EBP Compendium: Summary of Clinical Practice Guideline

American College of Chest Physicians
Cough and Aspiration of Food and Liquids Due to Oral-Pharyngeal Dysphagia: ACCP Evidence-Based Clinical Practice Guidelines*
Smith Hammond, C. A., & Goldstein, L. B. (2006).
Chest, 129(1 Suppl), 154S-68S.

AGREE Rating: Highly Recommended

Description:

This guideline provides recommendations for the evaluation and treatment of cough and aspiration of food and liquid as a result of oropharyngeal dysphagia. High-risk populations included, but were not limited to, individuals with Parkinson's disease, amyotrophic lateral sclerosis, dementia, head and neck cancer, stroke, and brain injury. The target audience of this guideline is speech-language pathologists. Levels of evidence are provided and defined as a strong recommendation (Grade A), a moderate recommendation (Grade B), a weak recommendation (Grade C), a negative recommendation (Grade D), or inconclusive or no recommendation possible (Grade I).

Recommendations:

• Assessment/Diagnosis
  • Assessment Areas
    • Swallowing
      • "Patients with high-risk conditions should be referred for an oral-pharyngeal swallowing evaluation" (Grade B Evidence) (p. 158S).
      • "If a patient with cough reports swallowing problems, further evaluation for oral-pharyngeal dysphagia is indicated" (Grade B Evidence) (p. 158S). Assessment from patient and caregivers regarding perceived swallowing problems should be completed.
      • "Patients with cough related to pneumonia and bronchitis who have received medical diagnoses and conditions associated with aspiration should be referred, ideally to a SLP, for an oral-pharyngeal swallow evaluation" (Grade B Evidence) (p. 166S).
  • Assessment Instruments
    • Swallowing
      • Bedside Swallowing Examination
        • “Alert patients with cough who are in high-risk groups for aspiration should be observed drinking small amounts of water (3 oz). If the patient coughs or shows clinical signs that are associated with aspiration, the patient should be referred for a detailed swallowing evaluation, preferably to a SLP” (Grade B Evidence) (p. 159S).
        • "In patients with cough, the value of the subjective assessment of [volitional cough] as the sole predictor of aspiration is uncertain because of poor reliability and an unclear association with evaluation" (Grade I Evidence) (p. 159S).
        • "The assessment of the [reflexive cough] response to inhaled irritants as a predictor of aspiration risk and subsequent pneumonia is not recommended due to a lack of adequate supportive studies" (Grade I Evidence) (p. 159S).
        • "In acute stroke patients, the expulsive phase rise time of [volitional cough] VC may predict aspiration. The use of this test has not been validated in other patient groups, and further studies comparing the accuracy of objective measures of VC to the clinical swallow evaluation to identify aspiration risk are needed" (Grade C Evidence) (p. 162S).
      • FEES/Videofluoroscopy
        • “Patients with dysphagia should undergo [videofluoroscopic swallow examination] VSE or [fiberoptic endoscopic evaluation of swallowing] FEES... to identify appropriate treatment" (Grade B Evidence) (p. 162S).
        • “In patients with dysphagia, [videofluoroscopic swallow examination] VSE or [fiberoptic endoscopic evaluation of swallowing] FEES can be useful for determining compensatory strategies enabling patients with dysphagia to safely swallow” (Grade B Evidence) (p. 163S).
        • "In patients with dysphagia, dietary recommendations should be prescribed when indicated, and can be refined by testing with foods and liquids simulating those in a normal diet during the [videofluoroscopic swallow examination] VSE or [fiberoptic endoscopic evaluation of swallowing] FEES” (Grade B Evidence) (p. 163S).
• Treatment
• Swallowing
• General Findings & Oral/Tube Feeding - “Patients with a reduced level of consciousness are at high risk for aspiration and should not be fed orally until the level of consciousness has improved” (Grade B Evidence) (p. 159S).
• Biofeedback, E-Stim & Oral Motor Exercises - "For patients with muscular weakness during swallowing, muscle strength training, with or without electromyographic biofeedback, and electrical stimulation treatment of the swallowing musculature are promising techniques but cannot be recommended at this time until further work in larger populations is performed" (Grade I Evidence) (p. 164S).
• Compensatory Strategies - “In patients with dysphagia, [videofluoroscopic swallow examination] VSE or [fiberoptic endoscopic evaluation of swallowing] FEES can be useful for determining compensatory strategies enabling patients with dysphagia to safely swallow” (Grade B Evidence) (p. 163S).
• Diet Modification - In patients with dysphagia, dietary recommendations should be prescribed when indicated, and can be refined by testing with foods and liquids simulating those in a normal diet during the [videofluoroscopic swallow examination] VSE or [fiberoptic endoscopic evaluation of swallowing] FEES” (Grade B Evidence) (p. 163S).

Keywords: Brain Injury; Swallowing Disorders; Stroke; Parkinson's Disease; Dementia; Huntington's Disease; Vocal Fold Paralysis; Head and Neck Cancer; Multiple Sclerosis; Amyotrophic Lateral Sclerosis

Access the Guideline

Note:

*Evaluated with "Introduction to the Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines. Northbook, IL: AACP, 2006 Jan.; "Methodology and Grading of the Evidence for the Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines." Northbrook, IL: ACCP, 2006 Jan.

Added to Compendium: November 2010