Dysphagia- Exam 1 (CSE)

Swallow screen vs Clinical Swallow Evaluation (CSE)

Screen: quick, low-cost, by nurses/doctors, pass/fail with referral. CSE: by SLP, case history, structure/function/CN exam, food/liquid trials, can include instrumental evals

What do we do before a CSE?

Chart review, oral mech, patient interview, interdisciplinary collaboration, sometimes a screener

3-oz water swallow test (Yale Swallow Protocol)

Patient drinks 3 oz of water consecutively without stopping; fails if signs/symptoms of aspiration

Volume-Viscosity Swallow Test (VVST)

Expands the water test with 5-20 cc of thin, nectar-thick, and pudding-thick; monitors for s/s of aspiration

Toronto Bedside Swallowing Test

Swallowing tasks plus a brief oral motor assessment

Cervical auscultation

Recording airway/swallowing sounds via stethoscope or laryngeal microphone; mixed evidence

Pulse oximetry in swallow assessment

Detects arterial oxygen changes in response to aspiration; mixed evidence

Steps of a CSE

Chart review; check with nursing/ordering provider; patient interview; OME; PO trials; trial liquids and solids

Indications for a CSE

Concerns from patient/family/caregiver/physician; weight loss/nutrition failure; pulmonary hx suggesting aspiration; current presentation; swallow screen performance

Goals of the CSE

First step for diagnostic/therapeutic info; links signs and symptoms to physiology; examines motor and sensory aspects of oral mechanism

Other purposes of the CSE

Decide timing for FEES vs VFSS/MBS; track progress across treatment; triage misguided radiologic requests

Features of normal deglutition

Bolus control, bolus clearance from oral and pharyngeal cavities, respiratory coordination, airway protection before/during/after, normal executive functions

What does the CSE help determine about the patient?

Physical, mental, emotional status; need for future testing/treatment; readiness for instrumented testing/treatment

Crucial CSE directive

Address the referral question specifically as sought by the patient, caregiver, and healthcare provider

CSE limitations: what it cannot do

Visualize the whole swallow tract; show timing/magnitude of pharyngeal events; show presence/amount of residue; confirm penetration/aspiration (only inferred); pharynx and larynx are not visualized

Additional CSE limitations

Client unable to cooperate, sedated/comatose, dementia, intolerant, no food available to test oral feeding

Another name for a CSE

Bedside swallow assessment

Clinical swallowing kit contents

Mirror, tongue blade, cup, spoon, straw, syringe, catheter, Q-tips, gauze, taste/smell items, flashlight, gloves, food/liquid/ice chips, emesis basin, suction, record sheet

Essential components of an adult CSE

Medical and feeding history; patient interview; exam of oral/pharyngeal anatomy and function; respiratory assessment; food assessment; documentation and recommendations

Chart review: additional items in CSE

Imaging (chest XR, brain imaging); vital signs/lab work (O2 sat, WBC count)

Sources for medical history

Medical record, professionals involved in care, referring professional, client or caregiver

Medical history items to gather

Primary dx, general medical status, referral question/source, client's physician, chief complaint, current and baseline diet

Antidepressants: swallowing concerns

Mucosal drying, drowsiness

Antipsychotics: swallowing concerns

Dyskinesias, altered mental status, muscle rigidity

Sedatives: swallowing concerns

CNS depressant, mucosal drying

Antihistamines: swallowing concerns

Mucosal drying, sedation

Diuretics: swallowing concerns

Dehydration, dryness

Mucosal anesthetics: swallowing concerns

Suppress gag and cough

Anticholinergics: swallowing concerns

Dry mouth, reduced appetite

Other medical history to review

Respiratory status (pneumonia, trach, mechanical ventilation), nutrition/GI status, dentition/mucosal inflammation, structural problems (cleft, surgical changes, osteophytes), cancer/tumors, prior surgeries, psychiatric and social history

Patient interview focus

Chief complaint, perception of problem, their terms, progression, activities of daily living, previous treatment

Coughing/choking suggests...

Possible aspiration

Food coming out of the nose suggests...

Poor velar closure

Food falling from the mouth suggests...

Poor lip seal/oral containment

Food stuck in the throat suggests...

Weak pharyngeal stage and residue

Something stuck in the throat (not food) suggests...

Globus sensation, usually reflux

Throat burning on swallow suggests...

Reflux

Food returning to the mouth suggests...

Pharyngeal pocket / Zenker's diverticulum

History of the swallowing problem: what to explore

Onset/progression/consistency; site (oral/pharyngeal/esophageal); timing (before/during/after); effects of consistency, temperature, posture, fatigue; feeding method; associated signs; subjective description; emotional impact; ancillary signs; compensations

Observations on entering the room

Posture, alertness, trach tube, awareness and secretion handling, ability to follow directions, overall conditioning, endurance

Oral-motor exam for head injury/severe neuro impairment

May need oral/rotary massage to masseter; check bite reflex; identify optimal oral-sensory stimuli (gauze, cloth, burlap, satin dipped in liquid) for taste, temperature, texture

Swallowing apraxia in the CSE

Patient may eat normally without verbal instruction (nonvolitionally); verbal commands during testing can make this difficult

Abnormal oral reflexes to identify

Hyperactive gag, tongue thrusting, tonic bite

Labial function tasks

Spread lips 'ee' and round 'oo' alternating x10; rapid 'pa'; tight closure; lips at rest; saliva during swallow; 'put the papers by the back door'

Anterior lingual function tasks

Protrusion/retraction, lateral movement, clearing lateral sulci, elevation to alveolar ridge, rapid 'ta', 'take time to talk to Tom'

Posterior lingual function tasks

Repeat 'ka'; 'can you keep the kitchen clean?'

Chewing function testing

Gauze pad dipped in pleasant-tasting liquid; patient holds and chews it

Velopharyngeal and oropharyngeal exam

Sustain 'ah' and watch the palate; gag reflex with cold instrument on palate, base of tongue, posterior pharyngeal wall; taste and touch reception

Laryngeal function assessment

Voice quality (gurgly, hoarse), indirect laryngoscopy, laryngeal DDK 'ha'/'ah', cough strength/quality, pitch range, MPT

Respiratory assessment items

Breathing rate, saliva swallow timing in respiratory cycle, cough timing, breath-hold duration, resting breathing pattern (oral vs nasal), respiration during swallowing and speech

Normal respiratory-swallow pattern

80-95% of bolus swallows interrupt expiration and are followed by expiration (Exp-Swallow-Exp); diminished in stroke and COPD

Oxygen saturation and eating

Healthy people maintain O2 sat while eating; some patients with dysphagia desaturate

NDD liquid levels

Thin, nectar-thick, honey-thick, pudding-thick

PO trials for NPO patients

Start easy; dry mouth interferes so use ice chips first; controlled amounts; listen to voice quality before/after each swallow

PO trials for oral eaters

Schedule evaluation near mealtime to observe typical tray foods

Cognitive/feeding/oral stage observations

Attention to process, stopping talking, neglect, bolus size selection, retrieving food from utensil, lip closure, leakage, food left on utensil

Oral sensori-motor observations during PO trials

Chewing adequacy; residue location (palate, midline tongue, lateral pocketing); awareness of residue; self-initiated or directed removal

Pharyngeal stage observations during PO trials

Breathing-swallow coordination; coughing/throat clearing/struggle; on every swallow or only after 5-10 min; laryngeal elevation; swallow timing

Laryngeal palpation finger placement

Index behind mandible; middle on hyoid; 4th on top of thyroid cartilage; little finger on bottom of thyroid cartilage

What does laryngeal palpation tell you?

Index: tongue movement initiation; index-to-middle interval estimates oral transit time; 4th-to-little finger movement = laryngeal elevation

Swallow delay threshold for nonfunctional oral eating

Delay of swallow in excess of 10 seconds

What info determines best posture and food choices?

Compensations for tongue/lip problems; pharyngeal/laryngeal compensation (chin tuck); optimal food position (based on oral sensitivity); food consistencies; swallowing instructions

CSE recommendation options

Diet recommendation; further evaluation (FEES/MBS); NPO with follow-up for repeat CSE

Questions to guide CSE decisions

Should oral eating start? Alternatives? Is the patient aspirating? Can aspiration be reduced by modification? Is instrumental assessment needed (confirm aspiration, detail impaired physiology, test compensations)?

Short-term NPO feeding option

Nasogastric (NG) tube

Long-term NPO feeding options

G-tube, J-tube, PEG, PEJ

When is NPO indicated?

Serious aspiration, reduced sensorium, severely diminished cognitive function, nutritional problems

Enteral nutrition

Tube feeding to supply nutrients/fluids when unable to safely chew or swallow

Supplemented PO

Inefficient oral intake for hydration/nutrition but able to safely ingest some nutrients

What happens with penetrated/aspirated material if cough is adequate vs inadequate?

Adequate (strong) cough: expectorated. Inadequate cough: material goes further into trachea toward the lungs

Other signs of aspiration

Cough, voice quality change, change in respiration during/after meal, reduced oxygen saturation

Silent aspiration

Aspiration with no overt signs; 40-60% of aspiration is not overt; limits the value of a CSE and necessitates further assessment

Six clinical indicators of aspiration risk (Daniels et al., 1997, stroke)

Dysarthria, abnormal gag reflex, abnormal volitional cough, dysphonia, cough after swallow, voice change after swallow

How many Daniels indicators signal aspiration risk?

Two or more; authors recommend additional testing