This is a Modified Barium Swallow Study (MBSS) report for a patient with oropharyngeal dysphagia that I worked with at Salinas Valley Health. The patient supported my learning in instrumental assessment, patient education, and dysphagia management. I used the Modified Barium Swallow Impairment Profile, Penetration Aspiration Scale, and Dynamic Imaging Grade of Swallowing Toxicity to categorize this patient's swallow (Martin-Harris et al., 2008; Rosenbek et al., 1996; Hutcheson et al., 2017). I recommended this patient participate in Expiratory Muscle Strength Training (EMST) to improve cough intensity and airway protection, and chin tuck against resistance (CTAR) to support pharyngeal swallow function (Kim et al., 2009; Park et al., 2021). I also considered the impact of a modified diet on their quality of life, with an understanding that the patient was considering hospice care (Smith et al., 2022; O'Keeffe, 2018). I believe that educating the patient on the results and recommendations of this study were important in supporting informed decision making. 

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Kim, J., Davenport, P., & Sapienza, C. (2009). Effect of expiratory muscle strength training on elderly cough function. Archives of Gerontology and Geriatrics, 48(3), 361–366. https://doi.org/10.1016/j.archger.2008.03.006

O'Keeffe S. T. (2018). Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified?. BMC geriatrics, 18(1), 167. https://doi.org/10.1186/s12877-018-0839-7

Park, J. S., & Hwang, N. K. (2021). Chin tuck against resistance exercise for dysphagia rehabilitation: A systematic review. Journal of oral rehabilitation, 48(8), 968–977. https://doi.org/10.1111/joor.13181

This is an oropharyngeal dysphagia treatment note for a patient I worked with at Salinas Valley Health. This patient contributed to my learning in dysphagia management and the SLP role in cough function. The patient performed EMST to improve maximum expiratory pressure and voluntary cough outcomes for improved airway protection (Baker, Davenport, & Sapienza, 2005; Pitts et al., 2009 as cited in Hegland and Sapienza, 2013). The patient also participated in effortful swallows to promote increased oral, pharyngeal, and esophageal pressures (Bahia & Lowell, 2020). In addition, she utilized principles of neuroplasticity through participation in spontaneous swallows (Bice & Galek, 2016). Ultimately, the patient was showing improvements with the implemented treatment plan. 

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Bahia, M. M., & Lowell, S. Y. (2020). A Systematic Review of the Physiological Effects of the Effortful Swallow Maneuver in Adults With Normal and Disordered Swallowing. American Journal of Speech-language Pathology, 29(3), 1655–1673. https://doi.org/10.1044/2020_ajslp-19-00132

Baker, S., Davenport, P., & Sapienza, C. (2005). Examination of strength training and detraining effects in expiratory muscles. Journal of speech, language, and hearing research: JSLHR, 48(6), 1325–1333. https://doi.org/10.1044/1092-4388(2005/092)

Bice, E., & Galek, K. E. (2016). The Use of Neuroplastic Principles Affects the Swallow Motor Plan of a Patient in Severe Cognitive Decline: A Case Study. Perspectives of the ASHA Special Interest Groups, 1(15), 79–83. https://doi.org/10.1044/persp1.sig15.79

Hegland, K., & Sapienza, C. (2013). SLP’s Role in Evaluation and Treatment of Cough Function. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 22(3), 85–93. https://doi.org/10.1044/sasd22.3.85  

This is a written case study for a patient I worked with at Salinas Valley Health, who is also featured in counseling artifact 1. This patient was treated for a profound pharyngeal dysphagia following a Myasthenia Gravis (MG) exacerbation that resulted in acute hypoxic respiratory failure and a 7-day intubation. MG is an autoimmune disorder that can be exacerbated by infection and is difficult to manage as it is often associated with respiratory failure (Rodrigues et al., 2022; Weiner et al., 1998). I was a part of this patient's 31-day hospitalization in which he participated in various dysphagia impairment targeted exercises. He was also placed on the free water protocol to support hydration and quality of life (Panther, 2005). He participated in EMST to improve cough and respiratory function, with careful consideration for the risk of muscle exacerbation and dyspnea because of his MG (Hegland & Sapienza, 2013; Weiner et al., 1998). Following treatment, his cough strength measured via Peak Expiratory Flow Rate (PEFR) increased from 160 L/min to 270 L/min and his Maximum Expiratory Pressure increased from 12 cm H20 to 20 cm H20. His final instrumental study revealed improvements in hyolaryngeal excursion, pharyngeal stripping wave, and ability to eject aspirated material. Unfortunately, he re-aspirated the material and was not safe for oral intake. I attended this patient's palliative care meeting, where he was presented with various long-term care options. He elected to receive a percutaneous endoscopic gastrostomy (PEG) tube and transfer to a skilled nursing facility. This experience taught me a lot about MG, dysphagia management, family involvement, and multidisciplinary practice. This patient supported my learning in various areas and greatly motivated me to pursue a career in acute care. 

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Hegland, K., & Sapienza, C. (2013). SLP’s role in evaluation and treatment of cough function. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 22(3), 85–93. https://doi.org/10.1044/sasd22.3.85

Panther, K. (2005). The Frazier Free Water Protocol. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 14(1), 4–9. https://doi.org/10.1044/sasd14.1.4

Rodrigues, C. L., de Freitas, H. C., Lima, P. R. O., de Oliveira Junior, P. H., Fernandes, J. M. A., D'Almeida, J. A. C., & Nóbrega, P. R. (2022). Myasthenia gravis exacerbation and myasthenic crisis associated with COVID-19: case series and literature review. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology, 43(4), 2271–2276. https://doi.org/10.1007/s10072-021-05823-w

Weiner, P., Gross, D., Meiner, Z., Ganem, R., Weiner, M., Zamir, D., & Rabner, M. (1998). Respiratory muscle training in patients with moderate to severe myasthenia gravis. The Canadian journal of neurological sciences. 25(3), 236–241. https://doi.org/10.1017/s0317167100034077

I participated in a flexible endoscopic evaluation of swallowing (FEES) elective course that benefitted my learning in dysphagia evaluation. This experience aided in my understanding of swallowing anatomy and function. I completed 10 passes on both a mannequin and my peers. Below, you will find a few pictures of this experience. I still need 15 passes under the supervision of an otolaryngologist and written verification of my competency to perform the procedure before I can independently implement this skill into my practice. As I progress in my career, I plan to complete this requirement and continue my education in FEES interpretation. 

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