Has the gold tarnished or is it yet to shine? A critique of the use of the videofluoroscopy swallow study to identify aspiration associated with oropharyngeal dysphagia

Abstract

The videofluoroscopy swallow study (VFSS) has heen used hoth as a screening tool for aspiration and as a tool to diagnose and treat oropharyngeal dysphagia. In fact, despite the VFSS not meeting the criteria of a ‘gold standard’ diagnostic test, it is seen hy many as the benchmark against which all new diagnostic technologies for dysphagia diagnosis and management are compared. Using the principles of evidence-based practice as outlined hy Sackett (Sackett et al., 1991), a review of the puhlished evidence evaluating the VFSS against other instrumental dysphagia assessment tools was conducted. Owing to the documented impact of aspiration pneumonia associated with dysphagia, ‘identification of aspiration’ was chosen as the outcome of importance against which the tests were evaluated. Evaluation of the puhlished evidence comparing VFSS with other instrumental diagnostic dysphagia assessment tools in its ability to identify aspiration revealed a majority of the evidence to be of a low level. A major problem noted within the literature was acceptance of the VFSS as the ‘gold standard’. If a diagnostic test that is considered the benchmark does not meet ‘gold standard’ criteria, how can other tests be accurately evaluated against it? Indeed, how can assessments be made regarding what is the ‘best’ test of aspiration, what is the ‘correct’ result and what is not? Future studies must continue to address the inherent problems associated with the use and interpretation of the VFSS, particularly in terms of improving its reliability and validity. This would permit more accurate evaluation of the reliability of dysphagia diagnostic tests to identify aspiration and dysphagia, and would enhance the accuracy of reporting dysphagia.