The Gugging Swallowing Screen (The GUSS Test)

Original Editor - Heba El Saeid

Top Contributors - Heba El Saeid and Lucinda hampton  

Objective[edit | edit source]

To determine the dysphagia severity and the risk of aspiration in acute stroke patients.

Intended Population[edit | edit source]

Acute stroke patients

Method of Use[edit | edit source]

GUSS is divided into 2 parts

  1. Preliminary assessment: indirect swallowing test
  2. Direct swallowing test. Consists of 4 item with 3 subtests (semisolid, liquid and solid) which must be performed sequentially.

Before starting the GUSS screen, the patient should sit in bed in at least a 60° upright position. Because neglect and apraxia can alter the swallowing test, the investigator should ensure that the patient can perceive the tester’s face, the spoon, and the textures in front of him/her.

The evaluation criteria used in the direct swallowing test are as follows, with deglutition, involuntary cough, drooling, and voice change checked in each subtest.

  • In the indirect swallowing test, additional evaluation is performed for vigilance, voluntary coughing, deglutition of saliva, drooling, and voice change.
  • Deglutition is determined by observing an effectual larynx elevation.
  • Voice change, particularly wet and gurgling voice qualities after swallowing or permanent, were found to be reliable parameters for detecting aspiration.
  • Drooling was discussed as a valid item indicating dysphagia. This item was included in the test because it is easy to assess. Larynx elevation has also been discussed as a valid clinical sign of swallowing. However, because of the difficulty in measuring this function during clinical observation and the absence of standard guidelines, we decided not to include it as an evaluation criterion.28
  • A weak or absent voluntary cough and/or throat clearing, as well as spontaneous cough before, during, or after swallowing, are regarded as predictive of aspiration risk.
  • Alertness is indispensable for detecting dysphagia; therefore, patients must be completely awake before bolus testing.
  • Vigilance was determined during the preliminary assessment.[1]

GUSS test form below.

GUSS Part 1, Preliminary Assessment: Indirect Swallowing Test[edit | edit source]

A simple saliva swallow is performed. Patients who are unable to produce enough saliva because of dry mouth are given saliva spray as a substitute. Vigilance, voluntary cough, throat clearing, and saliva swallowing are assessed.


GUSS Part 2: Direct Swallowing Test[edit | edit source]

The direct swallowing test consists of 3 sequentially performed subtests, starting with semisolid, then liquid, and finally solid textures.

Semisolid Swallowing Trial[edit | edit source]

Distilled water (aqua bi) is thickened with an instant food thickener into the consistency of pudding. One-third to one-half teaspoon is offered as a first bolus, followed by 5 more half-teaspoons. The investigator should observe the patient closely after each spoonful. Abort the investigation if 1 of the 4 aspiration signs (deglutition, cough, drooling, and voice change) is positive.


Liquid Swallowing Trial[edit | edit source]

Starting with 3 mL aqua bi in a beaker; the patient should be observed closely while swallowing the first amount. When swallowing is successful, the test is continued with increasing amounts of 5, 10, and 20 mL of aqua bi.15 A 50-mL test is the last task for the patient. The patient should drink the 50 mL as fast as he or she can.


Solid Swallowing Trial[edit | edit source]

A small piece of dry bread is the first bolus at the beginning of this subtest. The test is repeated 5 times. Ten seconds were established as the time limit for a small solid bolus, including the oral preparatory phase.


Reference[edit | edit source]

A point system was chosen in which higher numbers denote better performance, with a maximum of 5 points that can be reached in each subtest. This maximum must be attained to continue to the next subtest. Each tested item is valued as pathologic (0 points) or physiologic (1 point). Within the evaluation criteria for “deglutition” in the direct swallowing test, we used a different rating. Normal deglutition is assigned 2 points, a delayed swallow is assigned 1 point, and pathologic swallowing is assigned 0 points. Patients must complete all repetitions in the subtest to achieve the full score of 5 points. If a subtest results in <5 points, the examination must be stopped and a special oral diet and/or further investigation by videofluoroscopy or fiberoptic endoscopy is recommended. Twenty points are the highest score that a patient can attain, and it denotes normal swallowing ability without aspiration risk.

Reliability[edit | edit source]

the GUSS test was found to be a reliable tool for measuring dysphagia and estimating the risk of aspiration with excellent interrater reliability[6]

Validity[edit | edit source]

the GUSS score was proved to be valid and highly sensitive in detecting dysphagia and risk of aspiration in stroke patients[6]

References[edit | edit source]

  1. AbdelHamid A, Abo-Hasseba A. Application of the GUSS test on adult Egyptian dysphagic patients. The Egyptian Journal of Otolaryngology. 2017 Jan;33(1):103-10.
  2. Shelly Trapl-Grundschober. Gugging Swallowing Screen (GUSS) Preliminary Investigation. Available from:
  3. Shelly Trapl-Grundschober.Gugging Swallowing Screen (GUSS) "semi solids". Available from:
  4. Shelly Trapl-Grundschober.Gugging Swallowing Screen (GUSS) "Liquids". Available from:
  5. Shelly Trapl-Grundschober. Gugging Swallowing Screen (GUSS) "Solids". Available from:
  6. 6.0 6.1 Trapl M, Enderle P, Nowotny M, Teuschl Y, Matz K, Dachenhausen A, Brainin M. Dysphagia bedside screening for acute-stroke patients: the Gugging Swallowing Screen. Stroke. 2007 Nov 1;38(11):2948-52.