CLINICAL ASSESSMENT
Physical Examination

Daniels and Huckabee (2008) recommend beginning the clinical evaluation by observing the patient briefly at rest, taking note of his or her general appearance, alertness, positioning and respiratory rate. The patient may be connected to a respirator and have either a mask over his or her mouth or a cannula in his or her nose (Groher and Crary, 2010). It may be wise to liaise with a nurse as some clinicians prefer to partially wean the patient from ventilator support before attempting oral feeding (Groher and Crary, 2010). Observations of the patient’s breathing are significant because they can be suggestive of an impaired swallow. Rapid breathing, for example more than 40 cycles per minute, may leave the patient insufficient time for airway closure during the swallow (Groher and Crary, 2010).
Prior to beginning the physical inspection, the SLT should ensure that they have explained to the patient and family members what he or she is going to do. It would also be appropriate to ask for permission to touch the patient, as in Maori culture in particular, it can be considered offensive to touch a person's head (Manna, Wurtzburg, Huckabee & Blake, 2003).
Observations of the patient’s salivation and any pooling can be indicative of facial nerve weakness (Groher and Crary, 2010). Inadequate hydration can be demonstrated by dryness and flaking on the tongue’s surface (Daniels and Huckabee, 2008). The clinician should also become aware of the patient’s dentition, as dental decay and the need for oral care both contribute to the development of aspiration pneumonia (Daniels and Huckabee, 2008). As an inpatient, if the patient wears dentures, they are likely to be available but not inserted (Daniels and Huckabee, 2008).
Cranial Nerve Examination

By asking the patient to perform various motor and sensory acts, the clinician may gather valuable information about cranial nerve function (Daniels and Huckabee, 2008). Furthermore, its methodical execution and analysis allows the clinician to use a problem-solving approach to infer the pathophysiology of the patient’s impaired swallow. Daniels and Huckabee (2008) remind clinicians that the findings of the cranial nerve examination should be analysed with the patient’s overall status in mind. As a patient with bilateral hemispheric stroke may be acutely ill, it can be expected that they may have some difficulty carrying out the tasks in the cranial nerve examination and therefore should not be automatically linked to a neurological deficit (Daniels and Huckabee, 2008). Moreover, Daniels and Huckabee (2008) state that the reevaluation of acute stroke patients at a later time may provide significantly different results due to an improvement in their overall status.
For a brief description of the physiological signs of cranial nerve function, click here.

Evaluation of the Gag reflex
The elicitation of a gag reflex as part of the cranial nerve exam has been included in the link above, but it is controversial. The New Zealand guideline for management of stroke (Stroke Foundation NZ Inc., 2003) states that “the testing of the gag reflex is not a valid test of swallowing”. However, there is research which suggests that the identification of patients who are likely to aspirate is best established through clinical indicators including an abnormal gag reflex (Horner et al., 1990) (Daniels, Ballo, Mahoney and Foundas, 2000). Daniels and Huckabee (2008) state that the gag reflex can be seen as a “last chance” for airway protection and that while its absence holds little clinical value, its presence can indicate the sensory integrity of the glossopharyngeal fibres.
Please see this record sheet from the American Journal of Speech Language Pathology (1997) which illustrates some of the areas covered by the examination of oral, motor, laryngeal and pharyngeal functioning as part of the clinical assessment.


Evaluation of Oral Mechanism and Oral Intake

The assessment of oral intake allows the SLT to directly observe the oral phase of swallowing, as well as to make inferences as to the integrity of the subsequent stages of the swallow (Daniels and Huckabee, 2008). Observations from this portion of the clinical assessment should be integrated with the information obtained from the cranial nerve examination so that the SLT can develop a specific understanding of the patient’s swallow (Daniels and Huckabee, 2008). Establishing respect for the client and making an effort to make them feel comfortable is extremely important. For some people, being observed eating can be embarrassing and as a result may influence their swallowing process (Manna et al., 2003). Therefore, an understanding of a patient's cultural background and an overall awareness of the patient's feelings are invaluable.
A number of protocols are possible for assessing oral intake and Daniels and Huckabee (2008) state that while none is more appropriate than another, a skilled clinician will tailor the selected protocol to suit each patient. One way in which this can be done is through the selection of consistencies to be ingested by the patient. The patient with bilateral hemispheric stroke is most likely to be nil-by-mouth at this point, therefore the clinician should aim to be measured and careful when moving between consistencies (Daniels and Huckabee, 2008).
One protocol which is upheld in New Zealand is the Gugging Swallowing Screen (GUSS) (Ministry of Health, 2010). The GUSS is a bedside dysphagia screen designed to be executed by SLTs or stroke nurses for acute stroke patients (Trapl et al., 2007). Research has shown that it is a quick and reliable method of identifying dysphagia and aspiration risk in stroke patients (Trapl et al., 2007). The GUSS is an appropriate test to use with a patient with bilateral hemispheric stroke, as one of its main aims is to keep the risk of aspiration during the test at a minimum (Trapl et al., 2007). Moreover, the GUSS allows the clinician to observe oral intake of liquid and non-liquid textures where appropriate, which is consistent with research that recommends a variety of bolus types (Daniels 2009).
The clinician should refer to their observations of the patient’s overall status and in particular their level of neglect, as the patient’s inability to perceive the clinician, the spoon and the textures presented to them will greatly influence the test (Trapl et al., 2007). To perform the GUSS, the clinician should ensure that the patient is seated upright at at least 60 degrees. The clinician should also ensure the patient is wearing their dentures if normally worn (Daniels and Huckabee, 2008).
There are four criteria for evaluating the test swallows (Trapl et al., 2007):
  • deglutition (determined by laryngeal elevation);
  • voice change (particularly a wet or gurgly voice quality post swallow);
  • involuntary cough; and
  • drooling.

The procedure of the GUSS begins with the patient swallowing their own saliva (Trapl et al., 2007). If a patient is unable to produce enough saliva due to a dry mouth, the clinician should administer a saliva spray as a substitute (Trapl et al., 2007). The patient must perform a successful saliva swallow in order to move on to the next part of the test.
The second part of the GUSS encompasses three subtests, beginning with semisolid, then liquid, and ending with solid textures (Trapl et al., 2007). In the first subtest, the clinician administers up to six teaspoons of level 900 (formerly ‘pudding’) fluid to the patient (Trapl et al., 2007). If any one of the four aspiration signs appear, the test should be aborted. The decision to begin the direct testing with a semisolid texture is reflective of observations of stroke patients who are more adept at swallowing semisolid textures than liquids (Trapl et al., 2007). By beginning with a consistency that the patient is more likely to succeed with, the test minimises the likelihood of aspiration during the test, as well as identifying patients who can tolerate semisolid consistencies but not liquids (Trapl et al., 2007).
The second subtest involves administering increasing amounts of distilled water to the patient. The final task in this subtest is for the patient to consume 50ml of water as fast as possible (Trapl et al., 2007).
In the final subtest, the patient is given a small piece of dry bread (Trapl et al., 2007). This is repeated five times. A time limit of ten seconds per bolus is set as a parameter for scoring this test. If the patient can complete this final task, it will also allow the clinician to observe the patient’s ability to chew (Trapl et al., 2007).
Further information about administering, scoring and analysing the GUSS can be found here:



Adjuncts to the Clinical Assessment

Pulse Oximetry
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Sourced from: http://www.daviddarling.info/encyclopedia/P/pulse_oximetry.html
The authors of the GUSS acknowledge recent research which recommends the combination of oxygen saturation measurement with bedside assessments. Oxygen saturation is measured via a sensor which can be attached to the patient's finger or ear lobe. This sensor gauges the patient's ratio of oxygen to arterial blood flow.

The patient is said to be at risk of dysphagia if the ratio falls below 90% (Groher and Crary, 2010). Smith, Lee, O'Neil and Connolly (2000) found pulse oximetry provided a highly sensitive measure for detecting aspiration and laryngeal penetration during deglutition, resulting in increased accuracy in the clinical assessment. However, there is some disagreement in the literature about the efficacy of pulse oximetry in detecting aspiration. Despite the lack of consensus concerning the role of pulse oximetry in identifying episodes of aspiration, it is believed that it can provide valid and relevant information about the client's respiration (Cichero, 2006). By gaining a more profound understanding of the client's respiration, the clinician can make observations as to whether the patient has sufficient respiratory support to tolerate consumption (Daniels and Huckabee, 2008). Therefore, while pulse oximetry may not be a reliable method of determining aspiration, it can give further information about the likelihood of dysphagia in general (Cichero, 2006).
Cervical Auscultation
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Using a stethoscope, the clinician can use the sounds of swallowing and breathing to infer swallowing impairment. The presence of certain sound qualities, such as wetness or a "flushing sound" prior to the initiation of a swallow, are associated with aspiration (Daniels and Huckabee, 2008). Other indicators of dysphagia are deviations from the normal swallowing process, which is characterised by a brief period of apnoea followed by clear exhalation post swallow (Daniels and Huckabee, 2008). While this method can provide valuable insights into the patient's swallow, a specific knowledge of the sounds is required in order to be able to draw conclusions (Cichero, 2006). Furthermore, even when combined with other clinical assessment techniques, the pathophysiology of the patient's dysphagia cannot be accurately determined.