Advocacy, Clinical Focus, Education
ASHA, our governing body provides us guidance for clinical decision making. Below is the information they provide for adult dysphagia assessment. Note that the bolded text is from ASHA and the unbolded text is my own thoughts.Â
Instrumental Swallowing Assessment
SLPs use instrumental techniques to evaluate oral, pharyngeal, laryngeal, upper esophageal, and respiratory function as they apply to normal and abnormal swallowing. In addition, instrumental procedures are used to determine the appropriateness and the effectiveness of a variety of treatment strategies.
Instrumental techniques are usually conducted either independently by the SLP or by the SLP in conjunction with other members of the interprofessional team (e.g., radiologist, radiologic technologist, physiatrist). Competence in videofluoroscopic swallowing study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) requires appropriate training and education. SLPs help guide medical decision making regarding the appropriateness of these procedures given the severity and nature of the patient’s swallowing deficits. SLPs interpret and apply the results of objective testing to the formulation of dysphagia treatment plans, and they also determine patient capacity and safety for oral feeding.
Indications for an instrumental exam include the following:
- Concerns regarding the safety and efficiency of swallow function
- Contribution of dysphagia to nutritional compromise
- Contribution of dysphagia to pulmonary compromise
- Contribution of dysphagia to concerns for airway safety (e.g., choking)
At times we may fall into the trap of focusing in too closely on the patientâ€™s dysphagia only. We have to remember to look at the entire picture, look at the patient as a whole. When we collaborate with the medical team, the outcomes can only improve for the patient.Â
- The need to identify disordered swallowing physiology to guide management and treatment
We canâ€™t treat what we canâ€™t see. Let me say that again. We canâ€™t treat what we canâ€™t see.Â
- Inconsistent signs and symptoms in the findings of a non-instrumental examination
Remember that there is not always a cough response to aspiration. And sometimes, there will be a cough with aspiration of thin liquids but no cough with thickened. We canâ€™t depend on the bedside swallow evaluation to determine when aspiration happens.Â
- The need to assist in the determination of a differential medical diagnosis related to the presence of pathological swallowing
SLPâ€™s can sometimes be the first medical professional to identify signs/symptoms of a neurological condition.Â
- Presence of a medical condition or diagnosis associated with a high risk of dysphagia
Think CVA, TBI, COPD, HANC, Parkinsonâ€™s Disease, Progressive neurological conditions, MS, dementia, etc.Â
- Previously identified dysphagia with a suspected change in swallow function that may change recommendations
If there is a change in status for a patient with known dysphagia, an instrumental swallow study is warranted and needed whether it is a change for the better or for the worse.Â
- Presence of a chronic degenerative condition with a known progression or the recovery from a condition that may require further information for the management of oropharyngeal function
We are an important part of the care team for these patients.Â
Contraindications for an instrumental exam include the following:
- The patient is not medically stable enough to tolerate the procedure.
- The patient is not able to participate in an instrumental examination (e.g., cognitive difficulties, inability to maintain an appropriate level of alertness).
- The SLP’s clinical judgment indicates that the instrumental assessment would not change the clinical management of the patient.
Similar to non-instrumental assessment, instrumental assessment also includes a thorough case history; an oral mechanism exam; and assessment of overall physical, social, behavioral, and cognitive/communicative status (see previous section on Non-Instrumental Swallowing Assessment for details on these components of an evaluation).Â
The purpose of the instrumental examination is to enable the SLP to
- visualize the structures of the upper aerodigestive tract;
- assess the physiology of the structures involved in swallowing and to make observations, measures, and inferences of symmetry, sensation, strength, pressures, tone, range of motion, and coordination or timing of movement to determine the diagnosis of dysphagia;
- determine presence, cause, and severity of dysphagia by visualizing bolus control, flow and timing of the bolus, and the individual’s response to bolus misdirection and residue;
- visualize the presence, location, and amount of secretions in the hypopharynx and larynx, the patient’s sensitivity to the secretions; and the ability of spontaneous or facilitated efforts to clear the secretions;
- determine the cause(s) for laryngeal penetration and/or aspiration; and
- determine with specificity the relative safety and efficiency of various bolus consistencies and volumes.
You can see above that at no time does ASHA recommend that a clinician only rely on a bedside swallow examination when there is suspected dysphagia. We canâ€™t treat what we canâ€™t see. Mobile FEES with Midwest Dysphagia Diagnostics provides easily accessible, high quality instrumental examinations for your patients and residents. Reach out today!
American Speech-Language-Hearing Association. (n.d.). Adult Dysphagia. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Adult-Dysphagia/.