Dysphagia Final

Improving strength/mobility/endurance for components of swallowing

*1. Shaker exercise 2. Tongue strengthening 3. Masako maneuver 4. EMST 5. Transcutaneous e-stim 6. Effortful pitch glide* 7. Intramuscular stimulation 8. Neural stimulation

Temperature

- 'Icing of faucial pillars' to improve swallow initiation (this was very popular 20 years ago, most recent evidence does not support this method of stimulation) - Using ice chips to heighten sensory input

anatomical differences between babies and adults

· Smaller oral cavity, velum longer and flatter, everything is smaller/closer together, everything is more anterior

How do we identify the underlying mechanisms for impaired safety and/or efficiency?

- ASSESS INDIVIDUAL COMPONENTS OF SWALLOWING PHYSIOLOGY! - (MBSImP is a standardized way of doing that)

Lateral tilting of the head

- Bolus flow will be directed through the oral chamber biased to the downhill side; will enter the pharynx on the downhill side, but travel through the pharynx unaltered • Physiological Target(s) - Unilateral impairment of lingual movement, sensation or anatomy

VFSS pros

- Compare the patient across time and/or treatment (or degeneration) - Compare to other patients or populations (literature) - Compare to healthy normal (literature) - Share information across clinicians/facilities

Posterior tilting of the head

- Facilitates oral transit of thicker consistencies using gravity; patient must have adequate airway protection as this position puts them in a vulnerable position • Physiological target(s) - Impaired anterior-posterior bolus transport but with good airway protection

Management

Reducing the risk of Dysphagia Oral Health - Minimize the risk of pneumonia due to aspirated material Ex) Free water protocol, Oral cares Assistive Devices and Accommodations - Modifying environmental factors Ex) Nosy cup, straws, limiting distractions at mealtimes

Bolus Size

- Increasing bolus size may increase sensory awareness - Must test this in a logical and safe way

Alternatives to MBSImP - Description of swallowing

- PRO - easy, fast, no official training - CON - highly subjective, poor reliability, no transfer between clinicians

Alternatives to MBSImP -Measurement

- PRO - highly reliable, compare to research literature - CON - special training, costly, time-consuming

Lots of variation in documentation style by clinician and by institution

- SOAP note style - Descriptive reports that describe stages of swallowing - ASHA templates - MBSImP templates

Pediatric Dysphagia Treatment: Goals

- Safely support adequate nutrition and hydration - Determine the optimum feeding methods/technique to maximize swallowing safety and feeding efficiency - Collaborate with family to incorporate dietary preferences - Attain age-appropriate eating skills in the most normal setting and manner possible (i.e., eat and chew meals with peers in the preschool) - Minimize the risk of pulmonary complications - Maximize the quality of life - Prevent future feeding issues with positive feeding/oral experiences as able given medical situation - Help the child eat and drink efficiently and safely to whatever degree is possible

Taste

- Sour bolus to increase swallow frequency, and reduce penetration/aspiration (improved laryngeal closure?) likely due to increased CNV stimulation - Caution against aspiration of acid material

Is an effortful swallow a compensation, treatment, or management?

· Treatment (to strengthen swallow - facilitative maneuver)

What physiological component does the Shaker target?

· UES opening (functional consequence of poor UES opening is residue)

What are some reasons why you might choose FEES over VFSS?

·You can see all structures, it's portable to bedside, you can try it with different foods, repeatable (no Residue radiation), view tissues/mucosa, view for entire meal

Pediatric Feeding Assessment

1. Data collection 2. Nutritional Screening, Feeding Hx, and Developmental Milestones 3. Physical Assessment 4. Oral Sensory-Motor and Feeding Skills Assessment

What is the normal suck/swallow ratio for an infant?

1:1

____-____ of typically developing children demonstrate feeding and swallowing problems

25%-45%

How many frames per second is best for VFSS?

30

FEES

= Fiberoptic Endoscopic Evaluation of Swallowing • Typically, insert endoscope along the floor of the nose with the tip hanging freely in the oropharynx just inferior to the velum at rest during breathing • Allows the examiner to see: - Tongue base - Epiglottis - Piriform sinuses - Posterior cricoid area - Laryngeal structures

Zenker's Diverticulum

A ballooning out of the pharyngeal wall due to high pressure causing a diverticulum (pouch) • Globus sensation, regurgitation, penetration/aspiration of regurgitated material, halitosis, infection • If small and not causing discomfort, no intervention is warranted; when large and symptomatic, surgically managed • Endoscopic stapling • Fiberoptic laser

Documentation

A. Introductory statement (SUBJECTIVE/OBJECTIVE) • The introductory statement may include the patient's history, current subjective complaints, the reason for consultation, and/or summary from clinical bedside assessment. The clinician may discuss the pertinent medical and surgical history that is believed to be related to the swallowing disorder and the technical parameters of the examination. B. Results (ASSESSMENT) • The results section should contain objective statements about observable events only. Typically, results are broken down by swallowing phase. Additionally, document the effectiveness of compensatory techniques, postures, maneuvers, sensory enhancements, and bolus modifications. C. Impressions (ASSESSMENT) • The impressions section should contain subjective statements and should integrate the information that was objectively observed and reported in the results section. The reader expects a full analysis of what can be inferred from the observations, with a diagnostic statement and rationale to support the impression. The impression should project the impact of intervention based on the patient's medical condition, nutrition, and hydration, as well as the impact of differing interventions on the patient's quality of life. D. Recommendations and Plan The recommendations section should describe the interventions that are projected to serve the patient best. E. Patient education should be included at the close of the document

Treatment

Actively changing swallowing physiology Behavioral Therapies - Improve strength/mobility/endurance for components of swallowing Ex) Shaker, Masako, EMST Facilitative Maneuvers - Postures/gestures to improve safety/efficiency Ex) Effortful Swallow, Mendelsohn, Supraglottic

Iowa Oral Performance Instrument (IOPI)

Average maximal tongue strength values for isometric tongue presses (not swallows) reported in the literature. Strengthening tongue muscles should only be a goal when patients are UNDER normative range for their age. —Literature suggests that <40 kPa should be targeted for treatment.

Behavioral Therapies

Behavioral Therapies - Improve strength/mobility/endurance for components of swallowing Ex) Shaker, Masako, EMST

Pediatric OSME

Birth to 4 months • Assess the developmentally appropriate reflexes (next slide) • Assess oral/dental/tongue health • Gag? • Observe the lips and tongue and palpate the cricoid during swallowing. Take note of change in respiration, vocalization quality, coughing 5 to 7 months • Babies should be losing the primitive reflexes • Gain voluntary control of the oral cavity - open mouth at sight of food, manipulate food orally, start to initiate self feeding behavior • Behavior towards eating? • Tongue elevation should replace tongue protrusion • Early jaw manipulation - vertical (first), lateral (later) • Self-feeding behaviors (palmar grasp, holding bottle) 8 to 12 months • Primitive reflexes gone • Food manipulation and chew continue to develop; chew becomes more rotary • Tolerates expanding textures • Sits in midline with stability and independently holds cup/bottle • Starts pincer grasp • Increasing independence with self-feeding

Why Have a Free Water Protocol?

By far, the greatest concern about thickened liquid prescription is that individuals with dysphagia do not consume enough fluids

Bolus Manipulations

Changing properties of the bolus to reduce aspiration/residue Ex) Viscosity (thickness), Volume, Temperature

Reconstruction of Structures

Common anatomical corrections and/or reconstructions: - LIPS - TONGUE - PALATE - VF AUGMENTATION - VF MEDIALIZATION

Compensation, management and treatment - What would chin tuck for dysphagia fall under?

Compensation (bolus manipulation or postural compensation? Answer is postural comp)

Cricopharyngeal (CP) Bar

Failure of the cricopharyngeus muscle to relax during swallowing (as a result of fibrosis, GERD, neuromuscular disease). Causes increasing difficulty with increasing texture viscosity, significant post-swallow residue. Surgical Treatment: - Myotomy - Cut the CP muscle Non-surgical treatment: - Dilation - Physically expand UES - Botox - Inject Botox into CP muscle (temp)

FEES - Swallowing

FEES swallowing assessment basically consists of: 1. Observing the behavior of the food/liquid before the swallow is initiated - Spilling of material into the pharynx (vallecula, larynx, hypopharynx, pyriform sinuses) before swallow initiation - Penetration (material in supraglottic larynx) or aspiration (material below the VFs) BEFORE swallow initiation 2. Noting the safety and efficiency of the swallow after its completion - Residue (material left behind) after the swallow - Penetration/aspiration of residue after the swallow, during ongoing respiration - Evidence of aspiration that presumably occurred during the swallow (material on VFs, below in trachea) - Benefit of clearing swallows Tasks (start with small 5 ml of liquid*): • Hold bolus, then swallow on command; observe for premature spill • Examine pharynx, post-swallow, for residue - Sites, sidedness, estimate of amount are noted - Spontaneous clearing swallows are noted, if not observed, then ask for one - If residue is on the VFs, did patient cough or clear throat? If not (= silent aspiration), ask patient to cough/clear throat and swallow. Was it effective to clear the aspirate? • Progress in bolus volume, method of delivery (spoon, cup, straw) of liquids; then test puree and increasing solids as appropriate • Important to mimic VF protocol - allows you to compare * Milk or colored water (edible vegetable dye)

The hyoid one of a baby is in a more posterior position than that of an adult - T or F?

False, it's more anterior

Positioning - During and After Eating

For all patients with dysphagia: - Upright during all PO • For all patients with confirmed (or even suspected) residue: - Remain upright for 30 minutes post-PO *Positioning is also very important during oral care!

Shaker Exercise

Head-raising exercise to target improved UES muscle function. Patient lies on their back and raises their head to look at their toes WITHOUT lifting the shoulders. Recommended protocol includes both lifting exercises and sustained holding. Physiological Target(s) • Poor UES opening (extent and/or duration) resulting in post-swallow residue Desired Outcome • improve UES function, decrease pharyngeal residue NOTE: Not all patients can tolerate this exercise

Bolus placement

If sensory deficits are unilateral, we can increase sensory input by placing the bolus on the intact side

Compensation

Improving safety and efficiency without changing physiology Positioning/Postural Compensations - redirect bolus flow during eating/drinking Ex) Head rotation, Head tilt, Chin tuck Bolus Manipulations - Changing properties of the bolus to reduce aspiration/residue Ex) Viscosity (thickness), Volume, Temperature

Give a reason for aspiration during the swallow.

Incomplete airway protection/seal

Carbonation

Increase the 'texture' to a liquid bolus. Known to improve esophageal clearance, shorten pharyngeal transit times, and reduce aspiration and residue

infant swallow - breastfeeding

Infant breathes through nose (A) to allow unimpeded breathing (B). Milk can be contained in the oral cavity during sucking/breathing (C) and safely swallowed to the esophagus (E) thru the pharynx (D) when the airway is sealed via epiglottis to arytenoids.

The Goal of the VF Exam

Is NOT only to identify penetration/aspiration and residue (risk of aspiration), but to understand the underlying physiological cause of aspiration. [Not a pass/fail exam!] • What are the risks? • What behaviors/conditions lead to the risks? • Can you modify them? • Taken together, find a way to elaborate/improve a patient's potential for eating orally • Aspiration Risk (Safety?) - ID the underlying cause of impaired safety • Example: delayed and incomplete laryngeal vestibule closure - What can be done to modify the safety issues? • Test the Supraglottic Swallow? Test thicker liquids? • Residue Risk (Efficiency?) - ID the underlying cause of impaired efficiency • Example: poor bolus driving forces (posterior tongue, pharyngeal contraction, pharyngeal shortening) - What can be done to modify the efficiency issues? • Test the Effortful Swallow? Test clearing swallows?

Why would pairing neuromuscular electrical stimulation with swallow possibly improve hyolaryngeal excursion?

It's like swallowing against resistance because it depresses the hyolaryngeal complex - strengthening those muscles

Penetration-Aspiration Scale

It's not enough to rate PAS - you must comment on TIMING in relation to the swallow! • BEFORE - Spill of material from the mouth? Delayed swallow initiation? • DURING - Incomplete laryngeal closure? Delayed swallow initiation? • AFTER - Post-swallow residue? Abnormal respiratory-swallow pattern?

Anterior tilting of the head (aka "THE CHIN TUCK")

Keeps the bolus in the mouth until actively compressed by the tongue; compresses the airway closed • Physiological Target(s) - Premature spill, poor airway closure, penetration/aspiration before and/or during the swallow Note: If patient has lots of post-swallow residue, chin tuck may push more residue into the pharynx. MUST test with instrumentation.

Tongue Strengthening

Lingual resistance exercises for weak tongue musculature to improve strength required for swallowing. Resistance is best provided by a device (pressure-sensitive bulbs) but if these are not available, can be used with a tongue depressor. Physiological Target(s) • Poor bolus formation, premature spill, oral residue, poor base of tongue to posterior pharyngeal wall, pharyngeal residue Desired Outcome • Improve tongue strength to functional levels, impacting bolus formation, spill, bolus driving forces and post-swallow residue Iowa Oral Performance Instrument (IOPI)

Compensation, management and treatment - what would antibiotics for pneumonia fall under?

Management (managing what's already happened)

Head rotation

Maximal rotation to the weak side will compress the weak side and divert the bolus to the more functional side; it will also decrease and/or eliminate weaker piriform sinus • Physiological target(s) - Unilateral impairment in pharyngeal constriction and/or UES opening; unilateral post-swallow residue

Oral Health

Minimize the risk of pneumonia due to aspirated material Ex) Free water protocol, Oral cares

Assistive Devices and Accommodations

Modifying environmental factors Ex) Nosy cup, straws, limiting distractions at mealtimes

Effortful Pitch Glide

Patient phonates on a low-to-high gliding pitch with effort. This causes elevation of the arytenoids/larynx and constriction of the pharynx. Physiological Target(s) • Poor pharyngeal constriction, poor laryngeal elevation Desired Outcome • Improve pharyngeal constriction (and reduce residue) and/or improved laryngeal elevation (and improve safety)

Facilitative Maneuvers

Postures/gestures to improve safety/efficiency Ex) Effortful Swallow, Mendelsohn, Supraglottic

Give a reason for aspiration before the swallow.

Premature spillage, delayed swallow

Bolus Viscosity

Probably the MOST common compensatory strategy in use in clinical practice (unfortunately) • THE RATIONALE: Thin liquids move quickly-> high risk for aspiration. Slowing the liquids down (increasing the thickness/viscosity), allows more time for safe swallowing. Requires less agility and control than thin liquids

Mendelsohn Maneuver

Prolonged elevation of the larynx during swallowing to increase both displacement and duration of hyolaryngeal excursion. The goal is to improve or prolong UES opening. Physiological Target(s) • Early UES closure, incomplete UES opening, poor pharyngeal constriction... both result in post-swallow residue Desired Outcome • Improve and prolong UES opening to decrease pharyngeal residue *MUST* be assessed instrumentally*

Primitive reflexes

Reflexes • Rooting reflex (disappears at 3-5 months) • Suck reflex (disappears at 6 months) • Tongue protrusion reflex (disappears at 4 months) • Bite reflex (disappears at 3-5 months) • Gag reflex is "lifelong" (But... not present in everyone. Caution in interpreting the gag as meaningful!)

Give a reason for aspiration after the swallow.

Residue

The Masako Maneuver

Swallow initiated with the tongue held firmly between the teeth to improve posterior pharyngeal wall contraction (tongue is stabilized so that PPW must displace further to meet the tongue) Physiological Target(s) • Poor tongue to posterior pharyngeal wall contact, poor pharyngeal constriction, pharyngeal residue Desired Outcome • Improve bolus driving forces and post-swallow residue Note: 1. Limited evidence to support this. 2. Never do the Masako with a bolus!

'Effortful Swallow

• "Swallow as hard as you can, squeeze your throat muscles harder" • "Pretend like you are swallowing a big pill or a whole grape" Physiological Target(s) • Significant post-swallow residue, poor pharyngeal constriction, poor base of tongue to posterior pharyngeal wall Desired Outcome • Improve pharyngeal efficiency, decrease pharyngeal residue • Note: The effortful swallow can be used on the initial swallow, or as a second (clearing) swallow to reduce residue. • Note: Therapeutic benefit? This requires strength and endurance over a meal. Some SLPs would consider the effortful swallow an exercise/treatment.

FEES - An infant swallow

• Advantages - Direct visualization of the structures - Use of REAL foods - Repetitive use - Portable - No radiation • Limitations - Minimally invasive - Poorly tolerated (age-dependent) - No oral stage view; limited pharyngeal view due to "white-out" of structures during swallow

Evidence-based medicine (EBM) is multifactorial...

The current lack of efficacy for many of the exercises being taught and prescribed to patients with dysphagia should not imply that these should NOT be prescribed. It is simply a reminder that they have not yet been proven to help swallowing."

Free Water Protocol

The idea that we should allow patients who are on thickened-liquids 'free' access to water between meals after oral care

VFSS - An infant swallow

The study starts with normal rapid swallowing but this soon slows and the trigger becomes more delayed. Although aspiration is not seen, the swallow becomes more risky as time progresses.

TPN (total parenteral nutrition) is a method of providing nutrients intravenously - T or F?

True

Transcutaneous Electrical Stim

• Aka 'e-stim' or 'VitalStim' or 'NMES (neuromuscular electrical stim)' • = Using electrical current to stimulate the nerves or nerve endings that innervate the muscle(s) beneath the skin; goal is to induce muscle contraction through peripheral stimulation - Successfully applied in SCI, TMJ, hand dysfunction, incontinence • The claim: "Combining VitalStim and traditional therapy allows clinicians to accelerate strengthening, restore function, and help the brain remap the swallow." • Evidence for this is controversial, several of the experimental designs are weak

Use of an Anesthetic? (FEES)

• Anesthetic agent (gel, spray) is optional to improve comfort - May lead to sensory changes - Three Langmore studies (Lester et al., 2013; Fife et al., 2015; O'Dea et al., 2015) • Different volumes of 4% lidocaine (1ml, 0.5 ml and 0.2 ml) - Lidocaine does not worsen PAS or residue but does increase comfort

Signs/Symptoms of Feeding and Swallowing Disorders in Children

• Arching or stiffening of the body during feeding • Irritability or lack of alertness during feeding • Refusing food or liquid • Failure to accept different textures of food (e.g., only pureed foods or crunchy cereals) • Long feeding times (e.g., more than 30 minutes) • Difficulty chewing • Difficulty breast feeding • Coughing or gagging during meals • Excessive drooling or food/liquid coming out of the mouth or nose • Difficulty coordinating breathing with eating and drinking • Gurgly, hoarse, or breathy voice quality • Frequent spitting up or vomiting • Recurring pneumonia or respiratory infections • Less than normal weight gain or growth

Assessment With FEES

• Assessment of: - General tissue health, symmetry, pooling - Velopharynx - Pharynx - Larynx - Swallowing

In terms of outcome measures (improvements that show progress), what are two diet-based outcome measures (standardized scales)?

· ASHA-NOMS & Functional Oral Intake Scale (FOIS)

Why is it safe to feed a baby lying flat?

· Because the velum and epiglottis seal the oral cavity during breathing and sucking

What medications can cause higher risk for silent aspiration?

· Central nervous system depressants

Positioning/Postural Compensations

redirect bolus flow during eating/drinking Ex) Head rotation, Head tilt, Chin tuck

What are pill delivery options for people with dysphagia?

· Crush them, give them whole in puree, ask for a substitute in liquid form from the pharmacy

Why would you use FEES with one population over another?

· For example, if there's a voice issue, you could do a FEES and take a look at the vocal cords

What is the name of a device used in tongue strengthening?

· IOP (Iowa Oral Performance instrument)

EMST (Expiratory Muscle Strength Training)

• Calibrated, one-way, spring-loaded valve - The valve blocks the flow of air until enough pressure is produced. Once the valve opens, air flows through the device. • Designed to exercise the expiratory and submental muscles - These are muscles important for breathing out forcefully, coughing, and swallowing. • Proposed treatment lasts four to five weeks, with participants completing 25 breaths a day (5 sets of 5 repetitions) five days per week. Handheld respiratory device targeting improved respiratory function Physiological Target(s) • Weak cough, poor respiratory support, disrupted exhale-swallow-exhale pattern, (? poor hyolaryngeal elevation), penetration/aspiration caused by respiratory issues listed above Desired Outcome • Improve airway protection and respiratory support, possibly improve hyolaryngeal elevation

Indications for FEES

• Concerns regarding alteration of pharyngeal/laryngeal anatomy that is NOT appreciated from lateral 2D VFSS view • Concerns regarding sensory integrity of the larynx/pharynx • Concerns about swallow performance over time (? Fatigue) • High risk of aspiration (assess swallow without stimuli) • Concerns regarding symmetry of swallow and residue • Value of 'online' biofeedback • To assess/teach compensatory techniques • Patient cannot be transported to VFSS suite/VFSS is not available • Concerns about repeated radiation exposure or known rapidly changing condition

Children With Feeding and Swallowing Disorders Are at Risk For:

• Dehydration or poor nutrition • Aspiration (food or liquid entering the airway) or penetration • Pneumonia or repeated upper respiratory infections that can lead to chronic lung disease • Embarrassment or isolation in social situations involving eating

Feeding & Swallowing Team - Additional Specialists:

• ENT: detailed airway and upper aerodigestive tract assessment, FEES with SLP • Pulmonologist: medical and surgical treatment of airway, lung evaluation and treatment • Radiologist: VFSS with SLP, other radiographic diagnostics • Physical therapist: seating evaluations and modifications • Lactation consultant: specializes in breastfeeding support

FEES vs. VFSS

• FEES and VFSS should be viewed as complimentary exams - they yield different (and important) information • Depends on patient and situation. Keep the following in mind: - VFSS involves radiation exposure, specialized staff and equipment - VFSS is (primarily) collected in lateral view - VFSS allows you to see the whole swallow at once, including the option of looking to the esophagus - VFSS must be short in duration and must be collected using barium stimuli - FEES is portable - FEES can be used with more food/drink variety, for longer duration - FEES does not allow you to see the actual swallow 'white-out effect' - FEES allows you to observe post-swallow residue for long periods to assess aspiration risk

Supraglottic Swallow

• Goal is to close the airway prior to bolus entry into the pharynx and to keep the airway closed for the duration of bolus transport • "Put the bolus in your mouth, hold your breath, and keep holding it as you swallow. When the swallow is done, let your breath go in a sudden audible breath." [optional cough post swallow to clear the cords] Physiological Target(s) • Premature spill, delayed swallow initiation, delayed/poor laryngeal closure Desired Outcome • Ensure airway protection before and during the swallow Note: best tested under endoscopy or AP view of VF

Pediatric Dysphagia - Anatomical Differences

• Infant's oral cavity is smaller • Larynx is elevated (descends over first 4 years of life) • Hyoid is elevated and in a more anterior position • Longer and flatter velum

Types of Feeding Tubes

• Nasogastric (NG) - Short duration (<6-8 weeks) with no evidence of GERD. Non-invasive and cost effective. Most common • Nasoduodenal (ND) - Short duration with either GERD and/or slow stomach emptying (tube is placed past the pyloric sphincter). Requires commercial formulas (smaller tube, prone to plugging) • Nasojejunal (NJ) - Longer tube, more difficult to place (radiographic confirmation and/or endoscopic view) Extended placement into GI tract minimizes dislodgment. • ALL nasal tubes: - Placement should be confirmed with x-ray - Can cause sinusitis Gastrostomy (GT or G-Tube): If nasal route is unavailable, long-term needs, or swallow prognosis poor/slow. No reflux • Jejunostomy (J Tube): Minimizes aspiration of reflux, stomach does not need to be fully functioning - Both can be placed endoscopically (endoscope to stomach, light can be seen on the surface of the patient's abdomen, push on that spot while looking through the endoscope to find where the tube should be placed) • Total parenteral nutrition (TPN): A nutritional formula that contains critical nutrients such as glucose, amino acids, lipids, and added vitamins and dietary minerals - TPN comes in a higher concentration, and can only be administered through a larger vein. Peripheral parenteral nutrition (PPN) comes in a lesser concentration, and can be delivered through a peripheral vein - Both are short-term solutions for nutritional needs: takes 10-16 hours per day, costly, invasive, and has infection risk

Pediatric Dysphagia Instrumental Assessment - Potential Contraindications

• No clinical Ax has been performed • The infant has not had any oral feeding experience • The infant refuses oral intake • There is no history of chest illness • The child is unlikely to cooperate • The infant or child is unlikely to medically tolerate the procedure • Symptoms indicate sensory preference issues • Symptoms indicate esophageal or GI symptoms • Performing a repeat exam without (clinical) evidence of change • Findings won't change management

Limitations of FEES

• No oral phase • 'White-out' during swallow - Difficulties with assessing penetration and aspiration of swallowing • No measurement available - 'degree' of opening, constriction, elevation, etc. is not appreciable

Muscle Stimulation

• Ongoing research to look at the utility of intramuscular electrical stimulation - More precise but considerably more invasive - Early research phases, no clinical applications available

What Are We Assessing With Instrumentation?

• Oral prep deficits - Manifestation: pre-mature spillage (liquids only), piecemeal deglutition, pocketing, poor bolus formation • Efficiency deficits - Manifestation: post-swallow residue • Safety deficits - Manifestation: penetration, aspiration • Sensory deficit - Manifestation: lack of response

Pediatric Dysphagia Team

• Parents: primary caregiver and decision maker for child • Primary physician: medical leader • SLP: team co-leader (with other medical specialties), conducts feeding and swallowing evaluations, VFSS (with radiologist), FEES (with ENT) • Nurse: reviews medical records and parent information, coordinates follow-up, changes feeding tubes • Dietitian: assesses past and current diets, determines nutritional needs, monitors nutrition status • Psychologist: identifies and treats psychological and behavioral feeding problems, guides parents for behavior modification • OT: evaluates and treats problems related to posture, tone, and sensory issues • Social worker: assists with access to community resources, advocates for the child

HOW DO WE KNOW WHEN SOMEONE'S SWALLOWING HAS IMPROVED?

• Penetration aspiration scale. -VFSS -Modified for FEES • Residue - VFSS: Perceptual judgment of percent filled - VFSS: Normalized residue ratio scale. - FEES: Yale pharyngeal residue severity rating • Kinematic parameters (VFSS) - Extent of hyoid movement - Extent of UES opening - Extent of epiglottic inversion • Timing parameters (VFSS) - Stage transition duration - Pharyngeal transit time - UES opening duration • MBSImP scores (VFSS) Videofluoroscopic Outcomes Patient-Reported Outcomes Diet-Based Outcomes Etiology-Specific Scales Peripheral Changes Neural Changes Health Markers *The Best Approach • A combination... - Instrumental evaluation of swallowing - Patient perspective/QOL - +/- other quantified objective data*

Lateral vs. A/P View (Anterior/Posterior) VFSS

• Primary assessment done in lateral view - allows you to observe bolus flow through the oral - pharyngeal - upper esophagus while separately viewing the larynx and trachea. • In A/P, the esophagus and trachea are overlaid making impressions of impaired safety difficult. However, A/P is superior for observing asymmetries in physiology and post- swallow residue and permits you to pan down the esophagus if indicated.

Super Supraglottic Swallow

• Supraglottic swallow PLUS increased effort of airway closure (bear down) • "Put the bolus in your mouth, hold your breath and *bear down (like you are about to lift something very heavy*), and keep holding it as you swallow. When the swallow is done, let your breath go in a sudden audible breath." [optional cough post swallow to clear the cords] Physiological Target(s) • Premature spill, delayed swallow initiation, delayed/poor laryngeal closure, difficulty with VF closure Desired Outcome • Ensure airway protection before and during the swallow

Enteral Feeding

• The delivery of food directly to the GI tract • Aka 'tube feeding' • DOES NOT PREVENT ASPIRATION! - Why? 1. Saliva 2. Reflux

Positioning - To Influence Bolus Flow

• Used to REDIRECT the bolus in a way to improve swallowing safety or swallowing efficiency 1. Lateral tilting 2. Anterior tilting (aka 'chin tuck') 3. Posterior tilting 4. Head/neck rotation

FEES - Pharynx

• With scope in the upper pharynx, ask patient to phonate /a/, followed by tongue base retraction with a pharyngeal fricative • Examine for pooled secretions in the pyriform sinuses, vallecula, pharyngeal walls, base of tongue, and posterior cricoid area - If pooled secretions are observed (abnormal), touch this area to assess sensation. Then ask the patient to swallow. • If cleared -> sensation may be impaired • If not cleared -> motor function may be impaired • Have patient execute high pitch elevation to test pharyngeal constriction (presence, absence, unilateral?) • Ask patient to hold nose, and bear down to maximize pyriform sinus space • Have patient turn head from L to R and observe closure of the pyriform sinuses and any asymmetrical responses

FEES - Larynx

• With scope near tip of epiglottis - have patient phonate /i/ to observe glottis closure, laryngeal elevation, and vocal quality - Incomplete closure, poor elevation and poor vocal quality may indicate risk of airway protection • Have patient conduct a pitch glide to observe changes in vocal fold length, laryngeal elevation and pharyngeal constriction • Have the patient alternate /i/ with sniff to assess the abduction and adduction of the VFs • Observe true and false VF closure during breath holding task and coughing or throat clearing

FEES - Velopharynx

• With the scope between inferior and middle turbinates observe the velar elevation and constriction of the lateral and posterior pharyngeal walls during the following tasks: - Sustained vowel - Sustained /s/ - Non-nasal sentence ('is Sassy sick?') • Look for symmetry and contributions of each structure • Expect tighter closure during /s/ over vowel and expect maintenance of closure during the non-nasal sentence • Observe closure during dry (saliva) swallow • Check for leakage during a liquid swallow (optional)

Neural Stimulation

• rTMS - Repetitive Transcranial Magnetic Stimulation - Non-invasive brain stimulation using a magnetic field generator (= 'coil') to elicit small electrical currents in the cortical area of interest • tDCS - Transcranial Direct Current Stimulation - Low-current electrical neurostimulation delivered directly to the cortical area of interest