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Spring 2017 SASS Newsletter

Click to Read:   JCHAO Discovers FEES

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Fall 2016 SASS Newsletter

Welcome to the Fall 2016 SASS Newsletter

Read About Importance of Endoscope Cleaning Practices

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Summer 2016 SASS Newsletter

Welcome to the Summer 2016 SASS Newsletter

Read about Scoring FEES Studies

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Spring 2016 SASS Newsletter

Welcome to the Spring 2016 SASS Newsletter.

Click here to read about Old Dogs and New Tricks.

 

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Dysphagia FEES SASS Minute

Fall 2015 SASS Newletter

 

Welcome to the Fall SASS Newsletter. Read about our wonderful trip to Saudi Arabia!

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Summer 2015 SASS Newsletter

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Read about our wonderful visit to Egypt. Oral Care is not “care”; its infection control!!

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Spring 2015 SASS Minute

The Spring 2015 SASS Minute is here!  Find out why you need to know more than just IF a patient is aspirating, and see why you can start calling us SASSi!
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Winter 2014 SASS Minute

The Winter SA Swallowing Services Newsletter is here!  Check it out for a little gift from us and for all the news from SA Swallowing Services!
Click here to view the winter 2014 SASS Minute
Click here for our gift to you (a copy of the Yale Swallow Protocol & instructions for implementing it into your practice!)
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Dysphagia Professional Issues Research

December Research Tuesday

To Eat or Not to Eat: What Information do Clinicians Use in Recommending an Oral Diet?
I LOVE the holiday season.  I love the decorations, the spirit in the air, and spending time with friends and family.  And if you are at my house, that means food – lots of food.  Our family loves to cook and eat together, and I cannot imagine a time of year when it would be more difficult to not be able to eat. Making the recommendation for oral versus nonoral feeding is pretty much the most important decision we make as swallowing therapists.  There are very few things that more dramatically change a patient’s life than taking away their PO status.  We should not take these recommendations lightly.  With great power comes great responsibility, and we should constantly be assessing why we make certain decisions.  Back in 2008, Dr. Logemann and 24 colleagues investigated this topic – they wanted to know how and why clinicians make their oral or nonoral feeding recommendations – and luckily they published this information for us to use!
Logemann, J. A. et al. (2008). What information do clinicians use in recommending oral versus nonoral feeding on oropharyngeal dysphagia patient? Dysphagia, 23. (Full Text Here)
This study was comprised of two phases.  In the initial phase, a group of 23 experienced dysphagia clinicians identified the variables they might use in making NPO vs PO decisions.  Those variables were then rated by the clinicians to determine the most important of the identified variables.  The chart below describes the 13 most influential variables identified.
chart 12142
In the second phase of the investigation, 20 modified barium swallow studies with patient histories were sent to the SLPs for analysis.  For each patient, clinicians were asked whether they would recommend an oral diet, partially oral diet, or nonoral feeding.  They were then asked what diet consistency they would recommend if they gave a partially oral feeding, whether dental status affected their decision, and if they would recommend postures or maneuvers.
The decision for a full oral feeding was made 57% of the time, whereas the decision for limited oral comprised 15% of the recommendations and nonoral 26%. A Kappa statistic was used to determine the agreement between the clinicians.  A low Kappa statistic would signify low agreement between the clinicians whereas a high Kappa statistic would signify high agreement between the clinicians.  There was a statistically substantial Kappa statistic (meaning that the agreement was above chance happening) for the full oral decision (.72) and the nonoral decision (.66).  There was little agreement amongst the clinicians on the type of oral diet recommended. A lot of data was collected – see the full text to go through it.
The Results:
The four most influential variables for the PO versus NPO decision were
  1. amount of aspiration (by far the most frequently used variable – and a very subjective variable, as well – what is ‘a lot’ of aspiration?)
  2. frequency of aspiration
  3. diagnosis
  4. history of pneumonia (best agreement amongst the clinicians)
The most frequently recommended postures/maneuvers were
  1. effortful swallow
  2. head turn
  3. chin tuck
  4. super supraglottic swallow
  5. supraglottic swallow
  6. repeat swallow
Some thoughts:
While the frequency of recommendations for full oral feeding was the same amongst clinicians, the amount of experience was found to be an important factor in determining if limited oral feeding was allowed.  Those clinicians with fewer years of clinical experience were more conservative and recommended nonoral feeding more frequently than those with more experience.  They also recommended more maneuvers than the clinicians with more years of experience.
As I have grown in my career, I have become much more liberal with my diet recommendations and learned to trust my postures/maneuvers more.  In my earlier years I was so terrified to allow a patient to leave an evaluation without a strategy (or multiple strategies) to completely eliminate all aspiration.  While this is certainly an admirable goal, I now know so many other factors determine whether a patient actually gets pneumonia (like dependence on others for feeding/oral care, pulmonary status, etc – see my July Research Tuesday post on The Most Important Aspiration Pneumonia Article Ever for more details on this!).  I have witnessed many patients who aspirate buckets who never get pneumonia, and I have seen how well certain maneuvers/postures dramatically improve the swallow.  I don’t feel the need to have the patient use a supraglottic swallow with a head turn & chin tuck – especially if a head turn will suffice.  And how do I know all this?  I have seen it.  I have completed a MBS or FEES on the patient and determined the safest swallowing situation for them by visualizing them complete the strategy or swallow the consistency.
In our practice we have spoken with many younger clinicians who rely on bedside assessments because their facility will not allow them to get an instrumental and they are too afraid to rock the boat to demand one.  We see their patients with multiple strategies and limited diets based on the best “guess” the clinician could make from the bedside.  Is that really fair to the patient – to manipulate or forbid their mealtime  based off of a guess?  Know for sure – don’t let a bean counter take away your ability to properly determine a diet.
I really appreciate Dr. Logemann and colleagues for giving us this opportunity to glance into the radiology suites of 23 skilled clinicians.  We can learn so much from our colleagues.  I hope this article gives you new insights into your own clinical decision making, and don’t forget to share this information with some newbies!
Have a very happy holiday season from the SASS family!!

sass2sass

 

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out sasspllc.com or connect with Kelley on Twitter or LinkedIn.

Photo credit flikr for creative commons

 

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Dysphagia FEES Research

November Research Tuesday

 The Gamble of Blue Dye Testing
First I want to start off with what this post isn’t:
-The purpose of this post is not to bash the way many therapists have been practicing for years.
-The purpose of this post is not to convince therapists that they should never use blue dye ever again.
-The purpose of this post IS to objectively evaluate the reliability data behind the Modified Evans Blue Dye Test to best determine what we are actually observing when we do a blue dye tracheostomy swallowing exam.
So what is a Modified Evans Blue Dye Test (MEBDT)?  This clinical swallowing test was developed to identify aspiration in patients with tracheostomies with the help of suctioning by the respiratory therapist.  In the original Evans Blue Dye Test, the clinician would place a few drops of dye on a patient’s tongue and the respiratory therapist would suction the patient every few hours and report back as to whether blue dye was present in suctioned secretions.  Speech pathologists modified this to add blue dye to food and drinks to further evaluate aspiration with trials of certain consistencies. The Modified Evans Blue Dye Test was formally introduced in Dysphagia Journal in 1995.
It all makes sense.  If the patient is aspirating secretions or food consistencies, the blue dye will go into the trachea/lungs and the respiratory therapist will suction it out.  If the respiratory therapist doesn’t suction any blue out, then the patient must not be aspirating.  Bingo bango, our job is done!
Unfortunately life just isn’t that simple.  Less than 5 years after the introduction of the MEBDT, clinicians performing instrumental swallow exams began reporting on patients who had no blue dye return on MEBDT but who were found to be aspirating on instrumental exam.  Bummer.  Big bummer.
As SLPs we must critically look at any test we perform to ensure that the test is
  1. Reliable enough to produce the same results under consistent conditions
  2. Sensitive enough to identify those who do have the searched for criteria
  3. Specific enough that those who do not have the searched for criteria are not identified
There have a been many different studies looking at reliability, sensitivity and specificity of the MEBDT.  Because we are depending on pretty specific circumstances to obtain our outcome – the patient must aspirate, the respiratory therapist must suction enough and in the right spots to pull out the aspirated material, the dye must be dark enough to perceive in the secretions – many have claimed that the MEBDT may not be sensitive enough to identify everyone who aspirates.  The biggest concern with MEBDT is a false negative – this would occur if the MEBDT does not show aspiration but the patient actually is aspirating. This study, from Dysphagia Journal waaaay back in 1999,  was one of the first to identify the high likelihood of false negative results with MEBDTs.
Brady SL, Hildner CD, Hutchins BF.  1999. Simultaneous video- fluoroscopic swallow study and modified Evans blue dye procedure: an evaluation of blue dye visualization in cases of known aspiration. Dysphagia 14:146–149.  Full Text Here
This investigation analyzed 20 simultaneous MBS exams and MEBDTs to determine if the MEBDT correctly identified each aspiration event that occurred. Before the MBS, the investigators dyed thin, nectar and puree consistency barium blue.  During the MBS, if aspiration was observed, the respiratory therapist would suction the patient to identify if blue dye was present in their tracheal secretions.  The respiratory therapist also suctioned the patients at the termination of the study.  Two SLPs reviewed the MBS exams and identified the quantity of aspiration for the exam as either trace or greater than trace.  The investigators then compared the results of the MBS exams and the MEBDTs.
Results:
Aspiration occurred in 8/20 of the exams, however, suctioning after the aspiration event only identified aspiration in 4/20 exams.  Of those exams that were determined to have greater than trace amounts of aspiration, tracheal suctioning identified the aspiration in 100% of patients.  Of those exams which showed only trace amounts of aspiration, tracheal suctioning identified the aspiration in 0% of patients.  There were no charts or graphs in this study, so I made my own because I am a visual learner:

mebdt chart

In this study, the Modified Evans Blue Dye Test was shown to have a false-negative error rate of 50% in cases of observed aspiration on MBS.  Donzelli and colleagues replicated this study in 2001using FEES and found the exact same 50% false-negative error rate and only a 67% identification of aspiration in patients with large amounts of aspiration.
These are grim statistics.  Ultimately what we can take from this information is that the MEBDT is not sensitive enough to identify all aspiration events, especially when only trace amounts of aspiration occur.  This means that for every two MEBDTs performed that do not identify aspiration, one of the patients likely could be aspirating.  That is a gamble – a huge gamble – and a gamble that I don’t want to take with my patients.
So what can a MEBDT be used for?  It can be used as a screening device to positively identify aspiration.  That’s it.  If a test is performed and aspiration is identified, you can be pretty darn sure that aspiration is occurring.
Failure to consistently identify aspiration isn’t the only negative to the MEBDT.  Last time I checked, aspiration wasn’t the only indicator of dysphagia.  The MEBDT doesn’t identify penetration or significant residue- both of which constitute dysphagia.  It doesn’t identify the quantity and consistencies of penetration, aspiration or residue nor does it identify the actual physiological impairments that are causing the dysphagia or give us indications on how to treat them.
So how do we identify if a patient with a tracheostomy has dysphagia?  I think you know my answer…
GET AN INSTRUMENTAL SWALLOWING EVALUATION!!
This is the only way to objectively identify aspiration in a patient with a trach or without one.  Both MBS and FEES have generally good reliability, sensitivity and specificity.  They both will identify on which consistencies penetration, aspiration or residue occur, and they both will provide insight on the physiological deficits causing the dysphagia.
Don’t gamble with aspiration.  Get an instrumental exam and know for sure.

Works cited:

Donzelli J, Brady S, Wesling M, Craney M. Simultaneous modified Evans blue dye procedure and video nasal endoscopic evaluation of the swallow. 2001.  Laryngoscope;111:1746 –1750.

Peruzzi WT, Logemann JA, Currie D, Moen SG. 2001. Assessment of aspiration in patients with tracheostomies: comparison of the bedside colored dye assessment with videofluoroscopic examination. Respir Care 46:243–247.

Thompson-Henry, S., & Braddock, B. 1995. The modified Evan’s blue dye procedure fails to detect aspiration in tracheostomized patient: Five case reports. Dysphagia,10, 172–174.

O’Neil-Pirozzi TM, Lisieeki DJ, Monsek J, Connors JJ, Milliner MP. 2003. Simultaneous modified barium swallow and blue dye tests: a determination of the accuracy of blue dye test aspiration findings. Dysphagia;18:32-8.

 

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out sasspllc.com or connect with Kelley on Twitter or LinkedIn.

Photo credit flikr for creative commons