Dishing on Dysphagia from #ASHA14

I digested my ASHA 2014 dysphagia notes from 15 hours of courses into these five themes. I appreciate both the clarity from our physical therapy partner in item #1, as well as the tension and uncertainty underlining issues in #2-5 below. Here are the highlights:

1.  Inactivity is worse than smoking, obesity, and alcohol combined per the physical therapist, Mark Richards, at Evidence-Based, Optimal Strength Exercise Parameters: Practice Considerations for Speech Therapists.

SLPs need to review exercise physiology and advocate for effective strength training:

• Endurance exercise with many repetitions of low intensity at a constant load is NOT effective.
• Need progression of resistance with the load increasing, otherwise it is maintenance only.
• Quality strength training of even one set done to fatigue is better than an arbitrary 3 sets of 10.
• Use the BORG Scale – Rate of Perceived Exertion. The patient should feel the effort is “fairly light” to “somewhat hard” for a moderate level of exercise OR “somewhat hard” to “hard” at the high level.
• Increased muscle fiber mass and the motor neuron span of control.
• Increased muscle force strength also increases synchronization and timing for a complex coordinated task like swallowing.

2. A thorough Clinical Swallowing Evaluation (CSE) is valuable, necessary, and should be done prior to instrumental examinations (per James Coyle at Bedside Swallow Examinations: What They Can Do & What They Can't). Debra Suiter and Laura Sterling were co-presenters and reviewed what a CSE cannot do.

Additionally, Steven Leder, Debra Suiter and Heather Warner (at Simultaneous Clinical & Instrumental Swallow Evaluations: Findings & Consequences) reminded that the CSE should never diagnose pharyngeal dysphagia. Leder stressed the importance of the instrumental exam. For instance, CSE CANNOT evaluate:

• Bolus flow characteristics
• Pharyngeal/laryngeal anatomy
• Hyolaryngeal excursion
• Pharyngeal delay
• Pre-swallow spillage
• Post-swallow residue
• Swallow physiology. Therefore, we cannot make therapy recommendations based on a CSE (i.e., Masako, Shaker, double swallow, etc.).
• The following are NOT supported in research as predictors/signs of aspiration: absent gag, changes in oxygen saturation, wet voice, watering eyes, sneezing, and nasal drainage. Even the parameter of a cough can give you a false positive/false negative.

But here's what the CSE CAN do:

• Start the patient-clinician relationship. Paula Leslie advises to “shut up and listen,” and sense the feeling in the room.
• Identify patients who may have dysphagia, may be at risk for aspiration, and may be at risk for pneumonia (i.e., Langmore's research and oral hygiene research). We know from Leder & Suiter's research (see references below) that patients who are not oriented, cannot follow 1-step commands, and who have decreased lingual ROM are at increased risk for aspiration. Their research also tells us that if a patient cannot continuously drink 3 ounces of water, he is at an increased risk for aspiration. “Aspiration is volume dependent,” per Leder & Suiter's research. A patient will not silently aspirate if they are able to complete the full 3 ounces without distress or stopping. However, Stevie Marvin and Amy Baillies (at High-Risk ICU Patients: Managing their Dysphagia Care) showed a FEES exam of an ICU patient who easily consumed the 90 cc of fluid, but he had significant silent aspiration. Marvin & Baillies stressed taking in the big picture of dysphagia risk factors with ICU patients.
• Develop a hypothesis. Narrow down possible problems. Make appropriate referrals. Let's not waste time and money doing an oropharyngeal instrumental exam if it is clearly an esophageal issue (of course, keep in mind these frequently co-occur).
• Share your hypothesis with the radiologist at the MBSS to ensure a thorough instrumental exam, including deploying interventions.
• Train interventions that can be tested in the instrumental exam.
• Indicate if instrumental testing is appropriate or not. Is the patient ready for further testing? Will it change anything? Which instrumental exam will best answer the questions? If the goal is palliation, further testing may be academic. Then the CSE's purpose is to “help the patient aspirate more safely,” per Coyle.
• Observe lip seal and mastication. We need to realize that we are making an inferences about bolus manipulation and control once the mouth is closed.
• Observe coordination of respiration and swallowing. Palpating the swallow may not reliably evaluate delay or the extent of hyolaryngeal excursion, but we can note exhale versus inhale after the swallow. If the respiratory rate is >30, the patient may inhale after the swallow, placing him at a higher aspiration risk (per Coyle at What's Wrong With My Patient?).

The bottom-line is that we need to know why we are doing the CSE and what we expect to get out of it.

3. “Understanding the patient's disease process is one of the best tools a clinician can have,” reminded James Coyle at What's Wrong with my Patient? 2014 Update: Pulmonary, Cardiovascular, & Digestive Systems & Conditions Affecting Swallowing. For example, if we do not perform a thorough chart review as part of our CSE, we may think the patient's pneumonia is a dysphagia-related aspiration pneumonia when it is really a hematogenous pneumonia due to the patient's sepsis (bacteremia).

 4.“Not everything that can be counted counts. Not everything that counts can be counted.” (William Bruce Cameron, 1963). John Rosenbek and Paula Leslie reminded us of this quote at their session: Ethics & Evidence in Practice. Leslie stated that Evidence-Based Practice (EBP) is one of the most misunderstood issues, forgetting that research is just one aspect out of three. Leslie worded EBP as: an informed clinician checks her knowledge against best available evidence and against informed patient preferences. Rosenbek warned against the “tyranny of the RCT.” In “clean” RCT studies, he asked if we tend to have difficulty finding our patients. For example, Leder noted (at Simultaneous Clinical & Instrumental Swallow Evaluations: Findings & Consequences) how his research on the 3 ounce water swallow excluded patients with tracheostomy, head and neck cancer, and dementia.We should feel a tension between data and belief, per Rosenbek.

Another example of challenges in EBP was from Catriona Steele's lecture on Diet Texture Terminology. She noted how the Protocol 201 (which is often cited as a reason to not put patients on honey thick liquid) actually used 3000 cp for honey thick as opposed to 1750 cp. This means the research was really comparing nectar thick to pudding thick. “No clear agreed upon taxonomy causes a clear risk to our patients,” per Steele.

 5. “Safe and successful mealtimes are so much more than safe and successful swallowing,” per Samantha Shune at Eating is Not Just Swallowing: Redefining the “Swallowing” Process in the Elderly. This is the perfect example of how the CSE is much more than a screen of swallowing. The act of eating has an anticipatory phase. Shune showed that healthy elderly need more pre-oral time, using all proprioceptive and sensory feedback to prime the motor system. We can ensure that caregivers maximize the mealtime environment to ensure the patients have this compensatory advantage.

Bringing it home

So here's what all this means to me and what I am taking home: Our clinical swallow evaluation is not a screen. We all agree on the limitations of the CSE. However, physicians perform clinical bedside examinations on patients and bill accordingly. They then order instrumental examinations to test their differential diagnoses. We do the same, testing our hypotheses. Per my verbal communication with Steven Leder, he does bill for an evaluation when he performs the Yale Swallow Protocol. However, he also indicated that a nurse could perform this “screening” protocol. We cannot bill for screens. What we do bedside is at a much higher cognitive level of reasoning and critical thinking than just a screen. As Rosenbek said at Ethics & Evidence in Practice: “All of this is why we have frontal lobes.”

We heard our colleagues at the sessions lament that they do not have quick access to instrumental examinations, if at all. What can we do? Some ideas for starters:

• Document well, stating your hypotheses, as well as the limitations of a bedside CSE.
• Find Mobile FEES/FEESST and MBS services.
• Push for adequate staffing and equipment to be able to perform necessary instrumental exams on inpatients.
• Push for adequate time to review the MBS studies frame-by-frame to “make darn sure of what we see...our recommendations are depending on it,” per Martin Brodsky at Paying it Forward: Training Future Experts in Swallowing Diagnostics. For example, one cannot gather adequate information in real time on 17 components of a MBSImP.
• Stay open to changes in the field.
• Maintain positive dialogues.
• Teach students to expect/embrace uncertainty and realize that there are differing opinions.
• Thank our trail blazing researchers who are pushing us to question our long-held beliefs!

Speaking of trail blazing, see you next year at ASHA 2015 in Denver, Colorado!

Karen Sheffler, MS, CCC-SLP, BCS-S, graduated from the University of Wisconsin-Madison in 1995. Karen has enjoyed medical speech pathology for 20 years. She is a member of the Dysphagia Research Society and the Special Interest Group 13: Swallowing and Swallowing Disorders. Karen obtained her BCS-S (Board Certified Specialist in Swallowing and Swallowing Disorders) in August of 2012. She has lectured on dysphagia in the hospital setting, to dental students at the Tufts University Dental School, and on Lateral Medullary Syndrome at the 2011 ASHA convention. Special interests include neurological conditions, geriatrics, oral hygiene, and patient safety/risk management. Karen continues to work in acute care and is a consultant for SEC Medical. She started the website and blog www.SwallowStudy.com in May 2014. She has blog posts on ASHAsphere and www.DysphagiaCafe.com. You can also follower her on Twitter, Facebook or on Pinterest. Sheffler was one of four invited bloggers for ASHA’s 2014 Convention in Orlando.

References:

Leder SB, Suiter DM. The Yale Swallow Protocol: An Evidenced-Based Approach to Decision Making. Springer, NY, 2014.

Suiter DB, Leder SB. Clinical utility of the 3 ounce water swallow test. Dysphagia. 23:244-250, 2008.

Leder SB, Suiter DM, Green BG. Silent aspiration risk is volume dependent. Dysphagia 26:304-309, 2011.