Assessment

1
Assessment
2
History

• The bedside evaluation is an important component
  of swallowing assessment.
• It is cheaper than instrumental assessment, and
  not all patients are able or ready to participate
  in instrumental assessment.
• The first step in any assessment protocol is to
  take a history.
• This can be done through chart review and/or
  interview with nursing, staff, family.

3
History

• First, you want to determine the reason for
  referral.
• Does the dysphagia seem to stem from iatrogenic,
  neurologic/neurogenic, structural or
  pathological, and/or cognitive/functional or
  psychogenic causes?
• Common causes of iatrogenic dysphagia include
  multiple facial trauma (e.g., wired jaw),
  tracheostomy, and multi-system failure.
• Common neurological causes of dysphagia include
  CVA, TBI, and PD.
• Structural causes of dysphagia arise from cleft
  palate, removal/repair of oral/pharyngeal/laryngea
  l structures due to carcinoma, or from hiatal
  hernia, affecting the esophagus.

4
History

• Cognitive/functional or psychogenic dysphagia is
  associated with dementia, RHS, CHI, and failure
  to thrive.
• When reviewing the medical chart, be on the look
  out for
• Current diet level
• Body temperature values (e.g., temperature spikes
  in evening)
• Respiratory status (e.g., reduced tidal volume,
  COPD, intubation or extubation, tracheostomy,
  pneumonia) even patient complaints of chest
  feeling heavy
• Input/Outputvalues should match
• PO or alternative forms of nutritional
  intakewhat type (e.g., enteral vs. parenteral),
  how long, why.

5
History

• Length of time since onset of condition
• Blood gases (e.g., O2 and CO2)
• Co-morbid diseases/conditions (e.g., COPD,
  massive internal injuries, recent by-pass
  surgery) and
• Pre-existing legal agreements (e.g., living will,
  advanced directives, DNR).

6
Non-Instrumental Evaluation

• At bedside, perform a cranial nerve exam and make
  sure to observe the patients oral-facial
  structures.
• If necessary, use an assessment tool like the
  Frenchay Dysarthria Asssement to guide your
  assessment or oral-facial structures and their
  function (s).
• Look for the presence of primitive reflexes, such
  as the bite reflex, the suckle-swallow reflex,
  and the rooting reflex.

7
Non-Instrumental Evaluation

• If you determine unilateral weakness, you will
  want to make sure that you fluoro that side, as
  well as look at swallow in the AP view.
• When assessing laryngeal physiology, listen for
  signs of vocal fold weakness (breathy, hoarse),
  for vocal wetness/gurgle, for inspiratory
  stridor.
• Place 2-3 fingers over the thyroid cartilage and
  have the patient dry swallow, feeling for
  excursion/elevation.

8
Non-Instrumental Evaluation

• If vocal quality suggests glottal closure
  problems, refer to ENT.
• Assess cognitive function for direction
  following, attention to task, safety, and need
  for supervision during eating.
• Proceed to presentation of ice chips if patients
  cognitive level so permits.
• Look for bolus propulsion, swallow response, and
  number of swallows to clear.
• Listen for cough (may be delayed), throat clear,
  and/or wet/gurgly voice quality.

9
Non-Instrumental Evaluation

• Do again with ice chips, palpate for laryngeal
  excursion, and observe consistency of behavior
  with first presentation.
• Proceed with water presentation.
• If safe with water, present food.
• Proceed as long as safe to presentation of pureed
  food (applesauce), thick liquid (nectars),
  mechanical soft (some chewing), thin liquid
  (something not too acidic), and regular foods.

10
Non-Instrumental Evaluation

• Lemon-lime soda is particularly effective for
  head/neck patients with thick mucosa secondary to
  radiation.
• If residual remains, try some positioning and/or
  placement technique/maneuver with another bolus.
• With cognitively impaired individuals, typical
  residue consists of partially formed bolus on
  tongue midline or bilateral dispersal.

11
Non-Instrumental Evaluation

• When bedside assessment is complete, ask yourself
  the following questions
• Is dysphagia present? If so, what phase(s) seems
  most affected?
• Can dysphagia be resolved through
• Positioning?
• Changing consistency and/or temperature?
• Changing presentation?
• Neuro-muscular facilitation (strengthening/ROM
  exercises)?
• Can the patient protect the airway?

12
Non-Instrumental Evaluation

• Can the patient utilize compensatory techniques
  independently?
• Does the patient have the potential to learn
  techniques?
• Is there a staff and/or family member that can
  assist with techniques?
• Should the patient be referred for instrumental
  assessment? Now? Later?

13
Fiberoptic Endoscopic Evaluation of Swallow (FEES)

• FEES involves the insertion of a flexible
  endoscope into the hypopharynx via a naris.
• The placement of the endoscope is high in the
  hypopharynx, and allows a direct view of the
  larynx and pharyngeal structures.
• The swallowing examination involves the
  presentation of controlled amounts of food and
  liquid to the patient to swallow.
• Drops of green food coloring can be placed in the
  mouth to mix with saliva to assess the management
  of secretions.

14
FEES

• Varying food consistencies and amounts may be
  presented, depending on the patients status and
  the objectives of the particular exam.
• The exam can be videotaped to optimize clinical
  use and interpretation.
• Contraindications for endoscopy are patients with
  a history of bleeding disorders, epistaxis
  (severe nosebleeds), acute cardiac problems with
  predispose the patient to bradycardia, movement
  disorders (dyskinesia), and/or extreme agitation
  or combative behavior.

15
FEES

• Topical anesthetic or nasal decongestants are
  sometimes used to increase patient comfort prior
  to inserting the endoscope.
• These should not be used if the patient has a
  history of allergic reactions or
  contraindications due to present medical status
  or current medications.
• In a study by Leder, Ross, Briskin, and Saski
  (1997), there was no statistically significant
  difference in patient comfort levels during
  transnasal endoscopy with topical anesthetic,
  nasal decongestant, or a placebo if the endoscopy
  was performed by a trained endoscopist.

16
FEES

• Adverse reactions to endoscopy are rare, but
  possible.
• These include nosebleed, fainting, laryngospasm,
  allergic reaction to the topical anesthetic,
  and/or a possible stinging sensation or sneezing
  if a nasal decongestant is used.

17
VFSS (aka MBS/Cookie Swallow)

• The videofluoroscopic swallow study (VFSS) or
  modified barium swallow (MBS) procedure is
  designed to study the anatomy and physiology of
  the oral preparatory, oral, pharyngeal, and
  cervical esophageal stages of deglutition
  (Logemann, 1983).
• It is also used to define management and
  treatment strategies that will improve the
  oropharyngeal swallowing safety and efficiency.
• During VFSS, patients are initially viewed in
  their normal eating position, usually upright and
  in the lateral plane.

18
VFSS (aka MBS/Cookie Swallow)

• A lateral plan is used to examine two important
  aspects of the swallow that are the most visible
  and measurable in the lateral view the speed of
  swallow (i.e., oral and pharyngeal transit times)
  and the approximate amount of the bolus that may
  be aspirated.
• Because it is important to outline and not
  obliterate structures and physiology in the oral
  and pharyngeal cavities with radiopaque material,
  the patient is initially given a very small
  amount of material to swallow1 ml (1/3 tsp).

19
VFSS (aka MBS/Cookie Swallow)

• Then, bolus volume is slowly and systematically
  increased, as tolerated.
• The patient is also given food of at least three
  different consistencies in the process of a
  single study.
• Usually, these include a liquid, a paste or
  pudding like material (usually Esophatrast mixed
  with pudding), and something requiring
  mastication, e.g., ¼ easily chewed shortbread
  cookie.

20
VFSS (aka MBS/Cookie Swallow)

• In all cases, only a small amount of material is
  used initially, generally 1 ml, followed by 3 ml,
  5ml, and 10 ml of the liquid and cup drinking of
  the liquid, if tolerated.
• After each swallow, the oral cavity and pharynx
  should be kept in view rather than following the
  bolus into the esophagus.
• Many patients aspirate after the swallow and this
  type of aspiration might be missed if the fluoro
  tube follows the bolus into the esophagus.

21
VFSS (aka MBS/Cookie Swallow)

• It is also important to note if the patients
  coughs in response to aspiration, indicating
  normal laryngeal sensation, and whether the cough
  is productive.
• Residue in the pharynx after the swallow is
  another common sequela of dysphagia, and it is
  significant to note whether the patient dry
  swallows to clear this residue, indicating normal
  pharyngeal sensation.
• When the swallows of liquid, paste, and
  masticated materials have been completed in the
  lateral plane, the patient should then be viewed
  in the posterior-anterior (P-A) plan.

22
VFSS (aka MBS/Cookie Swallow)

• In the P-A plane, symmetry of the swallow can be
  assessed.
• To keep radiation exposure to a minimum, only
  swallows of the food consistencies that were most
  difficult for the patient in the lateral view
  should be repeated in the P-A view.

23
VFSS (aka MBS/Cookie Swallow)

• In summary, the VFSS is designed to
• examine the A P of the oral cavity and pharynx
  during deglutition
• identify the disorders in movement patterns of
  oropharyngeal structures that control the bolus
  and cause aspiration or inefficient swallowing
  (residue) and
• define treatment strategies that will eliminate
  aspiration and/or increase swallow efficiency.

24
Scintigraphy

• Scintigraphy is a diagnostic process that uses
  radioisotopes to yield information regarding
  specific anatomic areas of interest.
• It is performed in a hospitals nuclear medicine
  section.
• The patient ingests food or liquid that has been
  mixed with a radioisotope and is positioned in
  front of a gamma camera that determines the
  quantity of the isotope at various locations
  within the body.
• Because scintigraphic images are devoid of
  anatomic structures, three external cobalt
  markers must be placed at specific anatomic
  points.

25
Scintigraphy

• A cobalt marker should be taped (a) over the
  anterior cricoid cartilage (b) at the sternal
  notch and (c) on the mastoid just behind the
  right ear.
• The clinician chooses one medium to administer to
  the patient and needs 4 oz (120 ml) of that one
  texture.
• The choice of material depends on the clinical
  question the clinician is attempting to answer,
  e.g., can the patient consume thin liquids
  without significant aspiration (gt3 pulmonary
  aspiration).

26
Scintigraphy

• The nuclear medicine technician mixes a 5
  millicurie of technetium sulfur colloid (Tc 99m)
  isotope with the texture.
• The clinician drapes and positions the patient
  and presents the material.
• The patient is encourage to drink or eat the test
  material in a manner that is customary for meals.
• Static scans of the patients body are made after
  the patient ingests the test material.
• Static scans may be obtained immediately after
  ingestion, followed by a static scan at 30
  minutes, 60 minutes, and even 120 minutes.

27
Scintigraphy

• The precise amount of aspiration or residual
  bolus can be identified through computer analysis
  of the scans made at various time intervals.
• Quantification of aspiration has important
  implications in dysphagia management.
• A comparison of scans taken immediately following
  a swallow with those completed later can
  determine the extent to which the pulmonary
  protective functions have cleared the aspirate.
• It can offer quantification of aspiration and
  clearance across points in time, an important
  consideration when recommending to remove a
  patient from a tube feeding.

28
Scintigraphy

• Although repeat VFSS can be used to assess change
  in swallowing function over time, VFSS lacks the
  ability to quantify the degree of immediate
  aspiration and to appreciate the amount of
  aspirate that the patient is able to remove from
  the lungs over time.
• Scintigraphy is a practical technique when it is
  desirable to move patients from NPO or extremely
  limited oral intake status to a status that
  significantly increases oral intake.

29
Scintigraphy

• It is especially cost-effective for those
  candidates who have been NPO for a period of
  longer than 3 months, have no clinical signs of
  pulmonary aspiration, and are able to sit up or
  otherwise alter trunk position.
• Typically, scintigraphic swallowing assessment is
  not recommended for patients who
• Are known heavy aspirators
• Are suspected of having a temporary condition
  resulting in dysphagia for 2 months or less or
• Who have a progressively deteriorating condition
  such as ALS.

30
Scintigraphy

• Quality of life issues, such as finding even one
  safely tolerable texture, cannot be dismissed.
• In such cases, scintigraphy can be helpful.

31
Instrumental Assessment Summary

• The swallowing therapist should select an
  instrumental procedure for use in swallowing
  assessment and treatment based on the particular
  information needed.
• If understanding the patients pharyngeal anatomy
  is the question, such as in a post-surgical
  oropharyngeal cancer patient, then rigid
  videoendoscopy is probably the procedure of
  choice.

32
Instrumental Evaluation Summary

• If defining the presence (but not necessarily the
  cause of aspiration) of saliva is the desired
  goal, FEES is the procedure of choice.
• If understanding pharyngeal physiology in
  relation to symptoms such as aspiration is the
  issue of interest, then VFSS should be used.
• If quantification of the aspirate is the
  information needed for deciding what to do about
  a tube-feeding then scintigraphy would be
  appropriate.

33
Report Writing

• The narrative report should include an
  introductory statement describing the purpose of
  the examination and the patients current
  subjective complaints.
• The consistencies and volume of consistencies
  should be mentioned as well as the
  presentation/plane views employed.
• An example of an introductory statement follows

34
Introductory Statement

• Mr. Smith is a 58-year-old man, seven weeks
  status post CABG (coronary artery bypass graft)
  with postoperative tracheostomy placement and
  ventilatory support for four weeks. Mr. Smith has
  been weaned from ventilator, and is now fitted
  with a 8 metal trach tube. When plugged, voicing
  is breathy, cough is weak. Blue dye test (ice
  chips) was negative for dye at trach site and
  after deep suctioning. Clinical signs of
  aspiration (coughing) consistently noted
  following thin liquid swallows. Primary nutrition
  is provided via NG tube. Labs indicate good
  hydration and nutrition parameters, no active
  pulmonary problems or infection.

35
Introductory Statement

• The patient states it is "difficult to start a
  swallow."
• This assessment was performed to determine
  readiness for PO intake. The patient was seated
  upright and presented puree, thin liquids, thick
  liquids and solid foods in amounts ranging from
  2-35 cc. A barium capsule was also presented. The
  subject was viewed in the lateral and AP
  projections.

36
Results Section

• The results section is reserved for objective
  statements only.
• Just the facts are described without attempts to
  interpret the findings.
• Describe the events of the swallow as they occur
  in sequence, e.g., oral events are reported
  before pharyngeal events.
• When a phase is completed without obvious
  impairment, it should be stated as so.
• An example follows.

37
Results Sample

• In the lateral projection, small cervical
  osteophytes were noted at the level of C3-4. In
  the AP projection, movement of the true and
  ventricular folds was noted to be asymmetric with
  incomplete adduction on breath holding and
  phonation. Movement of the vocal folds appeared
  reduced on the patient's left side. The oral
  preparatory and oral stages of the swallow were
  unremarkable for all consistencies and volumes
  presented. The duration of the transition between
  the oral and pharyngeal stages of the swallow
  averaged 5 seconds and was noted with all
  consistencies presented.

38
Results Sample

• Puree and solid food boluses were noted to fall
  to the vallecular space prior to the initiation
  of the pharyngeal stage of the swallow. Liquid
  consistencies of all volumes were noted to fall
  to the level of the pyriform sinuses prior to the
  initiation of the swallow. Thin liquids presented
  in volumes greater than 20 cc were consistently
  noted to overflow the pyriform sinuses and fall
  into the laryngeal vestibule prior to the
  initiation of the pharyngeal stage of the
  swallow. Once initiated, the pharyngeal stage of
  the swallow was noted to be of adequate
  amplitude.

39
Results Sample

• There was no evidence of residue following the
  initial swallow attempt. The material falling
  below the vocal folds was completely cleared into
  the pharynx with spontaneous coughing. Chin-tuck
  positioning reduced the duration of the delay and
  consistently eliminated the penetration and
  aspiration of the liquids. The upper esophageal
  and esophageal stages of the swallow were
  screened. Esophageal transit for liquid
  consistencies was unremarkable.

40
Results Sample

• Solid food transit was complete but significantly
  longer. Solid food residue was noted to
  accumulate at the aortic arch. The patient
  perceived this stasis and reported the food to be
  "stuck" at the suprasternal notch. The residual
  was easily cleared from the esophagus with thin
  liquid swallows.
•  

41
Impressions and Recommendations

• The impressions section is reserved for tying
  together all of the findings from the
  examination.
• It is expected that the clinician will supply the
  consulting physician with the how and why of
  the dysphagia as it is manifest in the patient.
• The recommendation section is probably the only
  portion of the report to be thoroughly reviewed
  by anyone reading the narrative. 
• The recommendations are posed as suggestions not
  orders.
• Make sure to include the following

42
Impressions and Recommendations

• Per oral status (NPO, PO, PO with conditions,
  etc.)
• Diet recommendations with consistency and
  viscosity descriptors
• Feeding instructions
• Other consultations or orders (calorie counts,
  dental consultations)
• Follow-up schedule.

43
Impressions Sample

• Mr. Smith presents with moderate pharyngeal
  dysphagia characterized by an incoordination of
  bolus propulsion and airway protection resulting
  in thin liquid aspiration. Mr. Smith appeared to
  be sensitive to the aspirated material and
  demonstrated consistent and successful expulsion
  of the aspirant from the airway with coughing.
  Employment of a chin-tuck position prior to the
  initiation of the swallow was successful in
  eliminating the aspiration events.

44
Impressions Sample

• Airway protection likely is compromised due to
  recurrent, laryngeal nerve damage secondary to
  the CABG. However, the presence of protective
  coughing and robust pharyngeal and esophageal
  stages of the swallow and absence of pulmonary
  pathology or infection would indicate oral
  feeding. Due to the length of NPO status, the
  patient likely will need close monitoring during
  trial feedings.

45
Recommendations Sample

• If consistent with the overall plan of medical
  management, the following recommendations should
  be considered
• Advance diet to soft solid food with liquids
  thickened to nectar consistency.
• Coordinate calorie count with dietician to
  determine adequacy of PO intake.
• Allow water between meals.
• Initiate therapy to train chin tuck position.
• Continue to follow daily.