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140 Cards in this Set

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A clinical or bedside examination studies:
eating behavior
oromotor function
An x-ray study examines
oral physiology
phrayngeal physiology
Evidence gathered during a screening that identifies aspiration but does not provide physiological information as to why the patient aspirates is called
Indirect evidence
Screening answers the question
Is the patient dysphagic?
A diagnostic answers the question
What is the nature of the patient's physiology during swallowing?
Two characteristics of a good diagnostic procedure:
Should correctly identify those individuals who are actually aspirating or having residue (procedural specificity)
Should not generate many false positives or false negatives
Abnormal behaviors observed during eating in a child or cognitively impaired adult (that might suggest a swallowing difficulty)
rejection of food
food selectivity
open-mouth posture
12 types of information gleaned from the bedside or clinical examination
1. medical diagnosis/history, swallowing diagnosis/history
2. medical status (incl. nutritional and respiratory)
3. oral anatomy
4. respiratory function (in relation to swallow)
5. labial control
6. lingual control
7. palatal function
8. pharyngeal wall contraction
9. laryngeal control
10. ability to follow directions, monitor/control behavior
11. reaction to oral stim
12. reactions/symptoms during attempts to swallow
Tx Stat OrAnat Res LLPPL Able ReStim Sym
2 main parts of the bedside or clinical examination
Preparatory examination (no actual swallows)
Initial swallowing examination
Preparatory examination consists of:
Review of chart, gaining information on vocal tract control
Reviewing the patient's chart should identify:
1. current/past medical problems
2. current/recent medications
3. history of swallowing disorder
4. presence/type/duration/method of placement of any airway device
5. presence/type/duration of placement/adequacy/complications of oral/nonoral nutrition
Observations made upon entering the patient's room include:
1. posture in bed
2. alertness/reactions
3. trach tube and status
4. general awareness/handling of secretions and tube management
Observations of respiratory status include:
1. rate
2. timing of saliva swallows in relations to phase of respiratory cycle
3. timing of cough in relation to respiration.
4. duration of comfortable breath hold (IF FEASIBLE)
5. rest breathing pattern (oral or nasal?)
What comes first, breathing? Swallowing?
Trachs are placed for:
1. upper airway obstruction
2. potential upper airway obstruction
3. provision of respiratory care
Cuffed trachs are used when
1. needed for respiratory treatment (ventilation)
2. potential for aspiration
Minimal leak technique
Cuff is slightly deflated. This prevents tracheal stenosis, doesn't inhibit relearning to swallow, and places less pressure on the esophagus
What test is used to examine aspiration in ventilator-dependent patients?
Blue dye test (suction trach immediately after eating)
In an Oral-Motor Control Examination, you will check
1. ability to open mouth voluntarily
2. ID optimal oral-sensory and bolus types
3. ID and compensate for swallowing apraxia
4. ID and compensate for abnormal oral reflexes
5. collect management information
Typical size of trach used in adults
8; changed to a smaller size to encourage oral-nasal breathing (4-6)
What are fenestrated trach tubes for
They allow greater airflow into the upper tract for voicing and for individuals being weaned off a trach.
If a trach tube has been in place more than 6 months:
1. scar tissue may have formed, restricting laryngeal elevation
2. reduced vocal fold closure for swallowing and vocalization (subglottic sensory receptors)
During swallowing, an inflated cuff
Can reduce laryngeal elevation by creating friction against the tracheal wall
Swallowing can worsen when on a ventilator because
the ventilator controls the respiratory and the patient cannot lengthen the exhalation to allow for the swallow. Any delays can increase the risk of aspiration
Intubation can cause
reduced ROM of lips, tongue, pharynx, larynx for up to a week
Over ____ of patients who aspirate do not cough.
Patients who are aware that an oropharyngeal swallowing disorder is present are
highly reliable in their identification and description of the swallowing disorder
Liquids easy to swallow, pastes/thicker materials difficult may suggest
difficulty in oral transit because of poor tongue control
Thicker consistencies easier than thin liquids may suggest
a delayed or absent triggering of the pharyngeal swallow (thicker foods cling to tongue base/valleculae)
On the basis of a careful history, the swallowing therapist may have information on
1. the localization of the disorder in terms of the oral or phayngeal stage of the swallow (or both)
2. the easiest and most difficult types of material for the patient to swallow
3. the nature of the swallowing disorder
Examination of oral anatomy includes.
lip/hard palate configuration, soft palate and uvula (VPO), facial arches, tongue, adequacy of mandibular sulci, scarrin in oral cavity or on neck, asymmetries, dentition, secretions.
Oral-motor control examination should includ:
Range, rate, and accuracy of movement of lips, tongue, soft palate, pharyngeal walls during speech, reflexes, swallowing
Therapy for pts who have trouble opening mouth voluntarily
oral massage, verbal reinforcement, downward pressure on chin (check bite reflex)
Some patients with cognitive impairments produce most oral activity in response to particular combinations of
taste, texture, and temperature.
A patient with swallowing apraxia usually performs best at the bedside when
no directions are given regarding eating or swallowing
A patient with swallowing apraxia may perform poorly during an MBS because
verbal commands are given bring conscious focus to the act of swallowing.
Abnormal oral reflexes exhibited by patients with neurologic impairments include:
hyperactive gag, tongue thrust, tonic bite
To test labial function, the clinician should have the patient
spread lips widely on /i/, round on /u/, then alternate x10; check diadochokinetic rate, lip closure during rest and saliva swallowing, repeat sentence with lots of bilabials, chew while changing posture
Lingual function should be assessed
both anteriorly and posteriorly
Anterior tongue examination includes
1. extension and retraction
2. rapid alternation of lateral movements
3. clearing lateral sulci
4. rapid elevation/depression of tip w/ wide open mouth
5. diadochokinetic /ta/
6. tip-alveolar stop heavy sentence repetition
Posterior tongue examination includes
1. hold back of tongue in /k/ position for several seconds with mouth open
2. diadochokinetic /ka/
3. back velar stop heavy sentence repetition
Chewing assessment is most safely done
with gauze rather than food, which provides the flexibility of food with none of the risk
Function of soft palate is examined by
having the patient produce a strong sustained /a/, then rapidly repeat it.
What muscle elevates the palate?
levator palatini
What muscle retracts the palate?
Platal refelx is the __________ of the oral reflexes
least stable
What should be observed as the result of stimulating a gag reflex?
A strong symmetrical contraction of the entire pharyngeal wall and soft palate (aff IX and poss X; eff X and poss IX; V)
Does the presence or absence of a gag reflex in neurologically impaired patients indicate the patient's ability to swallow.
Er, no.
What triggers the gag? (Nerves too)
Noixious stimulus that needs to get up and out of the pharynx. (X and poss IX)
The gag is triggered from ________ whereas the swallow is triggered from _______
surface tactile receptors, deep proprioceptive receptors
Oral sensitivity exam should include an assessment of____. Why?
light touch. impacts placement of food in oral cavity.
Food should be placed in the oral cavity at
the point of maximum sensitivity
Laryngeal Function Examination includes
Voice quality, laryngeal diadochokinetic rate, cough, falsetto voice, phonation time (s/z)
Gurgle voice has been associated with ______ and warrants _______
aspiration, referral for a radiographic exam
Inability to change pitch may imply
reduced sensitivity within and surrounding larynx (internal superior laryngeal)
Information collected from the preparatory examination includes:
1. the posture that may result in best swallowing
2. the best position for food in mouth
3. the potentially best food consistency
4. some indication of the nature of the patient's swallowing disorder
Should trial swallows at bedside be attempted?
Yes, if the patient
1. can follow directions
2. can cough on command
3. has good pulmonary function
Should trial swallows at bedside be attempted?
No, if the patient
1. is acutely ill
2. has significant pulmonary complications
3. has a weak voluntary cough
4. is over 80 years old
5. cannot follow directions
6. may have a pharyngeal swallowing disorder
If the patient is being orally fed, clinician should note
1. reaction to food
2. oral movements (food manipulation/chewing)
3. coughing, throat clearing, struggling behaviors, changes in breathing relative to swallowing, and when during meal
4. changes in secretion levels
5. duration of meal and total intake
6. coordination of breathing and swallowing (uh, see 3)
_____ can be of great assistance in the management of swallowing disorders
Posture! Of course! What did you think it was?
Maneuvers to alleviate symptoms of laryngeal malfunction
supraglottic and super-supraglottic swallow to increase airway protection.
Pulmonary function testing helps the clinician...
determine whether the patient can tolerate any amount of aspiration (ordered and interpreted by physician)
Lack of awareness of light touch in the pharynx may indicate
poor awareneses of any pharyngeal residue remaining after a swallow
The patient has difficulty maneuvering the bolus in his mouth. What posture is suggested?
Tilt downward as food is introduced, then throw his head back to drain food from mouth.
The bolus it trickling over the base of the tongue and into the pharynx before the voluntary swallow is initiated. What posture is suggested?
Tilt downward as food is introduced, then throw his head back to drain food from mouth.
Tilting the head back is a safe technique if..
the patient has normal pharyngeal and laryngeal control
Patient has had a hemilaryngectomy. What posture is suggested?
Tilt head downward to widen valleculae, narrow airway entrance, and position epiglottis more posteriorly, diverting material away from airway.
Patient has a delay in triggering the pharyngeal swallow. What posture is suggested?
Tilt head downward to widen valleculae, narrow airway entrance, and position epiglottis more posteriorly, diverting material away from airway.
Patient has slightly inadequate laryngeal closure. What posture is suggested?
Chin tuck/tilting head downward may result in greater protection of the airway.
Patient has a unilateral pharyngeal paralysis resulting from medullary stroke. What posture is suggested?
Turning head towards the affected side, directing material down the more functional side.
Patient has a lingual hemiparesis in addition to ipsilateral pharyngeal dysfunction. What posture is suggested?
Tilting head towards the stronger side will direct material down that side during both the oral and pharyngeal stages of the swallow.
Patient has a unilateral reduction of oral and pharyngeal function. What posture is suggested?
Tilting head towards the stronger side will direct material down that side during both the oral and pharyngeal stages of the swallow.
Postural decisions should be made ______ attempting swallows at bedside, and should be based on _____________.
Prior to. the information collected in the preswallowing evaluation including history taking and chart review.
Liquid must be placed posteriorly in the oral cavity. How? Thicker foods?
Use a straw as a pipette, or a syringe. Use a tongue blade.
Patients with poor oral control do best with what food consistency?
Thickened liquids first, then moving toward thinner consistencies.
Patients with a delayed oral swallow do best with what food consistency?
Thicker (applesause, mashed potatos)
Patients with reduced tongue base or pharyngeal wall contraction do best with what food consistency?
Thin liquids.
Patients with reduced laryngeal elevation do best with what food consistency?
Patients with reduced closure of the laryngeal entrance do best with what food consistency?
Patients with reduced UES opening do best with what food consistency?
A patient with both a disturbance in oral function and a delayed pharyngeal swallow may do best with what food consistency? Why?
Something between a liquid and paste: gravity assists oral propulsion during oral phase, but material will cling to valleculae and epiglottis.
Selection of food texture to use during trial swallow depends on
1. history
2. oral control
3. pharyngeal and laryngeal control
Utensils used in an initial swallowing evaluation include:
1. 0 or 00 laryngeal mirror
2. tongue blade
3. cup
4. spoon
5. straw
5. syringe
If a patient is exhibiting any excess secretions, before initiating swallows what should happen?
Suctioning orally and transtracheostomy (if necessary)
Before deflating the cuff (yeah, don't forget to do that) and attempting any swallows, the clinician should
check with the patient's physician regarding advisability of deflation and patient's tolerance of aspiration.
Immediately after deflating the cuff
suction well to clear away any secretions sitting on the cuff.
During each swallow, a trached patient should
occlude the trach tube
Advantages of initiating swallowing therapy with trach in place
able to observe aspirations more directly (expectorations through the tube) and can eliminate aspirated material easily by coughing and suction.
Swallow problems arising related to trachs.
1. restriction of upward laryngeal movement (trachea is anchored to strap muscles and skin by scar tissue)
2. compression of the esophagus.
3. change in intratracheal pressure
Can swallowing problems be directly attributed to tracheostomies?
Very rarely.
Prior to asking the patient to swallow, the clinician should:
1. review and write down directions
2. give pt opportunity to practice several dry swallows
3. give adequate time to review and absorb instructions with clinician
It is usually advisable to assure the patient that the amount he or she will be given to swallow will be _______
When attempting to swallow, the patient should be encouraged to ______ whenever necessary
When checking the patient's swallow, the clinician should use approximately _____ for both the liquid and thicker consistencies. Why?
1/3 teaspoon. Will not block airway and will cause minimal difficulty if aspirated.
The clinician places her hand under the patient's chin during the patient's swallow. Where? Why?
Index finger behind the mandible (suprahyoid muscles), middle finger at the hyoid, third finger on top of thyroid cartilage, fourth finger at the bottom. To asses submandibular, hyoid, and laryngeal movement, assess initiation of tongue movement, rough estimates of oral transit time and pharyngeal delay time.
What is one way to check a perceived a possible pharyngeal delay during a trial swallow?
A second swallow using thermal-tactile stim (to compare to first swallow without it)
What can the clinician do bedside after a trial swallow to assess aspiration.
1. phonate ah immediately after (gargling sound)
2. pant for several seconds to loosen material in pharyngeal recesses.
3. phonate again to check for garglin
4. turn head to side and phonate, (pressuring pyriform sinus).
5. lift chin up and hold then vocalize (clearing valleculae).
The purposes of the MBS
1. to define the abnormalities in the anatomy and physiology causing the patient's symptoms
2. identify and evaluate treatment strategies that may immediately enable the patient to eat safely and/or efficiently
The MBS is designed to asses not only _____ the patient is aspirating, but also ___, so appropriate and efficient treatment can be initiated.
whether, why
During the MBS, liquid volumes are increased..
..unless or until the patient aspirates
How does the MBS differ from the traditional barium swallow?
TBS designed to diagnose structural lesions and anatomic deformities in the esophagus; the goal is to fill the esophagus with material (MBS uses very small amounts of liquid to minimize risks of aspiration)
_________ is less likely from aspiration of liquids than of thicker foods.
The most difficult and time-consuming part of the MBS is
positioning the patient
The fluoroscopy tube should focus on
the lips anteriorly, the hard palate superiorly, the posterior pharyngeal wall posteriorly and the bifurcation of the airway and esophagus inferiorly
It is important to get the patient's _______ as low as possible so the pharynx is not shadowed or covered.
The lateral view (MBS) permits visualization of:
1. oral and pharyngeal transit times
2. identification of bolus location
3. analysis of lingual movement patterns
4. gross estimate of residue and aspiration amounts
5. timing of aspiration relative to pharyngeal swallow
The P-A view (MBS) permits visualization of:
1. bolus pathway (one or both sides)
2. placement of bolus and residue in valleculae and pyriform sinuses
3. asymmetries in function of pharyngeal walls and vocal folds
Approximately ____ of normal swallowers swallow down only one side.
Prior to MBS, after patient is positioned, the clinician should tell/show the patient:
1. explain what will happen (swallowing different kinds of foods)
2. explain only small amounts at first
3. shown the material to be swallowed on spoon
4. feel free to cough!
5. try your best!
If aspiration occurs during MBS, then
therapeutic strategies should be introduced to stop the aspiration
On the last two swallows (Lorna Doone!), the instructions are different. How?
The patient is asked to chew the material well and initiate the swallow when ready. With the liquid and paste, the patient is asked to wait until commanded to swallow.
If the patient does well with the various foods presented using interventions or not, the clinician should also..
observe self-feeding radiographically to assure they follow the same procedure and is equally successful
Can the MBS be used with patients with dementia or severe cognitive problems?
Compensatory strategies introduced during the MBS include (in typical order of introduction)
1. postural techniques
2. techniques to increase oral sensation
3. swallowing maneuvers
4. diet (food consistency) changes
Who should be referred for videofluroscopy?
1. any patient suspected of aspirating
2. any patient with a swallowing disorder of suspected pharyngeal origin
3. any patient with a pharyngeal component to the disorder
Therapy planning and implementation for pharyngeal dysphagia cannot be done without_________. Because
a radiographic study/MBS/videofluoroscopy. the anatomic/physiologic cause of pharyngeal dysphagia cannot be ID'd at bedside.
Which compensatory treatment strategies introduced during MBS can easily be used by a wide range of people? Why?
Postural techniques and increasing oral sensation. Clinician controlled and do not require active cooperation
Why are swallowing maneuvers more difficult than other compensatory treatment strategies?
They require
1. the ability to follow directions
2. the ability to voluntarily manipulate the ongoing oropharyngeal swallow
3. increased work/muscular effort and increase potential for fatigue
Some patients cannot swallow successfuly without _____
swallow maneuvers
The best measure of postural effectiveness is:
amount of aspiration with and without the posture; OTT and PTT may also show improvement
What imaging procedure could be used to accurately measure effects of postural changes on residue and aspiration
Oral sensory techniques include:
1. increasing downward pressure of the spoon against the tongue in presenting food in the mouth
2. sour bolus
3. cold bolus
4. chewy bolus
5. larger volume bolus (>3ml)
6. thermal-tactile stimulation
Thermal-tactile stimulation has been shown to
facilitate faster triggering of the pharyngeal swallow and reducing the delay for several swallows after
How do you measure the effectiveness of oral sensory input procedures?
1. duration of time from command to swallow until initiation of the oral stage of swallow
2. OTT
3. Pharyngeal delay
Swallow maneuvers are designed to:
place specific aspects of pharyngeal swallow physiology under voluntary control
The swallow maneuvers are
1. supraglottic swallow
2. super-supraglottic swallow
3. effortful swallow
4. mendelsohn maneuver
The supraglottic swallow is designed to
close the airway at the level of the true vocal folds
Which swallow maneuver closes the airway at the level of the true vocal folds?
The supraglottic swallow
The super-supraglottic swallow is designed to
close the airway entrance before and during the swallow
Which swallow maneuver closes the airway entrance before and during the swallow?
The super-supraglottic swallow
The effortful swallow is designed to
increase tongue base posterior motion during the pharyngeal swallow, thus improving bolus clearance from the valleculae.
Which swallow maneuver increases tongue base posterior motion during the pharyngeal swallow, thus improving bolus clearance from the valleculae?
The effortful swallow
The Mendelsohn maneuver is designed to
increase the extent and duration of laryngeal elevation, thereby increasing duration and width of UES opening.
Which swallow maneuver increases the extent and duration of laryngeal elevation, thereby increasing duration and width of the cricopharyngeal opening?
The Mendelsohn maneuver
Which swallowing maneuver can improve overall coordination of the swallow?
The Mendelsohn maneuver.
Which compensatory treatment strategy should be examined last?
Food consistency (diet) changes, natch.
Not all therapy procedures can be introduced into the diagnostic setting, because..
..not all therapy procedures result in immediate effects (e.g. ROM exercises)
What goes into the videofluoroscopic study report?
1. OTTs and oral problems
2. Pharyngeal delay and variation with bolus volume/viscosity
3. PTTs and problems
4. Aspiration and its etiology
5. approx amounts of residue
6. intervention strategies and results
Recommendations given in a videofluoroscopic study report include
1. management of nutritional intake (oral/nonoral)
2. results of interventions and therapy attempted
3. procedures for swallowing
4. reevaluation
If the videofluoroscopic study report does not include _____ and ______, the study is incomplete
1. anatomic/physiologic reason for aspiration or residue
2. interventions attempted to reduce/eliminated symptoms and their effects or why they were not introduced