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Modified Mondays: A Match Made in Instrumental Assessment

Updated: Dec 19, 2022

A few weeks ago, we discussed the use of the chin tuck with caveats on why it really needs to be assessed during an instrumental for effectiveness. This week’s video is another great example of the need for a strategy, recommendation or maneuver to match the physiology, with bonus highlighting on inconsistent cough response.

The patient presented clinically with immediate cough and “delayed swallow” with thin and nectar, and “no cough” with pudding thick liquids. Pudding thick with large bites was subsequently recommended, with the assumption that since the larger, more dense bolus was not resulting in a cough, the deficit was impaired sensation resulting in a delayed swallow onset. The patient subsequently developed significant constipation, dehydration, and a UTI-all potentially complications of the thickened liquid recommendation.

In this clip, we see a tsp of thin, 2 presentations of tsp of nectar, and a tsp of pudding. We can see that the patient’s physiological impairment is actually incomplete airway closure and base of tongue retraction, with a fair amount of residue in the valleculae that increases with the pudding. Furthermore, the patient demonstrated no cough with the aspiration of nectar or pudding, despite the strong cough with thin-even though aspiration was present on all consistencies. In this case, the strategy of larger, more dense bolus types was not indicated for this patient-even though “on paper” it might have made sense. We really cannot adequately assess physiology clinically-period. Because of this, we also really cannot adequately recommend strategies based on clinical assessment only.

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