Peak Flow may be completed to assess the patient’s strength of the cough reflex, and to determine risk of aspiration. Peak Flow may also be used to determine baseline and progress with expiratory muscle strength training. A Peak Flow meter can be purchased from a medical supply store, or on Amazon. Several studies have shown accuracy in detecting aspiration risk in various populations using Peak Flow, including: 82% of patients post-stroke who were identified as aspirators at a PEF of <2.9 L (Smith-Hammond, 2009; Hammond & Goldstein, 2006; Hammond, Goldstein, Horner, Ying, Gray, Gonzalez-Rothi,& Bolser, 2009), 86% of patients with Parkinson’s were identified as aspirators at a PEF of <5.2 L (Pitts et al., 2010), and 74% of ALS patients were identified as aspirators at <4.0L (Suarez et al., 2002).
The 3-ounce water protocol is an assessment screen that can be used during a Clinical Swallow Evaluation (CSE). The patient is given 3 ounces of water, which they are expected to drink without stopping. If the person is unable to drink without stopping, or coughs during drinking, the screen is discontinued and the patient should be referred for further assessment. If they are able to continuously drink 3 ounces of water without coughing, the patient is considered to have passed the screening.
This screen is based on research by Dr. Steven Leader and Dr. Debra Suitor, who found that 3 ounces of liquids should be enough to stimulate a cough reflex in patients (Suiter & Leder, 2009). The 3-ounce water protocol has also been modified to include an oral mechanism screening and a brief assessment of cognition and has been published as the Yale Swallowing Protocol (Leder & Suiter, 2014).
The Toronto Bedside Swallowing Screening Test (TOR-BSST) (Martino et.al, 2009) is intended for use by health care professionals who have been trained to complete the screening. It was developed specifically for use with patients with stroke, and designed to be administered across healthcare settings. Areas evaluated include Vocal quality assessment before and after swallow, tongue symmetry, and water swallows (10 individual teaspoons).
The Modified Mann Assessment of Swallowing Ability (MMASA) (Antonios et al., 2010) was developed as a physician-administered (neurologists), dysphagia-screening tool for acute stroke patients that can be performed at the bedside. This screening tool is based on the psychometrically validated Mann Assessment of Swallowing Ability (MASA), and includes the following 12 of 24 items from the original MASA: alertness, cooperation, expressive aphasia, auditory comprehension, dysarthria, oral motor exam, respiration, and cough. There are no boluses presented in this screening examination.
Clinical Swallowing Evaluation (CSE)
Assessment of dysphagia is often a multistep process that begins with the chart review, labs review, medication review, and patient/caregiver interview. After obtaining a case history, the next step is often the Clinical Swallowing Evaluation (also known as the Bedside Dysphagia Evaluation).
Why the Cranial Nerve Exam and Clinical Swallow Evaluation (CSE) Is Important
The clinical swallow evaluation (CSE) can provide valuable information on the patient’s cognitive status, readiness for instrumental examination, past medical history, as well as a physical examination of oral structures that includes the integrity of the cranial nerves. The CSE can also provide a baseline for assessing changes in the patient. There are some clinical indicators from the CSE that can give valuable information about laryngeal function, such as dysphonia, cough, and vocal changes after the swallow. The CSE alone, however, cannot help determine with certainty that someone has penetrated, or aspirated, food and/or liquid nor can it assess swallow kinematics. This type of information can only be inferred. Therefore, the CSE should not be used as a replacement for instrumental assessment.
A cranial nerve examination is vital for assessment and treatment planning. As mentioned in Chapter1, the cranial nerves are responsible for transmitting sensory information from the oropharyngeal cavity to the Nucleus Tractus Solitarius, which then sends the information to the Nucleus Ambiguus, which transmits motor information to the muscles of the oropharyngeal cavity.
According to Watts et al. (2016) A small but growing body of literature supports the inclusion of cough testing in the CSE to provide an index of overall function and capacity of airway defense mechanisms to aide in clinical and diagnostic decision-making and assessment of potential risk of impairments in swallowing safety (p. 275).
Volitional cough testing involves asking a patient to cough. The typical instructions are “as hard as you can” or “like have something stuck in their throat.” Then assessing either subjectively by listening, or objectively with specialized equipment (Watts et al., 2016). The cough can be characterized by three phases:
• Inspiratory phase: The contraction of the external intercostal muscles elevating the anterior rib cage and drawing down the diaphragm. Laryngeal muscle activation allows for passage of air through the glottis, resulting in a negative pressure drawing air into the lungs.
• Compression phase: The adduction of the vocal folds builds and maintains subglottic pressure generation.
• Expiratory phase: This is the rapid abduction of the vocal folds (Webb, 1995).
When assessing the patient, it is advisable to begin measuring outcomes and establishing a baseline for patient progress. There are a variety of outcome measures available that are free, or available for purchase, outcome measres must be used only after training of use of the measure. These include:
Choosing an Instrumental Assessment
The most commonly used examinations to consider when choosing an instrumental assessment include the Modified Barium Swallow Studies (MBSS), and Flexible Endoscopic Evaluation of Swallowing (FEES). Instrumental assessment is necessary to determine the physiology of the pharyngeal swallow According to Langmore (2006) an instrumental examination is necessary if:
• Oral, pharyngeal, or esophageal dysphagia is suspected,
• Diagnosis needs more specificity
• Management depends on further information
The MBSS and FEES each offer a unique perspective of the swallow. For many clinicians, deciding between MBSS or FEES may be difficult due to unfamiliarity with what information can be gathered for each assessment.
It is important to remember that the instrumentatal assessment is NOT to determine if the person is aspirating, and to recommend a diet consistency. The instrumental assessment is key in determining the pathophysiology of the swallow mechanism, and helps develop an appropriate plan of care for the patient. It is not possible to evaluate bolus flow patterns, pharyngeal phase, or airway protection without instrumentation. It is necessary in order to determine the pathophysiology and kinematics of the swallow (Martin-Harris et al., 2008)
Only fluoroscopy can visualize bolus at the height of the swallow, assess the oral phase, including tongue retraction and hyoid and laryngeal elevation. It can also help identify abnormalities that lie beneath the surface of the mucosa, for example, esophageal issues, Zenker’s diverticula, osteophytes.
Only endoscopy can visualize the amount of secretions and the patient’s ability to manage them, directly assess sensation, and identify anatomical abnormalities, vocal cord mobility, arytenoid movement, and finally, bolus flow and location of bolus residue within the hypopharynx with specificity.
Indications for MBSS Assessment
Indications for FEES Assessment
Research to Practice: Interjudge Reliability of the Examinations
Few studies have tested the interjudge reliability (the consistency of measurement obtained when different judges or examiners independently administer the same test to the same individual) of other findings with FEES.
• FEES and fluoroscopy have similar (high) interjudge reliability ratings for penetration-aspiration (PA Scale) and residue severity (Colodny, 2002; Kelly et al., 2006).
• Few studies have tested the interjudge reliability of other findings with FEES.
• Fluoroscopy studies are often disappointing when looking at structural movements (McCullough et al., 2001; Stoeckli et al., 2003).
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