dysphagia final

clinical

Which comes first in assessment, clinical or instrumental eval?

false

done AFTER screening

T/F: Clinical examination is done before a problem has been identified (usually not by SLP).

all

Screening should be provided to --- patients in a category.

true positive: identified with true disease

true negative: identified with true absence of disease

false positive: identified with false disease

false negative: identified with false absence of disease

matching ~

A: identified with true disease

B: identified with true absence of disease

C: identified with false disease

D: identified with false absence of disease

terms ~ true positive / false positive / true negative / false negative

Sensitivity

:a test's ability to designate an individual with a disease as positive (few false negatives)

Specificity

a test's ability to designate an individual without a disease as negative (few false positives)

greater PPV

The more specificity in a test, the less likely the person with a positive test will be free of the disease = ---.

greater NPV

The more sensitivity in a test, the less likely the person with a negative test will have the disease = ---.

Positive predictive value

: probability that a patient with positive test result actually has the disease

Negative predictive value

: probability that a patient with negative test result actually does not have the disease

aspiration of saliva

a patient complaining of coughing when not eating may be a symptom of what?

consequences

With clinical evaluations, we watch a matching set of symptoms, signs, and ---.

difficulty chewing

match the sign and symptom:

Poor dentition; Tongue, jaw, lip weakness

difficulty initiating swallow

match the sign and symptom:

Xerostomia; Tongue weakness

Drooling

match the sign and symptom:

Infrequent swallows

nasal regurgitation

match the sign and symptom:

Bolus enters nasopharynx on VFS

swallow delay

match the sign and symptom:

Slow oropharyngeal transport on VFS

Food sticking

match the sign and symptom:

Residue in the esophagus on VFS

coughing and choking

match the sign and symptom:

Cough on test swallows

coughing when not eating

match the sign and symptom:

Aspiration of saliva on VFS

Reguritation

match the sign and symptom:

Positive pH probe study for acid reflux

weight loss

match the sign and symptom:

Measured weight below ideal standard

medical history

physical examinations

test swallow observations

what are the three main components of evaluation?

hospital records

What is the number one resource for medical history?

clinical observations

oral cavity inspections

cranial nerve assessment

aspects of physical inspection of swallowing:

50

If chest rise and fall rates are more than --- cycles per minute can indicate difficulty and/or abnormality.

~2-4 cm

What is the length for larynx elevation in a typical adult?

Alertness

Neuromuscular adequacy

Airway protection

swallow tests are reserved for patients who have demonstrated adequate:

false

T/F: Having failure in one swallow trial guarantees consistent failure.

3

Each bolus volume should be trialed --- times.

swallow safety

swallow efficiency

physiology

What do we look for in test swallows? (3)

cervical auscultation

-What is a method of making a judgment of delayed swallow response?

-technique for listening to a swallow response, involving a stethoscope placed at the level of the larynx

tongue

What causes the initial sound during cervical auscultation?

pharynx / esophagus / open

during cervical auscultation:

1st low-frequency burst: bolus enters ---

2nd low-frequency burst: bolus enters ---

3rd high-frequency burst: airway is ---

-Failure on thin or thick liquids

-wet voice or cough after swallow

-inability to self-feed

red flags for impaired airway protection: (3)

The 3-oz (85 ml) Water Test

Name the assessment:

Patients drink 3 oz. of water from a cup at self-determined pace, examiner notes cough or wet-hoarse voice for one minute

Impaired pharyngeal response

Male

Disabling stroke (Barthel <60)

Incomplete oral clearance

Palatal weakness or asymmetry

>70yrs of age

6 variables with significant predictive value for aspiration:

100 / 70

---% sensitivity and ---% specificity reported when a 50 ml water test is combined with a 2% drop in SpO2 in acute stroke patients, indicating aspiration.

McGill Ingestive Skills Assessment (MISA)

Name the assessment:

-Assesses functional eating skills in natural environment

-Designed initially for nursing home residents

Self-feeding*

Solid ingestion*

Texture management (variety of foods)*

In the MISA, what are the test areas that can show predicted value of time to death?

true

T/F: If a patient receives a score of <178 on the MASA, they are classified as having dysphagia.

Functional Oral Intake Scale (FOIS)

name the assessment:

documents patient's functional eating status

Functional Oral Intake Scale (FOIS)

Functional Oral Intake Scale (FOIS)

90% of patients who truly have the disease show positive results

A test shows 90% sensitivity, what does this mean?

90

---% of positive outcomes are truly positive

look at psychometrics (sensitivity, specificity, PPV, NPV)

efficiency

feasibility

easy to implement

good reliability (intra and interrater)

What factors impact the choices of a "good" assessment?

false

have LOWER odds

T/F: Patients who are tube dependent have the same odds of full recovery as someone without a feeding tube.

gag reflex shows pharyngeal constriction

"ah ah ah"

if they are able to do falsetto phonation

How do we directly evaluate the pharynx? (3)

thin liquids / solids / solids

pharyngeal dysphagia ~ difficulty with ----

oral dysphagia ~ difficulty with ---

esophageal dysphagia ~ difficulty with ---

mild dysphasia

aspiration

A patient scores 169 on the MASA, what does this indicate?

(2 items)

D

All the following rationales regarding clinical examination of swallowing are correct EXCEPT

A. Defining potential cause

B. Establishing a working hypothesis for the swallowing disorder

C. Establishing a tentative tx plan

D. Diagnosing an underlying disease

A

A dysphagia screening test with high sensitivity means

A. Most patients with dysphagia can be identified correctly

B. Most people with no dysphagia can be identified correctly

C. There is a high probability that a patient with a positive (abnormal) test result actually has dysphagia.

D. There is a high probability that a person with a negative (normal) test result actually has dysphagia.

A

Individuals with solid food dysphagia are more likely to have disorders of esophageal origin.

A. True

B. False

D

What is the associated sign with "food sticking"

A. Infrequent swallows

B. Bolus enters nasopharynx on VFS

C. Slow oropharyngeal transport on VFS

D. Residue in the esophagus on VFS

C

Clinical evaluation includes all the following, except

A. Obtaining a medical history

B. Inspecting the physical swallowing musculature

C. Conducting radiographic studies

D. Observing swallowing competence with test swallows

A

Oxygen saturation rates lower than 90% may indicate patients at risk for swallowing impairment.

A. True

B. False

A

Which test is specifically built to detect aspiration in patients with tracheostomy?

A. Modified Evans blue dye tests

B. Oxygen saturation tests

C. Videofluoroscopy

D. Water tests

B

Which of the following is a standardized test that evaluates a patient's functional eating skills in a natural environment?

A. Mann Assessment of Swallowing Ability

B. McGill Ingestive Skills Assessment

C. Mini Nutritional Assessment

D. Modified Barium Swallow Study

F - 6

What is the FOIS level in the following scenario? "Patient is eating a 'regular' diet except for salad, rice, meat, and bread"

A. Nothing by mouth (NPO) (1)

B. Tube dependent with minimal attempts at food or liquid (2)

C. Tube dependent with consistent intake of liquid or food (3)

D. Total oral diet of a single consistency (4)

E. Total oral diet with multiple consistencies but requiring special preparation or compensations (5)

F. Total oral diet with multiple consistencies without special preparation but with specific food limitations (6)

G. Total oral diet with no restriction (7)

C - 3

What is the FOIS level in the following scenario? "Patient on PEG but drinks different liquids daily and has tried some pudding level foods"

A. Nothing by mouth (NPO) (1)

B. Tube dependent with minimal attempts at food or liquid (2)

C. Tube dependent with consistent intake of liquid or food (3)

D. Total oral diet of a single consistency (4)

E. Total oral diet with multiple consistencies but requiring special preparation or compensations (5)

F. Total oral diet with multiple consistencies without special preparation but with specific food limitations (6)

G. Total oral diet with no restriction (7)

To determine the need for and the direction of swallowing rehabilitation

What is the purpose of MBS for speech pathologists?

lateral view for aspiration

AP view for symmetrical contraction

Name the best views of videofluoroscopy for aspiration and symmetrical oropharyngeal contraction.

VFE landmarks

landmarks

When the patient is at clear risk

When the clinical question has been answered

The issue of "when to stop" videofluoroscopy exam is not always clear, but two general guidelines are...

true

T/F: Recent work has suggested the order of bolus presentation does not impact the interpretation or outcome of fluoroscopic swallowing studies.

residue

There is a linear relationship between consistency and ---.

lower

Generally, the thicker the bolus, the --- the risk of airway compromise.

poor interrater reliability between clinicians

What is a downside of videofluoroscopy?

Modified Barium Swallow Impairment tool (MBSImp)

What is a highly validated and used tool for videofluoroscopy?

linear

There is a --- relationship between bolus volume and airway compromise and residue.

individualized

--- protocols are more common and advised for VFS.

a problem / penetration / aspiration / silent aspiration

The Penetration/Aspiration Scale interpretations:

more than 3 is considered ---

4-5 is considered ---

6-8 is considered ---

8 is considered ---

Pen/Asp Scale

name the exam:

This is NOT a dysphagia severity scale, it only ranks the depth of material entrance into the airway and patient's response.

Dysphagia Outcome and Severity Scale (DOSS)

name the exam:

-levels severity of dysphagia based on VFS data

-good interrater agreement

-downside: has not been validated

B

All the following indications suggest that an imaging swallowing examination is needed EXCEPT...

A. Respiratory issues create suspicion of dysphagia

B. Patient is too medically compromised

C. Swallowing safety is a concern

D. Dysphagia characteristics are unclear

D

All the following are among the objectives of Videofluoroscopy EXCEPT

A. Evaluating anatomy of swallowing mechanism

B. Evaluating swallow physiology

C. Identifying patterns of impaired swallow physiology

D. Evaluating the sensory aspect of swallowing

C

A patient reports a feeling of food being stuck after swallowing. VFS of oral-pharyngeal stages shows no sign of dysfunction. What is the next step?

A. Recommend thickened liquids for 3-5 days

B. Refer to ENT

C. Request an esophageal evaluation

D. Refer to psychologist

A

A patient shows no aspiration but increased residue on 5mL thick liquid. What would be appropriate to trial next?

A. 5 mL thin liquid

B. 5 mL pudding

C. 10 mL thin liquid

D. 10 mL thick liquid

B

A patient aspirates on 5mL thin liquid. What would be appropriate to trial next?

A. 5 mL thin liquid

B. 5 mL thick liquid

C. 5 mL pudding

D. 10 mL thin liquid

Purpose

Materials

Process of evaluation

list some similarities between endoscopy and videofluoroscopy: (PMP)

Technique

Image perspective

Portability

Repeatablity

Duration of examination

Sensory component

list some differences between endoscopy and videofluoroscopy: (TIPRDS)

Vocal cord closure

Laryngeal elevation

Epiglottic inversion

Pharyngeal closure

"White out"

Pharyngeal release

Laryngeal descent

Epiglottic return

Vocal fold re-opening

what do we see during a FEES exam?

58 / 7 / 35

Patterns of Maximal Vocal Fold Closure:

% = closed along entire glottis

% = posterior opening

% = no contact with small triangular opening

uvula and larynx

For endoscopy, between the --- and --- is the best place to start.

false

T/F: Decisions are often made on imaging alone.

fluoroscopy

Fluoroscopic vs. Endoscopic Swallowing Examinations:

-initial evaluation

-esophageal dysphagia

endoscopy

Fluoroscopic vs. Endoscopic Swallowing Examinations:

-paresis/paralysis

-anatomic deviations

-evaluate secretions

-patient cannot be transported

-repeated use

-biofeedback

true

T/F: Overuse of instrumental can weaken basic clinical precursor skills.

accuracy interpreting VFSS

Clinical knowledge of swallowing physiology is a significant predictor of ----.

clinical expertise / best research findings + patient values

Traditional clinical management focuses on --- and evidence based research focuses on ---.

best research evidence

patient values

clinical expertise

List the three parts of EBP:

Effectiveness

--- study: Treatment applied to a group to achieve a desired outcome with no control group for comparison.

Efficacy

--- study: Treatment applied to a group with a disorder and to another (control) group without the disorder to achieve a desired outcome.

systematic reviews of RCTs / expert opinion

What is the highest level of research? Lowest?

safely / adequate

General treatment consideration:

Can the patient --- resume or increase --- oral intake?

Passive Interventions

name the treatment choice:

-Limited patient engagement

-e.g. Oral hygiene, diet changes

active interventions

name the treatment choice:

-Patient engaged

-e.g. Techniques & maneuvers (Valsalva)

environmental interventions

name the treatment choice:

-Changes to the environment to facilitate feeding and swallowing

-e.g. Dining rooms, special mealtimes

behavioral

medical

surgical

What are the three categories of treatment options?

medical options

name the treatment option category:

-dietary modifications

-Pharmacological Management