dysphagia lecture 2 screening and assess

Clinical Indicators for Instrumental Assessment of Dysphagia (ASHA, 2000) : 

Clinical Indicators for Instrumental Assessment of Dysphagia (ASHA, 2000) Instrumental examination is indicated when: - The patient’s signs and symptoms are inconsistent with findings on the clinical examination - There is need to confirm a suspected medical diagnosis and/or assist in the determination of a differential medical diagnosis - Confirmation and/or differential diagnosis of the dysphagia is needed. - There is either nutritional or pulmonary compromise and a question of whether the oropharyngeal dysphagia is contributing to these conditions. - The safety and efficiency of the swallow remains a concern. - The patient is identified as a swallow rehabilitation candidate and specific information is needed to guide management and treatment decisions.

Clinical Indicators for Instrumental Assessment of Dysphagia (ASHA, 2000) : 

Instrumental examination is not indicated when: The patient is too medically unstable to tolerate the procedure. The patient is unable to cooperate or participate in an instrumental examination. In the speech-language pathologist’s judgment, the instrumental examination would not change the clinical management of the patient. Clinical Indicators for Instrumental Assessment of Dysphagia (ASHA, 2000)

Slide 3: 

Rationale for VFSS To identify normal and abnormal anatomy and physiology of the swallow To evaluate integrity of airway protection before, during, and after swallowing To evaluate effectiveness of postures, maneuvers, bolus modifications, sensory enhancement to enhance swallow To provide recommendations for optimum delivery of nutrition and hydration To determine appropriate therapeutic techniques To obtain information to educate collaborators Guidelines for speech-language pathologists performing videofluoroscopic swallowing studies (ASHA 2004)

Videofluorography = Modified Barium Swallow : 

Videofluorography = Modified Barium Swallow should only be done in approx 40% of patients (CARF report) some suggest testing in fatigued state i.e. more likely to have trouble e.g. chew gum before Placement of patient in radiology suite lateral view typically first if time anterior-posterior (a-p) view Place patient as vertical as possible focus from lips to UES place arms low so shoulder out of way explain to patient what you are about to do if possible let patient self-feed encourage patient to cough or spit out if necessary take all radiation precautions

MBS Procedures Logemann 1998 : 

MBS Procedures Logemann 1998 2 swallows of each consistency with: thin liquid barium 1 ml by spoon 3 ml by spoon 5 ml by syringe 10 ml by syringe if no aspiration cup drinking 1/3 tsp pudding mixed with esophatrast 1/4 cookie mixed with esophatrast Thickened liquids Possibly barium filled capsule (medicines)

Slide 8: 

MBS contraindications If unable to position patient If patient oversize If allergy to barium MBS limitations time limited because of radiation Limited swallow sample Contrast changes the viscosity of bolus Barium refusal

What to observe? : 

What to observe? 1) oral stage preparation time pattern of lip, jaw and lingual movements Oral preparation time Residue after swallow 2) oral transport transit time pattern of transit – tongue movements

What to observe? : 

3)reflexive stage time to initiate reflex - time to initiate once clears pillars - delayed reflex? pharyngeal transit time – reflex to clear the UES residue: Valleculae Pyriforms posterior pharyngeal wall What to observe?

What to observe? : 

4)Aspiration/penetration Aspiration looks like a vertical stream penetration looks like a horizontal pattern Why did it occur? Before swallow -due to poor oral control -due to delayed reflex During -due to poor laryngeal closure After -due to residue from pharyngeal weakness -due to cricopharyngeal dysfunction What to observe?

Slide 13: 

A-P view observe symmetry of swallow and residue Once aspiration observed, exam has just started! Need to continue to evaluate intervention strategies that keep patient safe Reliability of MBS judgments not optimal: best at identifying premature spillage, pooling in valleculae and pyriforms, delayed swallow, and poor bolus control (Wilcox et al., 1996)

Instrumental Examinationvideoendoscopy =FEESfiberoptic endoscopic evaluation of swallow – Langmore : 

Instrumental Examinationvideoendoscopy =FEESfiberoptic endoscopic evaluation of swallow – Langmore examines pharynx/larynx from direct superior view patient swallows colored boluses Advantages: no radiation exposure can view many swallows – whole meal

FEES : 

FEES Disadvantages when reflex triggers, view obliterated special training required for the technique some question about whether doctor will need to be present sometimes tube not tolerated Complications of FEES laryngospasm vasospasm nose bleeds adverse reactions to topical anesthetic Contraindications not useful in difficult patients platelet count < 75

MBS vs FEES : 

MBS vs FEES Aviv 2000 RCT – no difference between techniques in pneumonia outcomes Langmore 2003 - High agreement between the 2 techniques Colodny 2002 FEES better for penetration MBS better for different types of aspiration

Blue dye Tests : 

Blue dye Tests Add blue dye to saliva and monitor presence of blue dye in respiratory tract Used in trach patients O’Neil-Pirozzi et al 2003 compared to MBS, blue dye test 80% sensitivity/62% specificity for aspiration Donzelli et al 2001 compared FEES and blue dye test: 50% false negatives; positively identified 67% Overall take caution Swigert Div 13 2002 – Is it safe? Concerns about allergies to blue dye, so some place prohibit its use

Slide 23: 

other techniques are mainly research techniques: scintigraphy ultrasound electromyography pharyngeal manometry with videofluorography

Reliability of P-A Scale : 

Reliability of P-A Scale Colodny 2002 Found adequate reliability of PAS

Functional Oral Intake ScaleCrary et al 2004 : 

Functional Oral Intake ScaleCrary et al 2004 Level 1: nothing by mouth Level 2: tube dependent with minimal attempts of food or liquid Level 3: tube dependent with consistent oral intake of food or liquid Level 4: total oral diet of a single consistency Level 5: Total oral diet with multiple consistencies but requiring special preparation or compensation Level 6: total oral diet with multiple consistencies without special preparation, but with specific food limitations Level 7: total oral diet with no restrictions

Functional Oral Intake ScaleCrary et al 2005 : 

Functional Oral Intake ScaleCrary et al 2005 -high interrater reliability on coding -high content validity as highly associated with swallowing measures such as MASA (Mann) -associated with impairment on MBS -sensitive to changes in diet over 6 months

SWAL-QOL AND SWAL-CAREMcHorney et al 2000 : 

SWAL-QOL AND SWAL-CAREMcHorney et al 2000 Quality of life and quality of care outcomes tool SWAL-QOL 44 items – 5 pt rating scale Eating duration Eating desire Social functioning Burden Mental health SWAL-CARE – 15 items Reliability and validity documented McHorney et al 2002 Limited correlations with measures of swallow flow McHorney et al 2006 Measures something different and should be used along with swallowing exams

ASHA NOMs: Swallowing Scale : 

ASHA NOMs: Swallowing Scale Level 1: Individual is not able to swallow anything safely by mouth. All nutrition and hydration received thru non-oral means Level 2: individual not able to swallow safely by mouth for nutrition/hydration/but may take some consistency in therapy Level 3: alternative method of feeding required - <50% nutrition/hydration by mouth/ swallow is safe with consistent use of moderate cues – maximum diet restrictions Level 4: swallowing safe but usually requires moderates cues to use compensatory strategies; moderate diet restrictions and requires tube feeding and oral supplements Level 5 swallowing safe with minimal diet restrictions, minimal cueingto use compensatory strategies; all nutrition/hydration by mouth Level 6: Swallow safe and individual eats drinks independently and may rarely require minimal cueing; may need to avoid specific foods Level 7: Individuals ability to eat independently is not limited

FIM Eating ScaleFunctional Independence Measure : 

FIM Eating ScaleFunctional Independence Measure 7 Complete independence: uses utensils; all consistencies eaten safely 6 Modified independence: self-feed with some adaptive equipment or texture modification 5 Supervision or setup: supervision to cue or assist with preparation 4 Minimal Contact assistance: performs 75% or more of eating tasks 3 Moderate Assistance: performs 50-74% of eating tasks 2 Maximal Assistance: performs 25-49% of eating tasks 1 Total Assistance: performs <25% of eating tasks; or requires other means of feeding

Disorders of Swallowing: Stage Impairments/Physiological Targets and Typical Etiologies : 

Disorders of Swallowing: Stage Impairments/Physiological Targets and Typical Etiologies Important to distinguish between symptom and the disorder e.g. aspiration is a symptom but you must determine what is the disorder physiologically that leads to this symptom

Oral Preparatory and Transit Stage Impairments : 

Oral Preparatory and Transit Stage Impairments 1) reduced lip closure/tension -food may fall out of the mouth -determine whether nasal breathing possible during the chewing process -material may fall into the anterior sulcus 2) Tongue a) reduced tongue control -reduced motion -incoordinated tongue motion -poor tongue shaping of the bolus Liquids and paste -may spread around or escape prematurely -could lead to liquid aspiration before the swallow

Oral Preparatory and Transit Stage Impairments : 

Oral Preparatory and Transit Stage Impairments 2) tongue a) reduced tongue control Materials requiring mastication -may be difficult pulling all together into bolus -inability to lateralize material with tongue - visible on a-p view -bolus may be left over on tongue at end -may see residue on floor of mouth if tongue unable to completely remove the bolus

Oral Preparatory and Transit Stage Impairments : 

2) tongue b) Bolus transport: reduced/discoordinated anterior to posterior tongue movements increased oral transit times discoordinated squeezing against the roof from anterior to posterior not repetitive attempts, but disorganized motion multiple small movements may indicate prob with a-p movement repetitive rocking and rolling - esp in PKN, when posterior tongue doesn’t release the bolus appropriately, the bolus rolls back anteriorly and they have to reattempt the swallow again tongue thrust - inappropriate position of the bolus prior to transit may suggest tongue thrust swallow pattern which is abnormal as the child ages Oral Preparatory and Transit Stage Impairments

Oral Preparatory and Transit Stage Impairments : 

2) tongue c) Bolus transport: reduced tongue elevation poor tongue/velum contact -may see bolus adhere to hard palate if tongue not strong enough to propel backward - will worsen as viscosity increases -unable to use tongue elevation to compensate for poor tongue lateralization d) scarred tongue contour bolus may lodge in the scarring depression Oral Preparatory and Transit Stage Impairments

Oral Preparatory and Transit Stage Impairments : 

3) Velum – impairments in elevation and retraction reduced anterior movement of velum to hold bolus in place normal for masticated material to fall down prematurely - but this shouldn’t happen for liquids and pastes 4) Cheeks: bolus preparation - reduced buccal tension material may fall into lateral sulcus may be leftover debris may affect oral transit time because pressure provided by buccal tension also seems to play a role in backward propulsion of bolus Oral Preparatory and Transit Stage Impairments

Oral Preparatory and Transit Stage Impairments : 

5) Dentition- Bolus preparation/mastication inability to align dentition may see misalignment on a-p view 6) Impaired Jaw movements – bolus preparation/mastication difficulty closing mouth 7) oral sensation Necessary for bolus preparation: see residue in sulci Necessary for initiating swallowing response: Delayed reflex Oral Preparatory and Transit Stage Impairments

Oral Preparatory and Transit Stage Impairments : 

8) swallow apraxia disorganized ant to post tongue movement, repeated tongue pumping during oral prep delay to initiate swallow to verbal command, but once initiated swallow is normal - because this requires voluntary control 9) overall many of these may result in increased oral transit time piecemeal deglutition - swallows small portion at a time normal with a larger bolus, but not with small bolus typically used in each swallow *** aspiration before swallow may be associated with these types of disorders Oral Preparatory and Transit Stage Impairments

Pharyngeal stage disorders : 

Pharyngeal stage disorders symptoms you may observe and must account for -pharyngeal delay time -aspiration 1) delayed or absent pharyngeal swallow normally should trigger when bolus head reaches point where lower mandible/tongue base intersect <1 sec Certainly by epiglottis pharyngeal delay time should be noted >2 secs is definitely significant, and maybe even shorter delay if aspiration occurs associated with aspiration before swallow, especially liquids may see repeated pumping of tongue reattempting to initiate reflex

Pharyngeal stage disorders : 

2) reduced velar closure nasal penetration during swallow if later backflow observed, may indicate other problem, because later velum isn’t naturally in closed position Pharyngeal stage disorders

Pharyngeal stage disorders : 

3) pharyngeal problems a) reduced pharyngeal contraction unilateral/bilateral slight coating on pharyngeal wall may be normal as barium mixes with saliva *** more noticeable coating may suggest reduced contraction - best seen in a-p view normals often aware of this residue and may dry swallow when perceive it, abnormals not as likely to dry swallow to clear b) pharyngeal scarring e.g. pharyngocutaneous fistula may see pooling in depression of scar tissue Pharyngeal stage disorders

Pharyngeal stage disorders : 

4) reduced tongue base movement tongue moves posteriorly 2/3 of way, and post pharyngeal wall moves anteriorly 1/3 of way, so tongue base apparently more important often leads to pooling in valleculae which places patient at risk for aspiration examine carefully tongue base contact with post pharyngeal wall on a-p view see pooling in only one valleculae suggesting unilateral tongue weakness Pharyngeal stage disorders

Pharyngeal stage disorders : 

5) larynx a) reduced laryngeal elevation/anterior residue may remain and penetrate the larynx and risk for aspiration increases may actually lead to aspiration –during swallow - if aryts can’t come forward enough and close airway reduced anterior movement can lead to pooling in pyriform sinuses because doesn’t lift enough forward to open the cricopharyngeal sphincter – increases risk of aspiration after swallow b) reduced laryngeal closure only etiology for aspiration during swallow on a-p view, phonate and see vocal fold adduction some partial laryngectomee patients have vfs at different heights Pharyngeal stage disorders

Pharyngeal stage disorders : 

6) cricopharyngeal dysfunction reduced ability to clear bolus into esophagus can lead to residue in pyriform sinuses – and increase risk of aspiration after swallow can relate to reduced anterior laryngeal movement because this movement triggers relaxing of sphincter 8) epiglottis pseudoepiglottis - fold of tissue at base of tongue created after total laryngectomee may actually pull posteriorly during the swallow, blocking way for bolus transit Pharyngeal stage disorders

Pharyngeal stage disorders : 

9) cervical osteophytes can impede posterior flow of bolus and may direct bolus more anteriorly toward airway 10) overall penetration and aspiration can result from a number of disorders, so must evaluate video carefully to determine physiologic cause increased pharyngeal transit time may relate to any number of these features massive residue throughout pharynx may indicate a more generalized problem Pharyngeal stage disorders

Esophageal stage disorders : 

Esophageal stage disorders must be aware of some of these as they may masquerade as pharyngeal disorders 1) esphageal reflux failure of bolus to clear LES and eventually see backflow of bolus and place patient at aspiration risk can see irritation on vfs and pt complains of burning sensation 2) reduced esophageal peristalsis 3) esophageal diverticulum possible to develop a herniation near UES leaving a pocket (diverticulum) in which bolus can pool; then after swallow residue can flow out to larynx and place at risk 4) obstruction of esophagus 5) tracheoesophageal fistula -will cough after swallow as bolus irritates trachea