Validity and Reliability of the Swedish Version of the Gugging Swallowing Screen for use in Acute Stroke Care.

The purpose of this study was to cross-culturally validate the Swedish version of the Gugging Swallowing Screen (GUSS-S) for use in the acute phase of stroke. Further, to evaluate the inter-rater reliability between different healthcare professionals. GUSS was translated into Swedish using a forward-backward method followed by expert rating to obtain content validity. For criterion validity, the GUSS-S score was compared with Flexible Endoscopic Evaluation of Swallowing (FEES) assessed with the Penetration-Aspiration Scale (PAS) in acute stroke patients (≤ 96 h after stroke onset). Convergent validity was calculated by comparison with the Functional Oral Intake Scale (FOIS) as per the comprehensive FEES assessment, the Standardized Swallowing Assessment (SSA), and the National Institutes of Health Stroke Scale (NIHSS). To evaluate inter-rater reliability, a nurse and a speech-language pathologist (SLP) independently assessed 30 patients. In total, 80 patients (32 women, median age 77 years (range 29-93) were included, mean 1.7 ± 0.9 days after admission. With a cut-off value of 14 points, the GUSS-S identified aspiration with a sensitivity of 100% and a specificity of 73% (area under the curve: 0.87, 95% CI 0.78-0.95). Spearman rank correlation showed very strong correlation between the GUSS-S and PAS (rs=-0.718, P = < 0.001) and FOIS (rs=0.720, P = 0.001) and strong correlation between the GUSS-S and SSA (rs=0.545, P = < 0.001) and NIHSS (rs=-0.447, P = 0.001). The inter-rater agreement for GUSS-S was substantial (Kw=0.67, P = < 0.001). The results indicate that the GUSS-S is a valid and reliable tool for the assessment of dysphagia in acute stroke patients by different healthcare professionals.

Dysphagia and obstructive sleep apnoea in post-extubated intensive care unit patients.

OBJECTIVE: To determine the relationship between dysphagia and obstructive sleep apnoea and its association with age, gender and Glasgow Coma Scale in post-extubated patients in an intensive care setting. METHODS: The correlational study was conducted from July 1 to October 31, 2021, at the intensive care unit of Evercare Hospital, Lahore, Pakistan, and comprised post-extubated patients of either ender aged 45-70 years within 72 hours following extubation and having Glasgow comma scale score 11-15. Gugging Swallowing Screen and Obstructive Sleep Apnoea questionnaires were used for data collection. Data was analysed using SPSS 25. RESULTS: Of the 29 patients with a mean age of 57.45±8.74 years, 18(62.1%) were males. There was a significant correlation between dysphagia and obstructive sleep apnoea (p=0.005). The Obstructive Sleep apnoea score had a significant negative correlation with Glasgow Coma Scale score (p=0.01), while dysphagia revealed a significant positive correlation (p<0.001) with Glasgow Coma Scale score. Age and gender had no significant association with either dysphagia or obstructive sleep apnoea (p>0.05). CONCLUSIONS: There was a significant correlation between dysphagia and obstructive sleep apnoea in post-extubated patients under intensive care. Both dysphagia and obstructive sleep apnoea had a significant correlation with Glasgow Coma Scale score.

A bedside swallowing screen for the identification of post-extubation dysphagia on the intensive care unit - validation of the Gugging Swallowing Screen (GUSS)-ICU.

PURPOSE: Screening for dysphagia at the intensive care unit (ICU) soon after extubation can prevent aspiration, pneumonia, lower mortality, and shorten re-feeding interval. This study aimed to modify the Gugging Swallowing Screen (GUSS), which was developed for acute stroke patients, and to validate it for extubated patients in the ICU. METHODS: In this prospective study, forty-five patients who had been intubated for at least 24 h were recruited consecutively at the earliest 24 h after extubation. The modified GUSS-ICU was performed twice by two speech and language therapists independently. Concurrently, gold standard the flexible endoscopic evaluation of swallowing (FEES) was performed by an otorhinolaryngologist. Measurements were conducted within a three-hour period; all testers were blinded to each other's results. RESULTS: According to FEES, 36 of 45 (80%) participants were diagnosed with dysphagia; 13 of those were severe, 12 moderate, and 11 mild. Compared to FEES, the GUSS-ICU predicted dysphagia well (area under the curve for the initial rater pair: 0.923, 95% CI 0.832-1.000 and 0.923, 95% CI 0.836 -1.000 for the second rater pair). The sensitivity was 91.7% (95% CI 77.5-98.3%) and 94.4% (95% CI 81.3-99.3%); the specificity was 88.9% (51.8-99.7%) and 66.7% (29.9-92.5%); the positive predictive values were 97.1% (83.8-99.5%) and 91.9% (81.7-96.6%), and the negative predictive values were 72.7% (46.8-89%) and 75% (41.9-92.6%) for the first and second rater pairs, respectively. Dysphagia severity classification according to FEES and GUSS-ICU correlated strongly (Spearman's rho: 0.61 for rater 1 and 0.60 for rater 2, p < 0.001). Agreement by all testers was good (Krippendorffs Alpha: 0.73). The interrater reliability showed good agreement (Cohen`s Kappa: 0.84, p < 0.001). CONCLUSION: The GUSS-ICU is a simple, reliable, and valid multi-consistency bedside swallowing screen to identify post-extubation dysphagia at the ICU. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04532398,31/08/2020.

Are Oropharyngeal Dysphagia Screening Tests Effective in Preventing Pneumonia?

Oropharyngeal dysphagia, a clinical condition that indicates difficulty in moving food and liquid from the oral cavity to the esophagus, has a markedly high prevalence in the elderly. The number of elderly people with oropharyngeal dysphagia is expected to increase due to the aging of the world's population. Understanding the current situation of dysphagia screening is crucial when considering future countermeasures. We report findings from a literature review including citations on current objective dysphagia screening tests: the Water Swallowing Test, Mann Assessment of Swallowing Ability, and the Gugging Swallowing Screen. Pneumonia can be predicted using the results of the screening tests discussed in this review, and the response after the screening tests is important for prevention. In addition, although interdisciplinary team approaches prevent and reduce aspiration, optimal treatment is a challenging. Intervention studies with multiple factors focusing on the elderly are needed.

Signs of dysphagia and associated outcomes regarding mortality, length of hospital stay and readmissions in acute geriatric patients: Observational prospective study.

BACKGROUND AND AIMS: Dysphagia is a prevalent disorder in acute geriatric patients. This observational prospective study aimed at investigating adverse clinical outcomes linked to signs of dysphagia, including mortality, length of hospital stay (LOS), readmissions, among patients aged ≥ 65 years at a Danish acute medical unit (AMU). METHODS: Signs of dysphagia were assessed using bedside screening tools including the Eating Assessment Tool (EAT-10), a 30 mL Water Swallowing Test (WST) and the Gugging Swallowing Screen tool (GUSS), as described in the preceding cross-sectional study. Data for the follow-up was twice retrieved from electronic medical charts 30 days and 90 days after the patients' primary admission to the hospital. Statistical analysis included non-parametric tests of independence and proportional hazards modelling. RESULTS: 444 patients were recruited, 334 of whom completed the dysphagia screening with 144 (43.1 %) showing signs of dysphagia. Patients with signs of dysphagia, compared to those without, experienced higher mortality after 30 days (12.5 % vs. 1.6 %, p < 0.001) and 90 days (21.5 % vs. 5.8 %, p < 0.001), longer LOS (median [Q1; Q3]: 4 [2; 8] vs. 3 [1; 6] days, p = 0.004), more total hospital days (THD) during both the 30-day and 90-day follow-up (for 90d: median [Q1; Q3]: 6 [2.25; 12] vs. 4 [2; 9] days, p = 0.007), but no significant difference in frequency of readmissions. Multivariate proportional hazards modelling revealed signs of dysphagia, low performance status and high comorbidity to be independent risk factors for mortality. High comorbidity and low hemoglobin, but not signs of dysphagia, were revealed as independent risk factors for readmission. CONCLUSION: Dysphagia is a notable risk factor linked to increased mortality and length of hospital stay (LOS) for acute geriatric patients in general, not just those suffering from stroke, head and neck cancer or neurodegenerative diseases. Further research is needed to investigate the effectiveness and feasibility of systematic dysphagia screening within this population.

Prevalence of signs of dysphagia and associated risk factors in geriatric patients admitted to an acute medical unit.

BACKGROUND AND AIMS: Dysphagia is a prevalent disorder among the older persons. Despite this, signs of dysphagia often go unnoticed in hospital settings. This cross-sectional study aimed at investigating the prevalence of signs of dysphagia among patients aged 65 or older in a Danish acute care setting. METHODS: We studied 334 patients aged 65 years or older admitted to the acute medical unit (AMU) at Aalborg University Hospital, Denmark. Signs of dysphagia were assessed using bedside screening tools including the Eating Assessment Tool (EAT-10), a 30 mL Water Swallowing Test (WST) and the Gugging Swallowing Screen tool (GUSS). Other risk factors were assessed using the Eastern Cooperative Oncology Group Performance Status (ECOG-PS), the Nutritional Risk Screening 2002 (NRS), and the Charlson's Comorbidity Index (CCI). RESULTS: Signs of dysphagia were identified in 144 of 334 (43.1%) patients. Geriatric patients with signs of dysphagia were significantly older (79.5 years [74; 85] vs. 77 years [72; 84], p = 0.025) and had higher CCI scores (3 points [2; 4] vs. 2 points [1; 4], p = 0.001) than those with normal swallowing capacity. Furthermore, a multivariate logistic regression model found signs of dysphagia to be independently associated with nutritional risk (OR = 2.169, 95% CI 1.313-3.582, p = 0.002), cerebrovascular disease (OR = 2.209, 95% CI 1.235-3.953, p = 0.008), chronic pulmonary disease (OR = 2.276, 95% CI 1.338-3.871, p = 0.002) and rheumatic disease (OR = 2.268, 95% CI 1.099-4.683, p = 0.027). Age was not independently associated with signs of dysphagia among the geriatric patients. CONCLUSION: Signs of dysphagia were common among patients aged 65 or older in the acute care setting. Signs of dysphagia were associated with nutritional risk, higher CCI scores and specific comorbidities. These findings could indicate a need for systematic screening for dysphagia in acute geriatric patients, yet further investigation is needed to assess clinical outcomes associated with dysphagia within this population.

Dysphagia Screening in Parkinson's Disease. A diagnostic accuracy cross-sectional study investigating the applicability of the Gugging Swallowing Screen (GUSS).

BACKGROUND: Simple water-swallowing screening tools are not predictive of aspiration and dysphagia in patients with Parkinson's Disease (PD). We investigated the diagnostic accuracy of a multi-texture screening tool, the Gugging Swallowing Screen (GUSS) to identify aspiration and dysphagia/penetration in PD patients compared to flexible endoscopic evaluation of swallowing (FEES). METHODS: Swallowing function was evaluated in 51 PD participants in clinical 'on-medication' state with the GUSS and a FEES examination according to standardized protocols. Inter-rater reliability and convergent validity were determined and GUSS- and FEES-based diet recommendations were compared. KEY RESULTS: Inter-rater reliability of GUSS ratings was high (rs  = 0.8; p < 0.001). Aspiration was identified by the GUSS with a sensitivity of 50%, and specificity of 51.35% (PPV 28%, NPV 73%, LR+ 1.03, LR- 0.97), dysphagia/penetration was identified with 72.97% sensitivity and 35.71% specificity (PPV 75%, NPV 33.33%, LR+ 1.14, LR- 0.76). Agreement between GUSS- and FEES-based diet recommendations was low (rs  = 0.12, p = 0.42) with consistent NPO (Nil per Os) allocation by GUSS and FEES in only one participant. CONCLUSIONS AND INFERENCES: The multi-texture screening tool GUSS in its current form, although applicable with good inter-rater reliability, does not detect aspiration in PD patients with acceptable accuracy. Modifications of the GUSS parameters "coughing," "voice change" and "delayed swallowing" might enhance validity. The GUSS' diet recommendations overestimate the need for oral intake restriction in PD patients and should be verified by instrumental swallowing examination.

The Gugging Swallowing Screen in dysphagia screening for patients with stroke: A systematic review.

BACKGROUND: Dysphagia in patients with stroke can cause serious complications, such as aspiration and pneumonia, that often lead to increase in mortality and length of hospitalization. Several screening tests for dysphagia have been developed and are used in clinical practice to prevent dysphagia complications. The Gugging Swallowing Screen is 1 such screening test. It is suggested for use in the assessment of the ability of patients to swallow fluid and non-fluid foods separately. It also promotes effective communication between healthcare providers. OBJECTIVES: We aimed to investigate the validity and benefit of the Gugging Swallowing Screen. DESIGN: This was a systematic review. DATA SOURCE: We sourced data from electronic databases including Ovid MEDLINE, Ovid EMBASE, the Cochrane Library, KoreaMed, Research Information Sharing Service, and Korean studies Information Service System. REVIEW METHODS: We conducted a systematic review of electronic databases. We included studies published in English and Korean up to November 2018 that pertained to the Gugging Swallowing Screen. We designed strategies that included Medical Subject Headings and keywords, such as "dysphagia," "swallowing," "assessment," "screening," and "GUSS," used alone or in combination. RESULTS: Of the 297 studies that appeared in the search result, 219 articles were reviewed by 2 independent reviewers after duplicate studies were eliminated. Finally, 8 articles were included in this study. With regard to validity, the Gugging Swallowing Screen had a pooled sensitivity of 0.97 (95% confidence interval: 0.93-0.99), a pooled specificity of 0.67 (95% confidence interval: 0.59-0.74), and an area under the receiver operating characteristic curve of 0.9381. With regard to benefit, early systematic dysphagia screening using Gugging Swallowing Screen performed by nurses reduced both screening time and pneumonia rate compared to the control group (p = 0.004). The incidence of X-ray-verified pneumonia was significantly lower in the Gugging Swallowing Screen group than in the clinical screening group (p ˂ 0.01), but no significant difference was observed in the incidence of pneumonia compared to the value predicted using the 10 mL water swallowing test. CONCLUSIONS: The Gugging Swallowing Screen is a reliable and sensitive tool for screening dysphagia. Early and systematic assessment can prevent aspiration and pneumonia. However, further studies are needed to confirm the effectiveness of this tool.

Evaluation of the Chinese version of the swallowing screen in stroke patients with dysphagia.

OBJECTIVE: The purpose of this study was to validate a Chinese version of the modified Standardized Swallowing Assessment (SSA) instrument used by nurses in stroke patients with dysphagia and explore the feasibility of the simplified instrument. MATERIALS AND METHODS: This study involved a cross-sectional design. Nurses independently applied the modified SSA to 127 patients with stroke before a complete dysphagia evaluation conducted by a speech-language pathologist. Factor analysis of eight dysphagia variables in the modified SSA was performed to evaluate construct validity. The accuracy of the screening instrument was assessed through receiver operating characteristic (ROC) analysis. RESULTS: The comprehensive swallowing assessment revealed that 49.6% of the stroke patients had dysphagia. The modified SSA had an acceptable internal consistency coefficient. The inter-rater agreement between nurses using the modified SSA showed a Kappa coefficient of 0.509. All items had a communality loading of >0.5, and two factors accounted for 73.89% of the response variance. The area under the ROC curve was 0.79 (95% confidence interval: 0.71-0.87). The sensitivity and specificity derived for dysphagia detection were satisfactory according to the results obtained from the original 8-item and simplified 6-item scales (sensitivities = 82.50% and 81.00% and specificities = 59.40% and 64.10%, respectively; accuracy = 70.87% and 72.44%, respectively). CONCLUSION: This preliminary study suggests that the modified SSA is a potentially reliable and valid nurse-administered screening instrument for dysphagia detection in patients with stroke.

Low-risk assessment of swallowing impairment using flexible endoscopy without food or liquid.

OBJECTIVES/HYPOTHESIS: Flexible endoscopic evaluation of swallowing (FEES) is a relatively safe procedure to determine the safety of oral feeding, and consists of the introduction of food and liquid as well as a sensitivity test. However, the introduction of food and liquid can cause pneumonia or suffocation secondary to aspiration. To solve this problem, we investigated the possibility of performing FEES without introduction of food or liquid (referred to hereafter as FEES screen) to assess swallowing impairment severity. STUDY DESIGN: Retrospective study. METHODS: A total of 106 subjects with swallowing impairment underwent conventional FEES, and both their salivary pooling degree and larynx sensitivity were analyzed to detect swallowing impairment without the introduction of food or liquid. The subjects were divided into two groups: an undetectable swallowing impairment (USI) group and a detectable swallowing impairment (DSI) group. The general characteristics, functional impairment status, and clinical assistance requirements of the two groups were investigated and compared. RESULTS: The numbers of subjects in the USI and DSI groups were 64 and 42, respectively. The DSI group showed a significantly higher prevalence of aspiration during FEES, and their required levels of care were also significantly higher. Additionally, their levels of consciousness, oral intake ability, and activities of daily living were significantly low compared to the USI group. CONCLUSIONS: This study demonstrated the feasibility of FEES screen for assessment of swallowing impairment severity. Using our low-risk assessment, we were able to identify subjects with low oral intake ability as well as those who required intervention. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:2249-2252, 2019.

Risk Factors for Stroke Associated Pneumonia.

BACKGROUND: Stroke patients are at high risk for stroke-associated pneumonia (SAP). If patients suffer from pneumonia their prognosis will worsen. AIM: To identify factors that increases the risk of SAP in stroke patients. METHODS: A group of 508 patients hospitalized within 5 days after the onset of stroke were enrolled prospectively. RESULTS: The incidence of SAP was 13.4%. Some major risk factors for SAP are: mechanical ventilation (MV) had odds ratio (OR) 16.4 (p <0.01); the National Institutes of Health Stroke Scale (NIHSS) > 15 OR 9.1 (p <0.01); the Gugging Swallowing Screen (GUSS) 0-14 OR 11.7 (p <0.01). CONCLUSION: SAP is a frequent complication. We identified some risk factors of SAP, especially stroke severity (NIHSS > 15), swallowing disorder (GUSS < 15) and mechanical ventilation.

Clinical Validity of Gugging Swallowing Screen for Acute Stroke Patients

OBJECTIVE: To assess the validity of Gugging Swallowing Screen (GUSS) that allows separate evaluations for non-fluid and fluid textures for aspiration risk of acute stroke patients. METHOD: Fifty-five acute stroke patients were assessed prospectively. For interrater reliability, 2 independent physicians evaluated 40 patients in two hours. For external validity, another group of 15 patients were tested by dysphagia therapist. The validity of the GUSS was established by videofluoroscopic swallowing study (VFSS). After GUSS, all patients were investigated by VFSS within 1 hour. To compare the results of VFSS, they were graded according to the Penetration Aspiration Scale (PAS). RESULTS: The cut-off value of GUSS was 14 points and 5 stage of PAS. GUSS reached 100% sensitivity, 61.1% specificity, and 100% negative predictive value when compared with VFSS by physician A (p<0.001). By physician B, GUSS (p<0.001) reached 100% sensitivity and 60.0% specificity, and 100% negative predictive value and 100%, 85.7%, 88.9%, 100%, in the 15 patient group (p<0.05). The kappa-value was 0.916 between physician A and B (p<0.05). CONCLUSION: This study proposes that GUSS is a reliable method in identifying stroke patients with aspiration risk. Such a graded assessment can provide less discomfort for those patients who can continue with their oral feeding for semisolid food while refraining from drinking fluids.

Comparison between Gugging Swallowing Screen and Other Dysphagia Screening Tests

OBJECTIVE: Screening tests for dysphagia have been introduced to prevent complications arising from dysphagia in stroke patients. Among them, Gugging swallowing screen (GUSS) was proven as an effective screening tests for dysphagia of stroke patients in 24 hours after onset. We compared several screening tests and clinical scales including GUSS. METHOD: Subjects were 37 stroke patients 3 months after onset. GUSS, 3 oz water test, Burke dysphagia screening test (BDST) and Standardized swallowing assessment (SSA) were carried out at bedside. VFS was performed in 24 hours after other studies were done. Functional dysphagia scale (FDS) and Penetration-aspiration scale (P/A scale) were derived from VFS. Clinical scales such as American Speech-Language-Hearing Association National Outcome Measurement System (ASHA NOMS) swallowing scale and Clinical dysphagia scale (CDS) were measured to see the correlation between GUSS and another dysphagia scales. RESULTS: GUSS had a sensitivity of 90.9% and a specificity of 69.2%. 3 oz water test had a sensitivity of 81.8% and a specificity of 76.9%. Sensitivity and specificity of BDST were respectively 90.9%, 61.5%. Sensitivity of SSA was 90.9%, specificity 61.5%. Correlation between GUSS and FDS was significant (r =-0.527, p<0.01). Correlation between GUSS and P/A scale also showed significance (r=-0.747, p<0.01). ASHA NOMS swallowing scale and GUSS showed significant correlation (r=0.432, p<0.01). CDS and GUSS showed significant correlation as well (r=-0.815, p<0.01). CONCLUSION: The screening ability of GUSS was equal to other screening tests for dysphagia of stroke patients. Correlations among GUSS and other VFS and clinical scales showed availability of GUSS as a clinical scale for dysphagia.