Screening Test for Silent Aspiration at the Bedside

Periventricular White Matter Lesions as a Prognostic Factor of Swallowing Function in Older Patients with Mild Stroke

Older patients with stroke have poor functional prognosis compared to younger patients. Patients with stroke who have severe white matter (WM) lesions have been reported to have poor functional prognosis such as cognitive dysfunction, increased propensity for falling, and gait and balance problems. The aim of this study was to determine whether WM lesions exert negative effects on swallowing function in older patients with mild stroke. We conducted a retrospective analysis of 63 patients aged >65 years who had a National Institutes of Health Stroke Scale score ≤5 and who underwent videofluoroscopic swallowing examination after their first stroke. Linear regression analysis showed that oral transit time tended to increase as Fazekas grade increased (p = 0.003). In addition, inadequate mastication was related to the presence of lesions in the left hemisphere (p = 0.039). The presence of penetration could also be predicted by Fazekas grade (p = 0.015). Our findings suggest that WM lesions observed in brain magnetic resonance imaging scans can impact swallowing problems in older patients with mild stroke, regardless of initial stroke severity or other factors associated with lesion location. Accordingly, our data indicate that WM lesions are a predictive factor by which patients can be stratified into favorable or unfavorable outcomes with respect to dysphagia.

Cough reflex attenuation and swallowing dysfunction in sub-acute post-stroke patients: prevalence, risk factors, and clinical outcome

BACKGROUND

Cough and swallowing impairments in post-stroke patients (PSP) have been associated with increased risk for respiratory complications.

AIMS

To assess the prevalence of alterations in protective cough responses in subacute PSP and its association with oropharyngeal dysphagia (OD), clinical, and neurotopographic stroke factors and clinical outcomes.

METHODS

Three months after stroke, the cough reflex test (CRT) was performed by nebulizing incremental citric acid concentrations (7.8-1000 mmol L^-1 ) to determine the concentration that elicited two and five coughs; OD was assessed by the volume-viscosity swallow test. Clinical and neurotopographic stroke risk factors and complications (readmissions, respiratory infections, institutionalization, and mortality) were recorded from 3 to 12 months post-stroke.

RESULTS

We included 225 PSP. Prevalence of impaired CRT was 5.8%, that of OD was 40.4% (20.4% with impaired safety of swallow), and of both impairments was, 1.8%. No specific risk factors associated with impaired CRT were found; however, hemorrhagic, wide circulation infarction (TACI), and brainstem strokes delayed the cough response. OD was associated with age, TACI and poor functional and nutritional status. Outcome of PSPs was unaffected by impaired CRT but OD and impaired safety of swallow increased institutionalization, respiratory infections, and mortality with the poorest outcome for those with both impairments.

CONCLUSIONS

Prevalence of subacute post-stroke OD and swallow safety impairments was much higher than CRT attenuation, and risk factors strongly differed suggesting that the swallow response receives a stronger cortical control than the cough reflex. OD has a greater impact on PSP clinical outcome than impaired cough, the poorest prognosis being for patients with both airway protective dysfunctions.

Screening Accuracy for Aspiration Using Bedside Water Swallow Tests: A Systematic Review and Meta-Analysis

BACKGROUND

Hospitalizations for aspiration pneumonia have doubled among older adults. Using a bedside water swallow test (WST) to screen for swallowing-related aspiration can be efficient and cost-effective for preventing additional comorbidities and mortality. We evaluated screening accuracy of bedside WSTs used to identify patients at risk for dysphagia-associated aspiration.

METHODS

Sixteen online databases, Google Scholar, and known content experts through May 2015 were searched. Only prospective studies with patients ≥ 18 years of age given WST screenings validated against nasoendoscopy or videofluoroscopy were included. Data extraction used dual masked extraction and quality assessment following Meta-analysis of Observational Studies in Epidemiology guidelines.

RESULTS

Airway response (eg, coughing/choking) with or without voice changes (eg, wet/gurgly voice quality) was used to identify aspiration during three different bedside WSTs. Pooled estimates for single sip volumes (1-5 mL) were 71% sensitive (95% CI, 63%-78%) and 90% specific (95% CI, 86%-93%). Consecutive sips of 90 to 100 mL trials were 91% sensitive (95% CI, 89%-93%) and 53% specific (95% CI, 51%-55%). Trials of progressively increasing volumes of water were 86% sensitive (95% CI, 76%-93%) and 65% specific (95% CI, 57%-73%). Airway response with voice change improved overall accuracy in identifying aspiration.

CONCLUSIONS

Currently used bedside WSTs offer sufficient, although not ideal, utility in screening for aspiration. Consecutive sips with large volumes in patients who did not present with overt airway responses or voice changes appropriately ruled out risk of aspiration. Small volumes with single sips appropriately ruled in aspiration when clinical signs were present. Combining these bedside approaches may offer improved screening accuracy, but further research is warranted.

Comparison of cough reflex testing with videoendoscopy in recently extubated intensive care unit patients

PURPOSE

Orotracheal intubation is known to impair cough reflex, but the validity of cough reflex testing (CRT) as a screening tool for silent aspiration in this population is unknown.

MATERIAL AND METHODS

One hundred and six participants in a tertiary-level intensive care unit (ICU) underwent CRT and videoendoscopic evaluation of swallowing (VES) within 24 hours of extubation. Cough reflex threshold was established for each participant using nebulized citric acid.

RESULTS

Thirty-nine (37%) participants had an absent cough to CRT. Thirteen (12%) participants aspirated on VES, 9 (69%) without a cough response. Sensitivity of CRT to identify silent aspiration was excellent, but specificity was poor. There was a significant correlation between intubation duration and presence of aspiration on VES (P= .0107). There was no significant correlation between silent aspiration on VES and length of intubation, age, sex, diagnosis at intensive care unit admission, indication for intubation, Acute Physiology and Chronic Health Evaluation III score, morphine equivalent dose, or time of testing postextubation.

CONCLUSIONS

Intensive care unit patients are at increased risk of aspiration in the 24 hours following extubation, and an impaired cough reflex is common. However, CRT overidentifies risk of silent aspiration in this population.

Development of the Brief Bedside Dysphagia Screening Test - Revised: a Cross-Sectional Czech Study

AIM

The purpose of this study was to develop a revised version of the Brief Bedside Dysphagia Screening Test for determining penetration/aspiration risk in patients prone to dysphagia. The priority was to achieve high sensitivity and negative predictive value.

METHODS

The study screeners conducted bedside assessment of the swallowing function in 157 patients with a neurological (mainly stroke) or an ear, nose, and throat diagnosis (mainly head and neck cancer). The results were compared with a gold standard, flexible endoscopic examination of swallowing.

RESULTS

For the neurological subgroup (N = 106), eight statistically significant bedside assessment items were combined into the Brief Bedside Dysphagia Screening Test-Revised (BBDST-R). Cut-off score 1 produced the highest sensitivity (95.5%; 95% confidence interval CI [CI]: 84.9-98.7%) and negative predictive value (88.9%; 95% CI 67.2-96.9%).

CONCLUSION

The BBDST-R is suitable for dysphagia screening in departments caring for patients with neurological conditions.

An examination of factors related to aspiration and silent aspiration in older adults requiring long-term care in rural Japan

Swallowing disorders are a growing problem among the elderly in long-term care (LTC), and they can cause aspiration pneumonia. In order to detect swallowing disorders early, simple tools are needed to assess aspiration and silent aspiration (SA). To compile a sample of elderly people requiring LTC, and categorise them as having suspected aspiration and/or SA using simple screening tools. In addition, oral ability, severity of dementia, vital functions and nutritional status were compared in these groups. A total of 393 elderly people in LTC (89 men and 304 women; age ranging from 65 to 100 years) were included in the study. The modified water swallow test, cervical auscultation and cough test were used to assess swallowing function. The participants were categorised as having suspected aspiration and/or SA, and the following assessments were performed: (i) oral ability (lips function, tongue function, rinsing and gargling ability), (ii) dementia severity, (iii) vital functions and (iv) nutritional status. Suspected aspiration was apparent in 50.5% of patients, of which 24.0% had suspected SA. Those with suspected aspiration showed worsened oral ability, dementia severity, vital functions and nutritional status. Similarly, those with suspected SA showed worsened dementia severity, vital functions and nutritional status. Logistic regression analysis revealed that lip closure, lingual movement and rinsing ability were significantly associated with suspected aspiration. Dementia severity was the best predictor of suspected SA. Simple screening tools can be used to identify suspected aspiration and SA, which may facilitate early detection of aspiration pneumonia or swallowing disorder risk.

A Targeted Swallow Screen for the Detection of Postoperative Dysphagia

Postoperative dysphagia leads to aspiration pneumonia, prolonged hospital stay, and is associated with increased mortality. A simple and sensitive screening test to identify patients requiring objective dysphagia evaluation is presently lacking. In this study, we evaluated the efficacy of a novel targeted swallow screen evaluation. This was a prospective trial involving all adult patients who underwent elective cardiac surgery with cardiopulmonary bypass at our institution over an 8-week period. Within 24 hours of extubation and before the initiation of oral intake, all postsurgical patients were evaluated using the targeted swallow screen. A fiberoptic endoscopic evaluation of swallowing was requested for failed screenings. During the study, 50 postcardiac surgery patients were screened. Fifteen (30%) failed the targeted swallow screen, and ten of the fifteen (66%) failed the subsequent fiberoptic endoscopic evaluation of swallowing exam and were confirmed to have dysphagia. The screening test had 100 per cent sensitivity for detecting dysphagia in our patient population, and a specificity of 87.5 per cent. The overall incidence of dysphagia was 20 per cent. We have shown that a targeted swallow evaluation can efficiently screen patients during the postcardiac surgery period. Furthermore, we have shown that the true incidence of dysphagia after cardiac surgery is significantly higher than previously recognized in literature.

Bedside diagnosis of dysphagia: a systematic review

Dysphagia is associated with aspiration, pneumonia, and malnutrition, but remains challenging to identify at the bedside. A variety of exam protocols and maneuvers are commonly used, but the efficacy of these maneuvers is highly variable. We conducted a comprehensive search of 7 databases, including MEDLINE, Embase, and Scopus, from each database's earliest inception through June 9, 2014. Studies reporting diagnostic performance of a bedside examination maneuver compared to a reference gold standard (videofluoroscopic swallow study or flexible endoscopic evaluation of swallowing with sensory testing) were included for analysis. From each study, data were abstracted based on the type of diagnostic method and reference standard study population and inclusion/exclusion characteristics, design, and prediction of aspiration. The search strategy identified 38 articles meeting inclusion criteria. Overall, most bedside examinations lacked sufficient sensitivity to be used for screening purposes across all patient populations examined. Individual studies found dysphonia assessments, abnormal pharyngeal sensation assessments, dual axis accelerometry, and 1 description of water swallow testing to be sensitive tools, but none were reported as consistently sensitive. A preponderance of identified studies was in poststroke adults, limiting the generalizability of results. No bedside screening protocol has been shown to provide adequate predictive value for presence of aspiration. Several individual exam maneuvers demonstrated reasonable sensitivity, but reproducibility and consistency of these protocols was not established. More research is needed to design an optimal protocol for dysphagia detection.

Afferent nerve ending density in the human laryngeal mucosa: potential implications on endoscopic evaluation of laryngeal sensitivity

Laryngeal sensitivity is crucial for maintaining safe swallowing, thus avoiding silent aspiration. The sensitivity test, carried out by fiberoptic endoscopic examination of swallowing, plays an important role in the assessment of dysphagic patients. The ventricular folds appear to be more sensitive than the epiglottis during the sensitivity test. Therefore, this study aimed to investigate the mechanical sensitivity of the supraglottic larynx. In seven healthy adults undergoing microlaryngoscopy to remove vocal cord polyps, we excised mucosal samples from the epiglottis and ventricular folds. We measured afferent nerve fiber density by immunoelectron microscopy. All of the subjects underwent an endoscopic sensitivity test based on lightly touching the laryngeal surface of the epiglottis and ventricular folds. The discomfort level was self-rated by the subjects on the visual analog scale. Samples were fixed and stored in cryoprotectant solution at 4 °C. Sections were stained with the protein gene product 9.5, a pan-neuronal selective marker. Nerve fiber density was calculated as the number of fibers per millimeter length of section. The mean nerve fiber density was higher in ventricular samples than in epiglottis samples (2.96 ± 2.05 vs 0.83 ± 0.51; two-sided p = 0.018). The mean visual analog scale scores were significantly higher for touching the ventricular folds than for touching the epiglottis (8.28 ± 1.11 vs 4.14 ± 1.21; two-sided p = 0.017). The higher sensitivity of the ventricular region should be considered for further refining clinical endoscopic evaluation of laryngeal sensitivity.

Usefulness of the simplified cough test in evaluating cough reflex sensitivity as a screening test for silent aspiration

Objective

To assess cough reflex sensitivity using the simplified cough test (SCT) and to evaluate the usefulness of SCT to screen for silent aspiration.

Methods

The healthy control group was divided into two subgroups: the young (n=29, 33.44±9.99 years) and the elderly (n=30, 63.66±4.37 years). The dysphagic elderly group (n=101, 72.95±9.19 years) consisted of patients with dysphagia, who suffered from a disease involving central nervous system (ischemic stroke 47, intracerebral hemorrhage 27, traumatic brain injury 11, encephalitis 5, hypoxic brain damage 3, and Parkinson disease 8). The SCT was performed using the mist of a 1% citric acid from a portable nebulizer. The time from the start of the inhalation to the first cough was measured as the cough latency. All the dysphagic patients underwent the videofluoroscopic swallowing study.

Results

The cough latency was more significantly prolonged in the healthy elderly group than in the healthy young group (p<0.001), and in the dysphagic elderly group than in the healthy elderly group (p<0.001). The sensitivity and specificity of SCT were 73.8% and 72.5% for detecting aspiration in the dysphagic patients, and 87.1% and 66.7% for detecting silent aspiration in the aspirated patients.

Conclusion

Cough latency measured with the SCT reflects the impairment of cough reflex in healthy elderly and dysphasic subjects. The results of this study show that the SCT test can be a valuable method of screening aspiration with or without cough in dysphasic patients.

The prognosis of dysphagia patients over 100 years old

Several reports have recently been published regarding dysphagia in very elderly patients, and centenarian dysphagia patients have become more common in Japan. The aim of this study was to assess the prognosis of dysphagia in very elderly patients. Participants were 24 centenarian dysphagia patients. For each patient, we collected information on age, care level, past medical history, and changes in oral intake according to the Functional Oral Intake Scale (FOIS). Patients were divided into two groups based on the mode of food intake at the time of transfer or discharge: the per oral-only group (the PO-only group, i.e., oral intake alone) and the tube feeding-dependent group (the TF-dependent group, i.e., combination of oral intake and tube feeding, or tube feeding alone). In both groups, the FOIS score decreased significantly from pre-hospitalization to the time of transfer or discharge (p=0.006 for both). The FOIS score at initial assessment was higher in the PO-only group with the TF-dependent group (p=0.0004). Furthermore, the frequency of a FOIS score of 4 at initial assessment was significantly higher in the PO-only group, and the frequency of a FOIS score of 1 was significantly higher in the TF-dependent group (p=0.0006). These findings collectively suggest that oral intake can be recovered if the FOIS score is ≥ 4 at initial assessment, is difficult if the score is 1, and may be possible with a FOIS score of 2.

Effects of professional oral health care on elderly: randomized trial

OBJECTIVE

To better understand the role of the professional oral health care for elderly in improving geriatric oral health, the effects of short-term professional oral health care (once per week for 1 month) on oral microbiological parameters were assessed.

METHODS

Parallel, open-labelled, randomize-controlled trial was undertaken in a nursing home for elderly in Shizuoka, Japan. Thirty-four dentate elderly over 74 years were randomly assigned from ID number to the intervention (17/34) and control (17/34) groups. The outcomes were changes in oral microbiological parameters (number of bacteria in unstimulated saliva; whole bacteria, Streptococcus, Fusobacterium and Prevotella: opportunistic pathogens detection: and index of oral hygiene evaluation [Dental Plaque Index, DPI]) within the intervention period. Each parameter was evaluated at before and after intervention period. Four elderly were lost from mortality (1), bone fracture (1), refused to participate (1) and multi-antibiotics usage (1). Finally, 30 elderly were analysed (14/intervention and 16/control).

RESULTS

At baseline, no difference was found between the control and intervention groups. After the intervention period, the percentage of Streptococcus species increased significantly in the intervention group (Intervention, 86% [12/14]; Control, 50% [8/16]: Fisher's, right-tailed, P < 0.05). Moreover, DPI significantly improved in the intervention group (Intervention, 57% [8/14]; Control, 13% [2/16]: Fisher's, two-tailed, P < 0.05). The improvement in DPI extended for 3 months after intervention. None of side effects were reported.

CONCLUSION

The short-term professional oral health care can improve oral conditions in the elderly.

Dysphagia Rehabilitation: Similarities and Differences in Three Areas of the World

Although the goal of dysphagia rehabilitation is the same, population needs, clinical practice patterns, availability of resources, and dysphagia research varies greatly around the world. The goal of this review is to introduce the reader to the context in which dysphagia rehabilitation is practiced, to describe practice patterns, and to highlight the dysphagia research being performed in three distinct regions of the world: North America, New Zealand and Australia, and Japan.

Oropharyngeal dysphagia: screening and assessment

This article provides an overview of bedside screening and assessment tools in patients with oropharyngeal dysphagia including the diagnostic performance of screening tools; the gold standards in assessment of dysphagia (videofluoroscopic and fiberoptic endoscopic evaluation of swallowing); a variety of clinical assessment tools; patient self-evaluation questionnaires; and a list of supplementary methods. In addition, some methodologic issues are discussed, and the need for standardization of terminology, screening and assessment protocols, and the call for evidence-based clinical guidelines.

Cough reflex testing in Dysphagia following stroke: a randomized controlled trial

BACKGROUND

Significant health issues and service delivery costs are associated with post-stroke pneumonia related to dysphagia. Silent aspiration is known to increase pneumonia and mortality in this population. The utility of cough reflex testing (CRT) for reducing pneumonia in acute stroke patients was the subject of this randomised, controlled trial.

METHODS

Patients referred for swallowing evaluation (N = 311) were assigned to either 1) a control group receiving standard evaluation or 2) an experimental group receiving standard evaluation with CRT. Participants in the experimental group were administered nebulised citric acid with test results contributing to clinical decisions. Outcomes for both groups were measured by pneumonia rates at 3 months post evaluation and other clinical indices of swallowing management.

RESULTS

Analysis of the data identified no significant differences between groups in pneumonia rate (P = 0.38) or mortality (P = 0.15). Results of CRT were shown to influence diet recommendations (P < 0.0001) and referrals for instrumental assessment (P < 0.0001).

CONCLUSIONS

Despite differences in clinical management between groups, the end goal of reducing pneumonia in post stroke dysphagia was not achieved.

Swallowing dysfunction in head and neck cancer patients treated by radiotherapy: review and recommendations of the supportive task group of the Italian Association of Radiation Oncology

PURPOSE

Dysphagia is a debilitating complication in head and neck cancer patients (HNCPs) that may cause a high mortality rate for aspiration pneumonia. The aims of this paper were to summarize the normal swallowing mechanism focusing on its anatomo-physiology, to review the relevant literature in order to identify the main causes of dysphagia in HNCPs and to develop recommendations to be adopted for radiation oncology patients. The chemotherapy and surgery considerations on this topic were reported in recommendations only when they were supposed to increase the adverse effects of radiotherapy on dysphagia.

MATERIALS AND METHODS

The review of literature was focused on studies reporting dysphagia as a pre-treatment evaluation and as cancer and cancer therapy related side-effects, respectively. Relevant literature through the primary literature search and by articles identified in references was considered. The members of the group discussed the results and elaborated recommendations according to the Oxford CRBM levels of evidence and recommendations. The recommendations were revised by external Radiation Oncology, Ear Nose and Throat (ENT), Medical Oncology and Speech Language Pathology (SLP) experts.

RESULTS

Recommendations on pre-treatment assessment and on patients submitted to radiotherapy were given. The effects of concurrent therapies (i.e. surgery or chemotherapy) were taken into account.

CONCLUSIONS

In HNCPs treatment, disease control has to be considered in tandem with functional impact on swallowing function. SLPs should be included in a multidisciplinary approach to head and neck cancer.

A instituição asilar como fator potencializador da disfagia

OBJETIVO: verificar se as condições referentes à estrutura geral dos asilos, recursos humanos e rotinas diárias de alimentação em instituições asilares, podem potencializar alterações da dinâmica da deglutição em idosos. MÉTODOS: foi aplicado questionário aos dirigentes de cinco instituições asilares do município do Rio de Janeiro, no qual constavam perguntas em relação aos recursos materiais, humanos e rotina alimentar. RESULTADOS: o asilo do sistema privado foi o único a aproximar-se das condições ideais da estrutura geral para o atendimento do idoso. Em relação aos recursos humanos existentes, nenhum dos asilos possuía todos os profissionais exigidos pela portaria nº810/89. Em relação às rotinas diárias de alimentação, em uma das instituições pesquisadas, cuja maioria dos residentes não faziam uso de próteses dentárias, não havia restrição na consistência alimentar oferecida. Outro fator significativo diz respeito à negligência referente à higiene bucal, favorecendo a colonização de bactérias na cavidade oral, podendo agravar infecções pulmonares no caso de microaspirações. O fato dos idosos deitarem para dormir logo após o término das refeições, como ocorrido em três das instituições pesquisadas, tem grande importância na medida em que favorece a ocorrência de episódios de refluxo gastroesofágico. CONCLUSÃO: foram observados que em todas as instituições pesquisadas há fatores que podem potencializar um distúrbio de deglutição, como problemas em relação à estrutura geral e ou aos recursos humanos e ou relativos à rotina alimentar estabelecida.

Silent aspiration risk is volume-dependent

Clinical swallow protocols cannot detect silent aspiration due to absence of overt behavioral signs, but screening with a much larger bolus volume, i.e., 90 cc vs. 1-10 cc, may elicit a reflexive cough in individuals who might otherwise exhibit silent aspiration. A swallow screen that maintains high sensitivity to identify aspiration risk while simultaneously reducing the false-negative rate for silent aspiration would be beneficial. The purpose of this study was to investigate whether silent aspiration risk was volume-dependent by using a 3-oz. (90-cc) water swallow challenge to elicit a reflexive cough when silent aspiration occurred on smaller bolus volumes. A prospective, consecutive, referral-based sample of 4102 inpatients from the acute-care setting of a large urban tertiary-care teaching hospital participated. Silent aspiration was determined first by fiberoptic endoscopy and then each participant was instructed to drink 3 oz. of water completely and without interruption. Criteria for challenge failure were inability to drink the entire amount, stopping and starting, or coughing and choking during or immediately after completion. Improved identification of aspiration risk status occurred for 58% of participants who exhibited silent aspiration on smaller volumes, i.e., an additional 48% of liquid silent aspirators and 65.6% of puree silent aspirators coughed when attempting the 3-oz. water swallow challenge. A low false-negative rate was observed for the entire population sample, i.e., ≤2.0%. A combined false-negative rate for participants who silently aspirated was 6.9%, i.e., 7.8% if silently aspirated liquid and 6.1% if silently aspirated puree consistency. Determination of silent aspiration risk was shown to be volume-dependent, with a larger volume eliciting a reflexive cough in individuals who previously silently aspirated on smaller volumes. A 3-oz. water swallow challenge's previously reported high sensitivity for identification of aspiration risk combined with the newly reported low false-negative rate mitigates the issue of silent aspiration risk during clinical swallow screening.