11/10/11. Memorie M. Gosa, M.S. CCC-SLP, BRS-S Senior Speech-Language Pathologist/ PhD Candidate LeBonheur Children s Hospital/ University of Memphis

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1 Memorie M. Gosa, M.S. CCC-SLP, BRS-S Senior Speech-Language Pathologist/ PhD Candidate LeBonheur Children s Hospital/ University of Memphis Developed an 8 point interval scale to describe penetration & aspiration events Scores determined by the depth of the material into the airway & whether or not the material is expelled Intra & interjudge reliability were established Debra M. Suiter, PhD CCC-SLP, BRS-S VA Medical Center/ University of Memphis Penetration: Passage of material into the larynx that does not pass below the vocal folds Aspiration: Passage of material below the level of the vocal folds Score Description 1 Material does not enter the airway 2 Material enters the airway, remains above the vocal folds & is ejected from the airway 3 Material enters the airway, remains above the vocal folds & is NOT ejected from the airway 4 Material enters the airway, contacts the vocal folds & is ejected from the airway 5 Material enters the airway, contacts the vocal folds & is NOT ejected from the airway 6 Material enters the airway, passes below the vocal folds & is ejected into the larynx or out of the airway 7 Material enters the airway, passes below the vocal folds & is NOT ejected from the trachea despite effort 8 Material enters the airway, passes below the vocal folds & No effort is made to eject MBS images of 75 swallows were copied in random sequence Swallows elicited from 15 patients admitted with stroke Four experienced judges assigned a score to each of the 75 swallows to assess interjudge reliability The same judges reviewed the 75 swallows again to establish intrajudge reliability Acceptable intra & interjudge reliability were established Judges were almost as consistent with each other as they were with themselves Scale intended to be used as part of a total swallowing assessment 1

2 Acceptable reliability of the PAS was established on adult, stroke population (Rosenbek, Robbins, Roecker, Coyle, & Woods, 1996) The PAS has been used to differentiate normal and abnormal airway protection during swallowing in healthy and pathologic subjects (Robbins, Coyle, Rosenbek, Roecker, & Woods, 1999) PAS reliability also established for use with FEES (Colodny, 2002) No equivalent scale has been established for use with pediatric patients Previous published research on the PAS scale has been done exclusively with adult populations One study (Gosa et al., 2007) showed reliability of the 8-point Penetration- Aspiration scale for use with a select population of infants and young children. The present study sought to determine if the Penetration-Aspiration Scale could be used reliably in the assessment of infants and children with a broad range of medical diagnoses who also demonstrate dysphagia. Retrospective analysis 25 randomly chosen subjects from archived modified barium swallow studies performed at LeBonheur Children s Hospital between January 2002 and December 2002 Archived studies reviewed by four independent judges blinded to each other s ratings Two judges were students from AUSP at UM Two judges were practicing SLPs at LeBonheur Children s Hospital with at least two years of experience performing and interpreting modified barium swallow studies Subject Characteristics 16 M, 9 F Number of Swallows Per Subject Min, 11 Max, 168 Mean, 43.5 (SD 31.6) Mean Age = 4 years, 2 months Range: 1 week - 16 years Participants Medical History Pulmonary: 44% Neuro: 40% Gastro: 36% Cardiac: 32% Genetic/Craniofacial: 20% Poor Weight Gain: 12% Poor Feeding: 8% Prematurity: 4% 2

3 Frequency of Scale Scores: Most frequently assigned = 1 (3,763, 85.6%) 2 (259, 5.9%) 4 (76, 1.7%) 8 (70, 1.6%) Less frequently assigned = 5, 7 6 was never used Pattern of agreement 4 judges assigned same score to a swallow on both viewings in 4,186 of 4,396 instances (95.22% agreement) Percent agreement between judges first & second ratings: Judge 1: 98.4% (N = 1,081) Judge 2: 93.2% (N = 1,024) Judge 3: 93.4% (N = 1,027) Judge 4: 94.0% (N = 1,033) Overall: 95.2% (N = 4,187) When scores disagreed: Scores differed by 1 in 119/4,396 (2.71%) Scores differed by 2 in 39/4,396 (.89%) Scores differed by 3 in 33/4,396 (.75%) Scores differed by >3 in 19/4,396 (.43%) Intrajudge reliability by scale score Most reliable overall scores Rating of 1 (k =.8195, range ) Rating of 2 (k =.705, range ) Rating of 8 (k=.862, range ) Percent agreement between judge pairs: Judge 1-2: 95.5% (N = 1,049) Judge 3-4: 94.0% (N = 1,033 ) Overall: 89.5% (N = 5,097) 3

4 With disagreement by Judge Pairs: Judges 1-2: Scores differed by 1 in 39/1,099 (3.55%) Scores differed by 2 in 5/1,099 (.45%) Scores differed by 3 in 4/1,099 (.36%) Scores differed by >3 in 2/1,099 (.18%) With disagreement by Judge Pairs: Judges 3-4: Scores differed by 1 in 35/1,099 (3.18%) Scores differed by 2 in 12/1,099 (1.09%) Scores differed by 3 in 10/1,099 (.91%) Scores differed by >3 in 9/1,099 (.82%) Interjudge reliability by scale score Most reliable scores for Judges (k =.879, CI ) 2 (k =.813, CI ) 4 (k =.817, CI ) 8 (k =.977, CI ) Interjudge reliability by scale score Most reliable scores for Judges (k =.741, CI ) 2 (k =.580, CI ) 4 (k =.550, CI ) 8 (k =.739, CI ) Repeated measures ANOVA revealed: No significant judge by judge replicate interaction Significant differences among judges ratings Post Hoc (Pairwise Comparisons) Statistically significant differences (p <.001) between the ratings of Judge 1 & Judges 3 & 4 Statistically significant differences (p<.001) between the ratings of Judge 2 & Judges 3 & 4 Intrajudge Agreement by Judge : Adults Judge N % Overall Judge N % Overall

5 Combined Intra-judge Kappa Coefficient by Scale Score: Adults Mod-Very Good Scale Score Overall Kappa Combined Intra-judge Kappa Coefficient by Scale Score: Peds Mod-Good Scale Score Overall Kappa Interjudge Agreement by Judge Pairs : Adults Judges N % (75) Judges N % (1099) Average Inter-judge Kappa Coefficient by Scale Score: Adults Fair -Very Good Scale Score Kappa Scale Score Kappa There appears to be an experience effect on reliability of ratings Student judges (1-2) had slightly better intrajudge agreement Student judge ratings were significantly different from experienced judge ratings The PAS is an established tool for describing P-A events in the adult population This research project has established acceptable intra & inter judge agreement for the P-A Scale for use within pediatric populations Similar findings to original paper for intra and inter judge reliability of scale scores Use of PAS may provide objective evidence to document improvement in swallowing function over time 5

6 Stratify data by age/developmental level to determine reliability of scale for different ages/ developmental feeding stages Investigate the correlation between PAS scores & the feeding outcomes among infants & children Determine the predictive value of the PAS for pulmonary health in infants & children 6