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Clinical Nutrition (2008) 27, 806e815

available at www.sciencedirect.com

http://intl.elsevierhealth.com/journals/clnu

ORIGINAL ARTICLE

Accuracy of the volume-viscosity swallow


test for clinical screening of oropharyngeal
dysphagia and aspiration*
Pere Clave a,b,c,*, Viridiana Arreola a, Maise Romea a, Luca Medina a,
Elisabet Palomera a, Mateu Serra-Prat a,c

a
Unitat dExploracions Funcionals Digestives, Department of Surgery, Hospital de Mataro,
Universitat Autonoma de Barcelona, Carretera de Cirera s/n, 08304 Mataro, Spain
b
Fundacio de Gastroenterologia Dr. Francisco Vilardell, Barcelona, Spain
c
Centro de Investigacion Biomedica en Red, Enfermedades Hepaticas y Digestivas (Ciberehd),
Instituto de Salud Carlos III, Ministerio de Sanidad y Consumo, Spain

Received 5 January 2008; accepted 23 June 2008

KEYWORDS Summary
Oropharyngeal Aims: To determine the accuracy of the bedside volumeeviscosity swallow test (V-VST) for
dysphagia; clinical screening of impaired safety and efficacy of deglutition.
Silent aspiration; Methods: We studied 85 patients with dysphagia and 12 healthy subjects. Series of 5e20 mL
Pulse oximetry; nectar (295.02 mPa.s), liquid (21.61 mPa.s) and pudding (3682.21 mPa.s) bolus were
Malnutrition; administered during the V-VST and videofluoroscopy. Cough, fall in oxygen saturation 3%,
Bolus viscosity; and voice changes were considered signs of impaired safety, and piecemeal deglutition and
Deglutition disorders oropharyngeal residue, signs of impaired efficacy.
Results: Videofluoroscopy showed patients had prolonged swallow response (1064 ms); 52.1%
had safe swallow at nectar, 32.9%, at liquid (p < 0.05), and 80.6% at pudding viscosity
(p < 0.05); 29.4% had aspirations, and 45.8% oropharyngeal residue. The V-VST showed 83.7%
sensitivity and 64.7% specificity for bolus penetration into the larynx and 100% sensitivity
and 28.8% specificity for aspiration. Sensitivity of V-VST was 69.2% for residue, 88.4% for piece-
meal deglutition, and 84.6% for identifying patients whose deglutition improved by enhancing
bolus viscosity. Specificity was 80.6%, 87.5%, and 73.7%, respectively.

Abbreviations: OSR, oropharyngeal swallow response; VFS, videofluoroscopy; LV, laryngeal vestibule; V-VST, volume-viscosity swallow test;
HV, healthy volunteers; GPJ, glossopalatal junction; UES, upper esophageal sphincter.
*
Conference presentation: this study was presented in part at the 2007 Annual Scientific Meeting of the American Geriatrics Society, May
2e6, 2007, Seattle, WA, USA.
* Corresponding author. Tel.: 34 93 741 77 00; fax: 34 93 741 77 33.
URL: http://pclave@teleline.es

0261-5614/$ - see front matter 2008 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
doi:10.1016/j.clnu.2008.06.011
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Screening for dysphagia and aspiration 807

Conclusions: The V-VST is a sensitive clinical method to identify patients with dysphagia at risk
for respiratory and nutritional complications, and patients whose deglutition could be
improved by enhancing bolus viscosity. Patients with a positive test should undergo video-
fluoroscopy.
2008 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights
reserved.

Introduction accuracy are, therefore, needed to recognize patients


with oropharyngeal dysphagia, to identify patients at risk
Oropharyngeal dysphagia is a major complaint among many of aspiration and who should be referred for a VFS, and
patients with neurological diseases and among the elderly. to help select the most appropriate bolus volume and
The prevalence of functional oropharyngeal dysphagia is viscosity for those patients who cannot easily undergo VFS.9
very high: it affects more than 30% of patients who have This study was specifically designed to assess the
had a cerebrovascular accident, 52%e82% patients with diagnostic accuracy of a clinical bedside test, the volu-
neurodegenerative diseases, more than 35% patients with meeviscosity swallow test (V-VST), to predict signs of
head and neck diseases, and more than 60% of elderly dysphagia and impaired safety of deglutition (penetration,
institutionalized patients.1,2 Oropharyngeal dysphagia may aspiration) observed during VFS studies, and to identify
give rise to clinically relevant complications such as aspira- patients whose deglutition could be improved by increasing
tion pneumonia, malnutrition and/or dehydration. When bolus viscosity. To that end we studied patients with
a decrease in deglutition safety occurs, choking and prevalent conditions causing dysphagia such as old age,
tracheobronchial aspiration results in pneumonia in 50% of neurological diseases and head and neck diseases.
cases, with an associated mortality of up to 50%.1,2
Impaired safety also limits the ability of patients to ingest Material and methods
all the calories and water that they need to be adequately
nourished and hydrated.1,2 A 10-year review found the Sample
number of elderly patients with aspiration pneumonia
increased 93.8% while other types of pneumonia in the The study population included two main groups of
elderly decreased.3,4 A recent resolution of the Council of participants: Group 1 were healthy volunteers (HV)
Europe claimed that undernutrition among hospital (n Z 12) to assess normal swallow physiology (Table 1)
patients is highly prevalent and leads to extended hospital and Group 2 were patients with oropharyngeal dysphagia
stays, prolonged rehabilitation, and diminished quality of (n Z 85). We studied 85 consecutive patients with swallow-
life, and identified oropharyngeal dysphagia as a major ing difficulties8,13 whom we received for evaluation
contributor to malnutrition.5 The current state of the art between January and December 2006. Demographic infor-
of oropharyngeal dysphagia management aims at early mation of the study patients is shown in Table 1. Our study
identification of patients at risk for aspiration, assessment included (a) 40 elderly patients of whom 23 had cerebrovas-
of alterations in the biomechanical events of oropharyngeal cular disease; 8, chronic pneumopathy; 2, diabetes and 7,
swallow response (OSR), and prevention and treatment of other geriatric diseases; (b) 24 patients with neurodegener-
the potential complications of dysphagia such as aspiration ative diseases of whom 7 had amyotrophic lateral sclerosis;
pneumonia and malnutrition.6 4, multiple sclerosis; 2, Parkinsons disease; 2, Alzheimers
Videofluoroscopy (VFS) is the gold standard method for disease; 2, Huntingtons disease; 2, Duchenne muscular
studying the oral and pharyngeal mechanisms of dysphagia dystrophy and 5, other neurodegenerative diseases, and
and for evaluating efficacy, and safety of swallow.1,2,6 VFS (c) 21 patients with head and neck diseases of whom 4
can identify the main signs of oropharyngeal dysfunction, had Zenkers diverticulum or cricopharyngeal bars, and 16
which are delay in pharyngeal swallow, penetration of bolus patients had undergone previous surgery, 4 oral, 2
into the laryngeal vestibule (LV), tracheobronchial aspira-
tion and oropharyngeal residue, and can assess the short
term effect of therapeutic strategies on dysphagic Table 1 Age and sex of patients with oropharyngeal
patients.1,7 Using this technique, we have recently shown dysphagia and healthy volunteers included in the study
that patients with neurogenic dysphagia presented high (*p < 0.05 vs healthy volunteers, #p < 0.05 vs elderly
prevalence of impaired safety during liquid boluses and patients)
that increasing bolus viscosity to nectar and pudding
viscosity exerted a strong therapeutic effect on safety of Group/disease N n Median age Sex
deglutition.8 In contrast, increasing bolus volume impaired (years)  SEM (w/m)
safety of deglutition in these patients.8 High prevalence of Healthy volunteers 12 40  2.49# 6/6
dysphagia among vulnerable patients and the dynamic Patients with dysphagia 85 70  1.91* 30/55
condition of this symptom according to the natural history Elderly patients 40 75  2.85* 14/26
of each disease makes it unfeasible to perform a VFS on Neurodegenerative diseases 24 60  3.88*# 10/14
every patient or to repeat VFS studies during disease evolu- Head and neck diseases 21 70  3.04* 6/15
tion. Clinical screening methods with high diagnostic
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808 P. Clave et al.

pharyngeal, and 10 laryngeal, one-third of these patients obtained 2 min prior to starting the test. Cough and/or
with head and neck diseases had undergone tracheotomy. fall in oxygen saturation 3% were considered major
Protocol studies were approved by the Institutional Ethical clinical signs of tracheobronchial aspiration.12 The
Committee of the Hospital de Mataro (Mataro, Spain). volumeeviscosity method is an effort test in which boluses
of increasing volume and difficulty are administered to
Experimental design check for clinical signs of impaired efficacy and safety in
each swallow (Fig. 1). In addition the V-VST examines
Patients and HV were screened with the V-VST for clinical whether patients swallow efficacy and safety is improved
signs of oropharyngeal dysphagia and aspiration; and given by increasing viscosity. The V-VST was designed to protect
a VFS of swallow to assess VFS signs of safety and efficacy of patients from aspiration by starting with nectar viscosity
deglutition,7,8 OSR,8,10 and the effect of bolus volume and and increasing volumes from 5 mL to 10 mL and 20 ml
viscosity.8 Clinical and videofluoroscopic studies were con- boluses in a progression of increasing difficulty (Fig. 1A).
ducted on the same day starting with the V-VST (performed When patients completed the nectar series without major
by VA and MR) and followed by the VFS (performed by PC symptoms of aspiration (cough and/or fall in oxygen satura-
and LM), blind to the clinical results. The main aim of the tion 3%), a less safe liquid viscosity series was assessed
study was to assess the diagnostic sensitivity and specificity also with boluses of increasing difficulty (5 mL to 20 mL).
of the V-VST taking the results of the VFS of swallow study Finally, a safer pudding viscosity series (5 mLe20 mL) was
as the gold standard. assessed in the same way (Fig. 1A). If the patient presented
signs of impaired safety at nectar viscosity, the series was
interrupted, the liquid series was omitted, and a more
Measurement of bolus viscosity and volume
safe pudding viscosity series was assessed (Fig. 1B). If the
patient presented signs of impaired safety at liquid
Similar bolus volumes (5 mL, 10 mL and 20 mL) and viscosity, the liquid series was interrupted and the pudding
viscosities (liquid, nectar and pudding) were used for the series was assessed (Fig. 1C). All clinical explorations
V-VST and VFS studies. Bolus viscosity was measured by including oxygen saturation measurements were filmed
a rotational viscosimeter (Haake VT500, Thermo Electron with a digital video camera (DVR-PC100E, Mini DV, Sony
GmbH, Karlsruhe, Germany) in mPa.s at 25  C. For V-VST Corporation, Tokyo, Japan) and recorded for objective
studies, liquid viscosity was obtained by using mineral review.
water at room temperature (21.61  0.21 mPa.s), nectar
viscosity by adding 4.5 g of the thickener Resource
ThickenUp (Novartis Consumer Health SA, Barcelona, Spain) Diagnosis of videofluoroscopic signs
to 100 mL mineral water (295.02  25.91 mPas.s), and
pudding by adding 9 ge100 mL mineral water (3682.21  Subjects were studied in a lateral projection and images
223.20 mPa.s) (n Z 12). For VFS studies, liquid viscosity included the oral cavity, pharynx, larynx, and cervical
(20.40  0.23 mPa.s) was obtained by mixing 1:1 mineral esophagus.8,10 VFS recordings were obtained by using
water and the X-ray contrast Gastrografin (Berlimed SA, a Super X T-20 Toshiba Intensifier (Toshiba Medical Systems
Madrid, Spain) both at room temperature, nectar viscosity Europe, Zoetermeer, Netherlands) and images were
(274.42  13.14 mPa.s) by adding 3.5 g of thickener recorded at 25 frames/sec (Panasonic AG DVX-100B, Mat-
Resource ThickenUp (Novartis Consumer Health SA, Barce- sushita Electric Industrial Co., Ltd., Osaka, Japan). Swal-
lona, Spain) to liquid solution and pudding viscosity lows were analyzed by equipment (Swallowing Observer,
(3931.23  166.15 mPa.s) by adding 8 g of the thickener Image & Physiology SL, Barcelona, Spain) developed to
(n Z 12). Solutions were prepared 10 min prior to measure- capture and digitize the swallowing sequences to assess
ment. Boluses of 5 mL, 10 mL, and 20 ml of each viscosity VFS signs according to accepted definitions7,8,11 and to
series were offered to patients with a syringe during V- measure the OSR.8,10 Penetration was defined as the
VST and VFS studies to ensure accurate measurement of entrance of swallowed material into the LV, and aspiration
bolus volume.8 as the passage of this material below the vocal folds.7,8,10
During VFS studies, we used the same strategy to protect
Clinical assessment of dysphagia by the volumee patients from aspiration and the same bolus volume and
viscosity method viscosity as in the clinical assessment by the V-VST (Fig. 1).

Clinical assessment of dysphagia was conducted by expert Measurement of OSR


swallow therapists (VA, MR). The aim of the V-VST is to
identify clinical signs of impaired efficacy of swallow,11 Measurements of oropharyngeal reconfiguration during OSR
such as impaired labial seal, oral or pharyngeal residue, were obtained during 5 mL nectar swallows because all
and piecemeal deglutition (multiple swallows per bolus), patients swallowed this bolus. Timing of the opening or closing
and clinical signs of impaired safety during swallow such events occurring at the glossopalatal junction (GPJ), velophar-
as changes in voice quality (including wet voice), cough or yngeal junction, LV, and upper esophageal sphincter (UES)
a decrease in oxygen saturation 3% measured with a finger were measured, GPJ opening being given the value of
pulse-oximeter (Nellcor OxiMax, Philips Medical Systems, Time Z 0 (Fig. 2).8,10 Overall duration of OSR (GPJ opening -
Eindhoven, Netherlands) to detect silent aspirations.12,13 LV opening) and speed of oropharynx reconfiguration from
The probe of the pulse-oximeter was placed on the index a respiratory to digestive pathway (GPJ opening - LV closure)
finger of the right hand and baseline readings were were determined (Fig. 2). Patients with dysphagia were
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Screening for dysphagia and aspiration 809

SAFE SWALLOW IMPAIRED SAFETY AT NECTAR IMPAIRED SAFETY AT LIQUID

START START START

Bolus N / Volume Bolus N / Volume Bolus N / Volume


5ml 5ml 5ml
1 1 1
IMPAIRED
NECTAR

SAFE SAFE 10ml SAFE 10ml


10ml SAFETY
SWALLOW 2 SWALLOW 2 SWALLOW 2

20ml 20ml
3 3

5ml 5ml
4 4
LIQUID

SAFE SAFE 10ml IMPAIRED


10ml SAFETY
SWALLOW 5 SWALLOW 5

20ml
6

5ml 5ml 5ml


7 3 6
10ml
PUDDING

SAFE SAFE 10ml SAFE


10ml
SWALLOW 8 SWALLOW 4 SWALLOW 7

20ml
20ml 20ml
9 5 8

END EXPLORATION END EXPLORATION END EXPLORATION

Figure 1 Algorithms of bolus volume and viscosity administration during V-VST and VFS studies. (a) Patients with safe swallow
completed the pathway, (b) representative pathway for patients with impaired safety at 10 mL nectar, and (c) representative
pathway for patients with impaired safety at 10 mL liquid viscosity. Bolus Number (Bolus N) depicts the sequence of bolus admin-
istration in each pathway.

classified into those with safe deglutition and those with Results
impaired safety (penetration or aspiration).8
Demographics
Data analysis and statistical methods
Median age of all three groups of patients with dysphagia
Quantitative parameters were described by median (age) or was higher than that of HV (Table 1). Our group of patients
mean  S.E.M (physiological values), and comparisons were with oropharyngeal dysphagia included middle-aged
assessed by the non-parametric KurskaleWallis and Manne patients with neurodegenerative diseases and elderly
Whitney tests. Qualitative parameters were described by patients with cerebrovascular disease, geriatric diseases,
frequencies. Safety and efficacy of deglutition were or head and neck diseases (p < 0.05).
assessed by prevalence of clinical or VFS signs. The effect
of bolus volume and viscosity increments on the safety
and efficacy parameters was assessed by the non-para-
Clinical signs of oropharyngeal dysphagia by the
metric Cochran Q test, which compares multiple related volumeeviscosity test
proportions. When this test gave significant results, combi-
nations of two paired proportions were compared by the HV
McNemar test. The same methodology was used for clinical All volunteers presented a safe and efficacious swallow.
and VFS signs.8 The results for each group of patients with
safe or unsafe swallow and those of healthy subjects were Patients with oropharyngeal dysphagia
compared against each group using Students t-test for vari- Mean duration of clinical assessment of dysphagia by the V-
ables with normal distribution and the ManneWhitney U VST was 5.54  2.18 min. Piecemeal deglutition was
test for variables without normal distribution. Sensitivity, observed in up to 15.3% patients during liquid series,
specificity, and positive and negative predictive values of 25.9% patients during nectar series and 30.6% patients at
the clinical signs were calculated to assess the diagnostic pudding viscosity (p < 0.05, Fig. 3). Oral residue was
accuracy of all clinical signs or symptoms in predicting observed in only 3.5% patients during liquid series and
both videofluoroscopic aspiration and penetration (consid- was significantly enhanced to up to 10.6% patients during
ered the gold standard).14 Statistical significance was nectar series and 12.9% patients at pudding viscosity
accepted if p-values were <0.05. (p < 0.05 vs liquid series). Symptoms of pharyngeal residue
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810 P. Clave et al.

Figure 2 VFS recordings of 5 mL nectar swallow in: (A) healthy subject; (B) patient with dysphagia, safe swallow, and impaired
efficacy (note the residue in vallecula and pyriform sinus), and (C) patient showing an aspiration into the airway as the bolus
traverses the vocal cords and enters the trachea. Diagrams at the bottom of each tracing show means of temporal events at glos-
sopalatal junction -1-, velopharyngeal junction -2- laryngeal vestibule -3-, and upper esophageal sphincter -4- in the following
groups of subjects: (a) HV; (b) patients with dysphagia and safe swallow, and (c) patients with dysphagia and impaired safety; white
dot in diagram C represents timing of laryngeal penetration and the red point, time of aspiration.

were recorded in up to 15.3% patients during liquid series, Videofluoroscopic signs of oropharyngeal dysphagia
and significantly enhanced to up to 45.9% patients during
nectar series and 56.6% patients at pudding viscosity HV
(p < 0.05) (Fig. 3). Prevalence of patients with safe swallow All volunteers presented a safe and efficacious swallow.
is also represented in Fig. 3. Clinical signs of impaired
safety of swallow (Table 3) were observed in 50%e75.3% Patients with oropharyngeal dysphagia
patients during liquid series, 23.4%e39.2% patients during Piecemeal deglutition was observed in 10.6%e17.6% of
nectar series and 14.5%e27.6% patients at pudding viscosity patients during 5 mL swallows, 21.2%e27.1% patients
(p < 0.05), and were significantly increased by bolus volume during 10 mL swallows, and 24.7%e36.5% patients during
in each viscosity series (p < 0.05). 20 mL swallows (p < 0.05) and was unaffected by bolus

Figure 3 Prevalence of clinical signs of safety and efficacy of pharyngeal phase of swallowing for each bolus volume and viscosity
during the V-VST. All patients with oropharyngeal dysphagia are pooled and HV are not shown. Safety of swallow was expressed as
the percentage of patients that could swallow without clinical signs of cough, changes in voice, or a fall in oxygen saturation 3%.
*p < 0.05 effect of increasing bolus volume; #p < 0.05 vs liquid viscosity.
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Screening for dysphagia and aspiration 811

viscosity. Prevalence of patients with oral residue was low HV), and time to UES opening was 360  2 ms (p < 0.05 vs
(Fig. 4). In contrast, pharyngeal residue was a common HV, Fig. 2B). Patients with impaired safety (penetration
VFS sign in patients with dysphagia. Impaired vallecular or aspiration) presented a total OSR duration of
clearance was observed in 30.6% of patients during liquid 1162  7 ms and even a more severe delay in LV closure
series, 38.8% during nectar series and increased to 48.2% (541  6 ms, p < 0.05 vs patients with safe swallow and
at pudding viscosity (p < 0.005). Similarly, residue in the HV) and UES opening (410  4 ms, p < 0.05 vs patients
pyriform sinus was observed in 29.4% of patients during with safe swallow and HV, Fig. 2C). These results show
liquid series, 34.1% during nectar series and increased to that patients with oropharyngeal dysphagia presented
up to 44.7% at pudding viscosity (p < 0.005). Thereafter, slow oropharyngeal reconfiguration which correlates with
pudding viscosity significantly increased pharyngeal residue impaired safety of swallowing (Fig. 2).
(Fig. 4). Penetration into the LV during the pharyngeal
phase was the most prevalent cause of unsafe deglutition Diagnostic accuracy of the V-VST
and was observed in 37.6%e45.9% of patients when swal-
lowing liquid boluses and 24.7%e35.3% during nectar series. Table 2 summarizes the measurements of diagnostic
Increasing bolus viscosity to pudding significantly reduced accuracy (sensitivity, specificity, and predictive values) of
prevalence of patients with laryngeal penetration to less clinical signs of impaired safety and efficacy of swallow.
than 14.1% (p < 0.05). More than 80.6% patients presented Main results show that diagnostic sensitivity and specificity
safe swallow at pudding viscosity, a proportion that was of the V-VST for clinical signs of impaired safety of swallow
reduced to 52.1% during nectar series (p < 0.05) and further (aspiration or penetration) were 88.2% and 64.7%, respec-
reduced to 32.9% at liquid viscosity (Fig. 4) (p < 0.05). tively. A very important result was that the sensitivity of
Increasing bolus volume significantly impaired safety of the V-VST was 100% in recognizing patients with aspiration
swallow at liquid and nectar viscosity (Fig. 4). confirmed by VFS. Following a negative V-VST, the proba-
bility of no aspiration (negative predictive value) was also
Oropharyngeal swallow response 100%, and the probability of no penetration was 57.9%.
On the other hand, specificity (probability of a negative
OSR in HV result when the disease is absent) of the V-VST was low in
Total duration of swallow response (GPJ opening-LV the diagnosis of aspiration as a specific disorder, but
opening) for 5 mL boluses was short (760  2 ms). Recon- achieved 64.7% (which means a false positive rate of
figuration of the oropharynx from a respiratory to a diges- 35.3%) if penetration was also considered a sign of impaired
tive pathway was very fast: (a) time taken to close airway safety of swallow (Table 3). Overall, 25 patients presented
entrance at the LV was 157  1 msec and time to open aspiration during VFS studies and the V-VST identified clin-
the UES was 200  1 msec (Fig. 2A). ical signs of impaired safety of swallow in all these
patients. Table 3 shows no differences on basal oxygen
OSR in patients with oropharyngeal dysphagia saturation among patients with/without impaired safety
Total duration of the OSR in patients with dysphagia and at VFS. Up to 48% of patients with aspiration at VFS
safe swallow was 1064  4 ms, significantly longer than in (14.1% of all patients with dysphagia) did not present cough
HV (p < 0.05). The reconfiguration phase was also longer (silent aspirators) and were clinically recognized by a fall in
in patients compared with HV as time to LV closure in oxygen saturation 3% and/or changes in voice after
patients with safe swallowing was 302  2 ms (p < 0.05 vs swallow. One-third of patients with silent aspirations

Figure 4 Prevalence of VFS signs of safety and efficacy of pharyngeal phase of swallowing for each bolus volume and viscosity
during VFS studies. All patients with oropharyngeal dysphagia are pooled and HV are not shown. Safety of swallow was expressed
as the percentage of patients that could swallow without signs of contrast entering the LV or traversing the vocal folds for each
bolus volume and viscosity. *p < 0.05 effect of increasing bolus volume; #p < 0.05 vs liquid viscosity, yp < 0.05 vs nectar viscosity.
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812 P. Clave et al.

Table 2 Sensitivity, specificity and predictive values (PV) Table 3 Results of the volumeeviscosity swallow test
of the volumeeviscosity swallow test (V-VST) in patients (V-VST) according to videofluoroscopy (VFS) findings
with dysphagia VFS Clinical signs of V-VST
Sensitivity Specificity Positive Negative Basal O. Cough Voice Desaturation
(%) (%) PV (%) PV (%) Sat.a (%) (%) change by 3% (%)
Impaired safety 88.2 64.7 90.9 57.9 (%)
Aspiration 100 28.8 28.8 100 Safe swallow 98.13  2.55 14 36.4 0
Penetration 83.7 64.7 87.2 57.9 (n Z 22)
Oral residue 69.2 80.6 39.1 93.5 Penetration 97.86  2.49 15.8 60.5* 13.1*
Pharyngeal 86.4 34.6 75.0 52.9 (n Z 38)
residue Aspiration 97.15  2.67 52*# 56* 36*#
Piecemeal 88.4 87.5 96.8 63.6 (n Z 25)
deglutition
Results are expressed as % of patients presenting each clinical
sign.
*p < 0.05 vs patients with safe swallow, and #p < 0.05 vs
showed oxygen desaturation during swallow. Finally, patients with penetration.
a
sensitivity of the V-VST in selecting patients whose safety Indicates basal oxygen saturation.
of swallow could be improved by increasing bolus viscosity
was 84.6%, specificity was 73.4% and the probability of
a therapeutic effect of viscosity (positive predictive value)
dehydration and mortality.15e17 One-third of all stroke
reducing penetrations and aspirations in a patient identi-
patients develop aspiration pneumonia which is the first
fied by the V-VST was 89.9%.
cause of death in stroke patients after hospital
discharge.1,16 Dysphagia in patients with neurodegenera-
Discussion tive diseases causes suboptimal caloric and fluid intake
and high risk for pneumonia.18,19 In a previous VFS study
Our study found high prevalence of videofluoroscopic signs on patients with neurogenic dysphagia we found high
of impaired safety and efficacy of swallow indicating high prevalence (21%) of aspiration, and malnutrition (24.1%
risk of severe respiratory and nutritional complications in according to SGA B or C, or weight loss >10%), with a strong
a group of hospitalized patients with oropharyngeal correlation between severity of dysphagia and malnutri-
dysphagia. We also found that most of these patients at tion.8 We also recently found that prevalence of malnutri-
risk of complications could be quickly, safely and accu- tion (MNA < 17 in 33%), aspiration pneumonia, disability,
rately recognized by using a clinical bedside method we morbidity and mortality was significantly higher in older
have developed as the V-VST that systematically evaluates patients with dysphagia.20
the main clinical signs and symptoms of safety and efficacy Screening for oropharyngeal dysphagia should be low
of swallowing and monitors pulse oximetry to improve the risk, quick, and low cost and aim at identifying the highest
detection of patients with silent aspirations. Our study also risk patients for further assessment. The consequence of
shows that patients identified by a positive V-VST as a false-negative diagnosis of patient with oropharyngeal
presenting impaired safety of swallowing should be aspiration can lead to aspiration pneumonia and the death
referred for a VFS study to assess the severity, the of the patient. There is evidence that implementation of
physiopathology and potential treatment of the swallow dysphagia programmes, including screening,21 results in
disorder. substantial reductions in pneumonia rates22 and improve-
Dysphagia is a highly prevalent condition among ment in nutritional status.23 Other authors suggest,
vulnerable patients admitted to a general hospital with however, that clinicians cannot detect dysphagia,
neurological or neurodegenerative diseases, head and neck aspiration and abnormal swallow physiology by clinical
diseases, and among the elderly.1,6 Data from all these exploration.11,24 Current methods for clinical screening of
patients were pooled in our analysis because they share dysphagia are the water swallow test,25 the 3 oz water
many characteristics of the clinical complaints, pathophys- test developed in the Burke Rehabilitation Center,9 the
iology, and risk of nutritional and respiratory complications timed swallow test,26 and the standardized bedside swallow
caused by oropharyngeal dysphagia, as we found in our assessment.21,27 These existing screening tests involve
previous studies.2,3,6,8 In the present study we found the continuous swallowing of quite large amounts of liquid and
swallow response was severely impaired in patients with may place the patient at high risk for aspiration,11 and
dysphagia. Overall duration of swallow response in patients almost all methods have been validated only on patients
was significantly longer than in HV mainly due to delay in with dysphagia caused by stroke,9,12,13,15,16,21,22,27,28 limiting
the timing of the early phase of oropharyngeal reconfigura- the application of these tests on patients with dysphagia
tion from a respiratory to a digestive pathway. Our results caused by other diseases. Patients were asked to drink
on the prevalence of VFS signs and impaired swallow 50 mL,25 3 oz,9 150 mL,26 or 60 mL21,27 water from a glass
response agree with previous studies in neurological and without interruption, and coughing during or after comple-
elderly patients by our group8 and other authors.10,29 After tion or the presence of a post-swallow wet-hoarse voice
a stroke, dysphagia may persist in some patients for many quality, or swallow speed of less than 10 mL/sec were
months increasing the risks of chest infection, malnutrition, scored as abnormal. In the present study, up to 80.6%
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Screening for dysphagia and aspiration 813

patients could safely swallow pudding boluses; 52.1%, a safe, quick and accurate clinical method (V-VST) with
nectar boluses, and only 32.9% patients presented safe 88.2% sensitivity for impaired safety, 100% sensitivity for
swallow of liquids, further confirming the high risk of liquids aspiration and up to 88.4% sensitivity for impaired efficacy
and the therapeutic effect of bolus viscosity. For this of swallow. It is well known that diagnostic procedures with
reason we developed the V-VST as a simple and quick high rates of correct identification of aspirators usually
(mean duration <6 min) swallow effort test by starting have high rates of false positive results too11; that is,
with a safe (nectar) viscosity and low volume (5 mL) bolus they over-identify patients with less severe alterations of
and increasing bolus volume in a progression of increasing safety (penetrations) as aspirators. As the cost of a false-
difficulty. Liquids were only assessed if the patient pre- negative diagnosis of a patient with aspirations is high
sented a safe swallow at nectar thereby protecting patients (aspiration pneumonia) and the cost of a false positive clin-
from aspiration. In addition, up to 48% patients with aspira- ical diagnosis of impaired swallow is low (an unnecessary
tions observed in this and our previous VFS studies8 did not VFS study), our V-VST method has been designed to favour
present cough following aspiration so we added pulse diagnostic sensitivity. The high negative predictive value of
oximetry to the V-VST to help to identify these our clinical test also suggests that a patient with a negative
patients.2,13,21,28 We found both oximetry and changes in V-VST does not need any further assessment for aspiration;
voice quality after swallow as markers of impaired safety in contrast we recommend further assessment by VFS
clearly increased the diagnostic sensitivity of V-VST and studies in patients with V-VSTs showing any clinical sign of
the probability of identifying patients with silent aspira- impaired safety to assess its severity and pathophysiology
tions or bolus penetration into the LV. (Fig. 5). Finally, the V-VST can also help select the most
In many European hospitals there is a big discrepancy appropriate bolus volume/viscosity for patients with diffi-
between the high prevalence, morbidity, mortality and cult access to VFS studies because the probability of
costs caused by complications of oropharyngeal dysphagia a proved therapeutic effect of viscosity in a patient identi-
and the low level of resources dedicated to dysphagic fied by the V-VST is very high.
patients. In contrast, there is strong evidence that clinical Diagnosis and management of oropharyngeal dysphagia
bedside methods can detect dysphagia,21 although with need a multidisciplinary approach.6 Fig. 5 shows the algo-
differing diagnostic accuracy. The Burkes 3-oz water rithm of diagnosis and treatment of oropharyngeal
swallow test identified 80% of patients aspirating during dysphagia at our hospital. The V-VST is widely applied by
subsequent VFS examination (sensitivity 76%, specificity nurses, dietitians and speech-swallow therapists. Future
59%).9 The standardized bedside swallow assessment studies using V-VST on patients with malnutrition and pneu-
showed a variable sensitivity (47%e68%) and specificity monia will clarify the relevance of dysphagia in these
(67%e86%) for aspiration detection when used by speech- diseases and the clinical utility of the diagnostic method
swallow therapists and doctors.21,27 We presented here we have designed to avoid further complications and help

VULNERABLE PATIENT
Internal Medicine, Geriatrics, Neurology etc

DOCTOR/ NURSE RESPONSIBLE :


- Nursing procedures at admission

DIETITIAN SPEECH-SWALLOW THERAPIST


MALNUTRITION ASPIRATION AND/OR PNEUMONIA
Suspected impairment of deglutition Suspected SAFETY risk
EFFICACY

VOLUME-VISCOSITY
SWALLOW TEST
(V-VST)

V-VST = IMPAIRED
V-VST = SAFE SWALLOW SAFETY

FOLLOW UP DIAGNOSTIC TESTS: VIDEOFLUOROSCOPY


- Repeat V-VST according natural history of each - Signs of SAFETY and EFFICACY.
disease. - Aspiration vs penetration
- Swallow response
- Treatment.

Figure 5 Proposed algorithm for diagnosis and treatment of oropharyngeal functional dysphagia using the V-VST for screening
and VFS studies for patient assessment. Note the involvement of several professional domains of the dysphagia multidisciplinary
team and the flows of information.
Author's personal copy

814 P. Clave et al.

to select treatment. Patients with dysphagia need specific 860th meeting of the Ministers Deputies. Available at: http://
dietary adjustments.30 A recent resolution of the Council www.coe.int/T/CM/home_en.asp.
of Europe on food and nutritional care in hospitals recom- 6. Clave P, Almirall J, Esteve M, Verdaguer A, Berenguer J, Serra-
mended the development of dietary management as well Prat M. Oropharyngeal dysphagia. A team approach to prevent
and treat complications. In: Taylor S, editor. Hospital
as national guidelines for texture modification, texture-
Healthcare Europe 2005/2006. Campden Publishing Ltd.;
modified menus and patient and family education on 2005. p. N5e8.
dysphagia.5 We recommend routine assessment for oropha- 7. Logemann JA. Manual for the videofluorographic study of
ryngeal dysphagia by the V-VST for all patients at risk swallowing. 2nd ed. Austin, Texas: Pro-Ed; 2005.
admitted to general hospitals as the first step in this 8. Clave P, de Kraa M, Arreola V, et al. The effect of bolus
process. viscosity on swallowing function in neurogenic dysphagia.
Aliment Pharmacol Ther 2006;24(9):1385e94.
Conflict of interest statement 9. DePippo KL, Holas MA, Reding MJ. Validation of the 3-oz water
swallow test for aspiration following stroke. Arch Neurol 1992;
49:1259e61.
Grant support 10. Kahrilas PJ, Lin S, Rademaker AW, Logemann JA. Impaired deglu-
titive airway protection: a videofluoroscopic analysis of severity
Supported by grants from the Filial del Maresme de la and mechanism. Gastroenterology 1997;113:1457e64.
Academia de Ciencies Mediques de Catalunya i Balears, 11. Logemann JA. Evaluation and treatment of swallowing
Fondo de Investigaciones Sanitarias (FIS IF063678-1 and disorders. 2nd ed. Austin, Texas: Pro-Ed; 1998.
12. Zaidi NH, Smith HA, King SC, Park C, ONeill PA, Connolly MJ.
PI051554) and by Image & Physiology SL and Novartis
Oxygen desaturation on swallowing as a potential marker of
Medical Nutrition S.A. PC received grant support from aspiration in acute stroke. Age Ageing 1995;24:267e70.
Novartis Medical Nutrition and is a member of the Medical 13. Collins MJ, Bakheit AMO. Does pulse oximetry reliably detect
Advisory Board of Novartis Medical Nutrition. This sponsor aspiration in dysphagic stroke patients? Stroke 1997;199:
had no involvement in the design, collection, and analysis, 1773e5.
interpretation of data or writing the manuscript. 14. Chalmers TC. Data analysis for clinical medicine. The
quantitative approach to patient care in gastroenterology.
Statement of authors Rome: International University Press; 1988.
15. Smithard DG, ONeill PA, Parks C, Morris J. Complications and
outcome after acute stroke. Does dysphagia matter? Stroke
VA and MR carried out the clinical studies with the V-VST 1996;27:1200e4.
and measured the swallow response. PC and LM performed 16. Mann G, Hankey GJ, Cameron D. Swallowing function after
the VFS studies. EP and MSP performed the statistical stroke: prognosis and prognostic factors at 6 months. Stroke
analysis. PC developed the V-VST and the study, and 1999;30:744e8.
drafted the manuscript. All authors read and approved 17. Dennis MS, Lewis SC, Warlow CFood Trial Collaboration. Effect
the final manuscript. of timing and method of enteral tube feeding for dysphagic
stroke patients (FOOD): a multicentre randomised controlled
trial. Lancet 2005;365:764e72.
18. Miller RG, Rosenberg JA, Gelinas DF, et al. Practice parameter:
Acknowledgments the care of the patient with amyotrophic lateral sclerosis
(an evidence-based review): report of the Quality Stan-
dards Subcommittee of the American Academy of Neurology:
We would like to thank all our patients for their cooperation ALS Practice Parameters Task Force. Neurology 1999;52:
and all the members of the dysphagia team of Hospital 1311e23.
de Mataro who have participated in this study. We thank. 19. Ruiz de Leon A, Clave P. Videofluoroscopy and neurogenic
Dr. E. Palomeras (Neurology), Dr. M. Cabre (Geriatrics), dysphagia. Rev Esp Enferm Dig 2007;99(1):3e6.
Dr. J. Almirall (Intensive Care Unit), Mrs. M. Arus and C. 20. Clave P. New approaches to the diagnosis and management of
Ferreriro (Dietician), Mrs. R. Monteis, Mrs. I. Crespo, Mrs. M. dysphagia. In: David Thomas, editor. Proceedings of 2007
Annual Scientific Meeting. Seattle, WA: American Geriatrics
Sebastian (Nurse). We also thank Mrs. Jane Lewis for
Society; 2007. p. 14e8.
reviewing the manuscript.
21. Westergren RN. Detection of eating difficulties after stroke:
a systematic review. Int Nurs Rev 2006;53:143e9.
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Screening for dysphagia and aspiration 815

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