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Dysphagia (2008) 23:364370
DOI 10.1007/s00455-008-9150-7
ORIGINAL ARTICLE
Screening Test for Silent Aspiration at the Bedside
Yoko Wakasugi Haruka Tohara Fumiko Hattori Yasutomo Motohashi
Ayako Nakane Shino Goto Yukari Ouchi Shinya Mikushi
Syuhei Takeuchi Hiroshi Uematsu
Published online: 2 July 2008
Springer Science+Business Media, LLC 2008
Abstract Many screening tests for dysphagia can be
given at bedside. However, they cannot accurately screen
for silent aspiration (SA). We studied the usefulness of a
cough test to screen for SA and combined it with the
modified water swallowing test (MWST) to make an
accurate screening system. Patients suspected of dysphagia
(N = 204) were administered a cough test and underwent
videofluorography (VF) or videoendoscopy (VE). Sensi-
tivity of the cough test for detection of SA was 0.87 with
specificity of 0.89. Of these 204 patients, 107 were also
administered the MWST. Fifty-five were evaluated as
normal by the screening system, 49 of whom were evalu-
ated as normal by VF or VE. Sixteen were evaluated as
SA suspected by the screening system; seven of them
were normal, and seven were evaluated as having SA by
VF or VE. Nineteen were evaluated as aspirating with
cough, 14 of whom had aspiration with cough as shown by
VF or VE. Seventeen were evaluated as having SA, 15 of
whom had SA shown by VF or VE. The cough test was
Y. Wakasugi (&)
H. Tohara
A. Nakane
S. Goto

Y. Ouchi
S. Mikushi
S. Takeuchi
H. Uematsu
Department of Gerodontology, Division of Gerontology and
Gerodontology, Graduate School, Tokyo Medical and Dental
University, 1-5-45, Yushima, Bunkyo, Tokyo 113-8549, Japan
e-mail: wakasugi_y@yahoo.co.jp
H. Tohara
Department of Dysphagia Rehabilitation, Nihon University,
1-8-13, Surugadai, Kanda, Chiyoda, Tokyo 101-8310, Japan
F. Hattori
National Hospital Organization, Tokyo National Hospital, 3-1-1,
Takeoka, Kiyose, Tokyo 204-8585, Japan
Y. Motohashi
Department of Dentistry, Musashimurayama Hospital, 1-1-5,
Enoki, Musashimurayama, Tokyo 208-0022, Japan
123
useful in screening for SA. Moreover, a screening system
that included MWST and a cough test could accurately
distinguish between the healthy who were safe in swal-
lowing and SA patients who were unsafe.
Keywords Deglutition
Deglutition disorders

Screening test
Silent aspiration
Cough test
Videofluorography (VF) and videoendoscopy (VE) are
considered the most accurate methods for the examination
for dysphagia. However, many institutions lack the
equipment required for these diagnostic tests. Thus, alter-
native screening studies have been developed that easily
can be performed at the patients bedside. The criteria for
many current screening tests include the presence of a
cough [14]. Therefore, it is possible that diagnoses are
missed in patients who show aspiration without cough
(silent aspiration, SA) [5]. Furthermore, clinical bedside
assessment has been shown to miss up to 40% of dysphagia
patients with SA [6].
One study reported that SA was present in more than
70% of elderly patients with community-acquired pneu-
monia [7]. SA can cause aspiration pneumonia in the elderly
[8]. Patients with laryngeal penetration, tracheobronchial
aspiration, or silent tracheobronchial aspiration were
approximately 4 times, 10 times, and 13 times, respec-
tively, more likely to develop pneumonia than those with
normal swallowing [9]. There is no clear evidence that SA
relates to sensory loss. SA may relate to gradual desensiti-
zation if aspiration is chronic [10]. SA has been reported to
occur in over 40% of patients referred for dysphagia eval-
uation in a rehabilitation hospital and in as many as 77% of
ventilator-dependent patients [11]. Therefore, a screening
test for SA is clinically valuable.
Y. Wakasugi et al.: Screening Test of Silent Aspiration
We studied the usefulness of a cough test to screen for
SA. The cough test uses citric acid to detect SA. Because
the cough test looks at a patients cough rather than aspi-
ration, we then combined the cough test methods with
other usual screening tests for aspiration and investigated
whether the combined screening system could improve the
accuracy of dysphagia diagnosis.
Methods
Participants in this study were 204 patients (131 men and
73 women) who were suspected of having dysphagia and
underwent VF or VE. They included both inpatients and
outpatients who had several clinical symptoms of dyspha-
gia such as coughing with eating, difficulty with eating, a
fever or pneumonia by aspiration, and past history of suf-
focation. None had a history of asthma. The average age
was 69.90 11.70 years (mean SD) and ranged from
18 to 100 years. The following preexisting conditions were
found: 39% had cardiovascular disease (CVD), 24% head
or neck cancer, 17% neuromuscular disease, 15% respira-
tory disease, and 5% other diseases. This study received
approval from the ethics committee of the faculty of den-
tistry of the Tokyo Medical and Dental University.
Informed consent was obtained from all participants or
their legal guardians. The study conformed to the Tokyo
Medical and Dental University policies concerning
research on human subjects.
In the cough test, patients inhaled a mist of citric acid-
physiologic saline orally for 1 min with an ultrasonic
nebulizer. The inspector observed the number of times the
patient coughed during the 1 min of nebulizing. More than
five coughs was considered negative (normal), while less
than four coughs was regarded as positive [1214]. The
concentration of citric acid was 1.0 w/v% [15]. Subjects
were directed to breathe through the mouth mask because
inhaling through the mouth allows for a higher concen-
tration of inhaled particles than does inhaling through the
nose [16]. If patients had difficulty following these
instructions, a nose clip was applied to encourage the
patient to inhale orally. The ultrasonic nebulizer used was
an OMRON NE-U17 with a particle size of 18 lm and
output rate greater than 3 ml/min. The cough test was
conducted on the day before, the same day, or the day after
the VF or VE examination.
The cough test results were combined with the modified
water swallowing test (MWST) for diagnosis [17]. Cold
water (3 ml) was placed on the floor of the mouth using a
5-ml syringe. Placement on the floor of the mouth pre-
vented premature spillage of test water into the pharynx.
The patient was then instructed to swallow. If the patient
was unable to swallow, a score of 1 was given. If the
365
patient was able to swallow but experienced dyspnea
(difficulty breathing) after swallowing, a score of 2 was
given. If the patient was able to swallow and experienced
coughing or wet-hoarseness after swallowing, a score of 3
was given. Otherwise, the patient was asked to perform two
dry (saliva) swallows. If the patient was able to swallow the
water but unable to perform either of the two dry swallows,
a score of 4 was recorded. If the patient was able to
complete the water and both dry swallows, a score of 5 was
recorded. The entire procedure was repeated twice more
and the final score was defined as the lowest score on any
trial.
MWST was not conducted on patients clinically regar-
ded as severe saliva aspirators. As a result, the number of
the patients receiving both screening tests was 107
(83 men and 24 women),with an average age of
69.23 13.09 years.
All patients received VF (Medix-900DR, Hitachi Med-
ical Corp) or VE (Olympus ENF-P4) assessment of
swallowing to detect aspiration. VF was conducted fol-
lowed by modified barium swallow (MBS) [18] and VE
was followed by fiberoptic endoscopic evaluation of
swallowing (FEES) [19]. The consistencies of the test
foods used were thin liquid, thick liquid, cookies, and
cornflakes. All the foods used in the VF included barium
sulfate. Thin and thick liquids were colored with green
food dye for ease of visualization in the VE.
Data Analysis
Using the results of the VF or VE examination as the
standards, the sensitivity, specificity, efficiency, positive
predictive value (PPV), and negative predictive value
(NPV) for SA detection were calculated. Then the results
of the screening system combining the cough test and the
MWST were compared with the results of VF or VE.
Results
Results of the Cough Test
The results of cough tests are shown in Table 1. There were
97 patients who did not present with aspiration. Of these,
84 patients (86.6%) were negative and 13 patients (13.4%)
were positive. There were 37 patients who presented with
aspiration and cough. Of these, 36 patients (97.2%) were
negative and one patient (2.8%) was positive. There were
18 patients who presented with aspiration without cough
with a very little amount of aspiration (SA with a little
aspiration). These patients coughed when there was a large
amount of aspiration but did not cough with trace amounts
123
366 Y. Wakasugi et al.: Screening Test of Silent Aspiration

Table 1 Results of cough test included in the SA(-) analysis, sensitivity was 0.87,
VF/VE Cough test
specificity was 0.95, efficiency was 0.91, PPV was 0.94,
and NPV was 0.88 (Table 4). Likewise, if the SA with a
Negative Positive Total little aspiration group was included in the SA(+) analysis,
No aspiration 84 (86.6%) 13 (13.4%) 97 (47.5%) sensitivity was 0.67, specificity was 0.97, efficiency was
Aspiration with cough 36 (97.2%) 1 (2.8%) 37 (18.1%) 0.78, PPV was 0.98, and NPV was 0.61 (Table 5).
SA by little aspiration 16 (88.9%) 2 (11.1%) 18 (8.8%)
SA 7 (13.5%) 45 (86.5%) 52 (25.5%)
Results of the Cough Test and MWST
Total 143 (70.1%) 61 (29.9%) 204

The results of the combined screening system (the cough test

of aspiration. Of these, 16 patients (88.9%) were negative
and 2 patients (11.1%) were positive. There were 52
patients who presented with SA, 7 (13.5%) of whom were
negative and 45 (86.5%) were positive. These patients did
not have a cough regardless of the amount of aspiration.
Screening for SA Using the Cough Test
Some patients who coughed after large amounts of aspi-
ration did not cough after a little amount of aspiration. If
the group of patients presenting with SA with a little
aspiration was included in the SA(-) analysis group, sen-
sitivity was 0.87, specificity was 0.89, efficiency was 0.89,
PPV was 0.74, and NPV was 0.95 (Table 2). On the other
hand, if the group of patients presenting with SA with a
little aspiration was included in the SA(+) analysis group,
sensitivity was 0.67, specificity was 0.90, efficiency was
0.82, PPV was 0.77, and NPV was 0.84 (Table 3).
When data from patients who presented with aspiration
were examined, if the SA with a little aspiration group was
and MWST) are shown in Figure 1. In MWST we used a
cutoff score of 3 to indicate aspiration [14]. When a MWST
score of 4 or 5 and a negative cough test were observed,
patients were considered normal. When a MWST score of 4
or 5 and a positive cough test were observed, patients were
considered SA suspected. When a MWST score of 1-3
and a negative cough test were observed, patients were
considered as having aspiration with cough. When a
MWST score of 1-3 and a positive cough test were observed,
patients were considered as having SA. Using this diagnostic
scale, 55 patients were diagnosed as normal. When evalu-
ated by VF or VE, 49 (89.1%) of these patients were normal,
5 patients (9.1%) were silent aspirators with a little aspira-
tion, and 1 patient (1.8%) had SA. Sixteen patients were
diagnosed as SA suspected. Of these, seven patients
(43.8%) were normal, one patient (6.3%) had aspiration with
cough, one patient (6.3%) was a silent aspirator with a little
aspiration, and seven patients (43.8%) had SA. Nineteen
patients were diagnosed as having aspiration with cough.
Of these, 1 patient (5.3%) was normal, 14 patients (73.7%)
had aspiration with cough, 3 patients (15.8%) were silent

Table 2 Screening of SA by cough test Table 4 Screening of SA by cough test in patients with aspiration
VF/VE Cough test VF/VE Cough test
Positive Negative Positive Negative

SA(+) 45 7 SA(+) 45 7
a a
SA(-) 16 136 SA(-) 3 52
Sensitivity = 0.87; specificity = 0.89; efficiency = 0.89; PPV = Sensitivity = 0.87; specificity = 0.95; efficiency = 0.91; PPV =
0.74; NPV = 0.95; N = 204 0.94; NPV = 0.8; N = 1078
a a
SA with a little aspiration was included in SA(-) SA with a little aspiration was included to SA(-)

Table 3 Screening of SA by cough test Table 5 Screening of SA by cough test in patients with aspiration
VF/VE Cough test VF/VE Cough test
Positive Negative Positive Negative

SA(+)a 47 23 SA(+)a 47 23
SA(-) 14 120 SA(-) 1 36
Sensitivity = 0.67; specificity = 0.90; efficiency = 0.82; PPV = Sensitivity = 0.67; specificity = 0.97; efficiency = 0.78; PPV =
0.77; NPV = 0.84; N = 204 0.98; NPV = 0.61; N = 107
a a
SA with a little aspiration was included in SA(+) SA with a little aspiration was included to SA (+)

123
Y. Wakasugi et al.: Screening Test of Silent Aspiration
By VF/VE MWST
Normal:56
Aspiration with cough:1 Total:107
SA by little aspiration:6 4,5
SA:8
total:71
Cough test
negative positive negative
Aspiration
normal SA suspected
with cough
By VF/VE By VF/VE By VF/VE
Normal:49 Normal:7
Aspiration with cough:0 Aspiration with cough:1 Aspiration with cough:14 Aspiration with cough:0
SA by little aspiration:5 SA by little aspiration:1 SA by little aspiration:3 SA by little aspiration:1
SA:1 SA:7
total:55 total:16
Fig. 1 Screening flowchart
aspirators with a little aspiration, and 1 patient (5.3%) had
SA. Using the combined screening system, 17 patients
presented with SA. Of these, 1 patient (5.9%) was normal, 1
patient (5.9%) was a silent aspirator with a little aspiration,
and 15 patients (88.2%) had SA.
Discussion
The Method of the Cough Test
The medical efficacy of a nebulizer is influenced by par-
ticle size and the volume of particles attained in one
inhalation [20]. Two main parameters are generally used to
evaluate the performance of nebulizers: the droplet size
distribution of the aerosol and the drug output rate [21].
The particle size most effective at adhering to peripheral
tracheal branches and tracheal branches is 18 lm and to
the larynx 1020 lm [20, 22]. The ultrasonic nebulizer
makes microscopic (0.55.0 lm) particles of uniform size
consistently, while the size of particles produced by a jet
nebulizer is larger and influenced by the jet speed and
water current blown off and thus varies widely [23].
Studies have shown that breathing through the mouth
with a tube deposits more particles in the lower respiratory
tract compared with nasal breathing and mouth breathing
without a tube [24]. Iwata [16] studied the best way to
deliver particles to the airway and determined that the best
way was through the mouth with an ultrasonic nebulizer,
the second was through the nose with an ultrasonic nebu-
lizer, the next was through the mouth using a jet nebulizer,
and the worst was through the nose using a jet nebulizer.
Furthermore, a similar study showed that an ultrasonic
nebulizer deposited more particles to the middle and lower
pharynx compared to a jet nebulizer. Moreover, when
breathing deeply, the ultrasonic nebulizer carried particles
more deeply compared to eupnea normal, unlabored
breathing [25].
367
In summary, the previous literature indicates that to
By VF/VE
stimulate the airway one should use an ultrasonic nebulizer
Normal:2
Aspiration with cough:15
1,2,3 SA by little aspiration:4 with deep breathing through the mouth with a tube.
SA:16
total:36 Therefore, our cough test method was thought to be
Cough test appropriate.
positive
Usefulness of the Cough Test for Screening for
Dysphagia
SA
By VF/VE
Normal:1 Normal:1
There are many studies of swallowing assessments that can
SA:1 SA:15
be performed at bedside. Because of the high number of
total:19 total:17
patients with dysphagia, the bedside examination for
detecting aspiration is commonly used without VF and VE
evaluation.
The water swallowing test has several variations and is
widely used. The volume of water varies from 3 cc to 85 cc
[14, 17, 26]. McCullough et al. [26] states that the test
bolus of 5 cc may be superior to 3 oz (85 cc) because the 3-
oz water test had high sensitivity (86%) but low specificity
(50%). Most of these water-swallowing tests look for a
patients cough, which can be a weakness of these tests
when attempting to diagnose silent aspirators.
Pulse oximetry is a noninvasive way of performing a
bedside swallowing test [2729], but several studies have
shown no relationship between aspiration and desaturation
[30, 31], which occurs easily during a postural change,
cough, or swallow, in addition to during aspiration [32].
Thus, the usefulness of SpO2 for diagnosing aspiration is
now controversial.
Similarly, there have been many screening tests for
dysphagia [3337]. In general, the sensitivity of these tests
was high but the specificity was low. In addition, many of
these tests have weaknesses in practical use; for example, a
test may require a highly trained examiner or have limited
applicability to the patients. Furthermore, the usefulness of
these tests to screen for aspiration has been reported, but
the ability to detect SA is not mentioned.
Splaingard et al. [38] evaluated 107 patients using a
bedside clinical examination and VF and monitored swal-
lowing of various volumes and consistencies of food. The
bedside evaluation identified only 42% of the patients who
aspirated on VF. Twenty percent of the entire sample who
did not show any symptoms of aspiration on the bedside
evaluation had aspiration during VF. They concluded that
these screening tests were easy to perform without special
instruments and possessed good reproducibility, but they
were not able to detect saliva aspiration and SA.
There are many studies on the relationship between
cough and aspiration or pneumonia [3943], some of which
have examined the cough test with respect to aspiration and
pneumonia. Addington et al. [4447] studied the reliability
of the cough test in detecting the risk of pneumonia in
123
368
acute stroke patients. They concluded that the cough test
was sufficient to assess the cough reflex and risk of aspi-
ration pneumonia in stroke patients. Sekizawa et al. [13]
used the cough test to investigate whether weakness of the
cough reflex was related to aspiration pneumonia. Patients
with aspiration pneumonia did not cough at the highest
concentration. Hammand et al. [48] analyzed the coughs of
aspiration patients and healthy subjects. Objective analysis
of the cough was sufficient to detect aspiration without
stress. Patients with an absent or weak cough reflex were at
a higher risk of aspiration. They also assessed the cough
reflex and aspiration of patients with acute CVA, and the
cough test showed a sensitivity of 68% and specificity of
82%. Nakazawa et al. [49] determined that the thresholds
of the cough test and swallow reflex induction test of
patients who developed pneumonia were higher than those
of healthy subjects. Emergence of pneumonia was related
to weaknesses in the airway protective reflex and swal-
lowing ability. However, SA detection was not mentioned.
Horner et al. [39] investigated the gag reflex, cough reflex,
and swallowing reflex of acute stroke patients and found
that more than 60% of SA patients showed a weakened
cough response.
In summary, the relationship of the cough test and
aspiration or pneumonia has been reported in the past;
however, these studies did not specifically attempt to detect
SA. Furthermore, many of these studies demonstrated that
a weak or absent cough response resulted in a higher risk of
aspiration pneumonia.
The cough test is inexpensive and easy to perform, puts
little stress on the patient, and enables a fast diagnosis of
swallowing difficulty. It can be performed on patients who
have difficulty following instructions, who are at high risk,
and who have low immunity. From the results of our study,
the cough test has good statistical reliability in the detec-
tion of SA. Therefore, the cough test is a useful SA
screening tool.
Usefulness of the Combined Screening System
The bedside examination has limitations in accurately
predicting or detecting the occurrence of aspiration. By
combining tests that assess different important points
clinically, the accuracy will increase [6]. Several studies
have examined a combination of screening tests. Smith
et al. [50] combined oxygen saturation and standard bed-
side swallowing assessments on 53 patients with acute
stroke confirmed by CT. Sensitivity and specificity of
bedside swallowing assessment were only 80% and 68%,
respectively, and those of O2 desaturation were only 87%
and 39%. However, the combination of bedside assessment
and O2 desaturation were 73% and 76%. Lim et al. [6]
123
Y. Wakasugi et al.: Screening Test of Silent Aspiration
combined the oxygen saturation test and the 50-ml water-
swallowing test. Sensitivity and specificity of only oxygen
desaturation of 2% or more alone were 76.9% and 83.3%,
and those of the water-swallowing test alone were 84.6%
and 75.0%. On the other hand, the combination of these
tests had 100% sensitivity and 70.8% specificity. Similarly,
Tohara et al. [17] studied the accuracy of three nonvideo-
fluorographic (non-VFG) tests for assessing risk of
aspiration: MWST and the food test (4 g of pudding) and
the X-ray test (static radiographs of the pharynx are taken
before and after swallowing liquid barium). When MWST
was combined with the food test, sensitivity was 90% and
specificity was 56%. When all three non-VFG tests were
combined, sensitivity was 90% and specificity was 71%.
We combined the MWST and the cough test because we
wished to assess the swallowing reflex with the MWST and
assess the airway protective reflex with the cough test. We
chose to use the MWST because it is safe, requires little
volume, and its appropriateness was reported statistically.
In our combination screening system of MWST and the
cough test, 89.1% of the predicted normal group were
actually normal, 73.7% of the aspiration with cough group
were actually aspirators with cough, and 88.2% of the SA
group were actually silent aspirators. The confidence of the
combined screening system is thought to be clinically high.
Furthermore, the SA suspected group was actually half
normal and half SA. This demonstrates that if a patient is
considered normal by the MWST but abnormal by the
cough test, it is possible that the patient is SA up to 50% of
the time. The results of the combined screening system are
demonstrated in Figure 1.
When patients begin eating without VF or VE, we can
distinguish healthy patients who are safe in swallowing
from those who are SA who are not safe by using our
combined screening system. In other words, healthy is
normal with respect to both swallowing reflex and airway
protective reflex and can perform the eating exercise or
start ingestion. Aspiration with cough is seen as abnor-
mal with respect to swallowing reflex but normal with
respect to the airway protective reflex, so these patients can
eat when the conditions are taken into account. SA is
abnormal for both reflexes, so they should not perform the
eating exercise or start ingestion. SA suspected patients
have a normal swallowing reflex but an abnormal airway
protective reflex. SA and SA suspected patients need
a further careful examination with VF or VE (Fig. 2). Of
course, VF or VE should be done for patients with dys-
phagia if the facility is well-equipped to do so. However, at
present, some patients do have opportunity to be evaluated
by VF or VE because of lack of proper equipment,
accessibility, or other reasons. The screening tests dis-
cussed here were inferior to VF and VE in accuracy, but we
still could obtain good statistical values for screening. It is
Y. Wakasugi et al.: Screening Test of Silent Aspiration 369

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