Table 2 - The VA Boston Healthcare System VFSS Protocol
From the following article
How to perform video-fluoroscopic swallowing studies
Gary D. Gramigna
GI Motility online (2006)
doi:10.1038/gimo95
| Step of protocol | Reason |
|---|---|
| 1. Review of indications, contraindications, education of the patient and the family, review of transportation and positioning logistics | Suspected oropharyngeal dysphagia +/- need to examine anatomy and physiology of oral and pharyngeal regions during deglutition +/- need to define treatment strategies to improve or compensate for the dysphagia if identified. |
| 2. Baseline view of anatomy | Assess and identify anatomic structures prior to introduction of contrast |
| 3. Lateral view first | Best able to detect aspiration |
| 4. Sequence of pathophysiologies listed | View swallowing from front (lips) to back (posterior pharynx) and UES |
| 5. Begin with 3-mL thin liquid barium | Thin liquid may reveal airway protection issue sooner, and thus aspiration risk; swallow stages more discrete; small amount less likely to compromise respiratory status |
| 6. Continue with second 3-mL thin liquid swallow | Initial swallow may be more of a calibration swallow and second swallow of same condition may be more representative |
| 7. Increase volume to 5 mL | Watch for change in physiology with increase volume |
| 8. Increase volume to cup drink (unregulated) telling patient to "take a drink like you are thirsty." | This is both a challenge to the mechanism but also perhaps a more representative type of swallow done when meal is served |
| 9. Return to 5-mL amount and examine increased texture of thick liquid (nectar) | Observe for any change in physiology, or tolerance with increased texture cohesion; look for any increased residue with consistency as increased residue could increase aspiration risk |
| 10. Give puree condition 5 mL | Puree condition may reveal further weakness and residue or possibly oral stage disorganization more apparently |
| 11. Give solid condition (one quarter of a graham cracker cookie coated with the puree contrast from earlier administration | Allows assessment of chewing patterns and organization orally as well as pharyngeal clearance and potential choking/asphyxia risks |
| 12. An earlier swallow may be repeated at any time or a trial treatment strategy or maneuver may be attempted; pills may also be given if study unrevealing to this point | Seek to test hypotheses regarding treatment strategies or to remember that oropharyngeal and esophageal stage dysfunctions may coexist or esophageal dysfunction may masquerade as oropharyngeal symptomatology |
| 13. Record swallow timing events for transit and swallow response | Assists in judgments regarding normality of swallow event timing |
| 14. Turn patient to view anteroposterior view of swallowing | Look at swallow symmetry of bolus transit and determine any weakness asymmetry |
| 15. Our study concludes with viewing the patients laryngeal complex and vocal cords during production of a series of vowel /a-a-a/ | Look for any trace penetration in laryngeal vestibule and assess the symmetry and efficiency of true vocal cord movements |
| 16. Score degree of penetration/aspiration using standardized rating scale | Degree of penetration/aspiration assessed with each condition may provide information about improved performance during the study while suggesting patients risk level for developing pneumonia |
| 17. Combine VFSS observations to interpret overall severity rating | This may suggest possible management or allow for comparison of severity following a treatment program or at a later date of reassessment |
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