The Yale Swallow Protocol
I think that we have all looked for that simple and easy screen that we can use for patients to identify a possible dysphagia.
We want a screen that’s not only easy for us to administer as an SLP, but that we can teach other professionals to utilize to assist in their referrals.
Let’s face it. If you work in acute care, AND your building is stroke certified, you are probably already getting a referral to assess every single stroke patient that walks in the door.
So maybe we can use a screen, like the Yale Swallow Protocol to assist in screening patients.
The Yale Swallow Protocol was once known as the 3 Ounce Swallow. This came from research looking at how accurate a screening could be by having a patient drink 3 ounces of water. There is also a study looking at the efficacy of how much liquid is enough to elicit a cough response and 3 ounces seemed to be that magic number.
When administering the Yale Swallow Protocol, part of the protocol is an oral mech exam. You really want to take a look at the oral structures and how they are functioning.
You also assess cognition. How well does the person follow 1 step directions and accuracy of following yes/no questions. Leder, Suiter and Warner found that when patients are not oriented x3, they may be 31% more likely to aspirate.
There was also a correlation between aspiration and the ability to follow single step directions. When unable to follow single step directions, patients likelihood of aspiration of liquids increased to 57%, pureed 48% and deemed unsafe for any oral consistency to 69%.
The Yale Swallow Protocol is easy to administer:
- Give your patient a cup with 3 ounces of water. (I always given them water that is room temperature.)
- Have your patient drink all the water without stopping until it is gone.
- They pass if: they are able to drink all the water without stopping with no coughing or signs of swallowing difficulty.
- They fail if: they are unable to drink all the water without stopping or they cough while drinking the water or immediately after.
Now, there are populations with whom I DO NOT use this screen. I would not do this with someone who is:
- not medically stable
- has severe respiratory issues
- severe dysphagia
- aspiration on previous bolus administration
- unable to manage secretions.
Want more information?
DePippo, K. L., Holas, M. A., & Reding, M. J. (1992). Validation of the 3-oz water swallow test for aspiration following stroke. Archives of neurology, 49(12), 1259-1261.
Suiter, D. M., & Leder, S. B. (2008). Clinical utility of the 3-ounce water swallow test. Dysphagia, 23(3), 244-250.
Garon, B. R., Engle, M., & Ormiston, C. (1995). Reliability of the 3-oz water swallow test utilizing cough reflex as sole indicator of aspiration. Journal of Neurologic Rehabilitation, 9(3), 139-143.
Suiter, D. M., Leder, S. B., & Karas, D. E. (2009). The 3-ounce (90-cc) water swallow challenge: a screening test for children with suspected oropharyngeal dysphagia. Otolaryngology—Head and Neck Surgery, 140(2), 187-190.
Suiter, D. M., Sloggy, J., & Leder, S. B. (2014). Validation of the Yale Swallow Protocol: a prospective double-blinded videofluoroscopic study. Dysphagia, 29(2), 199-203.
Suiter, D. M., & Leder, S. B. (2009). 3 Ounces Is All You Need. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 18(4), 111-116.
Warner, H. L., Suiter, D. M., Nystrom, K. V., Poskus, K., & Leder, S. B. (2014). Comparing accuracy of the Yale swallow protocol when administered by registered nurses and speech‐language pathologists. Journal of clinical nursing, 23(13-14), 1908-1915.
Leder, S. B., & Suiter, D. M. (2014). The Yale Swallow Protocol: An evidence-based approach to decision making. Springer.
Leder, S. B., Suiter, D. M., & Warner, H. L. (2009). Answering orientation questions and following single-step verbal commands: effect on aspiration status. Dysphagia, 24(3), 290.