Definitions for the level of evidence, strength of recommendation, and net benefit follow the "Major Recommendations."
Medical Diagnoses and Conditions Associated With Aspiration and Silent Aspiration on Videofluoroscopic Swallow Evaluation (VSE)
Diagnoses and Conditions |
Description |
Neurologic impairment |
Cerebrovascular disease* Head trauma, closed head injured* Cervical spinal injury* Anoxia* Seizure disorder* Vocal fold paralysis* Degenerative disease (inclusion body myositis) Multiple sclerosis Parkinson disease* Amyotrophic lateral sclerosis* Huntington disease Brain and brain-stem tumors Myasthenia gravis Guillain-Barre syndrome Progressive supranuclear palsy Dementia, altered mental status Alzheimer disease*
|
Surgery related |
Head and neck cancer; postradiation effects* Anterior or posterior cervical spine surgery* Surgery-related muscular or neurogenic injury Vocal fold paralysis* Brain surgery* Coronary artery bypass grafting* Cervical spinal* (anterior and posterior approach) Esophagogastrectomy* |
Infectious |
Botulism toxin, anticholinergics, possible drug related Diphtheria Lyme disease Altered immune response: human immunodeficiency virus [HIV], leukemia Candida Mucositis (herpes, cytomegalovirus) Syphilis
|
Structural |
Osteophytes, diffuse idiopathic skeletal hypertrophy Diffuse idiopathic skeletal hyperostosis Cricopharyngeal bar Oropharyngeal tumors, glossectomy*, poor dentition, periodontal disease Congenital abnormalities of nasal, oral, and laryngeal cavities, cleft palate Tracheoesophageal fistula
|
Endocrine disease |
Diabetes, thyroid disorders |
Cardiac conditions |
|
Gastrointestinal (GI) problems |
Zenker diverticulum Esophageal dysphagia Laryngopharyngeal reflux* Globus |
Pulmonary |
Pneumonia Bronchitis* Chronic obstructive pulmonary disease (COPD) |
Tracheotomy |
|
Intubation |
>48 hours* Ventilated patients* |
Medication side effects |
Chemotherapy Sedatives* Neuroleptics* Antipsychotics |
*Diagnostic groups reported to have a high risk for aspiration and silent aspiration.
1. In patients with cough, a medical history particularly directed at identifying conditions increasing the likelihood of oralpharyngeal dysphagia and aspiration, as indicated in the table above entitled "Medical Diagnoses and Conditions Associated With Aspiration and Silent Aspiration on Videofluoroscopic Swallow Evaluation (VSE)", should be obtained. Patients with high-risk conditions should be referred for an oral-pharyngeal swallowing evaluation. Level of evidence, low; benefit, substantial; grade of recommendation, B
2a. Patients with cough and their caregivers should be questioned regarding perceived swallowing problems, including an association of cough while eating or drinking and a fear of choking while eating and drinking. If a patient with cough reports swallowing problems, further evaluation for oral-pharyngeal dysphagia is indicated. Level of evidence, low; benefit, substantial; grade of recommendation, B
2b. Further evaluation, including a chest radiograph and a nutritional assessment, should be considered in patients with cough or conditions associated with aspiration. Level of evidence, low; benefit, substantial; grade of recommendation, B
3. Patients with oral-pharyngeal dysphagia and cough should be referred, ideally to a speech-language pathologist (SLP), for an oral-pharyngeal swallow evaluation. Level of evidence, low; benefit, substantial; grade of recommendation, B
4. Patients with cough related to pneumonia and bronchitis who have received medical diagnoses and conditions associated with aspiration (see table above, titled "Medical Diagnoses and Conditions Associated With Aspiration and Silent Aspiration on Videofluoroscopic Swallow Evaluation (VSE)") should be referred, ideally to a speech-language pathologist (SLP), for an oral-pharyngeal swallow evaluation. Level of evidence, low; benefit, substantial; grade of recommendation, B
5. Patients with a reduced level of consciousness are at high risk for aspiration and should not be fed orally until the level of consciousness has improved. Level of evidence, low; benefit, substantial; grade of recommendation, B
6. Alert patients with cough who are in high-risk groups for aspiration (see table above, titled "Medical Diagnoses and Conditions Associated With Aspiration and Silent Aspiration on Videofluoroscopic Swallow Evaluation (VSE)") should be observed drinking small amounts of water (3 oz). If the patient coughs or shows clinical signs that are associated with aspiration (see Tables 2, 3 of the original guideline document), the patient should be referred for a detailed swallowing evaluation, preferably to an SLP. Level of evidence, low; benefit, substantial; grade of recommendation, B
7. In patients with cough, the value of the subjective assessment of voluntary cough (VC) as the sole predictor of aspiration is uncertain because of poor reliability and an unclear association with evaluation. Level of evidence, low; benefit, conflicting; grade of evidence, I
8. The assessment of the reflexive cough (RC) response to inhaled irritants as a predictor of aspiration risk and subsequent pneumonia is not recommended due to a lack of adequate supportive studies. Level of evidence, low; benefit, conflicting; grade of evidence, I
9. In acute stroke patients, the expulsive phase rise time of VC may predict aspiration. The use of this test has not been validated in other patient groups, and further studies comparing the accuracy of objective measures of VC to the clinical swallow evaluation to identify aspiration risk are needed. Level of evidence, low; benefit, small; grade of recommendation, C
10. Patients with dysphagia should undergo VSE or fiberoptic endoscopic evaluation of swallowing (FEES) evaluation of swallow to identify appropriate treatment. Level of evidence, low; benefit, substantial; grade of recommendation, B
11. Patients with dysphagia should be managed by organized multidisciplinary teams that may include a physician, a nurse, an SLP, a dietitian, and physical and occupational therapists. Level of evidence, low; benefit, substantial; grade of recommendation, B
12. In patients with dysphagia, VSE or FEES can be useful for determining compensatory strategies enabling patients with dysphagia to safely swallow. Level of evidence, low; benefit, substantial; grade of recommendation, B
13. In patients with dysphagia, dietary recommendations should be prescribed when indicated, and can be refined by testing with foods and liquids simulating those in a normal diet during the VSE or FEES. Level of evidence, low; benefit, substantial; grade of recommendation, B
14. For patients with muscular weakness during swallowing, muscle strength training, with or without electromyographic biofeedback, and electrical stimulation treatment of the swallowing musculature are promising techniques but cannot be recommended at this time until further work in larger populations is performed. Level of evidence, low; benefit, conflicting; grade of evidence, I
15. Patients with intractable aspiration may be considered for surgical intervention. Level of evidence, low; benefit, substantial; grade of recommendation, B
Definitions:
Quality of the Evidence
Good = evidence is based on good randomized controlled trials (RCTs) or meta-analyses
Fair = evidence is based on other controlled trials or RCTs with minor flaws
Low = evidence is based on nonrandomized, case-control, or other observational studies
Expert opinion = evidence is based on the consensus of the carefully selected panel of experts in the topic field. There are no studies that meet the criteria for inclusion in the literature review.
Strength of Recommendations
A = strong recommendation
B = moderate recommendation
C = weak recommendation
D = negative recommendation
I = no recommendation possible (inconclusive)
E/A = strong recommendation based on expert opinion only
E/B = moderate recommendation based on expert opinion only
E/C = weak recommendation based on expert opinion only
E/D = negative recommendation based on expert opinion only
Net Benefit
Substantial = There is evidence of benefit that clearly exceeds the minimum clinically significant benefit and evidence of little harm
Intermediate = Clear evidence of benefit but with some evidence of harms, with a net benefit between that defined for "substantial" and "small/weak"
Small/weak = There is evidence of a benefit that may not clearly exceed the minimum clinically significant benefit, or there is evidence of harms that substantially reduce (but do not eliminate) the benefit such that it may not clearly exceed the minimum clinically significant benefit
None = Evidence shows that either there is no benefit or the benefits equal the harms
Conflicting = Evidence is inconsistent with regard to benefits and/or harms such that the net benefit is uncertain
Negative = Expected harms exceed the expected benefits to the population
Table: Relationship of Strength of the Recommendations Scale to Quality of Evidence and Net Benefits
|
Net Benefit |
Quality of Evidence |
Substantial |
Intermediate |
Small/Weak |
None |
Conflicting |
Negative |
Good |
A |
A |
B |
D |
I |
D |
Fair |
A |
B |
C |
D |
I |
D |
Low |
B |
B |
C |
I |
I |
D |
Expert Opinion |
E/A |
E/B |
E/C |
I |
I |
E/D |