Screening tools for oropharyngeal dysphagia in stroke

For the selection of studies, the swallowing disorder descriptors stroke, screening, evaluation and dysphagia were used. MEDLINE, Embase, LILACS, SciELO and the Cochrane Library databases were consulted.

Selection criteria:

We selected articles in the English, Portuguese and Spanish languages published up to December 2014 whose methodological approach referred to screening tools for oropharyngeal dysphagia designed for adults with stroke. The parameters used in the various screening tools were grouped by equality and/or likeness. We performed a descriptive analysis and calculated the frequency of found parameters.

Results:

We found 688 articles and after consideration of the inclusion and exclusion criteria, 23 articles were effectively analyzed. Of the 20 tools found, 90% used some type of food offer orally in screening for dysphagia, mostly water. We found 19 different parameters not related to food offer and 12 parameters related to food offer.

Conclusion:

There is no consensus among the studies on the most sensitive and specific parameters to compose the screening method for oropharyngeal dysphagia in stroke.

Keywords:
Deglutition disorders; Mass screening; Stroke; Deglutition; Diagnosis

Selected articles	Population	Professional who administered	Tests used	Psychometric measurements/conclusions of studies
1. DePipo et al. (1992)(⁵5. DePippo KL, Holas MA, Reding MJ. Validation of the 3-oz water swallow test for aspiration following stroke. Arch Neurol. 1992;29(12):1259-61. http://dx.doi.org/10.1001/archneur.1992.00530360057018 http://dx.doi.org/10.1001/archneur.1992.... )	n=44 Stroke rehabilitation phase	Speech-language pathologists	Test with water	Water sensitivity: 76% Water specificity: 59% Thickened liquid sensitivity: 94% Thickened liquid specificity: 30% Sensitivity and specificity for laryngotracheal aspiration established by videofluoroscopy.
2. DePippo et al. (1994)(⁶6. DePippo KL, Holas MA, Reding MJ. The Burke dysphagia screening test: validation of its use in patients with stroke. Arch Phys Med Rehabil. 1994;75(12):1284-6.)	n=139 Stroke rehabilitation phase	Speech-language pathologists	Indirect items (questionnaire) and water test	Comparison carried out of tool with developing pneumonia, airway occlusion and death. Risk of developing complications was 7.65 times greater in individuals who failed than in individuals who passed
3. Smithard et al. (1996, 1997, 1998)(¹1. Smithard DG, O'neill PA, Park CL, Morris J, Wyatt R, England R et al. Complications and outcome after acute stroke does dysphagia matter? Stroke.1996;27(7):1200-4. http://dx.doi.org/10.1161/01.STR.27.7.1200 http://dx.doi.org/10.1161/01.STR.27.7.12... ,⁷7. Smithard DG, O'Neill PA, Park C, England R, Renwick DS, Wyatt R et al. Can bedside assessment reliably exclude aspiration following acute stroke? Age Ageing. 1998;27(2):99-106. http://dx.doi.org/10.1093/ageing/27.2.99 http://dx.doi.org/10.1093/ageing/27.2.99... ,⁸8. Smithard DG, O'Neill PA, England RE, Park CL, Wyatt R, Martin DF et al. The natural history of dysphagia following a stroke. Dysphagia. 1997;12(4):188-93. http://dx.doi.org/10.1007/PL00009535 http://dx.doi.org/10.1007/PL00009535... )	n=94 Acute phase - up to 24h. of stroke diagnosis	Physicians and speech-language pathologists	Indirect items and water test	Sensitivity: 47% speech-language pathologist 70% physician Specificity: 86% speech-language pathologist 66% physician reliability varied between physician and speech-language pathologist κ = (0.24-0.79) Sensitivity and specificity for dysphagia. Comparison established by videofluoroscopy. Lack of defining criteria used in considering the presence of dysphagia in the exam.
4. Daniels et al. (1997)(⁹9. Daniels SK, McAdam CP, Brailey K, Foundas AL. Clinical assessment of swallowing and prediction of dysphagia severity. American Journal of Speech-Lang Pathol. 1997;6(4):17-24. http://dx.doi.org/10.1044/1058-0360.0604.17 http://dx.doi.org/10.1044/1058-0360.0604... )	n=59 Acute phase - up to 5 days after stroke diagnosis	Speech-language pathologists	Indirect items and water test	Sensitivity: 92% Specificity: 67% 2 to 6 clinical characteristics Comparison established by videofluoroscopy. Sensitivity and specificity for laryngotracheal aspiration and penetration and not for dysphagia. The presence of laryngotracheal aspiration and penetration as well as severity was classified according to the frequency of penetrations/aspirations and quantity of aspirate consistencies observed in the exam.
5. Hinds and Wiles (1998)(¹⁰10. Hinds NP, Wiles CM. Assessment of swallowing and referral to speech and language therapists in acute care. Q J Med. 1998;91(12):829-35. http://dx.doi.org/10.1093/qjmed/91.12.829 http://dx.doi.org/10.1093/qjmed/91.12.82... )	n=115 Acute phase - up to 72h of stroke diagnosis	Physicians	Indirect items (questionnaire) and water test	Sensitivity: 97% Specificity: 69% Comparison based on clinical characteristics suggestive of dysphagia, such as: Need of SLP intervention, dietary changes, respiratory complications and death.
6. Westergren et al. (1999)(¹¹11. Westergren A, Hallberg IR, Ohlsson O. Nursing assessment of dysphagia among patients with stroke. Scand J Caring Sci. 1999;13(4):274-82. http://dx.doi.org/10.1111/j.1471-6712.1999.tb00551.x http://dx.doi.org/10.1111/j.1471-6712.19... )	n=160 Acute phase	Nurses	Indirect items and test with processed milk (thickened consistency) and water	Authors concluded that 77% of subjects were identified with dysphagia. Diagnostic confirmation was performed by clinical evaluation of swallowing. Lack of defining criteria used in considering the presence of dysphagia.
7. Perry (2001)(¹²12. Perry L. Screening swallowing function of patients with acute stroke: part one: identification, implementation and initial evaluation of a screening tool for use by nurses. J Clin Nurs. 2001;10(4):463-73. http://dx.doi.org/10.1046/j.1365-2702.2001.00501.x http://dx.doi.org/10.1046/j.1365-2702.20... )	n=123 Acute phase	Nurses Speech-language pathologists Physicians	Indirect items and water test	Sensitivity: 97% Specificity: 90% Positive predictive value (PPV): 0.92 Negative predictive value (NPV): 0.96 Comparison based on clinical indicators, as reports of swallowing difficulty described by the team, found in patients' medical records.
8. Massey and Jedlicka (2002)(¹³13. Massey R, Jedlicka D. The massey bedside swallowing screen. J Neurosci Nurs. 2002;34(5):252-60. http://dx.doi.org/10.1097/01376517-200210000-00005 http://dx.doi.org/10.1097/01376517-20021... )	n=25 Acute phase - up to 48h of stroke diagnosis	Nurses	Indirect items and water test	Sensitivity: 100% Specificity: 100% Comparison based on clinical data from medical records that indicated the presence or lack of presence of dysphagia. Dysphagia was determined by the need of SLP therapy, need of dietary adaptation and lung infection.
9. Nishiwaki et al. (2005)(¹⁴14. Nishiwaki K, Tsuji T, Liu M, Hase K, Tanaka N, Fujiwara, T. Identification of a simple screening tool for dysphagia in patients with stroke using factor analysis of multiple dysphagia variables. J Rehabil Med. 2005;37(4):247-51. http://dx.doi.org/10.1080/16501970510026999 http://dx.doi.org/10.1080/16501970510026... )	n=61 Patients with a diagnosis of stroke varied from 1 month to 3 months from stroke diagnosis	Physicians Speech-language pathologists	Indirect items and water test	Obtained results were compared with videofluoroscopy, which determined dysphagia by: oral phase changes (sluggish, escape or incoordination) or pharyngeal phase changes (aspiration, pharyngeal response delay and residue). Aspiration was defined as the entry of foods below the vocal folds. Indicated that only the variable cough and change in vocal quality were significantly associated with aspiration, with a sensitivity of 72% and specificity of 67%
10. Trapl et al. (2007)(¹⁵15. Trapl M, Enderle P, Nowotny M, Teuschl Y, Matz K, Dachenhausen A et al. Dysphagia bedside screening for acute-stroke patients. The Gugging Swallowing Screen. Stroke.2007;38(11):2948-52. http://dx.doi.org/10.1161/STROKEAHA.107.483933 http://dx.doi.org/10.1161/STROKEAHA.107.... )	n=50 Acute phase - up to 24h of stroke diagnosis	Speech-language pathologists Nurses	Indirect items and test with processed milk (thickened consistency) and water	Speech-language pathologist: Sensitivity: 100% Specificity: 50% NPV: 100% Nurse: Sensitivity: 100% Specificity: 69% NPV:100% sensitivity and specificity for the presence of laryngotracheal aspiration established by nasal endoscopy exam.
11. Turner-Lawrence et al. (2009)(¹⁶16. Turner-Lawrence DE, Peebles M, Price MF, Singh SJ, Asimos AW. A feasibility study of the sensitivity of emergency physician dysphagia screening in acute stroke patients. Ann Emerg Med. 2009;54(3):344-8.e1. http://dx.doi.org/10.1016/j.annemergmed.2009.03.007 http://dx.doi.org/10.1016/j.annemergmed.... )	n=84 Acute phase - up to 24h of stroke diagnosis	Physicians	Indirect items (questionnaire) and water test	Sensitivity: 96% Specificity: 56% Reliability: 97% Comparison established by clinical evaluation of swallowing. Dysphagia considered with the need of dietary changes after SLP assessment.
12. Bravata et al. (2009)(¹⁷17. Bravata DM, Daggett VS, Woodward-Hagg H, Damush T, Plue L, Russell S et al. Comparison of two approaches to screen for dysphagia among acute ischemic stroke patients: nursing admission-screening tool versus National Institutes of Health stroke scale. Rehabil Res Dev. 2009;46(9):1127-34. http://dx.doi.org/10.1682/JRRD.2008.12.0169 http://dx.doi.org/10.1682/JRRD.2008.12.0... )	n=101 Stroke phase not reported	Nurses	Indirect items and consistencies not reported but signs after swallowing reported.	Tool compared with NIH Stroke Scale (NIHSS). Reported 29% sensitivity and 84% specificity to detect dysphagia, which considered swallowing changes in solid and/or liquid as: changes in oral phase delay not considered dysphagia. The NIHSS, when compared to SLP assessment, had sensitivity of 79% and specificity of 68% concluded that the NIHSS had better dysphagia screening characteristics than the elaborated tool.
13. Courtney and Flier (2009)(¹⁸18. Courtney BA, Flier LA. RN dysphagia screening, a stepwise approach. J Neurosci Nurs. 2009;41(1):28-38. http://dx.doi.org/10.1097/JNN.0b013e31819345ac http://dx.doi.org/10.1097/JNN.0b013e3181... )	Not applied	––––––––––	Indirect items and test with multiple consistencies: applesauce, juice and cracker	Study related only the importance of screening tool implementation and psychometric measurements were not cited.
14. Martino et al. (2010)(¹⁹19. Martino R, Silver F, Teasell R, Bayley M, Nicholson G, Streiner DL et al. The Toronto bedside swallowing screening test (TOR-BSST) development and validation of a dysphagia-screening tool for patients with stroke. Stroke. 2009;40(2):555-61. http://dx.doi.org/10.1161/STROKEAHA.107.510370 http://dx.doi.org/10.1161/STROKEAHA.107.... )	n=311 108 patients in acute phase and 208 in stroke rehabilitation phase	Nurses	Indirect items and water test	Sensitivity 91.3% and NPV 93.3% in stroke acute phase and 89.5% in rehabilitation phases. Specificity: 67% Reliability: intraclass correlation coefficient 92% Sensitivity and specificity, determined to dysphagia, considered any change in swallowing physiology, including aspiration, and the diagnosis was determined by 4 SLP therapists in the analysis of videofluoroscopy.
15. Antonios et al. (2010)(²⁰20. Antonios N, Carnaby-Mann G, Crary M, Miller L, Hubbard H, Hood K et al. Analysis of a physician tool for evaluating dysphagia on an inpatient stroke unit: the modified mann assessment of swallowing ability. J Stroke Cerebrovasc Dis. 2010;19(1):49-57. http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2009.03.007 http://dx.doi.org/10.1016/j.jstrokecereb... )	n=150 Acute phase - up to 89h of stroke diagnosis	Physicians	Indirect items	Sensitivity: (Neurologist 1: 92%, Neurologist 2: 87%), Specificity: (Neurologist 1: 86.3%, Neurologist 2: 84.2%) PPV: (Neurologist 1: 79.4%, Neurologist 2: 75.8%) NPV (Neurologist 1: 95.3%, Neurologist 2: 92%) Reliability: κ=0.76 Sensitivity and specificity for dysphagia, which used the scoring of the Mann Assessment of Swallowing Ability (MANN) clinical assessment tool, was lower than 178.
16. Edmiaston et al. (2010)(²¹21. Edmiaston J, Connor LT, Loehr L, Nassief A. Validation of a dysphagia screening tool in acute stroke patients. Am J Crit Care. 2010;19(4):357-64. http://dx.doi.org/10.4037/ajcc2009961 http://dx.doi.org/10.4037/ajcc2009961... .²²22. Edmiaston J, Connor LT, Steger-May K, Ford AL. Simple bedside stroke dysphagia screen, validated against videofluoroscopy, detects dysphagia and aspiration with high sensitivity. J Stroke Cerebrovasc Dis. 2014;23(4):712-716. http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2013.06.030 http://dx.doi.org/10.1016/j.jstrokecereb... )	n=300 Acute phase - mean of 8h of stroke diagnosis	Nurses	Indirect items and water test	Study 1 Sensitivity/dysphagia: 91% Specificity/dysphagia: 74% Sensitivity/aspiration: 95% Specificity/aspiration: 68% PPV: 54% NPV: 95% Dysphagia was considered if the score of MASA was less than 178. A score less than 170 was consideration for a risk of laryngotracheal aspiration
	n=225 Acute phase			Study 2 Sensitivity/dysphagia: 94% Specificity/dysphagia: 66% PPV: 71% NPV: 93% Reliability: κ=93.6 Sensitivity/aspiration: 95% Specificity/aspiration: 50% Compared with videofluoroscopy and The Dysphagia Outcomes Severity Scale (DOSS) was used for dysphagia classification.
17. Schrock et al. (2011)(²³23. Schrock JW, Bernstein J, Glasenapp M, Drogell K, Hanna J. A novel emergency department dysphagia screen for patients presenting with acute stroke. Acad Emerg Med. 2011;18(6):584-9. http://dx.doi.org/10.1111/j.1553-2712.2011.01087.x http://dx.doi.org/10.1111/j.1553-2712.20... )	n=283 Application phase not reported	Nurses	Indirect items	Sensitivity: 96% Specificity: 56% Reliability: 97% Sensitivity and specificity for dysphagia was determined by observing the patient for 30 days after hospital admission, considering dysphagia: videofluoroscopy needed with altered result, needed alternative feeding pathway and dietary changes after SLP assessment.
18. Barnard (2011)(²⁴24. Barnard SL. Nursing dysphagia screening for acute stroke patients in the emergency department. J Emerg Nurs. 2011;37(1):64-7. http://dx.doi.org/10.1016/j.jen.2010.11.002 http://dx.doi.org/10.1016/j.jen.2010.11.... )	Not applied	–––––––––	Indirect items and test with multiple consistencies: applesauce and water	Study cited the tool, explaining the importance of a screening tool in dysphagia management. Application phase not reported.
19. Zhou et al. (2011)(²⁵25. Zhou Z, Salle J, Daviet J, Stuit A., Nguyen C. Combined approach in bedside assessment of aspiration risk post stroke: PASS. Eur J Phys Rehabil Med. 2011;47(3):441-6.)	n=107 Acute phase - up to 48h of stroke diagnosis	Physicians	Indirect items and water test	Tool is based on a battery of tests: 3oz WT and CPSA test Sensitivity: 89.1% Specificity: 80.8% sensitivity and specificity for aspiration defined in videofluoroscopy with entrance of food below vocal fold.
20. Daniels et al. (2013)(²⁶26. Daniels SK, Anderson JA, Petersen NJ. Implementation of stroke dysphagia screening in the emergency department. Nurs Res Pract. 2013;2013:ID 304190. http://dx.doi.org/10.1155/2013/304190 http://dx.doi.org/10.1155/2013/304190... )	Not applied	–––––––––––	Indirect items and water test	Refers on to implementation steps, with improvement in dysphagia screening after tool implementation, however, no data on its application.

Items unrelated to offer of food	Frequency of items in the study (n=20)	Items related to offer of food	Frequency of items in the study (n=20)
Level of alertness / attention	65% (13)	Cough/choke/throat clearing	90% (18)
Vocal quality	65% (13)	Wet voice	70% (14)
Saliva swallowing	50% (10)	Extra-oral escape/labial sealing deficit	25% (5)
Forced cough	45% (9)	Difficulty in swallowing	20% (4)
Gag reflex	40% (8)	Oral residue	15% (3)
Speech	35% (7)	Respiratory distress/drop in oxygen saturation	15% (3)
Movement/tongue force	35% (7)	Multiple swallows	5% (1)
Swallowing complaints	30% (6)	Delayed pharyngeal response	5% (1)
Movement/palate symmetry	30% (6)	Reduced laryngeal elevation	5% (1)
Movement/facial symmetry	25% (5)	Prolonged meal	5% (1)
Aphasia/comprehension/expression	20% (4)	Pain when swallowing	5% (1)
Breathing/fatigue	15% (3)	Nasal Reflux	5% (1)
Movement/labium symmetry	15% (3)	–	–
Control of head and trunk	15% (3)	–	–
History of pneumonia	10% (2)	–	–
Cooperation/collaboration	5% (1)	–	–
History of tracheal intubation	5% (1)	–
Stroke severity/location	5% (1)	–	–
Reduction prior to oral intake/use of alternative feeding pathway	5% (1)	–	–

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[1] Correspondence address: Roberta Gonçalves da Silva. Universidade Estadual Paulista (UNESP), Departamento de Fonoaudiologia. Av. Hygino Muzzi Filho, 737, Marília (SP), Brazil, CEP: 17525-900. E-mail: rgsilva@marilia.unesp.br