Bedside diagnosis of dysphagia: a systematic review

Abstract

Dysphagia is associated with aspiration, pneumonia, and malnutrition, but remains challenging to identify at the bedside. A variety of exam protocols and maneuvers are commonly used, but the efficacy of these maneuvers is highly variable. We conducted a comprehensive search of 7 databases, including MEDLINE, Embase, and Scopus, from each database's earliest inception through June 9, 2014. Studies reporting diagnostic performance of a bedside examination maneuver compared to a reference gold standard (videofluoroscopic swallow study or flexible endoscopic evaluation of swallowing with sensory testing) were included for analysis. From each study, data were abstracted based on the type of diagnostic method and reference standard study population and inclusion/exclusion characteristics, design, and prediction of aspiration. The search strategy identified 38 articles meeting inclusion criteria. Overall, most bedside examinations lacked sufficient sensitivity to be used for screening purposes across all patient populations examined. Individual studies found dysphonia assessments, abnormal pharyngeal sensation assessments, dual axis accelerometry, and 1 description of water swallow testing to be sensitive tools, but none were reported as consistently sensitive. A preponderance of identified studies was in poststroke adults, limiting the generalizability of results. No bedside screening protocol has been shown to provide adequate predictive value for presence of aspiration. Several individual exam maneuvers demonstrated reasonable sensitivity, but reproducibility and consistency of these protocols was not established. More research is needed to design an optimal protocol for dysphagia detection.

Conflict of interest statement

Conflicts of interest: None of the authors have any conflicts of interest to disclose

© 2015 Society of Hospital Medicine.

Figures

Figure 1. PRISMA flow diagram

Figure 2. Likelihood Matrix for curve for subjective clinical exam

Each point corresponds to a study as follows: 1=Smithard et al., 1998;, 2=Smith et al., 2000; 3=McCullough et al., 2001; 4=Chong et al., 2003; 5= Smith-Hammond et al., 2009, 6=Bhama et al., 2012, 7= Shem et al., 2012

Figure 3. Likelihood Matrix of Multi-Item Protocols

1=Splaingard et al., 1988; 2= Mari et al., 1997, 3=Logemann et al., 1999; 4=Smith et al., 2000; 5= McCullough et al., 2001, 6=Leder et al., 2002; 7=Tohara et al., 2003; 8=Ramsey et al., 2006; 9=Baylow et al., 2009, 10=Martino et al., 2009; 11=Leigh et al., 2010, 12=Mandysova et al., 2011, 13=Steele et al, 2011 (SLP assessment); 14=Edmiaston et al., 2011; 15=Steele et al (RN assessment), 16=Edmiaston et al, 2014 17=Rofes et al, 2014

Figure 4. Likelihood matrix of individual exam maneuvers

Studies in the LLQ demonstrating the ability to exclude aspiration were 56= Kidd et al., 1993 (abnormal pharyngeal sensation) 96=McCullogh et al., 2001 (dysphonia), 54=Steele et al., 2013 (dual axis accelerometry), 121=DePippo et al., 1992 (water swallow test) and 118=Suiter and Leder et al., 2008 (water swallow test). Key to other tests can be located in the appendix