Art of the Chart Review - GSHA 2020, Kara A

Art of the Chart Review - GSHA 2020, Kara A. 2/5/2021 Jones, M.A. CCC-SLP

DISCLOSURES

• Financial: Kara is an employee of the WellStar Health System. THE ART OF THE CHART REVIEW • Non-Financial: Kara is President of the Georgia Speech Language Hearing Association.

Efficiently Examining the Chart for Patients with Dysphagia Kara A. Jones, M.A CCC-SLP GSHA 2021 Convention

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WHY IS A THOROUGH CHART WHAT IS A CHART REVIEW? REVIEW SO IMPORTANT?

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AGENDA

1. Common Medical Diagnoses and Dysphagia 2. Lab Values 3. Vitals 4. Common Medical Imaging 5. Medical Interventions 6. Chart Review Case Study 7. Q&A

https://1drv.ms/w/s!AiN26_2p9CiDk CrNEmw2jZUkeAi1?e=x4hHVV

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1 Art of the Chart Review - GSHA 2020, Kara A. 2/5/2021 Jones, M.A. CCC-SLP

COMMON MEDICAL DIAGNOSES

Associated with Dysphagia

• Altman et al 2010

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RESPIRATORY FAILURE/ ARDS STROKE/ TBI

• CHF • 8.1–80 % of stroke patients (Takizawa et al 2016) • 27–30 % of TBI patients (Takizawa et al 2016) • COPD • Lesion Location (Daniels & Foundas, 1999) • And of course, Covid-19 • Anterior to central sulci > aspiration • Posterior to central sulci < aspiration • Large vessels > aspiration Coelho, 1987; Coyle 2010; Namasivayam-MacDonald • Small vessels/deep white matter < aspiration et al 2020; Takizawa et al 2016; Vergara et al 2020 • Brainstem, motor cortex, somatosensory cortex , insula, paraventricular white matter ( Daniels & Huckabee, 2014) Martino et al 2005

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COMMON SURGERIES TRAUMA ASSOCIATED WITH DYSPHAGIA

• Note the cause of trauma and relevant • Injuries sustained in Head & Neck • Surgical Interventions for Hip injuries in your Relevant History • Facial & Nasal fractures Fractures • Causes: • Cervical Spine fractures (Abel et al 2004) • Love et al 2013 • Multi-trauma from motor vehicle collisions, • Injuries sustained • ACDF/ Cervical Spine Fusion pedestrian versus auto • Pneumothorax, Rib Fx • Ground level falls • Liu et al 2017 • Hip fractures (Love et al 2013) • Fall from heights, stairs • Wired Jaw, ORIF Mandible • Gun shot wounds • Mechanical Thrombectomy, • Suicide attempts Craniotomy, Aneurysm clipping • Dunn & Rumbach 2019

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COMMON SURGERIES ASSOCIATED WITH DYSPHAGIA HEAD & NECK CANCER, OTHER CANCERS

• CEA • Kakisis et al 2017 • Site of lesion • Lung resection, Lung • Site of resection transplant • Effects of radiation treatment • Hales, P. & Mossy- Gaston, C. (2016) • Effects of Chemotherapy • Laryngectomy • Landera et al 2010 Hedstrom et al 2018, Ihara et al 2018 • Glossectomy • Jodi et al 2013

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OTHER DX

• PD • Tazikawa et al 2016; Altman et al 2010 LABS • UTI • Altman et al 2010 • weak association data for UTI + delirium in elderly (Balogun et al) & Dysphagia • Dementia • Alagiakrishnan et al 2013 • Pneumonia (HAP, CAP, Aspiration) • Siegel 2003, Tazikawa et al 2016

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LABS OVERVIEW

• CBC w/ Diff • Comprehensive Metabolic Panel • Procalcitonin • ProBNP • Labs to identify diseases from samples (sputum, urine, nasal swab)

Mills & Ashford, 2008; Pagana & Pagana, 2018

Mills & Ashford, 2008

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CBC W/ DIFF CBC + DIFF

• WBC Count • Platelet • Absolute Baso • WBC aka Leukocytes: • RBC Count • MPV • % Immature Granulocytes • Increased WBC (>10) indicates infection, inflammation, tissue necrosis or leukemic neoplasia. • HGB • Absolute immature • % Neutrophils granulocytes • Low WBC (<4) can occur w/ bone marrow failure (e.g., following chemo/rad tx, • Hematocrit • % Lymphs autoimmune diseases, dietary deficiencies) • Absolute neutrophils • MCV • % Monos • Serial draws will tell us trends • Absolute Lymphs • MCH • % EOS • Absolute Monos • MCHC • % BASO Pagana & Pagana, 2018; Mills & Ashford, 2008 • Absolute EOS • RDW • NRBCS

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• H&H CBC + DIFF • Hematocrit/ Hct • Critical High .65 • Critical Low .21 • WBC fight infection CBC + DIFF • Values decreased in elderly • Neutrophils exist in the blood only 6 hours, a sign of acute infection • Kill & digest bacteria • Hemoglobin/ HGB “phaygocytosis” • Critical High: 21 • Critical Low: 7

Pagana & Pagana, 2018; Mills & Pagana & Pagana 2018; Mills & Ashford, 2008 Ashford 2008

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COMPREHENSIVE METABOLIC PANEL SODIUM, POTASSIUM, CHLORIDE

• Sodium • Protein • Globulin • Electrolytes : overall hydration status • Potassium • Albumin • Anion Gap • Chloride • Calcium • GFR Sodium: • CO2 • Bilirubin • Normal: 136-145 mmoll/L • Glucose • Alkaline Phos • Critical High >160, Hypernatremia • Critical Low <120, Hyponatremia • BUN • AST • Creatinine • ALT Pagana & Pagana 2018; Mills & Ashford 2008

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PROTEIN, ALBUMIN, GLOBULIN BRAIN NATRIURETIC PEPTIDES

• Nutritional status markers • Albumin: • Closely tied to hydration status • Hypoalbuminemia • “ProBNP” • Associated with immune system • <3.5 • Identify patients with CHF - BNP correlates with left ventricular pressures • Associated w/ muscle loss • Refer to your health system for normative values • Prognostic factor for mortality Pagana & Pagana 2018 Cabrizeo et al 2015; Mills & Ashford, 2008; Pagana & Pagana, 2018

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UA, SPUTUM SAMPLE, VIRUS TESTING PROCALCITONIN

• Urinalysis (UA) • Used as marker for infection, especially bacterial • Sputum Sample Christ-Crain (2005) • Covid-19 testing

Pagana & Pagana, 2018

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ABG ABG

Critical Values: pH: <7.25, >7.6 PCO2: <20, >60 HCO3-: <10, >40 PO2: <40 O2 Saturation: 75% or lower Base/Excess: +/-3

Pagana & Pagana, 2018

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HEART RATE

• Normal Heart Rate: 60-100 beats per VITAL SIGNS minute (Sauer, n.d.) • Tachycardia • Bradycardia

& Dysphagia

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OXYGEN SATURATION – PULSE RESPIRATORY RATE OXIMETRY

• Normal Range: 95% – 100% • Normal Respiratory Rate 14-20 • Regarding work of breathing – Breaths/minute DiapHRaGM: • Under 90% is low – 75% critically low • Coyle (2010) RR > 30 may reduce • diaphoresis • Be mindful of wave form patient's ability to coordinate breathing • hypoxia • Consider oxygen delivery methods and swallowing • respiratory rate • Elevated CO2 can falsely elevated O2 • Again, be mindful of oxygen delivery • gasping Pagana & Pagana, 2018; Namasivayam- • accessory muscle MacDonald et al 2020; Britton et al 2018 Tulamiat (2017) DESATURATION DURING PO INTAKE IS NOT AN INDICATOR OF ASPIRATION

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BLOOD PRESSURE, MAP TEMPERATURE

Normal Ranges: • Normal Range: 37 °C (98.6 °F) – can vary by 1 °C • Systolic (Top) <120 • Fever: 38.3 °C or higher (100.9 °F) • Diastolic (Bottom) <80 Walter et al 2016

• Hypotensive • Hypertensive

• Mean Arterial Pressure (MAP) ≥ 65 mm Hg (Bonsall, 2001)

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REVIEW IMAGING REPORTS

• Check for surgical changes, abnormalities or fractures at head and neck (CT facial, COMMON MEDICAL IMAGING CT soft tissue of neck, CT of Cervical Spine) • Brain Imaging (MRI, CT, CT Perfusion)

& Dysphagia • Lungs (Chest X-Ray, CT of Chest, Bronchoscopy) • GI (Barium Swallow, EGD, CT abdomen/pelvis)

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CT ABDOMEN & CHEST X-RAY CT CHEST PELVIS

• Pagana & Pagana, 2018 • Review for abnormalities in GI system • More detailed/ sensitive than CXR that could be root cause of dysphagia • Coyle, 2010 • Perforation, tumors, inflammatory bowel disease, diverticulitis Images – theradiologistpage on IG

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CERVICAL SPINE/ SOFT FACIAL BONES TISSUES OF NECK

• CT or X-Ray • X-ray or CT

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MEDICATIONS THAT EFFECT THE CNS

• Psychosis • Sample Side Effects: MEDICAL INTERVENTIONS: • Depression • Xerostomia • Anxiety/Insomnia • slowed GI motility, constipation MEDICATIONS • Tardive dyskinesia • Seizures • Sedation • Pain • Decreased concentration • Bipolar Disorder & Dysphagia • Nausea/vomiting, decreased appetite • Parkinson’s Disease • Weakness • Alzheimer’s Disease • Pharyngeal and cricopharyngeal disfunction Carl & Johnson, 2006

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MEDICATIONS THAT EFFECT TASTE

Carl & Johnson, 2006 Carl & Johnson, 2006

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MEDICATIONS THAT MEDICATIONS THAT EFFECT TASTE EFFECT TASTE

Carl & Johnson, 2006

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LINES & DRAINS

• EVD MEDICAL INTERVENTIONS: • Chest Tube • Wounds with drains LINES, DRAINS & AIRWAYS • Feeding tubes • IV, PICC, Art line

& Dysphagia

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• Note oxygen delivery and flow rate/FiO2 • Mechanical Ventilation • Nasal Cannula & Flow rate • Vapotherm / Heated High Flow Nasal Cannula • BiPAP AIRWAYS & OXYGEN DELIVERY • Non Rebreather • History of endotracheal intubation

where have we been, where are we now and • Presence of tracheostomy tube where might we be headed…

Malandraki et al 2019; Namasivayam- MacDonald et al 2020

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PULMONARY INTERVENTIONS

• Paracentesis, Thoracentesis • NIV –Vapotherm MEDICAL INTERVENTIONS: • Increased nasopharyngeal pressures CURRENT NUTRITIONAL INTAKE • “It behooves the clinician to gain as much knowledge as possible regarding their diagnoses, respiratory condition, and swallowing physiology throughout the assessment process. Utilizing instrumental swallowing measures and placing the findings within the patient’s medical, but most importantly, respiratory context is necessary in light of this relatively unchartered territory” (Coghlan & Skoretz, 2017)

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9 Art of the Chart Review - GSHA 2020, Kara A. 2/5/2021 Jones, M.A. CCC-SLP

CURRENT NUTRITION STATUS

• NPO awaiting swallowing evaluation by SLP • Use of PEG, NG, etc CASE STUDY • TPN/PPN

• Prior level and reported weight loss/ poor intake/ failure to thrive ChartReviewTemplate.docx

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• Surgeries/Procedures completed during stay: CASE STUDY • Facial Laceration repair-Right face, Lip, left lateral neck (12/31/20) • Neck Laceration/ s/p Neck Exp (12/31) • EVD (1/2/20, now removed) • HPI: 24M arrives via EMS with cervical collar in place • ORIF R Talus and humerus with medial malleolus ORIF 1/1/20 and with backboard spinal • Past Medical History: Unable to precautions. Patient is altered and obtain • ORIF t transverse posterior wall acetabular fracture 1/5 cannot participate in questioning. • Past Surgical History: Unable to Per report he sustained numerous obtain • ORIF symphysis 1/5 injuries in single vehicle MVC. He was unresponsive on scene, GCS 3. • Medications: Unable to obtain • ORIF left iliac wing 1/5 An iGEL airway device was placed in • Allergies: Unable to obtain the field. No drugs were given. Upon arrival, iGEL replaced with ETT. • Social History: Unable to obtain Large laceration to anterior neck. Deformities to right ankle and right • Family History: Unable to obtain humerus.

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• Lines, Drains, Airways • Medical Diagnoses during course of stay • IV, Central Line • ETOH w/d • Pulmonary Status • Rhabdomyolysis • Orally intubated 14 days, extubated yesterday • Respiratory failure • Aspiration Pneumonia: Klebsiella pneumoniae/ Pseudomonas • Now on 2 L NC aeruginosa + fever • Pneumonia while on vent • Severe TBI (frontal Lobe Contusion injury) • Current nutritional status • OG tube was pulled when patient extubated. Patient is NPO with no source of nutrition, pending SLP eval • Hemodynamic Parameters: Keep < 130 and MAP > 65

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EXAM: CT FACE WITHOUT IV CONTRAST EXAM: CT HEAD WITHOUT IV CONTRAST TECHNIQUE: CT scan of the face with multiplanar reformatted images generated from the data set without IV contrast. Dose reduction TECHNIQUE: CT scan of the head with multiplanar reformatted images generated from the data set without IV contrast. techniques were utilized. Dose reduction techniques were employed. COMPARISON: None available. COMPARISON: None available. FINDINGS: There are comminuted depressed fractures of the anterior and posterolateral walls of the right maxillary sinus, retroantral fat has herniated through the posterolateral wall defect into the paranasal sinus. There is a depressed fracture of the right orbital floor FINDINGS: There is mild density within the bilateral frontal subarachnoid spaces, and several punctate densities within containing orbital fat. There is no evidence of entrapped extraocular muscle. There is a nondepressed fracture of the lateral wall of the right the cortex of the anterior left frontal lobe, which may represent contusion with small subarachnoid hemorrhage. No orbit. The right globe appears intact, there is a punctate density abutting the medial aspect of the globe, which may represent a bone abnormal mass or mass effect is demonstrated. The ventricles are normal in size, position, and configuration. The fragment or glass. There are foci of air in the retrobulbar space, no evidence of retrobulbar hematoma. basilar cisterns are patent. There is a fracture of the anterior left mandible with approximately 6 mm of distraction, and a nondisplaced fracture at the right mandible There are depressed fractures of the anterior and posterolateral walls of the right maxillary sinus, and fractures of the angle. right orbital floor and lateral wall. There is a dense punctate focus abutting the medial aspect of the left globe beneath There is there is hemorrhage in the right maxillary sinus and mild fluid in the right sphenoid sinus. The remaining paranasal sinuses are the eyelid, which may represent a bone fragment. Direct visualization is recommended. There are several foci of air clear. posterior to the globe, no definite drainable retrobulbar fluid collection is seen. There is diastases at the right aspect of the hyoid bone, likely traumatic, with multiple foci of air in the overlying subcutaneous tissues and There is a partially imaged nondepressed fracture of the right mandible angle. deep fascial planes. There is fluid in the right maxillary sinus and bilateral sphenoid sinuses, the remaining paranasal sinuses are clear. The There are multiple punctate densities within the subcutaneous and deep soft tissues of the face and imaged neck, likely representing retained foreign bodies. mastoid air cells are clear. IMPRESSION: Multiple facial fractures as described, including a right orbital floor fracture containing orbital fat, a fracture of the posterior lateral wall of the IMPRESSION: right maxillary sinus containing retroantral fat, and mandible fractures. Multiple facial fractures, please see the dedicated CT of the face for further details. A punctate density abutting the A punctate density abuts the right globe deep to the eyelid, likely resenting a retained foreign body. Recommend direct visualization. medial aspect of the right globe may represent glass or a bone fragment. Recommend direct visualization. Diastases of the right aspect of the hyoid bone, likely traumatic. Correlate clinically. Subtle density in the bilateral frontal lobe subarachnoid spaces may represent small subarachnoid hemorrhage Multiple punctate densities within the subcutaneous and deep soft tissues of the face and neck, likely representing retained foreign bodies. producing no significant mass effect. There are punctate densities in the left frontal lobe parenchyma, worrisome for contusion. Recommend close follow-up.

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EXAM: CT ANGIOGRAM NECK WITH IV CONTRAST Exam: NF XR CHEST PORTABLE - (1 VIEW) AORTA:The imaged portions of the aorta, brachiocephalic artery, and subclavian arteries demonstrate normal opacification. Clinical History: respiratory failure RIGHT CAROTID SYSTEM: The right common carotid, internal carotid, and external carotid arteries demonstrate normal opacification. No significant stenosis is demonstrated. Comparison: 01/08/2021, 0515 hours LEFT CAROTID SYSTEM: The left common carotid, internal carotid, and external carotid arteries demonstrate normal opacification. No significant stenosis is demonstrated. Technique: AP view(s) submitted. VERTEBRAL ARTERIES: Streak artifact limits evaluation of the right vertebral artery origin. No evidence of a traumatic vascular injury or flow-limiting stenosis in the vertebral arteries within these confines. Findings: NECK: Please refer to CT head and face for details regarding intracranial contents and facial fractures. Please refer to CT chest for details regarding intrathoracic findings. The thyroid gland is within normal limits within the confines of streak artifact. The left The ET tube tip lies at the level of the carina directed toward the RIGHT bronchus. internal jugular vein is not well opacified caudal to the level of the hyoid bone. There are multiple radiopaque foreign bodies and gas in the bilateral neck and anterior neck including an enlarged and edematous appearance of the right submandibular gland. The LEFT PICC tip remains in the RIGHT atrium. Radiopaque foreign bodies extending from the right anterior neck at the level of the inferior submandibular gland to the strap muscles and left neck coursing into the left submandibular space and left lateral neck adjacent to the sternocleidomastoid The NG tube tip remains in the proximal stomach directed cephalad. Lungs: Ill-defined opacity in muscle. No evidence of active extravasation in the neck. Focal narrowing of the distal external carotid artery approximately 1.0 cm proximal to the internal maxillary artery origin artery (image 150 series 404 ). the upper and lower RIGHT lung, greatest in the lower zone. Slight improvement in the basal RIGHT IMPRESSION: lung opacity with better visualization of the RIGHT hemidiaphragm. No evidence of a traumatic injury involving the carotid or vertebral arteries. No other interval change. Irregularity with mild focal narrowing of the distal right external carotid artery which could represent a grade 1 type injury versus vasospasm. No evidence of active extravasation in the neck. IMPRESSION: The left internal jugular vein is not well opacified caudal to the level of the hyoid bone, possibly related to preferential drainage through the right internal jugular vein versus compressive effect related to edema in the left neck or traumatic venous injury. Multiple radiopaque foreign bodies extending from the right anterior neck into the left lateral neck as described. 1. Slight improvement in RIGHT pneumonia. Enlarged and edematous appearance of the right submandibular gland possibly related to direct injury versus reactive changes given the adjacent right mandibular fracture. Please refer to CT head and face for further details. 2. Low ET tube position. Consider repositioning the tube.

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OUR RELEVANT HISTORY…

WRITE A RELEVANT Including but not limited to…

HISTORY BASED ON Patient is Age, Sex Chief complaint YOUR CHART REVIEW Hospital Course + injuries + surgeries Past Medical History

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WHAT ARE SOME HYPOTHESES FOR YOUR BEDSIDE SWALLOWING EVALUATION?

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12 Art of the Chart Review - GSHA 2020, Kara A. 2/5/2021 Jones, M.A. CCC-SLP

TAKE AWAYS

• Chart review needs to be used in combination with patient/caregiver interview, Q&A clinical swallowing exam and instrumental swallowing exam to truly assess and treat dysphagia

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REFERENCES REFERENCES

Abel, R., Ruf, S., & Spahn, B. (n.d.). Cervical https://jamanetwork.com/ S., Mayadevi, · Mydhili, Deepak Cabrerizo, S., Cuadras, D., Gomez-Busto, F., Artaza-Artabe, I., Coyle, J. L. (2010). Ventilation, Respiration, Pulmonary Hales, P., & Mossey-Gaston, C. (2016). Surgery for Lung Marín-Ciancas, F., & Malafarina, V. (2015). Serum albumin Diseases, and Swallowing. Perspectives on Swallowing and Cancer and the Consequences for the Swallow. Perspectives of Spinal Cord Injury and Deglutition Disorders. Balasubramanian, ·, & Iyer, S. (n.d.). Volume and and health in older people: Review and meta analysis. Swallowing Disorders (Dysphagia), 19(4), 91–97. the ASHA Special Interest Groups, 1(13), 162–168. https://doi.org/10.1007/s00455-003-0511-y Anderson, K. K., & Arnold, P. M. (2013). Location of the Defect as Predictors of Maturitas, 81(1), 17–27. https://doi.org/10.1044/sasd19.4.91 https://doi.org/10.1044/persp1.SIG13.162 Oropharyngeal Dysphagia after Anterior Cervical Swallowing Outcome After Glossectomy: https://doi.org/https://doi.org/10.1016/j.maturitas.2015.02.009 Ae, N. P., Dirix, P., Ae, A. E. D., & Nuyts, S. Spine Surgery: A Review. Correlation with a Classification. Dysphagia, 1, 3. Daniels, S. K., & Foundas, A. L. (1999). Lesion Localization in Hedström, J., Tuomi, L., Finizia, • Caterina, & Olsson, • (n.d.). Dysphagia in Head and Neck Cancer https://doi.org/10.1055/s-0033-1354253 Carl, L. L., & Johnson, P. R. (2006). Drugs and Dysphagia: Acute Stroke. Journal of Neuroimaging, 9(2), 91–98. Caroline. (n.d.). Correlations Between Patient-Reported https://doi.org/10.1007/s00455-020-10224-w How Medications Can Affect Eating and Swallowing. Pro-Ed. https://doi.org/https://doi.org/10.1111/jon19999291 Dysphagia Screening and Penetration-Aspiration Scores in Patients Treated with Chemoradiotherapy. Head and Neck Cancer Patients Post-oncological Treatment. https://doi.org/10.1007/s00455-009-9247-7 Balogun, S., Balogun, S., & Philbrick, J. T. Bonsall, L. (2011). Calculating the mean arterial Carl, L., & Johnson, P. (2008). Drugs and Dysphagia. Daniels, S. K., & Huckabee, M.-L. (2014). Dysphagia Dysphagia, 33. https://doi.org/10.1007/s00455-017-9847-6 (2013). Delirium, A Symptom of UTI in the pressure (MAP). Lippincott Nursing Center. Perspectives on Swallowing and Swallowing Disorders Following Stroke (Second). Plural Publishing. Alagiakrishnan, K., Bhanji, R. A., & Kurian, M. Elderly: Fact or Fable? A Systematic Review. (Dysphagia), 17(4), 143–148. https://www.nursingcenter.com/ncblog/december- https://doi.org/10.1044/sasd17.4.143 Dunn, K., Rumbach, A., Altman, K. W., Yu, G. P., & Schaefer, (2013). Evaluation and management of Journal of the American Medical Directors 2011/calculating-the-map S. D. (2019). Consequence of dysphagia in the hospitalized oropharyngeal dysphagia in different types of Association, 14(3), B21. Christ-Crain, M., & Müller, B. (2005). Procalcitonin in bacterial patient. Dysphagia, 34(2), 200–201. dementia: A systematic review. Archives of https://doi.org/10.1016/j.jamda.2012.12.059 Britton, D., Roeske, A., Ennis, S. K., Benditt, J. infections - Hype, hope, more or less? Swiss Medical Weekly, https://doi.org/10.1007/s00455-011-9331-7 Gerontology and Geriatrics, 56(1), 1–9. O., Quinn, C., & Graville, D. (2018). Utility of 135(31–32), 451–460. https://doi.org/2005/31/smw-11169 Beric, E., Smith, R., Phillips, K., Patterson, C., & Flores, M. J., Eng, K., Gerrity, E., & Sinha, N. (2019). Initiation https://doi.org/https://doi.org/10.1016/j.archger.20 Pulse Oximetry to Detect Aspiration: An Coelho, C. A. (1987). Preliminary findings on the nature of of Oral Intake in Patients Using High-Flow Nasal Cannula: A 12.04.011 Pain, T. (2019). Swallowing disorders in an older Evidence-Based Systematic Review. Dysphagia, dysphagia in patients with chronic obstructive pulmonary Retrospective Analysis. Perspectives of the ASHA Special fractured hip population. Australian Journal of 33(3), 282–292. https://doi.org/10.1007/s00455- disease. Dysphagia, 2(1), 28–31. Interest Groups, 4(3), 522–531. Altman, K. W., Yu, ; Gou-Pei, & Schaefer, S. D. Rural Health, 27(4), 304–310. 017-9868-1 https://doi.org/10.1007/BF02406975 https://doi.org/10.1044/2019_PERS-SIG13-2018-0019 (2010). Consequence of Dysphagia in the https://doi.org/10.1111/ajr.12512 Coghlan, K., & Skoretz, S. A. (2017). Breathing and Hales, P., & Mossey-Gaston, C. (2016). Surgery for Lung Hospitalized Patient Impact on Prognosis and Swallowing With High Flow Oxygen Therapy. Perspectives of Cancer and the Consequences for the Swallow. Perspectives of Hospital Resources. In Arch Otolaryngol Head Bhattacharya, S., Thankappan, · Krishnakumar, the ASHA Special Interest Groups, 2(13), 74–81. the ASHA Special Interest Groups, 1(13), 162–168. Neck Surg (Vol. 136, Issue 8). Joseph, S. T., Sheejamol, ·, Sukumaran, V., Shetty, https://doi.org/10.1044/persp2.sig13.74 https://doi.org/10.1044/persp1.sig13.162

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Ihara, Y., Crary, M. A., Madhavan, • Aarthi, David, •, Gregorio, Wang, H., Yang, S.-D., & Ding, W.-Y. (2017). Risk factors for Murry, T., Madasu, R., Martin, A., & Robbins, K. T. (1998). Pagana, K., & Pagana, T. (2018). Manual of Takizawa, C., Gemmell, E., Kenworthy, J., & Seedat, J., Starmer, H. M., Bolton, L., Clavé, C., Im, I., Ross, S. E., & Carnaby, G. D. (n.d.). Dysphagia and dysphagia after anterior cervical spine surgery A meta-analysis.Acute and chronic changes in swallowing and quality of life Oral Morbidities in Chemoradiation-Treated Head and Neck https://doi.org/10.1097/MD.0000000000006267 following intraarterial chemoradiation for organ preservation in Diagnostic and Laboratory Tests (Sixth Edit). Speyer, R. (2016). A Systematic Review of the P., Freitas, S. V., Bogaardt, H., Matsuo, K., de Cancer Patients. https://doi.org/10.1007/s00455-018-9895-6 patients with advanced head and neck cancer. Head & Neck, Elsevier Ltd. Prevalence of Oropharyngeal Dysphagia in Souza, C. 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