Evaluation of Swallowing

Question 1

Dysphagia Bedisde Screening is:

Answer 1

– quick, non-invasive, low risk, low cost

• 10-30min
• look inside mouth
• eat and drink something small

Trying to answer: DOES THE PATIENT HAVE DYSPHAGIA?

Question 2

Bedside Screening Includes (3):

Answer 2

1) Signs & symptoms
2) Chart review
3) Observation
- 3 oz water test
- Timed swallow test
* False positive = id’d as aspirating but aren’t
* False negative = id’d as not aspirating but are
* NOT 100% accurate!
* Further dx assessment needed

If there is any inclination that there is aspiration, follow up with a FEES and/or MBSS

Question 3

What is a false positive?

Answer 3

Id’ed as aspirating but they are not

better than false negative

Question 4

What is a false negative?

Answer 4

Id’ed as not aspirating but are actually aspirating

NOT good. DO NOT want this to happen

Question 5

Is a screening sufficient or is more assessment needed?

Answer 5

more dx assessment is needed

Question 6

Symptomatology: (look for)

Answer 6

1) Valleculae hesitation/pooling
2) Pyriforms pooling
3) UES dysfunction
4) Aspiration

Question 7

Symptom: If patient says they feel something is “stuck” high in throat

Answer 7

Valleculae hesitation/pooling (location and symptom)

Location: Base of tongue/ epiglottic area

Question 8

Symptom: Patient complains something is “stuck” in middle of throat

Answer 8

Pyriforms pooling

Just below larynx

Question 9

Symptom: Patient complains they feel something is “stuck” lower in throat or high in chest, pain in upper chest

Answer 9

UES dysfunction

Feels pain in upper chest or inches below larynx, about the level of vertebrate C6

Question 10

Symptom: Patient complains of:

• Coughing
• Choking

Answer 10

Aspiration

***50%+ aspirate without cough (silent)

Question 11

Bedside Clinical Exam Provides (8)

Answer 11

1) Medical dx, hx, pt’s perception
2) Pt’s medical status: nutritional (tube?), respiratory (trach tube? ventilator?)
3) Pt’s oral anatomy
4) Pt’s respiratory function
5) Control/fxn: labial, lingual, palatal, pharyngeal, laryngeal
6) Cognitive status: comprehension, awareness
7) Sensory: taste, temperature, texture
8) S/s during swallow attempts

Question 12

Bedside Clinical Exam

Materials (11)

Answer 12

1) Laryngeal mirror
2) Tongue blades (for oral mech)
3) Cup
4) Spoon
5) Straw
6) Syringe
7) Towel/ drape cloth
8) Gloves
9) Gown
10) Eyewear/ mask
11) Stethoscope

(never sit directly in front of the patient)

Question 13

Bedside Clinical Exam

PREP (6)

Answer 13

1) Chart review

2) Respiratory status /hx: trach? vent? intubated?
- Resp rate at rest (should me 6-12 cylces per min)
- Time saliva swallows (should be~every 2 min) & phase of respiration
- Time/gauge strength of cough (volitional and reflexive cough if it happens)
- Time apneic period– 1 sec, 3 secs, 5 secs?
- Breathing pattern: mouth or nose?

3) Dysphagia hx: onset? symptoms? pt awareness? localization?
4) Hx of pneumonia? Do they have a fever?
5) Nutritional status: diet type? duration? tubed? adequacy? complications?

6) Medications: xerostomia? ↓alertness?
delayed rxn time?

Question 14

Respiratory status /hx (taken during PREP part of bedside evaluation) (6):

Answer 14

1) trach? vent? intubated?
2) Resp rate at rest (should me 6-12 cylces per min)
3) Time saliva swallows (should be~every 2 min) & phase of respiration
4) Time/gauge strength of cough (volitional and reflexive cough if it happens)
5) Time apneic period– 1 sec, 3 secs, 5 secs?
6) Breathing pattern: mouth or nose?

Question 15

Bedside Clinical Exam
PHYSICAL EXAM (5)

Answer 15

1) Posture

2) Oral exam
- Anatomy
- Physiology

3) Laryngeal Function Exam
4) Pulmonary Function Testing (if warranted)
5) Pneumotachometry (if warranted)

Question 16

What to look for in Anatomy during the PHYSICAL EXAM:

Answer 16

LOOK AT:
lips, hard palate, soft palate, uvula, faucial arches, tongue, sulci, teeth, secretions

LOOK FOR:

• Scarring
• Asymmetry

Question 17

What to look for in Physiology during the PHYSICAL EXAM -ORAL EXAM (6):

Answer 17

1) Open mouth, stimuli (taste/texture/temp), chewing, sensitivity
2) Labial fxn: /i/, /u/, ddk /pa/, bilabial stops (p), lips around object)

3) Lingual fxn:
- anterior: extension/retraction, corners of mouth, clear sulcus, tip to alveolar ridge & behind bottom teeth w/open mouth, ddk /ta/, alveolar stops (t), rub along palate
- posterior: back elevated /k/, ddk /ka/, velar stops (k)

4) Soft palate: sustain /a/, palatal reflex, gag reflex
5) Apraxia (groping behaviors?)
6) Abnormal oral reflexes (↑ gag, tongue thrust, tonic bite)

Question 18

PHYSICAL EXAM

Laryngeal function exam (10)

Answer 18

1) Gurgly voice > definite penetration, aspiration?
2) Hoarseness/breathiness > incomplete gc?
3) Ddk’s, /ha/ > neuro impairment?
4) Hard cough/strong throat clear > reflexive? strong enough to clear?
5) Vocal scaling > CT m., SLN, intrinsics, ↓ laryngeal sensitivity?
6) Phonation time (/s/ or /z/) > ↓ laryngeal control? ↓ respiratory fxn?
7) Pulmonary function testing (PFT) if warranted
8) Spirometry: capacity (FVC, FEV1)
9) Manometry: strength (MIP, MEP)
10) Pneumotachometry if warranted (Insp, LCT, peak)

Question 19

Bedside Clinical Exam

TRIAL SWALLOWS: DO NOT attempt if (6):

Answer 19

1) acutely ill
2) ↓pulmonary
3) very weak cough
4) 90+ yrs old
5) ↓cognition
6) suspect silent aspiration

What should you go instead? go straight to MBSS or FEES for these pts

Question 20

Bedside Clinical Exam

TRIAL SWALLOWS: What do to (3)

Answer 20

1) Use material that is easiest for pt to swallow (small quantity of 3cc/ml recommended)
2) 3-finger position on neck lightly (1 figure on suprahyoids, 1 on thyroid cartilage, 1 on cricoid), other hand is used to put stethoscope on neck.
3) Cervical auscultation (Should sound like this in the stethoscope, want to hear a nice hard clunk. NOT a running shower. NOT dripping.)

Question 21

Bedside Clinical Exam

TRIAL SWALLOWS: What to note (8)

Answer 21

1) Pt’s reaction to food
2) Oral mvmts (chewing, manipulation, propulsion)
3) Coughing, throat clearing before/during/after
4) Secretion levels (don’t want to see drooling)
5) Meal duration (how long it takes) & amt (doc % they ate at each meal)
6) Resp/swallow coordination
7) Hyolaryngeal excursion (measured with the figure test)
8) Sound of swallow

Question 22

What cc / ml should you use with pts when doing trial swallows?

Answer 22

Cc = ml (the same thing)

3cc with pts generally

Question 23

What does new evidence say about how many cc’s should be used with CVA pts?

Answer 23

Current Evidence that shows the 9oz water test (higher volumes of water) is a better bolus size for pts with CVA

Probably because it creates more pharyngeal pressure and more muscle activity, so they are less likely aspirate on this amount.

Question 24

Bedside / Clinical Exam RESULTS

What is the Posture resulting in best/safest swallow?

Answer 24

Usually 90% of hip flexion

Question 25

Bedside / Clinical Exam RESULTS (5)

Answer 25

1) Position 2) Best positioning for food in mouth (If missing parts of mouth, may need to adjust) 3) Best food consistency (Never modify a diet and not send them for further evaluation. Always follow up so they are not stuck on that diet forever) 4) Hypothesis as to nature of swallowing disorder (e.g. pts show symptoms of __ which is indicative of ___) 5) Recommendations for dx (direct) (e.g. furthur testing is warranted. Recommended FEES and/or MBS)

Question 26

How often do we re-evaluate swallow for pts with dysphagia?

Answer 26

4-6 is typical | do not do MBS too often bc of radiation exposure so 4-6 week is more appropriate

Question 27

DX INSTRUMENTATION - Imaging (4)

Answer 27

1) MBS / Videofluoroscopy* (xray view) 2) FEES/FEESST/ Videoendoscopy (“raw” view) 3) Ultrasound/fMRI/PET 4) Scintigraphy

Question 28

DX INSTRUMENTATION - Nonimaging (4)

Answer 28

1) EMG (measures m. activity) 2) EGG (measures vf vibration at TH level) 3) Acoustics (accelerometer (mic on throat) or stethoscope to listen) 4) Manometry (measures pressure) (we don’t usually do this, can measure pharyngeal pressure)

Question 29

Imaging: VIDEOFLUOROSCOPY - MBS Indications – reason why to do MBS (6):

Answer 29

1) To identify normal and abnormal A & P of the swallow 2) To evaluate airway protection before/during/after swallowing 3) To evaluate the effectiveness of postures, maneuvers, bolus modifications, and sensory enhancements in improving swallowing safety and efficiency 4) To provide recommendations regarding the optimum delivery of nutrition and hydration (e.g., oral versus nonoral) 5) To determine appropriate therapeutic techniques 6) 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.

Question 30

Imaging: VIDEOFLUOROSCOPY - MBS Contraindications – reasons not to do an MBS (5):

Answer 30

1) Medically unstable, lethargic, unoriented, agitated, uncooperative, cognitive deficits 2) When the information obtained from the study is unlikely to change the patient's management (advanced care preferences-DNR, chronic disease, or end-of-life situations) 3) Patient is unable to be adequately positioned (e.g. spinal cord injuries, spasticity) 4) Size of patient prevents adequate imaging or exceeds limit of positioning devices 5) Allergy to barium (though this is quite rare)

Question 31

Imaging: VIDEOFLUOROSCOPY - MBS Limitations (5):

Answer 31

1) Time constraints due to radiation exposure 2) As the procedure only samples swallow function, it does not fully represent mealtime function 3) 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 4) Limited ability to evaluate a fatigue effect on swallowing, unless specifically evaluated 5) Barium is an unnatural food bolus with potential for refusal. and Barium may constipate you

Question 32

Imaging: | FEES (positives (4) and negatives (2)):

Answer 32

``` Positives +Examines A & P before and after (pharyngeal) swallow +No radiation exposure +No barium +Excellent view of vf’s & larynx ``` Negatives - No oral or esophageal stages visible - “White out” period - cannot see esophageal phase. When UES opens our view is “whited out” while the tongue base is retracting

Question 33

Imaging: | Ultrasound (positives (3) and negatives (2)):

Answer 33

Positives: +Tongue function +Oral transit time +Hyoid motion Negatives: - Can’t image pharynx - Oral stage only

Question 34

What consistencies do we use for FEES?

Answer 34

1) Thin liquid: water, juice, shakes 2) Nectar Thick liquid: V8 3) Honey Thick liquid 1) Puree (thin and thick): villina pudding 2) Mechanical soft / chopped: corned beef hash (corned beef), scrambled eggs (mechanical) 3) Regular Diet: cookies, crackers, chicken (needs to be masticated and bolus needs to be formed) ***Check dietary restrictions, food allergies, etc.

Question 35

Imaging: | fMRI (Functional Magnetic Resonance Imaging)

Answer 35

Neural basis/mechanisms | Neural mapping – cortical control

Question 36

Imaging: | PET (Positron Emission Tomography)

Answer 36

Neural activity assoc. w/ motion | Radiation exposure

Question 37

Imaging: Scintigraphy:

Answer 37

) Radioactive 2) Gamma camera 3) Amount of aspiration & residue 4) Mouth & pharynx not well-visualized – can’t id dysfunction 5) Can dx esophageal (GERD)