Screening
Screening for swallowing abnormalities is recommended in patients at risk for aspiration. History of coughing during swallowing, abnormal swallow time or positions, and difficulty handling secretions, particularly in older patients with a history of pneumonia, should prompt comprehensive swallow evaluation and management. Impaired gag reflex is not a reliable indicator of oropharyngeal dysphagia.[12] Nurse-driven screening questionnaires are being employed to reduce aspiration in stroke patients; their applicability to other at-risk populations needs investigation. Among hospitalized patients, an informal bedside water swallowing exam may identify aspiration, but is insufficiently sensitive and specific to serve as a substitute for a formal swallowing exam performed by a swallow therapist.[42]
Comprehensive swallow evaluation (usually by a swallow therapist) includes one or more of the following:
Clinical assessment: includes detailed pertinent history relating to swallow difficulty, detailed sensory and motor exam, and assessment of ability to swallow foods of different consistencies. Sensitivity for detection of aspiration is 80%, although ability to predict aspiration pneumonia is unclear.[12]
Video-fluoroscopic swallow assessment (also called modified barium swallow): most commonly used instrumental measure and considered the most specific and sensitive test.
Fiberoptic endoscopic evaluation of swallow (FEES): a more expensive test identifying aspiration, although esophageal/oral phases are not visualized and only anatomy of the pharynx/larynx can be appreciated.
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