Aspiration Risk Screening Tool
We use cookies to give you the best website experience. By using our website you agree to our use of cookies - SIGN Guideline 119: Management of Patients with Stroke: Identification and Management of Dysphagia 2 Initial clinical evaluation of swallowing and nutrition after stroke Dysphagia affects a large proportion of stroke patients. Swallowing difficulties can result in aspiration and reduced oral intake.
Aspiration Risk Screening Tool. Note If any of the above criteria is marked as ‘Yes’ then it will be regarded as High Risk Aspiration Pneumonia. To develop and validate a nurse-administered screening tool to identify aspiration risk in patients with suspected stroke.
These in turn can lead to the potentially serious complications of pneumonia, undernutrition and dehydration. As these complications may be avoidable or reversible, it is important to screen all stroke patients in order to identify those individuals at risk. 18,26,27 Evidence level 2,4 C All stroke patients should be screened for dysphagia before being given food or drink. 2.1 ASSESSING RISK OF PNEUMONIA The presence of dysphagia indicates an increased risk of lower respiratory tract infection.
26 Confirmed aspiration has been found to increase the risk of pneumonia by some, 11,28 although others have found no such link. 10 The aspiration of solid material or thickened fluids leads to an increased risk of developing pneumonia. 28-30 A prolonged pharyngeal transit time is also associated with increased risk of aspiration pneumonia. 31 Evidence level 2+,3,4 Pneumonia does not always occur in the presence of aspiration and may occur in the absence of aspiration, as a consequence of other factors present in the stroke patient (eg smoking, respiratory disease, immobility or comorbidity). 32-35 Evidence level 2+ The relationship between aspiration and pneumonia is complex, but aspiration is a risk factor and must be identified as a priority.
2.1.1 ASPIRATION RISK Coughing is a sign of material penetrating the airway, but the absence of cough does not indicate safe swallowing; up to 68% of patients seen to aspirate on videofluoroscopy fail to cough. 26 Evidence level 2 Risk of aspiration is suggested by the following: 36,37. wet, hoarse voice. weak voluntary cough.
any indication of reduced laryngeal function. Reduced conscious level is also an indicator of aspiration risk.
37 Evidence level 2+.2- The gag reflex is unreliable and insensitive as an independent predictor 26 and should only be used as part of a more detailed assessment procedure (see ). 38 Evidence level 2 One screening study suggests that reduced pharyngeal sensation may be associated with aspiration, 8 although other papers report conflicting results. 39 Testing of pharyngeal sensation in stroke patients may be useful in predicting aspiration, but there is currently insufficient evidence to recommend its use as a screening tool. Evidence level 3 Laryngopharyngeal sensory testing has also been described but insufficient evidence was identified to recommend it. 40 A water swallow test is often used to identify aspiration risk. The patient is given teaspoonfuls of water and the initiation of the swallow and any occurrence of coughing or alteration in voice quality are observed (see ). If there are no adverse signs, the patient is given a larger quantity to drink from a glass.
This test has a reported sensitivity of 70% and a specificity of 22-66% for prediction of aspiration 26 and has been found to be a useful and reasonably sensitive screening test. 16,41 Evidence level 2 B The water swallow test should be used as a part of the screening for aspiration risk in stroke patients. 2.1.2 OTHER RISK FACTORS Dysphagia in conjunction with pulmonary compromise (eg chronic obstructive pulmonary disease, smoking or cough that does not clear the chest adequately) may increase the risk of pneumonia. 27,33,42 Evidence level 2+ Requiring help with eating has been shown to be a significant risk factor in the development of aspiration pneumonia in elderly patients. 33 Evidence level 2+ Dental decay, the presence of cariogenic bacteria and other oral pathogens may be important risk factors for aspiration pneumonia in elderly patients. 33,43 Evidence level 2+ C Clinical history taking should take into account comorbidities and other risk factors (eg smoking or respiratory disease) to identify increased risk of developing aspiration pneumonia. Medications for pre-existing conditions that list dysphagia as a potential side effect should be excluded (eg bisphosphonate and potassium supplements, refer to the manufacturer’s recommendations).
2.2 SWALLOW SCREENING In clinical practice, the screening process is used to identify those patients who should be referred for full clinical assessment by a professional skilled in the management of dysphagia (usually a speech and language therapist; SLT). If the screening procedure does not identify any difficulties, the patient can be allowed to eat and drink, avoiding unnecessary restrictions on oral intake while awaiting a full clinical assessment. Screening tests are based on identified risk factors and should be carried out by healthcare professionals trained in the procedure. In the acute setting, this is usually a trained nurse.
Studies assessing the natural history of swallowing function after acute stroke suggest that many patients with dysphagia recover their swallowing within the first week 1,11-13 and the majority will have improved by the end of the second week.9,11 Evidence level 3,4 D Patients with dysphagia should be monitored daily in the first week to identify rapid recovery. Observations should be recorded as part of the care plan. Patients not fit for assessment should be screened daily to avoid delay in referral for full clinical assessment. 2.2.1 SWALLOW SCREENING PROCEDURES A number of similar screening procedures are described in the literature.
All rely on a small range of clinical features, designed to highlight swallowing dysfunction. 26 An example swallow screening procedure is shown in. Evidence level 2 B A typical swallow screening procedure should include:.
initial observations of the patient’s consciousness level. observations of the degree of postural control. If the patient is able to actively cooperate and is able to be supported in an upright position the procedure should also include:. observations of oral hygiene. observations of control of oral secretions. if appropriate, a water swallow test.
Screening protocols must include a clear pathway of action for all possible outcomes (eg onward referral, nil by mouth, commence oral diet). Patients who are nil by mouth or are on a modified diet should continue to receive clinically essential medication by an appropriate route as advised by a pharmacist. 2.3 ASSESSING RISK OF UNDERNUTRITION Observational studies have determined that between 16-49% of stroke patients, with or without dysphagia, are undernourished on admission to hospital.
44-46 In addition, dysphagia in itself is associated with undernutrition. 26 The predictors of undernutrition on admission to stroke rehabilitation are: 44.
the use of tube feeding. a prior stroke. diabetes mellitus.
The predictors of undernutrition at one week post stroke are: 44-46. pre-existing undernutrition. swallowing problems. increased free urinary cortisol. Low serum albumin levels on admission show a significant association with poor outcome.
15 Early and sequential screening for nutritional risk is needed to permit appropriate nutritional intervention. 2.4 NUTRITIONAL SCREENING Nutritional screening is a simple and rapid procedure that identifies clinical characteristics known to be associated with a reduction in nutritional status.
The results of the screening process should direct any further action required, eg referral to a dietitian for a comprehensive nutritional assessment, or the recording of food and fluid intake. Early and regular screening of stroke patients for undernutrition is important. 47-49 Evidence level 4 Stroke population based studies concluded that nutritional deficits develop throughout the rehabilitation phase indicating the need for more structured monitoring of nutritional status. 155 In one study 57% of patients were found to have lost weight from week one to six months post-stroke and 22% were undernourished at six months post stroke. 156 Evidence level 2+,2- Ongoing assessment of nutritional risk requires monitoring of a number of different parameters. A systematic review of eating difficulties post stroke highlighted the need to observe independant eating and volume of food consumed. 157 Other identified predictors of nutritional risk are severe stroke, higher dependence, low pre-albumin levels and impaired glucose metabolism and unintentional weight loss.
155,158 Evidence level 2+,2- The evidence supports the need to combine the results from these parameters to provide an accurate assessment of ongoing nutritional status rather than relying on any single measure. 159 Evidence level 2+,2- D Patients’ nutritional risk should be established using a valid and reliable screening procedure suitable for stroke patients. D Assessment of nutritional risk should be carried out within the first 48 hours with regular re-assessment thereafter during the patient’s recovery and be recorded prior to any discharge. D Assessment of a patient’s nutritional risk should include an assessment of their ability to eat independently and a periodic record of their food consumption.
D Ongoing monitoring of nutritional status should include a combination of the following parameters:. biochemical measures (ie low pre-albumin, impaired glucose metabolism). swallowing status. unintentional weight loss.
eating assessment and dependence. nutritional intake. D Results from the nutritional screening process should guide appropriate referral to a dietitian for assessment and management. 2.4.1 NUTRITIONAL SCREENING PROCEDURES The following screening parameters have been suggested by the Nursing and Midwifery Practice Development Unit (2002) 49 as suitable for the care of adults in hospital: Evidence level 4 D Nutritional screening should cover:. body mass index (BMI). ability to eat. appetite.
physical condition. mental condition. Although many screening tools use BMI as a criterion to assess undernutrition, a recent review concluded that weight and weight change were more sensitive and more dynamic screening parameters than BMI in older people. 50 Weighing and measuring stroke patients may present some practical problems, as specialist equipment and training may be required. The Malnutrition Universal Screening Tool (MUST), launched in 2004, has been endorsed by the British Dietetic Association, The Royal College of Nursing and the Registered Nursing Home Association.
Further information is available at 2.5 ASSESSING RISK OF DEHYDRATION Dysphagia is associated with dehydration but no evidence on the clinical predictors of dehydration was identified. 9,12,51 There is no evidence of a clear relationship between radiological aspiration and oral dehydration. 10,30 Evidence level 4 Scottish Intercollegiate Guidelines Network, Healthcare Improvement Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh EH12 9EB Tel. 0131 623 4720 Web contact Last modified 9/09/13 © SIGN 2001-2013.
Abstract The National Quality Forum and the Agency for Healthcare Research and Quality identified aspiration risk assessment as a practice to reduce the risk of harm to patients. Pennsylvania healthcare facilities submitted 133 nonanesthesia aspiration event reports to the Pennsylvania Patient Safety Authority from June 2004 through January 2009. Seventy-three (55%) of these event reports indicated that swallowing or aspiration assessments had been completed before the event occurrence.
The remaining 60 (45%) reports of nonanesthesia aspiration indicated patients had not received aspiration risk screenings or assessments before the aspirations. Thirty-eight (29%) of the nonanesthesia aspiration reports describe instances in which barriers were identified during aspiration risk screening and as aspiration precautions were implemented. While video fluoroscopic swallow evaluation is considered the “gold standard” for predicting aspiration, aspiration screening of patients on admission can help determine whether a more detailed aspiration assessment and fluoroscopic swallow evaluation are indicated and help to identify dysphagia and patients at risk for aspiration. The Problem The National Quality Forum and the Agency for Healthcare Research and Quality (AHRQ) identified the aspiration risk evaluation of each patient upon admission and regularly thereafter as a suggested patient care practice. 1 Patients who aspirate are at greater risk of developing serious respiratory complications such as airway obstruction or aspiration pneumonia.
Aspiration pneumonia is one of the most common forms of hospital-acquired pneumonia among adults and occurs in 4 to 8 of every 1,000 admitted U.S. 2 Patient conditions that present a high risk for aspiration include stroke or other neurologic impairment that affects swallowing, tracheostomy or endotracheal intubation, advanced age, changes in the oropharyngeal anatomy due to trauma, surgery complications, neoplasm, pneumonia, unexplained weight loss, or even body position.
3 Routine bedside aspiration risk assessments are noninvasive, typically evaluate patient symptoms, and are designed to be administered quickly. Invasive diagnostic procedures such as the fiberoptic endoscopic evaluation of swallowing (FEES) or a videofluoroscopic swallow evaluation (VSE) visualize the anatomy and physiology of a patient’s swallowing and are frequently used when a suspected swallowing disorder has been identified by a routine bedside aspiration screening. Many aspiration risk assessment tools are already available to assist anesthesia providers with aspiration prescreening criteria for patients receiving anesthesia, but there are few such tools for the newly admitted hospital patient. The benefit of adopting aspiration risk screening tools will provide organizations with the ability to promptly identify those patients who are experiencing dysphagia and may be at risk for aspiration. This screening may also provide healthcare providers with baseline information to complete a more detailed aspiration assessment to assist in the identification and treatment of patients with aspiration, to prevent aspiration events, to provide optimal patient care, and to ensure accurate patient information exchange through all levels of care. Pennsylvania Patient Safety Authority Reports Of the 133 nonanesthesia aspiration Incidents and Serious Events reported to the Pennsylvania Patient Safety Authority’s reporting system from June 2004 through January 2009, 73 (55%) of the events indicated that patients had been assessed for aspiration risk before the nonanesthesia aspiration event. Fifteen (11%) of the aspiration events required transfers to a higher level of care, and 7 (5%) resulted in patient death.
Events that resulted in transfer to higher levels of care include the following: The patient began to cough, followed by vomiting, developed worsening respiratory symptoms, and was transferred to the ICU intensive care unit with shortness of breath and aspiration. The patient was found with cyanotic face and lips upon entering the room to complete an assessment. The rapid response team was called. The patient began coughing up whole pieces of chicken. The patient was transferred to the ICU. The patient was eating a sandwich and began to choke. Heimlich attempts were unsuccessful.
The food particles were manually removed, and the patient was transferred to the ICU and intubated. Events that resulted in patient deaths include the following: A patient vomited during the night and the order to administer the patient nothing by mouth NPO was written. In the morning the patient was found unresponsive. Despite aggressive resuscitation efforts, the patient ceased to breathe. Silent aspiration is considered the cause of death.
A patient had moderate to severe dysphagia following a stroke. Family members brought in solid food, which the patient ate and immediately began to choke. Despite immediate resuscitation efforts, the patient expired. A patient with recent history of stroke was placed on pureed dysphagia diet after nutrition and speech evaluations. After being fed a meal by a family member, the patient became short of breath. Suctioning the patient produced the meal contents. The patient was intubated, transferred to the cardiac care unit, and died as a result of aspiration.
The remaining 60 (45%) reports of nonanesthesia aspiration indicated patients had not received aspiration risk screening or assessments before the aspiration events. Of the 55% of reports indicating patients had been assessed for aspiration risk before a nonanethesia aspiration event, analysis identified the following contributing factors:. Patients received inappropriate nutrition in 28 (38%) of the events, including delivery of incorrect nutrition to patients who were NPO (nothing by mouth), family members who fed patients who were NPO, or missed patient bedside NPO alerts. Miscommunication occurred between healthcare providers and departments in the hospital in four (5%) of the events (e.g., NPO notification between patient care areas and the dietary department).
Medication-related issues were evident in three (4%) of the events, including some patients who received unauthorized medication doses and incidence of staff knowledge deficit (e.g., NPO clarification between prescribers and nurses when patients are NPO except for medications versus exclusively NPO). Tubing insertion misplacement issues occurred in three (4%) of the events involving endotracheal, nasogastric, or gastrostomy tubes. The Complexity of Swallowing It is important for healthcare providers to understand the complexity of normal swallowing in order to recognize, identify, and treat patients with swallowing difficulties and aspiration. Furthermore, provider knowledge will assist in prevention efforts, help provide optimal patient care, ensure accurate communication and patient information exchange through all levels of care, and aid in educating patients and family members about abnormal swallowing. Normal Swallowing Normal swallowing is a complicated act that relies on independent cognition, upper extremity mobility, oral mobility, taste, smell, and vision capabilities. It involves more than 26 muscles that control facial, palatal, suprahyoid, and pharyngeal structures, whose actions are coordinated by the cerebellum.
4, 5 Normal swallowing also depends on the intact function of the trigeminal, facial, glossopharyngeal, vagus, and hypoglossal cranial nerves. 5 Successful swallowing occurs with the completion of the oral preparatory, oral propulsive, pharyngeal, and esophageal phases of swallowing. 2, 3, 4 Impairment to the oral phase of swallowing may result in difficulty retaining the food or liquid bolus in the oral cavity or chewing or moving the material toward the oropharynx.
Associated symptoms with impairment in the oral phase of swallowing may include drooling, pocketing of food in the buccal cavity, poor tongue movement, leakage of food or liquid from the mouth, or difficulty initiating the swallowing process. 5 The pharyngeal phase of swallowing is under involuntary neuromuscular control and triggers the swallowing reflex as the food or liquid moves with a progressive contraction wave from top to bottom. Impairment to the pharyngeal phase of swallowing can result in the food or liquid material being retained in the oropharynx and overflow aspiration after swallowing.
Associated symptoms with impairment in the pharyngeal phase of swallowing include nasal regurgitation, coughing, choking, hoarseness, or food sticking in the throat. 5 The esophageal phase of swallowing begins after the food or liquid passes through the upper esophageal sphincter. 1, 5 Impairment to the esophageal phase of swallowing may result in ineffective movement and retention of the bolus of food or liquid in the esophagus. Associated symptoms with impairment in the esophageal phase of swallowing may include burping, indigestion resulting from esophageal reflux, heartburn, chest pain, or silent aspiration. 5 Anything that interferes or impairs with any of the normal swallowing phases is defined as dysphagia, which may cause morbidity and mortality.
4 Dysphagia Dysphagia, or difficulty swallowing, may cause problems that range from symptoms of mild throat discomfort to an inability to eat. 1 Dysphagia may be a symptom of one or more underlying pathologies and may include complications related to age, structure, neurologic and neuromuscular impairment, medication side effects, surgery, infections, iatrogenic conditions, and irradiation effects of the head and neck. Fifty percent of adult patients in acute care facilities are reported to experience dysphagia, while 66% of those in long-term care facilities have swallowing difficulties. 7 Dysphagia makes a patient more prone to malnutrition, dehydration, aspiration, aspiration pneumonia, subsequent respiratory failure, and possible death. 8 Normal aging has subtle effects on all four stages of swallowing. 5 Presbyphagia, or normal changes in the swallowing mechanism secondary to aging, compounds the risk for aspiration.
9, 10 Aging causes changes in the structure, motility, coordination, and sensitivity of the swallowing process. 5, 9, 11 McCullough et al. Used an 8-point penetration-aspiration scale incorporating thin liquid, puree, and solid and bolus sizes from 5 mL to 3 ounces in 79 normal adults ranging in age from 21 to 103 years old. This study found that laryngeal penetration is common for older individuals, often resulting in retained material in the laryngeal vestibule after swallowing, which is consistent with changes in the swallowing physiology that occur with the aging process. Increase in the time to swallow has the potential to create problems, including aspiration. Penetration-aspiration was more common with older participants. Over- or undermanaging these changes may present unnecessary restrictions on nutritional intake or negative consequences that affect the quality of life, even though this study provided some data that supports that aspiration in small quantities is normal for some older adults.
Aspiration Risk Screening Tool
11 This makes it even more difficult for healthcare providers to assess aspiration risk for these patients. Common presenting symptoms of oral or pharyngeal dysphagia include coughing or choking with swallowing, difficulty initiating swallowing, food sticking in the throat, drooling, unexpected weight loss, change in dietary habits, recurrent pneumonia, change in voice or speech, and nasal regurgitation. Signs of esophageal dysphagia include the sensation of food sticking in the chest, oral or pharyngeal regurgitation, food sticking in the throat, drooling, unexpected weight loss, change in dietary habits, and recurrent pneumonia. 4, 5, 10 Aspiration Aspiration is the passage of food or liquid through the true vocal cords and is often caused by impaired laryngeal closure but may also occur because of the overflow of food or liquids retained in the pharynx.
Cervical spine surgery increases aspiration risk by more than 40%. 2 Factors that influence aspiration include quantity, depth (material in the distal airways is more dangerous than aspirating material in the pharynx), physical properties of the aspirate, and pulmonary clearance mechanisms. 4 The bedside swallowing assessment provides the early identification of those patients at greatest risk for dysphagia and aspiration. The VSE is the “gold standard” for predicting aspiration, and aspiration screening of patients on admission can help determine whether a more detailed aspiration assessment and fluoroscopic swallow evaluation are indicated; therefore, an accurate and valid risk assessment tool is vital. 2, 4, 12 This will help identify dysphagia and patients at risk for aspiration. Sitoh et al.’s prospective study of 65 geriatric patients used a bedside swallowing assessment that incorporated criteria known to be associated with aspiration risk, including cough upon swallowing, delay in swallowing, and drooling. The study found the simple assessment swallowing protocol was useful in helping to identify patients at risk for swallowing dysfunctions and those at risk for developing chest infections.
Fourteen of the 65 patients subsequently contracted hospital-acquired pneumonia; 13 of those had been identified as having swallowing dysfunctions, based on the bedside swallowing assessments. One limitation to the study was the lack of video-fluoroscopic or endoscopic confirmation of aspiration. 13 Overt aspiration may occur with patients who have dysphagia. Aspiration pneumonia is the second most common healthcare-acquired infection in hospitalized patients. 3, 14 Patients with endotracheal tubes have a high risk for aspiration and may also experience prolonged swallowing dysfunction after extubation. 3 The presence of a nasal or oral feeding tube, gastroesophageal reflux, or those patients tube fed in the supine position may have increased swallowing dysfunction, thereby increasing aspiration risk.
3, 14 The right lower lobe is the most frequent site of aspiration due to its larger caliber and straighter orientation of the right mainstem bronchus. The left lung is more difficult to suction secondary to the fact that the left bronchus is narrower, longer, and has a more horizontal angle than the right lung, making it more difficult to suction the intubated patient. 3 There are also patients who may regularly experience silent aspiration when food or liquid material is inhaled without a discernable gag reflex, cough, or other identifiable apparent difficulties. 10, 12 Silent Aspiration Silent aspiration is the occurrence of aspiration before, during, or after swallowing in the absence of cough or other apparent signs of distress. 2, 12, 15 Patients with silent tracheobronchial aspiration have a 13-fold increased risk for developing pneumonia. 2, 12 Silent aspiration cannot be diagnosed without the aid of instrumentation, since patients do not display overt signs (coughing) and often deny swallowing difficulty; thus, silent aspiration requires a higher index suspicion. As a result, the healthcare prescriber may elect to incorporate the assistance of a speech language pathologist (SLP) who may recommend performing a modified barium swallow study or FEES to rule out silent aspiration in these at-risk patients.
At-risk patients who have been found to silently aspirate include those with altered mental status and decreased awareness; decreased sensation due to stroke, neurological disorders, or head and neck cancers; gastrointestinal problems; and those who are generally weak or deconditioned. Researchers have found that very young and elderly patients are more susceptible to silent aspiration. 11, 12 Contraindication for use of VSE includes lethargy, absent swallow response, abnormal upper airway sounds, need for frequent oral/pharyngeal suctioning, those patients unable to cooperate, tachypnea, and some critically ill patients. 2 Clinical identifiers that may predict the need for a swallowing evaluation include a new cough, sputum, fever, rigors, breathlessness, wheezing, pleuritic chest pain, sore throat, and head cold symptoms. However, classic symptoms are often absent, diminished, or nonspecific in the elderly and may include tachypnea, lethargy, functional decline, incontinence (new onset), alteration in sleep-wake cycles, loss of appetite, and increased confusion or agitation.
Due to the high incidence of silent aspiration in acute care settings, SLPs do not rely solely on the absence of signs or symptoms to rule out silent aspiration. Patients determined to be at risk, but who are without cough or complaint, warrant further evaluation. Many factors predispose patients to silent aspiration, including altered level of consciousness, enteral feeding, cerebral vascular accident, increased age, gastroparesis, gastrophageal reflux, seizure, neurologic dysfunction, structural lesions, psychiatric disorder, connective tissue diseases, iatrogenic causes, neurologic disorders, and medication side effects. 2, 3, 4, 10, 12 Ramsey et al. Suggest that silent aspiration likely occurs in healthy individuals during sleep and in many disease states.
12 This make it more difficult for healthcare providers to assess aspiration risk for these patients. Smithard et al.’s prospective study concluded that bedside assessment alone lacks the necessary sensitivity to use as the sole screening tool in predicting acute stroke complications such as aspiration. In this study, 94 patients who had been admitted to 1 of 2 hospitals with a diagnosis of stroke underwent video-fluoroscopy, medical bedside assessments by physicians, and bedside assessments by SLPs. Twenty patients were identified to be aspirating on video-fluoroscopy. Twenty-one percent of these patients had not been recognized as actively aspirating from their medical bedside assessments.
The medical bedside assessment sensitivity was 70% compared to the SLPs’ bedside assessment of 47%. VSE is considered the gold standard in identifying aspiration risk, and the video-fluoroscopy is one portion of this assessment but may be cost prohibitive for predicting acute stroke complications such as aspiration. The study results suggest that the hospitals involved revise and simplify their aspiration bedside assessments to adequately predict aspiration risk following acute stroke diagnosis.
16 Guidelines In 2006, the American College of Chest Physicians (ACCP) developed 15 evidence-based clinical practice guidelines for cough and aspiration of food and liquid due to oral-pharyngeal dysphagia. 2 These guidelines address conditions that have a high risk for aspiration and silent aspiration. The conditions include neurologic impairment (e.g., cerebrovascular disease, head trauma, cervical spine injury, anoxia, seizure disorder, Parkinson’s disease, Alzheimer’s disease); surgery related (e.g., vocal fold paralysis, brain surgery, coronary artery bypass grafting, cervical spine surgery); structural (e.g., glossectomy); gastrointestinal problems; pulmonary problems (e.g., bronchitis); intubation for greater than 48 hours; ventilated patients; and medication side effects (e.g., sedatives, neuroleptics). 2 The guidelines suggest that those patients with high-risk conditions be referred for an oral-pharyngeal swallowing evaluation. Patients experiencing cough should be questioned regarding their perception of choking or fear of choking while eating or drinking and a chest x-ray, and a speech assessment may be considered to rule out aspiration. The evaluation of those patients with oral-pharyngeal dysphagia, cough, and those conditions associated with aspiration may include an oral-pharyngeal swallow evaluation. Those patients at high risk for aspiration, with reduced level of consciousness, should be kept NPO until there is an increase in sensorium.
Pokemon xy gba rom hack: software free download. The guidelines also suggest that alert patients with medical diagnosis and conditions associated with aspiration be assessed while drinking small sips of water. If the patient exhibits clinical signs of aspiration, the patient may be referred for a detailed swallowing evaluation. These guidelines suggest that those patients with dysphagia have VSE or FEES evaluation of their swallowing ability to determine appropriate treatment. An aspiration assessment relies on the clinician’s subjective evaluation, while the VSE and FEES provide direct visualization of the anatomy and physiology of swallowing. Limited economic and staffing resources make the regular use of VSE and FEES nearly impossible on every admitted patient, so dependence on the bedside aspiration assessment alone becomes essential when determining aspiration risk. 2 The guidelines also suggest that the management of patients with dysphagia be the responsibility of an organized multidisciplinary team, including a physician, nurse, an SLP, dietitian, and physical and occupational therapist. The goals of this team include focusing on aspiration reduction, improving swallowing ability in order to optimize the patient’s nutritional status and quality of life, determining compensatory strategies for those at high risk for aspiration patients to enable safe swallowing, and providing dietary recommendations.
2 Mitigation Strategies The development of mitigation strategies continues to be a priority when identifying patients with swallowing difficulties and those at risk for aspiration and silent aspiration upon admission. These strategies may include bedside swallowing screening and assessment, radiologic swallowing assessment, individualized swallowing treatment plan, and assessment for medications that affect swallowing. Bedside Swallowing Screening and Assessment Aspiration screening and assessment are two distinct procedures, conducted at separate times by different healthcare providers. The preliminary aspiration screening is typically performed by a nurse during the patient admission assessment. The full bedside swallowing assessment is typically conducted by the SLP after the preliminary screening identified the patient as high risk for aspiration. 15, 17 There are various types of full bedside swallowing assessments in the clinical literature, but the literature reports very few preliminary bedside screening tools.
Many of the preliminary bedside swallowing screening tools do not contain the sensitivity and specificity to identify dysphagia or aspiration. 7, 10, 15, 18 A preliminary swallowing screening performed at the admission assessment can be an effective tool to determine whether additional swallowing evaluations are warranted. 10 Hinchey et al.
Conducted a prospective study of 15 acute care hospitals in which 6 of the hospitals had formal dysphagia screening protocols. The hospitals’ adherence rate to the screening protocols rate was 78% compared with 57% for the other 11 acute care facilities that lacked formal dysphagia screening. The dysphagia screening was defined as a checklist that assessed patients for previous and current risk factors for aspiration, based on clinical findings. If the patient passed the initial screening, a water challenge followed, and the patient was observed. If the patient failed the initial screening, an NPO order was initiated, followed by further evaluation by an SLP. Dysphagia screens were performed before any oral intake by the patient.
The results for pneumonia rates at the hospitals with a formal dysphagia screen were 2.4% versus 5.4% for the hospitals that did not have formal dysphagia screening. Patients who experienced a stroke and had received a formal screening that were used to treat the patient were found to have significantly decreased odds (three-fold) of developing pneumonia after consideration for stroke severity. 19 A preliminary bedside swallowing screening tool may be in checklist or algorithm formats, which may be easily conducted with the patient admission assessment. 10, 18 The Massey bedside swallowing screen is an example of such a tool ( is available online from the Authority).
Aspiration Risk Screening
This particular tool has content that has been shown to have predictive validity and interrater reliability. Sensitivity and specificity were determined by retrospective chart analysis to determine postscreening evidence of dysphagia. 8 All preliminary bedside tools screen a patient’s swallowing abilities through a series of questions, the presence of a variety of symptoms, and the use of clinical indexes to identify patients with dysphagia, at risk of aspiration, or who have no prior history of dysphagia but meet the criteria for a full bedside swallowing assessment. 4, 8, 13, 17- 19 While AHRQ identified a suggested patient care practice to include the evaluation of each patient for aspiration risk upon admission and regularly thereafter, the use of preliminary bedside screening tools can provide facilities the minimum requirements and key elements needed to identify patients with dysphagia and those at greater risk for developing aspiration. While AHRQ has not recommended any single screening tool, the agency suggests a formal dysphagia screening protocol may decrease the risk of pneumonia by three-fold. 19 The Joint Commission dysphagia screening requires that patients who have experienced a stroke be assessed for dysphagia before any food, fluids, or medications are administered orally.
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A preliminary bedside swallowing screening will promptly identify those patients at high risk for dysphagia, developing aspiration, or those experiencing silent aspiration, so a timely full bedside swallowing assessment can be provided. 1 Several forms of full bedside swallowing assessments may be used to evaluate patients at high risk for aspiration or for those who have swallowing difficulties. Full bedside swallowing assessments typically involve a questionnaire that includes care history information; review of auditory, visual, and motor status; screening of cognitive/communications skills; a noninvasive oral-pharyngeal exam that includes the oral cavity; evaluation of oral motor skills and laryngeal function for phonation; observation of respiratory function; and functional swallowing trials. 1, 18 Various acceptable methods are included in a full bedside swallowing assessment, including a simple standard bedside swallowing assessment and formal evaluation by an SLP. 17 The Joint Commission excludes the National Institutes of Health Stroke Scale rating and the documentation of a gag reflex or positive gag as the full evaluation for screening dysphagia. The dysphagia screening may include the minimum of a formal bedside swallowing assessment. 18, 20 Patients who are waiting for the completion of the full bedside swallowing assessments are typically kept NPO until the testing is conducted so an individualized patient treatment plan may be developed.
Full bedside assessments may also include the patient’s health history, nutritional status, medications, physical examination, and diagnostic evaluation. 6 A diagnostic evaluation may be conducted through the VSE. Radiologic Swallowing Assessment ACCP practice guidelines identify VSE screening as beneficial for those patients with medical conditions or diagnosed as being at high risk for developing aspiration or those with silent aspiration. Penetration occurs when food or liquid material enters the laryngeal area to the level of the true vocal cords. Aspiration occurs when the food or liquid material moves below the true vocal chords and enters the trachea. 3 Silent aspiration is often not recognized and therefore is not treated.
A FEES is used by the SLP for the functional evaluation of the oropharyngeal stage of swallowing. The FEES does not replace the fiberoptic examination performed by an otolaryngologist, which assesses the integrity of the laryngeal and pharyngeal structures.