Leder Steven B, Espinosa Julian F
Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut 06504, USA.
Dysphagia. 2002 Summer;17(3):214-8. doi: 10.1007/s00455-002-0054-7.
Aspiration is an important variable related to increased morbidity, mortality, and cost of care for acute stroke patients. This prospective systematic replication study compared a clinical swallowing examination consisting of six clinical identifiers of aspiration risk, i.e., dysphonia, dysarthria, abnormal gag reflex, abnormal volitional cough, cough after swallow, and voice change after swallow, with an instrumental fiberoptic endoscopic evaluation of swallowing (FEES) to determine reliability in identifying aspiration risk following acute stroke. A referred consecutive sample of 49 first-time stroke patients was evaluated within 24 hours poststroke, first with the clinical examination followed immediately by FEES. The endoscopist was blinded to results of clinical testing. The clinical examination correctly identified 19 subjects with aspiration risk, when compared with the criterion standard FEES, but incorrectly identified 3 patients as having no aspiration risk when they did. The clinical examination incorrectly identified 19 subjects with aspiration risk but determined correctly no aspiration risk in 8 patients who did not exhibit aspiration risk on FEES. Clinical examination sensitivity = 86%; specificity = 30%; false negative rate = 14%; false positive rate = 70%; positive predictive value = 50%; and negative predictive value = 73%. It was concluded that the clinical examination, when compared with FEES, underestimated aspiration risk in patients with aspiration risk and overestimated aspiration risk in patients who did not exhibit aspiration risk. Careful consideration of the limitations of clinical testing leads us to believe that a reliable, timely, and cost-effective instrumental swallow evaluation should be available for the majority of patients following acute stroke.
误吸是与急性中风患者发病率、死亡率增加及护理成本相关的一个重要变量。这项前瞻性系统重复研究比较了由六个误吸风险临床指标组成的临床吞咽检查，即发音障碍、构音障碍、异常咽反射、异常随意咳嗽、吞咽后咳嗽及吞咽后声音改变，与吞咽功能的纤维内镜评估（FEES），以确定急性中风后识别误吸风险的可靠性。对49例首次中风患者的连续转诊样本在中风后24小时内进行评估，首先进行临床检查，随后立即进行FEES。内镜检查人员对临床测试结果不知情。与标准FEES相比，临床检查正确识别出19例有误吸风险的患者，但错误地将3例有误吸风险的患者判定为无风险。临床检查错误地将19例患者判定为有误吸风险，但正确判定8例在FEES上未显示误吸风险的患者无风险。临床检查敏感性=86%；特异性=30%；假阴性率=14%；假阳性率=70%；阳性预测值=50%；阴性预测值=73%。得出的结论是，与FEES相比，临床检查低估了有误吸风险患者的误吸风险，高估了无误吸风险患者的误吸风险。仔细考虑临床测试的局限性使我们相信，对于大多数急性中风后的患者，应提供可靠、及时且具有成本效益的仪器吞咽评估。
