1. Chapter 5 Part 2

2. * Define abnormalities in anatomy and physiology causing the patient’s symptoms * Identify and evaluate treatment strategies that may immediately enable the patient to eat safely.

3. * Seated in an upright position * Need to maintain some level of balance in the chair * Need to be able to transfer to a special videofluoroscopy chair

4. * Thin liquid barium * Thin liquids given in the following amounts: * 2 swallows of the following amounts * 1mL * 3mL * 5mL * 10mL * Cup drinking

5. * Barium paste mixed with chocolate pudding * Cookie coated with pudding esophatrast * 2 swallows of 1/3 teaspoon of pudding * 2 swallows of ¼ cookie

6. * If the patient passes the previous trials then: * Provide different types of foods, temperature, texture and taste * Mixed fruit, meat, bread * Allow them to feed themselves and drink from a cup normally * Trial a straw * All trials have to be mixed with barium liquid or barium paste

7. * Lateral View * Oral Transit time * Pharyngeal delay time * Pharyngeal Transit time * Identification of the bolus as it moves through the oral cavity, pharynx and into the esophagus * Identify any points of residue collection * Estimate the amount of aspiration for certain consistencies * Determine anatomic or physiologic reason for aspiration * Timing of aspiration

8. * Anterior-Posterior View * Examine residue in the pharynx after the swallow * Observe asymmetries in function * Can view a clear picture of vocal fold movement

9. * Start with thin liquids, two swallows of each * 1 mL, 3mL, 5mL * If no aspiration occurs, move to 10mL * If no aspiration occurs, give a cup to patient and ask them to drink normally * If aspiration occurs on any of the liquid volumes, treatment strategies should be attempted to eliminate aspiration

10. * Proceed to esophatrast pudding and cookie covered with esophatrast pudding * If patient does well with various foods presented to them, they should be given the opportunity to feed themselves * For patients with cognitive problems or dementia can be assessed-they can be fed during the study and the pharyngeal stage of the swallow can be viewed

11. * Any patient suspected of aspiration * Pharyngeal dysphagia signs and/or symptoms * Approximately 40% of patients who aspirated regularly during an MBS study were not identified aspirating when examined at the bedside- there were no overt s/s of aspiration

12. * Poor oral transit-Head Back- Utilize gravity * Delayed swallow trigger-Head down-Widens valleculae and narrows airway entrance * Reduced tongue base posterior motion-Head down-Pushes tongue base backward toward pharyngeal wall * Aspiration during swallow- Head down-places epiglottis in more posterior protective position, narrows laryngeal entrance

13. * Aspiration during swallow- Head rotated to damaged side-Increase vocal fold closure, narrows laryngeal entrance * Reduced laryngeal closure- aspiration during swallow-Head down- places epiglottis in more protective position, narrows airway entrance * Residue on one side of pharynx- Head rotated to damaged side- Twists pharynx, eliminates damaged side of pharynx from bolus path * Upper Esophageal Sphincter dysfunction- Head rotated- Pulls cricoid cartilage away from posterior pharyngeal wall

14. * Reduced range of tongue motion-Trial Thick liquid- Avoid Thick foods * Reduced tongue coordination- Trial Thick liquid- Avoid Thick foods * Reduced tongue strength- Trial liquid- Avoid thick, heavy foods * Delayed pharyngeal swallow- Trial Thick liquids and thicker foods- Avoid thin liquids * Reduced airway closure- Trial pudding and thick foods- Avoid Thin liquids

15. * Reduced laryngeal movement with UES dysfunction- Trial liquids- Avoid Thicker foods * Reduced pharyngeal wall contraction- Trial Liquids- Avoid Thicker foods * Reduced tongue base posterior movement- Trial liquids- Avoid Thicker foods