The word dysphagia means “difficulty swallowing,” but different people have different operational definitions for the clinical condition of dysphagia. We will propose a definition of oropharyngeal dysphagia based on the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) and discuss what is known about the prevalence of dysphagia as a feature of different clinical conditions.

The videofluoroscopy is a dynamic X-ray procedure that allows direct visualization of bolus flow and swallowing physiology. We will review the questions that can be answered about swallowing function and impairment using videofluoroscopy as well as questions that cannot be answered using this procedure.

We will use a case study format to identify priority questions regarding patient swallowing that can be answered by a VFSS.

We will discuss protocols for VFSS developed by early leaders in the field, including Drs. Jeri Logemann, Jeffrey Palmer, Bronwyn Jones, and Olle Ekberg. Through this review, we will discuss variations in swallowing behavior and VFSS exam results that may be attributable to protocol choices, such as task instructions, repetitions, volume and bolus administration choices, etc.

We will discuss three recently developed standard protocols for VFSS: MBSImP, DIGEST, and the Steele Swallowing Lab protocol.

We will review studies that suggest which tasks are most likely to reveal impairments in swallowing safety and efficiency.

We will describe how contrast agents work and what the desirable properties of a contrast agent are for VFSS. We will discuss the difference between on-label and off-label use of barium.

We will discuss how altering the concentration of barium through methods like dilution can alter what you see on the exam and how this may influence VFSS exam results.

We will discuss why it is important to understand manufacturer recommendations for preparing barium for use in VFSS and how off-label practices may influence the exam in undesirable ways.

We will review how fluoroscopic images are generated and explain the difference between continuous fluoroscopy and pulsed fluoroscopy.

In this chapter, we will explore the trade-off between fluoroscopy pulse rate and diagnostic information. We will illustrate how reducing pulse rate impacts the information that is available to the clinician.

In this chapter, we will explore the trade-off between pulse rate and radiation dose. We will discuss the ALARA principle and explore issues of examination length (and associated radiation dose) related to pulse rate. We will provide a list of points that clinicians can present to colleagues in radiology when determining optimal settings and protocols for VFSS in their facilities.

Although the Penetration-Aspiration Scale (PAS) is widely used, clinicians may be unfamiliar with its properties. In this chapter, we will describe the scale and its development and discuss its properties. We will explain why decimal places have no meaning on the scale.

In this chapter, we will discuss which scores on the 8-point Penetration-Aspiration Scale are expected in healthy people and which scores are rarely seen in both healthy people and patients with dysphagia.

Individuals who demonstrate penetration or aspiration do not necessarily do so consistently across repeated boluses of the same texture. In this chapter, we will explore what is known about the frequency and variability of penetration-aspiration events within individual patients with dysphagia and discuss the implications of this information for summarizing the results of an assessment in terms of swallowing safety.

In this chapter, we will explain what pharyngeal residue is and where it may be located.

In this chapter, we will discuss several different visuoperceptual approaches to describing residue severity. These include both bolus-derived and space-derived measures. We will discuss the reliability of these measures as reported in the literature.

In this chapter, we will describe and illustrate pixel-based measurement of residue severity. We will discuss different approaches to normalizing these measures to anatomical reference scalars and lead participants through a measurement activity.

In this chapter, we will explore the difference between compensatory and rehabilitative interventions for dysphagia and describe how videofluoroscopy can be used as a tool for measuring treatment effect.

The chin-down posture is an example of a commonly used intervention for dysphagia. In this chapter, we will use a case study methodology to illustrate how videofluoroscopy can be used to determine the impact of the chin-down posture and decide when it should be recommended for a patient.

Thickened liquids are one of the most common interventions recommended for managing penetration/aspiration in people with dysphagia. However, there is controversy about the effectiveness of this intervention. In this chapter, we will discuss the physiological mechanism behind thin liquid aspiration and the rationale for considering thicker liquids as a compensatory intervention. We will discuss evidence from a videofluoroscopy demonstrating the effect of thickening on swallowing safety and describe how a clinician can use videofluoroscopy to determine whether thickened liquids are likely to be helpful in a particular patient.

The effortful swallow is an example of a commonly used intervention for dysphagia. In this chapter, we will illustrate how videofluoroscopy can be used to measure outcomes of using the effortful swallow.