instrumental ax Flashcards
1
Q
goals of instrumental Ax
A
- Provide valuable information about the swallow anatomy & physiology
- Evaluate the ability of the person to swallow various materials
- Assess secretions and the person’s ability to manage them
- Assess the adequacy of airway protection and the coordination of breathing and swallowing
- Help evaluate the impact of compensatory strategies on swallowing function and airway protection
2
Q
instrumental examination is indicated when….
A
- Dysphagia characteristics are vague and require confirmation or further delineation
- Safety or efficiency of swallowing is a concern
- Direction for swallowing rehabilitation is needed
- Help is needed to assist in identifying underlying medical problems that contribute to dysphagia symptoms
3
Q
instrumental ax is not indicated when…..
A
- The patient no longer has dysphagia complaints
- The patient’s condition is too medically compromised or the patient is too uncooperative to complete the procedure
- The clinicians’ judgement is that the examination would not alter the clinical course or management plan
4
Q
who should you refer for instrumental ax?
A
- Clients with suspected or known oropharyngeal dysphagia when the nature of the problem needs to be identified
- Clients who are suitable for compensation and/or rehabilitation manoeuvres
- When you suspect silent aspiration
- Clients or their family/carers who would benefit from education about their dysphagia
- Clients should NOT be referred if the procedure/results are not expected to change their management
5
Q
who should you NOT refer for instrumental ax?
A
- When management will not change because of the instrumental assessment
- Clients who are confused, agitated, and disorientated
- For VFSS – depending on equipment and set up – clients who are obese, or have significant issues with stability
- For VFSS – when radiation exposure might be an issue
6
Q
what does VFSS stand for?
A
videofluoroscopic swallowing study
7
Q
what is VFSS?
A
- patient is given a small around of food/liquid mixed with barium
- provides detailed info about anatomy, physiology and timing of swallow
- offers info about effectiveness of compensatory/therapeutic techniques
8
Q
what can you see in the lateral view of VFSS?
A
- acceptance of bolus and oral prep
- movement of sp
- movement of h/exc and epig D
- larynx, VF, and trachea
- residue (difficult to tell if its bilateral)
9
Q
what can you see in the anterior-posterior view of VFSS?
A
- alignment of mandible
- symmetry of pooling in oral cavity
- asymmetry of vocal fold movement
- residue
10
Q
results of VFSS
A
- Ability to protect the airway (penetration/aspiration)
- UES (does the bolus enter the oesophagus?)
- Where was the swallow triggered from (anatomical site)
- Pharyngeal and oral residue – where?
- Pharyngeal region abnormalities (transport)
- Oral region abnormalities (transport – tongue function)
11
Q
advantages of VFSS
A
- Provide a view of oral and pharyngeal structures
- Can assess the duration of each phase
- Gives information about safety of different foods/fluids and/or compensation and rehabilitation techniques
- Can quantify aspiration
- Can review images in slow motion
- Very useful for providing education and tracking progress
12
Q
limitations of VFSS
A
- Radiation exposure
- Barium affects taste, texture and density (it is a solid and increases weight of what it is added to)
- VFSS is not representative of normal meal time – just a snapshot, can’t see fatigue over a meal
- Not always accessible, - rural settings; wait lists
- Fairly costly
- 2d image, 3d event
- Not all patients can tolerate
- Some individuals may not be able to participate due to patient size (obesity, cognition, stability)
13
Q
precautions to be taken with VFSS
A
- Involved minimal radiation
- Lead shield aprons / thyroid shields worn
- Radiation monitoring badges
- Limit time exposure to patient (<3 minutes)
- Client must be prepared and know any compensation/rehabilitation techniques
- Special consideration for clients or staff who may be pregnant
14
Q
what does FEES stand for?
A
- fibrooptic endoscopic evaluation swallowing
15
Q
how does FEES work?
A
- Endoscope passed transnasally to provide direct visualisation of the swallowing anatomy
- Can be done at bedside
- In a normal swallow the view is interrupted at the height of the swallow
- Can also test sensation during FEES informally and directly through touching the endoscope to the pharyngeal and laryngeal structures
- FEESST – pharyngeal and laryngeal response to a calibrated “puff of air”
16
Q
results of FEES
A
- Spillage into pharynx
- Initiation of the swallow
- Oral/pharyngeal clearance
- Aspiration before the sweallow
- Aspiration during the swallow (during white out – evident from residue after the air space returns)
- Sensory awareness and response
17
Q
advantages of FEES
A
- Portable/ bed side
- Reduced cost
- Uses real food/drink
- Ease of repeat procedure
- Direct assessment of the larynx & secretion management
- Use in an extended therapy session
- Can be used for biofeedback
18
Q
disadvantages of FEES
A
- “White out”
- Evidence of aspiration ‘assumed’ not observed
- Can’t quantify aspiration
- Can’t view the oral and oesophageal stage
- Client needs to be co-operative and follow instructions
19
Q
what is pulse oximetry?
A
- Measures amount of oxygen being carried in the bloodstream, give as a percentage
- Normal oxygen saturation (SpO2) is in the region of 95-100%
- readings below 90% are suggestive of significant problems
- Some interest in oxygen saturation levels providing an indicator of aspiration
20
Q
what is cervical auscalation?
A
- Assessment of swallowing sounds and swallowing-related respiration
21
Q
what are you looking for before CA?
A
- Listen to respiration before oral trials: if moist or wet, prompt client to cough/clear their throat
- Helps calculate oropharyngeal transit time/sound of bolus transit
22
Q
what are you looking for during CA?
A
- “double clunk”, “hard swallows”, “in-coordinated swallows”
- Presence of swallowing sounds & pharyngeal swallow events
- Measure the number of swallows needed per mouthful
23
Q
what are you looking for after CA?
A
- Is the glottal release sound delayed?
- Identify any change in respiration after oral trials
24
Q
what is manometry?
A
- Pressure sensors along a catheter
- Measures pressure – strength, patten and adequacy of contractions
- Mostly used for oesophageal difficulties but potential applications for pharyngeal stage difficulties
- Particularly useful for UES opening
