1. Instrumental Evaluation
Suspect aspiration (silent)
Suspect pharyngeal dysphagia

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

3. 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

4. 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.

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

6. 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

7. Fluoroscopy Equipment

9. 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

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

11. 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

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

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

14. 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

16. 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

17. 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

18. 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

19. 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

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

21. 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

22. 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

23. 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

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

25. 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

26. 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

27. 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