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Posts tagged ‘Dysphagia Assessment’

Go With the (Peak) Flow

A Clinical Swallow Evaluation is a series of screens that we use to determine if the patient requires more testing or not.

Let’s face it, whether we like it or not, insurance likes objective data, including numbers indicating a deficit or no deficit.   Peak Flow is a tool that gives us objective numbers to input into our reports.

What is Peak Flow?

A Peak Flow meter measures how fast air is expelled from the lungs in one fast blast.  A Peak Flow meter can be very beneficial to those with asthma.

Peak Flow also gives us information on the cough reflex and function of the cough, in turn, allowing us to determine patients that are at risk for penetration and/or aspiration.

Why do we care about coughing?

Coughing is a mechanism of airway clearance that adds to normal
ciliary function comprised of three events

  • Inspiratory effort
  • Followed by rapid vocal fold adduction
  • Contraction of the expiratory muscles

Respiratory Muscle Strength Training (RMST)

You can also use Peak Flow to determine baseline for RMST and to measure outcomes throughout your therapy using RMST.

So what has research told us about measuring Peak Flow?

We measure using PEF or Peak Expiratory Flow or PEFR Peak Expiratory Flow Rate.

  • Smith-Hammond, et al 2009-Peak flow identified 82% of aspirators
    (stroke patients) at PEF <2.9 L
  • Pitts, et al  2010-Peak flow identified 86% of aspirators (Parkinson’s) at
    PEF <5.2 L
  • Suarez, et al 2002 identified 74% aspirators (ALS) at
    <4.0 L
  • Plowman, et al 2016 identified voluntary cough airflow in patients with ALS at risk for penetration/aspiration

Peak Flow meters can be purchased to use.

PF 1        PF 2

A less expensive Peak Flow model will have a plastic piece on the side that moves as the person exhales or coughs into the device.   You can determine the PEF or PEFR by having the person exhale or cough into the device 3 times and figuring the average rate.

PF 3

You can also purchase a digital device which will give you a more accurate reading, but will cost you a bit more.

These devices can be purchased on Amazon or a medical supply store.   You can often purchase disposable mouth pieces so that you can use the device with multiple patients after cleaning.


Gregory, S. A. (2007). Evaluation and management of respiratory muscle dysfunction in ALS. NeuroRehabilitation22(6), 435-443.

Hammond, C. A. S., Goldstein, L. B., Horner, R. D., Ying, J., Gray, L., Gonzalez-Rothi, L., & Bolser, D. C. (2009). Predicting aspiration in patients with ischemic stroke: comparison of clinical signs and aerodynamic measures of voluntary cough. Chest135(3), 769-777.

Pitts, T., Troche, M., Mann, G., Rosenbek, J., Okun, M. S., & Sapienza, C. (2010). Using voluntary cough to detect penetration and aspiration during oropharyngeal swallowing in patients with Parkinson disease. Chest138(6), 1426-1431.

Plowman, E. K., Watts, S. A., Robison, R., Tabor, L., Dion, C., Gaziano, J., … & Gooch, C. (2016). Voluntary cough airflow differentiates safe versus unsafe swallowing in amyotrophic lateral sclerosis. Dysphagia31(3), 383-390.

Suárez, A. A., Pessolano, F. A., Monteiro, S. G., Ferreyra, G., Capria, M. E., Mesa, L., … & De Vito, E. L. (2002). Peak flow and peak cough flow in the evaluation of expiratory muscle weakness and bulbar impairment in patients with neuromuscular disease. American journal of physical medicine & rehabilitation81(7), 506-511.










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:

  1.  Give your patient a cup with 3 ounces of water.   (I always given them water that is room temperature.)
  2. Have your patient drink all the water without stopping until it is gone.
  3. They pass if:  they are able to drink all the water without stopping with no coughing or signs of swallowing difficulty.
  4. 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:

  1.  not medically stable
  2. has severe respiratory issues
  3. severe dysphagia
  4. aspiration on previous bolus administration
  5. unable to manage secretions.

Want more information?

You can earn continuing education with Debra Suiter on Medbridge

Purchase the book on Amazon

Listen to the Swallow Your Pride podcast episode with Debra Suiter


DePippo, K. L., Holas, M. A., & Reding, M. J. (1992). Validation of the 3-oz water swallow test for aspiration following stroke. Archives of neurology49(12), 1259-1261.

Suiter, D. M., & Leder, S. B. (2008). Clinical utility of the 3-ounce water swallow test. Dysphagia23(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 Rehabilitation9(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 Surgery140(2), 187-190.

Suiter, D. M., Sloggy, J., & Leder, S. B. (2014). Validation of the Yale Swallow Protocol: a prospective double-blinded videofluoroscopic study. Dysphagia29(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 nursing23(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. Dysphagia24(3), 290.

Assessing the Swallow: 101

Assessing the Swallow:  101

Assessment of the swallow can be one of the most valuable pieces of information in your treatment plan for a patient with dysphagia.  There are so many factors that need to be considered when you receive an order for a patient with dysphagia.

Clarification of the order

It is vital to get a clarification of your order.  Talk to the nurse for that patient if available or speak to the ordering physician to find out why a swallowing evaluation was ordered in the first place.  There are times that an evaluation is ordered because the person can’t swallow their potassium pill (I’m not sure if there are any people that can actually swallow that enormous pill!)

Chart Review

A thorough chart review should be performed prior to walking in to see that patient.   Personally, I like to review the chart prior to speaking to the nurse, doctor, patient or family member so that I know as much as possible about that patient.

There are several parts of the chart that can provide critical information for assessment of your patient.  The important areas of the chart to review include lab results, chest xray results, medications and patient history/diagnoses.

Lab Results

Lab results can give you an look at your patient’s current medical status.  These are typically drawn daily in the acute care hospital setting and may be taken periodically or as needed in a Skilled Nursing Facility (SNF), Long Term Acute Care Hospital (LTACH) or Home Health setting.  There are several labs that can give you a good overall picture of your patient.

Nutrition:  Body Mass Index (BMI) and Albumin/Prealbumin are numbers that give us good information of the overall nutrition/hydration status of our patients.

White Blood Count (WBC):  The number of WBC can tell us if the patient has an infection (number is high) or if the patient is at risk for infection (number is low).  It is important to note the Neutrophil number as these are the cells that are in the oral cavity and help to eliminate bacteria from the oral cavity.  When Neutrophils are high or low the patient may have an increased risk of developing a pneumonia.

Red Blood Count (RBC):  This number tells us how effective the body is in circulating oxygen through the body.  Important to note is that if Hemoglobin is below 8 or if Hematocrit is below 25%, therapy should be deferred as the patient is not medically stable to participate in therapy at that time.

Sodium, Potassium and Chloride give us a good look at nerve conduction and assist in muscle function.   Sodium, Potassium and Chloride are electrolytes.  These electrolytes also play a role in acid/base balance within the body. has a great review of lab values which you can find here.

Chest Xrays:

While chest xray results can be very valuable, interpretation can be tricky.  Typically the radiologist will indicate if there are infiltrates and which lung lobe the infiltrates are found.  Infiltrates do not always indicate aspiration of food or drink.  To be accurate in determination of what has been aspirated, a culture would have to be completed.   It is important to note as well that aspiration can be from refluxed or vomited material which would need medical management.  It is also important to note that aspiration of food/liquids can occur in either lobe, left or right.


Medication can alter many aspects of a patient’s functioning.  Medication can dry out mucosal membranes (antihistimines, allergy medications, antidepressants, anticholinergics, analgesics, diuretics), affect motor function (Parkinson’s medication, antidepressants, antiepileptics, anticholinergics) or medications such as Haldol can worsen the swallow.  It is important to note changes in function as they correlate with new medications or changes in medication.  Also remember that having the ability to look up medications can be vital as some diagnoses may not be listed for patients and medications can lead you to uncovering diagnoses not listed otherwise in the medical chart.

Patient History:

Patient history can absolutely be the meat of your chart review.   This is where you are looking at patient diagnoses, particularly any diagnosis that can lead to a dysphagia.  It is important to note if the patient has a history or diagnosis of dysphagia, recurrent pneumonia, degenerative diseases such as Parkinson’s or ALS, history of TBI or stroke or even diabetes that has not been managed well.

In the history will often also be a discussion on why the patient was admitted to the hospital or to the facility and may even touch on swallowing, whether the patient has had difficulty for some time or if there is new difficulty with swallowing.  If the history makes no indication of swallowing difficulty and the patient has an infiltrate in either lung, aspiration may not be related to swallowing difficulty.

After a thorough chart review, you are probably ready to see the patient.  It is very important, when possible, to interview the patient to see how they view the problem, whether or not there is a history of dysphagia that is not listed in the chart and the complaint that prompted an SLP evaluation.

Using Vital Signs

Vital signs such as oxygen saturation, heart rate, respiratory rate can all give you valuable information on your patients.  These can all give you an idea of current medical status and if the patient is able to have endurance for a meal or even for your evaluation.   Oxygen saturation and temperature have often been used to determine if a patient is aspirating, however there is no evidence that links a spike in temperature or a drop in oxygen saturation with an aspiration event.

During the Evaluation

During your Clinical Swallowing Evaluation (CSE), it is critical that you assess cranial nerve function.  Not sure how to do that?  We have you covered AND you can catch up on last minute CEU’s at the same time!  Northern Speech Services has a phenomenal cranial nerve course for assessment and treatment of the swallow (yes, I am a little biased!  Yes, I do receive a small amount of money for this course if you choose to purchase it, but no fear, I will not retire from your purchase!)  You can also use screens such as Peak Flow and the 3 ounce swallow in addition to food or meal trials to determine if further, instrumental assessment is required.

You Can’t Do it All During the CSE

It is critical to remember that you will not be able to complete a full, reliable evaluation at bedside.  You cannot reliably assess pharyngeal function, airway protection or the effectiveness of modification, compensation or maneuvers without visualizing all of these areas with instrumental assessment.  The Clinical Swallowing Evaluation can lead you to determine whether an instrumental assessment is required or if there is no need.

Instrumental Assessment

If you feel that the patient needs a modified diet, requires use of compensation, maneuvers or that you need to develop an effective treatment plan for your patient, instrumental assessment would be indicated.  You may only have Modified Barium Swallow Studies (MBSS) or you may only have Flexible Endoscopic Evaluation of Swallowing (FEES) available.  Both can be very effective in determining pathophysiology of the pharyngeal swallow, to determine how the bolus flows throughout the oropharyngeal cavity and into the esophagus, effectiveness of airway protection, diet modification as well as the accuracy and effectiveness of maneuvers and compensations.

If you are looking for guidance through the Clinical Bedside Evaluation (CSE) there is an app for that!  Look for Dysphagia2Go available through the App Store for your iPad.

There is also an app from Tactus Therapy called Dysphagia Therapy that can assist you with cranial nerves, the clinical exam and choosing therapeutic techniques.  You can buy that right here.

You may have also heard about this pocketguide that I helped to write.   It’s called The Adult Dysphagia PocketGuide Neuroanatomy to Clinical Practice.   This is a great guide to help you through the evaluation and treatment planning process.   If you don’t win a copy this year (2019) from my give-away, you can purchase a copy of the Pocketguide here.  Again, small amount of money for me, no fear of retirement from both the book and the apps!

Also, look for articles on Dysphagia Ramblings related to assessment including:

We Can’t Treat What We Don’t Know

Standardizing Dysphagia Assessment and Treatment

Aspiration Risk”

Oral Care

The Interview

  • Leder, S..B., Suiter, D.M., & Warner, H.L. (2009). Answering orientation qustions and following single-step verbal commands: effect on aspiration status.  Dysphagia, 24(3), 290-295.
  • Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia17(4), 298-307.
  • 57  Martin-Harris B, Brodsky MB,  Michel Y,  Castell DO Schleicher D, et al.  MBS Measurement Tool for Swallow Impairment—MBSImp: Establishing a Standard.  Dysphagia, 2008, Volume 23, Number 4, Pages 392-405.
  • Suiter DM, Leder SB.  3 Ounces is All You Need.  Perspectives on Swallowing and Swallowing Disorders (Dysphagia).  2009; 18(4):  111-116.
  • Logemann, J.A. (1998).  Evaluation and treatment of swallowing disorders (2nd ed).  Austin, TX: Pro-Ed.27 Wijting Y., Freed M. (2009).  Training Manual for the use of Neuromuscular Electrical Stimulation in the treatment of Dysphagia.
  • Hamdy, S. (2006). Role of cerebral cortex in the control of swallowing. GI Motility online.doi:10.1038/gimo8.




Course Alert-MBSImP


If you are a clinician working with patients with dysphagia, the Modified Barium Swallow Impairment Profile is an very thorough course.  The MBSImP targets modified barium swallow studies, however the anatomy learned through the course is amazing.

After taking the course, I wrote a review, which you can find here.

The MBSImP is taught by Dr. Bonnie Martin-Harris and available through Northern Speech Services.

The course seems a little costly, but at $600 for 2.1 CEUs it is a great value!

Books to Read-The Swallowing Pocket Guide

swallowing pocket guide

So, maybe it’s not so much a book to read as an excellent reference guide to have for daily use.  This book breaks down the anatomy and physiology into a very simple format.  This is a great reference book to have and it’s size makes it very easy to carry during your day.

The Swallowing Pocket Guide by Ianessa Humbert

Carbonated Beverages


Carbonated beverages have hit the dysphagia world by storm.  Much of the recent dysphagia research has focused on the sensory portion of the swallow and how sensory drives the swallowing process.  Part of the sensory process is carbonated beverages.  One of the common misconceptions at this time is that carbonated beverages act as a nectar thick liquid.

Carbonation is a sensory option for dysphagia rehabilitation.   It’s effective through a process called chemesthesis, where the “bubbly” or “fizzy” of the carbonated beverage acts as a Trigeminal irritant.  The Trigeminal Nerve or Cranial Nerve V is one of the major swallowing nerves.  The Trigeminal Nerve has bare nerve endings making it more susceptible to sensory or afferent input.

Rather than acting as a nectar thick liquid, the carbonated beverage actually increases the sensory stimulation for the swallow.  Sensory input (afferent drive) drives the motoric output (efferent drive).

Research of carbonated beverages shows:

No significant effect on oral transit time, pharyngeal transit time, initiation of pharyngeal swallow or pharyngeal retention.  Carbonated beverages sis however decrease penetration/aspiraiton with 5 & 10 ml swallows.  (Saravou & Walshe).

Carbonated thin liquid significantly decreased the incidence of spillover, delayed pharyngeal response and laryngeal penetration compared to non-carbonated thin liquids.  (Newman et al).

Drinks containing chemical ingredients that activate sour and heat receptors alter swallowing physiology greater than water.  (Krival & Bates).

It is likely that sour and carbonated beverages reflect a more organized activation of the submental muscles because of more effective afferent input to the Nucleus Tractus Solitarius.  (Miura, et al).

One of the important issues to consider when looking at research involving carbonated beverages is that the researchers in these studies do not use Coke, Pepsi or Sprite.  They use Ginger Brew, Club Soda or carbonated citrus.

It is vital, as with any other compensation or technique to view the effects of carbonated beverages.  As with other strategies, you may not see the same effect in every patient and sometimes, the strategy you choose may make the swallow worse.

Krival K, Bates C. Effects of Club Soda and Ginger Brew on Linguapalatal Pressures in Healthy Swallowing. Dysphagia (2012). 27: 228-239.

Newman, et al. Carbonated Thin Liquid Significantly Decreases the Incidence of Spillover, Delayed Pharyngeal Response and Laryngeal Penetration Compared to Non-Carbonated Thin Liquids. Dysphagia 2001: 16: 146-150.

Saravou K, Walshe M. Effects of Carbonated Liquids on Oropharyngeal Swallowing Measures in People with Neurogenic Dysphagia. Dysphagia(2012) 27: 240-250.

Miura, Yutaka, et al. “Effects of taste solutions, carbonation, and cold stimulus on the power frequency content of swallowing submental surface electromyography.” Chemical senses 34.4 (2009): 325-331.

Upcoming Articles!!

One thing I love about the Dysphagia journal, is not only the great research it provides me 4 times a year.  I love the abstracts for the upcoming (now past) Dysphagia Research Society (DRS) conference.  

This year was no exception for exciting new research to come!

Some titles that I am very excited to look into:

  • The Effects of Taste Concentration on SEMG in Swallowing-(Spoiler:  High concentraion sour stimuli elicit higher amplitudes and longer durations on SEMG).  
  • Esophageal Screening as an Adjunct to the Videofluoroscopic Study of Swallowing.  
  • Sour Bolus Facilitates Spontaneous Swallow in Parkinson’s Disease
  • Effects of Age and Sensation on the Anticipatory Stage of Swallowing
  • Physiological Factors Related to Aspiration Risk:  A Systematic Review
  • Pharyngeal Tactile Stimulation Using A Nylon Thread for Enhancing Pharyngeal Sensory Perception

These are just a few of the exciting titles that have caught my attention.  

If you are interested in the Dysphagia journal or the Dysphagia Research Society conference at a discount, make sure to join the Dysphagia Research Society!


Course Alert-Head and Neck Cancer

head and neck cancder

Northern Speech Services is offering a new course on head and neck cancer entitled:  Head and Neck Cancer Across the Continuum of Care: Addressing Swallowing Challenges.  The course is taught by Paula Sullivan who is an expert in dysphagia in the cancer population.

Per the NSS website:

This comprehensive online course will provide the participant an in-depth examination of head and neck cancer, its presentation, functional sequelae, evaluation approaches, treatment options, and provide an evidence-based approach of optimal patterns of care for head and neck patients with swallowing dysfunction.  Types of treatment for head and neck cancer and their impact on swallowing and communication function will be described, including both surgical and organ preservation. 

Assessment and evidence-based practice relevant to the head and neck cancer population will provide support for the practitioner in developing a holistic approach to rehabilitation which will optimize functional outcomes and, most importantly, quality-of-life.  Video presentation will be an integral part of this course.  By the completion of this course, the participant will possess a comprehensive understanding of dysphagia management in this challenging and rewarding population. Offered for 0.9 ASHA CEUs – 9 contact hours. 

This is definitely a course on my to-take list!

Has anyone taken this course yet?  If so, let us know what you thought!

The Patient Exercising Their Right to Choose (Formerly The Non Compliant Patient)


EDIT 1/4/17.  Due to a recent Facebook post, I wanted to change some wording on this post.  As with all areas of dysphagia, I continue to grow, learn and change my beliefs, mainly because of the patients I serve.

Although my belief stands that those patients who do not follow my recommendation continue to require SLP services, maybe we should look at these patients not as “non-compliant” but as “exercising their right to choose.”  

There was post recently on the Special Interest Group (SIG) 13 email blast.  An SLP was asking what to do with a noncompliant patient.

When I was first beginning of the ever-changing world of speech pathology, I first learned that if a patient is noncompliant then they are discharged.  The rationale was, a doctor would release a patient for noncompliance and our license is always at stake.

My belief system is not the same, fortunately for my patients!

First, think about this.  Aren’t the noncompliant patients who choose to not follow the SLP’s recommends the ones we should be the most concerned about?  The patients that are compliant are on a modified diet that has been determined to be the safest diet consistency for them, although there is always some risk with every recommendation we make.  They may be regulated by caregivers or a facility, but if they are following all instructions and diet recommendations, they should be safe.  The noncompliant patient who aspirates thin liquids, but continues to drink them is the one you should be the most concerned for their safety.  That is the patient that may be most at risk for aspiration pneumonia.

In my experience, patients are not compliant unless they are forced to be. I have worked with patients that will sneak a drink, sneak a bite whenever they have the opportunity.  I have had patients that were supposed to be on thickened liquids, went home, told me they were continuing the thickened liquids but were actually drinking all thin liquids.

The best thing we can do for our noncompliant patients is to educate and rehabilitate.  Why not make them safer with the consistency they choose?

The first thing I do with every patient that is cognitively able is teach them and/or their caregivers about oral care.  If you read anything about oral care and aspiration pneumonia, the take-home message should be that pneumonia is a result of the bacteria from the oral cavity traveling to the lungs through saliva or a liquid/food swallow.  I recently wrote a post about oral care which you can find here.

It’s important to remember that we want the patient to succeed with the diet they choose to consume.  We can recommend a safe diet and we can advise but we have to focus on the rehabilitation.  Just remember, not everybody that aspirates develops aspiration pneumonia.  There are functional aspirators.

You may have a patient that aspirates everything on the Modified Barium Swallow Study (MBSS), goes home and consumes a regular diet without ever having an aspiration event or a pneumonia.  Just because that patient does not choose the diet you recommend does not mean you give up on them.  If they are willing to put in the work and give you some time (they will have to buy-in to your program)  THOSE are absolutely  patients with whom we should work.

Books to Read-Drugs and Dysphagia

drugs and dysphagia

What a great reference for any medical Speech Pathologist.  This book talks about the medications that can affect the swallowing process and how they affect swallowing.  The nice part is that it is also a small, pocket-sized book making it easy to carry around with you as you work with patients.

Drugs and Dysphagia:  How Medications Can Affect Eating and Swallowing by Lynette Carl and Peter Johnson.