Videofluoroscopic Swallow Case Study
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Videofluoroscopic Swallow Case Study (VFSS)
Part one (Assessment plan)
a. Patient’s Summary
Mr. Saren Ghazel is a 67-year old male admitted to the rehabilitation ward with a confirmed diagnosis of infarct in the middle cerebral artery. He has a past medical history of depression, falls, constipation, and hypertension. He is married with four children and enjoys excellent social support. Mr. Ghazel fails the initial swallowing assessment and is put on a nil-by-mouth diet. He records fluctuating alertness and swallowing on repeated assessments. The son reports impaired cognition, as he understands English poorly of late.
The daughters manage his restaurant on his behalf. He is suspected of having developed aspiration pneumonitis during treatment. At the time of VFSS, he was afebrile, no current chest infections, but has intermittent coughing with meals. Mr. Ghazel has self-feeding problems and requires full assistance during meals. He is diagnosed with moderate oropharyngeal dysphagia. Mr. Ghazel is put on level 5 (Minced and moist) diet and level 2 (mildly thick fluids) after a videofluoroscopic swallow study (VFSS), and is due to be discharged home. Referral consent is obtained, and Mr. Ghazel is scheduled to receive speech pathology follow-up as an outpatient in Cheltenham Community Rehabilitation Centre. The VFSS results show moderately impaired parameters.
b. Questions to the client/carer
Planning for assessment and further interventions of Mr. Ghazel will consider his neurological condition, oral anatomy, and balance functions of the cerebellum. What consistency of foods can Mr. Ghazel take and retain comfortably? (Normal diet? Modified soft diet? The volume of feeds? Speed of feeding? Additional maneuvers to aid swallowing? Is swallowing supervised? What is the position of the head during swallowing?)Does he have dyspneic spells during swallowing or any associated coughing? And are there any other health care professionals like nurses, occupational therapists, and physical therapists assisting during swallowing?
c. The rationale for cranial nerve assessment and food/fluid trial in an outpatient
Mr. Ghazel has a confirmed righted sided infarct in the middle cerebral artery and presents with dysphagia, which is neurogenic in origin. A complete cranial nerve examination should include a comprehensive assessment of the five cranial nerves that control chewing and swallowing to determine their degree of impairment. They include trigeminal nerve, hypoglossal nerve, facial nerve, glossopharyngeal nerve, and vagus nerve (Koch et al., 2017).
The trigeminal nerve, in particular, gives motor innervation to the muscles of mastication. It also innervates the digastric muscles and the mylohyoid muscles, which permits the forward upgrading of the hyoid laryngeal muscle complex during the swallowing reflex (Panara & Padalia, 2019). Food/food trial in the outpatient setting is to determine the appropriate route of feeding, rehabilitation of the patient, and the type feeds and fluids to be used in nutrition and hydration. The patient, Mr. Ghazel, has moderate impairments in feeding and swallowing; hence the consistencies of feeds should be adjusted.
d. Procedure for food/fluid trial
The process for trial of feeds and fluids in patients with dysphagia begins with regular foods of varying textures (level 7). Level 7 tests for the ability to grasp, hold, bite and chew foods adequately to enable bolus formation and smooth swallowing, handle all textures of food without easy fatigability and remove bones and other hard substances that cannot be swallowed easily from the mouth. Level 6 follows with bite-sized and soft foods. Biting is not needed, but the chewing of these foods is required. Tongue force and control are, however, needed in bolus formation and swallowing. Level 5 (minced and moist foods) is then trialed. Here, minimal chewing with no biting is necessary. Tongue force aids in the formation of boluses and swallowing. Level 4 involves the pureed feeds eaten by spoon. No biting or chewing needed and requires little tongue propulsion effort. Level 3 (Liquidized food) is done last. Feeds can be drunk from a cup and require small propulsion efforts of the tongue. It, however, requires proper mouth control.
For fluids, trials are commenced from level 0 (thin liquids), slightly thick fluids (level 1), mildly viscous fluids (level 2), moderately viscous fluids (level 3), extremely viscous fluids (level 4) to capsules. Trials are conducted progressively and with all necessary support to the patient. The swallowing safety of Mr. Ghazel consists of upright sitting posture, adequate delivery of trial foods, and proper biting and chewing before swallowing solid foods. To determine the mealtime efficacy, I would check the patient’s excretion parameters such as large bowel movements, urine output, nutritional and hydration status, and retention of feeds.
e. Assessment tool
Videofluoroscopic swallow study (VFSS) has been used to assess the swallowing condition of Mr. Ghazel. The patient presents with hypertension, depression, and a history of falls, with a confirmed infarct of the right middle cerebral artery. This strongly suggests neurogenic dysphagia. VFSS is the best tool for evaluating the kinetics of swallowing. It shows a higher sensitivity to indicate dysphagia due to neurologic deficits. VFSS is a better contrast for the oral phase of swallowing, aspiration, and can also show residues in the valleculae (Audag et al., 2019).
f. The rationale for repeat VFSS before undertaking an intervention.
A repeat VFSS is recommended to assess the progress of the patient’s swallowing condition. Patients may record deterioration during the follow-up period and require adjustments in interventions. Also, it is vital to confirm the degree of dysphagia before imitating any therapy or interventions.
g. Observations made during VFSS.
During this procedure, a radiologist observes a liquid or semi-solid substance as it transit from the pharynx to the esophagus. Observations are made to determine the likely cause of dysphagia as either anatomical abnormalities, defects in bolus flow (such as timing, clearance or direction), the structural progression of the bolus, and the response of the swallowing tract to compensatory mechanisms. Defects in containment, chewing, and transfer of food boluses are also obtained. The VFSS identifies esophageal anatomical, motility, and neurologic disorders such as stenosis, Zenker’s diverticulum, strictures, hernia, and carcinomas (evidenced by an irregular defect in filling) that may impair swallowing. A severe motility disorder will imply enteric feeding and abolition of oral food (Re et al., 2019).
Defects in the transfer of the bolus from the oropharynx to the esophagus will imply food materials leaking into the trachea and causing aspiration pneumonitis. A stricture will mean that solid foods are no longer efficient for the patient and call for the need to start liquid feeding. The patient, Mr. Ghazel, who has difficulty in self-feeding, should be aided during mealtimes.
A rehabilitation strategy should ensure active feeding, preventing malnutrition and dehydration, weight loss, airway obstruction, and reducing the burden of hospital stay to the patient and family (Re et al., 2019).
Part two: Intervention plan
h. Short term rehabilitation goal
The short term rehabilitation goal for Mr. Ghazel is to maximize the protection of his airways. The oral and pharyngeal disorders of swallowing are responsive to rehabilitation. The rehabilitative techniques include dietary modifications and training in various swallowing methods and positional maneuvers. The VFSS results show moderate impairments in parameters of swallowing. Oral parameters (labial closure, lingual control, palatal closure, and digestion) are moderately impaired. The oropharyngeal transit, such as the position of the bolus at the onset of swallowing and relative timing at the beginning of swallowing, is also damaged. Laryngeal, crico-esophageal, and pharyngeal parameters are also impaired in this patient.
Direct methods such as alteration of the food consistencies can improve oral nutrition in this patient. Stimulation of the oropharyngeal mucosa and the adoption of compensatory postural techniques are also helpful rehabilitative strategies. Exercise to build up and gain strength, coordination, and functioning of the swallowing reflex is also encouraged.
Postural techniques such as chin-up, chin down, lying down, head tilted, and head turned, and a combination of these techniques during every meal times can be employed to aid in swallowing. After the eight weeks, the patient can be re-evaluated to gauge the progress of these rehabilitative strategies.
Each posture exerts a specific effect on different regions of the oropharynx and depending on the presenting abnormality. For instance, the chin-down technique best suits patients with disorders of the base of the tongue. In patients with impaired elevation of the larynx or bilateral damage of the pharynx, the reclining posture has been proven effective.
Tactile, chemical, and thermal stimulation have been associated with alteration of volume, taste, and temperature of feeds, therefore useful in modulating patients with human swallowing behavior defects.
Effortful swallow, Mendelsohn, super-supraglottic, and supraglottic maneuvers are available to aid in swallowing. Both healthy and dysphagic patients can use these techniques to swallow rehabilitation and compensate for defects in the pharyngeal swallow. In patients with oropharyngeal dysphagia, thickened foods can be used to prevent liquid aspiration. Exercises improve specific aspects of oropharyngeal swallowing (Zuercher et al., 2019).
Pharmacologic treatment options available for dysphagia include the Botulinum toxin type A. it is introduced endoscopically into the upper esophagus and gastroesophageal sphincter. It reduces the tone of the esophagus. This is useful in patients with cases of dysphagia caused by crico-pharyngeal spasms. 50 units per vial are adequate (Tarakad, 2019).
For the dietary management of Mr. Ghazel, level 5 foods (minced and moist) can be used since they don’t require forceful biting and chewing. Level 2 fluids (mildly thick fluids) are also recommended for easy swallowing and to prevent aspiration of liquids. Before the continuation of the oral feeds, the patient must pass the screening and swallow evaluation tests. Foods must be of high hygiene to prevent infections and of good nutritional content (Marie, 2018).
i. Short term compensatory goal
The short term goal for the patient is to maintain an adequate nutritional diet for the patient. The nutritional therapist should champion for feeds compatible with the texture recommended by the speech and language therapist. The regimens prescribed should meet almost all the dietary requirements of the patient, acceptable, available, and affordable to the patient. Nutritional management goals should focus on a safe feeding practice, prevent aspiration, prevent malnutrition and dehydration and implement the right and safe texture feeds.
Failure to meet the feeding by the oral route necessitates the change of feeding to nasogastric. Oral food is more safe and appealing to patients. In cases where the cause of dysphagia resolves, a transition to normal regular feeds may be attempted. In severe cases of neurological degeneration where deterioration is inevitable and progressive, transition feeding is encouraged to softer meals. Texture modification of feeds and fluids in modified consistency diets minimize the big risk of aspiration in patients with neurological impairments (Marie, 2018).
The often prescribed soft diets should be soft enough to be held by spoons or forks but should not be sticky or contain rough inclusions. Pured feeds should be soft, uniform and smooth and have no particles. These diets should be able to hold their shapes in order to give the patients most comfortable and easy control during swallowing (Triggs & Pandolfino, 2019).
Since achieving adequate intake form the modified consistency diets is impracticable, fortification of foods has been favored of late. Modified consistency diets should be palatable, of correct texture, well-presented and adequate nutritionally. Effective nutritional management has been shown to improve the general health of patients with dysphagia. Timely and appropriate nutritional intervention improves hydration and nutritional status of patients with dysphagia and promotes recovery.
Age related changes in laryngeal and pharyngeal sensations are associated with prolonged dysphagia and poor clinical outcomes in these patients. The management of Mr. Ghazel in the first few weeks should consist of small volume feeds. The volume and consistencies of the feeds should be adjusted depending on the progression of his clinical condition. After 8 weeks of follow up, an appropriate feeding plan should be in place (Triggs & Pandolfino, 2019).
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