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9633 Swallowing > L7: Screening and Clinical Ax > Flashcards

L7: Screening and Clinical Ax Flashcards

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1
Q

dysphagia is associated with increased risks for:

A

morbidity (pneumonia, malnutrition, dehydration)

length of stay: inc exposure to nosocomial infections, and inc healthcare costs

death

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2
Q

Smithard et al found that dysphagia on bedside assessment was….

A

an independent predictor of mortality and chest infection

identifies pts at risk for inadequate nutrition

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3
Q

asssessing every stroke patient doing a bedside assessement would be….

A

an enormous system-level burden

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4
Q

what are the goals of screening?

A

identify likeligood of dysphagia

outcome= pass/fail result

initiate referral process for diagnosis and treatment in order to minimize any consequent health risks associated w swallowing impairments

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5
Q

what are important properties of screening?

A

quick, easy, inexpensive

accurate = high sensitivity and specificity with low numbers of false positives and false negatives (we want high sensitivity bc we dont want false negs aka we dont want those w dys not being picked up)

should detect dysphagia in a large group of people who aren’t symptomatic, but some have dysphagia

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6
Q

screening tool implementation should…

screening protocol should result in …

A

improve health outcomes simply bc it was implemented

screenings taking place

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7
Q

observational studies: screening decreases…

A

pneumonia risk

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8
Q

RCT: insufficient data to determine is dysphagias screenings …

A

reduced risk for pneumonia, death, or dependency after stroke

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9
Q

screening pathway is associated w inc adherence …

screening optimizes…

A

rates to performing dysphagia screens

referral pathway

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10
Q

screening serves as a means…

A

for identifying pts who require referral to SLP for comprehensive evaluation of OP swallow functions

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11
Q

screening is not an …

A

adequate assessment of OP swallow function

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12
Q

screening is usually performed…

A

by other members of the healthcare team

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13
Q

SLPs are encouraged to lead dev of screening…

A

processes/tools; involved in training of other professionals to complete screening procedures

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14
Q

3-oz water swallow test works by…

further ax is required if…

A

drink 3 oz w/o interuption

unable to complete the task; coughing, choking, or a wet-hoarse vocal quality exhibited during or w/i 1 min of test completion

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15
Q

3-oz water swallow test identified…
sensitivity and specificity?

A

80% of pts who aspirated on subsequent MBS

sensitivity = 76%
specificity = 59%

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16
Q

3-oz water swallow test identified pts with…

sensitivity and specificity?

A

more severe dysphagia who aspirated larger amounts or thicker consistencies

sensitivity = 94% specificity = 26%

sensitivity 94%, specificity = 30%

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17
Q

what are the 3 steps of the yale swallow protocol?

A

exlcusion criteria
administation instructions
3-oz water swallow challenge

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18
Q

what are the exclusion criteria for the yale swallow protocol?

A

no concern

risk factors (if any, fail screening): unable to remain alert for testing, eating a modified diet due to pre-existing dysphagia, existing enteral tube feeding via stomach or nose, head of bed restrictions, tracheotomy tube present, NPO by physician order

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19
Q

what are the administration instructions for the yale swallow protocol?

A

brief cognitive screen

OME

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20
Q

what is involved in the yale swallow protocol for the 3 oz water challenge?

A

sit pt upright (80-90 degrees)

ask pt to drink entire 3 oz from cup or w straw, in sequential swallows, slow and steady but without stopping

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21
Q

pass on a yale swallow protocol

A

complete and uninterrupted drinking of all 3 oz w/o overt signs of aspiration (choking, coughing) either during or immediately after completion

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22
Q

fail on a yale swallow protocol

if fails…

A

inability to drink entire 3 oz in sequential swallows due to stopping/starting or pt exhibits overt signs of aspiration either during or immediately after completion

if fails, keep NPO and reco full objective swallowing eval

readminister protocol in 24h if pt demonstrates clinical improvement

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23
Q

yale swallow protocol:

inter-rater and intra-rater reliability….
sensitivity and specificity …

PPV and NPV….

all pts who passes the screening…

A

both IRR = 100% agreement
sensitivity = 100%
specificity = 64%
PPV = 78%
NPV= 100%

Did not aspirate on VFSS

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24
Q

the burke dysphagia screening test is used to …

A

identify pts at risk for pneumonia, upper airway obstruction, and death

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25
on the Burke dysphagia screening test pts fail or have a pos screen if they have one or more of the following:
bilateral hemisphere stroke brainstem stroke coughing associated w eating or 3 oz WST persistent failure to consume one half of meals prolonged time required for feeding nonoral feeding
26
Logemann et al 1999 = states that the best predictor of oral dysphagia is... best predictor of pharyngeal dysphagia is ... 2/3 asp episodes were predicted by...
a screening procedure for oropharyngeal dysphagia best predictor of oral dysphagia = dysarthria best predictor of pharyngeal dysphagia is = reduced laryngeal elevation 2/3 asp episodes were predicted by: - hx of recurrent pneumonia - coughing/throat clearing - reduced HLE
27
Martino et al (2000) did what? what did they dev? what does it focus on?
systematic review of lit from 1966-97 --> most screenings were related to laryngeal signs, most outcomes were related to physiology (not health outcomes) dev the toronto bedside screening test focuses on: - voice bf swallow - tongue movement - water swallow - voice after swallow
28
Daniels et al (2016) developed the rapid aspiration screening for suspected stroke - APMR - which looks at....
identified screening items based on sys review looked at items relative to asp on VFSS: - non swallow items: male sex, age >70y, lethargy, dysarthria, wet vocal quality, abnormal volitional cough - swallowing items: coughing after swallow, throat clear after swallow, wet vocal quality after swallow, inability to cont drink 90ml water, wet vocal quality after 1 min 93% sensitivity and 98% predictive value
29
clinical swallowing assessment (CSA) =
aka bedside/chairside swallowing assessment or clinical swallowing examination non invasive method to assess oral skills and infer pharyngeal swallowing function used in variety of settings can look quite diff across settings, clinicians = should strive for common components
30
what are the 4 goals of CSA?
evaluate overall health, cog status, physical limitations determine immediate safety and efficiency for oral intake determine if instrumental assessment is warranted and pts readiness for instrumental assessment determine if further referrals are needed
31
what can we used to test body functions/structures of ICF?
features of swallowing disorder OME, Trial swallows, FEES/MBS
32
what can we assess for activities of ICF?
dietary level, pt reported eating ability FOIS, EAT-10, RSI
33
what can we assess to test participation of ICF?
engagement in social eating PSS-HN, MDADI QOL = MDADI, SWAL-QOL
34
what are 4 indications for CSA?
failed swallow screen family caregiver/pt concerns weightloss or nutritional failure pulmonary hx suggestive of asp
35
describe the utility of CSA
enables SLP to describe and elucidate symps thru examination of sensory and motor aspects of the oral mechanism determine need and readiness for further assessment
36
5 limitations of CSA
cannot evaluate the entire upper aerodigestive tract cannot evaluate timing of events w/i the pharyngeal phase cannot evaluate the pharyngeal strength residue status is unknown asp status might not be definitvely known
37
4 factors to consider during CSA
medical diagnoses and stage/progression of diseases (prognosis) nature and severity of dysphagia pt/caregiver preferences and goals (consideration of advanced directives/cultural influences) available resources for further intervention
38
4 tasks of CSA
gather medical hx and info about swallowing complaint detail swallowing hx conduct clinical examination and/or observation report impressions and recos
39
what are the tools required for the CSA?
medical chart review, referral forms general observations pt/caregiver/HCP interview CN/OME Cough ax motor speech exam cog-comm/lang screen trial swallows/observe eating symp report/QOL questionaire
40
what info do we want to gather from the medical Hx and swallowing complaint?
primary diagnosis, medical status, referral Q swallowing complaint: onset time and type, symps, precipitating events, current character/manifestations of the prob readiness for ax
41
what other systems may we want to gather info about during the medical hx and swallowing complaint portion?
cardiac airway status GI neuro ENT oral care/dentition med probs, hospitalizations, surgeries prior voice/speech/swallow probs and interventions psychiartic and social hx meds
42
what do we want to know about the swallowing hx?
current method/mode of nutritional intake (oral vs nonoral) diet (type, amount, freq, food preference, eating habits) onset of prob (time/date, gradual vs sudden, concurrent w other med issues)
43
7 levels of functional oral intake scale (FOIS)
level 1 --> nothing by mouth level 2 --> tube dependent w minimal attempts of food or liquid level 3 --> tube dependent w consistent oral intake of food or liquid level 4 --> total oral diet of a single consistency level 5 --> total oral diet w multiple consistencies but requiring special preparation or compensations level 6 --> total oral diet w multiple consistencies w/o special prep level 7 --> total oral diet w no restrictions
44
what do we want to know about the description of the swallowing problem?
context (when, where, eating vs not eating) cough or choke, food getting stuck weight loss localization and characterization social/emotional impact
45
what variability and compensations should we consider in swallowing history?
variability: - foods: pills, solids, liquids - temp -eating time -secretions compensations: - rate - consistency - posture - other (bolus placement, straws, synringes etc)
46
during the CSA overall conditioning includes observing...
cognition, alertness/endurance, nutritional status, readiness for assessment/instrumental assessment
47
during the CSA posture includes ..
determining the need for support
48
during the CSA airway includes observing...
status, tracheostomy tube (type and status), room air/nasal prongs or mask work of breathing
49
during the CSA following instructions includes observing...
ability, need for verbal/gestural cues, hearing/vision loss, translator?
50
during the CSA self feeding potential includes observing...
current mode of nutritional intake independence w or w/o special equipment
51
during the CSA oral hygiene includes observing...
pt comfort, reduce risk of pulmonary complications resulting from aspiration evidence of oral sensory and/or motor diff
52
pt/caregiver interview during the CSA helps....
to gather info regarding current swallowing function (in comparison to previous function) where appropriate document pts report of the presenting prob determine risk for dysphagia/aspiration determine appropriateness for pt eval of swallowing function
53
CN exam and OME during the CSA helps to...
determine integrity of innervation to the head and neck musculature (strength, symmetry, ROM) to determine oral cavity and oropharynx sensitivity to determine level of neurological dysfunction - predict impact of dysfunction on swallowing function - some clinical signs are highly predictive of dysphagia/aspiration in adults
54
OME assesses...
structure sensation reflexes movement oral sensorimotor integrity secretions articulation resonance
55
OME pharyngeal/laryngeal function: vocal quality or changes can be observed as...
hoarsness or breathiness
56
OME pharyngeal/laryngeal function: pitch control or range can be observed as...
laryngeal agility
57
OME pharyngeal/laryngeal function: breathing can be observed as...
stridor, weak vocal intensity
58
OME pharyngeal/laryngeal function: volitional cough, throat clear shows...
ability to clear aspirate
59
OME pharyngeal/laryngeal function may also include
saliva swallow liquid and/or food swallows
60
motor speech examination during CSA is used to
characterize speech features and establish diagnosis if abnormal to determine level of neurological dysfunction - evidence suggests likihood of co-occuring motor speech disorder and dysphagia in adults
61
CSA cough assessment is used to
determine adequacy of airway defence may help determine if pt has adequate cough to clear aspirated material association bw cough effort and airway invasion
62
cog-comm/lang screen during CSA is used to
determine presence and severity of impairment disorientation is associated w inc risk of asp impairments in cog/lang function can influence dysphagia management
63
trial swallows during CSA under safe circumstances are used to... (3 reasons)
to observe signs or pt reported symps suggesting possible dysphagia/aspiration (if asp suspected, pt x10 more likely to asp on VFSS) to trial strategies to assess influence on swallowing safety and efficiency (further ax strategies during instrumental ax) to determine appropriateness for oral intake and assist in reco safest consistencies for oral diet (diet recos from CSA correlate w instrumental exam findings)
64
what are the three ways to modify the trial swallows?
modify the bolus --> thickened liquids, alter food texture modify bolus delivery --> modifiy administration, position, strategy observe a meal
65
when should we reconsider trial swallows? (when risk is high and benefit is low)
acutely ill not cleared for oral intake (post surgery) sig pulmonary compromise weak vol cough cannot follow directions and is suspected of having. pharyngeal swallowing disorder
66
the CSA is NOT..... water swallows?
a perfect predictor of asp in general, tends to underestimate dysphagia, and overestimate asp water swallows - large seq sips good at ruling out asp; small sips from teaspoon good at ruling in asp if clinical signs are present
67
Daniels et al (2000) found 6 clinical indicators that sig predicted risk of asp: presence of 2...
abnormal vol cough abnormal gag dysphonia dysarthria cough after swallow voice change after swallow presence of any 2 of 6 sig distinguished mod/sev dysphagia from mild dysphagia/normal swallowing
68
on a CSA symptom report/QOL helps to...
determine presence and impact of swallowing impairment on daily functioning and/or QOL can be used to document change of swallow function and effectiveness of dysphagia intervention
69
SWAL-QOL is ...
comprehensive but lengthy requires computer program for analysus validated for wide range of dysphagia etiologies
70
10 subscales on SWAL-QOL
food selection burden mental health social functioning fear eating duration eating desire communication sleep fatigue
71
on the MDADI a 10 pt diff is
considered a clinically sig difference
72
what should be included in a summary of info on a pt after CSA?
generally: pt specific risk factors for dysphagia/asp specifically: - method of administration of trial swallows - sign/symps present, when occured, on what consistency, freq of occurence - also, impression of factors that may impact/dictate further intervention
73
what should be reco after CSA?
intake status safe swallow strategies instrumental ax = if pt demonstrated s/s of asp; if unable to maintain nutrition/hydration, or associated w weight loss or compromised health other referrals
74
instrumental ax after CSA may include...
suspected airway invasion = VFSS or FEES Determine appropriateness of compensatory strategies, safest consistencies for oral intake (VFSS/FEES) determine rehab options based in imp physiology (VFSS)
75
referral to other professionals after CSA may be bc of ...
concern for eso dysfunction abnormal CN exam cog impairment oral hygiene/dentition concerns nasopharyngeal or laryngeal structural concerns
76
CSA reliability....
all swallowing ax require subjective clinical interpretation to some degree CSA requires sig clinical interpretation intra-rater reliability is generally stronger than inter-rater reliability (inherent issues w intra-rater including change in pt status, and ease of remembering prior findings) WRT to inter-rater reliability: - w no training less than half of items of CSA can be judged reliably - experienced clinicians tend to be more reliable of judgements of overall severity, but recos dont always align
77
Mann Assessment of swallowing ability (MASA)
only standardized CSA battery 23 item clinical dysphagia examination psychometric props initial evaluated in stroke pts results quantitative and qualitative appropriate for neurological and age-related swallowing diff
78
4 main limitations of CSA?
no study has shown that CSA can: - elucidate pharyngeal or upper eso physiology - guide effective treatment selection - prevent neg health consequences reliance on outcomes of CSA may depend on: - pt dx and health status, availability of additional ax options, clinician expertise
79
CSA is a critical component of our ax, and much more...
powerful than a screening tool
80
CSA =
a process that allows for systematic decision making based on known risk factors can serve to document evidence predictive of dysphagia/asp, and chart change over time

9633 Swallowing (11 decks)

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