Week2.1 Dysphagia disorders-quaz.pdf

What is dysphagia? Dysphagia: Is a swallowing disorder involving the oral cavity, pharynx, esophagus, or gastroesophageal junction. Consequences of dysphagia: Malnutrition and dehydration Aspiration pneumonia…. may lead to death if not treated early Chronic lung disease Other consequences: Long hosp...

What is dysphagia? Dysphagia: Is a swallowing disorder involving the oral cavity, pharynx, esophagus, or gastroesophageal junction. Consequences of dysphagia: Malnutrition and dehydration Aspiration pneumonia…. may lead to death if not treated early Chronic lung disease Other consequences: Long hospitalization…increase cost of care Date Your Footer Here 1 What is dysphagia? Incidence and prevalence of dysphagia In US: 3% of the inpatients age 45 years or older 22% of the inpatients aged 55 years and above In acute stroke, the incidence range from 55% to 64% Date Your Footer Here 2 Common causes of dysphagia Mostly due to neurological disorders but could occur as a result of non-neurological disorders - Stroke - Traumatic brain injury (TBI) - Spinal cord injury - Multiple sclerosis - Parkinson’s disease - Myasthenia gravis Also, patients receiving treatments for head and neck cancer and rheumatoid arthritis …etc. Date 3 The role of SLP in dysphagia SLP’s role is essential in assessment and management of dysphagia. The SLP roles in dysphagia include: Identifying signs and symptoms of dysphagia Identifying normal and abnormal swallowing anatomy and physiology supported by imaging Identifying indications and contraindications specific to each patient for various assessment procedures Identifying signs of potential disorders in the upper aerodigestive and/or digestive tracts and making referrals to appropriate medical professionals. Assessing swallow function as well as analyzing and integrating information from such assessment collaboratively with medical professional as appropriate Understanding a variety of medical diagnoses and their potential impacts on swallowing Being aware of typical age-related changes in swallow function Provide education and counseling to patients and their family Date 4 Continue…The role of SLP in dysphagia incorporating the client’s/patient’s dietary preferences and personal/cultural practices as they relate to food choices during evaluation and treatment services; respecting issues related to quality of life for individuals and/or caregivers; practicing interprofessional collaboration; determining the effectiveness and possible impact of current diet on overall health (e.g., positioning, feeding dependency, environment, diet modification, compensations). Date 5 Normal swallowing process Swallowing involve 4 stages: 1. Oral preparatory phase ( voluntary) 2. Oral transit phase ( voluntary) 3. Pharyngeal phase ( involuntary) 4. Esophageal phase ( involuntary) Date 6 Normal swallowing process Swallowing involve 4 stages: 1. Oral preparatory phase 2. Oral transit phase 3. Pharyngeal phase 4. Esophageal phase Date 7 Normal vs. abnormal swallow Date 8 Screening and assessment of Dysphagia Date Your Footer Here 9 Screening of dysphagia Screening: To determine the need for comprehensive assessment and make necessary referrals Could be done by SLP or any other member of the medical team Examples of swallowing screening: the 3-oz water swallow test (DePippo et al., 1992) the Yale Swallow Protocol (Suiter et al., 2014) Gugging Swallowing Screen (GUSS) (Trapl et al., 2007) Date 10 Screening of dysphagia Let’s have a look at GUSS Date 11 Assessment of dysphagia Comprehensive swallowing assessment: Consistent with ICF model Non-instrumental examination Instrumental examination Date 12 Assessment of dysphagia Comprehensive swallowing assessment: Non-instrumental examination: The goal is to determine the presence or absence of signs and symptoms of dysphagia Things to consider in non-instrumental assessment: - Medical history and chart review including medications that affect swallowing - Overall physical, social, and behavioral, and cognitive or communicative status - Vocal quality at baseline. - Oral-motor examination. - Physiological status and vital signs, including heart rate, oxygen saturation. Date 13 Screening and assessment of dysphagia Continue …Things to consider in non-instrumental assessment: - secretion management skills, which might include frequency and adequacy of spontaneous saliva swallowing and the ability to swallow voluntarily; - cranial nerve function (e.g., vagus nerve)..how to check the vagus nerve? - posture and positioning for feeding; and - status of oral care. Date 14 Assessment of dysphagia Things to assess after bolus delivery to the mouth: - Labial seal, anterior spillage and evidence of oral control. - mastication and food transit - manipulation of the bolus - Presence of hyolaryngeal excursion ( observed externally or to palpation) - Behavioral signs such as coughing and throat clearance (before, during, or after the swallow) - Changes in physiological status/vital signs/voice quality Date Non-instrumental dysphagia assessment is not sufficient to reveal specific information about the anatomical and physiological status of the larynx, pharynx, and upper esophagus and to develop an effective treatment plan and prevent consequences of dysphagia we need to the instrumental assessment 15 Assessment of dysphagia Swallowing evaluation form…..Example from ASHA Date 16 Assessment of dysphagia Instrumental swallowing assessment: Performing swallowing instrumental procedures and assessment is within the scope of practice of medical SLP Common procedures: 1. Videofluoroscopic swallowing study ( or modified barium swallow study (MBSS)) 2. Flexible endoscopic evaluation of swallowing (FEES) Other instrumental procedures include: 1. Ultrasonography 2. High-resolution manometry Date 17 Assessment of dysphagia 1. Videofluoroscopic swallowing study (VFSS) or modified barium swallow study (MBSS) VFSS or MBSS is a radiographic procedure that provides a direct, dynamic view of oral, pharyngeal, and upper esophageal function (Logemann, 1986) Conducted in a hospital in collaboration with a radiologist Use small amount of barium contrast with the food to track the bolus during swallowing Purpose: To identify relevant anatomical structure Evaluate the oral and pharyngeal phases of swallowing in real time and detect aspiration (including silent aspiration) To test different swallowing therapy techniques and observe The performance. Can be performed with different food consistencies (thin liquids, puree, and solid food) Date 18 Assessment of dysphagia 1. (VFSS) or (MBSS) procedure Date 19 Assessment of dysphagia 1. Videofluoroscopic swallowing study (VFSS) or modified barium swallow study (MBSS) Limitations of VFSS or MBSS: A limited sample of swallow function that may not be an accurate representation of typical mealtime function. Challenges in visualizing the swallow due to poor contrast. Challenges in representing food typically eaten by a patient. Limited evaluation of the effect of fatigue on swallowing. Refusal of the bolus, as barium is an unnatural food source and is not tolerated by some patients (Logemann, 1998). Date Positioning may not be optimal. 20 Assessment of dysphagia 2. Flexible endoscopic evaluation of swallowing (FEES) Procedure: The laryngoscope is passed through the nose to a point just above the epiglottis to observe hypopharynx and larynx while the patient is taking food. The procedures is video recorded for later analysis. - It’s portable device and can be performed at bedside Some considerations: The pt. must be able to follow simple commands. Small amount of anesthesia can be used if the pt. is sensitive to the scope Use dye (green/blue) with the food to track the bolus and any residues Date 21 Assessment of dysphagia 2. Flexible endoscopic evaluation of swallowing (FEES) Three main problems can be detected by FEES: 1- inability to initiate the swallow in a timely and coordinated manner 2- inadequate airway protection or VP (velopharyngeal)closure during the swallow 3-incomplete bolus clearance The problems that can be observed Spillage before the swallow Residue after swallow Laryngeal penetration Aspiration Date 22 Assessment of dysphagia 2. Flexible endoscopic evaluation of swallowing (FEES) Date 23 Assessment of dysphagia 2. Flexible endoscopic evaluation of swallowing (FEES) Limitations of FEES: Inability to visualize the oral or the esophageal phase of swallowing. Limited ability to visualize the pharyngeal phase. However, a clinician may be able to visualize the initiation of pharyngeal structural movements through the pharyngeal squeeze, superior movement, and/or epiglottis inversion. “White-out”—passage of the bolus and movement of the pharyngeal structures cannot be observed during the swallow because of reflected light from pharyngeal and laryngeal tissues into the endoscope Date 24 Assessment of dysphagia 2. Flexible endoscopic evaluation of swallowing (FEES) Risks associated with endoscopy : - Discomfort and irritation - Nasal bleeding - Laryngospasm - Aspiration Date 25 Decision about using either FEES or MBSS Date 26 Decision about using either FEES or MBSS Date 27 Assessment of dysphagia Disorders/diseases that are known to cause dysphagia Date 28 Assessment of dysphagia Medications known to affect swallowing: Date Perlman & Schultz( 1997) Assessment of dysphagia Medications known to affect swallowing: Date Perlman & Schultz( 1997) Dysphagia Management Date Your Footer Here 31 Management of dysphagia Based on the assessment findings, SLP can give recommendations for dysphagia management. Examples of the recommendations : Oral feeding without diet modification Oral feeding with diet modification ( e.g., puree only, no think liquid) and /or using compensatory strategies during swallowing ( e.g., chin down, head rotated to the weakness side) Alternative forms of nutrition and hydration (ANH) - Nasogastric tube (NGT) - Gastrostomy tube (G-tube, e.g., PEG-tube) Swallowing therapy ( indirect or direct) Date Management of dysphagia Examples of alternative forms of nutrition and hydration (ANH) : 1. Nasogastric tube (NGT) 2. Gastrostomy tube (G-tube, e.g., PEG-tube)—inserted through the abdomen to provide non-oral nutrition The decision on selecting the appropriate tube for the patient is the physician responsibility considerations of using alternative means of nutrition: Date Medical diagnosis and nature of the disease ( progressive, non-progressive Severe dysphagia Cognitive/behavioral status Nutritional status 33 Management of dysphagia Swallowing therapy: 1. Indirect swallowing therapy ( doing swallowing exercises without food) 2. Direct swallowing therapy ( doing the exercises with food) Date 34 Management of dysphagia Postural strategies during swallowing Date 35 Management of dysphagia Date 36 Management of dysphagia Shaker swallowing exercise: The purpose is to increase hyoid and larynx elevation and increase width and opening of the esophagus Procedure: the patients lie on their back and elevate their head just enough to see their feet for one minute followed by one minute reset…….for 30 times Date 37 Using special cups to control liquids Date Your Footer Here 38 Conclusion 1. Swallowing is a high specialized area in medical SLP practice 2. Practicing assessment and management of dysphagia requires special training on the noninstrumental and instrumental procedures ( e.g, using laryngoscope ) 3. This area of SLP practice is also requires collaboration with other medical professionals ( physician, dietitian, radiologist) Date 39