Unit 2 Notes - Bonnie Martin PDF

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Bonnie Martin...

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BSE, Chart Review 

03/06/2016

Exam Review

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Hyolaryngeal excursion: laryngeal elevation + hyoid excursion

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combined Don’t overthink medications on chart reviews – they are important,

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but allergies, surgical history, diagnoses are just as, or more relevant than medications are MBSS, not MBS… need that 2nd “S” in there

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FEESST, not FEEST Bolus containment is primarily the responsibility of the tongue – yes this is true, but palate and lips are involved as well All intrinsic tongue muscles ARE innervated by CN XII… palatoglossus is an extrinsic tongue muscle, and it is the only

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tongue muscle (both intrinsic and extrinsic) not innervated by CN XII (it is innervated by CN IX and X) Muscles of oral phase are primarily controlled by CN XII – bolus transport happens in this phase, which is primarily due to tongue

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Bolus article  Doesn’t make sense to do ultra-thick liquid in a cup… you would 

never drink pudding from the cup Ultra-thick usually refers to pudding thick… but in this article it may

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have referred to honey thick, which is a liquid More patients aspirated on a thin liquid > thick liquid > ultra thick liquid

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Pharyngeal stasis happened with all consistencies, so you might as

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well start with puree. If you have good oral care and aspirate on just water, research shows you probably won’t develop pneumonia. If you think patient

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will aspirate, use water, not juice! Starting with thin liquids saves time, but may not be safe. Puree  nectar  honey (if they do poorly) or thin (if they do well)

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Puree is a solid; and pudding-thick liquid is just as thick as puree

BSE Practice  Goal = determine safest, least-restrictive oral diet  Limit verbal and visual cues you do during oral mech exam (don’t 

demonstrate the tasks) Nectar-thick water: clear, has air bubbles in it, smells odd

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Honey-thick liquid: opaque (looks like white Gatorade), smells odd Bfore you do food trials: “We’re going to have you try some

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different types of food to make sure you are safe when you swallow.” Palpate during every swallow trial (including while they chew)

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After each bite, look inside mouth for oral residue, pocketing If patient is doing well, have them feed themselves – good way to

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judge impulsivity (do they take very large bites?) If patient coughs on nectar-thick, say “You coughed a bit on that,

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so we’re gonna try a little bit thicker” If patient does well with a spoonful of liquid, have them take a sip

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from cup If patient coughs but O2 stat stays stable, this indicates penetration not aspiration. o Have patient take consecutive swallows to tax the system

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After liquids, do solids – mech soft, then solids Patients sometimes refuse SLP recommendations if they don’t want to drink thickened liquids o Have them sign a waiver that they will not sue because of aspiration pneumonia o Be sure you document everything in patient chart, records, boards

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If patient does not have adequate oral clearance, do liquid wash on

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safest liquid SOAP note o S: Patient is a (age) (gender) who was admitted for (dx). Patient was (alert/not) and oriented x(number). Pt reported (yes/no) history of dysphagia.  x3 = person, place, situation  x4 = person, place, time, situation o O: SLP completed oral mech exam. Pt with adequate lavial/lingual RoM and strength. Pt with timely dry swallow upon palpitation and strong volutional cough. Pt safely tolerated regular solids and HTL via teaspoon with no overt s/s of dysphagia. Pt with adequate oral clearance following regular solid trials. Pt with coughing during NTL via teaspoon and HTL via cup. o A: Pt presents with mild-moderate pharyngeal dysphagia characterized by suspected decreased laryngeal closure causing moderate risk of aspiration. o P: Diet recommendation: regular solids and pudding thick liquids. ST tx 5x week x 4 weeks to improve laryngeal closure, tolerate least restrictive diet, and improve hydration. Recommend MBSS for determination of pharyngeal deficits.  Why MBSS over FEES? This deficit seems like it is

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happening during the swallow, and FEES cannot assess that. Chart review, talk to nurses, background info, cognition screen, oral mech exam, food trials o Start with puree – if patient does poorly, refer for MBSS  If NPO status will likely be short-term, recommend NG tube. If it will be long term, recommend G-tube. o If patient does well on puree, do nectar-thick liquids via spoon.  If they do well: nectar thick via cup  thin liquid via spoon  thin liquid via cup  thin liquid via straw  test solids  do liquid wash if there is any residue

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If they do poorly: honey thick via spoon  honey thick via cup  If they do poorly: pudding-thick liquids

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If patient is edentulous (no teeth), do not present mech soft or regular solids

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3 oz (90cc) water swallow screen  Sensitive, but not specific o Sensitive: good reliability in detecting people at risk for aspiration o Not specific: lots of false positives 

Should you give thin liquids first?

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Talk to nursing to see if patient is medically-stable Appropriate for P.O. intake? o Is patient hallucinating? AMS? Managing own secretions?

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Check oral hygiene before giving water – you could perform oral

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hygiene, too Only SLP should do this test

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Chart Review Activity  What aspects of the history (social, medical, surgical) may impact swallowing? o Right CVA  pharyngeal stage and cognitive deficits o Choking on liquids may be due to delayed pharyngeal swallow response

o Cognitive deficits  may have difficulty managing all of his 

medications What aspects of the physical exam may impact your clinical

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swallowing examination today? What are some deficits you would expect to see? How would this impact your approach to this examination (what bolus would you begin with)?

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Medical acronyms  MI = myocardial infarction  CAD = coronary artery disease  CHF = congestive heart failure   

CABG = coronary artery bypass graft BPH = benign prostatic hypoplasia (prostate issues) DM2 = diabetes

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HEENT = head and neck eval done by physician JVD = jugular venous distention

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ADLs = basic activities of daily living, like dressing, going to

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bathroom IADLs = activities of daily living requiring higher cognition, like

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paying bills D/C = discharge

MBSS 

03/06/2016 MBSImp Questions  Delayed initiation of tongue movement: delay of beginning of

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movement marked at oral transit; but it happens. It should happen right when the patient has a cohesive bolus. Slowed tongue movement: entire stripping wave motion is slow

Clarion video questions  What happens if you aspirate a solid? o Hopefully it was masticated enough to be absorbed by the 

lungs. When you do head tilt vs. head rotation? o Head tilt may be appropriate for adequate airway protection but unilateral pharyngeal weakness; head rotation would be

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to close off impaired side Normal aging process results in increased penetration and residue o Normal aging does not = pathology o Dysphagia is never normal – probably due to older person’s physiological status (inactivity, diabetes, etc.) o Older people have attenuated response to swallow exercises – they don’t get as strong as a younger person would  Improving physical activity can help swallow! Improve respiratory status  improve laryngeal mechanism

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Cervical auscultation – debatable if it is helpful o But… if you aren’t trained to do it, don’t do it

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Put cards with swallow recommendations (like “Take small bites and sips”, “No straws”) on SNF patient’s dining room spot – they will

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always sit in the same spot. If you know that patient/family is difficult, go into room with their favorite nurse and discuss dysphagia symptoms/management o If patient denies symptoms/services, document everything and have the nurse document it too o Waiver the patient signs doesn’t hold up much – you need to

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document! If patient cannot dry swallow at all, don’t do food trials

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SNF staff may be unfamiliar with MBSS vans – you need to seek them out on your own

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SNF = focus on medications, start tests with diet pt is currently on Hospital = cannot change medications (so note them and move on), start with puree because pt likely has neuromuscular disorder

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History  Lip and tongue RoM exercises do not have theoretical support  Jeri Logemann and Chuck Larson from NU! o Dr. Logemann created MBSS o Dr. Larson zapped a larynx, and patient swallow (typical…)

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Gold Standard Observations  Formation of the bolus – can see cohesive bolus contained against  

hard palate Tongue motion – stripping wave Coordination

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Timing – start “swallow” at laryngeal elevation Completeness of swallowing

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Movement of the epiglottis Elevation of the larynx UES opening

Findings that you cannot get from other exams  Abnormal tongue movements  Residual barium (stasis) in valleculae  Residual barium (stasis) in piriform sinuses 

Aspiration of barium

o Quantity of aspiration (trace, gross amount, full bolus) o Can see aspiration during swallow  

Compensatory Maneuvers – do these during MBSS to see if they

eliminate or prevent aspiration  Chin-tuck  Head turn/tilt  Supraglottic swallow  Mendelsohn maneuver  

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8-Step Scale – Rosenbek and Colleagues  1. Material does not enter airway  2. Remains above folds / ejected from airway  3. Contact folds / ejected from airway   

4. Contact folds / not ejected from airway 5. Contacts folds / not ejected from airway 6. Passes below folds / ejected into larynx or out of airway

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7. Passes below folds / not ejected despite effort 8. Passes below folds / no spontaneous effort to eject

How Charlie describes penetration and aspiration  Is it transient? (enters and is expelled)  Trace vs. gross?  Shallow (to true VFs) vs. deep penetration

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You have 5 minutes to adequately evaluate and recommend a diet

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It’s overwhelming You are making real time judgments You probably have back to back patients scheduled in 30 minute

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intervals The facility likely wants a written report following each pt (written in 5 minutes or less) o Combination of “O” and “A” of SOAP o Characterize the dysphagia

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Cannot recommend a diet without saying the functional deficits Keep handwritten report brief. o Pt. seen for initial MBSS with dx of Parkinson’s. Pt has mildmoderate dysphagia characterized by (start with oral stage) delayed AP transit time of 3-5sec, reduced tongue coordination and strength resulting in oral stasis. Delayed pharyngeal response resulting in premature entering into the valleculae spilling into pyriform sinuses. Aspiration on thin and NTL. Flash transient penetration noted on HTL. Reduced BOT retraction, hyolaryngeal excursion, and UES opening resulting in moderate pharyngeal stasis after the swallow with mechanical soft and puree solids, cleared with double swallow. o Recommend: mechanical soft solids, HTL, no straws, double swallow and alternate solids with liquids, supervision with

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meals, skilled SLP tx targeting oral and pharyngeal deficits. Elaborate findings in electronic report o Describe in a logical order: labial, lingual, laryngeal, pharyngeal deficits.  List “delayed pharyngeal response” as a transition between oral and pharyngeal stages o Concepts people forget about  Reduced pharyngeal peristalsis 

Zenker’s diverticulum

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BOT retraction, pharyngeal peristalsis, and laryngeal elevation all contribute to bolus pulsion force/UES

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opening Recommendations for ENT/GI referrals due to reflux, CP dysfunction, etc.

FEES 

03/06/2016 Chart Review Notes  Average length of stay in rehab hospital is 2-4 weeks  For acute care SLPs, 80-90% of caseload is dysphagia. Rehab SLPs 

get both dysphagia and cognitive cases. Pt must be in hospital for 3 days to qualify for Medicare coverage – so even if they are medically-stable, they should stay for 3 days to

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qualify for rehab funding Medical tx, treatment tx, reason for referral account for 30% of whether insurance will accept or deny your claim! Do these well!

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SOAP Note  Subjective o Patient’s perspective o Case history o Direct quote from patient/family  Objective o Test results o Data that can be perceived by the senses 

Assessment o Conclusion(s) based on subjective and objective data o Diagnosis – be sure to say if it is oral, oral-pharyngeal, or pharyngeal dysphagis

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Plan o What you plan to do next o Treatment, patient/family education, next visit, etc.

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Instrumental Evaluation: “Swallowing is a complex process that

involves interplay between two distinct but related phenomena, airway protection and bolus transport”   Most common

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FEES/FEESST: Flexible Endoscopic Evaluation of Swallowing / with Sensory Testing (right picture) o May be better for seeing aspiration before swallow o Zenker’s diverticulum is interesting to see on FEES

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MBS/VFSS Modified Barium Swallow (Study) Video Fluoroscopic Swallow Study (left picture)

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Flexible Endoscopic Evaluation of Swallowing (with Sensory Testing)

FEES/FEESST  With delayed pharyngeal swallow response, liquid fills valleculae  

and spills into pyriforms Get whiteout at height of swallow during laryngeal elevation If you don’t see whiteout, this indicates reduced BoT to pharyngeal wall approximation

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FEES, MBS, or Both?  MBSS o You have concerns about oral preparatory stage of the swallow… BSE could be beneficial too for seeing delayed mastication, oral stasis, loss of bolus. But not FEES! o You are concerned about inadequate airway protection during the pharyngeal stage. FEES would not work for this due to whiteout. 

FEES

o You want to assess a swallow without giving a bolus… could also do a dry swallow with palpation. But not MBSS – you need barium to see stuff during it. o You are concerned about radiation exposure o You want to assess secretion management… BSE works, too. 

Both MBSS and FEES o There is likely a problem at the level of the UES

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The only info you can get from BSE is about laryngeal elevation and oral stage. It does not really assess pharyngeal stage deficits.

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Penetration = entering anywhere in black circle drawn onto picture

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Aspiration = entering into open airway/below true VFs

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Secretions Rating Scale  Assessed using FEES  0 = normal. Ranges from no visible secretions in hypopharynx, to some transient secretions in valleculae and pyriforms o Secretions are not bilateral or deeply-pooled. 

1 = any secretions evident upon entry, or following a dry swallow in the protective structures surrounding the laryngeal vestibule that are bilaterally-represented or deeply-pooled o Includes cases in which there is a transition in accumulation

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of secretions during the observation segment. 2 = any secretions that change from a “1” rating to a “3” rating during the observation period. 3 = most severe. Any secretions in laryngeal vestibule o Pulmonary secretions are included if they are not cleared by swallowing or coughing by the close of the segment.

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People with bilateral stroke may have difficulty managing secretions.  Secretion management indicates the most severe cases of 

dysphagia. Only 11% of patients post-stroke had normal secretion management (Level 0)

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Nearly 30% had airway compromise due to secretions (Level 3)

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FEES

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1. Patient adducts VFs (no bolus)  Symmetrical VFs?

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2. Food trials  Swallow first time  still more to swallow; indicates piecemeal 

deglutition Pharyngeal stasis indicates poor pharyngeal contraction and

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laryngeal elevation Stasis on epiglottis indicates incomplete inversion Pooling into pyriforms, spilling into open laryngeal vestibule

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indicates aspiration All boluses (including liquid) needs to be dyed blue or green If bolus enters laryngeal vestibule, patient should cough

When you write a SOAP, first write everything down, then organize it. How do I grade dysphagia severity?  25% impairment = mild-moderate  50% impairment = moderate  75% impairment = moderate-severe  

>75% impairment = severe Trouble with secretion management = profound

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SOAP Note  S: Pt is a (age) female. Pt presents with PD. Pt is oriented x3.  O: SLP administered FEES. Pt presents with oral deficit of piecemeal deglutition Pt aspirated of thin liquids with delayed cough.

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Pharyngeal deficits include reduced hyolaryngeal excursion, reduced pharyngeal contraction, reduced epiglottic inversion, and reduced laryngeal closure. A: Pt presents with moderate-to-severe oropharyngeal dysphagia characterized by suspected decreased lingual stripping resulting in piecemeal deglutition, pharyngeal delay of swallow resulting in premature spillage into the valleculae spilling into the pyriforms and into the open laryngeal vestibule resulting in aspiration of thin liquids after the swallow. Pt presents also with moderate-to-severe laryngeal deficits of reduced hyolaryngeal excursion, reduced

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pharyngeal contraction, reduced epiglottic inversion, and reduced laryngeal closure. Pt presents with a severe risk of aspiration. P: Diet recommendations: Mechanical soft solids, NTLs with chintuck, supervised meals, and crushed pills. Skilled ST tx.

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PD patient – suspect laryngeal delay  If patient has lots of pharyngeal stasis, do chin-tuck first, not liquid 

wash Note that PD is a progressive disorder that is later compromised by dementia… avoid recommending things that patient will need to do independently

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Zenker’s diverticulum: on FEES, see bolus pass through pharynx, then

disappear, then come back. So these patients are at high risk of aspiration.   Class FEES  Uni weakness of VF closure  Pt presented with 1 teaspoon of puree solids. It took 11-12 

swallows to clear it. Trouble swallowing any of bolus