2014 Adult Swallowing Group - PowerPoint Presentation

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2014 Adult Swallowing Group NSW Speech Pathology Evidence Based Practice Network

Carly Bowen, Christian Wiley and Claire Layfield (Group Co-Leaders) Hans Bogaardt - Academic Member

Man vs MachineSlide2

Clinical questionWhat is the reliability of clinical vs instrumental assessment and does this change overall management of individuals with dysphagia?Slide3

Why this clinical questionShould we be doing more instrumental assessments?How much confidence should we have in our bedside assessments?Pressure from medical teams to perform MBS despite bedside assessment

Validating clinical practice – we feel we are more than just a screenWhat parts of the bedside assessment are the most salientSlide4

The Evidence: SearchingInitial searching by the group found 23 articlesFrom these 19 were CAPPEDArticles were excluded because they did not perform either the bedside swallow assessment or the instrumental assessmentsSlide5

The Evidence: Research DesignResearch designs Pseudo-Randomised Control TrialNon Randomised group DesignProspective observational Study

Case SeriesLevels of evidence 1 = level 218 = Level 3Slide6

The Evidence: ParticipantsParticipants oropharyngeal dysphagia

13 out of the 19 CAPS were for acute CVA populations (less than a week post onset)The remaining 6 studies were on small samples of various populations including degenerative neurology, dementia, head and neck, post extubation or general “dysphagia”. Slide7

The Evidence : MethodsVariability noted in type of instrumental assessment Either FEES or MBSVariability noted in administration of assessment

Schedules of instrumental and clinical assessmentsDegree of inter / intra-rater reliability and validityBlindingConsistencies and proportions of food /fluids providedSlide8

The Evidence: MeasurementMeasures included – Aspiration and/or penetration in all studies. Two studies considered patient perspective of

dysphagiaSeveral studies included measures of “dysphagia” in the oral and/or pharyngeal phase. These studies developed their own methods of measuring dysphagia severityVariety of bedside indications of aspiration included:Cough (volitional and reflexive), wet voice, dysphonia, gag, dysarthria, Cranial Nerve AxSlide9

The Evidence: How results were presentedSensitivity and specificityUsed in almost all the studies Positive and negative predictive valuesCorrelation between tests on severity rating scales

Likelihood ratiosSlide10

Reminder of sensitivity and specificitySensitivity– How many aspirators are identified correctlySpecificity– How many non-aspirators are identified correctlySlide11

FindingsEvidence for bedside swallow accuracy is clearest for acute CVA patients Due to small sample sizes and limited number of studies, the evidence for the accuracy of bedside swallow assessment

for populations other than acute CVA is unclear Differences in study methodology and robustness of the studies make it difficult to compare results We did not perform a meta analysis. Slide12

FindingsIn patients with dysphagia, clinical bedside assessment is more accurate at detecting aspiration than screening but not as accurate as instrumental assessment.

In patients post CVA the sensitivity of bedside swallowing examinations in identifying aspirators ranged from 75% to 85% in 11 out of 13 studies. The two exception studies reported sensitivity of 47% and 100%. Specificity ranged from 65% and 90% in 12 out of 13 studies. The exception study had a specificity of 30%.Slide13

FindingsUsing combinations of predictive signs increases the likelihood of predicting aspiration from clinical bedside evaluationWhen assessing a patient at bedside the

signs that most accurately predict whether a patient is aspirating include - cough post swallow, reduced volitional cough strength, wet voice quality, breathy voice quality, and history of pneumoniaSlide14

Applying these results to clinical practiceInstrumental Assessment will always be more objective than clinical assessment However we need to consider clinical feasibility and suitability We can be pretty confident in our bedside assessment for patients post CVA.

Instrumental assessment is not essential to make safe decisions regarding management for patients post CVA. Slide15

Thoughts from the groupFelt reassured at clinical practice and improved confidence in decision making. Implications for sites that have reduced access to instrumental assessment. Results are

only for CVA population. Results would be different in other populations. Dysphagia assessment has a diagnostic and therapy role which is not simply limited to the identification of aspiration. Similarly MBS and FEES are also used for diagnostic and therapy reasons, biofeedback, patient education. Not just aspiration identification. Research did not necessarily address limitations of MBS and FEES vs Bedside. Natural environment, more bolus sizes, self feed. Slide16

Future ResearchResearch investigating bedside swallow accuracy in different populations. What populations should we be more or less confident in our bedside assessment? How many patients is it okay to miss with regards to aspiration? Consider outcome measures other than aspiration including swallow rehabilitation, diagnosis, patient education.

Consider the severity of aspiration. How much aspiration in an individual is okay?Quality of life outcomesSlide17

A final word“A well-trained clinician appears to be able to make a statistically accurate judgment that aspiration has occurred in patients who have suffered an acute stroke. This does not mean that a well-trained clinician can detect and rule out aspiration in stroke patients at bedside. It means that, statistically, a well-trained clinician can be right more than wrong in that judgment. Clinically speaking, this may fall short of necessary expectations. Are we missing aspirators at bedside? Yes. Are there negative outcomes associated with the aspirators missed? That question has not been answered

.”McCollough 2005, p15. Slide18

Plans for 2015Swallow rehabilitation – looking at the evidence behind EMST and Shaker in dysphagia. Leader – Christian WileySlide19

Questions???Slide20

ReferencesBarquist, Brown, Cohn, Lundy, Jackowski

(2001) Postextubation fiberoptic endoscopic evaluation of swallowing after prolonged endotracheal intubation: A randomized, prospective trial. Critical Care Medicine 29,9,p1 710-1713Cabre, M. Serra – Prat, M., Palomera, E. , Almirall, J., Pallares, R. and Clave, P. (2010). Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age and Aging, 39, 39-45Chong, M. S., Lieu, P. K.,

Sitoh, Y. Y., Meng, Y. Y. & Leoh, L. P (2003) ‘Bedside Clnical Methods Useful as Screening Test for Aspiration in Elderly Patients with Recent and Previous Strokes’ Annals Academy of Medicine, Vol. 32, No. 6 pp. 790 – 794Daniels, Brailey, Priestly, Herrington, Weisberg m Foundas (1998) Aspiration n patients with acute stroke.

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ReferencesMcCullough, Wertz & Rosenbek (2001) Sensitivity and specificity of clinical/bedside examination signs for detecting aspiration in adults subsequent to stroke.

Journal of Communication Disorders. 34 (2001) 55-72McCullough, G.H., Rosenbek, J.C., Wertz, R.T., McCoy, S., Mann, G., & McCullough, K. (2005). Utility of Clinical Swallowing Examination Measures for Detecting Aspiration Post-Stroke. Journal of Speech, Language and Hearing Research, 48: 1280-1293Miles, Zeng, McLauchlan, Huckabee (2013) Cough reflex testing in dysphagia following stroke: A randomised controlled trial Noordally, S. O., Sohawon, S., De

Gieter, M., Bellout, H, and Verougstraete, G. (2011). A study to determine the correlation between clinical, fibre optic endoscopic evaluation of swallowing, and videofluroscopic evaluations of swallowing after prolonged intubation. Nutrition in clinical practice, 6(4), 457-62Rosenbek, McCullough & Wertz (2004) Is the information about a test important? Applying the methods of evidence-based medicine to the clinical examination of swallowing. Journal of Communication Disorders (

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Formal Swallowing evaluation and therapy after TBI improves dysphagia outcome.

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Smith, H., Steven, H., O’Neill, P. And Connolly, M. (2000). The combination of bedside swallowing assessment and oxygen saturation monitoring of swallowing in acute stroke: a safe and humane screening tool.

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