Estimating Risk of Pneumonia

James L. Coyle of the University of Pittsburgh wrote on the Dysphagia List-Serve:

"Eisenhuber et al (2002) developed a three point scale, using the height of retention in the vallecular and pyriform sinuses, as scale values.

A score of 1 corresponded to “less than 25% of the height” of the cavity described, 2 to “25-50% height”, and 3 to “>50% height”. They adapted a rating system published earlier by Perlman et al. (1994) by taking the published height values and attributing the values in the 3 point scale to the three measures created by Perlman.

They then used videofluoroscopy to determine whether pharyngeal retention seen on fluoroscopic images was predictive of laryngeal penetration or aspiration. They did not differentiate between the two (penetration, aspiration), instead lumping them together. This makes it difficult for the reader to know with certainty which outcome (penetration, aspiration) should be expected. They also lumped vallecular and pyriform sinus retention together in the attribution of aspiration/penetration risk however 83% of their patients had retention in both.

At any rate, The score “3” for pharyngeal retention was significantly more likely (about 4 to 1 odds of higher likelihood) to be followed by laryngeal penetration or aspiration than scores of 1 or 2. One finding that is a bit easier to swallow (ha ha) was that 93% of patients with pharyngeal retention (valleculae or pyriform sinuses or both) exhibited laryngeal penetration or aspiration whereas only 33% of patients without retention exhibited penetration or aspiration.

Robbins et al. (1999) used the penetration aspiration scale to differentiate between normals, and two groups of disordered swallowers (stroke, head and neck cancer). They found that 21% of normals exhibited high laryngeal penetration (no deeper than the vestibule-PAS scores of 2 or 3). Therefore deep penetration (to vocal folds) is not normal (nor is aspiration).

Combining the two measures, one can attribute risk of laryngeal penetration or aspiration to the height of pharyngeal retention, and the risk of inhalation of swallowed material to the severity of laryngeal penetration and aspiration. Added to the other host risk factors predisposing a patient to pneumonia, the clinician can generate a reasonable likelihood of pneumonia.

We use the two scales together to attribute risk associated with the dysphagia and discuss the additional risk factors to estimate pneumonia risk."

James L. Coyle

University of Pittsburgh

Reference List

Eisenhuber, E., Schima, W., Schober, E., Pokieser, P., Stadler, A., Scharitzer, M. et al. (2002). Videofluoroscopic assessment of patients with dysphagia: pharyngeal retention is a predictive factor for aspiration. American Journal of Roentgenology, 178, 393-398.

Perlman, A. L., Booth, B. M., & Grayhack, J. P. (1994). Videofluoroscopic predictors of aspiration in patients with oropharyngeal dysphagia. Dysphagia, 9, 90-95.

Robbins, J. A., Coyle, J. L., Rosenbek, J. C., Roecker, E. B., & Wood, J. L. (1999). Differentiation of normal and abnormal airway protection during swallowing using the penetration-aspiration scale. Dysphagia, 14, 228-232.