Swallowing Assessment in Stroke Patients
All stroke patients must undergo formal dysphagia screening using a validated multi-item screening tool within 4 hours of hospital arrival and before any oral intake of food, fluid, or medication. 1
Timing of Initial Screening
- Screen within 4 hours of hospital admission as the optimal timeframe, though screening within 24 hours is acceptable if earlier assessment is not feasible 1
- Never allow any oral intake (including medications) until screening confirms safe swallowing 1
- Approximately 50% of aspirations are silent and go unrecognized until pulmonary complications develop, making early screening critical 2, 3
Who Should Perform the Screening
- Trained healthcare professionals including nurses, speech-language pathologists, or other appropriately trained staff can perform initial screening 1
- Nurses are specifically recognized as appropriate screeners for initial dysphagia assessment 1
Recommended Screening Tools
Use a multi-item dysphagia screening protocol rather than single-item tests for superior accuracy 1. The best-validated options include:
Primary Screening Tools:
Gugging Swallowing Screen (GUSS): Demonstrates 97% sensitivity and 67% specificity, with 100% negative predictive value 1, 4
- Provides graded assessment starting with non-fluid textures before progressing to liquids
- Reduces aspiration risk during testing itself 4
Toronto Bedside Swallowing Screening Test (TOR-BSST): Shows 91.3% sensitivity with 93.3% negative predictive value for water-only swallowing 1
Water Swallow Test combined with lingual motor testing: The 10-teaspoon water intake test plus tongue movement assessment provides better accuracy than single-item protocols 1
Alternative Validated Tools:
- Provocative Swallow Test: 100% sensitivity and 83.8% specificity at first step 1
- Volume Viscosity Swallow Test (V-VST): Recommended as accurate for identifying dysphagia 1
What to Do After Screening
If Screening is Normal:
- Patient may resume oral intake with appropriate diet consistency 1
- Continue monitoring for signs of dysphagia 5
If Screening is Abnormal:
- Keep patient NPO (nothing by mouth) 5, 2
- Refer to speech-language pathologist within 24 hours for comprehensive clinical swallowing evaluation 1, 5, 2
- Specialist assessment should occur within 24-72 hours maximum 1
Comprehensive Assessment for Failed Screening
Patients who fail initial screening require both clinical bedside evaluation AND instrumental assessment 1, 5:
Clinical Bedside Evaluation:
- Provides diagnostic information about swallow mechanism 1
- Cannot predict presence or absence of aspiration alone - bedside evaluation has limited sensitivity for detecting silent aspiration 1, 3
- Should assess multiple consistencies and compensatory strategies 5
Instrumental Assessment (Required):
Choose either Videofluoroscopic Swallow Study (VFSS) or Fiberoptic Endoscopic Evaluation of Swallowing (FEES) 1:
- FEES is preferentially recommended over VFSS when available 1
- Instrumental evaluation is mandatory for patients suspected of aspiration to verify presence/absence and determine physiological reasons for dysphagia 1, 5
- Should be performed within 48 hours for high-risk patients 2
- Both methods are equally valid; choice depends on local availability 1
Critical Pitfalls to Avoid
- Never assume swallowing is safe based on lesion location alone - both cortical and brainstem strokes cause dysphagia 2
- Never rely on bedside assessment alone - it misses silent aspiration in approximately 50% of cases 2, 3
- Never delay screening - dysphagia increases aspiration pneumonia risk 7-fold and is an independent predictor of mortality 2, 3
- Do not use single-item screening tests - multi-item protocols are significantly more accurate 1