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 Machine

Clinical question

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

Why this clinical question Should 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 screen What parts of the bedside assessment

are the most salient

The Evidence: Searching

Initial searching by the group found 23 articles

From these 19 were CAPPED Articles were excluded because they did

not perform either the bedside swallow assessment or the instrumental assessments

The Evidence: Research Design

Research designs Pseudo-Randomised Control Trial Non Randomised group Design Prospective observational Study Case Series

Levels of evidence 1 = level 2 18 = Level 3

The Evidence: Participants

Participants 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”.

The Evidence : Methods

Variability noted in type of instrumental assessment Either FEES or MBS

Variability noted in administration of assessment Schedules of instrumental and clinical

assessments Degree of inter / intra-rater reliability and validity Blinding Consistencies and proportions of food /fluids

provided

The Evidence: Measurement Measures included –

Aspiration and/or penetration in all studies. Two studies considered patient perspective of

dysphagia Several studies included measures of

“dysphagia” in the oral and/or pharyngeal phase. ▪ These studies developed their own methods of

measuring dysphagia severity Variety of bedside indications of aspiration

included:▪ Cough (volitional and reflexive), wet voice, dysphonia,

gag, dysarthria, Cranial Nerve Ax

The Evidence: How results were presented

Sensitivity and specificity Used in almost all the studies

Positive and negative predictive values

Correlation between tests on severity rating scales

Likelihood ratios

Reminder of sensitivity and specificity

Sensitivity– How many aspirators are identified correctly

Specificity– How many non-aspirators are identified correctly

Findings

Evidence 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.

Findings

In 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%.

Findings

Using combinations of predictive signs increases the likelihood of predicting aspiration from clinical bedside evaluation

When 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 pneumonia

Applying these results to clinical practice

Instrumental 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.

Thoughts from the group Felt 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.

Future Research

Research 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 outcomes

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.

Plans for 2015

Swallow rehabilitation – looking at the evidence behind EMST and Shaker in dysphagia.

Leader – Christian Wiley

Questions???

References

Barquist, 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 710-1713

Cabre, 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, 39-45

Chong, 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 – 794

Daniels, Brailey, Priestly, Herrington, Weisberg m Foundas (1998) Aspiration n patients with acute stroke. Archives of physical medicine and rehabilitation ( 79) 1, 14-19

Heckert, K., Komaroff, E., Adler, U., and Barrett, A. (2009). Postacute re-evaluation may prevent dysphagia-associated morbidity. Stroke, (40) 1381-1385

Horner, J., Massey, W. (1988) Silent aspiration following stroke. Neurology (38) 317-319 Leder, S. & Espinosa, M. (2002). Aspiration risk after acute stroke: comparison of clinical

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References McCullough, 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) 55-72

McCullough, 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: 1280-1293

Miles, 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), 457-62

Rosenbek, 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 (37) 437–450

Schurr et al. (1999) Formal Swallowing evaluation and therapy after TBI improves dysphagia outcome. The Journal of trauma: injury, infection, and critical care 46 (5) 817-823

Smithard, O’Neill, Park, England, Renwick, Wyatt, Morris & Martin (1998) Can bedside assessment reliably exclude aspiration following acute stroke? Age and Ageing (27): 99-106

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. Age and Ageing. (29) 495-499

Zenner, Losiniski, Mills (1995) Using cervical auscultation in the clinical dysphagia examination in long term care

Deborah J. C Ramsey, David G. ‘Smithard & Lalit Kalra (2006) Can Pulse Oximetry or a Bedside Swallowing Assessment Be Used to Detect Aspiration After Stroke?’, Stroke Journal of the American Heart Foundation (37) 2984-2988