[Dysphagia] references please!

[pressmah at sjhmc.org (pressmah@sjhmc.org)]

These patients are ideal candidates for FEES.  For those SLPs spending most
of their time with these pts.  training in FEES would likely be very
worthwhile if an ENT is not available  Hilda Pressman

-----Original Message-----
From: Janet Finger [mailto:justjanetlynn@msn.com]
Sent: Friday, September 24, 2004 12:32 AM
To: dysphagia@b9.com
Subject: Re: [Dysphagia] references please!



My suggestion would be to try a bedside, trying to form an impression in 
your mind of the physiology, possible aspiration going on, & what your 
recommendations WOULD BE if they had to be based upon that clinical 
assessment. Then keep the pt NPO and follow-up with some sort of 
instrumental exam. Watch what happens and see if it is consistent with your 
clinical impressions. When I started at an LTAC 4 years ago (funny 
coincidence) I had trach/vent experience but not like working with it full 
time as I do now. I was certainly fearful. But over time I noticed that 
after the MBS I was often making the same recommendations & doing the same 
txs I would have done anyway. I also got a better sense of which types of 
pts (including many things such as age, diagnoses, secretions, etc) I did 
need to complete MBS on because it was more difficult to judge clinically. 
Over time I have done fewer MBSs and become more comfortable being more 
aggressive. The nursing & respiratory staff & physicians I work with trust 
my judgement because they know I won't keep pts NPO (or make restrictions) 
unless necessary. They support me when the pts complain because they know I 
have my reasons. When my pts do complain because they don't like the pureed 
food or the thick liquids or whatever, I tell them they are lucky to have me

because most SLPs would be too afraid to let them eat at all.

1 & 2. Also, you can deep suction with inline or sterile suction depending 
upon a person's physiology. Ask the respiratory therapists how they were 
taught to suction and you will get many answers. I am not aware of any 
definitive "right" way.
3. You are right that sometimes you end up basically reassessing rather than

doing "treatment" on all sessions. I was a bit unsettled about that at first

but do use tx techniques when possible. This does include exercises such as 
effortful swallows to improve tongue base retraction, mendelsohn maneuvers 
to improve laryngeal elevation, etc.
4. I think some people may feel manufactured blue foods are better because 
they are regulated. I have found that my blue dye tests seem to be more 
reliable when I add the food coloring myself. I find it is important for the

food/liquid to be oversaturated with the dye so that it bleeds out into 
surrounding secretions as well, makes it more visible during suctioning. 
That way if they only aspirate a tiny drop there will be more blue 
secretions than that to find on suctioning. There are other precautions I 
have mentioned in previous posts such as avoiding use on pts who are 
critically ill & especially septic.

Sorry for the length of this. It is not a simple topic by any means. 
Everyone has to find their comfort level. Although it sounds like I practice

more similarly to your supervisor, I would never pressure you the way she 
seems to be. When other therapists cover my pts I tell them to practice 
within their own comfort level. If they want to keep my pts NPO or not 
advance them or whatever until I get back that is fine. We have to respect 
each other as professionals. I would, however, be interested in any related 
references & info everyone has to contribute.


----- Original Message ----- 
From: "ROSSMAN, KIMBERLY M" <01kmrossman@bsu.edu>
To: <dysphagia@b9.com>
Sent: Thursday, September 23, 2004 7:36 PM
Subject: [Dysphagia] references please!


> Hi All,
> I know that this has been a topic many, many times before, but until 
> recently it wasn't an issue that I had direct contact.  I am hoping that 
> someone can send me a list of references, from both journals and books, 
> that state the efficacy of doing a beside swallow on vent dependant 
> patients.  My current supervisor, who is a speech therapist, has been 
> doing  BSSEs on vent patients in an LTAC  for the last 4 years, swears 
> that she has the clinical ability to identify aspiration on a vent patient

> using deep suctioning and skill.   I have refused to use this procedure to

> ID aspiration and refused to treat her patients if a BSSE has been 
> completed.  I have been told that I need references in order to continue 
> to refuse using this assessment.
>
> Besides the obvious, for those out there that are using this technique, 
> please explain:
> 1. What is considered deep suctioning...how far down and wouldn't that 
> change by person?
> 2.  As a speech therapist, I do in-line suctioning, but never deep 
> suctioning; therefore, I don't have the control or knowledge of  how the 
> suctioning should take place....some RT's do a quick up and down motion 
> others do a slow, stable suction, others twist a little...is one better?
> 3.  The therapy involves continuing to suction the patient while eating 
> for several days...how is that therapeutic?   Isn't that continually 
> assessing (which isn't billable), other than talking about an effortful 
> swallow to lift the trach, what are we suppose to be teaching?
> 4.  What is it about the 'pre-colored' food items, such as Blue's Clues 
> applesauce, that makes that any safer on a vent patient than adding food 
> coloring to regular applesauce?
>
> All responses would be greatly appreciated!
>
> Thank You,
> Kimberly
> LifeCare Hospitals of San Antonio
> > _______________________________________________
> Dysphagia mailing list
> Dysphagia@b9.com
> http://lists.b9.com/mailman/listinfo/dysphagia
> 
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