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

Abstract

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.

Perspective on dysphagia screening, assessment methods, and protocols in intensive care units: an opinion article

“…Water swallow tests and multi-consistency screenings are the two methods for screening ICU patients for suspected PED (Likar et al, 2024 ), while methods used to assess dysphagia can be classified under two broad categories: instrumental and non-instrumental. It is usually accepted that these two modalities should complement one another for a comprehensive understanding of dysphagia (Perren et al, 2019 ; Troll et al, 2023 ; Likar et al, 2024 ).…”

“…Similarly, despite the 3-ounce water swallow test not being validated in critically ill patients, its use is recommended to be performed by ICU nursing personnel, given that patients are alert and capable of sitting upright in a supported position (Macht et al, 2014 ). The Volume-Viscosity Swallow Test (V-VST) has demonstrated acceptable sensitivity and specificity in mixed and specific patient populations, but not specifically in critically ill patients (Perren et al, 2019 ; Troll et al, 2023 ) as limited evidence exists regarding its applicability in ICU patients (Zurbano et al, 2023 ). The Gugging Swallowing Screen (GUSS) is also included in the spectrum of clinical non-instrumental screenings aimed at specific patient populations (Perren et al, 2019 ; Troll et al, 2023 ).…”

“…The Volume-Viscosity Swallow Test (V-VST) has demonstrated acceptable sensitivity and specificity in mixed and specific patient populations, but not specifically in critically ill patients (Perren et al, 2019 ; Troll et al, 2023 ) as limited evidence exists regarding its applicability in ICU patients (Zurbano et al, 2023 ). The Gugging Swallowing Screen (GUSS) is also included in the spectrum of clinical non-instrumental screenings aimed at specific patient populations (Perren et al, 2019 ; Troll et al, 2023 ). Despite Muñoz-Garach et al ( 2023 ) arguing that GUSS may be suitable for dysphagia screening in the ICU, its validity has only been established for stroke patients (Trapl et al, 2007 ).…”

“…Several studies support the use of Videofluoroscopic Swallow Study (VFSS) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES) (Perren et al, 2019 ; Barker et al, 2022 ; Freeman-Sanderson et al, 2023 ; Mpouzika et al, 2023 ; Troll et al, 2023 ; Likar et al, 2024 ) as the designated reference-standard for the assessment of dysphagia, with FEES constituting the most preferred method within the ICU setting due to its accessibility (Likar et al, 2024 ). Nonetheless, instrumental examinations are not always widely available, readily accessible, or feasible (Barker et al, 2022 ).…”

“…Fewer than thirty percent of surveyed ICU practitioners employ dysphagia protocols, while less than 20% of nurses undergo formal dysphagia training regarding the screening of patients for suspected PED (Freeman-Sanderson et al, 2023 ). But dysphagia screening and thereafter assessment is particularly crucial for its early identification, management, prevention and mitigation of complications, optimization of nutritional support and ultimately enhancement of patient overall health outcomes (Freeman-Sanderson et al, 2023 ; Mpouzika et al, 2023 ; Troll et al, 2023 ; Zurbano et al, 2023 ).…”