Deborah J.C. Ramsey, David G.

Smithard and Lalit Kalra

Early Assessments of Dysphagia and Aspiration Risk in Acute Stroke Patients
Print ISSN: 0039-2499. Online ISSN: 1524-4628
Copyright 2003 American Heart Association, Inc. All rights reserved.
is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Stroke
doi: 10.1161/01.STR.0000066309.06490.B8
2003;34:1252-1257; originally published online April 3, 2003; Stroke.
http://stroke.ahajournals.org/content/34/5/1252
World Wide Web at:
The online version of this article, along with updated information and services, is located on the

http://stroke.ahajournals.org//subscriptions/
is online at: Stroke Information about subscribing to Subscriptions:

http://www.lww.com/reprints
Information about reprints can be found online at: Reprints:

document. Permissions and Rights Question and Answer process is available in the
Request Permissions in the middle column of the Web page under Services. Further information about this
Once the online version of the published article for which permission is being requested is located, click
can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Stroke in
Requests for permissions to reproduce figures, tables, or portions of articles originally published Permissions:
by guest on April 21, 2014 http://stroke.ahajournals.org/ Downloaded from by guest on April 21, 2014 http://stroke.ahajournals.org/ Downloaded from
Early Assessments of Dysphagia and Aspiration Risk in
Acute Stroke Patients
Deborah J.C. Ramsey, MRCP; David G. Smithard, MD; Lalit Kalra, PhD
Background and PurposeDysphagia is common after stroke and is a marker of poor prognosis. Early identification is
important. This article reviews the merits and limitations of various assessment methods available to clinicians.
MethodsAn electronic database search was performed of MEDLINE, EMBASE, and the Cochrane database using such
terms as stroke, aspiration, dysphagia, and assessment; extensive manual searching of articles was also conducted.
ResultsBedside tests are safe, relatively straightforward, and easily repeated but have variable sensitivity (42% to 92%),
specificity (59% to 91%), and interrater reliability (0 to 1.0). They are also poor at detecting silent aspiration.
Videofluoroscopy gives anatomic and functional information and allows testing of therapeutic techniques. However,
swallowing is assessed under ideal conditions that are different from clinical settings, and reliability is often poor (0
to 0.75) in the absence of assessor training. Fiberoptic endoscopy allows swallow assessment and sensory testing but
requires specialized staff and equipment. Oxygen desaturation during swallowing may be predictive of aspiration
(sensitivity, 73% to 87%; specificity, 39% to 87%) but is more useful in combination with bedside testing than in
isolation. Other methods of swallow testing are invasive and require specialized staff and equipment.
ConclusionsAlthough bedside tests remain an important early screening tool for dysphagia and aspiration risk, further
refinements are needed to improve their accuracy. (Stroke. 2003;34:1252-1257.)
Key Words: aspiration

deglutition disorders

dysphagia

process assessment (health care)

stroke
D
ysphagia after stroke is common, and its detection is an
important part of acute stroke management. The litera-
ture suggests that swallowing difficulties can affect 22% to
65% of patients, depending on methods of assessment
used,
17
and may persist in some patients for many months.
8,9
Dysphagia in acute stroke patients is a marker of poor
prognosis, increasing the risks of chest infection, malnutri-
tion, persistent disability, prolonged hospital stay, institution-
alization on discharge, and mortality.
1,57,9,10
In some patients with poorly coordinated swallowing,
material subsequently enters the airway below the level of the
vocal cords (aspiration), making oral feeding a significant
risk. In some patients, aspiration causes no outward signs of
distress. This is called silent aspiration,
24,10,11
the long-term
significance of which is unclear.
4,10
The aim of this study was
to identify the methods of swallow assessment available and
to consider their relative merits and limitations, particularly
with reference to management of acute stroke patients. An
electronic database search was performed of MEDLINE,
EMBASE, and the Cochrane Library using terms including
dysphagia, aspiration, assessment methods, and stroke. The
resultant information was supplemented by extensive manual
searching of references.
Assessment of Swallowing
The most frequently used swallow test is the bedside swallow
assessment, which covers a number of techniques used in a
ward environment. For further assessment, videofluoroscopy
(VF) is usually the next investigation of choice although other
methods have been used.
Bedside Assessment of Swallow
Several forms of bedside swallow assessment are used to
evaluate patients with an acute or recent cerebrovascular
event. Some studies have involved patients with other neu-
rological impairments, but the most common subgroup re-
mains stroke disease.
Linden and Siebens
12
looked for clinical factors correlating
with aspiration on VF. They performed a sensorimotor
examination, observed swallowing and related movements,
and found a high incidence of impaired pharyngeal gag and
dysphonia in patients exhibiting laryngeal penetration.
Splaingard et al
13
monitored swallowing of various volumes
and consistencies of food while watching for respiratory
distress and compared the results with VF findings.
Horner and colleagues
11,14
used similar methods in a small
sample of patients and found that a weak cough and dyspho-
nia correlated with aspiration on VF.
11
Regression analysis on
Received October 9, 2002; final revision received November 21, 2002; accepted November 25, 2002.
From the Department of Stroke Medicine, Guys Kings & St. Thomas School of Medicine, Kings College, London (D.J.C.R., L.K.), and Health Care
of Older People Department, William Harvey Hospital, Ashford, Kent (D.J.C.R., D.G.S.), UK.
Correspondence to Dr D.J.C. Ramsey, Department of Stroke Medicine, GKT Medical School, Bessemer Rd, London, SE5 9PJ UK. E-mail
deborah.ramsey@kcl.ac.uk
2003 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org DOI: 10.1161/01.STR.0000066309.06490.B8
1252 by guest on April 21, 2014 http://stroke.ahajournals.org/ Downloaded from
a larger sample showed that abnormal voluntary cough and
absent gag were independently associated with aspiration.
14
Stanners et al
15
also studied voluntary cough, gag reflex, and
dysphonia but found an association only between weak
voluntary cough and aspiration. These studies are limited by
small patient numbers, variable times between stroke onset
and assessment, and limited statistical analyses.
DePippo et al
16
compared a 3-oz water swallow test with
VF, showing that patients who coughed during or after
swallowing or developed a wet or hoarse voice were at risk of
aspiration. They proposed the Burke Dysphagia Screening
Test,
17
which also considered features such as stroke site and
difficulty with meals. Timed tests of swallow capacity have
noted the time and number of swallows required to swallow
150 mL water and have shown that delayed swallowing,
coughing, or dysphonia indicated swallowing problems.
7
Linden et al
18
used a clinical Dysarthria/Dysphagia Bat-
terya clinical battery of questions about respiration, anat-
omy, drooling, and parenteral feeding. Factors predictive of
subglottic penetration on VF included recumbent posture,
abnormal phonation, abnormal laryngeal elevation, abnormal
palatal gag, wet spontaneous cough, and impaired swallowing
of secretions, although these predicted only two thirds of
cases of subglottic penetration in a discriminant analysis.
Daniels and colleagues
19
performed an oropharyngeal ex-
amination and a clinical swallowing assessment using differ-
ent volumes of water while monitoring laryngeal elevation,
voice quality, and coughing. The presence of 2 of 6 features
(dysphonia, dysarthria, abnormal volitional cough, cough
after swallow, abnormal gag reflex, and voice change after
swallow) predicted greater dysphagia severity on VF. Logis-
tic regression identified abnormal volitional cough and cough
with swallow as independent predictors of aspiration.
3
McCullough et al
20
used a similar assessment and found 2
reliable items for detection of aspiration: cough during
swallowing and clinical estimate of the presence of
aspiration.
Many researchers have assessed difficulty in drinking
small volumes of water.
1,6,21
Smithard and colleagues
4
used
5-mL aliquots and then a larger volume (60 mL), looking for
dribbling, laryngeal movement, cough, dysphonia, and the
time taken to finish the drink. Logistic regression identified
impaired consciousness level and weak voluntary cough as
independent predictors for aspiration.
Addington et al
22
used a reflex cough test that evaluated the
laryngeal cough reflex with nebulized tartaric acid; a weak or
absent cough was regarded as predictive of aspiration risk.
Teramoto and Fukuchi
23
studied patients with aspiration
pneumonia and a nonrecent stroke. They developed a 2-step
swallowing provocation test that involved injecting boluses
(0.4 and 2 mL) of water into the suprapharynx of a supine
patient and noting the latent time for swallowing. The test
identified patients with aspiration pneumonia, but sample
sizes were small.
Gag Reflex and Laryngopharyngeal Sensation
An absent gag reflex has been suggested as predictive of
aspiration in some studies
3,12,14,18
but refuted in others.
4,11,15,20
Acute and nonacute stroke patients were studied, as were
patients dysphagic from other causes, and sample sizes varied
considerably. Davies and colleagues
24
have demonstrated that
up to 30% of healthy younger adults and 44% of healthy older
adults may have unilateral or bilateral absent gag reflexes.
Absent pharyngeal sensation appears rare in normal sub-
jects,
24
and Kidd et al
2
found abnormal pharyngeal sensation
(tested with an orange stick) in all stroke patients aspirating
on VF. However, sensation was also abnormal in 40% of
those not aspirating, and normal swallowing can occur with
complete local anesthesia.
25
Aviv and colleagues
26
have
developed a method of testing laryngopharyngeal sensation
by stimulating the mucosa endoscopically with air pulses and
determining sensory discrimination thresholds. Most dys-
phagic patients tested (predominantly stroke or chronic neu-
rological disease) had sensory deficits, and aspiration or
penetration was more common in those with severe deficits.
Sensory deficits were also demonstrated in acute stroke
patients without clinical dysphagia,
27
and it has been sug-
gested that silent sensory deficits may predispose to silent
aspiration.
Validity, Sensitivity, Specificity, and Reliability
The validity for most swallow tests has been determined by
comparison with VF. Detection of aspiration by bedside
testing has been variable (Table 1), with sensitivities between
42% and 92% and specificities between 59% and
91%.
4,13,16,19,28
Positive predictive values for bedside swallow
testing range from 50% to 75%; negative predictive values
range from 70% to 90%.
4,13,28
Interobserver and intraobserver reliability levels for clini-
cal examination vary considerably between studies, with
TABLE 1. Sensitivity, Specificity, and Predictive Values for Bedside Swallow
Tests Compared With VF
Researchers
Patients
Studied, n
Sensitivity,
%
Specificity,
%
Positive
Predictive
Value, %
Negative
Predictive
Value, %
Smithard et al
4
83 47 86 50 85
DePippo et al
16
44 76 59
Smith et al
28
53 80 68 50 90
Splaingard et al
13
107 42 91 75 70
(87 strokes)
Daniels et al
19
59 92 67
Ramsey et al Assessment of Aspiration Risk in Stroke Patients 1253
by guest on April 21, 2014 http://stroke.ahajournals.org/ Downloaded from
values of 0 to 1.0 quoted.
4,2931
Mann et al
29
calculated
values of 0.820.09 and 0.750.09 for interobserver
agreement on diagnosis of dysphagia or aspiration, respec-
tively, by 2 speech pathologists. The study by Smithard et al
4
found better agreement between assessments by speech ther-
apists (0.79; 95% CI, 0.55 to 1.0) than between doctors
(0.5; 95% CI, 0.26 to 0.73). Values for agreement between
a doctor and a therapist ranged from only 0.24 to 0.42.
Ellul and Barer
30
looked at interobserver reliability for a
bedside swallow test performed predominantly by nursing
staff and found more variable values (0.19 to 1.0).
McCullough et al
31
studied reliability between speech pathol-
ogists performing a clinical swallow examination and again
found wide-ranging values, from 0 to 1.0 for both inter-
judge and intrajudge reliability for the measures studied.
Videofluoroscopy
VF (or modified barium swallow) is often regarded as the
assessment of choice in testing swallowing ability.
32
The
patient stands or sits at 45 to 90 and consumes foods or
liquids of different consistencies impregnated with barium
while their swallow is imaged in lateral and anteroposterior
projections. VF provides a dynamic study in which the
therapist or radiologist can examine the anatomic structures
and the function of the oral and pharyngeal phases of
swallowing, as well as testing potential compensatory
techniques.
Although VF has been proposed as the gold standard for
swallow testing,
11,32
this view is not accepted universally. It
cannot be undertaken in patients unable to sit upright without
the use of a specialized chair, which does not replicate
physiological conditions. VF protocols vary, with some
workers using a standardized protocol for all patients and
others performing more functional, tailor-made studies.
32
The
radiation exposure for VF, although regarded as acceptable,
32
makes frequent test repetition inappropriate. The limited
procedure duration underestimates the time required for some
patients to eat and makes patient fatigue less obvious.
Test-test variability has been found within normal subjects
undergoing VF
33
; the differences were nonsignificant, but
repeated trials of each food consistency are advised.
VF is a relatively complex task to interpret, and interjudge
agreement can be very variable. Smithard et al
4
calculated
percentage agreement between 2 radiologists for VF assess-
ments as 76% (0.48; 95% CI, 0.2 to 0.76), whereas
Wilcox and colleagues
34
found only limited agreement on VF
features among 10 speech and language pathologists, possibly
reflecting their variable experience. Mann et al
29
looked at
agreement between a speech pathologist and a radiologist and
obtained statistics of 0.750.09 for VF diagnosis of
dysphagia and 0.410.09 for aspiration.
McCullough et al
35
examined common VF measures and
found that statistics for interjudge reliability ranged from
0 to 0.478; percentage agreement (calculated when was
not possible) reached 92% on some variables. Intrajudge
reliability has been greater in some studies but not in
others.
35,36
Reliability ratios in 1 study were highest for
aspiration, particularly for solids, and lowest for functional
swallowing components.
36
Levels of agreement in ratings
correlate with assessor experience
37
and improve with group
discussion among assessors
38
; similar methods of training to
criteria may form a way to improve reliability.
35
Pulse Oximetry
Pulse oximetry provides a noninvasive method of bedside
swallow testing. Most studies have found a good correlation
between oxygen saturations and arterial blood samples in
higher saturation ranges, with correlation coefficients quoted
at 0.82 to 0.99.
39
The manufacturers accuracy for the
monitors is 2% within the 50% to 100% saturation range. It
has been suggested that aspiration causes reflex bronchocon-
striction and therefore ventilation-perfusion imbalance, lead-
ing to hypoxia and desaturation.
40
Others have suggested that
abnormal swallowing leads to poor breathing and ventilation-
perfusion mismatching because of reduced inspiratory
volumes.
41
Initial reports of hypoxemia during oral feeding in neuro-
logically disabled individuals noted associations with certain
food textures, postulated to be secondary to aspiration of
those foods.
42,43
Zaidi et al
40
subsequently found greater
desaturation after swallowing water in acute stroke patients
than in matched control subjects, and the degree of desatu-
ration correlated with clinical assessment of aspiration risk,
although statistical criticisms have been leveled at their
analyses.
44
Sherman et al
45
performed pulse oximetry during
VF and demonstrated significant desaturation in patients who
suffered aspiration of material or penetration without clearing
compared with those in whom penetration occurred with
clearing or not at all, but patient numbers were small and age
was very variable. Some studies have found no clear rela-
tionship between desaturation and aspiration,
44,46
but 1 study
demonstrated persistently lower saturations in aspirators than
nonaspirators.
44
Other workers have found that desaturation of 2% from
baseline predicted aspiration on VF.
28,47
Sensitivity values
ranged from 73% to 87%, and specificity values ranged from
39% to 87% (Table 2) with poor positive predictive values
and possibly lower values in older subjects and those with
lung disease.
47
Using an end point of penetration or aspiration
rather than aspiration alone gave higher specificity and
positive predictive values.
28
Another study compared oxygen
saturation predictions with aspiration detected by fiberoptic
endoscopy rather than VF and obtained better specificities
and predictive values.
48
Two studies combined predictions
from bedside testing and saturation monitoring and achieved
good sensitivity and specificity values, particularly with
aspiration or penetration as end points.
28,48
Fiberoptic Endoscopy
Fiberoptic endoscopic evaluation of swallowing (FEES) can
give information on anatomy, the swallow process, pharyn-
geal motility, and sensory deficits.
26,49
Although aspiration
cannot be seen directly, it can be inferred from residue left
after swallowing or ejection of material out of the trachea
after coughing.
On comparison with VF in a small sample of dysphagic
patients, FEES gave sensitivity values of 0.88 for 3 of 4
parameters
49
: specificity ranged from 0.50 to 0.92, positive
1254 Stroke May 2003
by guest on April 21, 2014 http://stroke.ahajournals.org/ Downloaded from
predictive values were 0.69 to 0.88, and negative predictive
values ranged from 0.63 to 1.00. One study found fewer
aspiration pneumonias after a negative FEES result than a
negative VF result although this was not statistically signif-
icant.
50
The assessment can be conducted at bedside, can be
videotaped if required, and is safe and well tolerated.
51
It is,
however, dependent on a skilled operator and specialized
equipment, and limited information is available about the oral
and esophageal stages.
Other Methods
Cervical auscultation of the mechanical and/or respiratory
components of swallowing, combined with bedside testing,
has been compared with VF
52
and revealed significant agree-
ment for detection of aspiration. It can be performed at
bedside, but research into sound patterns is ongoing and
technique reliability is unclear.
Lateral cervical soft tissue radiographs have been used
after swallowing contrast,
53
but poor head posture causes
problems, and reporting is difficult for the inexperienced.
Ultrasonography is safe and moderately portable, but most
ultrasound probes are too small to visualize the whole
swallow
54
and are limited to nonbony areas.
Pharyngeal or esophageal manometry can provide useful
information, particularly when combined with VF,
55
and
other methods tried include scintigraphy
56
and electromyo-
graphy.
57
These techniques cannot be used at bedside, are
invasive, and require specialized staff and equipment, so they
have principally remained research tools.
Conclusions
Dysphagia is common in acute stroke patients, but swallow
recovers in 80% of patients within 2 to 4 weeks of stroke
onset.
1,8
The most important consideration initially is aspira-
tion risk and suitability for oral feeding. Although a detailed
examination of swallowing mechanisms may be desirable, it
is usually difficult and often unnecessary to subject patients
to such procedures, which may have greater relevance in
patients with persistent dysphagia. The challenge is to de-
velop simple bedside assessments that can be administered by
a range of professionals in day-to-day clinical practice.
A variety of bedside assessments have been proposed that
depend on the ability to swallow foods of various consisten-
cies. The features most predictive of aspiration risk include a
wet voice, weak voluntary cough, cough on swallowing,
prolonged swallow, or some combination of these. Although
abnormal gag reflex and reduced laryngopharyngeal sensa-
tion are associated with swallowing difficulties, they do not
appear to predict aspiration risk in isolation. Bedside swallow
tests are safe, therefore repeatable, and relatively straightfor-
ward to perform. However, sensitivities and specificities are
very variable, with many methods missing silent aspiration,
and assessments of reliability have been wide ranging.
All bedside swallow assessments have limitations, neces-
sitating pragmatic dysphagia management that takes available
facilities and user experience into consideration. In our unit,
all acute stroke patients undergo swallow screening by
trained nursing staff. The protocol assesses consciousness
level, posture, ability to cooperate with the test, and gross
oromotor function. Patients deemed safe are tested with sips
of water while monitoring for coughing or respiratory dis-
tress, voice changes, and laryngeal movement. Those without
obvious difficulties are offered a larger volume of water,
yoghurt, and normal foods and again are monitored. Patients
without problems receive a normal diet while we watch their
oral intake and respiratory status for 48 hours. Patients who
find eating effortful or with significant food residues are
given a soft, smooth diet and referred to speech and language
therapy. Any patient failing the test is kept nil by mouth and
referred to a speech and language therapist for a detailed
assessment, including VF if appropriate.
VF has advantages over bedside methods, especially in
assessing swallow mechanics and testing compensatory tech-
niques. However, the information provided is dependent on
operating procedures and the training of assessors to interpret
results. Limitations are imposed by patient cooperation,
availability and timing of studies, and the ability to generalize
to clinical settings. The radiation exposure involved makes it
an inappropriate test to repeat frequently to monitor changes.
The level of supervision and attention to posture during the
examination (rarely possible on general wards) means that
some patients considered safe on VF may remain at risk of
aspiration in clinical settings.
Pulse oximetry is straightforward and noninvasive, and
significant desaturation during feeding may correlate with
aspiration in dysphagic individuals. Although specificity and
TABLE 2. Sensitivity, Specificity, and Predictive Values for Desaturation
Compared With Aspiration on VF or Fiberoptic Endoscopy
Researchers
Patients
Studied, n
End
Point
Sensitivity,
%
Specificity,
%
Positive
Predictive
Value, %
Negative
Predictive
Value, %
Collins and Bakheit
47
54 Asp 73 87
Smith et al
28
53 Asp 87 39 36 88
Asp/Pen 86 54 69 76
Combined with BSA Asp 73 76 55 88
Combined with BSA Asp/Pen 65 96 95 70
Lim et al
48
* 50 Asp 77 83 83 77
Combined with BSA Asp 100 71 79 100
Asp indicates aspiration; Pen, penetration; and BSA, bedside swallow assessment.
*Compared with fiberoptic endoscopic assessment rather than VF.
Ramsey et al Assessment of Aspiration Risk in Stroke Patients 1255
by guest on April 21, 2014 http://stroke.ahajournals.org/ Downloaded from
predictive values for the technique are relatively poor in
isolation, they appear better when used together with bedside
swallow testing. Patients with significant dysphagia may be
detected even if they do not aspirate; predictive values are
better for aspiration or penetration than aspiration alone.
FEES provides useful swallow information and is portable
and safe, but specialized staff and equipment are required.
The limitations of the existing bedside tests that form the
cornerstone of early assessment of aspiration risk in stroke
must stimulate continued efforts to improve the accuracy and
repeatability of swallow assessment methods. More reliable
bedside tests would allow swallow screening by a range of
professionals who may be in earlier contact with stroke
patients than speech and language therapists. This should
reduce the number of patients who are not fed or are fed
inappropriately while awaiting assessment for dysphagia and
are therefore at risk of aspiration pneumonia or malnutrition.
Acknowledgment
The research was funded by Action Research.
References
1. Gordon C, Langton Hewer R, Wade DT. Dysphagia in acute stroke. BMJ.
1987;295:411414.
2. Kidd D, Lawson J, Nesbitt R, MacMahon J. Aspiration in acute stroke: a
clinical study with videofluoroscopy. QJM. 1993;86:825829.
3. Daniels SK, Brailey K, Priestly DH, Herrington LR, Weisberg LA,
Foundas AL. Aspiration in patients with acute stroke. Arch Phys Med
Rehabil. 1998;79:1419.
4. Smithard DG, ONeill PA, Park C, England R, Renwick DS, Wyatt R,
Morris J, Martin DF. Can bedside assessment reliably exclude aspiration
following acute stroke? Age Ageing. 1998;27:99106.
5. Smithard DG, ONeill PA, Park C, Morris J, Wyatt R, England R, Martin
DF. Complications and outcome after acute stroke: does dysphagia
matter? Stroke. 1996;27:12001204.
6. Barer DH. The natural history and functional consequences of dysphagia
after hemispheric stroke. J Neurol Neurosurg Psychiatry. 1989;52:
236241.
7. Hinds NP, Wiles CM. Assessment of swallowing and referral to speech
and language therapists in acute stroke. QJM. 1998;91:829835.
8. Smithard DG, ONeill PA, England RE, Park CL, Wyatt R, Martin DF,
Morris J. The natural history of dysphagia following a stroke. Dysphagia.
1997;12:188193.
9. Nilsson H, Ekberg O, Olsson R, Hindfelt B. Dysphagia in stroke: a
prospective study of quantitative aspects of swallowing in dysphagic
patients. Dysphagia. 1998;13:3238.
10. Holas MA, DePippo KL, Reding MJ. Aspiration and relative risk of
medical complications following stroke. Arch Neurol. 1994;51:
10511053.
11. Horner J, Massey EW. Silent aspiration following stroke. Neurology.
1988;38:317319.
12. Linden P, Siebens AA. Dysphagia: predicting laryngeal penetration. Arch
Phys Med Rehabil. 1983;64:281284.
13. Splaingard ML, Hutchins B, Sulton LD, Chaudhuri G. Aspiration in
rehabilitation patients: videofluoroscopy vs bedside clinical assessment.
Arch Phys Med Rehabil. 1988;69:637640.
14. Horner J, Brazer SR, Massey EW. Aspiration in bilateral stroke patients:
a validation study. Neurology. 1993;43:430433.
15. Stanners AJ, Chapman AN, Bamford JM. Clinical predictors of aspiration
soon after stroke. Age Ageing. 1993;2(suppl 2):A47. Abstract.
16. DePippo KL, Holas MA, Reding MJ. Validation of the 3-oz water
swallow test for aspiration following stroke. Arch Neurol. 1992;49:
12591261.
17. DePippo KL, Holas MA, Reding MJ. The Burke Dysphagia Screening
Test: validation of its use in patients with stroke. Arch Phys Med Rehabil.
1994;75:12841286.
18. Linden P, Kuhlemeier KV, Patterson C. The probability of correctly
predicting subglottic penetration from clinical observations. Dysphagia.
1993;8:170179.
19. Daniels SK, McAdam CP, Brailey K, Foundas AL. Clinical assessment of
swallowing and prediction of dysphagia severity. Am J Speech Lang Path.
1997;6:1724.
20. McCullough GH, Wertz RT, Rosenbek JC. Sensitivity and specificity of
clinical/bedside examination signs for detecting aspiration in adults sub-
sequent to stroke. J Commun Disord. 2001;34:5572.
21. Gottlieb D, Kipnis M, Sister E, Vardi Y, Brill S. Validation of the 50 ml
3
drinking test for evaluation of post-stroke dysphagia. Disabil Rehabil.
1996;18:529532.
22. Addington WR, Stephens RE, Gilliland K, Rodriguez M. Assessing the
laryngeal cough reflex and the risk of developing pneumonia after stroke.
Arch Phys Med Rehabil. 1999;80:150154.
23. Teramoto S, Fukuchi Y. Detection of aspiration and swallowing disorder
in older stroke patients: simple swallowing provocation test versus water
swallowing test. Arch Phys Med Rehabil. 2000;81:15171519.
24. Davies AE, Kidd D, Stone SP, MacMahon J. Pharyngeal sensation and
gag reflex in healthy subjects. Lancet. 1995;345:487488.
25. Bastian RW, Riggs LC. Role of sensation in swallowing function. Laryn-
goscope. 1999;109:19741977.
26. Aviv JE, Kim T, Sacco RL, Kaplan S, Goodhart K, Diamond B, Close
LG. FEESST: a new bedside endoscopic test of the motor and sensory
components of swallowing. Ann Otol Rhinol Laryngol. 1998;107:
378387.
27. Aviv JE, Sacco RL, Thomson J, Tandon R, Diamond B, Martin JH, Close
LG. Silent laryngopharyngeal sensory deficits after stroke. Ann Otol
Rhinol Laryngol. 1997;106:8793.
28. Smith HA, Lee SH, ONeill PA, Connolly MJ. The combination of
bedside swallowing assessment and oxygen saturation monitoring of
swallowing in acute stroke: a safe and humane screening tool. Age
Ageing. 2000;29:495499.
29. Mann G, Hankey GJ, Cameron D. Swallowing disorders following acute
stroke: prevalence and diagnostic accuracy. Cerebrovasc Dis. 2000;10:
380386.
30. Ellul J, Barer D. Interobserver reliability of a standardized bedside swal-
lowing assessment (SSA). Cerebrovasc Dis. 1996;6(suppl 2):152.
Abstract.
31. McCullough GH, Wertz RT, Rosenbek JC, Mills RH, Ross KB, Ashford
JR. Inter- and intrajudge reliability of a clinical examination of swal-
lowing in adults. Dysphagia. 2000;15:5867.
32. ODonoghue S, Bagnall A. Videofluoroscopic evaluation in the
assessment of swallowing disorders in paediatric and adult populations.
Folia Phoniatr Logop. 1999;51:158171.
33. Lof GL, Robbins J. Test-retest variability in normal swallowing. Dys-
phagia. 1990;4:236242.
34. Wilcox F, Liss JM, Siegel GM. Interjudge agreement in videofluoro-
scopic studies of swallowing. J Speech Hear Res. 1996;39:144152.
35. McCullough GH, Wertz RT, Rosenbek JC, Mills RH, Webb WG, Ross
KB. Inter- and intrajudge reliability for videofluoroscopic swallowing
evaluation measures. Dysphagia. 2001;16:110118.
36. Kuhlemeier KV, Yates P, Palmer JB. Intra- and interrater variation in the
evaluation of videofluorographic swallowing studies. Dysphagia. 1998;
13:142147.
37. Ekberg O, Nylander G, Fork F, Sjoberg S, Birch-Jensen M, Hillarp B.
Interobserver variability in cineradiographic assessment of pharyngeal
function during swallow. Dysphagia. 1988;3:4648.
38. Scott A, Perry A, Bench J. A study of interrater reliability when using
videofluoroscopy as an assessment of swallowing. Dysphagia. 1998;13:
223227.
39. Taylor MB, Whitwam JG. The current status of pulse oximetry. Anaes-
thesia. 1986;41:943949.
40. Zaidi NH, Smith HA, King SC, Park C, ONeill PA, Connolly MJ.
Oxygen desaturation on swallowing as a potential marker of aspiration in
acute stroke. Age Ageing. 1995;24:267270.
41. Teramoto S, Fukuchi Y, Ouchi Y. Oxygen desaturation on swallowing in
patients with stroke: what does it mean? Age Ageing. 1996;25:333336.
42. Rogers BT, Arvedson J, Msall M, Demerath RR. Hypoxemia during oral
feeding of children with severe cerebral palsy. Dev Med Child Neurol.
1993;35:310.
43. Rogers B, Msall M, Shucard D. Hypoxemia during oral feedings in adults
with dysphagia and severe neurological disabilities. Dysphagia. 1993;8:
4348.
44. Colodny N. Comparison of dysphagics and nondysphagics on pulse
oximetry during oral feeding. Dysphagia. 2000;15:6873.
1256 Stroke May 2003
by guest on April 21, 2014 http://stroke.ahajournals.org/ Downloaded from
45. Sherman B, Nisenboum JM, Jesberger BL, Morrow CA, Jesberger JA.
Assessment of dysphagia with the use of pulse oximetry. Dysphagia.
1999;14:152156.
46. Sellars C, Dunnet C, Carter R. A preliminary comparison of videofluo-
roscopy of swallow and pulse oximetry in the identification of aspiration
in dysphagic patients. Dysphagia. 1998;13:8286.
47. Collins MJ, Bakheit AMO. Does pulse oximetry reliably detect aspiration
in dysphagic stroke patients? Stroke. 1997;28:17731775.
48. 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;16:16.
49. Langmore SE, Schatz K, Olson N. Endoscopic and videofluoroscopic evalu-
ations of swallowing and aspiration. Ann Otol Rhinol Laryngol. 1991;100:
678681.
50. Aviv JE. Prospective, randomized outcome study of endoscopy versus
modified barium swallow in patients with dysphagia. Laryngoscope.
2000;110:563574.
51. Aviv JE, Kaplan ST, Thomson JE, Spitzer J, Diamond B, Close LG. The
safety of flexible endoscopic evaluation of swallowing with sensory
testing (FEESST): an analysis of 500 consecutive evaluations. Dys-
phagia. 2000;15:3944.
52. Zenner PM, Losinski DS, Mills RH. Using cervical auscultation in the
clinical dysphagia examination in long-term care. Dysphagia. 1995;10:
2731.
53. Bradford APJ, Begg T, Adams FG, Lees KR. Post stroke aspiration risk
assessment using a contrast lateral cervical soft tissue X-ray. Presented at
the British Association of Stroke Physicians Annual General Meeting,
Liverpool, UK, January 19, 2000.
54. Smithard DG. Assessment of swallowing following stroke. Stroke Rev.
2002;6:710.
55. Hila A, Castell JA, Castell DO. Pharyngeal and upper esophageal
sphincter manometry in the evaluation of dysphagia. J Clin Gastro-
enterol. 2001;33:355361.
56. Muz J, Mathog RH, Hamlet SL, Davis LP, Kling GA. Objective
assessment of swallowing function in head and neck cancer patients.
Head Neck. 1991;13:3339.
57. Palmer JB, Rudin NJ, Lara G, Crompton AW. Coordination of masti-
cation and swallowing. Dysphagia. 1992;7:187200.
Ramsey et al Assessment of Aspiration Risk in Stroke Patients 1257
by guest on April 21, 2014 http://stroke.ahajournals.org/ Downloaded from