Back to Basics: Applying Clinical Reasoning to the Clinical Swallow Assessment

Editor’s Note: This text is a transcript of the course, Back to Basics: Applying Clinical Reasoning to the Clinical Swallow Assessment, presented by Angela Mansolillo, MA, CCC-SLP, BCS-S. Learning Outcomes After this course, readers will be able to:Describe three components of a clinical swallow evaluation and the evidence that supports them.Identify risk factors for aspiration in various patient populations.Identify appropriate interventions based on results of clinical assessment.  Why Clinical Assessment? I am really thrilled to be talking about clinical assessment because this is one of my favorite topics. This course will help you apply some actual clinical reasoning to the clinical assessment process.  I am a big fan of the clinical assessment, the bedside swallow assessment, and that is not always a popular view in the field.  I understand that the clinical assessment sometimes gets a bad rap in the field of speech pathology. I understand its limitations and we will talk about some of those in this course.  I also understand that there are things that the clinical assessment does for us, that instrumental assessment simply doesn't do. I know that I can't definitively identify aspiration at the bedside. And it can't tell you anything about pharyngeal swallow physiology, but clinical assessment does allow us to gather information that is critical to the overall diagnosis.  It also provides information that allows us to do a more efficient instrumental assessment and engages patients in a way that instrumental assessments simply doesn't provide.  It allows for a much more natural sort of environment and natural interaction. Clinical Assessment versus Instrumental AssessmentI believe some questions are best answered by a clinical assessment.  There are some questions that instrumental assessment really doesn't answer well such as questions about cognitive assessment. Later, I will discuss what aspects of cognition can be assessed as part of our bedside evaluation. Clinical assessment allows us to look at positioning and self-feeding. We can look at a number of different utensil types and bolus types. We don't have the same kinds of time constraints that we do with an instrumental assessment. We can look for fluctuations in performance and look at the effects of fatigue and endurance. In my hospital, instrumental assessments are done at 9:00, 9:30, 10:00 or 10:30 a.m.  Those are our modified barium swallow slots. But I can do clinical assessment on patients in the hospital at any time. I may want to look at them a little later in the day to see if fatigue is having an effect? Do they really have poor endurance that's going to impact their swallow function? Again, those are questions that I can best answer with my clinical assessment. There are also no time limitation with a clinical assessment. Therefore, I can look at what happens over the course of the entire meal time to see if there are changes from the beginning of the meal to the end of the meal.   Clinical assessment is a way to simulate real-life eating and assess functional eating in a way that instrumental assessments simply doesn't allow. With clinical assessment, we are looking for signs and symptoms of aspiration, and I’ll talk more about that as we go through the course.  However, that's not the only thing that we're doing when we do the clinical assessment. Reviewing the Medical RecordChest X-Ray TerminologyWe start our clinical assessment, just like any other assessment, with a review of the available information. One piece that's often pertinent as we get ready to do a bedside or clinical swallow evaluation is the chest x-ray. This is particularly true if you're in a skilled nursing setting or an acute care setting.  Although SLPs are not the ones interpreting chest-x-rays, it is helpful to have an understanding of what some of the terminology means. So, if you see terms like density, opacity, consolidation, or infiltrate (although radiologists in my hospital tell me infiltrate is not being used very commonly anymore. It's being replaced by opacity), that tells you that something is in the air spaces.  The lungs are not functioning optimally because the air spaces are filled with something. We can't always tell what it is. It could be fluid or bacteria. But if you see one of those terms, then that could be associated with pneumonia. If you see the term atelectasis, that is indicating that some of the alveolar spaces have collapsed and there's subsequent loss in lung volume.  That too may be associated with pneumonia. However, you have to know what kind of chest x-ray was taken. If a portable chest x-ray was done while the patient was in bed, and the atelectasis is basilar, that may mean that the patient wasn’t able to expand their lungs sufficiently for the x-ray itself. Terms like edema or effusion included on indicate that there's some fluid present. That is typically not associated with pneumonia. Fluid in the lungs is more likely to be associated with congestive heart failure (CHF), but also potentially with pulmonary embolism or cancer. Typically, it’s not associated with pneumonia. Laboratory ValuesAnother important part of the medical record that sometimes doesn't get as much attention from us as it should are the lab values. There's a lot of lab work available to us. Again, we're not physicians or nurse practitioners. I'm not suggesting we would be the ones interpreting these labs. There are many things that abnormal lab results can mean. But we should have a basic understanding of what these labs are looking for so that we can ask better questions and have more informed conversations with our team members. Understanding lab terminology also allows us to be armed with more information before we go into the patient’s room and start that bedside swallow evaluation. You might see a complete blood count (CBC) in the medical record. There are a number of different measures that might be part of the CBC. One of those is likely to be a white blood cell count. If the white blood cells are high that alerts us to the presence of infection. It doesn't suggest pneumonia, it could be any kind...