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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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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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References

  1. 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.

    Article  PubMed  Google Scholar 

  2. 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.

    Article  PubMed  Google Scholar 

  3. 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.

    Article  CAS  PubMed  Google Scholar 

  4. 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.

    PubMed  PubMed Central  Google Scholar 

  5. 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.

    Article  PubMed  Google Scholar 

  6. 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.

    Article  CAS  PubMed  Google Scholar 

  7. 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.

    Article  PubMed  Google Scholar 

  8. 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.

    Article  PubMed  Google Scholar 

  9. 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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed Central  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  Google Scholar 

  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  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  PubMed Central  Google Scholar 

  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.

    Chapter  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  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.

    Chapter  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    Google Scholar 

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

    Article  Google Scholar 

  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.

    Article  PubMed  PubMed Central  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  PubMed Central  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  PubMed Central  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  PubMed Central  Google Scholar 

  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.

    Chapter  Google Scholar 

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

    Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

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Acknowledgements

We wish to acknowledge Amy Ashley and Julia Eckart for their assistance in data acquisition.

Funding

This project was funded, in part, by University of Florida Department of Surgery New Investigator Grant. IRB Protocol Number is 201802740, Clinical Trials Identifier is NCT03768739 approved on 1/10/19.

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Authors and Affiliations

  1. Aerodigestive Research Core, University of Florida, Gainesville, FL, USA

    Justine Dallal York, Amber Anderson, Lauren DiBiase & Emily K. Plowman

  2. Department of Speech, Language & Hearing Science, College of Public Health, Health Professions, University of Florida, 1225 Center Drive, PO Box 100174, Gainesville, FL, USA

    Justine Dallal York, Kelly Leonard & Emily K. Plowman

  3. Department of Surgery, Division of Cardiothoracic Surgery, University of Florida, Gainesville, FL, USA

    Eric I. Jeng & Emily K. Plowman

  4. Department of Neurology, University of Florida, Gainesville, FL, USA

    Emily K. Plowman

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This dataset was presented as a poster presentation at the Dysphagia Research Society meeting virtually in June of 2020.

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Dallal York, J., Leonard, K., Anderson, A. et al. Discriminant Ability of the 3-Ounce Water Swallow Test to Detect Aspiration in Acute Postoperative Cardiac Surgical Patients. Dysphagia 37, 831–838 (2022). https://doi.org/10.1007/s00455-021-10333-0

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