01/23/2026
Swallow safety is a pattern, not a single event.
Itâs tempting to let one dramatic moment during an instrumental define our clinical judgment. But the evidence consistently shows that airway invasion is variable, bolus-dependent, and often inconsistent across repeated swallows.
Research demonstrates that pe*******on and aspiration may appear on some thin liquid trials and not others, even within the same exam. New airway invasion continues to emerge across multiple boluses, which means a single swallow does not reliably represent true swallowing risk.
This is exactly why modern interpretation frameworks emphasize patterns:
⢠frequency of airway invasion
⢠severity across boluses
⢠consistency effects
⢠and interaction with pharyngeal efficiency
DIGEST v2 was updated to reflect this reality. Rather than automatically labeling isolated events as âmild dysphagia,â the revised criteria better align grading with clinical decision-making, recognizing that:
⢠a single event may not represent impairment
⢠isolated severe events must be interpreted in the context of the full bolus series
At the same time, we must remember that swallow safety and swallow efficiency are separate constructs. A swallow can be safe but inefficient (residue risk), or efficient but unsafe (airway risk). Both matter, and neither should be reduced to a single frame.
Clinical takeaway:
If youâre only giving 1â2 thin liquid trials, youâre likely under-sampling the system. Multiple boluses arenât redundant, theyâre diagnostic.
References:
đ Hutcheson KA et al. Refining measurement of swallowing safety in the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) criteria: Validation of DIGEST v2. Cancer, 2022.
đ Steele CM et al. Development of a non-invasive device for swallow screening in patients at risk of oropharyngeal dysphagia. Dysphagia, 2019
