Test 2

Question 1

Symptoms of GERD

Answer 1

Heartburn, Acidic taste, Regurgitation, Odynophagia, Dysphagia, Can reach level of larynx: voice difficulties (hoarseness)

Question 2

Treatment for GERD

Answer 2

• Diet (no spicy food; less lactose; etc.)
• Sleep (30-45 degrees head up on wedge to reduce chance of stomach acid going into larynx; posture)
• Meds (long-term negative effects)
• Surgery (If really severe)

Question 3

Zenker’s diverticulum

Answer 3

• Pharyngeal pouch due to weakening of pharyngeal wall near UES/PES
• Coughing up food after eating, complaints of GERD,
• Viewed best anteriorly/posteriorly on MBS study
• Tx: surgery

Question 4

Endotracheal tube

Answer 4

• Inserted in mouth via intubation, past VFs, into trachea
• Attached to ventilator and very medically fragile (usually ICU)
• Unfenestrated and cuffed (Closed airway so no vocalization)
• NPO (Latin: nil per os = nothing by mouth)
• Progression from endotracheal tube: If patient still needs ventilation, will insert tracheostomy tube

Question 5

Tracheostomy tube placement and size

Answer 5

• Placed in trachea, via trach stoma below VFs
• Different sizes (impinging on pharyngeal wall)- try to decrease size for comfort and better swallowing abilities because it will press against back of trachea and hit esophagus, which impinges swallow flow

Question 6

Outer cannula

Answer 6

holds stoma open

Question 7

Inner cannula

Answer 7

Inner cannula: fits inside outer cannula and removable for cleaning on daily basis

Question 8

Flange

Answer 8

neck plate anchored by neck ties that surrounds outer cannula to prevent tube movement

Question 9

Obturator

Answer 9

• used to open stoma if outer cannula is removed

- Like a “plunger” with a pointed edge in case stoma closes while things are being cleaned

Question 10

Cuffed vs noncuffed

Answer 10

• Cuffed (closed system): does not allow movement of trach tube or air to escape up the VFs, prevents aspiration, no vocalization
• Noncuffed (open system): suctioned to get secretions out, air escapes up the VFs and pt can vocalize

Question 11

Fenestrated vs unfenestrated

Answer 11

• Fenestrated (open system): hole on curvature of trach tube to allow increased airflow to upper airway and hit VFs for vocalization
• Unfenestrated (closed system): no opportunity for air to go through VFs so no vocalization

Question 12

decannulation

Answer 12

removal of trach tube

Question 13

progression of trach tube

Answer 13

• Decrease size of trach tube
• Cuffed to noncuffed
• Unfenestrated to fenestrated

Question 14

One-way valve

Answer 14

• Takes in air, air must exit through vocal folds

- Inner cannula is removed if one-way valve is used

Question 15

How do we conduct a bedside swallow evaluation with someone with a tracheostomy tube?

Answer 15

• Dye materials different colors
• if colour is seen around stoma = aspiration
• Deflate cuff, suction client to get secretions out of trachea & lungs
• DON’T stand directly in front of trach

Question 16

Describe the steps involved in a Bedside Swallow Evaluation

Answer 16

• 1/2 tsp puree
• “Hold it in your mouth”
• Place index finger on chin (jaw movement), middle finger on base of tongue (tongue pumping or other unwanted movement), ring finger on hyoid (feel for movement), and little finger on thyroid notch (feel for elevation)
• “Now swallow” (feel for wave motion, chin/tongue/hyoid/larynx movement)
• “Say ah” (listen for gunky or wet sounding “ah”)
• Can have them cough and then swallow and say “ah” again
• if still bad, do MBS
• otherwise do 1 tsp puree
• 1/2 tsp water, 1 tsp water
• small pieces of solid then bigger piece

Question 17

Limitations of bedside swallow

Answer 17

cannot see the structures and patient could silently aspirate w/out clinician knowing

Question 18

What are you looking for in bedside swallow?

Answer 18

• any delay or multiple swallows
• After each swallow, have the patient open their mouth and say “ah” listen for vocal quality and look for any signs of pocketing, which could indicate weakness or hemineglect. If the voice sounds wet or gurgly or coughing or choking is evident, recommend an instrumental dysphagia assessment to determine if there is any penetration or aspiration

Question 19

Parkinson’s disease

Answer 19

• Progressive
• Involuntary movement (tongue pumping- back and forth trying to push bolus posteriorly)
• Slowness (initiation) causes delay of swallow
• Drooling
• Esophageal abnormalities (e.g. GERD)

Question 20

Tx of PD

Answer 20

• Lee Silverman Voice Tx (LSVT): “Think loud, think big”, Recalibrate, Use muscles for swallowing, voice, & speech (strengthens pharyngeal musculature)
• Meds may temporarily help with symptoms (good time to eat)
• Monitor weight & nutrition (dietician/nutritionist, physician)
• Using spoon to place food more posteriorly on tongue to push it closer to oropharynx (but if weak pharyngeal phase… increase risk of penetration/aspiration)
• Chin-tuck: increase volume of valleculae to catch more food (but need to have strength to swallow)
• Alternative feeding (get patient perspective before too late)

Question 21

TBI

Answer 21

• Severity
• Recovery (agitation)
• May need alternative feeding
• Short bits of attention: can do swallow assessment (takes time; start with puree)
• Trach tube or ventilator
• Cognitive deficits, especially early on
• WM: Won’t remember what you tell them to do
• Sustained attention
• Lack of awareness
• Apraxia (Left hemisphere): Oral apraxia (cannot do oral mech movements) or apraxia of speech (cannot repeat speech)
• Reminder to chew & swallow

Question 22

CVA

Answer 22

• Acute stages (lethargy, fatigue, trach tube)
• Left CVA: Motor planning, right neglect, comprehension problems, More aware of penetration/aspiration
• Right CVA: Left neglect (pocket food on left side), cognitive deficits, silent aspiration, confabulation, Less aware of penetration/aspiration
• Could lead to: Aspiration pneumonia
• Tx: Control diet and hydration, Safety of oral intake, alternative feeding

Question 23

TNM system of cancer

Answer 23

-T (X to 4) = size of tumor
-N (X to 3) = affected the lymph nodes
-M (X to 1) = metastasis
-X = unable to assess
0 = no evidence (progressively worse as number increases)

Question 24

Chronic Obstructive Pulmonary Disease (COPD)

Answer 24

• Abnormal CO2 & O2 exchange, requires O2 with nasal cannula
• O2 desaturation during meals (add rest time between bites for breathing)
• Could lead to: Wet-sounding cough -> wet-sounding voice quality, Congestive heart failure, Aspiration pneumonia, Subcategories: emphysema, asthma, cystic fibrosis
• Tx: Meds relax LES but increase GERD potential

Question 25

During patient interviews, SLPs ask questions about dysphagia. What are typical questions we would ask?

Answer 25

- Medical history - What symptoms are you experiencing? Site of problem? -(may not be accurate) - Pt. interview/ caregiver interview - Provide questionnaire for dysphagia (which will vary by facility) - What is your current diet? Are there any textures you avoid or find hard to swallow? - Do you have symptoms of GERD? - Look for signs (clinical characteristics of dysphagia)

Question 26

When the SLP reviews the medical report for patients with possible dysphagia, what information should we focus on for swallowing issues?

Answer 26

- Congenital - Neurologic/neurogenic disorder - Psychiatric (e.g., Schizophrenia) - Surgical (anesthesia, endotracheal tube) - Cancer related - Systemic & Metabolic (e.g., diabetes, toxins) - Respiratory issues - Esophageal disorders - Prior swallowing studies - Advance directives (living will, feeding tube)

Question 27

Fibrosis:

Answer 27

- Thickening and scarring of connective tissue, usually as a result of injury or radiation for cancer - Affects mvmt of pharynx

Question 28

Trismus

Answer 28

reduced jaw opening

Question 29

Cervical auscultation

Answer 29

- Use of stethoscope placed laterally at level of VFs to assess swallowing sounds - Useful?

Question 30

Odynophagia

Answer 30

painful swallow

Question 31

Achalasia

Answer 31

- Nonrelaxing or incomplete relaxing LES | - Food cannot pass into the stomach so pt may regurgitate undigested food

Question 32

NPO

Answer 32

- “nil per os” (Nothing by mouth) | - Something nurses will put a pt as until evaluated by SLP

Question 33

Piecemeal deglutition

Answer 33

Little pieces being swallowed rather than cohesive bolus; saliva breaks away bits

Question 34

Describe the water test and why it is given.

Answer 34

- Other professionals give 3 oz of water to determine NPO until SLP can do study - Watch oxygen saturation level (usually below 90% = NPO) - Look for aspiration signs (water is the safest thing to aspirate as long as oral cavity is clean) - Coughing/choking - Changes in vocal quality - Not good at detecting ‘silent aspiration’