Speech Pathology – This is a dynamic and expanding profession with constantly developing technological and clinical advances. Speech Pathologists must have acquired the knowledge, skills, education, and experience necessary to perform evaluation and management of swallowing disorders. A Speech Pathologist must hold a Masters degree in their field; pass a standardized National Exam to receive the Certification of Clinical Competence. The American Speech and Hearing Association is the national organization representing this group of professionals. Each State has a Board the also governs the licensure of each professional.
Background on the role of Speech Pathologists in Swallowing Disorders
Speech Pathologists have been treating and managing oral feeding in children with Cerebral Palsy since the 1930s, the focus on swallowing disorders increased exponentially in the 1970s with published articles on clinical and bedside assessment and management and, subsequently, on the use of instrumental assessment procedures such as videofluoroscopy/Modified Barium Swallow Study.
Swallowing and feeding disorders occur with multiple medical diagnoses across the age spectrum from premature infants to geriatric adults. Incidence and prevalence vary among diagnostic groups. Morbidity related to dysphagia can be a major concern. For example, dysphagia resulting from stroke is considered a major cause of morbidity due to respiratory complications, such as pneumonia and malnutrition (Gresham, 1990, Logemann, 1985). Research has shown that individuals who exhibit swallowing difficulties have neurological conditions, treated head and neck cancer, and a variety of other medical and surgical conditions. Additionally, individuals demonstrate swallowing disorders of unknown etiology and those that occur during debilitating conditions.
Dysphagia – can be defined as a disorder of swallowing. Dysphagia can exist at any or all three stages of a swallow: oral (mouth), pharyngeal (throat), and/or esophageal (tube leading to the stomach).
Clinical Examination/Bedside Swallow Evaluation (BSE) – this is usually the first part of a comprehensive swallowing evaluation. There are usually 4 sections to a BSE; 1) Case history and review of medical records as well as interview with patient, family, and other health care professionals, 2) assessment of oral motor structures and their function, 3) assessment of speech and vocal quality, 4) assessing the individual skills and abilities in the natural environment, incorporating judgments of the adequacy of airway protection and coordination of respiration and swallowing for boluses of various size and consistencies. Research suggests that 40% of silent aspirators are not identified at bedside. Ideally, the BSE serves as a tool for identifying clinical presentations of dysphagia, for determining the need for an Instrumental evaluation, and for specifying diagnostic questions to be answered by an instrumental evaluation
Modified Barium Swallow Study (MBSS) – The MBSS incorporates a set of modifications in bolus size, texture, positioning, and radiographic focus to facilitate optimal visualization of the oral (mouth), pharyngeal-laryngeal (throat) structure and their function during the swallow. The MBS has been shown to be more accurate than a BSE in identifying if aspiration is occurring and the cause of aspiration. In addition, the MBSS can prevent unneeded or trial and error treatment
(Logemann et.al. 1998, Martin-Harris et. al, 1998) and can provide clinically useful information
(Martin-Harris, Logemann, 2000).
Management of individuals with dysphagia should be based on results of the comprehensive assessment. In providing treatment, the etiology of the dysphagia and the progression of the disease must be considered. Treatment of dysphagia involves the use of compensatory and rehabilitive techniques. Compensatory techniques are used to help the individual swallow safely, not to alter the physiology. The use of posture is one type of compensatory strategy. Modifications of food/liquid volume and viscosity can compensate for dysphagia. Other forms of treatment include oral and pharyngeal exercises and increasing sensory awareness. A new form of treatments known as Electrical Stimulation is now a popular modality for treating pharyngeal disorders. Regardless of the patient’s age and skill level, primary goals of feeding and swallowing intervention are to support adequate nutrition and hydration, minimize the risk of pulmonary complications and maximize the quality of life.
Often times during a dysphagia evaluation, a recommendation of NPO may occur due to the severity of the disorder and the risk of aspiration. Aspiration occurs when material such as gastric contents, saliva, food, nasopharyngeal secretions are inhaled into the airway or upper respiratory tract.
What one person considers “quality of life”, someone else may think differently. Artificial supplied nutrition and hydration is 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. Tube feeding is an art and a science that is increasingly used in our aging society as more people become physically incapacitated or have dementia. Properly used it can be helpful.
Advance Directive – A written document that tells what you want or do not want, if you become unable to make your wishes about health care treatments known.
AMA forms – Against Medical Advice forms. These forms vary from facility to facility. These forms are often signed by the family or patients when the recommendations for medical treatment are not followed. When signed, this form indicated that the family has been educated and understands the risk and outcomes that may occur by not following the recommendations for medical care.
Artificial Nutrition and Hydration – When synthetic food (or nutrients) and water are fed to you through a tube inserted through your nose into your stomach or into the intestine directly or into a vein. This recommendation is often made due to malnutrition, dehydration, and/or dysphagia.
Comfort Care – Care that helps to keep you comfortable but does not cure your disease.
Durable Power of Attorney – A document that appoints a specific individual to make health care decisions for you if you become unable to make those decisions your self.
Life-sustaining treatment – Any medical treatment this is used to delay death. A breathing machine (ventilator), CPR.
Living Will – Instructions you have made in advance that tell what medical treatment you do or do not want if you become unable to make your wished known.
NPO – Nothing Per Oral. This recommendation is often made to a severe dysphagia due to risk of aspiration/airway obstruction, and/or pulmonary distress, including pneumonia.