Swallowing Screen Why? How? and So What? พญ.พวงแก ว ธ ต สก ลช ย ภาคว ชาเวชศาสตร ฟ นฟ คณะแพทยศาสตร ศ ร ราชพยาบาล

Transcription

1 Swallowing Screen Why? How? and So What? พญ.พวงแก ว ธ ต สก ลช ย ภาคว ชาเวชศาสตร ฟ นฟ คณะแพทยศาสตร ศ ร ราชพยาบาล

2 Dysphagia in Stroke The incidence of dysphagia after stroke ranging from 23-50% 1 Location of stroke lead to different severity and clinical outcomes : Brainstem lesion is more severe Oropharyngeal dysphagia increases risk of aspiration pneumonia 2 patients with dysphagia RR = 3.17 patients with aspiration RR = Singh S, Hamdy S. Dysphagia in stroke patients. PostgradMedJ Martino et al. Dysphagia After Stroke: Incidence, Diagnosis, and Pulmonary Complications. Stroke 2005.

3 Anatomy

4 Phases of swallowing Oral preparation phase Oral propulsive phase Pharyngeal phase Esophageal phase

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6 The multidimensional neuronal network of the CNS controlling the oropharyngeal swallow response

7 Pathophysiology of swallowing after stroke Impaired efficacy of bolus propulsion Impaired pharyngeal sensitivity and contraction Delayed swallowing response Delayed laryngeal vestibule closure Vallecular and pyriform sinuses pooling Incomplete relaxation of UES

8 Swallowing problems??? Approach Assessment Screening tools Bedside swallowing evaluation History Clinical examination The water swallow test VFSS / FEES Diagnostic study Management GOAL Safe swallow Adequate nutrition&hydration

9 Screening tools Purpose: Identify risk of dysphagia and aspiration How to choose the proper tools? Who is your target population? Quality rating of measurement property Validity / Reliability / Sensitivity / Specificity Feasibility Time to administer Test procedure

10 Questionaires Screening tools The Eating Assessment Tool (EAT-10) Swallowing Disturbance Questionnaire (SDQ) Sydney Swallow Questionnaire (SSQ) Measurement tools assessed by medical personnel Acute stroke dysphagia screen (ASDS) Standardized Swallowing Assessment (SSA) Toronto Bedside Swallowing Screening Test (TOR-BSST)

11 EAT 10 Assessment Tool If score is 3 or higher, patient may have problems swallowing efficiently and safely

12 Bedside swallowing evaluation 1. History Signs & Symptoms Oral phase Pharyngeal phase Esophageal phase Drooling Oral / nasal regurgitation Food sticking Pocketing Food sticking Heart burn Chocking and coughing Wet / gurgling voice Multiple swallow

13 Clinical signs and symptoms of overt aspiration Coughing Choking Wet or hoarse voice Throat clearing Stridor after swallow

14 Bedside swallowing evaluation 2. Clinical swallow examination Pre-Swallow screen Cognitive/mental status function Oromotor function Laryngeal excursion: dry swallow Voluntary coughing Pulmonary function Trial swallow: water, modified water, diet

15 Oromotor function Lip Tongue Dentition Hard and soft palate Oral mucosa Cranial nerve V, VII, IX, X, XII Normal individuals might have no gag reflex, and individuals with severe dysphagia can have a normal gag reflex. Leder SB: Gag reflex and dysphagia, Head Neck 18(2): , 1996.

16 Laryngeal excursion on Dry swallow Mandible Hyoid bone Thyroid cartilage Cricoid cartilage Normal Duration 0.6 sec Hyoid elevation 2 cm.

17 Bedside swallowing evaluation 3. The water swallow test Various volume: 3,5,10,20,30,.60,90,100,150 cc Various way of administer: spoon, syringe, sipping Increasing volume resulted in higher sensitivity but lower specificity Combined with monitoring oxygen saturation Desaturation 2% :risk of aspiration

18 29 dysphagia screening tools The target population of the studies was mainly stroke patients in hospitals or rehabilitation units Most of the studies; the screening was performed by speech language therapists (SLPs) or doctors, 12 tools was administered by nurses

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20 Dysphagia Screening Measures for Use in Nursing Homes : A Systematic Review Based on the ratings given to the psychometric properties: 4 tools were acceptable; GUSS, Standardized Swallowing Assessment (SSA), Toronto Bedside Swallowing Screening Test (TOR-BSST), Acute Stroke Dysphagia Screen (ASDS). GUSS and SSA were identified as feasible tools with acceptable psychometric quality for dysphagia screening among nursing home residents

21 PMR Siriraj Swallowing Screening Modified from Standardized Swallowing Assessment (SSA)

22 PMR Siriraj Swallowing Screening

23 PMR Siriraj Swallowing Screening

24 How to detect silent aspiration

25 Swallowing assessment Methods Incidence of Dysphagia Screening techniques 37%-45% Clinical testing 51%-55% Instrumental testing 64%-78% Martino et al. Dysphagia After Stroke: Incidence, Diagnosis, and Pulmonary Complications, Stroke. 2005;36:

26 Instrumental evaluation Videofluoroscopic swallowing study: VFSS Fiberoptic endoscopic evaluation of swallowing: FEES

27 Purposes of Instrumental evaluation To identify abnormal anatomy and physiology of the swallow To evaluate airway protection during swallowing To evaluate the effectiveness of postures, maneuvers and bolus modifications in improving swallowing safety and efficiency

28 Indication for instrumental evaluation History of aspiration pneumonia in the last 3 months Persistent dysphagia more than 1 month after new onset of disease No clinical improvement after treatment for at least 5 sessions Clinician judgement: present tracheostomy, brain stem stroke, etc.

29 VFSS

30 VFSS

31 Contraindications of VFSS Medically unstable Unable to cooperate in examination Patient is unable to be adequately positioned Allergy to barium

32 FEES

33 FEES

34 Swallowing therapy Swallowing Therapy

35 Goal of swallowing therapy To provide safe swallow To promote adequate nutrition and hydration

36 Treatment Diet modification Exercise and facilitation techniques Postural adjustment Compensatory techniques Behavioral modification Adaptive equipments Alternative methods Medications

37 Diet modification Makes it easier to chew and move food in the mouth Reduces the risk of food going into the trachea The National Dysphagia Diet (NDD) is general national standard categorizes food and liquid levels by level of swallowing difficulty

38 Dysphagic diet in Siriraj Hospital NDD 1: Dysphagia pureed NDD 2: Dysphagia mechanically altered NDD 3: Dysphagia advanced NDD 4: Regular diet

39 National Dysphagia Diet Levels for liquid Thin liquid Nectar thick liquid Honey thick liquid Pudding thick liquid

40 Thickener

41 Oromotor exercises

42 Sensory stimulation Tactile Thermal: Ice chips Chemical: Sour, Spicy Thermal-tactile

43 Postural adjustments Chin tuck Head turn Head tilt

44 Behavioral modification Reduction of distractions Proper seating and positioning Upright during and 30 min after meal Modifying bolus volume and rate Proper oral hygiene Proper oral care reduces potentially pathogenic bacterial colonization Reducing the risk for aspiration pneumonia

45 Adaptive equipments

46 Conclusion Early detection and treatment of dysphagia are the best Goal of swallowing therapy To provide safe swallow To promote adequate nutrition and hydration To improve quality of life

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