Contribution

Validation of the 3-oz Water Swallow Test

for Aspiration Following Stroke
Kathleen L. DePippo, MS; Marlene A. Holes, US, W ichael J. Reding, U D

• A 3-oz water swallow test identified 80% (16/20) of Arch Neurol—Vol 49, December 1992
pa- tients aspirating during a subsequent
videofluoroscopic modified barium swallow examination
(sensitivity, 76%; specificity, 59%). It also identified
patients with more severe dysphagia aspirating larger
amounts (sensitivity, 94%; specificity, 26%) or thicker
consistencies (sensitivity, 94%; specificity, 30%) of test
material. The 3-oz water swallow test is a sensitive
screening tool for identifying pa- tients at risk for
clinically significant aspiration who need referral for
more definitive modified barium swallow evaluation.
(Arch Neurol. 1992;49:1259-1261)

Ttients
he incidence of dysphagia in patients following stroke
has been well documented, ranging from 14% for pa-
with unilateral-hemisphere lesions to 71% for pa-
tients with brain-stem lesions.’ Dysphagia can result in a
variety of medical complications, including upper airway
obstruction, aspiration pneumonia, dehydration, inani-
tion, and death.
It is widely accepted that the assessment of dysphagia
is most accurately achieved by videofluoroscopic
modified barium swallow (MBS) examination, in which
aspiration can be accurately identified and its cause
determined. Re- cent studies at The Burke Rehabilitation
Center, White Plains, NY, have shown that identification
of aspiration, the consistency of the material aspirated,
and the timing of aspiration all help identify those
patients who are at greater risk for developing the
medical complications of pneumonia and death.2
Although videofluoroscopic MBS examination is the
ac- cepted method of evaluating swallowing function, it
is impractical to perform this procedure on every patient
who is admitted for stroke rehabilitation. It has therefore
been necessary to develop clinical screening methods to
identify those patients who are at risk for aspiration and
therefore in need of more comprehensive MBS
swallowing evaluation.
The bedside swallowing evaluation has long been crit-
icized for its lack of accuracy in identifying aspirating
pa-

Accepted for publication April 2 Z, 992.

From Cornell University Medical College at The Burke
Rehabilitation Center, White Plains, BY.
Reprint requests to 785 Mamaroneck Ave, White Plains, NY 10605
(Ms DePippo).
tients. Splaingard and his colleagues 3 found that the
bed- side evaluation identified only 18 of 43 patients
who aspirated on MBS examination. Logemann et
a1 (as re- ported by Linden)’ found that experienced
clinicians missed diagnosing aspiration
approximately 50% of the time by bedside
evaluation alone.
Several authors have proposed the use of key
clinical signs and symptoms to predict possible
aspiration and the need for referral for MBS
examination. Horner and Mas- sey 5 reported that
aspirating subjects were distinguished from
nonaspirating subjects by a lower prevalence of sub-
jective complaints of swallowing difficulty and a
higher prevalence of both weak cough reflex and
dysphonia. Lin- den and Siebens6 wet-hoarse
voice quality and impaired pharyngeal gag reflex to
be correlated with the presence of aspiration on
MBS examination in nine of 11 patients they
studied. Scales et a17 identified seven clinical signs
that were common to many aspirating patients they
studied. Up to 42% of subjects with aspiration on
MBS ex- amination were identified with the use of
this clinical examination.
Gordon et al‘ have defined dysphagic individuals
as those who could not drink 50 mL of water or who
coughed more than once after completion of the
water swallow test. With these criteria, they found
that 45% of their population of patients with acute
stroke were dysphagia on admission. Because their
patients did not undergo MBS evaluation, the
relationship between an abnormal water swallow test
result and aspiration is unknown. Our goal was to
deter- mine the sensitivity and specificity of a
similar water swallow test, using 90 mL of water, to
predict aspiration, amount of aspiration, and
consistency of material aspi- rated on MBS
examination.
PATIENTS AND METHODS
Forty-four sequential patients who were resident on a
stroke rehabilitation unit and who had one or more of
the following fea- tures, indicating possible dysphagia,
were studied: (1) bilateral hemispheric stroke, (2) brain-
stem stroke, (3) history of pneumo- nia during the acute
stroke phase, (4) coughing associated with feeding, (5)
failure to consume half of meals, (6) prolonged time
required for feeding, and (7) nonoral feeding program
in progress. The above criteria are components of clinical
screening tools that have been described by other
authors.’"° They represent key signs and symptoms
associated with an increased risk of dysphagia.
Diagnosis of stroke was determined in all patients
based on clinical history, neurologic examination
findings, and computed tomography or magnetic
resonance imaging. Those
Water Swallow Tes DePippo et al 1259
patients who had any of the seven clinical features indicating possible
dysphagia were referred for both the 3-oz water swallow test and Table 1.—Relationship Between Cough and/or
MBS evaluation. Wet-Hoarse Voice Quality on the 3-oz Water
Patients were given 3 oz of water and asked to drink from a cup Swallow Test and Aspiration on Modified Barium
without interruption. Coughing during or for 1 minute after Swallow (MBS) Examination
completion or the presence of a postswallow wet-hoarse voice quality Variable No.
were scored as abnormal.
Total No. of patients 44
The MBS evaluation consisted of 5 mL of thin barium liquid,
5 mL of thick barium liquid, 5 mL of barium impregnated pud- Total with aspiration on MBS 20
ding, one fourth of a cookie coated with barium, 20 mL of thin Total with abnormal water swallow test result 27
barium liquid to be taken in one swallow, and 30 mL of thin bar-
Total with abnormal water swallow test result
ium liquid to be taken in consecutive swallows. Patients were
and aspiration on MBS 16
seated upright and viewed in the lateral position and then in the Total false-positive results jj
anteroposterior position for one 5-mL thin liquid swallow. The Total false-negative results 4
fluoroscopic studies were recorded with a videocassette recorder
with a video-counter timer (Panasonic AG-6200, Matshushita 5.37 P——.02)
Audio-Video Systems Division, Osaka, Japan) and viewed by
Sensitivity, % 76
two speech-language pathologists who determined the presence
or absence of aspiration and the consistency of material Specificity, % 59
aspirated and estimated the amount of material aspirated as less
than 109 or greater than 10'7 .
The data were analyzed comparing the results of the clinical 3-oz
water swallow test with the results of the videofluoroscopic MBS
examination using the chi-square statistic. The sensitivity and specificity
of the 3-oz water swallow test as an indicator of aspiration on MBS were Table 2.—Relationship Between Cough and/or
determined. Specificity expressed as a percentage was defined as (1 —B) Wet-Hoarse Voice Quality on the 3-oz Water
x 100, where B indicates the false-positive rate. Sensitivity expressed as a Swallow Test and Aspiration of Greater Than
percentage was de- fined as (1 —A)X 100, where A indicates the false- 10% of a Bolus OF Modified Barium
negative rate. Swallow (MBS) Examination
Variable No.
RESULTS Total No. of patients 44
The mean (*SD) age of the patients studied was 71 *10 Total with greater than 0% aspiration
years. Patients were evaluated a mean of 5 3 weeks fol- on MBS 8
lowing stroke. Fourteen patients had right-hemisphere Total with abnormal water swallow test
strokes, 17 had left-hemisphere strokes, three had bilateral result 27
hemispheric strokes, and 10 had brain-stem or other Total with abnormal water swallow test
strokes. The results of the 3-oz water swallow test showed result and aspiration of greater than
that 24 patients coughed, 12 had wet-hoarse voice quality, 10% on MBS 7
and 27 had some combination of these two features. The Total false-positive results 20
results of the videofluoroscopic MBS examination Total false-negative results 1
showed that 20 patients aspirated, eight patients aspirated y' Statistic 5.69 (P=.06)
greater than 10% of a test amount, and nine aspirated Sensitivity, % 94
thickened liquids or more solid consistency test material.
Specificity, % 26
When data were analyzed based on the presence of
cough and/or wet-hoarse voice quality, the 3-oz water swallow
test identified 16 of 20 patients with evidence of aspiration on
MBS examination and yielded abnormal re- sults in 11
patients without evidence of aspiration on MBS examination
z
(sensitivity, 76%; specificity, 59%› x . 5.37; P=.02). The water
swallow test result was also abnormal in eight of nine patients
Table 3.—Relationship Between Cough and/or
Wet-Hoarse Voice Quality on the 3-oz Water
with aspiration of thickened liquid or more solid consistencies hutuids or
Swallow Test and Aspiration of Thickened
of test material (sensitivity, 94%; specificity, 30%› x2, 5.9; More Solid Consistencies on Modified Barium
P=.05). It also identified seven of eight patients who aspirated Swallow (MBS) Examination
more than 10% of the test material administered (sensitivity, Variable No.
94%; specificity, 26%;
y , 5.69; P=.06). Tables 1 through 3 present additional data.
2 Total No. of patients 44
Total with aspiration of thicker consistencies
COM IENT on MBS 9
A review of the literature supports the fact that no clin- Total with abnormal water swallow test result 27
ical screening tests perfectly correlate with, and can there- Total with abnormal water swallow test result
fore substitute for, the MBS examination in the and aspiration of thicker consistencies 8
Total false-positive results 19
assessment of dysphagia and aspiration. However, it is Total false-negative results 1
impractical to assess all patients with stroke using this
procedure. There remains a need to identify patients who y 2 Statistic 5.91 7 \P——.0S)
are at great- est risk for dysphagia and aspiration and Sensitivity, % 94
therefore in need of more thorough examination. Our Specificity, % 30
study demonstrates that a 3-oz water swallow test is
sensitive enough to
1260 Arch Neurol—Vol 49, December 1992 Water Swallow Test—DePippo et at
 be useful as a screening tool for MBS examination
referral. The water swallow test had a sensitivity of 76%
in pre- dicting aspiration during the MBS study. This
percentage is much higher than that achieved by other
clinical screen- ing tools used to identify dysphagia.
False-negative results usually represented patients with
only trace aspiration or aspiration of less than 10% of
study material. False- positive results usually showed
other oral or pharyngeal swallowing abnormalities,
indicating an increased risk of
aspiration.
The water swallow test had a sensitivity of 94% in pre-
dicting patients who aspirated more than 10% of a given
bolus during MBS examination. Although no studies have
reported an increased risk of medical complications for
patients aspirating larger amounts of each bolus, the
amount of material aspirated seems intuitively important.
The water swallow test had a sensitivity of 94% in pre-
dicting patients who aspirated thickened liquids or more
solid consistencies. These patients have more severe dys-
phagia and are at an increased risk for pneumonia and
death.2
Our results show that the 3-oz water swallow test is
useful in screening patients for evidence of aspiration to
determine whether further evaluation via MBS examina- tion
is warranted. Patients must be alert enough to hold a cup and
drink from it and must be seated erect to ensure the test’s
safety. We recommend the use of the 3-oz water swallow
test in conjunction with the clinical symptom checklist cited
in the “Patients and Methods” section to
Arch Neurol—Vol 49, December 1992
identify patients who are at risk for aspiration and are
therefore in need of more comprehensive evaluation via
MBS examination.
This study was supported by US Public Health Service grant 1-ROI-
DC00885-01.
References
1. Kuhlemeier K, Rieve J, Kirby N, Siebens A. Clinical correlates of
dys- phagia in stroke patients. Arch Phys Med Rehabil. \ 989;70(special
annual meeting issue):56.
2. Holas MA, Halvorson KA, Reding Mj. Videofluoroscopic evidence
of aspiration and relative risk of pneumonia or death following stroke.
Presented as a poster at the Third Symposium on Dysphagia; March 22-
23, 1990; Bal- timore, Md.
3. Splaingard ML, Hutchins B, Sultan L, Chaudhuri G. Aspiration in
reha- bilitation patients: videofluoroscopy vs. bedside clinical
assessment. Arch Phys Med Rehabil. 988;69:637-640.
4. Linden P. Clinical observation: advantages and disadvantages.
Pre- sented at the Third Symposium on Dysphagia; March 22, 1990;
Baltimore, Md.
5. Horner J, Massey E. Silent aspiration fo(lowing stroke. Neurology.
1988;38:317-319.
6. Linden P, Siebens A. Dysphagia: predicting laryngeal penetration.
Arch Phys idled Rehabil. 1983;64:281-283.
7. Scales K, Patterson C, Linden P. Correlation between clinical and
mo- tion fluoroscopy observations of swallowing. Presented at the
American Speech-Language-Hearing Association Annual Meeting;
November 21, 1988; Boston, Mass.
8. Gordon C, Hewer RL, Wade DT. Dysphagia in acute stroke. BM).
1987;295:411-414.
9. Horner J, Massey E, Riski JE, Lathrop DL, Chase KN.
Aspiration following stroke: clinical correlates and outcome.
Neurology. 988;38: 1359-1362.
10. Logemann jA. Evaluation and Treatment of swallowing Disorders.
San Diego, Calif: College-Hill Press; 1983.
Water Swallow Yes —DePippo et al 1261