Dysphagia management: Does structured training improve the validity and reliability of cervical auscultation?

Figures & data

Figure 1. Cervical Auscultation (CA) Course Outline.

Table I. Swallow sound characteristics as recorded via FEES (Fiberoptic Endoscopic Evaluation of Swallowing).

Swallow sample				Clinical Features as per FEES
(length in seconds)	Dysphg	Safe	Severity	(Penetration-Aspiration Scale)^a
1, Thin fluids^b	yes	no	4	Severe delayed swallow, 3 swallows required, long white-out. Silent aspiration. (PAS = 8)
(20sec)
2, Thin fluids^c	no	yes	0	(Healthy volunteer)
(8sec)
3, Thin fluids	yes	no	4	Severely delayed swallow, aspiration, weak ineffective cough. (PAS = 7)
(22sec)
4, Thin fluids	yes	yes	1	Swallow initiation at pyriform fossa, 2 swallows required, long epiglottic closure / apnoeic period, diffuse residue. (PAS = 1)
(8sec)
5.1 (pre: swallow sound repeated)				5.1 = Repeat swallow sample 2 (randomly selected from swallow samples 1–4))
5.2 (post: swallow sound repeated)				5.2 = Repeat swallow sample 2 (randomly re-selected)
6, IDDSI-2	yes	no	3	Secretions. 2 swallows required. Valleculae residue. Penetration stasis inside surface of epiglottis, ? NGT influence + secretions. (PAS = 6)
(10sec)
7, IDDSI-2	no	yes	0	Normal
(3sec)
8, IDDSI-3	yes	no	4	Delayed with poor co-ordination. Penetration. (PAS = 2)
(8sec)
9.1 (pre: swallow sound repeated)				9.1 = Repeat swallow sample 7 (randomly selected from samples 6–8)
9.2 (post: swallow sound repeated)				9.2 = Repeat swallow sample 8 (randomly selected)

All swallow sounds (and repeats) were re-randomised between pre and post ratings.

^aPAS: Penetration-Aspiration Scale.

^bSwallow Sample 1, thin fluids, is available as electronic Supplementary material 1.

^cSwallow Sample 2, thin fluids, is available as electronic Supplementary material 2.

Table II. Interpretation of statistical analyses^a.

Agreement using Kappa statistic	Kappa 0.81–0.99	Kappa 0.61–0.80	Kappa 0.41–0.60
	Almost perfect agreement	Substantial agreement	Moderate agreement
Correlation with FEES	0.91–1.00	0.71–0.90	0.50–0.70
	Very high correlation	High correlation	Moderate correlation
Sensitivity and Specificity	0.90–1.00	0.75–0.89	0.60–0.74
	Very High values	High values	Moderate-high values

^aFor lower values (not relevant for the current study) please refer to original articles (Hinkle et al., 2003; Landis & Koch, 1977; Lange & Lippa, 2017).

Table III. Agreement with Fibreoptic Endoscopic Evaluation of Swallowing (FEES).

	Safe		Dysphagia		Severity
Results (n = 39)	Pre	Post	Pre	Post	Pre	Post
Exact agreement	76%	83%	85%	89%	55%	58%
Close agreement					84%	85%
Mean Kappa	K = 0.54	K = 0.67	K = 0.68	K = 0.77	Kw=0.62	Kw=0.65
(SD)	(0.17)	(0.22)	(0.27)	(0.20)	(0.19)	(0.16)
Statistical analyses	Sens = 0.98	Sens = 0.99	Sens = 0.96	Sens = 0.93	rs = 0.81	rs = 0.86
	Spec = 0.68	Spec = 0.76	Spec = 0.72	Spec = 0.85
	aROC = 0.83	aROC = 0.88	aROC = 0.84	aROC = 0.89
Distribution of difference in percent agreement (post - pre values)	Mean = 0.13, SD = 0.23,		Mean = 0.92, SD = 0.29,		Mean = 0.03, SD = 0.19,
	Median = 0.19,		Median = 0.00,		Median = 0.01,
	Min = −0.42, Max = 1.54		Min = −0.64, Max = 1.08		Min = −0.34, Max = 0.74
Significance between pre-post values	p < 0.001		p = 0.008		p = 0.39

Sens: sensitivity; Spec: specificity; aROC: area under the Receiving Operating Curve; r_s: Spearmans Correlation Coefficient; K: Cohen’s Kappa; Kw: Weighted Kappa; SD: standard deviation. Significance = p < 0.05 indicated by bolded font.

Figure 2. Intra-rater reliability pre-post training for (1) Safe, (2) Dysphagia, (3) Severity ratings, and significance between pre-post training. K = Cohen’s Kappa. Kw = Weighted Kappa Significence = p < 0.05, indicated by bolded font.

Figure 3. Intra-rater reliability pre-post training for (1) Safe, (2) Dysphagia, (3) Severity ratings, and significance between pre-post training. K_f = Fleiss Kappa. K_w = Weighted Kappa. ^a = mean of 780 Weighted Kappa. ns = not significant as indicated by overlapping Confidance Intervals.

Hinkle, D., Wiersma, W., & Jurs, S. (2003). Applied statistics for the behavioral sciences. Boston, MA: Houghton Mifflin.

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Lange, R.T., & Lippa, S.M. (2017). Sensitivity and specificity should never be interpreted in isolation without consideration of other clinical utility metrics. The Clinical Neuropsychologist, 31, 1015–1028. doi:https://doi.org/10.1080/13854046.2017.1335438

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