The Airway Protection Scale (APS) is a 5-point scoring scale developed by SASS clinicians specifically for scoring larynx airway protection during a swallowing event using FEES.  The basic premise for this scale was modeled after the scale used by Dziewas et al., 2008 in BMC Neurology. However, the APS incorporates the biomechanical actions of the larynx vestibule closing and collapsing during swallowing as a normal protective function, in addition to deeper vocal fold closure.  The APS is an nominal scale of much like the Penetration-Aspiration Scale used with MBS.

APS Reliability:

A pilot study using 25 randomized video files from actual FEES studies were independently scored by 5 experienced FEES clinicians using the APS scale to determine inter-rater reliability. Using the Kappa statistic for inter-rater agreement, the inter-rater reliability of the ASP scale was K = .910 (95% CL, .881 to .939; p<.0005). 0.81 - 1.00 is considered almost perfect agreement. (Ward & Johnson, 2022, manuscript.)

Airway Protection Scale (APS)©

1 – AIRWAY PROTECTED BY PRIMARY LARYNX REFLEX CLOSURE, SEAL, AND SQUEEZE.

2 – MATERIAL ENTERS THE LARYNGEAL VESTIBULE BUT IS CLEARED OUT BY A REFLEXIVE RESPONSE.

 Examples of reflexive clearing responses: (a) the initial motion of laryngeal closure and squeeze , (b)an immediate secondary swallow,  or (c) a cough or throat clear.

3 – MATERIAL ENTERS THE LARYNGEAL VESTIBULE BUT IS NOT CLEARED OUT BY A REFLEXIVE RESPONSE.

4 – MATERIAL PASSES BELOW THE PLANE OF THE TRUE VOCAL FOLDS INTO THE TRACHEA STIMULATING A REFLEXIVE RESPONSE SUCCESSIVELY CLEARING THE ASPIRATED MATERIAL FROM THE TRACHEAL AIRWAY.

Examples of reflexive responses: (a) a reflexive cough or throat clear, (b) passive pressure changes such as exhalation, talking, sneezing, etc.

5 – MATERIAL PASSES BELOW THE PLANE OF THE TRUE VOCAL FOLDS INTO THE TRACHEA STIMULATING A REFLEXIVE RESPONSE THAT DOES NOT CLEAR THE ASPIRATED MATERIAL FROM THE TRACHEAL AIRWAY, OR DOES NOT STIMULATE A PROTECTIVE REFLEX COUGH RESPONSE.

Diacritical markings may be added to improve the sensitivity of the scale:

“T” = very small, trace or droplet amounts entering either the laryngeal vestibule as penetrated material or aspirated into the trachea.  Examples:  3T  or 5T

“S” = Significant amounts of material entering the laryngeal vestibule as penetrated material, or aspirated into the trachea.  Examples:  2S  or 5S

“H” = High penetration – Material entering over the laryngeal rim and courses down but does not reach the superior surfaces of the ventricular folds.  Example: 3HT

“D” = Deep penetration -Material entering over the laryngeal rim and courses down reaching the superior surfaces of the ventricular folds and even to the superior surfaces of the true vocal folds, but not aspirated.

References:

Ashford, J. R., Ward, M. G., & Skelley, M. L. (in progress). Airway Protection Scale for FEES.

Butler, S. G., Markley, L., Sanders, B., & Stuart, A. (2015). Reliability of the penetration aspiration with flexible endoscopic evaluation of swallowing. Annals of Otology, Rhinology & Laryngology, 124 (6), 480-483. doi: 10.1177/0003489414566267

Colodny, N. (2002). Interjudge and intrajudge reliabilities in Fiberoptic Endoscopic Evaluation of Swallowing (FEES®) using the penetration-aspiration scale: a replication study. Dysphagia, 17,  308-315. doi:org/10.1007/s00455-002-0073-4

Dziewas, R., Warnecke, T., Hamacher, C., Oelenberg, S. Teismann, I. Kraemer, C., . . . Schaebitz, W. R. (2008). Do nasogastric tubes worsen dysphagia in patients with acute stroke? BMC Neurology, 8, 28-35. doi: 10. 1186/1471-237708-28

Hey, C., Pluschinski, P., Pajunk, R. et al. (2015). Penetration–Aspiration: Is Their Detection in FEES® Reliable Without Video Recording?. Dysphagia, 30, 418–422. doi.org/10.1007/s00455-015-9616-3

Holman, S.D., Campbell-Malone, R., Ding, P. et al. (2013). Development, reliability, and validation of an infant mammalian penetration–aspiration scale. Dysphagia, 28, 178–187 doi.org/10.1007/s00455-012-9427-8

Ludlow, C. L. (2015). Laryngeal reflexes: Physiology, technique and clinical use. Journal of Clinical Neurophysiology, 32(4), 284-293. doi: 10.1097/WNP.0000000000000187

Rosenbek, J. C., Robbins, J. A., Roecker, E. B., Coyle, J. L., & Wood, J. L. (1996). A penetration-aspiration scale. Dysphagia, 11, 93-98.

©2023. Swallowing Services, PLLC. This scale may be used for clinical purposes only without written permission. Use for presentations, publications, video/audio, internet communication or demonstration, or research is not permitted without the written consent of SA Swallowing Services.