swallow biomechanics • Unlimited review capabilities • Comprehensive perspective from lips - esophagus • Readily accessible (inpt) ```

Question 28

4 weaknesses of ISE

Answer 28

``` Time restraints due to radiation exposure • Sampled in artificial eating environment • Pooled secretions not captured • Limited access outside hosp ```

Question 29

2 terms: endoscopic evaluation of swallowing

Answer 29

Fiberoptic Endoscopic Evaluation of Swallowing (FEES) & Fiberoptic Endoscopic Evaluation of Swallowing w Sensory Testing (FEESST)

Question 30

MBS vs. FEES: Similarities

Answer 30

• Purpose • Process of Evaluation

Question 31

MBS vs. FEES: Differences

Answer 31

• Technique • Image Perspective • Portability • Repeatability • Duration of Exam • Sensory Assessment

Question 32

5 FEES components

Answer 32

1. Ax of pharyngeal & laryngeal anatomy 2.Eval of movement & sensation of pharyngeal structures 3. Ax of secretions 4. Direct Eval of swallowing Fn w oral trials 5.Eval of impact of compensatory maneuvers

Question 33

4 parts of the FEES equipment

Answer 33

• Fiberoptic Endoscope • Light Source • Camera • Video Recorder

Question 34

6 general procedures oFEES

Answer 34

1.Scope Passed 2.View Velopharyngeal Mechanism (hum, V, C, saliva swallow) 3.Advance to Oropharynx to visualize laryngeal & pharyngeal sts 4.Ask pt to perform non-swallow tasks to Ax anatomic movement & function of laryngeal & pharyngeal structures 5.Perform Oral trials 6.If impaired swallow ID: Ax effect of compensatory techniques

Question 35

6 things to look for during FEES

Answer 35

``` Anatomic integrity at each “level” of swallowing mechanism Movement characteristics Secretions Ax of swallow attempts Airway compromise Impact of maneuvers & compensations ```

Question 36

5 strengths of FEES

Answer 36

• Objective study of swallow physiology w unlimited review capabilities • Superior inspection of pharyngeal anatomy, sensations, secretions & laryngeal closure patterns then MBS • Accessibility • No radiation exposure • No time constraints

Question 37

5 weaknesses of FEES

Answer 37

``` No view of the oral cavity & esophagus • Assessment restricted to pharyngeal phase of swallow • ‘Whiteout’ during swallow • Potential med complications • Reqs further SLP training ```

Question 38

High level of agreement between MBS and FEES for detecting what 4 things? percent of agreement?

Answer 38

• Aspiration (86-90%) • Pharyngeal Residue (80-89%) • Laryngeal penetration (85-86%) • Premature spillage (61-66%)*

Question 39

Penetration aspiration scale

Answer 39

Score of 1-8. 1 = normal; 2-5 = penetration. 6-8 = aspiration

Question 40

Define: penetration

Answer 40

residue at or above the level of the true vocal fold

Question 41

Define: aspiration

Answer 41

residue below the level of the true vocal folds

Question 42

Purpose of oral mechanism exam

Answer 42

Determine the structural and functional adequacy of the oral mechanism for speech and swallow.

Question 43

OME Should be routine part of every evaluation, regardless of _________.

Answer 43

patient population/disorder

Question 44

3 things that OME findings may help shape

Answer 44

theory of etiology, diagnosis and prognosis for change, direction for treatment.

Question 45

Can an OME save someone's life?

Answer 45

YES!

Question 46

Parts of the OME

Answer 46

``` Gag Bite Cough Oral secretions Oral cavity Face: rest & movement Lips: rest & movement Tongue: rest & movement Mandible: rest & movement Palate: rest & movement Airway Phonation respiration Volitional swallow ```

Question 47

CN-I - name and function

Answer 47

olfactory- smell

Question 48

CN-II - name and function

Answer 48

optic- vision

Question 49

CN-III - name and function

Answer 49

oculomotor- eye movement, pupil constriction

Question 50

CN-IV - name and function

Answer 50

Trochlear- eye movement

Question 51

CN-V- name and function

Answer 51

Trigeminal, jaw movement

Question 52

CN-VI - name and function

Answer 52

Abducens, eye movement

Question 53

CN-VII - name and function

Answer 53

Facial- facial movement

Question 54

CN-VIII - name and function

Answer 54

Cochleovstibular- pharyngeal movement

Question 55

CN-IX - name and function

Answer 55

Glossopharyngeal- pharyngeal palate

Question 56

CN-X - name and function

Answer 56

Vagus- pharyngeal palatal and lingual movement

Question 57

CN-XI - name and function

Answer 57

Accessory- shoulder and neck movement

Question 58

CN-XII - name and function

Answer 58

Hypoglossal- tongue movement

Question 59

Cranial Nerves mnemonic device

Answer 59

On occasion our trusty truck acts funny, very good vehicle any how

Question 60

Cranial nerve sensory/motor mnemonic

Answer 60

Some say marry money, but my brother says big brains matter more

Question 61

6 cranial nerves pertinent to SLP

Answer 61

V, VII, IX, X, XI, XII

Question 62

3 sensory nerve branches

Answer 62

VI: Ophthalmic: forehead, eyes, nose ‰ V2: Maxillary: upper lip, maxilla, maxillary sinus, upper teeth, cheeks, palate ‰ V3: Mandibular: mandible, lower lip, a portion of the external ear, the first 2/3 of the tongue, the bottom set of teeth

Question 63

5 ways to assess CN-V

Answer 63

``` Sweep 4 quadrants of face: forehead, cheeks, jaw Touch front and back of tongue Ask about taste Bite: feel masseters Wiggle Jaw back and forth ```

Question 64

Sensory and motor innervations by CN VII

Answer 64

Sensory: taste anterior 2/3 tongue, preauricular skin Motor: facial muscles: frontalis, obicularis oris, obicularis oculi, stapedius

Question 65

4 ways to assess CN-VII

Answer 65

Ask to smile or repeat “eee” Ask to pucker or repeat “ewwww” Touch skin in front of ear Ask about taste

Question 66

Reasons for non-patent airway

Answer 66

Tumor Subglottic Stenosis or web Tracheomalacia Vocal cord paralysis Congenital abnormalities of the airway Large tongue or small jaw that blocks airway Inhalation or chemical burns to upper pharynx, laryngeal area Foreign body obstruction Wired jaws Laryngectomy (however, I will not address the H&N cancer population in this lecture) 2 ) lung protection from potential obstructions or aspiration; Need for prolonged respiratory support, Chest wall injury and Diaphragm paraylsis, injury or dysfunction

Question 67

Sensory and motor innervations by CN-IX

Answer 67

Sensory Taste posterior 1/3 tongue Motor Pharyngeal constriction

Question 68

How to assess CN-IX

Answer 68

How to assess- say aah. House-Beckman- used to classify degree of severity 0-5 scale (disfiguring droop, gold weight in eyelid), 1 would be normal

Question 69

Sensory and motor innervations of CN-X

Answer 69

``` Sensory: Posterior 1/3 tongue Gag? NO 13-37% normals have absent reflex Unless asymmetric Motor: Cricothyroid Levator veli palatini Salpingopharyngeus Palatopharyngeus Pharyngeal constrictors Intrinsic laryngeal muscles ```

Question 70

How to assess CN-X

Answer 70

Phonation; dysphonia or hypophonia could be indicative of unilateral RLN damage Velar elevation (say aaaah) also listen to resonance (hypenasality could indicate disordered velar movement) Cough Volitional swallow (multiple swallows/bolus=CP dysfunction)

Question 71

Motor innervations of and how at assess CN-XI

Answer 71

``` Motor Trapezius SCM How to assess: Shoulder shrug Head tilt against resistance ```

Question 72

Motor innervations of CN-XII

Answer 72

Motor: (extrinsic and intrinsic tongue) genioglossus styloglossus hyoglossus

Question 73

How to assess CN-XII

Answer 73

Tongue protrusion, lateralization (both volitional and against resistance); UMN deviates

Question 74

8 pathological resposes

Answer 74

Adiadochokinesis- inability to perform rapid alternating muscular movements Babinski- big toe extends or remains extended when sole of foot is simulated Suck/snout Diplopia- seeing double Echolalia- repeat Nystagmus- rapid involuntary eye movement in different directions Perseveration- unable to shift tasks Ptosis- eyelid drooping or looking sleepy

Question 75

Define: DDK (diadochokinetic)

Answer 75

how quickly an individual can accurately produce a series of rapid, alternating sounds. Have patient repeat them for as long and as quickly as possible

Question 76

For UF/Shands clinics, we use _____ as our electronic | medical record platform

Answer 76

EPIC

Question 77

Many outside clinics (do/don't) use this software

Answer 77

don't

Question 78

EPIC live- timing consideration

Answer 78

Many of our Outpatient SLP clinics did not go live onto EPIC until approximately Spring 2014- LOTS of archived paper charts, some of which are/are not scanned into EPIC for review

Question 79

EPIC access must be granted through the _____

Answer 79

UF privacy office

Question 80

Authorized personnel receive a _______ and _______

Answer 80

username and password

Question 81

Your access is renewed by ______ each _____.

Answer 81

supervisors, semester

Question 82

Clinician differences- EPIC consideration

Answer 82

Every clinician is different | about how they like you to document notes in EPIC

Question 83

Scanned documents older than 2014 appear in the ____ tab

Answer 83

Media

Question 84

____ make EPIC documentation more efficicent

Answer 84

smart phrases

Question 85

4 things in EPIC notes we are possibly concerned with

Answer 85

What did H&P and neurology notes say? What did we say? What was the last safest diet? Has this patient been seen in the past

Question 86

With inpatients, start with ______ when documenting in EPIC

Answer 86

H&P

Question 87

For outpatients, start with _______ when documenting in EPIC.

Answer 87

start with most recent office note from referring provider

Question 88

Always check for _______ hidden in the _____.

Answer 88

old SLP notes, media tab

Question 89

______ are your friend to sort notes

Answer 89

filters

Question 90

2 ways to not labor over every single note

Answer 90

We need you to be quick but efficient because there is more than one person to see in a day! ¡ Look for key things: why are they there, what treatments/interventions have they gotten, what do they want from us, do they already have a diet ordered, do they have nutritional access (e.g. feeding tube), do they have a trach/vent

Question 91

4 things to do when going to see the patient

Answer 91

1). Have your Pt list for the day printed/written out 2). Make a quick summary about each Pt to remind you at a quick glance 3). Ask your supervisor if they are ok with you taking notes in the room or waiting until you leave the patient 4). Have all of your tools ready to take into the room

Question 92

4 things to look for before entering a patient room

Answer 92

1. Check the front doors for precaution signs- FOLLOW them for your safety and the patient's 2. Speak to the RN before going in if possible 3. Take essentials only 4. Gel/Hand WASH

Question 93

3 important considerations in interacting with patients. Why?

Answer 93

1). ALWAYS introduce yourself to the patient and family/caregivers ¡ Patients have the right to know who is in their room and why ¡ You’re not “just a student,” you are an important member of the team who needs to be introduced ÷ “Hi my name is Julie, I am speech therapy graduate student/clinician” 2). If you are not sure who someone is, it’s ok to ask ¡ Don’t assume, you’ll get into trouble ÷ “Who do you have with you today” or “Are you family, friends, caretaker?” 3). Show the patient’s respect when speaking to them ¡ Call them Mr. or Ms., shake their hand if possible, make sure you look at them when you speak to them, thank them for their time, put them back how you found them

Question 94

3 more considerations when interacting with patients

Answer 94

1). Be confident with your voice and your demeanor  2). Let us know if you are uncomfortable with a patient or patient situation ¡ Politely step out or ask to speak to us in private 3). Listen to your body! ¡ If you are getting dizzy in a room, sit down or leave ¡ If you are sick that day, don’t come to clinic to get us and the patient sick….take care of yourself so you can care for others

Question 95

3 considerations in interacting with supervisors

Answer 95

1). Please don’t be scared of us! 2). Make sure to communicate your needs ¡ What type of feedback you like ¡ Family/work conflicts, disabilities, time commitments, etc. 3). We like questions… ¡ Make them constructive, try to relate something you do know about the topic, show us that you took the initiative to already find the answer before asking us ÷ PET PEEVE ALERT: asking us what an acronym means when you are sitting at a computer and are capable of looking it up! ¡ Sometimes we can’t answer the questions right away, but we will get back to you! ¡ Secret: we also have to look things up too!