Introductory Statement: Example entry for a patient in an acute care setting receiving a laryngoscopic evaluation of swallowing
Mr. Jones is a cognitively intact 72-year-old man 10 weeks post coronary artery bypass graft. A tracheostomy was performed postoperatively. Ventilatory support was initiated on 6-12-03 and, after a short period of weaning, was discontinued on 7-14-03. The patient is now fitted with a #6 metal trach tube. When the trach is occluded, voicing is hypophonic without wet dysphonia and the cough is weak. Primary nutrition is currently provided via nasogastric tube without complications. Hydration and nutrition parameters are essentially normal. Oral motor function is essentially normal. During trial swallows, inconsistent clinical signs of aspiration (coughing) were observed following thin liquid swallows. The cause of these clinical signs of aspiration is undetermined. This laryngoscopic evaluation was performed to determine the presence of aspiration and cause of the signs of dysphagia.
Examination Parameters: Example entry for a videofluoroscopic evaluation of swallowing
Ms. Smith was seated upright and viewed in the lateral and AP projections. Food and liquid with barium contrast were presented in controlled amounts ranging from 3–35 ccs. The patient also was observed during self-feeding of solid foods and spontaneous consumption of liquid from a cup.
Results: Example entry for a patient with poor oral containment of the bolus
Initial visualization reveals a normally configured oropharynx without obstruction or malformation. The oral preparatory stage of the swallow was normal for all consistencies and volumes presented. The duration of the transition between the oral and pharyngeal stages of the swallow averaged approximately two seconds for all consistencies presented. Prior to the initiation of the pharyngeal stage of the swallow, solid food and puree boluses were noted to fall to the vallecular space. Liquid consistencies of all volumes were noted to leak between the lingual velar seal and fall to the level of the pyriform sinuses prior to the initiation of the swallow. Thin liquids presented in volumes greater than 15 ccs were consistently noted to overfill the pyriform sinuses and flow into the laryngeal vestibule prior to the initiation of the pharyngeal stage of the swallow. The material falling below the vocal folds was completely cleared into the pharynx with spontaneous coughing. Once initiated, the pharyngeal stage of the swallow was essentially normal. There was no evidence of pharyngeal residue following initial swallow attempts. Chin-tuck positioning improved the oral containment of the bolus and reduced the duration of the transition between the oral and pharyngeal stages. This consistently eliminated the penetration and aspiration of liquids. There was no evidence of primary or secondary cricopharyngeal dysfunction or impairment of upper esophageal transit.
Impression: Example entry for the same patient
Mr. Jones presents with moderate oropharyngeal dysphagia characterized by poor oral containment of liquid boluses secondary to an impaired lingual velar seal. This impairment results in premature spillage of liquids into the pharynx prior to the onset of airway protection with subsequent aspiration. Without direct intervention to improve oral containment and airway protection, Mr. Jones is at risk of recurrent events of aspiration. During the examination, oral containment was modified and aspiration prevented by implementing the chin-tuck position prior to the initiation of the swallow. Short-term training and instruction in the use of this specific positioning technique (chin tuck) and specific oromotor exercises to improve the lingual velar seal are necessary to achieve a reduction in the risk of recurrent aspiration.
Recommendations: Example entry for a patient transitioning between enteral and oral intake of food and liquid
If consistent with all other care:
- Continue with delivery of primary nutrition and hydration via PEG tube.
- Initiate supervised therapeutic PO intake of puree foods and liquids thickened to a nectar consistency.
- Initiate twice-daily dysphagia rehabilitation sessions to focus on training the super-supraglottic swallow maneuver to improve airway protection and reduce the risk of aspiration.
- Order calorie count to determine adequacy of PO intake of food and liquid to ensure capability of maintaining nutrition and hydration.
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