Lincolnshire Knowledge and Resource Service This search summary contains the results of a literature search undertaken by the Lincolnshire Knowledge and Resource Service librarians in March 2012. All of the literature searches we complete are tailored to the specific needs of the individual requester. If you would like this search re-run with a different focus, or updated to accommodate papers published since the search was completed, please let us know. We hope that you find the information useful. If you would like the full text of any of the abstracts listed, please let us know. Alison Price Janet Badcock

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Librarians, Lincolnshire Knowledge and Resource Service NHS Lincolnshire Beech House, Waterside South Lincoln LN5 7JH

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Lincolnshire Knowledge and Resource Service Please find below the results of your literature search request. If you would like the full text of any of the abstracts included, or would like a further search completed on this topic, please let us know. A feedback form is included with these search results. We would be very grateful if you had the time to complete it for us, so that we can monitor satisfaction with the service we provide. Thank you! Disclaimer Every effort has been made to ensure that this information is accurate, up-to-date, and complete. However it is possible that it is not representative of the whole body of evidence available. No responsibility can be accepted for any action taken on the basis of this information. It is the responsibility of the requester to determine the accuracy, validity and interpretation of the search results. All links from this resource are provided for information only. A link does not imply endorsement of that site and the Lincolnshire Knowledge and Resource Service does not accept responsibility for the information displayed there, or for the wording, content and accuracy of the information supplied which has been extracted in good faith from reputable sources.

Lincolnshire Knowledge & Resource Service Beech House, Witham Park, Waterside South, Lincoln LN5 7JH

Literature Search Results Search request date: Search completion date: Search completed by:

26th March 2012 2nd April 2012 Alison Price

Enquiry Details

How reliable is blue dye in detecting aspiration in patients with a tracheotomy.

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Opening Internet Links The links to internet sites in this document are ‘live’ and can be opened by holding down the CTRL key on your keyboard while clicking on the web address with your mouse Full Text Papers Links are given to full text resources where available. For some of the papers, you will need a free NHS Athens Account. If you do not have an account you can register by following the steps at: https://register.athensams.net/nhs/nhseng/ You can then access the papers by simply entering your username and password. If you do not have easy access to the internet to gain access, please let us know and we can download the papers for you. Guidance on Searching within Online Documents Links are provided to the full text of each of these documents. Relevant extracts have been copied and pasted into these Search Results. Rather than browse through often lengthy documents, you can search for specific words and phrases as follows: Portable Document Format / pdf. / Adobe Click on the Search button (illustrated with binoculars). This will open up a search window. Type in the term you need to find and links to all of the references to that term within the document will be displayed in the window. You can jump to each reference by clicking it. You can search for more terms by pressing ‘search again’. Word documents Select Edit from the menu, the Find and type in your term in the search box which is presented. The search function will locate the first use of the term in the document. By pressing ‘next’ you will jump to further references.

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Advice and Comment from Professional Bodies Royal College of Speech and Language Therapists Article from the June 2005 professional bulletin ‘Why SLTs should be cautious about relying solely on blue dye to test for aspiration’ Bulletin attached. Reply re: the above piece in the August 2005 bulletin, giving a best practice example from an NHS Trust. Bulletin attached. American Speech, Language and Hearing Association - ASHA Reducing Pneumonia Risk Factors in Patients with Dysphagia Who Have A Tracheotomy: What Role Can SLPs Play? Christine T. Matthews & James L. Coyle Extract: Assessment Procedures Because aspiration, and more particularly silent aspiration, is a common occurrence in patients with tracheostomy tubes (Ding and Logemann, 2005; Davis et al. 2002; 2004; Elpern et al., 2000), thorough assessment and evaluation of all risk factors is indicated prior to the initiation of oral intake to reduce the likelihood of complications associated with aspiration. While instrumental testing is essential in providing the most accurate assessment of swallowing function (e.g. Elpern et al., 2000; Ding & Logemann, 2005), a clinical assessment may be the only type of assessment some patients undergo. O'Neil-Pirozzi et al. (2003) reported that a clinical swallowing exam which utilizes blue dye testing can serve as an aspiration screening prior to instrumental testing. They also report that the clinical exam can be used when the patient is not stable enough for an instrumental exam or because access to an instrumental exam is time or cost prohibitive. In cases where it is the only exam performed, clinicians should keep in mind the low sensitivity of the clinical exam procedures discussed in the following section, in detecting aspiration in this population. The Evan's Blue Dye Test (EBDT; Cameron et al., 1973) and Modified Evan's Blue Dye Test (MEBDT; Thompson-Henry and Braddock, 1995) were developed as screening tools for detecting aspiration of oral secretions and food or liquids, respectively. In the EBDT, the patient's oral secretions are stained by placing blue dye on the tongue and observing the patient over a period of time, and in the MEBDT, the blue contrast is added to boluses of food or liquid, with both involving serial suctioning of tracheal secretions. The presence of blue dye in the tracheal secretions is a positive sign that aspiration has occurred, but its absence does not necessarily indicate no risk of aspiration and should not be taken to mean that the patient did not or will not aspirate. A number of studies have compared the accuracy of the MEBDT in identifying aspiration to the results of simultaneous or successive instrumental exams. Overall, the studies assessing the accuracy of the MEBDT in identifying aspiration show much disagreement with instrumental testing (0-82% overall reported accuracy) because of the lack of a standard methodology for investigating this research question. Table 3 [PDF] provides additional study details. These studies have sought to compare the MEBDT and instrumental swallowing assessments to determine the sensitivity (accuracy of detecting aspiration when it does occur) and specificity (accuracy of correctly identifying the absence of aspiration when it does not occur) of the blue dye method.

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A major flaw in most studies examining the use of blue dye tests as a screening tool is their non-concurrent designs. When the blue dye and instrumental tests are not performed simultaneously, this design limitation weakens the reader's confidence in the reported sensitivity and specificity results. For example, Thompson-Henry and Braddock (1995) completed a FEES or MBS on five tracheostomized patients within four to 22 days following the MEBDT. They found that all of the patients aspirated during the instrumental assessments, but none of the MEBDTs were positive. In this first study that used blue dye in food and liquid consistencies, the researchers identified potential false negative findings using the blue dye methodology. Belafsky et al. (2003) completed FEES exams 24 hours following MEBDT on 30 patients. All of the patients had either cuffless tracheostomy tubes or their cuff was deflated; none were wearing one-way speaking valves; and 10 were on the ventilator during the assessments. The overall rate of aspiration for the cohort was 73% with FEES, and the sensitivity and specificity of the MEBDT in detecting aspiration was 38% and 82%, respectively. Three studies using concurrent MEBDT and instrumental testing deserve attention. Donzelli et al. (2001) performed simultaneous FEES and MEBDT on 15 patients and found an overall 50% sensitivity, and aspiration was identified with blue dye only when it occurred in more than trace amounts. Large amounts of aspiration were detected more accurately (67% of the time) than small aspiration volumes (0%). Unfortunately data on the seven patients that did not aspirate were not included to determine the specificity of the MEBDT. A possible methodological limitation, which may have impacted their findings, was the use of FEES as their instrumental method. Aspiration during the swallow may go undetected during FEES due to the loss of endoscopic visualization that occurs during the swallow, leaving the endoscopist to look for evidence of aspiration that may have eluded their line of sight by the time visualization is restored. However these investigators actually inserted the endoscope into the trachea to directly visualize the subglottal area to confirm whether aspiration had indeed occurred. Similar results were observed by Brady et al. (1999) who performed concurrent MEBDT and videofluoroscopic swallowing (VFS) evaluation were with 20 patients. Using simultaneous videofluoroscopy and MEBDT (both blinded), O'Neil-Pirozzi et al. (2003) evaluated 50 patients. They found 62% sensitivity and 79% specificity (the published study erroneously reversed the values of these two results). They also were able to identify "trace" and "gross" amounts of aspiration using the MEBDT procedure in their study. From these studies it seems that small-volume aspiration is not easily detected by MEBDT, and that overall, about 30% of aspiration goes undetected. Instrumental Assessments Many argue that the gold standard for instrumental swallowing assessments is the videofluoroscopic swallowing (VFS) evaluation, while others argue that fiberoptic endoscopic evaluation of swallowing (FEES) is equivalent without the radiation exposure and access issues that VFS evaluation may have. Some patients cannot be transported to radiology or undergo fiberoptic testing for various reasons, and in most cases clinical evaluation is performed before instrumental testing. Each instrumental evaluation method has its advantages and disadvantages and both provide valuable information that overshadows clinical observations in terms of precision. The debate regarding superiority of VFS or FEES notwithstanding, instrumental testing should be performed in the majority of patients with tracheostomies, unless the clinician is reasonably certain that swallowing function is a highly unlikely source of increased risk of adverse medical outcomes. www.asha.org/Publications/leader/2010/100518/Reducing-Pneumonia-Risk-Factors.htm

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UK Trust Policy Example Salisbury NHS Trust Referral of Patients with Tracheostomy for Swallowing Assessment Background Patients with spinal cord injury who also have a tracheostomy are more likely to have swallowing problems if they have certain associated risk factors. (Wolf and Meiners 2003) Assessment of swallowing ability requires skill and experience – even an experienced speech and language therapist (SALT) will miss 30% of aspirating patients as they aspirate silently. The Modified Blue Dye Test is a test that is used to assess swallowing, however it has been shown to be unreliable (Brady et al 1999) at both identifying patients who are aspirating and those who are definitely not aspirating. (O'Neil-Pirozzi et al 2003) SALT has two other methods of assessment they can utilize: Nasendoscopy (Fibreoptic endoscopic evaluation of swallowing – FEES) This is where a scope is passed to visualize the oral, pharyngeal, and laryngeal structures and mucosa, and vocal cord movement. It can identify pre-swallow and post swallow laryngeal penetration and aspiration. Barium swallow videofluoroscopy This is a sophisticated X-ray video which demonstates the motility and coordination of the oral, pharyngeal, laryngeal and oesophageal phases of swallow. It can identify pre, intra and post swallow laryngeal penetration and aspiration. These two assessment methods are able to provide a more definitive answer as to whether the patient is safe to eat and / or drink. The SALT is able to advise on any modifications to food and fluid consistencies, bolus size, timing of feeding, and swallowing stategies to enable safe feeding. www.icid.salisbury.nhs.uk/ClinicalManagement/SpinalInjuries/Pages/SwallowingAssessment.aspx

Guidelines Scottish Intercollegiate Guidelines Network: Management of patients with stroke: identification and management of dysphagia, 2010 The evidence-based extract relevant to swallowing assessment is reproduced overleaf:

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