L8: Instrumental Ax

Question 1

purpose of instrumental assessment

Answer 1

to inc objectivity of ax w enhanced documentation and ability to review results

Question 2

use of instrumentation to provide…

Answer 2

more detail regarding swallow anatomy and physiology

ex. videofluroscopy, endoscopy, manometry, ultrasound

Question 3

instrumental ax provides capacity for…

Answer 3

fine grained analysis of rapid seq of swallowing events

Question 4

choice of instrumentation dependent on the

Answer 4

type of info desired/needed

Question 5

what are the goals of instrumental ax? (6)

Answer 5

to assess movements patterns of swallow-related structures in UADT (form inferences re: physiologic integrity)

to assess swallowing-related movement patterns of structures in UADT

to identify airway compromise and inefficient swallowing

to identify and describe pooled secretions

to conduct cursory eval of eso anatomy and physiology

to gather info to inform clinical recos (route of nutrition, safest oral dietary level, need for mods/interventions)

Question 6

when is an instrumental study indicated? (4 reasons)

Answer 6

clinical exam fails to fully address clinical qs (HLE is only item predictive of swallowing physiology from clinical exam)

direction for swallowing rehab is needed

nutritional or resp issues raise suspicion of dysphagia

to identify other factors contributing to dysphagia

Question 7

when is an instrumental study not indicated (3 reasons)

Answer 7

no longer has dysphagia complaints

pts condition too medically compromised, or unable to participate in eval

examination would not alter clinical course or management

Question 8

videofluoroscopic swallow study (VFSS) =

objective?

preparedness?

Answer 8

also known as modified barium swallow (MBS)

objective = to obtain visualization of UADT during swallowing

must known radiographic anatomy, able to identify imp swallowing physiology

Question 9

what does VFSS examine?

Answer 9

study of safety and efficiency of swallow

assesses bolus flow thru oral cavity, pharynx, and cervical eso

antomic and/or physiologic abnoramlities can be identified

effects of modifications in bolus size/texture, pt positioning, compensatory strats, and sensory enhancements are evaluated to determine optimal swallow safety and efficiency

Question 10

VFSS should not be

Answer 10

performed independently

best if radiologist is present, if not may need to request input - re: if suspected anatomical or eso abnormalities

Question 11

4 major aims of VFSS

Answer 11

assess valves (lips, VP, laryngeal x2, pharyngoesophageal)

assess bolus flow thru chambers (oral, pharynx, eso)

identify asp and the cause of asp

identify strats to optimize safety and efficiency

Question 12

what equipment is needed for VFSS?

Answer 12

x ray= fluroscopy tube, table, monitor, PPE for xray

monitor, digital acq device, microphone

contrast medium, water, thickener, foods

disposable cups/utensils

PPE for infection control

equipment for positioning pt

Question 13

5 technical considerations for VFSS

Answer 13

contrast/brightness of image

imaging modes (cont vs pulsed, we want 30 pulses per sec)

spatial and temporal resolution (30 frames per sec)

contrast agent (barium conc = 20-40%)

safety and radiation exposure

Question 14

safety and radiation exposure is dependent on

Answer 14

equipment, set up, maintenance

proper utilization

radiology statff’s knowledge/training

proximity to radiation source

PPE

Question 15

PPE for radiation includes

Answer 15

lead apron, thyroid guard, eye protection, +/- gloves, dosimeters

Question 16

4 steps of protocol for VFSS

Answer 16

lateral view: standing or seated

anterior view in upright or habitual position

comm VFSS findings to pts, family, team members

write report

Question 17

describe the lateral view of VFSS “standing or seated”

Answer 17

rest position = check for structural abnormality, abnormal movements

speech production = look for movement of articulators

dry swallow

food presentation

compensatory maneuvers (ex. postural changes)

Question 18

describe the anterior view of VFSS in upright/habitual position

Answer 18

observe structural symmetry, vallecular and pyriform residue, lateral pouches, sym of bolus flow

elevate mandible and check VF position and adduction

repeat most diff consistencies

may repeat cup swallow if suspect lateral pouch

may repeat most effective compensatory maneuvers to confirm efficacy

Question 19

what are the 4 food consistencies for VFSS?

Answer 19

thin liquid = IDDSI 0

thickened liquid = mildly thick - IDDSI 2, mod thick IDDSI 3

puree = extremely thick, IDDSI 4

solid (cookie) = reg IDDSI 7

Question 20

volumes used during VFSS

Answer 20

1/2 tsp
1 tsp
10 ml
sip
seq swallows
1/2 cookie

Question 21

presentation of consitencies/vols during VFSS depends on

regardless…

Answer 21

which protocol you adhere to

regardless of protocol it should be standardized (consistent)

Question 22

MBSImp Lateral view 10 steps

Answer 22

5 ml thin via tsp (dont rate)
5 ml thin via tsp
sip thin cup
seq sips thin from cup
5ml nectar thick via tsp
sip nectar from cup
seq sips nectar from cup
5ml honey thick via tsp
5ml pudding via tsp
1/2 cookie w 3ml pudding

Question 23

MBSImp anterior/posterior view 2 steps

Answer 23

5ml nectar via tsp
5ml pudding via tsp

Question 24

DIGEST lateral view 5 steps

Answer 24

2x 5ml thin (IDDSI 0)
2x 10 ml thin (IDDSI 0)
2x cup sips thin (IDDSI 0)
2x tsp pudding (IDDSI 4)
2x 1/4 cracker/cookie (IDDSI 7)

Question 25

VFSS procedure 3 important considerations

Answer 25

optimal sit is to view entire aerodigestive tract from lips to C7 view prior to, during, and after each swallow to check for residue and potential for asp note spontaneous cough, throat clearing, or dry swallow after each swallow (if no spon behaviours observed, instruct pt to cough as you observe)

Question 26

what should we know about thin liquid on VFSS?

Answer 26

1/2 tsp, 1 tsp, 10 ml, sips from cup (in ped cases use bottle) self feeding if appropriate vol inc until/unless asp occurs (implement strategies to eliminate asp, if successful move to next vol) changing vols allows evaluation of the mechanism's ability to modulate based on vol (want allow pt to take thing liquids orally as many vols as possible)

Question 27

thin liquid is ...

Answer 27

the best consistency to define the reason for asp and amount of asp in first few swallows most easily asp but least likely to block airway - should reduce pts fear of swallow pneumonia may be less likely to occur from asp of liquids vs thicker foods less likely to have residue that would impeded visualization of further swallows

Question 28

for thin liquids we want to start with...

Answer 28

small amounts initially pts can be v ill, have poorer resp status, be aspirators >1tsp of barium in lungs can result in complications including resp arrest

Question 29

what should we know about thick consistencies on VFSS?

Answer 29

1/2 tsp, 1 tsp, sips from cup mildy thick, mod thick, extremely thick self feed if appropriate if asp occurs intro treatment strategies may need to place material further back on tongue surface if cant manage transport thru oral cavity or cant' take from spoon (eliminate challenge of ingestion and then assess swallowing safety and efficiency)

Question 30

what should we know about solids on VFSS?

Answer 30

1/4 cookie, 1/2 cookie, bread (tsp) brittle material (shatters), material requiring mastication if can manage these solids, intro mixed consistencies (ex. fruit cocktail) any materials the pt reports as being diff to manage (w/i reason)

Question 31

compensations... goals?

Answer 31

treatment efficiacy trial - specific to indv options that fit his/her particular swallow profile goals: to establish safe, efficient oral feeding immediately to identify therapeutic targets

Question 32

how do we analyze and interpret VFSS?

Answer 32

offline analysis slow speed, frame by frame many ways to organize observations

Question 33

radiation from xrays considerations:

Answer 33

ionizing radiation = considered hazardous bc it interacts w matter, can alter or break molecular bonds manners of exposure: medical, enviro, occupational

Question 34

medical radiation exposure can

Answer 34

contribute sig to one's lifetime accumulated dose needs to be prescribed by a physician (balance risks/benefits)

Question 35

enviro radiation exposure includes

Answer 35

materials in water, soil, and air are naturally radioactive; radioactive emissions from the sun and stars

Question 36

occupational exposure includes

Answer 36

radiation of humans (diagnostic, therapeutic, research)

Question 37

VFSS radiation exposure = ALARA =

Answer 37

0.04-1.0 ALARA = as low as reasonably achievable

Question 38

what are the limitations of VFSS?

Answer 38

invasive (radiation exposure) lack of correspondence to real-life eating context poor visibility of secretions can't assess sensation or pressure dep upon image quality must be mindful of freq

Question 39

FEES =

Answer 39

fiberoptic endoscopic evaluation of swallowing historically viewed as an effective adjunct to VFSS; many now view FEES as the procedure of choice particularly for some pts can be used both in assessment and treatment

Question 40

how can FEES be used as an additional approach to asses the pharyngeal phase of swallowing?

Answer 40

to detect asp and determine safety of oral feeding in pts for whom VFSS was diff or impossible ex. portability, positioning, behavioural cooperation, extremely ill (w inc risk of asp), timing of examination

Question 41

what is the protocol for FEES?

Answer 41

w pt in upright or habitual position intro scope, physical exam of structural movements food/liquid presentation (senstivity testing by ENT) intervention

Question 42

describe what is done during the physical examination during FEES?

Answer 42

scope passed thru inferior meatus first view VPP closure (speech tasks, dry swallow) scope is passed into oropharynx

Question 43

what is being looked for during oropharynx exam on FEES?

Answer 43

saliva in hypopharynx, appearance of pharynx/larynx, postion of epi dry swallow, breath hold, cough, phonation (vocal fold adduction, symmetry of VFs)

Question 44

what is done during sensitivity testing for FEES?

Answer 44

w tip of endoscope touch pharyngeal walls, laryngeal surface of epi, aryepiglottic folds, arytenoids this stimulus is much stronger than what is associated w swallow = could set off laryngo spasms which could interupt airway

Question 45

FEESST =

Answer 45

fiberoptic endoscopic eval of swallowing w sensory testing

Question 46

what are we looking for during FEES of the velopharyngeal valve? how is it assessed?

Answer 46

20 mm^2 for oral sounds, 100mm^2 in hypernasal speech, 0mm^2 during swallow assess using: sustained vowel, sustained /s/, sentence w/o nasal sounds, dry swallow, thin liquid to identify leaks look for symmetry and contributions of various structures

Question 47

what are we looking for during FEES of the pharyngeal chamber? how is it assessed?

Answer 47

BOT retraction w a pharyngeal fricative (cant assess during swallow) check pyriform sinuses, pharyngeal walls, BOT and postcricoid region for pooled sections (poor sensation and/or poor ability to clear) pharyngeal constriction w pitch elevation head rotation to evaluate closure of unilateral hypopharynx

Question 48

what are we looking for during FEES of the laryngeal valves (w lower scope position)? how is it assessed?

Answer 48

VF adduction and voice quality w sustained vowel change in VFs, laryngeal elevation and pharyngeal constriction w pitch glide tight VF adduction w breath hold - also medialization of FVFs, approx of arytenoids to epi throat clear/cough

Question 49

describe food presentation for FEES

Answer 49

measure amounts of food/liquid given to pt administer ice chips, then 5ml and 10 ml volumes of liquids and purees, and solids (might administer smaller amount of water if pt at great asp risk) all dyed w green/blue food colouring for contrast

Question 50

what are we observing during FEES?

Answer 50

bolus hold to assess premature spill (location of bolus at onset of pharyngeal swallow) penetration/asp bf swallow onset of laryngeal elevation and closure after swallow = residue (if residue look for 2nd swallow then cue, if residue on VFs watch for cough/throat clear, then cue and second swallow) penetration/asp after swallow ability to manage secretions determine efficacy of compensatory maneuvers

Question 51

analyze and interpret FEES with...

Answer 51

off-line analysis slow speed, frame by frame many ways to organize observations

Question 52

limitations for FEES

Answer 52

risks: vasovagal response, epistaxis (nosebleed), allergic rxn to anesthetic can't asses oral chamber or eso white out at height of swallow can't judge degree of BOT retraction, pharyngeal constriction, UES opening, HLE penetration/asp during swallow is inferred

Question 53

final thoughts about FEES...

Answer 53

detailed info of the anatomy/phys of the pharyngeal stage food presentation not necessary can proceed even when challenges present - re: mental status, ability to hold posture, ability to swallow on cue, accessing radiology can answer the q: can this pt swallow safely?

Question 54

6 indications for VFSS

Answer 54

unknown medical etiology; vague symps (need comprehensive view) visualize submucosal anatomy (ex. cervical osteophytes) assess oral stage/BOT movement UES stricture/hypertonicity examine movement of multiple structures at height of swallow laryngectomy w complaints

Question 55

9 clinical indications for FEES

Answer 55

visualize surface anatomy, mucosal abnormalities VP incompetence visualize laryngeal movement/VF motility severe dysphagia; need conservative exam (ex. compromised pulmonary clearance) clinical q of secretion management sensitivity pharyngeal symmetry extended therapeutic exam needed/desired biofeedback desired

Question 56

6 logistical indications for FEES

Answer 56

fluroscopy not available, wait time transportation to fluroscopy too risk (medically fragile) transportion to hospital is problematic family input during exam is desired positioning is problematic concern about radiation

Question 57

what are 4 other instrumental techniques?

Answer 57

pharyngeal manometry (pressure) electromyography (muscle activation) (surface EMG = sEMG) Cervical auscultation (sounds) pulse oximetry (O2 conc)

Question 58

pharyngeal manometry =

Answer 58

solid state pressure sensors - react to pressure changes during pharyngeal swallow catheter placed transnasally (tongue bases, UES, cervical eso) requires simultaneous VFSS to determine etiology of pressure changes

Question 59

electromyography (EMG)=

Answer 59

timing and relative amp of muscle contractions during swallow surface EMG most common app - electrodes placed on surface of skin under dhin or above thyroid cart - gaining popularity as biofeedback

Question 60

cervical auscultation =

Answer 60

use of listening device to assess sounds related to swallowing swallow sounds = laryngeal ascent/descent, bolus thru UES - not consistent! can include sounds of resp can be used as an adjunct w other techniques

Question 61

pulse oximetry =

Answer 61

eval of arterial o2 saturation during swallowing hyp = asp of food into airway causes reflex broncospasm leading to ventilation=perfusion mismatch and O2 desaturation accuracy questionable = how much aspirate needed to dec o2? could be other reasons for dec o2

Question 62

manometry and sEMG can...

Answer 62

contribute valuable data on specific aspects of the swallow include other instrumentation w caution