The science behind why positives and negatives don’t mix at bedside

Boy oh boy. If you’ve been keeping up with the latest The Leader lowdown, you might’ve had many thoughts running rampant in your mind when reading a particular article. Among these very intense thoughts, one might’ve been, “Where do I even start?!?!” (you may choose your own emoji here😉).

Well, after trying to not let things boil and burn down my extended holiday weekend, I figured this calls for a “Research Rescue” 🦸‍♀️🦹‍♂️ (thinkin’ about starting a comic book hero that saves clinicians out of situations with the help of research😅). Anyway, when it doubt, research it out, right?🤓

Instead of a big deep dive into one article analyzing and critically thinking about a single study, we already know what we’re after so, I felt surface-level crumbs of info would suffice for now to help lead others to the big picture.


 

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First up: Spaingard, Chaudhuri, and Hitchins (1988)

“One hundred and seven inpatients from a general rehabilitation hospital were evaluated over a four-month period. Of the total patient population, 43 (40%) aspirated at least one consistency of food during videofluoroscopy. Bedside evaluation identified only 18 (42%) of these patients. The positive predictive value of bedside assessment was 0.75; negative predictive value was 0.70.”

“it is clear that bedside evaluation alone underestimates the frequency of aspiration in patients with neurologic dysfunction.”  (Abstract)

Even though this came from the same year as acid-washed jeans, it’s pretty much the whole point. Nonetheless, let’s keep going (because we have a point to prove!!)


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Langmore & Logemann (1991)

“Studies show that approximately 38-40% percent of aspiration is undetected at the bedside. More important, the physiology of the pharyngeal swallow is not observable at the bedside, and the reason for any aspiration cannot be defined. “ p.1

To be honest, what more do we need than what these dysphagia queens explicitly state?? Well….

“A radiographic study is needed to define the physiology of the pharyngeal swallow, in particular whether pharyngeal peristalsis is normal, laryngeal elevation is adequate, airway closure is timely, and so forth, so that appropriate treatment can be initiated…A radiographic study should not be conducted for the sole purpose of determining whether or not a patient aspirates. Rather, the major question to be answered from a radiographic study is, ‘What is the physiologic or anatomic cause of the patient’s aspiration?’ “

And don’t all you Langmore groupies worry, she’s got her points well made too:

“The clinical/bedside evaluation is an excellent preliminary test but is insufficient in most cases of dysphagia. Critical information regarding the pharyngeal stage of the swallow is missing and, most important, events of aspiration may go undetected” p.4

 


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Linden, Kuhlemeier, & Patterson (1993)

“Although prediction of subglottic penetration, using our clinical battery and videofluorographic protocol, was found to be better than chance, approximately 1/3 of subglottic penetrators were not predicted. The conclusion we submit is that VFSS are justified because clinical signs are not consistently reliable indicators of subglottic penetration, a potentially life-threatening occurrence.

“Also it should be remembered that subglottic penetration in the neurologically impaired population is more often “silent penetration” than not. Furthermore, the VFSS is useful, if not essential, for treatment and dietary management.” p.3

Whoah. Anyone else starting to get prophet-like feels??? How mind-blowingly visionary!


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Warms & Richards (2000)

“This article describes the results of a study that investigated how well wet phonation can predict penetration and/or aspiration of ingested material in dysphagic patients…Results showed that there was no association between the presence of a wet voice and penetration or aspiration of prandial material after a swallow. The importance of detecting wet phonation by itself was therefore not considered diagnostic in detecting prandial penetration/aspiration by the bedside, but a wet voice may still be useful in identifying those with dysphagia who may have laryngeal dysfunction and therefore may be at risk of penetrating/aspirating any type of material, notjust prandial material.”

“The clinical bedside evaluation of dysphagia is still the most common method of assessing oropharyngeal dysphagia. However, the accuracy of the clinical evaluation has been a controversial issue in both the literature and clinical practice. p.1

Besides wet voice and many other things we may observe externally at the bedside, these still don’t give us any conclusions as to why, how, where, when, and with what. So really, just like how we felt at the time about Y2K, we still ain’t got a lot of answers…


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Mathers-Schmidt & Kurlinsky (2003):

“The purpose of this study was to determine the nature of swallowing evaluation practices.. specifically in terms of (a) components of the clinical examination most commonly used, (b) consistency of clinical examination practices across clinicians, and (c) consistency of clinical decision-making (instrumental vs. non-instrumental) given specific patient scenarios.”

“The results revealed that clinicians who responded to the survey differ somewhat regarding which components they include in a clinical examination of swallowing. There was a high degree of consistency for 11 of the 19 components. Inconsistency across clinicians was revealed in four areas: assessment of sensory function, assessment of the gag reflex, cervical auscultation, and assessment of trial swallows using compensatory techniques.”

“In general, participating clinicians varied widely in their clinical decision-making. These findings are compared with other studies where variability in clinical practice has raised concerns.” p.1

 

Sorry for not being able to locate the specific source, but they also re-quote the famous dysphagia-founder herself (and later admit that FEES is also included in this instrumental necessity as well😉👍):

“In fact, according to Logemann [10, pp. 337–338], ‘‘Without a modified barium swallow, accurate swallowing therapy cannot be planned, and time and money can be wasted in attempting to evaluate and treat the patient’s dysphagia at the bedside.’’

‘Nuff said!


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McCullough (2004) pretty much answers a lot of our eager, anxiety-inducing questions (and is also a super easy, easy, and interesting read😉):

“What do we really know about the CSE? Actually, we don’t even what to call it. The name of the clinical swallowing examination (CSE) has varied almost as much as sentiments regarding its purpose.” p.1

“Rather, treatments and compensation strategies are derived based on the underlying physiologic abnormalities of the swallow. And, despite the controversy surrounding all aspects of the CSE, the one fact that seems inarguable is that the CSE is a tool that does not employ instrumentation for direct, visual examination of swallowing function. It is not a matter of “what you see is what you get”; although, again, many might claim that’s exactly what you get: nothing. And the data are not far from supporting that view.” p.2

“Martino and colleagues (2000) evaluated 154 sources, 89 of which were original articles, on the CSE. Data, when available, were collapsed and re-analyzed for sensitivity, specificity, and likelihood ratio. Their results suggested few data are currently available to support the concept that clinicians are able to detect abnormal swallow physiology with a clinical examination and suggest that “large, well-designed trials are needed for more conclusive evidence of screening benefit.” p.2

“The subcommittee on the CSE reported, based on over 150 articles, that while data supported, with some dissent, the use of CSE measures to detect aspiration post-stroke, no data existed to support the use of the CSE to evaluate any of the physiologic measures deemed necessary for complete examination of swallowing function” p.3


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Clave´, Arreola, Romea, Medina, Palomera, Serra-Prat (2008)

“Our study also shows that patients identified by a positive V-VST [volume-viscosity swallow test] as presenting impaired safety of swallowing should be referred for a VFS study to assess the severity, the physiopathology and potential treatment of the swallow disorder.” p.7

Even with a “standardized” bedside clinical exam protocol, we’re still not good enough to know anything other than hypotheses!


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Martino, Flowers, Shaw, & Diamant (2013),

“This systematic review of recent literature identified 13 articles that have targeted development of new dysphagia tools, seven of which related to screening, five to clinical assessment, and one to instrumental assessment.”

“Across all articles, critical appraisal revealed that none of the recent articles addressing screening, clinical or instrumental assessment had sufficient methodological rigor, and therefore readiness, for implementation into clinical practice.” (Abstract)


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O’Horo, Rogus-Pulia, Garcia-Arguello, Robbins, & Safdar (2015),

“Our results show that most bedside swallow examinations lack the sensitivity to be used as a screening testfor dysphagia across all patient populations examined.” p.3

“We believe our results have implications for practicing clinicians, and serve as a call to action for development of an easy-to-perform, accurate tool for dysphagia screening. Future prospective studies should focus on practical tools that can be deployed at the bedside, and correlate the results with not only gold-standard VFSS and FEES, but with clinical outcomes such as pneumonia and aspiration events leading to prolonged length of stay.” p.8


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Vogels, Cartwright, Cocks (2015),

“The current study aimed to investigate what Australian speech-language pathologists frequently include in their bedside assessments in adult dysphagia, what factors influence these bedside assessments and whether they are consistent with the current evidence base.” p.1

“Studies in the US and UK that have investigated what SLPs frequently include in their bedside assessments via surveys have found that only some components are used frequently…This suggests that, across different samples, times and locations, consistency of practice in bedside assessments across SLPs is low.” p.1-2

“These interviews revealed that the participants ’university education, first clinical placements and first jobs influenced their bedside assessment more than the current literature.’ “ p.3

“Overall, consistency of practice across respondents to the questionnaire was low, with only 32% of components being utilized highly consistently, suggesting different respondents conduct different bedside assessments.” p.10

“Furthermore, it appeared this habitual inclusion of certain assessment components was not dependent upon whether the component was evidence-based, as stated by participant seven, ‘something that you’ve always done but I don’t know whether there’s actually any evidence — or firm evidence behind why we’re palpating [laryngeal excursion] ’” p.10


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Comparing Simultaneous Clinical Swallow Evaluations & Fiberoptic Endoscopic Evaluations of Swallowing: Findings and Consequences (Leder, 2015),

“A CSE does not have good clinical utility for determining pharyngeal dysphagia. The consequences of these results will be discussed” p.1

💥Boom💥. If you read any article, THIS (short and sweet) ARTICLE IS A MUST-READ.🙌🙌🙌

“Data do not support use of any CSE to diagnose dysphagia, determine aspiration status, or make oral diet recommendations for patient care” p.3

“And even if a swallowing problem is “guessed” correctly, results from any CSE provide absolutely no information on either its etiology or severity. Why? Because without visualization it is impossible for any CSE to determine pharyngeal and laryngeal anatomy and physiology or bolus flow characteristics, i.e., pre-swallow spillage to or post-swallow residue in the valleculae, pyriform sinuses, or laryngeal vestibule.”

“Importantly, silent aspiration which, by definition, occurs without any overt signs of dysphagia (i.e., coughing or choking), can only be determined with instrumental FEES or VFSS testing.” p.3

“There was no agreement between the CSE and FEES ratings regarding pharyngeal and laryngeal anatomy and physiology and bolus flow characteristics. When watching the CSE video alone, results indicated an 83% inability to determine pharyngeal and laryngeal anatomy and physiology, 90% inability to determine the bolus flow characteristics of pre-swallow spillage and post-swallow residue, and 88% inability to determine overall swallow safety” p.4

“The preliminary results of this study show they do not [know what happens in the pharynx/larynx at bedside]; and the consequences are troubling. A clinician may guess correctly 50% or 60% or 70% of the time but that is certainly not a standard-of-care to be proud of.” p.4

“I expect a lot of push-back from these findings. However, it is vital to continue to battle false beliefs and promote the truth with evidence.” p.5

“Long-held beliefs and practices are extremely difficult to change. Common examples from the history of medicine include resistance to use of anesthesia during surgery, blood-letting to rid the body of bad humors, and hand washing to prevent disease spread. Only when challenged with convincing evidence to the contrary will incorrect learned behavior perpetuated from experts to novitiates be eventually overwhelmed thereby allowing for advancement to best-practice.” p.4

 

It’s awesome enough to share twice, so here’s the author: Steven Leder

Here’s the [FREE ASHA ACCESS] article and link:

Comparing Simultaneous Clinical Swallow Evaluations & Fiberoptic Endoscopic Evaluations of Swallowing: Findings and Consequences (2015),

Enjoy😊🤗


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Lynch, Clark, Macht, et al (2017),

The Accuracy of the Bedside Swallowing Evaluation for Detecting Aspiration in Survivors of Acute Respiratory Failure”

“We found that 14% of patients who aspirated on FEES had a negative BSE. This may underestimate silent aspiration in our population, as it excludes patients who aspirated silently on one consistency but had clinical signs of aspiration on another. 3-ounce water swallowing test (3-WST) performed worse, with 23% of patients who aspirated on FEES having a negative 3-WST.p.6

“We found that 11% of patients recommended a regular diet based on a clinical swallowing exam aspirate on FEES. 48% of the patients with abnormal BSE and 6% of the patients kept NPO had no aspiration on FEES. The 3-WST was neither sensitive nor specific for aspiration.” p.7

“We did not find any consistency on BSE to be a good predictor of aspiration on FEES…No consistency was over 73% sensitive for detecting overall aspiration on FEES.” p.6


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Brates, Molfenter, & Thibeault (2019),

“Assessing Hyolaryngeal Excursion: Comparing Quantitative Methods to Palpation at the Bedside and Visualization During Videofluoroscopy”

“The aim of this study was to compare clinician ratings of hyolaryngeal excursion (HE) to quantitative measures of hyoid movement to determine whether significant differences in hyoid movement are present when HE is perceptually judged to be reduced versus normal.” p.2

“All aspects of swallow function assessed during the CSE require a certain degree of subjective interpretation. In particular, evaluation of HE may be at heightened risk for clinician bias..Increased submental adipose tissue can impede adequate appreciation of laryngeal movement, or the presence of a cervical collar may limit access to the hyolaryngeal complex.” p.2

“We found no significant interaction between perceptual differentiation of objective measures and level of experience, suggesting that experience level was not a factor in clinicians’ palpation sensitivity to greater and lesser magnitude of anterior hyoid movement.” p.7

“the results ofthis study suggest that clinicians should remain guarded when making clinical judgments about adequacy of hyolaryngeal movement.” p.8


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In case you’re running short on time, check out this exclusive look into all the above, written by the amazing Rinki Varindani Desai (FYI published in the 2019 Leader edition😉😏),

“Build a Case For Instrumental Swallowing Assessments in Long-Term Care”

“Hospital re-admissions due to consequences of dysphagia cost about $30,000 each.”

“Although quick and informative, the CSE cannot diagnose swallowing pathophysiology or allow objective decisions about bolus flow.”

“Detecting aspiration using a CSE is usually less than 70-percent accurate, while ruling it out is even less precise. Even if a swallowing problem is “guessed” correctly about 70 percent of the time by SLPs, results provide no information on its etiology or severity.”

“Without VFSS and/or FEES, SLPs cannot make physiology-based treatment decisions. We end up treating the symptom—and not the cause—of the disease, analogous to a neurologist diagnosing and treating a stroke based on the patient’s self-identified signs and symptoms, rather than using appropriate imaging techniques (CT or MRI) to make a definitive diagnosis.”

“Without an instrumental exam, we simply don’t know what to treat. We may also end up recommending ineffective, or even contraindicated, techniques.”


 

In searching and skimming all of this research by those in our field, some major points kept popping up n my mind.

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Okay. Let me explain. In case you didn’t get the point from all of those articles, we have worked soooo hard in our profession to advocate for our patients!! After moving so many steps forward over these last decades (DECADES people!!), it’s hard to accept something that has the potential to send us backward falling on our behinds.

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Another thought that I couldn’t shake was the fact that so many studies that tried to look at clinical bedside swallow evaluations, unfortunately, weren’t great quality.🥺😞

  • many didn’t have blinding, possibly leaving investigators to interpret what they “want to see,” or merely findings that tend to agree with their hypothesis
  • some had a group with an already known diagnosis of dysphagia to compare to a “healthy” control group, which can lead to an over-estimation for accurately diagnosing and findings
  • poorly defined terms and methods for studies which make it any kind of reproduce-ability hard for other researchers, let alone actual clinicians
  • too much focus on swallow safety (aspiration/penetration), and not enough inclusion for swallow efficiency (it takes 2!!), can lead to milder or more complex dysphagia diagnoses being overlooked because—in other words, Swallowing is complicated!

So, what do YOU think??

Do we need MORE good-quality, rigorous, detailed, and top-notch BSE studies?
OR
Do we need more studies looking at various aspects of why/when VFSS/FEES are needed, what the outcomes are, the overall impact on healthcare, nutrition/hydration aspects (do diet changes really make a difference?), costs, quality of life, etc. ????🤔🤔🤔

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I for one, have to believe that  CSE/BSE does have a place in our field. After all, with clinical assessment, we’re able to do an initial visit and observe the patient, all-the-while informally analyzing their cognition, appropriateness to participate in other further evaluations, possible need for other clinical specialty services, and also review their medical history and perform an interview with themself and/or family.

All the above research and evidence is not to shame using CSE/BSE. HOWEVER, they canNOT replace more in-depth visualization of specific impairments and assessment of risk.  Like a research article’s Abstract, they are something simple to start out with before moving forward to learn much more detailed, analyzed, and care information in regards to swallowing safety and efficiency.

 

There are no doubt other articles and information that I’ve probably missed, so please share what you think would also be relevant here so we can all learn and grow together!!

 

 

 


***Disclaimer***

Most of these articles were read and/or skimmed. Some quotes and parts were selected without fully acknowledging and critically appraising every study’s methodology and statistical results. 

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