PATHOLOGY and AUDIOLOGY

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Oct 29, 2013 (4 years and 12 days ago)

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DEPARTMENT OF SPEECH
PATHOLOGY and AUDIOLOGY

Role of the Speech Pathologist in
the Acute Care Setting

September 15, 2010

Department of Physical Medicine and
Rehabilitation


Dr. Elliot Bodofsky, Chief


Steve Nastasi, Manager


Physical Therapy


Occupational Therapy


Speech
-
Language Therapy


Audiology


Role of the Speech Language Pathologist
(SLP)


Specialists in human communication


Master’s or Doctoral degrees and have earned the Certificate of Clinical
Competence (CCC) of the ASHA, the American Speech
-
Language
-
Hearing
Association


New Jersey Licensure


Identify, diagnose, and provide treatment for individuals with disorders in:


Speech


Language


Voice


Cognitive communication


Swallowing


Fluency



Inpatients and Outpatients




Inpatient Populations


Nursing home patients


Stroke (left and right CVA)


Neurological diseases (MG, GBS, brain tumor, encephalitis,
etc)


Head & neck cancer (including post radiation therapy/chemo)


Respiratory problems


Medically fragile


Tracheostomy, VDRF


Voice


Traumatic Brain Injury

Speech Therapy Orders

SPEECH THERAPY (Consult to Speech therapy)

Problems to be treated: Aphasia, Cognitive
Communication Disorder, Dysarthria,
Dysphagia/Swallowing Disorder, Language
Disorder, Laryngectomy, Speech Disorder,
Voice Disorder, other (comment field)

CONSULT TO SPEECH VIDEO SWALLOW/BARIUM
SWALLOW WITH ESOPH

Modified Barium Swallow Study (MBSS)


(from ASHA treatment efficacy summary)


Swallowing difficulties are commonly found in over 6
million Americans


Unmanaged oropharyngeal dysphagia is associated
with an increased risk of airway obstruction,
aspiration pneumonia, death, malnutrition, and a
decreased quality of life


The speech pathologist’s intervention helps contain
medical costs by reducing the length of hospital
stays, decreasing the need for non
-
oral feedings,
reducing nutritional problems, and decreasing
expenses associated with pneumonia

Normal Swallowing Physiology


Normal deglutition is the act of transporting a
food or liquid bolus from the mouth to the
pharynx and esophagus into the stomach that
involves a complex series of voluntary and
involuntary neuromuscular contractions
divided into distinct phases: (1) oral, (2)
pharyngeal, and (3) esophageal.

Cranial Nerves affecting Speech and
Swallowing


CN I


Olfactory


to detect odors


CN V

Trigeminal
-
maxillary and mandibular branches
affect motor and sensory function


CN VII
-
Facial
-
labial closure, innervation of salivary
glands and taste of 2/3 of tongue


CN IX
-
Glossopharyngeal
-
sense of taste to posterior
third of tongue and gag reflex


CN X
-
Vagus Nerve
-
motor and sensory innervation to
the palate, pharynx, and larynx


CN XII
-
Hypoglossal
-
innervates the tongue



Acceptance and processing of the bolus. The
muscles mix the bolus with saliva and propel it
from the oral cavity to the hypopharynx. CN V,
VII and IX.




Single swallows of liquid last about 1 second;
For solid foods a delay of 5 to 10 seconds.

Oral Phase

Pharyngeal Phase


The pharyngeal phase is involuntary and reflexive
and initiates once the swallowing reflex is triggered


The soft palate rises, the hyoid bone and larynx move
upward and forward, the vocal folds move to
midline, the epiglottis folds to protect the airway, the
tongue pushes backward and downward to propel
the bolus down, the pharyngeal walls move inward
and down and the upper esophageal sphincter
relaxes and opens. CN IX and X

Esophageal Phase

The bolus is propelled downward by a peristaltic
movement. The lower esophageal sphincter
relaxes at the initiation of the swallow until
the bolus has been propelled into the
stomach. An interval from 8
-
20 seconds may
be required to drive the bolus.

Patients who require a speech therapy
evaluation


Current chest congestion/rales


History of CVA and previous dysphagia


History of unexplained weight loss


Low grade fever


Diagnosis of malnutrition, dehydration, or
failure to thrive


History of recurrent pneumonia




Other characteristics indicating a speech
therapy evaluation



Coughing with secretions


Wet or gurgly vocal quality with or without eating


Copious drooling with anterior oral leakage


Hoarse or aphonic vocal quality


Reduced tongue control/coordination


Decreased level of alertness/attention


Pocketing in the right or left anterior/posterior sulci


Complaints of odonyphagia


Delayed mastication


Incidence of Dysphagia with Stroke



27
-
50% of patients develop dysphagia


43
-
54% will experience aspiration


37% will develop pneumonia


Get with the Guidelines
requires all Stroke
patients to have their swallowing screened
within 24 hours of admission









Swallowing Screening for



Stroke Patients


Patients who do not demonstrate risks
or symptoms of dysphagia can
effectively be screened by a physician
or nurse for aspiration risk using a
simple 3 ounce water swallow test


Components of the Dysphagia Screening



Patient sits in an upright position

Patient is observed with three consecutive teaspoons of water

Signs of Dysphagia and/or aspiration:


Delayed swallow
-
oropharyngeal transit time exceeds 2
seconds


Presence of drooling


Cough during or within 1 minute of swallowing


Impairment of voice or speech


Wet phonation


Breathing difficulty or increased respirations after drinking



If none of these symptoms are observed, the
patient is given 2 oz. of water to drink
independently either via cup or straw



If any one of the symptoms is observed



Make the patient NPO



IV Hydration/Dht feeding may be initiated



Order speech therapy for a swallowing

evaluation

Bedside Swallow Evaluation


Includes


Patient history/complications


Current mental status


Oral motor evaluation


Dysphagia screening and evaluation


Test with different textures


Recommendations regarding diet and treatment strategies


Assess safety of PO diet versus non
-
oral mode of
nutrition/hydration


Aspiration Precautions

When is patient ready for bedside swallow
evaluation?



When the patient is awake/alert



Able to move oral structures



Managing their own secretions



Extubated usually at least 24 hours



What do we do during the bedside
evaluation?


Review patient history/complications/tests


Check current mental status


Oral motor evaluation


Dysphagia screening


Make recommendations regarding means of
nutrition, diet and treatment strategies

Oral Motor Evaluation


Assess lingual/labial strength, rate, and range
of motion


Check dentition and oral hygiene


Assess vocal quality, screen speech


Check for volitional/reflexive cough and throat
clear


Check for volitional/reflexive swallow

Dysphagia Screening


Involves looking for signs/symptoms of
oral/pharyngeal/esophageal dysphagia at
bedside


Speech therapist screens patient with various
food textures (i.e. ice chips, water, puree,
thickened liquids, soft solids) and observes
behavioral changes


Colored food trials are used with patients with
trach/ventilator dependency

Clinical Symptoms of Oropharyngeal
Dysphagia



Labial leakage


Labored mastication


Buccal pocketing


Increased time to consume meal


Delayed swallow initiation


Reduced or absent hyolaryngeal elevation


Multiple swallows


Coughing/throat clearing/change in vocal quality noted during
eating


Painful swallow (odynophagia)


Shortness of breath during eating


Possible Recommendations


Continue NPO with alternate mode of
nutrition/hydration


Initiate diet (regular or modified)


Recommend instrumental testing to obtain
more information regarding swallowing
function (MBS, FEES)


Possible consults: ENT, GI, Nutrition

Why is Instrumental Assessment of
Swallowing Needed?


A bedside examination is a screening tool.


The bedside evaluation cannot provide specific
information about the cause of the swallowing
problem, information that is necessary to plan
effective management/intervention.


An accurate prediction of aspiration cannot always
be made. With adults approximately 40% of
aspiration is not identified at bedside

Modified Barium Swallow Study


Performed in radiology by SLP and Radiologist


Patient is seated upright for the study and given various
consistencies of barium/regular food items coated with
barium


Visualizes oral cavity, pharynx, and upper esophagus before,
during, and after the swallow in order to:


Define the abnormalities in anatomy and physiology causing the
patients symptoms


Identify the presence/absence of penetration/aspiration


Identify and evaluate treatment strategies that may improve the
swallow and the patient’s ability to eat safely/efficiently


Provide recommendations regarding the optimum delivery of nutrition
and hydration



Therapy Treatments


Oral motor exercises


Head position maneuvers


Postural compensation techniques


Swallowing retraining


Therapeutic feeding trials


Diet modification


Vital stimulation


May recommend dilation through GI or ENT

Diets

Current diet textures


puree, ground, mechanical soft, regular


thin, nectar and/or honey thick liquids

National Dysphagia Diet


Level I Pureed


Level 2 Mechanically Altered


moist, soft textured
and easily formed into a bolus


Level 3 Dysphagia Advanced


regular textures with
exception of very hard, sticky, crunchy foods that can
be bite size pieces


What can you as physicians do during your
initial evaluation of a patient


Awareness of diagnostic groups that can result
in dysphagia


Find out the patient’s diet and swallowing
status prior to admission (talk to patient,
family, transfer form from Nursing Home,
check residents’ notes, radiology results
-
MBS
may have been completed during previous
admission)

Other considerations


Observe the patient’s level of alertness and cognitive status



Observe the respiratory rate,
Pulsox
, vocal quality, presence of coughing,
wetness, throat clearing,
dysphonia

or
dysarthria



Check the oral motor status



Observe a volitional swallow, cough, throat clear



If screening the swallow, present ½ tsp. of pudding if new or old
neurological problems/ ice chip or small sip of water if structural.



Remember that there is no cough with silent aspiration. A latent cough
may mean aspirate has hit the
tracheobronchial

tree



Consult Speech for patients with risk factors, signs and symptoms of
aspiration, and/or look like they can manage a diet upgrade.

Voice Problems

May include patients


s/p intubation


with trachs


diagnoses of head and neck cancer


GERD and esophageal dysfunction


asthma


Voice Evaluation


Vocal quality


Resonance


Breath support


Breath Control


Referral to ENT, GI, Pulmonary

Passy Muir Valves


Patients with trachs may be a candidate for a
one way speaking valve.


Referral to speech therapy to assess candidacy


Usage is for communication and is appropriate
only when the patient is awake and alert


Patient must be able to tolerate cuff deflation
and feel comfortable with respiratory status

Laryngectomy Post Op Evaluation


Oral motor examination


Post Op evaluation and counseling


Introduction to alternate modes of
communication


Electrolarynx trials


Assist with initiating purchase of
electrolarnges

Speech/Language Evaluation/Cognitive

Communication Evaluation




Did the patient suffer from CVA or TBI?


Are they exhibiting a change in mental status?


Does the patient have slurred speech?


Is the patient having difficulty expressing self?


Is the patient having trouble finding words?


Does the patient have trouble understanding
you?


Is the patient demonstrating severe neglect?


Is the patient having difficulty in orientation,
memory, problem solving, safety awareness,
attention?

SLP’s Role with Language Disorders


Obtain detailed case history


Systematic analysis of intact skills and
deficiencies


Ongoing assessment of language skills


Target behaviors that can be improved


Ethnocultural considerations


Family/patient education

Terms associated with Aphasia


Fluency
-
ability to produce uninterrupted
phrase length of more than four words


Prosody


Auditory Comprehension


Verbal repetition


Word recall/naming


Grammar


Paraphasias: literal, verbal, neologistic

Aphasia vs. Dysarthria


Neurogenic Language
problem


Main difficulty with
language formulation,
expression and
comprehension


Problems not due to muscle
weakness


Intelligibility not clearly
related to rate of speech, no
resonance, phonatory or
prosodic difficulties



Neurogenic speech problem


Main difficulty is speech
production


Speech difficulty related to
muscle weakness


Intelligibility related to rate
of speech, respiratory
problems, phonatory
problems, prosody
difficulty, resonance
disorders


Aphasia vs. Apraxia


Neurogenic language
problem


Agrammatism and
paraphasias often present


Misarticulations less
variable, more consistent


Some impairment in
auditory comprehension



Neurogenic speech problem


Agrammatism and
paraphasias generally
absent


Misarticulations more
variable, more inconsistent


Generally, no impairment
with auditory
comprehension with
repeated attempts at self
-
correction.


Errors are affected by
complexity of productions


Aphasia vs. Right Hemisphere CVA


More language based
problems


No left sided neglect


Good expression of emotion


Generally oriented to space
and surroundings


Pragmatic impairments less
striking




Only mild language
problems


Left
-
sided neglect


Difficulty expressing
emotions


Disoriented to space and
surroundings


Pragmatic impairments
more striking (eye contact,
topic maintenance, etc)


Aphasia vs. Dementia


Sudden onset


Damage to left hemisphere


Mood is usually
appropriate, may be
depressed or frustrated


Nonverbal cognition usually
intact


Most memory functions
intact


Fluent/non
-
fluent


Generally stable



Slow onset


Bilateral brain damage and
diffuse brain damage


May be moody, withdrawn
or agitated


Mild to severely impaired
cognition


Memory impaired to
various degrees, often
severely


Fluent until dementia
worsens


Generally progressive

Variables that affect Treatment
Outcome


Age of patient


Education


Occupation


Extent and location of lesions


Medical, behavioral, neurological status


Hearing ability and visual status


Motor skills


Severity of aphasia


Timing of treatment initiation


Treatment technique


Length and intensity of treatment


Family involvement


Spontaneous recovery


General Treatment Targets


Auditory comprehension


Point, follow commands, understands complex
material


Coarticulated speech


Builds on level of success (syllables, words and
phrases)


General Treatment Targets


Oral expression


Oral motor skills, automatic sequences, repetition, answering
questions, naming, word fluency, to reading words and sentences
aloud


Reading


Identify letters, words, match words and pictures, read sentences in
paragraphs, survival reading skills


Writing


Mechanics for writing basic information: alphabet, numbers, writing to
dictation, writing names, writing about a picture or event.


Naming


Gestures


Cognitive Communication Evaluations


Background medical history


Background educational history


Baseline language assessment


Auditory processing



Reading


Naming


Writing

Cognitive Communication Evaluation


Attention


Orientation


Concentration


Problem solving and judgment


Memory


Organization


Executive Functioning

Intervention and Recommendations



Inpatient versus outpatient services


Short term versus long term


Family Counseling/education


Referrals to other disciplines

Department of Speech and Hearing





3 Cooper Plaza






Suite 511





Camden, New Jersey


(856) 342
-
3060

Outpatient Speech Therapy for infants to adults
with speech, language, voice and swallowing
disorders.

Audiology Services (ABR, Tymps, Audiometric
Testing, Hearing Evaluations, CAPT)


Questions