Screening tool for oropharyngeal dysphagia in stroke – Part I: evidence of validity based on the content and response processes

Almeida, Tatiana Magalhães de; Cola, Paula Cristina; Pernambuco, Leandro de Araújo; Magalhães Junior, Hipólito Virgílio; Magnoni, Carlos Daniel; Silva, Roberta Gonçalves da

Tatiana Magalhães de Almeida ^**Correspondence address: Tatiana Magalhães de Almeida Instituto Dante Pazzanese de Cardiologia – IDPC Avenida Dr. Dante Pazzanese, 500, Vila Mariana, São Paulo (SP), Brazil, CEP: 04012-909. E-mail: tatiana.almeida@dantepazzanese.org.br

Instituto Dante Pazzanese de Cardiologia – IDPC - São Paulo (SP), Brazil.

Paula Cristina Cola

Universidade de Marília – UNIMAR - Marília (SP), Brazil.

Leandro de Araújo Pernambuco

Universidade Federal da Paraíba – UFPB - João Pessoa (PB), Brazil.

Hipólito Virgílio Magalhães Junior

Universidade Federal do Rio Grande do Norte – UFRN - Natal (RN), Brazil.

Carlos Daniel Magnoni

Instituto Dante Pazzanese de Cardiologia – IDPC - São Paulo (SP), Brazil.

Roberta Gonçalves da Silva

Universidade Estadual Paulista – UNESP - Marília (SP), Brazil.

Conflict of interests: nothing to declare.

*Correspondence address: Tatiana Magalhães de Almeida Instituto Dante Pazzanese de Cardiologia – IDPC Avenida Dr. Dante Pazzanese, 500, Vila Mariana, São Paulo (SP), Brazil, CEP: 04012-909. E-mail: tatiana.almeida@dantepazzanese.org.br

Author contributions TMA participated in the study design and research, obtaining and interpreting the data and writing the manuscript; PCC participated in the study design and research, critical review of the manuscript; LAP participated in the study design and research, critical review of the manuscript; HVMJ participated in the study design and research, critical review of the manuscript; CDM participated in the critical review of the manuscript; RGS participated in the study design and research, critical review of the manuscript.

Questions Stage I (Predicting factors of risk)	Questions Stage II (Signs and symptoms) - observations of the first meal
1a-Is there difficulty in keeping alert?	1b-Is there leakage of food or liquid from your oral cavity?

2a-Is there disorientation, confusion, and/or inattentiveness?	2b-Is there nasal reflux?

3a-Was there intubation for more than 24 hours?	3b-Is there multiple swallowing?

4a-Do you use a tracheostomy tube?	4b-Is there throat clearing?

5a-Is there cardiorespiratory difficulty?	5b-Do you cough during your meals?

6a-Is there history of swallowing difficulty?	6b-Do you choke during your meals?

7a-Is there difficulty to control your head and torso?	7b-Is there voice alterations?

8a-Is there motor impairment to the left?	8b- Is there food residue in your oral cavity?

9a-Is there difficulty in understanding simple verbal commands?	9b-Does the patient report feeling of saliva and/or food stuck in their throat?

10a-Is there difficulty in speech?	10b- Does the patient have increased meal time?

11a-Is there alteration in voice quality?	11b-Is there cardiorespiratory alteration during meal?

12a-Is there alteration in voluntary coughing?

13a- Is there facial asymmetry?

14a-Is there soft palate asymmetry?

15a-Is there deficit in nausea reflex?

16a- Is there difficulty in moving lips and tongue?

17a-Is there deficit in tongue strength?

18a-Is there difficulty in swallowing or managing saliva/secretions swallowing spontaneously or on command?

Stage I	Number of evaluators who considered the question appropriate	CVI-I
1a- Is there difficulty in keeping alert?^* * Items with CVI-I below 0.78	14	0.73
2a-Is there disorientation, confusion, and/or inattentiveness?^* * Items with CVI-I below 0.78	13	0.68
3a-Was there intubation for more than 24 hours?	19	1.00
4a-Do you use a tracheostomy tube?	19	1.00
5a-Is there cardiorespiratory difficulty?^* * Items with CVI-I below 0.78	08	0.42
6a-Is there history of swallowing difficulty?	19	1.00
7a-Is there difficulty to control your head and torso?	17	0.89
8a-Is there motor impairment to the left?^* * Items with CVI-I below 0.78	13	0.68
9a-Is there difficulty in understanding simple verbal commands?	18	0.94
10a-Is there difficulty in speech?	16	0.84
11a-Is there alteration in voice quality?	16	0.84
12a-Is there alteration in voluntary coughing?^* * Items with CVI-I below 0.78	14	0.73
13a- Is there facial asymmetry?	17	0.89
14a-Is there soft palate asymmetry?^* * Items with CVI-I below 0.78	13	0.68
15a-Is there deficit in nausea reflex?^* * Items with CVI-I below 0.78	13	0.68
16a- Is there difficulty in moving lips and tongue?	17	0.89
17a-Is there deficit in tongue strength?^* * Items with CVI-I below 0.78	09	0.47
18a-Is there difficulty in swallowing or managing saliva/secretions swallowing spontaneously or on command?	18	0.94
	CVI-T	0.80

Stage II	Number of evaluators who considered the question appropriate	CVI-I
1b-Is there leakage of food or liquid through the oral cavity?	11	0.89
2b-Is there nasal reflux?	12	0.89
3b-Is there multiple swallowing?^* * Items with CVI-I below 0.78	06	0.63
4b-Is there throat clearing?	09	0.79
5b-Do you cough during your meals?	09	0.79
6b-Do you choke during your meals?	10	0.84
7b-Is there voice alterations?^* * Items with CVI-I below 0.78	04	0.47
8b- Is there food residue in your oral cavity?	09	0.79
9b-Does the patient report feeling of saliva and/or food stuck in their throat?	13	1.00
10b- Does the patient have increased meal time?^* * Items with CVI-I below 0.78	06	0.58
11b-Is there cardiorespiratory alteration during meal?^* * Items with CVI-I below 0.78	04	0.37
	CVI-T	0.73

Questions Stage I – Version 1	Questions Stage I – Version 2
1a-Is there difficulty in keeping alert?	1a-Is there difficulty in keeping awake?
2a-Is there disorientation, confusion, and/or inattentiveness?	REMOVED
3a-Was there intubation for more than 24 hours?	2a-Was there intubation for more than 24 hours?
4a-Do you use a tracheostomy tube?	3a-Do you use a tracheostomy tube?
5a-Is there cardiorespiratory difficulty?	4a-Are there signs of respiratory discomfort?
6a-Is there history of swallowing difficulty?	5a-Is there history of swallowing difficulty?
7a-Is there difficulty to control your head and torso?	6a-Is there difficulty of remaining seated with a straight head?
8a-Is there motor impairment to the left?	REMOVED
9a-Is there difficulty in understanding simple verbal commands?	7a-Is there difficulty in understanding simple verbal commands?
10a-Is there difficulty in speech?	8a-Is there difficulty in speech? (distorted speech, difficult understanding)
11a-Is there alteration in voice quality?	9a-Is there alteration in voice? (hoarseness, weak sound, does not produce voice)
12a-Is there alteration in voluntary coughing?	REMOVED
13a- Is there facial asymmetry?	10a-Is there facial asymmetry?
14a-Is there soft palate asymmetry?	REMOVED
15a-Is there deficit in nausea reflex?	REMOVED
16a- Is there difficulty in moving lips and tongue?	11a- Is there difficulty in moving lips and tongue?
17a-Is there deficit in tongue strength?	REMOVED
18a- Is there difficulty in swallowing or managing saliva/secretions swallowing spontaneously or on command?	12a- Is there difficulty in swallowing or managing saliva/secretions swallowing spontaneously or on command?

Questions Stage II – Version 1	Questions Stage II – Version 2
1b-Is there leakage of food or liquid from your oral cavity?	1b- Is there leakage of food or liquid from the oral cavity?
2b-Is there nasal reflux?	REMOVED
3b-Is there multiple swallowing?	2b-Is there need to swallow 3 times or more the portion of food in the mouth?
4b-Is there throat clearing?	3b- Is there throat clearing, coughing, and/or choking during meals?
5b-Do you cough during your meals?
6b-Do you choke during your meals?	REMOVED
7b-Is there voice alterations?	REMOVED
8b- Is there food residue in your oral cavity?	4b-Is there residue of any food consistency in the oral cavity after swallowing?
9b-Does the patient report feeling of saliva and/or food stuck in their throat?	REMOVED
10b- Does the patient have increased meal time?	REMOVED
11b-Is there cardiorespiratory alteration during meal?	5b-Are there signs of respiratory discomfort?

Questions Stage I	% answers- structured scale
Questions Stage I	I understood the questions and how to apply them and I did not have doubts	I understood the questions partially and had doubts and/or difficulties of understanding the question and/or how to apply it	I did not understand the question and/or did not know how to apply it
1a Is there difficulty in keeping awake?	100	-	-
2a Was there intubation for more than 24 hours?	100	-	-
3a Do you use a tracheostomy tube?	100	-	-
4a Are there signs of respiratory discomfort?	100	-	-
5a Is there history of swallowing difficulty?	78.3	21.7	-
6a Is there difficulty in remaining seated with a straight head?	95.7	4.3	-
7a Is there difficulty in understanding simple verbal commands?	100	-	-
8a Is there difficulty in speech? (distorted speech, difficult understanding)?	100	-	-
9a Is there alteration in voice?	95.7	4.3	-
10a Is there facial asymmetry?	100	-	-
11a Is there difficulty in moving lips and tongue?	78.3	21.7	-
12a Is there difficulty in swallowing or managing saliva/secretions, swallowing spontaneously or on command?	91.3	8.7	-

Questions Stage II	% answers- structured scale
	I understood the questions and how to apply them and I did not have doubts	I understood the questions partially and had doubts and/or difficulties of understanding the question and/or how to apply it	I did not understand the question and/or did not know how to apply it
1b Is there leakage of any food consistency from the oral cavity?	100	-	-
2b Is there need to swallow 3 times or more the portion of food in the mouth?	90.47	9.52	-
3b Is there throat clearing, coughing, and/or choking during meals?	100	-	-
4b Is there residue of any consistency in the oral cavity after swallowing?	100	-	-
5b Are there signs of respiratory discomfort during meals?	95.24	4.76	-

Questions	Analysis of the response processes
6a-Is there difficulty of remaining seated with a straight head?	1 applicator requested the patient to rise from the bed to check if the patient could seat without support
	1 applicator considered the discomfort (pain) reported by the patient remaining seated with difficulty
	2 applicators considered the difficulty of positioning patients sitting down due to excess weight as a difficulty
8a- Is there difficulty in speech? (distorted speech, difficult understanding)	1 applicator considered speech as a language, reporting having reached their conclusion because the patient would speak well by forming coherent sentences
9a-Is there alteration in voice? (hoarse voice, weak voice, no voice production)	1 applicator did not understand the difference between speech and voice, stating that if the speech in the previous question was appropriate then voice would also automatically be
12a- Is there difficulty in swallowing or managing saliva/secretions swallowing spontaneously or on command?	3 applicators considered a difficulty when patients did not swallow their saliva when requested and 1 when the patient took too long to follow the command (patient with understanding deficit). They did not consider reflex swallowing and other signs such as absence of oral leakage, coughing, and/or choking.
2b- Is there need to swallow 3 times or more the portion of food in the mouth?	1 applicator did not understand the concept of multiple swallowing. The patient did not swallow the volume placed in their oral cavity and the professional understood this patient would need various swallowing commands in order to be able to swallow it.
5b-Are there signs of respiratory discomfort during meals?	1 applicator considered a longer breathing after swallowing as a sign of respiratory discomfort
5b-Are there signs of respiratory discomfort during meals?	2 applicators considered the respiratory discomfort previous to feeding as a sign observed during feeding

Stage I (Predicting factors of risk)
Instructions	Questions	Possible outcomes	Yes	No	Does not apply
Call the patient by their name and observe	Is there difficulty in keeping awake?	Does not respond, drowsy, needs verbal and tactile stimulation in order to stay alert
Check their clinical history	Was there intubation for more than 24 hours?	-
Check their clinical history and observe the patient	Was there use of a tracheostomy tube?	-
Observe the respiratory pattern	Are there signs of respiratory discomfort?	Shortage of breath, difficulty to breath, tiredness, use of accessory muscles, increased respiratory frequency
Ask the patient, Escort or check the patient’s chart	Is there history of swallowing difficulty?	Choking, coughing during feeding, use of alternative feeding pathway, need to previously adapt the diet.
Position the patient sitting down with their elevated decubitus	Is there difficulty in being sitting down with a straight head?	Does not control the head and/or torso even when supported
Ask the patient their names and request them to open and close their eyes	Is there difficulty in understanding simple verbal commands?	Is not able to respond, cannot or has difficulties to follow commands, needs gestures in order to perform the commands
Observe the voice of the patient during the conversation	Is there alteration in voice?	Hoarse voice, no sonorization, or little sonorization
Observe the speech and language of the patient during the spontaneous conversation	Is there difficulty in speech and/or language?	Does not speak, dragged speech, alterations in articulation (dysarthria), difficulty to understand the speech, fragmented oral expressions, incoherent speech
Observe their face at rest and request a pout and a smile	Is there facial asymmetry?	Reduction or total absence of movement of one of the sides of the face
Ask the patient to move their lips and tongue	Is there difficulty in moving lips and tongue?	Does not present movement, slow movements, movement deviation
Observe if the patient swallows their saliva (rising larynx movement) spontaneously or on command	Is there difficulty in swallowing or managing saliva/secretions swallowing spontaneously or on command?	Does not observe swallowing, saliva accumulation in the oral cavity, drooling, wet voice, noises in respiratory trait
Stage II (Signs and symptoms)- observations of the first meal
Instructions	Questions	Possible outcomes	Yes	No	Does not apply
Observe the swallowing of food (larynx rising)	Is there difficulty in swallowing the volume in the mouth?	Take too long to swallow, does not swallow, needs constant verbal orientation to swallow
Observe the oral region	Is there leakage of any food consistency from the oral cavity?	Leakage of food from the mouth
Observe the larynx rising	Was there swallowing of more than 3 times the portion placed in the mouth?	Swallows more than 3 times
Observe the signs	Is there throat clearing, coughing, and/or choking during meals?	Coughing, throat clearing, and/or choking during meals
After the patient swallows, observe their oral cavity	Is there residue of any food consistency in the oral cavity after swallowing?	Food accumulation inside the mouth
Observe the respiratory pattern during the meal (disregard previous discomfort)	Are there signs of respiratory discomfort during meals?	Shortage of breath, difficulty to breath, tiredness, use of accessory muscles, increased respiratory frequency, fall in oxygen saturation

[1] Conflict of interests: nothing to declare.

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Screening tool for oropharyngeal dysphagia in stroke – Part I: evidence of validity based on the content and response processes

ABSTRACT

Purpose

Methods

Results

Conclusion