Debra M. Suiter

Reliability for Identification of a Select Set of Temporal and Physiologic Features of Infant Swallows

There is little reported evidence regarding the reliability of temporal and physiologic features of infant swallowing from videofluoroscopic swallowing studies (VFSS). The purpose of this retrospective study was to determine a reliable set of temporal and physiologic features from infant swallowing that can be measured from analysis of VFSS. Temporal and physiologic features for testing were determined from review of previously reported features of infant VFSS in the literature. Two novel analysts underwent three training sessions to learn and practice visual recognition of the proposed features. The two analysts then assessed 25 swallows from 10 total subjects’ VFSS. To establish inter- and intra-rater reliability, calculation of Pearson’s r was used for features that met criteria for parametric analysis and Spearman’s rank correlation coefficient was used for the non-continuous features. Percent agreement was used to report on the reliability of the dichotomous features due to insufficient variability for Spearman’s rho analyses. Fifteen of the 16 tested features were found to have acceptable inter- and intra-rater reliability measures, with each analyst achieving a correlation of 0.75 or higher. This project identifies 15 variables that can be reliably measured from infant VFSS. This information can be used to assist with determination of normal versus abnormal swallow features and in developing and testing therapeutic strategies for infants with dysphagia.

Question: What About Silent Aspiration? Answer: Silent Aspiration Is Volume-Dependent

Determination of silent aspiration risk was shown to be volume-dependent with a larger volume eliciting a reflexive cough in individuals who previously silently aspirated on smaller volumes. A 3-ounce water swallow challenge’s previously reported high sensitivity for identification of aspiration risk combined with the newly reported low <2 % false negative rate mitigates the issue of silent aspiration risk during swallow screening with the Yale Swallow Protocol.

Deglutition in Patients with Tracheostomy, Nasogastric Tubes, and Orogastric Tubes

Swallowing, in both normal and disordered populations, with regard to the presence of a tracheotomy tube, one-way tracheotomy tube speaking valve, nasogastric tube, and orogastric tube is described. Specific subject areas include swallowing and tracheotomy tube use across the age span from pediatric to adult populations and swallowing success when mechanical ventilation via tracheotomy is required. Additional topics include swallowing success dependent on tracheotomy tube cuff status, i.e., inflated versus deflated, tracheotomy tube occlusion status, i.e., occluded versus open, and the presence versus absence of a tracheotomy tube itself. Also, current data and a discussion on swallowing and one-way tracheotomy tube speaking valve use are addressed. Lastly, nasogastric and orogastric tubes, by traversing the same path as a food bolus, can potentially impact on swallowing and information regarding their effect on swallowing is presented.

Screening Basics: Differentiating a Screen from a Diagnostic Tool

To provide knowledge and understanding of the statistical underpinnings pertinent to swallow screens with an emphasis on differentiating a screen from a diagnostic tool and why a reliable and validated swallow screen is valuable for patient care.

Development of a Programmatic Line of Research for Swallow Screening for Aspiration Risk: The First Step

To investigate the clinical utility of the 3-ounce water swallow challenge to determine aspiration risk status as well as oral diet recommendations in a large and heterogeneous hospitalized patient population. The important finding is that since FEES was the criterion standard for determination of aspiration status when the 3-ounce water swallow challenge is passed, diet recommendations can be made without the need for further instrumental dysphagia testing.

Criteria Necessary for a Successful and Reliable Swallow Screen

To discuss the criteria necessary for a swallow screen and why timely swallow screening with a reliable and validated screen as exemplified by the Yale Swallow Protocol is important.

Building a Foundation and Defining Terms

To discuss dysphagia versus aspiration risk, differences between the clinical or bedside examination versus a screening examination for aspiration risk, the importance of using a 3-ounce water swallow challenge, and building a research foundation and rationale for use of the Yale Swallow Protocol.

Recommending Specific Oral Diets Based on Passing the Yale Swallow Protocol

This chapter discusses the rationale and implementation of recommending specific oral diets based on passing the Yale Swallow Protocol. The combined results of a brief cognitive assessment, an oral mechanism examination, and a 3-ounce water swallow challenge were synthesized into a cohesive protocol. The Yale Swallow Protocol provides the clinician with a more nuanced and richer patient-oriented perspective on which to make timely and safe oral diet recommendations.

Implementation of the Yale Swallow Protocol by Other Health-Care Professionals

The accuracy of the Yale Swallow Protocol comprised of a brief cognitive screen, an oral mechanism evaluation, and drinking 3 ounces of water when administered and interpreted by registered nurses was compared with blinded ratings from speech-language pathology. Intra- and inter-rater protocol agreements for the two speech-language pathologists were 100 %. Inter-rater protocol agreement between registered nurses and speech-language pathologists was 98.01 % with a Cohen’s Kappa of 0.95. Results confirmed the reliability and accuracy of a registered nurse administered and interpreted swallow screening protocol.

Generalizing the Yale Swallow Protocol to Different Patient Populations: Time to Change

The Yale Swallow Protocol has been validated with referral populations from four broad patient groupings: (1) Pediatric; (2) Trauma; (3) Stroke; and (4) General Hospital. When the Yale Swallow Protocol is passed not only thin liquids but diet recommendations with puree and solid food consistencies can be made without the need for further instrumental dysphagia assessment.