Assessment of Dysphagia

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Introduction

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. 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. Donovan et al. 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." This article discusses most common non-instrumental and instrumental assessments of dysphagia.

Dysphagia Screening

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.

For a patient who experiences dysphagia, the first and the most important step is selecting the appropriate test to perform.

Patient History

When taking the patient's history the following standardised tools can be helpful:

• 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

All rehabilitation professionals should become competent to perform this part of the dysphagia evaluation. Key observation points in the evaluation of the patient with dysphagia include (1) general health status, including body mass index, (2) posture, (3) oral-motor skills, (4) inspection of oral cavity for oral cavity ulcerations, exophytic growths, abnormal motion of the palate, mucosal drying, tongue appearance and motion, and dental status, (5) nasal evaluation to rule out local tumours or postnasal drip.

Examination

Bedside Swallowing Evaluation (BSE)

• Completed by the speech language pathologists (SLPs)
• Assess swallowing function and airway safety during swallowing
• Helps to identify the risk of aspiration
• Used by SLPs to provide feeding recommendations
• According to Moss et al., "BSEs are relatively inaccurate for the detection of aspiration"

Standardised Protocol for BSE evaluation include the following elements:

• 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.

Videofluoroscopic Swallow Study (VFSS)

Videofluoroscopic swallow study is also known as modified barium swallowing test (MBST) and is considered the gold standard in diagnosing oropharyngeal dysphagia.

• Performed by experienced SLPs with radiologist or medical radiological technologist.
• May require advanced competency certification in Videofluoroscopic Assessment of Adult Swallowing Disorders.
• It is a radiographic assessment of swallowing.
• It should be "custom-tailored technique designed by radiologists and swallowing therapists on the basis of the patient’s clinical history and symptoms."
• A physician’s order is required to initiate a VFSS.
• A clinical swallow assessment must be completed before a VFSS is administered.

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

• Administered by SLPs trained in FEES examination.
• Because it requires professionals to perform the test, the test might not be feasible for community screening.
• 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.
• May induce pain and discomfort.
• 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:
    • score of 6 or more indicates aspiration
    • score of 6 or 7 indicates nonsilent aspiration
    • score of 8 represents silent aspiration

High-Resolution Pharyngneal Manometry (HRPM)

• Performed by a Speech-Language Pathologists (SLPs) with proper training in HRPM

• It helps to understand the mechanism of oropharyngeal dysphagia.
• It identifies individuals at risk for dysphagia in a neurological disorder like Parkison’s disease.
• It defines pharyngeal lumen occlusive pressures, hypopharyngeal intrabolus pressures, and upper esophageal sphincter (UES) function.
• Can be performed without ingesting any barium bolus.
• It is a safe assessment for dysphagia patients at high risk of aspiration.
• It detects changes in swallowing-related pressures in patients with early Parkinson's disease before the onset of dysphagia's signs and symptoms.

Barium Swallow

• uses real-time fluoroscopy and barium to evaluate for esophageal dysphagia
• It is helpful in assessing for any morphologic and motility abnormalities in the pharynx and esophagus.
• rarely used as a stand-alone investigation
• Then the gold standard, barium swallow test, also known as oesophagogram.

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