Screening and Clinical Assessment for Dysphagia: How to Decide.

Transcription

1 Screening and Clinical Assessment for Dysphagia: How to Decide. How to Decide. ASHA Convention 2014 James L. Coyle, Ph.D., CCC-SLP, BCS-S Associate Professor, Communication Science & Disorders, University of Pittsburgh

2 What is a CSE? Physician: did the patient pass the swallow evaluation? SLP: did the patient pass the CT scan and EKG? Nurse: did the patient pass the swallow evaluation? SLP: did the patient pass the admission nursing assessment? 2

3 PASS Screening Alone Screen FAIL Dysphagia POSSIBLE DIAGNOSES A B C D E POSSIBLE INTERVENTIONS 3

4 Clinical Swallowing Examination CSE POSSIBLE DIAGNOSES A B C D E POSSIBLE INTERVENTIONS 4

5 Limitations of clinical tests Uncertainty regarding diagnosis Cannot assess for pharyngeal abnormalities, silent aspiration Can t describe bolus flow characteristics Relies heavily on symptoms Which can be absent, false negatives! Once the mouth is closed, everything is inferred 5

6 Limitations of clinical tests SLP s do not like uncertainty. We like yes no. 6

7 What the examiner wants CSE POSSIBLE DIAGNOSES A B C D E POSSIBLE INTERVENTIONS 7

8 What test gives us this result? CSE The A FEES AUTOPSY test? ONE DIAGNOSIS D ONE INTERVENTION A VFS test? 2 8

9 When is a CSE necessary, valuable? A CSE is never necessary Fail a screen perform an instrumental test Pass a screen do nothing WE DISAGREE. 9

10 When is a CSE necessary, valuable? Instrumental test is not available/feasible Patient cannot be tested with the instrument Access to facility Time to set up visit for testing Can be very long in some settings A CSE is the ONLY option available 10

11 What if instrumentation is unavailable but NECESSARY? It is not OK to rely solely on clinical exams, because it is difficult to get an instrumental test. It is not just the instrument, it is the examiner Non ordinary cases need expertise Availability does not equal necessity! 11

12 When is a CSE necessary, valuable? And when instrumentation is available A CSE is ALWAYS necessary FIRST Hypotheses for testing during the imaging study Preparation for testing effects of interventions Adjustments for patient participation Communication with Radiologist re expectations 12

13 When is a CSE necessary, valuable? Instrumental test is not desirable to patient No, thank you, please do your best without it Palliation A CSE is the ONLY option available 13

14 When is a CSE necessary, valuable? Instrumental test will not contribute to the diagnosis or treatment plan I want to see what is going on I want to rule out silent aspiration And no logical reason to suspect it No suspicion of pharyngeal abnormalities Results will not alter the plan A CSE is the ONLY option available 14

15 Additional Value of a CSE Establishes clinician patient relationship And clinician patient trust Begins communication with patient/family with whom treatment may be deployed! Often proves that instrumental testing is unnecessary Half of our patients who failed the stroke dysphagia screens, do not need instrumental tests 15

16 Case example 95M, admitted with 3 rd pneumonia, dehydrated Coughing with all liquids, solids don t go down CSE performed Your pneumonia may be due to aspiration What are you going to do about it? A VFS; all options explained, risks and benefits I don t want any of that, I m OK with this 16

17 Case example STAT SLP consult 57M ICU with CVA; failed swallow screen BP rising precipitously and rapidly RN has tablet at bedside is this safe? CSE focused on important things Uncertainty Risks: another stroke, vs. aspiration of a pill Nothing bad happened (but we all needed a drink) 17

18 Thank you 18