ArkSHA2017

TowinoParamby,CScD.,CCC-SLP;BCS-S

10/12/2017

1

Unlocking Medical SLP’s Super Power- A Crash Course in Adult

Dysphagia Evalua@on

TowinoParamby,CScD.,CCC-SLP;BCS-S

AssistantProfessor

UniversityofCentralArkansas

Dysphagia

•  Greekroot:“Phagein”-Toingestorengulf•  Dys:“disorderordifficulty”

•  Dysphagia•  Notaprimarymedicaldiagnosis

•  Alwaysasymptom

•  Oral,pharyngealandesophageal

Swallowing

Food&Liquid

MouthDigesVveSystem

SharedbyaerodigesVveand

respiratorysystem

Dysphagia

Food&Liquid

MouthRespiratorySystem

Dysphagia

Pneumonia

DehydraVon

MalnutriVon

ChokingSocial

IsolaVon

Depression

Spiritual

SLP’ Role

• ClinicalswallowevaluaVon

• MBSS/VFSS

•  FEES• Management

•  Labvalues• ChestX-ray• ChestCT• MulVdisciplinaryTeam

ArkSHA2017

TowinoParamby,CScD.,CCC-SLP;BCS-S

10/12/2017

2

Screening in Dysphagia

Swallow Screening:

•  Swallowingscreeningisapass/failproceduretoidenVfyindividualswhorequireacomprehensiveassessmentofswallowingfuncVonorareferralforotherprofessionaland/ormedicalservices(ASHA,2004b).

•  Screeningfordysphagiamaybeconductedbyaspeech-languagepathologistorothermemberofthepaVent'scareteam.ScreeningdoesnotprovideadetaileddescripVonofthepaVent'sswallowfuncVonbut,rather,idenVfiesindividualswhoarelikelytohaveswallowingimpairmentsrelatedtofuncVon,acVvity,and/orparVcipaVonasdefinedbytheWorldHealthOrganizaVon(WHO,2001).

ASHAPracVcePortal:AdultDysphagia

Introduc<on

•  MinimallyinvasiveevaluaVon

•  Reducedcost•  Quick•  Yes/NO;�+�or�—�•  NeedsmoreevaluaVon

•  ScreeningtestisnotdiagnosVc(WHO)

•  CannotiniVatetherapy

Purpose of Screen:

Thepurposeofthescreeningistodetermine•  thelikelihoodthatdysphagiaexists•  theneedforfurtherswallowingassessment

Defini<on of Swallowing Screen RefertoaminimallyinvasiveevaluaVonprocedurethatprovidesquickdeterminaVonof:

1. Thelikelihoodthatdysphagiaexists2. WhetherthepaVentrequiresreferralforfurtherswallowingassessment;

3. WhetheritissafetofeedthepaVentorally(forthepurposesofnutriVon,hydraVon,andadministraVonofmedicaVon)

4. WhetherthepaVentrequiresreferralfornutriVonalorhydraVonalsupport

What dysphagia screening can tell us?

•  ObviousinformaVon•  NPO•  Riskfordysphagia

•  Aknownhistoryofdysphagia

•  Amedicaldiagnosisthatfrequentlyinvolvesswallowingimpairment(e.g.,stroke)

•  Reducedlevelofconsciousness

•  OvertsignsofaspiraVon•  Overtsignsorcomplaintsofdifficultyswallowing.

ArkSHA2017

TowinoParamby,CScD.,CCC-SLP;BCS-S

10/12/2017

3

Types of swallowing screening

• QuesVonnairesorinterview• Medicalhistoryreview(Marietal.,1997)

•  EvaluaVonofgagreflexorpharyngealsensaVon(Kidd,Lawson,Nesbil,&MacMahon,1993)

• ObservaVonofovertsignsofcoughorotherdifficultyduringplannedtrialswallowsorrouVneoralintake(Kiddetal.,1993)

• Oralmotor+speechmotorexaminaVons+trialswallowswithwater(Daniels,Ballo,Mahoney,Foundas,2000;Logemann,Veis,&Colangelo,1999)

• Decision-makingalgorithmsconsideringseveralfactors(Runions,Rodrigue,&White,2004)

• Coughduringorfollowingwaterswallows(DePippo,Holas,&Reding,1994;Kiddetal.,1993)

Types of swallowing screening

• Voicequalitychanges• Pulseoximetry

• CervicalauscultaVon•  Thelaryngealcoughreflex,whichlooksforacoughresponsetoinhalaVonoftartaricacidasamarkeroftheintegrityoflaryngealsensaVon

Good Screening

•  GoodsensiVvity•  Goodspecificity•  Sensi&vity:�thenumberofpaVentswithaswallowingproblemwhoarecorrectlyidenVfiedbythescreeningprocedureashavingaswallowingproblem.�

•  Specificity:�thenumberofpaVentswithnoswallowingproblemwhoarecorrectlyidenVfiedbythescreeningprocedureasnothavingaswallowingproblem.�

The MassachuseDs General Hospital-Swallow Screening Tool (MGH-SST)

Date of download: 2/18/2015

Copyright © American Speech-Language-Hearing Association

From: Creating a Swallow Screening Program at Mass General Hospital: A Model for Development and Implementation

Perspect Swal Swal Dis (Dysph). 2009;18(4):123-128. doi:10.1044/sasd18.4.123

89-93%sensiVvity

61-64%specificity

ArkSHA2017

TowinoParamby,CScD.,CCC-SLP;BCS-S

10/12/2017

4

TOR-BSST

•  TheTorontoBedsideSwallowingScreeningTest

Yale Swallow Protocol

Predictors and Outcomes of Dysphagia Screening ANer Acute Ischemic Stroke (2017) RaedA.Joundi,RosemaryMar3no,GustavoSaposnik,VasilyGiannakeas,JimingFang,MoiraK.Kapral

Variable Screen:Fail Screen:Pass

Number% 2457(47.8%) 2687(52.2%)

AspiraVonPneumonia 217(8.8%) 26(1.0%)

Severedisability 1256(52.4%) 470(18%)

LongTermcare 345(14%) 116(4.3%)

Introduc<on

• BedsideswallowevaluaVon• CSEEssenValpartofevaluaVon1.  Comprehensivemedical

history

2.  OralMechexaminaVon

3.  CranialNerveexaminaVon

4.  Assessmentoffoodintake

Signs vs. Symptoms

•  Symptoms– PaVentreport– SubjecVve

•  Signs– Whatwecanobserve

– ObjecVve

Medical history

• PaVent•  Mostimportantskill

•  Familymember

• Healthcareworker(RN,MD)

• DysphagiaquesVonnaire(page166,Box9-1)

ArkSHA2017

TowinoParamby,CScD.,CCC-SLP;BCS-S

10/12/2017

5

Medical History

•  SydneySwallowQuesVonnaire(SSQ)

•  EAT-10•  SWAL-QOL

Medical History

• Past&currentmedicalhistory

• Previousswallowingassessment

•  Socioculturalstatus•  Inyourmind!!•  Neurological(?)•  Structural(?)•  Systemic(?)

•  Iatrogenic(?)•  Psychogenic(?)

•  MedicaVons•  Xerostomia

•  GIupset•  Alertness•  CogniVvechanges•  Drowsiness,etc.

• AdvanceDirecVves

General Observa<on

•  ObservepaVent•  Outsideroom

•  Enteringroom

•  Posture•  SucVoning•  Tracheostomy

•  Coughing/throatclear

General Observa<on

• Mentalstatus•  Alertness•  OrientaVon•  MMSE

• NutriVonalstatus•  Tubefeeding

• Respiratorystatus•  RespiratoryRate•  SpO2

Oral-Mech & Cranial Nerve Examina<on

OM & CN Examina<on

• Atrest• Passively• AcVvely• Againstresistance

ArkSHA2017

TowinoParamby,CScD.,CCC-SLP;BCS-S

10/12/2017

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4 Characteris<c of Movement

1.  Symmetryofmovement

2.  Strength3.  RangeofmoVon

4.  CoordinaVon

Oral Trials

•  Safestwaytoevaluateswallow(minimalrisk)– Salivaswallow

•  Supplyneeded:– Ice-chips– Water(thinliquid)

•  Normaltemperature

•  Cold/Hottemperature

– Spoons,cupsandstraws– Thickliquids,puree&cracker

Thickened Liquid

•  Nectarthickliquid•  Honeythickliquid•  Pureedthickliquid

CSE Protocol

•  Ifsafeproceedwithoraltrials•  Step1:Ice-chips(3-5xtrials)•  Step2:Thinliquid•  Spoon(8-10x)•  Cup(smallsips&sequenValsips)

•  Straw•  Theirnaturalstyle

CSE Protocol

•  Step4:Pureefood– Applesauce– Vanilla/chocolatepudding

•  Step5:Solidfood– ToevaluatemasVcaVon

– Grahamcracker,etc

Compensatory strategies

•  IfpaVentcannottolerateregularsolidfoodandthinliquid

•  Alemptcompensatorystrategies•  Hardswallow•  Alternatethin&solid•  Chintuckposture•  Headturnetc

ArkSHA2017

TowinoParamby,CScD.,CCC-SLP;BCS-S

10/12/2017

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Always remember!! “Our job is to recommend least restric<ve diet”

Diet Modifica<on Trials

•  IfpaVentcannottolerateregularsolidandthinliquidwithcompensatorystrategies

•  Alemptdietarychanges

•  Thickenedliquid•  Sotsolid,choppedsolids,groundsolid

Laryngeal Palpa<on

Twomethods

FirstMethod:

•  Indexfingeronthyroidnotch•  remainingfingersonthyroidcarVlage

Laryngeal Palpa<on

SecondMethod:4FingerMethod

•  Indexfingersubmentally

•  Middlefingeronhyoid

•  LasttwofingeronsuperiorandinferiorthyroidcarVllage

No clinical and scien<fic evidence for!!

•  Wateryeyes

•  Runnynose•  Sneezing

Cervical Ausculta<on!!

• Burstsandclunks•  Leslieetal.,2007•  Noevidence

ArkSHA2017

TowinoParamby,CScD.,CCC-SLP;BCS-S

10/12/2017

8

Pulse Oximetry!!

•  NoevidenceforpenetraVon/aspiraVon

Leder(2000)

•  IngeneraltellsaboutrespiratoryrateandoxygensaturaVon

Standardized Tests

•  TheMannAssessmentofSwallowingAbility(MASA)

hlp://srl.phhp.ufl.edu/dysphagia-toolbox/MASA.pdf

U<lity of a Clinical Swallowing Exam for Understanding Swallowing Physiology (2016) Authors: Balaji Rangarathnam & Gary H. McCullough Results

• AuthorsacknowledgescorrelaVondoesnotmeancausality

•  StrongcorrelaVon:•  HyolaryngealelevaVonwithlaryngealelevaVonesVmaVon

•  StrongcorrelaVonbetweenoveralldysphagiaseverityanddietrecommendaVon

In Summary

CSEhelps!!•  Oralphase•  PredicVonswithaspiraVon/penetraVon(75%accurate)Smith

Hammondetal.,2009

• Voluntarycough(80%accurate)

CSEnotuseful!!•  SilentaspiraVon• DelayedswallowiniVaVon•  AnyduraVonalmeasures

•  PharyngealcharacterisVcsofswallowing

• UESopeningandduraVon

“Biomechanical Analysis”

Introduc<on

•  Swallowing•  Highlysynchronizedsequenceofevents

•  ShortduraVon•  IncoordinaVonleadto:Dysphagia

• Videofluoroscopicswallowstudy(VFS/VFSS;MBS)

ArkSHA2017

TowinoParamby,CScD.,CCC-SLP;BCS-S

10/12/2017

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Purpose of Biomechanical Analysis

•  InVFSSreport:“AspiraVon”“Residue”•  NomenVonofcauses

•  BadclinicalpracVce•  VFSS

•  DiagnosVc•  IntervenVonalprocedure(Logemann,1983)

•  “It’sthepaVentandnotthebarium”

•  Weneedtotreat/managepaVent

•  WecantreatpaVentsnotbarium

Oropharyngeal Biomechanics

StructuresacVveduringenVreoropharyngealswallow•  Mandible

•  Sotpalate•  Tongue•  Hyolaryngealcomplex

•  UES

• OropharyngealswallowisaconVnuum

• ArVficiallydividethisconVnuumintostagestodescribewhathappensinthisshortduraVonofVme

Anchors

• Anchoringalachmentforthetongue•  Mandible

•  Hyoidbone•  Skullbase

• MandibleanchorsanteriormusclesresponsibleforHLE

Mandible

•  DuringoralpreparatoryacVvity•  Mandibleelevated

•  i.e.:“closed”•  Tongueneartopalate•  Thisfacilitatetransferofthetongue’spropulsiveforcestobolus

•  Anteriortoposterior

Tasko,Kent&Westbury,2002

Common Law of Physics

• Boyle’slaw• P1V1=P2V2

•  PressuregeneraVon•  Tonguepumping

•  ApproximaVonofhardpalateandtongue

•  MandibleelevaVon

•  Pharyngealconstrictors

Linguavelar Seal

•  Tongueandsotpalate• Volumeshrinkinoralcavity

• Pressureincreases• Noseal:Abnormalbolusflow

•  Solid/MasVcatesolid

•  NormalvariaVonofswallow

ArkSHA2017

TowinoParamby,CScD.,CCC-SLP;BCS-S

10/12/2017

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Linguavelar Seal Release

• Releaseoforalcontainment

•  Bolusejectedtopharynx•  RelaVvelyhighpressure

(Nicosia&Robbins,2001)

•  SotpalateshititsposiVon•  Velopharyngealclosure•  TongueconVnuepropulsivemovement•  Contactsot&hardpalate•  Lateral&pharyngealwall

Airway Protec<on

•  Tonguebasecontactdistalepiglows

•  ElevaVonandanteriormovementoflaryngealcomplexduringHLE

•  Epiglows•  VerVcalposiVontohorizontalposiVon

•  Thyrohyoidshortening

Velopharyngeal Closure

• PreventnasopharyngealregurgitaVon

• Pressureleakage•  Lossofintraboluspressure•  LossofpropulsiveforcegeneraVon

Hyolaryngeal Excursion (HLE)

•  Importantevent

• Complexseriesofeventsthatachievesseveralbiomechanicalevent

• ContributorforEpiglowcinversion

• Netmovementofsuprahyoidmuscles•  Stylohyoid,PBD(Posterior)•  Mylohyoid,geniohyoid,ABD

•  Hyoglossus

• Orientairwayawayfromoncomingbolus

•  Shorteningoflarynx•  ThyrohyoidcontracVon•  BringlarynxunderinverVngepiglows

•  HLEiscontributortoopeningUESopening

UES opening

•  HLE•  InhibiVonofcricopharyngealporVonofUES•  Resultsinincreasedcompliance

•  Posteriorlaryngealwall(cricoidcarVlage)sharesanteriorwallofUES

•  Boyle’slaw•  Volumeincreaseandpressuredecrease

•  HypopharyngealsucVonpump(McConneletal.,1988)

Instrumental Evalua<on: FEES

ArkSHA2017

TowinoParamby,CScD.,CCC-SLP;BCS-S

10/12/2017

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Introduc<on

•  SusanLangmoreinMid80’s

•  EndoscopicevaluaVonofswallowing•  FiberopVcEndoscopicEvaluaVonofSwallowing(FEES)•  FiberopVcEndoscopicEvaluaVonofSwallowingwithSensoryTesVng(FEESST)

Comparison: VFSS vs. FEES

Similari3es • Purpose• Materials

• ProcessofevaluaVon

Differences•  Technique•  Portability•  Repeatability•  DuraVonofexaminaVon

•  Sensoryassessment

Procedure for FEES

Fivemaincomponents:

1.  Assessmentofpharynx/larynx

2.  MovementandsensaVonofstructures

3.  Assessmentofstructures

4.  DirectevaluaVonofswallowing

5.  EvaluaVonofcompensatorystrategies

Procedure

•  Step1:InstrucVon– Itsnotpainful– Itsuncomfortable

• Nasconstrictorsand/ornasalanesthesia

•  Physiciansupervision/administraVveapproval

•  Statelaws

Procedure

Step2

•  Endoscopepassthroughonenasalpassage

•  Inferiornasalmeatus

•  PosiVonedtoviewvelopharynx•  shortsentences,humming,dryswallows

Procedure

Step3

•  Visualizestructures•  PhonaVon•  Oraltrials

ArkSHA2017

TowinoParamby,CScD.,CCC-SLP;BCS-S

10/12/2017

12

Suggested Techniques and Observa<on during FEES •  Velopharynx•  Pharynx•  Larynx•  Swallowing

Velopharynx

•  AnatomicdeviaVon

•  MovementonphonaVon

•  Movementonswallows

•  SignsofnasalregurgitaVon

Pharynx

•  AnatomicdeviaVon

•  SecreVons•  Movementonfalselo(medialmovementoflateralpharyngealwall)

• Valsalvamaneuver-expandpharynx

Larynx

•  AnatomicdeviaVon

•  SecreVons• MovementonphonaVon

•  Movementonbreathhold/forcedbreathholdadducVon

• MovementonabducVon-inhale/sniff

•  RapidalternaVngmovement

• Cough

Swallow

•  Varyvolumeandconsistencyofmaterials

•  Oralcontainment-lingua-velarseal

•  “whiteout”degreeofpharyngealconstricVon

•  Residue•  Airwaycompromise

•  PaVent’sreacVontoresidueorairwaycompromise

•  ImpactofmaneuversandcompensaVons

Strengths and Weakness

Strength•  Pharynx/larynxanatomy

•  SecreVons•  SensoryevaluaVon• Portability• NoradiaVon• Biofeedbacktool•  LongerevaluaVonVme

Weakness• Discomfort

•  Limitedview(onlypharynx)

•  Whiteout•  Absenceof“whiteout”weakswallow

•  Nosebleed•  Vasovagalresponse•  Laryngospasm

ArkSHA2017

TowinoParamby,CScD.,CCC-SLP;BCS-S

10/12/2017

13

Thanks!!