Adult Dysphagia Assessment Outline:
Purpose: identify strategies to ensure immediate swallow safety
Determine swallow safety
Inform management decisions
Determine nutritional status
Determine need for and possibility of adapting existing diet
Determine the need for and appropriate of additional instrumental
assessment
Assessment typically includes screening, bedside (clinical evaluation)
and instrumental evaluation
Considerations for bedside evaluation
History (Gathering information on symptoms (e.g., coughing when
eating, sensation of food sticking), past medical history, medications,
and previous swallowing difficulties)
Clinical observations (e.g. feeding tubes, tracheostomy tubes,
respiratory patterns, mental status, saliva control, positioning and
postural control, consulting vitals such as heart rate, O2 saturation
when feeding and note, patient’s current state)
Trial swallows
Respiratory status feeding methods
Cranial nerve assessment
OSME
Assessment protocols
Voice quality- examine the vocal quality for any signs of "gurgling"
indicative of material sitting on the vocal cords
¾ finger test Method of “feeling” the swallow response to
determine: Timing of swallow, Laryngeal excursion (hyoid and
laryngeal movement) and Base of tongue retraction (submandibular
movement
Blue dye test
Cervical auscultation
Pulse oximetry
Water swallow test
Screening
Screeners tell you whether the person needs a full Ax.
NB: screener table.
Purpose of screening
Screening should be quick, non-invasive, low risk and low cost
Screening can be completed by another member of the team for more
appropriate referrals
Provides indirect evidence that swallowing disorders are present
Identifies highest risk patients in need for more in-depth physiological
assessment
Usually provides little information on the physiology of a disorder (i.e. does not
explain why signs/symptoms are present)
Good screening measure should yield true positives/negatives, and not many
false positives/negatives
No screening procedure has reached 100% accuracy
Screening information can be obtained by reviewing medical notes, observation
of eating, or observation of saliva management
Clinical Swallow Assessment
Clinical Swallowing Examination (CSE) allows a circumscribed exploration of a
patient’s muscle function, sensation, and airway protective functions (aka
swallow – can't protect airway then can't swallow).
Findings from the clinical examination are combined with information gathered
during the historical data collection and interview session.
At the close of the clinical swallowing examination, the clinician should be able to
develop confidently a management program for the patient or determine the
necessity of further instrumental assessment or sub-specialty referral (Murray,
1999 p. 37)”.
Considerations for clinical/ bedside evaluation
• History
• Clinical Observations
• Feeding method
• Respiratory status
• Mental status
• Cognitive screening
• Cranial nerve assessment
• Oral cavity inspection
• Trial swallows
• Mealtime Observations
Purpose of Bedside/Clinical Evaluation
Provides information on:
• the current medical diagnosis, medical history, history of the swallowing disorder,
patient's awareness of the swallowing disorder, and indications on the localization and
nature of the disorder;
• medical status, including nutritional and respiratory status;
• oral anatomy;
• respiratory function and its relationship to swallow;
• oral-motor control, including lip, jaw and tongue control;
• oropharyngeal function including palatal function and pharyngeal wall contraction;
• laryngeal control;
• patient's ability to follow directions and monitor and control his/her behaviour;
• oral sensory status, i.e. reactions to oral sensory stimulation, including taste,
temperature, and texture; and
• reactions and symptoms during attempts to swallow
Bedside Swallowing evaluation
1. Preparatory examination
• No actual swallows
• Observation of saliva management
• Perceptual characteristic
2. Initial Swallowing Exam
• actual swallowing attempted
• some aspects of physiology observed
Give date for admission so you can go back to date.
Look at the notes of other HCP’s.
A. Preparatory Examination
• Case history (medical file, interview, observation)
• Complete case history gains:
the localization of the disorder i.t.o. the oral and/or pharyngeal stage of the
swallow
the easiest and most difficult types of material for the patient to swallow; and
the nature of the swallowing disorder
Case History
• Name
• Age
• Main Complaint
o How long has this been going on?
o Has the complaint changed?
o What is the patient doing to compensate for it or improve it?
• Medical History
Medical History
Patient Prognosis
Other specialists
Course of treatment
What tests have been ordered/completed/results?
What physiological impairments are noted?
Current Meds
o Know about ALL medications, such as sedatives so you know when to assess px.
• Patient Wishes
• Previous Pneumonia
• Identify the presence of:
o Congenital Disease
o Neurological Conditions
o Surgical Procedures
o Systemic and Metabolic Disorders
o Respiratory Impairment
o Oesophageal Impairments
o Previous Test Results
Clinical Observations
Feeding tubes Check how long it has been in place. If px has had it for
a longer time, it will affect
sensory Ax.
Tracheotomy tubes.
Respiratory pattern. Such as “gasp breathing pattern”
Mental status.
Positioning and postural control (especially head and neck control).
Saliva control.
Comfortable breath hold. When you swallow, you have breath hold.
Physical examination / Oropharyngeal examination
• Before the examination, SLT must have knowledge of:
Airway
Cognition, level of consciousness, endurance.
Ability to follow instructions.
▪ If not, then you wont do the oropharyngeal examination.
o Body/muscle tone, size, posture, positioning.
o Self-feeding potential
B. Initial Swallow Evaluation (second part of bedside evaluation)
• risk-benefit ratio (acute, pulmonary complications, poor cough, older than
80, unable to
follow instructions, low GCS)
• If the patient can follow directions, cough on command, and has good
pulmonary function, the risk is relatively low and a few trial swallows can be
assessed
• If patient is orally fed, observe feeding to note:
o the patient's reaction to food;
o oral movements in chewing and food manipulation;
o any coughing, throat clearing, struggling behaviours or changes in
breathing and
their frequency relative to swallowing, and occurrence (beginning, during, or
end of
a meal);
o changes in secretion levels throughout the meal;
o duration of the meal and total intake; and
o coordination of breathing and swallowing.
Important Considerations
• Posture
• Selection of optimal food position in the mouth
information collected in the history;
o data on oral control; and
o information on pharyngeal and laryngeal control
Clinical Swallowing Evaluation
• Prior to the swallow - review instructions and procedure & practice several
dry swallows
• After the swallow the patient should be asked to:
o phonate /a/ for several seconds (look out for wet and gurgly voice quality);
o pant for several seconds immediately after the vocalization (if material is
residing in the pharyngeal recesses, valleculae or pyriform sinuses, it will be
shaken loose before it falls into the airway);
o vocalise again so that vocal quality can be evaluated;
o turn head to each side and vocalize (head rotation results in pressure on
each
pyriform sinus and may squeeze any residual material from the pyriform
sinus into
the pharynx, ready for swallowing);
o lift the chin up and hold it there for a few seconds and vocalize again (chin-
up
posture will cause the tongue base to push on the valleculae and as a result
material
from the valleculae will be cleared, which may cause a gurgly voice quality)
o Coughing and any materials expectorated or has a gurgly voice quality,
aspiration
can be suspected
o NB many patients are silent aspirators – be aware that material can enter
the airway
without any overt signs being displayed.
