Dysphagia Assessment at SFMC

1. Dysphagia Assessment at SFMC Denise Galbreath, SLP

2. 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

3. Swallowing:General Concepts • 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

4. Swallowing:General Concepts

5. Swallowing:General Concepts • 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

6. Swallowing:General Concepts

7. Swallowing:General Concepts • 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

8. 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.

9. 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

10. 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.

11. Dysphagia

12. 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

13. 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

14. 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

15. 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

16. 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

17. How You Can Help:Screening for Dysphagia 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

18. How You Can Help:Screening for Dysphagia 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

19. How You Can Help:Screening for Dysphagia 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.

20. How You Can Help:Screening for Dysphagia • 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

21. How You Can Help:Screening for Dysphagia

22. How You Can Help:Screening for Dysphagia • 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.

23. How You Can Help:Screening for Dysphagia

24. How You Can Help:Screening for Dysphagia • 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

25. How You Can Help:Screening for Dysphagia

26. How You Can Help:Screening for Dysphagia 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.

27. 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

28. How You Can Help:General Aspiration Precautions • 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.

29. How You Can Help:General Aspiration Precautions • 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.

30. 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.

31. References • American Speech-Language Hearing Association, Special Interest Division 13. (2006). Frequently Asked Questions on Swallowing Screening: Special Emphasis on Patients with Acute Stroke. http://www.asha.org/NR/rdonlyres/BBDD4A46-EE96-4821-A710-D19D903E389F/0/DysphagiaFAQ.pdf • 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), 1972-1976. • Joint Commission on the Accreditation of Healthcare Organizations. (2007). Stroke Performance Measurement Implementation Guide. http://www.jointcommission.org/CertificationPrograms/PrimaryStrokeCenters/guide_table_contents.htm • 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: 620-625 • Mann, G., Hankey, G.J., & Cameron, D. (1999). Swallowing function after stroke: prognosis and prognostic factors at 6 months. Stroke, 30(4), 744-748. • Mann, G., Hankey, G.J., & Cameron, D. (2000). Swallowing disorders following acute stroke: prevalence and diagnostic accuracy. Cerebrovascular Diseases , 10(5), 380-386. • Martino, R., Foley, N., Bhogal, S., Diamant, N., Speechley, M., & Teasell, R. (2005). Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke, 36(12), 2756-2763. • Martino, R., Pron, G., & Diamant, N. (2000). Screening for oropharyngeal dysphagia in stroke: insufficient evidence for guidelines. Dysphagia, 15(1), 19-30. • St. Mary’s Hospital, Bon Secours Richmond Health System (2008). Nursing Policy and Procedure: “ASPPREC.”