TITLE: Three-Ounce Water Swallow Challenge for Oropharyngeal Dysphagia: Diagnostic
Accuracy and Guidelines
DATE: 04 April 2016
RESEARCH QUESTIONS
1.
What is the diagnostic accuracy of the 3-ounce (90-cc) water swallow challenge for the
identification of oropharyngeal dysphagia in adults?
2.
What is the diagnostic accuracy of the 3-ounce (90-cc) water swallow challenge for the
identification of oropharyngeal dysphagia in children?
3.
What are the evidence-based guidelines regarding the use of the 3-ounce (90-cc) water
swallow challenge for the identification of oropharyngeal dysphagia in adults?
4.
What are the evidence-based guidelines regarding the use of the 3-ounce (90-cc) water
swallow challenge for the identification of oropharyngeal dysphagia in children?
KEY FINDINGS
Two non-randomized studies were identified regarding the diagnostic accuracy of the 3-ounce
(90-cc) water swallow challenge for the identification of oropharyngeal dysphagia in adults.
METHODS
A limited literature search was conducted on key resources including PubMed, The Cochrane
Library, University of York Centre for Reviews and Dissemination (CRD) databases, Canadian
and major international health technology agencies, as well as a focused Internet search. No
filters were applied to limit the retrieval by study type. Where possible, retrieval was limited to
the human population. The search was also limited to English language documents published
between January 1, 2011 and March 23, 2016. Internet links were provided, where available.
Disclaimer: The Rapid Response Service is an information service for those involved in planning and providing health care in
Canada. Rapid responses are based on a limited literature search and are not comprehensive, systematic review s. The intent is to
provide a list of sources of the best evidence on the topic that the Canadian Agency for Drugs and Technologies in Health (CADTH)
could identify using all reasonable efforts within the time allow ed. Rapid responses should be considered along w ith other ty pes of
information and health care considerations. The information included in this response is not intended to replace professional medical
advice, nor should it be construed as a recommendation for or against the use of a particular health technology. Readers are also
cautioned that a lack of good quality evidence does not necessarily mean a lack of effectiveness particularly in the case of new and
emerging health technologies, for w hich little information can be found, but w hich may in future prove to be effective. While CADTH
has taken care in the preparation of the report to ensure that its contents are accurate, complete and up to date, CADTH does not
make any guarantee to that effect. CADTH is not liable for any loss or damages resulting from use of the information in the report.
Copyright: This report contains CADTH copyright material and may contain material in w hich a third party ow ns copyright. This
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redistributed by email or stored on an electronic system w ithout the prior w ritten permission of CADTH or applicable copyrigh t
ow ner.
Links: This report may contain links to other information available on the w ebsites of third parties on the Internet. CADTH does not
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The summary of findings was prepared from the abstracts of the relevant information. Please
note that data contained in abstracts may not always be an accurate reflection of the data
contained within the full article.
SELECTION CRITERIA
One reviewer screened citations and selected studies based on the inclusion criteria presented
in Table 1.
Table 1: Selection Criteria
Population
Intervention
Comparator
Outcomes
Study Designs
Q1 and 3: Adults with suspected oropharyngeal dysphagia
Q2 and 4: children with suspected oropharyngeal dysphagia
3-ounce (90-cc) water swallow challenge (also referred to as the Yale
Swallow Protocol)
Q1 and 2: Endoscopic evaluation of swallowing (e.g., fiberoptic endoscopic
evaluation of swallowing [FEES]), videofluoroscopy (VFSS; also
referred to as modified barium swallow exam [MBS])
Q3 and 4: No comparator
Q1 and 2: Diagnostic test accuracy outcomes (e.g., sensitivity, specificity,
positive and negative predictive value)
Q3 and 4: Evidence-based guidelines regarding the use of the 3-ounce (90
cc) water swallow challenge for the identification of swallowing
disorders in children and adults
Health technology assessments, systematic reviews, meta-analyses,
randomized controlled trials, non-randomized studies, evidence-based
guidelines
RESULTS
Rapid Response reports are organized so that the higher quality evidence is presented first.
Therefore, health technology assessment reports, systematic reviews, and meta-analyses are
presented first. These are followed by randomized controlled trials, non-randomized studies,
and evidence-based guidelines.
Two non-randomized studies were identified regarding the diagnostic accuracy of the 3-ounce
(90-cc) water swallow challenge for the identification of oropharyngeal dysphagia in adults. No
relevant health technology assessments, systematic reviews, meta-analyses, or evidencebased guidelines were identified. No relevant literature was identified regarding use of the 3ounce (90-cc) water swallow challenge for the identification of oropharyngeal dysphagia in
children.
Additional references of potential interest are provided in the appendix.
OVERALL SUMMARY OF FINDINGS
Two non-randomized studies 1,2 were identified regarding the diagnostic accuracy of the 3-ounce
(90-cc) water challenge for the identification or oropharyngeal dysphagia in adults.
One study compared the water swallow challenge to videofluoroscopic swallow studies (VFSS)
in 25 male adults.1 The study results determined the diagnostic accuracy of the water swallow
challenge to have 100% sensitivity, 64% specificity, a 78% positive predictive value, and a
Three-Ounce Water Swallow Challenge for Oropharyngeal Dysphagia
2
100% negative predictive value. The authors concluded that the water swallow challenge was
useful and valid for determining aspiration risk, but specified that the patient population in this
study was limited.1
A second study used a combined approach to determine aspiration risk in patients following a
stroke.2 The water swallow challenge was used in conjunction with the Clinical Predicative Scale
of Aspiration (CPSA), and was compared with VFSS when results were discordant. The
diagnostic accuracy of the water swallow challenge was determined to have 87.3% sensitivity
and 42.3% specificity. The authors determined that a combined approach to screening for
aspiration risk that included the water swallow challenge was useful and more efficient than
relying on a single screening test.2
No relevant literature was identified regarding use of the 3-ounce (90-cc) water swallow
challenge for the identification of oropharyngeal dysphagia children; therefore, no summary can
be provided for this patient population.
Three-Ounce Water Swallow Challenge for Oropharyngeal Dysphagia
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REFERENCES SUMMARIZED
Health Technology Assessments
No literature identified.
Systematic Reviews and Meta-analyses
No literature identified.
Randomized Controlled Trials
No literature identified.
Non-Randomized Studies
1.
Suiter DM, Sloggy J, Leder SB. Validation of the Yale Swallow Protocol: a prospective
double-blinded videofluoroscopic study. Dysphagia. 2014 Apr;29(2):199-203.
PubMed: PM24026519
2.
Zhou Z, Salle J, Daviet J, Stuit A, Nguyen C. Combined approach in bedside assessment
of aspiration risk post stroke: PASS. Eur J Phys Rehabil Med. 2011 Sep;47(3):441-6.
PubMed: PM21508917
Guidelines and Recommendations
No literature identified.
PREPARED BY:
Canadian Agency for Drugs and Technologies in Health
Tel: 1-866-898-8439
www.cadth.ca
Three-Ounce Water Swallow Challenge for Oropharyngeal Dysphagia
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APPENDIX – FURTHER INFORMATION:
Systematic Reviews and Meta-Analyses – Specific Water Challenge not Identified
3.
Chen PC, Chuang CH. Accuracy of the Water Swallow Test for Dysphagia With Stroke: A
Meta-Analysis. J Nurs HealthC Res (Taiwan). 2015 Jan; 11(2): 161-169.
4.
Keage M, et al. A systematic review of self-reported swallowing assessments in
progressive neurological disorders. Dysphagia. 2015 Feb;30(1):27-46
PubMed: PM25280814
5.
O’Horo et al. Bedside diagnosis of dysphagia: a systematic review. Hosp Med. 2015
Apr;10(4):256-65.
PubMed: PM25581840
Non-Randomized Studies
No Comparator or Alternate Comparator
6.
Gonzalez-Fernandez M, Humbert I, Winegrad H, Cappola AR, Fried LP. Dysphagia in oldold women: prevalence as determined according to self-report and the 3-ounce water
swallowing test. J Am Geriatr Soc [Internet]. 2014 Apr [cited 2016 Apr 1];62(4):716-20.
Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4609899
PubMed: PM24635053
7.
Warner HL, Suiter DM, Nystrom KV, Poskus K, Leder SB. Comparing accuracy of the
Yale swallow protocol when administered by registered nurses and speech-language
pathologists. J Clin Nurs. 2014 Jul;23(13-14):1908-15.
PubMed: PM24033866
8.
Leder SB, Suiter DM, Warner HL, Acton LM, Swainson BA. Success of recommending
oral diets in acute stroke patients based on passing a 90-cc water swallow challenge
protocol. Top Stroke Rehabil. 2012 Jan;19(1):40-4.
PubMed: PM22306627
9.
Leder SB, Suiter DM, Warner HL, Acton LM, Siegel MD. Safe initiation of oral diets in
hospitalized patients based on passing a 3-ounce (90 cc) water swallow challenge
protocol. QJM. 2012 Mar;105(3):257-63.
PubMed: PM22006561
10.
Leder SB, Suiter DM, Warner HL, Kaplan LJ. Initiating safe oral feeding in critically ill
intensive care and step-down unit patients based on passing a 3-ounce (90 milliliters)
water swallow challenge. J Trauma. 2011 May;70(5):1203-7.
PubMed: PM21336196
Three-Ounce Water Swallow Challenge for Oropharyngeal Dysphagia
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Alternate or Unnamed Intervention
11.
Kanna SV, Bhanu K. A simple bedside test to assess the swallowing dysfunction in
Parkinson's disease. Ann Indian Acad Neurol [Internet]. 2014 Jan [cited 2016 Apr
1];17(1):62-5. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3992772
PubMed: PM24753662
12.
Martino R, Maki E, Diamant N. Identification of dysphagia using the Toronto Bedside
Swallowing Screening Test (TOR-BSST(c)): are 10 teaspoons of water necessary? Int J
Speech Lang Pathol. 2014 Jun;16(3):193-8.
PubMed: PM24833425
13.
Hey C, Lange BP, Eberle S, Zaretsky Y, Sader R, Stover T, et al. Water swallow
screening test for patients after surgery for head and neck cancer: early identification of
dysphagia, aspiration and limitations of oral intake. Anticancer Res. 2013 Sep;33(9):401721.
PubMed: PM24023344
14.
Osawa A, Maeshima S, Tanahashi N. Water-swallowing test: screening for aspiration in
stroke patients. Cerebrovasc Dis. 2013;35(3):276-81.
PubMed: PM23548854
15.
Patterson JM, Hildreth A, McColl E, Carding PN, Hamilton D, Wilson JA. The clinical
application of the 100mL water swallow test in head and neck cancer. Oral Oncol. 2011
Mar;47(3):180-4.
PubMed: PM21227737
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