CMDS 669: Instrumental Assessment Dysphagia PDF

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Professor Maggie-Lee Huckabee's lectures on objective measures in VFSS/MBSS, FEES, Pharyngeal manometry and ultrasound....

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Alternative forms of instrumental assessment Objective Measurement for Videofluoroscopic Swallowing Study VFSS can be very subjective -people have come up with objective measures  Aiming to increase reliability Scales  Using scales is ok but requires understanding of the stuff and you need the why for penetration/aspiration o Difficult in some respects -5 not worse than 6 cos ejection o

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Multiple trials -what do you score? Most likely to score the worst Accuracy of prediction varied based on scoring Also used MBSImP (not used much in NZ) o 80% inter- and intra- rater reliability o Designed for set terminology for dysphagia symptoms o Problem -commercialised scale, partially published, need to do a training program to use it and that's expensive  Training to improve interrater and intrarater reliability  Can't use scale unless 85% reliable  Price a big barrier to use in clinical practice In NZ -NZIMES o MLH first wrote this in 86 -reckons that there are better things now o Didn't go through validation/norming so not a standardised test o A lot of data collected on reliability -never published o Will go on learn o Subscale 1: 5 big categories with different physiological parameters, detailed description of what it should look like o Subscale 2: respiration, cognition etc o Good -standard communication, free o

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Bad -may be used badly, problematic bits -repetition with glossopalatal and pooling and delayed pharyngeal swallow -score physiology not symptoms o Rules with NZIMES  First swallow -look at whole swallow and find a place to focus  Focus on one phase and one feature at a time  If everything is bad -start with pharyngeal phase, look at individual phase after that  Look at moderate rating first and adjust accordingly  All swallows are different -mild one swallow, moderate  Tick as you go and make an average -lean towards severe  Remember that pts can be severely disordered in some physiological components and fine on others  Only guidelines -pt may not fit perfectly  Severity in each category indicated numerically Dynamic swallow study (leonard, kendall and mckenzie) o Biomechanical measures being encouraged by auckland uni o Frame-by-frame analysis of VFSS -timing and displacement measures -directly measure in ms and mm movement and timing o Good measures for pharyngeal strength -high correlation between this and pressure generation (manometry) -more precise measurement of delayed pharyngeal swallow o Practical things -metal ring of known diameter on midline under chin o Timer on recording of VFSS o Specific boluses presented o Bolus transit -rate of bolus movement o Gestures -physiological things o Measures  Oropharyngeal transit time -transit through oropharynx -posterior nasal spine to vallecula exit  Hypopharyngeal  UES opening  Airway closure  Hyoid maximum -displacement time  Pharyngeal constriction ratio o Limitations  Time-constraints  Big picture stuff  It's done in Auckland but they don't think that the extra work is clinically valuable Having a list helps -training to a list helps even more

Pharyngeal Manometry Low resolution manometry  Pressure in pharynx measured by tube o Through nose and into upper oesophagus o 3 sensors -bottom one at UES, laryngeal vestibule, base of tongue  When putting a tube in someone -hands on face somewhere and gloves o Point up to get past ridge, then hand needs to move above the nose so catheter points down o Will bump into PPW, pt looks up so angle straightens out

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Patient drinks water and swallows the catheter, push it a bit -try to swallow about 30cm down o Can do this with v dysphagic patients too M wave o Pull catheter out, look at sensor 1 wave form -high pressure as it goes in ues o Want to see elevated pressure in UES at rest, when hyoid elevates, sensor into UES, then cricopharyngeus opens and pressure drops, UES tightens -high pressure, larynx drops -pressure lowers o 3rd sensor in the right place if 'M' wave as described above Base of tongue to posterior pharyngeal wall -one peak when this happens -can measure duration o Sensor 3 -low pressure at UES, high pressure around the hyoid o Answers VFSS question -why pyriform residual? Can see that criopharyngeus pressure is/isn't changing Going out of favour o Needs to be paired with VFS o Catheters are one size fits all o Not reliable for UES -sensor 3 might be right in the oesophagus

High-resolution manometry  36 sensor, 12-16 measurement segments  Better for UES because you'll have a sensor in the cricopharyngeus  Easier to position, less comfortable as there are so many sensors and fatter o No need to be in exact locations  Use /kaka/ for velopharyngeal location  Limitations o High res gives too much data  People ignore wave form and look at pressure picture

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Software can give average pressure, and give 3 points like low-res But low-res is more specific Impedance manometry o Swallow it 

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Application to clinical practice  Differential dx -particularly if UES is measured well  Sequence of swallowing events o Case pt had low pharyngeal pressure -->might suggest weakness/motility o But manometry shows that pt was constricting inferior constrictor first and superior last -UES ok  Trish case o Management for pharyngeal strengthening based on VFSS --> effective o But nasal redirection Manometry shows upper and lower pharynx are contracting together rather than in a wave Fibreoptic Endoscopic Evaluation of Swallowing (FEES)  

Cyclic sound pressure waves, Hz. Ultrasound >20kHz Transducer goes through body tissue, and bounces back when there's an acoustic boundary o Fluid/soft tissue, soft tissue/bone  Uses this to measure time from emission to return of the echo  High freq -good res but not deep  Low freq -poor res, but can go deeper Applications to clinical practice  Muscle morphometry o Structure/location o Correlation between muscle fibre enlargement (hypertrophy) and increase in muscle strength o Ultrasound > MRI for floor of mouth muscles  Ultrasound has more definition o Pts undergoing radiation, tissue becomes inflamed o Measuring tongue thickness  Line at hyoid and mandible -midpoint and depth to back of image  Pts with dysphagia have stroke w dysphagia o Rose centre use ultrasound for biofeedback, other too  Upside down image o Shadows of bones MLH's opinion  Good inter- and intra- reliability, good sensitivity and specificity for ID problem  Handheld ultrasound available -connect to device with bluetooth

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Less reliable with some of these devices Not ready for clinical practice yet In clinical practice  Adjunct, not a replacement for VFSS  Good outcome measure -measuring muscle changes Ultrasound  

Cyclic sound pressure waves, Hz. Ultrasound >20kHz Transducer goes through body tissue, and bounces back when there's an acoustic boundary o Fluid/soft tissue, soft tissue/bone  Uses this to measure time from emission to return of the echo  High freq -good res but not deep  Low freq -poor res, but can go deeper Applications to clinical practice  Muscle morphometry o Structure/location o Correlation between muscle fibre enlargement (hypertrophy) and increase in muscle strength o Ultrasound > MRI for floor of mouth muscles  Ultrasound has more definition o Pts undergoing radiation, tissue becomes inflamed o Measuring tongue thickness  Line at hyoid and mandible -midpoint and depth to back of image  Pts with dysphagia have stroke w dysphagia o Rose centre use ultrasound for biofeedback, other too  Upside down image o Shadows of bones MLH's opinion  Good inter- and intra- reliability, good sensitivity and specificity for ID problem  Handheld ultrasound available -connect to device with bluetooth o Less reliable with some of these devices o Not ready for clinical practice yet In clinical practice  Adjunct, not a replacement for VFSS  Good outcome measure -measuring muscle changes...