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What Would You Do?

I would love to share a story with you. 

Now keep in mind, I’ve been an SLP for a lot of years and feel that I do a pretty good job.   Sometimes, I may even get a little over-confident in my skills and have to examine what I’m doing.

Let’s talk about a patient I’ve had.   All identifying information will be withheld. 

This person was referred after a family member was concerned with increased choking with food and drinks.   This patient has a history of dysphagia, which had resolved. 

I get the call to go in and go in prepared for an evaluation. I did everything I would normally do in an evaluation.

I did a cranial nerve exam which all the cranial nerves seem to be intact. I had the person eat and drink while I observed. I even palpated the larynx to see what I could feel. Everything seemed to be quite normal.

I have to do vitals for home health so I went ahead and got out my pulse oximeter to see if there is any change in the person’s sats. They were able to drink some water with no change in 02 saturation.

Everything seemed to check out pretty well however the family was still very concerned, so just to cover my bases and to make sure that I hadn’t missed something I requested a modified barium swallow study.

Now imagine my surprise when I get the report for that swallow study and find out that this person’s actually aspirating multiple consistencies.

The person has timing issues with laryngeal elevation and closure and with oral containment prior to the swallow.

I mean really how can that be?

There was no change in O2 sats for me. The larynx felt like it was moving pretty well. Cranial nerves seem to be intact and functioning.

Where did I go wrong?

I didn’t. I realized my limitation without visualization. I have read my research and know that O2 sats and palpation is not always accurate.

I did right by my patient and pushed for instrumental exams.

I had push-back at first. Do you really need an instrumental? Can’t you just treat? When I told the company I need the instrumentals or I’m referring patients to another company, they started approving my requests.

Do right by your patients.

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The Swallow in Detail

The Swallow in Detail

 

Taken from: *Dysphagia Foundation, Theory and Practice by Julie Cicheroand Bruce Murdoch*

 

Hunger

Smell of food, empty stomach or electrolyte imbalance informs hypothalamus of the need to eat.

Brainstemactivates nucleii of CN VII and IX to promote secretion of salivary gland juices to prep for bolus

 

Chewing 

Bolus in mouth.  CN VII ensures good lip seal (orbicularisoris) while CN V relays sensory info to brainstem to constantly modify the fine motor control of bolus prep.

Motor activity to CN V, VII, IX, X, XII to create an enclosed environment within the mouth to prepare the bolus.

Cheeksprovide tone (buccinator CN VII).

Soft palate tense and drawn down towards tongue (tensor velipalatini CN V and palatopharyngeusCN IX)

Tongue is drawn up towards the soft palate (palatopharyngeusCN X, styloglossus CN XII).

Hyoidbone is stabilized (infrahyoid muscles CN XII and C1-C3) to allow movement of the mandible).

Bolus prepared by closing (temporalis, masseter, meial pterygoid,lateral pterygoid, CNV) and opening (mylohyoid and anterior belly of digastric CNV, geniohyoid CNXII &C1-C3.)

Bolus pushed around the mouth by actions of the tongue to create a consistent, homogenous texture (hypoglossus, genioglossus,styloglossus and 4 groups of intrinsic muscles of the tongue CN XII). Taste sensations (CN VII and IX) provide info to cortex to stimulate areas of brain required to coordinate the swallow (insulaand cingulatecortex).

 

Voluntary initiation

Once bolus is adequately prepared.

Soft palate elevates slightly (levator veli palatini and palatopharyngeusCN X).

Slight elevation of hyoid bone (suprahyoid muscles contracting on rigid mandible with slight relaxation of infrahyoid muscles.

Pharyngeal tube is elevated (stylopharyngeus CN IX, palatopharyngeusand salpingopharyngeus CN X).

Tongue delivers bolus to force bolus distally towards posterior wall of the pharynx in a “piston-like” manner using hard palate for resistance. Sensation by CN XI and by CN X (pharyngeal plexus).

 

Larngeal elevation

1st motion for tongue to propel bolus into oropharynx is elevated anterior direction toward roof of mouth (mylohyoid and anterior belly of digastric, CNV; stylohyoid and posterior belly of digastric CNVII; palatoplossusCN X; genioglossus, hyoglossus and styloglossusCN XII; geniohyoid CN XII and C1-C3) affects hyoid elevation in an anterior direction.

Soft palate seals off nasopharynx.

Superior constrictors begin medialization of the lateral walls.

Larynx elevated and moved anteriorly in relation to hyoid bone by thyrohyoid CNX.

 

Laryngeal closure

During laryngeal elevation-vestibule closes and rises relative to thyroid cartilage (cricothyroid and intrinsic laryngeal muscles CN X).

Opposition and elevation of arytenoid cartilages provide “medial curtains” of pyriform recesses (aryeppiglottic folds).

Pressure exerted on base of epiglottis causing it to tip and cover the laryngeal vestibule.

Medial constrictors (CN X) “strip” the pharynx by medialization following on from superior constrictors.

Palatedescends (palatopharyngeus CN X), constrictors “strip” and tongue moves posteriorly (styloglossus CN XII) to close oropharynx.

Once the bolus has reached pharyngeal areas innervated by the internal branch of the superior laryngeal nerve swallow reflexive and cannot be stopped.

Anterior and elevated movement of larynx allows cricopharyngeus to be stretched (UES) and opened.

Inferior constrictor finishes medialization and bolus in esophagus.

 
 

Resting state

CNX

Cricopharyngeus resumes tonic state.

Glotticopens and larynx lowers.

Ifbolus present should cough.

Tongue and hyoid and palate return to resting position.

**Oral phase for liquid boluses should take 1 second and the pharyngeal phase with all consistencies should take 1 second.**The ability to contain a bolus is prognostic.**The swallow is a positive pressure phenomena where the pressure is always on the tail of the bolus.

 
 

Triggering the pharyngeal swallow response:

 

        The bolus stimulates CN IX, X, XI in the medullary reticular formation

        (nucleus tractus solitarius) (NTS).

 

        Incoporates (NTS) input from V, VII, XII

 

        NTS signals motor nuclei in teh nucleus ambiguus to help fire IX, X,

        XI.

 

        Nucleus ambiguus innervates muscles of the velum, pharynx, larynx,

        and upper esophagus (IX, X, XI) producing the pharyngeal swallow

        response.

 

       Strongest ties to the NTS=anterior faucial arches, posterior tongue at

       the lower edge of the mandible, valleculae, pyriform sinuses and

       laryngeal aditus.

 

       The anterior faucial arches have a strong connection between the

       sensory receptors and NTS via afferent fibers of the glossopharyngeal

       nerve (IX) creating a trigger point for younger adults.  (Swallows in

       older adults may trigger lower.)

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Dysphagia Assessment

Assessing Dysphagia

Always the same……

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 watched SLPs complete a thorough dysphagia bedside evaluation.  There is no standardization of the Clinical Swallow Evaluation (CSE) 

Thorough Chart Review

Every evaluation should include a thorough chart review.   What complaints does the patient have?  What is the reason for hospitalization?   Why do they need a speech evaluation?

You will want to ensure that the patient actually has an order for speech.   You also want to check past medical history, what contributing diagnoses are there for dysphagia, if there is a history of swallowing difficulty.   You want to look at medications, lab results, xray results.   Any of this information can be critical in your diagnosis of dysphagia.

If the person has had a stroke, you want to find as much information as possible on the stroke.   If the person has head and neck cancer you want to know where the tumor is and the tumor grade.   You want to know the course of treatment, if there was surgery, chemotherapy, radiation including how much and what kind.

Standardized Assessment

I have worked to standardize the manner in which I complete my Clinical Swallowing Evaluation. I have started using the SOPE, the MASA, the EAT-10 and the OHAT during every assessment, along with a thorough chart review and assessing dysphagia risk factors.  There are many other outcome measures available out there as well.   You can find an entire list of outcome measures with links!

I can complete a fairly thorough assessment. The SOPE assesses cranial nerves, taste buds and some muscle function. The OHAT assesses oral cleanliness and need for oral care. The MASA has been a fairly accurate indicator of dysphagia and aspiration.   The EAT-10 is a self-assessment tool that the patient can complete.

The Yale Swallow Protocol is a screening tool that can be used by nursing staff and the SLP to determine a need for further evaluation.  The Yale can be 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. 

Cognition

It is important to look at cognition when you are evaluating dysphagia.   You don’t have to do a complete battery assessment, however you can look at the patient’s ability to answer yes/no questions, answer orientation questions and follow simple, 1 step commands.   Leder, Suiter and Warner found that patients that are not oriented x3 are 31% more likely to aspirate.   They also found that liquid aspiration is 57% more likely, puree aspiration is 48% more likely and the patient being deemed to be unsafe with any consistency is 69% more likely in patients that are unable to follow 1-step commands.

Cranial Nerves

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 assess,  treat and write your report.

Another point that can drive your treatment protocol is that sensory input drives motor output. If you can increase the sensory input a person receives you can increase the motoric response.

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.  Changing taste, flavor, temperature, texture and size of bolus can influence a swallow.

Oral Care

You can actually tell a lot about a person by their oral hygiene. You can tell who will qualify for a Free 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. 

Looking for more information on oral care?

Motor Function

It is necessary to assess motoric function. You treat the motor dysfunction, if present, 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 squeeze, hyolaryngeal excursion (laryngeal elevation, hyoid protraction and hyoid thyroid approximation) and UES opening. All of these are areas assessed through the MBSImP.

Observation 

Observation of a person eating a meal can also a part of  the evaluation. Observation of how a patient swallows pills, how many pills a patient takes, do they self-feed?  These can all be indications of aspiration pneumonia.   Observation should not compromise every treatment session with the patient.   

Writing the Report

When you write up your Clinical Swallow Evaluation, make sure you are thorough in your writing.   Include all of the observations.   You may want to include vital signs, if the person is on O2, how the O2 is presented and at what level.   How was the patient position, if they were being fed or able to self feed.   Include any information that is helping you to determine dysphagia.

Did You Answer All of Your Questions?

If, at the end of the CSE, you have not answered all questions about the person’s swallowing,  you will need to consider instrumental assessment, either Modified Barium Swallow Study or Flexible Endoscopic Evaluation of Swallowing.   Either of these assessments will help to give you more information on the patient’s swallow.

A Thorough Evaluation

A thorough dysphagia exam is vital and necessary for treatment. A good Clinical Swallowing Examination with instrumental assessment will aid you in accurate assessment for thorough and appropriate treatment for dysphagia.

References:

Leder, S..B., Suiter, D.M., & Warner, H.L. (2009). Answering orientation questions and following single-step verbal commands: effect on aspiration status.  Dysphagia, 24(3), 290-295.

Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia17(4), 298-307.

Martin-Harris B, Brodsky MB,  Michel Y,  Castell DO Schleicher D, et al.  MBS Measurement Tool for Swallow Impairment—MBSImp: Establishing a Standard.  Dysphagia, 2008, Volume 23, Number 4, Pages 392-405.

Suiter DM, Leder SB.  3 Ounces is All You Need.  Perspectives on Swallowing and Swallowing Disorders (Dysphagia).  2009; 18(4):  111-116.

Logemann, J.A. (1998).  Evaluation and treatment of swallowing disorders (2nd ed).  Austin, TX: Pro-Ed.27 Wijting Y., Freed M. (2009).  Training Manual for the use of Neuromuscular Electrical Stimulation in the treatment of Dysphagia.

Hamdy, S. (2006). Role of cerebral cortex in the control of swallowing. GI Motility online.doi:10.1038/gimo8.

Coyle, J. L. (2015). The clinical evaluation: A necessary tool for the dysphagia sleuth. Perspectives on Swallowing and Swallowing Disorders (Dysphagia)24(1), 18-25.

Langmore, S. E., Kenneth, S. M., & Olsen, N. (1988). Fiberoptic endoscopic examination of swallowing safety: a new procedure. Dysphagia2(4), 216-219.

Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia17(4), 298-307.

Leder, S. B., & Espinosa, J. F. (2002). Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia17(3), 214-218.

Daniels, S. K., McAdam, C. P., Brailey, K., & Foundas, A. L. (1997). Clinical assessment of swallowing and prediction of dysphagia severity. American journal of speech-language pathology6(4), 17-24.

Garand, K. L., McCullough, G., Crary, M., Arvedson, J. C., & Dodrill, P. (2020). Assessment across the life span: The clinical swallow evaluation. American Journal of Speech-Language Pathology29(2S), 919-933.

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Screening and CVA

Our hospital recently became Stroke Certified.  My initial reaction was sheer joy.  How many evaluations would that create for me!?!?!?!

My new reaction is HOW many more evaluations do I have to do on patients  that did not really have a stroke!?!?!?!

In working on Stroke Certification, nursing staff was educated on administration and interpretation of the 3 Ounce Water Swallow Challenge.   Having the nursing staff give the patients 3 ounces of water to swallow was one of the easiest ways to incorporate screening in their assessment.  It is also backed by research.

http://www.ncbi.nlm.nih.gov/pubmed/18058175

http://archneur.jamanetwork.com/article.aspx?articleid=592082

http://link.springer.com/article/10.1007%2Fs00455-007-9127-y

I continue to evaluate ALL stroke patients, per our protocol.

I assess them at bedside with trial consistencies.  Cranial nerves are examined through an oral mech exam.

http://en.wikipedia.org/wiki/Cranial_nerve

http://www.wisc-online.com/Objects/ViewObject.aspx?ID=ap11504

If you have access to ASHA SIG 13 Perspectives, there is an excellent Food for Thought regarding Cranial Nerves by Dr. Giselle Carnaby.

The most important part of a cranial nerve exam is to understand the nerve functions so that you can assess dysfunction during your oral mech examination.

By understanding normal you will be able identify abnormal.

My nursing staff, so far, has responded well to the 3 ounce swallow assessment and we will continue it in our facility.

So, people may wonder what other screening tools are available for dysphagia.

Remember, when looking at these screenings, you want to examine validity and reliability.  Some research terms:

Accuracy:   The amount the test result reflects the true clinical state. If disease is present, a truly accurate test will always give a positive result, whilst if disease is not present, the test will always give a negative result. This is not the case for all tests.

Sensitivity:   Sensitivity is the measure used to report how effective a test is in identifying individuals with a disease. The higher the sensitivity/the proportion of positive results the better.

Specificity:   The measure used to report how effective a test is in identifying individuals without the disease. The higher the specificity/proportion of negative test results the better.

Reliability: Reliability is the degree of consistency of what a test measures i.e. the extent to which a test or any measuring procedure provides the same result on repeated trials. Within the study, reliability is concerned with the consistency of the measurement tool when employed by nurses compared against its use by the SLTR for determining the presence or absence of dysphagia and the appropriateness of referring acute stroke patients to the SLT.

Validity: The extent to which a test accurately measures what it is supposed to measure. Within the research programme, validity is concerned with the measurement tool’s success at detecting the presence or absence of signs of dysphagia and the appropriateness of decisions to refer patients for full clinical dysphagia assessment when used by nurses in a given context with the acute stroke population as measured against the ‘Gold standard (the SLTR’s bedside assessment of swallowing) measure outcomes.

(Information from the Thesis The Design and Evaluation of a Valid Dysphagia Screening Tool for Acute Stroke Patients)

Screening Information

TOR BSST

http://www.ncbi.nlm.nih.gov/pubmed/19074483

http://stroke.ahajournals.org/content/40/2/555.full.pdf?keytype=ref&ijkey=n0zDwfiMa6KDe1P

Massey Bedside Swallowing Screen

http://www.ncbi.nlm.nih.gov/pubmed/12391741

Clinical Assessment of Swallowing and Prediction of Dysphagia Severity

http://ajslp.asha.org/cgi/content/short/6/4/17

Clinical and cognitive predictors of swallowing recovery in stroke

(Information taken from the above link)

Using the following:

Clinical predictors of aspiration risk. Predictor Operational Definition

Dysphonia Voice disturbance in parameters of vocal quality, pitch, or intensity.

Dysphoria Speech disorder resulting from disturbances in muscular control that affect respiration, articulation, phonation, resonance, or prosody.

Abnormal Gag Reflex Absent or weakened velar or pharyngeal wall contraction, unilaterally or bilaterally, in response to tactile stimulation of posterior pharyngeal wall.

Abnormal Volitional Cough Weak, verbalized, or absent response upon command to cough.

Cough After Swallow Cough immediately after or within 1 min of ingestion of calibrated volumes of water (5, 10, and 20 mL in duplicate).

Voice Change After Swallow Alteration in vocal quality after ingestion of calibrated volumes of water.

Score         Classification                                   Description

1                Normal                                                   No airway invasion.

2                Mild                                                      Bolus enters airway                                                                                        with clearing.

3                Moderate                                              Bolus enters airway                                                                                         without clearing.

4    Moderate                                              Bolus contacts vocal                                                                                      cords with airway                                                                                            clearing.

5   Moderate                                              Bolus contacts vocal cords                                                                             without airway clearing.

6  Severe                                                    Bolus enters trachea and is                                                                            cleared into larynx or out                                                                                of airway.

7 Severe                                                   Bolus enters trachea and is not                                                                      cleared despite patient attempts.

8 Severe                                                   Bolus enters trachea and patient                                                                    does not attempt to clear.

Classification                    Description

Normal-Mild                       Range from no laryngeal penetration to                                                        evidence of laryngeal penetration.

Moderate                           Two or less aspiration episodes of one                                                            consistency.

Severe                               More than two aspiration episodes of one                                                     consistency or aspiration of more than one                                                     consistency

50 ml water swallow test and/or pulse oximetry

http://www.ncbi.nlm.nih.gov/pubmed/11213241

Pharyngeal Sensation Assessment, Oromotor Assessment, and 50-ml Water Test

http://www.problemsinanes.com/pt/re/merck/fulltext.00007670-200305000-00035.htm;jsessionid=RGnQDnhy6rW2cTdSQnsdKZj9Fp8TznvgBRhb5ph07wVW9HXrP6LT!1786591821!181195628!8091!-1?nav=reference

Gag Reflex

http://www.ncbi.nlm.nih.gov/pubmed/16172818

30-ml water swallowing test 

http://www.ncbi.nlm.nih.gov/pubmed/16024482

Swallowing Provocation Test

http://www.ncbi.nlm.nih.gov/pubmed/11083358

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)74258-6/fulltext

Standardized Swallowing Assessment (SSA)

http://www.ncbi.nlm.nih.gov/pubmed/11822494

http://www.medscape.com/viewarticle/726565

Timed Test of Swallowing and Questionnaire

http://www.ncbi.nlm.nih.gov/pubmed/10024948

Oxygen Saturation Monitoring

http://ageing.oxfordjournals.org/content/29/6/495.full.pdf

http://www.ncbi.nlm.nih.gov/pubmed/11191240

50ml Drinking Test 

http://www.ncbi.nlm.nih.gov/pubmed/8902426

Resources for screening of swallowing ability and stroke.

The following is a link to a review of different dysphagia screening tools.  Screening Tools

The following is an interesting article for dysphagia s/p stroke.  Dysphagia and Aspiration Post Stroke

History Taking and Physical Exam

Slides regarding dysphagia screenings

Swallow Screening for Stroke Patient Resource Guide

SIG 13 Frequently Asked Questions (FAQ) on Swallowing Screening: Special Emphasis on Patients With Acute Stroke 

Swallow Screen Assessments in Literature

Screening Tests in Evaluating Swallowing Function

The importance of looking at screenings and deciding which is best for you is the responsibility of individual SLPs.  Understanding what to look for in a screen is important.

Do I recommend a diet based on a screening?

Nope.