Introduction: Dysphagia: From Assessment to Discharge (14:08)
Meaghan Schaufele is a speech pathologist and works with many stroke victims. Clinicians do not treat the symptoms, but need to diagnose underlying abnormalities. Types of assessments include chart review, oral mechanism exam, clinical assessment, and the instrumental assessment; Schaufele discusses underlying causes that can cause dysphagia and lab results that apply to speech pathology.
Chart Review (11:47)
The University of Wisconsin conducted a study that demonstrated that Parkinson's patients breathe and swallow better prior to taking medications. Side effects that can cause dysphagia include Xerostomia, myopathy, reduced attention, impaired motor function, and GI motility. Schaufele discusses different terms she looks for when reviewing a patient's medical chart.
Reasons for Consults (07:20)
Understanding what the patients issue is prior to meeting him is helpful; CNAs are a great source of information about hospitalized patients. Many patients experience dysphasia, silent aspiration, and laryngeal pathology issues after extubation.
Clinical Assessment: Tools (09:56)
Schaufele discusses tools needed for a clinical assessment. Do not use lemon glycerine swabs to clean a patient's mouth. Tastings of a client's favorite beverage can improve performance during swallow therapy.
Clinical Assessment: The Interview Assessment (12:56)
The interview can establish rapport with a patient and help a speech pathologist learn about previous medical history and habits. Assess the family's hopes and goals because frequently the family members are more concerned than the patient. Be careful of swallow tests when worrying about a potential vocal fold dysfunction.
Clinical Assessment: The Oral Mechanism Exam: Trigeminal and Facial Nerves (14:02)
Schaufele discusses how the trigeminal and facial nerves aid the swallowing process. Learn how to assess these cranial nerves and potential discrepancies. Patients want to please their speech pathologist and occasionally lie.
Clinical Assessment: The Oral Mechanism Exam: Other Cranial Nerves (13:53)
Schaufele discusses how the glossopharyngeal, vagus, spinal accessory, and hypoglossal nerves aid the swallowing process. Learn how to assess these cranial nerves and potential discrepancies. Ask the patient to cough hard to assess lung capability.
Clinical Assessment: Cranial Nerve Exam (08:30)
Dr. Abbot performs an examination on a patient testing the trigeminal, facial, glossopharyngeal, vagus, spinal accessory, and hypoglossal nerves. Schafele gives oral care before and after testing.
Clinical Assessment: Swallow Trials (16:40)
Schafele advocates using Debra Suiter and Steven Leder's method, but cautions there is a high rate of false positives. Ice chips, lollipops, solids, and tastings should be incorporated during into the evaluation. Provide strategies to help the patient including posture, swallowing methods, and position.
Clinical Assessment: Cervical Auscultation and Palpation (09:10)
Experts disagree about the efficacy of cervical auscultation during an assessment; Schaufele uses the tool as a support tool contributing to a diagnosis. Speech pathologists need to observe oral residue, lingual movement, pocketing, postural changes, non-verbal communication, the pharyngeal phase, and breathing.
Diagnosis: Aspiration (04:49)
Schaufele suggests having a patient repeat a sentence after he swallows food or drink. Watering eyes, runny nose, increased respiration, and refusal to eat can suggest a silent aspiration diagnosis.
Instrumental Assessments (09:51)
Schaufele suggests doing instrumental assessments under a flouroscopy or fiberoptic endoscope evaluation of swallowing (FEES) if possible but most facilities will do a modified barium study instead. The American Speech-Language-Hearing Association encourages practitioners to obtain an anterior posterior (AP) view with each study.
Videos: Instrumental Assessments (15:03)
Schaufele presents a video of a normal and abnormal modified barium study. In the abnormal, the patient aspirates. In the FEES, the practitioner misses the actual swallow, but can notice abnormal tissues.
Other Assessment Techniques (03:34)
In ccintigraphy, patients are given nuclear medicine to assess trace aspiration. Researchers are studying the effectiveness of high-resolution manometry. Other assessment techniques include ultrasound imagery,
Diagnosis Made (12:15)
After the diagnosis is made, speech pathologists should make referrals to other specialists, consider nutrition, provide a system for safety and proper oral hygiene, and write goals. Call the specialist personally to inform him of issues. Schaufele discusses different types of feeding tubes.
Goal Writing (06:18)
Take into account the needs and desires of the patient and the diagnosis. When writing goals, remember they are supposed to be SMART: specific, measurable, attainable, relevant and timely. Patients need to agree with the goals.
Case Study (13:37)
A 56-year-old man complains of dizziness, nausea, hiccups, and difficulty swallowing. Participants believe a stroke is causing his symptoms, discuss how they will assess the patient, and how they will help the patient.
Approaches to Treatment (20:06)
Schaufele reminds participants to take a holistic approach with their patients and incorporate occupational therapists, physical therapist, neurologist, nutritionist, and specialists into treatment. Set up a wheelchair and mental health evaluations if necessary and monitor co-morbidities. Schaufele discusses issues with neuroplasticity, skill, and strength training.
Treatment Outcomes (06:51)
Good speech pathologists need to examine clinical expertise, external scientific evidence, and incorporate client-patient caregiver perspectives when considering treatment methods. The American Speech-Language-Hearing Association has a National Outcomes Measurement System that compares databases around the country; questionnaires include Swallowing Quality Of Life Questionnaire, the quality of care, and the eating assessment tool.
Treatment Strategies (12:16)
Modalities and techniques include neuromuscular electrical stimulation, the Iowa Oral Pressure Instrument, the Madison Oral Strengthening Therapeutic device, surface EMG, thermal tactile stim, deep pharyngeal neuromuscular stimulation, expiratory muscle strengthening, inspiratory inventory muscle strength training, kinesio tape, temperature control; and resistance training. Schaufele describes the various biofeedback tools.
Oral Manipulation Exercises (21:01)
Schaufele describes the Mendelsohnn, Masako, Shaker, the effortful swallow, pitch glides, and chin tuck against resistance. Myofascial release can help open up the esophagus. Other kinds of programs available to help patients with dysphagia include the Beckmann, Pharyngocise, the facial muscle program, Lee Silverman Voice Treatment, and deep pharyngeal neuromuscular stimulation.
Frazier Water Protocol (07:59)
Postures include chin tuck, supraglottic, super supraglottic, sideline, and head back. The Frazier Water Protocol requires oral care and timing. Shaufele describes a recent study where the subjects who were on the Frazier Water Protocol experienced less urinary tract infections than patients who drank nectar.
Back to the Case Study (10:34)
In the patient with the stroke, participants suggest DPNS, pharyngeal strengthening exercises, tastings, Frazier water protocol, and biofeedback. If the patient wants to eat, speech pathologists should advocate good oral care and swallow strategies.
Implementing Interventions (10:51)
Clear communication and being aware of recent advances is essential for effective dysphagia interventions. Schaufele recommends posting signs with pictures, patients wearing armbands, placemats, document all information.
Schaufele's facility requires education sessions. Educate nurses, CNAs and others involved in a patient's care about swallow issues, how to add a thickener, and the importance of oral care. Patients who have multiple medications or co-morbidities are at a higher risk to aspirate.
Palliative and Hospice Care (10:15)
Palliative care differs from hospice care because it is for seriously ill individuals at any stage of the disease and no treatment is eliminated. Schaufele describes the role of speech pathologists at both levels of care. The recent Dysphagia Research Society investigated noninvasive brain stimulation as a potential treatment.
Advances in Dysphagia (19:59)
ASHA created the International Dysphagia Diet Standardization Initiative to help build a framework for food types. New apps that can help patients and clinicians include Swallow Prompts, oral peripheral exams, oral disorders, dysphagia checklist, Dysphagia2Go, voice and sound meters, Dysphagia Therapy, and Cranial Nerves. Schaufele advocates purchasing a membership for the Dysphagia Research Society and the National Foundation of Swallowing Disorders to discover advances.
Another Case Study: Assessment and Diagnosis (17:39)
A 22-year-old man was recently in a car accident and was extubated after 24 hours. Participants discuss which tests and instrumental assessments to undertake. Reduce distractions when undergoing a trial test.
Another Case Study: Strategies of Treatment (09:57)
Participants suggest swallowing strategies, Masako exercises, DPNS, biofeedback, and VitalStim.
Final Case Study (05:24)
A 66-year-old female whose hypernasal speech is very deliberate complains of body cramps and poor balance. Participants suspect a neuromuscular disease and increased likelihood of aspiration or penetration. Refer to a neurologist and request a follow-up after her visit.
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