Post on 22-Jul-2020
transcript
Slide 1
The Use of Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
as a Tool for Clinical Decision Making in the Evaluation and
Management of Dysphagia
Rebecca L. Gould, MSC, CCC-SLP, BRS-SMSHA Convention 2012
March 29, 2012rebec26050@aol.com
(561) 833-2090www.med-speech.com
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 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
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 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
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 4
1991-98, number of
patients hospitalized for aspiration pneumonia increased by 93.5% making it the second most common reason for hospitalization.
American Journal Public Health 91:1121-1123, 2001
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 5
“IS IT SAFE TO FEED
THIS PATIENT?”
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 6
STATE
OF THE ART
EVALUATION
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 7
EVALUATION
Clinical “bedside” swallow evaluation.
Videofluoroscopic Swallowing Study (VFSS)
Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
(Reflexive cough test)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 8 SWALLOWING
Swallowing involves a highly coordinated series of events with voluntary and involuntary control
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 9
Innervation
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 10
The cranial nerves
I Olfactory
II Optic
III Oculomotor
IV Trochlear
V Trigeminal
VI Abducens
VII Facial
VIII Vestibular
IX Glosso-
pharyngeal
X Vagus
XI Accessory
XII Hypoglossal
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 11
RLG
Type of
nerve
Site of origin Site of
termination
Function
Sensory-afferent Mucus membrane
lining respiratory
& digestive tracts
Pharynx, larynx,
trachea,
esophagus, heart,
abdominal
viscera
Medulla Taste &
sensation from
larynx, neck,
thorax &
abdomen
Motor-efferent Medulla Muscles of
pharynx &
larynx
Parasym fibres
to abdominal &
thoracic viscera
[motor to all
smooth muscle;
almost all
thoracic &
abdominal
organs]
Swallowing,
movement of
pharynx &
larynx
Inhibitory fibres
to heart;
secretion of
gastric glands &
pancreas;
vasodilator
fibres to
abdominal
viscera
[secretory to all
glands]
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 12
The cranial nervesRLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 13 Swallowing
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 14 SWALLOWING STAGES BY PHASE
RLG
Oral Phase
The food is collected
Sealed between the roof of the mouth and the tongue
The tongue moves the food back with a stripping wave into the back of the throat (pharynx)
This begins the actual swallow
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 15
Oral peripheral examination should include assessment of dentition
Oral disease factor impacts pneumonia risk
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 16 SWALLOWING STAGES BY PHASE (cont’d)
RLG
Oro-pharyngeal Phase
Soft palate elevates
Preventing food from escaping into the nose
Tongue base moves back to contact pharyngeal
wall
Larynx (voice box) moves up and forward
Epiglottis (top part of larynx) is tilted down and
back to guide the food past the airway
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 17
RLG
Muscles of the pharynx create the
pharyngeal compression
during swallow
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 18 SWALLOWING STAGES BY PHASE (cont’d)
RLG
Esophageal Phase
Breathing momentarily stops
Vocal folds come together to further protect airway
Muscles of the pharynx contract
Move the food towards the esophagus (tube leading to stomach)
Upper esophageal sphincter relaxes
Food passes into the esophagus
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 19
SWALLOWING STAGES
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 20
•RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 21 PHYSIOLOGY
Swallowing
Muscular act involving muscles and structures in the oral, pharyngeal, laryngeal, and esophageal cavities
Coordinated to allow food to be transported from the oral cavity to the stomach without spillage, residue, or laryngeal penetration
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 22 Comments
Swallowing is everything but a simple system
Swallowing consist in 2 central patterns generators (CPGs)
Supramedullary control
Both excitation and inhibition
Neurons and neuronal pools in swallowing CPG are shared by other neuromuscular systems, for example breathing
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 23
•RLG
Clinical decision making flow chart provides framework for “thinking the question”
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 24
Clinical Evaluation
1. Case History
a) Onset (acute vs. chronic)
b) Progression (rocky vs. smooth)
c) Activity level (sedentary vs. mobile)
d) Cognition (treatment to patient or caretaker)
e) Family, caretaker support
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 25
Clinical Evaluation (cont’d)
2. Test Information
a) CXR/PFT results
b) Blood chemistries
c) Neurological system
d) Immune system
e) GI system
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 26 Clinical Evaluation (cont’d)
3. “Bedside” evaluation
Oral peripheral exam (gag, palatal function, state of dentition)
Cranial nerves (V, VII, IX, X, XII)
Motor speech exam
Presentation of food
Auscultation of swallow
Secretions
Tartaric acid test (Reflex cough)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 27
MBSS? or FEES?
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 28 Two Goals of Swallowing Evaluation:
1. Determine the Safest and Least Restrictive Level of P.O.
2. Determine the physiologic breakdown of the swallow so it can be rehabilitated in treatment.
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 29 FEES (FiberopticEndoscopic Evaluation of Swallowing)
•RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 30
•RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 31
•RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 32
Test ALL Types of Food/Liquid
Thin liquid
Thick liquid (nectar)
Puree
Solid
Mixed Consistency
Pills
Challenging food (i.e. nuts, peanuts, etc.)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 33
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 34 Give MULTIPLE trials of each consistency
CPG can break down
◦Large bolus size
◦Consistency
◦Fatigue
◦Lack of coordination (COPD)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 35
Typically use green food coloring
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 36
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
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 37
Assess secretions
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 38 Swallow Initiation
Bolus spills to valleculae or pyriform sinuses for greater than one second before the swallow (white-out).
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 39
FEES Interpretation
Four Main Parameters:
Delay in Swallow Initiation
Penetration
Aspiration
Residue
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 40 Timing of Penetration/Aspiration
Before the Swallow
During the Swallow
After the Swallow
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 41
PENETRATION
Entry of material into the laryngeal vestibule to the level of the vocal folds.
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 42
ASPIRATION
Entry of
material
below the
level of true
vocal folds.
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 43
ASPIRATION
FEES VFSS
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 44
ASPIRATIONRLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 45 ASPIRATION
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 46
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 47
RESIDUAL
Leftover material in the oral pharynx after swallow has occurred.
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 48 Residual
FEESVFSS
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 49
Issues With Residue
Residue in Valleculae?
Residue in Pyriform Sinuses?
Diffuse Pharyngeal Residue?
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 50
RESIDUAL
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 51
Zenker’s DiverticulumRLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 52
Esophageal Achalasia
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 53
RLG
Cervical
Osteophytes
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 54
Globus
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 55 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
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 56 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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 57 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
3incorrect identification of aspiration risk
19 incorrect identification of aspiration risk
8correct identification of no aspiration riskLeder, S.B. et al (2002)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 58
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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 59
Bastian nicely delineates +/- of VFSS vs. FEES
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 60 Indications for instrumental examinations
Unresolved clinical condition
Oral stage dysphagia (f)
Upper esophageal or esophageal stage dysphagia (f)
Vague complaints (f)
Clinically inexplicable weight loss (f)
Initial exam for longstanding dysphagia (f)
(f) fluoroscopy (e) endoscopy
Bastian, R.W. (1993)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 61 Indications for instrumental examinations (cont’d)
Unresolved clinical condition Food stuck at thyroid notch or lower (f) Sudden onset of pharyngeal dysphagia
(f) (e) Food “stuck” above thyroid notch (f) (e) Retest, pharyngeal dysphagia (f) (e) Biofeedback, pharyngeal dysphagia (f)
(e)
(f) fluoroscopy (e) endoscopy
Bastian, R.W. (1993)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 62 Indications for instrumental examinations (cont’d)
Unresolved clinical condition
Aspiration of secretions (e)
Anatomic anomalies (e)
Assess airway protection patterns (e)
Fluoroscopic unavailable (e)
(f) fluoroscopy (e) endoscopy
Bastian, R.W. (1993)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 63
Fluoroscopic Image
Views will include:pharynx
oral cavity
portions of the striated esophagus
- Opportunity to screen esophageal phase or perform full esophogram
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 64
Laryngoscopic Image
Views will include:nasal cavity
nasopharynx
hypopharynx
endolarynx
anterior wall of trachea
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 65
Studied reliability of the correlation between clinical indicators than events of dysphagia. Found that less than 50% of the measures that clinicians typically employ are rated with sufficient inter-and intrajudge reliability.
Murray, J. (2000)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 66
Studied six expert judges
Conclusion: Better at reporting normal
findings/absence of abnormal findings Less reliable for making definitive
pathophysiological diagnoses
Murray, J. (2000)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 67
VFSS appears more useful for determining which foods a subject can swallow without aspiration than it is for making definitive pathophysiologicial diagnoses.
Kuhlemeier, K. et al. (1998)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 68 The safety of Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST): An analysis of 500 Consecutive Evaluations
498 evaluations were completed 3 instances of epistaxis no cases of airway compromise no significant differences in heart rate
pre and posttest measurements 81% noted mild or not discomfort
FEEST is a safe method of evaluating dysphagia in the tertiary care setting.
Aviv, J.E. et al (2000)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 69 Role of the Speech-Language Pathologist in the performance and interpretation of Endoscopic Evaluation of Swallowing: Guidelines
ASHA Scope of Practice in Speech Language Pathology (ASHA, 2001) includes conducting instrumental swallowing evaluation, including fiberoptic endoscopic examinations of swallowing (FEES)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 70 Role of the Speech-Language Pathologist in the performance and interpretation of Endoscopic Evaluation of Swallowing: Guidelines
(cont’d)
ASHA Code of Ethics (ASHA, 2003) states “Individuals shall engage in only those aspects of the profession that are within their competence, considering their level of education, training, and experience”.
ASHA (2004) Role of the Speech-Language Pathologist in the performance
and interpretation of Endoscopic Evaluation of Swallowing: Guidelines
Http//www.asha.org/members/deskref-journals/deskref/default
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 71 Role of the Speech-Language Pathologist in the performance and interpretation of Endoscopic Evaluation
of Swallowing: Guidelines (cont’d)
FEES procedure as a comprehensive functional evaluation of the pharyngeal stage of swallowing, leading to recommendations regarding the adequacy of the swallow, the advisability of oral feeding and the use of appropriate interventions to facilitate safe and efficient swallowing (ASHA, 2004b)
ASHA (2004) Role of the Speech-Language Pathologist in the performance
and interpretation of Endoscopic Evaluation of Swallowing: Guidelines
Http//www.asha.org/members/deskref-journals/deskref/default
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 72 Role of the Speech-Language Pathologist in the performance and interpretation of Endoscopic Evaluation
of Swallowing: Guidelines (cont’d)
Purpose allows for: 1. Identification of normal and abnormal
anatomy and physiology of the swallow2. Integrity of airway protection as it relates to
swallowing function3. The effectiveness of postures, maneuvers,
bolus modifications, and sensory enhancements in improving swallowing.
4. Provision of recommendations regarding the optimum delivery and maintenance of nutrition and hydration
ASHA (2004) Role of the Speech-Language Pathologist in the performance
and interpretation of Endoscopic Evaluation of Swallowing: Guidelines
Http//www.asha.org/members/deskref-journals/deskref/defaultRLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 73
Comments Scanning the esophagus provides complete
study of all 3 dynamic phases of swallow. Failure to follow bolus into the stomach prevents visualization of diverticulums, stricture, achalasia, and LES. May not happen routinely due to: 1) reimbursement/ liability issues. 2) Inadequate communication between speech pathologist and radiologist. 3) Inadequate knowledge on part of SLP.
The MBS is viewed as the gold standard for evaluation of all 3 phases of swallow function. Drawbacks: radiation exposure, scheduling/logistics issues, number of people required to perform exam.
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 74
Comments
FEES: excellent repeat study. Some researchers suggest 90% correlation between these two studies in experienced clinicians. FEES: Advantages: no radiation exposure, less people required to perform test, may be done at bedside, great biofeedback, evaluates handling of secretions, no barium required. Disadvantages: do not see actual moment of swallow; however, may infer when aspiration occurred, not good for evaluation of oral and esophageal phases.
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 75
Competency
Currently, “competency” is granted by your employing institution/“In house,” competency standard is along with state law.
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 76
You can take ten courses; however, no course will certify you as an expert
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 77 Position of state licensing boards
RLG
Some states specifically include endoscopy in the speech-language pathology scope of practice and more recently some provide clear definition in statute.
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 78 Position of state licensing boards
For example Tennessee (2007)"The practice of speech-language pathology shall include the use of rigid and flexible endoscopes to observe the pharyngeal and laryngeal areas of the throat in order to observe, collect data, and measure the parameters of communication and swallowing for the purpose of functional assessment and rehabilitation planning."
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 79 Position of state licensing boards
New York has indicated that endoscopy is within the scope of SLPs' practice if they assume responsibility for its risks and do not administer any anesthesia.
[individual responsibility]
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 80
RLG
What is ASHA's response to the March 2003 position statement of the Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS)
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 81
1999:
"SLPs with specialized training are qualified to use FEES for assessment of swallowing function. Physicians use fiberopticendoscopic examinations to render medical diagnoses."
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 82 2003: "Physicians are the only professionals
qualified and licensed to render medical diagnoses related to the pathology affecting swallowing functions... Consequently; examinations should be viewed and interpreted by an otolaryngologist or other physician with training in this procedure."..."In addition, otolaryngologists or other physicians with training in this procedure should directly supervise non-physician professionals who are performing this procedure."
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 83
In 2005, ASHA issued a revised position statement that supports the SLPs' independent role in performing endoscopic evaluations of swallowing.
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 84 Some local Medical Review Policies (LMRPs) restrict payment to settings where a physician is available in the office suite. Many of these LMRPs also include wording indicating that in a hospital setting, the physician supervision requirement is presumed to be met and need not be documented. "Direct supervision" is used by Medicare to mean that the physician needs to be available in case assistance is needed, but "personal supervision" is not required by Medicare for these procedures.
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 85
Tell physicians the SLP role is to provide a functional diagnosis of swallowing, not a medical diagnosis.
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 86
•RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 87
ASPIRATION PNEUMONIA
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 88 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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 89 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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 90 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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 91
RLG
Thick, “crusted” mucous throughout hypopharynx.
Mucous appears moist and dispersed following hydration. (tsp. of water).
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 92 ClinicalPredictors 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)
delayed oral transit
RLG
Mann, G. & Hankey, G.J.(2001)
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 93
Tube feeding is associated with a higher rate of pneumonia than with patients who are eating.
M.J. Feinberg, MD (1990)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 94
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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 95 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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 96 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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 97 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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 98 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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 99
“Artificial feeding does not
seem to be a satisfactory solution for preventing pneumonia in elderly prandial aspirators”.
M.J. Feinberg, MD (1996)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 100 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
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 101 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
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 102 Pneumonia in acute stroke patients fed by nasogastric tube (cont’d)
Independent predictors Decreased level of consciousness Severe facial palsy.
ConclusionNasogastric tubes offer only limited protection against aspiration pneumonia in patients with dysphagia from acute stroke.
Dziewas R. et al, Jun 2004
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 103
189 male veterans (55 outpatients), 41 or 21.7% developed pneumonia. (Bivariate
analysis to determine predictive risk factors).
Langmore, et al (1998)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 104
RLG
Colonization (Altered Oropharyngeal Flora)
Dependent for oral care
Number of decayed teeth
Number of medications
Tube feeding
Aspiration into lungsLarge 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
PNEUMONIA
Langmore, S. (1997)
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 105
“Dysphagia and aspiration
are necessary but not sufficient conditions to predict development of aspiration pneumonia… a multifactorial phenomenon”.
Langmore,S. (1998)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 106
Focus on context of risk factors in given setting.
Assess strengths/weaknesses.
Langmore,S. et al(2000)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 107 Predictors of aspiration pneumonia in nursing homes patients
102,842 patient 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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 108 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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 109 Assessment of the adult with dysphagia
Conventional wisdom
Aspiration = Pneumonia
Prevention of aspiration = prevention of pneumonia
Tube feeding = safety
Murray, J. (Voice, Swallow & Airway 2002)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 110
Constructs for thinking
What makes the elderly different?
The prevalence of swallowing impairment increases with
age
Nilsson, H. et al. (1996)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 111
25% of the elderly suffer from oral dryness and related complaints
Salivary gland morphology and composition of saliva change with age
Vissink, A., et al. (1996)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 112 Impact of/on Nutritional status
Poor nutrition is cardinal feature of failure to thrive (FTT)
Associated difficulties:
Difficulty shopping 85%
Difficulty with meal preparation 85%
Poor appetite 55%
Weight loss 45% Chronic
anemia 42% Dehydration 36% Dysphagia 23% Pressure
sores 10% Alcohol abuse 7% Severe
constipation 6%
Murray, J. (Voice, Swallow & Airway 2002)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 113
What is a safe amount of aspiration?
What is the long term consequence of chronic aspiration?
What factors predict who will get pneumonia?
How important is age?
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 114
The Elderly
Lose weight Become apathetic Experience loss of cognitive/intellectual capacity
Experience loss of motor skill Fail to maintain social relatedness skills
Newhern, V. (1992)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 115 The Elderly
Loss of taste and smell are common in the elderly and result from normal aging
Schiffman, S. (1997)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 116
The Elderly
Clinical picture usually so diffuse that it provides few indications of the cause or of possible treatment.
The deterioration is disproportionate to the patient’s physical and physiological condition and beyond the expected age-associated “normal decline.
Newhern, V. (1992)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 117 The Elderly
Literature fails to answer these questions:
Risk for poor outcome Ability to maintain nutrition/hydration
via oral feeding Plan for management of safety and
vitality Means for improving physiology Plan manage decline and compensation Means for insuring quality of life
Murray, J. (Voice, Swallow & Airway 2002)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 118
Subgroups at risk
85 years of age and older
< age 65 FTT correlated with imminent death female (60%)
25 – 50% of patients were widowed
24 – 45% lived alone prior to admission to an acute care facility
Murray, J. (Voice, Swallow & Airway 2002)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 119 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-smokerRLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 120 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
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 121
SCALE PREDICTIVENESS OF
PNEUMONIA RISK IF FED (cont’d)
Score
< 7 = Use extreme caution
5–6 = fair – good
<3 = good – excellent
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 122 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
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 123 Outpatient
may have multiple diagnosis; however, “stable”
+ mobility number of medications if tube feeding, bolus fed typically are not dependent for feeding
smoking
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 124 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.
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 125
•RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 126
TREATMENT
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 127
SWALLOWING TREATMENT
“The human body is one of the greatest compensatory mechanisms.”
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 128
GOAL: TARGET MOST CRITICAL RISK FACTORS.
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 129 TECHNIQUES OF DYSPHAGIA THERAPY
- MENDELSOHN MANEUVER
- SUPRAGLOTTIC SWALLOW
- MODIFIED VALSALVA
EXPECTORATION MANEUVER
POSTURES &
POSITIONING
- E-STIM
- EMG
- ORAL MOTOR EXERCISES
- BOLUS WEIGHT
STRENGTHENING
- THICK
- THICKER
- THICKEST
MANIPULATION OF
CONSISTENCY
- RESPIRATORY CONTROL
- WHEN TO SWALLOW
- HOW MANY SWALLOWS
- SEQUENCE
TIMING
- COGNITION
- GENERAL HX.
- COPD
- ACTIVITY LEVEL
PATIENT
NUANCES
A UNIQUE
PATIENT
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 130
Dysphagia therapyAre we doing what we think
we are doing?
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 131
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 132 Types of Treatments MANGEMENT
Indirect therapy
Modifying food and environment
Teach compensatory strategies
Maintain function
Reduce morbidity
Should be short term
REHABILITIATION
Direct/active therapy
Training patient
Strengthens muscles
Improves swallow physiology
More lasting improvement
•Anticipated outcome: increase safe oral intake to advance diet
•Secondary outcomes: improved nutritional status and enhanced long term functioning
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 133 TECHNIQUES OF DYSPHAGIA THERAPY
Postures &
Positioning
•Mendelsohn Maneuver
•Supraglottic Swallow (swallow high &
strong)
•Modified Vasalva
•Expectoration Maneuver
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 134 Strength-Training Exercise in Dysphagia Rehabilitation: Principles, Procedures, and Directions for Future Research
Explored the over-riding principles of neuromuscular plasticity with regard to strength training.
Evaluated how current exercise-training interventions in dysphagia rehabilitation correspond to this principles, and
Postulated directions for future study of normal and disordered swallowing and determine how to incorporate this principles into dysphagia rehabilitation.
Burkhead, L et al. (2007)RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 135
“Chin Tuck”
It is not worth attempting if aspirated material is originating in the pyriform sinuses. Shanahan et al. (1993) had 30 aspirating patients use the chin-down posture. It eliminated aspiration in half (15) of them. However all 15 patients whose aspirated material originated I the pyriform sinuses continued to aspirate. This posture actually directs such residue into the larynx.
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 136 TECHNIQUES OF DYSPHAGIA THERAPY
•Strengthening
•Electrical Stimulation
(E-stim) Excellent for
Head neck CA patients/
couple with myo-facial
release
•EMG•Oral Motor
Exercises•Expectoration
maneuver
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 137 Thermal Stimulation
Thermal stimulation or thermal-tactile application has been investigated quite a bit and has largely been dismissed as it has been shown to produce only momentary and non-durable reductions in stage transition duration (pharyngeal delay time).
Rosenbek et al. (1991, 1996, 1998)
Hamdy et al. (2003)
Miyaoka et al. (2006)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 138 TECHNIQUES OF DYSPHAGIA THERAPY
RLG
•Manipulation of
Consistency
•Thick
•Thicker
•Thickest
•Diet
•Puree•Mechanical soft
“moist cohesive bolus”•Regular
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 139
Dysphagia Diet
PUREED or pudding texture:Hot cereal
Mashed potatoes
Custard-style yogurt
Pudding
“Anything can be pureed.”
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 140
Dysphagia Diet continued…
MECHANICAL SOFT or ground food texture:Macaroni and cheese
Soft, canned vegetables
Cottage cheese
Meat loaf
Diced canned fruit
Canned pasta products
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 141
Diet Modification
-Why do we change a person’s diet?-How do we know when to
upgrade/downgrade?rotary chewing?
cueing still needed?efficient, appropriate swallows?
good clearance? any signs/symptoms of aspiration?endoscopic/fluoroscopic results?
-Goal: gradually maximize safe oral intake to avoid compromising nutritional status
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 142
Dysphagia Diet continued…
ADVANCED or regular texture: EXCEPTIONS:
Dry, tough meats
Dried fruits
Nuts, popcorn, dry cookies
Hard, crunchy, stringy vegetables
Hard, crunchy food items (granola, tortilla chips)
Raw, hard, crunchy fruits (apples, pears, pineapple)
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 143 Liquids for Dysphagia Diets Pudding-like
texture: Very thick milkshakes Any liquid thickened
with a thickening agent
Nectar-thick texture: Syrups, tomato soup,
fruit-nectar, eggnog
Thin liquids:Water, milk, juices,
coffee, tea, carbonated beverages, broth-based soup
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 144 TECHNIQUES OF DYSPHAGIA THERAPY
RLG
•Patient Nuances
•Cognition
•General history
•COPD•Activity
Level
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 145 TECHNIQUES OF DYSPHAGIA THERAPY
•Timing
•Respiratory
control
•When to
swallow
•How many swallows (double
swallow)•Sequence
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 146
GOAL
Keep the patient swallowing for as long as possible to maintain swallow function,
nutrition and hydration – BUT we want to do it in a way wherein the person is
swallowing safely and efficiently.
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 147 Electrical Stimulation (ES)
“Neuromuscular electrical stimulation (NMES) is a noninvasive modality that directly stimulates the peripheral nervous system to evoke an action potential via surface electrodes “ (Biber et. al)
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 148
E-stim
Current FDA approved uses for NMES include:
muscle reeducation
prevent/retard disuse atrophy
relax muscle spasm
increase local blood circulation
immediate post surgical stimulation of calf muscles to prevent DVT
maintain or increase ROM
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 149 HISTORY
In past years E-stim has been used for:
Tremors in Parkinson’s (deep brain stimulation)
Wound healing
Pain management
Reduction of edema
Muscle enhancement, specifically: (Increasing ROM, Improving strength, Reeducating contraction patterns and timing & Correcting abnormal muscle tone)
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 150
HISTORY
E-Stim for treatment of dysphagia was introduced:
1975- Marcy Freed developed her protocol while at Hillcrest Hospital in Ohio.
1999- Teresa Biber in collaboration with PT and Otolaryngology departments while
at the Cleveland Clinic in Florida.
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 151 WHY E-STIM?
Traditional Treatment: Compensatory vs. Rehabilitative
Compensatory Intervention = “strategies that provide an immediate but typically transient effect on the efficiency or safety of swallowing. As a rule, if the strategy is not consistently executed, swallowing will return to the prior dysfunctional status. Posturing (chin tuck, head turn)
Diet/texture modifications
Tube feeding
Airway protection techniques (supraglottic swallow)
Thermal-tactile stimulation
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 152 WHY E-STIM?
Rehabilitative Intervention = “intervention that, when provided over the course of time, are thought to result in permanent changes in the substrates underlying deglutition: i.e., changing the physiology of the swallowing mechanism.” Oral motor exercises
Shaker Exercise
LSVT
Swallowing Maneuvers in combination with EMG biofeedback
E-Stim ???
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 153 HOW DOES E-STIM WORK?
Electrical impulses transmitted transcutaneously via 2 electrodes places on the submental area, away from carotid arteries and not directly on larynx.
Body tissue (muscle) conduct electricity, causing a depolarization of the nerve fibers, thus creating a muscle contraction by dispersing an action potential across the muscle fibers.
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 154 Normal vs. Stimulated muscle contraction
Normal muscle contraction occurs when action potential is transferred to the muscle by the nerve.
Stimulated muscle contraction occurs as a result of muscle fibers being directly stimulated by the electrical current from the voltage source.
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 155 GOAL/OBJECTIVE
Achieve adequate laryngeal elevation
Pair swallowing with e-stim to reeducate the brain
Change swallow mechanism not just trigger swallow
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 156 TREATMENT USES
Maintain/strengthen muscle mass during inactive periods
Maintain/gain ROM: Facilitates laryngeal elevation by strengthening the extrinsic laryngeal muscles (laryngeal muscles are like other skeletal muscles stimulated by PT or OT). Ultimately, airway protection is achieved.
Facilitate voluntary motor control (swallowing maneuvers)
Increase sensory awareness (laryngeal/pharyngeal)
Muscle reeducation
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 157 Transcutaneous electrical stimulation versus traditional dysphagia therapy: A nonconcurrent cohort study
The results of this nonconcurrent cohort study suggest that dysphagia therapy with transcutaneous electrical stimulation is superior to traditional dysphagia therapy alone in individuals in a long-term acute care facility.
Blumenfeld, L. et al (2006)
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 158 Timing of laryngopharyngealevents during swallow: an EMG perspective
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 159
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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 160 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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 161
Methods
Five normal subjects (4 male, 1 female)Human subject approvalSimultaneous 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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 162 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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 163
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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 164
Muscle examined
Superior pharyngeal constrictor (SPC)
Tongue base (GG)
Cricopharyngeus (CP)
Thyroarytenoid (TA)
McCulloch, T. (Voice, Swallow & Airway 2005)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 165 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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 166 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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 167 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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 168 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)
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 169 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.
RLG
McCulloch, T. (Voice, Swallow & Airway 2005)
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 170 Conclusions
However, please know help is available via skilled multidisciplinary team with skilled professionals: SLP, ENT, GI, Pulmonologist, Radiation-oncologist, Dietitian.
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 171 IDEAL
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”.
RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 172 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.RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 173
•RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 174
CASE STUDIES
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 175
Questions…Please contact me!
Rebecca L. GouldRebec26050@aol.com
See www.med-speech.com for more information about voice, swallow and airway disorders
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 176
•RLG
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________