Midterm Flashcards
List the two components of an evaluation of swallowing
Clinical assessment Instrumental assessment (includes videofluoroscopy and endoscopy)
Describe the purpose of the clinical examination
Provides a comprehensive profile of the patient
Interview patient and caregivers
Examine speech/swallow components
Observe what happens when the patient is fed
Provides an opportunity to teach potential compensations
Helps to tailor the instrumental examination
What structures are included in a visual inspection of the oral cavitiy
Lips, sulci, gums, dentition, faucial pillars, roof of mouth, tongue, posterior pharyngeal wall
List functional components assessed in swallow eval
Respiratory mechanism, laryngeal mechanism, velum/pharynx, tongue, lips/face/teeth, jaw
What should be included in a bedside assessment?
Interview patient and caregivers
Examine speech/swallow components
Observe what happens when the patient is fed
Teach potential swallowing compensations
What are some limitations of the clinical examination?
38 - 40% of patients who aspirate are not identified on clinical examination Logemann, Lazarus & Jenkins, 1982
Pharyngeal events are not observable
Basis for aspiration cannot be determined
What two methods have been used in addition to clinical assessment?
Modified blue dye test
Pulse oximetry test
What is the “philosophy” of instrumental assessment?
Flexible protocol or routine Tailored examination Medical status of patient Initial vs follow up study “Therapeutic” study Safest bolus first Predict diet based on bolus types
Provide some diagnostic challenges of instrumental assessments
Unreliable information Compromised communication skills Lack of awareness Lack of cooperation Unaware and/or uninvolved surrogate Denial and accomodation “Normal aging” myth
List potential causes of silent aspiration
Brain stem CVA Desensitization Tracheostomy Medications Decreased level of arousal
You can tailor instrumental assessments based on what features
Medical history
Interview
Speech/oral motor examination
Bolus trials
What questions should you ask when planning the VFSS?
What are the implications of impairments of each functional component?
How should I start—bolus consistency, amount, delivery method?
What compensations do I anticipate using?
What are the objectives of the VSS?
Obtain an image of anatomy and physiology relevant to swallowing
Identify abnormalities of anatomy and physiology relevant to swallowing
Assess individual’s ability to swallow different consistencies safely and efficiently
What are the objectives of the VSS?
Obtain an image of anatomy and physiology relevant to swallowing
Identify abnormalities of anatomy and physiology relevant to swallowing
Assess individual’s ability to swallow different consistencies safely and efficiently
Determine the need for and direction of swallowing rehabilitation and/or need for other consultations
Assess benefit of swallowing tx
Assess benefit of compensatory strategies
Obtain an objective and permanent record of swallowing status
List indications for the VFSS
When a swallowing disorder is suspected, or if an individual is at high risk for dysphagia
When the clinical examination is insufficient to answer relevant questions
When nutritional and respiratory issues are of concern
When the medical diagnosis is not established
When the direction for swallowing rehabilitation needs to be established
VFSS is not indicated in what scenarios?
When dysphagia is resolved
When the patient is too medically compromised or uncooperative
When clinical course or management would not be altered
What equipment is required for VFSS?
Videofluorography Video monitor Means of recording Ultra Visual Imaging in EPIC
Describe the technique for VFSS
Views Lateral Frontal Oblique Positions Erect Recumbent Initial swallow Center over symptomatic area
List the sequence of events for VFSS
Erect Lateral view Frontal view Oblique view Horizontal Introduce compensations when indicated Stress patient as indicated to elicit abnormalities
What features should be analyzed in the lateral view?
Oral and pharyngeal structures Patterns of lingual movement Oral and pharyngeal transit times Pharyngeal delay Movement of bolus Pharyngeal residue Aspiration and its mechanism Cervical esophagus Cervical spine Speech maneuvers “candy” “eee”
What should be analyzed in the frontal view?
Assess structures which were compounded and visually obscured in lateral view
Symmetry of structures and residue
Vocal fold movement
Sustain “eee”
Sniff
Difficult to assess aspiration b/c trachea and esophagus overlap in this view
What features should be analyzed in the oblique view of a VFSS?
Visualize structures that are obscured by density of spine
May need if patient is broad shouldered, stocky
Assess esophagus
What features should be analyzed in the horizontal view of a VFSS?
Must eliminate gravity to assess esophageal motility
Distend esophagus with continuous drinking of large mouthfuls
Use bolster for straining
Turn prone to supine to check for reflux
List features of the esophageal assessment
Upright left prone oblique (LPO)
Gulp thick liquid barium rapidly or gulp thick liquid barium rapidly after gas crystals
Right anterior oblique (RAO)
One to two swallows of thin liquid barium to assess peristalsis
Continuous drinking of thin liquid barium
Bolster
Turn supine
Water siphon
Cough or Valsava
What is included in interpretation of VFSS?
Aspects Functional or motor abnormalities Structural abnormalities Need to know Anatomy/physiology of normal swallow Radiographic anatomy Signs of compensation/decompensation Disorders in one stage can affect another stage
Provide the structures analyzed in a VFSS
Tongue Hard palate Velum Epiglottis Hyoid/larynx Pharyngeal constrictors Cricopharyngeus/UES Esophagus
Provide the actions analyzed in a VFSS
Oral phase Tongue-palate seal Nasopharyngeal seal Compression/propulsion of bolus Hyoid/laryngeal elevation Epiglottic tilt Cricopharyngeal opening Esophageal peristalsis
Describe the strengths of the VFSS
Dynamic
Thorough
Unlimited review capacity
Readily available in hospital setting
Describe the weaknesses of the VFSS
Exposure to radiation “Snapshot” of swallow function Abnormal environment Transport to radiology may be problematic Not easily accessible outside hospital
Give characteristics of the FEES
Fiberoptic Endoscopic Evaluation of Swallowing - FEES uses a special camera on a small scope to look at the throat while swallowing foods and liquids
The narrow tube is inserted into the nose and positioned to view the throat
Pictures are taken as the foods and liquids move through the throat
List other techniques that can be used for instrumental assessment of swallowing
Imaging Videoendoscopy Ultrasonography Scintigraphy Nonimaging EMG EGG Cervical auscultation Manometry pH probe
