Dysphagia Knowledge Hub — 吞嚥困難知識庫
GUSS: Gugging Swallowing Screen — Bedside Protocol
Overview
The GUSS (Gugging Swallowing Screen) is a validated bedside screening tool for dysphagia developed by Trapl et al. (2007) at the Gugging Stroke Unit in Austria. Unlike many dysphagia screens that give a binary pass/fail result, the GUSS produces a severity grade (0–20) that directly maps to a dietary texture recommendation, making it immediately actionable at the bedside.
The GUSS is designed for administration by trained nurses or other allied health professionals, without requiring specialist speech-language pathology involvement at the screening stage. This makes it particularly suitable for acute stroke units, where SLT access may be limited and rapid feeding decisions are needed.
Validation Evidence
Trapl et al. (2007) validated the GUSS against fibre-optic endoscopic evaluation of swallowing (FEES) in 50 acute stroke patients:
- Sensitivity for aspiration: 100% (95% CI 62.9–100%)
- Specificity: 50% (95% CI 36.8–63.2%)
- Sensitivity for penetration: 100%
- Negative predictive value: 100% — a normal GUSS reliably rules out aspiration
The high sensitivity with moderate specificity means GUSS is an excellent rule-out tool, though it over-screens (false positives). This is appropriate for patient safety in acute settings.
PMID: 17894481
The Two-Part Protocol
Part 1: Indirect Swallowing Test (Pre-requisite Check)
Before any food or liquid is given, assess the patient’s alertness and baseline swallow function:
| Item | Score |
|---|---|
| Vigilance (alert for ≥15 min) | 1 |
| Voluntary cough or throat clear (sufficient) | 1 |
| Saliva swallow: successful | 1 |
| Saliva swallow: no drooling | 1 |
| Saliva swallow: no voice change | 1 |
| Part 1 maximum | 5 |
If Part 1 score <5: Stop. The patient is not safe to proceed to direct swallowing test. Nil by mouth; refer to SLT urgently.
If Part 1 score = 5: Proceed to Part 2.
Part 2: Direct Swallowing Test
Test three consistency types in sequence: semi-solid, liquid, solid. Each step is only performed if the previous one was passed.
Semi-solid (e.g., thickened water or pudding — test with ½ teaspoon × 3–5 attempts):
- Swallowing possible: 1
- No drooling: 1
- No voice change: 1
- No coughing: 1
- No additional movements (throat clearing, repeated swallows required): 1
- Max: 5
Liquid (water — test with 3 ml × 3 attempts, then 5 ml × 2, then 50 ml if passed): Same 5-item scoring as above.
- Max: 5
Solid (dry bread): Same 5-item scoring.
- Max: 5
Total GUSS score = Part 1 + Part 2 = 0–20
Severity Grading and Dietary Recommendations
| GUSS Score | Severity | Dietary Recommendation |
|---|---|---|
| 20 | Minimal/no dysphagia | Normal diet and thin liquids; follow-up at 24 h |
| 15–19 | Mild dysphagia | Normal diet; thickened liquids (mildly thick); SLT assessment |
| 10–14 | Moderate dysphagia | Pureed diet; moderately thick liquids; SLT assessment |
| 0–9 | Severe dysphagia | Nil by mouth; SLT assessment; consider enteral nutrition |
Administration Tips
- Position: Sitting upright ≥60°, head slightly forward (chin tuck is not imposed but natural positioning is preferred).
- Materials needed: Thickened water or smooth yoghurt (for semi-solid), a measured cup of thin water, a small piece of bread.
- Timing: Part 1 takes 3–5 minutes; Part 2 adds 5–10 minutes if all steps are reached.
- Documentation: Record individual item scores and the total, not just the pass/fail. This allows trend monitoring.
- Repeat screening: Repeat at 24 hours post-admission and whenever clinical status changes (fever, oxygen desaturation, reduced consciousness).
Clinical Integration
Stroke pathway: GUSS is recommended within 4 hours of stroke admission in many European stroke protocols, consistent with ESO (European Stroke Organisation) and NICE guidelines recommending swallowing screen before oral intake.
Non-stroke use: GUSS has been applied in Parkinson’s disease, traumatic brain injury, and general medical wards, though its primary validation is in stroke.
Limitation: GUSS has lower specificity in patients with very mild deficits and may over-restrict diet. In stable patients with mild GUSS scores, SLT clinical swallowing examination (CSE) adds precision.
References
- Trapl M, et al. (2007). Dysphagia bedside screening for acute-stroke patients: the Gugging Swallowing Screen. Stroke, 38(11):2948–52. PMID: 17894481
- Edmiaston J, et al. (2010). Validation of a dysphagia screening tool in acute and sub-acute stroke patients. Am J Crit Care, 19(4):357–64. DOI: 10.4037/ajcc2009961
- Intercollegiate Stroke Working Party (2023). National Clinical Guideline for Stroke, 6th ed. Royal College of Physicians, London.