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The American Broncho-Esophagological Association Releases their Position Statement on the Use of Swallowing Fluoroscopy in Adults

By Shumon Dhar, MD FACS (ABEA Position Statement Development Team Leader & NFOSD Medical Advisor)

Swallowing fluoroscopy, radiographic diagnostic modalities which include the video fluoroscopic swallowing study (VFSS) and esophagram, are widely considered the gold standard in the investigation of swallowing impairment. However, until recently, there was no uniformly accepted or comprehensive standard of practice in the United States. Consequently, there has been a wide array of protocols and interpretative strategies in use across the country.

Notably, in May 2022, the American Broncho-Esophagological Association (ABEA), a preeminent society of physicians, researchers and allied professionals published their position statement on swallowing fluoroscopy in The Laryngoscope ( Their recommendations issued in the form of expert consensus statements are meant to guide the development of best practices in swallowing fluoroscopy in adults in both outpatient and inpatient settings.

The position statement development team, chosen by ABEA leadership, was a diverse, multi-specialty group of swallowing specialists. They included Otolaryngologists, Broncho-esophagologists, Radiologists, and Speech Language Pathologists in active clinical practice that demonstrated expertise in swallowing fluoroscopy.

The first step in the project’s methodology was a systematic literature review of various topics within swallowing fluoroscopy which the team used to formulate candidate statements. After the candidate statements were formulated a modified Delphi protocol was used to refine the statements and create a final list of recommendations and quality of evidence score. Forty statements were ultimately approved by the development team addressing patient selection, specific study choice, radiation safety, fluoroscopy team members and training requirements, VFSS and esophagram technique and protocol, and study interpretation.  

Patient Selection recommendations focused on identifying at risk populations for swallowing dysfunction and discuss the use of swallowing fluoroscopy for indications other than dysphagia. With regards to Study Choice, recommendations focused on indications for VFSS vs. esophagram and the usefulness and limitations of each study.

On the topic of Radiation Safety consensus statements focused on appropriate training of staff, use of safety checklists, and adherence to the “as low as reasonably achievable” ALARA principle. With regards to fluoroscopy team members and training, recommendations focused on comprehensive training, certification, and quality control for the fluoroscopy supervisor, SLP, and radiology technician.  In addition, they empowered otolaryngologists and other physicians who treat swallowing disorders to become credentialed as fluoroscopy supervisors.

VFSS technique had the greatest number of accepted statements meeting criteria. These focused on standardized stepwise escalating protocols, using multiple consistencies, volumes, maneuvers at 30 frames per second and including a screen of the esophagus. With regards to esophagram technique recommendations focused on the utility of monophasic vs biphasic studies, and their role in screening for obstructive pathology, mucosal disease, motility disorders, and GE junction pathology. 

As for VFSS Interpretation, consensus statements emphasized objective or semi-objective analysis, clear/comprehensive reporting and treatment recommendations. Lastly, with regards to Esophagram Interpretation only one statement met criteria. This focused on comprehensive analysis from presence of aspiration/penetration, obstructive pathology, dysmotility, GE junction pathology, and details of how a patient tolerated the study.

In addition to making recommendations based on the available evidence, the development team also were tasked with identify gaps in knowledge that require further research before specific recommendations can be made. Accordingly, they found a paucity of evidence to guide certain aspects of esophagram indication criteria and technique.

The ABEA development team concluded that VFSS and esophagram are valuable tools for the comprehensive assessment of swallowing. They require a standardized multidisciplinary approach to be conducted safely, efficiently, and accurately. It is the goal of the ABEA that these forty consensus statements be actively used in institutions around the country to reduce practice variation and improve the quality of care for patients suffering with swallowing dysfunction.