Original articleAccuracy of the volume-viscosity swallow test for clinical screening of oropharyngeal dysphagia and aspiration☆
Introduction
Oropharyngeal dysphagia is a major complaint among many patients with neurological diseases and among the elderly. The prevalence of functional oropharyngeal dysphagia is very high: it affects more than 30% of patients who have had a cerebrovascular accident, 52%–82% patients with neurodegenerative diseases, more than 35% patients with head and neck diseases, and more than 60% of elderly institutionalized patients.1, 2 Oropharyngeal dysphagia may give rise to clinically relevant complications such as aspiration pneumonia, malnutrition and/or dehydration. When a decrease in deglutition safety occurs, choking and tracheobronchial aspiration results in pneumonia in 50% of cases, with an associated mortality of up to 50%.1, 2 Impaired safety also limits the ability of patients to ingest all the calories and water that they need to be adequately nourished and hydrated.1, 2 A 10-year review found the number of elderly patients with aspiration pneumonia increased 93.8% while other types of pneumonia in the elderly decreased.3, 4 A recent resolution of the Council of Europe claimed that undernutrition among hospital patients is highly prevalent and leads to extended hospital stays, prolonged rehabilitation, and diminished quality of life, and identified oropharyngeal dysphagia as a major contributor to malnutrition.5 The current state of the art of oropharyngeal dysphagia management aims at early identification of patients at risk for aspiration, assessment of alterations in the biomechanical events of oropharyngeal swallow response (OSR), and prevention and treatment of the potential complications of dysphagia such as aspiration pneumonia and malnutrition.6
Videofluoroscopy (VFS) is the gold standard method for studying the oral and pharyngeal mechanisms of dysphagia and for evaluating efficacy, and safety of swallow.1, 2, 6 VFS can identify the main signs of oropharyngeal dysfunction, which are delay in pharyngeal swallow, penetration of bolus into the laryngeal vestibule (LV), tracheobronchial aspiration and oropharyngeal residue, and can assess the short term effect of therapeutic strategies on dysphagic patients.1, 7 Using this technique, we have recently shown that patients with neurogenic dysphagia presented high prevalence of impaired safety during liquid boluses and that increasing bolus viscosity to nectar and pudding viscosity exerted a strong therapeutic effect on safety of deglutition.8 In contrast, increasing bolus volume impaired safety of deglutition in these patients.8 High prevalence of dysphagia among vulnerable patients and the dynamic condition of this symptom according to the natural history of each disease makes it unfeasible to perform a VFS on every patient or to repeat VFS studies during disease evolution. Clinical screening methods with high diagnostic accuracy are, therefore, needed to recognize patients with oropharyngeal dysphagia, to identify patients at risk of aspiration and who should be referred for a VFS, and to help select the most appropriate bolus volume and viscosity for those patients who cannot easily undergo VFS.9
This study was specifically designed to assess the diagnostic accuracy of a clinical bedside test, the volume–viscosity swallow test (V-VST), to predict signs of dysphagia and impaired safety of deglutition (penetration, aspiration) observed during VFS studies, and to identify patients whose deglutition could be improved by increasing bolus viscosity. To that end we studied patients with prevalent conditions causing dysphagia such as old age, neurological diseases and head and neck diseases.
Section snippets
Sample
The study population included two main groups of participants: Group 1 were healthy volunteers (HV) (n = 12) to assess normal swallow physiology (Table 1) and Group 2 were patients with oropharyngeal dysphagia (n = 85). We studied 85 consecutive patients with swallowing difficulties8, 13 whom we received for evaluation between January and December 2006. Demographic information of the study patients is shown in Table 1. Our study included (a) 40 elderly patients of whom 23 had cerebrovascular
Demographics
Median age of all three groups of patients with dysphagia was higher than that of HV (Table 1). Our group of patients with oropharyngeal dysphagia included middle-aged patients with neurodegenerative diseases and elderly patients with cerebrovascular disease, geriatric diseases, or head and neck diseases (p < 0.05).
HV
All volunteers presented a safe and efficacious swallow.
Patients with oropharyngeal dysphagia
Mean duration of clinical assessment of dysphagia by the V-VST was 5.54 ± 2.18 min. Piecemeal deglutition was observed in up to
Discussion
Our study found high prevalence of videofluoroscopic signs of impaired safety and efficacy of swallow indicating high risk of severe respiratory and nutritional complications in a group of hospitalized patients with oropharyngeal dysphagia. We also found that most of these patients at risk of complications could be quickly, safely and accurately recognized by using a clinical bedside method we have developed as the V-VST that systematically evaluates the main clinical signs and symptoms of
Grant support
Supported by grants from the Filial del Maresme de la Acadèmia de Ciències Mediques de Catalunya i Balears, Fondo de Investigaciones Sanitarias (FIS IF063678-1 and PI051554) and by Image & Physiology SL and Novartis Medical Nutrition S.A. PC received grant support from Novartis Medical Nutrition and is a member of the Medical Advisory Board of Novartis Medical Nutrition. This sponsor had no involvement in the design, collection, and analysis, interpretation of data or writing the manuscript.
Statement of authors
VA
Acknowledgments
We would like to thank all our patients for their cooperation and all the members of the dysphagia team of Hospital de Mataró who have participated in this study. We thank. Dr. E. Palomeras (Neurology), Dr. M. Cabré (Geriatrics), Dr. J. Almirall (Intensive Care Unit), Mrs. M. Arús and C. Ferreriro (Dietician), Mrs. R. Monteis, Mrs. I. Crespo, Mrs. M. Sebastian (Nurse). We also thank Mrs. Jane Lewis for reviewing the manuscript.
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Conference presentation: this study was presented in part at the 2007 Annual Scientific Meeting of the American Geriatrics Society, May 2–6, 2007, Seattle, WA, USA.