Instrumented Eval_VFSS

Instrumented Evaluation of Swallowing

Introduction

  • Presented by: Rebecca S. Bartlett, PhD, CCC-SLP

Importance of Instrumented Evaluation

  • Assesses swallowing physiology: timing, range of motion (ROM), and coordination.

  • Evaluates compensatory maneuvers: how patients compensate for swallowing difficulties.

  • Supports clinical decision-making: guides recommendations for diet modifications and treatment strategies.

Types of Instrumented Tests

  1. Videofluoroscopic Swallow Study (VFSS)

    • Also known as: Modified Barium Swallow Study, Video swallow study, Videofluoroscopy, Videofluorography, MBS, Cookie swallow.

  2. Fiberoptic Endoscopic Examination of Swallowing (FEES)

  3. High Resolution Manometry (HRM)

    • Status: Considered the gold standard.

Videofluoroscopic Swallow Study (VFSS)

  • Method: Video evaluation of oropharyngeal swallow using barium as a contrast agent.

  • Radiation Concerns:

    • Average VFSS duration: 4.82 minutes.

    • Radiation stats: It takes 40 VFSS to exceed annual radiation exposure limits.

    • Typical radiation exposure: 3-5 minutes.

    • Safety measures: Thyroid cover, wearing lead vests, and using radiation dosimeters.

  • Image Capture Rate:

    • Recommended minimum: 30 images/second.

    • Lower rates (e.g., 15 images/sec) can miss critical events like penetration/aspiration.

    • The pharyngeal swallow is quick (700 msec), highlighting the importance of image capture speed.

  • Analysis Techniques:

    • Frame-by-frame analysis during MBSImP and routine clinical practice is encouraged.

MBSImP Scoring Criteria

  • Elements assessed:

    1. Lip Closure

    2. Tongue Control/Bolus Hold

    3. Bolus Preparation/Mastication

    4. Bolus Transport/Lingual Motion

    5. Residue issues in oral and pharyngeal phases and more.

Barium Materials for VFSS

  • Premixed options include: Thin liquid, nectar liquid, honey, pudding thick, barium pill.

  • Bolus sizes: 5 mL (tsp), 10 mL liquids; average cup sip = 20 mL.

VFSS Procedure

  • Key elements:

    • Preparation of barium materials on a tray.

    • Patient positioning (usually upright) and transport to radiology.

    • Conducted with team involvement (radiologist, tech, SLP).

    • Flexible protocol with various consistencies and strategies employed live.

    • Education for patients/caregivers and proper documentation required.

VFSS Evaluations

  • Key Focus Areas:

    • Timing, range of motion, and coordination during swallowing.

    • Observational markers:

      • Prolonged or rushed timing, reduced oral coordination or ROM.

      • Evaluating premature spillage versus swallow onset delay.

Observations of Swallow Mechanics

  • Posterior Lingual Propulsion:

    • Timing of the tongue sweep relative to the bolus.

    • Assessment of ROM if the tongue does not contact the pharyngeal wall.

  • Swallow Trigger Assessment:

    • Presence/absence of trigger and response timing.

Pharyngeal Phase Observations

  • Laryngeal Closure: Checking for epiglottic inversion and hyolaryngeal elevation.

  • UES Opening Timing: Analyzing presence/absence and degree of opening for different bolus sizes.

  • Residue Assessment: Evaluating vallecular and pyriform sinus residue, along with identifying any functional impairments.

Compensatory Strategies and Their Evaluation

  • Therapeutic Techniques: Chin tuck, head turn, supraglottic swallow.

  • Bolus Modifications: Size and consistency adjustments; delivery methods studied.

Advanced Assessment Techniques

  • Airway Assessment: Understanding penetration and aspiration across the swallowing process.

  • Reporting: Use of Penetration-Aspiration Scale (PAS) for assessing airway involvement and effectiveness of clearing mechanisms.

Additional Considerations

  • Esophagram: Fluoroscopic exam focused on esophagus, capabilities, and potential diagnoses like GERD.

  • MBSImP Scoring Steps: Includes assessing hyoid bone movement and timing of the pharyngeal swallow initiation.

Summary and Future Steps

  • Next Course: FEES Skills Lab preparation and group assignment details for VFSS assessment.

  • Use of Resources: Reference the Canvas for additional materials and handouts.