Introduction
Dysphagia, if not optimally managed, negatively affects patient outcomes, hospital lengths-of-stay, medical and total health care costs [
1‐
5]. For the individual, the burden of dysphagia is well documented, impacting a person’s nutrition and hydration status [
6], quality of life and psychosocial status [
7]. The importance of dysphagia identification and management cannot be underestimated. Research data have identified that early screening, assessment and management of dysphagia improve patient outcomes, lower the risk of pneumonia, and health-care costs [
3].
Assessment of swallow function commonly occurs via (1) a Clinical Swallow Examination (CSE) and/or (2) instrumental assessments such as Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and/or Videofluoroscopic Swallow Study (VFSS), the latter two considered to be the gold standard in dysphagia assessment [
4,
5,
8]. In recent years, holistic management using evidence-based medicine principles have identified that all three assessments contribute to optimal dysphagia and oral intake management considering person-centered care [
6,
8‐
10].
Evidenced-based medicine (EBM), first coined by Sackett [
11], challenges clinicians to consider (1) relevant scientific evidence, (2) clinical judgement, with (3) patient values and preferences. Optimal dysphagia and oral intake management requires information not from one assessment only, but from all clinical signs, symptoms, patient factors, health support services and various influencing factors [
8,
10,
12]. In recent years, the concept of EBM has expanded and now requires the clinician to consider also the health system (e.g. availability of services, treatments, assistive devices, health insurance coverage), and the service organization (e.g. spectrum and training level of health professionals, availability of diagnostic, and treatment devices) [
13].
In terms of contemporary EBM principles, the management of safe and efficient swallowing along with adequate hydration and nutritional intake across all meal-times is a challenge often requiring high level skills and interpretation of instrumental assessments as well as ongoing clinical examination/reviews [
8,
10,
14]. Instrumental assessments and clinical swallow examinations provide different yet complementary clinical information, and together they allow for improved person-centered care and EB dysphagia management, all in-line with the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) model [
8,
12‐
15]. For example, in terms of ICF it is essential to consider (1) body structures and functions (optimally assessed via instrumental exam), also (2) a person’s activity, participation, and (3) environmental and personal factors (information obtained from a range of sources, including ongoing dysphagia review and/or mealtime observation using the clinical swallow exam). To this end, the CSE is referred to as the CSE/review, since it is often utilized not only as an initial exam but also for ongoing dysphagia management and follow-up reviews [
5,
6,
9,
12].
It is well-established that instrumental assessments are necessary for (1) diagnostics, (2) to identify the pathophysiological causes for dysphagia which subsequently underpins effective rehabilitation, and (3) trial compensatory and/or rehabilitation interventions [
5,
6,
14,
16]. The CSE/review complements instrumental assessment. In line with dysphagia management as per ICF, the CSE/review allows for (1) at times, earlier assessment prior to an instrumental; (2) more regular re-assessment for identification of changes in dysphagia/oral intake abilities, depending on fluctuations in cognition, function and medical status, albeit acute or non-acute fluctuations; (3) the opportunity to review dysphagia, oral intake and feeding/compensatory maneuvers/strategies during an entire meal; (4) incorporate and adapt management to patient preferences/abilities; and (5) provide ongoing follow-up of patient/dysphagia progression to further adjust/upgrade diets and/or feeding strategies in a timely manner [
5,
8,
9,
14].
In recent years, there has been a growing body of evidence, in both pediatric and adult research, identifying that using cervical auscultation as an adjunct to the CSE improves the accuracy of the CSE, as compared with instrumental assessment [
17‐
19]. Cervical auscultation involves listening to and interpreting swallow sounds and swallow-respiratory coordination using stethoscopes, microphones or accelerometers [
17‐
20]. Cervical auscultation, however, is considered controversial in some dysphagia circles with a 2016 systematic review identifying only six articles of moderate-good quality. Results reported sensitivity ranges from 23 to 94% and specificity 50 to 74% with poor to fair inter rater reliability [
21]. This systematic review, however, excluded studies using an accelerometer or microphone, the latter predominantly used in pediatric cervical auscultation [
17,
18,
22].
Recent work by Bergström & Cichero [
12] identified that early CA studies, often reported poorer CA validity and reliability results [
23‐
26]. These CA studies were conducted with suboptimal methodology, including (1) poor swallow-respiration sound and sampling methodology, (2) inconsistent/no CA training, (3) variable assessment parameters/ratings for CA versus instrumental assessment, and (4) no provision of definitions
\(-\) all critical factors for robust research within CA. Research that has focused upon the swallow-respiratory coordination and characteristics, indicates that CA is able to distinguish normal from abnormal swallows [
18,
22,
27,
28]. Within CA research and non-CA dysphagia research, dysphagic swallows may be characterized by an incoordinated (inhalation post swallow) or changed pre-post swallow-respiratory pattern, longer deglutition apnea, longer swallow sounds and/or increased number of swallows per bolus [
20,
29‐
31].
Given the incongruent literature and earlier poor CA methodology, the current study aimed to address these previous research limitations. A crucial component to swallowing, and therefore to CA, is the swallow-respiratory coordination. The physiology and swallow-respiratory interplay within both normal and dysphagic swallows is well described in the literature [
22,
27,
28,
32‐
36]. Respiratory swallow patterns are represented by expiration-swallow-expiration as the most common pattern followed by inspiration-swallow-expiration as the second most frequent pattern [
32,
33,
37]. Both of these patterns include a period of apnea (1) preceding the swallow response and (2) present during the swallow. Studies show that patients with dysphagia have disrupted swallow-respiratory coordination usually represented by an inspiration post swallow, which increases the risk of penetration or aspiration, and a shorter duration of post swallow expiratory sounds than compared with healthy swallow-respiratory sounds [
29,
30]. Swallow-respiratory patterns which deviate from normal are prevalent in several different (adult) patient groups including stroke, chronic obstructive pulmonary disease/respiratory diseases, Parkinson’s disease, head and neck cancer [
34‐
36,
38]. Within pediatrics (neonatal and older children), the (suck-) swallow-breathe synchrony is again essential for safe and efficient feeding and swallowing [
8,
17,
18,
22,
31].
Although earlier CA research has not always included the swallow-respiratory component within their study samples [
23‐
26], a growing body of research highlights this to be a critical feature for improved reliability and validity when compared against instrumental assessment [
17,
19,
27,
28,
30]. Subsequently, this study aimed to address previous CA research limitations by ensuring not only (1) CA recordings of pre-post swallow respirations, but also (2) appropriate CA training, with (3) a structured rating protocol and established CA rating definitions. Specifically, the following aims were investigated.
(1)
Primary aim: To investigate the validity and reliability of CA-trained clinicians to identify if a swallow (including pre-post respiration) is safe on a particular consistency, as compared with a simultaneously recorded FEES reference test.
i.
To investigate the validity and reliability of CA-trained clinicians to identify if a patient is dysphagic (as compared with simultaneous FEES) by listening to recorded swallow-respiratory sounds of a patient swallowing several thin and thick liquid boluses.
ii.
To investigate the effect of bolus viscosity on validity and reliability of CA-trained clinicians in identifying if a swallow is safe as compared with simultaneously recorded FEES.
Acknowledgements
We would like to acknowledge and thank management and colleagues from North Älvsborg County Hospital (Norra Älvsborgs Länssjukhus), including but not limited to Bengt Alsén, Lena Eriksson, Carina Karlsson, Anna Åberg, Helen Larsson and Petra Martikainen. Thank you also to the following SLPs for their contribution: Annika Ståhl, Arvid Persson, Carolyn Johnson, Emma Bäckeper, Lill Sandlund, Nicola Clayton, Rachel Brennan, Shabeena Miskin.
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