The Blue Dye Test involves using a small drop of blue food
coloring mixed with a bolus and to determine if there is
aspiration by monitoring for blue food color in tracheostomy
tube suction. This is done as augmented version to a
traditional bedside swallow test.  When this test is
used alone, without FEES or MBS,  there is heightened
risk for a high false negative rate.  Research has
revealed that the bedside blue dye test is not able to
recognize all tracheal aspiration found on modified barium
swallow (MBS)  (Peruzzi WT et al 2001). What does
clinical experience suggest? Blue dye bedside swallow test
alone only shows if aspiration is present or absent and this
is not always accurate when in trace or small amounts. This
method of testing doesn’t tell when aspiration is
happening (before, during, after swallow). Blue dye test
doesn’t show the route of bolus laryngeal penetration: (
anterior into larynx over epiglottic rim, posterior spillage
over
 the arytenoid cartilage, lateral entry over the
aryepiglottic folds), which potentially leads to the
aspiration. FEES/MBS benefit with tracheostomy patient is
identification of precise behaviors resulting in aspiration
risk, before the aspiration happens. This is particularly
important with compensatory techniques and postures. In
contrast, with beside blue dye exam and no MBS/FEES,SLP may
observe signs of aspiration risk and may get blue food color
in suction. But, there is no specific information as to
events leading up to aspiration. Blue dye test alone without
FEES/MBS seems to be more of a screening measure.

Blue dye test at bedside, may not likely show trace amounts
of aspiration (Donzelli J et al. 2001). Clinical experience
has shown that recurrent aspiration in trace amounts in
ventilator weaning patients may create further pulmonary
compromise and prolong weaning in certain cases. When using
blue dye testing alone without FEES/MBS, clinical experience
has shown that one consistency tested at a time can
potentially allow for  the identification of what
consistency was aspirated, if there was nothing else given
to the patient. When a clinician provides multiple
consistencies at once with blue dye at bedside without
FEES/MBS and there is aspiration, it could be more difficult
to determine what portion of a particular bolus consistency
was aspirated or which consistency was aspirated. The
clinical practice of blue dye testing without FEES/MBS may
also reveal positive aspiration that is not bolus related.
The presence of blue dye in suction of the
 tracheostomy tube can also reflect aspiration of
secretions. Clinical practice has shown, that use of FEES or
MBS is critical in the complete assessment of patients with
tracheostomy tubes.

Dr Eric Blicker MA CCC-SLP.D BRS-S

Wada, S., Tohara, H., Iida, T., Inoue, M., Sato, M., & Ueda, K. (2012). Jaw-Opening exercise for insufficient opening of upper esophageal sphincter. Archives of Physical Medicine and Rehabilitation, 93(11), 1995-1999.

The outcome of this no named new Dysphagia exercise is increasing hyoid elevation, Upper Esophageal Sphincter (UES) opening, pharynx passage time, and decreasing pharyngeal residue after swallowing at preexercise and postexercise evidenced by VFSS.

As per Dr. James Coyle this exercise is also designed to increase UES opening by using strengthening the anterior muscles of the floor of the mouth (submandibular suprahyoid) muscles. It exercises these muscles by depressing the mandible. We do it with gentle resistance and use the same schedule that is published in the studies on tongue strengthening. Coyle


During a swallow, the UES is open, and works closely b/c of the location of the cricopharyngeal muscle. The cricopharyngeal muscle is attached to the cricoid cartilage and is relaxed upon swallowing as it is pulled by the hyoid laryingeal structures. "The UES does not open automatically. Successful opening of the UES requires an anterior-superior traction of the hyoid and larynx and further UES relaxation and hyoid traction on the larynx precedes UES opening" Wade.   Further described, when the hyoid decreases laryngeal elevation can cause dysphagia resulting from UES opening.


This exercise involves jaw opening and multiple muscles therefore during ones' Oral Periphieral Exam Jaw as well as Labial muscles must be assessed for this exercise. It doesn't mean they have to have within normal limits, but it must be documented. The suprahyoid muscle group including mylohiyoid muscle, the anterior belly of the digastric muscles and the geniohyoid muscles are also involved in hyoid elevation and some in jaw opening. These muscles include the mylohyoid muscle, the anterior belly of the digastric muscles, and the geniohyoid muscle.

Given the above mechanisms, the authors performed a jaw-opening/strenghening exercise among patients with UES dysfunction and assessed the effect of this exercise on swallowing function with a videofluorographic swallowing study (VFSS).

Evidence has shown that there was significant improvements when you compare swallow functions pre-exercise and post-exercise.  Advances were demonstrated in the extent of upward movement of the hyoid bone, the amount of UES opening, and the timing of pharyeal passage.  Four (4) weeks after initiating the exercise. Some subjects evidenced decreased pharyngeal residue. No increases were noted in any subjects.

The conclusion demonstrated that this jaw-opening exercise is an effective treatment for dysphagia; caused by dysfunction of hyoid elevation and UES opening.

Early Intervention with ABA

There has never been a more accurate mantra in the field of developmental disability: “Early diagnosis leads to timely intervention…timely intervention leads to better outcome.”  We know that children with Autism Spectrum Disorder (ASD) demonstrate signs of the disorder even before the age of nine months.  However, the average child with ASD is not diagnosed with the condition until the age of six.  As a result of this delay, there are several years of lost opportunity. This is especially important because the years from birth to three are so crucial in a child’s life. So what’s the best way to implement early intervention strategies?

Applied Behavior Analysis (ABA) therapy is considered by many researchers and clinicians to be the most effective evidence-based treatment approach for children with ASD. According to the U.S. Surgeon General, thirty years of research on the ABA approach have shown very positive outcomes when it is used as an early intervention tool for ASD. Studies show about 50% of children with autism who were treated with the ABA approach before the age of four had significant increases in IQ, verbal ability, and social functioning.

ABA teaches communication, social, and motor behaviors in addition to reasoning skills and self-help skills that are useful to promote independent living.  ABA treatment specializes in teaching behaviors to children with ASD who may otherwise not learn on their own as other children would.

The ABA approach can be used by a parent, counselor, or certified behavior analyst EVERYWHERE! It aims to help children with autism lead more independent and socially active lives. Research shows that this positive outcome is more common for children who have received early intervention, when the brain is critically developing during the preschool years.

As a parent or educator working with a child with Autism obtaining the necessary training to implement effective ABA treatment can be difficult juggling a home and work schedule. So, Special Learning is bringing the convenience of online training to you! Our ABA Online Training Program provides comprehensive training in the methods if ABA implementation, so you can start helping your child TODAY! Visit www.special-learning.com/aba_online_training for more information or to register for one of our upcoming courses!

Take the first steps in securing a brighter and more successful live for your child today!

Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) is approved by the United States Food and Drug Administration (FDA) to assess quantitatively laryngopharyngeal sensory perception related to deglutition. Sensory discrimination testing during FEESST is conducted via delivered air pulses to the laryngopharyngeal musculature infiltrated by the internal branch of the superior laryngeal nerve (ISLN). Jafari, Prince, Kim, and Paydarfar (2003) implied that the afferent nerve transmission from the ISLN was essential for a functional pharyngeal swallow, specifically in supplying information to primary efferent neural functions that control adduction of the laryngeal musculature during the pharyngeal phase of the swallow. Their research proposed that ISLN damage was a major factor in the development of dysphagia and aspiration.

During the FEESST procedure protocol, as described in Aviv and Murray (2005), a flexible endoscope is passed transnasally, along the floor of the nose,  past the velopharyngeal port and into the hypopharynx. Sensory discrimination thresholds during FEESST are obtained bilaterally by endoscopically providing air pulse stimuli directly anterior to the arytenoid cartilage at the juncture of the aryepiglottic fold because this mucosa in the laryngopharynx is innervated by the ISLN. The stimulus is designed to trigger a laryngeal adductor reflex (LAR) via direct stimulation of the ISLN (Aviv et al., 1993). Ludlow, Van Pelt, and Koda (1992) found that stimulation of this mucosa elicited the LAR, which was an involuntary, concise closure of the true vocal cords. Aviv et al. (1999) found that this airway defense LAR was maintained by brainstem function. Once the air-pulse testing is done, the patient is then fed food and liquid consistencies mixed with green or
blue food coloring for contrast while the pharyngeal phase of the swallow is assessed evaluating food, liquid, and secretions.

FEESST assessments are performed with patients who demonstrate dysphagia, a difficulty in swallowing, as defined by Logemann (1998). Clinical experience has shown that the presence of dysphagia might place the patient at risk for tracheal aspiration. As described by Marik and Kaplan (2003), the event of tracheal aspiration occurs when a bolus, particulate matter, or patient secretions enter the trachea. Research has shown that further airway entry into the lungs because of tracheal aspiration can become a catalyst for infection and pneumonia (Kalra, Ramsey, & Smithard, 2003). FEESST was designed to obtain data that is more objective regarding laryngopharyngeal sensation, when compared to the clinical bedside swallow evaluation, which is a more subjective evaluation.

Clinical practice has shown that instrumental assessment is especially important in those patients who have silent penetration when the bolus enters the larynx at or above the level of the true vocal cords without a sensory clearing response. As discovered by Logemann (1998), the same importance for instrumental assessment holds true for the identification of silent aspiration, when the bolus enters the trachea without a sensory clearing response. Aviv et al. (1996) suggested that the importance of sensory discrimination testing in these patients might be significant because decreased sensation in the laryngopharynx could contribute to dysphagia and aspiration. Sensory loss in the laryngopharynx might be a catalyst in dysphagia and aspiration, presuming that, if the patient did not sense a bolus or secretions within the laryngopharynx, regular upper airway shielding reflexes might be deficient. Research has shown that patients with more severe sensory
loss in the throat with FEESST have shown a higher frequency and occurrence of silent aspiration into the trachea, suggesting that there is some association between the sensory nerve for the laryngopharynx (ISLN) and the sensory nerve for the trachea (recurrent laryngeal nerve RLN), which are both branches of cranial nerve X, the vagus nerve (Blicker, 2008).

Written by Dr Eric Blicker MA CCC-SLP.D BRS-S

Eric's ASHA approved CE Provider website can be found here:  WWW.CEUALLIEDHEALTH.COM

Nothing makes me happier than to open up my email and see an email from a fellow colleague, student, or husband or wife trying to help each other or their child, and thanking me for my easy to read website.  Putting out this hard to understand information in the simplistic of terms.  Being as unbiased as I can (in some cases) and helpful in most.  I want to continue to bring all of this to you, my readers, but with a question or two that I'd like you to respond to;

1.  What do you like/dislike most on my website?
2.  what is most helpful to you as whomever you are as a visitor?

I prefer that you answer below in the comment box so everyone can see and a conversation could start.  But if you don't feel comfortable and have something to say, feel free to email me at amy@amyspeechlanguagetherapy.com

When I decided to take on this blog, I decided it was about providing information.  But as it grew, it became bigger than I ever dreamed.  Now I feel obligated to provide everyone with information as such as the follwoing.

Is this Obamacare or just a conicidence?  I find myself asking my question quite often.  I'm I guess what you call a quiet political.  I care, but I don't get involved. Being not only a healthcare provider but also a patient, I'm suddently seeing quite a bit of changes, and changes I don't like.

POLST, MOST, A Physician Orders for Life Sustaining Treatment (POLST) form is a document created by you and your doctor that informs emergency care providers what kinds of treatments you want (and don't want) in a medical emergency.  POLST forms are like Do Not Resuscitate (DNR) orders in that they 1) must be signed by a doctor and, 2) instruct emergency medical whether to administer cardiopulmonary resuscitation (CPR).  However, POLST forms cover many additional types of medical interventions, such as intubation, antibiotic use, and feeding tubes.
POLST forms are available in almost half of the states in the U.S. and they go by various names – MOLST, POST, COLST, TPOPP, LaPOST, etc.  Learn more about the POLST form in your state in the articles below.
 
One example of a problem with a POLST from a reader would be; an ambulance is called to your home, no one is there to tell them of your medical directives for your mother.  She has a DNR to which they are unawar.  Without a POLST, they will initiate life saving measures.  With a POLST, they won’t.This reeader informer me that she has had her mother keep hers posted on her refrigerator as well as herself and all her loved ones.  

To find out if it's currently in your state click here:
http://www.nolo.com/legal-encyclopedia/physicians-orders-life-sustaining-treatment