Instrumental Evaluation Suspect aspiration (silent) Suspect pharyngeal dysphagia

Fluoroscopic Evaluation Fluoroscopy Dynamic x-ray Cinefluoroscopy Film Frame by frame analysis Videofluoroscopy Videotape Immediate playback capabilities Audio recording capabilities

Purpose of Videofluoroscopy Assess overall swallow function Oral preparation and transit Pharyngeal phase Esophageal phase Modified Barium Swallow Determine the presence of aspiration Why is the pt aspirating Alleviation symptoms Consistency postural

What is fluoroscopy? Fluoroscopy is an imaging technique that takes live x-ray images of the body by passing a continuous x-ray beam through the structure being studied. The x-ray images appear on a video screen in real time, which allows the radiologist to see how well the structure is functioning.

Type and Amount of Material Consistencies Thin/thick liquids Purees Cookie/cracker Food trays Contrast medium Try all consistencies unless contraindicated Small/large presentations

Patient Positioning Can be the most-time consuming portion of the evaluation Standing or seated As close to 90o as possible Lateral plane Image Oral cavity Pharynx Bifurcation of the trachea/esophagus Superior esophagus

Fluoroscopy Equipment

Measures/observations Oral transit time Pharyngeal transit time Pharyngeal reflex triggering Stasis/residual material Nasal regurgitation Vallecular stasis Pyriform sinus Penetration Aspiration Before During After the swallow

Anterior-Posterior View Asymmetries Collection of material Unilateral Bilateral Postural changes Vocal fold function Gross assessment Screening of esophageal function

Procedure Liquid first Unless otherwise indicated via bedside evaluation or patient report Hold in the oral cavity until directed to swallow Aspiration Before During After Purees Cookie/cracker Swallow when masticated

Extras Therapeutic techniques Chin press/tuck Head turns Head tilts Mendelsohn maneuver Liquid modification Solid-liquid manipulation Clear pharyngeal stasis Supraglottic swallow

Fiberoptic Endoscopic Evaluation of the Swallow (FEES) Equipment requirements: Flexible/Fiberoptic endoscope Camera Light source SVHS recorder Monitor microphone

FEES Procedures Flexible scope is inserted transnasally Moved until it is situated above the level of the valleculae Various bolus consistencies and volumes are administered Events prior to and subsequent to the swallow are observed Colored water milk

Pros of the FEES No radiation Can do extensive testing Numerous bolus consistencies Numerous volumes Pre-post compensatory techniques Treatment strategies can be studied Feedback Portability Cost effectiveness of procedure

Cons of FEES Oral phase cannot be viewed Obscures events during the swallow Cost of equipment Cost of training Pt cooperation/tolerance for nasal endoscopy Movement disorders contraindicated

Ultrasound High-frequency sound waves are emitted, reflected and received by an ultrasound transducer and assembled into a video image Tissues are differentiated by their ability to reflect sound waves

Pros/Cons of Ultrasound Non-invasive Risk free Can be used for extensive examination with numerous administrations Easy to use with all age groups Equipment/set-up costs Training Limited to oral cavity/oropharynx

Electromyography Electromyography (EMG) is the study of muscle activity Electrical activity is amplified and monitored Surface electrodes Intramuscular electrodes Auditory signal can be monitored

Pros/Cons of EMG Pros: Cons: Can be non-invasive Surface electrodes Indication of muscle activity Can be used for biofeedback Cons: Difficult to compare from session to session Equipment set-up costs Training Interpretation of EMG output Difficult to pinpoint muscle groups

Cervical Auscultation Cervical auscultation is relatively new low-tech technique to facilitate accurate bed-side evaluation of the swallow. Monitors the sounds of the swallow Stethoscope Microphone accelerometer

CA Procedures Listening/recording device is placed over the thyroid lamina Listen to air-exchange, respiration before swallow Turbulence in the flow of air Evidence of material in the vestibule Can material be cleared

CA Procedures Listen during swallow Normal sequence Inhalation Apnea Two clumps-clicks exhalation

Abnormal sounds Changes in respiratory rate No clearing exhalation Delayed clearing exhalation A muffling/melding of the distinct clumps of sound No apnea Prolonged apnea Prolonged swallow sounds Turbulence in the air-exchange Stridor bubbling squeaks Wheeze gurgling crackling

Upper and Lower Airways Upper airway Mechanisms that protect the upper airway Normal sequence/structures Three valves Epiglottic inversion, sealing the laryngeal vestibule Ventricular fold adduction True fold adduction Lower airway Mechanisms that protect the lower airway Cough Ciliary action Alveolar macrophages

Lung sounds Apnea-total cessation of breathing Dyspnea- difficult, labored and/or painful breathing Cheyne stokes- cycles of breathing that increase then decrease in rate and depth with periods of apnea between cycles. Rales- discrete crackling sounds typically heard on inspiration when air collides with secretions Indicates fluid in lung fields Rhonchi- coarse sounds heard throughout the respiratory cycle Exhalation Wheezing- indicates narrowing of the bronchioles, possibly bronchiospasm