1
Q
Swallowing 101 Facts
A
- 26 muscles and 6 cranial nerves to swallow
- How long- .5 to 1 sec (exclusive of the esophageal phase)
- Swallow 600-1000 times a day, each meal 250+ and 50x while sleeping
- How long does it take to digest, 90 mins (up to 6 hours for high fat)
- How long is the GI tract- 30 feet
- How long does food stay in the GI tract 4-72 hours
- .5 to 1.5 liters of saliva a day
2
Q
What is the MBS or VFSS
A
- Recorded dynamic radiography that utilizes continuous x-rays to objectively assess swallowing function
- instrumental exam
- Provides real-time images of bolus transport and oropharyngeal motility
- Provides a means for off-line assessment of the patients swallowing status.
- Bedside is subjective (you have to infer with eyes and ears, MBS you can see all stages of the swallow)
- Real time image
- You can suggest compensations (postures, maneuvers, or sensory enhancements) check stimulability under x-ray and see if there is a less restrictive way to help the pt. than just modifiying their diet.
3
Q
Why do an instrumental exam instead of a bedside? 1
A
- The bedside is inconclusive.
- If pharyngeal or esophageal dysphagia is suspected.
- The patient’s pulmonary status or nutritional status is compromised and dysphagia might be part of the cause of the problem.
4
Q
Why do an instrumental exam instead of a bedside? 2
A
- You cannot develop an appropriate treatment plan without information obtained on the instrumental examination.
- The patient continues to show signs of aspiration even though the initial bedside eval did not indicate a pharyngeal problem.
- The patient has had a previous instrumental exam and now you think the patient has changed (improved or declined).
5
Q
What information do we obtain from a MBS? 1
A
- Not only to determine whether or not the patient is aspirating, but to figure out why the patient is and if there is a way to prevent it.
- To evaluate swallowing physiology, timing and coordination.
*** Timing and coordination is very important
- To identify the impact of abnormal swallowing physiology, timing and coordination.
- We can see all phases of the swallow
- Individuals with structural/mechanical problems should have MBS (cancer pts.)
6
Q
What information do we obtain from a MBS? 2
A
- Identify the etiology, timing and amount of penetration and/or aspiration
- Reaction to laryngeal penetration/aspiration
- Make note of sensory awareness and reaction to residue, penetration and/or aspiration.
- Identify etiology, percentage and location or residue.
7
Q
What information do we obtain from a MBS? 3
A
- To see the effects of compensations (posture changes such as chin tuck and head rotation), bolus/texture modification, maneuvers such as the supraglottic swallow, sensory enhancements
- To look at therapeutic intervention trials.
- To determine patient stimulability to perform maneuvers and compensations.
— With an MBS we can provide biofeedback to patients with behavioral disorders
8
Q
Rationale for MBS
A
- To simulate a natural feeding environment, as possible
- To provide recommendations regarding optimum delivery of nutrition and hydration
- To collaborate with and educate other team members, referral sources, caregivers and patient re: recommendations for optimum swallowing safety and efficiency.
9
Q
MBS/VFSS
A
- Most frequently used procedure to assess the pharyngeal phase of the swallow.
- Considered by most to be the “Gold Standard”.
- Procedure usually performed by an SLP and a radiologist.
- Allows for visualization of all phases of the swallow, from the oral preparatory phase through the esophageal phase.
- This view is captured on a video media for later review
- Pts. With COPD (you need to be able to hold your breath long enough to swallow) If people are getting really out of breath while they are eating or drinking, you want to do a MBS
- If pt. is medically unstable, it may be better to do FEES or a bedside
- MBS may not be best for the elderly with a poor posture
- Size of the individual may prevent a MBS from being preformed, the MBS room is small, and the larger the room, the larger the x-ray beam which makes the view of the swallow difficult
10
Q
Indications of Swallowing Issues
- 3 types of impairments
A
- Known or suspected medical diagnoses of:
a. Neurological impairment
b. Structural/Mechanical impairment
c. Functional/Behavioral disorders
11
Q
Signs/symptoms of dysphagia 1 (6)
A
- Complaint of difficulty swallowing
- Overt coughing/choking/strangling during eating or drinking
- Increased effort with swallowing
- Multiple respiratory infections
- History of new or recurrent pneumonia
- Respiratory changes with eating/feeding
12
Q
Signs/symptoms of dysphagia 2 (5)
A
- Food refusal/avoidance
- Decreased nutritional status
- Failure to thrive
- Change in oral intake behavior
- Impaired oropharyngeal/laryngeal sensory/motor functions
13
Q
Contraindications of MBS (5)
A
- Patient is medically unstable
- Patient is unable to cooperate or participate in instrumental exam
- Patient is unable to be adequately positioned
- Size of patient prevents adequate imaging or exceeds limit of positioning devices
- Allergy to barium
14
Q
Limitations of MBS
A
- Time restraints due to radiation exposure
(Should only be in the MBS room for 3-5 mins, radiation is always an issue) - Procedure only samples swallow function
- Viscosity issues (thickness with barium may not be accurate)
- Command vs. natural swallow (command, you tell the pt. to hold the food then swallow, but you want to use the natural swallow)
- **not a natural setting
- Barium, unnatural food bolus with potential for refusal or alteration of swallow
15
Q
Patient Positioning of MBS
A
- Patient positioned between table & fluoroscopy tube (need to be able to sit at straight 90 degree angle)
— Fluoroscopy views are either lateral or anterior posterior view
— Typically seated upright to simulate normal ingestion.
- The video image should include the entire oropharyngeal region, with the borders including:
a. the lips anteriorly
b. the palate superiorly
c. the cervical spine posteriorly
d. the subglottic airspace inferiorly
16
Q
Identify Structures at Rest 1
A
- lips
- dentition
- mandible
- tongue
- velum and velopharyngeal port
- valleculae
- epiglottis
- hyoid
17
Q
Identify Structures at Rest 2
A
- pharynx
- posterior pharyngeal wall
- pyriform sinuses
- larynx
- trachea
- upper esophageal sphincter
- cervical esophagus
- cervical spine
18
Q
Procedure for MBS
A
- Typically begins in the lateral view
- Follows a protocol
- Begin with the liquid consistency most tolerated, or thin liquids
- Liquids are given in small amounts (3cc, 5cc, 10cc) and progress to larger amounts if the patient is swallowing safely.
- Liquids are tried from a cup, straw, and spoon
- Original Logemann protocol involved 6 swallows
19
Q
Lateral View for MBS 1
A
- Allows visualization of the oral preparatory and oral phases as the patient manipulates the bolus.
- You can see anterior loss, material falling to the floor of the mouth or anterior or lateral sulci, residue on the hard palate, and premature spill of the bolus over the back of the tongue.
20
Q
Lateral View for MBS 2
A
- Allows assessment of the pharyngeal phase such as delay in initiation of the pharyngeal swallow, penetration into the laryngeal vestibule, aspiration before, during, or after the swallow,and residue in valleculae or pyriforms.
- It also allows for screening of the esophageal phase of the swallow.
21
Q
Anterior-Posterior View (AP)
A
- Allows visualization of symmetry of movement in the pharynx
- Allows for observation of shortening and contraction of the pharynx.
- It provides a view of the movement of the vocal cords toward the midline
- Can see bolus clearance through the esophagus during screening sweep
22
Q
Logemann Barium Protocol
A
- 1/3 teaspoon of thin liquid barium with one time confirmation
- 1/3 teaspoon esophatrast barium paste with one time confirmation
- ¼ cookie coated with esophatrast barium paste with one time confirmation
23
Q
Expanded Modified Barium Swallow Protocol
A
- Thin, nectar, and honey thick liquids mixed with thin barium or barium powder
- Puree consistencies such as pudding and applesauce mixed with thin barium or barium powder
- Mechanical soft consistencies such as or banana and ground meat mixed with barium
- Mixed consistencies such as fruit cocktail, w/barium
- Solid consistencies such as bread and regular meat or hard cookie coated with barium
24
Q
Modified Barium Swallow Impairment Profile (MBSImP) 1
A
- A valid and reliable instrument
- A standardized protocol for MBS
administration with consistent contrast viscosities and reporting method. - Web-based learning environment
- Designed to improve the quality and accuracy of MBS practice.
25
Modified Barium Swallow Impairment Profile (MBSImP) 2
Recommends standardized Barium preparations
- Lateral view
1. Thin: 5ml tsp, command swallow
5ml tsp, command swallow
10ml controlled single sip sequential swallows
2. Nectar: 5ml tsp, command swallow
10ml controlled single sip sequential swallows
3. Honey: 5ml tsp, command swallow
4. Pudding: 5ml tsp, spontaneous swallow
5. Solid: ½ Lorna Doone, 3ml pudding consistency, chew & spontaneous swallow
26
Modified Barium Swallow Impairment Profile Protocol 3
- Anterior-Posterior View (with esophageal follow-through)
- Nectar: 10ml, command swallow
- Pudding: 5ml, spontaneous swallow
27
Sequence of Events of swallow 1
- Oral bolus containment by labial seal & tongue to palatal seal.
- Mastication and bolus manipulation.
- Recollection of bolus on midline tongue.
- Upward and posterior movement of the tongue.
- Initiation of the pharyngeal swallow.
- Tongue base retraction.
28
Sequence of Events of swallow 2
- Soft palate elevation
- Anterior-superior movement of the hyo-laryngeal complex.
- Laryngeal elevation and laryngeal vestibule closure.
- Epiglottal retroflexion
- Pharyngeal contraction and shortening.
- PE segment opening (cricopharyngeus muscle)
- Pharyngeal stripping wave.
- Esophageal clearance.
29
Critical physiologic events in the swallow (4)
- Tongue base movement
- Triggering the pharyngeal swallow
- Airway protection
- Cricopharyngeal opening
30
Components of the MBS
- ORAL STAGE 1
- Lip Closure – look for the presence and location of bolus material seen between or outside of the lip seal.
- Tongue control during bolus hold – looking at the patient’s ability to seal the tongue to the hard & soft palate
31
Components of the MBS
- ORAL STAGE 2
- Bolus preparation/mastication
- Bolus transport/lingual motion – judged at the onset of productive tongue movement directed to propelling the bolus through the oral cavity.
- Oral residue – judged after the completion of the first swallow
- Initiation of the pharyngeal swallow – look at the position of the bolus head (leading edge) at the time of first initiation of the brisk, superior-anterior hyoid trajectory.
32
Components of the MBS
- Pharyngeal Stage
- Soft palate elevation – contact between the soft palate and posterior pharyngeal wall at the height of the swallow.
- Laryngeal elevation – judged during initial elevation of the larynx and prior to the height of the swallow
33
Pharyngeal Stage 2
- Anterior hyoid excursion – judged at the height of the swallow.
- Epiglottic movement – judged at the height of the swallow.
- Laryngeal vestibule closure – judged at the height of the swallow. Closure at the entrance to the airway between the epiglottic base and the arytenoids.
- Pharyngeal stripping wave – judged along the full length of the pharyngeal wall from the nasopharynx to the UES segment.
34
Pharyngeal Stage 3
- Pharyngeal contraction – judged in AP. Looking for symmetry.
- Pharyngoesophageal segment opening – judged during maximum distension. (aka cricopharyngeal opening)
- Tongue base retraction – judged at maximum retraction of the tongue base. Looking at contact of tongue base to the posterior pharyngeal wall.
- Pharyngeal residue – the amount of bolus material remaining in the pharynx after the initial swallow. (valleculae, pyriform sinus’, posterior pharyngeal wall, diffuse)
35
Esophageal Stage
Esophageal clearance – typically best scored from the AP view.
36
Penetration
- Material enters the laryngeal vestibule and remains above the vocal cords.
- May or may not be ejected.
37
Aspiration
- Material touches or goes below the vocal cords.
- May or may not be ejected.
- Can occur:
--- Before the swallow
--- During the swallow
--- After the swallow
38
Aspiration before the swallow, due to: (3)
- Reduced oral control
- Timing issues
- Reduced sensation
39
Aspiration during swallow, due to (3)
- Poor hyo-laryngeal excursion
- Poor laryngeal closure
- Poor vocal fold closure
40
Aspiration of residue after the swallow, due to: (4)
- Reduced laryngeal elevation
- Reduced pharyngeal stripping wave
- Reduced cricopharyngeal opening
- Reduced hyolaryngeal elevation
41
Penetration-Aspiration Scale
1-3
1. Material does not enter the airway.
2. Material enters the airway, remains above the vocal folds, and is ejected from the airway.
3. Material enters the airway, remains above the vocal folds, and is not ejected from the airway.
42
Penetration-Aspiration Scale 4-6
4. Material enters the airway, contacts the vocal folds, and is ejected from the airway.
5. Material enters the airway, contacts the vocal folds, and is not ejected from the airway.
6. Material enters the airway, passes below the vocal folds, and is ejected into the larynx or out of the airway.
43
Penetration-Aspiration Scale 7-8
7. Material enters the airway, passes below the vocal folds, and is not ejected from the trachea despite effort.
8. Material enters the airway, passes below the vocal folds, and no effort is made to eject.
44
Bedside vs. MBS
- Beside Assessment:
1. Examines oral cavity
2. Infers pharyngeal & esophageal deficits
3. Infers safest oral intake
- Modified Barium Swallow:
1. Examines oral cavity, pharynx, larynx, screens esophagus
2. Defines etiology & physiology of penetration & aspiration
3. Assesses speed of swallow, mobility & motility
4. Objectively determines plan of treatment for safest oral intake
45
MBS vs. Barium Swallow Study
- MBS
1. Examine oral cavity, pharynx, & larynx
2. Small amount of liquid used (paste, masticated material)
3. Position patient upright
4. View laterally and anterior posterior
5. Screening sweep of esophagus with 1 – 2 solid bolus’
Barium
1. Examines esophagus more thoroughly
2. Large amount of liquids used
3. Position patient supine
4. View anterior/posterior
5. Follows bolus with liquids
46
Clinical Impressions and Documentation 1 (5)
- Anatomic and physiologic swallow disorder
- Impact of disorder
- Sensory awareness
- Effectiveness of clearance
- Effectiveness of compensatory techniques, postures, maneuvers, sensory enhancements, bolus modifications
47
Clinical Impressions and Documentation 2 (6)
- Tolerance of and response to examination
- Recommendations re: method of delivery, modifications, therapeutic interventions required
- Precautions
- Positioning
- Rehab plan
- Referrals
48
Radiation Safety
- As x-rays enter matter, some will be absorbed partially or completely while others will pass without interaction.
- Scatter are x-rays that interact with matter and change direction
- The majority of the radiation dose received by the SLP comes from scattered radiation from the patient.
- Scatter radiation exposure is present within at least a six foot radius of the patient.
- Scatter radiation does not linger in the room. It is only present when the x-ray beam is on.
49
Radiation Guidelines: ALARA
- Time
- Distance
- Shielding
*** ALARA- As low as resonably achievable
50
Radiation Guidelines: ALARA
- Time
- Duration of study should be reduced whenever possible
- Fluoro time should not exceed five minutes
- Halving time halves personal exposure
51
MBS Survey
- 1 –2 minutes of radiation exposure – 22%
- 2 – 3 minutes – 30%
- 3 – 4 minutes 29%
- Industry standard – keep the fluoro time under 5 minutes in adults, shorter in children.
- During that time, must assess for bolus modifications, compensatory techniques, maneuvers and postures and potential treatment techniques.
52
Radiation Guidelines: ALARA
- Distance
- SLP should remain as far from the patient and x-ray tube as practical
- Increasing distance is one of the most effective means of reducing exposure.
- The amount of radiation exposure one receives is inversely related to the distance one is from the source.
- Doubling your distance from the patient will decrease your radiation exposure by half.
53
Radiation Guidelines: ALARA
- Shielding (5)
- Lead apron
- Thyroid shield
- Protective glasses
- Protective gloves
- Dosimetry badges
54
Monitoring radiation exposure
- SLP will wear a film badge (dosimetry badge) on the outside of the lead apron at the neck area which will be reviewed periodically by the RSO.
- Second badge recommended under apron
- SLP’s who feed the patient may wear a ring dosimetry badge
- SLP will not receive more than 5 rem/year
55
Pregnant SLPs
- Should wear a lead wrap-around apron
- May require more frequent dosimetry badge review.
- Some facilities do not encourage SLP’s to do fluoro when pregnant.
56
Pharyngeal Manometry
- Measures the pressure in the upper and lower esophageal sphincters.
- Sensors measure pressure at specific points
- Can be done in conjunction with MBS.
57
Ultrasound
- Uses high frequency sounds to produce dynamic images of soft tissues.
- Study completed by holding a transducer under the chin.
- Useful in studying the oral and oral preparatory phases of swallowing
- Does not allow for observation of aspiration or analysis of the pharyngeal phase.
