Dysphagia General

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Position
Paper
Dysphagia: General
Copyright The Speech Pathology Association of Australia Limited 2004
Disclaimer: To the best of the Speech Pathology Association of Australia Limiteds (the
Association) knowledge, this information is valid at the time of publication. The Association
makes no warranty or representation in relation to the content or accuracy of the material in this
publication. The Association expressly disclaims any and all liability (including liability for
negligence) in respect of the use of the information provided. The Association recommends you
seek independent professional advice prior to making any decision involving matters outlined in
this publication.
The Speech Pathology Association of Australia Limited

ABN 17 008 393 440
Speech Pathology Australia
Contents
Speech Pathology Australia Position Statement ..................................................................... 1
1. History of the Dysphagia Position Paper.......................................................................... 2
2. Definitions ......................................................................................................................... 2
2.1 Dysphagia ................................................................................................................. 2
2.2 Service/Service Providers ......................................................................................... 2
3. Client Groups and Disorders ............................................................................................ 2
4. Changes and Trends......................................................................................................... 4
5. Client Services .................................................................................................................. 4
5.1 Service Delivery......................................................................................................... 4
5.2 Models of care .......................................................................................................... 4
6. Referral.............................................................................................................................. 5
6.1 Sources of Referral ................................................................................................... 5
6.2 Methods of Referral .................................................................................................. 5
6.3 Reasons for Referral ................................................................................................. 5
6.4 Information Required at Time of Referral.................................................................. 5
6.5 Prioritisation .............................................................................................................. 6
6.6 Urgent Referrals ........................................................................................................ 6
7. Team Work........................................................................................................................ 7
8. Assessment, Diagnosis and Management ....................................................................... 8
8.1 Background History .................................................................................................. 8
8.2 General Observation ................................................................................................. 9
8.3 Communication Status............................................................................................ 10
8.4 Clinical Oropharyngeal Assessment ....................................................................... 10
8.5 Suitability for Oral Trial ............................................................................................ 10
8.6 Oral Trial/Bedside Examination/Mealtime Observation.......................................... 11
8.7 Referral for Instrumental assessment (as appropriate)........................................... 11
8.8 Overall Impression .................................................................................................. 12
8.9 Diagnosis................................................................................................................. 12
8.10 Management Plan ................................................................................................... 12
9. Treatment........................................................................................................................ 13
9.1 Oral phase disorders............................................................................................... 15
9.2 Velopharyngeal disorders ....................................................................................... 15
9.3 Oropharyngeal transit disorders ............................................................................. 16
9.4 Pharyngeal disorders .............................................................................................. 16
9.5 Cricopharyngeal disorders...................................................................................... 17
9.6 Penetration + Aspiration ......................................................................................... 17
10. Documentation ............................................................................................................... 17
10.1 Timelines ................................................................................................................. 18
10.2 Standards ................................................................................................................ 18
10.3 Reporting requirements .......................................................................................... 18
10.4 Discharge and Resolution Planning ........................................................................ 19
10.5 Confidentiality ......................................................................................................... 19
11. Education and Counselling ............................................................................................. 19
11.1 At Referral ............................................................................................................... 19
11.2 After Clinical Assessment ....................................................................................... 19
11.3 Prior to Discharge ................................................................................................... 20
11.4 Client/Carer Education............................................................................................ 20
Dysphagia: General Position Paper

Copyright The Speech Pathology Association of Australia Ltd 2004
12. Services Management .................................................................................................... 20

12.1 Qualifications........................................................................................................... 20
12.1.1 Skills and Minimum Standards.......................................................... 20
12.2 Professional Development ...................................................................................... 20
12.3 Information Technology .......................................................................................... 21
12.4 Budgets ................................................................................................................... 21
12.5 Workplace Health and Safety Issues ...................................................................... 21
12.6 Physical Resources................................................................................................. 21
12.7 Continuous Quality Improvement ........................................................................... 21
12.7.1 Measuring Methods........................................................................... 21
12.8 Marketing and Public Relations .............................................................................. 22
13. Education ........................................................................................................................ 22
13.1 Clinical Education.................................................................................................... 22
13.2 Staff Training ........................................................................................................... 22
13.3 Research ................................................................................................................. 22
13.3.1 Funding.............................................................................................. 23
14. Legal Issues .................................................................................................................... 23
14.1 Code of Ethics......................................................................................................... 23
14.2 Knowledge and Skills.............................................................................................. 23
14.3 Speech Pathologists Responsibilities.................................................................... 23
14.4 Duty of Care ............................................................................................................ 23
14.5 Standard of Care..................................................................................................... 24
14.6 Proxy Intervention ................................................................................................. 24
14.7 Consent for Speech Pathologist Involvement ........................................................ 24
14.8 Indemnity Cover and Insurance .............................................................................. 24
14.9 Service Guidelines................................................................................................... 25
14.10 Summary............................................................................................................... 25
Appendices............................................................................................................................. 26
Appendix A: Glossary of Assessments of Dysphagia .................................................... 26
Appendix B: Acknowledgements ................................................................................... 29
References.............................................................................................................................. 30

ii
Speech Pathology Australia Position Statement
Speech pathologists have a pivotal role to play in the assessment and management of
dysphagia (swallowing disorders). The speech pathologist may act as clinician,
consultant, team manager, educator, and/or researcher. The extent of involvement
depends on the nature of the clinical setting and population.
Safety guidelines should be followed where they exist. For this reason clinicians should
be familiar with workplace occupational health and safety policies, relevant Position
Papers from Speech Pathology Australia and other relevant legislation and guidelines.
Speech pathologists should be aware of the medico-legal implications and the

responsibilities of working with clients who have dysphagia.
Speech pathologists should be familiar with and follow local workplace and government
policies and procedures where available.
Speech pathologists should have knowledge of the current Speech Pathology Australia
Code of Ethics (2000) and the Principles of Practice (2001) that states that decisionmaking in dysphagia should incorporate awareness of the ethical principles of
autonomy, non-maleficence, beneficence and justice.
Speech pathologists should work within their scope of practice. Where experience or
skills are limited appropriate advice, mentoring and peer support should be sought.
Consistent, full and accurate recording and documentation of all areas of client
assessment and management should occur.
Projects on feeding / swallowing / dysphagia should be incorporated into general

departmental Quality Assurance or Total Quality Management Procedures as
appropriate.
Speech pathologists should manage clients with dysphagia as part of a team where
possible to achieve the best possible outcomes.
This paper reflects available evidence, issues and current clinical practice as it presents
at this point in time.
This paper contains minimum standards of practice. It is a guideline for speech

pathologists assessing, treating and managing clients with dysphagia, not an exhaustive
examination of the topic.
This Position Paper should be reviewed every three years.

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1. History of the Dysphagia Position Paper

Work on the first Dysphagia Position Paper was commenced in 1991, as a result of an increasing
involvement in the field of dysphagia by Australian speech pathologists. The paper was released
in 1994, the same year the first Competency Based Occupational Standards (CBOS) for Speech
Pathologists were released. Both these papers established baseline competency skills for newly
graduated and experienced speech pathologists. Australian university speech pathology
programs undergo regular accreditation to demonstrate that graduates meet the basic
competencies established by Speech Pathology Australia.
2. Definitions
2.1 Dysphagia
Etymologically the term dysphagia is compounded from the Greek words dys = disordered
and phagein = to eat (Winstein, 1983), meaning a swallowing disorder.
Dysphagia is not a disease in itself but is a term that refers to a condition, a disorder or a
symptom that may be genetic, developmental, acquired, functional or iatrogenic in origin. It can
be caused by structural, physiological and /or neurological impairments affecting one or more
stages of swallowing, namely the preparatory, oral, pharyngeal, and/or oesophageal stages. This
may present as a difficulty with sucking, drinking, eating, controlling saliva, protecting the airway
or swallowing. As a consequence dysphagia may lead to asphyxiation or pneumonia (Langmore,
Terpenning, Schork, Chen, Murray, Lopatin and Loesche 1998; Martin, 1994), or failure to meet
an individuals nutrition, hydration (Davalos, Ricart, Gonzalez-Huix, Soler, Marrugat, Molins, Suner
and Genis (1996); Langmore et al 1998; Martin, 1994) and social needs (Ekberg, Hamdy, Woisard,
Wuttge-Hannig & Ortega, 2002) as well as impacting on development of oral and communication
skills (Morris, 1985).
2. 2 Service/Service Providers
The term service or service provider refers to the person or organisation that is providing a
service to an individual. It incorporates all speech pathologists, including those who are
employed by organisations such as state departments of health, community service, and
education and training, non-government agencies, universities and speech pathologists in private
practice.
3. Client Groups and Disorders

Reports of dysphagia are common, especially among people with a disability and those of
increasing age. The incidence of dysphagia in adults older than 50 years vary between 7 to 44%
although this number may be artificially low as clients with this problem do not always seek
medical advice (Wilkinson & de Picciotto, 1999; Bloem, Lagaay, van BeeK, Haan, Roos and
Wintzen, 1990; Tibbling & Gustafsson, 1988).
Up to 25% of hospitalised clients and 30 to 60% of clients in nursing homes experience
swallowing problems (Lin, Wu, Chen , Wang and Chen, 2002); Lee, Sitoh, Lieu, Phua and
Chin,1999; Layne, Losinski, Zenner and Ament, 1989; Brin & Younger, 1988; Groher &
Bukatman, 1986; Siebens, Trupe, Siebens, Cook, Anshen Shanauer and Oster, 1986).
Precise prevalence figures are not available for childhood dysphagia due to a lack of consistent
diagnostic criteria and an absence of large-scale studies using standard classification schemes.
A review of studies conducted in the late 1980s and 1990s cites rates between 2 and 29% in
children without other developmental or health problems (Kedesdy & Budd, 2001) whereas
approximately 50% of individuals with cerebral palsy have dysphagia (Groher, 1991; Groher &
Bukatman, 1986).

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The disorders listed below illustrate the diversity of clients who may experience
dysphagia but are by no means exhaustive.
Neurological
Cerebrovascular disease
Traumatic brain injury
Brain tumour
Hypoxic brain injury
Cranial nerve abnormalities
Meningitis
Dementia
Parkinsons Disease
Motor Neurone Disease
Myasthenia Gravis
Huntingtons Disease
Multiple Sclerosis
Cerebral Palsy
Developmental disability including chromosomal and congenital syndromes
Post Polio Syndrome
Mechanical
Cancer
Tracheostomy
Cervical spine disease
Pharyngeal pouch, Zenker's diverticulum
Cricopharyngeal dysfunction
Pharyngeal and oesophageal webs
Oropharyngeal malformations; for example, cleft lip and palate
Craniofacial anomalies
Oesophageal disorders including gastro oesophageal reflux

Surgical
Head and neck surgery including oral surgery, partial and total laryngectomy,
thyroidectomy, neck dissections
Oesophagectomy
Vascular surgery; for example, carotid endarterectomy
Cervical spine surgery
Other surgery involving or gaining access through the head or neck

Trauma
Intubation injury
Trauma to the head and neck; for example, blow to the neck, object penetration
Inhalation burns
Metabolic
Diabetes
Thyroid dysfunction
Other
Radiation to the head and neck
Age related changes
Respiratory difficulty; for example, shortness of breath, Chronic Obstructive Airway

Disease (COAD)
Scleroderma
Decreased or fluctuating level of consciousness

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Medication; for example, sedatives, antipsychotics, chemotherapy

Psychiatric conditions
HIV/AIDS
4. Changes and Trends

The proportion of speech pathologists' time devoted to the assessment and
management of dysphagia has increased markedly over recent years. This has come
about through a number of factors:
Increased research on the incidence and diversity of client groups shown to be affected
by dysphagia;
Political factors, such as pressure to reduce length of hospital stay where intervention
by speech pathologists for dysphagia is perceived as reducing the incidence of
aspiration pneumonia and the time needed for alternative nutrition;
Philosophical shift, recognising the value of intervention in improving nutrition, health
and well-being;
Medical advances which have resulted in speech pathologists treating more medically
complicated patients who are often more acutely ill and therefore more likely to be
dysphagic;
Recognition by health professionals of the role of the speech pathologist in the
management of dysphagia in neonates;
Improvement of and access to technology available for assessment and treatment;
The move to evidence based practice underpinning work practice;
The recognition that teams which include speech pathologists have better outcomes for
clients with dysphagia (Logemann, 1988).
5. Client Services
5. 1 Service Delivery
Speech pathologists assess and manage dysphagia in metropolitan, regional, rural and remote
settings.
They work with individuals across the lifespan and may be employed in hospitals or other health
services, disability services, community services, non-government agencies, education
authorities (Speech Pathology Services in Schools, 2002), residential facilities or private practice.
The speech pathology service provided will depend on the needs of the client, the location, the
policies of prioritisation and available resources.
5.2 Models of Care
Speech pathologists working with dysphagic clients may utilise a range of service delivery models
including:
Assessment, diagnosis, and management of dysphagia in both general and specialist

swallowing clinics
Consultation
Education of client, carer, health professional
Resource development and provision
A speech pathologists role need not be restricted to a single area. They may work concurrently
in:
Different service delivery models

Provision of services in a variety of facilities
Provision of student supervision

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Provision of service delivery may at times need to be re-evaluated in line with changing needs.
These may be influenced by changes in:
Policy at a Local, State/Territory or Federal government level

Philosophy of the service provider
Availability of human and financial resources
6. Referral
6.1 Sources of Referral
Each facility should have a policy documenting from whom referrals can be accepted. Referral
sources may include, but are not restricted to:
Hospital medical staff

General practitioners
Nursing staff
Allied health professionals
Client/family/carers
Teachers
Blanket referral ie neurology ward
6.2 Methods of Referral

Referrals for dysphagia services may be received verbally (via pager/phone/in person), or in
writing. Each facility should determine the preferred method of referral and ensure all referring
agents are aware of how to refer to the speech pathology service.
6.3 Reasons for Referral
A client may be referred for an evaluation of swallowing function based on the presence of
symptoms of dysphagia or known risk factors. These include, but are not limited to, the following:
Oral-pharyngeal disturbances including reduced movement or sensation of oral

structures, weak or incoordinated suck, delayed swallow, weak cough or alterations in
respiratory status during oral intake
Neurological impairment: birth trauma, stroke, head injury, cervical spine injury, brain
injury, and progressive neurological disease
Respiratory conditions; for example, excessive oxygen desaturation during feeding,
COAD, chest infection, aspiration pneumonia
Diminished level of alertness
Poor oral condition; for example, gum disease
Presence of tracheostomy
Dysphonia post extubation
Oral-pharyngeal surgery
Presence of feeding tubes
Feeding dependency
Premature birth
Advanced age
Self report of difficulty swallowing
Anxiety/fear of swallowing
6.4 Information Required at Time of Referral
Name and role of the person making the referral

Consulting physician or general practitioner
Client identifying information (e.g. name, date of birth)
Gestational age (where applicable)

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Location of client (e.g. address, ward, contact details)

Reason for referral (see above)
Degree of urgency (to assist in prioritisation)
Medical diagnosis
Type of nutrition; for example, Nil By Mouth (NBM), Naso Gastric Tube (NGT)
Medication and method of administration
6.5 Prioritisation
Dysphagia has been implicated in the development of dehydration and malnutrition (Davalos et al
1996), chest infection and pneumonia (Langmore et al 1998; Martin, 1994). Early identification and
management is therefore critical in order to prevent or minimise such complications.
Services to clients with dysphagia should be provided in an effective, safe and timely manner.
The nature of dysphagia and its potentially serious consequences need to be reflected in
prioritisation of dysphagia services.
Prioritisation systems will vary depending upon the individual service and evidence regarding
best practice for that setting, the available resources and geographical location. Each service
should document its prioritisation process using clearly defined parameters. Prioritisation of new
referrals against the current caseload needs to be considered. Prioritisation policies should be in
accordance with the Code of Ethics (2000).
It is common practice for a benchmark to be set for response time to dysphagia referrals.
Reference to local policy and procedures and relevant national, state/territory guidelines should
be made.
6.6 Urgent Referrals
The definition of an urgent referral is multifactorial, and will depend on local policies and
procedures. Below are some of the client and clinical factors that should be considered when
determining urgency:
Acute versus chronic presentation (e.g. neonates, recent inability to tolerate oral
intake,critical care);
Medical condition (e.g. diagnosed/suspected aspiration pneumonia, documented
coughing, choking or gagging on oral intake or saliva);
Medical prognosis (e.g. palliative care) (N.B. In some cases it may be too early,
inappropriate or insufficient information may be available to provide a prognosis.);
Nutritional status (e.g. NBM, with no enteral nutrition, suspected dysphagia with
consequent malnutrition/significant weight loss/failure to thrive);
Mitigating medical factors (e.g. inability to swallow medication).
In settings where client intake/admission occurs out of regular working hours, consideration
should be given to after-hours management of dysphagia, such as in the evenings, on weekends,
or on public holidays. Services should have resources or contingency plans to meet urgent afterhours needs. This may include having in place procedures that determine the management of a
client who is admitted after hours with dysphagia. For example, clients at potential risk of
dysphagia may be kept Nil By Mouth overnight with hydration until seen by a speech pathologist,
or provision of an on-call speech pathologist on weekends or public holidays. Other team
members such as medical, nursing, and dietetics staff involved in the care of the client with
dysphagia need to be consulted in planning these procedures.
In a community/out-patient setting consideration should also be given to the availability of urgent
appointment slots.
Documentation of the prioritisation process as part of a policies and procedures manual enables
the speech pathology service to provide clients and referring agencies with a rationale for
caseload management decisions.

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7. Team Work
Clients should have access to a multidisciplinary team to ensure the provision of a holistic
service. This pertains not only to the evaluation of the swallowing problem and determination of
its aetiology, but also to its treatment and management (Logemann, 1994; Miller & Languor,
1994). The multidisciplinary team works in close cooperation with the client, their family and/or
significant others.
Multidisciplinary teams are cost-effective, and have been shown to improve clients weight and
caloric intake, reduce the risk of aspiration, have better outcomes and provide a source of
support for clients, and carers (Jones & Altschuler, 1987; Lucas & Rodgers 1998; Martens,
Cameron & Simonsen, 1990). In addition the team approach can increase staff awareness of
swallowing problems and their symptoms (Logemann, 1998).
Key team members on the dysphagia management team include:
Speech pathologists
Medical personnel - the medical team may include specialists from disciplines such as
otorhinolaryngology, gastroenterology, neurology, paediatrics, radiology, rehabilitation
medicine, respiratory medicine, general practice
Dentistry, orthodontics, dental hygienists
Nursing
Direct support workers/carers
Client/patient
Family members
Physiotherapists
Occupational therapists
Social workers
Dietitians
Pharmacist
Other team members may include, but are not limited to, radiographers, teachers,
psychologists and social workers.

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8. Assessment, diagnosis and management

Assessment, Diagnosis and Management Flow Chart
(The headings and their application in this flow chart are expanded over the page)
Background history
Immediate observations
Communication status
Clinical oropharyngeal assessment
Suitable for oral trials
Unsuitable for oral trials
Referral for instrumental assessment (as appropriate)
Overall impression / Diagnosis
Management plan
The speech pathologist is essential to the assessment and management of the client, including
screening, clinical or bedside assessment, instrumental assessment and swallowing treatment.
Dysphagia management is a seamless process that may begin in the acute phase of medical
intervention and proceeds as the client advances through the continuum of care. Services can be
introduced at any stage of the continuum and
will terminate when the client is either nutritionally stable or able to eat at his or her highest
functional level with or without swallowing compensations (Sonies, 2000, p.101).
Information in all sections below should be applied as pertaining to the workplace. That is,
prenatal history will be relevant for those assessing paediatric clients but not for those in aged
care; similarly jaw function will be evaluated using different parameters depending on whether the
clinician is assessing chewing of solids or sucking from a bottle.
When assessing the client, ensure that any aids for communication, vision and hearing are
available for the examination. Clinicians must comply with occupational health and safety
requirements; for example, gloves, eye protection, nose mask, hand washing, current
immunisation (e.g. Hepatitis B).
Even when a client is non-compliant with the assessment, or aspects thereof, it should be
documented that assessment of these areas was attempted.
See the glossary for further information and references for the following techniques.
8. 1 Background History
Basic Competence implies the basic knowledge that would be expected from a grade one/new
graduate speech pathologist. Advanced Competence implies a greater knowledge and
understanding of how additional physical, mental and physiological factors can impact on
swallowing. These skills are expected of clinicians who operate specialist clinics, have greater
experience and or are at higher grades. These competencies should be supported by evidencebased practise and supporting research where available.

Page 8
Basic Competence
Relevant background history

(prenatal/birth history, developmental
history including feeding, biographical,
cultural, religious, behavioural, surgical)
Knowledge of previous speech pathology
involvement including the relevant reports
where available
Previous swallowing or related difficulties
Medical history/diagnosis
Nutritional, respiratory and cognitive
function)
Premorbid nutritional status, including
method of intake
Current form and method of nutrition
(including breast, bottle, tube feeding for
infants, texture, technique and
precautions)
Vision and hearing
Education/vocation
Prognosis
Clients/carers goals
Communicable diseases
Relevant medications and their method of
administration (e.g. liquid/tablets etc.)
Related issues such as gastrooesophageal disorders
History of current swallowing difficulties
Advanced Competence
Potential side effects of medications on

swallowing, appetite, salivary function,
alertness and nutrient absorption
Review relevant x-rays/x-ray reports

when applicable
8. 2 General Observation
Basic Competence
Level of alertness/responsiveness
Posture/position
Level of activity/mobility
Presence of nasogastric tube,
tracheostomy tube (size, type),
gastrostomy tube, intravenous line,
central line
Implications of the presence of a
nasogastric tube or tracheostomy tube on
swallowing function
Ability to be positioned in optimal feeding
position and number of staff required to
obtain same
Presence of primitive and/or abnormal
reflex patterns
Respiratory function at rest and during
speech where applicable
Spontaneous swallow frequency
Presence of oral dyspraxia
Advanced Competence

Oxygen requirements/oxygen saturation

levels if available
Knowledge of causes and implications of
variations in body temperature regulation
Hand to mouth coordination
Mouthing behaviours
Shortness of breath (SOB)/respiratory
rate for all clients with a respiratory
diagnosis
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8.3 Communication Status

(Assessment of communication status may not be applicable in infants or in some adults.)
Basic Competence
Orientation
Comprehension
Hearing
Speech/vocalisation/intelligibility
Language
Voice quality
Obtain interpreter if required (refer to
workplace policy and procedures)
Advanced Competence
Assessment of need for augmentative
and alternative communication strategies
in the event of complex communication
needs
8.4 Clinical Oropharyngeal Assessment

Basic Competence
Inspection of face, oral cavity and

oropharynx
Comment on structure, symmetry,
sensation
Ensure oral cavity is cleared prior to
assessment
Oral tissue (colour/moisture/integrity)
Speech production and oral motor (praxis)
tasks
Cranial nerve assessment
Saliva management
Airway protection
Oral hygiene
Presence and condition of teeth
Advanced Competence
Visuoperceptual ability
Knowledge of the maturation of the
swallow
8.5 Suitability for Oral Trial

Basic Competence
Evaluate and comment on
Level of alertness
Airway protection
Positioning
Fatigue
Voice quality
Impact of the environmental setting

In addition
Familiarity with emergency procedures for

aspiration/choking
Ensure physiotherapist/nursing staff

available if required (e.g. tracheostomy
assessment)
Knowledge of the importance of

strategies for optimal positioning
Advanced Competence

Knowledge of the impact of spinal

deformity on lung and gastric function
Competency in the assessment and
management of tracheostomy.
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8.6 Oral Trial / Bedside Examination / Mealtime Observation

Basic Competence
Comment on
Mouth opening
Lip seal/spillage
Lip closure on spoon
Sucking ability
Jaw function
Tongue function/movement
Chewing efficiency
Oral control of bolus
Efficiency of oral transfer
Oral residue post swallow
Initiation of swallow
Laryngeal elevation/hyoid movement
Cough
Swallow-respiratory coordination
Voice change
Rate/quantity of bolus given
Trial appropriate management strategies
(e.g. swallowing manoeuvres see
treatment section)
Impact/use of mealtime equipment
Impact of taste, temperature, size of bolus
on swallowing
Carer participation/skill and knowledge
Advanced Competence
Knowledge of how feeding dependence

vs independence can affect swallowing
Associated mealtime behaviours; for
example, PICA of foreign objects,
regurgitation, distractibility
Impact of nasal congestion/upper
respiratory tract infection on taste and
swallowing
Impact of cranio-facial abnormalities on
swallowing
8.7 Referral for Instrumental Assessment (as appropriate)

Basic Competence
Knowledge of the application and

limitations of, and suitability for,
videofluoroscopic evaluation
Advanced Competence
Knowledge of the application, limitations and
suitability of the following assessments:

Fiberoptic endoscopic evaluation of

swallowing (FEES)
Cervical auscultation (CA)
Pharyngeal manometry
Pulse oximetry
Ultrasound
Nuclear scintigraphy
Blue dye test (Trache clients only)
Electromyography
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8.8 Overall Impression

Basic Competence
Advanced Competence
Integration of significant features gained

from background, observations,
communication status, clinical
assessment, suitability for oral trials,
instrumental assessment and swallowing
trials
Comment on possibility of gastro

oesophageal dysfunction and its effect
on oropharyngeal swallowing disorders
Relate communication/feeding/
swallowing to other areas of physical
and cognitive function
8.9 Diagnosis
Basic Competence
Advanced Competence
Document type of dysphagia: preparatory;

oral; pharyngeal; oesophageal
Describe the underlying causes
Determine and document severity: mild/
moderate/severe/profound. Relate to
expectations of normal development
where applicable
Evaluate risk of aspiration and airway
obstruction
Describe contributing factors such as

medication regime
8.10 Management Plan

Basic Competence
Advanced Competence
Recommendation of oral or non-oral

status
Awareness of implications of non-oral

intake
If oral intake recommended, indicate food

texture and fluid consistency
Recommended method and equipment

for feeding (e.g. breast/bottle, spoon)
Advise on optimal positioning for feeding/

swallowing
Recommended bolus size and rate of

intake
Advise re clients ability to take

medication or the need to modify this
Reiterate the need for a formal oral care

plan for all clients
Education of client, carer or medical team

to reduce risk of aspiration and/or
improve swallow function
Use of appropriate AAC strategies as

indicated
Identify and teach strategies/techniques

to optimise oral intake
Identify and teach strategies/techniques to assist
progression to oral intake
Advise client/family/carers of treatment

Where available apply appropriate

outcomes tool to measure changes
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Basic Competence
Advanced Competence
options, their risks, benefits, efficacy and

evidence base
Document proposed frequency and form
of intervention; for example, ongoing
assessment, treatment, monitoring,
intermittent reviews
Institute a mealtime management plan for
staff/carers detailing all the above
including: when not to feed, under what
circumstances oral intake should be
ceased, and when to initiate a speech
pathology review
Involve the client in the management plan
Recommend/document the need for
further medical/allied health assessment if
indicated
Collaboration with multidisciplinary team
in provision of recommendations to
address nutritional needs, seating and
positioning, equipment for meals/feeding,
and respiratory health
Consideration of legal and ethical
implications in design of management
plan
9. Treatment
Treatment plans should only be formulated following the assessment of the clients swallowing
abilities. The treating speech pathologist must be able to determine and describe the presenting
symptoms, which aspect(s) of swallowing function is impaired (e.g. poor airway protection), and
the cause of dysfunction (e.g. vocal fold paresis caused by recurrent laryngeal nerve damage) to
enable the introduction of appropriate treatment.
The goals of effective dysphagia management/treatment include:
1. Increasing swallowing efficiency (through intervention)
2. Increasing swallowing safety, to minimise aspiration risk. (Whilst all care should be taken
to reduce risk it cannot be fully eliminated. Thus considered evaluation of risks and
benefits are critical in determining management.)
3. To recommend the most appropriate diet/fluid consistency and to determine when
transition from one form of nutrition to another is appropriate, such as from enteral to
oral, or puree to a soft-chopped diet
4. To determine, in conjunction with a dietitian and/or medical officer, the most appropriate
method to maintain or increase nutrition and hydration; this may include oral, or non-oral
means, or a combination of these
5. Maximising the social aspect of eating/drinking where possible
Effective management includes the ability to recognise:
1. Factors which are impeding progress and the ability to modify goals and treatment
programs accordingly
2. The need for involvement of other service providers
3. The need for involvement and support of family/carers
4. When goals have been achieved and services should cease

Page 13
Logemann (1998) reports that the key to effective dysphagia management is understanding a
clients anatomy and swallow physiology, medical diagnosis, and prognosis. Client management
will also differ according to individual client needs.
Logemann (1998) divides treatment into two general categories of management, these being
compensatory management and therapeutic strategies. Compensatory management includes the
use of techniques to compensate for loss of function. Compensatory strategies are utilised to
assist in altering the flow of the bolus in a way that compensates for compromised oropharyngeal
function, without changing the underlying physiology (e.g. head turn, chin tuck). In contrast,
therapeutic strategies are designed to improve swallow function by changing the underlying
swallow physiology and facilitating optimal functioning of available oropharyngeal structures (e.g.
improving the strength and range of movement of muscles used in swallowing). Swigert (2000)
identifies that some treatment techniques can be both compensatory and therapeutic (facilitative).
Swigert (2000) uses the example of the super-supraglottic swallow being used as a therapeutic
strategy to close the airway entrance before and during the swallow. In doing so the risk of
misdirection of food into the airway is reduced allowing oral intake. The swallow is still impaired;
however the technique allows the person to compensate sufficiently to eat.
The application of therapeutic strategies depends on several factors, including client ability,
clinical competence and the resources available at the speech pathology clinic. In some
instances other team members (e.g. nursing staff), the client and / or the clients next of kin may
be trained by the speech pathologist in compensatory or therapeutic strategies.
An outline of recognised compensatory and therapeutic strategies is listed below. The list is not
exhaustive and should be used as a guide only. For more detail on specific treatment techniques,
their use and application, clinicians should seek appropriate texts and journal publications. In
selecting suitable strategies clinicians must evaluate the suitability of the treatment based on the
clients needs, and the perceived outcome. Clinicians should also ensure that where possible the
techniques selected are underpinned by evidence and that the basis of this evidence be regularly
evaluated.
For convenience, the techniques are presented according to recognised stages of swallowing;
however, these can in no way be considered discrete as the success or failure of each stage will
have flow-on effects to other aspects of the swallow. In the management of adult clients,
strategies are defined as compensatory and rehabilitative (therapy); however, it should be noted
that any compensatory strategy that results in swallowing (either of bolus or saliva) is also
rehabilitative. In paediatric management the intervention seeks to facilitate normal developmental
stages and the refinement of oral feeding skills. In effect, both seek to establish successful oral
nutrition whilst minimising risk.
Finally:
Strategies associated with swallowing disorders with clients with tracheostomies are
not dealt with in this paper.
Techniques annotated with an * may be new and require further research and/or may
require the clinician to avail themselves of further training.
Surgical and medical procedures such as cricopharyngeal myotomy, laryngeal
diversion, botulinum toxin injection, vocal fold injection to improve airway closure or
medication designed to affect saliva are not addressed as these practices are beyond
the scope of the speech pathologist. The speech pathologist, however, should be aware
of these options and when and to whom to refer.
Biofeedback may include a number of instrumental techniques including manometry,
videofluoroscopy, cervical auscultation, respitrace and glottography.
Training in the use of Cervical Auscultation and SEMG is highly recommended before
use.

Page 14
9.1 Oral phase disorders

Possible indicators
Possible strategies
Clinical:
Compensatory:
Spillage from the lips

Oral pooling or residue post swallow
Prolonged oral phase
Reduced tongue movement (may include
weak suck)
Multiple swallows
Biting of soft tissues
Loss/change of taste, temperature
perception
Postural (chin up/down)

Positioning (e.g. seating)
Labial/chin support
External pressure to cheek
Dump & swallow
Modified texture diet
Lip and tongue exercises
Changing sensory input (taste,
temperature)
Changing feeding process - consider
rate, presentation of food, assistive
devices, placement of equipment into
mouth
Dentures in situ
Oral hygiene
Teach client to clear mouth (finger,
cheek muscle recruitment, rinse / spit)
Instrumental:
Poor bolus preparation
Poor bolus propulsion
Prolonged oral phase
Premature loss of bolus
Contd. Over
Possible indicators
Possible strategies
Rehabilitation:
Targeted oro-motor exercises (lips,

tongue tip/blade/base, buccal, jaw)
Mouthing toys to increase strength and
decrease hyper-sensitivity
Targeted instrumental techniques which
are used as a biofeedback measure in
muscle strengthening (SEMG, Electrical
stimulation)*
9.2 Velopharyngeal disorders

Possible indicators
Possible strategies
Clinical:
Compensatory:
Misdirection of food or fluid to nasopharynx

Slow/prolonged breast/bottle feeding
Hypernasal speech/vocalisation
Instrumental:
Loss of food fluid to naso-pharynx
Inappropriate tongue humping
Poor velopharyngeal closure for

swallow
Palatal prosthesis
Selection of specialised equipment such as
teats or straws
Texture modification of food/fluids
Rehabilitation:
Velopharyngeal exercises

Page 15
9.3 Oropharyngeal transit disorders

Possible indicators
Strategies
Clinical:
Compensatory:
Delayed onset of swallow

Uncoordinated suck-swallow
Multiple swallows
Coughing/gagging on swallowing
Instrumental:
Sounds of food/fluids in pharynx prior

to initiation of swallow on cervical
auscultation
Sounds of swallow-respiratory
incoordination on cervical auscultation
Bolus to valleculae/pyriform prior to

initiation of swallow.
Chin tuck
Enhancing sensory input
Multiple swallows
Changing bolus size
Selection of specialised equipment such as
teats or straws
Modifying texture of food/fluids (thicker)
Modified rate of intake
Supra-glottic swallow
Rehabilitation:
Brushing & icing/thermal tactile stimulation
SEMG/Biofeedback *
Electrical stimulation *
9.4 Pharyngeal disorders

Possible indicators
Possible strategies
Clinical:
Compensatory:
Reduced laryngeal excursion

Multiple swallows
Altered voice quality (wet voice)
Coughing/gagging on swallowing
Instrumental:
Increased sounds post swallow on

cervical auscultation (e.g. gurgling,
wet respirations or increased
respiratory rate)
Reduced base of tongue to

pharyngeal wall
Inadequate or untimely epiglottic

deflection
Uncoordinated swallow
Asymmetry
Pharyngeal residue
Head rotation/tilt
Super-supraglottic swallow
Effortful swallow
Rehabilitation:
Pharyngeal range of movement exercises

(vocal fold/tongue base & pharyngeal wall,
laryngeal elevation
Masako (tongue hold) manoeuvre
Shaker (head lift) exercises
SEMG/biofeedback *
Electrical stimulation to improve muscle

strength*

Page 16
9.5 Cricopharyngeal disorders

Possible indicators
Possible strategies
Clinical:
Compensatory:
Client complains of food sticking in

throat
Multiple swallows
Hoicking/throat clearing
Instrumental:
Reduced upper oesophageal

sphincter opening (duration or degree)
Residue in pyriform sinus
Uncoordinated swallow
Reduced laryngeal elevation
Mendelsohn (laryngeal elevation) manoeuvre

Modification of food/fluids (thinner)
Rehabilitation:
Effortful swallow (co-ordination)
Shaker manoeuvre (laryngeal excursion)
SEMG to train Mendelsohn and Effortful

swallows
9.6 Penetration + aspiration

Possible indicators
Possible strategies
Clinical:
Compensatory:
Wet voice
Throat clearing
Cough
Change in breathing pattern
Fever
Change in lung status
Instrumental:
Sounds of food/fluid entering larynx

prior to swallow initiation (CA)
Wet respiration post swallow on

auscultation
Penetration to laryngeal vestibule/

through vocal folds
Optimal positioning during feeding/

swallowing
Supraglottic swallow
Rate/pacing of intake
Modification of feeding equipment
Super supraglottic swallow
Effortful swallow
Texture modification of food and fluids
(thicker/smoother) *
Free water protocol *
Alternative feeding (NG, PEG)
Rehabilitation:
Biofeedback (Respiritrace, Glottograph) *
SEMG to support effortful swallow *
Shaker manoeuvre (hyo-laryngeal elevation)
* may be new and require further research and or may require the clinician to avail themselves of
further training
10. Documentation
Documentation should ensure all medico-legal and accreditation requirements are met. Thorough
documentation is important and should include but not be limited to:
A baseline of the clients condition

Assessment results and management plan
Progress or decline
Changes in the clients condition which may impact on progress
Advice to staff and/or carers
Precautions

Page 17
Recommendations for further investigation

Reasons for ceasing treatment/intervention
Speech pathologists need to ensure that advice is recorded in writing. Verbal information, advice
or management changes should be followed up by written confirmation. The speech pathologist
should also refer to their employers departmental policy, relevant legislation and guidelines
10.1 Timelines
Documentation following client contact should occur in a timely manner as appropriate to the
requirements of the service. This should be clearly defined in each services Policy and Procedure
manual.
10.2 Standards
Standards of documentation should be specified in local organisational Policy and Procedure
manuals. The following is recommended as a minimum standard:
Brief summary of background information relevant medical history, medications,

current medical diagnosis and reason for referral.
General observations; for example, posture/positioning, presence of feeding
tubes/oxygen, cognitive status and alertness; current feeding status.
Communication: brief summary of speech and language and functional communication.
Clinical oromuscular assessment: all structures and their function to be commented on,
even when no abnormalities are detected (lips, tongue, palate, voice, cough, laryngeal
and hyoid movement).
Decision related to advisability of conducting an oral food trial.
Swallow function based on the oral trial or mealtime observation. In some cases more
than one assessment may be indicated and the rationale for delaying judgement should
therefore be documented. The outcome of the food/fluid trial, including the amount
taken, and level of assistance required.
Manoeuvres/strategies trialled and their effectiveness.
Overall impression and diagnosis: integrate assessment results, including severity,
significant features of the swallowing function, provide a dysphagia diagnosis by
expounding the underlying causes, presence or absence of signs of laryngeal
penetration, perceived aspiration risk from oral intake or saliva.
Plan/Goals - Determine and provide therapy plans including: diet/fluid modifications;
Strategies for swallowing (including medications); Referral to other agencies; Referral for
instrumental assessment if clinically indicated; Timeline for review; Signs which indicate
that the client should cease oral intake and be reviewed by speech pathology as a
matter of priority. Document whether this plan has been communicated to other team
members and/or relevant others.
As in other areas of practice, all documentation must be signed, dated and when part of
nursing or progress notes, the time should also be included.
10.3 Reporting requirements
It is important that speech pathologists report on findings of assessment and progress

or outcomes of intervention according to Speech Pathology Australia guidelines on
documentation and maintenance of individual records.
It is recommended that speech pathologists report back to the referral agency regarding
assessment findings in language that can be understood by the referring agent, whether
this be a relative/family member /carer, a medical practitioner, teacher, or other allied
health professional.
Reports should provide case specific recommendations for management of an
individuals dysphagia.
Care must be taken to ensure that all reports remain confidential and reports conform to the
provisions of the relevant privacy legislation.

Page 18
The service is expected to establish an appropriate system for the preparation and storage of
written documentation including assessment results, reports, client management plans,
interventional goals, progress notes and outcomes. Reference should be made to local policy.
10.4 Discharge and Resolution Planning
Once a client is discharged from Speech Pathology care, documentation regarding the rationale
for discharge and need for an ongoing treatment program should be specified in the clients
medical file or speech pathology file, whichever is applicable.
Reasons for discharge may include the following:
Goals achieved
Client reached optimal pre-morbid level of functioning
Intervention inappropriate (due to medical deterioration, lack of client/carer cooperation,
as determined by medical team)
Client discharged from hospital
Client/carer fails to attend
Client transferred to another facility/speech pathology service
Clients level of function plateaued
Client deceased
People to be informed of clients discharge status:
Medical team and/or caring practitioner

Client/family/carer
Relevant health professionals involved in clients care
Should the client require ongoing care, with the clients permission a written care plan including
the following information should be forwarded to the client /carer and all health professionals
involved:
Background information of client

Speech pathology intervention and progress to date (including current
recommendations, outcomes of instrumental assessment and management plan)
Recommendations for follow up by health professionals as indicated (e.g. private
speech pathologist, dietitian)
10.5 Confidentiality
Client documentation is to remain confidential at all times in accordance with the Code of Ethics
(Speech Pathology Australia, 2000), CBOS (Speech Pathology Australia, 2001) and relevant
privacy legislation.
The storage, duration and appropriate means of disposal of client information should be as
specified by organisational and state/territory requirements.
11. Education and Counselling

11.1 At Referral
Provision of information that answers, What is dysphagia?

Explanation of the risks associated with dysphagia
Explanation of symptoms/signs for the client, which might be consistent with dysphagia
Explanation of the assessment process
11.2 After Clinical Assessment
Explanation of the results of the assessment, including prognosis

Page 19
Explanation of further assessment that may be warranted

Presentation of the proposed management plan, including rationale and discussion of
any risks associated with that plan (e.g. risk of dehydration that may be associated with
poor intake of thickened fluids). This may also include provision of information regarding
methods and outcomes of alternative/supplementary feeding.
All information must be balanced, evidenced based where possible and presented in lay
terms. Visual presentation to support verbal information (diagrams text, video and
computer images and anatomical models) may assist and should be used as
appropriate.
11.3 Prior to Discharge
Ensure that the management plan is understood by all parties involved.

Ensure that strategies are in place to support that plan.
Ensure that client/carer is aware of signs / symptoms associated with a deterioration in
swallowing function and aspiration-related complications. Provide information on what
to do and who to contact in this event
Negotiate appropriate follow-up with the client/significant others.
11.4 Client/Carer Education

The managing speech pathologist should ensure that where training is required for the client or
carer to implement a management plan that they are provided with an optimal method to
maximise understanding of what is required. This may include use of interpreters, visual and
written aids.
12. Services Management

12.1 Qualifications
Speech pathologists should be eligible for Practising membership of Speech Pathology Australia.
Further information is available from the Speech Pathology Australia website at
http://www.speechpathologyaustralia.org.au
12.1.1 Skills and Minimum Standards
It is recommended that the speech pathologist dealing with a person with dysphagia has
knowledge of and skills to fulfil minimum standards for management of dysphagic clients
as documented in this paper. The level of skill may need to be identified for both
employer and employee prior to appointment. A speech pathologist should recognise
and acknowledge their limitations and not work beyond the scope of their competence
(Speech Pathology Australia, 2000, Code of Ethics, Section 5.3; Speech Pathology
Australia, 2001, CBOS). Where skill is lacking appropriate training, supervision and
mentoring should be sought.
12.2 Professional Development
All practising speech pathologists are:
Encouraged to maintain, update and extend their knowledge through participation in

ongoing professional development activities (Speech Pathology Australia, 2000, Code
of Ethics);
Jointly obligated with the service employer to identify individual training needs and
negotiate as to the most appropriate method to achieve this (Speech Pathology
Australia, 2001, Principles of Practice);
Expected to undertake selfeducation activities as part of this commitment to

professional development such as participation in the Professional Self Regulation
program conducted by Speech Pathology Australia;
Encouraged to share their knowledge and expertise with their colleagues (Speech
Pathology Australia, 2001, Principles of Practice);

Page 20
Support others who are expanding the knowledge base of the profession (Speech
Pathology Australia, 2001, Principles of Practice).
12.3 Information Technology

Access to information technology has become an integral component of service delivery and
professional development. Organisations should aim to provide access to information technology
for staff.
12.4 Budgets
Budgetary considerations may limit the extent of resources available. For this reason documented
prioritisation will assist with service provision.
12.5 Workplace Health and Safety Issues
Employers are legally obligated to provide a suitable work environment. This should comply with
Commonwealth, State and local regulations for building, fire and safety. Individual requirements
will vary according to the method of service provision. General standards are outlined in the
Principles of Practice (Speech Pathology Australia, 2001), and specific information pertaining to
schools can be found documented in the Speech Pathology Services in Schools Position Paper
(Speech Pathology Australia, 2003). Policies should exist for:
Infection control
Occupational Health & Safety requirements for conducting instrumental swallowing
assessments
Manual handling
Emergency evacuation
Staff requirements in Cardio-Pulmonary Resuscitation (CPR), fire training
Management of Coughing and Choking policy
Mealtime assessments in external facilities (i.e. schools)
Duty of care
12.6 Physical Resources

Equipment of a sufficient standard should be supplied to allow the speech pathologist to fulfil the
minimum requirements for assessment, and treatment of dysphagia.
12.7 Continuous Quality Improvement
The practising speech pathologist should be aware of and performing continuous

quality improvement activities in relation to dysphagia management.
Quality procedures are an integral part of continuous quality improvement.
Development of quality procedures should be related to evidence based best practice and any
guidelines or standards outlined by Speech Pathology Australia.
12.7.1 Measuring methods
Measurement tools are wide and varied, and range from clinical observational
measures and reports of significant others, to checklists, screening tests, and
assessments designed to measure presence of symptoms of dysphagia and
severity of dysphagia. The most frequently used outcomes tools in Australia are
the Therapy Outcome Measures Dysphagia Scale for a) Disability (TOMDD) and
b) Impairment (TOMDI) and the Royal Brisbane Hospital Outcome Measure for
Swallowing (RBHOMS) (Gupta, 1998)
Such measures may be utilised before, during and after intervention
It is important that the speech pathologist is aware of available tools and is
competent, in recognising when to use them and how to interpret them
Speech pathologists should be aware of the World Health Organization
definitions for health, disease, body structure and function, and need.

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12.8 Marketing and Public Relations

Speech pathologists should liaise with their supervisor regarding policies on media contact.
Caution should be exercised in any public statements and when talking to the media individuals
should clearly state whom they are representing. Further information may be found in the
Principles of Practice (Speech Pathology Australia, 2001). It is expected that speech pathologists
will act in accordance with the Code of Ethics (Speech Pathology Australia, 2000).
13. Education
13.1 Clinical Education
All Australian university speech pathology courses equip students with basic skills in
dysphagia (Speech Pathology Australia, 2001, CBOS). Practical skills in the area of
dysphagia are, however, dependent upon the individual students clinical placement.
Whilst every effort is made to ensure students receive sound practical skills, individual
students experiences will vary from setting to setting.
Speech pathology students should be provided with the opportunity to observe an
experienced speech pathologist conducting a dysphagia assessment and intervention
where possible.
Speech pathology students should be provided with the opportunity to participate as
much as their skill allows in the assessment, interpretation and management of clients
with dysphagia during their clinical training where possible.
The supervising speech pathologist may provide the opportunity for students to
become clinically competent in the assessment and treatment of dysphagia however
they ultimately maintain clinical responsibility for the clients care.
13.2 Staff Training
Speech pathologists have an important role in contributing to the training of other health
professionals in identifying symptoms of dysphagia.
Speech pathologists may train, monitor and supervise other health professionals
involved in supporting a client with dysphagia.
Training may include provision of information, demonstration, supervision or monitoring
of practice of other staff about an individual or a group of people with dysphagia. This
training may enable other staff to carry out therapeutic manoeuvres as recommended
by the speech pathologist with an individual on a regular basis, in order to effect a
greater response to that intervention. The speech pathologist has a responsibility to
tailor the level of information to the needs and abilities of the person receiving the
training. Documentation detailing the information provided in such training sessions is
required. Any variations to these instructions must be given in writing. The speech
pathologist must document at what point they are transferring duty of care. Speech
pathologists maintain the responsibility for monitoring, supervising and altering the
treatment program.
13.3 Research
A large proportion of dysphagia research is mediated by teaching staff at Australian

Universities.
There are a growing number of post-graduate courses at Masters and Doctoral level
(PhD and Professional Doctorate) that provide opportunities for research into
dysphagia.
Speech pathologists in clinical practice should be encouraged to apply the rigors of
research to their quality improvement projects and to share their results with speech
pathology colleagues in clinical and research communities.

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13.3.1 Funding
Postgraduate positions and research grants may be available through philanthropic

trusts, universities, Speech Pathology Australia or in conjunction with the speech
pathologists place of employment.
Some tertiary institutions have initiated conjoint research positions that span the
university, health or educational setting.
From time-to-time State and Federal government bodies may offer health-related
grants. Although often very competitive, these grants should be investigated as a
source of research funding.
14. Legal Issues

The following matters should be considered by speech pathologists working with clients with
dysphagia.
14.1 Code of Ethics
Speech pathologists should adhere to the Speech Pathology Australia Code of Ethics (2000) and
to any codes, directions or principles applicable to the body employing the speech pathologist,
(e.g. Code of Conduct for the Victorian Public Sector).
14.2 Knowledge and Skills
Speech pathologists working with clients with dysphagia should understand and possess the
skills to meet standards for speech pathology services documented in this position paper. The
employing body or service purchaser may determine the level of skill which it requires prior to
appointment of the speech pathologist. All speech pathologists should understand the
Competency Based Occupational Standards (CBOS) for Speech Pathologists (Speech Pathology
Australia, 2001).
Speech pathologists should undertake any mandatory training required of employees of the
employing body or service purchaser; that is, workplace, health and safety training, child
protection training.
14.3 Speech Pathologists Responsibilities
Individual speech pathologists responsibilities will usually be identified in their position
description, employment contract, contract for services, or policies and procedures of the school,
the employing body, or service purchaser.
However, regardless of the specified responsibilities, the law imposes a duty on all speech
pathologists to exercise reasonable care and skill in the provision of advice and treatment (i.e. an
obligation to exercise the standard of care) where the speech pathologist owes a duty of care
(see section 14.4 below).
14.4 Duty of Care
A speech pathologist owes a duty of care to another person where the speech pathologist ought
reasonably to foresee that their conduct may be likely to cause loss or damage to a class of
persons to which the other person belongs. On this basis, it is clear that speech pathologists
owe a duty of care to their students. Speech pathologists may also owe a duty of care to their
employing body or service purchaser.
Where a speech pathologist owes another person a duty of care and the speech pathologist
breaches the standard of care required, (either by a specified act, a failure to act, or providing
misleading information or advice), the speech pathologist may be liable for damages in a civil
action brought by or on behalf of the person to whom the speech pathologist owed the duty of
care.

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14.5 Standard of Care

The standard of care which must be exercised by a speech pathologist is the reasonable care
and skill of the ordinary skilled speech pathologist exercising or professing to have this special
skill. It is important to note that an inexperienced speech pathologist must meet the standard of a
reasonably competent and experienced practitioner providing speech pathology services.
Accordingly, a speech pathologist who is aware that they lack the required level of skill in a
particular area must seek further advice and guidance immediately. Such further advice and
guidance may involve requesting support from a more experienced speech pathologist, the
employing body or the service purchaser.
The courts will determine the standard of care required of a speech pathologist in each particular
case. In the past courts have found medical practitioners to be negligent; that is, to have
breached the standard of care required, notwithstanding that the medical practitioners treatment
was in accordance with a practice accepted as proper by a reasonable body of medical opinion
skilled in the relevant field. However, a court must have strong reasons for substituting its
judgement for the clinical opinion of the medical practitioner where it has been properly arrived at
and is supported by a responsible body of medical opinion. Accordingly, speech pathologists
advice and treatment should always be in accordance with practices accepted as proper by a
reasonable body of opinion skilled in speech pathology, but speech pathologists should be aware
that acting in such a manner will not automatically preclude a court from finding them negligent.
Further, it is important that speech pathologists are aware of recent literature in their field, current
best practices carried out by others in their field, and Speech Pathology Australias Code of
Ethics (2000).
14.6 Proxy Intervention
Where a speech pathologist does not carry out an intervention personally, and instead instructs
and/or supervises another person carrying out the intervention, the speech pathologist may be
liable for any negligence resulting from the intervention, irrespective of the fact that the speech
pathologist was not carrying out the intervention personally. The law refers to this as vicarious
liability and it may render the speech pathologist liable where their agent or proxy breaches the
duty of care owed by the speech pathologist while the proxy acts as a representative of the
speech pathologist. Therefore, it is necessary for proxies to exercise the same standard of care
as that required of the speech pathologist instructing or supervising them, and for all
documentation (i.e. Individual Education Plans, progress notes, negotiated contracts) regarding
proxy interventions to be maintained. In addition, the service plans must include adequate time
and resources to train proxies and monitor programs.
14.7 Consent for Speech Pathologist Involvement
The speech pathologist must obtain the clients consent prior to providing speech pathology
services, including assessment, to the client. The client must be informed in broad terms of the
nature of the treatment to be provided prior to giving consent. Consent should be in writing and is
invalid unless it is voluntary. A client under the age of 18 years can consent to the provision of
speech pathology services, provided the client has sufficient intelligence and maturity to
understand the nature and consequences of the particular treatment. Where the client lacks the
capacity to consent, or their capacity to consent is in doubt, the consent of the clients parent or
guardian must be obtained.
All processes employed by speech pathologists should adhere to privacy legislation and freedom
of information legislation.
14.8 Indemnity Cover and Insurance
It is the responsibility of speech pathologists to ensure they have appropriate professional
indemnity insurance cover. Professionals should be aware that there may be instances where the
employing body will not necessarily indemnify them for their actions. It is recommended that all
practising Speech Pathology Australia members have professional indemnity insurance.

Page 24
Speech pathologists should clarify the insurance situation for accidental loss, theft or damage to
resources during transport with their insurer.
14.9 Service Guidelines
It is recommended that the speech pathologist adhere to all approved guidelines of the
employing body in terms of clinical and service management.
14.10 Summary
In summary, a speech pathologist managing clients with dysphagia should:
Adhere to the Speech Pathology Australia Code of Ethics (2001) and any employing
bodys code of conduct.
Adhere to the code of conduct and all relevant policies/service guidelines of the
employing body.
Not undertake intervention that is outside their experience or expertise as a
professional.
Not overstate their expertise.
Seek advice from senior speech pathologists and/or fellow professionals as
appropriate.
Prior to treatment, obtain the client and/or parent/guardians consent to treatment.
Admission to hospital may imply global consent in some instances or a generic consent
may be obtained on admission
Keep the client and parent/guardian well informed of the intervention program.
Keep up-to-date with professional developments.
Ensure that proxies receive suitable training.
Undertake all mandatory training.
Keep accurate records.
Ensure that all advice given to the client, parent/guardian, professionals or staff is
documented.
Keep copies of all reports.
Keep up-to-date with report writing.
Ensure that the client environment is safe.
Ensure that there is adequate professional indemnity insurance cover.

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Appendix A: Glossary of Assessments of Dysphagia

A.1 Bedside or clinical dysphagia assessment
The bedside assessment, unlike the cranial nerve assessment examines the dynamic integration
of oral pharyngeal function during swallowing. Miller (1992) documented that the aims of any
dysphagia examination are to: (a) establish the possible cause of dysphagia (b) assess the
persons ability to protect their airway (c) determine the likelihood of safe oral intake (d)
recommend alternative nutritional management (e) determine the need for further diagnostic
studies and (f) establish a baseline of clinical data. It is true that at its most basic level it indicates
a clients ability to eat and drink. However it can tell a clinician much more than this. Observations
of alertness, independence, decision making, and visuoperceptual skills can be made. The
bedside, or clinical dysphagia assessment, is one of the most controversial, yet widely used
assessments of dysphagia. This clinical assessment is unreliable in detecting aspiration and
identification of aspiration should not be the purpose of the swallowing assessment (DePippo et
al., 1992; Groher, 1994; Linden et al., 1993; Ruf & Stevens, 1995; Splaingard, Hutchins, Sulton &
Chaudhuri, 1988). Rather it is an evaluation of the entire mealtime event. This is especially
important for those clients for whom more invasive investigation would be difficult or in whom it
may be contra-indicated. In these situations, efforts should be made to use additional noninvasive assessments such as pulse oximetry or cervical auscultation.
A.2 Blue dye test
The blue dye test has been previously used with clients with a tracheostomy tube in situ. The
client is given fluid or food impregnated with an inert blue dye, obtainable upon prescription.
Saliva may also be impregnated with blue dye. Following administration of the bolus, the
presence of blue dye in or around the tracheostomy tube is noted upon suctioning (a) during the
swallow, (b) immediately after the swallow, and/ or (c) after a set observation period. A blue dye is
chosen as it provides a non-organic colour immediately distinguishable from blood, sputum or
mucous. There have been conflicting reports of the validity of the technique (Wilson, 1992;
Logemann, 1994; Thompson-Henry & Braddock, 1995). There is also some evidence that clients
may experience gastric irritation from food dyes. At present there is no standardised protocol for
this procedure. Speech pathologists who are not experienced in tracheostomy tube management
are not advised to use this test unless there is adequate qualified supervision.
A.3 Cervical auscultation
Cervical auscultation is an assessment of the sounds of swallowing and swallow-related
respirations. It is intended to complement the clinical or bed-side assessment of swallowing as
described above. Cervical auscultation is a non-invasive, non-imaging tool. Using a stethoscope
clinicians can monitor the quality of swallowing sounds and respiratory sounds post swallow. The
number of swallows required to clear a bolus and the delay in swallow reflex initiation can also be
scrutinised. Healthy swallowing sounds and post swallow sounds are different to the swallow and
post swallow sounds of dysphagic individuals. The clinician skilled in cervical auscultation can
also determine whether compensatory strategies are assisting the dysphagic client. For example,
the clinician can determine whether the client is actually holding their breath during the
supraglottic swallow manoeuvre, and how effective the manoeuvre is for that individual.
Swallowing sounds can also be recorded, and digitised so that that they can be evaluated using
computer software. A contact microphone or accelerometer is placed on the skin surface of a
specified point on the cervical region with the signal recorded onto audiotape or videotape (as in
simultaneous videofluoroscopy), or directly onto the computer. The recorded sounds are digitised
and can then be analysed using acoustic software programs such as the Computer Speech
laboratory (CSL by Kay Elemetrics). The duration of swallowing sounds, their intensity and their
frequency characteristics can then be analysed to objectively show differences between healthy
swallows and dysphagic swallows (Cichero & Mudoch, 1998; Cichero & Murdoch, 2002a, Cichero
& Murdoch 2002b). Additional training will be required to use this method correctly.

Page 26
A.4 Electroglottography
The electroglottograph (EGG), also known as the Laryngograph, was initially developed as a noninvasive electrical impedence device for observing vocal fold contact during phonation
(Logemann, 1994; Perlman & Liang, 1991). It is hypothesised that the EGG could capture the
activity of the larynx as the airway closes during swallowing (Sonies, 1991). During
electroglottography an electrode is placed on either side of the neck over the thyroid cartilage.
One electrode transmits a signal, while the other receives the signal after it has been modified by
the impedance of the neck. The deflections can be used as an indicator of laryngeal elevation. It
is however subject to interference of artefact by movements of the head and tongue (Kaatzke et
al, 1996). It is not a routinely used assessment and requires additional training.
A.5 Electromyography
Electromyography describes the recording and study of the intrinsic electrical properties of
skeletal muscle (Dorland, 1982). Electromyography as it relates to swallowing assessment
describes the technique of assessing the function of the muscles involved in swallowing
(Logemann, 1994; Sonies & Baum, 1998). It provides information about the timing and relative
amplitude of muscle contraction during swallowing and the frequency of motor neurone firing.
EMG can be invasive or non-invasive. Muscles typically under investigation include the floor of
the mouth, or submental muscles, and those associated with laryngeal elevation. Additional
training will be required to use this method correctly.
A.6 Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
FEES is able to demonstrate via imaging the presence of dysphagia including laryngeal
penetration, tracheal aspiration, pharyngeal residue and bolus spillage into the pharynx prior to
the initiation of the swallow. FEES is considered to be a specialist skill requiring the speech
pathologist to undertake further training in its application.
The procedure, reported by Kidder, Langmore and Martin (1994) is an extended version of flexible
fiberoptic laryngoscopy (Langmore, Schatz & Olsen, 1988; Sonies 1991). Kidder, reported that the
technique is versatile, portable, provides immediate information and can be recorded onto
videotape for later analysis. He suggested that it complements, rather than replaces
videofluoroscopy swallowing studies and that the equipment and necessary expertise is available
in most hospitals. An advantage of the FEES is that the anatomy can be viewed directly.
It is not possible to view the total dynamics of the swallow during a FEES assessment, as the
movement of the epiglottis temporarily obscures the view during swallowing. It is possible to
detect aspiration occurring prior to a swallow, or from residue remaining in the pharynx after a
swallow. It is reported that if aspiration occurs during the swallow, residue would be visible in the
larynx and trachea once those regions return to view after the epiglottis has returned to an upright
position (Langmore et al., 1988; Sonies, 1991). FEES is able to show the direction of bolus flow
and reportedly, the appropriateness of certain treatment techniques. The technique can also be
used for review assessment to gauge improvement or decline in status.
A.7 Nuclear scintigraphy
Nuclear scintigraphy uses radionuclide scanning during the ingestion of a radioactive bolus
(usually technetium-99m) (Sonies & Baum, 1988; Sonies, 1991; Silver et al., 1991; Silver & Van
Nostrand, 1994) to track the bolus as it passes from the oropharynx to the oesophagus. The
radiopharmaceutical is not absorbed after ingestion, nor does it become attached to the
gastrointestinal mucosa (Benson & Tuchman, 1994).
Scintigraphy is an expensive, dynamic assessment of swallowing, requiring a gamma scintillation
camera, a low-energy collimator and a dedicated computer (Sonies & Baum, 1988). Measures
such as pharyngeal transit time, number of swallows required to clear pharyngeal residue and
regurgitation can be obtained. Although scintigraphy is said to offer precise quantification of
bolus volume in any area at a particular time or over time, (Fleming et al, 1990; Hamlet et al, 1989;
Humphries et al, 1987) there is much debate in the literature as to the tool's ability to detect and
quantify aspiration (Benson & Tuchman, 1994; Sonies & Baum, 1988). In the field of dysphagia,

Page 27
scintigraphy has been used primarily for the assessment of gastrointestinal reflux (Silver et al,
1991). Nuclear scintigraphy is conducted by a medical officer trained in nuclear medicine
imaging techniques.
A.8 Pharyngeal manometry
Pharyngeal manometry assesses the pressure dynamics of the pharynx and upper oesophageal
sphincter during swallowing. Pharyngeal manometry provides a means of measuring motor
activity of the pharyngeal muscles, by measuring pressure changes caused by muscle
contraction in the pharynx. It is predominantly used to investigate (a) pressure response of the
upper oesophageal sphincter (UES) to swallowing, (b) timing of pharyngeal contraction, (c) UES
relaxation and (d) the relationship between these events (Sonies, 1991). Pharyngeal manometry
requires the use of solid state pressure sensors that have a sufficiently fast response frequency to
react to rapid pressure changes that occur during the pharyngeal stage of the swallow. The
sensors are encased in a fine diameter tubing, typically 3 mm, and are passed transnasally so
that sensors are located at (a) the base of the tongue, (b) UES, and (c) cervical oesophagus
(Logemann, 1994). Other investigators, such as McConnel (1988), have an additional sensor
placed at the laryngeal inlet. Pharyngeal manometry is a procedure performed by a
gastroenterologist. Manofluorography (simultaneous manometry and fluoroscopy) is used
predominantly for research purposes. Pharyngeal manometry is frequently used where
gastroesophageal reflux is suspected.
A.9 Ultrasound
Ultrasound of swallowing is a technique that visualises the soft tissue of the oral cavity and
hypopharynx during swallowing, using a transducer placed submentally below the chin to obtain
an image. It does this by "the imaging of deep structures of the body by recording the echoes of
pulses of 1-10 megahertz ultrasound reflected by tissue planes where there is a change in
density" (Dorland, 1982, p.703). Any commercial ultrasound real-time sector or phased-array
system can be used, and the equipment and necessary expertise is available in most hospitals
and radiology services. The information is transmitted to a monitor where the image is updated
many times per second. The image represents a single 2D plane at any one time.
The physics of sound travel proves a limitation to the ultrasound technique. While sounds travels
through fluids and soft tissues, it does not travel well through fat, due to its complex tissue
structure. This limits the type of client with whom ultrasound swallowing assessment can be
used. Another limitation of the technique is that sound will not pass through bone or air. It will be
completely reflected (Benson & Tuchman, 1994). Therefore, the trachea cannot be visualised as it
is an air-filled space and thus ultrasound is unable to detect penetration or aspiration of contents
into the trachea. These factors limit its use in characterising the pharyngeal phase of the swallow,
however the oral cavity is well-visualised during ultrasound. An ultrasound assessment of
swallowing is conducted by an ultrasound technician and a speech pathologist trained in its
application.
A.10 Videofluoroscopic swallowing study
Videofluoroscopy (also known as the Modified Barium Swallow) is the so called gold-standard
against which many new dysphagia diagnostic techniques are compared for validity and reliability
purposes.

Page 28
Appendix B: Working Party

The valuable contributions of the following people are acknowledged is the writing of this
document:
Task Force Coordinator
Monika Kaatzke-McDonald
Core Task Force:
Maria Berarducci, Julie Cichero, Nicola Clayton, Tia Croft, Cindy Dilworth, Jai Gupta, Bronwyn
Hemsley, Grainne OLoughlin and with particular thanks to Ingrid Scholten.
Additional contributions by:
Stacey Baldac, Noni Bourke, Melita Brown, Julia Filipi-Dance, Gaye Murrills, Anne Rosten, Chris
Sheard, Sarah Starr, Chris Stone, Margaret Trzcinka and Louise Williams

Page 29
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