Yale Swallow Protocol in Extubated Patients

Dysphagia is prevalent in recently extubated patients with estimates ranging from 29-84% of
recently extubated patients having some form of dysphagia with elevated risk for silent
aspiration.One challenge providers face when managing post extubation dysphagia (PED) is that
there are no best practice guidelines on how to evaluate for PED, specifically how to
evaluate for silent aspiration (aspiration without cough response).

One method that has been suggested is the Yale Swallow Protocol (YSP), a pass/fail screen for
aspiration consisting of a three ounce water challenge as well as a brief cognitive screen
and oral motor exam. The assumption of the YSP is that silent aspiration (aspiration without
a cough response) is volume dependent. This is based on a study of over 4000 patients that
underwent both a FEES (5mL puree and 5mL liquid boluses) and a 3oz water challenge. Results
from previous literature indicated that the 3oz water swallow had a high sensitivity for
detecting aspiration (98%). This was again studied with a double blind research design with
25 patients, comparing results of the 3oz water challenge with results of videofluoroscopic
swallow study. This showed 100% sensitivity for detecting aspiration, 64% specificity, 78%
positive predictive value, and 100% negative predictive value. However, no published study
has evaluated the YSP in recently extubated patients and so it is unclear if the high
sensitivity and specificity would be retained. Investigators aim to determine the sensitivity
and specificity of the Yale Swallow Protocol in identifying aspiration in recently extubated
patients.

Inclusion Criteria:

1. Intubation greater than 24 hours

2. Age 18 and older

3. All races

4. Males and females

5. English speaking

6. Swallow consult ordered by the team within 48 hours of extubation

Exclusion Criteria:

1. Known history of oropharyngeal dysphagia

2. Contraindication for FEES due to facial fractures, nothing by mouth (NPO) status for
other procedures, elevated bleeding risk, reduced level of alertness, or significant
agitation.

3. Allergy to dairy