Clinical Utility of the 3-ounce Water Swallow Test

Abstract

The 3-ounce water swallow test is frequently used to screen individuals for aspiration risk. Prior research concerning its clinical usefulness, however, is confounded by inadequate statistical power due to small sample sizes and varying methodologies. Importantly, research has been limited to a few select patient populations, thereby limiting the widespread generalizability and applicability of the 3-ounce test. The purpose of this study was to investigate the clinical utility of the 3-ounce water swallow test for determining aspiration status and oral feeding recommendations in a large and heterogeneous patient population. Fiberoptic endoscopic evaluation of swallowing (FEES) was performed in conjunction with the 3-ounce water swallow test on 3000 participants with a wide range of ages and diagnoses. A total of 1151 (38.4%) passed and 1849 (61.6%) failed the 3-ounce water swallow test. Sensitivity of the 3-ounce water swallow test for predicting aspiration status during FEES = 96.5%, specificity = 48.7%, and false positive rate = 51.3%. Sensitivity for identifying individuals who were deemed safe for oral intake based on FEES results = 96.4%, specificity = 46.4%, and false positive rate = 53.6%. Passing the 3-ounce water swallow test appears to be a good predictor of ability to tolerate thin liquids. However, failure often does not indicate inability to tolerate thin liquids, i.e., low specificity and high false-positive rate. Use of the 3-ounce water swallow test alone to make decisions regarding safety of liquid intake results in over-referral and unnecessary restriction of liquid intake for nearly 50% of patients tested. In addition, because 71% of participants who failed the 3-ounce water swallow test were deemed safe for an oral diet, nonsuccess on the 3-ounce water swallow test is not indicative of swallowing failure. The clinical utility of the 3-ounce water swallow test has been extended to include a wide range of medical and surgical diagnostic categories. Importantly, for the first time it has been shown that if the 3-ounce water swallow test is passed, diet recommendations can be made without further objective dysphagia testing.

Screening tools for dysphagia: a systematic review

“…The sample size ranged from 25 to 3,000 participants. The article with 3,000 participants (32) reported a very heterogeneous population, with individuals of both genders, aged between 2 and 105 years, and with various pathologies. Chart 2 shows the characteristics relating to the underlying pathology for each study population selected.…”

“…Generally, a failure in one of the issues analyzed indicates a risk for swallowing disorders. There are also studies (26,30,32) that used instruments that involved only the swallowing test with water for screening. In these studies, the patient had to ingest the liquid and some signs were observed during and after the intake.…”

“…The Videofluoroscopy Swallow Study was used in five articles (19,25,29,31,35) ; clinical assessment of swallowing was reported in five (21,22,27,30,37) ; fiberoptic endoscopic evaluation of swallowing (FEES) was reported in three papers (26,32,38) , and clinical evaluation and FEES were reported in one (33) . Another study (28) conducted the follow-up of patients for a specific time-period and included indicators such as consultation with a speech-language pathologist; special type of diet, and clinical symptoms of aspiration pneumonia to verify the presence of dysphagia.…”

“…Logemann et al (19) ; Belafsky et al (24) ; Suiter et al (26) ; Boczko (27) ; Sitoh et al (30) ; Suiter and Leder (32) ; Kawashima et al (34) ; Holland et al (36) ; Cohen and Manor (38) Chart 2. Underlying pathologies sensitivity, change of glottal closure, early rear food loss, and nasal regurgitation (12,45) .…”

Physiological Characteristics of Dysphagia Following Thermal Burn Injury

“…This enabled information on both oral and pharyngeal stage deficits to be compiled. The CSE consisted of a patient interview, visual examination of the oromusculature, oromotor examination, perceptual evaluation of voice quality, and a series of oral intake trials of fluids and foods that also included a water swallow test [14][15][16][17] when appropriate. All participants were trialled with the fluids/foods considered to be least normal first (i.e., extremely thick fluids, puree diet), with progression towards normal dietary consistencies and textures (i.e., thin fluids, general diet), during oral intake trials if appropriate.…”