Detection of Airway Invasion During Flexible Endoscopic Evaluations of Swallowing: Comparing Barium, Blue Dye, and Green Dye

Abstract

Purpose The aim of this study was to assess the effects of barium, blue dye, and green dye on the frequency and reliability of detecting airway invasion (penetration and aspiration) seen during flexible endoscopic evaluations of swallowing (FEES). Method Thirty patients with neurodegenerative disease and suspected dysphagia underwent an FEES. Patients were presented with 10-cc boluses of water colored with blue dye, green dye, and barium, within the same examination, in a randomized order. Airway protection outcomes were blindly analyzed by a panel of expert raters. Outcomes included the presence of residue on airway structures (epiglottis, laryngeal vestibule, vocal folds, subglottis) and abnormal Penetration–Aspiration Scale (PAS; Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996 ) scores (PAS ≥ 3). Statistical analyses were performed to determine group differences in the frequency of airway residue and abnormal PAS scores, as well as reliability. Results Airway residue was observed most frequently with barium when compared to blue dye ( p < .05) or green dye ( p < .05). Abnormal PAS scores were also observed most frequently with barium when compared to blue dye ( p < .0005) and green dye ( p < .0005). There were no significant differences in the observed frequency of airway residue nor abnormal PAS scores when comparing blue and green dye ( p > .05). Intrapanel reliability scores for airway residue and PAS scores, respectively, were very good ( k = .83) and good ( k = .67) for barium, very good ( k = 1.00) and moderate ( k = .50) for green dye, and moderate ( k = .47) and fair ( k = .33) for blue dye. Conclusion Airway invasion was detected significantly more frequently and with greater reliability with barium when compared to blue and green dye. Given these findings, standardized use of barium is recommended at some point during FEES, especially when attempting to detect subtle signs of airway invasion.