1. Evaluation and Management of Dysphagia a Team Approach
Rebecca L. Gould, MSC, CCC-SLP
(561)
Script for me…thankyou for being here-It is an honor and a privilege – overview: discus tools we have for evaluating dysphagia in addition to discussing the salient/pertinent variables to consider as we do.
Background of each participant…

2. “More than 15 million Americans have some degree of dysphagia, and with regular treatment 83% recover or significantly improve”.
Bello, J. (1994) compiled by Communication Facts. ASHA Research Division
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3. Pneumonia occurs in 38% of all stroke victims and is the most common respiratory complication. Pneumonia contributes to about 34% of all stroke deaths and represents the third cause of mortality in the first month following stroke Stepphens & Addington, 1999
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4. “IS IT SAFE TO FEED THIS PATIENT?”
MD’s question
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5. EVALUATION Clinical “bedside” swallow evaluation.
Videofluoroscopic Swallowing Study (VFSS)
Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
(Reflexive cough test)
All are tools in our armory to address problem. No one test is best without viewing entire context.
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6. MBSS? or FEES?
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7. Two Goals of Swallowing Evaluation:
Determine the Safest and Least Restrictive Level of P.O.
Determine the physiologic breakdown of the swallow so it can be rehabilitated in treatment.
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8. FEES (Fiberoptic Endoscopic Evaluation of Swallowing)
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12. RESIDUAL
Leftover material in the oral pharynx after swallow has occurred.
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13. PENETRATION
Entry of material into the laryngeal vestibule to the level of the vocal folds.
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14. ASPIRATION
Entry of material below the level of true vocal folds.
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23. Assess secretions
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24. Leder, Sasaki, Burrell (1998)
FEES/Fluoro Comparison, n = 56
96% Agreement:
1 silently aspirated during MBS but coughed during FEES
1 did not aspirate during MBSS but did during FEES
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25. Will Test ALL Types of Food/Liquid
Thin liquid
Thick liquid (Nectar)
Puree
Solid
Mixed Consistency
Pills
Challenging food (i.e. nuts, peanuts, etc.)
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26. Will give MULTIPLE trials of each consistency
CPG can break down
Large bolus size
Consistency
Fatigue
Lack of coordination (COPD)
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27. Protocol Saliva – Secretion rating Anatomy screen
Laryngeal physiology assessment
Swallowing physiology assessment
Functional – Patient self-administer bolus
Diet recommendations
Recommendations for swallowing therapy/follow-up
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28. Typically use green food coloring

29. FEES Interpretation 4 Main Parameters: Delay in Swallow Initiation
Penetration
Aspiration
Residue
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31. Swallow Initiation
Bolus spills to valleculae or pyriform sinuses for greater than one second before the swallow (white-out).
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35. Penetration/Aspiration

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38. Timing of Penetration/Aspiration
Before the Swallow
During the Swallow
After the Swallow
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39. Issues With Residue Residue in Vallecula? Residue in Pyriform Sinuses?
Diffuse Pharyngeal Residue?
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46. Zenker’s Diverticulum

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49. Cervical Osteophytes

50. Cervical Osteophytes
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51. Globus

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53. In General
FEES = better detector of role of anatomy on swallowing physiology, aspiration, and appropriate diet
ModBASW = better detector of role of UES and esophagus on pharyngeal function
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54. Gurgly vocal quality predictive of who will aspirate on VFSS
Linden (1993)
Clinical bedside +/-…..a lot of studies address varibles that will help us know who to test and who not to test
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55. Incidence and patient characteristics associated with silent aspiration in the acute care setting
1001 patients underwent videoflurographic evaluation of their swallowing during a 2-year period:
469 aspirated
276 were silent aspirating
Coughing is a physiologic response to aspiration in normal healthy individuals. No cough in response to aspiration silent aspiration
Smith, C.H. et al (1999)
This is when case hx is so important.
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56. Aspiration risk after acute stroke: Comparison of clinical examination and Fiberoptic Evaluation of Swallowing
Conclude: Clinical exam underestimated aspiration risk. FEES accurately assessed.
19 correct identification of aspiration risk
3 incorrect identification of aspiration risk
19 incorrect identification of aspiration risk
8 correct identification of no aspiration risk
Leder, S.B. et al (2002)
If you have any doubt and instrumentation is available-test- especially if it is going to impact your decision making
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57. 14% false negative rate – most important
20% false negative rate for VFSS
0% false negative rate for endoscopy
“Fallacy to rely on bedside evaluation when instrumentation is possible”
Aviv, J.E. (1997)
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58. Oropharyngeal secretions and swallowing frequency in predicting aspiration
Presence rated with endoscopic view.
Scale 0, 1, 2, 3,
Strong association between the presence of oropharyngeal secretions in the laryngeal vestibule and the likelihood of aspiration of food or liquid.
Patients who demonstrate trouble in clearing oropharyngeal secretions for whatever reason will also demonstrate the same trouble with food or liquid while swallowing.
J. Murray et al. (1996)
More I do endoscopy, I realize that what you find when you take the time to look is not always what you would expect-easier to treat when you have aclear picture of the function of the mechinism you are addressing
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59. Oropharyngeal secretions and swallowing frequency in predicting aspiration (cont’d)
Significant decrease in the frequency of swallowing in the aspirating hospitalized patients.
The frequency of spontaneous swallows can be easily sampled at bedside with simple instrumentation or palpation of the larynx to monitor elevation associated with the pharyngeal stage of the swallow.
J. Murray et al. (1996)
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60. A randomized control study to determine the effects of unlimited oral intake of water in patients with identified aspiration
Small number: 20 patients with aspiration pneumonia.
10 with thick water
10 with “free water”
Results: “No patient in either group developed pneumonia”
Garon, B. et al. (1997)
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61. Thick, “crusted” mucous throughout hypopharynx.
Mucous appears moist and dispersed following hydration. (tsp. of water).
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62. Predictors of Dysphagia
Measured radiographically
>70 years
male gender
disabling stroke (Barthel score <60)
palatal weakness or assymetry
incomplete oral clearance
impaired pharyngeal response (cough/gurgle)
Mann, G. & Hankey, G.J.(2001)
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63. Clinical predictors of aspiration
Measured radiographically
delayed oral transit
incomplete oral clearance
Will pt clear w/o instruction?
Mann, G. & Hankey, G.J.(2001)
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64. Tube feeding is associated with a higher rate of pneumonia than with patients who are eating.
M.J. Feinberg, MD (1990)
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65. Look to correlate frequency of pneumonia with prandial aspiration
Look to correlate frequency of pneumonia with prandial aspiration. Found there is not a simple relation between liquid aspiration and pneumonia.
M.J. Feinberg, MD (1996)
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66. Studied 152 SNF residents - average age of 86. Followed for 3 years.
Begin of study
50 non aspirators
51 minor aspirators
51 major aspirators
End of study 37 38 47
30 artificial feeding expired
M.J. Feinberg, MD (1996)
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67. SNF PATIENT (very elderly and/or frail) - RISK FACTORS
Delayed recognition of pneumonia as signs and symptoms are subtle and different from younger individuals.
Advanced age
Difficult antibiotic treatment:
difficult to identify pathogen
altered drug metabolism
medication side effects M.J. Feinberg, MD (1996)
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68. SNF PATIENT - RISK FACTORS (cont’d)
Dependency for feeding.
Depressed and/or fluctuating levels of consciousness (medication and/or neurological disease).
Microaspiration of oropharyngeal secretions that had been pathologically colonized
overgrowth gram negative enteric rods associated with functional decline
Anaerobic bacteria overgrowth secondary to gum disease or dentures M.J. Feinberg, MD (1996)
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69. Pneumonia frequency was higher in months of artificial feeding.
Patients with artificial feeding are at risk for aspiration of refluxed material.
PEG’s/JEG’s do not help to protect those who are known to aspirate.
M.J. Feinberg, MD (1996)
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70. “Artificial feeding does not seem to be a satisfactory solution for preventing pneumonia in elderly prandial aspirators”.
M.J. Feinberg, MD (1996)
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71. PNEUMONIA Colonization (Altered Oropharyngeal Flora)
Dependent for oral care
Number of decayed teeth
Number of medications
Tube feeding
Aspiration into lungs
Large volume aspiration (liquid, food, GER, saliva) Microaspiration (saliva, plaque, GER)
Dependent for feeding
Host resistance
Pulmonary clearance
Now smoking
Systemic Immunologic response
Multiple Medical Diagnoses
Langmore, S. (1997)
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PNEUMONIA

72. Pneumonia in acute stroke patients fed by nasogastric tube
100 consecutive patients with acute CVA (outcome was assessed at three months)
Determine risk given the frequency of pneumonia in acute stroke patients fed by nasogastric tube.
Identify variables significantly associated with the ocurrence of pneumonia and those related to a poor outcome.
Dziewas R. et al, Jun 2004
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73. Pneumonia in acute stroke patients fed by nasogastric tube (cont’d)
Results:
Pneumonia was diagnosed in 44% of the tube fed patients.
Most patients acquired pneumonia on the second or third day after stroke onset.
Patients with pneumonia more often required endotracheal intubation and mechanical ventilation.
Dziewas R. et al, Jun 2004
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74. Pneumonia in acute stroke patients fed by nasogastric tube (cont’d)
Independent predictors
Decreased level of consciousness
Severe facial palsy.
Conclusion
Nasogastric tubes offer only limited protection against aspiration pneumonia in patients with dysphagia from acute stroke.
Dziewas R. et al, Jun 2004
Agrees with feinberg’s finding that ng tubes don’t prevent aspiration in know aspirators
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75. 189 male veterans (55 outpatients), 41 or 21. 7% developed pneumonia
189 male veterans (55 outpatients), 41 or 21.7% developed pneumonia. (Bivariate analysis to determine predictive risk factors).
Langmore, et al (1998)
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76. “Dysphagia and aspiration are necessary but not sufficient conditions to predict development of aspiration pneumonia… a multifactorial phenomenon”.
Langmore,S. (1998)
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77. Focus on context of risk factors in given setting.
Assess strengths/weaknesses.
Langmore,S. et al(2000)
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78. Predictors of aspiration pneumonia in nursing homes patients
suctioning use
COPD
CHF
presence of feeding tube
bedfast
3,118 pneumonia = 3%
delirium
weight loss
swallowing problems
UTI’s
mechanically altered diet
Langmore, S. et al. (2002)
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79. Predictors of aspiration pneumonia in nursing homes patients (cont’d)
dependence for feeding
bed mobility
locomotion
number of medications
age
CVA
tracheotomy care
1998 Predictors
dependence for oral care
smoking
multiple medical diagnosis
numerous decayed teeth
Langmore, S. et al. (2002)
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80. Impaired cough reflex in patients with recurrent pneumonia
Capsaicin cough sensitivy
2-6 episodes of pneumonia
Cough threshold was significantly higher in patients than in controls
Conclusion: Impaired cough reflex may be involved in the pathogenesis of recurrent pneumonia.
Niimi A., et al (2003)
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81. What is a safe amount of aspiration?
What is the long term consequence of chronic aspiration?
What factors predict who will get pneumonia?
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82. SCALE PREDICTIVENESS OF PNEUMONIA RISK IF FED
FACTORS
Multiple or progressive disease/one diagnosis
Multiple medications (>5)/ <5 medications
NPO (PEG)/ oral
Oral hygiene fair – poor/ good – excellent
Smoker / non-smoker
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83. SCALE PREDICTIVENESS OF PNEUMONIA RISK IF FED (cont’d)
FACTORS
Inpatient / outpatient
Physical ability (mobile)/ sedentary
Reflexive cough (present) / absent – delayed
Cognitive status (fair-poor)/ good – excellent
Secretion Pooling (minimal) / copious
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84. SCALE PREDICTIVENESS OF PNEUMONIA RISK IF FED (cont’d)
Score
< 7 = Use extreme caution
5–6 = fair – good
<3 = good – excellent
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85. Inpatient “sick” (acute/ exacerbation of chronic condition)
+ sedentary “bed rest/ bathroom privileges”
number of medications
multiple medical diagnosis.
tube feeding
dependent for oral care/ hygiene status
dependent for feeding
smoking
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86. Outpatient may have multiple diagnosis; however, “stable” + mobility
number of medications
if tube feeding, bolus fed
typically are not dependent for feeding
smoking
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87. Consensus VFSS and FEES/FEEST are good for identifying aspiration.
However, identifying aspiration is not sufficient for predicting who will and who won’t develop pneumonia.
Some chronic aspirators appear to fair quite well i.e. head and neck CA, hemilaryngectomees, supraglottic laryngectomees.
Status of reflexive cough appears important.
Flow chart for decision making
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88. “The human body is one of the greatest compensatory mechanisms.” RLG
SWALLOWING TREATMENT
“The human body is one of the greatest compensatory mechanisms.”
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89. GOAL: TARGET MOST CRITICAL RISK FACTORS.
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90. TECHNIQUES OF DYSPHAGIA THERAPY
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91. Timing of laryngopharyngeal events during swallow: an EMG perspective
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92. Electrode Placement Genioglossus (GG)
Superior pharyngeal constrictor (SPC)
- Posterior pharyngeal wall below level of the soft palate, lateral to the midline
Longitudinal muscles of the pharynx (LP)
- Transorally in the midportion of the posterior tonsillar pillar
McCulloch, T. (Voice, Swallow & Airway 2005)
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93. Electrode Placement (cont’d)
Thyroarytenoid (TA)
- Local, transcutaneously, subjects phonated, at level to the cricothyroid membrane angle 30 degrees superior and 30 degrees medial to normal plane, verification maneuvers
Cricopharyngeus (CP)
- Local, transcutaneously at level of the cricothyroid membrane, needle advanced in a posterior and inferior direction, verification maneuvers
McCulloch, T. (Voice, Swallow & Airway 2005)
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94. Methods Five normal subjects (4 male, 1 female) Human subject approval
Simultaneous endoscopy (fiberoptic endoscope, camera and video recorder) multichannel electromyography (hook wire electrodes, amplification, filtration, and on line monitoring) during swallow
Time code generator (time lock endoscopic and electromyographic events)
McCulloch, T. (Voice, Swallow & Airway 2005)
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95. Instructions The supraglottic swallow - “Inhale and hold your breath
- Swallow while holding your breath
- Cough immediately after your swallow without breathing in”
The Mendelsohn Maneuver
- “Swallow your saliva several times and pay attention to your neck as you swallow
- Now, when you swallow feel your Adam’s apple/voice box lift and lower
Swallow don’t let your Adam’s apple drop
Hold it up with your muscles for several seconds”
McCulloch, T. (Voice, Swallow & Airway 2005)
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96. Emphasis
EMG of the cricopharyngeus (CP) during the Mendelsohn maneuver
EMG of the thyroarytenoid (TA) and CP during the supraglottic swallow
McCulloch, T. (Voice, Swallow & Airway 2005)
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97. Muscle examined Superior pharyngeal constrictor (SPC) Tongue base (GG)
Cricopharyngeus (CP)
Thyroarytenoid (TA)
McCulloch, T. (Voice, Swallow & Airway 2005)
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98. Discussion
A number of studies have concluded the Mendelsohn maneuver prolonges UES opening, these employed manometric recordings and videofluorgraphic evaluation. None have employed the use of simultaneous
Studies have demonstrated that the UES diameter may increase with the use of swallowing maneuvers without increasing the duration of UES opening
McCulloch, T. (Voice, Swallow & Airway 2005)
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99. Discussion
Traction of the anterior wall of the UES during the Mendelsohn may lead to a prolongation of opening of the UES, despite the resumption of tone in the Cricopharyngeus (CP)
The study presented was that of normal volunteers, with normal swallowing function. We cannot predict the efficacy of these maneuvers on the head and neck patient who is status post anatomic and physiologic changes from neurologic/ surgical insults. In such patients these maneuvers may improve coordination of swallowing.
McCulloch, T. (Voice, Swallow & Airway 2005)
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100. Conclusions
Swallowing is the result of a series of coordinated neuromuscular events.
Certain aspects of swallowing may be superceded by volitional control.
The thyroarytenoid (TA) activity in the supraglottic swallow and the Mendelsohn it is prolonged along the “tail” end of the swallow.
McCulloch, T. (Voice, Swallow & Airway 2005)
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101. Conclusions
Cricopharyngeal quiescence is not prolonged by changes in swallowing maneuvers.
The basic order of events swallowing is predetermined.
The physical ends results may be modified by extraneous biomechanical forces.
McCulloch, T. (Voice, Swallow & Airway 2005)
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102. Conclusions
We are able to eat, talk, breath and swallow like a great orchestra.
Timing is everything.
There is a delicate balance.
The “escalation” neuromuscular patterns add to the efficiently of the system.
It is no wander that patients with nearly any head or neck problem are at risk for dysphagia.
McCulloch, T. (Voice, Swallow & Airway 2005)
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103. IDEAL REALITY Instrumental exam for each patient. Coordinated team.
Plenty of time.
Medical experts making decisions.
Salient/clear data presented.
REALITY
Treatment without exam.
Piece meal.
Little time.
3rd party payer control.
Lengthy reports. Check lists-important information lost “in the trees”.
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104. SOLUTIONS Assess your environment.
Establish “partnership”/collaborative working relationships with instrumental source. “Trust and understand results”.
Streamline reports. Highlight pertinent information.
Foster open communication among practitioners.
Focus on what you can do. “Prioritize”.
Be resourceful.
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