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CHHS18/034

Canberra Hospital and Health ServicesClinical Guideline Dysphagia – Management in Adults and Children (Speech Pathology) Contents

Contents....................................................................................................................................1

Guideline Statement.................................................................................................................3

Scope........................................................................................................................................ 3

Section 1 – Training requirements for Speech Pathologists......................................................3

Section 2 – Service provided.....................................................................................................3

Section 3 – Eligibility criteria.....................................................................................................4

Acute Support.......................................................................................................................4

Rehabilitation, Aged and Community Care (RACC)...............................................................5

Section 4 – Referral...................................................................................................................5

Section 5 – Assessment.............................................................................................................6

5.1 Bedside Dysphagia Assessment.......................................................................................7

5.2 Adjunct Assessment........................................................................................................8

5.3 Instrumental Assessment................................................................................................9

5.4 Assessment tools...........................................................................................................10

5.5 Diagnosis.......................................................................................................................10

5.6 Repeat assessment and reviews...................................................................................11

5.7 Clinical record review....................................................................................................11

Section 6 – Management and Intervention.............................................................................11

6.1 Pre oral Intake...............................................................................................................12

6.2 Compensation...............................................................................................................13

6.3 Rehabilitation Strategies...............................................................................................14

6.4 Education...................................................................................................................... 14

6.5 Other dysphagia management considerations..............................................................15

Section 7 – Documentation.....................................................................................................15

Section 8 – Discharge/Transfer...............................................................................................15

Implementation...................................................................................................................... 16

Related Policies, Procedures, Guidelines and Legislation.......................................................16Doc Number Version Issued Review Date Area Responsible PageCHHS18/034 1 30/01/2018 01/02/2021 Medicine - Acute

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References.............................................................................................................................. 17

Definition of Terms................................................................................................................. 18

Search Terms.......................................................................................................................... 18

Attachments............................................................................................................................18

Appendix 1 Clinical assessment of dysphagia 1...................................................................19

Appendix 2 Compensatory Techniques...............................................................................22

Appendix 3 Rehabilitation Techniques................................................................................23

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Guideline Statement

To provide Canberra Hospital and Health Services (CHHS) Speech Pathologists with evidence based minimum practice standards in the management of dysphagia.

BackgroundDysphagia is the medical term for difficulty or inability to swallow. It may present as difficulty with sucking, swallowing, chewing, drinking, eating, controlling saliva, taking medication or protecting the airway. Dysphagia can occur at any time during the life span and may be short or long term. The most common causes of dysphagia are related to underlying medical or physical conditions, however it can also manifest in psychological or psychiatric conditions.1

Key ObjectiveThis guideline will ensure patients with dysphagia at CHHS receive evidence based care.

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Scope

This document applies to all CHHS Speech Pathologists, speech pathology students and assistants working under the direct supervision of a Speech Pathologist.


Section 1 – Training requirements for Speech Pathologists

Speech Pathologists providing dysphagia management are to be assessed as being competent in dysphagia management (including specification of caseload e.g. Head and Neck cancer) by their clinical supervisor

Speech Pathologists are required to read the current Speech Pathology Assessment Dysphagia Clinical Guideline

Refer to Competency Based Occupational Standards (CBOS), Speech Pathology Australia, for detail of minimum speech pathology occupational competencies.


Section 2 – Service provided

The objectives for the Speech Pathologist managing a patient with dysphagia are as follows: To assess the presence/absence of a feeding/swallowing difficulty. To increase swallowing safety, to prevent/minimise aspiration risk. To increase swallowing efficiency (through intervention). To determine the most appropriate method to maintain or increase nutrition and

hydration; this may include oral, or non-oral means, or a combination of these.


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To recommend the most appropriate diet/fluid consistency support the transition from one form of nutrition when appropriate.

To holistically manage the patient with dysphagia in a timely manner. To maximise the social aspect of eating/drinking where possible. To educate patients, carers and health professional staff on swallowing disorders and

safe swallowing practices. To respect patient choices regarding quality of life decisions and provide relevant

education in support of their decision. To integrate all members of the multidisciplinary team as appropriate to the individuals’

management.1,2

These objectives are achieved through: Assessment, diagnosis, therapeutic intervention and ongoing management. Education, counselling, consultation with patients, families, carers, staff and students. Encouraging and respecting patient choices, such as quality of life. Community awareness and education.

Along with the person with dysphagia, their family and carers, Speech Pathologists work collaboratively with the multidisciplinary team to maximise the individual’s ability to obtain nutrition and hydration. Multidisciplinary team members may include but are not limited to: Clinical Psychologists Dietitians Medical team Neuropsychologists Nursing staff Occupational therapists Physiotherapists Social Workers.


Section 3 – Eligibility criteria

Acute SupportSpeech Pathologists and Speech Pathology Assistants provide services to eligible acute inpatients of Canberra Hospital (note exclusion to wards 11A/4B, 11B, GAPU, 12B and RILU) and outpatient populations. Eligible outpatient populations presenting with dysphagia include: Head and Neck trauma/surgery patients Paediatric populations with dysphagia/feeding problems resulting from an underlying

medical condition General adult populations requiring assessment and diagnosis of dysphagia resulting

from an underlying medical condition.


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Rehabilitation, Aged and Community Care (RACC)Speech Pathologists and Speech Pathology Assistants provide services to inpatients and outpatients of the CHHS that meet the RACC Speech Pathology Criteria: Acute and sub-acute geriatric wards at Canberra Hospital Adults (over the age of 65), residing in the ACT with dysphagia resulting from the ageing

process. Adults (over the age of 18), residing in the ACT with dysphagia resulting from a

neurological event.

For further detail refer to Community Rehabilitation Team Eligibility and Prioritisation Procedure on the Policy register.


Section 4 – Referral

For all referrals to Speech Pathology, patient consent to referral and intervention must be obtained by the referrer or the Speech Pathologist prior to commencing Speech Pathology interventions. Refer to the Consent to Treatment Policy available on the policy register.

Acute Support InpatientInpatient referrals to speech pathology must be supported by a medical officer. A written referral from a medical officer in the patient’s clinical record is preferable, however a direct verbal referral from the medical officer will be accepted with the Speech Pathologist responsible for documenting receipt of medical referral in the clinical record at time of the first consult. Exceptions exist with Neurosurgical and Stroke patients, where verbal multidisciplinary referrals will be accepted. Written referrals must be actioned by phoning the Speech Pathology Department and requesting an initial assessment.

OutpatientReferral requirements to each outpatient caseload are defined as below. Referrals should be sent via fax/post to the Speech Pathology Department at Canberra Hospital. Paediatric Populations: verbal self (parent) referral and/or documented health

professional/ medical officer referral indicating parent consent and reason for referral. Adult dysphagia, including outpatient videofluoroscopy: written medical referral is

preferred however referrals will be accepted from other health professionals and/or self-referral. A videofluoroscopy referral must be accompanied by a medical referral and a signed Medical imaging request form.

Head and Neck Surgical/Trauma patients: written medical referral is preferred however referrals will be accepted from the Capital Region Cancer Service Head, Radiation Oncologists, Neck Cancer Nurse Care Coordinator, interstate Speech Pathologists or self-referral.

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InpatientInpatient referrals to speech pathology can be made by any member of the multidisciplinary team, documentation in medical notes from the managing medical team is required. Written referrals must be actioned by phoning the speech pathology department and requesting an initial assessment.

Outpatient Outpatient referrals to RACC Speech Pathology are received through Community Health Intake (CHI) on 6207 9977.

For further detail on RACC referral processes refer to the following documents (available on the Policy Register): RACC Intake Referral Management Procedure Community Rehabilitation Team Eligibility and Prioritisation Procedure


Section 5 – Assessment

Once a referral has been received, consent should be gained from the patient/carer as per the CHHS Consent and Treatment Policy, i.e.: Confirm patient identification utilising the 3 point patient identification check. Gain the patient’s verbal consent (or parent/guardian, in the case of a minor) before

proceeding with any intervention. If consent cannot be gained due to the patient’s communicative difficulties, document in

the patients clinical record, including where consent denoted through compliance. If patient has a Health Attorney or Enduring Power of Attorney, discuss and document

consent for services.

The aim of an assessment is to determine the presence/absence of swallowing/feeding difficulties and the safety and efficiency of oral intake.

The assessment process encompasses establishing a holistic view of the patient’s swallowing abilities and difficulties, from the pre-clinical evaluation through to bedside and instrumental assessment (as indicated).

Detailed pre-clinical assessment provides the speech pathologist with: Information determining the appropriateness of assessment and/or intervention. Background information regarding pre-morbid swallowing ability in relation to

developmental levels. Information regarding the timing, methodology and scope of further assessment.

Detailed clinical assessment provides the Speech Pathologist with: Diagnosis of extent and nature of the swallowing impairment and independence with

self-feeding.


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Identification of effective strategies to maximise safety of swallowing including appropriate diet and fluid textures.

A baseline measure to determine change. Factors affecting rehabilitation of swallowing, e.g. cognition, family involvement. Information to plan ongoing therapeutic intervention in consultation with the patient,

family and carers. Ability to determine the most appropriate course of intervention i.e. timing, frequency,

location and ongoing referral.

Dysphagia assessment must have a clearly identified rationale before the selection and administration of assessment methodology. It may involve:

5.1 Bedside Dysphagia AssessmentThe following parameters should be assessed:General Observations Case history (including observation charts)

o Current medical status and medications Oral intake/nutritional status prior to assessment, including pre-morbid diet

o Previous swallowing problems +/- speech pathology intervention Level of alertness

o Drowsy/awake, orientated; state and state regulation for infants and children o Cognitiono Ability to participate/ respond

Communication statuso Presence of language impairments, motor speech disorderso Language barriers (English as a second language)o Impaired hearing/vision

Posture/positioning for oral intake Respiratory status

o Current chest status and respiratory rateo Presence of tracheostomy tubeso Oxygen saturation levels.

Clinical Oropharyngeal Assessment Orofacial musculature/structures

o Assess range of movement, strength and co-ordination of Lips (VII), Jaw (V), Tongue (XII), Palate (IX, X), Larynx (X)

o Presence/Absence primitive reflexeso Oral structures - appearance/symmetry/sensationo Dentition

Management of secretions/airway protection o Saliva management – spontaneous swallowso Ability to cough/throat clear

Oral hygiene.


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The Speech Pathologist will then have gathered adequate information to make a clinical judgement with regard to selection of method and safety of oral food/fluid trials.

Food / Fluid TrialsSamples of food/fluids are presented to the patient, with following observations noted: Oral Preparatory Phase:

o Self-feeding abilityo Mouth opening to stimuli.

Oral stage: o Lip closure/sealo Efficiency and effectiveness of mastication OR efficiency and effectiveness of suckingo Oral transit timeo Nasal regurgitation o Food/fluid residue/pooling in oral cavity.

Pharyngeal stage:o Initiation of swallow reflexo Co-ordination of swallowo Laryngeal elevation.

Signs of airway penetration/aspiration including:o Cough/throat clearo Wet sounding voice qualityo Changes in breathing patterno Changes in oxygen saturation if observed.

Fatigue or other variables (such as cognition) affecting feeding skills and safety.

The Speech Pathologist will determine the amount and consistency of food/fluid given during the trial in order to minimise risks to the patient and make a clinical judgement regarding ability to safely consume a complete meal/drink.

Refer to Attachment 1: Clinical assessment of dysphagia for further detail.

5.2 Adjunct Assessment Adjunct procedures to the clinical swallowing assessment may be included as indicated.

5.2.1 Cervical AuscultationCervical Auscultation is an assessment of the sounds of swallowing and swallow-related respirations. It is intended to complement the clinical or bedside assessment of swallowing. Cervical Auscultation is a non-invasive, non-imaging method of adjunct assessment.

Using a stethoscope, clinicians can monitor the quality of swallowing sounds and respiratory sounds post swallow. The number of swallows required to clear a bolus and the delay in swallow reflex initiation can also be scrutinised. Healthy swallowing sounds and post swallow sounds are different to the swallow and post swallow sounds of patients with


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dysphagia. The clinician skilled in Cervical Auscultation can also determine whether compensatory strategies are assisting the patient with dysphagia. For example, the clinician can determine whether the patient is actually “holding their breath” during the supraglottic swallow manoeuvre, and how effective the manoeuvre is for that individual.

Cervical Auscultation can also be used to determine feeding efficiency and milk transfer in breastfeeding and bottle feeding neonates. Auscultation during feeding can add information on suck-swallow ratio, bolus size and length of sucking bursts.

It should be noted that there is inconsistent evidence regarding the use of Cervical Auscultation in reliably determining the occurrence of aspiration. Use must be in conjunction with the bedside clinical swallow evaluation and not be used solely in clinical decisions regarding a patient’s swallow presentation.3 Cervical Auscultation plus clinical bedside assessment increases identification of aspiration in neonates and children <12 months compared to bedside assessment alone and should be the base standard of practice.4

Speech Pathologists working for CHHS are required to complete external training which involves listening and rating normal swallows prior to commencing use of Cervical Auscultation with patients.5

5.2.2 Pulse OximetryPulse oximetry is a non-invasive continuous measure of a person’s oxygen saturation levels. A probe is attached to a pulsating vascular bed (i.e. finger, toe, ear lobe) and measures capillary oxygenation. Normal oxygenation levels are between 95-100%. Pulse oximetry can be used to record a measure of oxygenation before and after the patient has swallowed food and/or liquid. A baseline measurement is required, and an aspiration event is suggested by a a ≥5% drop from the individuals baseline level after the patient has swallowed food/drink.1

5.3 Instrumental AssessmentInstrumental assessment is used to more thoroughly evaluate the oral, pharyngeal and oesophageal phases of swallowing. 1

5.3.1 Videofluoroscopic Swallow Study (VFSS)A VFSS, also commonly referred to as a Modified Barium Swallow (MBS), is a dynamic radiological examination of the swallow used to assist the speech pathologist in diagnosing symptoms and causes of dysphagia through visualisation of swallowing anatomy and physiology. The VFSS typically follows the clinical assessment when identified symptoms of dysphagia require further investigation and allows the analysis of the structures and physiology of the swallow.

5.3.2 Fibre optic Endoscopic Evaluation of Swallowing (FEES) FEES is an instrumental imaging technique used to evaluate and manage dysphagia. It is performed in conjunction with Ear Nose and Throat Specialists (ENT) and involves passing a flexible laryngoscope trans-nasally to provide direct visualisation of the velopharyngeal port,


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pharynx and larynx enabling anatomical and functional assessment and diagnosis of swallowing disorders.

Therapeutic techniques can be trialled during both VFSS and FEES to assess effectiveness of swallowing and can inform recommendations for oral intake or effectiveness of rehabilitative or compensatory strategies or manoeuvres.

Both FEES and VFSS may provide additional information to assist with: Maximising pulmonary safety Enhancing nutritional adequacy/sustainability Monitoring for disease progression Establishing compensatory and rehabilitative dysphagia management plans Decisions regarding quality of life.

For further evidence and detail regarding FEES and/or VFSS refer to: Dysphagia: Modified Barium Swallow Clinical Practice Guideline, Speech Pathology

Australia (2005) Fibre optic Endoscopic Evaluation of Swallowing (FEES) An Advanced Practice for Speech

Pathologists (2007)

ALERT: Speech pathologists must undergo formal competency training prior to conducting VFSS and FEES independently.6

5.4 Assessment tools Assessment Tools and checklists are located in the resource area of the Speech Pathology department or located on the speech pathology shared drive.

Tools may include – tongue depressors, small torch, spoons, straws, gloves, samples of thickened fluids and food items. Additional items for clinical assessment may include a pulse oximeter or stethoscope for Cervical Auscultation.

5.5 Diagnosis After considering all factors within the assessment, the Speech Pathologist should then be able to comment on: The type of dysphagia (preparatory/oral/pharyngeal), linked to underlying causes (e.g.

CVA/resection of oral structures) The severity of dysphagia (mild/moderate/severe/profound) Expectations of prognosis for recovery Acquisition of developmental feeding skills, if applicable The risk of aspiration and airway protection factors Ability/safety to commence oral diet and fluids Possibility of oesophageal dysfunction impacting on oropharyngeal swallowing disorders How feeding/swallowing skills relate to other areas of cognitive and physical function.


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5.6 Repeat assessment and reviews.Frequency of repeat assessment/review is guided by the individual clinician’s clinical judgement, determined by patient need and risk associated with the dysphagia management plan and supported by the clinical priority tool.

When a review is conducted, the following should be documented: Current swallowing status Changes from initial baseline assessment, including comment on change in chest status,

presence/absence coughing with food/fluid , improvement/deterioration in status Update the patient, family , relevant MDT members on specific aspects of progress Update intervention goals, including frequency and intensity of ongoing intervention.

5.7 Clinical record reviewThe managing Speech Pathologist may delegate the task of reviewing the patients’ file to the allied health assistant (AHA), in order to monitor tolerance of a recently introduced or modified diet or fluid plan. Patients who are not appropriate to be reviewed by the AHA include patients with a tracheostomy, infants and patients with complex medical needs.

Dysphagia indicators as described in the patient’s observation chart and progress notes may include changes to: Temperature Oxygen saturation Respiratory rate Level of oxygen support as documented in the patients’ observation chart Level of alertness Fatigue Tolerance i.e. coughing when swallowing food/fluid.

The managing Speech Pathologist is responsible for all clinical activity undertaken by the AHA in requesting a clinical record review, including specific instruction on dysphagia indicators to review and feedback required from the AHA. It is outside of the scope of the AHA to assess a patient’s swallow or to make recommendations.


Section 6 – Management and Intervention

Treatment of dysphagia involves specific, targeted intervention of impaired functions7 and should only be formulated following thorough assessment of the patient’s swallowing abilities. This involves determining the presenting symptoms, which aspect(s) of swallowing function is impaired (e.g. poor airway protection) and the cause of dysfunction (e.g. vocal fold paresis caused by recurrent laryngeal nerve damage). Treatment without accurate


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identification of the underlying cause and mechanism of dysphagia has the potential for harm.1

In selecting a suitable treatment approach clinicians must evaluate the suitability of the treatment based on safety, the patient’s needs and the perceived outcome. Clinicians should also ensure that where possible the techniques selected are underpinned by evidence and that the basis of this evidence be regularly evaluated. 1 It is the role of the treating Speech Pathologist to ensure that the treatment programs prescribed are regularly reviewed and modified as appropriate. 3

The goals of effective dysphagia management/treatment include: Maximising swallowing efficiency Maximising swallowing safety, to minimise aspiration risk. (Whilst all care should be

taken to reduce risk, it cannot be fully eliminated. Evaluation of risks and benefits are critical in determining management.)

Recommending the most appropriate diet/fluid consistency and to determine when transition from one form of nutrition to another is appropriate, such as from enteral to oral, or smooth puree to a minced and moist diet

Determining in conjunction with a Dietitian and/or Medical Officer, the most appropriate method to maintain or increase nutrition and hydration; this may include oral, or non-oral means, or a combination of these

Determining if compensation (e.g. modified food or fluid +/- strategies) will maximise outcomes

Maximising the social aspect of eating/drinking where possible Optimising quality of life aspects associated with eating/drinking/feeding. 1

Effective management includes the ability to recognise: Factors which are impeding progress and the ability to modify goals and treatment

programs accordingly The need for involvement of other service providers The need for involvement and support of family/carers When goals have been achieved and services should cease.

6.1 Pre oral IntakeThe Speech Pathologist should ensure the patient is adequately prepared for oral intake before recommending or commencing oral diets and/or specific techniques or manoeuvres.

This may include addressing the following: The environment (e.g. reducing distractions/noise/social interactions) The presentation of food and fluid and mealtime equipment Optimal posture/body position (which may include the consideration of seating

requirements) Reducing oral aversions and hyper- and hypo-sensitivities Best timing for oral intake (e.g. post-medications) Oral care/hygiene is addressed


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Participation of care givers.

6.2 CompensationCompensatory techniques are aimed at altering the flow of food/fluid to compensate for impaired oral and pharyngeal function.

6.2.1 Food and fluid texture modificationModifications of food and liquid consistencies, temperature, taste and texture can improve swallow safety and efficiency. 3 Any modifications to food/fluids need to be assessed by the Speech Pathologist to determine the effectiveness in reducing dysphagia symptoms. In modifying a patient’s diet or fluids, the Speech Pathologist must consider the frequency, timing and size of meals presented as well as the influence of taste and temperature in addition to texture changes in improving swallow safety and efficiency. 3

Food textures at the Canberra Hospital (least to most modified) using Australian standard terminology: General (No modifications) Soft diet (Texture A) Mince and Moist diet (Texture B) Smooth Pureed diet (Texture C).

Note: The Speech Pathologist may also at their discretion request changes to the patient’s diet away from the standard menu (where possible). For example, additional sauces/gravy.

Fluid textures at Canberra Hospital (least to most modified): Thin fluid Mildly thick (Level 150 thick fluid) Moderately thick (Level 400 thick fluid) Extremely thick (Level 900 thick fluid).

Paediatric specific food textures include transitional foods which start as one texture but change to another when moisture is applied, e.g. bite and dissolve foods.

Paediatric specific fluid textures include slightly thick (Level 80 thick fluid), also known as anti-reflux (AR) thick fluid.

6.2.2 Teat modificationModification of teats and bottles as well as other feeding equipment (including cups, syringes, spoons etc.) can improve infant feeding efficiency, safety and comfort.8 Any modification needs to be assessed by the Speech Pathologist to determine the effectiveness in reducing dysphagia symptoms. Care must be taken when modifying teats and using thickened fluids together due to the nature of non-newtonian fluids and the sheer effect of thickened fluid through a small teat, resulting in inconsistent bolus size or timing and increasing aspiration risk.9


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6.2.3 Notification of modifications Once a diet or fluid has been modified, the Speech Pathologist is to notify the patient’s

nurse of any changes and instructions and call the nutrition department (Canberra Hospital, ext. 42567) to notify the Nutrition Technicians of the change to diet and fluids. In addition to documentation in the clinical record, the medical team may also need to be notified of results of assessment and recommended modifications.

Once a teat or feeding regime has been modified, the Speech Pathologist is responsible for notifying the patient’s nurse, parent’s formula room and sterilising room as appropriate and for displaying a cot-side teat recommendation sign.

ALERT: Where Nil By Mouth (NBM) is recommended, the medical team must be notified if the patient does not already have alternate feeding in situ.

Refer to Attachment 2 for further detail of compensatory techniques

6.3 Rehabilitation StrategiesRehabilitation strategies are designed to improve swallow function by changing the underlying swallow physiology and facilitating optimal functioning of available oropharyngeal structures.7 The application of rehabilitation techniques must take into consideration the patient’s ability to cognitively participate in therapy techniques. Please note that clinician discretion is required for all strategies and a videofluoroscopy of the swallow is indicated before trial of most strategies.

Refer to Attachment 3 for further detail of rehabilitation strategies.

6.4 EducationThe treating Speech Pathologist will instigate education and training for the patient, carers and other treating team members responsible for the person with dysphagia in order to increase their awareness and understanding of the persons swallowing disorder, management and prognosis. 3 The Speech Pathologist should ensure that where training is required to implement a management plan, an optimal method is used to maximise understanding. For example, use of written or visual aids, or an interpreter.

Education and counselling, at a minimum should occur at the point of referral, after clinical assessment, and prior to discharge.

6.5 Other dysphagia management considerationsEffective and holistic dysphagia management, were relevant should include consideration of: Oral hygiene Activity and participation factors Teaching new feeding/eating skills to infants and children Free water protocol Non oral feeding and hydration


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Palliative Care.Refer to Speech Pathology Association Dysphagia Clinical Guideline for further detail.


Section 7 – Documentation

Patient clinical record entries are written in accordance with the Clinical Records Policy available on the Policy Register.

A file note must be made in the clinical record for every contact provided to the patient or family. Each entry should have a corresponding statistical entry in ACT Patient Administrative System (ACTPAS).

Completed assessment form templates, such as the videofluoroscopy report are to be retained in the patient’s clinical record. Where an assessment is not documented on an approved form, results must be documented comprehensively in the patient’s clinical record as part of the progress note.


Section 8 – Discharge/Transfer

A patient with dysphagia will be deemed suitable for discharge from speech pathology once they have returned to their premorbid swallowing function and/or have reached their optimal level of swallowing function, or if directed by the medical team that no further speech pathology intervention is required. Discharge may also occur as a result of transfer to another facility/speech pathology service, if a patient is non-compliant, declines the service or is no longer suitable for ongoing care.

Note: Speech Pathologists also provide services for patients experiencing communication impairment. Patients may be receiving services for both communication and swallow impairment. Discharge from speech pathology would occur when intervention for both communication and swallowing impairment is complete and/or care is transferred to another facility / speech pathology service.

Discharge/Transfer report:A discharge/transfer report is a formal report documented in addition to standard documentation completed in the patient’s clinical record. The need for a discharge/transfer report will be dependent on the patient’s complexity and ongoing needs.

Where a patient reaches their optimal swallowing status or is returned to their premorbid diet and no Speech Pathology follow-up is indicated on discharge from hospital, a discharge/transfer report is not required.


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Where a patient is discharged from hospital or transferred to another facility and a significant change has been made to their preadmission swallowing status (e.g. now requiring thickened fluids when previously on unmodified fluids) and/or the patient requires ongoing speech pathology services, a discharge/transfer should be provided to the facility or service provider (e.g. nursing home, general practitioner (GP), private Speech Pathologist) in a timely manner. A Speech Pathology Discharge/Transfer template can be completed, or an in depth report written.

Note: RACC Speech Pathologists should complete the Allied Health Discharge Report, found on the clinical forms register, for all patients discharging from the Canberra Hospital inpatient wards.


Implementation

This guideline will be available to all staff via the Policy Register.It will be communicated to staff via an all staff email and team meetings.It will be incorporated into the orientation of Speech Pathology staff.


Related Policies, Procedures, Guidelines and Legislation

Policies CHHS Consent and Treatment Policy CHHS Clinical Records Management Policy CHHS Patient Identification and Procedure Matching Policy

Procedures CHHS Healthcare Associated Infections Clinical Procedure CHHS Clinical Records Management Manual CHHS Patient Identification and Procedure Matching Procedure RACC Intake Referral Management Procedure Community Rehabilitation Team Eligibility and Prioritisation Procedure

Standards Dysphagia Clinical Guideline, Speech Pathology Australia 2012 Scope of Practice in Speech Pathology, Speech Pathology Australia 2003 Competency Based Occupational Standards, Speech Pathology Australia 2011

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Work Health and Safety Act 2011


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References

1. Speech Pathology Australia (SPA)(2012) Dysphagia: Clinical Guideline 2. Speech Pathology Australia (SPA) (2004) Dysphagia: General Position Paper3. Royal College of Speech and Language Therapist (RCSLT) Clinical Guidelines; Dysphagia

(2005) UK4. Frakking, Chang, O’Grady, David, Walker-Smith and Weir (2016). The use of cervical

auscultation to predict oro-pharyngeal aspiration in children: A randomised controlled trial. Dysphagia, 31 (6): 738-748.

5. Cichero, J. & Murdoch, B. Dysphagia: Foundation,Theory and Practice (2006) Wiley UK6. Speech Pathology Association of Australia (2005) Dysphagia: Modified Barium Swallow

Position Paper. SPA position paper.7. Logemann, J. Evaluation and treatment of swallowing disorders (1998). (2nd Ed) Pro-Ed

Inc8. Ross, E., Fuhrman, L. (2015). Supporting oral feeding skills through bottle selection.

Perspectives on swallowing and swallowing disorders (dysphagia), 24 : 50-57. 9. September, C., Nicholson, T., and Cichero, J. (2014). Implicatins of changing the amount

of thickener in thickener formula for infants with dysphjagia. Dysphagia, 29: 432-437. 10. Kidder, Langmore & Martin, Indications and techniques of endoscopy in evaluation of

cervical dysphagia: Comparisons with radiographic techniques (1994) DYSPHAGIA 9 (4): 256-261

11. Langmore, SE, Terpenning, MS, Schork, A, Chen, YM, Murray, JT, Lopatin, D, Loesche, WJ. Predictors of aspiration pneumonia: how important is dysphagia? (1998) DYSPHAGIA. 13 (2): 69–81

12. National Stroke Foundation. (2005). National Clinical Guidelines for Stroke Rehabilitation and Recovery. Australian Government: National Health and Medical Research Council

13. National Stroke Foundation. (2007) Acute Stroke Management Clinical Guidelines Australian Government: National Health and Medical Research Council

14. Perry, A. & Skeat, J. (2004). AusTOMs for Speech Pathology. Melbourne, Victoria: La Trobe University.

15. Speech Pathology Association of Australia (2011). Competency Based Occupational Standards. SPA Position Paper

16. Speech Pathology Association of Australia (2007) Fibreoptic Endoscopic Evaluation of Swallowing (FEES) An Advanced Practice for Speech Pathologists. SPA Position Paper.


Definition of Terms

Dysphagia refers to a condition, a disorder or a symptom that may be genetic, developmental, acquired, functional or iatrogenic in its origin. It can be caused by structural, physiological and/or neurological impairments affecting one or more stages of swallowing, namely the preparatory, oral, pharyngeal and/or oesophageal stages. This may present as a


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difficulty with sucking, drinking, eating, controlling saliva, protecting the airway or swallowing. As a consequence, dysphagia may lead to asphyxiation or pneumonia 10, 11, or failure to meet an individual’s nutrition, hydration and social needs 10, 11 as well as impacting on development of oral and communication skills. 2


Search Terms

Dysphagia, swallowing, speech pathology, management, assessment, Back to Table of Contents

Attachments

Attachment 1: Clinical assessment of dysphagiaAttachment 2: Compensatory techniquesAttachment 3: Rehabilitation techniques

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 10/01/2018 Complete Review Kerry Boyd, Director of

Allied Health (Medicine)CHHS Policy Committee

This document supersedes the following: Document Number Document NameCHHS13/384 Speech Pathology Management of Dysphagia

Appendix 1 Clinical assessment of dysphagia 1

1. Background Medical diagnosis including medical status Complexity of medical condition (e.g. more than one body system involved: cardiac +

respiratory diagnosis) Current nutritional status and immediate nutritional needs (food allergies or

intolerances; breast or bottle feeding; nutritional supplements) Cultural, educational, religious and vocational background Level of stress or concern of patient/carer regarding the feeding/swallowing difficulty.

2. Immediate Observations Patient awareness of their environment Patient level of alertness


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Patient ability to participate in feeding/swallowing assessment Presence of tubes: intravenous line, nasogastric tube, gastrostomy tube, tracheostomy

tube Patient state (e.g. agitation or fussiness) Ability to manage oral secretions Respiratory status (e.g. oxygen assistance; depth and rate or respirations) Posture and positioning.

3. Communication, Cognition and Behaviour Ability to follow instructions Visual and auditory skills (e.g. need for glasses, hearing aids) Need for communication device Paediatric age appropriate developmental motor, communicative and cognitive

milestones Psychological variables (e.g. depression in adult patients or adult carers) Insight into their condition.

4. Oropharyngeal Assessment Structure and presentation of the oral anatomy, oral mucosa, posterior pharyngeal

anatomy and mucosa (e.g. soft palate, posterior pharyngeal wall) Oral hygiene and dental status (blisters, oral candida, dry mucosa) Cranial nerve assessment, specifically:

o CN V – Trigeminal (motor + sensory)o CN VII – Facial (motor + special sensory)o CN IX – Glossopharyngeal (sensory + special sensory +secretomotor + motor)o CN X – Vagus (sensory + special sensory + motor)o CN XII – Hypoglossal (motor)

In addition, for paediatrics, presence or absence of age appropriate oral reflexes (e.g. rooting, sucking, swallowing, tongue extrusion and lateralisation, phasic bite, gag, cough reflexes)

Presence or absence of spontaneous swallows of saliva Ability to protect the airway (e.g. presence or absence of spontaneous cough reflex).

5. Oral Trial/Feeding Assessment Patient suitability to participate in oral trial (e.g. contraindication includes decreased

level of alertness, extreme agitation, extreme fatigue, inability to protect the airway) Appropriate positioning for feeding/swallowing trial Appropriate range of regular and texture modified liquids and/or solids to determine

current level of function regarding swallow safety (including infant formula) Appropriate feeding or adaptive equipment to make a sound clinical judgment (e.g. teat

types, plate guards) Ability to coordinate breathing and swallowing (e.g. presence of deglutition apnoea) Promptness of swallow reflex initiation Presence of laryngeal excursion


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Alterations to patient state during or after feeding/swallow trials (e.g. change in rate or depth of respiration; regurgitation; distress)

Evidence of oral residue post swallow trials Stamina and fatigue levels.

6. Referral for Other Assessments Need for further information regarding the pharyngeal or oesophageal phases of

swallowing What additional information will the instrumental assessment provide? Will the additional information change patient management?

7. Overall Impression and Diagnosis Integration of all information gathered to determine dysphagia severity and prognosis Swallowing safety Degree of risk for choking or aspiration Ability to consume sufficient food/liquid orally to meet nutritional needs Determination of primary location of dysphagia Oral preparation Oral Pharyngeal Oesophageal Dysphagia severity: Mild, moderate, severe dysphagia Normal, possible impairment, probable impairment, definite swallowing impairment

8. Management Plan Food and/or liquid prescription (e.g. need for texture modified foods or liquids; adaptive

equipment) Requirement for assistance or supervision with feeding (including posture and

positioning) and training Referrals to other health professionals Circumstances that will prompt staff/carer to request speech pathology review Oral hygiene plan Suitability for rehabilitation or treatment (consider patient new learning ability;

patient/carer motivation to comply with treatment; stamina to participate in treatment; overlying psychological issues such as depression in patient or carer)

Referral for instrumental assessment of swallowing Frequency of speech pathology review Utilisation of Allied Health Assistant with implementing the management plan.


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Appendix 2 Compensatory TechniquesCompensatory technique Paediatric examples Adult examplesLiquid modification Thickened breastmilk or infant

formula (viscosity < Level 150 – mildly thick); thickened liquids for infants and children (as per adult examples).

Thickened liquids (Level 150 -mildly thick Level 400 - moderately thick; Level 900 – extremely thick) as determined by assessment.

Food texture modification Use of texture modified foods (e.g. Texture A – Soft; Texture B – Minced and Moist, Texture C – Smooth Puree) as determined by assessment. In addition, use transitional food textures, e.g. lumpy puree, funny puree and dissolvable food textures.

Use of texture modified foods (e.g. Texture A – Soft; Texture B – Minced and Moist, Texture C – Smooth Puree) as determined by assessment.

Food/liquid sensory adjustments e.g. Temperature, Flavour, Tactile

Warm or cool bolus. Flavour of infant formula; use of food flavourings to encourage acceptance of different food types and textures.

Cold bolusSour bolusCarbonated bolus

Dose modification for medication administration

Example: Provision of liquid medicine.

Example: Provision of suppositories, patches, injectable medicine in accordance with the Pharmacist’s recommendations.

Bolus volume modification

Cross-cut teat; teats with different flow rates; bottle with small volume dispensing capacity.

Smaller cup size or supervised ingestion.

Method of bolus delivery Breastfeeding, supply line, bottle feeding, teaspoon, cup, straw, other special feeding equipment.

Open cup, spoon, straw, spout cup, sports bottle.

Body posture Football hold, prone position, swaddling of infant.

Supported upright with or without pillows.

Head of facial posture Jaw, lip of cheek support Jaw of lip supportHead turnHead rotation/tiltChin tuckHead extensionEffortful swallowMendelsohn manoeuvreSupraglottic swallowSuper-Supraglottic swallow

Pacing of food or liquid rate of ingestion

Recommendations of patient specific rate of liquid or solid ingestion to assist carers.

Environmental adjustments

Optimal lighting, limit distractions, recommendations for frequency of feeds/meals, timing of feeds/meals, volume or size of feeds/meals.

Prosthetic devices Obturator or palatal augmentation prosthesis.Adapted from Speech Pathology Australia (2012) Dysphagia: Clinical Guideline


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Appendix 3 Rehabilitation Techniques Rehabilitation technique Used For Population appropriate forMasako manoeuvre Proposed to exercise the

glossopharyngeus muscle (a portion of the superior pharyngeal constrictor) and thereby improve tongue base to pharyngeal wall valving.

Validated on adults; may be appropriate for older children with adequate cognitive and communicative abilities to follow instructions

Shaker of Head life manoeuvre

Proposed to strengthen the suprahyoid complex to improve hyolaryngeal excursion.


Electrical stimulation The application of low voltage electrical currents to muscle tissue, causing contraction of the muscle fibres.

Suitable for some adults

Biofeedback Visual display such as that offered by sEMG (e.g. a wave amplitude and timing of contraction); visual display offered from modified barium swallow of FEES; acoustic feedback offered from swallow-respiratory amplification.


Surface electromyography (sEMG)

A means of measuring the myoelectric impulses generated by the muscle just before it contract.


Strengthening exercisesJawLipsCheekTongue

Exercises need to be functional. For example, tongue lateralization practice assists with the development of chewing skills; tongue protrusion is not a functional skills for efficient and safe swallowing.

Adults and children > 6 months

Swallowing practice The best exercise for swallowing is swallowing.

All individuals

Chin tuck against resistance (CTAR)

CTAR exercises may be as effective as Shaker exercises in building submental muscle strength and improving pharyngeal dysphagia related to reduced hyoid movement.

Adults for whom Shaker manoeuvre is contraindicated due to age, history of cardiac or chronic illness or head/neck injury.

Adapted from Speech Pathology Australia (2012) Dysphagia: Clinical Guideline


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