The Volume-Viscosity Swallow Test for

Clinical Screening of Dysphagia and

Aspiration
Laia Rofes, Viridiana Arreola and Pere Clavé

Oropharyngeal dysphagia is a major complaint among many patients

with neurological diseases and in the elderly, but is often underdiagnosed
[1]. It is necessary to develop clinical screening methods with high diag-
nostic accuracy to recognize and follow up patients with oropharyngeal
dysphagia, to identify patients who are at risk of aspiration or malnutri-
tion, to identify patients who should be referred for a videofluoroscopy to
assess swallow function and to help select the most appropriate bolus vol-
ume and viscosity for those patients who cannot easily undergo a video-
fluoroscopy [2]. The volume-viscosity swallow test (V-VST) is a bedside
method to screen patients for dysphagia [3].
The V-VST was designed as an effort test to identify clinical signs of
impaired efficacy (efficacy of labial seal, presence of oral or pharyngeal
residue and presence of piecemeal deglutition) and safety (voice changes,
cough and decrease in oxygen saturation ≥3%) of swallow. To protect the
safety of patients, the test starts with nectar viscosity (295 mPa s) and
increasing bolus volumes (from 5 to 10 and 20 ml) in a progression of
increasing difficulty. If patients complete the nectar series without major
symptoms of aspiration, a less safe liquid viscosity (21 mPa s) series is
assessed and, finally, a safer pudding viscosity (3,682 mPa s) series is per-
formed in the same way (fig. 1). If the patient presents signs of impaired
safety at nectar viscosity, the series is interrupted, the liquid series is omit-
ted, and a more safe pudding viscosity series is assessed and, if the patient
presented signs of impaired safety at liquid viscosity, the liquid series is
interrupted and the pudding series is assessed. Two extra viscosities (con-
servative spoon-thick 1,098 mPa s consistency, and honey 766 mPa s) can
be added to the end of the algorithm of the V-VST to evaluate the mini-
mum amount of thickener needed to allow a safe and effective swallow.
The V-VST is a quick (it takes 5–10 min to complete), safe and accu-
rate screening procedure for dysphagia in hospitalized and independently

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 SAFE SWALLOW IMPAIRED SAFETY AT IMPAIRED SAFETY AT
NECTAR LIQUID
START START START
Bolus N/volume Bolus N/volume Bolus N/volume
5 ml 5 ml 5 ml
1 1 1
NECTAR

SAFE SAFE IMPAIRED SAFE

10 ml 10 ml 10 ml
SWALLOW 2 SWALLOW 2 SAFETY SWALLOW 2
20 ml 20 ml
3 3

5 ml 5 ml
4 4
LIQUID

SAFE SAFE 10 ml
IMPAIRED
10 ml
SWALLOW 5 SWALLOW 5 SAFETY
20 ml
6
PUDDING

5 ml 5 ml 5 ml
7 3 6
SAFE SAFE SAFE
10 ml 10 ml 10 ml
SWALLOW 8 SWALLOW 4 SWALLOW 7
20 ml 20 ml 20 ml
9 5 8

END EXPLORATION END EXPLORATION END EXPLORATION

Fig. 1. V-VST short algorithm. Left diagram: patients with safe swallow com-
pleted the pathway. Middle diagram: representative pathway for patients with
impaired safety at 10 ml nectar. Right diagram: representative pathway for patients
with impaired safety at 10 ml liquid.

living patients with multiple etiologies, and improves the management of

dysphagic patients. The V-VST presents a sensitivity of 88.2% and a speci-
ficity of 64.7% to detect clinical signs of impaired safety of swallow (aspi-
ration or penetration) and a sensitivity of 100% in recognizing patients
with aspiration, subsequently confirmed by videofluoroscopy. By means
of the V-VST, signs of oropharyngeal dysphagia were detected in 27.2%
of independently living older persons [4] and 61.2% of acute poststroke
patients [5].
The V-VST combines good psychometric properties, feasibility, a
detailed and easy-to-perform protocol, an algorithm designed to protect
the safety of patients, validated end points to evaluate safety and effi-
cacy of swallowing and a system to detect silent aspirations. The V-VST
detects patients who need a full diagnostic study and changes in diet –
including recommendation of viscosity adaptation of fluids by thicken-
ers – when videofluoroscopic examination is not possible. Therefore, we
believe that the V-VST is an excellent clinical tool to screen patients for
dysphagia.

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 References
1 Cook IJ, Kahrilas PJ: AGA technical review on management of oropharyngeal dys-
phagia. Gastroenterology 1999;116:455–478.
2 Connolly MJ: Of proverbs and prevention: aspiration and its consequences in older
patients. Age Ageing 2010;39:2–4.
3 Clave P, Arreola V, Romea M, et al: Accuracy of the volume-viscosity swallow
test for clinical screening of oropharyngeal dysphagia and aspiration. Clin Nutr
2008;27:806–815.
4 Serra-Prat M, Hinojosa G, Lopez D, et al: Prevalence of oropharyngeal dysphagia and
impaired safety and efficacy of swallow in independently living older persons. J Am
Geriatr Soc 2011;59:186–187.
5 Sebastián ML, Palomeras E, Clave P, et al: La disfágia en el ictus agudo: actuaciones
de Enfermeria. Rev Cient Soc Esp Enferm Neurol 2009;29:8–11.

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