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.