Posted on 6 Comments

Modified Barium Swallow Study……Part 2

I was recently directed to a blog post by Clinical Colleagues Confidential. regarding Modified Barium Swallow Studies (MBSS).

 The title of the blog post is:

 I have all the answers but nobody is asking me any questions

The original blog post can be found at:  http://cccslp.net/whats-the-frequency-3/

 This is part 2, because I recently wrote a post about MBSS.

 Being an SLP that actually completes MBSS, I felt I needed to address some of these issues comments.

1) I stopped the MBS because I was afraid the patient would aspirate.  Patients aspirate……it happens.  They have probably been aspirating for a long time prior to your study.  If you are afraid of aspiration, how can you assess the patient’s true swallow function?

2) The patient was coughing so I changed him to pudding at bedside.  Patients cough.  You need to check the patient’s meds (some actually cause a cough) and trial a consistency more than once to determine if the consistency is causing the cough.  It is also helpful if you use an instrumental exam such as FEES or MBSS to determine the physiology of the swallow.

3) I didn’t try thin during the MBS because at the nursing home he was already on nectar so I started there.  I use the protocol employed by the MBSImP.  Thin is tested.  I don’t stray from my consistencies.  I use thin, nectar, pureed and cookie with every patient (unless there is a very valid reason to not do a certain consistency).

There are many pieces of information you can use when you assess thin that you don’t get from nectar.  That’s why I don’t skip it.

4) There’s no speech at nursing homes so I put her on the safest diet; puree and pudding thick.  Who says that pureed and pudding thick is the safest.  Sometimes thick is not necessarily better.  Many people eat safely, millions in fact without the presence of speech.  You should not punish your patient because of lack of SLP.

5) A suspected timing delay of the epiglottis might be present and could lead to aspiration even though none was apparent on the MBS but to be safe I recommend nectar thick liquids.  If you did the MBSS, you should know if there is a delay of the epiglottis or not.  You SHOULD be assessing the epiglottis.  You should also know that epiglottic movement is indicative of hyolaryngeal excursion.  Sometimes you don’t see aspiration on the MBSS but you should be looking at airway protection and hyolaryngeal excursion which is an indicator.

 6) I didn’t want to recommend something they might aspirate and get sued.

I wish there was no number 6. Sadly, I think it is the driving force behind many of the recommendations. But, I would spread some words of caution to my peers, especially the younger ones. The only thing that avoids litigation is luck. The thing that wins litigation is expertise and documentation.

If you make a swallowing recommendation in isolation of the needs of whole patient to save him from aspiration pneumonia and he goes into renal failure…that’s a big problem.  I agree….documentation is key.  If you document that the patient appears safe, that is your finding.  You should be confident in your skills and you should be effective in your skills in completing MBSS.  This is not an area we can make a mistake because that can put your patient at high risk for pneumonia, respiratory issues, maybe death.  You recommend what’s appropriate for that patient without worry about litigation.

We seriously need to take a look at our profession.  WE are the experts in dysphagia.  We need to demonstrate our skills as experts.  Dysphagia is not an area we can “tinker” in.  

I highly recommend that any SLP completing MBSS that has made any of the above statements, take the Modified Barium Swallow Impairment Profile (MBSImP) by Bonnie Martin Harris.  This is becoming the gold standard for standardization of modifieds.  

Our responsibility as SLPs completing MBSS is to determine the physiology and etiology of the swallow/dysphagia.  We need to determine what is functioning and what is not functioning in the oropharyngeal mechanism.  Our job is not to state aspiration or penetration or….I coulnd’t do that because I was scared of this.  Our job is to state epiglottic dysfunction, lingual dysfunction, decreased laryngeal elevation, decreased arytenoid movement, and so on.  

SLPs need to take a stand and become experts in the area of dysphagia.

 

untitled design-2

Posted on 8 Comments

Go With the (Peak) Flow

 

A Clinical Swallow Evaluation is a series of screens that we use to determine if the patient requires more testing or not.

Let’s face it, whether we like it or not, insurance likes objective data, including numbers indicating a deficit or no deficit.   Peak Flow is a tool that gives us objective numbers to input into our reports.

What is Peak Flow?

A Peak Flow meter measures how fast air is expelled from the lungs in one fast blast.  A Peak Flow meter can be very beneficial to those with asthma.

Peak Flow also gives us information on the cough reflex and function of the cough, in turn, allowing us to determine patients that are at risk for penetration and/or aspiration.

Why do we care about coughing?

Coughing is a mechanism of airway clearance that adds to normal
ciliary function comprised of three events

  • Inspiratory effort
  • Followed by rapid vocal fold adduction
  • Contraction of the expiratory muscles

Respiratory Muscle Strength Training (RMST)

You can also use Peak Flow to determine baseline for RMST and to measure outcomes throughout your therapy using RMST.

So what has research told us about measuring Peak Flow?

We measure using PEF or Peak Expiratory Flow or PEFR Peak Expiratory Flow Rate.

  • Smith-Hammond, et al 2009-Peak flow identified 82% of aspirators
    (stroke patients) at PEF <2.9 L
  • Pitts, et al  2010-Peak flow identified 86% of aspirators (Parkinson’s) at
    PEF <5.2 L
  • Suarez, et al 2002 identified 74% aspirators (ALS) at
    <4.0 L
  • Plowman, et al 2016 identified voluntary cough airflow in patients with ALS at risk for penetration/aspiration

Peak Flow meters can be purchased to use.

PF 1        PF 2

A less expensive Peak Flow model will have a plastic piece on the side that moves as the person exhales or coughs into the device.   You can determine the PEF or PEFR by having the person exhale or cough into the device 3 times and figuring the average rate.

PF 3

You can also purchase a digital device which will give you a more accurate reading, but will cost you a bit more.

These devices can be purchased on Amazon or a medical supply store.   You can often purchase disposable mouth pieces so that you can use the device with multiple patients after cleaning.

References:

Gregory, S. A. (2007). Evaluation and management of respiratory muscle dysfunction in ALS. NeuroRehabilitation22(6), 435-443.

Hammond, C. A. S., Goldstein, L. B., Horner, R. D., Ying, J., Gray, L., Gonzalez-Rothi, L., & Bolser, D. C. (2009). Predicting aspiration in patients with ischemic stroke: comparison of clinical signs and aerodynamic measures of voluntary cough. Chest135(3), 769-777.

Pitts, T., Troche, M., Mann, G., Rosenbek, J., Okun, M. S., & Sapienza, C. (2010). Using voluntary cough to detect penetration and aspiration during oropharyngeal swallowing in patients with Parkinson disease. Chest138(6), 1426-1431.

Plowman, E. K., Watts, S. A., Robison, R., Tabor, L., Dion, C., Gaziano, J., … & Gooch, C. (2016). Voluntary cough airflow differentiates safe versus unsafe swallowing in amyotrophic lateral sclerosis. Dysphagia31(3), 383-390.

Suárez, A. A., Pessolano, F. A., Monteiro, S. G., Ferreyra, G., Capria, M. E., Mesa, L., … & De Vito, E. L. (2002). Peak flow and peak cough flow in the evaluation of expiratory muscle weakness and bulbar impairment in patients with neuromuscular disease. American journal of physical medicine & rehabilitation81(7), 506-511.