EBP Compendium: Summary of Clinical Practice Guideline

Royal College of Speech & Language Therapists; Department of Health (UK); National Institute for Clinical Excellence (NICE)
RCSLT Clinical Guidelines: 5.8 Disorders of Feeding, Eating, Drinking & Swallowing (Dysphagia)
Taylor-Goh, S., ed. (2005).
RCSLT Clinical Guidelines. Bicester, Speechmark Publishing Ltd.

AGREE Rating: Highly Recommended

Description:

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, stroke, traumatic brain injury, autism spectrum disorder, cerebral palsy, Parkinson’s disease and head and neck cancer. Each recommendation is graded A (requires at least one randomized controlled trial), B (requires at least one well-conducted clinical study), or C (requires evidence from expert committee reports).

Recommendations:

• Assessment/Diagnosis
  • Assessment Instruments
    • Swallowing
      • Clinical Examination
        • “Subsequent to information gathering, the Speech & Language Therapist will make a judgment with regard to whether they proceed in assessing the individual with food and liquid” (Level C Evidence) (p. 64).
        • The SLP will 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 (Level C Evidence) (p. 67).
        • “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" (p. 66).
        • "The individual swallow will be assessed using a speaking valve to determine if there is an improvement in safety and efficiency” (Level B Evidence) (p. 66).
        • The following aspects should be considered during the clinical evaluation
          • Case history
          • Oro-facial examination
          • Vocal tract function
          • Motor skills, posture, and tone
          • Nutrition/hydration
          • Respiratory status
          • Gastro-oesophageal reflux
          • Secretion management
          • Tracheostomy
          • Cognitive level
          • Alertness level
          • Medications
          • Oral hygiene
          • Dental health
          • Dietary preferences
          • Participation
          • Feeding patterns
          • Emotional state, mood, and behavior (Level C Evidence) (p. 64).
        • The speech-language pathologist (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
          • Utensils
          • The environment (Level B Evidence) (p. 64).
      • Videofluoroscopy and Endoscopy
        • "A videofluoroscopic or fibre-optic 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 (Level A Evidence)" (p. 65).
        • “Research has demonstrated poor inter-rater reliability in the interpretation of [Videofluoroscopic Evaluation of Swallowing (VFES)], and the Speech & Language Therapist should therefore exercise caution” (Level A Evidence) (p. 65).
      • Ultrasonography - "Ultrasound, scintigraphy, manometry and [electromyography (EMG)] are each tools to evaluate discrete components of swallowing function; therefore it is not appropriate to use any as a stand-alone evaluation technique (Level B Evidence)" (p. 65).  
      • Other Instruments
        • “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” (Level B Evidence) (p. 65).
        • "Ultrasound, scintigraphy, manometry and [electromyography (EMG)] are each tools to evaluate discrete components of swallowing function; therefore it is not appropriate to use any as a stand-alone evaluation technique (Level B Evidence)" (p. 65).
• Treatment
  • Swallowing
    • General Findings
      • The speech-language pathologist must ensure that the individual is at their optimal alertness level and appropriately manage hypo- and hyper-sensitivity (Level B Evidence) (p. 67).
      • Modification to the environment to reduce distractions and noise level, increase lighting, and facilitate social interaction may optimize the mealtime experience (Level B Evidence) (p. 69).
      • Interventions may involve bolus placement and/or bolus modification, pacing, use of adaptive feeding utensils and/or alternative nutrition.
    • Behavioral Intervention - “The Speech & Language Therapist will identify which behavioural strategies facilitate the eating and drinking process and communicate these to the relevant carers. These may include
      • Situational strategies prior to, during and after mealtime
      • Verbal cues
      • Written cues and/or symbols
      • Physical cues
      • Visual cues” (Level A Evidence) (p. 68).
    • Biofeedback - “Some instrumental procedures (e.g., Surface [electromyography (EMG)], ultrasound, videoendoscopy) can be used to provide biofeedback to patients undergoing swallowing therapy” (Level C Evidence) (p. 68).
    • Compensatory Treatment - The effectiveness of compensatory strategies such as postural changes and manoeuvres should be evaluated prior to implementation (Level C Evidence) and optimal body positioning should be identified (Level C Evidence) (p. 69).
    • Dietary Modification
      • “The Speech & Language Therapist will assess the effect of modified presentation of the bolus upon swallow function, in order to identify the method that facilitates the safest and most efficient swallowing” (p. 67).
      • Adjustments to the placement, size, consistency and temperature, taste and texture of the bolus, as well as changes in pacing, utensil, and frequency and timing may be necessary (Level B Evidence) (pp. 67-68).
    • Oral Motor Treatment
      • “The Speech & Language Therapist will provide therapy to maintain and/or improve oromotor function, which will be within agreed optimal time frames. This may include range of motion, chewing and swallowing exercises, and thermal and tactile stimulation. This may be contraindicated for cardiac and certain degenerating conditions” (Level B Evidence) (p. 69).
      • Children receiving non-oral feeding should be given oral stimulation as appropriate to "normalise sensation and maintain and promote skills" (Expert Opinion) (p. 70).
      • The speech-language pathologist will consider and potentially modify "oral-motor skills to include organisation of non-nutritive suck in infants (Level B Evidence) (p. 67).
    • Pacing & Equipment/Utensils - Interventions may involve bolus placement and/or bolus modification, pacing, use of adaptive feeding utensils and/or alternative nutrition.
    • Positioning Techniques
      • Body positioning should be identified for optimal swallow function (Level C Evidence) (p. 69). Position of trunk, limbs, shoulder and head support should be considered.
      • Positioning interventions may involve specialized seating equipment (Level C Evidence) (p. 69).
    • Tube Feeding
      • Speech-language pathologists should be involved in the clinical decision for non-oral nutrition and hydration as part of the multidisciplinary team (Level C Evidence) (p. 70).
      • Children receiving non-oral feeding should be given oral stimulation as appropriate to "normalise sensation and maintain and promote skills" (Expert Opinion) (p. 70). 

Keywords: Swallowing Disorders

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Added to Compendium: November 2010