As you all know from
Part One, I went to school for speech-language pathology. I received an undergraduate degree in communications, with a concentration in disorders, and I went to grad school and received a master's of science in speech language pathology. This post is pretty lengthy, but I figured it would be better to say more than to say less - for this particular post. Anything I don't explain is linked. Enjoy!
I was recently hired as a SLP for the inpatient population at a near-by hospital. The main disorder we treat in the acute setting is dysphagia - which is the medical term for a swallowing disorder; however, we also see patients for
aphasia,
apraxia,
dysarthria,
voice, and
cognition. Dysphagia typically occurs in the elderly population; however anyone can suffer from the disorder - including premature babies. When we receive a swallowing eval referral from a doctor, our patients usually suffer from one of the following: stroke, Parkinson's disease, muscular dystrophy, cancer of the head and neck, brain injury, heart, brain, or neck surgery, and problems with the esophagus such as acid reflux. So basically anything that causes a patient to have pain or difficulty swallowing is a cause of dysphagia.
Typical signs that a patient is suffering from dysphagia are coughing and/or throat clearing during or after eating or drinking, a "wet" or gurgly sounding voice after eating or drinking, needing extra effort or time to chew or swallow, food/liquid that's leaking or getting stuck in the mouth (pocketing), recurrent pneumonia, weight-loss, dehydration, or malnutrition.
When the referral comes in I do my research on the patient - look at why they were admitted, their past medical history, CT/MRI/MRA of the brain, and what diet they are currently on, if any (sometimes they are NPO - nothing per oral - until we do our evaluation). From this research I can get an initial picture in my mind about how this patient might do when evaluated. Before going into the patient's room I talk with the nurse. Nurses are a great resource to us as they are constantly with the patient and can give great information about how they did eating a meal or taking their pills - this is also true for family members as they can provide an accurate baseline of the patient before being admitted.
The initial eval that I do is called a bedside evaluation. I go in, explain who I am and what I'll be doing, I ask the patient a few questions just to see how oriented they are, and then I do an oral mechanism exam. During an oral mech I typically have them move their tongue around, pucker their lips, and smile - I'm basically looking at coordination and symmetry - I also check out their dentition. I don't want to give an elderly man with no teeth a hard cracker...
At bedside, I give the patient trials of several different food and liquid consistencies. Typically the patient is given ice chips, pureed food (applesauce or pudding), honey-thick liquid, nectar-thick liquid, thin/regular liquid, soft food (nutrigrain bar), and regular food (cracker) - in that order. Now, every patient is different - some ending up trialing all of these and some we have to stop after the pureed. It just depends on the patient. From this evaluation I determine if the patient is safe for oral intake. If so, I decide on a diet that is safest for the patient, call the patient's doctor to discuss the results and my suggested plan, he'll say "ok", and I'll write the order in their chart - at the next meal time the patient is ready to eat! If I feel like a patient isn't safe for food or liquids or I feel like I need to see what's going on during the swallow I will call the doctor, explain what's going on, and ask that a Modified Barium Swallow Study (MBSS) be ordered.
A MBSS is a moving x-ray of the patient's swallow. We give the patient all the foods and liquids mentioned above except with this test we put contrast (barium) on the food and in the liquids so that we can see the food/liquid and exactly where it's going during a swallow. I say "we" because there's always a SLP (me) and a radiologist in the room, giving the test. So you can get better idea of this test, here is a link of a MBSS for
a patient who aspirates (watch the second swallow) and
one who swallows normally.
Another swallow study performed by SLPs is called a Fiberoptic Endoscopic Evaluation of Swallowing (FEES). This test is different in that it can be performed at bedside and instead of doing a moving x-ray, it's a camera that looks down on the patient's
larynx. So basically, in layman's terms, a FEES is done with a flexible fiberoptic endoscope (camera) that is inserted through the nasal cavity and looks down onto the vocal folds, trachea, and esophagus. Here is an
example of a FEES - it's a longer video, but it gives you a good idea of how the camera is inserted, what you look at during the test, and the swallowing mechanism itself. At the hospital I am currently working at, we do not have any FEES machines - some hospitals have them, some don't. At the hospital I did my clinicals at they did have them - so I've seen my fair-share of FEES.
After either of these test we have a clearer picture of exactly what's going wrong during the patient's swallow. From there we can determine an appropriate diet and/or if further testing needs to take place - sometimes an esophagram or a neuro consult if we think the dysphagia is secondary to something else that's going on.
Shew! That's a lot! I've spent the majority of this post talking about dysphagia because it's honestly 80-90% of what we see with the inpatient population. I hope I was clear and thorough in my explanations above. Let me know if you have questions - I'd love to answer them or explain anything further. Also, here I am in my scrubs:
