Yale Swallow Protocol

Step 1: Exclusion Criteria

____ Yale Swallow Protocol Deferred due to NO concern for aspiration risk.

Any YES answer to the following risk factors will also defer administration to protocol:

Yes    No

____    ____ Unable to remain alert for testing.

____    ____ Eating a modified diet (thickened liquids) due to pre-existing dysphagia.

____    ____ Existing enteral tube feeding via stomach or nose.

____    ____ Head-of-bed restrictions <30°.

____    ____ Tracheostomy tube present.

____    ____ Nil per os by physician order.

If the patient’s clinical status changes resulting in a new risk for aspiration, the protocol must be readministered before oral alimentation or medications are ordered.

Step 2: Administration Instructions

If patient is deemed an aspiration risk and all exclusion criteria in Step 1 are checked “NO,” proceed with protocol:

  •       Brief Cognitive Screen:

            What is your name?

           Where are you right now?

            What year is it?

  •      Oral-Mechanism Examination

            Labial closure

            Lingual range of motion

            Facial symmetry (smile/pucker)

  •      Perform 3-ounce water swallow challenge:

            Sit patient upright at 80-90° (or as high as tolerated >30°).

            Ask patient to drink the entire 3 ounces (90cc) of water from a cup or with a straw, in sequential swallows, and slow and steady but without stopping. (Note: Cup or straw can be held by clinician or patient.)  Assess patient for interrupted drinking and coughing or choking during or immediately after completion of drinking.

Note: Information from the brief cognitive screen and oral mechanism examination provide information on odds of aspiration risk with the 3-ounce water swallow challenge and should not be used as exclusionary criteria for screening.

Step 3: Pass/Fail Criteria

Results and Recommendations:

_____  PASS:  Complete and uninterrupted drinking of all 3 ounces of water without overt signs of aspiration, i.e., coughing or choking, either during or immediately after completion.

  •       If patient passes, collaborate with MD/PA/LIP to order appropriate oral diet. If dentate, order a soft solid consistency or

regular consistency diet.  If edentulous, order a liquid and puree diet.

_____  FAIL:  Inability to drink the entire 3 ounces in sequential swallows due to stopping/starting or patient exhibits overt signs of aspiration, i.e., coughing or choking, either during or immediately after completion.

  • If patient fails, keep nil per os (including medications) and discuss with the MD/PA/LIP the need for an objective

swallowing evaluation by speech-language pathologist.

  •       Readminister the protocol in 24 h if patient shows clinical improvement.

(Taken from: Suiter, D.M., Sloggy, J., & Leder, S.B. (2014). Validation of the Yale Swallow Protocol: A prospective double-blinded videofluoroscopic study. Dysphagia, 29, 199-203.)

 Validation Information

1. Three-ounce water swallow test validation first reported on 44 stroke patients by DePippo et al. (1992). Failure required referral for objective (VFSS) dysphagia test.

2. A revised 3-ounce water swallow challenge administered to 3,000 hospitalized patients with 14 distinct diagnoses and referenced with FEES as the standard correctly predicted aspiration 96.5% of the time, with a negative predictive value of 97.9%, and a false negative rate of ≤2.0%. (Suiter, D.B. & Leder, S.B. [2008]. Clinical utility of the 3-ounce water swallow test. Dysphagia, 23, 244-250.)

3. Validation study of Yale Swallow Protocol was reported using 25 subjects with categorical diagnoses of esophageal surgery, head & neck cancer, neurosurgery, medical issues, or neurological (CAV, MS, TBI) and using VFSS as the standard reference.  Seven participants passed and 18 failed the 3-ounce swallow challenge.  Of the 18 who failed, 14 aspirated on VFSS (true positives) and 4 did not aspirate on VFSS (false positives). Sensitivity for the protocol = 100%, specificity = 64%, positive predictive value = 78%, and negative predictive value = 100%. All participants who passed the protocol, i.e., deemed to have no aspiration risk, also did not aspirate during VFSS. (Suiter, D.M., Sloggy, J., & Leder, S.B. [2014). Validation of the Yale Swallow Protocol: A prospective double-blinded videofluoroscopic study. Dysphagia, 29, 199-203.)

4. A validation study of the use of the Yale Swallow Protocol (YSP) compared to FEES was reported by Ward et al., (2020).  In a prospective, double-blind multi-rater study, a referred sample of 240 volunteers with varying medical were administered the YSP withing 30 minutes of receiving a FEES study.  Results of the YSP were blinded to the FEES clinicians.  Later, the YSP and FEES results were compared. The sensitivity of the Yale Swallow Protocol was 95.4% in determining the presence of aspiration or no aspiration, a specificity of 66.9% and a positive predictive value of 77.6% and a negative predictive value of 92.4%.

References:

DePippo, K. L., Holas, M. A., & Reding, M. J. (1992). Validation of the 3-oz water swallow test for aspiration following stroke. Archives of neurology, 49(12), 1259-1261.

Garand, K. L., Suiter, D. M., Reyes, S., York, J. D., & Chen, I. H. A. (2021). Aspiration Screening in Motor Neuron Disease: Preliminary Results From Utilization of the Yale Swallow Protocol. American Journal of Speech-Language Pathology, 30(6), 2693-2699.

Suiter, D. M., & Leder, S. B. (2008). Clinical utility of the 3-ounce water swallow test. Dysphagia, 23, 244-250.

Suiter, D. M., Sloggy, J., & Leder, S. B. (2014). Validation of the Yale Swallow Protocol: a prospective double-blinded videofluoroscopic study. Dysphagia, 29, 199-203.

Ward, M., Skelley-Ashford, M., Brown, K., Ashford, J., & Suiter, D. (2020). Validation of the Yale swallow protocol in post-acute care: a prospective, double-blind, multi-rater study. American Journal of Speech-Language Pathology, 29(4), 1937-1943.

Warner, H. L., Suiter, D. M., Nystrom, K. V., Poskus, K., & Leder, S. B. (2014). Comparing accuracy of the Yale swallow protocol when administered by registered nurses and speech‐language pathologists. Journal of clinical nursing, 23(13-14), 1908-1915.