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Measuring Outcomes for Success…..What are You Using?

The Dysphagia Toolbox

I have written about the Dysphagia Toolbox before.    The Dysphagia Toolbox used to be a website that offered links to standardized and reliable tools that you can use in dysphagia assessment and with reassessment.  

 

                                       

 

Why a toolbox?

The one thing I can’t help thinking is why we call it a toolbox.  Do most of you actually carry a toolbox full of your must-have dysphagia assessment/treatment equipment?  Mine is usually jammed in my lab coat pockets or on top of my clipboard, if I remember to even bring that with me!  Although I often imagine SLPs running around with a toolbox.   

 

Dysphagia Apron?

Maybe saying our dysphagia “apron” would be more appropriate??  Now, I have recently seen the SLP fanny pack, which may also be an option!

 

                                                     

 

Anway, I digress…

 Outcome Measures

There are several outcome measures that are freely available for us to use for your Dysphagia Toolbox.  Outcomes should be taken at baseline, when therapy is initiated and can be used to show progress during reassessment and to show progress for discharge. 

There are questionnaires that the patient completes, indicating current symptoms when eating/drinking including:

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Laryngeal Palpation

 

Why Are You Strangling the Patient?

Relax…..  You may walk in to observe a Clinical Swallow Evaluation and see an SLP with 3 fingers on a patient’s neck as the patient is swallowing.

What in the World are they Doing??

It’s called laryngeal palpation.   The ring finger goes on the patient’s cricoid notch, the middle finger is on the Adam’s Apple and the index finger is on the hyoid bone.  As the patient swallows, the SLP “feels” the hyolaryngeal movement and judges the speech of elevation.

What in the Heck is Hyolaryngeal ExWhatsion?

There are many factors to examine during hyolaryngeal excursion.   Hyoid “burst”, superior and anterior excursion of the hyolaryngeal complex.   Many of these key factors have to be viewed during MBSS using frame by frame imaging to determine amount of hyolaryngeal excursion.

The Evidence

One study (Brates, et al 2019) examined 87 patients through laryngeal palpation and Modified Barium Swallow Study to examine Hyolaryngeal Excursion (HE).   In 16 of the patients, HE was thought to be normal at bedside, but was found to be reduced during MBSS.   17 of the patients were thought to have reduced HE at bedside, but found to have normal HE during MBSS.   29 patients were judged to have normal HE at both bedside and during MBSS.

Te authors also stated that “Perceptual judgment is typically used in clinical settings to assess adequacy of hyolaryngeal excursion (HE), though the validity of perceptual techniques for assessing this physiologic component of swallowing has not been established.”

(McCullough and Martino 2003)  “The larynx should be palpated for timing and completeness of the swallow, as well as the number of swallows.” Poor laryngeal elevation on palpation can be an indicator of reduced laryngeal elevation or closure, particularly when combined with coughing or wet voice.

Bretan and Henry 1997 assessed 14 dysphagic patients and a group with normal swallows by palpating both to determine deviance of the dysphagic group.  They found that direct measurement and palpation of laryngeal mobility during swallowing tasks is noninvasive and can be used to evaluate dysphagia and the risk for aspiration as well as to physically monitor progression of dysphagia.

But Can You See It?

Palpation can be a part of your Clinical Swallow Evaluation, however remember that to truly understand hyolaryngeal excursion, you need to be able to visualize the movement of the structures.

References:

Brates, D., Molfenter, S. M., & Thibeault, S. L. (2019). Assessing hyolaryngeal excursion: comparing quantitative methods to palpation at the bedside and visualization during videofluoroscopy. Dysphagia34(3), 298-307.

McCullough, G. H., & Martino, R. (2013). Clinical evaluation of patients with dysphagia: Importance of history taking and physical exam. In Manual of diagnostic and therapeutic techniques for disorders of deglutition (pp. 11-30). Springer, New York, NY.

Bretan, O., & Henry, M. A. (1997). Laryngeal mobility and dysphagia. Arquivos de gastroenterologia34(3), 134-138.

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Cervical Auscultation

 

What is Cervical Auscultation?

Using Cervical Auscultation (CA) involves the use of a stethoscope, placed on the throat to “listen” to the sounds of the swallow.

Clinicians often use CA to assess swallow sounds and airway sounds.  Judgements are made on the normality of the swallow or the degree of impairment of swallowing.

Cervical Auscultation and Swallowing

In theory, “there are specific sounds related to events of the swallow.”   Some clinicians indicate that a swoosh, a click or a clunk can indicate physiologic events such as premature spillage, aspiration, laryngeal vestibule closure, penetration, etc.

Many clinicians swear by cervical auscultation, even replacing imaging with auscultation.

There is also an argument that there is no evidence on what causes swallowing sounds or whether these sounds correspond to physiological swallowing events.

The evidence tells us that CA may not be all it’s cracked up to be.

What does the Evidence Tell Us? 

A systematic review of cervical auscultation by Legarde et al 2016, reviewed 90 articles.  Using inclusion and exclusion criteria 6 articles were included in the review as the other articles did not meet criteria to be included.   (Full article can be accessed at the link below.)

The review found that the reliability of Cervical Auscultation is insufficient to be used as a stand-alone tool in dysphagia in adults.  There is no evidence of reliability or validity in Cervical Auscultation in the pediatric population.   Cervical Auscultation should not be used as a stand-alone tool in the diagnosis of dysphagia.

When CA was synchronized with endoscopy (Leslie, et al, 2007), they found that there was a wide-spread degree of the timing of swallowing sounds and physiologic events.  No individual sounds was consistently associated with any physiologic event.  There was no link between:

  • Pre-Click and onset of apnea
  • Pre-Click and the start of epiglottic excursion
  • Click and the epiglottis returning to rest
  • Click and the end of swallow apnea

They also found that the absence of a swallowing sound was not a sign of pathologic swallowing but that a repeated abnormal pattern may indicate an impairment.

In conclusion there is no robust evidence to support CA in dysphagia and judgement between SLP interpretation of sounds or absence of sound was poor.

Do You have an Opinion?

What do you think?  Are you for or against CA?  Maybe you have no opinion either way.  Let me know in the comments!

References:   

Lagarde, M. L., Kamalski, D. M., & Van Den Engel-Hoek, L. E. N. I. E. (2016). The reliability and validity of cervical auscultation in the diagnosis of dysphagia: a systematic review. Clinical rehabilitation30(2), 199-207.

Dudik, J. M., Coyle, J. L., & Sejdić, E. (2015). Dysphagia screening: Contributions of cervical auscultation signals and modern signal-processing techniques. IEEE transactions on human-machine systems45(4), 465-477.Leslie, P., Drinnan, M. J., Zammit-Maempel, I., Coyle, J. L., Ford, G. A., & Wilson, J. A. (2007). Cervical auscultation synchronized with images from endoscopy swallow evaluations. Dysphagia22(4), 290-298.

Leslie, P., Drinnan, M. J., Zammit-Maempel, I., Coyle, J. L., Ford, G. A., & Wilson, J. A. (2007). Cervical auscultation synchronized with images from endoscopy swallow evaluations. Dysphagia22(4), 290-298.

Leslie, P., Drinnan, M. J., Finn, P., Ford, G. A., & Wilson, J. A. (2004). Reliability and validity of cervical auscultation: a controlled comparison using videofluoroscopy. Dysphagia19(4), 231-240.

Borr, C., Hielscher-Fastabend, M., & Lücking, A. (2007). Reliability and validity of cervical auscultation. Dysphagia22(3), 225-234.

Stroud, A. E., Lawrie, B. W., & Wiles, C. M. (2002). Inter and intra-rater reliability of cervical auscultation to detect aspiration in patients with dysphagia. Clinical rehabilitation16(6), 640-645.

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The Yale Swallow Protocol

 

I think that we have all looked for that simple and easy screen that we can use for patients to identify a possible dysphagia.

We want a screen that’s not only easy for us to administer as an SLP, but that we can teach other professionals to utilize to assist in their referrals.

Let’s face it.  If you work in acute care, AND your building is stroke certified, you are probably already getting a referral to assess every single stroke patient that walks in the door.

So maybe we can use a screen, like the Yale Swallow Protocol to assist in screening patients.

The Yale Swallow Protocol was once known as the 3 Ounce Swallow.   This came from research looking at how accurate a screening could be by having a patient drink 3 ounces of water.  There is also a study looking at the efficacy of how much liquid is enough to elicit a cough response and 3 ounces seemed to be that magic number.

When administering the Yale Swallow Protocol, part of the protocol is an oral mech exam.  You really want to take a look at the oral structures and how they are functioning.

You also assess cognition.  How well does the person follow 1 step directions and accuracy of following yes/no questions.   Leder, Suiter and Warner  found that when patients are not oriented x3, they may be 31% more likely to aspirate.

There was also a correlation between aspiration and the ability to follow single step directions.   When unable to follow single step directions, patients likelihood of aspiration of liquids increased to 57%, pureed 48% and deemed unsafe for any oral consistency to 69%.

The Yale Swallow Protocol is easy to administer:

  1.  Give your patient a cup with 3 ounces of water.   (I always given them water that is room temperature.)
  2. Have your patient drink all the water without stopping until it is gone.
  3. They pass if:  they are able to drink all the water without stopping with no coughing or signs of swallowing difficulty.
  4. They fail if:  they are unable to drink all the water without stopping or they cough while drinking the water or immediately after.

Now, there are populations with whom I DO NOT use this screen.  I would not do this with someone who is:

  1.  not medically stable
  2. has severe respiratory issues
  3. severe dysphagia
  4. aspiration on previous bolus administration
  5. unable to manage secretions.

Want more information?

You can earn continuing education with Debra Suiter on Medbridge

Purchase the book on Amazon

Listen to the Swallow Your Pride podcast episode with Debra Suiter

References:

DePippo, K. L., Holas, M. A., & Reding, M. J. (1992). Validation of the 3-oz water swallow test for aspiration following stroke. Archives of neurology49(12), 1259-1261.

Suiter, D. M., & Leder, S. B. (2008). Clinical utility of the 3-ounce water swallow test. Dysphagia23(3), 244-250.

Garon, B. R., Engle, M., & Ormiston, C. (1995). Reliability of the 3-oz water swallow test utilizing cough reflex as sole indicator of aspiration. Journal of Neurologic Rehabilitation9(3), 139-143.

Suiter, D. M., Leder, S. B., & Karas, D. E. (2009). The 3-ounce (90-cc) water swallow challenge: a screening test for children with suspected oropharyngeal dysphagia. Otolaryngology—Head and Neck Surgery140(2), 187-190.

Suiter, D. M., Sloggy, J., & Leder, S. B. (2014). Validation of the Yale Swallow Protocol: a prospective double-blinded videofluoroscopic study. Dysphagia29(2), 199-203.

Suiter, D. M., & Leder, S. B. (2009). 3 Ounces Is All You Need. Perspectives on Swallowing and Swallowing Disorders (Dysphagia)18(4), 111-116.

Warner, H. L., Suiter, D. M., Nystrom, K. V., Poskus, K., & Leder, S. B. (2014). Comparing accuracy of the Yale swallow protocol when administered by registered nurses and speech‐language pathologists. Journal of clinical nursing23(13-14), 1908-1915.

Leder, S. B., & Suiter, D. M. (2014). The Yale Swallow Protocol: An evidence-based approach to decision making. Springer.

Leder, S. B., Suiter, D. M., & Warner, H. L. (2009). Answering orientation questions and following single-step verbal commands: effect on aspiration status. Dysphagia24(3), 290.