Assessment of Dysphagia
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Introduction[edit | edit source]
Dysphagia screening and assessment helps with early identification, management, prevention and mitigation of complications related to swallowing difficulties. It facilitates optimisation of nutritional support and can enhance patient overall health outcomes. However, according to Freeman-Sanderson et al.[1] only thirty percent of practitioners working on the ICU complete a formal dysphagia training and administration of dysphagia protocol. A competency training in dysphagia screening for healthcare practitioners can benefit patients with neurological disorders, cardiopulmonary diseases, gastrointestinal diseases, and patients post endotracheal intubation or tracheostomy who are often affected by oropharyngeal dysphagia. [2] Donovan et al.[3] supports screening dysphagia tests conducted by various healthcare professionals to accelerate the screening process of patients with acute stroke, and stated that the "absence of consensus on the best screening instrument does not mean no screening should be performed."[3] This article discusses most common non-instrumental and instrumental assessments of dysphagia.
Dysphagia Screening[edit | edit source]
Two general types of dysphagia screening and assessments are currently available : non-instrumental and instrumental. Non-instrumental tests include dry swallowing test, water swallowing test, the 3-ounce water swallow test, cough reflex test, and bedside swallowing evaluation. Instrumental examinations include Videofluoroscopic Swallow Study (VFSS) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES). The instrumental assessments are not always available, accessible, or feasible.[4]
For a patient who experiences dysphagia, the first and the most important step is selecting the appropriate test to perform.
Patient History[edit | edit source]
When taking the patient's history the following standardised tools can be helpful:[5]
- Eating Assessment Tool 10 (EAT 10)
- It is used to screen for dysphagia and aspiration risk
- Can be completed by the patient, caregiver, or during an interview with a clinician
- Each question is rated on a scale of 0 (no problem) to 4 (severe problem)
- See Eating Assessment Tool 10 (EAT 10) here
- Dysphagia Handicap Index (DHI)
- Completed by the patient
- Self-assessment questionnaire
- Includes 25 statements to assess functional, physical, and emotional aspects of life of the patients with dysphagia
- See Dysphagia Handicap Index (DHI) form here
Observation[edit | edit source]
Palpation[edit | edit source]
Examination[edit | edit source]
General Rules[edit | edit source]
Dry Swallowing[edit | edit source]
Water Swallowing Test[edit | edit source]
Modified Water Swallowing Test[edit | edit source]
Bedside Swallowing Evaluation (BSE)[edit | edit source]
- Completed by the speech language pathologists (SLPs)
- Assess swallowing function and airway safety during swallowing[6]
- Helps to identify the risk of aspiration [6]
- Used by SLPs to provide feeding recommendations
- According to Moss et al.[6], "BSEs are relatively inaccurate for the detection of aspiration"
Standardised Protocol for BSE evaluation include the following elements:[6]
- review of the patient’s medical record
- physical examination:
- lip movement and seal
- tongue movement and strength
- volitional cough strength
- dentition
- voice quality
- amount of assistance required with feeding
- patient is positioned as upright as possible
- The SLP administered five standard consistencies: (1) ice chips, (2) nectar thin liquids, (3) pureed solids , (4) thin liquids, and (5) solids in successive boluses that increased in size
- The SLP administers all boluses unless they consider it unsafe based on the patient's response
- The SLP observes for five clinical signs for aspiration after each bolus: cough, throat clearing, change in vocal quality, wet breath sounds, or stridor.
Swallowing Reflex Test (Cough Reflex Test)[edit | edit source]
Videofluoroscopic Swallow Study (VFSS)[edit | edit source]
- Performed by experienced SLPs with radiologists
- May require advanced competency certification in Videofluoroscopic Assessment of Adult Swallowing Disorders
- It is a radiographic assessment of swallowing.
- A physician’s order is required to conduct a VFSS.
Fiberoptic Endoscopic Evaluation of Swallowing (FEES)[edit | edit source]
- Administered by SLPs trained in FEES examination.
- Because it requires professionals to perform the test, the test might not be feasible for community screening.[7]
- Fiber-optic or distal chip endoscopes are used for the evaluation.
- The endoscope is inserted through the nose to observe the pharynx and larynx when the individual is swallowing saliva with and without food of varying consistencies. [7]
- May induce pain and discomfort.[7]
- Every institution must develop protocol for FEES administration.
- Video and sound is recorded and use to determine a penetration-aspiration scale (PAS) score for each of the boluses administered:
- PAS is an 8-point, equal-appearing interval scale describing penetration and aspiration events: [8]
- score of 6 or more indicates aspiration
- score of 6 or 7 indicates nonsilent aspiration
- score of 8 represents silent aspiration
- PAS is an 8-point, equal-appearing interval scale describing penetration and aspiration events: [8]
Resources[edit | edit source]
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References[edit | edit source]
- ↑ Freeman-Sanderson A, Hemsley B, Thompson K, Rogers KD, Knowles S, Hammond NE. Dysphagia in adult intensive care patients: Results of a prospective, multicentre binational point prevalence study. Australian Critical Care. 2023 Nov 1;36(6):961-6.
- ↑ Hsiao MY, Wu CH, Wang TG. Emerging Role of Ultrasound in Dysphagia Assessment and Intervention: A Narrative Review. Front Rehabil Sci. 2021 Aug 11;2:708102.
- ↑ 3.0 3.1 Donovan NJ, Daniels SK, Edmiaston J, Weinhardt J, Summers D, Mitchell PH; American Heart Association Council on Cardiovascular Nursing and Stroke Council. Dysphagia Screening: State of the Art. Invitational conference proceeding from the State-of-the-Art Nursing Symposium, International Stroke Conference 2012. Stroke. 2013 Apr;44(4):e24-31.
- ↑ Demetriou M, Georgiou AM. Perspective on dysphagia screening, assessment methods, and protocols in intensive care units: an opinion article. Front Hum Neurosci. 2024 Apr 9;18:1375408.
- ↑ Jamróz B, Pabian M, Chmielewska, Milewska M, Niemczyk K. Screening tests for dysphagia. Polish Otorhinolaryngology Review Pol Otorhino Rev 2017; 6(4).
- ↑ 6.0 6.1 6.2 6.3 Moss M, White SD, Warner H, Dvorkin D, Fink D, Gomez-Taborda S, Higgins C, Krisciunas GP, Levitt JE, McKeehan J, McNally E, Rubio A, Scheel R, Siner JM, Vojnik R, Langmore SE. Development of an Accurate Bedside Swallowing Evaluation Decision Tree Algorithm for Detecting Aspiration in Acute Respiratory Failure Survivors. Chest. 2020 Nov;158(5):1923-1933.
- ↑ 7.0 7.1 7.2 Lim HJ, Lai DK, So BP, Yip CC, Cheung DSK, Cheung JC, Wong DW. A Comprehensive Assessment Protocol for Swallowing (CAPS): Paving the Way towards Computer-Aided Dysphagia Screening. Int J Environ Res Public Health. 2023 Feb 8;20(4):2998.
- ↑ Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia. 1996 Spring;11(2):93-8.
