[Dysphagia] RE: Dysphagia Digest, Vol 16, Issue 11

[brownsr at health.missouri.edu (Brown, Suzanne R.)]

Adding our 2 cents into the conversation about using food in the VFSS

> VFSS is intended to examine the dynamics of the swallow and to determine whether various compensatory interventions might be helpful - in real life.
>Dr I Campbell-Taylor

 
 
FIRST, we don't use barium paste with all solids (only on tough meats)...we use powder on rice, fruit cocktail, and applesauce so that the consistency is as close to normal food as we can get. 
SECOND, how do we know the dynamics of the swallow if we don't test the swallow under different conditions (cohesive moist solids, dry/crumbly solids, tough to chew solids, solids mixed with liquid - fruit cocktail or soup)?  The swallow might be adequate with a cohesive moist solid bolus (applesauce or pudding) but a little weak for tough or dry solids. If it's a little weak for dry or tough solids then they have to swallow several times to get each bite down.  In a patient who has been in therapy all day, this is a lot of effort and could lead to muscle fatigue which makes the swallow even weaker putting them more at risk for aspiration.  AND aspiration has lead to pneumonia in some of our patients.  We get a lot of patients who have compromised respiratory systems or who don't get out of their wheelchair all day.  In normal healthy people, aspiration shouldn't be a problem, but in a patient that has been in the hospital for 2 months to 1 year who has... hemiparesis, generalized weakness, COPD, vent dependent, bed/wheelchair bound, cognitively impaired, etc,   it seems that aspiration can be the straw that breaks the camel's back.
THIRD, using the VFSS to assess effectiveness of compensatory strategies.  If you don't mix barium with the consistencies that are giving the patient trouble, then how do you know which compensatory technique will work, or how it works?  If you can't see what is happening to the food, then how do you know if it's any different than a swallow without any compensatory strategy?  Does a head turn to the left versus right change bolus flow for the better or worse?  If you can't see the bolus flow, then how do you know where it went and why it went that way?

FINALLY - I do think that we need to look at a couple DRY swallows before presenting any food or liquid to see how the muscles are moving in the first place.  When food/liquid is presented, we tend to just look for pooling, residue, penetration, and aspiration and FAIL to look for WHY these things happen.  We need to train ourselves to look at the base of tongue, pharyngeal bulging (following the bolus), and anterior hyoid movement, before we can really understand WHAT is happening with the swallow.  Instead we often just note the results of dysphagia and neglect to report the actual problem. 

Kerri_
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Chris and Claire Langdon <chris_claire@bigpond.com> wrote:
Bronwyn Jones advocates using solid boluses (bread, bagel soaked in barium;
barium paste on a cookie or a pill) to evaluate dysphagia for solids ("A
solid bolus should be given if a subtle stricture, or solid-induced spasm,
is suspected, or if a patient with symptoms of solid food dysphagia has a
normal study with liquid barium. A solid bolus, however, should be given
with caution to the patient with pharyngeal decompensation, especially if
pharyngeal retention indicating pharyngeal weakness is seen with liquids."

*** The above refers to patients with gastroesophageal problems - gastroenterologists have used marshmallows, bagel "pills" etc for decades to identify esophageal obstruction and that's what the above is all about. Yes, caution should be used with solids i.e. bread pellets etc. in the patient with oropharyngeal problems because of the risk of asphyxia. If the problem is with solids only - it is gastroesophageal.

I am talking about the VFSS of the patient with oropharyngeal dysfunction who is given various foods mixed with barium that, among other things bears no resemblance to the food alone. Also, as has been stated many times by Groher among others, VFSS does not reflect the reality of eating a meal and to give food mixed with barium removes it even further from real life. VFSS is intended to examine the dynamics of the swallow and to determine whether various compensatory interventions might be helpful - in real life.




Dr I Campbell-Taylor
Clinical Neuroscientist
Exclusive Distributor:
www.interactivetherapy.com

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End of Dysphagia Digest, Vol 16, Issue 11
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