How do you assess bulbar function?

From the Guidelines

Bulbar function should be assessed through a comprehensive clinical evaluation, including symptoms and clinical signs of dysphagia, as well as instrumental assessments such as videofluoroscopy (VFS) or fiberoptic endoscopic evaluation of swallowing (FEES), to identify alterations in the swallowing process and detect silent aspirations. This assessment is crucial in patients with conditions like amyotrophic lateral sclerosis (ALS), as dysphagia can lead to serious complications including aspiration pneumonia, malnutrition, and respiratory compromise 1.

Clinical Evaluation

The clinical evaluation of bulbar function should include:

• Observation of the patient's speech for dysarthria, noting any slurring, nasal quality, or hoarseness
• Evaluation of swallowing by asking the patient to drink water and watching for coughing, choking, or regurgitation
• Testing the gag reflex by touching the posterior pharyngeal wall with a tongue depressor
• Assessment of palatal movement by having the patient say "ah" and observing for symmetrical elevation of the soft palate
• Examination of tongue function by asking the patient to protrude their tongue, move it side to side, and checking for atrophy, fasciculations, or deviation
• Testing jaw strength by having the patient clench their teeth while you attempt to open their mouth

Instrumental Assessment

Instrumental assessments, such as VFS or FEES, can provide valuable information on the physiopathological alterations in the swallowing process and detect silent aspirations 1. The Volume-Viscosity Swallowing Test (V-VST) has been shown to have a high sensitivity to identify patients at risk of aspiration 1.

Frequency of Evaluation

The frequency of dysphagia clinical evaluation at follow-up should depend on the presence and the progression of clinical signs, with a general recommendation of every 3 months 1. Clinical severity scales, such as the ALS Functional Rating Scale-Revised (ALSFRS-R) or the ALS Swallowing Severity Scale (ALSSS), can be used to evaluate the presence and severity of dysphagia 1.

Importance of Early Detection

Early detection of bulbar dysfunction is crucial, as it can lead to serious complications including aspiration pneumonia, malnutrition, and respiratory compromise 1. Therefore, a comprehensive clinical evaluation, including symptoms and clinical signs of dysphagia, as well as instrumental assessments, should be performed in patients with conditions like ALS to identify alterations in the swallowing process and detect silent aspirations.

From the FDA Drug Label

Patients treated with botulinum toxin products, including JEUVEAU, may require immediate medical attention should they develop problems with swallowing, speech, or breathing Deaths as a complication of severe dysphagia have been reported after treatment with botulinum toxin. Dysphagia may persist for several months, and require use of a feeding tube to maintain adequate nutrition and hydration.

To assess bulbar function, monitor patients for signs of dysphagia (swallowing difficulties), respiratory problems, and speech difficulties after treatment with botulinum toxin products, including JEUVEAU 2.

• Be aware of the risk of aspiration due to severe dysphagia.
• Patients with pre-existing respiratory disorders or swallowing difficulties are at higher risk.
• Immediate medical attention is required if problems with swallowing, speech, or breathing occur.

From the Research

Assessing Bulbar Function

To assess bulbar function, several methods and scales can be utilized, depending on the specific context and disease being evaluated. The following are some key points to consider:

• Clinical Evaluation: Clinicians can make direct observations of the degree of speech, swallowing, and salivation impairment in patients 3.
• Scales and Measures: Various scales, such as the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R) and the Center for Neurologic Study Bulbar Function Scale (CNS-BFS), can be used to assess bulbar function 3, 4.
• Speech and Swallowing Assessment: Objective measures of speech motor function, including assessment of respiratory, phonatory, articulatory, and resonatory subsystems, can be used to evaluate bulbar dysfunction 5.
• Respiratory Complications: Bulbar dysfunction can lead to respiratory complications, such as upper airway obstruction, aspiration, and pneumonia, which should be evaluated and managed accordingly 6.
• Patient-Reported Assessment: Patient-reported scales, such as the SMA-Bulbar Scale, can capture and quantify patient-reported experiences with bulbar dysfunction, providing valuable insights into the impact of bulbar problems on daily functioning 7.

Key Considerations

When assessing bulbar function, the following factors should be considered:

• Disease Severity: The severity of the underlying disease, such as amyotrophic lateral sclerosis (ALS) or spinal muscular atrophy (SMA), can impact bulbar function 3, 7.
• Symptom Severity: The severity of bulbar symptoms, such as speech and swallowing difficulties, can vary widely among patients 3, 7.
• Respiratory Function: Respiratory function should be evaluated in patients with bulbar dysfunction, as respiratory complications can be a major cause of morbidity and mortality 6.
• Patient Perspective: Patient-reported outcomes and perspectives should be incorporated into the assessment of bulbar function, as they provide valuable insights into the impact of bulbar problems on daily functioning 7.