Dysphagia Final

Front 1

What is a clinical swallow study?

Back 1

 After the consult from the MD is received, it is the first assessment done on the patient.
 You will determine diet level, treatment techniques and a dysphagia therapy plan for the majority of your patients based on your findings on the clinical swallow study alone.
 Most patients do NOT get an instrumental examination because a thorough clinical swallow study can yield adequate information for the clinician to make recommendations.

Front 2

Components of a clinical swallow study

Back 2

 History
 Gross clinical observation of patient
 Interview with patient, family and/or caregivers
 Oral-Motor Examination for swallowing
 PO trials
 Treatment technique trials
 Recommendations

Front 3

History

Back 3

 Take a thorough history from the medical record to get an impression of the pt’s potential to swallow.
 Pull together info from all the different professionals on the team to piece together the “puzzle” and come out with a more successful swallow study by preparing ahead of time
 Reason for current admission and current medical status
 Medical/surgical status prior to admission
– Respiratory status
– Baseline mental status
– Baseline swallowing status
– Any etiologies for dysphagia
– Past medical/surgical history
 Current nutrition/hydration status
 Current respiratory status and CXR findings

Front 4

Clinical Observations

Back 4

 Position of patient in bed or chair
 Drooling
 Feeding tube type
 Tracheotomy tube model and size
 Mental status
– Level of attention and alertness
– Orientation
– Communication
– memory

Front 5

Interview with patient, family and/or caregiver

Back 5

 Can the patient participate in the interview?
– Level of alertness
– Confused or agitated
– Able to speak?

Front 6

If trouble swallowing is confirmed get a specific description of the problems:

Back 6

– Nature, onset and duration of the problem
– Problems with mastication
– Trouble swallowing saliva, food, liquids or pills
– Coughing or choking on what and when
– Locate the sensation of food or liquids getting stuck
– Odynophagia
– Reflux
– Identify types of foods or liquids avoided because they can’t swallow them
– What’s the easiest thing to swallow?
– How’s the appetite?
– Self-feed or need assistance?

Front 7

Oral-Motor Examination for Swallowing

Back 7

 Lips
 Dentition
 Tongue
 Soft Palate
 Vocal Quality
 Dry swallow

Front 8

Decision Time

Back 8

 At this point, you have A LOT of information.
 Based on all of this information, you should have a good expectation of the outcome of the clinical swallow study even BEFORE you have ever placed anything in your patient’s oral cavity
 Do you continue with PO trials? Which treatment techniques might be attempted, if any? What consistency will you start with and why?

Front 9

Clinical Signs of Aspiration

Back 9

 Coughing before, during or after the swallow
 Throat clearing with PO intake
 “wet” phonation after PO intake
 Audible chest congestion after PO intake

Front 10

PO Trials

Back 10

 If a patient is NPO or an out-patient, then a selection of foods and liquids will be brought by the SLP
– Solids: raw carrot, graham cracker, pudding and applesauce
– Liquids: thick (honey), semi-thick (nectar) and thin (water).
– Cup, spoon, straw, suction
 If the in-patient is already receiving a diet, then assess during a meal
 For the NPO patient, unless otherwise indicated by the information you have already gathered, start with the applesauce because it is the easiest to handle.
 Present the ½ tsp-sized bolus and place finger on the thyroid notch.

Front 11

Observations during PO trials:
Oral Preparation

Back 11

 Oral Preparation
– Patient readily accepts bolus?
– Anterior spillage?
– Oral manipulation of bolus?
– Mastication ability?

Front 12

Observations during PO trials:
Oral Transit

Back 12

– Check for residue in oral cavity after the swallow

Front 13

Observations during PO trials:
Pharyngeal Transit

Back 13

– Prompt triggering of the pharyngeal swallow?
– Check vocal quality
– Check if there is a sensation of something stuck and note location (sternum? Pharynx?)
– Note any clinical signs of aspiration, when and on which consistency

Front 14

Observations during PO trials:
Esophageal Phase

Back 14

– Suspicious if patient consistently reports feeling something stuck at the level of the sternum

Front 15

Make these observations consistent after each swallow

Back 15

 How many swallows needed?
 Check vocal quality
 Ask patient if anything feels stuck in his throat or chest.
 Does patient report odynophagia?
 Ask patient if it felt like it went down the right way
 Check for oral residue
 Note any clinical signs of aspiration
 Plan your next 2 steps (techniques, consistencies, bolus sizes)
 **Be aware of your rationale for the next steps

Front 16

Typical order of texture presentation (if NPO)

Back 16

 ½ tsp of applesauce
 1 tsp applesauce
 ½ tsp of pudding
 1 tsp of pudding
 1 sip of THICK liquid
 1 sip of SEMI-THICK liquid
 1 sip of THIN
 1 bite of Graham cracker
 1 bite of raw carrot
**This is a typical order of presentation, but it can vary depending upon the patient.

Front 17

Interpretation of the clinical swallow study

Back 17

 Mentally summarize your observations for an overall picture of the patient’s swallow
 Compare your clinical observations to each component of the normal swallow
 Did any treatment strategies eliminate clinical signs of aspiration consistently?

Front 18

Recommendations

Back 18

 Most liberal food and liquid textures that the patient swallowed without clinical signs of aspiration.
 Treatment techniques that are effective for the patient
 SLP plan of treatment will include exercises, patient and family training regarding treatment techniques and diet consistencies and education of WHY these recommendations are important.

Front 19

Advantages of Clinical Swallow Study

Back 19

 Natural setting
 Normal foods
 Can observe self-feeding and/or care giver
 If receiving a diet, can observe through a meal

Front 20

Disadvantages of Clinical Swallow Study

Back 20

 Limited primarily to the oral phase for direct observation
 Have to infer about pharyngeal and esophageal phases
 Cannot detect silent aspiration.

Front 21

When to consider an Instrumental Exam (3 things)

Back 21

 Inconsistent clinical signs of aspiration with and without treatment techniques

 No clinical signs of aspiration, but presents with symptoms of a pharyngeal dysphagia not alleviated by treatment techniques (e.g.; globus, feeling residue stuck in throat)

 Clinical signs of aspiration are alleviated with treatment techniques, but the patient respiratory status is poor (e.g.; active lung disease requiring meds, active TB, receiving >2L of O2 or h/o recurrent aspiration PNA’s)