Dysphagia Assessment at SFMC

Dysphagia Assessment at SFMC
Denise Galbreath, SLP

Swallowing: General Concepts
Swallowing involves the entire process food and liquid take from the mouth to the stomach There are four phases of swallowing that are dynamic and overlap each other I am here today to discuss with you some general concepts about swallowing and its disorders, methods of assessment in detecting swallowing disorders, why identifying swallowing disorders is important in the hospital setting, and how you can play a vital role in that process. To start, let’s define specifically the concept of swallowing. Swallowing is a process, and it includes the entire process that food and liquid take from the time they enter the mouth to when they reach the stomach. There are generally considered to be four phases in that process, and rather than being four distinct phases, those phases are dynamic and overlap each other.

Oral Preparatory Phase The anticipation of eating or drinking Food or liquid is taken into the mouth (bitten off, taken from utensil, taken from a cup or straw) Food is chewed and mixed with saliva Oral Phase Food or liquid is collected in the mouth The tongue moves the food or liquid to the back of the mouth and into the throat with a stripping motion The first phases is the oral preparatory phase and is the anticipation and preparation for eating and drinking. Food or liquid are taken into the mouth. Solid food is chewed during which it mixes with saliva. Then, during the oral phase, that food or liquid is collected in the mouth and the tongue transports it to the back of the mouth and into the throat. The tongue uses a stripping motion to move the food or liquid into the throat.

Pharyngeal Phase Soft palate elevates to keep food/liquid from leaking into the nasopharynx Tongue contacts the pharyngeal wall Larynx elevates and moves forward Epiglottis tilts down and back to protect the airway and divert food/liquid into the esophagus Vocal folds come together to add more airway protection Muscles of the pharynx contract to push the food The upper esophageal sphincter relaxes and the food moves into the esophagus During the pharyngeal phase, the soft palate elevates to close off the nasopharynx during the swallow. The tongue elevates to contact the back of the throat, or the pharyngeal wall. The larynx elevates and moves forward, causing the epiglottis to fold down and back to close the airway. The vocal folds also come together to further close the airway. The muscles of the pharynx contract and with that contraction, the food is pushed toward the esophagus. The upper esophageal sphincter which is tight at rest during breathing, relaxes and allows the food or liquid to enter the esophagus.

Esophageal Phase Contraction in a wave pattern (peristalsis) moves the food through the esophagus The lower esophageal sphincter relaxes and the food passes into the stomach Once the food or liquid enters the esophagus, further muscular contractions in a wave pattern known as peristalsis moves the food or liquid through the esophagus and toward the stomach. The lower esophageal sphincter, just like the UES, is closed at rest during breathing, then relaxes allowing the food or liquid to pass into the stomach. At the end of these four stages, all the muscles and anatomical structures return to rest position until the next swallow.

Dysphagia Dysphagia indicates difficulty in one or more phases of the swallow. Dysphagia may result from a variety of disorders and medical conditions. A few include stroke, Parkinson’s disease, head and neck cancer, tracheotomy, and dementia. Depending on the type and severity of their dysphagia, some patients with dysphagia are at risk for aspiration, subsequent pneumonia, malnutrition and dehydration which can increase hospital length of stay and the patient’s risk for mortality. Now that we know the basics about what swallowing involves, let’s talk about what happens when the process does not happen as it is intended. Dysphagia is a term indicating difficulty in one or more phases of the swallowing process. It can result from a variety of disorders and medical conditions, including CVA, progressive neurologic diseases such as Parkinson’s or MS, head and neck cancer, tracheotomy, and dementia. Why is dysphagia so important to know about? Well, depending on the type and severity of their dysphagia, patients may be at risk for aspiration which we will discuss in a bit which can then lead to pneumonia, malnutrition, dehydration and a host of other complications. When these complications occur in patients with dysphagia, we know that it can increase the time they are in the hospital and can increase their risk for death.

Dysphagia Oral phase dysphagia typically is caused by weakness or poor coordination of the lips, cheeks, or tongue and may result in: Difficulty keeping food or liquid in the mouth Difficulty manipulating or chewing food/liquid Weakness or difficulty propelling food/liquid from the mouth to the throat Ineffective clearance of food/liquid from the oral cavity What specific difficulties do occur in the swallowing process? During the oral phase, dysphagia typically results from weakness or poor coordination of the muscles of the lips, cheeks, or tongue. Evidence of oral dysphagia includes difficulty keeping food or liquid in the mouth, difficulty manipulating boluses or chewing, weakness or difficulty propelling the food or liquid from the front to the back of the mouth and into the throat, and ineffective clearance of the mouth with residue in the mouth after the swallow.

Dysphagia Pharyngeal phase dysphagia results from pharyngeal muscle weakness, difficulty initiating a swallow, or uncoordinated timing of muscle contractions and airway closure Food or liquids may not move through the pharynx well due to weakness and may be left behind after the swallow If airway protection is inadequate due to muscle weakness or coordination of airway closure, food/liquid may escape into the trachea and even past the vocal cords, resulting in aspiration Signs of pharyngeal dysphagia include coughing, choking, or gagging while eating/drinking or shortly after; a wet, gurgling vocal quality while eating or shortly after; or complaints of “something sticking” after eating/drinking. Some patients may present with no physical signs of their dysphagia. These patients are at risk for silent aspiration. Pharyngeal phase difficulties typically result from muscle weakness, difficulty initiating a swallow due to poor sensory responses, or uncoordinated timing of muscle contractions and closure of the airway. During the pharyngeal phase, if dysphagia is noted, food or liquids may not move through the throat well and may leave residue behind after the swallow. Additionally, if airway closure is incomplete or uncoordinated, food or liquid may escape into the trachea which is called penetration, and may even travel past the vocal cords which is defined as aspiration. Although we cannot see inside the pharynx to know exactly what is occurring, there are signs to look for pharyngeal dysphagia. Those include coughing, choking, or gagging with food or liquid or soon after eating, a wet vocal quality while eating or after, and complaints of something sticking after eating. However, if there is sensory involvement, patients may show no physical signs of their pharyngeal dysphagia. These patients are at risk for silent aspiration, meaning there may be incomplete or uncoordinated airway protection with subsequent aspiration but we cannot detect it at bedside due to the lack of physical signs.

Dysphagia

Dysphagia Clinical Impact of Aspiration May Include:
Respiratory Status Decline Acute airway obstruction Bacterial infections including pneumonitis, infiltrates, lung abscess Decreased respiratory status may result in: Death Intubation Mechanical ventilation Patient discomfort and longer hospital stay Why exactly does aspiration matter to us? Aspiration can lead to respiratory status decline. Acutely, patients can have airway obstruction. More typically, bacterial infections can develop over time including pneumonitis, infiltrates, or lung abscesses. Their decreased respiratory status may result in patients’ death in the worst case, or in intubation/mechanical ventilation, patient discomfort, and a longer hospital stay.

Dysphagia Esophageal stage dysphagia may be a result of neurological disorders, a mechanical issue (such as a stricture), or weak/uncoordinated muscle contraction Reflux results from food/liquid moving from the stomach back through the esophagus Many individuals with esophageal dysphagia complain of feeling that “something is stuck,” avoid certain foods, or have frequent instances of reflux, regurgitation, or discomfort/burning while eating or shortly after There can also be difficulties during the esophageal stage that result from neurologic disorders, an anatomic or mechanical issue, or weak/uncoordinated muscle contraction. Common esophageal dysphagia diagnoses include strictures, reflux, and dysmotility. Many patients who have esophageal dysphagia have symptoms including complaints of feeling something is stuck in their throats, avoiding certain foods, and frequent instances of reflux, regurgitation, or discomfort/burning while eating or after.

Evaluating Dysphagia A speech-language pathologist (SLP) is a professional extensively trained to assess oral and pharyngeal stage dysphagia and screen for esophageal dysphagia. The SLP may evaluate a patient with a clinical bedside exam or with one or more instrumental examinations including: Modified barium swallow study or videofluroscopic swallowing examination: A series of xray films taken continuously as a patient swallows Fiberoptic Endoscopic Evaluation of Swallowing: A special camera on a small scope is inserted into the nose and the throat is watched as the patient swallows foods and liquids So we know there are some physical signs of dysphagia we can look for…but how do we best evaluate for dysphagia?? A speech language pathologist is a professional who is extensively trained in the assessment of dysphagia, particularly in the oral and pharyngeal phases, and can screen for esophageal dysphagia to make referrals as needed. The SLP can evaluate patients initially with a clinical bedside exam. If the SLP needs more information, though, we may choose to have the patient participate in one or more instrumental exams. Two examples are the modified barium swallow study which is a series of xray films taken continuously as the patient swallows a variety of consistencies and textures and the fiberoptic endoscopic evaluation of swallowing which involves using a camera inserted through the nasopharynx to watch as the patient swallows foods or liquids.

Treating Dysphagia Depending on which phase of the swallow is affected and depending on the cause of the dysphagia, a patient may benefit from: Dietary modifications Dysphagia therapy including exercises, strategies to make eating/drinking safer, and postural modifications Medical or surgical interventions Once the SLP fully evaluates the swallowing process and determines the location, extent, and cause of the dysphagia, the SLP may recommend dietary modifications, dysphagia therapy including exercises, strategies to make eating safer, or postural modifications to make the swallow more efficient/effective, or medical/surgical interventions.

How You Can Help: Screening for Dysphagia
Although the SLP is the best trained to fully evaluate and treat oral and pharyngeal dysphagia, other professionals need to be competent to screen patients for dysphagia and refer appropriate patients for full evaluation and treatment by the SLP Although the SLP is the best trained professional to fully evaluate and treat dysphagia, you still have a role to play in screening patients and referring appropriate patients for full evaluation and treatment so that long term complications are avoided.

Checking for a gag reflex is one assessment method used historically but is not a sensitive tool for screening a patient’s ability to swallow safely The gag reflex is a neurologic sign but is not reflective of a patient’s ability to elevate and move the larynx forward to invert the epiglottis and close the airway for a safe swallow Some patients without a gag reflex are able to swallow safely; some patients with an intact gag reflex demonstrate aspiration and are at risk for developing pneumonia In the past, checking for a gag reflex has been used to screen a patient’s ability to swallow safely. Although it is a sign of neurologic integrity, it is not necessarily reflective of a patient’s ability to elevate and move the larynx forward, which is ultimately the key to airway protection. We know that some patients who do not have a strong gag reflex are able to swallow safely, and many patients who have an intact gag reflex may still demonstrate aspiration and are still at risk for developing pneumonia.

Although SLPs use a variety of techniques in their clinical bedside assessment of dysphagia and find them effective in making clinical decisions, literature and research suggests that screening tools that include a water swallow challenge are the most sensitive in identifying patients who are at risk for aspiration Clinical screening for dysphagia is best accomplished by completing an initial assessment of the patient’s appropriateness to participate in screening with P.O. trials and if so, offering P.O. trials and monitoring for common difficulties seen in the oral and pharyngeal phases of swallowing SLPs use a variety of techniques to detect dysphagia during clinical bedside assessments. Literature and research suggest that including a water swallow challenge during the clinical bedside assessment enhances the sensitivity of the assessment. So, in considering screening patients for dysphagia, we first want to determine the patient’s appropriateness to participate and then offer oral trials to monitor for difficulties particularly in the oral and pharyngeal phases.

Dysphagia screening may occur at any point in a patient’s hospitalization. All patients who have a history of dysphagia or have a medical condition that carries the possibility for dysphagia and a risk for aspiration should be screened on admission prior to receiving any food, liquid, or medication. Patients who meet screening criteria but are not appropriate to be evaluated or cannot participate in evaluation initially who then demonstrate improved status should be screened prior to receiving any food, liquid, or medication. Any patient who experiences a change in status during hospitalization and after change in status has a medical condition which meets screening criteria should be screened for dysphagia prior to receiving any food, liquid, or medication. When should this screening take place and who needs to be screened?? Dysphagia screening can occur at any point during a patient’s hospitalization. Any patient who has a history of dysphagia should be screened on admission and any patient with a medical condition that carries the possibility for dysphagia and the risk for aspiration—such as those we discussed earlier—CVA, Parkinson’s, head and neck cancer, etc.— should be screened on admission. Screening should occur before the patient receives anything by mouth, including food, liquid, and even medication. Additionally, if a patient has a change in status during hospitalization and then meets screening criteria, the patient should then be screened before eating, drinking, or taking medications.

STAND Screening: Initial Assessment is done for all patients to examine: Is the patient too lethargic or unable to maintain oxygen saturations above 90%? Is the patient exhibiting a gurgly vocal quality or inability to handle oral secretions? Does the patient have a history of dysphagia (e.g., on thickened liquids prior to admission, has a PEG tube in place, etc.)? If YES to any of the above and corresponding box checked, patient is to be held NPO and screening STOPS If patient alert enough, able to handle secretions and maintain oxygen saturations above 90% and there is no history of dysphagia, indicate this with a checked box and you can PROCEED to the swallow challenge At St. Mary’s Hospital in Richmond, VA with assistance from our partner for therapy services, Sheltering Arms Physical Rehabilitation Centers, we developed a specific screening tool for nurses to use to screen patients for dysphagia and refer appropriate patients for full evaluation as needed to the SLP. We want to share that tool with you today in hopes that it will be useful to you in your daily practice at your facilities. We initially assessed this tool for reliability and validity in our acute stroke population, so we called it the Screening Tool for Acute Neurologic Dysphagia or STAND; however we also have used it in a med/surg population with equal success. The STAND tool starts with an initial assessment that is done with all patients who are screened. The nurse is asked to assess whether the patient is too lethargic or unable to keep oxygen saturations at or above 90%, whether the patient has a gurgling vocal quality or an inability to manage oral secretions, or has a history of dysphagia. If any of these assessments are marked as true or present, the tool instructs the nurse to stop, keep the patient NPO, and ask for a speech consult from the physician. However, if the patient is alert, can handle oral secretions, is maintaining oxygen saturations at an acceptable level, and has no history of dysphagia, the nurse proceeds.

STAND Screening: Swallow challenge: 1. Give the patient a teaspoon of applesauce or pudding. If patient exhibits no difficulty with puree, PROCEED to step 2. If patient exhibits difficulty, refer to Problem List and document problems noted. STOP screening. 2. Give the patient 3oz. of water via cup drinking and 3 oz. of water via straw drinking. If patient exhibits no difficulty, PROCEED to Assessment, Actions, and Documentation and start diet ordered. If patient exhibits difficulty, refer to Problem List and document problems noted. Complete Assessment, Actions, and Documentation. Section 2 consists of a swallow challenge. The nurse first offers the patient a tsp full of applesauce or pudding and observes for problems. Problems are listed to the side, so all the nurse has to do is write the number corresponding to the observed problem on the line. If any difficulty is noted, the nurse is again asked to stop the screening process, notify the physician, and ask for a speech consult. If no difficulties with the puree trial are noted, the nurse again proceeds. Then nurse then offers the patient 3oz. Of water from a cup and then from a straw, again watching and monitoring for any signs of difficulties and documenting any problems that occur. If difficulties are noted, the nurse again stops the screening process, notifies the physician, and asks for a speech consult.

STAND Screening: Assessment: Document normal findings OR… Indicate if any findings were abnormal in initial assessment or swallow challenge Actions: Document your actions if any abnormal findings including: The physician was notified of any abnormal results Medication route was addressed with the physician Speech therapy consult for swallowing evaluation was ordered by the physician Section 3 involves a series of assessments to document findings and actions taken. The unique feature of our tool is that the nurse is asked to document whether medication route has been addressed with the physician. For example, if the patient does well on the puree trial, but fails on the water trial…the nurse has the option to report this to the physician so that meds can be given in puree rather than immediately changed to IV. If the patient does pass all sections of the screen, the nurse is still instructed to continue to monitor all patients to note any signs of aspiration including temperature spikes, oxygen de-saturation with eating, or change in lung auscultation.

Initial Assessment One or more items marked “Abnormal” All items marked “Normal” Swallow challenge: purees Difficulties noted STOP screening. Call the physician. Discuss with physician: Necessary diet order changes/NPO status Need for medication route change Speech therapy consult for swallowing evaluation Educate patient and family No difficulties noted Swallow challenge: --3 oz. water by cup --3 oz. water by straw Difficulties noted No difficulties noted Proceed with diet as ordered. Continue to monitor for signs of silent aspiration.

How You Can Help: General Aspiration Precautions
General Aspiration Precautions are taken to prevent aspiration and respiratory status compromise in any patient that is eating ORALLY or receiving ENTERAL feeding In addition to screening patients for dysphagia and being aware of the clinical impact of dysphagia, I want to discuss with you other ways to reduce the risk for aspiration in patients with swallowing difficulties. One way to do this is by following general aspiration precautions which are the precautions taken to prevent aspiration and subsequent respiratory status compromise and these are precautions that will benefit both patients who are eating orally or are receiving enteral feedings.

Monitor level of alertness and only feed patients orally who are FULLY alert. Position patients FULLY upright during P.O. or enteral feedings and for at least 30 minutes after. This means as close to 90° angle between the top of the body and the bottom of the body as possible. Observe for any change in vital signs during feedings. Listen for cough, shortness of breath, or congestion during or after feeding. General aspiration precautions involve monitoring levels of alertness and feeding patients orally only when they are alert, positioning patients as close to upright position as possible during oral or tube feedings, observing for any changes in vitals during feedings, and listening for coughing, SOB, or congestion during or shortly after feeding.

Listen for any changes in vocal quality during and after eating. Be alert if the voice becomes wet, gurgly. Watch for any spikes in temperature. Be alert for non-cardiac chest pain. Listen for any changes in lung/chest sound auscultation. Be alert for any patient complaints of difficulty. They also involve listening for changes in vocal quality, watching for spikes in temperature, being alert for non-cardiac chest pain, listening for changes in lung auscultation, and being alert for patient complaints of difficulty with feedings.

How You Can Help: Encouraging Safe Swallowing
If you are caring for a patient who has dysphagia, remind the patient to: Sit upright when eating, drinking, or taking medication and for at least a half hour after eating. Take one bite or sip at a time. Finish chewing and swallowing the first bite or sip before taking another. Do not talk while chewing and swallowing. Take small bites and sips and don’t go too fast. Clean the oral cavity after meals with a toothbrush or swab. If there is weakness on one side of the face, make sure no food or liquid is left on the inside of the mouth on the weak side. In addition to general aspiration precautions, you can help patients with dysphagia by encouraging safe swallowing while they are eating orally. Remind the patient to sit upright anytime they are eating, drinking or taking meds, and for at least a half hour after eating. Remind the patient to take one bite or sip at a time and finish chewing and swallowing the first bite or sip before taking another. Encourage the patient not to talk while swallowing and to take small bites and sips at a slow rate. Finally, help the patient clean the oral cavity after meals to clear any food or liquid that may be left in the mouth after the swallow. Remember, you are the most direct contact with the patient on a minute by minute basis and you can help prevent the complications caused by aspiration by knowing who, when, and how to screen for dysphagia, referring appropriate patients to the SLP for full evaluating, following general aspiration precautions, and encouraging safe swallowing strategies. You now have the knowledge and tools to prevent complications resulting from undetected and untreated dysphagia.

References American Speech-Language Hearing Association, Special Interest Division 13. (2006). Frequently Asked Questions on Swallowing Screening: Special Emphasis on Patients with Acute Stroke. Centers for Disease Control. (2003). Guidelines for preventing healthcare associated pneumonia: Recommendations of CDC and Healthcare Infection Control Practices Advisory Committee. Hinchey, J.A., Shephard, T., Furie, K., Smith, D., Wang, D. & Tonn, S. (2005). Formal dysphagia screening protocols prevent pneumonia. Stroke, 36(9), Joint Commission on the Accreditation of Healthcare Organizations. (2007). Stroke Performance Measurement Implementation Guide. Katzan, I.L., Cebul, R.D., Husak, S.H., Dawson, N.V., & Baker, D.W. (2003). The effect of pneumonia on mortality among patients hospitalized for acute stroke. Neurology. 25: Mann, G., Hankey, G.J., & Cameron, D. (1999). Swallowing function after stroke: prognosis and prognostic factors at 6 months. Stroke, 30(4), Mann, G., Hankey, G.J., & Cameron, D. (2000). Swallowing disorders following acute stroke: prevalence and diagnostic accuracy. Cerebrovascular Diseases , 10(5), Martino, R., Foley, N., Bhogal, S., Diamant, N., Speechley, M., & Teasell, R. (2005). Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke, 36(12), Martino, R., Pron, G., & Diamant, N. (2000). Screening for oropharyngeal dysphagia in stroke: insufficient evidence for guidelines. Dysphagia, 15(1), St. Mary’s Hospital, Bon Secours Richmond Health System (2008). Nursing Policy and Procedure: “ASPPREC.”

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