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OJHAS Vol. 9, Issue 4:
(Oct-Dec, 2010) |
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| Creation
of a 13-Item Bedside Dysphagia Screening Test |
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Petra Mandysova, Vice-Dean, Faculty
of Health Studies, University of Pardubice, Pardubice, Czech Republic; Neurology Clinic,
Pardubice Regional Hospital, Czech Republic,
Jana
Škvrňáková, Vice-Dean, Faculty
of Health Studies, University of Pardubice, Pardubice, Czech Republic; Otorhinolaryngology
and Head and Neck Surgery Clinic, Pardubice Regional Hospital, Czech
Republic,
Edvard Ehler, Chief of Staff,
Neurology Clinic, Pardubice Regional Hospital, Czech Republic; Faculty of Health
Studies, University of Pardubice, Pardubice, Czech Republic
Michal
Černý, Otorhinolaryngology
and Head and Neck Surgery Clinic, Pardubice Regional Hospital, Czech
Republic; Faculty of Health
Studies, University of Pardubice, Pardubice, Czech Republic |
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Address For Correspondence |
Faculty of Health Studies,
University Pardubice,
Průmyslová 395,
532 10 Pardubice,
Czech Republic.
E-mail:
Petra.Mandysova@upce.cz |
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Mandysova P, Škvrňáková J, Ehler E,
Černý M. Creation
of a 13-Item Bedside Dysphagia Screening Test. Online J Health Allied Scs.
2010;9(4):6 |
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Submitted: Dec 10,
2010; Accepted: Dec 28, 2010; Published: Jan 20, 2011 |
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| Abstract: |
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Dysphagia is a common problem
that affects people with many health conditions and that can have serious
complications. Various dysphagia screening tests exist; however, their
creation was associated with certain weaknesses, e.g. none of them used
“objective” instrumental tests (e.g., videofluoroscopy or flexible
endoscopic examination of swallowing, FEES) in all patients to
verify the results. In addition, most dysphagia screening tests were
developed for stroke patients. The purpose of this study was
to fill this gap. Our research included not only patients with stroke
but also patients with other neurological and otorhinolaryngologic conditions.
We tested 33 physical examination items in 44 patients and analyzed
the results by comparing them to FEES results. Our study is the first
one that performed this kind of comparison in all the patients enrolled
in the study. Data mining was used to create a 13-item dysphagia screening
test that has 88.2% sensitivity.
Key Words:
Dysphagia; Dysphagia Screening;
Flexible Endoscopic Examination of Swallowing; Physical Examination;
Videofluoroscopy
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Impaired swallowing is a relatively
common health problem. The exact prevalence of dysphagia reported in
the literature varies depending on the studied population and the study
design. For example, the prevalence of dysphagia in the general non-treatment-seeking
population ranges between 6 and 16%,(1-2) and in the “well” elderly,
between 13.8% and 33%.(3-4) Specific patient populations have an even
higher prevalence of dysphagia – it is estimated to occur in 29% to
78% of patients with stroke,(5-9) up to 34% of patients with multiple
sclerosis, 81% of patients with Parkinson’s disease,(5) 24% of patients with
myasthenia gravis,(10-11) and 71.8% to 72.4% of patients with head and
neck cancer.(12-13)
The most common complications
of dysphagia include dehydration, nutritional deficiency, and weight
loss.(12,14) Aspiration is a particularly serious complication as it
can lead to aspiration pneumonia and even death.(9,12,15) Furthermore,
patients with dysphagia frequently report distress and a negative impact
on social activities such as eating out in restaurants or at friends’
houses.(12-13)
Because dysphagia is such a
common and potentially serious problem, it is very important to detect
its presence as early as possible. The two most common instrumental
methods used to detect dysphagia are videofluoroscopy and flexible endoscopic
evaluation of swallowing (FEES).(16) However, it may not be realistic
to use these methods on a large scale because instrumental testing requires
access to sophisticated equipment and trained specialists. Simpler dysphagia
assessment methods exist, mainly dysphagia screening tools, which consist
in bedside physical examination of the patient. Such tools can have
positive outcomes: for example, Hinchey et al. showed that health care
institutions using dysphagia screening protocols had lower pneumonia
rates compared to hospitals without such protocols.(17) However, the
quality and difficulty of the published swallowing screening tools varies.
One of the simplest tools, designed for nurses caring for stroke patients,
consists solely of “a water swallow test”
– the patient is offered three
teaspoons and then half a glass (60 mL) of water and is observed for
any swallowing difficulties such as coughing, choking, breathlessness,
and a wet or gurgly voice after swallowing.(18) However, the authors
(18) did not provide any information on the test’s sensitivity and specificity. The
Massey Bedside Swallowing Screen (MBSS), consisting of physical examination
of the patient and a water swallow test, was reported to have a 100%
sensitivity and specificity.(19) However, such high diagnostic performance
of the test may be disputable, especially since the MBSS was developed
on the basis of a study of only 25 stroke patients, of whom even fewer
patients—four—underwent videofluoroscopy to verify the results obtained
by screening.(19) The Toronto Bedside Swallowing Screening Test (TOR-BSST)
was developed based on a much larger study – it had enrolled 311 stroke
patients, 20% of whom had been randomly allocated to videofluoroscopic
assessment of swallowing in order to confirm the findings obtained by
screening.(7) The final version of the TOR-BSST contains 4 items and
its sensitivity is 91.3% and negative predictive value is 93.3% and
89.5% in acute and rehabilitation settings, respectively.(7) However,
implementation of the TOR-BSST may not be easy as it requires training
by a speech language therapist, who first needs to obtain certification
by attending a workshop organized by the authors of the tool. The Gugging
Swallowing Screen (GUSS), developed by Trapl et al., is interesting
due to the fact that the authors replaced the above mentioned water
swallow test by a thickened fluid swallow test, which they considered
safer.(8) The test was developed based on a study of 50 stroke patients,
49 of whom underwent not only physical examination of the swallowing
function but also FEES to verify the results obtained by screening.(8)
This comparison enabled to determine the test’s sensitivity (100%), specificity (50-69%),
and negative predictive value (100%).(8)
A critical analysis and comparison
of the mentioned dysphagia screening tools leads to the following summary:
a) most dysphagia screening tools include the use of unthickened water
even though the use of thickened water may be safer; b) none of the
mentioned screening tools have been evaluated by comparing them to “objective”
tests (videofluoroscopy, FEES) in all patients, c) the published
dysphagia screening tools focus on stroke patients, and d) implementation
of the published dysphagia screening tools may not always be easy.
The current study aimed to
fill the identified gaps in existing research and to develop a screening
tool that could be used to conduct dysphagia screening not only in stroke
patients but also in patients with other diseases. It was planned that
the tool would be developed based on a comparison of physical examination
of the swallowing function and FEES results; FEES was to be performed
in all the enrolled patients, which would mean that our study
would be supported by “objective” data to a higher degree than all
the other mentioned research studies, where fewer than 100% of the patients
underwent FEES or videofluoroscopy.
The study was initiated on
January 1, 2009. Patients admitted to a regional hospital in the Czech
Republic and meeting a set of criteria (prone to dysphagia based on
the main diagnosis, medically stable, sufficiently alert, able to collaborate,
able to maintain a sitting position) were enrolled in the study. Most
patients had a neurological or otorhinolaryngologic disease (cerebrovascular
accident, myasthenia gravis, multiple sclerosis, amyotrophic lateral
sclerosis, or cancer of the head or neck).
A trained clinician (an advanced-degree
nurse) performed a detailed bedside physical examination that focused
on swallowing and a fluid swallow test using thickened and unthickened
fluids. In total, this examination consisted of 33 items that had been
selected based on the MBSS (19) and discussions with dysphagia experts
(physicians, speech therapists, nurses). Based on Trapl et al.’s
GUSS,(8) the swallow test consisted in using thickened fluids in the
1st step (Fig. 1) and unthickened fluids in the 2nd step. Thickened
fluids of pudding consistency were used; this consistency was obtained
by mixing 60 mL of plain tea with 2 measuring scoops of a commercial
thickener (starch-based thickening powder) sold in pharmacies. Not all
33 items were always tested – sometimes, patients did not collaborate
(e.g., they did not understand all the clinician’s instructions). Other times, a specific
test item (e.g., drinking unthickened tea from a cup) was not deemed
to be safe based on the patient’s performance on the other items and
was therefore omitted.
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Figure 1: Thickened tea
of pudding consistency |
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Figure 2: FEES |
A specially trained physician
performed FEES (Fig. 2) on the above patients and scored them using
Rosenbeck’s Penetration Aspiration Scale (PAS)
(Table 1).(16) The results of the bedside physical examination and the
patient’s PAS score were compared, with the
aim to identify those items of physical examination that were abnormal
and that correlated with abnormal FEES results. These items would form
the basis of a dysphagia screening test.
The study was
approved by the hospital ethics committee. The patients were to sign an informed
consent to participate in the study. Patients who agreed to undergo physical
examination but refused FEES were excluded from data analysis.
Statistics
Data were entered into a Microsoft
Excel spreadsheet, setting out the FEES results and physical examination
items as columns (1 = normal result, 2 = abnormal result) and allocating
one row for each patient. Next, rows (patients) and columns (FEES and
physical examination items) with zero variability were identified. A
patient having the same result across the whole row (i.e., having number
1 in all the columns) was a “healthy” patient, and such patients
were deleted from further analysis. Similarly, those test items that
displayed zero variability were removed from further analysis. The aim
of these two steps was to eliminate rows (patients) and columns (physical
examination items) that would not contribute to the explanation of variation
that was observed and to prepare a data matrix for further analysis
using data mining. In addition, FEES results (PAS scores) were converted
to binary data (PAS score 1 = 1, i.e. normal, and PAS scores 2-8 = 2,
i.e. abnormal). The relationship between explanatory variables (physical
examination items entered in columns) and the response variable (FEES
results, i.e. PAS scores) was examined and those explanatory variables
that were abnormal (their value was 2) while the FEES was abnormal (had
a value of 2) were identified.
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Table 1: Rosenbeck’s Penetration Aspiration Scale (16) |
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Score |
Description of Event |
| 1. |
Material does not enter airway |
| 2. |
Material enters the airway,
remains above the vocal folds, and is ejected from the airway. |
| 3. |
Material enters the airway,
remains above the vocal folds, and is not ejected from the airway. |
| 4. |
Material enters the airway,
contacts the vocal folds, and is ejected from the airway. |
| 5. |
Material enters the airway,
contacts the vocal folds, and is not ejected from the airway. |
| 6. |
Material enters the airway,
passes below the vocal folds, and is ejected into the larynx or out
of the airway. |
| 7. |
Material enters the airway,
passes below the vocal folds, and is not ejected from the trachea despite
effort. |
| 8. |
Material enters the airway,
passes below the vocal folds, and no effort is made to eject. |
There were 44
patients who entered the study. Of these, 3 patients were found to be “healthy”,
i.e. their physical examination and FEES were normal. Of the remaining 41
patients, 17 had an abnormal FEES result and 24 patients had a normal FEES
result (Table 2). Among the 17 patients with abnormal FEES results, 11 patients
had a very high PAS score (PAS score 6 or 7). At the same time, one patient with
an abnormal FEES result had normal physical examination – this patient was
included in the analysis. Next, 9 columns (physical examination items) with zero
variability were identified and were deleted from further analysis, meaning that
the final number of physical examination items used for analysis was 24.
There were 7 physical examination
items that were always normal in normal-FEES patients and that
were abnormal in more than 10% of abnormal-FEES patients (Table 2).
These items are described in terms of their abnormal response: 1) “inability
to clench teeth”, 2) “soft palate movement is not symmetrical, uvula
deviation occurs”, 3) “inability to swallow thickened fluids without
choking”, 4) “voice hoarseness after swallowing thickened fluids”,
5) “thickened fluids dripping from the mouth”, 6) “voice hoarseness
after swallowing unthickened fluids given by a teaspoon”, and 7) “unthickened
fluids dripping from the mouth after drinking from a cup and swallowing”. Of
these 7 items, “voice hoarseness after swallowing thickened fluids” was abnormal
the most frequently (in 17.6% of abnormal-FEES patients); the other 6 items were
abnormal in only 11.8% of abnormal-FEES patients.
Furthermore, the original PAS
scores were examined in relation to these 7 physical examination items.
It was found that all but one abnormal physical examination item result
were associated with very high PAS scores, i.e. PAS = 6 or 7. If the
7 physical examination items were used to create a dysphagia screening
test (where only one abnormal item would mean that the entire screening
test was abnormal or positive), the sensitivity, specificity and efficiency of such a test in
our sample would be 52.9%, 100% and 80.5%, respectively (Table 3). Sensitivity
is the probability that a patient with dysphagia is positive on the
screening test (i.e., the patient’s physical examination is abnormal
for at least one of the tested items), specificity is the probability
that a patient with no dysphagia is negative on the screening test (i.e.,
the patient’s physical examination is normal for
all the tested items), and efficiency is the overall percentage of patients
correctly identified.(20)
Table 2: Results of FEES
testing and physical examination items [Click Here]
In contrast with the above-mentioned
7 physical examination items, other physical examination items were
abnormal in abnormal-FEES patients much more frequently; in fact, 3
items were abnormal in more than half of the abnormal-FEES patients.
These 3 items are “voice change”, “facial weakness or asymmetry”
and “dysarthria” and they were abnormal in 88.2%, 76.5% and 58.8%
of the abnormal-FEES cases, respectively (Table 2). In addition, 3 other
items that were abnormal quite frequently could be included in the dysphagia
screening test because they did not increase the test’s difficulty
as the patient would be swallowing thickened and unthickened fluids
to test some of the previously mentioned items anyway. These 3 items
are: “coughs after swallowing thickened fluids” (abnormal in 35.3%
of the abnormal-FEES patients), “coughs after swallowing teaspoons
of unthickened fluids” (abnormal in 17.6% of the abnormal-FEES patients)
and “coughs after drinking and swallowing unthickened fluids” (abnormal in 11.8%
of the abnormal-FEES patients) (Table 2). Whether or not the patient starts
coughing during a fluid swallow test is not dependent upon the clinician’s
instructions or commands; instead, cough develops if the fluid enters the
patient’s respiratory pathways.
The inclusion of the above
six items in the dysphagia screening test aimed to improve the screening test’s
sensitivity without increasing its difficulty too much. In our sample, these six
items in combination with the above mentioned 7-item physical examination test
had 88.2% sensitivity (Table 3).
Table
3: Sensitivity, specificity and efficiency of
the 13-item and 7-item dysphagia screening tests
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Dysphagia
based on "objective" testing (FEES) |
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Abnormal
FEES (PAS = 2-8) |
Normal
FEES (PAS = 1) |
Screening
test (total) |
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Results
of 13-item physical examination screening test |
Abnormal
(positive) |
a
= 15 (true positive) |
b
= 20 (false positive) |
a
+ b = 35 |
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Normal
(negative) |
c
= 2 (false negative) |
d
= 4 (true negative) |
c
+ d = 6 |
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True
dysphagia status (total) |
a
+ c = 17 (dysphagia present) |
b
+ d = 24 (dysphagia absent) |
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| Sensitivity =
a / (a + c) = 15/17 = 88.2% |
| Specificity =
d / (b + d) = 4/24 = 16.7% |
| Efficiency =
(a + d) / (a + b + c + d) = 19/41 = 46.3% |
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Results
of 7-item physical examination screening test |
Abnormal
(positive) |
a
= 9 (true positive) |
b
= 0 (false positive) |
a
+ b = 9 |
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Normal
(negative) |
c
= 8 (false negative) |
d
= 24 (true negative) |
c
+ d = 32 |
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True
dysphagia status (total) |
a
+ c = 17 (dysphagia present) |
b
+ d = 24 (dysphagia absent) |
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| Sensitivity =
a / (a + c) = 9/17 = 52.9% |
| Specificity =
d / (b + d) = 24/24 = 100% |
| Efficiency =
(a + d) / (a + b + c + d) = 33/41 = 80.5% |
The downside is that the added
6 items were abnormal in normal-FEES patient as well. As Table 2 demonstrates,
these 6 items were abnormal in normal-FEES patients with the following
frequencies: “voice change” in 75%, “facial weakness or asymmetry
in 45.8%”, “dysarthria” in 29.2%, “coughs after swallowing thickened
fluids” in 16.7%, “coughs after swallowing teaspoons of unthickened
fluids” in 20.8% and “coughs after drinking and swallowing unthickened
fluids” in 25% of the cases. As a result, the inclusion of these six
items in the dysphagia screening test increased the number of “false
positive” cases from 0 to 20 and consequently, it lowered the screening
test’s specificity to 16.7% (Table 3).
The
results show that it was possible to identify 7 physical examination
items whose abnormal results were in association with abnormal FEES
results while not producing any abnormal results in normal-FEES
patients. However, the frequency of such abnormal results in the
abnormal-FEES patients is quite low (11.8-17.6%). In addition, in all
but one case, these seven items were abnormal in patients whose PAS
scores were 6 or 7. In other patients with abnormal FEES results (PAS
scores 2-4), the results of these 7 physical examination items were
normal. In other words, the 7 physical examination items may not be
able to detect problems in abnormal-FEES patients if their PAS scores
are not too high.
At this point, the question
of screening tool sensitivity and specificity emerges. While screening
tests that employ stringent criteria have high specificity and low false
positive rates, more people who are at risk will be missed by such screening
tests (low sensitivity, high false negative rates).(20) This could be
acceptable in situations where limited resources exist to follow up
all patients who screen positive. However, given the fact that undetected
dysphagia can lead to pneumonia and even death, (9,12,15) it may better
to establish dysphagia screening that uses lenient—and not strict—criteria
and that is as sensitive as possible. In addition, lenient criteria,
and many positive outcomes, are suitable when the probability of a condition
(in this case, dysphagia) is high, even if only some of the cases are
true positives and the rest are false positives.(21) As was mentioned
above, the frequency of dysphagia in selected disorders, mainly neurological
and otorhinolaryngologic diseases, is high. In our sample, 17 out of
44 patients (38.6%) had dysphagia (i.e. had an abnormal PAS score) according
to the FEES results, which supports the findings mentioned in the literature.
If we consider that dysphagia is a frequent problem and that undetected
dysphagia can have serious consequences, our 7-item physical examination
(dysphagia screening) test is not lenient enough. It has 52.9% sensitivity,
meaning that only slightly more than half of the patients who had dysphagia
(had an abnormal PAS score on FEES) were identified using this screening
test. Achieving higher sensitivity and detecting more patients with
dysphagia is preferable. Therefore, we decided to extend the 7-item
screening test by including three physical examination items that were
abnormal very frequently (each item was abnormal in more than half of
the abnormal-FEES patients): “voice change”, “facial weakness
or asymmetry” and “dysarthria” and another three physical assessment
items (“coughs after thickened fluids/after teaspoons of unthickened
fluids/after drinking unthickened fluids”) that were abnormal less
frequently but that did not increase the difficulty of the test. Graph
1 illustrates the process of physical item selection for the final dysphagia
screening test (Table 2).
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Graph 1: The process
of item selection for the final 13-item
dysphagia screening test |
Including these 6 criteria
enabled us to create a much more lenient dysphagia screening test with
significantly improved sensitivity (88.2%). On the other hand, the inclusion
of these criteria produced more (20) false positives and decreased the
test’s specificity (from 100% in the 7-item dysphagia screening test
to 16.7%) and efficiency from 80% to 46.3% (Table 3).
It is interesting to compare
individual items contained in our 13-item dysphagia screening test to
other tests published in the literature. Some of our items overlap with
items present in the mentioned GUSS (“voice change”, “cough”,
“drooling” and “voice change after swallowing”);(8) however,
other items contained in the GUSS (“voluntary cough” and “ability to swallow
saliva”) were not included in our screening test because they had not been
abnormal in too many of our patients.
In our study, one abnormal
physical examination item was sufficient to label a patient as “positive”
(i.e. possibly having dysphagia) and to warrant further investigation.
This approach supports the idea of lenient criteria, as discussed above.
While the GUSS method (8) uses the same approach, other dysphagia screening
tools do not always label patients as “positive” despite the presence
of several abnormal results. For example, the mentioned MBSS contains
a decision tree according to which the patient’s physical examination
should be stopped if the patient does not have a “gag reflex”, “voluntary
cough” and “swallow reflex” and is not able to “swallow secretions”;(19)
however, no further instructions are available and it is not clear whether
the patient should be labeled as “positive” and more detailed investigation
should be recommended. In our view, the dysphagia screening process should be
clearly defined and it should be based on lenient criteria so that maximum
sensitivity could be achieved.
A very interesting observation
can be made if we focus on the difference between items tested after
swallowing thickened and unthickened fluids. We tested four items after
the patient was given thickened fluids (“inability to swallowing without
choking”, “voice hoarseness after swallowing”, “cough after
swallowing” and “fluids dripping from the mouth”) and abnormal
results were obtained in 11.8-35.3% of the abnormal-FEES patients (the
most frequent abnormality was “cough after swallowing”) (Table 1).
In normal-FEES patients, three of these items always produced normal
results and for only one item—“cough after swallowing”—, abnormal
results were obtained in 16.7% of the cases (Table 1). On the other
hand, we tested four items after the patient was given unthickened fluids
(two items —“cough after swallowing” and “voice hoarseness after
swallowing”—were tested after teaspoons of unthickened fluids and
two items —“cough after swallowing” and “fluids dripping from
the mouth” after drinking unthickened fluids from a cup). In abnormal-FEES
patients, the frequency of abnormal results upon testing the items ranged
from 11.8-17.6% of the cases. In normal-FEES patients, two items produced
only normal results, and the third and fourth item produced abnormal
results in 20.8% and 25% of the cases, respectively. In other words,
unthickened fluids produced abnormal results in normal-FEES patients
more frequently than in abnormal-FEES patients. Given this result, it
appears than testing with thickened fluids is more accurate than testing
with unthickened fluids although we admit that many of the abnormal-FEES
patients did not complete unthickened fluid testing, which did not enable us to
conduct a complete analysis of this aspect of testing.
The fact that some physical
examination items were abnormal yet the FEES result was normal can be
explained by the fact that FEES cannot detect problems in the oral phase
of swallowing.(22) For example, the patient may have facial weakness;
however, this problem will not be detected by the endoscope. In addition,
FEES is not able to visualize the period of “white out” that occurs
in the beginning of the pharyngeal phase of swallowing.(22) This is
one of the study’s limitations, as discussed below. Experts developing
screening tools through comparisons with videofluoroscopy may claim
that videofluoroscopy can assess not only the pharyngeal but also the
oral phase of swallowing and so it would be interesting to compare our
results to studies using videofluoroscopy rather than FEES to confirm
physical examination findings. However, even in large studies, such
as the mentioned Martino et al.’s study leading to the development
of TOR-BSST,(7) videofluoroscopy was performed in only a low percentage of the
examined patients, which did not enable detailed and accurate comparisons to
physical examination items.
To conclude, health care institutions
wishing to adopt a dysphagia screening tool that is based on bedside
physical examination should realize that each screening tool has its
limitations and should implement protocols that maximize positive outcomes.
Our study identified 7 physical examination items that had excellent
specificity; however, since the aim of screening is to alert the team
caring for the patient (the physician, speech language therapist, etc.)
that the patient may be experiencing swallowing problems and will need
further assessment, we recommend the 13-item dysphagia screening test,
which has very good sensitivity. As Graph 2 shows, some of the test’s
items can be tested together; e.g., the patient is given thickened fluids
and is observed for the occurrence of four items simultaneously: “inability
to swallow without choking”, “voice hoarseness after swallowing”,
“fluids dripping from the mouth after swallowing” and “cough after
swallowing”. This means that although the test contains 13 items,
the clinician does not have to perform 13 separate examinations but
only 8. Before the procedure is initiated, the patient should meet preliminary
criteria that were mentioned in the methods section. We believe that
even some patients who are not medically stable could undergo screening
(in our study, patients who were not stable were excluded mainly due
to the fact that they needed to undergo FEES in addition to bedside
physical examination, which we considered somewhat demanding).
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Graph
2: The procedure:
13-item dysphagia screening test |
The study’s limitation is the fact that some
physical examination / fluid swallow items were not tested. This situation
occurred especially if the patient had problems with swallowing thickened
fluids – at this point, the test was stopped as it was deemed unsafe
to continue and to offer the patient unthickened fluids. If we had continued
with testing, more patients would have abnormal findings upon swallowing
unthickened fluids as well. We believe that further research in this
area is necessary; it would be beneficial to determine whether indeed,
screening tests using thickened fluids are more beneficial than screening
tests using unthickened fluids.
Furthermore, universality of
the FEES method that consists in scoring patients according to the PAS
is limited given the fact that this method evaluates only penetration
and aspiration of food and not other aspects of dysphagia (prolonged
mastication, escape of fluid through the nose, etc.). In this respect,
the proposed dysphagia screening test is a test focusing on the risk
of penetration and aspiration as well. Future research should focus
on easy and quick identification of those patients who have swallowing
problems that do not necessarily cause aspiration (swallowing problems
mainly in the oral phase of swallowing) but that affect the patient’s
food intake and associated emotional and social functioning. Such research
may require the use of “objective” tests other than FEES or videofluoroscopy
to verify the findings. Finally, dysphagia research should focus on
patients with a variety of diseases and conditions and on non-treatment-seeking
people living in the community, mainly the elderly.
This study was supported by
Grant SGFZS01 from the Internal Grant Agency, University of Pardubice,
Czech Republic.
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