Bedside Evaluation History (6)
- Respiratory Status (ventilator, trach, pnemonia?)
- History of Swallowing Problem (How long, what type, describe it, what type of food causes choking, and how often)
- Nutritional Status (How do they get their nutrition, Do they have trouble with liquids, soft foods, or meat (we don’t need to know their food preferences)
- Neurological Examination Results (any disorders that can cause swallowing issues)
- Otolaryngologic Examination Results (any VF paralysis)
- Dysphagia Symptoms
— What type of medications is the pt. on, do they reduce salivia, do they have dry mouth?
— Has the pt. had any other swallowing evals? (what is the outcome, did it help, what compensatory treatments did they learn?
— ask about symptoms
Observation of Patient (7)
1 Patient Posture (Do they have good tone, weakness, head falling forward)
2 Patient level of alertness (pt. must be alert and cooperative)
- – Must be able to follow directions
- – If the pt. can not produce a voice you cannot do a bedside exam, need to do a MBS, because you must be able to voice to see if a pt. is aspirating
- – You can feel the swallow, even if they cannot voice, but you still have to do MBS
- – Pt. w/ dementia, they may be alert, but not cooperative so you need to do a MBS
3 Patient management of their own secretions (Individuals who are drooling, frothing, and unable to handle secretions are very severe and should have a MBS)
4 Presence of congestion (May be a sign of pneumonia, refer for a modified if you cannot clear the congestion. Have the pt. try to clear the congestion and then say /a/, it could be due to excess mucus on the VF. If voice was clear after clearing throat you can do a bedside. If gurgly/wet voice continues, do MBS)
5 Presence of Tracheostomy tube & status (How long has the pt. had the trach?, we don’t do swallow studies on pts. who have been extubated unless it has been 24 hours, larynx needs to recover
6 Ability to follow directions
7 Correspondence of observation with information from chart & nursing staff ( ask the nurses about choking and talk to the family)
*** If pt. can’t do water (may have weak musculature) Thin liquids, water, is the most difficult to swallow (but water is safest to aspirate)
*** If pudding causes a problem (thicker consistencies maybe a pharyngeal issue, pharyngeal parastylsis issues, think about innervation what’s causing it?)
Patient Report (6)
- Patients description of Problem ( a lot of pts. have trouble describing swallowing problems)
- Onset of the problem
- Course of the problem (has it gotten worse or better)
- Management of various food consistencies (better with liquids, solids, soft foods, hardest consitency is water because it moves the fastest)
- Localization of disorders
- Presence of coughing (signifies aspiration, could be silent)
Oral Motor & Anatomy Exam
- Anatomical Assessment
- Functional Assessment of articulators
- Areas to look at:
— Labial Functions
— Lingual Functions
— Soft Palate Functions
— Oral Reflexes
— Laryngeal Functions (diaodichokinetic rate /i/ /i/ /i/, or have pt. cough voluntarily)
Labial Functions
- Lip spreading/rounding
- Rapid alterations /i/, /u/
- closure (tight closure, how long can they do it)
Lingual Functions
- Lingual Functions
1. Tongue tip /ta/
— Tongue Extension
— Rapid alternations (lateralize quickly)
— Tongue activation
— Diadochokinetic rate
- Posterior of the tongue /ka/ (therapy technique)
— Lift back of tongue & hold
— Diadochokinetic rate
— Sentence repetition
Soft Palate Reflexes
- Sustain /a/
- Rapid repetition /a/
*** Listen for hypernasality
Oral Reflexes (3)
- Palatal Reflex (elevation of the palate)
*** Say /a/ and watch bilateral movement
- Junction of hard & soft palate
- Junction of soft palate & uvula
2. Gag Reflex - Base of tongue or posterior pharyngeal wall
3. Swallow Reflex (tongue triggers swallow) - Base of anterior faucial pillar
Laryngeal Functions 1
- Voice Quality
- Diadochokinetic Rate
- Hoarse or breathy
- Poor laryngeal closure, laryngeal function examination - Does it sound breathy when they do /puh, tuh, kuh/?
- Ask to patient to cough (voluntarily) is it strong or weak (can VF go together)
Laryngeal Functions 2
- Pitch
- Sustain /s/ & /z/
- Length of Phonation
- Slide voice up and down scale
— Evaluates external superior laryngeal nerve which triggers the swallow reflex
— Inability to change pitch
—– Cricothyroid
- If pitch is monotone, we know that the cricothyroid muscle is impaired
- Assess pitch if you think that the pt. has a pharyngeal phase issue (Same CN innercation for the cricothyroid as base of pharynx)
2. How long?
3. Measures respiratory capacity
Time swallow & up and downward excursion of larynx
- Index finger at the base of the tongue
- Middle finger on hyoid bone
- Place 3rd finger on top thyroid cartilage
- Place 4th finger on bottom thyroid cartilage
- To assess initiation time (time bolus moves through oral cavity to initiation of swallow)
- Normal Swallow time is between 1 & 2 seconds
Behavioral Assessment
- Memory (Dementia patient could have trouble with swallowing because they can’t remember how to do it)
- Self-Discipline
- Ability to Follow Directions
Food Assessment Materials 1 (6)
- Size 00 laryngeal mirror
- Metal spoon
- Straw
- Tongue blade
- Suction machine (trachs and vents)
- Blue food coloring (used with trachs and vents, allergies can be an issue, not used everywhere)
Food Assessment Materials 2 (food) (8)
- Glass of H2O
- Nectar thick liquids
- Honey thick liquids
- Applesauce (thin puree)
- Pudding (thick puree)
- Fruit cocktail or banana (mechanical soft)
- Ground meat
- Bread
*** You can thicken liquids if the pt. is at risk of aspirating (safer to aspirate water with thick it)
Bedside Swallow Test
What are you looking for? (3)
- Using the tray of food, the SLP will determine:
— use of the lips, cheeks tongue to take in food and swallow it,
— watch for signs of aspiration,
— make recommendations about how the patient should eat (types of food and liquid, position, kinds of utensils
- For each consistency you are making an assessment + taking notes
- Start with the pts. original diet ( if pt. is on nectar thick liquids, start there.
- Lots of aspiration, stop and switch to MBS
Clinical Signs of Aspiration (5)
- Coughing and choking
- Wet sounding voice- have pt. clear throat and get a baseline. Then have pt. swallow and try to produce /a/ again.
- Throat clearing
- Swallowing multiple times for a small bite
- Limited movement of the larynx in the neck
- ** With every consistency listen to the voice afterwards (you need to have voice)
- – Have the patient sustain /a/
Procedures Sometimes Used During Bedside Swallowing Screenings
- Cervical Auscultation
- 3 ounce water swallow test
- Blue dye test
Cervical Auscultation
- Means listening to a patient’s breath sounds
- Procedure:
–flat diaphragm of the stethoscope is placed laterally on the neck
–clinician listens with stethoscope to breath sounds
Sound of Normal Swallow Sequence
- Breath sounds are heard
- Breathing stops (usually in the middle of an exhalation
- A sound described as a clunk or a swish is heard
- Breath sounds are heard again
Can you hear aspiration?
- Aspiration is suspected if a flushing sound of material is heard prior to the initiation of the swallow
- With wet breath sounds,
- Coughing, or
- A distorted voice after the swallow
3 ounce Water Swallow Test
- Patient given 3 ounces of water in a cup and asked to drink without interruption
- Abnormal response:
- – coughing during or for one minute after completion of the swallow, or a wet gurgly voice quality after the swallow.
Blue Dye Test 1
- This test is a screening test for aspiration that may be used at beside with the tracheostomized patient
- The patient can be given measured amounts of blue-dyed foods and the tracheostomy suctioned immediately after the swallow for the presence of the blue-dyed foods, indicating aspiration the test does not reveal
— The anatomic or physiologic causes of aspiration
- The result is clearly positive however, if the blue dye is evident through the coughing or suctioning from the tracheostomy tube the clinician should recommend a radiographic study.
Blue dye test 2
- Blue tinged secretions that are later suctioned from the tracheostomy
— Do not necessarily mean that the patient is aspirating
- It is normal for the blue dye to mix with secretions and gradually coat the trachea
- Unless a variety of food consistencies are presented the patient may not aspirate on the food consistency tested but may aspirate on other food consistencies
Procedures for Blue Dye Test
- The nurse should suction
- Consider the optimum food & posture positions
- Begin with easiest consistency
- Use small amounts of materials
- Provide detailed instructions to the patient
- Proceed slowly
