Term
| What happens during the oral prep stage? |
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Definition
Begins: food or liquid enters the mouth
Purpose is to break down food to a consistency appropriate for swallowing and mixing it with saliva to form into a bolus.
Sensory recognition of food
Neuromuscular actions: labial seal, lateral motion of the tongue and jaw, increased buccal/facial tone, bulging of soft palate. Larynx and pharynx at rest
CNs V, VII, X, XII: trigeminal, facial, vagus, hypoglossal |
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Term
| What happens during the oral stage? |
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Definition
Begins: tongue moves bolus posteriorly
Propulsion/stripping action: Indicated when the tongue moves the entire bolus back
Pressure!!- pushing up and squeezing through the oral cavity
Labial seal
CN XII: hypoglossal (tongue control) |
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Term
| What happens during the pharyngeal stage? |
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Definition
Begins: trigger of swallow
Triggers at faucial arches and the tongue base passes ramus of the mandible
key components:
1. Closure of the VP port (seals off the nasopharynx)
2. Elevation of hyoid (goes forward) and larynx (up)
3. Epiglottis inverts
4. Closure of larynx (on 2 levels false and true VF close)
5. Relaxation/opening of the UES or PES
6. Tongue base retraction (contacts pharyngeal wall)
CN IX, X, XI: Glossopharyngeal, Vagus, Spinal Accessory |
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Term
| What happens during the esophageal stage? |
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Definition
Begins when the UES opens & ends: when the LES opens and the bolus passes into the stomach.
Involuntary
Three types of peristalsis contraction
CN X: Vagus |
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Term
| What do you do first for a patient who is NPO prior to any evaluation? |
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Definition
—Wet their mouth!
Saliva is very important to the swallow but No lemon glycerin swabs!! (b/c coated with alcohol which dries out mouth)
Use washcloth or toothette or ice chips? |
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Term
| When would you discontinue a bedside swallow evaluation? |
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Definition
—Absent swallow
—Absent laryngeal elevation
—Significant respiration distress/Vomiting
—Drop in 02 stats
—Fear of swallowing which cannot be resolved
—Severe coughing/choking--See how well they recover. If they cough, eyes water, in distress then that is obviously worse than just coughing once and are okay.
—Patient cannot maintain alertness |
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Term
| When you write up your bedside swallow what are the 4 main objectives you should always include in your report. |
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Definition
-Diagnosis—oral; cannot dx pharyngeal on bedside swallow- only suspect!
-Aspiration risk
-Recommendations
-Patient education/participation in poc (plan of care)--Tell them what they have, what the dx is, and what their response is |
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Term
| What are the limitations of the bedside swallow assessment? |
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Definition
-—Can only assess oral stage
—-Suspect pharyngeal/esophageal stage involvement (screening tool) -Should get in for dx test if you suspect pharyngeal problem.
—-Evidence of high rate of false positive 40-60%--—meta-analysis by dixon et al., 2001; —Too many end up thickening liquids and changing diets because they think there is a swallowing problem.
-Can do general transit times but not accurate enough information on pharyngeal stage can be collected
-Since you do not have xray vision you cannot know the structures or pathophysiology of pharyngeal stage so you cannot treat!
—(if you are treating pharyngeal stage you MUST have dx test -to back it up)
-—Isn’t very sensitive for diagnosing aspiration. |
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Term
| When should you refer a patient on for a diagnostic test after doing your bedside swallow and when should you NOT? |
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Definition
When to go on for a dx test:
-Patient is showing pharyngeal stage or esophageal stage s/s
-Pt is not showing any signs but had unexplained symptoms related to swallowing/nutrition that cannot be explained
-Pt has recurrent medical outcomes in which an etiology cannot be found which may be related to swallowing.--—Have repeated pneumonias
When not to go on to a dx test:
-—The family/pt is not going to comply with the recommendations regardless of results
-The information received on the dx test will not improve the pt’s outcome or change his QoL |
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Term
| What is the correct protocol for a neurogenic patient recommended by Horner and Massey for a modified barium swallow without any history of a respiratory dx? |
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Definition
H & M say that the majority of neurogenic patients aspirate on thin liquids
Therefore, start with pureed boluses THEN proceed to thin liquids, then solids. |
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Term
| Name and describe one other test utilized to diagnose swallowing. |
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Definition
Ultrasound
-Used to study oral cavity, tongue function, movement of hyoid bone
-—Cannot visualize pharynx |
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Term
| What does the diaphragm do during inspiration? |
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Definition
| During inspiration, the dome shaped diaphragm flattens as it contracts, which increases the height of the thoracic cavity |
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Term
| Expiration in healthy people is mainly___________. |
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Definition
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Term
| What phase does the swallow occur in and how does it trigger? |
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Definition
Pharyngeal
-Sensory receptors deep in oropharynx and tongue
-Hypothesized that trigger comes from lower brainstem
-Trigger continued
-Evidence= trigger of pharyngeal swallow in most adults happens at Faucial arches and the tongue base passes lower rim or “ramus” of the mandible
Older adults (60 and older) middle of swallow
--5 key activities in pharyngeal stage:
-Close of the velopharyngeal port
-Elevation of hyoid and larynx
-Closure of larynx (false then true vfs)
-Relaxation/opening of the UES (upper esophageal sphincter) or PES (pharyngoesophageal segment) PE segment
-Tongue base retraction (contracts pharyngeal wall) |
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Term
| What is swallow apnea? What happens during it? |
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Definition
Airway closes for a fraction of a second
No chest movement
Depending on size of bolus-longer apneic periods (.5 to 3.5 seconds) |
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Term
| What can make swallow apnea variable? |
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Definition
| Larger volumes, Solid food, Cup drinking |
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Term
| What is a pulmonary toilet? |
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Definition
-Basically your body’s pulmonary hygiene
-The body’s natural way of clearing secretions
-“good pulmonary toilet” able to get rid of secretions on their own
-Pulmonary toilet is composed of: Cilia, Coughing, Expectorating (spitting) |
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Term
| Why do people who are not eating have poor pulmonary toilets? |
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Definition
No hydration—nothing to make saliva production
Saliva helps mucocilliary clearance |
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Term
| What is the difference between a cuffed trach and a non-cuffed trach |
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Definition
Cuffed: balloon that goes around the trach tube
-inflated: purpose=to reduce the risk of aspiration (esp. with saliva).
-The pt may still aspirate around the cuff (can aspirate saliva or liquids)
Non-cuffed: no balloon
-deflated: air can move around |
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Term
| How do tracheal tubes affect swallowing? |
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Definition
-Swallowing is pressure driven --trach tubes reduce pressure
-Reduction in subglottic pressure
-Low powered studies that show reduction in laryngeal -elevation
-“tethered affect”
-Acts as an anchor and may pull everything down
-May cause reduced elevation |
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Term
| Why should you wait at least 24 hours before evaluating a patient who recently has been extubated? |
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Definition
Give time for swelling of VOCAL FOLDS to go down
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Allow patient’s feeling of sensation to return
- Stabilize respiratory status
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Term
| What is a PMSV or passy muir speaking valve? |
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Definition
| special cap placed on tube |
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Term
| What are the two things you should do when you are choosing treatment for a patient? |
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Definition
--Gather information
›assess patient’s anatomy and physiology
›Gather more info on patient’s medical status, prognosis, behavior, and cognition.
Can he follow directions? Is he uncooperative?
›Does he have short term memory issues that he/she will not retain the information you are training him with?
›Fatigue/endurance
--Gather/Understand evidence
›Grading system (A-F) (›F=lousy study)
›Randomized control trials are ideal
›Large sample size
›Blinded investigators
›Is it the correct population?
›How many studies on normals? |
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Term
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Definition
Evidence based practice
evidence on treatment
your experience with treatment on similar populations
patient’s wishes |
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Term
| What is the long term goal of any swallow treatment? |
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Definition
Patient focused treatment:
Safety swallow
maintaining nutrition and hydration |
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Term
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Definition
Pureed: All food is blended
Soft mechanical: food is chopped
Regular: anything |
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Term
| Name the characteristics of the swallow of a Parkinson’s patient. |
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Definition
—-Oropharyngeal control=poor bolus control
—-Random tongue movement
—-Tongue pumping/lingual rolling
—-Weak swallow reflex
—-Drooling=increased risk of silent aspiration
—-Incoordination of swallow and respiration
—-Swallow as progressive as disease
-In case it is in a case study: Early-exercises; moderate--dietary; severe--counseling on enteral nutrition & QoL |
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Term
| Name the characteristics of the swallow of a brainstem CVA patient. |
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Definition
Lower:
—Difficulty triggering the pharyngeal swallow
—Absent pharyngeal swallow (Bolus hangs in the valleculae space for 15 seconds)
—Delayed pharyngeal swallow
—Reduced laryngeal elevation
—Reduced UES/PES opening
Upper:
Region of the pons
—Severly hypertonic
—Absent pharyngeal swallow or severely delayed
—Spastic pharyngeal wall or paralysis
—Recovery poor…very slow! |
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Term
| What is the difference between penetration and aspiration? |
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Definition
Penetration: Food or liquid starts to enter the area above the airway but it does not drop into airway
-penetration is normal in the elderly
Aspiration: Aspiration is when food or liquid enters the area below the vocal folds |
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Term
| What national standardized assessments are there for a bedside swallow? MBS? |
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Definition
MASA--Mann Assessment of Swallowing Ability
SSA--Standard Swallowing Assessment |
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Term
| Review the average time for stroke recovery. |
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Definition
-recovery of subcortical stroke usually takes 3-6 weeks if no other complications.
-Brainstem stroke is the worst
Overall recovery:
first stroke:
-Full oral intake usually 3-4 weeks
-most progress occurs first 3-4 weeks |
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Term
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Definition
RDS-Respiratory Distress Syndrome
–Affects lungs of preterm neonates due to a lack of “surfactant” or (fluid secreted by lungs to stabilize and prevent them from collapsing upon exhalation) |
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Term
| What is silent aspiration? |
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Definition
| means there are no signs (cough, throat clear). You can’t tell they’re aspirating. This is commonly written by doctor’s in the hospitals |
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Term
| Why is it important to START with liquids on a bedside swallow or modified barium swallow first instead of starting a thicker viscosity or puree for a patient who has a recent history of a respiratory diagnosis or present respiratory diagnosis? Be as detailed as possible |
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Definition
-less likely to adhere and stick after the first swallow so you can view the structures easier as the test goes on
-would rather have the pt aspirate a small amount of thin liquids than a pudding bolus
-thickened liquids doesn’t show what is wrong with the pathophysiology |
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Term
| You should always treat the patient and NOT the xray when doing a modified barium swallow how do you make sure you are doing this? |
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Definition
| Ask them about their QoL: how important is swallowing to them |
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Term
| What is the “white out” period during a FEES? |
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Definition
| occurs when the epiglottis inverts during the swallow, which causes a white out that does not allow aspiration to be dx because there is no direct view of it |
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Term
| What is the purpose of tracheal tubes? |
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Definition
Reduce aspiration and protect the lungs
Used in patients who have poor respiratory status so they may improve |
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Term
| What can anti-psychotic drugs do to the swallowing physiology and produce |
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Definition
can produce iatrogenic aspiration :
produce tardive dyskineasia: twitching, irregular movements of the mouth
slows down the nervous system, which will slow down the swallow
slows esophageal motility
increase aspiration
alter transport
overall uncoupling and delay |
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Term
| What are waivers? Do they hold up in court? |
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Definition
Waivers - collection of documentation that substantiates the patient’s wishes and facilitates proper management
Makes patient’s want/needs known to family, facility, patients, staff, therapists
Would be used in court if patient decides to go against SLP’s recommendations |
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