2024-03-20 05 Panel 3 Instrumental Swallowing Evaluations and Therapeutic Interventions

>> Which I think is a good transition from drinking your coffee and pulverizing your snacks. You can listen to us talk about instrumental assessment. I am really pleased to be here moderating the panel with my colleagues from America, Bridget Harrington from Colorado, Lisa from Rady in San Diego and we’re really excited to welcome Sylvana who is with us here from Argentina. Just having trouble advancing the slides. Okay, hold on. Pediatric instrumental assessment. What instrumental assessment do you utilize at your facility? The gold standard is typically the video fluorescence swallow study also called the modified barium swallow study at some facilities and then we have the FEAST, the fiber optic endoscopic evaluation of swallowing. And I think as speech pathologists and occupational therapists, whenever we’re reviewing a report from a physician and it says they passed their MBS or they failed their MBS, I think we all sort of tense up a bit as it is not a pass/fail exam. It is a dynamic assessment of the physiology of swallowing. It’s done in radiology with our radiologists and there’s variability of that in facilities. We recognize we have a lack of standardization especially in the interpretation of pediatric video fluoroscopy. Most scales are adult normed. We do have the penetration aspiration scale and the MBS IMP normed on adults. The instrumental assessment gives us a window into the complex physiology of swallowing but if our aero digestive patients are a house, there are lots of windows. Some are open, some are closed. So this is one window in time. With that, on the left that is a video. This is a patient with a type 1 laryngeal cleft sent for video fluoroscopy. And here we see direct aspiration during the swallow. And if we play the second video, this is a patient on moderately thick liquid from a level 3 nipple where the aspiration has resolved. So I always think of the pre and post laryngeal cleft modified barium swallow study as what happens in between is most important. We meet the child in radiology. They’ll see the aero digestive team. Parents may be anxiously awaiting the post laryngeal cleft repair video fluoroscopy but what happens between really is the aero digestive journey. I think the video is playing. I’m just trying to go to the next slide. Okay. Quick overview. This is our radiology suite with our tumble form seats on the right that come in three sizes from infants. And this would be a supportive positioning for an older child. On the left we use the TIMS recording equipment which is excellent. We can go back. We can reanalyze. We can download into PowerPoint. We can upload to our synapse or our PACS system. In terms of materials and liquid consistencies that we use during the modified barium swallow study, we use the Veribar products. We have thin, slightly thick which other institutions may call half nectar. We have mild, moderately thick in pudding. I think we’re making a real concerted effort in America to use the IDDSI levels. So half nectar is slightly, nectar thick is now mildly thick following the IDDSI standardization initiative. So the International Dysphagia Diet Standardization Initiative. I know we’ve talked to Silvana and some of our SLP colleagues here in South America about introducing and trying to implement the IDDSI testing because it really does allow us to all speak the same language that if I see a patient in Boston and they’re going to follow up in Denver and I’ve done the syringe IDDSI testing, I can call Bridget and tell her what I’m doing and we can replicate that. So in the interest of time, we won’t get into the weeds about the IDDSI testing. What I will say is that it’s translated into 20 languages. So we will teach families based on what thickener they have access to and what they’re using, what the recipe would be, remembering that hypoallergenic formulas and some thickeners don’t bind and don’t thicken properly. We also talked about using some more natural thickeners such as guar gum with some families. And so the IDDSI testing, if you look at the YouTube link here, is translated into many languages and parents actually do find it fairly user friendly once the clinician will teach them. So this allows us to talk about thickening in the same terms using the same terminology. And then one other point to bring up is when conducting the video fluoroscopic swallow study, the importance of having it at 30 pulses per second and that if the radiologist has it at 15 pulses per second that we really may miss microaspiration, we may miss laryngeal penetration. So if we reduce the pulse rate, we’re reducing the temporal resolution. And I just have a reference to a recent article, again, it’s based on the adult literature because obviously we can’t fluoro normal babies to find out like what does a normal swallow really look like. I really think laryngeal penetration is a variant of normal in infants. But if we are only conducting a study at 15 pulses per second, you’re likely going to have a longer study. So in fact, you may be increasing the exposure to radiation. So reducing the pulse rate also isn’t aligned with a LAHRA, which is our as low as reasonably achievable principle that we’re all following. And now I pass it to Lisa. >> So now that you have kind of the basics of the logistics of the study, what do you do when you have a patient who’s very medically fragile or so orally averse that you feel like you’re not going to get them to eat anything during your study? So this information can be helpful for SLPs who are here, but I’m also hoping to bring some insight to the surgeons on what’s going on in the background with helping your patients meet their feeding outcome, improve your patients’ feeding outcomes. So when we’re thinking about a patient with like a cardiopulmonary patient, my first thought is energy conservation. So how can our developmental services team support the completion of these studies, make it easier on their SLPs? So with this population, we’re thinking mostly energy conservation. You don’t want your PT coming in and doing 20 minutes of tummy time prior to you needing to do them to do a phase if you’re worried about, you know, their energy reserve. But conversely, if this is an infant who has really poor state regulation, it might be really helpful to have an OT come and tell you what strategies help them get in the perfect state for eating so that you’re not wasting your time calming them or wasting their energy in the radiology suite or prior to your fees. When it comes to our neuromuscular patients with neuro deficits, PTs and OTs, we have this wonderful expertise in tone management, and not just to get them in appropriate position in the chair that you saw earlier, which you can imagine how difficult that may be with some of the patients we see in aerodigestive, but also to help determine what is tone versus what is a compensatory strategy. I have a couple of videos. A couple weeks ago, one of the speech therapists asked me to, or reached out to me. She had a four-year-old with neuro deficits in radiology, and she could not get their head in alignment for the study. So in reviewing the case, it did not appear to me that this was an extensor tone pattern. There was no extension happening at her hips. Her head control was appropriate. It wasn’t falling forward when you put her upright. So I mentioned to the speech therapist, let her eat an extension. This could be a compensatory pattern that she needs. So she did just that, and as you can see, it’s running. And of course, it’s not a perfect swallow. It’s very effortful. It’s a lot of work, but she didn’t aspirate. In the next study, what you see a few days later, this happened on a Friday. On Monday, for some reason they repeated the study. I’m not sure. It wasn’t at work that day. I’m assuming that the medical team looked at the imaging and felt, wow, look at her head. It’s in horrible positioning. We need to redo this in upright. So they redid this in upright, and if you could play the second one, what you see, she looks pretty uncomfortable, and she aspirates. So use your expertise and your OT and PT if you’re dealing with tone issues. When it comes to our patients who have severe oral aversions for whatever reason, from their frequent hospitalizations, lots of suctioning, intubations, or they’re on autism spectrum, something, or they have a lot of anxiety coming in for the study, what’s been proven helpful for us is having them work with an OT prior, practicing white foods so that they’re willing to eat the barium, practicing having some sessions in the radiology suite. So it just saves the SLPs so much time and effort when it comes down to actually completing the assessment. With our musculoskeletal differences, anatomic differences, practicing the positioning ahead of time, like if a child has fragile bones, can be really helpful. I have a really cute story that was shared with me from one of our SLPs with a toddler with arthrogryposis, who he was very nervous about completing the study because this toddler very developmentally appropriately insisted on feeding himself. So he reached out to his OT, found out a way to set up that radiology suite appropriately so he had a table in front, his universal cuff, and he was willing to eat because he could feed himself. So all in all, use your team to make these studies easier on yourself. And now, oops, can I go forward? And hopefully Silvana will give you some input on some cases. >> Hola, buenos dias. [ Speaking in Spanish ] >> Today I would like to share with you how important aero digestive crossroads is when I’m going to evaluate with video fluoroscopic evaluation of swallowing. We want to see the functional vital confluent of Robin where we have an intersect in the pharynx. And this has to happen in total harmony where when I’m going to swallow, respiration stops for milliseconds. So if I have this crossroads that has the apofacial mass, the mandible, the jaw, the spine that will have variations in its shape and volume, they are modified as we can see in the image to the right where we have a craniofacial malformation. This will narrow and then it won’t work. It won’t happen in the same way, the respiration and the swallowing. So we do have structural changes like we saw in the craniofacial malformation. This space, this aero digestive crossroads, modifies depending on whether we’re speaking on about an infant, a toddler, or a bigger child. So we have to take into account when we are assessing also. What happens in a patient with an Apert syndrome? We know it’s a genetic disorder affecting the development of skull and facial development where we will have differences in the morphology of the airway and also regarding the size. So the characteristics presented by this malformation will have an impact upon the airway and breathing and therefore on soloing. So I have a case here, a female patient, five months old, from Formosa, which is a province to the north of Argentina. She had to travel, what you see in red, to come to Buenos Aires to the Italian hospital, Hospital Italiano, where she came for an evaluation previous to a surgery of frontal-orbitary advancement. She’s a girl that was born with 38 weeks of gestation, with an adequate wait for gestational age. The parents have a neurotypical development like the brothers and sisters. It was a cesarean section and during the birth, they detect she has this Apert syndrome at the moment of delivery. So when the evaluation is done with the frontal-orbital advancement, you can see craniosynostosis inductively of hands and feet and also the mitral valve failure, the baby could hold had cephalic control. She had hypotonia though. She had a complete morning moral reflex and severe malnutrition. She weighed five kilos with five months and the mother said she had apneas during the first months of life but then became occasional and global delay in development. Surgery was performed after surgery is where we can intervene. As Karen said, sometimes you have to see which are the teams, which are the groups they will consult. First, it had been the malformation clinic so it was not an aero-digestive clinic. This is why since we work with the malformation clinic and also with the aero-digestive clinic, we were in touch with this baby. During the session, you see that she is bottle fed. She has to interrupt several times the feeding because the mother realizes that the baby gets tired if she offers a continuous feeding with the bottle. She takes eight bottles a day, about 125 cubic centimeters and the position is always sitting and she’s holding her in her arms. If we see this way of feeding, we suggest doing a video-feroscopy to be able to check what was going on with this baby. This baby was sitting down in a little chair. It was done with her bottle. It had a bias because more fluid came in and she didn’t have to do such an effort. She didn’t have to get that tired where you see there is suction which is rhythmic which allows her to obtain food so it’s a safe feeding because it doesn’t go to the airway. We check what happens in the suffagial area to check whether everything is all right and go to the suffagial emptying. So based on this study, what do we define? We could also see the nasal reflex due to the palate cleft she had as I mentioned before. What do we suggest? To work together with physical therapy and occupational therapist to think about the feeding that is coming afterwards. Thinking about her chronologic aid, she should be starting with purees taking into account first the posture of the patient, whether she can hold her head or ride on the trunk or ride, whether she can sit and touch the food, remember the hands she had. Adapt the tools, both the bottle, the type of bottle, the dish that she will use, allow her to explore the temperatures, the textures, the smells, to work with nutrition specialist to achieve appropriate caloric intake to establish a routine for feeding to work together with CNTs to keep her in evaluation and check whether eventually she would need a possible airway surgery and basically the social health insurance problem. Why? Because we are very much restricted when we do the evaluation of this baby because many times her insurance didn’t allow us to do some consults. So we have restricted ourselves in what we can do, what we want to do, and what we really have. If she had a very complete report for social insurance and if that was sent, and then she is sent to Formosa for them to continue with all the therapies that had been suggested, see if she can do it in Formosa, her original place where she lives. That’s all. Thank you very much. That was so interesting to see all these cases. I’m just waiting for the last minute. I’m going to wait for the last minute. I’m going to wait for the last minute. I’m going to wait for the last minute. I’m going to wait for the last minute. I’m going to wait for the last minute. I’m going to wait for the last minute. I’m going to wait for the last minute. I’m going to wait for the last minute. I’m going to wait for the last minute. I’m going to wait for the last minute. I’m going to wait for the last minute. I’m going to wait for the last minute. I’m going to wait for the last minute. I’m going to wait for the last minute. I’m going to wait for the last minute. I’m going to wait for the last minute. 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I’m going to wait for the last minute. I’m going to wait for the last minute. I’m going to wait for the last minute. I’m going to wait for the last minute. I’m going to wait for the last minute. The type A OCD SLPs will always get you back on track. We can take questions or I know that there is a generalized Q&A at the end of — oh, okay. So if anybody has any questions, we’d be happy to take those for any of our panelists. If not, I have a question for Bridget if nobody else does. Good morning. Excellent presentations. I’m Dana Williams from Phoenix. One question. By mingling with everyone in this wonderful group, I realize that the availabilities of simple radiologic techniques such as the video fluoroscopic evaluation of swallow in South America differs from institution to institution. So I was wondering — but fees seem to be a little bit more available because of ENTs may have that in their clinics. So my question to you is what is your perspective, each one of you or one of you, on how to be smart about the tests that we have to use? Silvana, do you want to tell us about the availability of video fluoroscopy where you are in Argentina? I’m going to ask you a question. I’m going to ask you a question. [ Speaking in Spanish ] I think we have a lot of room to grow with these as well. Especially with breastfeeding fees, that’s relatively new. I think the fees is accessible. I think if you have a lot of training in webinars, I think it’s difficult because we do miss that noncompliant population where all these kids live from one year to three and a half years of age. But certainly if you don’t have video fluoroscopic accessibility, you could do fees. If you have neither of those, then I think number one is stability of respiratory status and pulmonary health. And I think that’s a really important part of the conversation. I think it’s important to have a lot of flexibility in terms of the quality of the patient’s health. I think it’s important to have a lot of flexibility in terms of the quality of the patient’s health. I think it’s important to have a lot of flexibility in terms of the quality of the patient’s health. I think that’s a really important part of the conversation. .[APPLAUSE] (audience