[Dysphagia] Screening

[eripley at yahoo.com (Irene Campbell-Taylor)]

        Screening swallowing function of patients with acute stroke. Part one: identification, implementation and initial evaluation of a screening tool for use by nurses
   Journal of Clinical Nursing
Volume 10 Page 463  - July 2001
      Lin Perry MSc, RGN, RNT
      ? Stroke is a major cause of acute and chronic disability in the developed world, producing a wide range of impairments, including dysphagia, which impact upon eating.
  ? Dysphagia affects between one and two thirds of patients with acute stroke, with the potential for life-threatening airway obstruction, aspiration pneumonia and malnutrition.
  ? Whilst associated with increased impairment, dysphagia may present in isolation or accompanied by minimal disability; universal screening of swallowing function is recommended.
  ? This study describes the process undertaken to review the evidence for dysphagia screening methods in patients with acute stroke. It also identifies, implements and establishes sensitivity and specificity of a screening tool (the Standardized Swallowing Assessment, SSA) for use by nurses.
  ? Not all ward staff had completed training to use the SSA by conclusion of the patient audit. Nonetheless 123 out of 165 assessable patients (74.5%) had their swallow function screened, 64 by SSA (52%). Based on 68 completed screening episodes by independently competent nurses, a comparison with summative clinical judgement of swallow function revealed a sensitivity of 0.97 and specificity of 0.9 for detection of dysphagia, with positive and negative predictive values of 0.92 and 0.96. This was significantly better than gag reflex performance, supporting the use of the SSA by competent ward nurses.
  See also:
  http://stroke.ahajournals.org/cgi/reprint/34/5/1252
   
  and
          Arch Phys Med Rehabil. 1994 Dec;75(12):1284-6.
     
  
Comment in: 
  Arch Phys Med Rehabil. 1995 Aug;76(8):788.
  
The Burke dysphagia screening test: validation of its use in patients with stroke.

DePippo KL, Holas MA, Reding MJ.

Department of Speech/Language Pathology, Cornell University Medical College, Burke Rehabilitation Hospital, White Plains, NY.

The objective of this study was to validate a dysphagia screening test to identify patients in the rehabilitation phase post stroke at risk for pneumonia, recurrent upper airway obstruction, and death. The setting was an inpatient stroke rehabilitation unit. One hundred thirty-nine consecutive patients met the following criteria: stroke confirmed by clinical history and neurological exam with compatible computed tomography (CT) or magnetic resonance imaging (MRI) scan; ages 20 to 90 years inclusive; and no known history of significant oral or pharyngeal anomaly. The main outcome measures were pneumonia, recurrent upper airway obstruction, and death. The Burke Dysphagia Screening Test (BDST) identified 11 of 12 patients who subsequently developed pneumonia, recurrent upper airway obstruction, or death (Fisher's exact test: p = .03). The relative risk for the occurrence of any of these complications was 7.65 times greater for those failing versus passing the BDST. The BDST
 identified 9 of 9 patients who developed pneumonia (Fisher's exact test: p = .01). We concluded that the BDST is of value in identifying patients in the rehabilitation phase poststroke at risk for pneumonia, recurrent upper airway obstruction, and death.
   
  Also:
  http://stroke.ahajournals.org/cgi/content/full/27/7/1200?ijkey=0ee12b5da019768a6ecb29176cf6402cc2bd731f
   
  which contains the following:
  Table 5. Bedside Swallowing Assessment 
                  Name                 
    Registration No.                
     
      Date           
    Day            
     
        
---------------------------------
  
  
      Conscious level
    (Alert=1, drowsy but rousable=2, response but no eye opening to speech=3, responds to pain=4)
    [ ]
      Head and trunk control
    (Normal sitting balance=1, sitting balance not maintained=2, head control only=3, no head control=4)
    [ ]
      Breathing pattern
    (Normal=1, abnormal=2)
    [ ]
      Lip closure
    (Normal=1, abnormal=2)
    [ ]
      Palate movement 
    (Symmetrical=1, asymmetrical=2, minimal/absent=3)
    [ ]
      Laryngeal function
    (Aah/ee) (Normal=1, weak=2, absent=3)
    [ ]
      Gag
    (Present=1, absent=2)
    [ ]
      Voluntary cough
    (Normal=1, weak=2, absent=3)
    [ ]
      Stage 1: Give a teaspoon (5 mL) of water 3 times.
     
     
      Dribbles water
    (None/once=1, >once=2)
    [ ]
      Laryngeal movement on attempted swallow
    (Yes=1, no=2)
    [ ]
      "Repeated movements" felt?
    (None/once=1, >once=2)
    [ ]
      Cough on swallowing
    (None/once=1, >once=2)
    [ ]
      Stridulous on swallowing
    (No=1, yes=2)
    [ ]
      Laryngeal function after swallowing 
    (Normal=1, weak/wet=2, absent=3)
    [ ]
      Stage 2: If the swallow is normal in stage 1 (2 of 3 attempts), try 60 mL of water in a beaker (plastic cup in England)).
     
     
      Able to finish?
    (Yes=1, no=2)
    [ ]
      Time taken to finish in seconds
     
    [ ]
      Number of sips
     
    [ ]
      Cough during or after swallowing
    (No=1, yes=2)
    [ ]
      Stridor during or after swallowing
    (No=1, yes=2)
    [ ]
      Laryngeal function after swallowing
    (Normal=1, weak/wet=2, absent=3)
    [ ]
      Do you feel aspiration is present?
    (No=1, possible=2, yes=3)
    [ ]
  
       
     
      And
     
             
          
    
    Arch Neurol Vol 49, 1992


  Validation of the 3-oz water swallow test for aspiration following stroke
  K. L. DePippo, M. A. Holas and M. J. Reding 
Cornell University Medical College, Burke Rehabilitation Center, White Plains, NY. 
  A 3-oz water swallow test identified 80% (16/20) of patients aspirating during a subsequent videofluoroscopic modified barium swallow examination (sensitivity, 76%; specificity, 59%). It also identified patients with more severe dysphagia aspirating larger amounts (sensitivity, 94%; specificity, 26%) or thicker consistencies (sensitivity, 94%; specificity, 30%) of test material. The 3-oz water swallow test is a sensitive screening tool for identifying patients at risk for clinically significant aspiration who need referral for more definitive modified barium swallow evaluation. 
   
   


Dr I Campbell-Taylor
Clinical Neuroscientist
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