Dysphagia Quiz 2

Front 1

What does a bedside exam tell you?

Back 1

1. Defined medical and swallowing history
2. Language, cognitive, and memory abilities
3. Oral anatomy, sensation, and bolus control
4. Secretion management
5. Fatigue, alertness, behavior
6. Screens for the need for instrumental procedures

Front 2

Why use instrumental exams?

Back 2

- The bedside exam has limitations—you can’t see EVERYTHING.

- Aspiration cannot be confirmed or ruled out

*** The bedside is unable to identify the physiological cause of the symptom (pharyngeal and esophageal)
- If you suspect pharyngeal involvement you need to investigate further

Front 3

Instrumental Considerations

Back 3

• Risks of each test
• Side effects
• Invasiveness
• Comfort level
• Individual patient

Front 4

Video fluoroscopy = Modified Barium Swallow

What is it? What Q's does it answer? Purpose

Back 4

Designed to examine the oral, pharyngeal and esophageal phase of the swallow (All the phases)

Answers the question: Does the patient have pharyngeal phase dysphagia?

Purpose:
• Visualizes pattern of food flow (sequence) start to end
• Visualizes pharyngeal symptoms (residue, aspiration, penetration)
• Look at anatomy and physiology-try to find the abnormalities that are causing the symptoms.
• Identify Tx strategies to help the patient eat safely.

Front 5

Advantages and Disadvantages of MBS

Back 5

Disadvantages
- Uses x-ray ***damages tissues, vascular changes, shrinks glands
- Doesn’t give pressure info - dunnowhy bolus goes slow
- Cannot view the VFs unless there is aspiration
- Some people do not like the barium

Advantages
• Relatively high comfort
• Relatively low invasiveness

Front 6

Fiberoptic Endoscope Evaluation of Swallowing (FEES,FEEST)

What is it? What Q's does it answer? Purpose

Back 6

Flexible endoscope passed transnasally in the pharynx to examine the laryngeal function during the swallow
Answers the questions:
• Does pt have an anatomical problem of the pharynx, larynx? (ie: vocal cord paralysis)
• Is there aspiration before/after swallow? (not during)
• Where is the residue after the swallow?

Purpose and procedure of FEES: 2basic parts +1 sensory
1. Visualize pharyngeal/laryngeal structure & fn
2. Swallowing is assessed, patient is presented with a variety of textures (dyed in blue-optional) Compensatory techniques are attempted.
3. Pulse of air to the wall of the pyriform sinus or touch the tip of the scope to the pharyngeal mucosa

Front 7

Fiberoptic Endoscope Evaluation of Swallowing (FEES,FEEST)

Advantages

Back 7

Advantages: FEES
1. No radiation
2. More easily see airway closure by true vocal cords, false cords, and arytenoid movement
3. Amount and location of the residue/ and pooling of secretions (in living color)
4. Pharyngeal sensitivity component
5. Coordination of breathing and swallowing
6. Can be used for biofeedback in therapy

Front 8

Fiberoptic Endoscope Evaluation of Swallowing (FEES,FEEST)

Disadvantages

Back 8

Disadvantage: FEES
1. “White out”
2. Not able to view the oral prep and oral phase
3. Uncomfortable and some say interferes with swallow
4. Not tolerated by children under the age of 6-8, patients with decreased cognition and/or agitated patients
5. Some rare side effects: Nose bleeding, allergies to nasal spray, and laryngo-spasm.

Front 9

Pharyngeal Manometry

What is it? What Q's does it answer? Purpose

Back 9

NOT for SLPs
o Tube is placed transnasally into the pharynx sensors measure pressure of pharynx at different points and at the UES.
o This technique measures:
• The pressure generated in the pharynx
• The timing of the pharyngeal contraction
• Relaxation of the cricopharyngeus muscle
o Answers the questions:
• Does the patient have adequate pharyngeal pressure?
• What does the residue result from?
o Primarily used by physicians (gastroenterologists) NOT SLP’s and still considered experimental.

Front 10

Respect Culture

Back 10

o Ethnically based diets (foods and condiments)
o Family roles and how they vary
o Translated educational materials
o Expand your concept of family

Front 11

Predictors of aspiration pneumonia include:

Back 11

o Diminished consciousness
o Dementia, Parkinson’s, ALS, and seizure disorders
o Critically ill due to extended use of intubation (impairs the swallow reflex)
o Use of PEG
o One study asp pneumonia occurred 55% of pts up to a month of PEG placement due to reflux (Kitamaura, 2007)
o SLP OATH: do everything you can to avoid aspiration pneumonia because it can be debilitating

Front 12

Oral Preparatory Phase

Back 12

o Food is manipulated in mouth and chewed if necessary (approx 5-10 seconds)
• Sensory recognition
• Viscosity of the material
• Labial seal
• Bolus cohesiveness- personal preference
• Soft palate is pulled down and forward
• Rotary lateral movement for mastication

Front 13

Disorders of the Oral Prep

Back 13

o 1. Cannot hold food in mouth anteriorly
o 2. Cannot form a bolus
o 3. Cannot hold a bolus (spread in oral cavity)
o 4. Material falling into the anterior and/or lateral sulcus, floor of mouth
o 5. Abnormal hold position
o 6. Unable to align teeth