The Gugging Swallowing Screen (GUSS) determines the dysphagia severity and the risk of aspiration in acute-stroke patients. It was created out of a need for a new screening procedure for the assessment of aspiration risk and dysphagia.

Previous swallowing screens had been restricted to water testing procedures, which determine only the risk of aspiration for water but do not give any information on dietary recommendations.

Several studies have shown that acute-stroke patients have more problems swallowing thin liquids (such as water) than semisolid textures (Doggett et al. 2001, Steele et al. 2015).

We therefore developed a stepwise assessment tool to enable a graded rating with separate evaluations for non-fluid and fluid nutrition. The screening tool starts with the use of non-fluid textures as these do not pose as big of a safety challenge for patients.

The GUSS might enable a considerable proportion of acute stroke patients to continue eating semi-solid food while fluids are administered as indicated via intravenous line or nasogastric tube. A renunciation of oral food uptake altogether should be prevented, if possible.

Validated and scientifically investigated criteria such as swallowing not possible/delayed, drooling, cough and voice change were used as risk indicators of aspiration.


Test Construction

Compared to other dysphagia screenings, the test sequence of the GUSS is unique: it starts with saliva swallowing followed by swallowing of semi-solid food and finally fluid and solid textures.

The GUSS consists of 4 subtests and is divided into 2 parts: the preliminary assessment or indirect swallowing test (Subtest 1) and the direct swallowing test, which consists of 3 subtests. These 4 subtests must be performed sequentially.

In the indirect swallowing test: 1. vigilance; 2. voluntary cough and/or throat clearing; 3. saliva swallowing (swallowing, drooling, voice change) are assessed.

The direct swallowing test assesses the deglutition, involuntary cough, drooling and voice change within the semi-solid swallowing, liquid swallowing and solid swallowing trial.


Levels of severity

A maximum of 5 points can be reached in each subtest. This maximum must be attained to continue to the next subtest. Thus twenty points are the highest score that a patient can attain, and it denotes normal swallowing ability without aspiration risk.

In total 4 levels of severity can be determined:

0-9 Points: severe dysphagia and high aspiration risk.

10-14 Points: moderate dysphagia and moderate risk of aspiration

15-19 Points: mild dysphagia with mild aspiration

20 Points: normal swallowing ability

For each level of severity different diet recommendations are given.

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