Royal College of Speech & Language Therapists Clinical Guidelines: 5.8 Disorders of Feeding, Eating, Drinking & Swallowing (Dysphagia)
Taylor-Goh, S. (ed). (2005).
Bicester (United Kingdom): Speechmark Publishing Ltd., 63-71.
This guideline provides recommendations for the assessment and management of swallowing disorders in children and adults. This guideline is intended for speech-language pathologists. Populations included (but were not limited to) individuals with stroke, traumatic brain injury, autism spectrum disorder, cerebral palsy, Parkinson's disease, and/or head and neck cancer.
Royal College of Speech & Language Therapists (United Kingdom)
<div>The speech-language pathologist (SLP) should assess the effect of modified textures and swallowing strategies in order to identify methods that safely and efficiently improve swallow function. This may include adjustments to the placement, size, consistency, temperature, taste, and texture of the bolus. Alternatively, this may involve changes in pacing, utensil, and frequency and timing of presentation (Grade B Evidence; pp. 67-68).</div>
<div>In some cases, SLPs can refer patients to a maxillo-facial prosthodontist. SLPs may work alongside this profession to recommend and design intra-oral palatal shaping, lifting and obturating prostheses. (Grade C Evidence).</div>
<div>Ultrasonography, manometry, and electromyography "are each tools to evaluate discrete components of swallowing function; therefore it is not appropriate to use any as a stand-alone evaluation technique" (Grade B Evidence; p. 65).</div>
<div>Children receiving non-oral feeding should be given oral stimulation as appropriate to "normalize sensation and maintain and promote skills" (Expert Opinion; p. 70).</div>
<div>Modification to the environment to reduce distractions and noise level, increase lighting, and facilitate social interaction may optimize the mealtime experience (Grade B Evidence; p. 69).</div>
<div>Research has demonstrated poor inter-rater reliability in the interpretation of video fluoroscopic swallow studies (VFSS). As such, SLPs should therefore exercise caution. (Grade A Evidence).</div>
<div>SLPs should be involved in the clinical decision for non-oral nutrition and hydration as part of the multidisciplinary team (Grade C Evidence; p. 70).</div>
<p>"For an individual who has a tracheostomy, it is physiologically contraindicated to assess or feed with the cuff inflated. However, in rare circumstances, a team decision may be taken to feed with the cuff inflated. Where a tracheostomy is sited, the individual should have a swallow assessment following the same principles as discussed above, having the adjunct of blue dye added to secretion and food and liquid and cuff deflation" (Grade B Evidence; p. 66).</p>
<div>Instrumental procedures (e.g., electromyography, ultrasonography, endoscopy) can be used to provide biofeedback to patients undergoing swallowing therapy (Grade C Evidence).</div>
<div>The SLP should observe the individual (and feeding support persons) while eating and drinking and take note of mealtime interaction, positioning, bolus size, pacing and presentation and the environment (Grade B Evidence; p. 64).</div>
<div>Following a review of the patient's case, the SLP should make a clinical judgment about whether or not dysphagia assessment should occur with food and liquid boluses (Grade C Evidence).</div>
<div>The SLP should provide therapy "to maintain and/or improve oromotor function, which will be within agreed optimal time frames" (p. 69). These may include, but is not limited to, range of motion exercises, oropharyngeal exercises, and thermal and tactile stimulation. Some dysphagia treatments may be contraindicated for cardiac or some degenerative conditions" (Grade B Evidence).</div>
<div>SLPs should identify which behavioral strategies facilitate successful eating and drinking and provide education to relevant care partners. "These may include situational strategies prior to, during and after mealtime; verbal cues; written cues and/or symbols; physical cues, or visual cues" (Grade A Evidence; p. 68).</div>
<div>A videofluoroscopic or fibreoptic endoscopic evaluation of swallowing should be carried out if necessary (and if there are no clinical contraindications) to improve visualization of the upper aerodigestive tract, assess aspiration and residue, facilitate techniques and therapeutic strategies to reduce aspiration and improve swallowing efficiency, compare baseline and post-treatment function, and to further diagnose (Grade A Evidence; p. 65).</div>
<div>"To date, there is inconsistent evidence that the use of pulse oximetry and cervical auscultation can assist in reliably determining the occurrence of aspiration. Clinical decisions should not be based solely upon information gained from these procedures" (Grade B Evidence; p. 65).</div>
<div>Body positioning should be identified for optimal swallow function. Position of trunk, limbs, shoulder and head support should be considered. Positioning interventions may involve specialized seating equipment (Grade C Evidence; p. 69).</div>
<div>SLPs should train care partners and care staff that supporting eating and drinking in order to increase their awareness and understanding of eating and drinking difficulties. Compensatory strategies to swallowing and behavioral problems may be provided (Level B Evidence).</div>
<div>The SLP should consider the swallowing impairment within the context of the individual's overall development, emotional and behavioral well-being, current status, prognosis, and setting and may determine that intervention is not appropriate at a given time (Grade C Evidence).</div>
<p>The following aspects should be considered during the clinical swallowing evaluation in children and adults:</p>
<ul>
<li>case history;</li>
<li>oro-facial examination;</li>
<li>vocal tract function;</li>
<li>motor skills;</li>
<li>posture and tone;</li>
<li>nutrition/hydration;</li>
<li>respiratory status;</li>
<li>gastro-oesophageal reflux;</li>
<li>secretion management;</li>
<li>tracheostomy;</li>
<li>cognitive level;</li>
<li>alertness level;</li>
<li>medications;</li>
<li>oral hygiene;</li>
<li>dental health;</li>
<li>dietary preferences; and</li>
<li>emotional state, mood, and behavior (Grade C Evidence; p. 64).</li>
</ul>
<div>The SLP should consider and potentially modify "oral-motor skills to include organization of non-nutritive suck in infants" (Grade B Evidence; p. 67).</div>
<div>The SLP must ensure that the individual is at their optimal alertness, calmness, and receptiveness prior to administering any PO trials during treatment. The SLP should appropriately consider and manage oral and facial hypo- and hyper-sensitivity (Grade B Evidence; p. 67).</div>
<div>The effectiveness of compensatory strategies, including but not limited to postural changes and swallowing maneuvers, should be evaluated prior to implementation, and then "implemented to improve swallowing function" (Grade B Evidence; p. 69).</div>
<div>Individuals post-tracheostomy should be assessed using a speaking valve to determine if there is an improvement in swallowing safety and efficiency (Grade B Evidence; p. 66).</div>
