So many people assess dysphagia in the same manner, at least from my observations. Sit with them while they eat a meal, feel laryngeal elevation and trial diet modifications. I have rarely seen people do a thorough dysphagia bedside evaluation.
I’m trying to standardize the manner in which I complete my bedside evaluation. I have started using the SOPE, the MASA and the Sage during every assessment, along with a thorough chart review and assessing aspiration risk factors. I can complete a fairly thorough assessment. The SOPE assesses cranial nerves, taste buds and some muscle function. The Sage assesses oral cleanliness and need for oral care. The MASA has been a fairly accurate indicator of dysphagia from my standpoint. I also do the traditional feel for laryngeal elevation, but I also feel for hyoid protraction. I have started assessing with water and graham crackers. If I need to, I will thicken the liquids, but usually wait for an instrumental assessment. I also have started using the 3 ounce water swallow challenge, which has been a good indicator for aspiration from what I have done so far.
It is important to assess cranial nerves and to understand the cranial nerves. For instance CN XII, the hypoglossal nerve has no sensory pathways, only motor. This definitely affects the means by which you will treat. Another point that has been drilled into my head is that sensory input drives motor output. If you can increase the sensory input a person receives you can increase the amount of output in the muscle functions. Cranial nerve assessment is vital in understanding dysphagia. Sensory input such as olfactory and optical help to prepare the person for the swallow by increasing saliva and telling the body that it is going to masticate and swallow food/drink. Sensory input can also be established through tactile, thermal, or NMES input. In fact, Vitalstim placement 1 has the highest sensory input of all the Vitalstim placements. DPNS is highly driven by sensory input to the cranial nerves through use of frozen lemon swabs, along with thermal, tactile stimulation (TTS).
You can actually tell a lot about a person by their oral hygiene. You can tell who will qualify for Frazier Water Protocol. Also, by oral hygiene, you can make an assumption that the person is at higher risk for aspiration pneumonia because of the poor hygiene of the oral cavity. It is important to let nursing and nursing staff know how often to complete oral cavity for patients that are unable to complete this task with independence.
It is vital to assess motoric function. You treat the motor dysfunction, not the symptoms, i.e. aspiration. If you assess a person and can only tell that they are aspirating, but not WHY they are aspirating, you are no better off than you were before the assessment. There are many areas of function that are vital to swallowing, labial closure, lingual to palate contact, bolus management and propulsion (lingual strength), velar elevation, tongue base retraction, pharyngeal sqeeze, hyolaryngeal excursion (laryngeal elevation, hyoid protraction and hyoid thyroid approximation) and UES opening. I am extremely excited about the MBSImP which will be published next year with certification courses to follow!!
The 3 ounce water swallow challenge is fairly new. It is an indicator of aspiration as it is believed, people that silently aspirate small amounts of liquid will choke with larger volumes. 3 ounces of water is enough to make a person choke, as it is stated per this protocol that silent aspiration is volume dependent. With this challenge, the person is given 3 ounces of water, either by straw or cup sip. They drink the water continuously. Any coughing, throat clearing or inability to drink all 3 ounces at one time is considered a fail. If the person can continuously drink the water and not cough during or for a minute after the challenge, they pass. Those that fail are then assessed instrumentally.
Watching a person eat is also very critical to the evaluation. One predictor of aspiration is inability to self-feed. Medication can often affect a person’s ability to swallow, affect amount of saliva a person has to help break-down the food orally or affect the person’s alertness.
A thorough dysphagia exam is vital and necessary for treatment. A good bedside examination with instrumental assessment will aid you in accurate assessment for thorough and appropriate treatment for dysphagia.