Clinical Swallow Evaluation (CSE) Flashcards
Clinical Swallow Evaluation
Designed to provide the clinician with the
following info:
- Current medical dx
- Medical history
- Medical status
- Oral anatomy of patient
- Respiratory function
- Oromotor function
- Cognitive-Communicative status
- Patient reactions/symptoms during PO trials
Swallow Screening
- Used to determine the need for a full
swallow evaluation and make further
referrals - Screens are a “pass/fail” procedure (ASHA)
Involves: - Review chart/client interview
- Identify risk factors via observation and/or trial
swallows - Identify warning signs
- Identify signs and symptoms of dysphagia
Screening procedures attempt to answer: Is the person possibly dysphagic?
They do NOT answer the question: What is the nature of the patient’s physiology during the swallow?
Examples of Swallow Screens
- Modified Mann Assessment of Swallow
Ability (MMASA) - Toronto Bedside Swallowing Screening Test (TOR-BSST)
- Gugging Swallow Screen (GUSS)
Yale Swallow Protocol
(aka 3 Ounce Water Test)
- One of the most frequently used screening approaches
- Starts with simple cognitive screen and oral mech
- Ask the client to drink 3 ounces of water without
interruption
- Coughing, choking, wet-gurgly vocal quality during
test or 1 minute later-”fail screen”
- If fail water test, refer for CSE and possibly get MBS?
FEES? (Suiter & Leder , 2008)
- If “pass”- reg diet/thin liquids with dentures
- If edentulous, puree diet/ thin liquids
- If patient improves, retes
Volume-Viscosity Swallow Test (V-VST)
- Present 5- to 20-cc amounts of thin-liquid and
pudding and nectar liquids - Monitor for s/s of swallow difficulty
Indications for CSE
- For any patient referred for assessment of
suspected swallowing problem - Usually occurs when patient, caregiver,
family, feeder, and/or physician express
concerns with eating/swallowing
What is the goal of the CSE…?
- To form a working hypothesis of the problem
- Begins the process towards treatment
strategy recommendations - But unfortunately, we do NOT have X-Ray
vision so the CSE is limited….let’s discuss!
Components of CSE
- Thorough Chart Review
- Obtain case history
- Oral-motor exam
- Assess structural and functional integrity
- Assess safety of oral feeding via PO trials
- Determine need for additional diagnostic
tests and/or referrals - Gather baseline data
Parts of Case history
- Current Medical Diagnosis
- Chief Complaint (e.g. duration, frequency)
- Reason for Referral
- Medical and surgical history
- Swallowing history
- Respiratory status (labored breathing? On oxygen?)
- Medications
- Observations (e.g., cognitive status, voice quality,
fatigue) - Staff and family observations
Common Clinical Findings in People
with Dysphagia
General Health Status:
- weight loss
- fluctuation low fever
- pulmonary infiltrates
- increased or insufficient oropharyngeal secretion
- lacking teeth
- drooling
- ineffective cough
Behaviors of Observations During Mealtimes
- resistance to eating/drinking
- increased time to consume meal
- oral residue
- difficulty in swallowing foods of specific texture
- complaint of food stuck in throat
- coughing or choking during or after swallow
- wet vocal quality during or after mealtime
Patient Interview
Patient Self-Perception/QOL Questionnaires:
- SWAL-QOL & SWAL-CARE (McHorney et al., 2006)
- EAT-10 (Belafsky et al., 2008)
- Sydney Swallow Questionnaire (SSQ; Wallace et
al., 2000);
- MD Anderson Dysphagia Inventory (MDADI; Chen
et al., 2001)
- Dysphagia Handicap Index (DHI; Silbergleit et al.
2012)
Other things to consider
- Method & Schedule of Feeding/Eating
- Current Diet: Functional Oral Intake Scale
- Variability: Foods, Eating Time, Temperature, Secretions
- Compensations: Rate, Consistency, Posture
Assessing Cognitive-Communication During CSE
- Alertness/Arousal/Consciousness
- Speech (Dysarthria? Apraxia?)
- Voice (dysphonia?)
- Language (Comprehension? Expression?)
- Cognitive-linguistic skills: attention, memory, following directions (1,2,3 step), problem solving, safety awareness, insight
Equipment for CSE
- Pen and paper
- Small flashlight
- Tongue blades
- Lateral view diagram of anatomy (useful to explain normal swallow)
- Spoons/cup/straw
- Food/liquids (e.g., water, ice chips, thick liquid, puree, soft solid, crackers)
- Emesis basin, washcloth, or paper towels (just in case!)
Oral Peripheral Examination
- Oral motor structure and function
- Inspect oral cavity for xerostomia, appearance or oral mucosa, dentition
Cranial Nerve Assessment:
- Facial symmetry
- Labial, lingual, and buccal structure and function:
- Symmetry
- Range of motion (ROM)
- Strength
- Precision
- Coordination
- Sensation
- Velopharyngeal structure and function: some physicians still think no gag = no swallow (yikes)
- Laryngeal function: voice (quality/loudness/pitch), strength of cough/throat clear
Swallowing Assessment
- Controlled trials of food
- Assess acceptance of food, chewing and bolus manipulation, timeliness of movements, signs/ symptoms of aspiration
- Palpate submandibular, hyoid, laryngeal movements
Other techniques used by some (with caution!)
* Cervical auscultation-normal swallow sounds are “crisp”,
abnormal swallow sounds are “bubbly” (very controversial!)
* Pulse Oximetry – measure oxygen saturation level (SpO2) of hemoglobin in blood, may help in identifying aspiration, normal range >90% (though several factors impact readings…
Assessment of Liquid/Food Trials
- Dry swallow: Saliva
- Controlled trials of food
- Liquids: Thin, Thickened liquids (nectar-thick, honey-thick), Pudding, Solids: Puree, Ground/ Mechanical Soft solid, Solid
*Liquid or solid food trials should only be attempted if
patient is deemed safe to attempt PO
Assessment of Food Trials via Standardized Measure
- Test of Mastication and Swallowing
Solids (TOMASS) - Quantifiable measure of oral preparatory
phase: Number of masticatory cycles per cracker, Number of swallows per cracker, Total time to ingest cracker - Normative data available for various crackers (including Nabisco Saltines)
More Standardized Bedside
Swallow Assessments
- Clinical Observational Dysphagia Assessment (CODA)
- Mann Assessment of Swallowing Ability (MASA)
- Swallowing Ability and Function Evaluation (SAFE)
Signs/Symptoms of Dysphagia
- Difficulty recognizing food
- Difficulty controlling food/ liquid
- Difficulty controlling saliva
- Coughing/Throat Clearing
- Change in vocal quality
- Abnormal volitional cough
- Dysphonia
- Dysarthria
- Cough after swallow
- Abnormal gag reflex
Assessing Compensation during CSE
Compensatory strategies:
- Address the sign
- But do we really know this info on the CSE?
- How do we know the compensation is truly working?
Impressions & Recommendations
- Summary should provide an impression of factors that may impact and likely dictate further intervention
- Indication of problems at pharyngeal stage of swallow will warrant an instrumental assessment; can say what you “suspect”, but cannot say for sure
- E.g., Cannot say “Patient aspirated” during CSE
- Provide baseline info re: swallow function to track and
compare change over time - First and crucial step toward providing critical info
relevant to both diagnostic & therapeutic process…
Limitations of CSE
- Doesn’t allow for evaluation of entire
swallowing tract - Cannot tell you about timing of the swallow
through pharynx or pharyngeal strength or if
residue remains - Cannot provide definitive info about
aspiration - HOWEVER, it still provides important info
- Info obtained, in conjunction with instrumental
exam, will facilitate and optimize appropriate tx decisions. - Cannot rule out aspiration
- 50-60% of patients who aspirate do not respond to aspiration with e.g. a cough (“silent aspiration”)
- 40% of patients with aspiration are not adequately
diagnosed at bedside (Logemann, 1997) - Provides limited information on the
physiological impairments underlying dysphagia
Summary of CSE
- Develop a rapport with the patient, family,
caregivers, and team to better serve them ongoingly. - Assess the patient’s cognitive-linguistic status,
especially orientation and ability to follow
commands. - Deficits in these areas have been shown to increase
the odds of aspiration (Leder, et al, 2009). - Assess oral motor status, especially lingual strength
and range of motion. - Leder, Suiter, Murray & Rademaker (2013) found
patients with decreased lingual range of motion had a
higher aspiration risk. - Analyze the speech and voice.
Develop a hypothesis regarding the patient’s ability to take in food, liquid, and medications effectively and safely. - Make good judgements as to when a patient requires an instrumental examination (MBSS or FEES)
- Train, educate and counsel the patient, family,
caregivers and medical team regarding the safest
interventions to take prior to instrumental testing. - If the patient refuses further testing, and especially in
instances of palliative care, you may be able to help them
“aspirate more safely” - Trial interventions. Train and prepare the patient for the
next steps (i.e., prepare them for the instrumental
testing) - All of this is a holistic approach to dysphagia
management
