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Checking a patient’s gag, cough, and swallow reflexes determines how well a patient can protect his airway, according to Laura M. Criddle, MS, RN, CS, CEN, CCRN, CNRN, emergency, trauma, and neurological clinical nurse specialist at Oregon Health and Sciences University in Portland.
Level of consciousness is the key factor, she stresses. "It is unusual for a normally alert patient to have a gag, cough, or swallow problem unless you’re dealing with a throat emergency," she says. "Therefore, any patient with an altered level of consciousness is at risk."
Patients with head injuries, stroke, metabolic disturbances, and toxicologic emergencies are at high risk, she warns. Criddle says to start your assessment by simply observing level of consciousness. Next, examine how well the patient is dealing with oral secretions. "Is he drooling? Listen for upper airway noises," she recommends. "Is there any rattling or gurgling going on?"
If you have a patient who is at least minimally alert, try having the patient take a small sip of water, she suggests. "You can also use a tongue blade or Q-Tip to stroke the back of the patient’s mouth to check for gag reflexes," Criddle says. "In the cooperative patient, ask him to take a deep breath and cough."
The second instance in which gag, cough, and swallow are assessed is in the deeply comatose patient, she says. "In this case, the patient should already be intubated," Criddle explains. "Now you’re using gag, cough, and swallow reflexes simply to test brainstem function."
Suction the patient through the endotracheal tube to stimulate the carina, which should cause a cough, and also suction the posterior pharynx, which should stimulate a gag, says Criddle. "The absence of these findings represent a loss of very basic brainstem functions and are associated with a poor prognosis, unless the patient is deeply sedated or chemically paralyzed," she says.
[Editor’s Note: For more information about assessment of spinal cord injuries, contact Laura M. Criddle, MS, RN, CS, CEN, CCRN, CNRN, Oregon Health & Sciences University, Mail Code UHS 8Q, 3181 S.W. Sam Jackson Park Road, Portland, OR 97201. Telephone: (503) 494-1350. Fax: (503) 494-7441. E-mail: firstname.lastname@example.org.]