HOW TO MAKE A
Dysphagia Diagnosis

One of the greatest obstacles besides becoming comfortable with the anatomy during a Videofluoroscopy of VFFS is becoming familiar with that anatomy while moving during scanning and accepting different consistencies.  The only way to become proficient and eventually specialized is with study and practice.  This comes with reviewing as Videos as possible.  Becoming a reliable observer, learning how to interpret evidence, learn how to recognize and interpret anatomical and physiological differences will contribute to developing the swallowing specialists trained eye. 

Provided from from the University in Minnesota in Duluth Department of Communications and Sciences Department provided the following, albeit quick clips and difficult to interpret, but it's definitely a good start for students looking to study!
REMEMBERING ALL OF YOUR NORMATIVE DATA, to understand swallowing, make a clear diagnosis, and set clear goals for treatment.


Normal Videoflouroscopy Studies










Dysphagia Treatment Options

Once your Videofluoroscopy Exam is completed, your Speech Language Pathologist is then able to determine if there is a swallowing problem and exactly where the problem lies.  Once a diagnosis of Dysphagia is confirmed, many different things can occur depending on the severity and location. Your Speech Language Pathologist should discuss their initial findings with you at the time of your examination however, you should make a follow up appointment to discuss your plans and their findings further. 

Swallowing problems can occur for many different reasons.  They don't necessarily mean a dysphagia diagnosis is imminent.  However, once a diagnosis of dysphagia is given, it's important to note that dysphagia is not a disease but a symptom of an underlying disease/disorder.  As your Speech Therapist decides on your dysphagia treatment course, identifying and understanding the underlying disorder is necessary in order to understand how the body will respond to treatment.

It is extremely important to follow the explicit directions of your Speech Language Pathologist, along with your Physician and if needed, a Nutritionist.  Should you have concerns about this new lifestyle that you may have to become accustomed to, it is important to discuss them with your therapist so they can find ways to alternate your treatment plan to the best of their ability so as to keep you in the safest and least restrictive diet possible while also retaining your quality of life. 

Depending on the severity of the Dysphagia, several recommendations may be made which can include any of the following:

  1. Diet restrictions:  Diet restrictions can include a variety of different things which may include simple things from simply changing the temperature from which your food is served, to which the texture you may chew or not chew, to suggesting altering the volume to which swallow your food, as well as modifying your liquids.

  Examples - National Dysphagia Diet (NDD)

  • NDD Level 1: Dysphagia-Pureed (homogenous, very cohesive, pudding-like, requiring very little chewing ability).
  • NDD Level 2: Dysphagia-Mechanical Altered (cohesive, moist, semisolid foods, requiring some chewing).
  • NDD Level 3: Dysphagia-Advanced (soft foods that require more chewing ability).
  • Regular (all foods allowed).
  • Modified Regular Food Diet
  • May note certain foods to avoid
  • May restrict liquids completely
  • May alter liquids to either Thicken liquids; nectar thick or honey thick or how they are swallowed (i.e., use of teaspoon). 
  • Parenteral and Enteral Nutrition

2.    Swallowing Therapy:  Private swallowing therapy can include a variety of               different things, again depending on the severity of your dysphagia and the site of             your dysfunction. 

Examples
  • Therapy can include various types of exercises and swallowing strategies taught during sessions which will then be able to be practiced and utilized at home. 
  • Exercises can include tongue strengthening and muscle strengthening
  • Practices may be taught to modify swallow techniques referred to as compensatory strategies (ie., "chin tuck", "head turn", etc.) to assure safe swallow
  • Some may call to use special techniques and devices such as Thermal Stimulation, Vital Stimulation, E-Stimulation, and/or use bio-feedback devices such as Surface Electromyography.  

It is important to note that some recent procedures claim to treat dysphagia but lack in evidence supporting this claim.  Several of these devices look fancy to the patient who expects a device to do the work for them, yet, the device may be doing more damage than good.  Logeman (2006) states there have been a number of experimental procedures described recently for improvement of motor control of swallow. None of these procedures has any experimental evidence to support its effectiveness. These procedures include myofascial release, designed to release any scar tissue or connective tissue inhibiting movement of structures in the pharynx; neuromuscular electrical stimulation (NMES), designed to improve the strength of muscle contraction during swallow; and deep pharyngeal neuromuscular stimulation (DPNS), designed to utilize reflexive activity in the pharynx to improve swallow. The rationale for many of these procedures and their effectiveness are unclear. These types of procedures should be utilized with care until efficacy data are clearly identified.  Humbert (2011) wrote the article Against E-Stim, however an opposing article For the use of E-Stim for Swallowing was in the same Journal of Perspectives. 

For a detailed description of the various therapy techniques go to Dysphagia Treatment


Parenteral & Enteral Nutrition;
Tube Feeding

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Artificial supplied nutrition and hydration are a medical treatment to be considered in the same light as other technological procedures and not considered life support in the medical field. Literature supports PEG placement in patients recovering from a traumatic accident or expected to make a recovery process. It is considered a medical intervention, not obligatory care.  Properly used it can be helpful.  Recent studies identify frequent regurgitations, micro-aspirations and aspirations in critically ill tube fed patients.  Therefore tube feeding is not a treatment to be used to decrease the risk of aspiration as the risks of aspiration remain. 


Enteral feeding (EN) refers to tube feeding.  Ultimately it is the family's decision, with the physician's advice, who makes the decision regarding tube placement.  Please see Patient Advanced Directives for more information and help on the family's rights on these life saving decisions. 

Parenteral Nutrition (PN) refers to feeding via IV route used in patients who cannot meet their nutritional goals by the oral or enteral route.



Types of Nonoral Feeding


NG Tube- Nasogastric Tube
Thin flexible tube inserted into the nasal cavity through the pharynx, esophagus, down into the stomach. Usually consider for a short-term/temporary alternative. The diameter of the tube varies, however a narrow tube is preferred to create minimal irritation in the pharynx. Disadvantages of the NG tube are the physical presence in the pharynx and esophagus and the potential for regurgitation. Dobhoff tube is designed to reduce the potential for reflux and aspiration by extending into the jejunum. Tracheal placement of the tube is common in patients with a reduced gag reflex. Due to the fact that each anatomy is different the effect of the presence of an NG tube will vary patient to patient.

PPN/TPN
TPN is Total Parenteral Nutrition and PPN is Peripheral Parenteral Nutrition both of which are provided by IV. It is used in patients who cannot meet their nutritional goals by the oral or enteral route. When the gut is not working, PN is also used for long-term nutrition support in the home setting. PN should only be initiated in patients who are hemodynamically stable and who are able to tolerate the fluid volume, protein, carbohydrate, and lipid doses necessary to provide adequate nutrients.   The gastrointestinal tract is always the preferred route of support, i.e., "If the gut works, use it". Most would agree that EN is safer, more cost effective, and more physiologic that PN. Improvements over the past few years have greatly expanded choices in enteral formulas, equipment, and techniques.

Orogastic Tubes
Inserted via mouth through the pharynx, esophagus, and into the stomach.  Used in premature infants and eliminates the risk for potential obstruction of the nasal airway.  Provides short-term nutritional maintenance.  Disadvantages of the Orogastic Tube is that it proves interference with lip-closure and tongue function in the early stages of development and presence of a foreign body in the pharynx and esophagus. 

Nasoduodenal Tubes
Inserted into the nasal cavity, through the pharynx, guided into the esophagus and through the stomach into the duodenum.  Primarily used when there is a problem with reflux and long - term feeding problems. 

Nasojejunal Tubes
Inserted into the nasal cavity through the pharynx, guided into the esophagus and through the stomach into the jejunum.  The Nasojejunal Tube is typically used for patients who need a long - term feeding solution.  The tube poses an inability to completely close off the soft palate which may result in reduced intraoral pressure needed for effective sucking and swallowing. 

PEG Tube – Percutaneous Endoscopic Gastrostomy
Also known as G- Tubes.  Surgical procedure that creates an external opening in the abdomen that leads to the stomach. 125,000 procedures are performed annually. A soft flexible tube is inserted into this opening that leads into the stomach. It is performed under general anesthesia. Blended foods or other specially prepared nutritional supplements can be given with a catheter-tip syringe or feeding pump through G-tube or PEG. Considered more long term, but not permanent. Often causes reflux and may lead to further surgeries to reduce gastroesophageal reflux.  Sometimes there can be leakage around the tube site which can cause discomfort. 

J - Tube - Jejunostomy Tube - Percutaneous Endoscopic Jejunostomy
are inserted into the jejunum (the portion of the small intestine between the duodenum and the ileum).  The J- Tube is less likely to cause reflux, however there can also be leakage around the tube site. 

G-J Tube - Gastrostomy - Jejunostomy Tube
A connected tube with one end inserted into the stomach and the other into the jejunum which allows for removal of stomach contents and nutrition to be delivered to the jejunum.  G-J Tube surgery is a more invasive procedure as two sites are being exposed therefore increasing the chances of leakage around both (2) tube sites. 



Decreasing Risks of Aspiration with Tube Feeding
Despite multiple risk factors, enteral nutrition remains the safest and most cost effective means to promote nutritional requirements in the hospitalized patients who cannot take nutrition orally (Braunschweig et al, 2001). Implementation of prevention strategies is a key factor for improving safety if tube feeding and decreasing risk of aspiration.

· Maintain HOB above 30 degrees at all times

· Routinely verify tube placement

· Remove Naso/oroenteric tubes as soon as possible

· Clinical assessment of GI tolerance including Abdominal distention, Fullness, Discomfort, Excessive residual trends