Water-Swallowing Test: Screening for Aspiration in Stroke Patients

Background and Purpose: The water-swallowing test (WST) is frequently used in clinical practice as a functional assessment to detect aspiration and prevent pneumonia. It is a standardized test used all over the world, but the amount of water given varies depending on the examiner. Furthermore, there are very few reports on the simultaneous performance of the WST and videofluorography (VF). This study compared the amount of swallowed water to investigate the reliability of WST to exclude aspiration following acute stroke. Methods: We assessed 111 stroke patients (65 men and 46 women) with suspected dysphagia/difficulty in swallowing and performed VF upon obtaining consent from the patients and their families. Patients were aged between 20 and 98 years (65.6 ± 13.4 years); 64 had cerebral infarction, 26 cerebral hemorrhage, 13 subarachnoid hemorrhage, and 8 had other cerebrovascular disease. The time from stroke onset to VF was 16.6 ± 10.3 days (range, 2-55). WSTs using 5, 10, 30, and 60 ml and the modified WST (MWST) were performed during VF. Results: We found that the number of instances of choking, cough, wet voice, and aspiration increased with higher amounts of water. The sensitivity and specificity of WST for aspiration ranged from 34.8 to 55.7% and from 78.9 to 93.2%, respectively. The MWST, which used only 3 ml of water, yielded a sensitivity of 55.3% and a specificity of 80.8% for aspiration. There was a positive correlation between the time for one swallow and age, but there was no difference between genders. There was also no connection between clinical findings during WST or the presence of aspiration with the number of swallows, swallowing speed, or time for one swallow. Conclusions: WSTs are not as powerful as VF as a screening instrument in acute stroke. WSTs with more water detected aspiration with greater sensitivity, but there is no justification for overconfidence when investigating aspiration. We recommend using WST as well as VF to investigate swallowing in stroke patients.

[1]  D. Prakash.  Dysphagia in acute stroke. , 1987, British medical journal.

[2]  E. Massey,et al.  Silent aspiration following stroke , 1988, Neurology.

[3]  D H Barer,et al.  The natural history and functional consequences of dysphagia after hemispheric stroke. , 1989, Journal of neurology, neurosurgery, and psychiatry.

[4]  O. Ekberg,et al.  Videofluoroscopy in elderly patients with aspiration: importance of evaluating both oral and pharyngeal stages of deglutition. , 1991, AJR. American journal of roentgenology.

[5]  Susan E. Langmore,et al.  Endoscopic and Videofluoroscopic Evaluations of Swallowing and Aspiration , 1991, The Annals of otology, rhinology, and laryngology.

[6]  J. Macmahon,et al.  Aspiration in acute stroke: a clinical study with videofluoroscopy. , 1993, The Quarterly journal of medicine.

[7]  P J Kahrilas,et al.  Effects of bolus volume, viscosity, and repeated swallows in nonstroke subjects and stroke patients. , 1993, Archives of physical medicine and rehabilitation.

[8]  M. Reding,et al.  The Burke dysphagia screening test: validation of its use in patients with stroke. , 1994, Archives of physical medicine and rehabilitation.

[9]  D. Gottlieb,et al.  Validation of the 50 ml3 drinking test for evaluation of post-stroke dysphagia. , 1996, Disability and rehabilitation.

[10]  M J Collins,et al.  Does pulse oximetry reliably detect aspiration in dysphagic stroke patients? , 1997, Stroke.

[11]  Maria Gabriella Ceravolo,et al.  Predictive value of clinical indices in detecting aspiration in patients with neurological disorders , 1997, Journal of neurology, neurosurgery, and psychiatry.

[12]  Rolf Olsson,et al.  Dysphagia in Stroke: A Prospective Study of Quantitative Aspects of Swallowing in Dysphagic Patients , 1998, Dysphagia.

[13]  C. M. Wiles,et al.  Assessment of swallowing and referral to speech and language therapists in acute stroke. , 1998, QJM : monthly journal of the Association of Physicians.

[14]  Clarence T. Sasaki,et al.  Fiberoptic Endoscopic Evaluation of Dysphagia to Identify Silent Aspiration , 1998, Dysphagia.

[15]  D. Smithard,et al.  Can bedside assessment reliably exclude aspiration following acute stroke? , 1998, Age and ageing.

[16]  Graeme J. Hankey,et al.  Swallowing Disorders following Acute Stroke: Prevalence and Diagnostic Accuracy , 2000, Cerebrovascular Diseases.

[17]  Yeun-Chung Chang,et al.  Evaluating Swallowing Dysfunction Using a 100-ml Water Swallowing Test , 2003, Dysphagia.

[18]  E. Saitoh,et al.  Three Tests for Predicting Aspiration without Videofluorography , 2003, Dysphagia.

[19]  A. Takise,et al.  Barium sulphate aspiration , 2004, The Lancet.

[20]  C. M. Wiles,et al.  Swallowing in neurological outpatients: Use of a timed test , 2004, Dysphagia.

[21]  Meigen Liu,et al.  Identification of a simple screening tool for dysphagia in patients with stroke using factor analysis of multiple dysphagia variables. , 2005, Journal of rehabilitation medicine.

[22]  Robert W. Bastian,et al.  The videoendoscopic swallowing study: An alternative and partner to the videofluoroscopic swallowing study , 2005, Dysphagia.

[23]  C. André,et al.  Bedside Assessment of Swallowing in Stroke: Water Tests Are Not Enough , 2008, Topics in stroke rehabilitation.

[24]  J. Cichero,et al.  Triaging dysphagia: nurse screening for dysphagia in an acute hospital. , 2009, Journal of clinical nursing.

[25]  T. Hino,et al.  Creating flowcharts of eating and swallowing , 2010 .

[26]  Influence of Dysphagia on Short-Term Outcome in Patients with Acute Stroke , 2011, American journal of physical medicine & rehabilitation.

[27]  D. Streiner,et al.  MRI-Based Neuroanatomical Predictors of Dysphagia after Acute Ischemic Stroke: A Systematic Review and Meta-Analysis , 2011, Cerebrovascular Diseases.

[28]  E. Mohammadi,et al.  Barriers and facilitators related to the implementation of a physiological track and trigger system: A systematic review of the qualitative evidence , 2017, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[29]  H. Reichmann,et al.  Prediction of outcome in neurogenic oropharyngeal dysphagia within 72 hours of acute stroke. , 2012, Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association.

[30]  H. Daw,et al.  Barium aspiration , 2012, BMJ Case Reports.

[31]  S. Daniels,et al.  Valid Items for Screening Dysphagia Risk in Patients With Stroke: A Systematic Review , 2012, Stroke.

[32]  W. Longstreth,et al.  Swallowing Screens After Acute Stroke: A Systematic Review , 2012, Stroke.

[33]  R. Rosenfeld.  Patients , 2012, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[34]  S. Y. Phua,et al.  Accuracy of Bedside Clinical Methods Compared with Fiberoptic Endoscopic Examination of Swallowing (FEES) in Determining the Risk of Aspiration in Acute Stroke Patients , 2014, Dysphagia.