Water Swallow Challenge Research Articles

A Cross-Sectional Evaluation of Wellness in New York City Community-Dwelling Seniors (P01-035-19)

ObjectivesThe older adult population is increasing worldwide, placing significant burden on healthcare and support systems. Meeting nutrition and physical activity guidelines is critical to maintain health and quality of life (QOL). The objective of this study was to assess nutrition, swallowing, body composition, and physical function in community-dwelling seniors (CDSs) and describe the prevalence of poor status. MethodsCDSs (n = 54; 42 female; age = 80.1 ± 6.7; body mass index [BMI] = 25.2 ± 4.1 kg/m2) participated in a wellness visit to assess a) nutrition (Dietary Screening Tool [DST], an instrument that identifies nutritional risk), b) swallowing (90 ml water swallow challenge; EAT-10 swallowing screening tool) c) body composition (waist circumference; calf circumference; body fat mass index [BFMI]; fat-free mass index [FFMI]), and d) physical function (SARC-F, a five item sarcopenia screener; Short Physical Performance Battery [SPPB], testing balance, gait speed, and sit to stand). Height was measured using a portable stadiometer; weight with a Seca digital scale. Waist and calf circumferences were measured in triplicate. Body composition was assessed via bioelectrical impedance analysis using the Quad Scan 4000 multifrequency analyzer (BodyStat). BFMI (fat mass, kg/[height, m]2) and FFMI (fat-free mass, kg/[height, m]2) were determined. ResultsThe DST revealed that 11(20.4%) and 35(64.8%) of the CDSs were “at risk” and “possible risk” for poor nutritional status, respectively. Although the EAT-10 documented swallowing difficulties in 5(9.3%) of the CDSs, 12 (22.2%) failed the 90 ml water swallow challenge, consistent with risk of swallowing impairment. Excess adiposity was found in 31(57.4%) using waist circumference and 30(55.6%) using BFMI. Low muscle mass, captured by FFMI, was found in 35(64.8%) of the CDSs. Calf circumference values revealed malnutrition in 3(5.6%) of the CDSs. Six (11.1%) of the CDSs had SARC-F scores associated with poor physical function indicating significant muscle loss in aging. Similarly, SPPB results revealed 14(25.9%) had poor lower extremity physical function. ConclusionsCDSs exhibit impairments in these measures of wellness, placing their health and QOL at risk. Research examining the impact of lifestyle interventions on these measures is needed. Funding SourcesNone

Preoperative predictors of postoperative aspiration risk after cardiac surgery

Background: Aspiration is a common complication among hospitalized patients, and patients undergoing cardiac surgery are at increased risk. Our aim was to determine if screening for frailty could identify patients at risk for aspiration. Patients and Methods: A prospective cohort study of patients 65 and older undergoing nonemergent heart surgery at a single community hospital for 1 year was performed. All patients were screened for frailty before surgery using the 5-m walk test. All patients were screened for aspiration before and after surgery using 90-mL water swallow challenge protocol. Preoperative risk factors and postoperative outcomes were analyzed. Results: Of 166 patients studied, 16 (9.6%) were considered frail. Eleven patients (6.6%) failed the swallow screen preoperatively, and 34 patients (20.5%) failed postoperatively. Frail patients were 3.4 times more likely to fail the postoperative swallow screen than their nonfrail counterparts (odds ratio [OR] = 3.36; 95% confidence interval [CI]: 1.42–7.96; P = 0.01). After adjusting for age, comorbidities, and surgical factors, the likelihood of aspiration risk was still three times higher in frail patients (OR = 3.01; 95% CI: 1.06–8.98; P = 0.04). Conclusions: Frail patients are at increased risk of aspiration after cardiac surgery, but frailty screening does not identify all patients at risk. The 90-mL water swallow challenge is a simple and inexpensive test that can be used to identify patients at risk for aspiration.

Is Dysphagia After Cardiac Operations a “Preexisting Condition”?

Controversy exists about the incidence of dysphagia after cardiac operations, and very little is known about the baseline risk in this patient population. This study evaluated the incidence of dysphagia both preoperatively and postoperatively in patients undergoing cardiac operations. Patients undergoing cardiac operations were screened for dysphagia preoperatively using a 90-mL water swallow challenge protocol, a mini cognitive/speech screen, and a modified oral mechanism screen. The tests were repeated after extubation once the patient was alert and oriented. Patient characteristics were analyzed in conjunction with the results of the swallow screens to identify risk factors for dysphagia. Of 176 patients tested, 15 (8.5%) failed the swallow screen preoperatively. Age, gender, and comorbidities were compared. Patients who failed the swallow study preoperatively were slightly older (76.1 vs 73.3 years, p = 0.047) and had a higher incidence of chronic renal failure (13.3% v. 0.6%, p = 0.017), but gender and other comorbidities were not significantly different. Postoperatively, 38 patients failed the swallow screen (21.6%). Those who failed the postoperative screen were also older (75.6 vs 72.9 years, p = 0.012), but other factors (including chronic renal failure) were not significantly different. All of the patients who failed the swallow screen preoperatively also failed postoperatively. Unrecognized dysphagia in patients who need cardiac operations is a common problem and accounts for a substantial portion of that seen postoperatively. Older patients are at increased risk of dysphagia, but gender and medical comorbidities are not useful predictors of this risk.

Five Days of Successful Oral Alimentation for Hospitalized Patients Based Upon Passing the Yale Swallow Protocol

This study aimed to determine the success of oral alimentation and patient retention rate 1 to 5 days after passing the Yale Swallow Protocol. Participants were 200 consecutive acute care inpatients referred for swallow assessment. Inclusion criteria were adequate cognitive abilities to participate safely, completing an oral mechanism examination, and passing the 3-ounce water swallow challenge. Exclusion criteria were altered mental status, failing the 3-ounce challenge, preadmission dysphagia, head-of-bed restrictions < 30°, and a tracheotomy tube. Electronic medical record monitoring post-protocol passing for 1 to 5 consecutive days determined success of oral alimentation and retention rate. All patients who remained medically and neurologically stable drank thin liquids and ate successfully 1 to 5 days after passing the protocol. Mean (SD) volume of liquid ingested per day was 474.2 (435.5) cc. Patient retention declined steadily from day of testing (n = 200) through post-testing day 5 (n = 95). Passing the Yale Swallow Protocol allowed for initial determination of aspiration risk followed by successful oral alimentation for 1 to 5 days in medically and neurologically stable acute care hospitalized patients and without the need for instrumental dysphagia testing. The decline in patient retention was expected because of increasingly rapid transit through the acute care setting, which often renders longer follow-up problematic.

Comparing accuracy of the Yale swallow protocol when administered by registered nurses and speech‐language pathologists

(1) To describe the results of a web-based teaching module used by registered nurses to identify patients at risk of aspiration and (2) to determine accuracy of the registered nurse-administered 3-ounce water swallow challenge protocol, that is, drinking three ounces of water, a basic cognitive screen and oral mechanism evaluation, when compared with blinded ratings from speech-language pathology. Early identification of potential swallowing problems is important prior to ingestion of food, fluid and medications. Unfortunately, current nurse-administered screens use a variety of non-evidence-based assessments. It would be beneficial to use a valid, reliable and evidence-based screen, that is, the Yale swallow protocol. Prospective, blinded, referral-based. Fifty-two registered nurses and 101 inpatients participated. First, each participant was administered the 3-ounce water swallow challenge protocol by a speech-language pathologist. Second, a nurse administered the protocol to the same patient within one hour and independently recorded results and diet recommendations. The nurse was blinded to the study's purpose and results of the speech-language pathologist's initial screening. Out of view, but simultaneous with the nurse-administered protocol, a speech-language pathologist rerated the patient's challenge for comparison with initial results and determined the accuracy of the nurse-administered protocol. Intra- and inter-rater protocol agreements for the two speech-language pathologists were 100%. Inter-rater protocol agreement between registered nurses and speech-language pathologists was 98·01%. Results confirm the reliability and accuracy of a registered nurse-administered Yale swallow protocol. The consequence of 98% accuracy combined with previously reported 96·5% sensitivity, 97·9% negative predictive value and <2% false negative rate allowed for adoption of the protocol for the entire general hospital population. Avoidance of preventable prandial pulmonary aspiration as a cause of nosocomial infection is an important goal for all acute care hospitalised patients deemed at risk of aspiration.

Letter by Daniels Regarding Article "Silent Aspiration Risk is Volume-Dependent"

Leder and Suiter [1] have proposed the 3-oz. water swallowchallenge as a screening tool for dysphagia in all patientpopulations. Their study was of a retrospective referral-based cohort, i.e., consecutive admissions were not tested.Studies on referral-based patients have the potential forbias. In addition, blinding was not part of this study as thesame investigator interpreted both the fiber-optic evalua-tion of swallowing (FEES) and the 3-oz water swallowchallenge. In their article it was stated that FEES wasperformed prior to the administration of the 3-oz. waterswallow challenge. In a most recent article [2], the sameauthors again studied a large cohort of referred patients,primarily the same patients in the previous study. As in theearlier study, FEES was conducted prior to the 3-oz. waterswallow challenge with the same examiner completingboth. This time, however, the authors reported that over400 patients were excluded from the 3-oz water swallowchallenge due to safety issues, e.g., aspiration of largeamounts of various consistencies on FEES. This detail callsinto question the authors entire body of work and raisesstrong safety concerns about the validity of the 3-oz. waterswallow challenge. When screening a patient, the potentialfor dysphagia and aspiration is unknown; this is the entirereason to screen. Given the information about the exclusionof patients from the 3-oz. water swallow challenge, howare clinicians to decide who is and is not a safety risk priorto actual screening? This methodological informationregarding patient exclusion begs the question: Werepatients excluded in initial study but not reported? Theauthors have not reported any negative consequences ofadministering the 3-oz. water swallow challenge. Theremay have been a lack of negative consequences due to thepreferential selection of patients who underwent thescreening. In order to clarify these issues, the authorsshould undertake a well-designed prospective study inwhich all patients, or a particular subpopulation of patients,are studied, not just referrals. Blinding must be in place;otherwise, the potential for bias will always exist. Lastly,the 3-oz. water swallow challenge MUST be administeredto all patients. In addition, morbidity of patients should bereported. Only after such a study is undertaken can health-care personnel be confident in using the 3-oz. water swal-low challenge as a screening tool.References

Success of Recommending Oral Diets in Acute Stroke Patients Based on Passing a 90-cc Water Swallow Challenge Protocol

Purpose: This study investigated the success of recommending specific oral diets following an acute stroke based on passing a 90-cc water swallow challenge protocol. Method: The study was a single group consecutively referred case series design. The study took place in a large, urban, tertiary care teaching hospital and involved 75 acute adult stroke inpatients in a 90-cc water swallow challenge. The volume (in cc) of liquid ingested, percent of meal eaten, and specific diet recommendations made 12 to 24 hours after passing a 90-cc water swallow challenge were accessed electronically from routine oral intake information entered by nursing staff on each participant’s daily flow sheets. Nurses were blinded to the study’s purpose. Results: All 75 participants were drinking thin liquids and eating food successfully 12 to 24 hours after passing a 90-cc water swallow challenge. The mean volume of liquid ingested was 385.4 cc and percent of diet eaten ranged from 10% to 100%. Flow sheets indicated that specific diet recommendations were followed with 100% accuracy. Conclusions: Successfully recommending specific oral diets to acute stroke patients based on passing a 90-cc water swallow challenge protocol was supported. A 90-cc challenge is an easily administered, highly reliable, cost-effective, and validated clinical assessment that can be used by a variety of qualified health care professionals to identify aspiration risk. When a 90-cc challenge protocol is passed, specific diet recommendations can be made safely and confidently without the need for further objective dysphagia testing.

Safe initiation of oral diets in hospitalized patients based on passing a 3-ounce (90 cc) water swallow challenge protocol

Safe and timely oral alimentation is crucial for optimum patient care. To determine the short-term success of recommending specific oral diets, including drinking thin liquids, to acute care hospitalized patients at risk for dysphagia based on passing a 3-ounce water swallow challenge protocol. Prospective single group consecutively referred case series. Large, urban, tertiary care, teaching hospital. 1000 hospitalized patients. 3-ounce (90 cc) water swallow challenge protocol. Specific diet recommendations and volume (in cc) of liquid ingested at the next day's meal 12-24 h after passing a 3-ounce challenge protocol were accessed electronically from oral intake information entered on each participant's daily care logs. Eating and drinking success, clinically evident aspiration events and compliance with ordering the recommended diet were recorded. Care providers were blinded to the study's purpose. Of 1000 patients, 907 met the inclusion criteria of stable medical, surgical or neurological conditions 12-24 h after passing a 3-ounce water swallow challenge protocol. All 907 were both eating and drinking thin liquids successfully and without overt signs of dysphagia. Median volume of liquid ingested was 340 cc [interquartile range (IQR), 240-460]. Specific diet recommendations were followed with 100% accuracy. A 3-ounce water swallow challenge protocol successfully identified patients who can be safely advanced to an oral diet without subsequent identification of overt signs of aspiration within 12-24 h of testing. Importantly, when a clinical 3-ounce challenge protocol administered by a trained provider is passed, specific diet recommendations, including drinking thin liquids, can be made safely and without the need for additional instrumental dysphagia testing.

Initiating Safe Oral Feeding in Critically Ill Intensive Care and Step-Down Unit Patients Based on Passing a 3-Ounce (90 Milliliters) Water Swallow Challenge

Pulmonary aspiration is a leading cause of nosocomial infection in the intensive care unit (ICU) and step-down unit (SDU). A key goal is to identify patients who exhibit increased aspiration risk before beginning oral alimentation. This study investigated the success of recommending specific oral diets to ICU and SDU patients based on passing a 3-oz water swallow challenge. A referral-based sample of 401 ICU and 92 SDU patients were prospectively analyzed. Amount of liquid and food ingested at the next day's meal 12 hours to 24 hours after passing a 3-oz challenge and specific diet recommendations were accessed electronically from oral intake information entered on each participant's daily care sheets. Drinking and eating success, clinically evident aspiration events, and accuracy of diet order recommendations were recorded. Care providers were blinded to the purpose of the study. All 401 ICU and 92 SDU patients were successfully drinking thin liquids and eating 12 hours to 24 hours after passing a 3-oz challenge. Mean volume of liquid ingested at the next day's meal was 360 mL±181.2 mL for ICU and 356.4 mL±173.5 mL for SDU patients. Percent of meal eaten ranged from 10% to 100%. Patient care sheets indicated specific diet recommendations were followed with 100% accuracy. Successfully recommending specific oral diets for ICU and SDU patients based on passing a 3-oz water swallow challenge was supported. Importantly, when a simple bedside 3-oz challenge administered by a trained provider is passed, specific diet recommendations can be made safely and confidently without the need for further objective dysphagia testing.

Silent Aspiration Risk is Volume-dependent

Clinical swallow protocols cannot detect silent aspiration due to absence of overt behavioral signs, but screening with a much larger bolus volume, i.e., 90cc vs. 1-10cc, may elicit a reflexive cough in individuals who might otherwise exhibit silent aspiration. A swallow screen that maintains high sensitivity to identify aspiration risk while simultaneously reducing the false-negative rate for silent aspiration would be beneficial. The purpose of this study was to investigate whether silent aspiration risk was volume-dependent by using a 3-oz. (90-cc) water swallow challenge to elicit a reflexive cough when silent aspiration occurred on smaller bolus volumes. A prospective, consecutive, referral-based sample of 4102 inpatients from the acute-care setting of a large urban tertiary-care teaching hospital participated. Silent aspiration was determined first by fiberoptic endoscopy and then each participant was instructed to drink 3oz. of water completely and without interruption. Criteria for challenge failure were inability to drink the entire amount, stopping and starting, or coughing and choking during or immediately after completion. Improved identification of aspiration risk status occurred for 58% of participants who exhibited silent aspiration on smaller volumes, i.e., an additional 48% of liquid silent aspirators and 65.6% of puree silent aspirators coughed when attempting the 3-oz. water swallow challenge. A low false-negative rate was observed for the entire population sample, i.e., ≤2.0%. A combined false-negative rate for participants who silently aspirated was 6.9%, i.e., 7.8% if silently aspirated liquid and 6.1% if silently aspirated puree consistency. Determination of silent aspiration risk was shown to be volume-dependent, with a larger volume eliciting a reflexive cough in individuals who previously silently aspirated on smaller volumes. A 3-oz. water swallow challenge's previously reported high sensitivity for identification of aspiration risk combined with the newly reported low false-negative rate mitigates the issue of silent aspiration risk during clinical swallow screening.

Three-Ounce Water Swallow Challenge as a Screening Tool for Children With Suspected Oropharyngeal Dysphagia

Accurate assessment of children who are risk for oropharyngeal dysphagia is vitally important because unrecognized prandial aspiration can lead to a number of serious medical complications, including failure to thrive, dehydration, oral aversion, and pneumonia (Martin et al., 1994; Langmore et al., 1998). Videofluoroscopy and endoscopy are the two most widely used instrumental tools to assess swallow function. However, videofluoroscopy exposes children to radiation, is expensive, and involves swallowing substances different from those a child might typically ingest. Endoscopy can be frightening and potentially uncomfortable for some children. Additionally, clinicians may not always have access to these instrumental evaluations.

The 3-ounce (90-cc) water swallow challenge: A screening test for children with suspected oropharyngeal dysphagia

To investigate the clinical utility of the 3-ounce (90-cc) water swallow challenge alone to determine both aspiration status and oral feeding recommendations in children. Cross-sectional evaluation of a diagnostic test with a consecutive, referral-based sample. Urban, tertiary care, teaching hospital. Fifty-six children (age range 2-18 years; mean 13 years) referred for swallowing evaluations. Aspiration status during fiberoptic endoscopic evaluation of swallowing (FEES) was the objective criterion standard with which results from the 3-ounce water swallow challenge were compared. Twenty-two (39.3%) participants passed and 34 (60.7%) failed the 3-ounce challenge. Sensitivity for predicting aspiration status during FEES = 100.0 percent, specificity = 51.2 percent, and false-positive rate = 48.4 percent. Sensitivity for identifying individuals who were deemed safe for oral intake based on FEES results = 100.0 percent, specificity = 44.0 percent, and false-positive rate = 56.0 percent. If the 3-ounce water swallow challenge is passed, not only thin liquids but diet recommendations with puree and solid food consistencies can be made without the need for further instrumental dysphagia assessment. The 3-ounce water swallow challenge has been shown to be a clinically useful screening test for oropharyngeal dysphagia in children.