dysphagia lecture 2 screening and assess

Purpose: Dysphagia screening : 

Purpose: Dysphagia screening To suggest that patient has dysphagia, but not how or why? i.e. Indicates that a thorough swallow examination is warranted ASHA Preferred Practice Patterns: goal of screening -looking for signs and symptoms that patient at risk for dysphagia that could lead to airway compromise or inadequate nutrition/hydration and to determine that further evaluation is necessary Needs to be completed by medical professional (SLP, nurse, MD) available 24/7 (Div 13 FAQs 06)

Purpose: Dysphagia screening : 

Purpose: Dysphagia screening JCAHO – Joint Commission on Accreditation of Healthcare Organizations requires ‘screen for dysphagia should be performed on a ischemic/hemorrhagic stroke patients before being given food, fluids, or medication by mouth’ (Swigert et al. 2007 ASHA Leader ) That is, great need exists for proper screening tools

ASHA Stages of screening: : 

ASHA Stages of screening: 1) interview of patient and/or caregiver 2) observation of signs and symptoms of oropharyngeal swallowing dysfunction 3) observation of routine feeding situation if indicated 4) interpretation of results: Is the patient dysphagic? 5) formulation of recommendations - including need for swallowing assessment 6) communicate results/recommendation to patient care team

Concepts relevant to screening/assessment : 

Concepts relevant to screening/assessment sensitivity = ability of procedure to correctly identify abnormality, i.e., true positives, and no false positives specificity= ability of procedure to correctly indicate that an abnormality does not exist, i.e., true negatives, and no false negatives truth yes no Test yes Results no Sensitivity Specificity

Concepts relevant to screening/assessmentMcCullough et al JSHR 2005 : 

Concepts relevant to screening/assessmentMcCullough et al JSHR 2005 truth yes no Test yes Results no A 20 B 17 37 C 17 D 103 120 37 120 Sensitivity = a / a+c = 20/20+17 = 54% Specificity = d / b+d = 103/17+103 = 86% Positive predictive value = a / a+b = 20/ 20+17 = 54% Negative predictive value = d / c+d = 103/ 17+103 = 86% Positive likelihood ratio = sensitivity/ 1- specificity = .54/ 1-.86 = 3.8

Concepts relevant to screening/assessment : 

Positive predictive value: sensitivity X true prevalence of problem Negative predictive value: specificity X true prevalence of lack of problem Likelihood ratios: LR+ = sensitivity/1-specificity LR- = 1-sensitivity/specificity Concepts relevant to screening/assessment

What is an effective screening for dysphagia? : 

What is an effective screening for dysphagia? -younger than 3 years old - never screen, simply assess 1) Children, and dev delay adults: any of these indicators suggests need for eval: rejection of food gagging on multiple feeding attempts open-mouth posture

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-Others including Adults: 2) medical diagnosis of stroke – fails screening e.g. stroke - 50-70% may have dysphagia 30-70% of stroke patients aspirate (Daniels et al., 1997; Horner & Massey, 1988; Linden & Sieben, 1983) Silent aspiration: 20-40% (Logemann, 1983; Daniels et al., 1997) problem: risk of some false positives and can’t MBS everyone

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3) Screening Checklist in Logemann 1998 Table 5.1 Chart review and brief patient observation Any one or more of characteristics, warrants assessment (p. 138) Problem: no data History of recurrent pneumonia 4. Severe respiratory problems Diagnosis of 5. Gurgly voice, cry partial laryngectomy 6. Coughing before, during, and or after oral resection swallowing Full course radiation head or neck 7. Poor awareness and poor control secretions Anoxia 8. Infrequent swallowing (<1 per 5 minutes) Parkinson’s disease 9. Constant copious chest secretions Motor neuron disease 10. During eating or saliva swallows: Myasthenia gravis breathing difficulty Polio increased secretions Anteiror cervical spinal fusion voice changes (gurgly) Brainstem stroke multiple swallows per bolus Guillain-Barre’ reduced laryngeal lifting on swallow Laryngeal trauma throat clearing 3. History of prolonged or traumatic coughing intubation or emergency tracheostomy significant fatigue

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4) DePippo et al 1992 - Burke Dysphagia Screening Test 7 items bilateral stroke brainstem stroke history of pneumonia in acute stroke coughing associated with feeding or 3 oz water swallow failure to consume ½ of meals prolonged time for feeding non-oral feeding in progress -presence of any 1, fails screen No sensitivity/specificity data

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5) 3-oz water swallow test to predict aspiration (DePippo et al 1992) failed if followed within 1 minute by coughing or wet-hoarse voice sensitivity - 76% (16/20) specificity - 59% (16/27) 44 # pts 20 # aspiration on MBS 27 # abnormal water swallow 16 # abnormal water swallow and aspiration on MBS Mari et al JNNP, 1997 high sensitivity, but low specificity Warms & Richards, Dysphagia 2000 Only 17% of individuals with wet voice in association with material in larynx -so must be careful of this as a measure

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6) Martino et al, Dysphagia 2000 Review of Literature Coughing or wet phonation on 5 ml water swallow Lack of pharyngeal sensation when touched with tip of thin stick -associated with 2.5-5 times more likelihood of aspiration -depending on results of screening – move to full assessment

Purpose of Swallowing Assessment : 

Purpose of Swallowing Assessment 1) identify causes of swallow dysfunction in terms of anatomy and physiology - WHETHER dysphagia and aspiration occurs WHY dysphagia and aspiration occurs (prandial aspiration – food) 2) assess ability of patient to protect airway determine risk for aspiration determine risk of complications if aspirate 3) identify effective treatment strategies to enable safe or efficient swallow 4) determine need to refer to other sources 5) establish baseline clinical data

Stages in Swallow Assessment : 

Stages in Swallow Assessment chart review/case history bedside clinical examination eating evaluation/trial swallows instrumental exam

Chart review/Case history : 

Chart review/Case history Medical history: focus on conditions that can cause dysphagia or aspiration risk neurological and structural conditions location and extent of stroke – bilateral, brainstem history of pneumonia Surgeries radiation also note medical conditions that can affect prognosis and aspiration risk COPD – chronic obstructive pulmonary disease GERD – gastro-esophageal reflux disease CHF – chronic heart failure Diabetes Hypertension Recent vomiting Condition of teeth/mouth (e.g. dental caries)

Chart review/Case history : 

Chart review/Case history Clinical observations respiratory status - pulmonary functions and pneumonia tracheostomy tube/ mechanical ventilation/intubation intubation – no swallowing appropriate until respiratory status changes to trach tracheostomy tube status – info from invited lecture if possible, with medical permission, cuff needs to be in deflated position during assessment current nutritional status: oral/nonoral NPO (nulla por os) NG tube = nasogastric G tube = gastrostomy PEG = percutaneous endoscopic gastrostomy J-tube = jujenostomy Recent weight loss Hydration status Blood/enzyme work

Chart review/Case history: Medications : 

Chart review/Case history: Medications ASHA Leader 2002 plus online references Decreased saliva Oxybutynin (Ditropan) Diphenhydramine (Benadryl) Impairs chewing/swallowing Haldol -Thorazine -Risperidone Impairs cognition/attention Diazepam (valium) -Lorazepam (Ativan) Antispasticity drugs – weaken muscles Some also antipsychotic drugs-extrapyramidal movements and can impair alertness Benzodiazepines (Diazepam, Clonazepam, Olanzapine) Baclofen (Lioresal) -Dantrolene Sodium Tizanidine (Zanaflex)

Chart review/Case history : 

Chart review/Case history Observation of certain behaviors during history taking - Cognitive status: language, memory, orientation, visual/perceptual level of arousal, awareness, posture -indicates ability to implement strategies management of secretions

Chart review/Case history : 

Chart review/Case history respiration at rest -oral or nasal? If nasal obstruction, makes difficult to breath during chewing/swallowing if in distress, is inappropriate to proceed with swallowing note timing of secretory swallows in relation to respiration should swallow during expiration and continue expiration after the swallow any mouth odors dysarthria?

Chart review/Case history : 

history related to swallowing problem : descriptions of the swallowing problem - patient & family report describe symptoms – what happens tell about history of the problem types of food having trouble with, temperatures, textures do you avoid certain foods when do you have most trouble do you choke/cough? where are the sensations any speech/voice problems going on sleep problems Chart review/Case history

Bedside Examination of SwallowingClinical Swallowing Examination : 

Bedside Examination of SwallowingClinical Swallowing Examination very thorough oral-peripheral examination some argue sufficient to make decisions for 80% of patients (Crary) others argue not sufficiently informative regarding the abnormal physiology of the swallow, particularly with regards to aspiration (McCollough Div 13, 2004)

Bedside Examination of SwallowingClinical Swallowing Examination : 

Structural observations shape asymmetries irregularities scars dentition mucosa secretions Functional observations: consider role in swallowing Motor Range Rate Strength Accuracy Symmetry Sensory Bedside Examination of SwallowingClinical Swallowing Examination

AJSLP Nov 1997 p. 24 : 

AJSLP Nov 1997 p. 24 Lips at rest vowels /i/ /u/ /puh/ frown/pucker hold straw/suck stroke lips/cheeks – sensation

tongue : 

tongue protrude retract elevate lateralize lick lips lick palate clear buccal sulci pa, ta, ka, pataka lingual gag reflex stroke tongue – sensation -sweet -citrus -salt anterior tip – CN VII lateral margin – CN VII/ IX posterior tongue – CN IX

jaw : 

jaw rest bite chewing motion open against resistance close against resistance

velum : 

velum at rest repeated /a/ palatal gag reflex – both sides sensory taste – hard palate/soft palate margin (CN VII)

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Picture of gag reflex points

larynx : 

larynx voice quality volitional cough – how strong excursion during trial swallow max phonation time head turn and phonation pitch range – reduced sensation assoc with reduced pitch

respiration : 

respiration breath hold 1 ,3, 5 secs need 5 seconds for managing all consistencies sensation determine optimum oral-sensory stimuli to see optimal movement textures – gauze, burlap, satin around strw temperature – hot, cold, room flavor-sour, sweet, bitter, salty

Mann Assessment of Swallowing Ability : 

Mann Assessment of Swallowing Ability Follows basic bedside protocol Gains points for each task/behavior Max score = 200 Cut-off=185 Mild = 173 Moderate = 160 Severe = 132

Mann Assessment of Swallowing Ability : 

Mann Assessment of Swallowing Ability Determining presence of aspiration with MASA – Sensitivity specificity <120 7.1 100 <130 14.3 98 <140 25 97 <150 57.1 89 <160 64.3 84 <170 82.1 73 <180 92.9 55 <190 100 27 <200 100 4

Trial Swallows at Bedside : 

Trial Swallows at Bedside consider risk/benefit ratio – higher risk, then less likely to try equipment laryngeal mirror tongue blade cup spoon straw to use as pipette syringe suction needs to be nearby – especially if not managing secretions remind patient to cough

Trial Swallows at Bedside : 

Cherney – start with ice chip – lemon ice if possible then if possible, 1/3 tsp liquid, paste/pudding consistencies place hand along neckline and feel movement of tongue and larynx immediately after trial swallow phonate pant then vocalize again lateralize head each way and then phonate chin up then phonate red flag – coughing or gurgly voice quality after trial swallows, have patient remain seated at least 30 minutes Trial Swallows at Bedside

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For individuals currently on PO statusobserve during meal Note number swallows, delays in swallows, cough, time to complete Textures having difficulty or good progress Brush et al 2006 suggest this questions when observing eating… Who is this person? Preferences, dislikes, habits, vision When do eating difficulties arise? What is being served? Where does the person sit? What is happening in the environment?

Cervical AuscultationMills (Div 13 Dec 2004) : 

Cervical AuscultationMills (Div 13 Dec 2004) use of stethoscope to listen to swallowing sounds Sounds during the swallow: Double click – fast -usually more distinct in the normal swallow -click – eustachian tube opening -clunk – UES opening Other interpretations: Cichero & Murdoch (1998) 1st click: simultaneous closing of larynx and pressure of tongue against post. pharyngeal wall; maybe also laryngeal elevation 2nd click: tongue against post. pharyngeal wall plus pharyngeal clearing ? or pressure of bolus into esophagus 3rd click? unvalving of the system

Cervical AuscultationUyama et al 1996 : 

swallows without aspiration are faster than swallows with aspiration/penetration Airway sounds surrounding the swallow – turbulence, wet sounds -can it detect silent aspiration? If using auscultation, need a good stethoscope -bell more sensitive to lower frequencies associated with aspiration Littmann Cardiology II Hewlett-Packard Rappaport-Sprague with medium bell and small diaphragm Cervical AuscultationUyama et al 1996

Cervical AuscultationUyama et al 1996 : 

place laterally on neck for best acoustics listen over several breath cycles first listen during cup swallow – listen for turbulence phonate, pant, turn head – listen again – perhaps changed sounds Indications of abnormality: normal sounds followed by turbulence after swallow turbulence prior that is increased after swallow turbulence that increases after the phonate/head turn movements Cervical AuscultationUyama et al 1996

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Bronchial Auscultation to detect aspiration? Shaw et al (2004) Compared BA and videofluro aspiration high specificity (88%) ; sensitivity 45%

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McCullough et al AJSLP Clinicians’ preferences and practices in conducting clinical/bedside and videofluoroscopic swallowing examinations in an adult, neurogenic population Procedures vary – distinct need to improve reliability, validity, sensitivity, and specificity of these methods

Predicting Aspiration RiskDaniels et al AJSLP 1997; APMR 2000 : 

Predicting Aspiration RiskDaniels et al AJSLP 1997; APMR 2000 Findings of bedside exam that suggest aspiration risk ***presence of 2 of 6 clinical features 1-dysphonia - wet-hoarseness, strained, harsh, breathy 2-dysarthria 3-abnormal gag - absent or reduced, unilaterally or bilaterally 4-abnormal volitional cough - weak or phonation 5-cough after swallow 6-voice change after swallow sensitivity 92.3 specificity 66.7

Gag reflex??Ramsey et al 2005 : 

Gag reflex??Ramsey et al 2005 Absent gag: 88.6% with dysphagia Intact gag: 31.3% with dysphagia Gag absent in 38.6% with dysphagia Gag absent in 3.5% with no dysphagia Specificity: 96 Sensitivity: 39

Predicting Aspiration Risk from bedside examinationMcCullough et al JCD 2001 : 

Predicting Aspiration Risk from bedside examinationMcCullough et al JCD 2001 22/60 pts aspirated on MBS Significantly associated with: Pneumonia Poor nutrition Feeding tube Dysarthria Difficulty with secretions Wet voice Poor resonance Dysphonia ***spontaneous cough during trial swallows– best sensitivity/specificity -52 eventually returned to regular diet

Predicting Aspiration Risk from bedside examinationMcCullough et al JSHR 2005 : 

Predicting Aspiration Risk from bedside examinationMcCullough et al JSHR 2005 N=165 Highest likelihood of aspiration (>3.0) associated with: Pneumonia Poor oral hygiene Drools Bilateral jaw weakness Dysphonia Wet/gurgly voice Breathy voice Strained voice Delayed oral transit on 3 oz water swallow

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Cough measures altered in stroke Compared to controls

Assessing cough reflexAJPMR 2003 : 

Assessing cough reflexAJPMR 2003 Cough reflex test – with nebulized tartaric acid – (question about whether SLPs can do this???) Normal cough reflex: none developed pneumonia (100% specificity) Abnormal cough reflex: 5/30 developed pneumonia New info that needs further investigation in SLP community (Hammond 2006)

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Not a good predictor

Clinical Exam predictors of aspirationRosenbek et al 2004 : 

Clinical Exam predictors of aspirationRosenbek et al 2004 Sensitivity Specificity Delayed swallow 48 68 Spontaneous cough 68 82 Wet voice 50 63 3 ounce swallow 86 50 presence dysphagia 91 47 Dysphonia 100 27 Dysarthia 77 55 Tongue strength 50 27 Cough strength 70 45 Secretions 50 84

Predicting Aspiration RiskLogemann et al 1999 : 

Predicting Aspiration RiskLogemann et al 1999 predict aspiration when 2 of 3 indicators present coughing/throat clearing on trial swallows reduced laryngeal elevation on trial swallows history of recurrent pneumonia sensitivity 69% specificity 73% correctly classify 71%

Risks of Pneumonia Pikus et al 2003 : 

Risks of Pneumonia Pikus et al 2003 Risk of pneumonia greatest in those with silent aspiration, aspiration, and less so penetration Much smaller risk of pneumonia in those with dysphagia and not penetration or aspiration

Predictors of Aspiration Pneumonia RiskLangmore et al. 1998 : 

Predictors of Aspiration Pneumonia RiskLangmore et al. 1998 dependent for feeding dependent for oral care tooth decay tube fed multiple medications multiple medical diagnoses current smoker -more than one, increases sensitivity

Predictors of pneumonia in those who aspirate – Ding & Logemann 2000 : 

Predictors of pneumonia in those who aspirate – Ding & Logemann 2000 Retrospective of 378 patients 50% aspirated Predictors of pneumonia as compared to no pneumonia group -multiple location strokes -history of COPD -aspiration on MBS Acute pneumonia associated with -hypertension -diabetes -aspiration -decreased laryngeal elevation

Pulse oximetry as a measure of aspiration risk: Colodny (Div 13, Dec 04) : 

Pulse oximetry as a measure of aspiration risk: Colodny (Div 13, Dec 04) Hypoxemia (SpO2 <90%) some studies show reduced SpO2 associated with aspiration (Zaidi et al 1995; Sherman et al., 1999; Colodny, 2000) Chong et al 2003 – sensitivity 55.9%, specificity 100% Leder (2000) showed no association between pulse oximetry levels and aspiration Wang et al 2005 – showed no association between aspiration and pulse oximetry mixed literature suggests not a valid, reliable indicator by itself

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Crary 1999 – says observations of clinical exam sufficient to make decision for 80% of patients Confident no abnormality – PO decision Confident abnormality – may need to continue to MBS Need to know who needs modified diet Who needs NPO