This article provides an overview of bedside screening and assessment tools in patients with oropharyngeal dysphagia including the diagnostic performance of screening tools; the gold standards in assessment of dysphagia (videofluoroscopic and fiberoptic endoscopic evaluation of swallowing); a variety of clinical assessment tools; patient self-evaluation questionnaires; and a list of supplementary methods. In addition, some methodologic issues are discussed, and the need for standardization of terminology, screening and assessment protocols, and the call for evidence-based clinical guidelines.
| FEES | Fiberoptic endoscopic evaluation of swallowing |
| FHS | Functional health status |
| HRQOL | Health-related quality of life |
| Se | Sensitivity |
| Sp | Specificity |
| VFS | Videofluoroscopy |
Key points
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Bedside screening is an essential first step in the management of patients at risk for dysphagia. If patients fail the screening further assessment is required.
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Assessment may relate to different aspects of swallowing. Abnormalities in swallowing are not necessarily correlated and may show dissimilar changes after treatment. Therefore, including several evaluation techniques when studying swallowing problems may be useful.
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There are a great variety of screening and assessment tools for dysphagia available; use of a particular tool must be justified based on its reliability and validity and its discriminative and evaluative purpose.
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There is an urgent need for evidence-based clinical guidelines for screening and assessment of patients with oropharyngeal dysphagia.
Introduction
Because the human aerodigestive tract caters to the combined functions of breathing, vocalizing, and swallowing, the large supralaryngeal space created by the low larynx positioning in adults increases a risk of aspiration or choking. Any dysfunction in this system may lead to dysphagia. Dysphagia is associated with high morbidity and mortality rates. It can lead to dehydration, malnutrition, or aspiration pneumonia and may have major effects on social and psychological well-being. Early and reliable screening for symptoms of dysphagia in subject populations at risk is an effective and vital first step in appropriate dysphagia management. Those patients that fail the initial screening need to be referred for further clinical assessment. Apart from videofluoroscopic (VFS) and fiberoptic endoscopic evaluation of swallowing (FEES), a variety of assessment tools and patient self-evaluation questionnaires are found in the literature. This article provides an overview of bedside screening and assessment tools for patients with oropharyngeal dysphagia with emphasis on diagnostic performance and methodology.
Introduction
Because the human aerodigestive tract caters to the combined functions of breathing, vocalizing, and swallowing, the large supralaryngeal space created by the low larynx positioning in adults increases a risk of aspiration or choking. Any dysfunction in this system may lead to dysphagia. Dysphagia is associated with high morbidity and mortality rates. It can lead to dehydration, malnutrition, or aspiration pneumonia and may have major effects on social and psychological well-being. Early and reliable screening for symptoms of dysphagia in subject populations at risk is an effective and vital first step in appropriate dysphagia management. Those patients that fail the initial screening need to be referred for further clinical assessment. Apart from videofluoroscopic (VFS) and fiberoptic endoscopic evaluation of swallowing (FEES), a variety of assessment tools and patient self-evaluation questionnaires are found in the literature. This article provides an overview of bedside screening and assessment tools for patients with oropharyngeal dysphagia with emphasis on diagnostic performance and methodology.
Bedside screening
An Overview
It is generally agreed that the first step in the management of patients at risk for oropharyngeal dysphagia is bedside screening. Bedside screening aims at identifying patients at risk for aspiration or unsafe swallowing as a step before further clinical assessment. Screening tools need to meet several criteria: easy administration, few time-consuming procedures, noninvasive methods avoiding distress to patients, and well-defined noncomplex training of health allied practitioners. Above all, screening methods need to be valid and reliable. In 2009, Bours and colleagues published a systematic review on the psychometric characteristics of bedside screening tests for detecting dysphagia in adult patients with neurologic disorders using either VFS or FEES as a reference test. Meanwhile, Kertscher and colleagues have carried out an updated review of the literature including recent literature up to December 2012. In both reviews, criteria on validity, generalizability, and reliability were adapted from the Dutch Cochrane Center ( Table 1 ) and used to assess the methodologic quality of the included studies on diagnostic tests. An overview of studies with an overall sufficient methodologic quality is presented in Table 2 . Next, diagnostic performance was determined by calculating prevalence, sensitivity, specificity, positive and negative predictive value, and likelihood ratio of a negative or positive test. Sufficient diagnostic performance was defined as high sensitivity (≥70%) and moderate specificity (≥60%). Studies showing sufficient methodologic quality and describing bedside screening tests having sufficient diagnostic performance are summarized in Table 3 . The list of different types of bedside screening includes trial swallow tests using different aliquots of water, various viscosities and/or volumes, or combining the results of pulse oximetry. Furthermore, data are available on the application of oxygen desaturation using a single water swallow, the screening for clinical features during an oropharyngeal examination, and the implementation of a standardized form on clinical identifiers to detect unsafe swallow. The feasibility of the screening tests in terms of complexity and time required to execute the screening proved to be sufficient for all 10 studies. Further details on the studies that were included in the review, especially on other psychometric characteristics, such as likelihood ratios of screening tools, can be found in the original articles and in the systematic reviews by Bours and colleagues and Kertscher and colleagues.
| Number | Quality Criteria a | Domain |
|---|---|---|
| 1 | Were the reference test and the index test interpreted independently (blinded)? | Validity |
| 2 | Was the reference test applied to all patients who received the index test? | |
| 3 | Was the index test applied independent of relevant information on clinical data of the patient regarding the target condition? | |
| 4 | Was the period between the reference test and the index test short enough to be reasonably sure that the target condition did not change between the two tests? (within 24 h in acute stroke, and within 7 d in order neurologic diseases) | |
| 5 | Was the selection of the study population valid? | |
| 6 | Are data presented in enough detail to calculate appropriate test characteristic? | |
| 7 | Was the study population appropriate to evaluate the proposed use of the index test? | Generalizability |
| 8 | Was the index test described in detail so it could be reproduced? | Reliability |
| 9 | Were satisfactory definitions used for normal/abnormal reference test results and normal/abnormal index test results? |
a Scoring of criteria: +, if item has been addressed; −, if item has been violated; ?, if no information is available.
| References (N = 16) | Type of Bedside Screening | Diagnostic Performance |
|---|---|---|
| Chong et al, 2003 | Trial swallow using water | + |
| Trial swallow using water in combination with oxygen desaturation | + | |
| Trial swallow using different viscosities in combination with oxygen desaturation | + | |
| Oxygen desaturation | − | |
| Clavé et al, 2008 | Trial swallow using different viscosities | + |
| Trial swallow using different viscosities in combination with oxygen desaturation | + | |
| Daniels et al, 1997 | Trial swallow using water | − |
| Clinical features | + | |
| Leder & Espinosa, 2002 | Standardized form with clinical features | − |
| Lim et al, 2001 | Trial swallow using water | + |
| Trial swallow using different viscosities in combination with oxygen desaturation | + | |
| Oxygen desaturation | + | |
| Logemann et al, 1999 | Trial swallow using various viscosities | − |
| Clinical features | − | |
| Standardized form with clinical features | − | |
| Mann, 2002 | Standardized form with clinical features | + |
| Mari et al, 1997 | Trial swallow using water | − |
| Martino et al, 2009 | Trial swallow using water | + |
| McCullough et al, 2001 | Trial swallow using different viscosities | + |
| Clinical features | − | |
| History components | − | |
| Smith et al, 2000 | Trial swallow using different viscosities | + |
| Trial swallow using different viscosities in combination with oxygen desaturation | + | |
| Oxygen desaturation | − | |
| Smithard et al, 1998 | Trial swallow using water | + |
| Suiter & Leder, 2008 | Trial swallow using water | − |
| Trapl et al, 2007 | Trial swallow using different viscosities | + |
| Wakasugi et al, 2008 | Cough elicitation | − |
a Methodologic quality is considered to be sufficient if no more than one criteria (see Table 1 ) has been allocated a minus or a question mark.
b Diagnostic performance is considered to be sufficient (+) when minimum criteria of specificity ≥60% and sensitivity ≥70% are met; other studies are indicated by a minus (−).
| Type of Bedside Screening | References (N = 11) | Description Bedside Screening | End Point Bedside Screening | Psychometric Characteristics | |
|---|---|---|---|---|---|
| Sensitivity | Specificity | ||||
| Trial swallow using water | Chong et al, 2003 | 5 × 10 mL of water | Coughing, choking, or voice change | 79 | 63 |
| Lim et al, 2001 | 5 × 10 mL of water | Coughing, choking, or voice change | 85 | 75 | |
| Martino et al, 2009 | Toronto Bedside Swallowing Screening Test 1st step : screening for abnormalities (eg, breathiness, gurgles, hoarseness, whisper quality of voice, and tongue moments); 2nd step : 10 × 1 tsp. of water | Failure at any item (of 1st or 2nd step) | 91 (all patients) | 67 (all patients) | |
| 96 (acute patients) | 64 (acute patients) | ||||
| 80 (rehabilitation patients) | 68 (rehabilitation patients) | ||||
| Smithard et al, 1998 | 1st step : 3 × 5 mL of water; 2nd step : 60 mL of water (in 2 min) | Coughing, choking, and/or wet voice: present in two out of three trials (1st step) or any swallow (2nd step) Assessment by physician | 70 | 66 | |
| Trial swallow using different viscosities | McCullough et al, 2001 | 4 sections : history, oral motor (speech and praxis), voice, and trial swallows Protocol trial swallows Thin liquid (2 × 5 mL); Thick liquid (2 × 5 mL); Puree (2 × 5 mL); Solid (2 × 0.25 of a cookie) | Subjective overall judgment of likelihood of aspiration | 78 (trial swallows) | 63 (trial swallows) |
| Smith et al, 2000 | Variety of quantities and consistencies | Subjective assessment of aspiration | 80 | 68 | |
| Trapl et al, 2007 | Gugging Swallowing Screen 1st step : Indirect swallowing test (saliva test); 2nd step : Direct swallowing test; S emisolid (one-third to one-half tsp., 5 × 0.50 tsp. of thickened water); Thin liquid (3, 5 10, 20, 50 mL of water); Solid (5 × small piece of dry bread) | Risk of aspiration on Gugging Swallowing Screen | 100 | 63 | |
| Clavé et al, 2008 | Volume-Viscosity Swallowing Test Nectar (5, 10, and 20 mL); Water (5, 10, and 20 mL); Pudding (5, 10, and 20 mL) | Penetration | 84 | 65 | |
| Piecemeal deglutition (multiple swallows per bolus) | 88 | 87 | |||
| Trial swallow using water in combination with oxygen desaturation | Chong et al, 2003 | Water test 5 × 10 mL of water Pulse oximetry (during fiberoptic endoscopic evaluation of swallowing) 3 to 5 spoons of 8 mL honey, nectar, thin and paste consistency | Coughing, choking, or voice change or ≥2% desaturation | 94 | 63 |
| Trial swallow using different viscosities in combination with oxygen desaturation | Chong et al, 2003 | Water test 5 × 10 mL of water Pulse oximetry (during fiberoptic endoscopic evaluation of swallowing) 3 to 5 spoons of 8 mL honey, nectar, thin and paste consistency | Coughing, choking, or voice change or ≥2% desaturation | 94 | 63 |
| Clavé et al, 2008 | Volume-Viscosity Swallowing Test Nectar (5, 10, and 20 mL); Water (5, 10, and 20 mL); Pudding (5, 10, and 20 mL) Finger pulse oximetry (during Volume-Viscosity Swallowing Test) | Impaired safety (eg, voice change including wet voice, cough, or decrease in oxygen saturation ≥3%) | 88 | 65 | |
| Lim et al, 2001 | Water test 5 × 10 mL of water Pulse oximetry 10 mL of water | Coughing, choking, or voice change or ≥2% desaturation | 98 | 70 | |
| Smith et al, 2000 | Swallow test Various quantities and viscosities Pulse oximetry (during videofluoroscopy) 3, 5, 10, and 20 mL thick liquid; Same quantities dilute liquid; 5 mL yoghurt; 5 ml solid (bread) | Subjective assessment of aspiration and ≥2% desaturation | 73 | 76 | |
| Oxygen desaturation | Lim et al, 2001 | Oxygen desaturation test (10 mL of water) | ≥2% desaturation | 77 | 83 |
| Clinical features | Daniels et al, 1997 | Oropharyngeal examination including examination of gag reflex, volitional cough, speech, and voice | Feature/end point: dysphonia (present/absent) | 73 | 72 |
| Standardized form with clinical features | Mann, 2002 | Clinical assessment including oral-motor-sensory examination (voice, speech, and language function) | Feature/end point: dysphagia (definite/probable/possible) | 73 | 89 |
| Swallow test: 5 and 20 mL of water, thickened fluid | Feature/end point: aspiration (definite/probable/possible) | 93 | 63 | ||
Selection of Bedside Screening
Summarizing all studies, both cited literature reviews conclude that no statistical pooling proved possible because of the heterogeneity of the bedside screening tests, the differences in implementation of tests, and diversity in end points either in the reference or in the index test. Only a few tests met the criteria for sufficient methodologic quality and diagnostic performance. Still, when deciding which type of bedside screening to implement in a clinical setting several factors need to be considered. First of all, the criteria used to describe study quality may sometimes be open to discussion and different interpretation. Furthermore, the psychometric characteristics of a diagnostic test need to be taken into account. In both literature reviews sufficient diagnostic performance was defined as high sensitivity and moderate specificity: sensitivity greater than or equal to 70% and specificity greater than or equal to 60%. These fixed cutoff points, however, could be argued. Apart from the fact that cutoff points may be somewhat arbitrary, possibly excluding screening tests by only failing a few percentages, different bedside tests may aim at different goals in distinct clinical settings. For example, the 3-oz water swallow test by Suiter and Leder did meet the original methodologic quality standards but failed the criteria on psychometric characteristics. Although the sensitivity was very high (97%) the specificity was only 49%, suggesting an optimal patient safety by missing hardly any patients at risk for aspiration, but meanwhile having many false-negatives. Failing the screening protocol indicates the need for further assessment, but not all work settings may be able to deal with so many requests for follow-up. Another choice to be made is the type of boluses used in the screening test. Clavé and colleagues introduce the volume-viscosity swallowing test, a trial swallow protocol including three different viscosities and volumes. The test results may provide direct indications for choices on oral intake after screening with regard to advised viscosities and volumes unlike, for example, the 3-oz water swallow test by Suiter and Leder or the Toronto Bedside Swallowing Screening Test by Martino. These two screening tools focus on identifying aspiration or dysphagia after which, in case of failing the screening protocol, further assessment is required. The concept of screening may differ from study to study and the distinction between what is considered to be screening and what is considered to be assessment may become an underlying issue.
Differences between screening protocols may not always have major implications for patients’ well-being, but the consequences for health care professionals within their work settings may be substantial. In general, it is accepted that a screening tool needs to be valid, reliable, and feasible. Other requirements resulting from the implementation of a chosen screening protocol may affect the number of health care professionals involved, changes in workload and time pressure, or need for training of staff in screening procedures to improve outcome reliability. Furthermore, the availability of follow-up assessments, such as FEES or VFS, must be addressed and the need for trained personnel in performing these gold standard assessments. Future cost-effectiveness studies are required to measure the effects of bedside screening for oropharyngeal dysphagia in relation to increased health care costs because of the complications as a result of aspiration.
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