Team Collaboration: The Role of the SLP

Reggie Smith, M.A.,CCC-SLP

Speech-Language Pathologist

Presented at Comprehensive Stroke Conference

June 1, 2018

Whittier, CA

Disclosure and Acknowledgment

No conflicts of interest Reggie Smith is employed by PIH Health Hospital Reggie Smith is a volunteer treasurer for the Medical Speech

Pathology Council of California

Defenses to protect our airway

Epiglottis

FVFs

TVFs

Cough Reflex

4

Video Clip - Normal

• Video Clip

Role of the SLP: identifying aspiration risk and strategies to prevent PNA, dehydration, malnx,

pressure sores while collaborating with stroke team re: safe swallow guidelines.

Neurology of Swallowing & Associated Respiratory

Reflexes

S-M

Cortex

Prefrontal

Cortex

NTS &

Reticular

F.

V * Inter-

neurons

Sensory

Nucleus

VII XII

Nucleus

Ambiguus IX, X, XI

Thalamus Subcortical Sites

Central Pattern Generator

CN Motoneuron Pools

VII IX X Palate, pharynx,

larynx, mouth, tongue

Face mouth tongue

Jaw,

palate,

submental

Lips, face,

submental Palate,

pharynx,

larynx,

esophagus

Tongue

submental

Stretch receptors in lungs Diaphragm Intercostals

V

*Acts as a link between sensory/motor neurons

For educational use only and not for distribution: © complied/designed by Reggie Smith

Swallowing is everything but a simple process

Acute CVA: swallowing problems by site of lesion

1. Left or Right CVA (Cortical): If stroke is uncomplicated,

improvement in swallowing is with 1-3 weeks.

2. Medulla (lower brainstem): Improvement estimated from 1-2

weeks.

3. Pons (upper brainstem): Expect slow recovery from 1-4

weeks

4. Subcortical Stroke (Basal Ganglia): improvement in

swallowing is within 3-6 weeks.

5. Multiple Infarcts: Recovery patterns unpredictable.

Neurologic disease is 1 of 4

predisposing factors to aspiration Identification of Hospitalized Patients at Risk for Aspiration- Dr. Festic, Mayo Clinc, Jacksonville Florida, May 7, 2017

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Video Clip- Abnormal

Role of the SLP: identifying aspiration risk and strategies to prevent PNA, dehydration, malnx,

pressure sores while collaborating with stroke team re: safe swallow guidelines.

Fails the nursing swallow screen Bedside Swallow Evaluation or VFSS (aka: MBSS) is requested

If h/o silent aspiration, SLP will jump right to a VFSS if

patient is appropriate

GOLD standard is a VFSS

Usually do NOT repeat a VFSS before 2 weeks

FEES will be suggested if question of impaired VF function

and dysphonia is present

Fact or Fiction: Is the VFSS a good test of airway function?

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Acute CVA: Stats & Facts

Silent Aspiration Facts

“55% of stroke patients with

dysphagia demonstrate aspiration and

up to 40% silently aspirate.” -Source:

Shutter, L., (June 1, 2002). Advanced Issues In Dysphagia Management. Jo

Puntil Conference Handout, LBMMC, (2015) pp. 17-28. Respiratory

Infections in Acute Stroke: NG tubes/Immobility are stronger predictors than

Dysphagia - 2013

Dysphagia is present in…

30-65% of patients with acute ischemic stroke

Evidence points to multiple factors to develop PNA in the first week of CVA

Dysphagia present in 58% on admission; Dysphagia present in 1st week now to 30%; Overall respiratory infections = 11%.

[based on 536 CVA pts] Jo Puntil Conference Handout, LBMMC, 17-28.

Prevalence

Oropharyngeal dysphagia post-stroke – up to 78%

Persist 6 months after stroke in 50% of stroke patients

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Acute CVA: Some Facts

Odds of liquid aspiration are significantly greater for CVA’s NOT oriented to person, place & time.

Odds of liquids/puree aspiration are significantly greater for CVA who cannot follow 1 step commands. (Leder, Suiter, Warner 2009)

Absence of gag reflex does NOT appear to be a predictor of dysphagia. (Leder 1996)

Myth buster: There are plenty of patients with a normal gag, but with severe dysphagia. Gag reflex is not related to swallowing. It is a primitive function and is not controlled by the cerebral cortex. It is a protective reflex.

Odds of liquids aspiration are significantly higher for individuals with reduced lingual ROM. (Leder,

Suiter, Murray, 2013)

Breathiness, hoarseness, harshness may be predictive of aspiration. (Daniels et al 1998)

Presence of dysarthria aspiration risk in stroke patients. (Daniels et. Al. &

McCollough et al 2005) - Motor movement problem (respiration, phonation, resonance, articulation)

Jo Puntil-Medically Fragile Issues Across the Lifespan – July 2015 – LBMMC Presentation

Stats and Facts re: PNA CDC (2011) – $22,875 was the average extra cost of treating one case of PNA

PNA occurs in 38% of all stroke

victims and is the most common

respiratory complication.

PNA contributes to 34% of all

stroke deaths (Stephens &

Addington, 1999)

Asp PNA is… due to

oropharyngeal dysphagia and the

most common form of HCAP

Risk of PNA ’d • 4x with observed laryngeal PEN

• 10x with observed aspiration

• 13x with “silent” aspiration

Gajic et al. AJRCCM 2011;183(4): 462-70

Aspiration

Dysphagia

Poor cough reflex

Silent aspiration

Poor oral care

Bacterial contamination

Oropharyngeal secretion

Gastric secretion GER

Pneumonia

Fact or Fiction: Does a PEG prevent PNA?

Abnormal Esophageal Phase

with the hx of L-CVA

DYSPHAGIA

What are we looking at?

Cognitive ability – attention, impulsivity, awareness, ability to

follow directions

Oropharyngeal phases & overt s/s of aspiration/penetration

with trials if appropriate

Respiratory status

How fragile and/or how ambulatory is the patient

Does patient have h/o dysphagia

Treatment Approaches

NMES with sEMG

Postural techniques

Swallow maneuvers

Neuromuscular

Re-education

Food/Liquid

modifications

Education and Care Provider

Training, including stroke team

Safe swallow guidelines

• sitting posture

• oral care check

• tray set up

• bolus size

• postural techniques

• swallow maneuvers

• assist needed

• adaptive equipment

Education and Care Provider

Training, including stroke team

See Handout re:

Oral hygiene guidelines

Resources: www.swallowstudy.com/oral-care-procedures

Dysphagia after acute stroke

Consequences of missed swallowing impairment by the stroke team members:

• Pulmonary compromise

• Intubation

• Antibiotics

• Alternate feeding method

• LOS by 3.8 days longer than non-dysphagic inpatients

• 33% higher inpatient care costs

• 2.8% times more likely to require post acute care services

• 1.7 fold high odds of dying in the hospital vs. non-dysphagic

patients.

Bottomline: A dx of dysphagia appears to be an indicator of

worse outcomes/higher costs. Patel et al (2018) – Economic/survival burden of dysphagia among inpatients in the United States.

Diseases of the Esophagagus

Patel D A, Krishnaswami S, Steger E, et al. Economic and survival burden of dysphagia among hospitalized patients. Diseases of the Esophagus 2017; 31: 1-7.

Aphasia and Cognitive Deficits

Source: www.aphasiatoolbox.com – Visual definition of aphasia

What is aphasia?

Loss of language

Affects ability to comprehend and communicate

Can affect auditory and reading comprehension

Can affect verbal and written expression

Aphasia types (4 Fluent and 4 Nonfluent)

Fluent Aphasia: Wernicke’s, Transcortical Sensory,

Conduction, Anomic

Nonfluent Aphasia: Broca’s, Transcortical Motor, Global

Aphasia, Mixed Transcortical

Fact: PWA = Communicate better than they talk!

Aphasia Stats & Facts

Prevalence

• Up to 38 % of stroke patients have aphasia

• Approximately, 1/3rd will fully recover

• Initial severity, early recovery, and site/size of lesion are

good predictions of outcome (Plowman et al., 2011)

• Spontaneous recovery is best during the first 6 months

• PWA can continue to improve years after onset with speech

therapy that focuses on the patient’s environment and

activities of personal relevance for self-management.

NOTE: Most PWA will have some trouble with speaking,

writing, understanding, and/or reading. Some will have

dysarthria (slur/nasality) and/or apraxia (mix up sounds in

words, say the wrong sounds, struggle to say sounds-motor

planning/programming problem).

Cognitive Impairments Post Stoke

Definition: Cognition is an impairment in speed of processing

heard/seen information, attention, verbal/visual memory, executive function

is an umbrella term for lots of cognitive processes having to do with

inhibition (e.g., verbal perseveration), and working memory.

• 75% of acute stroke patients have cognitive impairments

• Cognitive impairment influences spontaneous recovery in the first 12

months

• Cognitive impairments have to do with poor functional outcomes

• If cognition (memory, self-regulation) are faulty, patients may have

difficulty keeping those gains made in therapy over time

• Predictors of response to speech therapy includes: visual-spatial

memory; attention, executive function; and verbal learning (ability to learn

new words, novel words for objects and this correlates with tx outcome)

Aphasia – Role of SLP

Assess language (aphasia), cognition, and motor speech

(dysarthria, apraxia)

Utilize informal and formal measures

Provide intervention (direct and/or indirect)

Provide education to patient and family members

Collaborate with the stroke team

First step: Fluency

Is patient fluent?

Speech is fluent when the patient can say six or more words in a

sentence

To determine fluency

Ask the patient, “Why are you here?

If he answers with six or more words in a sentence, by definition he

is fluent.

Ask patient to repeat simple words, then phrases, then complex

sentences

Repeat after me… Fork, Table, Answer to phone, Eastern

Pentecostal, The neighbor sheared the sheep.

Next step: Auditory Comprehension

Can she understand what she hears?

Begin with one step commands and then advance to more complex

commands

One-step command: Touch ________(eyes, nose, or ears)

Two-step direction: Point to the ceiling, then to the floor or Touch your

nose, then your knee.

Multi-step command: Tap each shoulder twice with two fingers,

keeping your eyes shut.

Can assess with yes/no questions? Are you in a bank?

Are you in a hospital? Are you a woman? Is your name…?

Education and Care Provider

Training, including stroke team

General Communication Guidelines…Simplify

• Handle only one ideas at a time.

• Use short sentences with simple, common

words.

• Repeat or rephrase direction as needed.

• Ask simple, personal yes/no questions.

Are you hot? Are you in pain?

Education and Care Provider

Training, including stroke team

-Slow down and allow time.

-Clue him in.

-Do not assume he understands

everything.

-Guess and confirm.

-Be clear and validate.

-Respect.

-Be flexible.

-Helpful hints. • Be direct, concise.

• Explain what and why you are doing something