Dysphagia Management with the Patient who is acutely or critically by mikesanye

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									                                                                Why should we know about
    Dysphagia Management with the                               medical status/conditions?                              Systems we’ll discuss
    Patient who is acutely or                                      You then treat from a more informed                    Cardiopulmonary
    critically ill                                                  perspective                                            Endocrine
                                                                   You are a better member of the health care             Neurological
                                                                    team                                                   Digestive
Nancy B. Swigert, M.A., CCC-SLP, BRS-S
                                                                   You can discuss the case more effectively
                                                                    with physicians and nurses
Director: Speech-Language Pathology & RespiratoryCare
Central Baptist Hospital
Nswigert@aol.com Nancy B. Swigert, M.A., CCC/SLP,                                Nancy B. Swigert, M.A., CCC/SLP,                       Nancy B. Swigert, M.A., CCC/SLP,
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                                                                Relationships between cardiac                           Relationships between cardiac
    Cardiopulmonary                                             and pulmonary systems                                   and pulmonary systems
       Proper functioning of the cardiopulmonary                  Physiology: Oxygen/carbon dioxide                      Chronic heart failure (HF) is associated
        system is essential for a human being to survive.           exchange in lungs                                       with mild to moderate changes in
                                                                       Delivered by heart                                  pulmonary function, including restrictive
                                                                   They reside in common enclosure (chest                  and obstructive changes as well as a
                                                                    wall)                                                   reduction in lung diffusing capacity
                                                                                                                            (DLCO)


                     Nancy B. Swigert, M.A., CCC/SLP,                            Nancy B. Swigert, M.A., CCC/SLP,                       Nancy B. Swigert, M.A., CCC/SLP,
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    Relationships between cardiac
    and pulmonary systems                                       Cardiopulmonary relationships                           Cardiopulmonary
       Heart failure induced causes of altered lung               Relationship also exists between cardiac               Cardiac size may pose significant
        function remain unclear                                     volume and maximal expiratory airflows as               constraints on the lungs and likely plays a
       Attributed to respiratory muscle weakness,                  well as the DLCO.                                       major role in the restrictive breathing
        pulmonary hypertension, changes in lung                    As cardiac filling pressures increase and               patterns often reported in HF patients.
        fluid balance, and chronic neurohumoral                     pulmonary congestion progressively
        changes                                                     develops, blood flow may back up into the
                                                                    bronchial circulation and influence airway
                                                                    caliber resulting in airflow limitations
                     Nancy B. Swigert, M.A., CCC/SLP,                            Nancy B. Swigert, M.A., CCC/SLP,                       Nancy B. Swigert, M.A., CCC/SLP,
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                                                                                                                                                                               1
 Respiratory System Functions
                                                                   Respiratory status                                                 Respiratory status by radiograph
Ventilation
 Transfer of oxygen rich air into lungs                              Lung sounds                                                       Chest x-rays
                                                                            Rhonchi: coarse, secretions in bronchial tubes                  Infiltrate location dependent on position of
 Transfer of oxygen depleted/waste air out of 
                                                                            Rale: abnormal breath sound may indicate fluid in                patient at time of aspiration
   lungs
                                                                             the alveoli                                                          If recumbent, posterior segments of upper lobes
Respiration                                                                 Wheeze: whistling breath sound
                                                                                                                                                  If upright, involvement of basal segments of lower
 Transfer of oxygen to circulatory system, then to
                                                                                                                                                   lobes
  working organs                                                                                                                                       Der Sahakian et al 2007; Mark, 2001

 Removal of some waste from working organs, via
  circulatory system
                     Nancy B. Swigert, M.A., CCC/SLP,                                Nancy B. Swigert, M.A., CCC/SLP,                                         Nancy B. Swigert, M.A., CCC/SLP,
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Relationship of respiration and                                    Relationship of respiration and                                    Relationship of respiration and
swallowing                                                         swallowing                                                         swallowing
   Breath phase at which swallow is initiated                    Swallow breathing pattern can be altered by                           Swallowing can alter breathing
    determines volume of the swallow                               either swallowing or breathing (Martin-Harris, 2005)                      E.g. During repetitive swallowing, there are
       Near end of inspiratory-expiratory phase =                     E.g. Increase in ventilatory drive during                             greater inspiratory-expiratory times, yet tidal
        largest volumes                                                 hypercapnia (increased CO2) decreases                                 volume and minute ventilation are maintained
       That is, large swallows are found when lungs                    swallowing frequency                                                      Issa & Porostocky 1994)
        remain inflated at end of tidal breath                         Swallow during hypercapnia associated with
       Allows more oxygen reserves to be available                     increased incidence of aspiration and laryngeal
        for blood O2 saturation (Paydarfar, et al 1995)                 irritation (Nishino et al 1998)

                     Nancy B. Swigert, M.A., CCC/SLP,                                Nancy B. Swigert, M.A., CCC/SLP,                                         Nancy B. Swigert, M.A., CCC/SLP,
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Relationship of respiration and                                    Diseases of cardiopulmonary
swallowing                                                         system                                                             Cardiac-related conditions
   Swallow breathing pattern can be                                  Cardiac disease                                                   In large study (N=1340)                    Large percentage of
                                                                                                                                          re: FEEST, largest patient
    volitionally modified                                                                                                                                                             these patients had
                                                                      CABG                                                               subgroup was stroke
                                                                                                                                         2nd largest (22%) was                       significant vagal
       Subjects instructed to breathe out to residual                Obstructive lung disease                                           cardiac-related                             nerve sensory
        volume and then swallow – overall duration
                                                                      Restrictive airway disease                                            Most following open-                    dysfunctions
        of swallow was prolonged (slower swallows)                                                                                            heart surgery (almost
                                                                      Pneumonia                                                              60% of cases)                          Hypothesized they
       Swallows at total lung capacity were shorter                                                                                              Heart attack
                                                                                                                                                                                      were then at risk for
        in duration (faster swallows)                                                                                                             Congestive heart failure
              Gross et al 2008
                                                                                                                                                  Newly diagnosed                    silent aspiration
                                                                                                                                                   arrhythmias


                     Nancy B. Swigert, M.A., CCC/SLP,                                Nancy B. Swigert, M.A., CCC/SLP,                                         Nancy B. Swigert, M.A., CCC/SLP,
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                                                                                                                                                                                                                   2
   Post cardiac surgery                                                     Pneumonia                                                                             Medical status - pneumonia
                                                                                 Pneumonia is not a                          Where pneumonia is
      Other side effects include:                                                                                                                                   Relationship between pneumonia and
                                                                                  single illness but                           acquired is often part
                                                                                  rather many different                                                               aspiration not clear
                                                                                                                               of the description:
•Discomfort or itching from healing incisions                                     ones, each caused by                                                               Not everyone who aspirates gets aspiration
                                                                                  a different                                       Hospital-acquired
•Swelling of the area where an artery or vein was taken for grafting                                                                                                  pneumonia
•Muscle pain or tightness in the shoulders and upper back                         microscopic                                       Community acquired
•Fatigue (tiredness), mood swings, or depression                                  organism—whether it                               Ventilator-associated
•Difficulty sleeping or loss of appetite                                          is a bacterium, virus,
•Constipation                                                                     fungus


                       Nancy B. Swigert, M.A., CCC/SLP,                                               Nancy B. Swigert, M.A., CCC/SLP,                                           Nancy B. Swigert, M.A., CCC/SLP,
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   Medical status - pneumonia                                               Medical status - pneumonia                                                            Medical status - pneumonia
      Feinberg (1990) - patients who aspirated                                  Schmidt et al (1994) - patients were 7.6 X                                         Who will get pneumonia?
       thin liquids on fluoroscopy got no more                                    more likely to develop pneumonia if they                                           How much is aspirated?
       pneumonia than patients who did not                                        aspirated on fluoroscopy                                                           Are lungs able to clear material?
       aspirate (unless they were tube fed)                                      Non-compliers with dysphagia                                                       What was baseline pulmonary status?
      Corghan et al (1994) - no difference in                                    recommendations had more hospital
       number of patients who got pneumonia                                       admissions because of chest infections or
       when comparing known aspirators to those                                   aspiration pneumonia
       who did not                                                                     Low et al 2001
                       Nancy B. Swigert, M.A., CCC/SLP,                                               Nancy B. Swigert, M.A., CCC/SLP,                                           Nancy B. Swigert, M.A., CCC/SLP,
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       Risk factors for developing                                          Risk factors for chest infection in
       pneumonia (patients:OP, acute care, nursing home)                    acute stroke                  Dunnett et al 2007                                      Aspiration pneumonia
      Langmore (1998)                                                    412 patients admitted in UK                      Independent predictors                Highest mortality rate of any infection
        dependent for feeding                                            Subjects who developed                            of pneumonia were:
                                                                                                                                                                   Among hospitalized elderly, development
                                                                           pneumonia were:                                        Age >65
        multiple medical diagnoses
                                                                               Older                                             Dysarthria or no
                                                                                                                                                                    of pneumonia is associated with 43%
        current smoker                                                        Had higher NIHSS scores                            speech due to aphasia            mortality rate
        tube fed                                                              History of chronic obstructive
                                                                                pulmonary disease
                                                                                                                                  Modified Rankin Scale           Pneumonia 2nd most common infection in
                                                                                                                                   score >4
        dependent for oral care                                               Lower AMT (Abbrev. Mental                                                           nursing homes
                                                                                Test) scores                                      AMT <8
        number of decayed teeth                                                                                                                                   Up to 80% of nosocomial pneumonia may
                                                                               Higher Oral Cavity Score                          Failed water swallow
        number of meds                                                        Greater proportion with                            test                             be aspiration pneumonia
                                                                                positive bacterial culture from
                                                                                oral swabs
                       Nancy B. Swigert, M.A., CCC/SLP,                                               Nancy B. Swigert, M.A., CCC/SLP,                                           Nancy B. Swigert, M.A., CCC/SLP,
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                                                                                                                                                                                                                         3
                                                                                                                                                                                  High incidence of respiratory
Aspiration pneumonia                                                                       Aspiration pneumonia                                                                   infections in NPO stroke patients
                                                                                                                                                                                  Langdon et al 2007


   Kasprisin (1989) - compared two groups of                                                 Kasprisin conclusions                                                            369 acute stroke patients –                  75% of survivors fed by
                                                                                                                                                                                 Perth Australia                               NG or PEG were treated
    treated patients with group of untreated                                                      Even mildly dysphagic patients are at risk for                                                                              with antibiotics for
                                                                                                                                                                                51 respiratory infections in                  infections
    patients                                                                                       the development of aspiration pneumonia                                       330 survivors
                                                                                                                                                                                                                           Oral factors found to be
   Both treated groups had significantly less                                                    Severely dysphagic patients responded to                                     Dysphagia at 48 hours and 7                   significant in predicting
                                                                                                   management of their swallowing problems                                       days was strongly associated                  respiratory infections
    aspiration pneumonia than the untreated                                                                                                                                      with respiratory infection
                                                                                                                                                                                                                           Subjects who had poor
    group                                                                                                                                                                       Survivors NPO at 48 hours                     oral hygiene and were
                                                                                                                                                                                 and 7 days were significantly                 NPO 48 hours post stroke
                                                                                                                                                                                 more likely than survivors                    had risk ration of
                                                                                                                                                                                 fed orally to develop                         respiratory infection of
                                                                                                                                                                                 respiratory infection                         18.39
                            Nancy B. Swigert, M.A., CCC/SLP,                                                   Nancy B. Swigert, M.A., CCC/SLP,                                                        Nancy B. Swigert, M.A., CCC/SLP,
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Aspiration considered as possible cause
for Community Acquired Pneumonia                                                           Atelectasis                                                                            Endocrine system
(CAP)                                                                                         Atelectasis is a condition             Common cause of
                                                                                                                                                                                      The endocrine system is one of the body’s main
                                                                                               in which all or part of a               atelectasis is a blockage of
                                                  Concludes that elderly                      lung becomes airless and
                                                                                                                                       one of the bronchi                              systems for communicating, controlling and
                                                                                                                                      The blockage may be caused
   Review article                                 patients with clinical                      collapses.                              by something inside the                         coordinating the body’s work.
                                                                                           
    discusses implications                         signs suggestive of                         Blockage of the bronchial               bronchus, such as a plug of
                                                                                                                                       mucus, a tumor, or an                          It works with the nervous system, reproductive
                                                   dysphagia and/or who                        tubes is a common cause of
    of community-                                                                              atelectasis.
                                                                                                                                       inhaled foreign object (such
                                                                                                                                       as a coin, piece of food, or a                  system and other organs to help maintain and
    acquired pneumonia                             have CAP should be                         Shortness of breath is the
                                                   referred for swallow
                                                                                                                                       toy).                                           control the following: body energy level,
                                                                                               only symptom that                      Alternatively, the bronchus
                                                   evaluation                                  atelectasis itself causes.              may be blocked by                               reproduction, growth and development, responses
                                                                                                                                       something pressing from the
                                                                                              Chest x-ray is used to                  outside, such as a tumor or                     to surroundings, stress, and injury.
                                                                   Marik & Kaplan,
                                                                                               confirm the diagnosis.                  enlarged lymph nodes.
                                                                    2003
                            Nancy B. Swigert, M.A., CCC/SLP,                                                   Nancy B. Swigert, M.A., CCC/SLP,                                                        Nancy B. Swigert, M.A., CCC/SLP,
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                                                                                                                                                                                  Diseases of neurological system
Diabetes                                                                                   Complications of gastroparesis                                                         (a few examples)
   Peripheral neuropathy can result in oropharyngeal
    dysphagia                                                                                 Gastroparesis can make diabetes worse by making                                        CVA, TIA, hemorrhage
   Gastroparesis is a disorder affecting people with both type 1                              it more difficult to manage blood glucose.
    and type 2 diabetes, where the stomach takes too long to                                      When food that has been delayed in the stomach finally                             Progressive disorders (MS, Parkinson’s)
    empty its contents. It happens when nerves to the stomach are                                  enters the small intestine and is absorbed, blood glucose
    damaged or stop working.                                                                       levels rise.                                                                       Dementia
   Signs and symptoms of gastroparesis (delayed gastric emptying) are:
   heartburn
                                                                                              If food stays too long in the stomach, it can cause
   nausea                                                                                     problems like bacterial overgrowth because the food
   vomiting of undigested food                                                                has fermented.
   an early feeling of fullness when eating
   weight loss                                                                                   Also, the food can harden into solid masses called
   abdominal bloating                                                                             bezoars that may cause nausea, vomiting, and obstruction
   erratic blood glucose (sugar) levels                                                           in the stomach. Bezoars can be dangerous if they block
   lack of appetite                                                                               the passage of food into the small intestine.
   gastroesophageal reflux
   spasms of the stomach wall
                            Nancy B. Swigert, M.A., CCC/SLP,                                                   Nancy B. Swigert, M.A., CCC/SLP,                                                        Nancy B. Swigert, M.A., CCC/SLP,
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                                                                                                                                                                                                                                                                4
Converging evidence about                                         Dysphagia and Stroke:                                            Neuroanatomy of swallowing
neurology of swallowing                                           Demographics                                                     lesions
   Common sites of involvement are evident                        2000 people per million worldwide                                 Dysphagia may result from bilateral
   Distributed neural network                                     700,000 individuals annually in U.S.                               hemispheric and brainstem strokes
                                                                                                                                              Horner et al 1990
       Both cerebral hemispheres and subcortical                  Dysphagia occurs in about 55% of patients
        structures                                                                                                                            Kim et al 2000
                                                                    with acute stroke
       Involvement of multiple levels                                                                                                Dysphagia may results from unilateral
                                                                   40% demonstrate aspiration on
           May induce more severe or protracted dysphagia                                                                             strokes of either cerebral hemisphere
                                                                    videofluoroscopic evaluation                                              Robbins et al 1993
                                                                   40%-70% demonstrate silent aspiration

                    Nancy B. Swigert, M.A., CCC/SLP,                                       Nancy B. Swigert, M.A., CCC/SLP,                              Nancy B. Swigert, M.A., CCC/SLP,
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Neuroanatomy of swallowing                                        Neuroanatomy of swallowing                                       Neuroanatomy of swallowing
lesions                                                           lesions                                                          lesions
   There are contradictory findings                                 Swallowing behavior differs in left and right                   Hemispatial neglect significantly
                                                                      hemispheric stroke (Robbins et al)
    concerning swallowing lateralization                                                                                               associated with initial non-oral intake
                                                                         Left hemisphere stroke
       Dysmotility pattern and aspiration risk may                           Oral dysmotility                                       Aphasia not associated with swallowing
        be related to the hemisphere lesioned                            Right hemisphere stroke                                      outcome (Schroder, et al 2006)
           Robbins et al, 1993, 1988; Smithard et al 1997                    Pharyngeal dysfunction
                                                                              Aspiration
       Hemisphere may not discriminate dysmotility
                                                                     Swallowing behavior does not differ in left and
        pattern or risk of aspiration                                 right hemisphere strokes
           Daniels & Foundas, 1999; Alberts et al 1992                  Daniels et al 1999

                    Nancy B. Swigert, M.A., CCC/SLP,                                       Nancy B. Swigert, M.A., CCC/SLP,                              Nancy B. Swigert, M.A., CCC/SLP,
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Parkinson’s Disease                                               Parkinson’s Disease                                              Parkinson’s Disease
   Progressive degenerative disorder                                Oral phase problems                                             Pharyngoesophageal
       Loss of striatal dopamine                                                                                                         Delayed onset pharyngeal response
                                                                              Impaired lingual movement for transfer of
                                                                                                                                          Abnormal pharyngeal wall movement
   Related impairments include:                                               bolus (rocking or pumping)
                                                                                                                                          Impaired bolus transport
       Cognitive impairment                                                  Incomplete oral clearance                                      Residue
       Drooling                                                                                                                          Decreased hyolaryngeal movement
                                                                              Premature loss over back of tongue
       Jaw rigidity                                                                                                                      Incomplete UES and LES opening
       Head and neck posture                                                                                                             GER
       Upper extremity limited mobility                                                                                                  Tertiary contractions
       Impulsive feeding behavior                                                                                                        Esophageal stasis
                    Nancy B. Swigert, M.A., CCC/SLP,                                       Nancy B. Swigert, M.A., CCC/SLP,                              Nancy B. Swigert, M.A., CCC/SLP,
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                                                                                                                                                                                                 5
     Dementia                                                                        Dementia                                                                          Digestive system
    Changes throughout the course of the degenerative disease                          Estimated that 45% of institutionalized                                          Digestion involves mixing food with
     process.
    In the early stage, the individual with dementia may forget to                      patients with dementia have dysphagia                                             digestive juices, moving it through the
                                                                                         (Easterling & Robbins, 2008)
     eat, may become depressed and not want to eat, or may                                                                                                                 digestive tract, and breaking down large
     become distracted and leave the table without eating.                              Two independent predictor factors for                                             molecules of food into smaller molecules.
    In the middle stage, the individual with dementia may be                            development of pneumococcal infections
     unable to sit long enough to eat, yet at this stage may require                                                                                                      Digestion begins in the mouth, when you
     an additional 600 calories per day because of wandering and                         are dementia and seizure disorders (Lipsky et al 1986)
     motor restlessness.                                                                                                                                                   chew and swallow, and is completed in the
     In the late stage, the individual with dementia does not have                                                                                                        small intestine.
     intact oral motor skills for chewing and swallowing, thus
     becoming subject to malnourishment and "wasting away."
                           Nancy B. Swigert, M.A., CCC/SLP,                                                        Nancy B. Swigert, M.A., CCC/SLP,                                               Nancy B. Swigert, M.A., CCC/SLP,
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     Digestive system tied closely to
     endocrine system                                                                Diseases of digestive system                                                      Esophageal disorders
   Hormone Regulators                                                                  The list is almost endless                                                       GERD/LPR
   The major hormones that control the functions of the                                       Celiac                                                                    GERD and LPR are implicated in the
    digestive system are produced and released by cells                                                                                                                    development of a variety of respiratory tract
    in the mucosa of the stomach and small intestine.                                          Crohn’s                                                                    diseases, including:
   These hormones are released into the blood of the                                          Irritable bowel syndrome                                               
                                                                                                                                                                       
                                                                                                                                                                           Chronic laryngitis (Johnson, 2000)
                                                                                                                                                                           Hoarseness (Weiner et al 1989)
    digestive tract, travel back to the heart and through                                      Lactose intolerane                                                        Laryngeal cancer (Freije et al 1996)
                                                                                                                                                                          Globus (feeling of knot or tightness in chest) (Halstead 1999)
    the arteries, and return to the digestive system where
                                                                                               Ulcers                                                                    Cough and Paradoxical Vocal Fold Motion (Altman et al 2002)
    they stimulate digestive juices and cause organ                                                                                                                       Laryngeal stenosis and laryngomalacia (Halstead 1999)
    movement.                                                                                                                                                             Sleep disturbance (Penzel et al 1999)
                                                                                                                                                                          Chronic rhinosinusitis (Contencin et al 1991)
   The main hormones that control digestion are gastrin,
    secretin, and cholecystokinin (CCK)
                        Nancy B. Swigert, M.A., CCC/SLP,                                                           Nancy B. Swigert, M.A., CCC/SLP,                                               Nancy B. Swigert, M.A., CCC/SLP,
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     Common structural problems of                                                   Common motility problems of
     esophagus                                                                       the esophagus                                                                     Other esophageal
   Peptic stricture is the most common stricture of the esophagus.                     Esophageal dismotility is a decrease in the primary contraction wave
                                                                                         of the esophagus
                                                                                                                                                                          The esophagus may also be affected in
    About 10% of patients with severe reflux disease have such a
    stricture of the LES. However, the stricture can also occur in                      Achalasia is the best characterized esophageal motility disorder and              collagen vascular diseases such as
                                                                                         affects swallowing of liquid and solids. The patient may complain of
    proximal esophagus, causing aspiration and choking.                                  a burning sensation or pain behind the sternum. It is chronic and gets
                                                                                                                                                                           dermatomyositis/polymyositis and
   Esophageal rings and webs can occur proximally (such as in                           worse gradually. When assessed manometrically, it is characterized                progressive systemic sclerosis. Effects may
    Plummer-Vinson or Paterson-Brown-Kelly syndrome) and                                 by lack of esophageal peristalsis and lower esophageal sphincter
                                                                                         relaxation.                                                                       range from GERD to reduced UES
    cause aspiration. These proximal webs may be associated with
    Zenker’s diverticulum.                                                                    The view on fluoroscopy is described as a bird’s beak because               opening. (Shaker, 2003).
                                                                                               the esophagus is dilated and full of food, no squeezing is
       Distal rings are located at the LES and are usually accompanied by a                   occurring and because the LES doesn’t relax the column of food             In instances of true cricopharyngeal dysfunction,
        hiatal hernia. Dysphagia is intermittent and usually related to solid
        foods These are called Schatzki’s rings. (Shaker, 2003).
                                                                                               in the esophagus ends in a point looking like a bird’s beak.                the upper esophageal sphincter fails to relax.
                           Nancy B. Swigert, M.A., CCC/SLP,                                                        Nancy B. Swigert, M.A., CCC/SLP,                                               Nancy B. Swigert, M.A., CCC/SLP,
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                                                                                                                                                                                                                                                 6
    Cardiac monitors                                                                 Pulse Oximetry                                             Pulse Oximetry (Leder, 2000)
   Cardiac or heart                                                                    Colodny (2000)                                         FEES with monitoring of arterial oxygen
    monitors: Cardiac
    monitors are used to                                                                181 subjects                                            saturation, heart rate and blood pressure
                                                         60-80 normal
    monitor the electrical                                                              104 with dysphagia
    activity of the heart.                               100-200                                                                               No significant differences in SpO2 levels
                                                                                        Aspirators had lower SpO2 levels before, during
    The monitor looks like a                              tachycardia                                                                            based on aspiration status or oxygen
    computer screen with                                                                 and after feeding
    lines, or tracings,                                  40-50 bradycardia             Solid aspirators most compromised                       requirements
    moving across the                                                                   No relation found between SpO2 levels and              Higher heart rate during and 5 minutes post
    screen. The monitor has
    electrodes that are                                                                  aspiration
                                                                                                                                                Higher blood pressure during and lower post
    attached to the patient's                                                           Conclusion: Individuals with dysphagia have
    chest with sticky pads.                                                                             pulmonary systems
                                                                                         compromised Nancy B. Swigert, M.A., CCC/SLP,
                       Nancy B. Swigert, M.A., CCC/SLP,                                                                                                         Nancy B. Swigert, M.A., CCC/SLP,
                                    BRS-S                                       55                                BRS-S                    56                                BRS-S                 57




    Swan-Ganz                                                                        Arterial lines                                             Tubes and catheters
       Swan-Ganz catheter: A Swan-Ganz, or pulmonary
        artery catheter, is used to measure the amount of fluid
                                                                                        Also called intra-arterial lines, art lines, A-
        filling the heart as well as to determine how the heart                          lines
        is functioning.
       It is inserted through the large vessels of the neck or                         Placement of an arterial line is indicated for
        upper chest and threaded into the heart.                                         continuous monitoring of arterial pressure
       http://www.pulmonologychannel.com/icu/equipment.s
        html                                                                             and direct arterial blood sampling.
                                                                                        Typically placed in radial artery


                     http://www.nlm.nih.gov/medlineplus/ency/imagepages/18087.htm
                        Nancy B. Swigert, M.A., CCC/SLP,                                              Nancy B. Swigert, M.A., CCC/SLP,                          Nancy B. Swigert, M.A., CCC/SLP,
                                   BRS-S                                        58                                 BRS-S                   59                                BRS-S                 60




    Central Venous catheter                                                          Central Venous catheters                                   Intravenous (IV):
       Central venous catheter (CVC): This type                                     CVCs are used:                                                An IV is a plastic catheter (tube) that is
        of catheter is a soft, pliable tube that is                                   to administer frequent or continuous                         inserted into the veins (peripheral IV) or a
        inserted into a large vessel (vein) in the neck                                medication;                                                  larger size catheter inserted into the larger
        (internal jugular vein), in the upper chest                                   to administer large multiple IV products that
                                                                                                                                                    veins of the neck. Fluids, medications,
        (subclavian vein), or in the groin area                                        do not fit in one line; and                                  nutrition preparations, and blood products are
        (femoral vein).                                                                                                                             administered through IV catheters. Patients in
                                                                                      to measure central venous pressure (the
       Ends up in vena cava or atrium of heart                                                                                                     ICU often have multiple IVs.
                                                                                       amount of fluid in the vessels).
          Peripherally inserted Central Catheter
                                                                                      CVCs carry some risk of bloodstream infection
            PICC line goes into arm                                                    and thrombosis (tenderness and abnormal
        Patients are sedated and receive a local anesthetic
    
        prior to insertion. Sutures secure the CVC, which can
                                                                                       fluid collection in tissues, impaired
                                                                                       movement, and engorged veins).
        be left in place for days or weeks.
                       Nancy B. Swigert, M.A., CCC/SLP,                                               Nancy B. Swigert, M.A., CCC/SLP,                          Nancy B. Swigert, M.A., CCC/SLP,
                                    BRS-S                                       61                                 BRS-S                   62                                BRS-S                 63




                                                                                                                                                                                                        7
                                                                                                                                          Interpreting data from medical
Chest tubes                                                    Urinary catheter                                                           record
   Chest tubes are inserted through                              Urinary catheters(Foley catheters)                                        Laboratory values
    the chest wall into the space                                 inserted through the urethra into the bladder.
                                                                                                                                                 Blood gas values
                                                                   Kept in place by a balloon, which is inflated,
    around the lung to drain fluid or                          
                                                                   at the end of the catheter.                                               Nutritional values
    air that has accumulated and                                  Urinary catheters continuously drain the                                  Pharmacological information – what
    prevent the lung from being able                               bladder and allow for accurate measurement
                                                                   of urinary output, which is extremely
                                                                                                                                              different drugs do
    to expand.
   http://davezanni.com/blog/wp-                                  important in fluid management and in                                      Physician consults (neuro, gastro,
    content/uploads/2007/12/chest_tubes.jpg                        assessing kidney function.
                                                                                                                                              radiology)
                                                                  http://www.malecare.com/nr551580.jpg
                     Nancy B. Swigert, M.A., CCC/SLP,                                Nancy B. Swigert, M.A., CCC/SLP,                                       Nancy B. Swigert, M.A., CCC/SLP,
                                  BRS-S                   64                                      BRS-S                              65                                  BRS-S                                     66




                                                                                                                                          Mills & Ashford Health Status
Lab values                                                     What can lab values tell us?                                               Model
   Russell “Hank” Mills                                          43% to 54% of patients with acute CVA                                     Relationship                         Oral, pharyngeal and
                                                                                                                                                                                    esophageal components
   John Ashford                                                   will aspirate                                                              between dysphagia                     of swallow at core
        Department of Veterans Affairs Directive                 Of patients who do not aspirate, 37% will                                  and the organism                     Surrounding that are six
         2006-32                                                                                                                                                                    areas of health status:
                                                                   develop pneumonia and 63% will not                                                                                     RBC indices
        “Management of Patients with Swallowing                                                                                                                                          Hydration
         (Dysphagia) and Feeding Disorders                            WHY?
                                                                                                                                                                                          Renal function
                                                                                                                                                                                          Nutrition
                                                                                                                                                                                          Immune system status
        Summarized in Perspectives 17 (128-134)                                                                                                                                          Presence of infection
         December 2008
                     Nancy B. Swigert, M.A., CCC/SLP,                                Nancy B. Swigert, M.A., CCC/SLP,                                       Nancy B. Swigert, M.A., CCC/SLP,
                                  BRS-S                   67                                      BRS-S                              68                                  BRS-S                                     69




Lab values as indicator of health
status                                                         CBC                                                                        CBC
   Blood tests assembled into panels:                            Three red blood cell indices                                              Total white blood cell count (WBC)
        Complete Blood Count (CBC)                                   Red Blood Cell Count (RBC)                                                Total number of leukocytes present
                                                                                                                                                   Lymphocytes
        Complete Metabolic Panel (CMP)                               Hematocrit (HCT)
                                                                                                                                                   Neutrophils
             See Appendix for Reference Ranges of most               Hemoglobin (Hgb)                                                            Basophiles
              helpful tests from the panel                                Responsible for transporting oxygen molecules                           Eosinophils
   Using a finding from a single test is an                               throughout all parts of organism                                        Monocytes

    over-simplification                                                   Depressed values may indicate anemia                                  All have differing functions related to the
                                                                              Common symptoms of anemia include fatigue, loss of                 immune system
                                                                               energy, SOB, difficulty concentrating and dizziness

                     Nancy B. Swigert, M.A., CCC/SLP,                                Nancy B. Swigert, M.A., CCC/SLP,                                       Nancy B. Swigert, M.A., CCC/SLP,
                                  BRS-S                   70                                      BRS-S                              71                                  BRS-S                                     72




                                                                                                                                                                                                                        8
CMP                                                           CMP – Forms of dehydration                                             CMP
   Includes electrolytes: sodium, potassium,                    Hypernatremia                                                         Blood Urea Nitrogen (BUN) and
    chloride                                                         Greater water loss from the body than sodium                       Creatinine are waste products of
   Indicators of hydration status                                   Causes profuse sweating, severe diarrhea,                          metabolism
                                                                      vomiting                                                              Elevated values may indicate renal
   Under-hydration and over-hydration can
                                                                 Hypovolemia                                                                impairment
    take several forms
                                                                                                                                                Renal impairment = decreased urine output, dry
       Not all are reflected in “out of reference                   Equal losses of fluid and electrolytes
                                                                                                                                                 mouth, loss of appetite, nausea, vomiting,
        range”                                                                                                                                   dehydration


                      Nancy B. Swigert, M.A., CCC/SLP,                           Nancy B. Swigert, M.A., CCC/SLP,                                        Nancy B. Swigert, M.A., CCC/SLP,
                                   BRS-S                 73                                   BRS-S                             74                                    BRS-S                       75




CMP                                                           CMP                                                                    CMP
   Albumin is measure of protein stores                         Weaknesses to albumin measurements                                    Albumin value important b/c nutritional
       Used as measure of nutritional status                        Hydration sensitive                                                status tied to strength of immune system
   Low albumin may indicate body has been                             Dehydrated patient may have artificially elevated               So, aspiration in normally hydrated patient
    depleted of protein and that the patient is                         albumin levels
                                                                                                                                         with low albumin level (e.g. 2.0 gm/dl)
    malnourished                                                       Reflects protein status over last 18-21 days
                                                                                                                                         should indicate extreme caution in
       Without intervention for low albumin levels,                   Pre-albumin reflects last 1-2 days, so that test will

        hospitalized elderly consumed only 14.5% of                     show if a treatment is working                                   treatment planning, as immune system
        their estimated energy requirements                                                                                              compromised
           Byrnes, Statton & Wright (1998)
                      Nancy B. Swigert, M.A., CCC/SLP,                           Nancy B. Swigert, M.A., CCC/SLP,                                        Nancy B. Swigert, M.A., CCC/SLP,
                                   BRS-S                 76                                   BRS-S                             77                                    BRS-S                       78




The immune system                                             The immune system: neutrophils                                         Immune system- Neutrophils
   Body’s ability to fight infection in patients with           Bacteria fighters first to arrive at site of                          Patients with values of 500 to 1500/mm3 have
    dysphagia is critical                                                                                                                reduced number of neutrophils = mild
                                                                  infection                                                              neutropenia and at minimum risk to develop
   Two subsystems combine to seek out and destroy
    pathogenic microorganisms                                    Neutrophil count expressed in two ways:                                infection
       Specialized immunoglobulins & complement                 Total percent – 40%-70% of WBC                                        ANC values less than 500/mm3 = moderate to
        proteins                                                                                                                         severe neutropenia and at increased risk for
       Specialized white blood cells (WBC), called              Absolute Neutrophil Count (ANC) –                                      developing infection
        leukocytes                                                1500/mm3 or >                                                         ANC values > 7500/mm3 or neutrophil counts >
           Lymphocytes (B- & T-)
           Phagocytes
                                                                                                                                         70% = neutrophilia and this may indicate acute
           Granulocytes (these include neutrophils)                                                                                     bacterial infection
                      Nancy B. Swigert, M.A., CCC/SLP,                           Nancy B. Swigert, M.A., CCC/SLP,                                        Nancy B. Swigert, M.A., CCC/SLP,
                                   BRS-S                 79                                   BRS-S                             80                                    BRS-S                       81




                                                                                                                                                                                                       9
        Illness and immune system                                                    Immune system and the mouth                                               Other lab values/tests
                                                                                        Neutrophils trap and degrade bacteria in                          PT and INR                               Why get tested?
           Serious illness (e.g. CVA, surgery) may
                                                                                         oral cavity                                                                                                  To check how well
            result in temporary neutropenia                                                                                                                Also known as: Prothrombin                blood-thinning
                                                                                        Onset of stress from serious illness (e.g.                         Time, Pro Time, Protime
               Coupled with aspiration of over-colonized                                                                                                   Formal name: Prothrombin
                                                                                                                                                                                                      medications (anti-
                oropharyngeal bacteria may result in                                     CVA, surgery) may alter the regulation of                          Time and International                    coagulants) are working
                pneumonia                                                                the immune system                                                  Normalized Ratio                          to prevent blood clots;
                                                                                                                                                                                                      to help detect and
           Elevated WBC values indicate presence of                                        Reduced protection allows oral pathogens to                                                              diagnose a bleeding
                                                                                             increase                                                      www.labtestsonline.org
                                                                                                                                                                                                      disorder
            peripheral inflammatory response (and that
                                                                                            If aspirated into immune-compromised lower
            infection is bacterial in nature)                                                respiratory system, could trigger pneumonia
                         Nancy B. Swigert, M.A., CCC/SLP,                                             Nancy B. Swigert, M.A., CCC/SLP,                                               Nancy B. Swigert, M.A., CCC/SLP,
                                      BRS-S                                 82                                     BRS-S                         83                                               BRS-S                               84




        Other lab values/tests                                                       Other lab values/tests                                                    Other lab values/tests
       Glucose                              Why get tested?                       A1c and eAG                             Why get                          AST                                How is it used?Testing for AST is
        Also known as: Blood                  To determine if blood                  Also known as:                                                             Also known as:                      usually used to detect liver
                                              glucose level is within                Hemoglobin A1c,                          tested?                                                               damage.
        sugar, Fasting blood                  healthy ranges; to screen                                                       To monitor a                      Serum glutamic-                    AST levels are also often compared
                                                                                     HbA1c,
        sugar, FBS, blood                     for, diagnose, and                                                                                                oxaloacetic                         with levels of other liver enzymes,
        glucose, Oral Glucose                 monitor hyperglycemia,
                                                                                     Glycohemoglobin,                         person’s                          transaminase,                       to determine which form of liver
                                                                                     Glycated hemoglobin,                     diabetes and to                                                       disease is present.
        Tolerance Test (OGTT                  hypoglycemia, diabetes,
                                                                                     Glycosylated                                                               SGOT
                                              and pre-diabetes                                                                                                                                     Even though AST is found in heart
        or GTT), Urine glucose                                                       hemoglobin                               aid in treatment                  Formal name:                        and other muscles, another
                                              part of a urinalysis
        Formal name: Blood                                                           Formal name: A1c                         decisions                         Aspartate                           enzyme, creatine kinase (CK), is
        Glucose and Urine                                                            and estimated Average                                                                                          present in much higher amounts
                                                                                                                                                                aminotransferase                    and is usually used to detect heart
        Glucose                                                                      Glucose                                                                                                        or muscle injury.


                         Nancy B. Swigert, M.A., CCC/SLP,                                             Nancy B. Swigert, M.A., CCC/SLP,                                               Nancy B. Swigert, M.A., CCC/SLP,
                                      BRS-S                                 85                                     BRS-S                         86                                               BRS-S                               87




                                                                                 CK-MB
                                                                                                                                                          Troponins
                                                                                 Also known as: CK MB, CPK MB                                             Also known as: TnI, TnT, cTnI, cTnT
        Other lab tests/values                                                   Formal name: Creatine Kinase–MB
                                                                                                                                                          Formal name: Cardiac-specific Troponin I and Troponin T

   ALT                                       How is it used?The ALT
                                               test detects liver injury.
                                                                                        When is the test used? 
    Also known as:                             ALT values are usually                    To determine if the patient has had a heart                          How is it                                  The troponin test is
    Serum glutamic-                            compared to the levels of
                                                                                         attack and whether certain clot-dissolving                            used?Troponin tests                         used to help
                                               other enzymes, such as
    pyruvic transaminase,                      alkaline phosphatase                      drugs are working                                                     are primarily ordered                       diagnose a heart
    SGPT                                       (ALP) and aspartate                                                                                             for people who have                         attack, to detect and
    Formal name: Alanine                       aminotransferase                                                                                                chest pain to see if they                   evaluate mild to
                                               (AST), to help determine                                                                                        have had a heart attack                     severe heart injury,
    aminotransferase                           which form of liver
                                                                                                                                                               or other damage to                          and to distinguish
                                               disease is present.
                                                                                                                                                               their heart.                                chest pain that may
                                                                                                                                                                                                           be due to other
                                                                                                                                                                                                           causes
                         Nancy B. Swigert, M.A., CCC/SLP,                                             Nancy B. Swigert, M.A., CCC/SLP,                                               Nancy B. Swigert, M.A., CCC/SLP,
                                      BRS-S                                 88                                     BRS-S                         89                                               BRS-S                               90




                                                                                                                                                                                                                                           10
                                                                                               AFB Smear and Culture
         Myoglobin                                                                             Also known as: TB culture and sensitivity ; Sputum culture
         Formal name: Myoglobin                                                                                                                                             Gram stain
                                                                                               Formal name: Acid-fast bacillus smear, culture, and sensitivity
        How is it used?As a                       Sometimes, a test for                    How is it used?AFB                           They are used to help              How is it used?                           Often, determining
         cardiac biomarker,                         myoglobin is used to                                                                    determine whether the
                                                    detect elevated levels in                 smears and cultures are                                                          A Gram stain and                           whether an infection
         myoglobin is used in                                                                                                               TB is confined to the
         conjunction with                           the urine of patients that                used to determine whether                     lungs (pulmonary) or                culture of the                             is caused by an
         troponin to help
                                                    have had extensive
                                                                                              there is an active                            has spread to organs                material from an                           organism that is
                                                    damage to their skeletal
         diagnose or rule out a                                                                                                             outside the lungs                   infected site are the                      Gram positive or
                                                    muscles. Myoglobin is toxic               Mycobacterium
         heart attack. Myoglobin                    to the kidneys.                                                                         (extrapulmonary).                   most commonly                              Gram negative will
         levels start to rise within                 If severe muscle injury                  tuberculosis infection, an                    They are ordered to                                                            be sufficient to allow
         2-3 hours of a heart
                                                                                                                                      
                                                                                                                                                                                performed
                                                    occurs, blood levels of                   infection due to another                      identify M. tuberculosis                                                       a doctor to prescribe
         attack or other muscle                     myoglobin may rise very                                                                 and determine the most              microbiology tests
         injury, reach their                        quickly and the kidneys,
                                                                                              member of the                                                                     used to identify the                       treatment with an
                                                                                                                                            effective antimicrobial
         highest levels within 8-                   which clear myoglobin                     Mycobacterium family, or                      agents to treat the                 cause of an                                appropriate antibiotic
         12 hours, and generally                    from the blood and excrete                TB-like symptoms due to                                                                                                      while waiting for
                                                    it in the urine, may be                                                                 infection.                          infection.
         fall back to normal                                                                                                                                                                                               more specific tests to
         within one day.                            damaged by the increased                  another cause.
                                                    amounts.                                                                                                                                                               be completed
                            Nancy B. Swigert, M.A., CCC/SLP,                                                        Nancy B. Swigert, M.A., CCC/SLP,                                                Nancy B. Swigert, M.A., CCC/SLP,
                                         BRS-S                                       91                                          BRS-S                                 92                                        BRS-S                                      93




     Blood culture                                                                               Lab values: Arterial blood gases                                           Lab values: Arterial blood gases
        How is it used?                                                                            Essential part of diagnosing and managing                                 Acidic state                               Alkalotic state
        Blood cultures are done to detect the                                                       patient’s oxygenation status and acid-base                                      Decrease in force of                        Interferes with tissue
         presence of bacteria or yeasts, which                                                       balance                                                                          cardiac contractions                         oxygenation
         may have spread from a specific site in                                                    Acid-base balance                                                               Decrease in vascular                        Interferes with
                                                                                                                                                                                      response to                                  normal neurological
         the body into the bloodstream.                                                                 pH is measure of acidity or alkalinity of blood
                                                                                                                                                                                      catecholamines                               and muscular
        For example, if a person has bacterial                                                         Normal pH range 7.35 to 7.45
                                                                                                                                                                                     Diminished response                          functioning
         pneumonia or bacterial meningitis,                                                             Too low = acidic Too high = alkalotic                                        to effects of certain
         the causative organism may be                                                                  Normal range has to be maintained for normal                                 meds
         recovered from the blood                                                                        metabolism to take place
                            Nancy B. Swigert, M.A., CCC/SLP,                                                        Nancy B. Swigert, M.A., CCC/SLP,                                                Nancy B. Swigert, M.A., CCC/SLP,
                                         BRS-S                                       94                                          BRS-S                                 95                                        BRS-S                                      96




     Acid base disorders                                                                         Arterial blood gases                                                       Metabolic disorders
   Respiratory acidosis(any                       Respiratory alkalosis                           Blood pH changes according to level of                                    Metabolic acidosis                         Metabolic alkalosis
    condition with hypoventilation                  (any condition that                                                                                                              Bicarb level < 22 and pH
                                                                                                     CO2 present                                                                      < 7.35                                      Bicarb > 26 with pH
    can cause)                                      causes hyperventilation)                                                                                                                                                       > 7.45
        CNS depression related to                        Psychological responses                      Triggers lungs to > or < rate and depth of                            Causes of increased
         CHI, meds                                         (fear, anxiety)                                                                                                      acids:                                     Symptoms
                                                                                                         ventilation                                                                 Renal failure
        Impaired respiratory muscle                      Pain                                                                                                                                                                   Neurological
         function (spinal cord injury,                                                              The kidneys excrete or retain bicarbonate                                       Diabetic ketoacidosis
                                                          Increased metabolic                                                                                                                                                    Musculoskeletal
         neuromuscular diseases)                           demands (fever, sepsis)                                                                                                   Starvation
        Pulmonary disorders
                                                                                                     to maintain the pH                                                              Salicylate intoxication
                                                          Meds (resp stimulants)
         (pneumonia, atelectasis, etc)                    CNS lesions                                                                                                         Symptoms in CNS,
        Massive pulmonary embolus                                                                                                                                              cardiovascular,
                                                                                                                                                                                pulmonary and GI
                            Nancy B. Swigert, M.A., CCC/SLP,                                                        Nancy B. Swigert, M.A., CCC/SLP,
                                                                                                                                                                                systems         Nancy B. Swigert, M.A., CCC/SLP,
                                         BRS-S                                       97                                          BRS-S                                 98                                       BRS-S                                       99




                                                                                                                                                                                                                                                                 11
                                                                            Nutrition-tips from a Chief                                                        Nutrition-tips from a Chief
Nutrition                                                                   Dietitian                                                                          Dietitian
                                                                                                                                                             Look for anemia                              Anemia
   Current diet                                                               Tests used in surveys of “healthy”
                                                                                                                                                                  Low hemoglobin and other
       Amount eaten                                                            populations to suggest nutritional status are                                      factors may indicate                           If problem is B12
                                                                                                                                                                   macrocytic anemia due to                        and problem is
       Restrictions                                                            often affected by disease processes and                                                                                            prolonged,
                                                                                                                                                                   folate or vitamin B12
                                                                                may be useless in acute care or in chronic                                         deficiency                                      permanent damage
                                                                                disease                                                                           Tests for serum B12 and                         to nerve cells can
   Alternate method of feeding                                                                                                                                    folate may indicate                             result
                                                                                    E.g. hemoglobin                                                               “nutritional” anemia and
   Oral health/dentures affecting?                                                                                                                                can be addressed with
                                                                                    Serum albumin
                                                                                                                                                                   supplementation

                   Nancy B. Swigert, M.A., CCC/SLP,                                              Nancy B. Swigert, M.A., CCC/SLP,                                                   Nancy B. Swigert, M.A., CCC/SLP,
                                BRS-S                                 100                                     BRS-S                                 101                                          BRS-S                                  102




Nutrition-tips from a Chief                                                 Nutrition-tips from a Chief                                                        Nutrition-tips from a Chief
Dietitian                                                                   Dietitian                                                                          Dietitian
   Albumin                               Look at the body                    Nitrogen balance study to               Comparison of                            Serum glucose or                       Serum sodium and
       Possible protein                         Measure various               compare amount of                        nitrogen in/out can                       Hemoglobin A1C for                      chloride as rough
                                                                                nitrogen in the protein                                                            glucose tolerance/diabetes              indicators of fluid
        status indicator                          circumferences or                                                      indicate if body is in:
                                                  skin fold thickness to        going into the body (oral,                                                         care                                    status (retention vs.
                                                                                enteral or parenteral)                         Catabolic
                                                  assess relative                                                               (traumatized)
                                                                                                                                                                  Blood urea nitrogen,                    dehydration)
                                                  leanness, muscle             With nitrogen exiting the                                                          serum creatinine, serum                Serum phosphorus,
                                                                                body in urine (urinary urea                    Anabolic (growing                  potassium, serum
                                                  wasting or obesity                                                                                                                                       magnesium and
                                                                                nitrogen) and add to that                       or healing)                        phosphorus to assess
                                                                                                                               Maintaining
                                                                                                                                                                                                           potassium when “re-
                                                                                fecal material, sweat, skin                                                        nutritional implications for
                                                                                                                                                                                                           feeding” – may have
                                                                                sloughing                                                                          kidney disease
                                                                                                                                                                                                           to slow process
                   Nancy B. Swigert, M.A., CCC/SLP,                                              Nancy B. Swigert, M.A., CCC/SLP,                                                   Nancy B. Swigert, M.A., CCC/SLP,
                                BRS-S                                 103                                     BRS-S                                 104                                          BRS-S                                  105




Malnutrition                                                                Dehydration                                                                        Dehydration
   Patients following                    Protein calorie                     Dehydration is the excessive loss of                                               The majority of the body is made up of water,
    stroke at high risk for                malnutrition (PCM)                   body water.                                                                         with up to 75% of the body's weight due to
    malnutrition                           most common type                                                                                                         H2O.
                                                                               Number of causes of dehydration
   May be as high as                     PCM fatigues                                                                                                            Most of the water is found within the cells of
    56% during a 3-week                    muscles, alters
                                                                                including heat exposure, prolonged                                                  the body (intracellular space).
    hospital stay                          neuromuscular                        vigorous exercise, and some diseases
                                                                                                                                                                   The rest is found in the so-called
                                           function, thus                       of the gastrointestinal tract.                                                      extracellular space, which consists of the
                                           increasing severity of                                                                                                   blood vessels (intravascular space) and the
                                           dysphagia                                                                                                                spaces between cells (interstitial space).
                   Nancy B. Swigert, M.A., CCC/SLP,                                              Nancy B. Swigert, M.A., CCC/SLP,                                                   Nancy B. Swigert, M.A., CCC/SLP,
                                BRS-S                                 106                                     BRS-S                                 107                                          BRS-S                                  108




                                                                                                                                                                                                                                              12
                                                                                                                                                               Meds: Anticholinergics
        Complications of dehydration                                            Medications                                                                   Anticholinergic means blocking the effects of the
                                                                                                                                                               neurotransmitter acetylcholine. Since acetylcholine is
   Cerebral edema                                                                 Drugs that cause change in mental status,                                  involved with learning and memory, glands and involuntary
   Seizures                                                                        confusion, sedation                                                        muscles, an anticholinergic drug can cause:
   Hypovolemic shock -low blood volume causes a drop in                             Anticholinergics                                                        Dry mouth
    blood pressure and a corresponding reduction in the                                                                                                       Decrease in perspiration
    amount of oxygen reaching your tissues.
                                                                                     Analgesics
                                                                                                                                                              Increased heart rate
           If untreated, severe hypovolemic shock can cause death in a              Psychotropics
                                                                                                                                                              Constipation
            matter of minutes.                                                       Anti-epileptics                                                         Increase in blood pressure
   Kidney failure. Occurs when the kidneys are no longer                            Sedatives                                                               Blurred vision
    able to remove excess fluids and waste from your blood.
                                                                                     Antibiotics                                                             Memory problems
                                                                                                                                                              Loss of coordination (ataxia)
                               Nancy B. Swigert, M.A., CCC/SLP,                                        Nancy B. Swigert, M.A., CCC/SLP,                       Sensitivity to heat Nancy B. Swigert, M.A., CCC/SLP,
                                            BRS-S                         109                                       BRS-S                            110                                     BRS-S                         111




        What are anticholinergics?                                              Meds: Neuroleptics                                                             Meds: Barbituates
            Drugs that have anticholinergic effects                               Antidepressants                           Antipsychotics                     Treatment of insomnia
             include but are not limited to:                                            E.g. Elavil                                 E.g. Haldol,                    E.g. Phenobarbitol, Nembutal
                                                                                                                                      Thorazine
            Tricyclic antidepressants                                             Result in drying of
                                                                                                                                                                  CNS depressant (drowsiness causing
                                                                                    mucosa, drowsiness                        Can cause Tardive
            Antipsychotics                                                                                                                                        decompensation of patients with cognitive
                                                                                                                               Dyskinesia
            SSRI antidepressants (Prozac, Zoloft,                                                                                                                 deficits)
             Paxil)
            Diphenhydramine (Benadryl, other generic
             antihistamines)
                               Nancy B. Swigert, M.A., CCC/SLP,                                        Nancy B. Swigert, M.A., CCC/SLP,                                          Nancy B. Swigert, M.A., CCC/SLP,
                                            BRS-S                         112                                       BRS-S                            113                                      BRS-S                        114




        Meds: Antihistamines                                                    Meds: Diuretics                                                                Meds: Antihypertensives
            For relief of nasal congestion and cough                              Treatment of edema (e.g. associated with                                      Used to treat high blood pressure
                 E.g. cold and cough preparations                                  CHF)                                                                          Most have some degree of
            Drying mucosa, sedative effects                                            E.g. Lasix                                                                parasympathomimetic effect
                                                                                   Signs of chronic dehydration (dryness of                                          Dry mucosa
                                                                                    mouth, thirst, weakness, drowsiness)



                               Nancy B. Swigert, M.A., CCC/SLP,                                        Nancy B. Swigert, M.A., CCC/SLP,                                          Nancy B. Swigert, M.A., CCC/SLP,
                                            BRS-S                         115                                       BRS-S                            116                                      BRS-S                        117




                                                                                                                                                                                                                                 13
                                                                    CVA-Tissue Plasminogen Activator
Meds to treat disorders                                             (tPA)
                                                                                                                                                       Intra-arterial tPA
   Moving from meds to treat “unrelated”                                Tissue plasminogen activator (tPA) is a
                                                                          thrombolytic agent (clot-busting drug).                                           Neurovascular specialist
    disorders that have an impact on                                                                                                                       inserts a thin, flexible
                                                                         Approved for use in certain patients having a
    swallowing                                                            heart attack or stroke.
                                                                                                                                                           catheter into an artery
                                                                                                                                                           (usually in the groin area)
             TO                                                          The drug can dissolve blood clots, which                                         and steers it up to the area
   Meds that are designed to treat the disorder                          cause most heart attacks and strokes.                                            of the clot then administers
                                                                          tPA is the only drug approved by the U.S.                                       the tPA through the catheter.
    causing the dysphagia
                                                                          Food and Drug Administration for the acute
                                                                          (urgent) treatment of ischemic stroke.

                 Nancy B. Swigert, M.A., CCC/SLP,                                              Nancy B. Swigert, M.A., CCC/SLP,                                           Nancy B. Swigert, M.A., CCC/SLP,
                              BRS-S                           118                                           BRS-S                                119                                   BRS-S                  120




                                                                    Impact of dopaminergic
Medications to treat disorder                                       stimulation on swallowing                                                          Medications to treat disorder
   Parkinson’s: one case study reported                               Small study (15 patients)                     Small study (12                    Myasthenia Gravis
                                                                       Withheld meds and performed                    patients)
    improvement in swallowing with                                      MBS                                                                                    Mestinon peak effectiveness two hours after
                                                                                                                      MBS before and after
    adjustment in timing of medication                                 Found some changes in more
                                                                                                                       administering meds
                                                                                                                                                                administration
                                                                        automatic, non-voluntary
    (Sinemet most effective one hour post                               components of the swallow
                                                                                                                      50% showed
                                                                        (e.g. pharyngeal phase time)
    administration) (Fonda et al 1995)                                                                                 objective
                                                                       “Unlike the cardinal motor
                                                                        features of Parkinson’s Disease,               improvement after
                                                                        swallowing dysfunction is                      levodopa treatment
                                                                        predominantly resistant to                           Jong-Ling, et al
                                                                        dopaminergic stimulation” Hunter et
                                                                        al 1997                                               1997
                 Nancy B. Swigert, M.A., CCC/SLP,                                              Nancy B. Swigert, M.A., CCC/SLP,                                           Nancy B. Swigert, M.A., CCC/SLP,
                              BRS-S                           121                                           BRS-S                                122                                   BRS-S                  123




Medications to treat disorder:
GERD                                                                Other treatments                                                                   Instruments and devices
   Antacids                            Proton pump                     Mechanical ventilation                                                          Ventilators
                                         inhibitors                      Non-invasive ventilation                                                          Medical device that ventilates a patient
   Histamine-2 receptor                 (Omeprazole,                    Other modes of oxygen delivery
                                         Prilosec, Protonix)                                                                                                Ventilation:process of moving gases
    antagonists (Zantac,                                                 Dialysis
    Pepcid, Tagamet)                    Motility drugs –                                                                                                    into and out of the lungs
                                                                                 Peritoneal
                                         prokinetic (Propulsid)                                                                                             Respiration: actual exchange of gases
                                                                                 Regular
                                                                         Tube feeding                                                                       between air breathed in and cells of the
                                                                         Chemoradiation                                                                     body

                 Nancy B. Swigert, M.A., CCC/SLP,                                              Nancy B. Swigert, M.A., CCC/SLP,                                           Nancy B. Swigert, M.A., CCC/SLP,
                              BRS-S                           124                                           BRS-S                                125                                   BRS-S                  126




                                                                                                                                                                                                                    14
Why are patients placed on
ventilators?                                                              Positive pressure ventilators                                           Modes of ventilation
                                                                             Push air into the airways to inflate the                               Assist control
   Experiencing periods of apnea                                                                                                                        Every breath delivered to
                                                                                                                                                                                               Synchronized Intermittent
                                                                              alveoli                                                                     the patient is at a set               Mandatory (SIMV)
   In acute ventilatory failure                                             Pressure ventilation is set on the ventilator
                                                                                                                                                          volume but does allow
                                                                                                                                                          the patient to have
                                                                                                                                                                                                    Waits for patient to breathe
                                                                                                                                                                                                     as deeply and quickly as
                                                                                                                                                          spontaneous effort at the
   Impending ventilatory failure                                             and the exhaled volume will vary based on                                   pre set volume.                            they want; gives breath with
                                                                                                                                                                                                     patient’s effort
                                                                              lung compliance                                                        Mandatory control
   Need hyperventilation for intracranial                                                                                                               Does not rely on patient             Spontaneous
                                                                             Volume ventilation is set to a desired                                      to start the breath this is               Just assists the patient
    pressure control                                                          volume and the required pressure varies
                                                                                                                                                          only if the patient is so
                                                                                                                                                          sedated that there is no                   with end expiratory
                                                                                                                                                          spontaneous respiratory                    pressure called PEEP,
                                                                              based on lung compliance.                                                   effort. Not used much                      may add pressure
                                                                                                                                                          anymore
                                                                                                                                                                                                     support if necessary
                  Nancy B. Swigert, M.A., CCC/SLP,                                             Nancy B. Swigert, M.A., CCC/SLP,                                          Nancy B. Swigert, M.A., CCC/SLP,
                               BRS-S                            127                                         BRS-S                           128                                       BRS-S                                     129




Augmentative modes                                                        Non-invasive ventilators: CPAP                                          Non-invasive ventilators: BiPAP
                                                                          Continuous positive airway pressure (CPAP) refers to a                    BiPAP stands for Bi-level Positive Airway Pressure.
   Positive End                         Continuous Positive             medical device used primarily for the treatment of sleep
                                                                           apnea, although it may also be employed to transition patients             It is a breathing device that delivers a pressure
    Expiratory Pressure                   Airway Pressure                  in hospitals from breathing tubes, or intubation, to regular               during inhalation called pressure support and allows
    (PEEP)                                (CPAP)                           breathing.                                                                 a PEEP during exhalation.
                                                                                                                                                     Created in the 1990s, it developed out of the C-PAP,
   Gives added pressure                 Mode used during
                                                                          Those with chronic obstructive pulmonary disorder or other                 which stands for Continuous Positive Airway
    to maintain                           weaning                          breathing disorders may also use a CPAP or a BiPap unit at                 Pressure
    oxygenation                                                            night
       Used with any mode
        of ventilation to
        increase oxygenation

                  Nancy B. Swigert, M.A., CCC/SLP,                                             Nancy B. Swigert, M.A., CCC/SLP,                                          Nancy B. Swigert, M.A., CCC/SLP,
                               BRS-S                            130                                         BRS-S                           131                                       BRS-S                                     132




BiPap                                                                     Other oxygen devices                                                    Oxygen therapy
   Air delivered through a mask can be set at                               Non-Rebreather                                                         Mode of delivery
    one pressure for inhaling and another for                                     allows high
    exhaling.                                                                                                                                            Face mask
                                                                                   percentage of
   This makes BiPAP much easier for users to                                      oxygen to be                                                          Nasal cannula
    adapt to and also allows neuromuscular                                         delivered by not
    disease sufferers to use the device.                                           allowing the patient
                                                                                  to re-breathe exhaled
    Because of these dual settings, BiPAP
                                                                                   gases.
    allows people to get more air in and out of
    the lungs without the natural muscular effort
    needed to do so.
                  Nancy B. Swigert, M.A., CCC/SLP,                                             Nancy B. Swigert, M.A., CCC/SLP,                                          Nancy B. Swigert, M.A., CCC/SLP,
                               BRS-S                            133                                         BRS-S                           134                                       BRS-S                                     135




                                                                                                                                                                                                                                      15
     Intubation and Tracheotomy
     tubes                                                                       Oral or nasal intubation                                  Oral or nasal intubation
        Endotracheal tube                                                        How long is too long?                                    Leder et al. (1998)
            Regular ETT                                                          de Larminat (1995) - marked impairment in                Intubated at least 48 hours
                                                                                   sensitivity of swallowing response after as              FEES about 24 hours after extubation
            Hi-lo evac tube                                                       short a time as 24 hours                                 Aspiration in 45%, and 44% of those were
            Silver ETT                                                           Colice (1989,1992) described the kind of                  silent aspirators
                                                                                   damage as mucosal lacerations along                      89% of aspirators resumed oral diet 2-10
                                                                                   posterior-medial aspects of both cords and                days after extubation
        Nasotracheal tube                                                         edema
                                                                                                                                            Your evaluation may prevent aspiration
                      Nancy B. Swigert, M.A., CCC/SLP,                                            Nancy B. Swigert, M.A., CCC/SLP,                          Nancy B. Swigert, M.A., CCC/SLP,
                                   BRS-S                                   136                                 BRS-S                 137                                 BRS-S                 138




     Recovery of feeding following
     intubation       Barker et al 2007                                          Trach tubes                                               Effects of trach on swallowing
   Retrospective review      Incremental factors predicting risk                  Tracheostomy tube                                        Bonnano (1971) - limited laryngeal elevation and
                               for developing post-extubation                                                                                  limited anterior rotation of the larynx
    of 254 patients            dysphagia included:                                      outer flange
   Intubated 48 hours or           Longer duration of endotracheal                    outer cannula                                        Trach tube seems to act as anchor
                                     intubation                                                                                               May be some loss of protective reflexes
    longer                          Occurrence of peri-operative stroke                inner cannula
   Dysphagia identified            Presence of peri-operative sepsis                  obturator                                            Shaker et al. (1995) - vocal cords close
                               Occurrence of dysphagia and                                                                                    completely, duration of closure shorter for
    in 51%                                                                              universal hub
                                duration of endotracheal intubation                                                                            patients with trachs
                                were only independent factors                           cuff                                                 Timing of apnea related to vocal cord closure also
                                predicting delayed return to normal                     fenestrations                                         altered
                                enteral feeding and delayed
                                discharge
                      Nancy B. Swigert, M.A., CCC/SLP,                                            Nancy B. Swigert, M.A., CCC/SLP,                          Nancy B. Swigert, M.A., CCC/SLP,
                                   BRS-S                           139                                         BRS-S                 140                                 BRS-S                 141




     Incidence of dysphagia with                                                 Incidence of dysphagia with
     trachs                                                                      trachs                                                    What about cuffs on trach tubes?
      Between 65% and 87%                                                        Tolep et al (1996) - MBS studies abnormal                  Generally preferable that cuff be deflated
      Patients who are orally intubated and then                                  in 83% of patients                                         Elpern et al. (1987)- inflated cuffs did NOT
       trached - double deficit                                                   Laryngoscopy revealed decreased sensation                   prevent aspiration.
      DeVita et al. (1990) - Mean of six deficits                                 of the cords, pooled secretions above the
                                                                                   cords, limited vocal cord movement, and                    Aspiration occurred with greater frequency
       per patient (from list of 11)
                                                                                   edema of the arytenoids                                     when cuffs inflated to occlusion than when
      Delayed triggering and pharyngeal pooling
                                                                                  Elpern et al (1994) - 50% of their patients
                                                                                                                                               slight leak present
      Some patients’ deficits continued after tube
       removed                                                                     aspirated (77% silently)
                      Nancy B. Swigert, M.A., CCC/SLP,                                            Nancy B. Swigert, M.A., CCC/SLP,                          Nancy B. Swigert, M.A., CCC/SLP,
                                   BRS-S                                   142                                 BRS-S                 143                                 BRS-S                 144




                                                                                                                                                                                                     16
Speaking valves and swallowing                                                 Speaking valves and swallowing                                        Speaking valves and swallowing
                                                                                  Eibling and Gross (1996)                                             Leder (1996; 1998)                    Leder (1999)
   Advantage to wearing speaking
                                                                                                                                                        Occlusion of trach                    Incidence of aspiration
    valve during eating - allows                                                  Supports role of subglottic pressure in                               tube had no effect on                  not affected by one-
                                                                                   swallowing efficiency                                                 prevalence of                          way trach valve
    patient to communicate                                                                                                                               aspiration
                                                                                  11 patients known to aspirate on MBS                                                                        Authors concluded
   However, disagreement whether                                                 Significant decrease or elimination of
                                                                                                                                                        No trends related to                   that patients with trach
                                                                                                                                                         bolus consistency,                     tubes often have risk
    the valve really helps swallowing                                              aspiration with Passy-Muir Valve on.                                  type of tube,                          factors other than the
                                                                                                                                                         presence/absence of                    tube that predisposes
                                                                                                                                                         NG                                     them to aspirate
                          Nancy B. Swigert, M.A., CCC/SLP,                                        Nancy B. Swigert, M.A., CCC/SLP,                                       Nancy B. Swigert, M.A., CCC/SLP,
                                       BRS-S                             145                                   BRS-S                          146                                     BRS-S                                   147




Cuff deflation and one-way
speaking valve and swallowing                                                  Suctioning - if SLP wants to do it                                    Dialysis
   14 non-ventilator dependent patients had VFSS                                 Scope of Practice - does not list it, but does                       End stage kidney failure
    under three conditions (cuff up, down, valve on)                               not exclude it. Not a new area of practice,                          When about 85 to 90 percent of kidney
   Scores on penetration-aspiration scale not                                     but a tool
                                                                                                                                                         function has been lost
    significantly affected by cuff status                                         Code of Ethics - assure that you have
   One-way valve placement significantly reduced                                  demonstrated competence
    scores on penetration-aspiration scale for liquid                             Position Statement of Multiskilled
    bolus                                                                          Personnel (1996) - “cross-training of basic
            Suiter, et al 2003
                                                                                   patient care skills is a reasonable option”
                          Nancy B. Swigert, M.A., CCC/SLP,                                        Nancy B. Swigert, M.A., CCC/SLP,                                       Nancy B. Swigert, M.A., CCC/SLP,
                                       BRS-S                             148                                   BRS-S                          149                                     BRS-S                                   150




                                                                                                                                                    Two major kinds of peritoneal
Hemodialysis                                                                   Peritoneal dialysis                                                  dialysis.
   Artificial kidney (hemodialyzer) is used to remove waste                      Blood is cleaned inside the body.                                    Continuous                             Continuous Cycling
    and extra chemicals and fluid from the blood.                                 Catheter in abdomen to make an access.                                Ambulatory                              Peritoneal Dialysis
   Surgical placement to make an access (entrance) into the                      During the treatment, the abdominal area (the                         Peritoneal Dialysis                     (CCPD).
    blood vessels.
                                                                                   peritoneal cavity) is slowly filled with dialysate                    (CAPD)
                                                                                                                                                                                                       machine called a
        Sometimes, an access is made by joining an artery to a vein                                                                                         done without
         under the skin to make a bigger blood vessel called a fistula.            through the catheter.                                                                                                cycler.
                                                                                                                                                              machines
        May use a soft plastic tube to join an artery and a vein under the       The blood stays in the arteries and veins that line                                                                  Each cycle usually
                                                                                                                                                             Patient puts a bag of
         skin(graft)                                                               the peritoneal cavity.                                                     dialysate (about two                      lasts 1-1/2 hours
        A narrow plastic tube, called a catheter, which is inserted into a            Extra fluid and waste products are drawn out of the                   quarts) into the
         large vein in the neck. This type of access may be temporary,                                                                                        peritoneal cavity
                                                                                       blood and into the dialysate.
         but is sometimes used for long-term treatment.
                                                                                                                                                              through the catheter.
                          Nancy B. Swigert, M.A., CCC/SLP,                                        Nancy B. Swigert, M.A., CCC/SLP,                                       Nancy B. Swigert, M.A., CCC/SLP,
                                       BRS-S                             151                                   BRS-S                          152                                     BRS-S                                   153




                                                                                                                                                                                                                                    17
                                                                                                                                                                             Does feeding tube affect
PEG vs. PEJ                                                                                  PEG and pneumonia                                                               aspiration on FEES                        Leder 2007


   Meta-analysis of 11 clinical trials                                                         Aspiration pneumonia occurred in 52% of                                        Prospective study 1,260 consecutive peds
       Gastric feeding instead of postpyloric feeding                                           patients up to a month after PEG placement                                      and adult patients with variety of diagnoses
                                                                                                 (Kitamura et al 2007)
        did not increase the risk of aspiration or                                                                                                                              Some with (61% small bore; 39% large
        pneumonia or hospital mortality (Ho, Dobb & Wedd 2006)                                  However, patients with PEG often have
                                                                                                 clinical conditions predisposing to the                                         bore) NG and some without
   PEJ associated with lower complication                                                                                                                                      Presence of NG Tube did not affect
                                                                                                 direct aspiration of oropharyngeal contents
    rates, but does not eliminate risk of                                                                                                                                        incidence of aspiration for either liquid or
                                                                                                 and GE reflux
    aspiration Shike, et al 1996                                                                                                                                                 puree consistencies during FEES®

                   Nancy B. Swigert, M.A., CCC/SLP,                                                                      Nancy B. Swigert, M.A., CCC/SLP,                                     Nancy B. Swigert, M.A., CCC/SLP,
                                BRS-S                                          154                                                    BRS-S                            155                                 BRS-S                            156




Nutrition for NPO                                                                            Who gets TPN?                                                                   Chemoradiation
   Total Parenteral Nutrition (TPN)                                                            Patient whose gut is non-functional                                            ACUTE EFFECTS                       LATE EFFECTS
                                                                                                         Severe persistent diarrhea                                            Due to effects on                   5-10 years post
   IV directly into bloodstream
                                                                                                                                                                                 mucosa, taste buds,                 Injury to salivary
   Central line inserted into large vein (often                                                         Lymphoma
                                                                                                                                                                                 salivary glands                      glands = xerostomia
    under collar bone)                                                                                   Motility disorders of esophagus and GI tract                                                               Damage to
                                                                                                         Colorectal CA                                                                                               connective tissue
                                                                                                                                                                                                                      (fibrosis) resulting in
                                                                                                                                                                                                                      trismus and
                                                                                                                                                                                                                      pharyngeal dysphagia

                   Nancy B. Swigert, M.A., CCC/SLP,                                                                      Nancy B. Swigert, M.A., CCC/SLP,                                     Nancy B. Swigert, M.A., CCC/SLP,
                                BRS-S                                          157                                                    BRS-S                            158                                 BRS-S                            159




How can we identify dysphagia?                                                               Bedside evaluation or screening?                                                Bedside evaluation
   Screening                             Incidence of                                 Screening does not identify the                        Rosenbek indicates
                                                                                         nature of the problem
                                                                                                                                                                              Usually the first step in assessing a patient
   Clinical evaluation by                 dysphagia per type of                                                                                 screening is pre-
                                                                                            But the bedside exam can identify                                                This evaluation yields important
    SLP                                    procedure:                                        the nature of the oral dysphagia                    symptomatic testing
                                                 Screening 37-45%                                                                               with aim of early             information about the oral phase of the
   Instrumental                                                                        Screening identifies who is at
                                                 Clinical exam by                       risk for significant dysphagia                          diagnosis                     swallow and..
    evaluation by SLP
                                                  SLP 51-55%                                We’re getting better at this, but
                                                                                                                                                Therefore, the               Provides clues about the pharyngeal phase
                                                                                             even predicting who will aspirate
                                                 Instrumental testing                       does not tell us why                                bedside is not a
                                                  64-78%
                                                                                                                                                 screening according
                                                         Martino et al 2005
                                                                                                                                                 to those criteria
                   Nancy B. Swigert, M.A., CCC/SLP,                                                                      Nancy B. Swigert, M.A., CCC/SLP,                                     Nancy B. Swigert, M.A., CCC/SLP,
                                BRS-S                                          160                                                    BRS-S                            161                                 BRS-S                            162




                                                                                                                                                                                                                                                  18
                                                                          Purposes of clinical exam                                                    Efficacy of clinical/bedside
                                                                          Clinical Indicators for Instrumental
 Bedside evaluation                                                       Assessment of Dysphagia: ASHA 2000                                           evaluation
        If treatment for suspected pharyngeal                               Integrate info from                   Determine need for                Logemann et al                     All lead to a
                                                                              interview, case hx,                    instrumental                                                           likelihood ratio
         disorder is based solely on bedside                                                                                                           McCullough et al
                                                                              medical records,                      Determine if patient
         evaluation, patient is placed at risk                                                                                                         Mann 2002                          If patient has certain
                                                                                                                     appropriate candidate for
                                                                              protocols,                                                                                                    signs, symptoms,
        Aspiration cannot be confirmed or ruled                                                                     tx
                                                                              collaboration                                                                                                 history what is the
                                                                                                                    Recommend route of
         out                                                                 Observe and assess                     nutritional mgt                                                        increased likelihood
        Up to 65% of patients may be silent                                  oral motor function                   Recommend interventions                                                of dysphagia or
         aspirators                                                          Characteristics of                    Counsel and educate                                                    aspiration?
                                                                              dysphagia
                          Nancy B. Swigert, M.A., CCC/SLP,                                    Nancy B. Swigert, M.A., CCC/SLP,                                      Nancy B. Swigert, M.A., CCC/SLP,
                                       BRS-S                       163                                     BRS-S                             164                                 BRS-S                               165




                                                                          How accurate are bedside                                                 How accurate are bedside
Risk ratio example (Logemann, et al 1999)                                 evaluations?                                                             evaluations?
        Identified                     Aspiration 71%                      Logemann et al concluded:                                                McCullough et al (2000)
         variables that                 Oral stage disorder 69%                 “Even if screening procedures become 100%                            Fewer than 50% of the measures clinicians
         were able to                   Pharyngeal delay 72%                     accurate in defining the presence of aspiration
         classify
                                                                                                                                                        typically employ are rated with sufficient
                                        Pharyngeal problem 70%                   or the presence of problems in the oral stage of
         patients                                                                                                                                       inter- and intra-judge reliability
                                                                                  the swallow, the pharyngeal triggering, or the
         correctly as                                                             pharyngeal stage of the swallow, in-depth
         having or not                                                            diagnosis is still needed to define the anatomic
         having:                                                                  and/physiologic nature of the problem and the
                                                                                  effects of treatment strategies….”
                          Nancy B. Swigert, M.A., CCC/SLP,                                    Nancy B. Swigert, M.A., CCC/SLP,                                      Nancy B. Swigert, M.A., CCC/SLP,
                                       BRS-S                       166                                     BRS-S                             167                                 BRS-S                               168




 McCullough (2000)                                                       Risk ratio example (Mann & Hankey, 2001)                                  Risk ratio example (Mann & Hankey, 2001)
                                                                             Clinical items as independent predictors of                              Clinical predictors of aspiration
       Best history measure: pneumonia                                       dysphagia (measured radiographically)
       Best oral motor measure:jaw strength
       Best voice: wet and dysphonia                                        Age > 70                                                                 Delayed oral transit
                                                                             Male                                                                     Incomplete oral clearance
                                                                             Disabling Stroke (Barthel < 60)
                                                                             Palatal weakness or asymmetry
                                                                             Incomplete oral clearance
                                                                             Impaired pharyngeal response (cough/gurgle)
                          Nancy B. Swigert, M.A., CCC/SLP,                                    Nancy B. Swigert, M.A., CCC/SLP,                                      Nancy B. Swigert, M.A., CCC/SLP,
                                       BRS-S                       169                                     BRS-S                             170                                 BRS-S                               171




                                                                                                                                                                                                                           19
Mann Assessment of Swallowing
Ability (MASA)Delmar                                                                   Reliability of MASA                                       MASA
   Yields probabilities of presence of                                                   41 first ever stroke patients assessed within             Sensitivity of MASA                        Sensitivity of MASA
    dysphagia and of aspiration on instrumental                                            36 hours of admit with MASA and FEES                       for dysphagia was                           for aspiration was
    exam                                                                                                                                              96% and specificity                         87% sensitive and
                                                                                          Prevalance of dysphagia                                    75%                                         51% specific
   5 and 10 point scaling of 24 items                                                         73% MASA           68% FEES                          Positive predictive                        Positive predictive
   200 points maximum                                                                    Prevalance aspiration                                      value 89%                                   value 57%
   Definite, probable, possible or unlikely                                                   65% MASA            43% FEES                         Negative predictive                        Negative predictive
    dysphagia OR of aspiration on VFSE                                                                                                                value 90%                                   value 85%

                        Nancy B. Swigert, M.A., CCC/SLP,                                                Nancy B. Swigert, M.A., CCC/SLP,                                  Nancy B. Swigert, M.A., CCC/SLP,
                                     BRS-S                                       172                                 BRS-S                 173                                         BRS-S                                   174




Procedures sometimes used
with/instead of bedside                                                                3 oz. Water Swallow Test                                  3 Ounce Water Swallow Test
   3 oz. Water swallow test                                                            DePippo et al (1992)
   Timed Test of Swallowing                                                            Stroke rehab patients                                        Contribution of 3 ounce water test to detection of
                                                                                        Abnormal response considered to be:                          aspiration during clinical (bedside) swallow
   Cervical auscultation                                                                                                                             screening has been reported, but no clear
                                                                                            Inability to complete task
   Blue Dye Test                                                                                                                                     consensus because of inadequate statistical power
                                                                                             coughing during or for one minute after
   Pulse Oximetry                                                                                                                                    due to small sample sizes and varying
                                                                                            wet-hoarse vocal quality
                                                                                                                                                      methodologies
   Reflex Cough Test                                                                     Patients then underwent MBS (not clear                    (DePippo, 1992; Garon, 1995; Mari, 1997; McCullough et al., J Comm Dis,
                                                                                           when this occurred)                                        34:55-72, 2001; Rosenbek et al., J Comm Dis, 37:437-50, 2004)

                        Nancy B. Swigert, M.A., CCC/SLP,                                                Nancy B. Swigert, M.A., CCC/SLP,                                  Nancy B. Swigert, M.A., CCC/SLP,
                                     BRS-S                                       175                                 BRS-S                 176                                         BRS-S                                   177




                                                                                       Clinical Utility of the 3 Ounce Water
3 Ounce Water Swallow Test                                                                                                                       3 Ounce Water Swallow Test
                                                                                       Swallow Test
                                                                                                                                                 Purpose
                                                                                          Steven B. Leder, Ph.D.
•   Clinical utility of 3 ounce water swallow
                                                                                           Yale University School of Medicine                    • Examine the clinical usefulness of the
    test focused primarily on adults with
                                                                                          Debra M. Suiter, Ph.D.                                  3 ounce water swallow test for
    neurological disease, i.e., stroke
                                                                                           University of Memphis
    •   (DePippo, 1992; Garon, 1995; Mari, 1997; McCullough et al., 2001; Rosenbek
        et al., 2004)                                                                                                                              determining aspiration status and oral
•   Variable sensitivity and specificity ranging                                       Dysphagia (2008) 23: 244-250                                feeding recommendations in a large
    from sensitivity as high as 0.86 but with                                                                                                      and heterogeneous population sample
    specificity as low as 0.50
    •   (Rosenbek et al., 2004)

                        Nancy B. Swigert, M.A., CCC/SLP,                                                Nancy B. Swigert, M.A., CCC/SLP,                                  Nancy B. Swigert, M.A., CCC/SLP,
                                     BRS-S                                       178                                 BRS-S                 179                                         BRS-S                                   180




                                                                                                                                                                                                                                     20
           3 Ounce Water Swallow Test                                      3 Ounce Water Swallow Test                                         3 Ounce Water Swallow Test
         3 Research Questions Asked:                                           Methods                                                            Methods
       1. Does the 3 ounce water swallow test ID patients                  •    All FEES performed from Dec. 1999-Sept. 2006                  •   Immediately after FEES, each patient given
          who aspirate thin liquids?                                                                                                              3 ounces of water and asked to drink
                                                                           •    All patients allowed to swallow spontaneously,
       2. Does a failed 3 ounce water swallow test ID pts.                                                                                        without interruption
                                                                                i.e., without verbal command
          who are also unsafe for oral alimentation based on
          results of instrumental evaluation?                              •    Food Challenge:                                               •   Criteria for Test Failure:
       3. Does a successfully passed 3 ounce water swallow                       •   3 boluses of puree then                                       •   Inability to complete task
          test permit specific diet rec. to be made without                      •   3 boluses of liquid                                           •   Coughing or choking
          further objective assessment?                                    •    Safe Swallow: No aspiration during FEES                            •   Post-swallow wet/hoarse vocal quality
                            Nancy B. Swigert, M.A., CCC/SLP,                                    Nancy B. Swigert, M.A., CCC/SLP,                                Nancy B. Swigert, M.A., CCC/SLP,
                                         BRS-S                   181                                         BRS-S                 182                                       BRS-S                 183




       3 Ounce Water Swallow Test                                          3 Ounce Water Swallow Test                                         3 Ounce Water Swallow Test
            Statistics                                                         Statistics                                                Statistics
       •     Diagnostic value of a test expressed by                       •   Predictive Value: The chance that persons with a          •   True Positive: + asp. FEES/Failed 3 ounce test
             means of its:                                                     certain test score actually have the disease
                                                                                                                                         •   True Negative: - asp. FEES/Passed 3 ounce test
              •   Sensitivity: Probability that a Diagnostic sign          •   Positive Predictive Value: Which part of persons
                  will be positive given that disease (aspiration)             under study with a positive test score actually have      •   False Positive: - asp. FEES/Failed 3 ounce test
                  is truly present                                             the disease                                               •   False Negative: + asp. FEES/Passed 3 ounce test
              •   Specificity: Probability that a Diagnostic sign          •   Negative Predictive Value: Which part of persons
                  will not be positive given that a disease is                 under study with a negative test score are healthy
                  truly not present
                            Nancy B. Swigert, M.A., CCC/SLP,                                    Nancy B. Swigert, M.A., CCC/SLP,                                Nancy B. Swigert, M.A., CCC/SLP,
                                         BRS-S                   184                                         BRS-S                 185                                       BRS-S                 186




            Does the 3 ounce water swallow test                            Does a failed 3 ounce water swallow test ID pts. who
                ID patients who aspirate thin liquids?                     are also unsafe for oral alimentation based on results             3 Ounce Water Swallow Test
                                                                           of instrumental evaluation?
Question #1: YES                                                       Question #2: NO (over-identifies)                                  Discussion
The 3 ounce water swallow test is:                                                                                                        The combination of low specificity with a high
                                                                       However, failure on 3 ounce test often does not
   •        Sensitive for ID aspiration of thin liquids: 96% who                                                                           false positive rate results in approximately 50%
            aspirated on FEES also failed 3 ounce test                   indicate inability to tolerate safely thin liquids                of screened pts. referred unnecessarily for
   •        Also, 3 ounce test had high negative predictive             Specificity for determining liquid aspiration                     further testing
            value (98%), i.e., if passed also no aspiration on           during FEES = low, 50%, and false positive rate                  3 ounce test fails as a screening tool because it
            FEES                                                         high (50%), i.e., half of patients who failed the 3               over-refers and unnecessarily restricts liquid
   •        Therefore, passing 3 ounce test = good predictor to          ounce test did not aspirate during FEES                           intake for almost 50% of patients tested
            safely tolerate thin liquids
                            Nancy B. Swigert, M.A., CCC/SLP,                                    Nancy B. Swigert, M.A., CCC/SLP,                                Nancy B. Swigert, M.A., CCC/SLP,
                                         BRS-S                   187                                         BRS-S                 188                                       BRS-S                 189




                                                                                                                                                                                                         21
Does a successfully passed 3 ounce water swallow
     test permit specific diet rec. to be made
     without further objective assessment?                   3 Ounce Water Swallow Test                                    3 Ounce Water Swallow Test
    Question #3: Yes, but…..                                     BUT…. nearly 71% of pts. who failed the 3                  Discussion
                                                                  ounce test were deemed safe for some form                 Clinical Judgment and Experience
   For the first time with objective data, if the                of oral intake based on FEES                              Although 98.3% of patients who passed the
    3 ounce water swallow test was passed,                                                                                   3 ounce test were successful with an oral
    patients can have an oral diet without
    further diagnostic dysphagia testing.                        Failure on the 3 ounce water swallow test                  diet, other patient-specific factors are
      Puree diet if edentulous
                                                                  did not accurately reflect true oral feeding               important for an oral diet to be safe and
      Soft/Regular diet if dentate
                                                                  status.                                                    successful

                   Nancy B. Swigert, M.A., CCC/SLP,                               Nancy B. Swigert, M.A., CCC/SLP,                                Nancy B. Swigert, M.A., CCC/SLP,
                                BRS-S                  190                                     BRS-S                 191                                       BRS-S                     192




3 Ounce Water Swallow Test                                   3 Ounce Water Swallow Test                                    3 Ounce Water Swallow Test
    Discussion                                                Discussion                                                    Conclusions
    For ex.:                                                 All patients with dysphagia benefit from                     Caveat: Due to high false positive rate and low
    Dementia: Following directions, self-feeding               encouragement and monitoring as work towards                  specificity, the 3 ounce test is not an efficient
    Stroke: Assess neglect, limb apraxia, hemiplegia           the goal of normal eating progresses                          screening tool
                                                              Dysphagia specialist must synthesize objective,              However, over-referral, although conservative, is
    TBI: Impulsivity and task attentiveness
                                                               subjective, and behavioral data on an individual              not in and of itself a negative, as it allows greater
    De-Conditioned: Diet modifications and                     basis to promote safe and successful eating                   objective ID of aspiration and the potential to
                     assistance with eating                                                                                  determine diet rec. and Rx to promote safe eating

                   Nancy B. Swigert, M.A., CCC/SLP,                               Nancy B. Swigert, M.A., CCC/SLP,                                Nancy B. Swigert, M.A., CCC/SLP,
                                BRS-S                  193                                     BRS-S                 194                                       BRS-S                     195




Methodological weaknesses                                    Cervical Auscultation                                         Cervical Auscultation
    Examiner and order bias                                    Cardiac Analogy Hypothesis:                                  Methodology:
                                                                   Pharynx contains valves and pumps that                        Spectra of sounds of swallowing transduced with an
    Patients not randomized                                                                                                       accelerometer, demonstrate important frequency
                                                                    produce reverberations with the pharynx to                     sensitivity in higher ranger
    Criteria for passing FEES® different than                      generate swallowing sounds
     for passing 3 ounce water swallow                             Heart sounds are propagated via vibration of
                                                                                                                              Conclusion:
                                                                    muscles and valves
                                                                                                                                  Two stethoscope models have superior transmission
                                                                   Limit of Dx Potential-Cause of swallowing                      characteristics for use in cervical auscultation of
                                                                    sounds                                                         swallowing sounds
                                                                            Cichero & Murdoch, 1998                                          Hamlet, Penney, Formolo, 1994


                   Nancy B. Swigert, M.A., CCC/SLP,                               Nancy B. Swigert, M.A., CCC/SLP,                                Nancy B. Swigert, M.A., CCC/SLP,
                                BRS-S                  196                                     BRS-S                 197                                       BRS-S                     198




                                                                                                                                                                                               22
Cervical Auscultation                                               Cervical Auscultation                                           Cervical Auscultation
Aim of Study:                                                       Conclusion (continued)                                             Investigate:
 Study symmetry and reproducibility of                              Support for use of unilateral site for                             n=14 normal subjects
  swallowing sounds from bilateral cervical
                                                                      detection of swallowing sounds                                     Type of acoustic detector unit suited to an
  auscultation                                                                                                                            acoustic analysis of pharyngeal swallow
                                                                     Reproducibility suggest that evaluation of
Conclusions:                                                                                                                             Type of adhesive suited for attachment of the
 No significant differences for any parameters in
                                                                      acoustic characteristics of swallowing
                                                                                                                                          detector
  both time and frequency domain analyses between                     sounds should be from repeated swallows
                                                                                                                                         Optimal site for sound detection of pharyngeal
  swallowing sounds detected bilaterally                              vs. single swallow
                                                                                  Takahashi, Groher, Michi, 1994
                                                                                                                                          swallow
                       Nancy B. Swigert, M.A., CCC/SLP,                                  Nancy B. Swigert, M.A., CCC/SLP,                                  Nancy B. Swigert, M.A., CCC/SLP,
                                    BRS-S                 199                                         BRS-S                 200                                         BRS-S                 201




Cervical Auscultation                                               Cervical Auscultation                                           Cervical Auscultation
   Conclusion:                                                      Growing clinical use as compliment                               Benchmark methodology
       Site over lateral border of the trachea                      Lack of randomized controlled studies                                Acoustic detector unit sensitive to swallowing
        immediately inferior to cricoid cartilage is the                                                                                    sounds
                                                                     How do dysphagic swallow sounds differ                               Best placement
        optimal site for detection of swallowing sounds
        (Greatest signal to noise ratio with smallest                 from normal swallow sounds?                                                   Takahashi et l, 1994

        variance)                                                        Study of normal swallow                                          New instrumental standards
                 Takahashi, Groher, Michi, 1994                                                                                              Microphone vs. accelerometer
                                                                        Acoustic signals differed for variables: age and
                                                                                                                                             Placement consistent with Takahashi
                                                                          bolus volume                                                              Cichero & Murdoch, 2002
                                                                                  Cichero & Murdoch, 2002

                       Nancy B. Swigert, M.A., CCC/SLP,                                  Nancy B. Swigert, M.A., CCC/SLP,                                  Nancy B. Swigert, M.A., CCC/SLP,
                                    BRS-S                 202                                         BRS-S                 203                                         BRS-S                 204




                                                                                                                                  Cervical Auscultation used to study post
Cervical Auscultation                                               Cervical auscultation                                         swallow respiratory sounds Cichero et al 2003
 Growing clinical use as compliment                               Recorded sounds of swallow                                       Non-dysphagic individuals (18-60+)
                                                                   Rated by 19 SLPs
 Lack of randomized controlled studies                                                                                              Called it the ‘glottal release sound’
                                                                   Compared to radiographically defined aspiration 66%
 How do dysphagic swallow sounds differ                            specificity and 62% sensitivity                                  Found to occur consistently in close

  from normal swallow sounds?                                      Reliability of individual judges varied widely                    proximity following the swallowing sound
                                                                   Those raters with good intra-rater reliability made              Sound has distinct features and these
     Study of normal swallow
                                                                    good predictions                                                  change depending on volume and viscosity
     Acoustic signals differed for variables: age and
                                                                   Group consensus(17 of 20)was good                                 of bolus swallowed
      bolus volume
                Cichero & Murdoch, 2002                           So…in ‘principle’ use of swallow sounds should be                Further research required
                                                                    reliable                       Leslie, et al 2004
                       Nancy B. Swigert, M.A., CCC/SLP,                                  Nancy B. Swigert, M.A., CCC/SLP,                                  Nancy B. Swigert, M.A., CCC/SLP,
                                    BRS-S                 205                                         BRS-S                 206                                         BRS-S                 207




                                                                                                                                                                                                    23
Inter- and intra-rater reliability w/
cervical auscultation to detect                                           Cervical Auscultation                                        Use of blue dye
aspiration        Stroud et al 2002
                                                                             Cervical auscultation is at present an imprecise             Issues:
                                                                              tool and information gained should be used                         1.) Is it a reliable way to detect aspiration
                                                                              cautiously                                                          using the Modified Evans Blue Dye Test ?
    Swallowing sounds                       SLPs could not
     recorded                                 reliably classify                                                                                  2.) If used in MEBDT or FEES®, is blue
     simultaneously with                      swallows into those                                                                                 dye safe?
                                                                                 Cichero & Murdoch, 1998
     videofluoroscopy                         with or without                    Hamlet et al, 1994
    5 SLPs listened to the                   aspiration                         Takahashi et al, 1994
     sounds in isolation                     Over detected                      Zenner et al, 1995
                                              aspiration
                         Nancy B. Swigert, M.A., CCC/SLP,                                    Nancy B. Swigert, M.A., CCC/SLP,                                      Nancy B. Swigert, M.A., CCC/SLP,
                                      BRS-S                         208                                   BRS-S                  209                                            BRS-S                                            210




 Use of blue dye                                                          Use of blue dye                                              Simultaneous MBS and Blue Dye (BDT)
  20 consecutive simultaneous MEBDT and                                     15 consecutive simultaneous MEBDT and                       Pilot study                                   Certain trach conditions
                                                                                                                                          50 simultaneous Blue                           associated with more
   MBS                                                                        video nasal endoscopic exams                                                                                accurate BDT aspiration
                                                                                                                                           Dye and MBS with
  50% false negative rate                                                   50% false negative rate                                                                                     results:
                                                                                                                                           trach patients
                                                                                                                                                                                              Trach tube conditions:
  MEBDT better at identifying aspiration in                                 MEBDT identified aspiration in 67% of                       Blue dye 80%                                               cuff deflation
   patients who aspirate more than a trace                                    patients who aspirated more than trace                       sensitivity(Did not correctly                             use of speaking valve
                                                                                                                                           identify 20% of patients who were
                                                                                                                                           aspirating)                                        Food consistencies
   amount                                                                     amounts                                                                                                                Pureed solids
                                                                                                                                          Blue dye 62%                                                     O’Neil, et al 2003
         Brady, Hilldner & Hutchins (1999)                                        Donzelli, Brady, Wesling & Craney (2001)               specificity       (Thought 38% were
                                                                                                                                                                                                        



                                                                                                                                           aspirating when they were not)

                         Nancy B. Swigert, M.A., CCC/SLP,                                    Nancy B. Swigert, M.A., CCC/SLP,                                      Nancy B. Swigert, M.A., CCC/SLP,
                                      BRS-S                         211                                   BRS-S                  212                                            BRS-S                                            213




 Use of blue dye in tube feeding                                          Use of blue dye in FEES®                                     Reflex cough test
    Patients experienced discolored serum, urine and                      Amount differs from that used in tube                          Reflex cough test (RCT)
     skin from Blue Dye No. 1                                               feeding                                                        20% tartaric acid
    Several deaths reported
                                                                           Reports of infection from opened and                           Tube in mouth
    Occurred in patients with gut permeability (sepsis,                    unopened bottles of blue dye
     cardiac bypass, major vascular surgery, renal                                                                                         Pinched nose and inhaled
     failure, AAA repair, cystic fibrosis, non-steroidal                         File, Tan & Thomson, 1995
                                                                                                                                           Cough or no cough
     anti-inflammatory drug use)                                                 Knoll, 1993
                                                                                                                                                       Addington et al 1999
         Maloney, Ryan, Brasel, Binion, Johnson, Halbower,
          Frankel, Nyffeler & Moss, 2002)
                         Nancy B. Swigert, M.A., CCC/SLP,                                    Nancy B. Swigert, M.A., CCC/SLP,                                      Nancy B. Swigert, M.A., CCC/SLP,
                                      BRS-S                         214                                   BRS-S                  215                                            BRS-S                                            216




                                                                                                                                                                                                                                       24
                                                                                     RCT: An analysis                                                              RCT: An analysis
  Reflex cough test                                                                           Murray et al 2002                                                           Murray et al 2002
   Compared two hospitals: RCT vs. standard                                            No inclusion/exclusion criteria                                              Binary decision of pass/fail
   RCT hospital 5/400 pneumonia                                                        No discussion site, type, size of lesion                                     No interjudge reliability for pass/fail
   Standard hospital 27/204 pneumonia                                                  No attempt to determine if had pneumonia                                     “Pneumoflex”
   Author’s conclusion: Normal RCT after                                                on admit                                                                     “Scientifc validity and reliability of the
    acute stroke indicated a neurologically
    intact laryngeal cough reflex, protected                                            More or less co-morbidities                                                   RCT have not been demonstrated to date”
    airway and low risk for developing                                                  No control for differences in tx approaches                                   (p.10)
    pneumonia with PO
                   Nancy B. Swigert, M.A., CCC/SLP,                                                       Nancy B. Swigert, M.A., CCC/SLP,                                             Nancy B. Swigert, M.A., CCC/SLP,
                                BRS-S                                          217                                     BRS-S                               218                                      BRS-S                              219




  Clinical ‘tests’ to predict                                                                                                                                      Instrumental assessments for
  aspiration                                                                         Do we all do bedsides the same?                                               patients in ICU
     Researchers continue                Predicted aspiration                         High degree of                          Also inconsistent in                MBS                                    FEES
      to search for non-                   on MBS with 90%                               consistency on 11 of                     what was                            Transporting patient to                Portable
      instrumental methods                 sensitivity and 71%                           19 components                            recommended next                     Radiology
                                                                                                                                                                                                              No patient
      for predicting                       specificity                                  Inconsistencies in                       after the clinical                  Nursing staff, respiratory
                                                                                         assessment of:                                                                care staff must                         transportation
      aspiration                          Combination of two                                                                     evaluation
                                                                                            Sensory function                                                          accompany                              Can be repeated
     Combination of three                 without the X-ray                                                                                                          Still the best view for                 easily
                                                                                            Gag
      tests (water swallow;                with 90 sensitivity                              Cervical auscultation                                                     assessing efficacy of
      pudding swallow; still               and 56% specificity                                                                                                                                                Don’t “see” during
                                                                                            Trial swallows with                        Mathers-Schmidt               compensation techniques
      X-ray)                                             Haruka, et al 2003                                                             2003                                                                  complete swallow
                                                                                             compensations
                   Nancy B. Swigert, M.A., CCC/SLP,                                                       Nancy B. Swigert, M.A., CCC/SLP,                                             Nancy B. Swigert, M.A., CCC/SLP,
                                BRS-S                                          220                                     BRS-S                               221                                      BRS-S                              222




                                                                                                                                                                 Clinical Utility of MBS (Martin-Harris et al 2000)
                                                                                     Efficacy of the MBS
Efficacy of instrumental assessment                                                     Many studies have shown that the MBS allows                                  Database of                     83% had change in at least
                                                                                         the SLP to identify specific problems in                                      nonrandom sample of              one other variable:
      The outcome of a videofluoroscopic                                                anatomy/physiology and try appropriate treatment                              608 studies                     26.3% referral to specialist
      evaluation can be immediate return to full                                         techniques                                                                                                    48.4% compensatory
      or partial oral intake                                                                                                                                          10.4% normal
                                                                                        Several studies that indicate MBS more accurate                                                                strategies
       Horner et al 1988                                                                than bedside in identifying cause of                                         32.4% aspiration                37.2% swallowing therapy
       Logemann et al 1993                                                              aspirationHead and neck cancer patients assessed                             57.2% swallowing                 recommended
       Rasley et al 1993                                                                by MBS (vs. bedside) when planning treatment                                  abnormality                     31.4% change in mode of
                                                                                         ultimately had better swallow times and more                                                                   intake
       Swigert unpublished data
                                                                                         efficient swallows (Logemann et al 1992)                                                                      43.8% change in diet texture
                   Nancy B. Swigert, M.A., CCC/SLP,                                                       Nancy B. Swigert, M.A., CCC/SLP,                                             Nancy B. Swigert, M.A., CCC/SLP,
                                BRS-S                                          223                                     BRS-S                               224                                      BRS-S                              225




                                                                                                                                                                                                                                             25
                                                          Identified physiologic
MBSImp (Martin-Harris et al 2008 Dysphagia)               components                                                              MBSImp
                                                             Lip Closure

   First standardized tool for the                          Hold Position/Tongue Control
                                                                                                                                     Example of a five-point rating scale on the
                                                             Bolus Preparation/Mastication
    measurement of swallowing impairment                     Bolus Transport/Lingual Motion                                          component “initiation of pharyngeal swallow”
    based on judgments of structural
                                                             Initiation of Pharyngeal Swallow                                        ranges from a score of “0” when the
                                                             Soft Palate Elevation and Retraction
                                                                                                                                      pharyngeal swallow initiates (onset superior-
    movement relative to bolus flow from                  
                                                          
                                                              Laryngeal Elevation
                                                              Anterior Hyoid Excursion                                                anterior hyoid movement) as the bolus head
    videofluoroscopic images using                           Epiglottic Movement
                                                                                                                                      approximates the posterior ramus of the
    standardized bolus volumes and                        
                                                          
                                                              Laryngeal Vestibular Closure – Height of Swallow
                                                              Pharyngeal Stripping Wave                                               mandible to a “4” if there is no appreciable
    consistencies                                            Pharyngeal Contraction (A/P VIEW ONLY)                                  initiation of hyoid movement at any bolus
                                                             Pharyngoesophageal Segment Opening
                                                             Tongue Base Retraction                                                  location.
                                                             Esophageal Clearance (upright)
                 Nancy B. Swigert, M.A., CCC/SLP,                               Nancy B. Swigert, M.A., CCC/SLP,                                   Nancy B. Swigert, M.A., CCC/SLP,
                              BRS-S                 226                                      BRS-S                          227                                 BRS-S                 228




MBSImp                                                    MBSImp                                                                  MBSImp
   The study demonstrated that it was not                   Oral and Pharyngeal Impairment scores were                             Creating web-based training modules on the
    necessary to score each swallow for                       significantly associated with penetration-                              administration and scoring of the MBSImP
    every volume and consistency                              aspiration scores from the Penetration-                                 tool. Each component will be represented by
                                                              Aspiration Scale (PAS) and this scale is used                           videofluoroscopic images across patient
   Rather, an overall impression (Overall                    in conjunction with the MBSImP.                                         populations with corresponding 3-D
    Impression Score –OI) of the impaired                    However, there were many patients who                                   animations.
    components across all textures could                      exhibited swallowing impairment with                                   Prototypes ready for peer review in spring to
    be captured.                                              nutritional and quality of life implications, but                       mid-summer ’09 and plans to offer ASHA CE
                                                              who did not penetrate or aspirate                                       credit for the training.
                 Nancy B. Swigert, M.A., CCC/SLP,                               Nancy B. Swigert, M.A., CCC/SLP,                                   Nancy B. Swigert, M.A., CCC/SLP,
                              BRS-S                 229                                      BRS-S                          230                                 BRS-S                 231




                                                          Murray’s rating scale for                                               Predicting aspiration from
Efficacy of FEES ®                                        secretions                                                              secretions
                                                             0 = no visible secretions                2 = any secretions           All of hospitalized patients with secretions
                                                             1 = any secretions                        that changed from a 1         rating of 2 or above were observed to
   FEES® - Excess secretions visualized with
                                                              evident on entry or                       to a 3 during
    FEES® have high predictive value for                      following a dry swallow                                                 aspirate on FEES
    aspiration                                                                                          observation period
                                                              in channels surrounding                                                0 = 21% aspirated
                                                              laryngeal vestibule                      3 = Any secretions
                                                              bilaterally represented or                seen in the area             1 = 53% aspirated
                                                              deeply pooled. Includes                   defined as laryngeal
                                                              transitions
                                                                                                                                     2 = 100% aspirated
                                                                                                        vestibule
       Murray et al 1996                                                                                                            3 = 100% aspirated
                 Nancy B. Swigert, M.A., CCC/SLP,                               Nancy B. Swigert, M.A., CCC/SLP,                                   Nancy B. Swigert, M.A., CCC/SLP,
                              BRS-S                 232                                      BRS-S                          233                                 BRS-S                 234




                                                                                                                                                                                            26
Comparison MBS & FEES(R)                                            FEES and MBS comparisons                                                 How do the two studies compare?
   Oral phase observed
   Pharyngeal wall and tongue           Structures of the                                                                                     34 patients with each, total agreement in
                                                                       Briani et al (1998): “videofluoroscopy most
    base movement during                  larynx and pharynx
    swallow                                                             sensitive technique in identifying                                       76.4% of patients for propulsion and 82.3%
                                         Amount and location                                                                                    for aspiration (Perie et al 1998)
   Elevation and forward                 of secretions
                                                                        oropharyngeal alterations of swallowing”
    motion of larynx
                                                                       “videofluoroscopy also capable of                                       21 subjects, 75% of subjects who had
                                         Laryngeal sensation
   Opening of cricopharyngeus                                                                                                                   penetration on FEES also had on MBS
                                         Closure of true cords         detecting pre-clinical abnormalities in non-
   Tipping of epiglottis                                                                                                                       88% of subjects who aspirated on FEES
   Movement of bolus during             Arytenoid movement            dysphagic patients who later developed
                                                                                                                                                 did so on MBS (within 48 hours)
    swallow                              Residue in lateral            dysphagia”                                                               Langmore 1991
                                          channels
                  Nancy B. Swigert, M.A., CCC/SLP,                                       Nancy B. Swigert, M.A., CCC/SLP,                                   Nancy B. Swigert, M.A., CCC/SLP,
                               BRS-S                          235                                     BRS-S                            236                               BRS-S                 237




FEES and MBS comparisons                                            Reliability MBS (McCullough et al 2001)
   Langmore (1991)                                                    Intra-judge reliability                 Inter-judge reliability
                                                                        on measures of:                          of most measures
   75% of subjects who had penetration on                                 Penetration-aspiration               (with exception of
    FEES® also had penetration on MBS                                      Lingual function                     aspiration yes/no)
   88% who aspirated on FEES® also                                        Oral residue                         varies among
                                                                           Vallecular residue
    aspirated on MBS                                                                                             clinicians
                                                                           Pyriform sinus residue
                                                                           Hypopharyngeal                      Unacceptable
                                                                            residue
                                                                       Are acceptable
                  Nancy B. Swigert, M.A., CCC/SLP,                                       Nancy B. Swigert, M.A., CCC/SLP,
                               BRS-S                          238                                     BRS-S                            239




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