2013 Charleston Swallowing Conference

Transcription

1 Providing Quality Affordable Continuing Education and Treatment Materials for over 30 years Charleston Swallowing Conference Session 9 Bedside Assessment: What Does It Tell You? 10:00 11:30 am Saturday, Oct. 12, 2013 CE Seminars On-line CEUs Products Authors: Logemann & McCullough Facebook.com/NorthernSpeech 325 Meecher Road PO Box 1247 Gaylord, MI Phone: Fax: info@northernspeech.com

2 Jeri Logemann, PhD, CCC-SLP, BRS-S 1 * 10-15% in elderly patients * in multiple medical diagnoses * Length of stay * Medicare requirements Physiologic assessment needed for pharyngeal disorder No reimbursement for hospital-acquired pneumonia Result: Increased pressure for rapid dysphagia evaluation and targeted treatment 2 * Screening Yes/No Dysphagia No reimbursement * Bedside Assessment Oral Stages Diagnostic Pharyngeal Stage Screening * Physiologic Assessment Define specific pharyngeal dysfunction(s) Evaluate/identify treatment effectiveness 3 1

3 Jeri Logemann, PhD, CCC-SLP, BRS-S * Medical Diagnosis Stroke Head Injury Spinal cord injury Treatment for head and neck cancer Degenerative neurologic disease Elderly with reduced reserve 4 Medications Coughing/Throat clearing Reduced alertness Complaint of dysphgia Reduced cognition 5 Y N? Reduced Lip Closure Y N? Tongue Thrust Y N? Reduced Tongue Control/Shaping Y N? Reduced Vertical Tongue Movement Y N? Reduced Manipulation and Propulsion of The Bolus (Reduced A-P Tongue Movement) Y N? Rocking/Rolling Tongue Motion Y N? Reduced Lateral/Anterior Tongue Stabilization Y N? Reduced Tongue Lateralization Y N? Reduced Tongue Strength Y N? Oral Apraxia (Oral Initiation Delay)? Y N Delayed Pharyngeal Swallow Y N? Absent Pharyngeal Swallow 6 2

4 Jeri Logemann, PhD, CCC-SLP, BRS-S Y N? Reduced Velopharyngeal Closure Y N? Reduced Tongue Base Retraction Y N? Incomplete Laryngeal Vestibule Closure Y N? Reduced Laryngeal Elevation Y N? Reduced Glottic Closure Y N? Unilateral Pharyngeal Weakness Y N? Bilateral Pharyngeal Weakness Y N? Reduced Cricopharyngeal Opening Y N? Visible Cricopharyngeal Bar Y N? Esophageal Stricture Y N? Functional Swallow Y N? Other (please detail): 7 3

5 Bedside Assessment What Are You Assessing? What Should You Be Assessing? Gary H. McCullough, Ph.D., CCC- SLP Available Assessment Tools Direct visualization of at least some aspects of the swallow Videofluoroscopy Nasoendoscopy Indirect observations Clinical/bedside examination Bedside follow- up 2 Assessing Swallowing in Clinical Setting Utilize as many different tools as are available to: solidify knowledge of anatomy and physiology acquire an appreciation for the depth and breadth of this challenging mechanism 3 4

6 Management Decisions Could be based on: One type of swallowing assessment, or tool, and one individual assessing More than one type of examination and more than one medical professional 4 Use of Intuition No one tool provides a comprehensive three- dimensional examination of entire swallow Requires use of intuition gained with time and experience 5 Nasoendoscopic Examination Inability to directly visualize swallow Inferences are required Can see symptoms of dysphagia, but difficult to determine physiologic cause 5

7 Videofluoroscopy Visualize all aspects of oropharyngeal swallow 2 dimensional, black and white limitations Radiation and time limits exploration of strategies Still questions regarding reliability and utility of most measures Making good decisions requires Use of assessment tools and review of related research Understanding strengths and weakness of tools Knowledge of reliable judgments of tools 8 Why do we do a clinical/bedside examination? 6

8 Aspiration Focus Most widely employed (McCullough, 1999) Often used clinically as a screening tool for aspirators Many publications aimed a detecting aspiration in patients Daniels, Brailey, Priestly, Harrington, Weisberg, & Foundas, 1998 Logemann, Veis, & Colangelo, 1999 Martino, Pron, & Diamant, 2000 McCullough, Wertz, & Rosenbek, 2001, 2004, More to Assessment Than Aspiration Aspiration should not be beginning and end of story for assessment and treatment Look at history, medical, and nutritional context Determine physiology of patient s swallow 11 We must remember It is critical that the C[B]E not be relegated to the status of a screening tool. It is far too powerful. Rosenbek, McCullough, Wertz

9 Comprehensive clinical evaluation includes History taking Chart review Basic oral mechanism exam Oral motor functioning Cranial nerve testing Assessment of the functional aspects of feeding & swallowing 13 Historical and Medical Information Gathering Dependency for oral care Dependency for feeding Number of medications Decreased alertness 14 Additional Critical Historical Info Medical stability, including neurologic and physical functioning Overall nutritional status and lab values Nutritional risk profile Quality of life assessment 848 hits on deglutition disorders & QOL 15 8

10 What do you really want to know? Level of function? Independence Health Mental and physical functioning Who this person is and what are his/her needs toward improving QOL? QOL/Handicap SWAL- QOL MD Anderson Dysphagia Inventory Dysphagia Handicap Index Oral Motor/Cranial Nerve V Mastication & Oral Sensation VII Facial Muscles & Anterior Tongue Taste IX Posterior Tongue Taste & Oral & Hypopharynx Touch X Palate, Pharynx, Larynx, & Esoph Motor & Interior Larynx Touch XII Intrinsic Tongue C1- C2 Extrinsic Tongue Hyoid Movement = V, VII, XII, C1- C2 18 9

11 Oral Motor Also Includes Apraxia Laryngeal Function Voice Cough Dysarthria 19 During the Swallow When patient says ah, listen for vocal quality Clinician palpates (feels) larynx Timeliness of swallow Completeness of swallow Number of swallows Patient says ah again 20 Trial Swallows Patient is fed controlled consistencies and amounts of food and liquid, and observed for signs of dysphagia Does it assess How long does it take patient to eat a meal? Does patient sit up at 90 degrees to eat? Does patient feed self? How well? How much? What types of foods does the patient believe are difficult? 21 10

12 Research No investigations for use of comprehensive CSE in characterizing the patient in terms of medical status, nutritional status, and quality of life No research on CSE s utility for examining the functional aspects of feeding No research defining outcomes from bedside exam alone v instrumental v combined 22 Recent Report on CSE and Physiology Utilized data collected on 60 patients who had suffered a stroke Consecutive stroke patients within 2 weeks of stroke Original focus on detection of aspiration and dysphagia 11

13 History (professional) is Important Logemann et al. (1999) Direct comparison of delayed pharyngeal swallow Sensitivity.80, Specificity.58 Clinical hyolaryngeal elevation v. pharyngeal dysphagia Sensitivity.72, Specificity.67 McCullough et al. (2001,2005) After Administration of Complete CSE, significant association with VFSS for presence of dysphagia and, separately, aspiration. 12

14 4- Point Severity Scale 1 = normal 2 = mild dysphagia 3 = moderate dsyphagia 4 = severe dysphagia 4 Point Diet Recommendation Scale 1 = regular oral diet 2 = regular oral diet with facilitative strategies (i.e., chin tuck, repeat swallows, small bites etc.) 3 = oral diet with a modified consistency (i.e., thickened liquids or puree) 4 = non- oral diet. Non- oral diet does not preclude the use of therapeutic feeds. Conclusions There are no data to suggest the CSE can define swallowing function and provide accurate and safe recommendations for all patients. Data do suggest, however, clinicians are gleaning at least some critical information, suggesting additional research into CSEs and swallowing physiology is warranted. With new guidelines emerging for dining practices in residential facilities (2011) that recommend fewer instrumental evaluations of swallowing and an increased focus on patient desires, this line of research may not only be warranted but critical. Rangarathnam & McCullough (2013) 13

15 Why do a clinical/bedside exam? Because health care practitioners of all types require a basic clinical assessment of an individuals overall health and functional status. What Should You Be Assessing? A Person NOT an image, be it black and white or color. Creating Clinical Goals Aimed at improving everyday functioning & quality of life 14

16 What to Look for in the Future? More on physiology from the CSE More on outcome measures with and without instrumentation for when options are limited More focus on overall promotion of health and well- being and less on aspiration 15