Dysphagia Other Assessments

Dysphagia Other Assessments

1. Pulse Oxometry

   • Smith et al. (00) Screen by saturation detects 86% of asp./pen. follow immediate w. bedside S.A. (best. pos prediction)
   • Sellars et al (98) - small study. Not a clear cut relationship between arterial oxygenation and aspiration. Some support for altered ox and oral feeding in people with dys.
     • i.e. that resp status may be altered
   • Non invasive, minimal patient cooperation
   • Desaturate by 2% or more, NBM*
   • Doesn't tell you exactly the mechanism causing the desaturation
   • Collins & Bakheit (97) - Pulse ox is a reliable method of detection of asp in most dys patients. Careful if they have pulmonary disease though

2. 3 Oz water swallow test

3. Cervical Auscultation

   • Doesn't tell you what the problem is, only that there may be one
   • Mills (13) "C.A. should be used as a screen only"
   • Leslie et al. (07) no evidence to suggest that sounds are consistenly associated with physiologic event!!
   • Hibbs (13) found agreement between C.A. and V.F. findings on determining oral delay and aspiration
   • Stroud (02) Did not find SLT's classification reliable. However, some individual SLTs = high reliability - what internal criteria using???
   • Median line cricoid
   • Sound of bubbles if resp. mixed with fluid
   • Can be digital

4. Cough Reflex Testing

   • Miles et al (13), found positive association between failed CRT and aspiration but also weak CRT and weak resp to asp. NUMBERS TOO SMALL for statistical anal.
   • Threshold at which an individual can no longer supress a cough
   • 92.5% people (healthy) show natural cough, 0.8mol/L of irritant (nebulized citric acid e.g.)
   • Nebulizer may rule out those with weak face muscles (confound)
   • Pass if you cough.
   • Clinicians judge if strong or weak
   • Results not used along but combined with MDT dysp. management & other ass.
   • Does not answer dysphagia severity or pnumonia risk

5. Fibreoptic Evaluation of swallowing (FEES)

   • Flexible endoscope inserted through nose
   • Coloured food / liquid of different consistencies given to patient to assess swallow
   • Colodny (02) Fees more reliable on ass. penetration that VF, VF better on severity of aspiration, Equal on desc. betwn pen and asp
     • Leder & Espinosa (02), stroke patients (blind testing). Clinical examination correctly identified 19 of 49 people at risk, but missed 3 people picked up on FEES. Clinical exam also INCORRECTLY identified 19 as being at risk (when not of FEES). Clinical exam less reliable
   • Image qual not as good as rigid endoscope
   • Could detect posterior overspill before swallow trigger
     • Pharyngeal residue
     • Suitable diet in terms of consistency
       • Does not visualise oral stage, or ACTUAL SWALLOW due to white out
         • Pos better for patients with lower awareness / cog issues, but does not give info about their mental state like VF
         • No oes. stage or bolus flow
   • Puffs of air to test sensory reception

6. Videoflouoroscopy (VFS)

   • Bolus flow and biomechanics
     • TIMING
     • DIRECTION
     • CLEARANCE
   • Gold standard: ORAL, PHARNG, & OES stages observed
   • Determining swallow safety
   • Effects of compensatory managment
   • Determinatino of app diet
   • Planning of rehab approaches
     • AIRWAY invasion, PRE, DURING or POST - only see on VFS
   • Radiation exposure limits length of ass.
     • Patient positioning prob with hemiplegia
   • Preferred initial for STROKE PATIENTS (Daniels & HUckabee 14)
   • View frame by frame, w sound 30fps
     • Usually lateral position
       • POst swallow residue, might do Ant - post position to see if uni, or bilateral
         • Unilateral pharyn. hemiparesis results in residue in contralesional pyriform sinus
         • Also good to identify unilateral VF paresis
   • IF NG in, may affect stage of transit duration and UES opening (Huggins et al. 99)
     • May also result in early evocation of pharn swallow - sometimes removed for VFSS
   • Protocol driven or patient driven... For STROKE combination of the two recommended
     • Small vol thin liquid: less risk is asp and also less residual - therby smaller effect on subsequent swallows
       • SEQUENTIAL SWALLOWS evaluated if managing large volume already
         • OES. dysfunction may contribute to phar. dysfunction (Martin-Harris & Easterling 06)
           • Only cursory screen on VFSS
     • SELF admin preferred
       • Cup vs straw not empirically investigated
       • Calibrated volumes can help w recommendations, 3-5ml uo to 20-25ml (normal size bolus volume)
       • Some people demo a 'warm up' period
   • THINGS TRIALLED
     • 1. Postural compensation
       • 2. Consistency mod.
     • How many cues nec to instigate a strategy
   • SOLIDS: Barium alone or mixed with food, e.g. mash

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