The Clinical Swallow Evaluation: More than Applesauce and Graham Crackers

Understanding the intricacies of a clinical swallow evaluation is crucial for accurately assessing dysphagia and ensuring patient safety. This evaluation is not just a routine procedure; it is a comprehensive assessment that provides critical information about a patient’s ability to safely consume food and liquids. Dysphagia, or difficulty swallowing, can lead to severe complications such as aspiration pneumonia, malnutrition, and dehydration if not properly managed. Therefore, this evaluation plays a vital role in preventing these outcomes and maintaining a patient’s overall health.

In this article, we’ll explore the importance of a thorough clinical swallow evaluation, its components, and how it goes beyond a simple test involving applesauce and graham crackers.

A Personal Perspective

Several years ago, I had an experience that substantially shaped my view of the clinical swallow evaluation. I’d been called to complete a swallow evaluation for a woman before her discharge that day. Her physician wanted her swallow function reviewed, and she and her son were waiting on my arrival to begin the discharge process. The son was understandably frustrated by the wait, not quite understanding the value of a detailed swallow assessment. This encounter made me realize just how often the complexity and necessity of these evaluations are misunderstood.

Evaluating Swallow Function

I arrived to find a pleasant elderly woman, who had been admitted several days earlier with renal failure and respiratory difficulties, and her (perhaps understandably) irritated son.

Her evaluation went as follows:

• She reported no difficulty swallowing and denied any signs of dysphagia, such as coughing or vocal changes.
• Her oral mechanism examination was unremarkable, prompting me to quickly proceed to swallow trials.
• She consumed the applesauce and crackers I provided and managed serial water swallows with ease—all while engaging in a lively conversation about her day!

Patient and Family Member Perceptions of Swallow Evaluations

From a clinical standpoint, it was clear that her swallow function was normal. However, as I prepared to report my findings to her physician and expedite her discharge, her son voiced his frustration: “Are you kidding me? We’ve been waiting almost an hour for applesauce and graham crackers? I could have given her applesauce and graham crackers!”

Initially, I felt the urge to defend my practice. But then, I realized that I needed to see the clinical swallow evaluation through his perspective. To him, a therapist had entered his mother’s room, engaged in casual conversation, and offered a snack.

Why Patients Don’t Always See the Value of Clinical Swallow Evaluations

This experience underscores both the challenge and the strength of the clinical swallow evaluation. As clinicians, we aim to simulate real-life eating scenarios, making the “evaluation” less visible to family members, staff, and even the patient. Swallowing is a complex, variable process, and the parameters of the swallow response—tongue propulsion, tongue base retraction, pharyngeal stripping, hyolaryngeal excursion, upper esophageal sphincter opening—differ based on utensil used, bolus size and viscosity, and various patient-specific characteristics.

The Complexity Behind Clinical Swallow Evaluations

To better understand the importance of a swallow evaluation, it is essential to delve into its complexity. Swallowing involves a highly coordinated sequence of events that engage multiple muscle groups and neurological pathways. A thorough assessment must consider:

• The consistency and volume of the bolus
• The patient’s cognitive state and ability to follow instructions
• Anatomical and physiological factors that could influence the safety and efficiency of the swallow

These factors underscore why a simple snack does not encompass the full scope of a clinical swallow evaluation. Instead, the assessment is a multi-faceted process that provides invaluable insights into the patient’s swallowing safety.

Staying Focused on Your Responsibilities

Our task is to accurately interpret our observations, identify aspiration risk factors, and evaluate them in the context of the patient’s medical history and current medical status. Aspiration is a serious concern, but it must be evaluated within the broader context of:

• The patient’s immune system function
• Nutritional status
• Overall degree of disability
• Respiratory function

A clinical swallow evaluation doesn’t require special equipment or technology, but it does require training, expertise, and a comprehensive understanding of each patient’s unique situation. Applesauce and graham crackers indeed!

Communicating the Value of Clinical Swallow Evaluations to Patients and Families

It’s important to bridge the gap in clinical practice and patient understanding. Educating patients and their families about the complexities involved in a clinical swallow evaluation can foster greater appreciation and cooperation. Simple explanations about why certain foods are chosen for the test or how the evaluation assesses specific swallowing mechanics can demystify the process and align expectations. This communication helps ensure that everyone understands the critical role these evaluations play in patient care.

Wrapping Up: The Essential Role of Clinical Swallow Evaluations