Screening- Dysphagia

screening goal:

identify individuals at risk for swallowing difficulties so that

appropriate f/u assessments and interventions can be initiated to improve

their safety and quality of life, particularly in healthcare settings like hospitals or long-term care facilities

outcome of coordinated movements

If all movements are executed properly, then output would be accurate

reduced strength

reduced accuracy, tone and ROM

increased/variable tone

reduced/variable speed, ROM, steadiness, and accuracy

reduced ROM

variations in speed,tone, and accuracy

at rest our face should be: 

grossly symmetric with normal tone and little spontaneous movement

things we should ask when assessing face

• is their face symmetric?

• is their face droopy?

• how are the angles of their mouth?

• is there flattening of nasolabial fold?

• pt should be instructed to attempt a spontaneous smile

screening is defines as:

• Non-billable process

• Identify patients who may be candidates for

dysphagia evaluation and treatment

• “Hands-off”

• Do NOT touch patient!!

• Takes approximately 15 minutes

• No doctor’s orders are required

• Patients with risky diagnosis should be

screened

screening is completed for two reasons:

Exclude patients who do not need an evaluation

because:

• No swallowing problem or a risky diagnosis

(leg or arm fx)

OR

• Need to be NPO either temporarily or

permanently due to some other reason (long

hx of NPO)

red flag behaviors for screenings

1. recurrent pneumonia

2. unplanned weight loss

3. coughing with meds or at meals

4. ent consult with cord paralysis

5. labored breathing (especially after eating)

6. reporting of wet vocal quality (gurgly voice)- suggests pooling on surface of VF

7. difficulty with chewing

8. reported loss of appetite

9. dehydration- changes in skin integrity

10. recurrent temperature spikes w/ no known cause

11. history of gastrointestinal problems

12. recent changes in eating habits

13. non-oral feeding (or any Hx thereof)

14. abnormal oral feeding

diagnosis with high risk of dysphagia

• cerebrovascular accident (CVA)

• brainstem infarcts

• intracerebral hemorrhage

• multiple sclerosis

• cerebral palsy

• myasthenia gravis

• alzheimers dementia

• Hx of malnutrition

• Parkinson’s Disease

• Muscular Distrophy

• Tardive dyskinesia

• Spinal cord injury, esp in affected cervical or thoracic vertebrae

if patient has spinal injury on these cervical vertebrae can cause dysphagia

• C3, c4, C5

enteral feeding

by way of gastrointestinal tract, through nose, mouth, or stomach via tube typically

parenteral feeding

other than gastrointestinal tract (vein or artery)

components of screening process

• read chart

• look for red flags

• question staff and family on onset of illness, patent awareness, hadicapping etc

interview with patient staff and family

1. Sudden changes in patient’s food

   preference

   2. Documented difficulty chewing

   3. Recent diet changes

   4. Duration of patient’s mealtime

   5. Necessity for assistance at mealtime

   6. Choking, coughing, discomfort, drooling

   7. Unusual posture at mealtime

   8. Time between end of meal and sleep or nap

   9. Refusal to eat

   10.Evidence of pocketing

face to face screening with patient

• Observe patient during mealtime to see how he/she

manages food and liquids

• Look for any red flags

• Observe rate and amounts of food presentation

• Is there coughing/choking?

• Is the patient pocketing?

• Does patient lose most food before it is masticated?

• All of these would warrant further evaluation

observe patients cognitive and awareness

• Put all observational and anecdotal information

together to make professional judgment

• Is the patient a candidate for evaluation AND

treatment?

• If so, request doctor’s order for further evaluation –

Clinical or Bedside Evaluation

• If not, provide palliative recommendations to doctor

and family for patient’s well-being…

request doctor’s orders for eval and tx

• This is a must for reimbursement!

•Many doctors will be angry if SLP begins

assessment and/or treatment without doctor

knowledge and consent

•Doctor’s order must contain:

•Diagnosis

•Issue to be evaluated

•Clarification order:

•After evaluation

•Indicates intensity of tx

screening does not

• identify the nature of the problem

• just identifies who is at risk

clinical/bedside evaluates ____ phase and can provide clues about ____- phase

oral; pharyngeal

bedside evaluation

• initial step

• sometimes all we can do if pt is agitates/combative/lethargis

  • patient only has oral phase issues

If pharyngeal phase is a concern:

• Patient is at risk for aspiration

• Usually diet is modified or patient is made

NPO

aspiration cannot be confirmed or ruled out solely with a bedside exam

40-67% of patients may be silent aspirators with no signs/symptoms

purpose of clinical exam

• Integrate info from interview, case history, medical records, and collaboration between SLP and Nursing (NSG)

• Determine need for

interview, case history,

instrumental exam

medical records, and

• Determine if patient is

collaboration between

candidate for therapy

SLP and Nursing

• Recommend route of

(NSG)

nutrition and hydration

• Observe and assess

• Recommend tx

oral motor function

• Counsel and educate

• Characteristics of

patient and family, along

dysphagia

with MD if necessary

components of clinical/beside exam

• Chart Review

• Case History with a list of signs and

symptoms – chart/patient interview

• Nutrition history – chart

• Respiratory status - chart

• Nursing Assessment – chart/Nurse interview

• Bedside Exam/Clinical dysphagia eval:

• OM and Laryngeal exam

• Respiratory status and Cognition

• Swallowing

info to obtain from chart:

• medical history

• referral

• signs of dysphagia

• nutrition/hydration status

• medication list

• respiratory status

• nursing assessment- to determine pts cognitive status

  • other evals/procedures patient has undergone

medical history

• Admitting diagnosis

• Functional problems observed

• Level of alertness (LOA)

• Previous diagnoses and treatment

• Advance directive (i.e., any interventions which can

be performed)

• Pre-morbid status (i.e., ADLs)

case history is affected by:

• Patient’s cognitive abilities

• Patient’s personality

• Whether patient perceives a problem

• What has already been established by other

professionals

• Severity of speech deficit (breathy=no or

inadequate VF adduction)

• History can be provided by someone close to patient

• History should be controlled by clinician not patient

case history

• why are you here?

  • provide SLP more info about orientation, awareness abut speech and/or swallowing

    • ability to provide hx and depth and manner of hx provides info about language abilities

    • age/education, occupation, family ststua

    • Hx of childhood speech, language, or hearing deficit, any tx and if problem has resolved

signs

what the SLP observes, what we see while watching pt such as choking, gurgly voice, etc

symptoms

what patient reports is wrong/ family

signs of possible aspiration

• Increased temperature

• Drooling/increased secretions

• Weight loss

• Coughing/choking

• Pocketing food

• Pneumonia

• Self-imposed changes in diet

• Dehydration

symptoms of aspiration

• Pain (odynophagia)

• Globus

• Heartburn

• Bad taste in mouth

• Food “won’t go down”

• Nasal burning or dripping

• Takes too long to eat

• Vomiting-immediate or later?

• Voice has changed

• Other neurological symptoms

nutrition history

• Current diet

• Amount eaten

• Restrictions

• How long does it take to eat?

• Alternate method of feeding – Ensure or Boost

• Oral health/dentures affecting?

respiratory status

•Lung sounds

• Rhonchi: coarse, dry rale in bronchial tubes

• Rale: abnormal respiratory sound

• Wheeze: whistling respiratory sound

• Chest x-rays

•Infiltrates

•Does the lobe matter?

•Right Mid and Lower

•Oxygen therapy

•Mode of delivery

•Face mask

•Nasal cannula

nursing assessment

• Cognitive assessment

• Observations of patient

• Previous living situation

• Family support/involvement

• Sensory impairments

• Blind

• Hard of Hearing (HOH)

other evals we can do

oral motor exam 

• Observe symmetry of structures, condition of

dentition, and oral hygiene

• Assess strength, coordination, and mobility of oral

structures

6 features in production of speech

• Strength and Speed

• ROM and Steadiness

• Tone and Accuracy

strength

sufficient amount to function normally along with a reserve for periods of extended contraction without fatigue or against resistance 

if the muscle is weak 3 patterns may emerge:

• No contraction (failure to move = no mvmt)

• Fatigue quickly with detrimental effects on

contraction (lessens with time)

• Unable to sustain contraction (lessens

immediately)

strength affects all three speech valves

• Articulation (i.e., at point of constriction)

• Velopharyngeal (i.e., VPI or nasal

regurgitation)

• Laryngeal (i.e., weak or breathy voice)

speed

• Muscle activity during speech is rapid

• Quick, unsustained, discrete mvmts are phasic

• Slow mvmt is common and has greater capacity for

sustained work

• Affects all valves and all aspects of production

• Produce 14 phones per second in conversation

• Single contraction or rep. of same contraction

• Contraction begins quickly, reaches target and relax

rapidly

ROM

• Distance traveled by speech structures is precise

• Excessive ROM is uncommon

• Restricted ROM is common in presence of slow,

normal, or rapid rate

• Affects prosody

• Illustrated in perceptual/acoustic analysis, visible in

speech and non-speech movement of articulators, and

measured physiologically

steadiness

• Normal movement typically has no interruption or

oscillation

• At rest, there is 8 to 12 Hz oscillation of muscles

• Amplitude can increase to visibly detectable levels in

healthy humans

• Physiologic tremor occurs during extreme fatigue,

emotional stress, and shivering

• Most common hyperkinesia is tremor, which consists

of alternating, repetitive, rhythmic oscillations of a

body part (3 to 12 Hz)

how does neurologic impairment affect steadiness?

steadiness breaks down and results in involuntary movement

4 types of tremor: 

• Resting tremor = tremor at rest

• Action tremor = during movement

• Terminal tremor = end of a movement

• Postural tremor = when a structure is

maintained against gravity

• Holding arms out from body for extended

period of time

4 types of hyperkinesia

dystonia, dyskinesia, chorea, athetosis

dystonia

a movement disorder characterized by sustained or intermittent involuntary muscle contractions that cause abnormal postures and movements

dyskinesia

involuntary, uncontrolled, and erratic muscle movements. These abnormal movements can affect a single part of the body, such as the head or a limb, or the entire body

chorea

a hyperkinetic movement disorder characterized by involuntary, unpredictable, and often restless movements that can affect the face, trunk, and limbs

athetosis

a movement disorder characterized by slow, writhing, involuntary movements of the limbs, face, neck, and trunk, often linked to damage to the brain's basal ganglia

tone

Gamma motor neurons indirect activation pathways are

crucial

• GMN keeps muscle spindles taut and adjusts

sensitivity to allow alpha neurons to fire

• Volitional movement is superimposed upon this

framework

• May be excessive or reduced

• Will affect all valves and all aspects of production

• Tone may be excessive or reduced, fluctuate in regular

fashion, wax or wane unpredictably, slowly or quickly

types of abnormal tone:

flaccid tone, spastic tone, hypokinetic tone, hyperkinetic tone

flaccid tone

tone is consistently reduced

spastic or hypokinetic tone

consistently increased

hyperkinetic tone

variable

modified tongue anchor test

• having the pt puff cheeks and
  protrude tongue simultaneously. Push on cheeks.
  If their velopharyngeal functioning is within
  normal limits, their cheeks will remain puffed up.
  • Not valid if there is significant tongue or facial
  weakness
  • Rationale is that patients cannot use back of
  tongue to aid in velopharyngeal closure
  • Compensatory strategy
  • Velopharyngeal closure can only be examined
  through videofluoroscopy or nasoendoscopy

larynx adduction can be tested using two tasks:

1. cough- assesses cough sharpness, not loudness

   1. weak/breathy cough can reflect adductor weakness/poor respiratory support

2. coup de glotte/glottal coup- sharp glottal stop or a grunt

   1. does not require respiratory force or sustained airflow- assess sharpness

weak cough with strong glottal coup indicates:

respiratory weaknessw

weak coup/normal cough or equally weak coup/cough indicates:

laryngeal weakness or combined laryngeal respiratory weakness

vocal cord abduction

vocal cord adduction

vocal cord abduction can be assessed through:

presence of inspiratory stridor (typically a sign of an obstructed or narowed upper airway) 

laryngeal exams should be conducted when:

structural or LMN lesions are suspected

structural impairments to the vocal cords

polyps or nodules can alter mechanical properties of cords

weakness/paralysis can alter cord mobility

to assess inspiratory stridor

have the patient take a few quick breaths

normal reflex

occurs as a reflection of normal nervous system function

• absence of normal reflex reflects PNS

release phenomena

reduction in cortical inhibitory influence on lower centers of brain and can reappear with age

gag/pharyngeal reflux

• elicited by bottom of uvula, stroking back of tongue,
  posterior pharyngeal wall or faucial pillars on both
  sides
  • Sensory = glossopharyngeal nerve (IX)
  • Motor = vagus (X)
  • Response is elevation of palate, retraction of tongue,
  sphincteric contraction of pharyngeal walls
  • Gag reflex is only significant if asymmetry is noted
  • Ask if it feels different on the two sides- a lack of
  sensation could be responsible for decreased gag
  reflex

jaw jerk reflex

• maxillary reflex

• primitive deep muscle stretch reflex that may be pathologic in adults

• patient should be relaxed with lips parted and jaw halfway open

• tongue depressor is placed on chin and is tapped with other hand or a reflex hammer

• response is pathologic if jaw closes quickly

• present in approximately 10% of normal adults

  • may be a confirmatory sign of bilateral UMN lesions at a level above mid-pons (affecting motor/sensory branches of the trigeminal nerve)

sucking 

• primitive reflex
  • Elicited by stroking lip from lateral aspect towards
  philtrum on both sides
  • Pathologic response is pursing of lips
  • Can be a confirmatory sign of UMN damage,
  especially to premotor cortex
  • Frequently elicited in demented patients
  • Rooting reflex occurs as an exaggerated reflex when an object approaches the mourh

snoit reflex

• similar to sucking reflex

• elicited by a light tqp of finger on philtrum or tip of nose or backwards pressure on midline of upper lip and philtrum

pathological snout reflex

puckering or protrusion, along with evaluation of lower lip and depression of the lateral angles of the mouth

cognitive-communicative ability can be measured with the following questions:

• can pt follow simple directions?

  • oral motor and dysphagia exercises

• can pt remember and restate a technique?

  • determine if pt can participate in treatment

• can pt follow and remember directions independently for functional swallow?

what would a trial feeding look like? 

• present small amounts of variety of textures for both
  liquids and solids
  • Begin with ice chips, small sips of water, puree,
  mechanical soft and regular consistencies
  • Observe for any problems with specific consistency or
  for oral phase issues
  • If patient exhibits difficulty, attempt compensatory
  technique

oral placement purpose

determine which placement facilitates the safest swallow

anterior oral placement

prone to aspirate but good bolus controlp

posterior oral placement

• mastication/AP transit problem; no pharyngeal issues

left oral placement

R weakness

right oral placement

L weakness

midline oral placement

reduced sensitivity

3 oz water swallow test

• A 3-ounce (approximately 90 milliliters) volume
  of water is measured and poured into a cup.
  • Patient is instructed to take small sips of the
  water and swallow it in a controlled and
  CONSECUTIVE manner.
  • SLP observes the patient’s swallowing, looking
  for signs of difficulty or abnormalities (coughing,
  choking, throat clearing)

timed test of swallowing

1. A specific volume of liquid (typically water) is measured,
and patient is instructed to take a sip of the liquid and
swallow it as quickly and safely as possible.
2. The goal is to complete the swallow without coughing,
choking, or experiencing any other signs of aspiration
3. SLP uses a stopwatch or timer to measure the time it
takes for the individual to initiate and complete the
swallow, from the moment the liquid enters their mouth
to the moment they signal that the swallow is complete.
4. The test may be repeated several times with different
volumes of liquid to assess the individual's swallowing
abilities across different conditions.

cervical auscultation

a clinical procedure that involves listening to the sounds produced by swallowing in the neck region

pulse oximetry

monitors oxygen saturation levels
(the percentage of hemoglobin in the blood that is
carrying oxygen, compared to the total amount of
hemoglobin available).

reflex cough test

A small amount of a substance
known to induce coughing is applied to the back of
the patient's throat (often citric acid, tartaric acid,
distilled water, or a similar irritant). Individual's
response to the test substance is observed (i.e.,
coughing, throat clearing, or other signs of
discomfort).

non surgical enteral procedures

Oral nutrition – p.o. intake via diet
modification
• Enteral tube feeding – through tube or
catheter that delivers nutrients
bypassing oral intake
• NG tube (nasogastric tube) through
nose and inserted down esophagus
into stomach – usually for less than
30 days
• NJ tube (nasojejune) intestinal tract
– less than 30 days

surgical procedures

Gastrostomy – PEG (percutaneous endoscopic
gastrostomy)
• Tube inserted directly through a surgically
produced stoma in stomach
• Used for greater than 30 days duration
• Jejunostomy – PEJ (percutaneous endoscopic
jejunostomy)
• Tube inserted directly into intestines through
an incision
• Used for greater than 30 days duration
• Often used if PEG tube fails or becomes
infected

parenteral feeding

• Provision of some or all
  nutrients by means other than
  gastrointestinal tract (usually
  IV)
  • Peripheral – delivered thorough a
  peripheral vein (hand or forearm)
  through IV
  • Central – delivered through a
  large diameter vein (superior
  vena cava via the jugular vein)
  • “Central line”