Acute Care Dysphagia, Videofluoroscopy, and Planning Therapy

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Acute Care Dysphagia, Videofluoroscopy, and
Planning Therapy

• Amy Chaffee, MA, CCC/SLP
• United Health Services Hospitals
• April 26, 2004

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Why So Different?

• Pt is not always medically stable
• Decreased LOA
• More conservative with PO recommendations
• Not hospitalized for long periods of time
• Need to be flexible
• May not do therapy per se unless patient is very
  alert or long stay
• May just observe meals, increase or decrease
  solid or liquid texture

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Bedside/Clinical Swallow Evaluationthe chart

• Need to look at H P, consultations, progress
  reports, radiology reports, nursing reports (e.g.
  temperature, respiratory status, of meal
  consuming), transfer reports (e.g., prior to
  admission diet)
• Talk to nurse taking care of patient. Have they
  fed the pt? If so, how did they do?
• Talk to family member if available. If not, may
  need to call
• Visually observe everything you can about the
  patient (e.g., respirations, body wt., skin
  integrity)
• Nutrition information
• Medications
• Cardiac-respiratory symptoms
• Systemic disease

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• Remember!Just because a patient has a disease
  that can cause dysphagia, it doesnt mean that it
  is causing dysphagia

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Important History Data---the patient

• Position
• Speech
• Variability, comprehension
• Feeding time (beginning to end of meals)
• Dysphagia for liquids, solid, or both
• Coughing
• Weight loss
• Fatigue with eating
• Oral mechanism exam (if able). Example.
• Presentation of food. Food textures presented is
  directly related to what the patient has told you
  and what you have gathered from the chart. For
  example, a pt that is currently NPO and MD wants
  to feed

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After Presenting food textures

• Is the Patient ready for PO?
• Is the person aspirating (showing overt s/s of
  aspiration)? Does positioning or compensatory
  strategies help? Is the patient able to
  consistently do? Thickening liquids?
• Can the patient tolerate aspiration? Nutrition
  status?
• Does the patient have a NGT? Is it interfering
  with the swallow?
• Need to make solid texture recommendations
• Need to make liquid level recommendations.

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• Do you need further objective swallowing
  assessment???? If yes, why? And what are you
  going to do when you go down to do the VF. YOU
  NEED A PLAN!!!
• Which objective study would you choose? Handout
• At the moment

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Before we discuss objective swallowing
studies..

• Lets go through some basic nutrition.

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You Need to Stop and Think about Nutrition

• Dysphagia can lead to malnutrition and
  malnutrition can lead to dysphagia
• Can this patient meet nutritional needs
• Has this patient been meeting nutritional needs
• Do I need to consult the RD?

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Some Nutritional Parameters you can check

• Weight
• Height
• Ideal body weight/BMI
• Lab values
• Sources of malnutrition (e.g., sepsis, GI)
• Weight gain, weight loss
• Current and prior to admit diet order
• Handouts

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THE VIDEOFLUOROSCOPY/MBS/COOKIE SWALLOW/THREE
PHASEMust be tailored to the patient/client
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The Exam

• Initial client position, centering, and initial
  contrast
• Vary bolus consistency
• Cold or hot bolus
• solid bolus if solid food dysphagia
• Dr. Crary example

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Before the swallow is initiatedExamine anatomy
for any abnormalities and watch for movement
disorders (e.g. tremors, spasms)
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Anatomical

• Cervical vertebrae
• Valleculae
• Tongue base
• Airway entrance
• Have patient phonate ee
• Why?

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This elevates soft palate to appose passavants
cushion, thus revealing the tonsillar fossa. It
increases the size of the valleculae and
straightening the aryepiglottic folds. The
maneuver stretches the posterior wall on the
pharynx and if there are any nodules in this
area, it may become more obvious with prolonged
phonation
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After the bolus is in the mouth, observe

• Oral phase
• Tongue-palatal seal
• Nasopharyneal seal
• Compression and propulsion of bolus
• Hyoid/laryngeal/epiglottic tilt
• Cricopharyngeal opening
• Esophageal peristalisis

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During the swallow

• Does the bolus hesitate?
• If so, where? For how long?
• Where is the bolus head when the swallow is
  triggered?
• Does any bolus enter airway, before, during,
  after the swallow?
• How was the tongue movement?
• Was cricopharyngeal opening complete?
• Watch the tongue base
• does it contact the anterior inferior corner of
  the 2nd cervical vertebra and the anterior
  superior corner of the 3rd cervical vertebra?
• Watch airway entrance
• Does it close completely?
• Does anything go below the vocal folds?

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Immediately after the swallow, identify location
of residue

• If in the oral cavity, go back and review the
  oral tongue movement
• If in the valleculae, go back and review the
  tongue base/pharyngeal wall movement
• If in the pyriform sinus, go back and review the
  laryngeal elevation and cricopharyngeal opening
• If on the pharyngeal walls, observe the
  pharyngeal wall contraction

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Esophagus

• Esophageal dysphagia may result in pharyngeal
  dysphagia
• Observe motility of the esophagus
• Can be assessed in the horizontal position only.
  
• In the erect position, the esophagus empties by
  gravity, not peristalsis. So if you do a
  functional scan of the esophagus you can only
  comment with gravity in stand/erect position!!!
  If something is observed..make a referral

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Aspiration

• The timing of aspiration has important
  therapeutic implications.
• Certain modifications, laryngeal elevation, bolus
  size and textures, and swallow/respiration/cough
  sequence can be tried based on analysis of why
  and when the aspiration is occurring

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Timing Cause

• Failure of the glossopalatal seal with premature
  leakage from the mouth and entry into the open
  larynx.
• Poor laryngeal elevation
• Poor laryngeal closure
• Incomplete epiglottic tilt
• Over flow of retained bolus
• Late emptying of a pouch or diverticulum
• Regurgitation from the esophagus
• GERD

• Prior to swallowing
• During swallowing
• After swallowing

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Management Strategies During and After the VFSS

• Oral Phase
• Head back - May help in allowing gravity to help
  transport bolus. Helps when there is impaired
  bolus propulsion. Unfortunately it can make
  elevation of the pharynx and larynx more
  difficult.
• Head tilted - toward stronger side maybe helpful
  with unilateral oral or pharyngeal weakness by
  allowing gravity to pull the bolus down the
  stronger side
• Delayed Pharyngeal Swallow
• Try different bolus sizes
• If aspiration occurs, try chin down/tuck/flexed -
  This widens the valleculae and narrows the
  laryngeal vestibule, decreasing laryngeal
  penetration and aspiration. It also facilitates
  pharyngeal clearance
• Increase sensory input sour bolus
• Different consistencies

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Reduced supraglottic closure (into laryngeal
vestibule but not below the vocal folds)

• Chin tuck
• Head rotation/turn - improves transport from the
  pharynx into the esophagus in pts. with
  unilateral pharyngeal weakness or paralysis by
  closing the affected side of the pharynx and
  directing the bolus down the stronger side.
• Chin tuck with head turn
• Super supraglottic swallow
• take deep breath, bear down, continue bearing
  down until completion of the swallow, exhale, and
  cough. Helps facilitate sealing of the vocal
  cords.
• if aspirates, try chin tuck with super
  supraglotttic swallow
• thicken liquids

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Reduced Laryngeal (vocal cord) closure

• Chin tuck
• Head turned (toward damaged side)
• Chin tuck and head turn
• Supraglottic, chin tuck, head turn
• Supraglottic swallow
• take breath, hold breath, keep holding breath
  while swallowing, clear throat, swallow again.
  Helps prevent aspiration before and during the
  swallowing by producing volitional closure of the
  glottis before and during the swallow
• Thicken liquids

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Reduced laryngeal elevation and anterior movement
causing decreased cricopharyngeal opening
(residue in pyriform sinus)

• Head turn (try both ways)
• Mendelsohn Maneuver
• Have pt. feel upward movement of the larynx
  during swallowing by palpating the larynx. Teach
  the pt. to catch the larynx in the elevated
  position and hold it there for several seconds by
  voluntarily contracting the suprahyoid and
  thyrohyoid muscles. Used to improve the opening
  of the UES, pharyngeal clearance and laryngeal
  elevation
• Mendelsohn and head turn

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Reduced base of tongue movement (residue in the
valleculae)

• Chin tuck
• Effortful swallow
• For pts that have residue in valleculae
• Chin tuck and effortful swallow

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Treatment-Sensory Procedures

• Change bolus volume, taste, temperature
• Thermal tactile stimulation
• Pressure of spoon
• Self feeding
• Chewing

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Pharyngeal Clearance Maneuvers

• Alternating food consistencies
• Multiple swallows
• Effortful/hard swallow
• Mendelsohn

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Other Treatment Maneuvers

• Tongue hold
• for pts. the have residue in the valleculae
  because of decreased base of tongue retraction
• Shaker Exercise
• For pts. with decreased UES opening, that are
  deconditioned

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Videofluoroscopies