How to Master a Clinical Bedside Evaluation

We Don’t Have X-Ray Vision

Unpopular opinion: clinical bedside swallow evaluations are way more difficult to analyze than a MBSS’/FEES. Let me explain why— when we are looking at an instrumentation, we are able to detect anatomic anomalies and make judgements about swallow safety and efficiency. But the reality is, there is limited access to instrumentation and YOU, as the trained professional, will still have to identify suspected dysphagia and create a Plan of Care without instrumentation.

While I am grateful that my professor in graduate school really advocated for MBS/FEES, I personally felt like I learned more about the limitations of a clinical bedside swallow evaluation, rather than its strengths. Yes, it is true that clinical bedside swallow evaluations often lead to false-positive diagnoses, however they are a valuable tool if we are thorough. One thing I’ve learned is that dysphagia CAN be present without overt s/sx. Think about it—if every patient that coughed on thin liquids had dysphagia— it would be so easy for nurses to identify and we would not have a job.

Step 1: Case History

The case history, in my opinion, is the most important part of a CBE. It tells us dysphagia risk factors and potential unmanaged dysphagia and risk for pneumonia. We all know that CVAs' and TBIs’ are common dysphagia risk factors. Below I will list other risk factors that I personally believe get overlooked:

• Prolonged intubation - post-extubation dysphagia can lead to laryngeal injury, decreased laryngeal sensation, and oropharyngeal muscle atrophy. Aside from the mechanical causes, it can even lead to cognitive disturbances with residual effects of narcotics and anxiolytic medications.

• Penetrating injury to chest or heart- potential damage to the recurrent laryngeal nerve can lead to silent aspiration.

• Pulmonary embolism/COPD/hemothroaxic/acute respiratory failure- respiratory distress can alter breathe-swallow pattern and lead to discoordinated swallow function

• Esophagitis/GERD- inflammation of esophagus can lead to upstream affects of pharyngeal function

• High Flow Nasal Canula- can alter breathe-swallow pattern, increases peak pharyngeal presssure and can stent the airway open for swallowing

• Rheumatoid arthritis- can affect oropharyngeal swallow function due to xerostomia, decreased mastication with TMJ involvement, cricoarytenoid and laryngeal joint dysfunction, and esophageal/upper esphogeal sphincter dissmobility.

• Cardiac surgery- cranial nerve X is adjacent to the large blood vessels near the heart and often can be affected or damaged during cardiac surgery. This can result in vocal cord dysfunction, paraylsis, or swallow dysfunction.

Step 2: Labs/X-Ray

• Low potassium (Hypokalemia): can cause weakness and fatigue that could contribute to dysphagia

• High levels of ammonia: if the liver is not removing toxins from the blood, patients can dysphagic due to the significant cognitive and neurological changes

• Dehydration/malnutrition/weight loss: while these do not directly cause dysphagia, it can be a result of unmanaged/undiagnosed dysphagia

• CT chest bibasilar densities/masses: the right lower lobe is most frequently involved with aspiration pneumonia if the patient is positioned upright. Aspiration pneumonia is gravity dependent based on how the patient is positioned therefore opacities in the lungs/any remarkable findings should be considered.

Step 3: Oral Integrity

Oral health is one of the 3 pillars of aspiration pneumonia. The Oral Health Assessment Tool (OHAT) is a recognized, proven screening tool for just such purposes. The mouth is a reservoir of bacteria populating the lungs and gastric system. Here are some examples of important things to document in regards to oral health observations:

• Denture stomatitis: inflammation under dentures

• Reduced salivary flow

• Xerostomia

• Gingivitis

• Dental plaque

• Tooth decay

• Upper/lower dentures

• Missing dentition

• Oral secretion management

• Sialorrhea (excessive drool)

Step 4: Cognition

Is the patient alert and oriented? If not alert, DO NOT continue with PO trials. Documenting cognition is important because it is important to note if the patient can follow directions to complete compensatory safe swallow strategies (e.g., chin-tuck). Impaired sensation can lead to reduced sensation, reduced muscle motility, delayed/absent swallow response, reduced airway protection. Difficulty following directions had 57% chance of aspirating on thin liquid.

Step 5: Cough

Does the patient have a strong reflexive cough/volitional cough? This tells us their muscle strength, vocal fold function, respiratory capacity to protect the airway. I always tell my nurses: COUGHING IS NOT A BAD THING because it shows abilty to protect the airway.

Step 6: Respiratory Rate

Norm RR at rest is 10-14 bpm. Is the breathing shallow? Uncoordinated? Note low-baseline oxygen saturation <94% and rapid RR > 25bpm. Respiratiion is important for swallow-respiratory intact. Dyspnea, or breathing discomfort should be noted. The predominant respiration-swallowing pattern in adult humans is the “exhale – swallow – exhale.” Uncoordinated respiration post-swallow can indicate silent aspiration.

Step 7: Cranial Nerve Examination

Cranial Nerve Examination is important and gives us clinical implications. We should note CN V, VII, IX, X, XII. Suspected impairment to cranial nerve X tells us there is potential reduced VF closure, aspiration during swallow, silent aspiration d/t reduced sensation, and no attempt to clear residual d/t reduced sensation. If I suspect CN X is involved, I always order an instrumental.

Step 8: PO trials

While our observations are limited with PO trials, I note everything that I CAN see:

• Is mastication timely and efficient? Does the patient present with vertical mastication?

• Is there adequate labial seal? Anterior bolus loss/oral residue? If so— is it on the L-side or R-side or both?

• Is there complete oral clearance?

• Does the patient need assistance with feeding/tray set-up?

• Any respiratory changes or fatigue?

• Does the patient independently self-monitor and use compensatory safe swallow strategies without cues?

Step 9: Recommendations

Personally, I do not prescribe an exercise program without instrumentation. There is no evidence to support the benefits of oral motor exercises. If no further evaluation via instrumentation is indicated, I target my goals based on use of compensatory safe swallow strategies make recommendations for swallowing precautions or maneuver, and based on demonstrated improvement during the swallowing evaluation when the precaution or maneuver was tested.

Overall, a clinical bedside evaluation is a valuable tool and should be thorough if we do not have access to instrumentation.