Become a Creator today!Start creating today - Share your story with the world!
Start for free
00:00:00
00:00:01
Dysphagia Assessment and Management with Jayme Inkpen
327 Plays1 year ago
Join host Wilmari Myburgh and occupational therapist Jayme Inkpen as they discuss dysphagia assessment and management.
In this episode, Jayme explains how she became interested in dysphagia therapy and developed her skills through mentorships. She gives an overview of her role as a dysphagia therapist and the importance of an interdisciplinary approach. Jayme discusses common populations seen and problems encountered, along with details on comprehensive assessments. She covers addressing dysphagia by understanding patient goals and values.
Jayme talks about developing documentation policies and procedures within her healthcare system. She provides recommendations for therapists to continue learning about dysphagia through mentorships, research reviews, and online communities. Jayme stresses the importance of critical thinking when reading research articles.
At the end, Wilmari and Jayme discuss some fun questions about favorite foods. Tune in to learn more about dysphagia therapy in occupational therapy practice!
Recommended
Transcript
Introduction and Guest Welcome
00:00:01
Speaker
Welcome to this episode of Growing OT, the podcast that's developed and produced by the Society of Alberta Occupational Therapists. SAOT wants to get listeners excited about the wonderful world of OT. I'm your host, Vilmarie Myberg. Please take a moment to subscribe or leave us a review on Apple Podcasts, Spotify, or wherever you're listening to us right now.
00:00:26
Speaker
Today we are chatting with Jamie Inkpen and this is particularly exciting as Jamie is the very first OT to be on the show.
Jamie Inkpen's Clinical Experience
00:00:36
Speaker
No pressure. Jamie is a licensed and certified occupational therapist with 18 years of clinical experience working within various settings including continuing care, outpatients and acute care. She has been a dysphagia therapist for 18 years.
00:00:54
Speaker
Jamie has worked within Alberta Health Services since 2005 and currently practices in a busy Edmonton area acute care centre. When not working clinically, Jamie instructs and creates curriculum within the Interdisciplinary Therapy Assistant Program at Norquest College, where she teaches both OT-specific and interdisciplinary communication courses.
00:01:19
Speaker
Jamie has participated in various AHS initiatives to develop OT-specific policies and procedures for feeding and swallowing assessment, as well as to provide OT-specific insight into ConnectCare feeding and swallowing documentation. Jamie, thank you so much for joining us today. We're excited to hear about your extensive experience as a dysphagia therapist.
Interest in Dysphagia Therapy
00:01:43
Speaker
So to kick things off, Jamie, could you please share with us what initially sparked your interest in this specialized area of occupational therapy and how you found your way into becoming a dysphagia therapist?
00:01:57
Speaker
Sure. Thank you so much for having me on the show. I'm really humbled by your request to have me when people talk to me and say, well, you're an expert in this. I'm like, Oh no, like, I think, I think you're talking to the wrong person. I think you should be talking to someone else. I think I've always felt like I, I've just always been sort of nervous with the title of a specialist or an expert, but from what I've been told, I know a bit. Hopefully the things that I can share with you today are helpful and enlightening.
00:02:25
Speaker
on some level and change your practices in a meaningful way. So to answer your question, my first job was actually in long-term care in a rural Alberta community.
00:02:37
Speaker
And honestly, I wouldn't say that I went looking for dysphagia. I would kind of say that dysphagia found me in that population. So there was a need for dysphagia assessment and treatment and management within my client population. And I knew from obviously school that this was an area that we could contribute to. And so it began.
00:02:59
Speaker
I think I was always a little bit nervous when practicing in this area, especially given some of the animosity that developed within sort of the SLP OT relationship in terms of dysphagia. I was always hypervigilant that I was on top of the research and I understood as much as I possibly could. And I was really, really lucky as a rural therapist. You don't always have the opportunities that I got, but I had great
00:03:27
Speaker
SLP and OT mentors and they were really encouraging and really wise and helped me sort of hone my skill set as a dysphagia therapist.
00:03:39
Speaker
That's great. That sounds like your ability to learn from mentors that were SLPs and OTs really informed your practice as you were learning about this area.
Role and Impact of Dysphagia Therapy
00:03:52
Speaker
So along those lines, I'm wondering if you could provide us with an overview of your role as a dysphagia therapist and the importance of an interdisciplinary approach in this setting.
00:04:04
Speaker
Yeah, well, currently I'm a frontline dysphagia therapist at an acute care hospital, as well as being an occupational therapist. So I'm still completing functional assessments and cognitive assessments and ADL equipment prescription and assistive device recommendations and those types of things. But one of my major roles is the evaluation and management and treatment of dysphagia.
00:04:29
Speaker
So at the hospital where I work, OTs are typically the first professionals that receive the referral to evaluate a patient's feeding and swallowing. And we screen the referrals for appropriateness and if appropriate, we'll complete an initial assessment of the patient's feeding and swallowing, including our motor exam and looking at diagnostic imaging, laboratory panels, speaking to family members or patients about
00:04:57
Speaker
any sort of issues that they've been having, those kinds of things. And then once we're done that, we get the opportunity to collaborate with the interdisciplinary team. And our team includes pharmacists and physicians, SLPs, nurses, dieticians, nurse practitioners.
00:05:16
Speaker
physical therapists, healthcare aides, and sometimes even social workers to ensure that our clients or patients receive optimal interventions and monitoring.
00:05:28
Speaker
I don't really think I realized the importance of an interdisciplinary approach to dysphagia until I'd been practicing in the area of dysphagia for several years, especially when I was in long-term care where you don't always have immediate and direct access to all the team members. I didn't necessarily understand the chain reaction that recommendations for dysphagia management could set off and the number of sort of professional treatment plans that it could affect.
00:05:56
Speaker
And so when I say that, when I started really reflecting on it, I pictured in my mind one of those cartoons where the character bends down to pick up like a quarter and their butt sort of inadvertently pushes over a column that's holding up a building, which sort of pushes over the next column, holding up the building and so on until the character turns around and realizes the whole building has now collapsed. And then they were like,
00:06:23
Speaker
Was that me? And it's funny, but I had a bit of a crisis of conscience once I realized that by changing a patient or a resident in long-term care setting where I was initially working, by changing their diet or changing something about the way that their meals were presented, I was also changing many other things for them. As an example, if I recommended thickened fluids or crushing meds,
00:06:49
Speaker
Nursing had more work to do to deliver meds and they needed to be more cognizant of what the patient or the residents are drinking. Many of our residents had cognitive impairments and so if they're thirsty, they'll go to their sink in their room and they'll take a drink of water. It really increased the work for our health care aides and our nursing staff.
00:07:09
Speaker
Also, learning things like thickened fluids can affect the bioavailability of some medications, and this can mean that pharmacy and the physicians need to change the dosing of medications. They might not work for our clients or our residents or our patients properly.
00:07:26
Speaker
Thickened fluids and a change in diet can also lead to patients or residents eating and drinking less. It can be a result of these things like being unfamiliar to them, having cognitive impairments and then being used to fluids that run pretty freely to things that are thickened. And if that happens, then the dieticians really need to look at different ways to ensure that our residents or patients or clients don't become malnourished and dehydrated.
00:07:50
Speaker
which can cause many other problems, but up to and including pneumonias and death. So changing dials can also, it just can affect the amount of time it takes for someone to eat a meal, which can mean that they miss some important physical therapy or rec therapy program and decreases their mobility and places them at risk for physical complications related to that. So there was just this whole sort of, I had this sort of aha moment where I was like, okay, whoa, wait a minute. I just thought I was picking up a quarter.
00:08:19
Speaker
but I felt a whole building. And so like I said, there was a bit of a crisis of conscience and that's when I really started to really pay attention to the importance of interdisciplinary collaboration and really bringing everybody into the fold as early as possible to ensure that the client wasn't negatively affected by decisions that I had made.
00:08:39
Speaker
Right, and you have touched on this a little bit in your answer, but I'm wondering if you can talk to us a little more about how swallow impacts function.
Swallowing and Life's Aspects
00:08:50
Speaker
I feel like we could talk about this for hours, even just looking at it on the surface for healthy individuals with no swallow dysfunction. Eating and drinking are safe and pleasurable and highly sociable activities. So eating and swallowing kind of not only meet our basic needs of nutrition and hydration, but they're also a large part of how we connect with one another and celebrate and mourn.
00:09:15
Speaker
And so many holidays are celebrated over food and beverages. And when individuals pass away, what do we do? We tend to bring the family food. We eat with them and we eat at the funeral and we talk about our fond memories of that person. We talk to our families and check in with our kids over the dinner table. I mean, I just, I think about as an OT wearing that OT hat, I have to say it. If we just look at the Canadian model of occupational performance and engagement, swallowing and eating really touches on
00:09:45
Speaker
many aspects of that, the physical, so nourishment, physical abilities, right? If you're malnourished, if you're weak, you lose things, you lose mobility. You can also lose some of your cognitive functioning. You can become hyponatremic. You can have other medical conditions. So if you can't eat, you can't swallow, if it's uncomfortable for you and you decide, I just would rather not, we know that there's going to be some problems for you down the line. There's social, there's spiritual, there's cultural.
00:10:13
Speaker
aspects and an argument can be made for even leisure and perhaps productivity if we can look at the aspect of food preparation, right? I mean often when we're preparing food we're really looking forward to eating it. So swallowing and sort of the sequelae of the experience of having an abnormal swallow can really be life altering from a functional perspective.
00:10:32
Speaker
Now you did say when you put your OT hat on, I'm curious, is your OT hat slightly different from your dysphagia therapist hat? Is it kind of the same hat with mixed in colors? No, I don't think so. I think it's interesting. I talk about my OT hat. I do think
00:10:53
Speaker
And I can't remember who told the story or how I remember this, but there's this sort of wise tale or this tale where there's these two young fish and they're hanging out in the lake. And there's this old fish that comes along and says, good morning, lads. The water's really, the water's really great today. And they're like, yeah.
00:11:15
Speaker
Thanks, old older man. And they look at each other and go, like, what the heck is water, right? And so I feel like the Canadian model of occupational performance and engagement is kind of my water. And I don't necessarily always acknowledge that it's just this part of who I am as a clinician. So whether I'm a dysphasia in that sort of realm of I'm a dysphasia therapist, I can't
00:11:44
Speaker
It's not mutually exclusive of me being an OT, and it shouldn't be, but I mean, certainly they do tend to sometimes make more of a delineation in the literature, and I would argue that.
00:11:56
Speaker
be one of the benefits of being part of an interdisciplinary team is that we all bring our own flavor to it. And so yeah, I mean, I think that's a good question. So no, I don't think I kind of delineate that in my mind. I think no matter what I'm doing, even if I'm assessing dysphagia, I'm also looking at what ciscline's fine motor skills look like. How can we facilitate the meeting independently? All of those things are always just in my mind, but they're my water. So I don't necessarily always concentrate on that.
00:12:24
Speaker
I really liked that metaphor. Thank you for sharing that. Yes. Well, I didn't make it up and I can't take credit for it, but I remember the story and I remember sort of thinking, I get it. Like I get what they mean by that. Throughout your 18 years of experience, what are some of the most common populations you've worked with and what kind of dysphagia problems have you encountered through the course of your practice?
Elderly Populations and Dysphagia
00:12:50
Speaker
The most common population that I've worked with
00:12:53
Speaker
hands down has been elderly individuals. We know that advanced age can lead to things like sarcopenia, so age-related muscle loss in oral motor structures, multiple medical conditions that lead to polypharmacy, right? And polypharmacy comes with kind of some of its own problems, like serostomia or dry mouth, dysarthria,
00:13:19
Speaker
can lead to things like tardive dyskinesias as well as thrush, which is like a yeast infection in the mouth that can extend down into the throat and into the esophagus and cause some major problems for us. Reduced immune system functions and changes in breathing and swallowing coordination, which is actually seen in normal aging. And it's really important in terms of our ability to close off our airway and kind of cleanly pass that bolus into our esophagus.
00:13:48
Speaker
as well as lower levels of ADL function that can lead to poor oral hygiene. And this can be exacerbated for our elderly population by living on fixed incomes and not being able to afford dental care, as well as just like a lack of access to dental care.
00:14:07
Speaker
in the 11 years that I worked in long-term care, I kind of digress, but I think maybe a handful of my residents saw a dentist. And that was just crazy to me because we know how important dental care and dental health is, too, that it's one of the number one predictors, actually, of the development of pneumonia. So I digress. I didn't know that. No, that's a fact. But I do feel, yeah. But I mean, it's kind of a digress message. I feel like we need to do better on this.
00:14:33
Speaker
I think we could probably actually prevent a large number of pneumonias in particular in long-term care residents just by getting them some dental care. But anyway, that's another soapbox that I regularly talk from. But the majority of the issues that I encounter in this population to answer your question are things like,
00:14:57
Speaker
seeing dysphagia at the end of meals just as a result of fatigue of the oral and the pharyngeal muscles from frequent swallowing and mastication because they have had that age-related sarcopenia or some muscle wasting, frequent chest infections because they're generally immunocompromised, where they have multiple medical conditions that lead to
00:15:23
Speaker
them not being able to fight off when they do aspirate. And we, we all aspirate. Um, we know this, we know that 50% of us aspirate when we're sleeping, but we don't develop pneumonia. So that's, that's a whole other discussion. Maybe we'll, we'll touch on it somewhere down the line here during the interview. And they're experiencing things like, like I talked about that Tardive dyskinesias or dry mouth or difficulty with articulation or thrush. And this all needs to be.
00:15:52
Speaker
This is all sort of the issues that we encounter that are leading to the problem of the dysphagia. And much of this we're assessing through oral motor exams, diagnostic tests, if they're available, like labs and imaging, and observation, like just looking into the oral cavity and really trying to get in there to see what's going on, which can be somewhat of a challenge for some of our more cognitively impaired clients.
00:16:18
Speaker
Can you tell us a little bit more about that assessment
Assessing Dysphagia
00:16:22
Speaker
process? It sounds like you're starting with observation, kind of looking to see what else is going on. Yeah, for sure. So, I mean, when we're doing any initial assessment, I think I kind of alluded to it previously, but we really want to look at our client's sort of dietary history. So, I mean, in a lot of places, right, with the sort of
00:16:47
Speaker
the electronic charting has been really nice because the nursing staff in most places will be charting how much clients are eating. And so we'll look at things like, has there been a change in their intake, right? Especially when we have clients and many of my clients, I would say 75% of my clients even in an acute care setting now have cognitive impairments. And so they have a difficult time sort of
00:17:11
Speaker
speaking about or articulating what their concerns are. So one of the ways that they tell us that there's a concern is they'll stop eating or they'll stop drinking or they'll get really anxious around those times. So we'll look at what's the trend in their diet. And of course the dieticians are awesome at looking at that. We'll look at things like weight. Have they had weight loss? We always start our assessment with a full oral motor exam. So we're looking at
00:17:36
Speaker
We're doing a quick cranial nerve screen to see that everything's working the way it should. The innervations seem to be appropriate. We're looking at the musculature. I also like to look at the coordination of the tongue within the oral cavity because we know that swallowing is a series of valves that really need to be opened and closed at very specific times.
00:18:02
Speaker
And if there's a discordination there, there's a leak in the system and that can often lead to issues with feeding and swallowing. I like to look at breast support because if individuals are having difficulty just breathing, they're going to have difficulty swallowing.
00:18:19
Speaker
And the reason for that is because we cannot breathe and swallow at the same time. And if you are working really hard to breathe, so if you're breathing in every second, we have a problem because it takes about two seconds from the time we put food or fluid in our mouths to the time that we actually swallow it. So if you're breathing in within a second of that, you're breathing something into your lungs typically.
00:18:43
Speaker
So I'd like to look at just their overall general health too, and then we actually will start presenting different foods, different fluids, different textures to see how the client responds. And can you tell us how you would confirm that someone has dysphagia?
00:19:00
Speaker
Yeah, that's an interesting question, isn't it? Right. Because I mean, uh, that's a huge question. When I was in long-term care, we didn't have access to the technology, including video fluoroscopic swallowing studies. Right. And that's the study where you take food and fluid that has barium. We actually take a video of the client swallowing it in an AP view. And we can see if a client aspirates.
00:19:30
Speaker
Now it's an interesting question because I've taken individuals to the video swallowing suite that we were pretty certain we're, we're aspirating based on some of the things that we picked up on our bedside assessment, which I can talk about in a couple of seconds here, as well as the fact that they, their chest status wasn't getting any better. So they continue to have chest infection, even though they were being treated.
00:19:58
Speaker
medically for it and they haven't aspirated at all. So sometimes it's that moment in time, they're doing better. They could have asked, they could have aspirated before, but they're not aspirating now. But really for me, when I'm, when I'm really questioning, okay, is this person aspirating and is this aspiration causing
00:20:22
Speaker
problems for them from a pulmonary perspective and a nutritional perspective. The types of things that I'm looking for and again like this is not an absolute, it's quite nuanced when you really sort of get into the thick of it, but you're looking to see are they really coughing and hacking every time they eat.
00:20:40
Speaker
are when are they coughing? If they have a baseline cough, then that's not really a great predictor. But if they're not really coughing and then they take a drink and they're just hacking, that's a pretty good indicator that something went down, as we say, the wrong tube, right? Because our body has definite defenses in terms of how to combat that. And one of those things is to cough to try to eject things out of our airway. Things like
00:21:07
Speaker
food being pocketed and lots of residue on the tongue. It's normal for us to have some residue, but if clients have a whole bunch of pocketing in their oral sulci, for example, or a whole bunch of residue on their tongue and then they fall asleep and they're breathing as they're sleeping, things are typically going to end up in their airway. I'm spoiled in that I have access to laboratory values, so we tend to
00:21:35
Speaker
really have a good look at and follow their white blood cell count. In particular, neutrophils are correlated, higher neutrophils are correlated with pneumonias and aspiration pneumonia currently in the literature. And that's a whole other topic as well that maybe we'll talk about a little bit I think when we get down to some of the other questions. And of course, just generally the overall oxygen status of the client.
00:22:04
Speaker
if they're eating and they're drinking and we have them on a regular diet and we're treating them medically with medication, antibiotics and steroids or whatever the physician has decided or the nurse practitioner is the appropriate approach and they don't get better and their oxygen demands continue to increase. So if they're on one liter of oxygen when we start to see them and now they're on five liters of oxygen, that to me also is indicative that, yeah, maybe something's going on, potentially the habit dysphagia.
00:22:34
Speaker
I hope that kind of answers the question. That really does. Thank you very much. The answer is it's complicated. It sounds like at least you have access to a lot of different tools that can inform your decision-making and practice. Absolutely. And I think I recognize coming from that long-term care perspective that we do not always have that. So I'm a little bit spoiled at this point.
00:23:01
Speaker
Now, can you speak a little about you've suspected dysphagia, you've gone through the assessment process and you've confirmed that someone has dysphagia.
Addressing Dysphagia Challenges
00:23:13
Speaker
How do you then begin to address that? Yeah. So how to address dysphagia is probably
00:23:22
Speaker
like the biggest question, right? I think what we need to do is really start with the assessment and get the data that you can in front of you. And then you really need to bring in the client and their caregivers or their family or the decision makers or all of them and really discuss the philosophy of care. Evidence-based practice requires us to incorporate the needs and the values of our patients and balances with the client's sort of swallowing safety.
00:23:51
Speaker
So often needs and values are nuanced and they're really multifaceted. And so the goal isn't always for the client or the client's decision maker based on what they feel the client would have wanted. The goal is not always, I want to avoid aspiration at all costs and I want to avoid the risk that I will develop a pneumonia in relation to that aspiration. Number one.
00:24:20
Speaker
We know that it will never be possible, even with tube feeding, in particular with tube feeding, actually, which is kind of a bit of a catch-22, but to avoid aspiration. And number two, considerations like quality of life, nutrition, hydration, and just satiety also need to be considered.
00:24:40
Speaker
So how do we address the dysphagia? What we do is we give them sort of the quantitative data that we have managed to gather, whether that be from the bedside, because I mean, I'm just going to be honest, in rural Alberta, it could take up to eight months for me if I really felt that somebody needed a video fluoroscopy.
00:25:01
Speaker
could take up to eight months before I could get a video for Roscopy. So what am I supposed to do? Say like, let's not feed this person for eight months. I mean, that's ridiculous. I'll kill them that way, right? Right. If I made that recommendation. So we have to really, we have this recommendation, this quantitative data that says we think
00:25:22
Speaker
that you are aspirating on thin fluids and we would like to thicken your fluids to whatever level or consistency we feel you can manage, right? And that's based on, when I was in rural Alberta, that was based on my bedside assessment. That was based on, okay, when I give you thin fluids, you're hacking like you're coughing up your lungs, right? When I give you mildly thick fluids or
00:25:48
Speaker
nectar thick fluids or whatever sort of system you're using to address the levels that you've thickened to, you don't. And you seem to be able to manage that. And when we put you on these fluids, we were able to treat your chest infection and you seem to get better and you haven't had another episode of a chest infection in eight months. So my best guess is that you were aspirating on the thin fluids and that was just causing
00:26:15
Speaker
you to be overloaded and you couldn't fight off the bacteria or what that was being washed down and you developed that pneumonia. Now that being said,
00:26:27
Speaker
We have this, what I would call sort of loosely quantitative because it's not a gold standard. It's not a video fluoroscopy. If we have a video fluoroscopy and we can show them right here, you can see, like we'll show our clients a video. This is your video. And as you can see, you are clearly aspirating this fluid and you can see it go down into the lungs. We'll show them that. But even then.
00:26:47
Speaker
Really addressing the dysphagia is a, it's a conversation. It's us presenting sort of the data and then the client or their decision maker guardian or whomever has that, that sort of right to make those decisions for the client. If they can't make decisions for themselves, it's about what are you, what's the philosophy of care? What are your goals of care? And for some of the clients, especially clients in long-term care, they're like.
00:27:17
Speaker
I've had somebody say death by chocolate. If I can't eat chocolate, I'd rather be dead. If I can't eat ice cream, I might as well not go on living.
00:27:28
Speaker
Okay, doesn't get any more clear than that. Yeah, exactly. So when you're working with your interdisciplinary team to address this eating, feeding, and swallowing, how do you leverage each other's skill sets to meet the client or the resident's goals of care?
00:27:51
Speaker
I think having the opportunity to touch base every morning at rounds, like in my current setting with the InterD team is huge. And like I keep saying, I realize coming from that long-term care background where we just didn't have the opportunity for many different reasons, that I'm super spoiled in this regard. But I would say that sort of meeting every morning gives us the opportunity to check in on our patients.
00:28:14
Speaker
all of them, of course, not just the ones with dysphagia, and what challenges relating to their dysphagia that they're facing, and really problem solve. It can be something as simple as, yeah, they've been on thickened fluids for five days, and we're noticing that their tremors are coming back. And then the pharmacist and the physician are like, well, maybe it's a bioavailability problem. Maybe we need to look at the dosing of their medication.
00:28:40
Speaker
But even professionals that you may not expect to be deeply involved in dysphagia management, they will contribute meaningfully to the team. An example would be our social worker might help with funding for thickeners on discharge. A lot of people like, I can't afford this.
00:28:58
Speaker
or they may help with on-demand sort of meals, things like, I'm not exactly sure, but meals on wheels or sage meals or heart to home that can sometimes provide modified texture type meals. And they may be able to help with different funding options and things for that for our clients.
00:29:16
Speaker
Transition coordinators can assist us with ensuring that there's a continuation of care when patients are discharged. And these are like incredibly important and practical pieces of dysphagia management, that having the interdisciplinary team right there really makes a difference. Even when we're managing individuals with acute chest infections, our physio is a huge resource through some of their pulmonary exercises and the mobility stuff.
00:29:42
Speaker
We know that getting people up and moving really helps with facilitate that mucociliary exhalated escalator helps clear the lungs. It's that idea that our main goal is to help our clients be well again, whatever that means for them, and to help them get to where they need to go out of the hospital.
COVID-19 and Dysphagia
00:30:04
Speaker
Okay, now shifting gears a little bit, I'm curious to know what your observations about how a COVID and possibly a long COVID diagnosis might have impacted feeding and swallowing in the patients that you've worked with recently.
00:30:22
Speaker
There's some current evidence on COVID-19 associated oropharyngeal dysphagia that's showing that like neuro neurologic complications, including things like myopathy, so affecting the muscles that control voluntary movement and poly neuropathy. So where many
00:30:42
Speaker
nerves in different parts of the body are involved in patients with COVID-19 are linked to damage of the swallowing neural network. So we have some sort of research that's like evolving, like just coming out.
00:30:57
Speaker
There's changes in the efficiency often in these clients of the normal breathing and swallowing pattern. So we had that discussion about how we can't breathe and swallow at the same time. The most common normal breathing and swallowing pattern is for us to exhale, swallow, and then exhale. Of course, that's our body's way of protecting. So we're exhaling after the swallow because if we have anything left in there, we don't want to take a nice deep breath in and suck it all into our lungs.
00:31:25
Speaker
And there's definitely some research out there that suggests that swallowing pattern, that normal breathing and swallowing pattern due to the pulmonary complications associated with COVID will make eating exhausting and challenging for some clients. I've had clients say that they experience coughing and breathlessness during eating and drinking to the point where, again, it affects their sort of drive to even do those things because they feel that it just sucks all of their energy.
00:31:55
Speaker
And how do I do other things? The biggest complication that I've seen because at the hospital, the mat, we have a, we have an ICU has been complications that we've been aware of for a long time that are associated with endotracheal tubes and tracheostomies. Of course, endotracheal tubes we know can lead to oral and laryngeal trauma, which in turn makes it really difficult for clients to swallow.
00:32:23
Speaker
because we've sort of damaged the structures that are required to do that. Currently, I'd say we're really treating all of these complications the same way that we would treat them when they're the result of other conditions. So the myopathy, the polyneuropathy is the disruption in swallowing and breathing patterns. We see these things in other neurological diseases, chronic obstructive pulmonary disease is an example for
00:32:53
Speaker
a lot of clients that have issues with the swallowing breathing patterns.
00:32:57
Speaker
But I wouldn't say we're doing anything new currently to approach it, but trying to stay on top of it. And perhaps some new treatment ideas are in the works or will come of this. Perhaps someone with more time than me is looking into if there's better ways to treat these. But really, we're really using a lot of the research that we already have established, because many of these complications are complications of other conditions.
00:33:23
Speaker
I can imagine it's rarely just one thing causing the dysphagia. It's a domino effect, it sounds like. That's right, yeah.
Policy Development and Collaboration
00:33:34
Speaker
I'm wondering if you can speak a bit about your work developing policies and procedures specific to feeding and swallowing assessment and how this maybe has impacted the landscape for OTs practicing in this area. It's not as glamorous as it sounds. Really, it's been consultation for anybody familiar with ConnectCare. When ConnectCare first came out, there was a real sort of concentration on the use of a part of the system called flow sheets.
00:34:02
Speaker
And so it was really more initially about what do we put in the flow sheets? What do we put under oral MAC exam? So what are our constructs there and what should we name it so that everybody understands what that is. And then as Connect Care rolled out,
00:34:19
Speaker
There was a question of could we as occupational therapists, could we do orders? Could we change diet orders? There was a consultation about if we can or we can't. So I actually consulted the college, the Alberta College of Occupational Therapists to see what our role was in that and found out that yes, it was in our scope of practice as long as we are competent in the area.
00:34:45
Speaker
And then they came back to what constitutes competency in that area and some of the things about that. And they have a really good position statement on the OT's role of feeding and swallowing on the ACOT website. And it's been updated to reflect some of the questions I think that we brought forward to them. So it was about how do we communicate our recommendations? Because once we had a way of documenting them, we also had to have a way of communicating them.
00:35:13
Speaker
via our charting. And so it was really about that. So it's not, like I said, as glamorous as it sounds, but it was about sort of the practicalities of how do we ensure that everybody is on the same page with the terminology and how do we ensure that
00:35:28
Speaker
we're all following the same policies and procedures. And of course, I guess I just have to state the caveat is even though the Alberta College of Occupational Therapists states that we can make those diet orders, different institutions or different health conglomerates just may have different policies and procedures about that. So you have to make sure to check on that. I work with NHS and that's something that we are permitted to do.
00:35:52
Speaker
Thank you for clarifying. And as you were going through that process of streamlining things, was that interdisciplinary as well? Absolutely. Of course, the dieticians were really involved because there were sites that were using different vocabulary for the different levels of thickened fluid. So some people were using level one, level two, level three, some people were using
00:36:18
Speaker
nectar honey pudding. Some people were using mildly thick, moderately thick, and extremely thick. So we all had to come together and as well as of course the SLPs and really say what are the operational definitions, so to speak, of what we're doing here. And so we all had to come and agree on what the terms were going to be and what they
Promoting Dysphagia Workshop
00:36:43
Speaker
meant.
00:36:43
Speaker
Besides registering for your interdisciplinary adult dysphagia workshop through SAOT, for those listening at home, there are online live sessions happening on November 18th and December 1st. Where would be the best place for therapists to start if they're seeking additional education in this area?
00:37:07
Speaker
Definitely, I would say mentorship. I'd say find an SLP, find an OT that has experience in these areas. I mentor when we get new staff and new graduates and students from the university. I mentor them. I think also that's been, for me, that's been the most meaningful, the most meaningful learning tool is the mentorship that I've gotten. And I wish I could shout out and name all of the
00:37:35
Speaker
amazing mentors I've had, but that would take a long time. And I know we only have so much time. But I think mentorship is very, very important. I think reading and critically thinking about current dysphagia research articles. So obviously there is a journal dysphagia, which I tend to peruse pretty regularly, but there's others. And I think
00:38:01
Speaker
The piece that I want to highlight is critically think about those research articles because I would say when I was a new grad, I was like, great. I would read a research paper and I'd be like, yes, this is gospel and I'm going to apply it just as exactly as they've said it. And I've really come to understand that.
00:38:20
Speaker
It's really not that way. One of the best examples of that is the use of the term aspiration ammonia. There's really no operational definition of what aspiration ammonia means. And not even radiologists, if you talk to them, can really describe, how do you know when you say on here that it's suggestive of an aspiration ammonia? How do you know that? And they're like, well, we don't really know. And so that's really a whole interesting topic that
00:38:46
Speaker
I could talk about that in particular for probably three hours. So 50% of normal healthy adults aspirate while they sleep and we don't develop aspiration pneumonia.
00:38:58
Speaker
Why is this? And when you really take a look at the research, the terms pneumonia and aspiration pneumonia are often really used to mean the same thing, but there are many different types of pneumonia and many of them aren't related to aspiration. And there's good research out there that suggests that radiologists diagnosing like any type of pneumonia with about a sensitivity of 69% on chest X-ray.
00:39:22
Speaker
And they don't really have an idea of what caused this pneumonia. So they'll say it's suggestive of an aspiration pneumonia, but we don't know. It used to be thought that pneumonia is in the gravity dependent lower lobe.
00:39:34
Speaker
were indicative of aspiration ammonia, but they've also found that that might not be the case. So it's really interesting because there's been many, many articles that talk about aspiration ammonia, one of the most famous being Langmore et al in 1998.
00:39:54
Speaker
They published an article that is widely, widely cited. I see it everywhere. It was a well done study. It was called Predictors of Aspiration Ammonia, How Important is Dysphasia? It was one of those things that really honestly just altered the landscape of what it meant to work in dysphagia because it basically went on to say that the best predictors
00:40:22
Speaker
of aspiration pneumonia weren't really aspiration. It was individuals being dependent for feeding, dependent for oral care like we talked about, the number of decaying teeth they had, if they were tube fed, and if they had more than one medical diagnosis, they were on a number of medications or if they smoked.
00:40:42
Speaker
Like aspiration wasn't even on the list. I always kind of raise my eyes brow a little bit when I read aspiration ammonia, because the fact of the matter is I don't think we're really good at defining what that is, which makes it really difficult when your initial training, and we have to start somewhere, is aspiration is the enemy. Aspiration is, and now the question is like, what is the enemy?
00:41:07
Speaker
Right. And so I think one of the things you will find and individuals who are really delving into and decide to take the dive and go down the rabbit hole with dysphagia is that the more you learn
00:41:26
Speaker
the less you know, and that's okay because at the end of the day, my advice when it starts to feel overwhelming, which often it does for my mentees and myself, is we have to do the best we can with the information that we have. We're clinicians, right?
00:41:45
Speaker
I could go on, but we have to read research articles critically and not think that just because it's published, that all of it is necessarily true. And we also have to be careful of what we read. I've had articles that I've read and individuals have made statements in it and referenced other articles. And then I've gone to the other article that they've referenced and I've been like, that's not what this article says at all.
00:42:13
Speaker
Do you know what I mean? Right. Yeah. And so they interpreted this completely different from the way that I'm interpreting it. And so, yeah, we have to be critical, but it's what we have. Current research, you want to look for RTCs, these types of things, but you also have to understand that clinically randomized control trials are the gold standard for
00:42:34
Speaker
for research, of course, but in a clinical situation, you don't get this perfect inclusion and exclusion criteria that we need to use in randomized control trials. And so we have to be really mindful. And sometimes I'll read research and they'll do things like
00:42:52
Speaker
We had a bunch of people on Optiflow, for example, which is a type of breathing assistance that's not a tracheotomy, like an endotracheal tube or a tracheotomy. So it's kind of like a step before we look at doing those things before, not me, I don't make those decisions, but before the physicians look at doing those things. And they'll say, you can feed people when they're on
00:43:15
Speaker
this apparatus is breathing assist apparatus and i'll look at the research and i'll go they did this research on like healthy thirty five year old men. These are not the patients that i have that are on.
00:43:29
Speaker
Optiflow. I don't have a healthy 35-year-old man in an ICU bed on Optiflow. So yes, potentially healthy 35-year-olds can overcome some of the limitations that being on Optiflow impose. But that's not my client or that's not my patient. Thank you for sharing your thoughts on rigorously reviewing
00:43:58
Speaker
papers that we are reading. No problem. I have a couple of other recommendations though that are kind of more fun. Okay. And then I'll leave you. Perfect. Like I said, I could honestly love dysphagia. I could talk about it for hours, so you don't want to get me started. But anyway, I really love to like peruse. There's a couple of sites, dysphagiacafe.com is one, swallowstudy.com.
00:44:21
Speaker
is another and dysphagiarambulance.com. Those are really great. I'm kind of a geek and I just like to read them in my spare time. So there's sort of, there are a lot of like opinion pieces, but they're written by
00:44:35
Speaker
frontline clinicians, summer researchers, and they're referencing research and sometimes they're critiquing it, which is also nice to see. There's also some really good textbooks out there about interdisciplinary dysphagia teams, although many of them come out of the States where the SLP is much more involved than the OT for various reasons. And so I always read them sort of, I kind of look at them when I'm reading them as SLP and OT being interchangeable.
00:45:02
Speaker
Great. That's a great tip. Thank you. And for the folks listening at home, what would be the best way for them to connect with you online if they'd like to chat further?
Contact Information and Personal Note
00:45:16
Speaker
Well, I don't do social media at all.
00:45:20
Speaker
Yeah. So I think I have, they could contact me. I have an email address that I use for some of the education that I provide and it's incpenotedconsultingatgmail.com. Perfect. Thank you. And I don't check it all the time, but I certainly will try to get back to individuals and answer questions as they come up for people.
00:45:49
Speaker
Now, because we've spent so much time talking about feeding and swallowing, I have to know what your favorite food is. Oh, pizza. I love pizza. I just, yeah. No hesitation. No, no hesitation. One food for the rest of my life, it would be pizza. Okay. And what food do you absolutely hate? Oh. Oh.
00:46:15
Speaker
I know my partner is Portuguese and he likes sardines and I don't like sardines. And it's like a big thing in Portugal, sardines. And I'm like, no, I can't do it. So definitely sardines. Okay, perfect. Well, thank you so much for your time and energy. It's been a delight getting to know more about you and this specialized area of OT practice. I know our listeners will find a ton of value.
00:46:44
Speaker
in the thoughts you shared about the importance of interdisciplinary practice and also critical thinking when reading research articles among others. So thank you so much for your time this evening. We really appreciate it. Thanks for having me.