1. No category

Dysphagia in the Medically Complex
Patient with: Factors Impacting
Evaluation and Intervention for the
Continuum of Care
Shari Bernard, OTD, OTR/L, SCFES
[email protected]
Mayo Clinic, Rochester, MN
Marcia Cox, MHS, OTR/L, SCFES
[email protected]
Kettering Health Network, Kettering, OH
Objectives
1. Have knowledge of medical, respiratory,
neurological and aging considerations impacting
dysphagia for the complex patient.
2. Gain experience in synthesis and interpretation
assessment data related to special concerns of
the medically complex patient with dysphagia
throughout the continuum of care.
3. Develop a comprehensive intervention plan
related to the medically complex client, context
and performance of feeding, eating, and
swallowing.
April 2015
AOTA Nashville, TN
Prevalence
• Advancements in medicine, technology, and
public health have a positive impact on the
health and well-being of the population of the
United States, allowing adults to live well into
their 60’s, 70’s, 80’s and beyond.
• The population of Americans aged 65 years or
older during the next 25 years will rise to 72
million. US Dept of Health and Human
Services, CDC (2013).
April 2015
AOTA Nashville, TN
US Census Bureau
Numbers in Thousands
80000
70000
60000
85+
50000
75-84
40000
65-74
30000
55-64
20000
10000
0
Older Adults 2010
April 2015
Older Adults 2011
AOTA Nashville, TN
Older Adults 65+
• Older adults will account for 20% of the U.S.
population by 2030
• United States, the primary cause of death has
shifted from infectious and acute diseases to
noncommunicable diseases (NCD), accounting
for 88% of all deaths
World Health Organization, 2014
April 2015
AOTA Nashville, TN
Non Communicable Diseases Deaths
Heart Attack and Stroke
31%
Cancer 23%
Chronic respiratory
disease 8%
Diabetes 3%
Other 23%
Communicable disease
22%
April 2015
AOTA Nashville, TN
Chronic Disease and
Degenerative Illnesses
• Chronic disease and degenerative illnesses
impact more than 25% of the US population,
and two-thirds of every older adult with have
multiple chronic conditions, accounting for
66% of the country’s health care budget
April 2015
AOTA Nashville, TN
Health Care Costs Among
Medicare Enrollees 65 +
Centers for Medicare and Medicaid Services: Medicare Current Beneficiary Survey
Short term
Institution/hospice/dental
100
90
Prescription Medications
80
70
Home Health Care
60
50
Nursing home/long-term
inst
40
Physician/outpatient
hospital
30
20
Inpatient hospital
10
0
http://www.agingstats.gov/Main_Site/Data/2012_Documents/docs/EntireChartbook.pdf
April 2015
AOTA Nashville, TN
Chronic Disease
• Chronic disease impacts individual’s ability to
perform both daily living tasks of self care
including feeding, eating, and swallowing and
personal and oral hygiene.
• Instrumental activities of daily living as shopping,
preparing meals, and medication management
may also be impaired further compounding risk
to health.
• These impairments require care giving by family
members, non-professional, or professional
caregivers increasing health care burden.
April 2015
AOTA Nashville, TN
Dysphagia, Aging and Chronic illnesses
• Dysphagia may involve a single or multiple components
of the swallowing mechanism
• Swallowing disorders may occur as an acute or chronic
process, and with sudden or gradual onset
• The aging process appears to impact strength and
timing of the ability to swallow.
• Medical and technological advances enable individuals
to survive chronic illnesses
• Clients with complex medical, respiratory, and
neurological conditions are at high risk for dysphagia.
April 2015
AOTA Nashville, TN
April 2015
AOTA Nashville, TN
Etiology of Adult Dysphagia
30 -49
50- 59
• Autoimmune
disease
• Multiple sclerosis
• GERD and LP GER
• Nasopharyngeal
cancer
• Stroke
• Inflammatory
myopathy
• Nonspecific
motility disorder
• Head and neck
cancer
• Diabetes type 1
April 2015
60 – 69
• Stroke
• Parkinson’s
disease
• Amyotrophic
lateral sclerosis
• Esophageal
disorders
• Head and neck
cancer
• Alzheimer’s
disease
• Fronto-temporal
dementia
AOTA Nashville, TN
70 +
• Stroke
• Parkinson’s
disease
• Alzheimer’s
disease
• Fronto-temporal
dementia
• Esophageal
stricture
• Achalasia
Physiology
Phases of Swallowing
Oral Preparatory
Oral
Pharyngeal
Esophageal
(Pharyngo-esophageal)
April 2015
AOTA Nashville, TN
Posterior Oral Cavity
Mallampati Class I
http://en.wikipedia.org/wiki/Image:Tonsils_diagram.jpg
April 2015
AOTA Nashville, TN
Stages of Swallow
• Oral preparatory – Acceptance of food or fluid
into the mouth and preparing substances to be
swallowed. Chewing if needed and forming
a fluid or food “bolus”.
• Oral –Transit of the food or fluid from the
mouth to the hypopharynx and initiating a
swallowing response.
April 2015
AOTA Nashville, TN
Oral preparatory phase
Functional
•Under voluntary/ and
automatic control
•Recognition of
food/fluid/saliva in mouth
•Oral control and
manipulation of
food/fluid/saliva in the
mouth to form a “bolus”
http://medicine.medscape.com/article/317667-overview
April 2015
AOTA Nashville, TN
Oral Phase
Functional
• Voluntary control
• Duration: 1-3 seconds
• Begins with tip of tongue
positioning at alveolar ridge
and pressing the bolus
against the palate in a
posterior movement
• Ends with the bolus trigger
of a swallow response at
the anterior faucial arch
http://medicine.medscape.com/article/317667-overview
April 2015
AOTA Nashville, TN
Stages of Swallow
• Pharyngeal – Clearance of the bolus from
the throat while protecting the airway.
April 2015
AOTA Nashville, TN
Pharyngeal phase
Functional
• Transition of the
bolus through the
pharynx past the
elevated and
sealed airway
• 1-2 second
• No residue
http://medicine.medscape.com/article/317667-overview
April 2015
AOTA Nashville, TN
Stages of Swallow
• Esophageal – Passage of the bolus
through the esophagus and into the
stomach
April 2015
AOTA Nashville, TN
Esophageal phase
Functional
• Primary peristalsis is a
proximal to distal initial
wave beginning at
Passavant’s ridge. It is
CNS mediated.
• Secondary peristalsis
result of distension,
clears residue and reflux.
http://medicine.medscape.com/article/317667-overview
April 2015
AOTA Nashville, TN
Esophageal Landmarks
April 2015
www.mayoclinic.com/troubleswallowing
AOTA Nashville, TN
Muscles of the anterior neck
http://www.google.com/imgres?imgurl=http://media-2.web.britannica.com/eb-media/49/123649-004C05422F1.jpg&imgrefurl=http://www.britannica.com/EBchecked/media/119400/Muscles-of-theneck&h=400&w=500&sz=55&tbnid=3M7SkTcDY9ZbiM:&tbnh=90&tbnw=113&prev=/search%3Fq%3Dmuscles%2Bof%2Bthe%2Bneck%26tbm%3Disch%26tbo%
3Du&zoom=1&q=muscles+of+the+neck&usg=__aUX4CoN8QP5sdIDCPFtyQzv7ho=&hl=en&sa=X&ei=279IUL6QIqXa2QWnlYHgDQ&sqi=2&ved=0CDEQ9QEwAg&dur=1557
April 2015
AOTA Nashville, TN
VFSS to be inserted
• NORMAL ORAL PREPARATORY AND
ORAL
A-P
DELAYED SWALLOW RESPONSE
ABNORMAL ORAL PREP, ORAL,
PHARYNGEAL AND ESOPHAGEAL
April 2015
AOTA Nashville, TN
Normal Oral Preparatory and Oral
• VFSS to be inserted
April 2015
AOTA Nashville, TN
Delayed Swallow Response
• VFSS to be inserted
April 2015
AOTA Nashville, TN
Abnormal Oral Prep, Oral,
Pharyngeal, Esophageal
• VFSS to be inserted
April 2015
AOTA Nashville, TN
Penetration/Aspiration Scale
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•
•
•
•
•
•
•
Level 1 not in airway
Level 2 enters above vc, w/o residue
Level 3 above vc with residue
Level 4 contacts vc w/o residue
Level 5 contacts vc with residue
Level 6 passes glottis w/o residue
Level 7 passes glottis, residue with response
Level 8 passes glottis, residue w/o response
April 2015
AOTA Nashville, TN
Prevalence and impact of Cortical, Subcortical, and Brain Stem
Infarcts on Swallowing
• 159,000 individuals with stroke will suffer from neurogenic
oropharyngeal dysphagia per year.1
• Neurogenic oropharyngeal dysphagia is a significant sequela of stroke,
and is reported to be present in up to 78% of acute stroke patients. 2
• Oropharyngeal dysphagia with aspiration is identified as a severe
complication of stroke, and is linked to prolonged hospitalization,
medical complications, and mortality.3
• Individuals with dysphagia are discharged twice as frequently to longterm care facilities than are those with stroke without a feeding, eating,
and swallowing disorder complication.
1
American Stroke Association, 2012
2 Altman, Richard, Goldberg, Frucht, & McCabe, 2013
3 Ickenstein, et al., 2012
April 2015
AOTA Nashville, TN
Dysphagia in Stroke
• Oropharyngeal dysphagia is frequent in the acute
phase of stroke at 22-77% and in 50% of medullary
strokes
• Dysphagia impairs quality of life and prognosis
• Dysphagia after stroke have a higher incidence of
pneumonia, dehydration, malnutrition and death.
April 2015
AOTA Nashville, TN
Aspiration in Cerebral Vascular Accident: Cortical,
Subcortical, and Brain Stem Infarcts
• Aspiration in stroke is determined to be between
29% and 81%.
• Silent aspiration is present in half of clients with
acute stroke.
• There is a wide range in reported aspiration rate
due to different diagnostic parameters, lesion
site, and length of time following stroke.2
1
Altman, Yu, and Schaefer, S. D., 2010
2 Falsetti et al., 2009
April 2015
AOTA Nashville, TN
Cortical infarcts
Right parieto-temporal infarcts - sensory and attention deficits
Left middle cerebral artery infarcts - buccal-facial apraxia
Right or left precentral gyrus - motor function of lips, cheeks, and tongue
Cortico-Bulbar
Tract
motor, sensation,
coordination, timing
April 2015
Medullary Swallow Center
oral transit, pharyngeal, and
proximal esophageal
segments
AOTA Nashville, TN
Medullary Swallowing Center Stroke
• Impairment of sensation and movements in
areas of:
– Posterior oral and pharyngeal muscles
– Laryngeal elevation and adduction
– Pharyngeal constrictors
– Upper esophageal sphincter
opening
Falsetti, et al., 2009
April 2015
AOTA Nashville, TN
Chronic Obstructive Pulmonary
Disease
• Chronic obstructive pulmonary disease (COPD)
is defined by the Centers for Disease Control
and Prevention (2012) as a group of
progressive, debilitating respiratory conditions
that include emphysema and chronic
bronchitis.
• Aspiration and COPD is a concern in this highrisk respiratory compromised group.
April 2015
AOTA Nashville, TN
Altered swallowing function with
COPD
• Oral and pharyngeal transit slower than normal, diminished
coordination and strength of the oral and pharyngeal
musculature, and a reduced ability to use pulmonary air to
clear the larynx and ensure airway protection
• Diminished airway protection during swallowing
coordinated with the expiratory phase of breathing
• Consistent laryngeal penetration and aspiration in
individuals with COPD at a higher rate than for normal
subjects at the inspiratory/expiratory transition phase.
• Laryngo- pharyngeal sensitivity is diminished requiring
greater laryngeal adductor reflex input
• Increased pharyngeal residue is present resulting in
increased aspiration risk.
April 2015
AOTA Nashville, TN
CAP – Community Acquired Pneumonia
• CAP is a major cause of morbidity in the elderly
• 6 times higher > 75 years than those <60
• Estimated annual health-care cost in the US of $4.4
billion.
• Oropharyngeal aspiration, due to abnormalities in
swallowing and of the upper airway protective
reflexes has been found to be an important
pathogenetic mechanism leading to CAP in the
elderly.
April 2015
AOTA Nashville, TN
November, 2009
April 2015
AOTA Nashville, TN
DECEMBER, 2010
April 2015
AOTA Nashville, TN
December , 2010
April 2015
AOTA Nashville, TN
Some Other Diagnoses to Consider in
Acute Care Hospital Setting
•
•
•
•
•
•
•
•
Cerebral Vascular Accident (CVA)
Cardiac Surgery
Left Ventricular Assist Device (LVAD)
Total Artificial Heart (TAH)
Heart/lung Transplant
Pneumonia/COPD
Extracorporeal Membrane Oxygenation
(ECMO)
Head and Neck Cancers
April 2015
AOTA Nashville, TN
Cancer
Head and Neck
•
•
•
•
Surgical Resections, radiation
Partial lingual resection
Partial resection of tongue base
Partial resection of pharynx- pharyngeal wall,
tonsils, soft palate
• Partial laryngopharyngectiomies
April 2015
AOTA Nashville, TN
Organ Sparing, Non-surgical
• Radiation- 33 radiation treatments
• Sequelae: Salivary, tissue, pain, anxiety,
nutrition
April 2015
AOTA Nashville, TN
ECMO: extracorporeal membrane
oxygenation
An extracorporeal technique of providing
both cardiac and respiratory support to
patients whose heart and lungs are so
severely diseased or damaged that they
can no longer serve their function
April 2015
AOTA Nashville, TN
Special Dysphagia Concerns for the
Medically Complex Patient
•
•
•
•
•
Length of stay in Intensive care unit
Level of alertness
Length of intubation
Alternative methods for nutrition
Medically stable to leave hospital room for
further evaluation with a videofluoroscopy
• Positioning
April 2015
AOTA Nashville, TN
Intensive Care Unit Patients
•
•
•
•
•
•
•
Endotracheal and tracheostomy tubes
Delirium
Mechanical Ventilation
Nasogastric tube
Oral Cares
Feeding in bed, independence in feeding
Inability to leave ICU room
April 2015
AOTA Nashville, TN
Intubation
•
•
•
•
•
•
•
Planned vs Emergent
Prolonged Intubation
Extubation
Oral intake guidelines following extubation
Changes in voice
Sore throat
Re-intubation/extubation
April 2015
AOTA Nashville, TN
April 2015
Mayo Clinic
AOTA Nashville, TN
Possible Consequences of Intubation
• Inflammation, edema
• Ulceration
• True vocal fold paralysis
• Glottic stenosis
April 2015
AOTA Nashville, TN
Dysphagia Considerations with
intubation
• Impaired swallow function identified in > 50% of pts
intubated for > 48 hours, including those following cardiac
surgery (Leder et al., 1998; Ajermian et al., 2001; Barker et
al., 2009).
• Silent aspiration reported in 25% of pts intubated > 48
hours (Leder et al., 1998; Ajermian et. al., 2001).
• Patients intubated for > 24 hours demonstrate severe but
temporary delayed swallow response following extubation;
greatest delay seen 0-24 hours post extubation (de Larminat
et. al., 1995).
• Aspiration occurred in 80% of pts traumatically intubated
(Leder et al., 1998)
April 2015
AOTA Nashville, TN
Consequences of
Intubation/Extubation
• In alert postoperative cardiac surgery pts, laryngeal ability
to prevent aspiration is adversely affected after tracheal
extubation, particularly within the first eight hours (Burgess
et al., 1979).
• In a recent systematic literature review, studies that
reported the highest incidence of dysphagia also reported
prolonged intubation times (Skoretz et al., 2010).
• Aspiration detected with Fiberoptic Endoscopic Evaluation
of Swallowing (FEES) in 69% of critically-ill ICU patients post
extubation who demonstrated s/s of aspiration during
bedside eval (Hafner et. al., 2007).
April 2015
AOTA Nashville, TN
Considerations with Intubation and
Dysphagia
• Laryngeal edema and mucosal ulcerations of the
vocal folds were found in 94% of patients who
had been intubated for more than 4 days (Colice
et al., 1989).
• Dysphagia due to prolonged intubation can last
for up to 3 weeks (Goldsmith, 2000).
• Dysphagia has been identified as an independent
factor associated with delayed hospital discharge
(Barker et al., 2009).
April 2015
AOTA Nashville, TN
Dysphagia Considerations of Patients
in the ICU
•
•
•
•
•
•
•
•
Patients post extubation at risk for dysphagia include
“Prolonged” intubation
Traumatic intubation
Presence of tracheostomy
Stroke or other central nervous system injuries
Altered Mental Status
Low Glasgow Coma Scale (GCS) score on admission
0-24 hour window post extubation
April 2015
AOTA Nashville, TN
Dysphagia Risk Signs
Respiratory/pulmonary
• Pneumonia/Aspiration
pneumonia/Ventilator associated
pneumonia
• If requiring full face mask oxygen, consider
nothing by mouth (NPO)
• Borderline swallowing with COPD
• Oxygen Saturation <90%
• Respiratory rate: Above 25 bpm
April 2015
AOTA Nashville, TN
Level of Alertness
• Delirium
• Assessing level of alertness prior to oral intake
• Assessing level of alertness for medication
administration
• Nursing education for increase awareness of
level of alertness for oral cares and feeding
April 2015
AOTA Nashville, TN
Mechanical Ventilation
•
•
•
•
•
•
•
New tracheostomy tube
Change in tracheostomy tube
Tracheostomy tube open to air
Capping/corking the tracheostomy tube
Using a passy-muir valve
Inflated/deflated cuff
Grape juice test
April 2015
AOTA Nashville, TN
Tracheostomy Tubes are Typically
Placed for:
• Upper airway obstruction above the true vocal
cords
• Potential airway obstruction such as edema
after surgery
• Prolonged need for mechanical ventilation
April 2015
AOTA Nashville, TN
Some Variations of Tracheostomy
Tubes
• Cuffed, when inflated used when a patient is
requiring mechanical ventilation, provides a
closed system, rubs against the tracheal wall
during a swallow
• Decreases risk of aspiration as it seals the
lower airway from secretions above, does not
prevent aspiration
• Cuffed, when deflated can have tracheostomy
tube capped
April 2015
AOTA Nashville, TN
http://www.daviddarling.info/encyclopedia/T/tracheostomy.html
http://intensivecarehotline.com/tracheostomy/
April 2015
AOTA Nashville, TN
http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/tracheostomy-care-andmanagement-review/
April 2015
AOTA Nashville, TN
1 - Vocal folds
2 - Thyroid cartilage
3 - Cricoid cartilage
4 - Tracheal rings
5 - Balloon cuff
https://en.wiki2.org/wiki/Tracheotomy
April 2015
AOTA Nashville, TN
Dysphagia Concerns with
Tracheostomy Tubes
• Reduced motion of swallow structures,
laryngeal elevation may be diminished
• Air pressure changes, decreased build up of
pharyngeal pressures during the swallow
• Reduced sensation
• Deceased coordination
• Reduced protection mechanisms, inflated cuff
does not allow for a reflexive cough or throat
clearing
April 2015
AOTA Nashville, TN
Feeding Tubes
• Orogastric feeding tube
• Nasogastric feeding tube
• Percutaneous endoscopic gastrostomy feeding
tube
• Percutaneous endoscopic jejunostomy tube
April 2015
AOTA Nashville, TN
Oral Cares in the ICU
•
•
•
•
Swabbing
Swabbing with Suction
Allowing for swish/spit if able
Nursing to assess for maintaining oral
moisture
• Posture during oral cares
• Inspection of the oral cavity
April 2015
AOTA Nashville, TN
Considerations for Intensive care unit
Dysphagia Evaluations & Treatment
• Do a dysphagia screen when
consult is received from the
ICU (Chart review for
medical stability and briefly
see patient to confirm level
of alertness and goals of
medical care)
April 2015
AOTA Nashville, TN
Figure 1 The BJH Stroke Dysphagia Screen. Abbreviation: BJH, Barnes–Jewish Hospital.
Journal of Stroke and Cerebrovascular Diseases, Volume 23, Issue 4, 2014, 712 - 716
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2013.06.030
April 2015
AOTA Nashville, TN
Things to Consider
• Is the patient intubated, on a ventilator or have a tracheostomy tube
and on the ventilator?
• Ask nursing if the patient is requiring frequent suctioning or using the
Yaunker (Oral suctioning) for oral secretions. If this is occurring the
patient is not able to manage their own secretions and a formal
evaluation may need to be delayed
• Can the patient maintain respirations of <32 breaths/minute? (difficult
to coordinate a breathing pattern with increased breaths/minute)
• Has the patient tolerated spontaneous breathing trials (SBT) with use
of trach collar, passy-muir valve, or capped for 2-3hrs. at a time? (SBT
allows for patient’s increased endurance to allow patient to maintain
upright position for meal times)
• If patient is on the ventilator consider trach placement and presence
of bloody secretions (New trach. placement may have bloody
secretions. If grape juice test is done, it may be difficult to
differentiate between grape juice and bloody secretions when
suctioned)
April 2015
AOTA Nashville, TN
Things to Consider
• In chart review consider severity of diagnosis with
regards to dysphagia like; CVA, Ivor Lewis, GERD,
Dementia, s/p surgery or history of dysphagia.
• Check most recent chest x-ray for noted infiltrates.
• If not on ventilator when was patient extubated? Usually
consider trial of oral intake 24 hrs. after extubation
• Be aware of presence of NG tubes.
• Consider and assess patient’s level of alertness/cognition
• Consider patient’s physical/mobilization limitations. Can
they tolerate sitting up in a chair for 1-2 hours for meal
times.
April 2015
AOTA Nashville, TN
Recommendations to Consider if Patient is not Ready
for a Formal Bedside Dysphagia Evaluation
• Consider use of ice chips following the Mayo Free
Water Guidelines, encourage 1-3 ice chips routinely
to maintain oral moisture
• Make sure to education staff and patients about the
free water guidelines
• Education in oral cares:
• Educate nursing, patient and family with regards to
an oral care routine
• Education in Positioning and oral motor or
swallowing exercises:
• Educate patient and nursing in proper positioning
during oral cares, when taking ice chips and
exercises
April 2015
AOTA Nashville, TN
April 2015
Mayo Clinic
AOTA Nashville, TN
Occupational Therapy Outcomes to
consider in planning intervention
•
•
•
•
•
•
Occupational performance
Client satisfaction
Role competence
Adaptation
Health and wellness
Prevention
AOTA Occupational Therapy Framework, p 629
April 2015
AOTA Nashville, TN
Dysphagia Interventions for Medically
Complex Patient
CLIENT FACTORS
INTERVENTION
CLINICAL
ASSESSMENT
PLAN
HOLISTIC
FACTORS
INSTRUMENTAL
ASSESSMENT
April 2015
REHABILITATION
Remediation
AOTA Nashville, TN
Support
Factors Impacting Intervention
OCCUPATION OF FEEDING,EATING,
AND SWALLOWING PLAN OF CARE
SYNTHESIS OF CLINICAL AND
INSTRUMENTAL ASSESSMENT
HOLISTIC FACTORS
HOLISTIC FACTORS
REHABILITATION
•Psychological, Family, and Community Interactions
•Alternate Nutrition and End-of-Life Issues
• Nutrition, Hydration, Medication mgt.
•Posture
• Self-feeding
•Positioning and Strength
•Sensory/Motor Techniques
•Strategies and Modalities
•Neuromuscular electrical stimulation (NMES)
•Texture Modification
•Water Protocol
•Compliance in Recommendations, Home Program
OUTCOME
April 2015
AOTA Nashville, TN
Use of Free Water Guidelines in Critical Illness Survivors with Dysphagia
Shari Bernard, O.T. D., OTR/L, SCFES ¹, Vicki Loeslie, RN, C.N.P. ², Jeffrey Rabatin, M.D. ²
Divisions of Physical Medicine and Rehabilitation¹, Pulmonary and Critical Care Medicine²
Mayo Clinic, Rochester, MN
Abstract
Methods
The Frazier Water Protocol (FWP) is a part
of dysphagia rehabilitation designed to
allow patients whose diet restriction include
thickened liquids (nectar, honey, or pudding
consistency) to also have water and ice
chips. Use of the FWP remains
controversial due to the concern for
pneumonia. There is limited information
regarding use of the FWP for hospitalized
patients with pulmonary diagnoses and the
FWP is commonly discouraged due to risk
of aspiration.
Inclusion criteria:
• Patient > 18 years of age
• Inpatient admission to the RCU
• Dysphagia evaluation indicating need
for thickened liquids
The FWP used for this study was modified
from its original version and was referred to
as the free water guidelines (FWG). The FWG
allowed for small sips of water and ice chips
between meals with oral cares 3-5 times daily.
Repeat dysphagia evaluations were
conducted at approximate 2 weeks intervals.
All patients remained on the FWG until their
diet was advanced to include thin liquids.
Objectives
The purpose of this study was to evaluate
the FWP in those patients with a
compromised pulmonary status.
Table 1: Study Characteristics
• 14/15 patients (93%) had diet advanced
with repeat dysphagia evaluations
• 1/15 patient (7%) had diet regression
with repeat dysphagia evaluations
• 1/15 patient (7%) was diagnosed with
pneumonia after initiation of FWG.
Figure 3: Dismissal Disposition
Died , 1
Rehabilitation, 4
April 2015
Home, 1
Figure 2: Hospital admission diagnosis
Figure 1: Methods
Esophageal
cancer, 1
Abdominal pain,
1
Respiratory
failure, 4
Neuromuscular
disease, 2
• Use of ice chips and free water per the
Skilled Nursing
Facility (SNF), 6
Long Term Acute
Care Hospital
(LTACH), 3
Figure 4: Survival
FWG in patients with a compromised
pulmonary status showed a low
incidence of aspiration pneumonia
References
1. Crary, M.A. & Groher M.E. 2003. Introduction to Adult Swallowing
Disorders. Butterworth-Heinemann, St. Louis, Missouri.
Videofluoroscopic
dysphagia evaluation
2. Franceschini T. 2007. Lecture: Dysphagia Practice: Taking
services to the next level of evidence-based practice. October 2728, 2007.
2 weeks
The Respiratory Care Unit (RCU) cares for
patients requiring a tracheostomy and
mechanical ventilation (MV) following a stay
in a medical or surgical intensive care unit
(ICU). The RCU focuses on ventilator
liberation and rehabilitation needs under the
guidance of a multidisciplinary team.
• The original version of the FWP was
modified to meet the needs of the
patients
• Small sample size
• Use of the FWG with patients had a
low incidence of development of
aspiration pneumonia, therefore,
may play a crucial role for
increasing quality of life for patients
with dysphagia
Conclusions
Provide primary investigation for evidencebased intervention for all medical
professionals on the use of the Free Water
Guidelines (FWG)
Setting
Discussion
Results
Repeat
videofluoroscopic
dysphagia evaluation
TKA infection, 1
pneumonia, 1
Pancreatitis, 1
Apical
ballooning, 1
Cardiothoracic
surgery, 3
AOTA Nashville, TN
3. Garon B.R., Engle M., Omiston C. 1997. A randomized control
study to determine the effects of unlimited oral intake of water in
patients with identified aspiration. Journal of Neurologic
Rehabilitation, 1997; 11: 139-148.
4. Panther, K. March 2005. The Frazier Free Water Protocol.
Swallowing and Swallowing Disorders.
 2012 Mayo Foundation for Medical Education and Research
Free Water Guidelines
• Oral care/hygiene should be done upon the client awakening
every morning, prior to any oral intake. Brush teeth and/or
dentures 3-5x/day. Rinse and spit whenever mouth is dry.
Keep mouth moist.
• If a client is on a modified diet, that includes thickened liquids,
free water and/or ice chips are allowed between meals, up
until first bite of a meal but restricted until after 30 minutes of
finishing a meal. No water and/or ice chips during meals and
no other thin liquids are allowed other than water.
• If a client requires use of compensatory techniques for safe
oral intake, the client, their family and the nursing staff will be
instructed on these techniques by occupational therapy.
April 2015
AOTA Nashville, TN
Diet Textures
National Dysphagia Diet
FLUID
Thin
Nectar –like
Honey – like
Spoon - thick
SOLIDS
Dysphagia Advanced – III
Thin-sliced tender meats
Dysphagia Mechanically Altered – II
Easy to chew food, baked potato
Dysphagia Smooth- I
Puree
April 2015
AOTA Nashville, TN
Functional Oral Intake Scale
1: Nothing by mouth.
2: Tube dependent w/ minimal attempts of food or liquid.
3: Tube dependent w/ consistent oral intake of food or liquid.
4: Total oral diet of a single consistency.
5: Total oral diet with multiple consistencies, requiring
special preparation or compensations.
6: Total oral diet with multiple consistencies w/out special
preparation, but with specific food imitations.
7: Total oral diet with no restrictions.
FUNCTIONAL ORAL INTAKE SCALE FOR DYSPHAGIA, Crary
Arch Phys Med Rehabil 2005, 86:1516-20.
April 2015
AOTA Nashville, TN
Postural Strategies
Neck and trunk
• Stable, supported posture
• Chin neutral, turned or
down
• Self feeding with inclusion
of impaired extremity
April 2015
AOTA Nashville, TN
Compensation Techniques
Mendelsohn’s Maneuver Supraglottic Swallow
• Developed as a method • Developed as method
to prolong airway
to speed flow of fluid
opening
and food past open
airway and valleculae
• Performed by
technique to hold
• Performed by slight
laryngeal elevation
hold or pause after
placing food/fluid in
mouth with “Effort” or
“Push” swallow
April 2015
AOTA Nashville, TN
Direct Intervention
• Interventions that addresses client factors and swallowing
performance skills within the context of eating .
• Performance skills, activity demands, including texture,
feeding, and adaptive equipment pattern, context and client
factors -during ingestion of food. Ex. Food texture variation
trials, chin turn during swallow, anterior holding of bolussupraglottic swallow, Mendelsohn’s maneuver, alteration of
environment at meal.
April 2015
AOTA Nashville, TN
Indirect Intervention
• Interventions that addresses strengthening client
factors and swallowing performance skills outside
the context of eating.
• Oral/pharyngeal exercises, sensory processing
facilitations, posture and positioning techniquesnot including ingestion of food. Ex: Masako
maneuver, oral sensory stimulations, postural
exercises, lingual exercises.
April 2015
AOTA Nashville, TN
Case Study Specifics
• Nonischemic dilated cardiomyopathy (chronic left
ventricular systolic and diastolic and right ventricular
systolic heart failure), status post previous
placement of a permanent pacemaker and ICD
(2006) and subsequent replacement (2008), now
status post secondary median sternotomy and
placement of HeartMate II left ventricular assist
device as destination therapy, February 18, 2015
• Severe tricuspid regurgitation, status post secondary
median sternotomy and tricuspid valve repair,
February 18, 2015
• History of native aortic valve disease, status post
primary median sternotomy and aortic valve
replacement (2003)
• Hypertension
April 2015
AOTA Nashville, TN
•
•
•
•
•
•
•
Obesity with a BMI of 30
History of nonsustained ventricular tachycardia, status post
permanent pacemaker and ICD placement
Atrial fibrillation
Requirement for chronic systemic anticoagulation secondary to the
preceding
Previous history of pacemaker pocket infection, status post device
extraction and subsequent replacement (September 2008)
Complex sleep apnea
History of COPD with pulmonary function tests showing a nonspecific
pattern and no significant bronchodilator response distributive,
hypovolemic, improving
April 2015
AOTA Nashville, TN
• Chronic kidney disease stage 3, likely secondary in part to cardiorenal
syndrome in association with No. 1
• Type 2 diabetes mellitus with poor glycemic control, most recent
hemoglobin A1c of 7.6
• Gout
• Anemia, acute blood loss
• Acute thrombocytopenia secondary to blood loss and platelet
destruction while on cardiopulmonary bypass
• Perioperative coagulopathy, resolving, requiring mediastinal
reexploration and temporary chest closure
• Hypokalemia, resolving
• Shock, multifactorial, cardiogenic, distributive, hypovolemic, improving
April 2015
AOTA Nashville, TN
• Initial bedside completed following surgery not ready for oral intake, just
extubated, decreased resp. status, level of alertness
• Patient was seen by Occupational therapy dysphagia service for a Video
Fluoroscopic Swallow Study 2 weeks later
• Patient was given trial of honey consistency which patient had a weak swallow
and difficulty clearing of residue
• Patient demonstrated delayed oral transit
• Patient's epiglottis did not invert beyond vertical position during initial first
swallow. Patient's epiglottis did invert with subsequent swallows
• Patient had significant pooling in the vallecula and piriform sinuses, which
spilled over into laryngeal vestibule and resulted in silent aspiration
• During the oral phase patient had poor oral control
• Laryngeal excursion was within normal limits
Types of Consistencies recommended:
NPO
Exercises:
Effortful swallow
Mendelsohn maneuver
Masako Maneuver (Tongue Holding)
Tongue base retraction exercises
April 2015
AOTA Nashville, TN
• Patient was seen by Occupational therapy dysphagia service for a
Video Fluoroscopic Swallow Study 2 weeks later
• Patient had flash penetration with nectar and thin liquids with and
without a chin tuck
• Patient had premature spillage and delayed pharyngeal swallow with
thin and nectar consistency
• Patient had significant pooling with honey consistency with an initial
swallow, but it was cleared with subsequent swallow
• Patient did not have any penetration or aspiration with pudding and
honey consistency
• During the oral phase patient had poor oral control, which resulted in
premature spillage
• Laryngeal excursion was within normal limits and the epiglottis
inverted fully.
April 2015
AOTA Nashville, TN
Initial Video Fluoroscopic Swallow
Study
April 2015
AOTA Nashville, TN
Repeat Video Fluoroscopic Swallow
Study
April 2015
AOTA Nashville, TN
Show Video Fluoroscopic Swallow
Study
April 2015
AOTA Nashville, TN
VIDEO SUMMARY/RECOMMENDATIONS:
Types of Consistencies recommended:
Group 3-honey thick liquids
Group 4-pureed foods
Group 5-mechanical soft foods
Medications in food
Medications crushed
Exercises:
Effortful swallow
Masako Maneuver (Tongue Holding)
Tongue base retraction exercises
Swallowing Interventions/Compensation Techniques:
Swallow twice with each bolus
Chin tuck
April 2015
AOTA Nashville, TN
Case Study Specifics
• 70 year old male, status post cerebrovascular accident
• Past medical history includes coronary artery disease and
hypertension
• Initially aspiration with thick/thin liquids, remained at risk for
aspiration
• Dysphagia evaluations performed acutely and once a month for
four months
• Initially Tube feedings for nutrition; no oral intake
• Participated in VitalStim therapy for 10 sessions
• Final Video Fluoroscopic Swallow Study was performed 4 months
after date of cerebrovascular accident
April 2015
AOTA Nashville, TN
Video Fluoroscopic Swallow Study
Prior to Intervention
April 2015
AOTA Nashville, TN
Intervention
Treatment sessions were 60 minutes in duration. Each session began with
good oral cares. VitalStim was used in conjunction with swallowing
exercises.
Plan of Care:
• Initiate use of VitalStim
• Incorporate swallowing exercises: Strap muscle strengthening, effortful
swallow, Mendelsohn maneuver, Masako maneuver and bolus control
• Consider use of biofeedback in conjunction with exercises
Goals:
1. Patient will participate in VitalStim 3-5 times per week in preparation
for a repeat Video Study.
2. Patient will improve to Functional Oral Intake Scale, Level 5 upon
completion of repeat Video Study.
3. Patient will participate in a swallowing home exercise program with
assistance from family.
April 2015
AOTA Nashville, TN
Functional Outcomes
• EAT-10, Initial score- 33/40, If the EAT-10 score is
3 or higher, you may have problems swallowing
efficiently and safely
• Patient’s Functional Oral Intake improved from
Level 1: No Oral Intake to Level 5: Total oral
intake of multiple consistencies requiring special
preparation.
• An initial quality of life question indicated patient
strongly disagrees that eating/feeding provided
pleasure, as he was NPO and receiving tube
feedings.
April 2015
AOTA Nashville, TN
Final Video Fluoroscopic Swallow
Study
April 2015
AOTA Nashville, TN
Repeat Video Study performed:
• One incident of flash penetration with honey thick liquid,
patient had penetration above the level of the vocal cords
with thin liquids
• Minimal residual in the valleculae and piriforms that
eventually cleared with second dry swallows.
• Laryngeal excursion was within normal limits.
• The epiglottis did not invert past the upright position.
• No aspiration was observed with any consistency.
Patient’s Functional Oral Intake improved from Level 1: No Oral
Intake to Level 5: Total oral intake of multiple consistencies
requiring special preparation.
April 2015
AOTA Nashville, TN
Functional Outcomes
EAT-10, Initial score- 33/40, If the EAT-10 score is 3 or
higher, you may have problems swallowing efficiently and
safely
Patient’s Functional Oral Intake improved from Level 1:
No Oral Intake to Level 5: Total oral intake of multiple
consistencies requiring special preparation.
• An initial quality of life question indicated patient
strongly disagrees that eating/feeding provided
pleasure, as he was NPO and receiving tube feedings
April 2015
AOTA Nashville, TN
VitalStim: Case Study
Case Study: Use of VitalStim in Occupational Therapy Dysphagia
Rehabilitation
Shari Bernard, OTD, OTR/L, SCFES; Katherine Carlin, MA, OTR/L,
Division of Physical Medicine and Rehabilitation
Mayo Clinic, Rochester, MN
Background
Status Prior to VitalStim
The VitalStim is an FDA approved application of
neuromuscular electrical stimulation to the
swallowing muscles that can be used in dysphagia
rehabilitation. In combination with swallowing
exercises the VitalStim application can be used to
strengthen and re-educate the swallowing muscles
and improve the motor function of the swallowing
mechanism. This application of neuromuscular
electrical stimulation to the swallowing musculature
requires specialty certification in order to use.
Video Study performed June 12, 2013 demonstrated:
• Delayed oral phase, decreased bolus control,
delayed pharyngeal phase, tongue base
weakness, infrahyoid weakness (reduced
laryngeal elevation), poor epiglottic movement,
difficulty managing secretions, and aspiration
• EAT-10, Initial score- 33/40, If the EAT-10 score is
3 or higher, you may have problems swallowing
efficiently and safely
• Functional Oral Intake Scale = Level 0 (No Oral
Intake; Tube dependent)
Results indicate increased risk of penetration and
aspiration due to residual observed in piriform
sinuses; decreased quality of life with regards to
eating, feeding and swallowing; difficulty managing
secretions; and continued use of PEG tube.
Dysphagia: “Difficulty with any stage of swallowing
(oral, pharyngeal, esophageal); dysfunction in any
stage or process of eating; includes any difficulty in
the passage of food, liquid, or medicine during any
stage of swallowing that impairs the client’s ability
to swallow independently or safely.” (Avery, 2010, p.
271)
Figure 2
Placement 2b (Wijting, 2011)
Channel 1: electrodes aligned
along midline, over geniohyoid
belly
Channel 2: electrodes placed at
either side of thyroid notch, over
thyrohyoid muscle belly
This particular placement focuses on hypolaryngeal
excursion. It offers good facilitation of geniohyoid,
mylohyoid and thyrohyoid muscles.
VitalStim Intervention
Objective: Increase occupational therapist’s
awareness to options for dysphagia rehabilitation.
Figure 1
Case Study
• 70 year old male, status post stroke in April
2013
• Past medical history of posterior fossa
ependymoma, parietal meningioma, coronary
artery disease and hypertension
• Dysphagia from stroke (438.82)
• Tube feedings for nutrition; no oral intake
• Participated in VitalStim Therapy for 10
sessions
VitalStim Unit and Electrodes
(Wijting, 2011)
Treatment sessions were 60 minutes in duration. Each
session began with good oral cares. VitalStim was used
in conjunction with swallowing exercises.
Plan of Care:
• Initiate use of VitalStim
• Incorporate swallowing exercises: Strap muscle
strengthening, effortful swallow, Mendelsohn
maneuver, Masako maneuver and bolus control
• Consider use of biofeedback in conjunction with
exercises
Goals:
1. Patient will participate in VitalStim 3-5 times per
week in preparation for a repeat Video Study.
2. Patient will improve to Functional Oral Intake Scale,
Level 5 upon completion of repeat Video Study.
3. Patient will participate in a swallowing home
exercise program with assistance from family.
Functional Oral Intake Scale
TUBE DEPENDENT (levels 1-3)
1. No oral intake
2. Tube dependent with minimal/inconsistent oral intake
3. Tube supplements with consistent oral intake
TOTAL ORAL INTAKE (levels 4-7)
4. Total oral intake of a single consistency
5. Total oral intake of multiple consistencies requiring
special preparation
6. Total oral intake with no special preparation, but must
avoid specific foods or liquid items
7. Total oral intake with no restrictions
Results
Repeat Video Study performed July 12, 2013:
• One incident of flash penetration with honey thick
liquid, patient had penetration above the level of
the vocal cords with thin liquids
• Minimal residual in the valleculae and piriforms
that eventually cleared with second dry swallows.
• Laryngeal excursion was within normal limits.
• The epiglottis did not invert past the upright
position.
• No aspiration was observed with any consistency.
Patient’s Functional Oral Intake improved from Level
1: No Oral Intake to Level 5: Total oral intake of
multiple consistencies requiring special preparation.
Conclusions
This patient was a good candidate for VitalStim
therapy. He had a neurologic diagnosis of a stroke.
He was seen in an outpatient setting and was able to
attend the clinic up to 5 times per week for a month.
Patient had good family support and was able to
follow-through with a home dysphagia exercise
program. Literature supports the use of VitalStim to
assist with increasing speed and strength of swallow
for increased laryngeal elevation.
An initial quality of life question indicated patient
strongly disagrees that eating/feeding provided
pleasure, as he was NPO and receiving tube
feedings. Patient was unable to participate in followup after final Video Fluoroscopic Swallow Study.
Unable to obtain quality of life rating post final Video
Fluoroscopic Swallow Study.
References
Avery, W. (Ed.). (2010). Dysphagia Care and Related Feeding Concerns for
Adults Second Edition. Bethesda, Maryland: AOTA Press.
Crary MA, Carnaby-Mann GD, Groher ME. Initial psychometric assessment
of a functional oral intake scale for dysphagia in stroke patients. Arch
Phys Med Rehabil 2005;86:1516-1520.
Freed ML, Freed L, Chatburn RL, Christian M. Electrical stimulation for
swallowing disorders caused by stroke. Respir Care, 2001; 46:466-74.
Gallas S, Marie JP, Leroi AM, and Verin E. Sensory Transcutaneous
Electrical Stimulation Improves Post-Stroke Dysphagic Patients.
Dysphagia 2009.
Park JW, Oh JC, Lee HJ, Park SJ, Yoon TS, and Kwon BS. Effortful
swallowing training coupled with electrical stimulation leads to an
increased in hyoid elevation during swallowing. Dysphagia 24: 296-301,
2009b.
Wijting Y, Freed M. (2011). VitalStim Certification Program Training Manual
for the use of Neuromuscular Electrical Stimulation in the treatment of
Dysphagia. Gulf Breeze, Florida: CIAO Seminars.
Xia W, Zheng C, Lei Q, et al. Treatment of post-stroke dysphagia by
vitalstim therapy coupled with conventional swallowing training. J
Huazhong Univ Sci Technolog Med Sci. Feb;31(1):73-76.
© 2014 Mayo Foundation for Medical Education and Research
April 2015
AOTA Nashville, TN
Acute Care Clinical Assessment
Patient CS is an 83 yo retired Captain, married with supportive wife, son
Diagnosis: Acute care admission January, with RML pneumonia, pancytopenia
(decreased production of red and white blood cells), atrial fibrillation with
RVR, acute urinary retention, sepsis, and hypotension, TME
Medical History: November: diagnosed with stage II seminoma treated with
chemotherapy. 3ppd smoker, quit in 1960.
Medical intervention: 5 units platelets, 4 units red blood cells, Neupogen (white
blood cell production stimulant), cardiac medications, abx,
Pertinent Medications: Omeprazole (Prilosec) 20 mg delayed-release
Social History/Prior Status/Code Status:
Mental Status:
Cognition/Orientation: Alert; but confused with difficulty following commands
Subjective: Patient states he does not want any tube down his nose. Patient’s
nurse reports choking with nectar thickened fluids.
Pain: no pain reported by patient
April 2015
AOTA Nashville, TN
Acute Care Clinical Assessment
Respiratory Status: 2L O2
Secretion Mgt: wet, gurgly voice
Breath sounds: improving per chart
Nutrition/Hydration: IV fluid
Communication:
Articulation: WFL
Voice: Wet-sounding
Physical Status:
Hand Dominance:
Right
Able to Self feed:
With moderate assistance
Mobility/Tol.
HOB elevated
April 2015
AOTA Nashville, TN
Oral Exam : Functional facial, lingual, mandibular movements. Gag deferred
Swallowing Trials nectar and honey thickened fluids with spoon, and
pudding with spoon
Moderate-severe oropharyngeal dysphagia with deficits in oral bolus
formation and transit. Noted to lose track of bolus-decreased attention.
Delayed swallow with diminished strength of laryngeal elevation for all
trials.
Wet-sounding voice s/p trials with cued cough/clear
April 2015
AOTA Nashville, TN
Acute care VFSS- Aspiration
April 2015
AOTA Nashville, TN
Acute Care Nectar Laryngeal Entry
April 2015
AOTA Nashville, TN
Acute Care VFSS Honey Thickened Fluid
April 2015
AOTA Nashville, TN
Acute Care Esophageal Stasis Lateral
April 2015
AOTA Nashville, TN
SNF following LTAC
Referral for VFSS
Our retired captain, now participating in swallowing therapy at
SNF. Patient has PEG for tube feedings due to return to
critical care with sepsis.
His wife is present with him for the study.
Mental Status:
Cognition/Orientation: Alert; follows multi-step commands; but
is confused with decreased cognition.
Subjective: He would like to be able to eat again.
Respiratory Status: Room air
Secretion Mgt: audible pharyngeal secretions
Breath sounds: improving per chart
April 2015
AOTA Nashville, TN
Communication:
Articulation: WFL
Voice: Wet-sounding
Physical Status:
Hand Dominance:
Right
Able to Self feed:
With moderate assistance
Mobility/Tol.
Decreased endurance,
tolerates
upright seating
Swallowing Trials with VFSS:
Thin 3ml;nectar 5 ml, cup; honey 5 ml; puree 5 ml
April 2015
AOTA Nashville, TN
SNF VFSS Laryngeal entry nectar cup
April 2015
AOTA Nashville, TN
Laryngeal entry nectar cup
April 2015
AOTA Nashville, TN
SNF VFSS Aspiration pre and during swallow
April 2015
AOTA Nashville, TN
SNF VFSS s/p repeat swallow w/nectar
April 2015
AOTA Nashville, TN
SNF VFS A-P Post Nectar
April 2015
AOTA Nashville, TN
Outpatient
Client is now discharged home. He is referred by
oncologist as PCP said “I will never be able to
swallow again.”
Jevity 1.5 calories 4 cans with water during the
day and 4 cans at night on pump
Client is without any oral intake and is waking
multiple times at night to use the bathroom
April 2015
AOTA Nashville, TN
OP Initial w/ thin small sip
April 2015
AOTA Nashville, TN
OP Airway protection thin w/o
epiglottal retroflexion
April 2015
AOTA Nashville, TN
OP Cup thin
April 2015
AOTA Nashville, TN
OP pudding residual
April 2015
AOTA Nashville, TN
Nectar Laryngeal Entry
April 2015
AOTA Nashville, TN
Post Swallow
April 2015
AOTA Nashville, TN
April 2015
AOTA Nashville, TN
April 2015
AOTA Nashville, TN
Chin tuck w/ laryngeal elevation pre- fluid swallow
April 2015
AOTA Nashville, TN
Airway protection with large thin
swallow
April 2015
AOTA Nashville, TN
Final diffuse esophageal dysmotility
April 2015
AOTA Nashville, TN
April 2015
AOTA Nashville, TN
Kettering Health Network IOTA
November 15, 2014
• Clinical signs:
weight gain
clear lungs
• QOL:
Going out to eat
Joining wife and family at meals
• MD
Stop night feedings and make appt. to remove GTube
• Son – wait three weeks, call for appt.
April 2015
AOTA Nashville, TN
Kettering Health Network IOTA
November 15, 2014
References
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on videofluoroscopy with full esophagram results. Head & Neck, 34: 264-269.
doi: 10.1002/hed.21727
Altman, K. W., Richards, A., Goldberg, L., Frucht, S., & McCabe D. J. (2013). Dysphagia in stroke,
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and management. (pp: 1137-1149). Philadelphia, Elsevier.
Altman, K. W., Yu, G-P., & Schaefer, S. D. (2010). Consequence of dysphagia in the hospitalized patient:
impact on prognosis and hospital resources. Archives of Otolaryngology-Head, and Neck Surgery,
136(8), 784-789. doi:10.1001/archoto.2010.129.
American Occupational Therapy Association (2007). Specialized knowledge and skills in eating and
feeding for occupational therapy practice. American Journal of Occupational Therapy, 61
(November, December), 686-700.
American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain
and process (3rd ed.).American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48.
http://dx.doi.org/10.5014/ajot.2014.682006
April 2015
AOTA Nashville, TN
American Occupational Therapy Association. (2014). AOTA specialty certification in feeding,
eating, and swallowing: 2014 candidate handbook—Occupational therapists. Bethesda,
MD: Author.
Avery, W. (2010). Dysphagia issues in contemporary health care. In Avery, W. (Ed.),
Dysphagia Care and Related Feeding Concerns for Adults, 2nd edition (pp. 1-20).
Bethesda, MD: The American Occupational Therapy Association, Inc.
Barker, J., et al. (2009). Incidence and Impact of Dysphagia in Patients Receiving Prolonged
Endotracheal Intubation After Cardiac Surgery. Canadian Journal of Surgery. 52(2):11925.
Belafsky, P.C., Mouadeb, D.A., Rees, C. ., Pryor, J.C., Postma, G N., Allen, J., Leonard, R. J.
(2008). Validity and reliability of the Eating Assessment Tool (EAT-10). Annals of
Otolaryngology and Rhinology, 117(12),919-924.
Bernard, S. & Cox, M. (2013). Videofluoroscopy swallow study: Promoting positive
outcomes for interventions in feeding, eating, and swallowing. OT Practice 18, 17-18.
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Burgess, G., et al. (1979). Laryngeal Competence after Tracheal Extubation. Anesthesiology.
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April 2015
AOTA Nashville, TN
Colice, G., et al. (1989). Laryngeal Complications of Prolonged Intubation. Chest. 96:877-884.
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Crary, M. A., Carnaby, G. D., LaGorio, L.A., & Carvajal, P. J. (2012). Functional and
physiological outcomes from an exercise-based dysphagia therapy: a pilot investigation of
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April 2015
AOTA Nashville, TN
Hafner, G., et. al. (2007). Fiberoptic Endoscopic Evaluation of Swallowing in Intensive
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April 2015
AOTA Nashville, TN
Padovani, ER., et al. (2008). Orotracheal Intubation and Dysphagia: Comparison of
patients with and without brain damage. Einstein. 6(3):343-9.
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Penetration-Aspiration Scale. Dysphagia 11, 93-98.
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April 2015
AOTA Nashville, TN