Professional Documents
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So here’s what we have planned out for you this morning…there’s still time to sneak
out if this doesn’t sound like it is up your alley….All right… We decided we wanted to
try and build on each other so…
First, I’m going to discuss the purpose and components of Bedside Clinical Swallow
Evaluation or what I am going to refer to from here on out as the CSE – Clinical
Swallow Evaluation. Basically, break the CSE down to it’s fundamental components.
And finally, Dr. Coyle will mop up after us as he’s been fond of saying and he will
examine for us how we put information gleaned from the CSE together to make
clinical decisions.
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This is where I work. Houston Methodist Hospital – it’s important to know that this
was taken from across the street where we also have a building where we see
patients. Let’s just say there is a lot of travelling time. The hospital is located in the
Texas Medical Center ‐‐ we currently have about 825‐850 open…we have a capacity
for about 1100. Our hospital alone employs over 6000 people. It’s not a trauma
hospital lots of neuro and transplants. The majority of my day, is spent doing
swallowing evaluations and treatments.
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The Clinical Bedside Swallowing is just one component of the dysphagia diagnostic process. That
process has three steps – screening, clinical exam and instrumental assessment. Not all patients
will need all three steps of the process and Dr. Coyle will discuss this more. But each step of the
process requires increasingly advanced knowledge and skills to have the expertise to perform and
interpret accurately.
The Clinical Swallowing evaluation that we are focusing on today is a Clinical Examination and not
unlike the clinical examination ANY physician performs before ordering an instrumental
assessment. A neurologist examines a patient before sending them for an MRI or EMG. The CSE
itself is not a single evaluation – think about it – it’s really several small tests and we put them all
together to form an impression. Inside each of those tests we have clinical criteria we are looking
for to move forward – example: oral motor exam and speech language eval tongue deviation YES;
follows commands NO. We put all the information from these tests together to make decisions
about moving forward with the exam and our overall impressions.
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A screening and a clinical swallowing evaluation are NOT the same thing. A screening is a
quick noninvasive procedure is to identify those at risk of a certain condition or behavior.
When we’re discussing swallowing, that condition would be dysphagia or aspiration depends
on the design of the screening. Criteria on a screening is pass/fail; yes/no.
Patients are all screened in some manner prior to any clinical exam. Take a stroke ‐
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A gal is at work and develops a facial droop and slurred speech. That work place has
recently had an lunch program from a stroke coordinator at a local hospital who
passed out FAST cards – to ID stroke signs – FACE droop – ARMS drift – SPEECH
slurred – TIME. This is a screen anyone can do. Her co‐workers identify the signs
based on this screen and EMS is called. The pt receives a clinical exam by a
neurologist and a CAT Scan is ordered. So, screening, clinical exam, instrumental
assessment.
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OK – A screening identifies those at risk of dysphagia or aspiration. The clinical swallowing
evaluation begins to identify who has dysphagia. Let me say that again. In some settings, the CSE
is the only available diagnostic procedure to assess swallowing function. In acute care, the CSE is
completed prior to an instrumental assessment. The CSE allows us to ID patients who warrant
instrumental assessment. Some people are just too agitated to down to fluoroscopy. The CSE
allows clinicians to develop a hypothesis of the pathophysiology of the swallow function – I always
ask students/new clinicians what they expect they are going to see in a videofluroscopic swallow
study so they start to think about applying their CSE findings – now granted I have been surprised…
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You suspect reduced airway closure due to reduced anterior and superior movement of
the hyoid and larynx and you find the lady has her partials lodged in her pharynx.
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The CSE also allows the SLP to trial intervention that are going to be tested during an instrumental
assessment. I find it advantageous to train the patient to do a supraglottic swallow or a chin tuck
and head turn prior to going into the fluoroscopy suite. It provides me the opportunity of being
able to train the patient without feeling crunched for time and I get an idea if the strategy is of any
benefit.
Finally the CSE allows us to develop some ideas regarding management. Is the patient going to be
able to participate in 30 min or 60 min of therapy. Does he have the attention span to complete
exercises independently or will we have to rely on a caregiver to administer?
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So let’s break down the CSE – the first component is the Chart review where we start
doing our investigative work. We are looking for things that raise a red flag.
Something that may make a patient more vulnerable to a swallowing disorder or
something that suggests a person may be suffering from dysphagia. What’s the
reason for admission? SOB? Persistent cough? Pneumonia? Medical and surgical
history –Gather all baseline information avail, any predisposing conditions such as a
progressive neurological disease or multiple strokes that may put the patient at risk
of a dysphagia. Does the patient have COPD or CHF? Any condition that may increase
respiratory rate may affect coordination with swallowing. Look at the imaging and
labs for clues…
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The imaging you look at may depend on your patients diagnoses. We have a lot of neuro things going
on so I will look at the results of the head CT or MRI. This provides an idea of if the pt is aphasic, what
type of aphasia they may have or if they may be more prone to cognitive issues that might affect
management. Because we’ve been consulted to assess the patient’s swallow function, a look at the
most recent chest xray reading is very imperative. Infiltrates in EITHER lung base are suspicious as being
caused by aspiration while eating or drinking (or refluxing or vomiting) when the patient is seated
upright when the aspiration occurred. The Right lower lobe is a myth – both bases are equally
suspicious though in many humans the right mainstem bronchus is more vertically positioned under the
carina – where the trachea splits into R and L. It’s important to pay attention to the findings of
infiltrates in either lung base and think of them in the context of the patient.
Knowing specific lab values isn’t so necessary these days as they come back with big red flags and
arrows on them. However It is necessary to understand how certain lab values can affect a patient. For
instance – white blood cell count. An elevated WBC suggests infection. That combined with new
infiltrates on a chest xray may mean “SOMETHING”. An arterial blood gas or ABG measures the acidity
(pH) and the levels of oxygen and carbon dioxide in the blood from an artery to check how well the
lungs are moving oxygen into the blood and removing carbon. Carbon dioxide retention aka respiratory
distress leads to acidosis – this results in lower plasma Ph– and ends up stimulating the medullary
respiratory nuclei to make the patient breathe faster which may affect coordination with swallowing.
So a lower Ph on an ABG will raise a red flag for a higher respiratory rate.
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Check the nursing notes for any insight – how much the patient is eating, what diet the
patient is on, level of assistance…any report of difficulty. I generally touch base with the
nurse or ‐ we have PCAs – patient care assistants to get any kind of scoop on the patient I
can.
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The case history is the portion of the program where you speak with the patient and
the family. This is where we dig in deeper to get the patient and family’s impression
of the problem. Does the patient feel they have a problem swallowing? What has
the family observed. When does the problem occur and how frequently? What
consistency is more problematic. I would like to try to recreate the difficult during my
CSE if I can. How long does it take to eat a meal – this allows the clinician to form an
impression of efficiency of intake and the patients ability to meet their needs by
eating by mouth. Are there any associated complaints of pain with swallowing, has
the patient developed chest congestion? Have they noticed weight loss or voice
changes associated with their difficulty swallowing. All this information is part of the
bigger puzzle that the clinician is trying to sort out at the bedside to form a working
hypothesis about the nature of the patient’s swallowing impairment.
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The oral motor/cranial nerve exam is the clinican’s opportunity to assess the oral health of
the patient, the patient’s ability to manage secretions, and to evaluate the sensory motor
function of the oral cavity, face , head and neck. If you aren’t familiar with the evidence
regarding the importance of oral hygiene in the fight against pneumonia then please talk to us
after this session. This is only an hour presentation so we can’t run through an oral motor or
the cranial nerve exam. That’s another presentation. But if you’re skipping one of these
components like the oral motor exam – you’re losing important data not taking inventory of
articulatory errors, and type of dysarthria. Motor speech disorders can reflect oral or possibly
pharyngeal motor impairments that may in turn predict other impairments. There’s nothing
like telling residents you think the stroke is in the basal ganglia before the pt has had
imaging…and when they find out your were correct? PRICELESS
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I’ve broken this CSE into components but the truth is we should observing and
assessing behavior, speech/language and cognition from the moment we enter the
patient’s room. I’m starting to make judgments about patient management as soon
as I hear their response to my query “Can you tell me your name?”. We need to
know if they are going to be able to participate in testing. Can they follow commands
so that they can be trained in strategies or participate in an instrumental assessment.
Does their level of cognitive involvement put them at increased aspiration risk?
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Bolus presentations. How do you decide? Don’t some people make you nervous? I get consulted on
some people I’m afraid to give an ice chip to….what do you consider when contemplating the risk
benefit ratio of presenting PO trials? n her textbook, Dr. Logemann stated If the patient is acutely ill,
has significant pulmonary complications, has a weak voluntary cough, is over 80 years old, cannot
follow directions is suspected of having a pharyngeal dysphagia then the risk is high and the benefit
is low. Now I used to live here in FL and that describes nearly ever pt admitted to the hospital but
the bottom line is it is important to consider the case holistically. That’s why all these components
are so important. The swallow is many different systems working together and we need all the clues
we can get. How many people use a protocol? It can be published or your facilities protocol but if
you do not do the same thing and present the same amounts to each patient how do you know
when something is not normal? You certainly do not have to present all consistencies to a patient if
it is going to place the patient at risk.
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Finally, we’ve given our PO presentations ‐‐‐ what do we know or what can we learn about the
ORAL STAGE?????? We should already know about unilateral or bilateral weakness, decreased
sensation from the oral motor and cranial nerve exam but there’s the thing….if your patient eats
with their mouth closed as most of us were taught – you don’t see anything. You can’t judge bolus
formation, cohesiveness, tongue coordination, tongue pumping, or posterior loss of bolus into the
pharynx. You can’t see it. You can however see labial leakage often due to unilateral weakness,
open their mouth and see residue and pocketing – and folks some residue is normal – have you
ever looked into your mouth after you eat a graham cracker – especially if you have not eaten in
several days or even several weeks. Don’t make a disorder where there isn’t one!
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This brings me to the findings of the pharyngeal stage of the swallow. What can the CSE tell
us about the pharyngeal stage of the swallow. It can tell us if there are any overt clinical
signs that we associate with aspiration. It cannot tell us anything about swallowing
physiology. We cannot determine delay from a bedside swallow. We cannot quanitfy
hyolaryngeal excursion. Unless you can have xray vision you cannot determine if there is
residue in the hypopharynx during a CSE and though there may be clinical signs you cannot
verify that there is aspiration. We just can’t see these things. Dr Suiter will further address
the evidence behind what what we can learn from the CSE in her section.
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