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Dysphagia Update: Evidence, Tools & Practice Dr. Timothy J. Shephard, CNS, CNRN Stroke Systems Consulting, Charlottesville, VA Bon Secours Health System,

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Presentation on theme: "Dysphagia Update: Evidence, Tools & Practice Dr. Timothy J. Shephard, CNS, CNRN Stroke Systems Consulting, Charlottesville, VA Bon Secours Health System,"— Presentation transcript:

1 Dysphagia Update: Evidence, Tools & Practice Dr. Timothy J. Shephard, CNS, CNRN Stroke Systems Consulting, Charlottesville, VA Bon Secours Health System, Richmond, VA The Author has no disclosures

2 Definitions Dysphagia-difficulty swallowing…due to obstruction or motor dysfunction Aspiration-penetration below the level of the vocal cords Silent aspiration- penetration below the level of true vocal cords without outward signs of difficulty (~16%)

3 Facts Current standards require dysphagia screening prior to any PO intake Formal dysphagia screening process decreases the rate of pneumonia 9 There are multiple tested and validated tools There are multiple barriers to successful implementation

4 Evidence ~700,000 new and recurrent strokes in the US annually Dysphagia clinically present in 42-67% in the first 3 days 1, 2 50% of patients with dysphagia experience aspiration 1, 2 ~33% of patients with dysphagia develop pneumonia requiring treatment 2 35% of post stroke deaths caused by pneumonia 2 A 3-fold increase in risk of death when diagnosed with pneumonia after stroke 3

5 Oral Prep Phase of Swallowing Tongue strength & movement Facial palsy Edentulous Drooling Pocketing

6 Oral Phase of Swallowing Tongue strength & movement Impaired vocal quality Facial palsy Plate elevation Gag reflex Cough

7 Pharyngeal Phase of Swallowing

8 Screening Methods Used Initial Awake & alert History NIHSS – screen based on stroke severity and/or suspected location of lesion On Exam 4 Dysarthria – 42% Tongue movement – 42% Gag reflex – 57% Palate elevation – 55% Voluntary cough – 27%

9 Cranial Nerves for Swallowing CN V -- Trigeminal contains both sensory and motor fibers that innervate the face important in chewing CN VII -- Facial contains both sensory and motor fibers important for sensation of oropharynx & taste to anterior 2/3 of tongue CN IX -- Glossopharyngeal contains both sensory and motor fibers important for taste to posterior tongue, sensory and motor functions of the pharynx CN X -- Vagus contains both sensory and motor fibers important for taste to oropharynx, and sensation and motor function to larynx and laryngopharynx. important for airway protection CN XII -- Hypoglossal contains motor fibers that primarily innervate the tongue

10 GI Motility online (May 2006) | doi: /gimo8 Analysis of BOLD responses during volitional swallow (Blood-Oxygen- Level-Dependent fMRI)

11 Tools Massey Bedside Swallow Screen 5 N = 25 Clench teeth, close lips, face symmetry, tongue & uvula midline Gag, cough, secretions, swallow reflex Plus water challenge (teaspoon & glass) Reported sensitivity & specificity were 100% Tested by research staff

12 Tools Standardized Swallowing Assessment (SSA) 6,7 N = 161, 8 item scale Alert, position Cough, control secretions, tongue movement, respiration Vocal quality Water challenge Repeated testing and validation Poor item agreement (61-69%) with exception of water challenge (90%) Results not compared to MBS results

13 Tools 3-0z water swallow test 8 N=44 Secretions, facial palsy, alert, oxygen, History of (asp) pneumonia, dysphagia, stroke Water challenge Sensitivity & specificity 76% & 59% respectively Increased sensitivity for more severe aspiration Compared to MBS

14 Tools STAND Screening Tool for Acute Neurological Dysphagia N = 97, 21 with MBS, tested in clinical practice Alert, vocal quality/secretions, history Puree & water challenge Allows PO meds if puree challenge passed & SLP consult if water challenge failed Sensitivity for dysphagia= 92% 92% of patients with dysphagia will be detected with this screen (small chance of false negative) Specificity for dysphagia = 60% 60% of patients without dysphagia will be ruled out with this screen (higher risk of false positive)

15 STAND Predictive Value: Dysphagia Positive predictive value: the probability that a person has the disease given a positive test result Positive Predictive Value =.90 Based on positive (dysphagia present) screening results,.90 probability that patient has dysphagia. Negative predictive value: the probability that a person does not have the disease given a negative result Negative Predictive Value =.60 Based on negative (dysphagia absent) screening results,.60 probability that patient does not have dysphagia

16 STAND Data: Aspiration Sensitivity for aspiration = 90% 90% of patients who will aspirate on MBS will be detected with this screen (small chance of false negative) Specificity for aspiration = 55% 55% of patients who will not aspirate on MBS will be ruled out with this screen (higher risk of false positive) Positive Predictive Value =.66 Based on positive (dysphagia present) screening results,.66 probability that patient will aspirate during MBS Negative Predictive Value =.83 Based on negative (dysphagia absent) screening results,.83 probability that patient will not aspirate during MBS

17 Tools Analysis Use a tested and valid tool (or ALL the components of one) Multiple step tool with automatic STOPS for SLP consult Generally requires: LOC & history Clearly visible & defined exam items Absolutely requires water swallow challenge A tool tested for stroke isnt necessarily adequate for use with other populations Visible assessment items need clear definitions

18 Methods for Implementation Options: location of screening process Emergency Department Must either perform screen or maintain strict NPO Clearly document PO intake/NPO for indicator abstraction Potential barriers Emergent need for PO meds (ASA/Plavix?) Patient demand for food/fluids (RRT or consult) Off-service attending MD (order sets, data & education) CN exam will suffice (not a CN deficit)

19 Identified Sources of Resistance Nursing Leadership Additional training, documentation, liability burden Application of current research, autonomy in practice More control over PO intake/nutritional status/medication route Formalized screening process reduces risk Speech Language Pathology Reduction in consults & control Reduction in task consults Increase in diagnostic (MBS) & treatment consults Data supports additional FTEs

20 Identified Sources of Resistance Medicine Resistance to use of screening method, relying on informal exam findings Pre-printed order sets ED screening before PO Decrease calls/pages for change in PO medication route Decreased complications, LOC, costs Requires education of standard, benefits of adherence, liability of non-compliance

21 Summary of Pearls Use a tested & validated tool, the best tool has not been designed Clinical exam findings need clear definitions & have limited screening value if not linked to water challenge CN exam alone is least effective form of screening Determine best location for implementation Determine single location for documentation of D/T for screen and first PO intake. Overcome resistance by highlighting positive clinical and fiscal impact of implementation SPECIFC to the source of resistance.

22 References 1. Perry L * Love CP. Screening for dysphagia and aspiration in acute stroke: a systematic review. Dysphagia 2001; 16: Kidd D, Lawson J, Nesbitt R, MacMahon J. The natural history and clinical consequences of aspiration in acute stroke. QJM. 1995;88: Diagnosis and treatment of swallowing disorders (dysphagia) in acute-care stroke. Evidence report/technology assessment Ref. Type: Report 4. Mann G & Hankey G. Initial clinical and demographic predictors of swallowing impairment following acute stroke. Dysphagia 2000;16: Massey R & Jedlicka D. The Massey bedside swallowing screen. Journal of Neuroscience Nursing 2002;24(5): Perry L. Screening swallowing function of patients with acute stroke: Part one. Journal of Clinical Nursing 2002;10: Perry L. Screening swallowing function of patients with acute stroke: Part one. Journal of Clinical Nursing 2002;10: DePippo K, Holas MS, Reding MJ. Validation of the 3-oz water swallow test for aspiration following stroke. Archives of Neurology 1992;49: Hinchey JA, Shephard TJ, Furie K, Smith D, Wang D, Tonn S, For the Stroke Practice Improvement Investigators. Formal dysphagia screening protocols prevent pneumonia. 2005;36:

23 For Copies of This Lecture ASA International Stroke Conference CD-ROM American Association Of Neuroscience Nursing Online Resource Area THANK YOU!!


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