Dysphagia Final

Consequences of Swallowing Impairment (5)

1. Caregiver burden

2. Expensive for hospitals

3. malnutrition

4. dehydration

5. aspiration pneumonia

Why Assess Swallowing? (8)

1. Answer clinical questions

2. presence or absence of impairment

3. describe typical and atypical structures and functions affecting swallowing

4. identify severity

5. relate impairment to what triggered referral

6. describe effect of impairment on activities and participation, as well as contextual barriers and facilitators

7. make prognosis

8. make recommendations

How do we measure neurophysiology/anatomy?

Indirectly through performance, which is hard

Why do a CSA?

1. Integrate information

2. assess structures

3. identify characteristics of dysphagia

4. determine need for instrumental assessment

5. determine candidacy for treatment/management

6. recommend route for nutritional management

7. recommend interventions

Parts of a CSA

1. Medical History

2. Explanation/Education and informed consent

3. Case Hx/Client Interview

4. Observations of communication/cognition

5. Physical Exam

6. Trial Swallows/TOMASS and/or Meal Ax

7. Management Plan/Next Steps/Instrumental Ax

Parts of a Physical Exam

1. Isometric tongue strength (40kPA lower boundary for adults 60+)

2. Cough testing (Mini Wright, cough reflex testing)

3. Trismus Test

4. Oral Mech

CSA Outcome measures

1. EAT-10 **

2. SSQ **

3. MDADI

4. DHI

5. FOIS **

6. IDDSI-FDS

7. SWAL-QOL **

8. CARES

** = came up the most in class

CSA: How to evaluate efficiency

1. multiple swallows per bolus?

2. lingual pressure

3. masticating and swallowing

CSA: How to evaluate safety

1. voice change, throat clear, cough

2. peak expiratory flow during volitional cough

The TOMASS is a tool that emphasizes what?

oral bolus prep

What was the TOMASS originally developed for?

A treatment study on swallowing impairment associated with Parkinson’s disease

Instructions for TOMASS

1. eat cracker as quickly as comfortably possible

2. say your name out loud when done

3. record total time, # masticatory cycles, # discrete bites, # swallows

What can we not evaluate using the CSA?

Underlying impairment

Cannot make recommendations about rehab/techniques using CSA alone!

Can we see aspiration or residue in CSA?

No we can’t!

Why is the CSA still important?

Evaluate current functioning and concerns, determine if instrumental eval is needed, and develop hypotheses

Things you can recommend after a csa:

1. a diet without the need for further testing

2. further testing

3. referral to another professional

What can screening NOT do?

determine pharyngeal/laryngeal anatomy/physiology or bolus flow characteristics

What CAN screening do?

determine the presence or absence of aspiration risk

3 things an ideal screening should determine

1. likelihood of dysphagia and aspiration

2. further assessment needed?

3. safe to feed patient orally?

sensitivity (screening)

captures the patients it is intended to capture

specificity (screening)

rules out the patients who do not have the problem

Non Swallowing Items to Assess/Risk Factors

1. Level of Alertness

2. Previous Medical Hx

3. Oral Motor testing

4. Sensory testing

5. voice/speech quality

6. cough

Swallowing items for bolus trials

1. single swallows of thin liquids

2. single swallows of various consistencies

3. consecutive swallows of thin liquids

3oz water test

• screening

• can be done by many practitioners

• drink 3oz through a straw sequentially without stopping

• high sensitivity low specificity

• patient fails if they can’t finish it. can’t do it without stopping, or show throat clearing, coughing/choking, wet or hoarse voicce up to 1min post

Benefits of Swallow screening

timely ID important for early intervention!!

Identification of dysphagia risk via screening has been shown to (3)

1. decrease risk of pneumonia

2. shorten hospital stay

3. reduce costs

4 puzzle pieces of feeding

1. social and emotional development

2. physical, sensory, and oral motor development

3. communication and cognitive development

4. mealtimes

Why is feeding important? (6)

1. nutrition and hydration

2. growth and development

3. general health

4. immunity

5. social skills

6. pleasure

Domains of PFD (at least one dysfunctional)

1. Medical

2. Psychosocial

3. Nutritional

4. Feeding Skills

PFD definition

impaired oral intake that is not age appropriate and dysfunction in at least one domain

Adverse effects of PFD

1. poor weight gain, growth, malnutrition, FTT

2. lack of energy, poor development

3. week immunity

4. cognitive impairment

5. emotional dysfunction

6. poor academic performance

7. sensory aversions

8. life threatening conditions

what is the most common reason for late hospital discharge (peds)

inability to oral feed

what is important to know about kids and aspiration?

silent aspirators!!!

Examples of some peds measures

• behavioural pediatrics feeding assessment scale

• children’s eating behaviour questionnaire

what is cervical auscultation

listening to sounds and vibrations of the throat

this is NOT an instrumental assessment

who can you not assess with VFSS?

breastfeeding infants

manometry

pressure flow and movement in pharyngeal and esophageal phases → research developing

dynamic ultrasound

• non invasive

• visualize oral muscles/mastication

• evidence for tongue movements

• ONLY for research

multidisciplinary vs interdisciplinary care

inter = share patients and goals

multi = share patients but working on different goals

common symptoms of swallowing pathology in peds (3)

1. vomiting/regurgitation/reflux

2. Crying/discomfort

3. Changes in vital signs

swallowing is a ____ feeding is a ____

skill, holistic concept

what is a significant factor affecting oral prepardness?

prematurity

compensatory interventions are ___ and habilitative are ____

adaptations, skill development

compensatory approaches (4)

1. postural modifications

2. utensils

3. bolus changes (texture, volume, temp, size)

4. swallow maneuvers

Creating a positive feeding environment (7)

1. communication

2. observe and respond to child

3. establish healthy attachments

4. introduce developmentally appropriate texture

5. avoid unsafe feeding equipment

6. introduce food play

7. respect autonomy and independence

Therapeutic strategy examples peds (5)

1. baby-centred feeding

2. oral stimulation (chewytubes → good for teaching when you don’t want to use a bolus yet)

3. phagenesis

4. SOFFI

5. SOS feeding

when MBS is indicated (6)

1. patients symptoms inconsistent with CSA findings

2. need to confirm suspected diagnosis

3. confirm a differential diagnosis

4. nutritional or pulmonary compromise, need to confirm if dysphagia is contributing

5. safety/efficiency a concern

6. patient is a rehab candidate → guide treatment

when MBS may be indicated (4)

1. patient has a condition associated w/ high risk for dysphagia

2. cognitive or communication deficits = can’t complete CSA

3. previously diagnosed dysphagia, change in swallow function suspected

4. patient has a disease with known progression or is in stable or recovering condition → function may require further definition or management

ALARA means

as low as reasonably possible

msV

milliSieverts = how much radiation you receive (like in an MBS)

Gray or milliGray

amount of radiation you were exposed to (will see this re: radiation therapy)

MBS radiation exposure

0.20-0.35 mSv

estimated risk 1 in 39000

optimal frame rate for MBS

at least 30fps (many are lower than this)

barium concentrations adequate for visualization and better “ultrathin”

40% w/v and 22% w/v

DIGEST

Dynamic Imaging Grade of Swallowing Toxicity Scale

intra-rater reliability good

compatible MBS grade

PCR

Pharyngeal constriction ratio

PCR higher in older afults

high correlation between PCR and peak pharyngeal pressure on manometry

PAS

Penetration Aspiration Scale

measures depth of airway invasion and ejection of material

what does FEES stand for

Flexible Endoscopic Evaluation of Swallowing

what can FEES assess? (4)

1. velopharyngeal function during speech and swallowing

2. TVF mobility

3. Secretions

4. specific contributing mechanisms of pharyngeal sage (inference of oral and esophageal)

FEES risks (6)

1. minor side effects (discomfort, vomiting)

2. epistaxis (nosebleed)

3. vasovagal syncope (fainting)

4. laryngospasm (killed Joan rivers)

5. Reactions to anesthesia (if applied)

6. Reactions to decongestant (if applied)

FEES Procedure Steps

• put in nasal meatus, evaluate velopharyngeal mechanism

• move scope into oropharynx

• evaluate hypopharynx at rest and secretion management

• evaluate base of tongue and pharyngeal function

• evaluate laryngeal function

• attempted swallows with a range of materials → self feed until there is a problem

examples of secretion scales

Murray (4 point)

Donzelli (5 point)

NZSS (8 point)

Pharyngeal Squeeze Maneuver

judged as normal or abnormal → PCR higher in people with absent PSM, indicates valid measure

What is visible on FEES? (9)

1. symmetry

2. base of tongue propulsive movement (infer re: timing)

3. pharyngeal initiation/delay

4. penetration before swallow

5. medialization of pharyngeal walls

6. medial/anterior movement of arytenoids

7. epiglottic retroflexion (before and after swallowing)

8. white out during swallow

9. bolus retention

3 distinct patterns of abnormality (FEES)

1. incomplete bolus clearance

2. misdirected swallow

3. delayed or mistimed swallow

motor control aspects involved in swallow (5)

1. briskness of initiation of movement

2. speed of movement

3. precision, timing, or coordination of multiple movements

4. force or strength of the movement

5. amplitude of the range of movement

What is FEES more sensitive at detecting than MBS?

pharyngeal residue

Components of EBP

Current Best Research Evidence

Client/Patient Values

Clinical expertise

5 factors to consider in treatment planning

1. empirical evidence

2. experiential evidence

3. physiologic rationale

4. values of patient, family, clinician

5. system features (economic, legal, cultural)

foundations of treatment

1. theoretically sound and follow accepted principles of neuroplasticity and motor learning

2. supported by empirical evidence as much as possible

3. set realistic treatment goals

when there is a lack of evidence what should you use?

a theory driven approach

Where should you start when planning treatment?

Identify the main driver of impairment (there may be lots going on at once, see what will give you the most bang for your buck)

Guiding principles of treatment (4)

1. fundamentals of training and exercise

2. principles of neural plasticity

3. principles of motor learning

4. motor adaptation and feed-back/feed-forward loops

isometric vs isotonic

isometric = muscles stay the same length, static

isotonic = dynamic exercise

Three pillars of management

1. compensation

2. rehabilitation

3. prevention

what is the problem with aspiration pneumonia?

there is no agreed upon definition, diagnosis can be circular, you can get it because of lots of other things that aren’t diet related → is every pneumonia just an AP?

three pillars of aspiration pneumonia

1. impaired health status

2. impaired airway protection

3. impaired oral environment

VAP

ventilator association pneumonia

leading cause for nosocomial infection in ICU

should you use chlorohexidine in critically ill patients?

nope! may cause excess mortality AND fail to prevent VAP

outcome for oral health example

OHAT (Oral Health Ax Tool)

patients w/ dysphagia had sig worse oral health scores at beginning of study

how many cases of death from pneumonia in nursing home residents could be prevented by improving oral hygiene?

1/10

Elements of Rehab Treatment specification system

Target (aspect of functioning targeted directly for change)

Mechanism of Action (How the treatment is expected to work)

Ingredients (what the clinician does or selects)

compensatory maneuvers (5)

1. Head extension

2. head flexion-chin tuck

3. head rotation

4. head turn to side of deficit

5. head tilt to strong side

options without evidence (4)

1. multiple swallows

2. liquid wash

3. voluntary cough

4. voluntary throat clear

adjustments that can be rehab or compensatory

1. Supraglottic swallow

2. super-supraglottic swallow (can induce valsalva*)

3. effortful swallow

4. Mendelsohn Maneuver

examples of sensory stimulation

thermal tactile (V and IX)

increased pressure with spoon (V and IX)

sour

bolus requiring chewing

larger bolus volume (V and IX)

smell

flavour

carbonation

who are thin liquids most difficult for?

reduced oral control and delayed pharyngeal swallow

what can thin liquids be useful for?

reduced peristalsis (to wash residue) and UES disorders (to increase flow through UES)

thickened liquids for:

mildly reduced oral control and mild delay in pharyngeal stage

ppl who would be at risk w/ thin fluids

pudding for:

moderate delay in pharyngeal stage and aspiration potential, reduced laryngeal closure → may be hard if they have oral/pharyngeal weakness (residue)

Pureed for:

like pudding: moderate delay in pharyngeal stage and aspiration potential, reduced laryngeal closure → may be hard if they have oral/pharyngeal weakness (residue)

mechanically altered means

cohesive, moist, semisolid

requires some chewing

2 main alternate modes of feeding

enteral (GI tract functional)

Parenteral (GI tract not functional → TPN)

kinds of enteral nutritional support (3)

1. gastronomy (PEG) → percutaneous endoscopic gastronomy

2. jejunostomy → into jejunum (small intestine)

3. nasogastric (NG) → preferred for short term use

parenteral nutritional support

1. TPN → via a central vein, sterile procedure performed at bedside

2. PPN → via a peripheral vein, feeding required 7-10 days

who are feeding tubes not recommended for?

adults with advanced dementia

Rehab Exercises

1. Shaker (Head lift)

2. Modified head lift (recline)

3. Masako (risky prob won’t use on exam lol)

Lingual strengthening tool

IOPI

Expiratory Muscle Strength Training

• studies in patients with parkinson’s ALS, stroke, MS, HNC

• 5 sets 5 reps 5 days per week 4 weeks

sEMG Biofeedback

• displays actiivty from muscles involved in swallowing

• enhance learning and peformance