I’ve heard that I should do a “bedside” or check out the cranial nerves, can you show me how to do that?
(Asking for a friend.)
Download the pdf of the CSE tool for your friend here!
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Ok, so we’ve all heard “you need an instrumental” only about no less than 934,235,234 times now. Ok, I get it, I know I need to order an MBSS or a FEES, but which one do I need to order? And how do I justify to my administrator that I need one? (Not sure why you need instrumentals? Check out this post.) She said to just use my best clinical judgement, and I told her my patient is choking at meals, and she said sometimes old people do that and we don’t need an expensive test to know why.
Ok fine, I’ll just hang my head in shame and feel completely helpless that I honestly don’t know what to do with this guy.
Maybe I’ll just ask on Facebook to see if anyone has an idea of what I should do.
They said I should start with a bedside.
They said I should do a 3oz water test.
They said I should do a cranial nerve exam.
No one ever taught me how to do any of these.
“Can you show me how to do these? (Asking for a friend.)”
Sure, we can absolutely let your friend know what these mean.
And believe you me, I am always the first person up on my soapbox screaming and picketing that we need instrumentals, but there is some darn good info we can glean (my friends across the pond taught me that one 
from the CSE.
Wait, what’s a CSE? (Asking again for my friend.)
A CSE stands for a clinical swallow exam. It used to be called a bedside swallow exam, or BDSE, but CSE sounds much fancier, so that’s where we are. Actually, you can refer to McCullough, Wertz, Rosenbek, Dineen (1999), if you really want to read about the differentiation. Spoiler alert: It’s as clear as mud.
According to O’Horo (2015), “no bedside screening protocol has been shown to provide adequate predictive value for presence of aspiration. Several individual exam maneuvers demonstrated reasonable sensitivity, but reproducibility and consistency of these protocols was not established.”
Wait? So WTH is the point?
Some people in the past may have even touted that the CSE is purely a screen (author hangs head in guilt, but she has since learned to Swallow Her Pride.)
According to Daniels and Huckabee (2008),
The CSE is not a “screening” as connotations emerge of a cursory, minimalist assessment. Such was eloquently stated by Jay Rosenbek,”…it is critical that the CSE not be relegated to the status of screening tool. It is far too powerful.” (Rosenbeck, McCullough, & Wertz, 2004.)
Ok well I’ve seen some pretty powerLESS CSEs in my day, so I probably still haven’t convinced you of the point especially because a thorough CSE is so limited in its diagnostic ability.
But, continuing to quote Daniels and Huckabee (2008),
“Swallowing pathophysiology cannot be defined [on a CSE]; thus compensatory and rehabilitative strategies should not be recommended based on results of the CSE alone. However, the information gleaned from the CSE will clearly contribute to the ultimate diagnosis of the patient when paired with more specific information. The instrumental swallowing exam provides detailed info about biomechanics and ultimately pathophysiology. Data from this detailed assessment are integrated with clinical observation and history and are used to develop a comprehensive and efficacious management approach.”
Boom, that’s what we’re trying to get at.
It’s all part of the big puzzle. If only our patient’s were as cookie cutter as we try to make them where we can just throw the Betty Crocker cookbook at them and poof they can swallow.
But, alas. Not so fast. We NEED all of this information that we can get.
We NEED to be doing a strong case history and chart review.
We NEED to be doing a thorough cranial nerve exam.
We NEED to be doing a valid 3oz. water test [affiliate].
And we NEED to be doing a CSE!
Furthermore, I don’t really want to go down the rabbit hole of advocating for instrumentals (well because I already did that), but I do think when our DORs or administrators request more information on a patient to justify why they need an instrumental exam that may cost anywhere from a few hundred to a few thousand dollars, perhaps we can try to meet them in the middle. Should they pushback every single time? Absolutely not. But should we gather ALL of the pertinent information related to that patient? Yes, yes we should, and we can!
I know I sound like a broken record when I say that we NEED to assess the entire patient, but for the love of all things swallowing, let’s please assess the ENTIRE patient!
Ok, well I hear you Theresa, but what other parts of the patient do I need to know about?
Good question.
Patient factors include, most importantly, the patient’s goals of care, medical status, and patient’s ability to participate in an exam. These are all factors that must be considered when making recommendations for an instrumental exam.
An exam at the bedside that considers alertness, patient report of symptoms, cranial nerve function, and a 3 oz water swallow test all help us to answer our question.
The information regarding implications for cranial nerve deficits and Yale Swallow Protocol items (alertness and orientation) assist with planning for an instrumental exam, allowing us to formulate a hypothesis about potential deficits in swallowing physiology.
This tool also includes useful portions for chart review notes and recommendations, as well as a mini head and neck cancer screen.
Now, since we do not have a “standard” clinical swallowing exam, this tool was created to unify several elements of an evidence-based bedside exam, and to answer the question “Does this patient have dysphagia?”
This tool was created by the wonderful Ashley Brasfield, (Ash Lee Bee on Facebook) out of collective desperation by members of my MedSLP Newbies group for some guidance with this task. Ashley has been working on this for quite some time, and I am beyond grateful to her for sharing it with all of our wonderful colleagues! She had it peer reviewed by several fellow clinicians and researchers in the field too, so if something doesn’t sit right with you, please hold your fire.
Use the template below to guide your clinical swallow exam. Please note that editing will be needed, depending on your patient and the circumstances.
Ready, Set, Aim:
Click the green box at the top to download the pdf of this chart!!
If this entire post and chart are completely greek to you, or if you would just like some additional support while trying to stay afloat on dysphagia island, please consider joining us for the Medical SLP Collective.
References:
Daniels, S. K., & Huckabee, M. L. (2008). Dysphagia following stroke. San Diego: Plural Pub.
McCullough GH, Wertz RT, Rosenbek JC, Dineen, C., (1999). Clinicians’ Preferences and Practices in Conducting Clinical/Bedside and Videofluoroscopic Swallowing Examinations in an Adult, Neurogenic Population., American Journal of Speech-Language Pathology • Vol. 8 • 149–163.
O’Horo, J., Rogus-Pulia, N., Garcia-Arguello, L, Robbins, J, Safdar, N. (2015) Bedside Diagnosis of Dysphagia: A Systematic Review. J Hosp Med; 10(4): 256–265.
Rosenbek JC, McCullough GH, Wertz RT. (2004). Is the information about a test important? Applying the methods of evidence-based medicine to the clinical examination of swallowing. J Commun Disord. Sep-Oct;37(5):437-50.
If this entire post is completely greek to you, or if you would just like some additional support while trying to stay afloat on dysphagia island, please consider joining us for the Medical SLP Collective. We provide brand new weekly resources in the form of handouts and videos, a panel of experts to answer ALL of your Medical SLP questions (anonymously, and not limited to dysphagia) and monthly webinars for ASHA CEUs.