What is the role of the Gugging Swallowing Screen (GUSS) in assessing dysphagia in stroke patients?

The Gugging Swallowing Screen (GUSS) in Assessing Dysphagia in Stroke Patients

The Gugging Swallowing Screen (GUSS) is a highly reliable and sensitive screening tool for detecting dysphagia in stroke patients, with a sensitivity of 97% and specificity of 67%, making it one of the preferred screening methods for early identification of aspiration risk. 1

What is the GUSS?

The GUSS is a stepwise bedside screening tool specifically designed for stroke patients that:

• Uses a graded assessment approach, starting with non-fluid textures before progressing to fluids 2
• Allows separate evaluations for non-fluid and fluid nutrition 2
• Provides a quantitative score (maximum 20 points) with a cut-off value of 14 points indicating aspiration risk 2, 3
• Minimizes the risk of aspiration during the testing procedure 2
• Recommends specific diet modifications based on the severity of swallowing impairment 2

Clinical Performance of GUSS

The GUSS demonstrates excellent clinical validity:

• Pooled sensitivity of 97% (95% CI: 0.93-0.99) 1
• Specificity of 67% (95% CI: 0.59-0.74) 1
• Negative predictive value of 100% in validation studies 2, 3
• Area under the ROC curve of 0.938, indicating excellent diagnostic accuracy 1

Recent validation studies have confirmed these findings:

• A 2017 revalidation study found 96.5% sensitivity and 55.8% specificity 3
• A 2025 Swedish validation study showed 100% sensitivity and 73% specificity 4

Implementation in Clinical Practice

The GUSS should be administered:

• As soon as the stroke patient is alert and ready for oral intake 5
• Before any oral intake of food, liquid, or medication 6, 5
• Ideally within the first few hours of hospital admission 6, 5
• By trained healthcare professionals, including nurses, speech-language pathologists, or other appropriately trained staff 6, 5

GUSS Testing Procedure

The GUSS follows a sequential assessment approach:

1. Preliminary assessment:

   • Vigilance/alertness evaluation
   • Voluntary cough and throat clearing
   • Saliva swallowing assessment

2. Direct swallowing test:

   • Begins with semisolid textures (safer than liquids)
   • Progresses to liquid textures
   • Concludes with solid textures if previous tests are passed

3. Scoring and interpretation:

   • Total score ranges from 0-20 points
   • Scores ≤14 indicate aspiration risk 2, 3
   • Diet recommendations are provided based on score ranges

Clinical Implications and Benefits

• Early systematic dysphagia screening using GUSS reduces pneumonia rates compared to control groups 1
• The stepwise approach (starting with semisolids rather than liquids) provides greater safety during testing 2
• Allows patients who can safely consume semisolid foods to continue oral feeding while restricting fluids if necessary 2
• Facilitates effective communication between healthcare providers 1

Limitations and Considerations

• GUSS performance varies with stroke severity - higher sensitivity but lower specificity in more severe strokes (NIHSS ≥15) 3
• May overestimate the need for nasogastric tube feeding compared to instrumental assessments 3
• No single screening tool has 100% sensitivity and specificity for detecting aspiration 6, 5
• Clinical bedside assessments including GUSS may miss silent aspiration 5

Follow-up Assessment

• Patients who fail the GUSS screening (score ≤14) should undergo:
  • More comprehensive assessment by a speech-language pathologist 6
  • Instrumental evaluation such as FEES or VFSS/VSS if available 6, 5
• Regular reassessment is necessary throughout recovery as swallowing function may change 5

The GUSS offers a practical, reliable, and validated approach to dysphagia screening in stroke patients, helping to prevent aspiration pneumonia and guide appropriate dietary modifications while minimizing patient discomfort during the assessment process.