Dysphagia Exam 2: Clinical Swallowing Evaluation or Bedside Swallow Exam

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janessamarie
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279759
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Dysphagia Exam 2: Clinical Swallowing Evaluation or Bedside Swallow Exam
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2014-07-26 16:40:54
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dysphagia swallowing exam CSE
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Screenings at bedside
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  1. Differences between screening and evaluation
    Screening: 15 minutes or less, little/no client contact; chart review; not billable; may be performed by another discipline

    Evaluation: billable, thorough client contact, SLP only (not SLPA)
  2. Screening criteria
    • Sensitive
    • Specific
    • Easy to administer
    • Time and cost effective
    • Work setting (staff, training opportunities, work load)
  3. What are the 4 studies identified with sufficient methodological quality of screenings? Explain them.
    Volume Viscosity Swallow Test (VVST)--3 viscosities/volumes via syringe, pulse oximetry, determine type of oral intake

    Toronto Bedside Swallowing Screening Test (TOR-BSST)--OME screening, 10,1 tsp water pass/fail criteria, fail, refer to SLP, good reliability w/ training

    3 oz water test: given by cup or straw w/o interruption, cough, choke, wet voice can't complete; good predictor of ability to tolerate thin but high false-positive rate; now referred to as Yale Swallow Protocol

    Cough test: Inhale citric acid; physiologic salie orally via nebulizer; count coughs; limited sensitivity
  4. What is the Burke Dysphagia Screening (BDST)?
    • Use with acute CVA pts
    • 3 oz water plus checklist
    • ID those at risk for pneumonia and recurrent upper airway obstruction
    • Present/not present rating >- 1 = referral for evaluation
    • Facility specific screening
  5. What are purposes of evaluation? (11)
    • Define potential cause
    • Working hypothesis that defines disorder
    • Tentative tx plan
    • Questions for further study
    • Readiness to cooperate with further testing
    • Swallow safely
    • Nutritional status
    • Safety of present diet (if applicable) 
    • Need for tx
    • Necessary referrals
    • Establish medical diagnosis and/or pathogenesis for swallowing disorder
  6. Medical History in Clinical Evaluation
    Chart Review--what to look for? Components?
    • Med hx/contributing factors, focus onc conditions that contribute to presence of dysphagia, effect on nutrition, hydration, pulmonary status, quality of life
    • Congenital disease, neurologic disease, systemic/metabolic disorders, respiratory impairment, esophageal disease, previous test results, advance directives

    • Dx, onset, resolution
    • Surgical procedures: date, resolution
    • Airway status
    • Pulmonary status: pneumonia, radiographs
    • Nutrition: oral or enteral, parenteral intake, weight change, lab values/blood parameters
    • Hydration: I&O, serum sodium, osmolality
  7. What to ask in an interview?
    • Chief complaint
    • Perception of problem
    • character of compliant, consistency, frequency, pain, globes
    • course of complaint
    • ADLs related to feeding and oral hygiene
    • Previous treatment
  8. What is a clinical swallow exam?
    • standard exploration of muscle function, sensation, and airway protection
    • Mental status, voice, airway function, followed by motor and sensory systems and if appropriate, presentation of food and liquid
  9. What to observe during CSE?
    Posture, alertness, secretion management, trach present, language and cog function
  10. What to observe about mental status
    MMSE, GCS (3-15-eyes, motor response, verbal response), Racho Los Amigos Cog Scale (Levels 1-8), Narrative description
  11. What to observe about speech/articulation
    intelligbilty, rate, error patterns
  12. what to observe about positioning
    Habitual body position (sitting erect, leaning with self support, supported by apparatus, reclined, bed bound), alteration independent or assisted

    Habitual head position--and elicited (symmetrical, flexed, extended, lateralization, oration, alteration--independent or assisted)
  13. What to look for in salivary flow/appearance of oral mucosa
    • Salivary flow--should look wet, note appearance of dry, cracked, or flaking mucosa
    • Appearance of oral mucous--appearance and color of gums
  14. What is the Adult Dysphagia Bedside Exam
    • Format varies across settings
    • (Example used during OME)
    • Part 1: Hx/chart review, cog status, integrity of musculature, strength, ROM, coordination
  15. Jaw observations?
    Lips?
    Tongue?
    Pharynx?
    Larynx?
    • SRC, dentition
    • SRC, drooling, sensory testing
    • SRC, articulation, sensory testing
    • VP movement
    • Gag reflex
    • Sustained phonation, throat clear, volitional cough, laryngeal elevation, loudness, vocal quality
  16. Volition swallow/laryngeal elevation--How to test?
    Dry and/or bolus swallows

    Ring, middle, and index fingers along anterior throat; thyroid notch between ring and middle, index finger resting on supra hyoid muscles, request swallow with fingers in position 

    Ice chip can be used if xerostomia present
  17. Exam part 2: Food trials, note symptoms, awareness, independent compensatory maneuvers, cued compensatory maneuvers 

    How do you determine if food trials should continue? What should you use?
    Integrate ALL info; safety above all else (laryngeal elevation and protective cough); posture that may result in best swallow; best position for food in mouth; potential best food consistency; some indication and nature of swallow disorder

    Ice chips, puree, soft solid, solid, thin and thick piques (easiest volume and consistency first)
  18. Data during food and liquid swallows: How to take data during:
    Timing/speed
    # of swallows
    oral signs
    airway signs
    • Palpation of laryngeal elevation
    • swallows per bolus
    • observe oral cavity after each bolus
    • wet, dysphonia, spontaneous cough, awareness, timing of cough
  19. Consistency: General guidelines (Impairments, type of consistency)
    Poor oral control
    Delayed pharyngeal swallow
    Reduced BOT or pharyngeal wall contraction
    Reduced laryngeal Elevation or reduced UES
    Reduced laryngeal closure
    • Thick liquids first then move toward thin (otherwise risk for aspiration before swallow)
    • Puree
    • Liquids
    • Liquids
    • Thicker consistency
  20. Food positioning?
    Postures?
    • Side, sensitivity
    • Chin tuck, head tilt, head turn, combination
  21. Aspiration and the clinical exam

    Only what % of aspiration is detected during clinical eval?

    What are significant predictors of aspiration post stroke?
    • 60-70%
    • Impaired pharyngeal response, male, disabling stroke, incomplete oral clearance, palatal weakness/asymmetry, >70
  22. **Other screens (3 oz, timed water test, o2 saturation, modified Evans Blue Dye test) efficacy low; look at slide
  23. Assessment of Aspiration
    What % of patients who aspirate do not cough?
    What % of aspiration is missed during CSE?
    • Ask patient to sustain phonation before bolus
    • Sustained phonation immediately after swallow
    • Pant, then recheck photon (if any aspiration, will pop food on top)
    • Turn head then recheck
    • Tilt head back then recheck
    • 50-60
    • 40
  24. Management Objectives (5)
    • Implement adjustments to diet to maximize nutrition, hydration, and safety
    • Implement changes in positioning and use of maneuvers to maximize safety and efficiency 
    • Develop and carry out a treatment plan to address physiological impairments that cause disability
    • Determine need for further instrumental assessment
    • Refer to another discipline to address diagnostic concern beyond scope of practice
  25. Dissemination of Results
    Chart, staff, patient, family, other referral sources
  26. Instrumental evaluation indications
    • Any suspicion of aspiration
    • suspected pharyngeal stage disorder
    • define swallow physiology causing aspiration
    • confirm CSE impressions and trial therapy techniques
  27. Definite instrumental indications
    • Clinical exam doesn't answer clonal question
    • vague dysphagia characteristics
    • nutritional or respiratory issues suggest dysphagia
    • safety of efficiency of swallow a concern
    • rehab goals needed
    • help to assist underlying medical problems contributing to dysphagia
  28. May be indicators of instrumental exam
    • medical condition with high risk for dysphagia
    • overt change in swallow function
    • unable to cooperate for clinical exam
  29. NOT indicator of instrumental exam
    • no dysphagia complaints
    • too medically compromised or uncooperative
    • judgment that the exam wouldn't alter clinical course or management plan
  30. Other eval tools:
    Mann Assessment of Swallowing Ability (MASA)
    Functional Oral Intake Scale (FOIS)
    24 items rated 5-10 points; quick; free total=200, <- dysphagia, lower = more severe

    level of safe oral intake meeting nutritional nd hydration needs; based on interview with patient/fmaily; Levels 1-7, 4-7 based on food only

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