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135 Cards in this Set

  • Front
  • Back
  • 3rd side (hint)
Screening procedures provide the clinician with some _____ evidence that the patient has a swallowing disorder but do not provide information on the ______ of that order.
Screening procedures tend to identify the _____ and _____ of dysphagia.
Screenings should be _____, ____ ___, and ____ ____.
low risk
low cost
What two characteristics are statistically examined during a screening?
1. correctly id those who aspirate or have residue (true positives)
2. should not generate many false positives or false negatives.
Name the four abnormal behaviors that are indicators of the need for an in-depth physiologic study.
rejection of food
food selectivity
open-mouth posture
Rejection of food
rejection of oral intake, these indv should receive a MBS
Food selectivity
children limiting their oral intake to only selected foods;; should test reaction to various tast, temp, and texture combos.
indicates several diff abnormalities:
tactile agnosia
Open-mouth posture
need to assess the upper airway and dental structure
At the end of the screening, the clinician should indicate whether the patient is: _ _ _ or whether the _ _ _ _ is _.
a normal swallower
risk of dysphagia is high
Name the 12 things a bedside exam is designed to provide
1. info on current dx and medical hx
2. pt's medical status
3. pt's oral anatomy
4. pt's respiartory function and its relationship to swallow
5. pt's labial control
6. pt's lingual control
7. pt's palatal function
8. pt's pharyngeal wall contraction
9. pt's laryngeal control
10. pt's general ability to follow directions and monitor and control her/his behavior
11. pt's reaction to oral sensory stim (tast, texture, temp)
12. pt's reactions and symptoms during attempts to swallow
The preparataory examination begins with:
the collection of information from the pt's chart and includes complete examination of vocal tract control
Chart review should be used to determine pt's: (3)
respiratory status (ie pneumonia, trach tubes -current or hx)
hx of swallowing problems (such as duration, medical status, ability to follow directions, motivation)
nutritional status
What are the two parts of a bedside/clinical examination
preparatory examination
initial swallowing examination
Name the 5 things a chart review and hx should id
1. current and past medical problems
2. current and immediate past medications (esp for xerostomia, reduced alertness, or delayed reaction time)
3. hx of swallowing disorder (time and nature of onset, symptoms, and pt's awareness of problems)
4. presence, type, duration, and method of placement of any airway device
5. presence, type, duration of placement, adquacy, and complications of oral and nonoral nutrition
Name five observations that should be made when entering a pt's room
1. pt's posture in bed
2. pt's alertness and reaction to clinician's entrance
3. trach tube and it's status
4. pt's awareness and handling of secretions
5. pt's management of the tube
page 140
What is the physiologic hierarchy?
1. respiration
2. swallowing
3. speech
page 140
dry mouth
page 140
Aside from observing respiratory rate, name 4 things you should observe.
1. time of saliva swallows relative to phases of the resp cycle
2. timing of any coughing relative to respiration - swallow coordination
3. duration of comfortable breath hold (1, 3, 5 sec)
4. pt's rest breathing pattern - oral or nasal?
page 141
Tracheostomy tubes are normally placed for: (3)
1. upper airway obstruction at or above the level of the true vocal folds
2. potential upper airway obstruction
3. provision of respiratory care
page 141
Three parts of a tracheostomy
outer cannula
inner cannula
page 141
The _ cannula always stays in place
page 141
The - cannula remains in the tube except for cleaning
page 141
the _ is inserted only to provide a smooth, rounded tip during inital insertion
page 141
Two procedures for weaning pt's off of trach tubes
1. changing tube to a smaller size to encourage oral-nasal breathing + trach breathing

2. plugging the trach for periods of time
page 142
What are the two important variations to trach tubes?
1. cuffed or uncuffed

2. fenestrated or unfenestrated
page 142
Cuffed trach tubes are placed when there is: (2)
1. need for respiratory tx

2. potentional for the pt to aspirate
page 144
When the cuff is fully inflated:
no material from above the larynx ac pass thru into the trachea and bronchi
page 144
The cuff must remain inflated if a pt is on mechanical ventilation that operates on postive pressure principles.

True or False?
page 144
When is the cuff inflated?
to deliver respiratory tx
to prevent aspiration pneumonia (for those who aspirate their saliva)
page 144
Why aren't cuffs left fully inflated for a long time?
It causes tracheal irriation, ischemia and tracheal stenosis
page 144
What is the minimal leak technique?
inflating cuff until no air can pass around it, then taking out 1 or 2 cc of air which prevents tracheal stenosis
page 145
An inflated trach cuff may inhibit:
a patients relearning to swallow by restricting laryngeal elevation,

reducing laryngeal senstivity,

or placing pressure on the esophagus viea the common posterior wall
page 145
Fenestrated trach tubes are used when:
a pt is having difficulty producing voice w/a normal trach tube; fenestrated tubes are usually NOT cuffed
page 146
At the beginning of the beside/clinical or radiogrpahic study the clinician should examine the trach tube to: (4 things)
1. determine the presence of a cuff and the status of the cuff

2. the size of the trach tube

3. the presence of fenestration

1. review length of time pt has had trach
page 147
If the trach has been in place longer than _ months, scarring my have formed and restrict laryngeal elevation
page 147
A tube in place longer than six months results in: (3)
reduced airflow

reduced stimulation to subglottic sensory receptors

reduced vocal fold closure
page 148
Most swallows occur during the _ phase of the respiratory cycle
page 149
Use of a _-_ _ on the trach tube may help in place of light digital occulsion
one-way valve - also helps with speech production
page 149
_ and _ are reciprocal
swallowing and respiration
page 149
The normal swallow usually occurs _ _ _ _ exhalation
toward the beginning of
page 150
What test is used for tracheotomized pt's during the bedside?
the blue dye test
page 150
Compare tracheostomy to intubation.
intubation involves placing a tube through the mouth or nose, the pharynx and larynx, to the lower trachea; intubation usually done in emergency situations; intubation is considered a more stable airway
page 150
Do you do swallowing exercises with someone who is intubated?
page 150
Based on a careful history, the clinician will have info on: (3)
the localization of the disorder (in terms of stage)

the easiest and most difficult types of material for the pt to swallow

the nature of the swallowing disorder
page 150
Oral anatomy examination looks at: (6)
lip confinguration
hard palate config
softe plate and uvula dimensions
faucial arches
lingual config
adquacy of the sulci
page 153
oral-motor control exam should include: (3)
1.eval of range, rate, and accuracy of the:
soft palate
pharyngeal walls

2.reflexive activity
3. swallowing
page 153
Pt's w/head injury or severe neurologic impairments have difficulty:
opening their mouth, takes 3 to 5 minutes
page 153
Severely impaired neurologic pt's would benefit from:
oromotor stimulation to help open the mouth more easily via massage
page 153
How do you determine if a bite reflex is present?
using a 4x4 gauze roll to touch the teeth and alveolar ridge
page 153
If bite reflex is present, feed them with:
a spoon that doesn't break or splinter
page 153
Do NOT give these to apraxic pt's during bedside:
verbal directions regarding eating or swallowing
page 154
Name three abnormal oral reflexes
hypersenstive gag
tongue thrust
tonic bite
page 154
lingual function should be assessed both _ and _.
anteriorly and posteriorly
page 155
For anterior tongue mov't, the pt should be asked to: (6)
1. extend tong forward and back as far as possible
2. touch corner of mouth and do lateral movts
3. attmept to clear lateral sulcus
4. open mouth wide and elevate tongue to alveolar ridge
5. repate /ta/
6. repeat a sentence with a lot of tip-alveolar stops
page 155
Pt w/difficulty in oral transit find _ easiest to swallow
page 152
Pt w/delayed or absent trigger do best with a _ consistency
page 152
Posterior tongue function is assessed by: (3)
1. open mouth and lift the back ofgue as if saying /k/ and hold the back of the tongue elevated for several seconds

2. repeat the syllable /ka/ as rapidly as possible

3. repeat a sentence containing a number of back velar stop phonemes
page 155
Assessment of chewing is most safely done with _ rather than _
page 155
Food _ is not recommended for bedside assessment
page 156
How do you elicit a palatal reflex?
Use a cold instrument w/ a laryngeal mirror against the juncture of the hard and soft palates or the inferior edge of the soft palate and uvula
page 156
What does a palatal reflex do?
Stimulates soft palate movt but does not generate a total pharyngeal response of a gag reflex
page 156
What nerve carries the palatal reflex?
afferent =glossopharyngeal (and possibly the vagus)

efferent = vagus (and possibly glossopharyngeal)

trigeminal may be involved
page 156
Is there a relationship between presence or absence of a gag reflex and pt's ability to swallow?
page 157
What nerves carry the gag reflex?
CN X and maybe CN IX
page 157
Compare and contrast the swallow vs gag reflex.
Gag: triggerd by noxious stimulus (vomit or reflux), a motor response designed to squeeze material up and out of pharynx, triggered from surface tactile receptors

swallow: an organized set of motor actions to take food safely and efficently from mouth to stomach thus clearing noxious material from the pharynx; triggered from deep proprioceptive receptors
page 157
All food should be positioned at the point of _ sensitivity
page 158
Examination of laryngeal function should begin with assessment of _ _.
voice quality
page 158
gurgly voice
associated w/aspiration; warrants referral for a radiographic examination
page 158
suspected reduced laryngeal closure during swallow
page 158
asking the pt to slide up and down a vocal scale allows evaluation of
function of cricothryoid muscle
and intrinsic muscles of the vocal cords

test the superior laryngeal nerve (which innervates the cricothyroid muscle)
page 158
Name two techniques that could be used to increase a pt's airway protection prior to initiating any swallows
page 159
What are the guidelines for the amount of aspiration a pt can tolerate before developing pneumonia?
there are no guidelines; physican comes up with own
page 159
What info is collected from the bedside exam? (4)
1 posture that may result in the best swallowing

2. best position for food in the mouth

3. the potentially best food consistency

4. some indication of the nature of the pt's swallowing disorder
page 159
When is risk high and benefit low? (6 instances)
pts is acutely ill

significant pulmonary complications

weak voluntary cough

over 80

can't follow directions

suspected of having a pharyngeal swallowing disorder
page 160
When is risk low and benefit high?
pt can follow directions

pt can cough on demand

has good pulmonary function
page 160
If pt is being fed orally, the clincian should observe feeding to note: (6)
1. pt's reaction to food

2. oral movts in food manipulation and chewing

3. any coughing, throat clearing, or struggling behaviors or changes in breathing and their frequency relative to swallowing and when it occurs (before, during after)

4 changes in secretion levels throughout meal

5. duration of meal and total intake

6. coordination of breathing and swallowing
page 160
tilting the head down allows for (3 anatomical)
wider vallecular space

narrowed airway entrance

epiglottis farther back
page 160
With head downward, material is more likely to rest in the _ long enough for the _ _ to _
pharyngeal swallow
page 160
Selection of food texture to use in the swallowing eval should depend on (3)
1 info collected in hx

2 data on oral control

3 info on pharyngeal and laryngeal control
page 162
Pt's w/ poor oral control do best with _ liquid first
page 162
Pt's w/ delayed pharyngeal swallow will do best with a _ consistency
page 163
Pt's w/reduced tongue base or pharyngeal wall contraction do best w/_
page 163
Pt's w/reduced closure of the laryngeal entrance do best with _ consistency
page 163
What utensils should the clinician have for a swallowing eval (6)
1. a size 0 or 00 laryngeal mirror

2. a tongue blade for wiping material onto the posterior tongue

3. a cup to give to give pt a small amt of material

4. a spoon for presenting liquids and paste

5. a straw to place liquid in the back of mouth

6. a syringe to squire 1 ml of liquid into the posterior oral cavity
page 163
Steps in working w/a trach pt and swallowing (3)
1. deflate cuff
2. suction orally and trach
3. have pt occulde trach
page 164
Advantages to swallow tx w/trach tube in place
clinician can see aspiration more directly
page 164
Problems related to trachs and swallow tx: (3)
1. restriction of upward laryngeal movt to protect the airway b/c of scarring

2. compression of the esophagus by the tube

3. change in intratracheal pressure
page 164
The clinician can place her fingers on the pt's neck to assess: (2)
oral transit time

phayrngeal delay time

NO info on pharyngeal stage of swallow can be collected
page 167
The fluoroscopic procedure designed to examine the details of oral, pharyngeal and cervical esphageal physiology during swallowing is:
the modified baruim swallow procedure
page 169
Name the three ways a MBS differs from a traditional upper gastrointestinal, or barium swallow
type and amount of material used
procedures used
page 169
Two purposes of MBS
define abnomral anatomy and phsyiology

id and evaluate treatment strategies
page 169
The MBS assesses (2)
whether pt is aspirating
why pt is aspirating
page 169
Compare and contrast the MBS to the traditional barium swallow
trad bs: gives info on structural competence of the esophagus, particularly the lower two thirds of the esophagus, w/little attention paid to details of swallowing phsyiology in the oral cavity and pharynx.
page 169
Describe the MBS
two swallows of 1, 3, 5, 10 ml
cup drinking of think liquid
1/3 tsp pudding
1/3 of a Lorna Doone cookie coated w/barium
page 170
Define oral transit time
time for movt of bolus thru oral cavity from initiaation of posterior movt of bolus til head passes mandible/tongue base crossing
page 174
Define pharyngeal transit time
time of pharyngeal phase
page 174
pharyngeal delay time is
time from end of oral transit time til trigger
page 174
The P-A view is helpful in looking at (2)
symmetries in function
viewing residues in valleculae and pyriform sinuses
page 177
Can pharyngeal physiology be determined at bedside?
page 179
introduction of treatement strategies (4 in order)
postural techniques
tech to incr oral sensation
swallowing maneuvers
diet changes
page 180
Swallow maneuvers cause:
page 180
Name the five postural techniques
head back
head down
head roated (to damaged side)
head tilted (to better side)
lying down
Postural techniques do two things:
1. redirect food flow
2. change pharyngeal dimensions
page 181
Reduced posterior propulsion of bolus by tongue:
name posture to use and why
head back;
uses gravity to clear oral cavity
page 181
Delayed trigger:
name posture to use and why
head down;
widens valleculae; narrows airway entrance
page 181
reduced tongue base posterior movt:
name posture to use and why
head down;
pushes tongue base back to wall
page 181
unilateral wall dysfunction:
name posture to use and why
head down or head rotated to damaged side;
head down to push back epiglottis and narrow laryngeal entrance

head rotated to increas vocal fold closure and narrow laryngeal entrance
page 181
reduced laryngeal closure
name posture to use and why
head down;
places epiglottis in more protetive position; narrows airway entrance
page 181
reduced pharyngeal contraction:
name posture to use and why
lying down on one side;
changes gravitation effect on phayrngeal residue
page 181
unilateral pharyngeal paresis:
name posture to use and why
head rotated to damaged side;
twists phayrnx, eliminates damaged side of pahrynx from bolus path
page 181
cricopharyngeal dysfunction:
name posture to use and why
head rotated;
pulls cricoid cartilage away from posterior pharyngeal wall, reducing resting pressure in UES
page 181
When are oral sensory techniques used?
delayed onset of oral swallow
delayed trigger of pharyngeal sw
page 182
Sensory techniques include: (6)
1. inc downward pressure of sppon on tongue
2. presentation of sour bolus
3. presenation of cold bolus
4. presentation of a bolus requiring chewing
5. presenation of a laryger volume bolus
6. thermal-tactile stimulation
page 182
Measures of the effectiveness of sensory procedures to increase oral sensory input include: (3)
1. duration of time from command to swallow uintil initiation of the oral stage of swallow
2. oral transit time
3. pharyngeal delay time
page 182
Oral onset time and oral transit times can be measured from:
page 182
Name the four swallowing maneuvers:
1. supraglottic swallow
2. super-supraglottic swallow
3. effortful swallow
4. Mendelsohn
page 183
Supraglottic swallow
designed to close the airway at the level of the true vocal folds before and during the swallow
page 183
Super-supraglottic swallow
designed to close the airway entrance before and during the swallow
page 183
Effortful swallow
designed to increase tongue base posterior motion during the pharyngeal swallow, thus improving bolus clearance from the valleculae
page 183
Mendelsohn maneuver
designed to increase the extent and duration of laryngeal elevation and thus increases the duration and width of the UES

also improves overall coordination of swallow
page 183
Order of interventions introduced (four)
1. postural
2. tech to improve oral sensation
3. swallow maneuvers
4. food consistency/diet changes
pages 181-183
reduced range of tongue motion:
easiest consistencies and those to avoid
easiest: thick liquid
avoid: thick foods
page 184
reduced tongue coordination:
easiest consistencies and those to avoid
easiest: thick liquid
avoid: thick foods
page 184
reduced tongue strength:
easiest consistencies and those to avoid
easiest: liquid
avoid: thick, heavy foods
page 184
delayed pharyngeal swallow:
easiest consistencies and those to avoid
easiest: thick liquids and thicker foods
avoid: thin liquids
page 184
reduced airway closure:
easiest consistencies and those to avoid
easiest: pudding and thick food
avoid: thin liquids
page 184
reduced laryngeal movt contributing to criocopharyngeal dysfunction:
easiest consistencies and those to avoid
easiest: liquid
avoid: thicker, higher viscosity food
page 184
reduced pharyngeal wall contraction:
easiest consistencies and those to avoid
easiest: liquid
avoid: thick, higher viscosity food
page 184
reduced tongue base posterior movt:
easiest consistencies and those to avoid
easiest: liquid
avoid: higher viscosity food
page 184
The report begins with:
a description of the pt's symptoms or complaints
page 185
The second part of the report:
measures of oral transit time for each material swallowed, followed by a description of any neuromuscular or anatomic problems observed in the oral phase
page 185
The third part of the report:
pharyngeal transit times and any anatomic or neuromuscular problems; amount of aspiration; etiology of aspiration
page 185
Last part of the report (4):
1. management of nutritional intake and any swallow management strategies to be used at meals
2. results of the interventions and tx used in the study
3. procedures for swallowing tx
4. reevaluation
page 185
If the report does not contain the anatomic or _ reason for aspiration or residue AND the _ attempted to reduce or eliminate these symptons and their effects the study is _.
page 185