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15-07-2021 | Heart Surgery | Original Article

Discriminant Ability of the 3-Ounce Water Swallow Test to Detect Aspiration in Acute Postoperative Cardiac Surgical Patients

Authors: Justine Dallal York, Kelly Leonard, Amber Anderson, Lauren DiBiase, Eric I. Jeng, Emily K. Plowman

Published in: Dysphagia | Issue 4/2022

Abstract

Dysphagia is a common complication of cardiac surgery (CS) contributing to morbidity and mortality. Although early dysphagia detection is important, no current screening guidelines or validated tools exist in the cardiac intensive care setting. We therefore aimed to examine the discriminant ability of the 3-ounce water swallow test (3 oz. WST) to detect aspiration in acute postoperative CS patients. 196 postoperative CS patients were enrolled in this prospective single-center study. Participants completed the 3 oz. WST and a standardized Flexible Endoscopic Evaluation of Swallowing. Independent duplicate ratings of the penetration aspiration scale (PAS) were performed in a blinded fashion (100% agreement criteria). Receiver operating characteristic curve and area under the curve (AUC) analyses were performed with sensitivity, specificity, positive, and negative predictive values (PPV, NPV) derived. Fifty-four CS patients (28%) were confirmed aspirators (PAS ≥ 6), of whom 48% (n = 26) were silent aspirators (PAS = 8). Both the sensitivity and specificity of the 3 oz. WST to identify instrumentally confirmed aspiration was 63% (AUC: 0.63, 95% CI: 0.54, 0.72), and PPV was 39% and NPV 82%. The 3 oz. WST demonstrated fair discriminant ability to detect aspiration in acute postoperative CS patients. The high rate of silent aspiration may explain, in part, these findings given that the screening fail criteria include an overt cough response. In isolation, the 3 oz. WST does not represent a sensitive screen of aspiration in postoperative CS patients with a need to identify alternative screening tools for this setting.

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Miles A, McLellan N, Machan R, Vokes D, Hunting A, McFarlane M, Lynn K. Dysphagia and laryngeal pathology in post-surgical cardiothoracic patients. J Crit Care. 2018;45:121–7. https://doi.org/10.1016/j.jcrc.2018.01.027.CrossRefPubMed

Grimm JC, Magruder JT, Ohkuma R, Dungan SP, Hayes A, Vose AK, Whitman GJR. A novel risk score to predict dysphagia after cardiac surgery procedures. Ann Thorac Surg. 2015;100(2):568–74. https://doi.org/10.1016/j.athoracsur.2015.03.077.CrossRefPubMed

Rousou JA, Tighe DA, Garb JL, Krasner H, Engelman RM, Flack JE, Deaton DW. Risk of dysphagia after transesophageal echocardiography during cardiac operations. Ann Thorac Surg. 2000;69(2):486–90. https://doi.org/10.1016/S0003-4975(99)01086-3.CrossRefPubMed

Barker J, Martino R, Reichardt B, Hickey EJ, Ralph-Edwards A. Incidence and impact of dysphagia in patients receiving prolonged endotracheal intubation after cardiac surgery. Can J Surg. 2009;52(2):119–24.PubMedPubMedCentral

Skoretz SA, Yau TM, Ivanov J, Granton JT, Martino R. Dysphagia and associated risk factors following extubation in cardiovascular surgical patients. Dysphagia. 2014;29(6):647–54. https://doi.org/10.1007/s00455-014-9555-4.CrossRefPubMed

Ferraris VA, Ferraris SP, Moritz DM, Welch S. Oropharyngeal dysphagia after cardiac operations. Ann Thorac Surg. 2001;71(6):1792–6. https://doi.org/10.1016/S0003-4975(01)02640-6.CrossRefPubMed

Daly E, Miles A, Scott S, Gillham M. Finding the red flags: Swallowing difficulties after cardiac surgery in patients with prolonged intubation. J Crit Care. 2016;31(1):119–24. https://doi.org/10.1016/j.jcrc.2015.10.008.CrossRefPubMed

Starks B, Harbert C. Aspiration prevention protocol: decreasing postoperative pneumonia in heart surgery patients. Crit Care Nurse. 2011;31(5):38–45. https://doi.org/10.4037/ccn2011462.CrossRefPubMed

Miyata E, Tanaka A, Emori H, Taruya A, Miyai S, Sakagoshi N. Incidence and risk factors for aspiration pneumonia after cardiovascular surgery in elderly patients. Gen Thorac Cardiovasc Surg. 2017;65(2):96–101. https://doi.org/10.1007/s11748-016-0710-8.CrossRefPubMed

10.

Bicer Y, Simsek S, Yapici N, Aydin O, Sogut F, Aykac Z. Risk factor analysis of pneumonias developing after open heart surgery. Crit Care. 2005. https://doi.org/10.1186/cc3073.CrossRefPubMedCentral

11.

Plowman, E. K. P., Anderson, A. R. A., Dallal York, J. D. Y., Vasilopoulos, T., DiBiase, L. B. D., Lawrence, S. L. L., Eckart, J. N. E., Jeng, E. I. J. (2020). Incidence, risk factors and associated morbidity of Dysphagia in postoperative cardiac surgery patients. In European Society for Swallowing Disorders. Oral Presentation at 10th ESSD Virtual Congress

12.

Kozlow JH, Berenholtz SM, Garrett E, Dorman T, Pronovost PJ. Epidemiology and impact of aspiration pneumonia in patients undergoing surgery in Maryland, 1999–2000. Crit Care Med. 2003;31(7):1930–7. https://doi.org/10.1097/01.CCM.0000069738.73602.5F.CrossRefPubMed

13.

Bray BD, Smith CJ, Cloud GC, Enderby P, James M, Paley L, Rudd AG. The association between delays in screening for and assessing dysphagia after acute stroke, and the risk of stroke-associated pneumonia. J Neurol Neurosurg Psychiatry. 2017. https://doi.org/10.1136/jnnp-2016-313356.CrossRefPubMed

14.

Palli C, Fandler S, Doppelhofer K, Niederkorn K, Enzinger C, Vetta C, Gattringer T. Early dysphagia screening by trained nurses reduces pneumonia rate in stroke patients: a clinical intervention study. Stroke. 2017;48(9):2583–5. https://doi.org/10.1161/STROKEAHA.117.018157.CrossRefPubMed

15.

Leder SB, Warner HL, Suiter DM, Young NO, Bhattacharya B, Siner JM, Schuster KM. Evaluation of swallow function post-extubation: is it necessary to wait 24 hours? Ann Otol Rhinol Laryngol. 2019;128(7):619–24. https://doi.org/10.1177/0003489419836115.CrossRefPubMed

16.

Perren A, Zürcher P, Schefold JC. Clinical approaches to assess post-extubation dysphagia (PED) in the critically Ill. Dysphagia. 2019;34(4):475–86. https://doi.org/10.1007/s00455-019-09977-w.CrossRefPubMed

17.

Cichero JA, Heaton S, Bassett L. Triaging dysphagia: nurse screening for dysphagia in an acute hospital. J Clin Nurs. 2009;18(11):1649–59. https://doi.org/10.1111/j.1365-2702.2009.02797.x.CrossRefPubMed

18.

Clark S, Ebersole B. Understanding the role of speech language pathologists in managing dysphagia. Nursing. 2018;48(12):42–6. https://doi.org/10.1097/01.NURSE.0000547723.69610.20.CrossRefPubMed

19.

Hinchey JA, Timothy S, Karen F, Don S, David W, Sarah T. Formal dysphagia screening protocols prevent pneumonia. Stroke. 2005;36(9):1972–6. https://doi.org/10.1161/01.STR.0000177529.86868.8d.CrossRefPubMed

20.

Matesic, E. (2010). Evaluation of Testing and Implementation of Evidence-based RN Bedside Swallow Screen for Dysphagia: A Clinical Practice Change. DNP Projects. https://uknowledge.uky.edu/cgi/viewcontent.cgi?article=1008&context=dnp_etds

21.

Al-Khaled M, Matthis C, Binder A, Mudter J, Schattschneider J, Pulkowski U, Royl G. Dysphagia in patients with acute ischemic stroke: early dysphagia screening may reduce stroke-related pneumonia and improve stroke outcomes. Cerebrovasc Dis. 2016;42(1–2):81–9. https://doi.org/10.1159/000445299.CrossRefPubMed

22.

Christensen M, Trapl M. Development of a modified swallowing screening tool to manage post-extubation dysphagia. Nurs Crit Care. 2017;23(2):102–7.CrossRef

23.

Dallal York J, Miller S, Chapin J, Gore S, Jeng E, Plowman EK. Swallowing screening practice patterns for nurses in the cardiac surgery intensive care unit. J Clin Nurs. 2020;00:1–10. https://doi.org/10.1111/jocn.15490.CrossRef

24.

Depippo KL, Holas MA, Reding MJ. Validation of the 3-Oz water swallow test for aspiration following stroke. Arch Neurol. 1992;49(12):1259–61. https://doi.org/10.1001/archneur.1992.00530360057018.CrossRefPubMed

25.

Garon BR, Ormiston C, Engle M. Reliability of the 3-Oz water swallow test utilizing cough reflex as sole indicator of aspiration. Neurorehabilit Neural Repair. 1995;9(3):139–43. https://doi.org/10.1177/154596839500900301.CrossRef

26.

Hey C, Lange BP, Eberle S, Zaretsky Y, Sader R, Stöver T, Wagenblast J. Water swallow screening test for patients after surgery for head and neck cancer: early identification of dysphagia, aspiration and limitations of oral intake. Anticancer Res. 2013;33(9):4017–21.PubMed

27.

Lim SHB, Lieu PK, Phua SY, Seshadri R, Venketasubramanian N, Lee SH, Choo PWJ. Accuracy of bedside clinical methods compared with fiberoptic endoscopic examination of swallowing (FEES) in determining the risk of aspiration in acute stroke patients. Dysphagia. 2001. https://doi.org/10.1007/s004550000038.CrossRefPubMed

28.

Wakasugi Y, Tohara H, Hattori F, Motohashi Y, Nakane A, Goto S, Uematsu H. Screening test for silent aspiration at the bedside. Dysphagia. 2008. https://doi.org/10.1007/s00455-008-9150-7.CrossRefPubMed

29.

Leder SB, Suiter DM, Warner HL, Kaplan LJ. 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. J Trauma. 2011;70(5):1203–7. https://doi.org/10.1097/TA.0b013e3181fc607a.CrossRefPubMed

30.

Suiter DM, Sloggy J, Leder SB. Validation of the Yale swallow protocol: a prospective double-blinded videofluoroscopic study. Dysphagia. 2014;29(2):199–203. https://doi.org/10.1007/s00455-013-9488-3.CrossRefPubMed

31.

Brodsky MB, Suiter DM, González-Fernández M, Michtalik HJ, Frymark TB, Venediktov R, Schooling T. Screening accuracy for aspiration using bedside water swallow tests: a systematic review and meta-analysis. Chest. 2016;150(1):148–63. https://doi.org/10.1016/j.chest.2016.03.059.CrossRefPubMedPubMedCentral

32.

Leder SB, Suiter DM. Development of a programmatic line of research for swallowing screening for aspiration risk: the first step. In: The yale swallow protocol. Cham: Springer; 2014. p. 35–48. https://doi.org/10.1007/978-3-319-05113-0.CrossRef

33.

Suiter DM, Leder SB. Clinical utility of the 3-ounce water swallow test. Dysphagia. 2008;23(3):244–50. https://doi.org/10.1007/s00455-007-9127-y.CrossRefPubMed

34.

Suiter DM, Leder SB, Karas DE. The 3-ounce (90-cc) water swallow challenge: a screening test for children with suspected oropharyngeal dysphagia. Otolaryngology. 2009;140(2):187–90. https://doi.org/10.1016/j.otohns.2008.11.016.CrossRef

35.

Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, Inouye SK. Evaluation of delirium in critically ill patients: validation of the confusion assessment method for the intensive care unit (CAM-ICU). Crit Care Med. 2001;29(7):1370–9.CrossRef

36.

Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia. 1996;11(2):93–8. https://doi.org/10.1007/BF00417897.CrossRefPubMed

37.

Steele CM, Peladeau-Pigeon M, Barbon CAE, Guida BT, Namasivayam-MacDonald AM, Nascimento W, Wolkin TS. Reference values for healthy swallowing across the range from thin to extremely thick liquids. J Speech, Lang, Hear Res. 2019;62(5):1338–63. https://doi.org/10.1044/2019_JSLHR-S-18-0448.CrossRef

38.

Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81. https://doi.org/10.1016/j.jbi.2008.08.010.Research.CrossRefPubMed

39.

Nashef SAM, Roques F, Sharples LD, Nilsson J, Smith C, Goldstone AR, Lockowandt U. Euroscore II. Eur J Cardiothorac Surg. 2012;41(4):734–45.CrossRef

40.

Shahian DM, Jacobs JP, Badhwar V, Kurlansky PA, Furnary AP, Cleveland JC, O’Brien SM, The Society of Thoracic Surgeons. Adult cardiac surgery risk models: part 1—background, design considerations, and model development. Ann Thorac Surg. 2018;105(5):1411–8. https://doi.org/10.1016/j.athoracsur.2018.03.002.CrossRefPubMed

41.

Chapin JL, Gray LT, Vasilopoulos T, Anderson A, DiBiase L, York JD, Plowman EK. Diagnostic utility of the amyotrophic lateral sclerosis functional rating scale-revised to detect pharyngeal dysphagia in individuals with amyotrophic lateral sclerosis. PLoS ONE. 2020;15(8):e0236804. https://doi.org/10.1371/journal.pone.0236804.CrossRefPubMedPubMedCentral

42.

Suiter DM, Warner HL. Adult swallow screening and clinical swallow evaluation. In: Suiter DM, Gosa MM, editors. Assessing and treating dysphagia: a lifespan perspective. New York: Thieme Medical Publishers Inc; 2019.CrossRef

43.

Leder SB, Espinosa JF. Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia. 2002;17(3):214–8. https://doi.org/10.1007/s00455-002-0054-7.CrossRefPubMed

44.

Safari, S., Baratloo, A., Elfil, M., & Negida, A. (2016). EVIDENCE BASE MEDICINE Evidence Based Emergency Medicine; Part 5 Receiver Op-erating Curve and Area under the Curve. Emergency (Vol. 4). Retrieved from www.jemerg.com. Accessed 5 Oct 2020.

45.

Aschengrau A, Seage G. Essentials of epidemiology in public health. 3rd ed. Burlington: Jones and Barlett Publishers LLC.; 2014.

46.

Bowles BJ, Puntil-Sheltman J, Mullins D, Craig KM, Benuzillo J. Preoperative predictors of postoperative aspiration risk after cardiac surgery. Res Cardiovasc Med. 2017;6(4):24–8. https://doi.org/10.4103/rcm.rcm_27_17.CrossRef

47.

Harrington OB, Duckworth JK, Starnes CL, White P, Fleming L, Kritchevsky SB, Pickering R. Silent aspiration after coronary artery bypass grafting. Ann Thorac Surg. 1998;65:1599–603.CrossRef

48.

Dhillon N. Anatomy. In: Lalwani AK, editor. Current diagnosis & treatment otolaryngology head and neck cancer surgery. 2nd ed. New York: McGrawHill Companies; 2008. p. 1–30.

49.

Amer K. The recurrent laryngeal nerves and the thoracic surgeon. CTSNet. 2017. https://doi.org/10.25373/CTSNET.5345176.CrossRef

50.

Krisciunas GP, Langmore SE, Gomez-Taborda S, Fink D, Levitt JE, McKeehan J, Moss M. The association between endotracheal tube size and aspiration (during flexible endoscopic evaluation of swallowing) in acute respiratory failure survivors. Crit Care Med. 2020. https://doi.org/10.1097/CCM.0000000000004554.CrossRefPubMedPubMedCentral

51.

Kallesen M, Psirides A, Huckabee ML. Recovery of cough after extubation after coronary artery bypass grafting: a prospective study. J Crit Care. 2015;30(4):758–61. https://doi.org/10.1016/j.jcrc.2015.03.013.CrossRefPubMed

52.

Watts SA, Tabor L, Plowman EK. To cough or not to cough? Examining the potential utility of cough testing in the clinical evaluation of swallowing. Curr Phys Med Rehabil Rep. 2016;4(4):262–76. https://doi.org/10.1007/s40141-016-0134-5.CrossRefPubMedPubMedCentral

53.

Leder SB, Suiter DM, Green BG. Silent aspiration risk is volume-dependent. Dysphagia. 2011;26(3):304–9. https://doi.org/10.1007/s00455-010-9312-2.CrossRefPubMed

54.

Arora RC, Brown CH, Sanjanwala RM, McKelvie R. “NEW” prehabilitation: a 3-way approach to improve postoperative survival and health-related quality of life in cardiac surgery patients. Can J Cardiol. 2018;34(7):839–49. https://doi.org/10.1016/j.cjca.2018.03.020.CrossRefPubMed

55.

Saxena P, Luthra S, Dhaliwal RS, Rana SS, Behera D. Early changes in pulmonary functions after mitral valve replacement. Ann Thorac Med. 2007;2(3):111–7. https://doi.org/10.4103/1817-1737.33699.CrossRefPubMedPubMedCentral

56.

Plowman, E. K., Anderson, A., Dallal York, J., DiBiase, L., Vasilopoulos, T., Arnaoutakis, G., Jeng, E. I. (2021) Dysphagia following cardiac surgery: prevalence, risk factors and associated outcomes. J Thorac Cardiovasc Surg doi: https://doi.org/10.1016/j.jtcvs.2021.02.087

57.

Hazelwood RJ, Armeson KE, Hill EG, Bonilha HS, Martin-Harris B. Identification of swallowing tasks from a modified barium swallow study that optimize the detection of physiological impairment. J Speech Lang Hear Res. 2017;60(7):1855–63. https://doi.org/10.1044/2017_JSLHR-S-16-0117.CrossRefPubMed

58.

Herzberg EG, Brates D, Molfenter SM. Physiological compensation for advanced bolus location at swallow onset: a retrospective analysis in healthy seniors. J Speech Lang Hear Res. 2019. https://doi.org/10.1044/2019_JSLHR-19-00169.CrossRefPubMedPubMedCentral

59.

Glumac S, Kardum G, Karanovic N. Postoperative cognitive decline after cardiac surgery: a narrative review of current knowledge in 2019. In: Medical science monitor. New York: International Scientific Information Inc; 2019. https://doi.org/10.12659/MSM.914435.CrossRef

60.

Yogev-Seligmann G, Hausdorff JM, Giladi N. The role of executive function and attention in gait. In: Movement Disorders. New York: Wiley; 2008.

61.

Ardenghi LG, Signorini AV, Maahs GS, Selaimen F, Deutsch KM, Dornelles S, de Mello Rieder CR. Deglutition impairment during dual task in parkinson disease is associated with cognitive status. Int Arch Otorhinolaryngol. 2021;25(1):41–7. https://doi.org/10.1055/s-0039-3402440.CrossRef

62.

Cichero JAY. Age-related changes to eating and swallowing impact frailty: aspiration, choking risk, modified food texture and autonomy of choice. Geriatrics (Switzerland). 2018;3(4):69. https://doi.org/10.3390/geriatrics3040069.CrossRef

63.

Ward M, Skelley-Ashford M, Brown K, Ashford J, Suiter D. Validation of the yale swallow protocol in post-acute care: a prospective, double-blind, multirater study. Am J Speech Lang Pathol. 2020. https://doi.org/10.1044/2020_ajslp-19-00147.CrossRefPubMed

64.

Macht M, Wimbish T, Bodine C, Moss M. ICU-acquired swallowing disorders. Crit Care Med. 2013;41(10):2396–405. https://doi.org/10.1097/CCM.0b013e31829caf33.CrossRefPubMed

65.

Zuercher P, Moret CS, Dziewas R, Schefold JC. Dysphagia in the intensive care unit: epidemiology, mechanisms, and clinical management. Crit Care. 2019;23(1):1–11. https://doi.org/10.1186/s13054-019-2400-2.CrossRef

66.

Brodsky MB, Mayfield EB, Gross RD. Clinical decision making in the ICU: Dysphagia screening, assessment, and treatment. Semin Speech Lang. 2019;40(3):170–87. https://doi.org/10.1055/s-0039-1688980.CrossRefPubMed

Title: Discriminant Ability of the 3-Ounce Water Swallow Test to Detect Aspiration in Acute Postoperative Cardiac Surgical Patients
Authors: Justine Dallal York
Kelly Leonard
Amber Anderson
Lauren DiBiase
Eric I. Jeng
Emily K. Plowman
Publication date: 15-07-2021
Publisher: Springer US
Keywords: Heart Surgery
Foreign Body Aspiration
Foreign Body Aspiration
Aspiration
Heart Surgery
Dysphagia
Dysphagia
Dysphagia
Published in: Dysphagia / Issue 4/2022
Print ISSN: 0179-051X
Electronic ISSN: 1432-0460
DOI: https://doi.org/10.1007/s00455-021-10333-0

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Discriminant Ability of the 3-Ounce Water Swallow Test to Detect Aspiration in Acute Postoperative Cardiac Surgical Patients

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