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Can bedside assessment reliably exclude aspiration following acute stroke?
University Departments of Geriatric Medicine Withington Hospital, Manchester, UK
1Speech and Language Therapy Withington Hospital, Manchester, UK
2Department of Radiology Withington Hospital, Manchester, UK
3Department of Medical Statistics Withington Hospital, Manchester, UK
4The Robert Barnes Medical Unit, Manchester Royal Infirmary Manchester, UK
D. G. Smithard, Department of Elderly and Stroke Medicine, William Harvey Hospital, Kennington Road, Willesborough, Ashford TN24 OLZ, UK. Fax: (+44) 1233 616008
Objective: to investigate the ability of a bedside swallowing assessment to reliably exclude aspiration following acute stroke.
Subjects: consecutive patients admitted within 24 h of stroke onset to two hospitals.
Methods: a prospective study. Where possible, all patients had their ability to swallow assessed on the day of admission by both a doctor and a speech and language therapist using a standardized proforma. A videofluoroscopy examination was conducted within 3 days of admission.
Results: 94 patients underwent videofluoroscopy; 20 (21%) were seen to be aspirating, although this was not detected at the bedside in 10. In 18 (22%) of the patients the speech and language therapist considered the swallow to be unsafe. In the medical assessment, 39 patients (41%) had an unsafe swallow. Bedside assessment by a speech and language therapist gave a sensitivity of 47%, a specificity of 86%, positive predictive value (PPV) of 50% and a negative predictive value (NPV) of 85% for the presence of aspiration. Multiple logistic regression was used to identify the optimum elements of the bedside assessments for predicting the presence of aspiration. A weak voluntary cough and any alteration in conscious level gave a sensitivity of 75%, specificity of 72%, PPV of 41% and NPV of 91% for aspiration.
Conclusion: bedside assessment of swallowing lacks the necessary sensitivity to be used as a screening instrument in acute stroke, but there are concerns about the use of videofluoroscopy as a gold standard. The relative importance of aspiration and bedside assessment in predicting complications and outcome needs to be studied.
Keywords: speech and language therapy, stroke, video fluoroscopy
Received February 28, 1997;
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