New Zealand Speech-language Therapy Clinical Practice Guideline on Videofluoroscopic Swallowing Study (VFSS)
Miles, A., Davison, F., et al. (2020).
Auckland (New Zealand): New Zealand Speech-language Therapists' Association, 1-62. Retrieved November 25, 2020 from https://speechtherapy.org.nz/.
This updated guideline from the New Zealand Speech-Language Therapists' Association provides recommendations on the use of videofluoroscopic swallowing study (VFSS) for pediatric and adult dysphagia patients.
New Zealand Speech-language Therapists' Association
New Zealand Speech-language Therapists’ Association; Royal Australian and New Zealand College of Radiologists (2020 pending); New Zealand Medical Radiation Technologists Board (2020 pending)
<div>After conducting a videofluoroscopic swallow study (VFSS), a comprehensive report should be written that describes:</div>
<ul>
<li>symptoms observed including details of any aspiration;</li>
<li>hypothesized swallowing pathophysiology;</li>
<li>dysphagia severity rating;</li>
<li>hypothesized prognosis for recovery of swallowing;</li>
<li>safety of oral intake;</li>
<li>compensatory strategy recommendations;</li>
<li>dysphagia rehabilitation recommendations;</li>
<li>referrals to other professionals (e.g., ENT, dietician) as needed; and</li>
<li>follow-up SLT recommendations (Grade C).</li>
</ul>
<div>Any adverse incidents that occur during a VFSS should be reported according to local policy (Grade A).</div>
<div>Speech-language pathologists who conduct videofluoroscopic swallow studies (VFSS) should ensure they have good knowledge of normal swallowing biomechanics across the lifespan (Grade A), should receive ongoing training on using VFSS through continuous professional development to maximize accuracy of their interpretations (Grade A), and should receive radiation safety training and maintain knowledge of radiation safety practices for themselves and their patients (Grade A). </div>
<div> </div>
When conducting a videofluoroscopy swallow study, speech-language pathologists should gain informed consent and educate patients and their family on the procedure and its purpose (Grade A).
Safety considerations for conducting a videofluoroscopy swallow study (VFSS) include:
<ul>
<li>wearing lead aprons, thyroid shields, radiation monitoring badges (if required by the institution), and if in close proximity to the patient for feeding, lead gloves and glasses (Grade A);</li>
<li>minimizing a patient’s radiation exposure through having a VFSS assessment plan that includes carefully selecting liquid and food (Grade A); and</li>
<li>establishing local infection control precautions for patient populations with known or suspected infectious diseases (Grade A).</li>
</ul>
Prior to conducting a videofluoroscopy swallow study (VFSS), a clinical swallowing/feeding evaluation should occur and results should be made available (i.e., case history, medical history, speech and voice assessment, oral motor exam, cranial nerve exam, and optional observation of feeding) to the team performing and analyzing the VFSS (Grade C). Speech-language pathologists should have a clear reason for VFSS referral and be prepared for management decisions resulting from VFSS (Grade C). The advantages and disadvantages of the available instrumental swallow assessment options should be weighed (Grade B).
A videofluoroscopy swallow study (VFSS) is a clinically valid assessment tool for a variety of populations in both acute and non-acute settings (Grade A) and is recommended for the following:
<ul>
<li>determining the presence or absence of dysphagia including swallowing biomechanics, bolus flow, and airway protection during swallowing to (Grade A);</li>
<li>identifying aspiration in patients with dysphagia (Grade A);</li>
<li>enhancing nutritional adequacy and safety through compensatory strategies and diet modification (Grade A);</li>
<li>monitoring changes in patients already diagnosed with dysphagia (Grade C);</li>
<li>supporting inconclusive clinical swallowing or feeding evaluation results (e.g., patient’s condition does not match assessment results) (Grade C);</li>
<li>determining appropriate rehabilitation strategies (Grade A);</li>
<li>supporting quality of life decisions (e.g., alternative feeding methods) (Grade C); and/or</li>
<li>providing objective information on swallow function to the patient, family, and multi-disciplinary team (Grade C).</li>
</ul>
VFSS is not considered appropriate for patients who are:
<ul>
<li>medically unstable, drowsy, or agitatied;</li>
<li>unable to be positioned safely;</li>
<li>allergic to barium and/or contrast; and/or</li>
<li>without a clear rationale for assessment or where management is unlikely to change (Grade C).</li>
</ul>
During a videofluoroscopic swallow study (VFSS), a speech-language pathologist should trial compensatory strategies to assess their efficacy (Grade B). Clinical judgment of the patient’s physical condition should be used to recommend the need for treatment for aspiration (e.g., nursing, medical, physical therapy) (Grade B). Consistencies and delivery modes (e.g., spoon, cup) should be selected based on specific patient needs (Grade B). Many rehabilitative approaches should not be recommended without objective assessment such as VFSS (Grade B).
<div>When conducting a videofluoroscopy swallow study (VFSS), a multidisciplinary team with clear roles and responsibilities should be involved in the procedure and analysis (Grade C). For medically complex patients (e.g., ventilator dependent, spinal injury) or when esophageal or anatomical abnormalities are suspected, a medical practitioner should be present during the procedure (Grade C). A radiology staff member must be present to work the fluoroscopy equipment (Grade A) and be present or available to review recordings of the procedure (Grade C). Speech-language pathologists are not qualified to make medical diagnosis or identify structural deviations. Any observed esophageal or anatomical abnormalities should be referred to a medical practitioner if one is not present during the VFSS (Grade A).</div>
<div> </div>
When conducting a videofluoroscopic swallow study, a speech-language pathologist (SLP) should be aware of the individual patient's cultural beliefs and customs regarding food and meal practices. While no single clinician is expected to have knowledge of every cultural belief, the SLP should demonstrate a willingness to access information in order to provide culturally competent services (Grade A).
When conducting a videofluoroscopic swallow study (VFSS), an objective, standardized procedure should be used for interpretation (Grade A). VFSS assessment should include:
<ul>
<li>oral parameters at rest and during swallowing of varying consistencies;</li>
<li>oral transit parameters including transit timing calculations;</li>
<li>pharyngeal parameters at rest and during swallowing of varying consistencies;</li>
<li>laryngeal parameters including penetration/aspiration measures;</li>
<li>crico-esophageal parameters; and</li>
<li>esophageal parameters (Grade A).</li>
</ul>
VFSS equipment should provide:
<ul>
<li>high quality images and slow motion playback (Grade A); </li>
<li>high image rate using either continuous or pulsed fluoroscopy of 30 frames/pulses per second or greater(Grade A);</li>
<li>voice recording and counter timer (Grade C).</li>
</ul>
A standardized procedure of contrast agents use should be followed to ensure uniform consistency administration. Consistency of barium recipes, especially for liquid thickness, should be tested using the [International Dysphagia Diet Standardization Initiative] IDDSI flow test (Grade C). Water should be used as the liquid medium for barium powders (Grade C). Low density barium (20-40% weight/volume concentration) in suspension should be used where possible to avoid aspiration of high density barium (Grade A). Barium concentration should be described in all assessment reports (Good Practice).
