April 2008 Newsletter
Clinical Café Newsletter
By: Ronda Polansky M.S. CCC-SLP
Monthly Motivator: Gratitude
In expressing gratitude, never forget that the highest appreciation is not to speak words, but to live by them.
MARK YOUR CALENDAR for the 7.5 CEU` E-Stim Conference! April 26, 2008– Houston, Texas – Deciphering Dysphagia with E-Stim updated for 2008. Professional Imaging LLC is a Mobile MBSS company in East Texas, Houston, Austin, and San Antonio, not a part of DiagnosTEX, LLC. They have invited us as guest speakers; please call their Corp office 1-866-675-MBSS to register or any questions.
Dates to remember in April
April 22 – Earth day www.earthday.net
April 24– Take your daughter to work day www.DaughtersandSonsWork.org
April 27-may 3 – National Volunteer Week www.pointsoflight.org
National Occupational Health Month
National Parkinson’s Awareness Month
ATTENTION – NEW required paperwork for Home Health Patients (included)
Unfortunately this paperwork has become necessary. We are doing so many more home health’s and we have had too many instances in which the family and or patient was unaware of what the procedure involved. Many have had no way to get outside the house (no wheelchair, no ramp etc.); they have refused to leave their home, and/or no one to transfer them from their bed to a chair. DiagnosTEX staff can not make physical transfers from the bed to a wheelchair and/or back to bed. Also we have had scheduling/communication issues involving no one answering the phone at their home, even when they are home. There have been too many times we have arrived at the address and no one was home. If we can not get confirmation by phone that they are home before we arrive the study will be cancelled. This new paperwork will require that you or the home health agency to review this with the patient and/or family prior to scheduling the MBSS and have them initial each line and sign the bottom of the page so they have a full understanding of this procedure. Thank you for your assistance with this. It will help make serving your home health patients much more productive. Please remember, a Home health is very difficult to schedule. We try to work around our other scheduled facility locations on the vans, Most HH families and/or patient’s place time restrictions and days on us, therefore we will be unable to get these completed in a 24-48 hour period.
Scheduling an MBSS in the afternoon– There have been several situations recently in which studies were cancelled or not allowed to be scheduled by the facility and staff due to the patient being “tired” in the late afternoons. Although we understand those concerns, please consider the following: 1) If the patient fatigues in the afternoons, but is still required to eat another meal that day, specifically dinner. Would you not want to know how the patient performs at that level instead of the a level you feel they are at their best, this allows you to consider the times and fatigue levels at which they are at highest risk for PO. This is very important information to know in treating the whole patient. Please note that we cannot be at every facility before noon, therefore declining an afternoon schedule time may delay the study several days.
Dysphagia Tidbit – FEES vs. MBSS
The use of fiberoptic endoscopy to evaluate the pharyngeal stage of the swallowing is a procedure developed by Susan Langmore, Ph.D., Kenneth Schatz, M.A., and Nels Olsen, M.D. Parameters than can be evaluated include pharyngeal pooling, premature spillage, penetration/aspiration, and residue. The procedure is mildly invasive and is limited to the events immediately before the swallow and after the swallow event. With FEES, during the time of the swallow/airway closure, the swallow cannot be visualized, as the pharyngeal walls contract over the bolus it collapses the lumen over the endoscope (“whiteout phase”). Oral phases are only indirectly evaluated and no evaluation of the esophageal phase (Gerber, M., Vaeronneau, M., 2002, ASHA, 2002)). Risks can include: laryngospasm, reaction to anesthesia, nosebleed, vasovagual/cardiac response. Contraindications: FEES are not indicated for patients with movement disorders, those who can not tolerate endoscopy, severe cognitive deficits, or history of bronchospasm or laryngospasm (Carrau, R., Murray, T., 1999). Indications for FEES: 1) problematic positioning, 2) MBSS is unavailable, 3) concern about radiation exposure, and 4) need to assess fatigue or swallow status over an entire meal.
Indications for an MBSS over FEES (Langmore et. al., 1996)
1) Esophageal phase problem suspected or need to be screened
2) Globus complaints
3) Vague symptomology noted at bedside
4) Need to verify aspiration of liquids during the swallow
5) Need to get impression of the amount of aspiration.
MBSS is necessary to determine “WHEN” penetration or aspiration is occurring. An MBSS provides more information about the oral phase dynamics, coordination of oropharyngeal movements, posterior tongue movement and apposition with the posterior pharyngeal wall, hyolaryngeal elevation, aspiration DURING the swallow, UES opening, esophageal phase dynamics, and evaluation of the effortful swallow technique and the Mendelsohn maneuver (Langmore & McCulloch, 1997). The MBSS remain the pre-eminent method to view the oral, pharyngeal, and esophageal phase in real time and to diagnose the underlying cause(s) for the symptoms of aspiration and penetration, as it also allows visualization of the pharyngeal phase while compensatory strategies are tested for their ability to increase swallowing safety and efficiency. Currently, no other technology has this versatility (Lewis, K., Liss, J., Sciortino, K., 2004). SLP’s should be aware of current research that continues to support the efficacy of the MBSS and its overall cost efficiency against inpatient hospital costs for the management of pneumonia or pulmonary complications secondary to aspiration (Lewis, K., Liss, J., Sciortino, K., 2004). Call DiagnosTEX for diagnosis of your dysphagia patients!
National Dysphagia Awareness Month being considered – see insert included