Evaluation

Question 1

Evaluation

Implementation of dysphagia programs is accompanied by substantial reductions in pna rates

Answer 1

3 programs evaluated pre- and post- implementation of formal dysphagia eval programs = pna rate dropped from 8.2% to 1.3%- an average of an 87% decline across programs
Aspiration increases the relative risk of pna by 6.5%
A reduction in pna by as little as 1/3 could result in savings of more than $1 billion annually nationwide

Question 2

Improved quality of life…

Limited published data on this,

Answer 2

SLPs are able to help avoid PEGs and / or overly restrictive diets

Question 3

Measures of Swallowing (Objective)

Answer 3

Clinical Swallow Evaluation / Bedside Swallow
Modified Barium Swallow Study / Videofluoroscopic Swallow Study
Fiberoptic Endoscopic Evaluation of Swallowing

Question 4

Measures of Swallowing (Subjective)

Answer 4

Clinical Swallow Eval

Question 5

Requirements

Answer 5

MD order
Chart Review
Go see the patient
Patient / caregiver report
Brief speech, language, cognitive screen
Oral Motor Eval
Bolus Presentations
Make appropriate recommendations

Question 6

Physician’s Order

Will contain the patient’s basic info:

Answer 6

Name
Age
DOB
MR Number
Location
Primary Diagnosis
Reason for Request

Question 7

Chart Review

Answer 7

1. Past Medical History
   - —Related medical history (CVA, COPD, pna, cancer)
   - —Related psycho-social history
2. Current Medical Status /
   - ——Reason for Admit
   - —–List of meds
   - —–POC
3. Other Physician Consultations (ENT, GI, Neurology, Neurosurg)
4. Other Ancillary Services (OT/PT, Nursing, Social Work)
5. Lab work / Diagnostic Testing Results
   - –Head CT / MRI — GI work up
   - –CXR — Bloodwork
6. Other
   - –Current po status
   - –Overall mental status

Question 8

Go See the Patient: Formal and Informal Observations

Introduction

Answer 8

Explanation of why you are there
Talk to the patient, talk to the caregiver
Brief cognitive screen 
(A & O X 3) person, place, and date 
Speech, language, apraxia screen
Decision making abilities

Question 9

Speech Intelligibility

Impact of Dysarthria

Answer 9

Muscles as face aren’t moving as efficiently as they should
Is the Patient easily understood?
With / without careful listening and attention
Could this be correlated to a swallowing problem?
Weak speech muscles = weak swallowing muscles
Possible lingual strength and coordination deficits

Question 10

Cough Production

Strength of Volitional Cough and Throat Clear

Answer 10

Is it productive enough to move material out of larynx?
Are there secretions that currently need to be cleared?
General pulmonary power / effort

Question 11

Voicing

Answer 11

Normal
Wet
Breathy?  Hoarse?  Strained?  
Volume
Aphonic
Resonance
Positioning

Question 12

What position is the patient in?

Answer 12

Flexed:
Flaccid
Leaning to one side
Leaning back
Head position  -  up, down, rotated
----Reclined 45 degree 
----Supporting apparatus  (OT/PT aides)

Question 13

Safety concerns

Answer 13

C-spine precautions, drain in place, lumbar puncture

Question 14

Secretion Management

Answer 14

No overt secretion difficulties
Wet breath sounds at baseline
Coughing at baseline
Suction set up at the bedside
Anterior spillage of secretions
Pooled secretions in mouth

Question 15

Other Considerations

Answer 15

Respiratory Rate
Heart Rate
Oxygen Saturations

Question 16

Patient Report

Answer 16

1.Do you have difficulty swallowing? In what way?
2.Is the swallowing difficulty greater for solids or liquids?
3.Do you have this sensation without swallowing food?
4.How long has swallowing difficulty been present?
5.Has heartburn been associated with your dysphagia?
6.Is swallowing painful?
7.Do you get chest pain?
8.Does food get stuck when you swallow? If so, where?
9.Do you choke or cough when you swallow?
10Is there temperature sensitivity to dysphagia (especially cold)?
11.Has there been weight loss?
12What types of foods or liquids are hardest for you to swallow
13Have you lost any weight?
14Do you have frequent respiratory issues, such as pna or bronchitis?

Question 17

Facial

Answer 17

movement: VII
sensation: V
.Lips
Tongue
Buccal Cavity
Soft and Hard Palate
Gag
Lip movement
Closure
Strength of closure
Pucker / Smile
Droop
Eye brow lift
Symmetry in general
Unilateral, Bilateral?
Jaw movement and strength

Question 18

Tongue

Answer 18

Protrusion
Deviation noted
	Always deviates to the weak 
ROM (range of motion)
Strength
Coordination + ROM
Diadochkinesis
Dysarthria?

Question 19

Soft Palate

Answer 19

Palate Movement
Quick?
Symmetry
Deviation of uvula indicates palatial weakness
Motion of PPW?

Question 20

Interior sensation

Answer 20

Tongue
Buccal Cavities
Gag
Anterior faucial pillars
PPW?

Question 21

Dentition

Answer 21

Number of teeth
Location
Status
Decaying? Clean?

Question 22

Saliva

Answer 22

Wet / shiny mucosa in oral cavity and tongue
Hypo salivation
Tongue may be cracked
Whitish-grey in color
Dried secretions

Question 23

Oral care (done before

Answer 23

feeding or swallow study)
Supply as needed
toothbrush 
sponge
mouthwash

Question 24

Laryngeal Palpation

Answer 24

Thyroid notch between the middle and ring fingers

Should move in a superior and anterior direction to clear or nearly clear the middle finger

Question 25

Know the patient’s medical status. May re-consider moving forward if:

Answer 25

``` Pt is not alert enough to swallow Pt cannot cough Pt cannot manage own secretions Pt cannot volitionally swallow Trial of ice chip ```

Question 26

Bolus Presentation

Answer 26

``` Mastication / Oral stage Swallow Initiation Laryngeal Elevation Cough, throat clear, other s/sx aspiration (change in vocal quality, eye watering, changes in breathing) Use of cervical auscultation? ```

Question 27

Bolus Consistencies Typically Used | Ice chip

Answer 27

``` Water Nectar thick liquid (gross) Honey thick liquid (gross) Extra thick liquid – pudding Puree Soft solid Solid Mixed consistency (liquid and solid) ```

Question 28

Bolus Presentations:
Volumes Typically Used

Answer 28

``` Siphoned sip via straw ½ teaspoon Teaspoon Cup sip Straw sip Multiple sips Progression of bolus presentation ```

Question 29

Start with an ice chip almost always Then, small sip of water vs. teaspoon of puree Progression of bolus presentation:

Answer 29

If no clinical s/sx aspiration noted, move on to the next “easiest” consistency If started with water, may try puree next If started with puree, may try water next If difficulties noted with purees or water, may try thickened liquids If the pt does well with water, likely do not need to try thickened liquids If too many difficulties noted, consider discontinuing the eval Continue this process throughout the consistencies, concluding with mixed consistencies and large, multiple sips of liquids Have pt self administer pos as able

Question 30

Progression of bolus presentation:

Answer 30

If no clinical s/sx aspiration noted, move on to the next “easiest” consistency If started with water, may try puree next If started with puree, may try water next If difficulties noted with purees or water, may try thickened liquids If the pt does well with water, likely do not need to try thickened liquids If too many difficulties noted, consider discontinuing the eval

Question 31

Continue this process throughout the consistencies, concluding with mixed consistencies and large, multiple sips of liquids

Answer 31

Have pt self administer pos as able Stop eval at consistent aspirations During each bolus presentation

Question 32

Timing of each stage?

Answer 32

Feel for laryngeal elevation After each bolus presentation Listen to the pt’s voice Recommend a type of liquid and type of solid

Question 33

Other considerations:

Answer 33

``` Consistent / Inconsistent s/sx aspiration? Soft clinical s/sx aspiration? Effects of NGT on swallowing? When to terminate eval? Secretion management? ```

Question 34

Posture

Answer 34

Upright positioning?, Limitations- Shunt? Fractures? Drains? | Need for objective swallow study?

Question 35

Types of Diet Recommendations | If recommending pos, make recommendation on solid consistency and liquid consistency

Answer 35

``` Regular solids -- Thin Soft mechanical solids -- Nectar Chopped -- Honey Ground Purees ```

Question 36

Types of Diet Recommendations | Dysphagia diets may be used in some institutions

Answer 36

``` Dysphagia 1: Pureed Dysphagia 2: Minced Dysphagia 3: Ground Dysphagia 4: Chopped Dysphagia 5: Modified Regular (Soft Mech) ```

Question 37

Silent aspiration may be occurring if:

Answer 37

The pt exhibits a clear voice prior to presenting a bolus… and a wet voice after There is a drop in the pt’s oxygenation There is an increased work of breathing noted The pt has a delayed cough (greater than 1 minute)

Question 38

The Gag

Answer 38

30% of healthy younger adults and 44% of healthy older adults may have unilateral or bilateral absent gag reflexes Absent gag reflex can be associated with dysphagia, but does not predict aspiration risk in insolation Absence of gag alone is not statistically significant in predicting aspiration Abnormal cough and abnormal gag predicts aspiration 85% of the time

Question 39

Accuracy of the CSE

Answer 39

Presence of aspiration can be predicted 66% of the time by trained SLPs Ability to detect aspiration Absence of aspiration can be predicted 67% of the time by trained SLPs Ability to detect no aspiration Aspiration is more frequently silent in the neurogenic population 50% of patients who aspirated during the MBSS complained of difficulties swallowing to their medical team or SLP Often complaints of swallow difficulty do not produce evidence of actual swallowing disorder when measured objectively Up to 90% noted in one study So… Is a CSE sufficient How acceptable is an ~30% false negative rate when dealing with aspiration? Conversely, how acceptable is a 30% over-identification rate?

Question 40

Clinical consequences include oral feeding and medications incorrectly withheld in a large number of patients until an objective swallow study can be performed, or overly restrictive diets are recommended

Answer 40

Certain patients can tolerate a degree of aspiration | True, but a CSE is not sufficient in determining amounts of aspiration

Question 41

Why not go straight to an objective?

Answer 41

Lose valuable information re: CN function and involvement, cognitive linguistic abilities, pulmonary status

Question 42


Aspiration Prevalence

Answer 42

59% of acute care patients are silent aspirators with highest incidence in the youngest, oldest, and neurologically impaired age groups 58% of patients with dysphagia are silent aspirators Further Considerations: 30 – 50% of CVA population aspirate 40% of patients with Unilateral CVA aspirate 56% of patients with Bilateral CVA aspirate 67% of patients with Brainstem CVA aspirate

Question 43

How does the CSE direct treatment? | PROS

Answer 43

``` Generally effective for straight forward patients Relatively few supplies Patient directed and centered SLP can typically readily do Cost effective Non-invasive ```

Question 44

CONS

Answer 44

Do not detect pharyngeal delay or pharyngeal residue

Question 45

Sometimes need to know more than aspiration vs. no aspiration Effectiveness of compensatory strategies?

Answer 45

``` Ability to clear aspiration materials Amount of aspiration Referrals to other specialists There are many benefits to the CSE However, when readily available, objective swallow evaluations are often significantly more useful than clinical evaluations alone in the assessment of patients with dysphagia ```

Question 46

Types of Nutrition Parenteral / Hyperalimentation Via the veins

Answer 46

``` Bypasses the intestines Infusion, injection or implantation of medications or nutrition Pharmacological uses (to administer meds) IVs TPN Central Lines Enteral Nasogastric tube (NGT) Corpak, panda, dubhoff Gastrostomy feeding tube percutaneous endoscopic gastrostomy (PEG) Jejunostomy tube (J-tube) ```

Question 47

Enteral

Answer 47

Absorption through the GI tract NG Tubes Not permanent, most temporary NG Tubes Can be used to administer liquid tube feeds/nutrition/medications Or can be set to suction- meaning they are used to suction out gastric contents that the stomach or intestines may not be able to pass through (i.e. in patients diagnosed with a GI bleed) (take a look back at the last slide- this is pictured in the top right corner)

Question 48

FOOD for THOUGHT: Can SLP’s perform a swallow eval on patients with an NGT in place?

Answer 48

YES

Question 49

Corpak

Answer 49

Not permanent, but can remain in place longer than NGTs | Inserted similarly to NGTs

Question 50

G Tubes

Answer 50

Permanent, but removable | Does not decrease the risk of pneumonia for patients with advanced dementia

Question 51

J Tubes

Answer 51

``` Helpful for individuals with: Poor gastric motility Chronic vomiting At high risk for aspiration Patients in whom G-tubes are contraindicated ```