Instrumental Assessment Flashcards
What does VFSS stand for?
Videofluroscopic Swallowing Study
What does FEES stand for?
Fibreoptic Endoscopic Evaluation of Swallowing
When to refer for instrumental assessment?
- oropharyngeal dysphagia suspected but not accurately identified at bedside
- suspected silent aspirator, recurrent pneumonias
- mechanism underlying the dysphagia is unclear
- differential diagnosis required (i.e. ‘globus’ symptoms - rule out possible oesophageal issues)
- need detailed information for treatment/rehab planning
- visualise pharyngeal (and oesophageal) phases
- ability to check efficacy of treatment strategies
What is VFSS?
- radiological investigation
- industry accepted gold standard
- unequivocal info about all phases of swallowing
- patient swallows food/fluid with BARIUM added
- allows visualisation of the bolus as it is swallowed
Why would you choose the VFSS as the assessment tool?
- need to see oral, pharyngeal and oesophageal stages
- ability to view coordination of swallow across the stages of the swallow
- can observe if aspiration occurs
- suspected structural issues
- looking for swallow asymmetry
What should be considered before conducting VFSS?
- radiation exposure
- barium does not taste nice and can make patients nauseous
- barium changes the composition of foods/fluids
- patient ability to cooperate
- patient alertness and ability to interact
- not portable
- cost of staff involved
List the contraindications for VFSS
- decreased conscious state
- unstable medical conditions
- severely confused/cannot cooperate
- issues with size/positioning for VFSS
What is the SLP role in VFSS?
- request a referral from treating Dr.
- explain procedure to patient
- conduct the assessment
- work alongside radiologist for diagnostic issues
- interpret results and write report of findings
- provide education to patient and family
List the roles of the a) radiographer and b) nurse in the VFSS
a) runs/manages equipment and conducts procedure
b) assists with patient positioning and handling
Describe the positioning of the patient to conduct a VFSS assessment
- upright
- can be sitting or standing
- lateral plane first
- shoulders as low as possible
Explain why we begin with the lateral view in the VFSS
- can observe the bolus + movement of structures involved in swallow (tongue, velum, etc.) in each stage of swallow (oral prep, oral, pharyngeal, oesophageal)
- identify issues including residue and penetration/aspiration
Explain why we do the anterior-posterior view second in the VFSS
- done after lateral to check for symmetry and check flow through oesophagus to stomach
- do 1-2 fluid trials in anterior/posterior plane
- rule out any unilateral weakness
- full scan down to stomach - can also check for barium aspiration in lungs
How is a VFSS conducted, and what should you tell the patient during?
- Begin with controlled swallows
- ‘hold it in your mouth until I tell you to swallow’ - Liquids first
- easier to expectorate, won’t block the airway or leave residue in the pharynx - How much?
- around 3 swallows of each consistency
- begin with teaspoon size, then trial larger amounts
Why is the VFSS assessment recorded?
- recorded for later analysis
- output from fluoroscopy machine directly into digital recording systems
- used for replay and reporting
How do you interpret a VFSS?
Initial analysis:
- occurs live during assessment
- real time
- SP observes trials and determines what is safe
- reports presence of aspiration
Full analysis:
- takes place after assessment
- rewatching
- identify symptoms
- understanding underlying physiological deficit causing symptoms
- the ‘why’ informs how you treat
Assessment proformas:
- guides you systematically through each stage of swallow
- grading systems/definitions
- structural statements/observations
- analysis of the functioning of the components of the swallow
- penetration or aspiration rating scales
- dysphagia outcome severity scale
What equipment is used in a FEES?
- flexible endoscope with light source hooked up to monitor (to allow viewing) - usually connected to DVD or swallowing workstation to record study for later analysis
How is the FEES inserted? Include a comment about the use of anaesthesia
Scope inserted into the patent airway - gel added to scope to assist through nasal cavity
Anaesthetic is used unless critically necessary; nasal spray anaesthetic will travel down into pharynx and causing sensory loss to pharynx and potentially impact swallow
Compare the two views of the FEES
Home position:
- initial placement for observation of structures + bolus flow
Lower view:
- see aspiration
The FEES is the assessment of choice for what population and its advantages and limitations?
- Patients with dysphonia; or requiring assessment of true vocal fold function
- Pharyngeal and laryngeal Anatomy – allows visualization of normal mvt AND normal structure
- Patients requiring assessment of sensation in laryngeal or pharyngeal region
- Severe dysphagia – allows short fast check of status
- Pts with Secretions + Secretion management issues
- Great for seeing pooling and residue
Easy to visualise absent airway protection
Advantages:
- Portable
- Done at bedside
- Cost effective
- Readily available
- No issue/limits of positioning
- More natural foods used (not barium coated)
- No concern with radiology
- Longer study
- Can be done simultaneously with VFSS
Limitations:
- Invasive
- Unsuitable for some populations (i.e. Maxillary fractures, Craniofacial changes, Limiting scope access, Demented, confused, agitated)
- Risks (i.e. Vasovagal reaction - cardiac dysrhythmia, Laryngospasm, Nasal haemorrhaging, Possible adverse reactions to nasal anaesthetic, Infection control)
What are the steps involved in the FEES assessment procedure?
- Evaluation of structure relating to swallowing (velopharynx, pharynx, larynx)
- Evaluation of secretions
- Sensory testing
- Swallowing trials
What tasks can be used to elicit and test structure and function?
Velum - nasal and non-nasal sounds, watch dry swallow
Breath hold and blow out cheeks - widens pyriform sinus
Speech tasks ‘earl, whirl, curl’ - BOT movement
Cough
High /ee/ - pharyngeal wall recruitment
Ee- sniff - ee - opens and closes vocal folds
Pitch range - laryngeal elevation and lengthening of vocal folds
Light versus strong breath hold - see arytenoid tilt in strong breath hold
Breath hold for count of 5 - ability to do this for future swallow manoeuvres
How can you gather sensory information on a FEES?
- reaction to presence of scope
- touching scope on the pharyngeal walls, laryngeal vestibule, arytenoids, etc.
- normal response would be some airway protection or swallow
- if no response. . . hypothesis there will be potential non-response to residue aspiration
Explain the FEES swallowing trials
IDDSI fluids and foods:
- determine safe, functional intake for patient
- can be more flexible and trial other foods
- added food dye to assist visualisation
Cannot see actual swallow: can infer problems from pre- and post- swallow behaviours
How do you interpret the FEES?
- Initial analysis:
- occurs live during the assessment
- real time
- SP observes trials an determines what is safe
- reports presence of aspiration - Full analysis
- takes place after assessment
- watching over and over
- identifying symptoms
- understanding ‘why’; and then treating! - Assessment proformas
- guides you systematically through each stage of swallow
- grading systems/definitions
- structural statements/observations
- analysis of the functioning of the components of the swallow
- penetration or aspiration rating scales
- dysphagia outcome severity scale
When deciding between the FEES and VFSS, consider. . .
- neither exam is 100% accurate
- more than 90% of all aspiration events are seen before or after the swallow
- depends on what you’re trying to see
- condition of patient
- equipment available
What is pharyngeal manometry? Include the measures it assesses, and a comment of limitations of this clinical tool
- solid state pressure sensors passed transnasally into pharynx
- different sensor arrays depending on system
- sensors typically positioned at a) base of tongue, b) UES, c) cervical oesophagus +/- d) laryngeal inlet
Measures:
- pressure response of UES
- timing of pharyngeal contraction
- UES relaxation
- relationship between these events
- information about intrabolus pressure
- info about strength of pharyngeal constrictors
Limitations:
- invasive
- conducted +/- VFSS
How is Imaging (ultrasound) used as a clinical tool in the assessment of swallowing?
- records echoes of pulses reflected by tissue planes where there is a change in density
- travels well through fluids + soft tissues
- doesn’t travel well through fat
- won’t pass through bone/air
Oral cavity best visualised:
- no radiation, portable, inexpensive, repeat studies, non-invasive
- best for investigations of oral phase of swallow
How can you incorporate telepractise into your CSE?
- video conferencing system (split screen, additional camera, additional microphone)
- commercial video conferencing systems
- modifications to CSE equipment and procedure
- model uses allied health assistant at patient end
