How do healthcare providers order a swallow test for patients with suspected dysphagia?

How Healthcare Providers Order a Swallow Test

Healthcare providers should refer patients with suspected dysphagia directly to a Speech-Language Pathologist (SLP) for an oropharyngeal swallow evaluation, which includes both clinical bedside assessment and instrumental testing (videofluoroscopic swallow evaluation [VSE] or fiberoptic endoscopic evaluation of swallowing [FEES]) to guide treatment decisions. 1, 2

Step 1: Identify High-Risk Patients Requiring Referral

Refer patients to an SLP when any of the following are present:

Medical History Red Flags

• Neurological conditions: stroke, Parkinson disease, dementia, ALS, multiple sclerosis, brain injury 1, 3
• Cough associated with eating/drinking or history of aspiration pneumonia 1
• Patient/caregiver reports of swallowing difficulty with liquids or solids 1
• Unintentional weight loss, malnutrition, or dehydration 1
• Abnormal chest radiograph showing patchy opacity, lower lobe infiltrate, or air space disease 1

Clinical Signs During Bedside Assessment

• Coughing or choking while drinking water (observe patient drinking 3 oz of water) 1, 2
• Wet or gurgling voice quality after swallowing 1, 2, 3
• Dysarthria or dysphonia 1
• Weak voluntary cough 1
• Drooling or poor secretion management requiring frequent oral/pharyngeal suctioning 1
• Nasal regurgitation after swallowing 1

Step 2: Ensure Patient Is Safe for Evaluation

Do NOT proceed with swallow testing if the patient has: 1, 2, 3

• Lethargy or reduced level of consciousness
• Absent swallow response on command
• Respiratory rate >35 breaths/minute
• Inability to manage oral secretions
• Delirium

These patients are at extremely high risk for aspiration and should not be fed orally until their condition improves. 1

Step 3: Order the Appropriate Swallow Evaluation

Initial Clinical Evaluation by SLP

The SLP performs a bedside clinical swallow evaluation that includes: 2, 3

• Medical history review
• Cranial nerve examination
• Assessment of lip closure and saliva pooling
• Observation of swallowing with various consistencies

Important caveat: Bedside evaluation alone has 84-88% sensitivity but cannot reliably detect silent aspiration, which occurs in up to 55% of aspirating patients. 3, 4 Therefore, instrumental assessment is essential.

Instrumental Assessment (Required for Treatment Planning)

Order VSE (videofluoroscopic swallow evaluation) or FEES (fiberoptic endoscopic evaluation of swallowing) to: 1, 2, 5

• Directly visualize aspiration and penetration
• Identify which therapeutic techniques eliminate aspiration
• Detect silent aspiration (aspiration without cough reflex)
• Guide diet modifications and compensatory strategies

VSE is the gold standard and provides motion picture radiography of swallowing structures with barium-mixed food/liquid in lateral and anterior-posterior positions. 1 FEES can be performed at bedside and provides direct visualization of pharyngeal and laryngeal anatomy before and after swallowing. 1, 6, 5

The ACCP guidelines emphasize that instrumental assessment is not just diagnostic but therapeutic—it determines which specific interventions will prevent aspiration during oral feeding. 1 Implementation of SLP screening and evaluation programs has resulted in dramatic reductions in aspiration pneumonia rates. 1, 2

Step 4: Practical Ordering Process

Write the referral/order as: "Consult Speech-Language Pathology for dysphagia evaluation including clinical swallow assessment and instrumental testing (VSE or FEES) to determine aspiration risk and guide treatment recommendations." 1, 2

Include relevant clinical information: 1

• Underlying diagnosis (stroke, neurological disease, etc.)
• Specific symptoms (coughing with meals, weight loss, etc.)
• Current diet status and feeding route
• Recent chest imaging results if available

Common Pitfalls to Avoid

• Do not rely on bedside assessment alone to determine treatment—instrumental testing is required to identify silent aspiration and guide therapy. 1, 3
• Do not delay referral in high-risk populations (stroke, Parkinson disease, elderly with multiple comorbidities)—early detection prevents aspiration pneumonia. 2, 3
• Do not order a "modified barium swallow" for esophageal dysphagia—this test only evaluates oropharyngeal function, not esophageal anatomy. 1
• Older adults have higher rates of silent aspiration, making clinical evaluation less reliable in this population. 3