The effect of liquid consistency on penetration-aspiration: a Bayesian analysis of two large datasets

James C Borders; Catriona M Steele

doi:10.3389/fresc.2024.1337971

The effect of liquid consistency on penetration-aspiration: a Bayesian analysis of two large datasets

Front Rehabil Sci. 2024 Feb 23:5:1337971. doi: 10.3389/fresc.2024.1337971. eCollection 2024.

Authors

James C Borders¹, Catriona M Steele^{2

3

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Affiliations

¹ Laboratory for the Study of Upper Airway Dysfunction, Department of Biobehavioral Sciences, Teachers College, Columbia University, New York, NY, United States.
² Swallowing Rehabilitation Research Laboratory, KITE Research Institute-University Health Network, Toronto, ON, Canada.
³ Department of Speech-Language Pathology, Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
⁴ Canada Research Chair (Tier 1) in Swallowing and Food Oral Processing, Canada Research Chairs Secretariat, Ottawa, ON, Canada.

Abstract

Introduction: Thickened liquids are commonly recommended to reduce the risk of penetration-aspiration. However, questions persist regarding the impact of bolus consistency on swallowing safety. The common practice of summarizing Penetration-Aspiration Scale (PAS) scores based on worst scores is a bias in prior analyses. The aim of this study was to examine the impact of liquid consistency on PAS scores using a Bayesian multilevel ordinal regression model approach, considering all scores across repeated bolus trials. A second aim was to determine whether PAS scores differed across thickener type within consistency.

Methods: We analyzed two prior datasets (D1; D2). D1 involved 678 adults with suspected dysphagia (289 female; mean age 69 years, range 20-100). D2 involved 177 adults (94 female; mean age 54 years, range 21-85), of whom 106 were nominally healthy and 71 had suspected dysphagia. All participants underwent videofluoroscopy involving ≥3 boluses of 20% w/v thin liquid barium and of xanthan-gum thickened barium in mildly, moderately and extremely thick consistencies. D2 participants also swallowed trials of slightly thick liquid barium, and starch-thickened stimuli for each thickened consistency. Duplicate blinded rating yielded PAS scores per bolus, with discrepancies resolved by consensus. PAS ratings for a total of 8,185 and 3,407 boluses were available from D1 and D2, respectively. Bayesian models examined PAS patterns across consistencies. We defined meaningful differences as non-overlapping 95% credible intervals (CIs).

Results: Across D1 and D2, penetration occurred on 10.87% of trials compared to sensate (0.68%) and silent aspiration (1.54%), with higher rates of penetration (13.47%) and aspiration (3.07%) on thin liquids. For D1, the probability of a PAS score > 2 was higher for thin liquids with weighted PAS scores of 1.57 (CI: 1.48, 1.66) versus mildly (1.26; CI: 1.2, 1.33), moderately (1.1; CI: 1.07, 1.13), and extremely thick liquids (1.04; CI: 1.02, 1.08). D2 results were similar. Weighted PAS scores did not meaningfully differ between thin and slightly thick liquids, or between starch and xanthan gum thickened liquids.

Discussion: These results confirm that the probability of penetration-aspiration is greatest on thin liquids compared to thick liquids, with significant reductions in PAS severity emerging with mildly thick liquids.

Keywords: aspiration; consistency; deglutition disorders; dysphagia; thickened liquids; videofluoroscopy.

Abstract

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