Introduction: Daniels, McAdam, Brailey, and Foundas (1997) reviewed literature from Linden, Kuhlemeier, and Patterson (1993) and examined signs of aspiration, but specifically six risk factors, including dysphonia, dysarthria, abnormal gag reflex, abnormal volitional cough, voice change after swallow, and cough after swallow. They then designed their study in an attempt to link the six signs of aspiration to the diagnosis and severity of dysphagia. The purpose of the study was to determine whether the six risk factors approximated the VSS in identification of dysphagia severity (Daniels et al., 1997).
It was hypothesized that the presence of any one factor could predict at least mild dysphagia or normal swallowing on a video fluoroscopic swallow study (VSS) and that two factors could predict moderate dysphagia. Methods (Procedures): Fifty-nine male veterans, ages 41-88, with recent neurological deficits were recruited for the study and had one of the following issues: unilateral left hemispheric damage (22 men), bilateral hemispheric damage (18 men), and bilateral hemispheric damage (13 men), or brainstem lesions (6 men).
The men were assessed by a neurologist using CT or MRI scans upon admission to view and localize lesions. They were then rescanned 2 weeks later if the initial scans yielded negative results. Excluded from the study were agitated patients and patients with a history of disorders and diseases other than stroke that would cause dysphagia. Within 5 days of admission, the men were given an oropharyngeal exam of gag reflex, volitional cough, speech, and voice. A video fluoroscopic assessment was also given that consisted of 3,5,10, and 20 ml, and ½ tsp of barium paste along with half of a cookie to be swallowed. A swallow study was also performed by administering 5 ml of liquid, and then giving 10 and 20 ml volumes, which were administered twice each, unless the patients immediately had a negative reaction such as a cough. After each swallow, the men phonated “ah” to see if there was a change in vocal quality.
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Results: The VSS served as the outcome variable in determining dysphagia severity, which ranged from mild dysphagia to normal swallowing (scores 0-1; 1 if two or more of the six risk factors were present and 0 if one or less were present) to moderate to severe dysphagia (scores 2-4).
The reliability for the scores was 92%. 74% of the 59 patients had varying dysphagia severity, while 5.1% had severe dysphagia. 13.6% had moderate to severe dysphagia along with aspiration, while 25.4% had moderate dysphagia, and 25.4% had normal swallowing. 47% had dysphonia, 63% had dysarthria, 27% had abnormal volitional cough, 42% had abnormal gag reflex, 41% had a cough after swallow, and 19% had voice change after swallow (Daniels et al., 1997).
Discussion/Conclusion: The results of this study demonstrated that this clinical assessment has utility in the evaluation of acute stroke patients with probable dysphagia who may be at risk for the development of aspiration (Daniels et al., 1997).
Also discussed was the fact that this assessment does not account for silent aspiration. In conclusion, early detection of aspiration by using this short assessment can reduce aspiration and pneumonia in patients if addressed early in their hospital stay. Commentary: This article provides helpful information for clinicians practicing in a medical setting. The article includes a flow chart to help determine which patients require further evaluation. Ill and physically challenged patients can avoid the physical distress of unnecessary testing with a proper bedside evaluation, and moderate to severe respiration can be caught early to prevent pneumonia. This study was performed in 1997, and clinicians are still using this method today, proving its reliability in early detection of aspiration.
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