Indications
Contraindications
Need to thoroughly evaluate oropharyngeal swallowing function
Insufficient medical stability to tolerate the evaluation or transport to the fluoroscopy suite
Presence of feeding concerns or poor weight gain for which oropharyngeal dysphagia is a suspected contributing factor
Patient-specific factors that would preclude adequate participation (e.g., cognitive impairment, inadequate alertness, limited willingness to accept oral intake due to severe oral aversion)
Presence of unexplained respiratory complications (e.g., chronic cough, recurrent pneumonia, or frequent or prolonged upper respiratory infections)
Instances in which the evaluation would not change the patient’s plan of care [4]
Presence of clinical signs or symptoms of oropharyngeal dysphagia, penetration, or aspiration
Presence of significant risk factors for oropharyngeal dysphagia, even in the absence of clinical signs or symptoms
Need to evaluate strategies (e.g., positioning; bottle flow rate; liquid viscosity; need for implementation of an exercise-based dysphagia program) to determine appropriate recommendations for treatment and safe, efficient feeding
Need to re-evaluate swallowing function in a patient with a history of dysphagia and a suspected change in swallowing function
Inability to complete flexible endoscopic evaluation of swallowing (FEES) due to poor tolerance or anatomic abnormalities which limit visualization of the relevant laryngopharyngeal structures or preclude passage of a nasendoscope
Need for additional information in cases where FEES identifies but cannot fully define the characteristics of an oropharyngeal dysphagia
For patients who are not medically stable enough to bring to the fluoroscopy suite but are determined to be appropriate for instrumental swallowing evaluation, flexible endoscopic evaluation of swallowing (FEES), described in detail in the chapter by the same name, may be a viable alternative.
- 1.
Do patient history, clinical evaluation, or both indicate suspicion for oropharyngeal dysphagia?
- 2.
Do the results of the VFSS have the potential to clarify diagnosis and inform management?
- 3.
Is the child ready and able to participate in the study?
- 4.
Will the findings impact the child’s care?
Careful consideration of these factors and employment of sound clinical judgment will ensure that VFSS is appropriately utilized and that nonessential evaluations are avoided. These same questions are applicable to the determination of appropriate timing for re-evaluation. Additional consideration should be given to the level of suspicion for change in swallowing function and whether confirmation of such a change would meaningfully change management. For example, a repeat VFSS may be necessary to determine when it is appropriate to advance the diet of a patient with silent aspiration; however, repeating the study too soon may result in unchanged results and the need for additional studies to facilitate future care management.
Purposes of VFSS
To ensure optimal utilization of VFSS and the information it can provide, it is of the utmost importance that the clinician understand that VFSS is not simply a tool to determine whether a patient is aspirating. The primary purposes of VFSS include identifying and defining abnormal anatomy and physiology contributing to the patient’s symptoms and evaluating potential treatment strategies to enable safe, efficient, and/or adequate oral intake [6].
Structural (congenital or acquired), neurological, respiratory, cardiac, metabolic, and inflammatory disorders can all have an impact on feeding and swallowing in pediatric populations [1, 7, 8]. Aspiration and inefficient swallowing can occur for a variety of reasons including delayed or absent pharyngeal swallow trigger, inadequate tongue base retraction or pharyngeal constriction, inadequate laryngeal vestibular closure, and dysfunction of the UES. Treatment varies depending on etiology; thus determination of the anatomic and physiologic origin of the problem is essential to providing appropriate and effective intervention.
Advantages and Limitations
Comparison of VFSS and FEES
VFSS/MBSS | FEES | |
|---|---|---|
Description | Instrumental swallow evaluation utilizing fluoroscopy and administration of various consistencies of a contrast (barium) to evaluate swallowing function | Instrumental swallow evaluation utilizing a flexible nasendoscope to evaluate swallowing function |
Location | Fluoroscopy suite (radiology) | Bedside or clinic |
Anatomy | Grayscale images of the oral cavity, pharynx, and cervical esophagus | Full color video of hypopharynx and larynx |
View | Sagittal and A/P view of the head and neck | Superior view of pharynx and larynx |
Contrast | Barium | Green/blue/white food dye (may also use barium or naturally green or white food) |
View of swallow | Comprehensive view of all swallowing phases – oral, pharyngeal, cervical, esophageal phases | Able to view pharyngeal phase except for brief (less than 1 s) “white out” during height of swallow. Unable to view oral phase or esophageal phase |
Advantages | Can assess all phases of swallow including the moment of the swallow | Can evaluate management of secretions |
Noninvasive and generally well tolerated in pediatric population | Can evaluate swallow with very small volumes | |
Radiologic view of structure and function | Can be conducted in most locations including clinic and bedside | |
Can modify position, viscosity, feeding equipment, and strategies during the assessment | Can evaluate laryngeal and pharyngeal structures from superior view | |
Can detect presence of structural abnormalities such as type I laryngeal cleft, tracheoesophageal fistula (TEF), etc. that are difficult or impossible to visualize on nasendoscopy | Allows for assessment of breastfeeding | |
Allows for assessment of child or infant’s typical foods | ||
No time constraints | ||
No radiation exposure | ||
Potential assessment of sensory threshold | ||
Can modify position, viscosity, feeding equipment, and strategies during the assessment | ||
Easy to position child in parent’s lap for comfort and typical feeding | ||
Disadvantages | Radiation exposure and time constraints | Nasendoscope can be uncomfortable and is not tolerated well by all children |
Can be an unfamiliar setting for young children | Does not allow for evaluation of the moment of swallow due to “white out” during the swallow | |
Cannot evaluate child’s typical foods without addition of barium | Does not allow for evaluation of oral or cervical esophageal phase | |
Cannot evaluate breastfeeding | May be difficult to evaluate for aspiration due to anatomic interference (arytenoids or epiglottis obscuring view) | |
Brief snapshot of swallow function due to time limitations | ||
Does not allow for visualization of saliva/secretion management, as these substances are not radiopaque |
VFSS is noninvasive, which can facilitate cooperation and allow for instrumental assessment of patients who are not able to tolerate a flexible endoscopic evaluation of swallowing (FEES); however, the procedure requires the administration of foods and liquids impregnated with barium, the taste, texture, and appearance of which may be unappealing to some patients and decrease willingness to participate. A sufficient amount of barium must be consumed during the study to allow for adequate evaluation of swallowing function; thus VFSS would not be appropriate for a patient with significant oral aversion or limited experience with oral intake [7, 12]. The need for use of radiopaque barium also precludes the evaluation of breastfeeding via VFSS.
A major disadvantage of VFSS is radiation exposure, both for the child and for the parent or caregiver tasked with feeding the child during the study [7, 12]. Radiation exposure can be managed by limiting the “fluoro-on” time to a maximum of 2–3 min unless a longer study is absolutely necessary [10]. The need for relatively brief “fluoro-on” time is another limitation of the exam, as this “snapshot in time” may not capture deficits that are infrequent or inconsistent.
VFSS must be completed in the fluoroscopy suite, meaning that the patient must be able to tolerate being transported. The equipment in the suite itself may be intimidating for some children, which may result in a nonrepresentative feeding. Patients must be positioned such that the relevant structures can be visualized, which may preclude evaluation in their natural feeding position. VFSS can yield highly useful information about oropharyngeal swallowing function; however, to obtain an optimal study, it is important that clinicians understand the limitations of VFSS such that patient selection and procedure planning may be performed appropriately.
Speech-Language Pathologist Approach
History
Duration, onset, and characteristics of swallowing complaints
Current diet
Components of a typical feeding, including positioning, use of specific feeding implements (bottles, spoons, cups, etc.), or any other adaptations employed in the child’s home environment
History and timing of any past pneumonias or pulmonary compromise
Recent concerns with growth or weight gain
Impact of swallowing impairment on quality of life
Other contributory factors
A thorough case history can facilitate VFSS planning by clueing the clinician into possible etiologies for the swallowing problem and identifying variables (e.g., bolus consistency, flow rate) that should be assessed during the procedure.
Preparing the Patient and Parent/Caregiver
In preparation for a pediatric VFSS caseload, optimization of the physical setup of the fluoroscopy suite can be beneficial. Try to keep the environment child-friendly and inviting. If available, draw on the expertise of your facility’s child life specialists. These professionals have specialized training in infant, child, and adolescent development and well-being and use strategies such as play, developmentally appropriate communication, and psychological preparation to help children and families cope with and minimize adverse effects of healthcare experiences [13, 14].
Adequate preparation of the patient and parent/caregiver is an essential step to ensure a successful evaluation. The purpose and logistics of the procedure should be described to the caregiver in advance so that they may help to prepare the patient. Whenever possible, the parent should accompany the child into the fluoroscopy suite so as to keep the child at ease. Particularly for young children, using parents as feeders may increase cooperation and acceptance of the foreign barium products [10]. Ideally, families should be encouraged to schedule the study at a time of day when the child is alert, rested, and well-regulated. Instruct families to withhold food and liquid for up to a few hours prior to the study, as thirst and hunger may increase the child’s willingness to consume the test barium products; however, keep in mind that discomfort from being overly hungry may result in reduced willingness to participate in some children. Caregivers should be instructed to bring feeding implements (e.g., cups, bottles, spoons, containers) that the child typically uses at home and a variety of preferred foods, including consistencies that have presented a problem in the past. For young children, bringing a security item such as a favorite toy or lovey may help the child to feel secure.
Positioning
Positioning of the pediatric patient is an important consideration, as one must balance the need to visualize the structures involved in the oropharyngeal swallow with the need to evaluate the impact of positioning on swallowing function [15]. There are a wide variety of chairs on the market which can facilitate optimal positioning [10, 11]. When possible, start the evaluation with the patient in his or her typical feeding position so as to evaluate what swallowing function looks like under natural feeding conditions. If possible, use a seat (high chair, adaptive chair, etc.) similar to that which the child uses at home. Consider the physical needs of the child, and, when appropriate, reach out to the child’s occupational therapist (OT) in advance of the evaluation regarding recommendations for optimal positioning. If the child exhibits poor head, neck, or trunk support, work to position the child such that they are adequately stable to support optimal swallowing. The child’s head should be at midline with the spine in neutral alignment, shoulders slightly forward, lower extremities relaxed and slightly flexed, feet flat and well-supported, and hips in natural alignment [16]. Towels may be used to facilitate midline positioning of the head, bring shoulders forward, and align hips [7]. Sidelying or sidelying semi-upright positioning can be considered for children with issues such as poor muscle tone, micrognathia, or laryngomalacia. This can be accomplished by placing the table horizontally or at a slight incline and positioning the patient directly on the table. A wedge may be used to help keep the patient in place. Regardless of the chair or positioning strategy used, it is important that any adaptive seating setup be adequately secured to ensure the safety of the patient.
Children with medical complexity or those considered to be at high risk for aspiration may require additional equipment and monitoring to ensure safety during VFSS. When needed, suctioning equipment should be available, and personnel or caregivers comfortable administering suctioning should be present in the fluoroscopy suite throughout the study. Children who require O2 supplementation should be hooked up to a portable oxygen tank. Cardiac monitors, respiratory monitors, and pulse oximetry should be available for at-risk patients and personnel versed in reading the output from these monitors and assisting in the event of a status change should be on hand [17].
Procedure
VFSS is typically performed by a speech-language pathologist (SLP) in conjunction with a radiologist or radiology technician who operates the machinery, documents any structural findings, and monitors the overall safety of the study such that it can be terminated if the patient’s safety is at risk. In cases where the radiologist is not in the room during the study, he or she should be consulted as necessary to confirm any structural findings. Other specialists, such as otolaryngologists or gastroenterologists, can review the VFSS as needed to provide additional input in cases where issues requiring medical management are identified. During VFSS, the SLP is responsible for determining the order, size, and type of barium-impregnated foods and liquids to be presented, selecting appropriate feeding implements (bottle with specific nipple flow; special utensils, special cups, etc.), interpreting the data obtained from the study, testing feeding modifications (altered bolus flow rate, modified cups or spoons, modified viscosity, changes in posture/positioning, implementation of external pacing, etc.), and making recommendations for diet, feeding modifications, or other therapeutic interventions indicated based on the results of the study.
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