What is the next best step for a patient with a right-sided middle cerebral artery stroke and suspected aspiration, who is currently nothing by mouth (NPO) and has a weak cough?

Videofluoroscopic Swallow Study Should Be Obtained

This patient with acute stroke who is coughing during bedside swallow evaluation should undergo a videofluoroscopic swallow study (VSS) to definitively assess aspiration risk and guide safe feeding recommendations. 1

Clinical Reasoning

Why This Patient Needs Instrumental Evaluation

This elderly woman presents with multiple high-risk features for aspiration that mandate formal swallowing assessment:

• Weak cough is a critical predictor of aspiration risk, with 84% of aspirators in bilateral stroke patients identified by weak or absent voluntary cough 1
• Coughing during bedside swallow evaluation is a clinical sign strongly associated with aspiration 1
• Right-sided MCA stroke affecting the dominant hemisphere for swallowing control places her at substantial risk, with aspiration observed in over one-third of acute stroke patients 1
• Currently NPO status indicates the clinical team already suspects dysphagia 1

Why Not the Other Options

Antibiotics (Option A) are premature because:

• The chest radiograph is normal 1
• She has no fever (temperature 36.7°C) 1
• Coughing during swallow evaluation indicates aspiration risk, not established pneumonia 1
• Prophylactic antibiotics do not reduce pneumonia risk in stroke patients 1

Fiber optic evaluation (Option C) is an alternative to VSS but not superior in this context:

• Both VSS and FEES are equally valid for dysphagia assessment 1
• VSS has the advantage of visualizing all phases of swallowing in lateral and anterior-posterior views 1
• Most importantly, VSS can simultaneously test therapeutic interventions (postural maneuvers, thickened liquids) to determine which strategies eliminate aspiration—this cannot wait 1

Acid suppression (Option D) has no role because:

• Guidelines explicitly recommend against prescribing antireflux medications for isolated dysphagia without prior laryngoscopy 2
• There is no evidence of reflux-related symptoms 1

The Critical Evidence for VSS

Guideline Recommendations

The ACCP guidelines provide clear direction:

• Patients with cough who show clinical signs associated with aspiration during water swallow should be referred for detailed swallowing evaluation 1
• Patients with dysphagia should undergo VSS or FEES evaluation to identify appropriate treatment (Grade B recommendation) 1
• VSS or FEES can determine compensatory strategies enabling patients to safely swallow (Grade B recommendation) 1

Why Timing Matters

The AHA/ASA stroke guidelines emphasize:

• Clinical signs may not identify patients at risk for aspiration, necessitating instrumental testing 1
• Early assessment by speech-language pathologist within 24 hours is associated with dramatic reduction in aspiration pneumonia from 6.4% to 0% 1
• Wet voice after swallowing predicts high aspiration risk 1—this patient is already coughing, an even more concerning sign

The Therapeutic Advantage

VSS is not merely diagnostic—it guides immediate management:

• 77% of patients with aspiration had it eliminated during VSS using postural maneuvers (chin-down, head rotation, etc.) 1
• Testing with varied consistencies during VSS determines which textures can be swallowed safely 1
• The cost of VSS is offset by just a 10% reduction in pneumonia rates, which is easily achievable given detection of silent aspiration 1

Common Pitfalls to Avoid

Silent Aspiration

• Clinical bedside examination alone cannot rule out aspiration—research shows it can accurately identify aspiration when present but is problematic for ruling it out when absent 3
• Up to 50% of aspiration may be "silent" (without cough or clinical signs) 1, 4
• This patient is already showing overt signs (coughing), but VSS will reveal the full extent

Delayed Evaluation

• Do not wait for pneumonia to develop before obtaining instrumental assessment 1
• Do not continue NPO status without objective data on what this patient can safely consume 5
• Research shows that acute stroke patients with thin liquid aspiration on VSS can safely transition to oral feeding with thickened liquids, with aspiration pneumonia rates of only 1.9% 5

Inadequate Bedside Testing

• The 3-ounce water swallow test has value for screening but cannot provide the detailed anatomic and physiologic information needed for treatment planning 1
• Gag reflex presence does not indicate swallowing safety 1

Next Steps After VSS

Following the VSS, management should include:

• Multidisciplinary team approach with speech-language pathologist, dietitian, and nursing 1
• Implementation of compensatory strategies identified during VSS (postural techniques, pacing) 1
• Dietary modifications based on which consistencies were safely swallowed during VSS 1
• Reassessment if dysphagia persists or worsens 2