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SPCH3206 > Instrumental Assessment > Flashcards

Instrumental Assessment Flashcards

1
Q

What does VFSS stand for?

A

Videofluroscopic Swallowing Study

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2
Q

What does FEES stand for?

A

Fibreoptic Endoscopic Evaluation of Swallowing

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3
Q

When to refer for instrumental assessment?

A
  • 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
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4
Q

What is VFSS?

A
  • 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
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5
Q

Why would you choose the VFSS as the assessment tool?

A
  • 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
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6
Q

What should be considered before conducting VFSS?

A
  • 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
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7
Q

List the contraindications for VFSS

A
  • decreased conscious state
  • unstable medical conditions
  • severely confused/cannot cooperate
  • issues with size/positioning for VFSS
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8
Q

What is the SLP role in VFSS?

A
  • 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
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9
Q

List the roles of the a) radiographer and b) nurse in the VFSS

A

a) runs/manages equipment and conducts procedure
b) assists with patient positioning and handling

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10
Q

Describe the positioning of the patient to conduct a VFSS assessment

A
  • upright
  • can be sitting or standing
  • lateral plane first
  • shoulders as low as possible
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11
Q

Explain why we begin with the lateral view in the VFSS

A
  • 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
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12
Q

Explain why we do the anterior-posterior view second in the VFSS

A
  • 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
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13
Q

How is a VFSS conducted, and what should you tell the patient during?

A
  1. Begin with controlled swallows
    - ‘hold it in your mouth until I tell you to swallow’
  2. Liquids first
    - easier to expectorate, won’t block the airway or leave residue in the pharynx
  3. How much?
    - around 3 swallows of each consistency
    - begin with teaspoon size, then trial larger amounts
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14
Q

Why is the VFSS assessment recorded?

A
  • recorded for later analysis
  • output from fluoroscopy machine directly into digital recording systems
  • used for replay and reporting
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15
Q

How do you interpret a VFSS?

A

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

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16
Q

What equipment is used in a FEES?

A
  • 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
17
Q

How is the FEES inserted? Include a comment about the use of anaesthesia

A

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

18
Q

Compare the two views of the FEES

A

Home position:
- initial placement for observation of structures + bolus flow

Lower view:
- see aspiration

19
Q

The FEES is the assessment of choice for what population and its advantages and limitations?

A
  • 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)
20
Q

What are the steps involved in the FEES assessment procedure?

A
  1. Evaluation of structure relating to swallowing (velopharynx, pharynx, larynx)
  2. Evaluation of secretions
  3. Sensory testing
  4. Swallowing trials
21
Q

What tasks can be used to elicit and test structure and function?

A

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

22
Q

How can you gather sensory information on a FEES?

A
  • 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
23
Q

Explain the FEES swallowing trials

A

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

24
Q

How do you interpret the FEES?

A
  1. Initial analysis:
    - occurs live during the assessment
    - real time
    - SP observes trials an determines what is safe
    - reports presence of aspiration
  2. Full analysis
    - takes place after assessment
    - watching over and over
    - identifying symptoms
    - understanding ‘why’; and then treating!
  3. 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
25
Q

When deciding between the FEES and VFSS, consider. . .

A
  • 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
26
Q

What is pharyngeal manometry? Include the measures it assesses, and a comment of limitations of this clinical tool

A
  • 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

27
Q

How is Imaging (ultrasound) used as a clinical tool in the assessment of swallowing?

A
  • 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

28
Q

How can you incorporate telepractise into your CSE?

A
  • 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
29
Q
A

SPCH3206 (12 decks)

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