Ebp Language Group 2009

Ebp Language Group 2009

Man vs Machine 2014 Adult Swallowing Group NSW Speech Pathology Evidence Based Practice Network Carly Bowen, Christian Wiley and Claire Layfield (Group Co-Lea Hans Bogaardt - Academic Member Clinical question What is the reliability of clinical vs instrumental assessment and does this change overall management of individuals with dysphagia?

Why this clinical question Should we be doing more instrumental assessments? How much confidence should we have in our bedside assessments? Pressure from medical teams to perform MBS despite bedside assessment Validating clinical practice we feel we are more than just a screen What parts of the bedside assessment are the most salient The Evidence: Searching Initial

searching by the group found 23 articles From these 19 were CAPPED Articles were excluded because they did not perform either the bedside swallow assessment or the instrumental assessments The Evidence: Research Design Research designs Pseudo-Randomised Control Trial Non Randomised group Design

Prospective observational Study Case Series Levels of evidence 1 = level 2 18 = Level 3 The Evidence: Participants Participants oropharyngeal dysphagia 13 out of the 19 CAPS were for acute CVA populations (less than a week post onset) The remaining 6 studies were on small

samples of various populations including degenerative neurology, dementia, head and neck, post extubation or general dysphagia. The Evidence : Methods Variability noted in type of instrumental assessment Either FEES or MBS Variability noted in administration of assessment Schedules of instrumental and clinical

assessments Degree of inter / intra-rater reliability and validity Blinding Consistencies and proportions of food /fluids provided The Evidence: Measurement Measures included Aspiration and/or penetration in all studies. Two studies considered patient perspective of dysphagia

Several studies included measures of dysphagia in the oral and/or pharyngeal phase. These studies developed their own methods of measuring dysphagia severity Variety of bedside indications of aspiration included: Cough (volitional and reflexive), wet voice, dysphonia, gag, dysarthria, Cranial Nerve Ax The Evidence: How results were presented Sensitivity and specificity

Used in almost all the studies Positive and negative predictive values Correlation between tests on severity rating scales Likelihood ratios Reminder of sensitivity and specificity Sensitivity How many aspirators are identified correctly

Specificity How many nonaspirators are identified correctly Findings Evidence for bedside swallow accuracy is clearest for acute CVA patients Due to small sample sizes and limited number of studies, the evidence for the accuracy of bedside swallow assessment for populations other than acute CVA is unclear Differences in study methodology and robustness of the studies make it

difficult to compare results We did not perform a meta analysis. Findings In patients with dysphagia, clinical bedside assessment is more accurate at detecting aspiration than screening but not as accurate as instrumental assessment. In patients post CVA the sensitivity of bedside swallowing examinations in identifying aspirators ranged from 75% to 85% in 11 out of 13 studies. The two exception studies reported sensitivity of 47% and 100%. Specificity ranged from 65% and 90% in 12 out of 13 studies. The exception study had a

specificity of 30%. Findings Using combinations of predictive signs increases the likelihood of predicting aspiration from clinical bedside evaluation When assessing a patient at bedside the signs that most accurately predict whether a patient is aspirating include cough post swallow, reduced volitional cough strength, wet voice quality, breathy voice quality, and history of pneumonia Applying these results to clinical practice Instrumental

Assessment will always be more objective than clinical assessment However we need to consider clinical feasibility and suitability We can be pretty confident in our bedside assessment for patients post CVA. Instrumental assessment is not essential to make safe decisions regarding management for patients post CVA. Thoughts from the group Felt reassured at clinical practice and improved confidence

in decision making. Implications for sites that have reduced access to instrumental assessment. Results are only for CVA population. Results would be different in other populations. Dysphagia assessment has a diagnostic and therapy role which is not simply limited to the identification of aspiration. Similarly MBS and FEES are also used for diagnostic and therapy reasons, biofeedback, patient education. Not just aspiration identification. Research did not necessarily address limitations of MBS and FEES vs Bedside. Natural environment, more bolus sizes, self feed. Future Research Research

investigating bedside swallow accuracy in different populations. What populations should we be more or less confident in our bedside assessment? How many patients is it okay to miss with regards to aspiration? Consider outcome measures other than aspiration including swallow rehabilitation, diagnosis, patient education. Consider the severity of aspiration. How much aspiration in an individual is okay? Quality of life outcomes A final word A well-trained clinician appears to be able to make a statistically accurate judgment that aspiration has occurred in patients who have suffered an acute stroke. This does not

mean that a well-trained clinician can detect and rule out aspiration in stroke patients at bedside. It means that, statistically, a well-trained clinician can be right more than wrong in that judgment. Clinically speaking, this may fall short of necessary expectations. Are we missing aspirators at bedside? Yes. Are there negative outcomes associated with the aspirators missed? That question has not been answered. McCollough 2005, p15. Plans for 2015 Swallow rehabilitation looking at the evidence behind EMST and Shaker in dysphagia.

Leader Christian Wiley Questions??? References

Barquist, Brown, Cohn, Lundy, Jackowski (2001) Postextubation fiberoptic endoscopic evaluation of swallowing after prolonged endotracheal intubation: A randomized, prospective trial. Critical Care Medicine 29,9,p1 710-1713 Cabre, M. Serra Prat, M., Palomera, E. , Almirall, J., Pallares, R. and Clave, P. (2010). Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age and Aging, 39, 39-45 Chong, M. S., Lieu, P. K., Sitoh, Y. Y., Meng, Y. Y. & Leoh, L. P (2003) Bedside Clnical Methods Useful as Screening Test for Aspiration in Elderly Patients with Recent and Previous Strokes Annals Academy of Medicine, Vol. 32, No. 6 pp. 790 794 Daniels, Brailey, Priestly, Herrington, Weisberg m Foundas (1998) Aspiration n patients with acute stroke. Archives of physical medicine and rehabilitation ( 79) 1, 14-19 Heckert, K., Komaroff, E., Adler, U., and Barrett, A. (2009). Postacute re-evaluation may prevent dysphagia-associated morbidity. Stroke, (40) 1381-1385

Horner, J., Massey, W. (1988) Silent aspiration following stroke. Neurology (38) 317-319 Leder, S. & Espinosa, M. (2002). Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia (17) 214-218 Lim, S. H. B., Lieu, P. K., Phua, S. Y., Seshadri, R., Venketasubramanian, N., Lee, S. H., & Choo, P. W. J. (2001). Accuracy of bedside clinical methods compared with fiberoptic endsoscopic examination of swallowing (FEES) in determining the risk of aspiration in acute stroke patients. Dysphagia, (16) 1-6 Logemann, J., Veis, S., and Colangelo, L. (1999). A screening procedure for oropharyngeal dysphagia. Dysphagia (14) 44-51 References

McCullough, Wertz & Rosenbek (2001) Sensitivity and specificity of clinical/bedside examination signs for detecting aspiration in adults subsequent to stroke. Journal of Communication Disorders. 34 (2001) 55-72 McCullough, G.H., Rosenbek, J.C., Wertz, R.T., McCoy, S., Mann, G., & McCullough, K. (2005). Utility of Clinical Swallowing Examination Measures for Detecting Aspiration Post-Stroke. Journal of Speech, Language and Hearing Research, 48: 1280-1293 Miles, Zeng, McLauchlan, Huckabee (2013) Cough reflex testing in dysphagia following stroke: A

randomised controlled trial Noordally, S. O., Sohawon, S., De Gieter, M., Bellout, H, and Verougstraete, G. (2011). A study to determine the correlation between clinical, fibre optic endoscopic evaluation of swallowing, and videofluroscopic evaluations of swallowing after prolonged intubation. Nutrition in clinical practice, 6(4), 457-62 Rosenbek, McCullough & Wertz (2004) Is the information about a test important? Applying the methods of evidence-based medicine to the clinical examination of swallowing. Journal of Communication Disorders (37) 437450 Schurr et al. (1999) Formal Swallowing evaluation and therapy after TBI improves dysphagia outcome. The Journal of trauma: injury, infection, and critical care 46 (5) 817-823 Smithard, ONeill, Park, England, Renwick, Wyatt, Morris & Martin (1998) Can bedside assessment reliably exclude aspiration following acute stroke? Age and Ageing (27): 99-106 Smith, H., Steven, H., ONeill, P. And Connolly, M. (2000). The combination of bedside swallowing assessment and oxygen saturation monitoring of swallowing in acute stroke: a safe and humane screening tool. Age and Ageing. (29) 495-499 Zenner, Losiniski, Mills (1995) Using cervical auscultation in the clinical dysphagia examination in long term care

Deborah J. C Ramsey, David G. Smithard & Lalit Kalra (2006) Can Pulse Oximetry or a Bedside

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