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Shu K, Perera S, Mahoney AS, Mao S, Coyle JL, Sejdić E. Temporal Sequence of Laryngeal Vestibule Closure and Reopening is Associated With Airway Protection. Laryngoscope 2023; 133:521-527. [PMID: 35657100 PMCID: PMC9718890 DOI: 10.1002/lary.30222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/05/2022] [Accepted: 05/11/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Upper esophageal sphincter opening (UESO), and laryngeal vestibule closure (LVC) are two essential kinematic events whose timings are crucial for adequate bolus clearance and airway protection during swallowing. Their temporal characteristics can be quantified through time-consuming analysis of videofluoroscopic swallow studies (VFSS). OBJECTIVES We sought to establish a model to predict the odds of penetration or aspiration during swallowing based on 15 temporal factors of UES and laryngeal vestibule kinematics. METHODS Manual temporal measurements and ratings of penetration and aspiration were conducted on a videofluoroscopic dataset of 408 swallows from 99 patients. A generalized estimating equation model was deployed to analyze association between individual factors and the risk of penetration or aspiration. RESULTS The results indicated that the latencies of laryngeal vestibular events and the time lapse between UESO onset and LVC were highly related to penetration or aspiration. The predictive model incorporating patient demographics and bolus presentation showed that delayed LVC by 0.1 s or delayed LVO by 1% of the swallow duration (average 0.018 s) was associated with a 17.19% and 2.68% increase in odds of airway invasion, respectively. CONCLUSION This predictive model provides insight into kinematic factors that underscore the interaction between the intricate timing of laryngeal kinematics and airway protection. Recent investigation in automatic noninvasive or videofluoroscopic detection of laryngeal kinematics would provide clinicians access to objective measurements not commonly quantified in VFSS. Consequently, the temporal and sequential understanding of these kinematics may interpret such measurements to an estimation of the risk of aspiration or penetration which would give rise to rapid computer-assisted dysphagia diagnosis. LEVEL OF EVIDENCE 2 Laryngoscope, 133:521-527, 2023.
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Affiliation(s)
- Kechen Shu
- Department of Electrical and Computer Engineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Subashan Perera
- Division of Geriatrics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amanda S. Mahoney
- Department of Communication Science and Disorders, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shitong Mao
- Department of Electrical and Computer Engineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James L. Coyle
- Department of Electrical and Computer Engineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Communication Science and Disorders, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Otolaryngology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ervin Sejdić
- Edward S. Rogers Department of Electrical and Computer Engineering, Faculty of Applied Science and Engineering, University of Toronto, Toronto, Ontario, Canada
- North York General Hospital, Toronto, Ontario, Canada
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Abstract
Surgical emergencies are common in the critical care setting and require prompt diagnosis and management. Here, we discuss some of the surgical emergencies involving the gastrointestinal, hepatobiliary, and genitourinary sites. In addition, foreign body aspiration and necrotizing soft-tissue infections have been elaborated. Clinicians should be aware of the risk factors, keys examination findings, diagnostic modalities, and medical as well as surgical treatment options for these potentially fatal illnesses.
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Affiliation(s)
- Vikram Saini
- Division of Infectious Disease (Drs Saini and Bhanot), Division of Pulmonary and Critical Care Medicine (Drs Saini and Ashraf), Department of General Surgery (Dr Babowice), and Division of Trauma Surgery and Surgical Critical Care (Ms Hamilton and Dr Khan), Allegheny Health Network, Pittsburgh, Pennsylvania
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Nasal Microbiota, Olfactory Health, Neurological Disorders and Aging—A Review. Microorganisms 2022; 10:microorganisms10071405. [PMID: 35889124 PMCID: PMC9320618 DOI: 10.3390/microorganisms10071405] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 02/07/2023] Open
Abstract
The nasal region is one of the distinct environments for the survival of various microbiota. The human microbial niche begins to inhabit the human body right from birth, and the microbiota survive as commensals or opportunistic pathogens throughout the life of humans in their bodies in various habitats. These microbial communities help to maintain a healthy microenvironment by preventing the attack of pathogens and being involved in immune regulation. Any dysbiosis of microbiota residing in the mucosal surfaces, such as the nasal passages, guts, and genital regions, causes immune modulation and severe infections. The coexistence of microorganisms in the mucosal layers of respiratory passage, resulting in infections due to their co-abundance and interactions, and the background molecular mechanisms responsible for such interactions, need to be considered for investigation. Additional clinical evaluations can explain the interactions among the nasal microbiota, nasal dysbiosis and neurodegenerative diseases (NDs). The respiratory airways usually act as a substratum place for the microbes and can act as the base for respiratory tract infections. The microbial metabolites and the microbes can cross the blood–brain barrier and may cause NDs, such as Parkinson’s disease (PD), Alzheimer’s disease (AD), and multiple sclerosis (MS). The scientific investigations on the potential role of the nasal microbiota in olfactory functions and the relationship between their dysfunction and neurological diseases are limited. Recently, the consequences of the severe acute respiratory syndrome coronavirus (SARS-CoV-2) in patients with neurological diseases are under exploration. The crosstalk between the gut and the nasal microbiota is highly influential, because their mucosal regions are the prominent microbial niche and are connected to the olfaction, immune regulation, and homeostasis of the central nervous system. Diet is one of the major factors, which strongly influences the mucosal membranes of the airways, gut, and lung. Unhealthy diet practices cause dysbiosis in gut microbiota and the mucosal barrier. The current review summarizes the interrelationship between the nasal microbiota dysbiosis, resulting olfactory dysfunctions, and the progression of NDs during aging and the involvement of coronavirus disease 2019 in provoking the NDs.
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Groher ME. Ethical Considerations. Dysphagia 2021. [DOI: 10.1016/b978-0-323-63648-3.00012-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kyodo R, Kudo T, Horiuchi A, Sakamoto T, Shimizu T. Pureed diets containing a gelling agent to reduce the risk of aspiration in elderly patients with moderate to severe dysphagia: A randomized, crossover trial. Medicine (Baltimore) 2020; 99:e21165. [PMID: 32756094 PMCID: PMC7402755 DOI: 10.1097/md.0000000000021165] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
GOALS The aim of this study was to evaluate the effectiveness of adding a gelling agent to pureed diets to prevent aspiration pneumonia in elderly patients with moderate to severe dysphagia. BACKGROUND Pureed diets are often used to reduce aspiration in patients with dysphagia. However, the ideal texture of a pureed diet to prevent aspiration pneumonia remains unclear. MATERIALS AND METHODS We prospectively conducted a randomized, crossover trial of pureed rice with or without a gelling agent in patients with moderate to severe dysphagia (ClincialTrials.gov number, NCT03163355). The primary outcome measure was pharyngeal residuals using an endoscopic scoring system. The secondary outcome was the sense of material remaining in the throat following swallowing. RESULTS Sixty two patients (58% men), mean age 83 ± 9 years with moderate to severe dysphagia were included. Residuals in the throat were significantly less likely with pureed rice with than without the gelling agent (median cyclic ingestion score (range); 1 (0-4) vs 2 (0-4); P = .001). Irrespective of the presence or absence of the gelling agent, the sense of material remaining in the throat was significantly less frequent in older patients (87 ± 7.6 vs 75 ± 9.1 years, P < .01; 86 ± 7.3 vs 75 ± 8.6 years, P < .01). CONCLUSIONS Pureed diets containing a gelling agent may reduce the risk of aspiration pneumonia possibly by decreasing pharyngeal residues in elderly patients with moderate to severe dysphagia.
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Affiliation(s)
- Reiko Kyodo
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo
- Digestive Disease Center
| | - Takahiro Kudo
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo
- Digestive Disease Center
| | | | - Torao Sakamoto
- Department of Rehabilitation, Showa Inan General Hospital, Komagane, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo
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Liu Y, Lin Y, Di P. A modified implant abutment holder fabricated with fused deposition modeling to improve the transfer process for implant-supported restorations. J Prosthet Dent 2020; 125:411-414. [PMID: 32248997 DOI: 10.1016/j.prosdent.2020.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 01/05/2020] [Accepted: 01/06/2020] [Indexed: 10/24/2022]
Abstract
Ingestion or aspiration of an implant abutment can occur in patients during the process of abutment transfer for implant-supported restorations, especially in the posterior region. A technique of fabricating an abutment holder is described to prevent ingestion or aspiration by computer-aided design (CAD) and fused deposition modeling (FDM). The modified abutment holder has a serrated handle for a firm grip and a barrel-shaped fixed portion that firmly secures the abutment. The modified holder is more secure than the conventional hexagon screwdriver. Furthermore, abutment holders can be easily manufactured by using 3D printers and repeatedly used for multiple implants restoration without substitution.
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Affiliation(s)
- Yanping Liu
- PhD candidate, Department of Oral Implantology, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - Ye Lin
- Professor, Department of Oral Implantology, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - Ping Di
- Professor, Department of Oral Implantology, Peking University School and Hospital of Stomatology, Beijing, PR China.
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Animal Models of Aspiration Pneumonia. RESPIRATORY DISEASE SERIES: DIAGNOSTIC TOOLS AND DISEASE MANAGEMENTS 2020. [PMCID: PMC7298540 DOI: 10.1007/978-981-15-4506-1_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Appropriate animal models of aspiration pneumonia may be required for studying the mechanism of aspiration and aspiration-induced pneumonia. Animal models of AP allow us to investigate distinct types of pneumonia at various disease stages, studies that are not possible in patients. AP animal models should have features of bacterial pneumonia and swallowing abnormality. Our animal model of aspiration, using recombinant E1-deleted Ad vectors, may be advantageous relative to earlier models for assessing the development of aspiration pneumonia in association with disturbed upper airway reflexes, since DNA virus infection of bronchiolar epithelial cells in the lower respiratory tract can be assessed by the localization and intensity of LacZ gene expression The other candidate model of aspiration was applied for the experimental stroke in mice induced by occlusion of the middle cerebral artery. Aspiration pneumonia was caused by intranasal application of a small amount of Streptococcus pneumoniae. Acid pneumonitis is a major cause of sterile acute lung injury (ALI), resulting in acute respiratory distress syndrome (ARDS) or Mendelson’s syndrome. Several types of animal models of acid aspiration are available using a wide range of developed transgenic models. Different types of animal models of both aspiration pneumonia and aspiration pneumonitis have considerably aided our understanding of disease pathogenesis and testing and developing of new treatment strategies.
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Re GL, Terranova MC, Vernuccio F, Calafiore C, Picone D, Tudisca C, Salerno S, Lagalla R. Swallowing impairment in neurologic disorders: the role of videofluorographic swallowing study. Pol J Radiol 2018; 83:e394-e400. [PMID: 30655916 PMCID: PMC6334091 DOI: 10.5114/pjr.2018.79203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 08/06/2018] [Indexed: 11/17/2022] Open
Abstract
Patients with neurologic diseases almost inevitably develop various degrees of swallowing disorders during their life. Dysphagia is one of the main negative prognostic factors in this class of patients, leading to severe morbidity (i.e. aspiration pneumonia, dehydration, malnutrition, and life quality deterioration) and to a noticeable increase in public health spending. Videofluorographic swallowing study is considered the gold standard technique for swallowing impairment assessment. It is aimed at early identification of the risk of aspiration, definition of the kind and grade of dysphagia, and an indication to suspend oral nutrition and adopt other feeding strategies, and define when the patient is able to return to physiological nutrition. Every radiologist should be familiar with the main videofluorographic swallowing features in neurological patients, not only because early diagnosis of deglutition disorders widely improves their prognosis, but also because customising feeding strategies has a great impact on patients' quality of life.
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Pisegna JM, Langmore SE. The Ice Chip Protocol: A Description of the Protocol and Case Reports. ACTA ACUST UNITED AC 2018. [DOI: 10.1044/persp3.sig13.28] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jessica M. Pisegna
- Department of Otolaryngology, Boston Medical Center
Boston, MA
- Speech-Language Pathology Sciences, Boston University School of Medicine
Boston, MA
| | - Susan E. Langmore
- Department of Otolaryngology-Head & Neck Surgery, Boston University Medical Center
Boston, MA
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11
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Wang CM, Li HY, Lee LA, Shieh WY, Lin SW. Non-invasive Assessment of Swallowing and Respiration Coordination for the OSA Patient. Dysphagia 2016; 31:771-780. [PMID: 27515710 DOI: 10.1007/s00455-016-9740-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 07/28/2016] [Indexed: 12/14/2022]
Abstract
The objectives of this study are to investigate swallowing and its coordination with respiration in patients with obstructive sleep apnea (OSA). This is a prospective cohort study conducted in a tertiary referred Medical Center. A non-invasive method of assessing swallowing was used to detect the oropharyngeal swallowing parameters and the coordination with respiration during swallowing. The system used to assess swallowing detected: (1) movement of the larynx using a force-sensing resistor; (2) submental muscle activity using surface electromyography; and (3) coordination with respiration by measuring nasal airflow. Five sizes of water boluses (maximum 20 mL) were swallowed three times, and the data recorded and analyzed for each participant. Thirty-nine normal controls and 35 patients with OSA who fulfilled the inclusion criteria were recruited. The oropharyngeal swallowing parameters of the patients differed from the controls, including longer total excursion duration and shorter duration of submental muscles contraction. A longer swallowing respiratory pause (SRP), temporary coordination with respiration during swallowing, was demonstrated in the patients compared with the controls. The frequency of non-expiratory/expiratory pre- and postswallowing respiratory phase patterns of the patients was similar with the controls. There was significantly more piecemeal deglutition in OSA patients when clumping 10- and 20-mL water boluses swallowing together (p = 0.048). Oropharyngeal swallowing and coordination with respiration affected patients with OSA, and it could be detected using a non-invasive method. The results of this study may serve as a baseline for further research and help advance research methods in obstructive sleep apnea swallowing studies.
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Affiliation(s)
- Chin-Man Wang
- Department of Physical Medicine and Rehabilitation, Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No.5, Fu-Hsing Street, Gueishan District, Taoyuan City, 33305, Taiwan, ROC.
| | - Hsueh-Yu Li
- Department of Otorhinolaryngology-Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No.5, Fu-Hsing Street, Gueishan District, Taoyuan City, 33305, Taiwan, ROC.
| | - Li- Ang Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No.5, Fu-Hsing Street, Gueishan District, Taoyuan City, 33305, Taiwan, ROC
| | - Wann-Yun Shieh
- Department of Computer Science and Information Engineering, Chang Gung University, Taoyuan City, 33305, Taiwan, ROC
| | - Shih-Wei Lin
- Department of Pulmonary and Critical Care Medicine, Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan City, 33305, Taiwan, ROC
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12
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Effects of tongue pressing effortful swallow in older healthy individuals. Arch Gerontol Geriatr 2016; 66:127-33. [PMID: 27318884 DOI: 10.1016/j.archger.2016.05.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 05/15/2016] [Accepted: 05/29/2016] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The risk of swallowing disorders is increased for older individuals due to weak tongue and pharyngeal muscle strength. This study was appraised the value of a preventative approach by developing the tongue pressing effortful swallow (TPES) applied using a home-based and self-administered procedure. The TPES was developed by combining two swallowing exercises: tongue strengthening exercise and the effortful swallow. The purpose of this study was to examine the effects of the TPES on maximum tongue pressure and peak amplitude of submental muscle activity in older individuals. MATERIAL AND METHODS 27 older individuals (mean 73 years) performed a 4-week TPES. The exercise program was adapted to a home-based and self-administered procedure. The maximum tongue pressure was measured by the Iowa Oral Performance Instrument and peak amplitude of submental muscle activity by surface electromyography (sEMG). Statistical comparisons were made by a matched pairs t-test (p<0.05). RESULTS The results of this study showed that the TPES had statistically significant and positive effects on increasing maximum tongue pressure, but the peak amplitude of the submental sEMG did not differ between before and after exercises. CONCLUSIONS The TPES had a positive impact in older individuals. The TPES, a combining exercise, was possible because two exercises had common physiological events. The TPES was a more innovative and efficient approach than the tongue strengthening exercise alone. In addition, older individuals were able to perform the swallowing exercise at home and by themselves with little assistance. Future research needs to refine the TPES and apply it to patients with dysphagia.
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13
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Groher ME. Ethical Considerations. Dysphagia 2016. [DOI: 10.1016/b978-0-323-18701-5.00011-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Rodrigues Hoffmann A, Proctor LM, Surette MG, Suchodolski JS. The Microbiome: The Trillions of Microorganisms That Maintain Health and Cause Disease in Humans and Companion Animals. Vet Pathol 2015. [PMID: 26220947 DOI: 10.1177/0300985815595517] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The microbiome is the complex collection of microorganisms, their genes, and their metabolites, colonizing the human and animal mucosal surfaces, digestive tract, and skin. It is now well known that the microbiome interacts with its host, assisting in digestion and detoxification, supporting immunity, protecting against pathogens, and maintaining health. Studies published to date have demonstrated that healthy individuals are often colonized with different microbiomes than those with disease involving various organ systems. This review covers a brief history of the development of the microbiome field, the main objectives of the Human Microbiome Project, and the most common microbiomes inhabiting the human respiratory tract, companion animal digestive tract, and skin in humans and companion animals. The main changes in the microbiomes in patients with pulmonary, gastrointestinal, and cutaneous lesions are described.
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Affiliation(s)
- A Rodrigues Hoffmann
- Department of Veterinary Pathobiology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX, USA
| | - L M Proctor
- National Human Genome Research Institute, National Institute of Health, Bethesda, MD, USA
| | - M G Surette
- Department of Medicine, Department of Biochemistry and Biomedical Sciences, Faculty of Health Sciences, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - J S Suchodolski
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX, USA
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Troche MS, Brandimore AE, Godoy J, Hegland KW. A framework for understanding shared substrates of airway protection. J Appl Oral Sci 2014; 22:251-60. [PMID: 25141195 PMCID: PMC4126819 DOI: 10.1590/1678-775720140132] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 05/06/2014] [Indexed: 02/01/2023] Open
Abstract
Deficits of airway protection can have deleterious effects to health and quality of
life. Effective airway protection requires a continuum of behaviors including
swallowing and cough. Swallowing prevents material from entering the airway and
coughing ejects endogenous material from the airway. There is significant overlap
between the control mechanisms for swallowing and cough. In this review we will
present the existing literature to support a novel framework for understanding shared
substrates of airway protection. This framework was originally adapted from Eccles'
model of cough28 (2009) by Hegland,
et al.42 (2012). It will serve to
provide a basis from which to develop future studies and test specific hypotheses
that advance our field and ultimately improve outcomes for people with airway
protective deficits.
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Affiliation(s)
- Michelle Shevon Troche
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, FL, USA
| | | | - Juliana Godoy
- Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil
| | - Karen Wheeler Hegland
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, FL, USA
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Abstract
Aspiration pneumonia is one of the most life-threatening diseases in the elderly. A 73-year-old woman was diagnosed with aspiration pneumonia after a mandibular fracture. Because her persistent aspiration pneumonia was accompanied by a diminished swallowing function that was believed to be due to a double fracture of the mandible, the patient underwent an open reduction while having pneumonia. Her symptoms of aspiration pneumonia improved immediately after the surgery. The hyoid bone was repositioned to its original position, and the movements of the hyoid bone and mandible were recovered after the surgery. In cases in which the medial bone segment of the mandible moves inside because of a double fracture and the movement of the hyoid bone declines, we strongly suggest that an open reduction should be performed as soon as possible to prevent aspiration pneumonia caused by a swallowing dysfunction.
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Endoscopic removal of an aspirated healing abutment and screwdriver under conscious sedation. IMPLANT DENT 2014; 23:250-2. [PMID: 24819812 DOI: 10.1097/id.0000000000000100] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Aspiration of foreign bodies during dental treatment is a medical emergency that requires prompt removal. In this study, aspiration of screwdriver and healing abutment is reported with literature review. MATERIALS AND METHODS A 26-year-old male patient was referred from a local dental clinic with the suspicion of ingestion of a screwdriver and healing abutment during the second-stage surgery. The patient reported symptoms including dyspnea, cough, and foreign body sensation. On the chest radiograph, a radiopaque foreign body resembling the screwdriver and healing abutment was observed at the right mid lung. RESULTS Bronchoscopic examination using flexible cable was performed under conscious sedation, and microforceps were used to remove the instruments. Aspirated screwdriver and healing abutment were removed safely under intravenous sedation. The patient did not have any symptoms associated with lung aspiration after removal of the foreign body during follow-up periods. CONCLUSION Bronchoscopic removal is the most recommended procedure for removal of the aspirated foreign body. This can be performed under conscious sedation. Precautions, such as tethering the screwdriver, are recommended during implant procedures.
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The Loss of Topography in the Microbial Communities of the Upper Respiratory Tract in the Elderly. Ann Am Thorac Soc 2014; 11:513-21. [DOI: 10.1513/annalsats.201310-351oc] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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Dua KS, Surapaneni SN, Kuribayashi S, Hafeezullah M, Shaker R. Effect of aging on hypopharyngeal safe volume and the aerodigestive reflexes protecting the airways. Laryngoscope 2014; 124:1862-8. [PMID: 24281906 DOI: 10.1002/lary.24539] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 11/05/2013] [Accepted: 11/25/2013] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS Studies on young volunteers have shown that aerodigestive reflexes are triggered before the maximum volume of fluid that can safely collect in the hypopharynx before spilling into the larynx is exceeded (hypopharyngeal safe volume [HPSV]). The objective of this study was to determine the influence of aging on HPSV and pharyngo-glottal closure reflex (PGCR), pharyngo-UES contractile reflex (PUCR), and reflexive pharyngeal swallow (RPS). STUDY DESIGN Comparison between two groups of different age ranges. METHODS Ten young (25 ± 3 standard deviation [SD] years) and 10 elderly (77 ± 3 SD years) subjects were studied. PGCR, PUCR, and RPS were elicited by perfusing water into the pharynx rapidly and slowly. HPSV was determined by abolishing RPS with pharyngeal anesthesia. RESULTS Frequency-elicitation of PGCR and PUCR were significantly lower in the elderly compared to the young during slow water perfusion (47% vs. 97% and 40% vs. 90%, respectively, P < .001). RPS was absent in five of the 30 (17%) slow injections in the elderly group. In these elderly subjects, HPSV was exceeded and laryngeal penetration of the water was seen. The threshold volume to elicit PGCR, PUCR, and RPS was significantly lower than the HPSV during rapid injections. Except for RPS, these volumes were also significantly lower than HPSV during slow injections. CONCLUSIONS PGCR, PUCR, and RPS reflexes are triggered at a threshold volume significantly lower than the HPSV in both young and elderly subjects. Lower frequency-elicitation of PGCR, PUCR, and RPS in the elderly can predispose them to the risks of aspiration.
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Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A.; VA Medical Center, Milwaukee, Wisconsin, U.S.A
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Shim JS, Oh BM, Han TR. Factors associated with compliance with viscosity-modified diet among dysphagic patients. Ann Rehabil Med 2013; 37:628-32. [PMID: 24231801 PMCID: PMC3825938 DOI: 10.5535/arm.2013.37.5.628] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 05/28/2013] [Indexed: 12/04/2022] Open
Abstract
Objective To investigate compliance with a viscosity-modified diet among Korean dysphagic patients and to determine which factors are associated with compliance. Methods We retrospectively reviewed medical records of patients who had been recommended to use thickeners in the previous videofluoroscopic swallowing study (VFSS). Among 68 patients, 6 were excluded because tube feeding was required due to deterioration in their medical condition. Finally, 62 patients were included in the study. Patient compliance was assessed using their medical records by checking whether he or she had maintained thickener use until the next VFSS. To determine which factors affect compliance, the relationship between thickener use and patient characteristics, such as sex, age, inpatient/outpatient status, severity of dysphagia, aspiration symptoms, follow-up interval of VFSS, and current swallowing therapy status were assessed. For noncompliers, reasons for not using thickeners were investigated by telephone interview. Results Among 62 patients, 35 (56.5%) were compliers, and 27 (43.5%) were noncompliers. Eighteen (90%) of 20 inpatients had followed previous recommendations; however, only 17 (40.5%) of 42 outpatients had been using thickeners. Of patient characteristics, only admission status was significantly correlated with compliance. When asked about the reason why they had not used thickeners, noncompliers complained about dissatisfaction with texture and taste, greater difficulty in swallowing, and inconvenience of preparing meals. Conclusion Among Korean dysphagic patients, compliance with a viscosity-modified liquid diet was only about 50%. Betterments of texture and taste along with patient education might be necessary to improve compliance with thickener use.
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Affiliation(s)
- Jae Seong Shim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, Korea
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Suiter DM, Gosa MM, Leder SB. Intraoral Dwell Time Results in Increased Bolus Temperature and Decreased Bolus Viscosity for Thickened Liquids. TOP CLIN NUTR 2013. [DOI: 10.1097/tin.0b013e31827df962] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Carlaw C, Finlayson H, Beggs K, Visser T, Marcoux C, Coney D, Steele CM. Outcomes of a pilot water protocol project in a rehabilitation setting. Dysphagia 2012; 27:297-306. [PMID: 21928099 PMCID: PMC3417096 DOI: 10.1007/s00455-011-9366-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Accepted: 08/12/2011] [Indexed: 11/28/2022]
Abstract
There is considerable clinical interest in the risks and benefits of offering oral water intake, in the form of water protocols, to patients with thin-liquid dysphagia. We describe the design and implementation of a water protocol for patients in a rehabilitation setting with videofluoroscopically confirmed thin-liquid aspiration. The GF Strong Water Protocol (GFSWP) is an interdisciplinary initiative, with roles and accountabilities specified for different members of the interprofessional health-care team. Rules of the water protocol specify mode of water access (independent, supervised), the implementation of any safe swallowing strategies recommended on the basis of the patient's videofluoroscopy, and procedures for evaluating and addressing oral care needs. Trial implementation of the water protocol in 15 participants showed that they remained free of adverse events, including pneumonia, over the course of an initial 14-day trial and continuing until discharge from the facility (range = 13-108 days). Seven participants were randomly assigned to a 14-day control phase in which they received standard care (without water access). Fluid intake measures taken after the oral water intake phase were increased (mean = 1,845 cc; 95% confidence interval: 1,520-2,169 cc) compared to those in the control phase (mean = 1,474 cc; 95% CI: 1,113-1,836 cc), with oral water intake measures comprising, on average, 563 cc (range = 238-888 cc) of the total post water trial fluid intake values. Fluid intake increased at least 10% of the calculated fluid requirements in 11/15 participants who received oral water access. These participants reported favorable quality-of-life outcomes, measured using the Swal-QOL. These findings support the implementation of the GFSWP, including its exclusion criteria, rules, and plans of care, for rehabilitation patients who aspirate thin liquids.
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Affiliation(s)
- Caren Carlaw
- GF Strong Rehabilitation Centre, Vancouver, BC, Canada.
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Kind A, Anderson P, Hind J, Robbins J, Smith M. Omission of dysphagia therapies in hospital discharge communications. Dysphagia 2011; 26:49-61. [PMID: 20098999 PMCID: PMC2888892 DOI: 10.1007/s00455-009-9266-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Accepted: 12/15/2009] [Indexed: 11/26/2022]
Abstract
Despite the wide implementation of dysphagia therapies, it is unclear whether these therapies are successfully communicated beyond the inpatient setting. The aim of this study was to examine the rate of dysphagia recommendation omissions in hospital discharge summaries for high-risk subacute care (i.e., skilled nursing facility, rehabilitation, long-term care) populations. We performed a retrospective cohort study that included all stroke and hip fracture patients billed for inpatient dysphagia evaluations by speech-language pathologists (SLPs) and discharged to subacute care from 2003 through 2005 from a single large academic medical center (N=187). Dysphagia recommendations from final SLP hospital notes and from hospital (physician) discharge summaries were abstracted, coded, and compared for each patient. Recommendation categories included dietary (food and liquid), postural/compensatory techniques (e.g., chin tuck), rehabilitation (e.g., exercise), meal pacing (e.g., small bites), medication delivery (e.g., crush pills), and provider/supervision (e.g., 1-to-1 assist). Forty-five percent of discharge summaries omitted all SLP dysphagia recommendations. Forty-seven percent (88/186) of patients with SLP dietary recommendations, 82% (93/114) with postural, 100% (16/16) with rehabilitation, 90% (69/77) with meal pacing, 95% (21/22) with medication, and 79% (96/122) with provider/supervision recommendations had these recommendations completely omitted from their discharge summaries. Discharge summaries omitted all categories of SLP recommendations at notably high rates. Improved post-hospital communication strategies are needed for discharges to subacute care.
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Affiliation(s)
- Amy Kind
- Geriatrics Section, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 2500 Overlook Terrace, Madison, WI 53705, USA.
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Answering Orientation Questions and Following Single-Step Verbal Commands: Effect on Aspiration Status. Dysphagia 2009; 24:290-5. [DOI: 10.1007/s00455-008-9204-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Accepted: 11/10/2008] [Indexed: 10/21/2022]
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Abstract
INTRODUCTION In the normal population, inadvertently swallowed foreign objects enter the gastrointestinal tract more frequently than the tracheobronchial tree. There is a typical patient population that is at higher risk for aspiration. DISCUSSION Sequelae may range from relatively benign partial obstruction to the immediately life-threatening total airway obstruction. Foreign objects lodged in the upper aspect of the trachea may be retrieved with simple instrumentation. CONCLUSION Some cases may complicate and may require direct access through a tracheotomy, as the case shown in this paper.
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Abstract
Research on treatment of oropharyngeal dysphagia has supported several treatment approaches. Treatment can include postural changes, heightening preswallow sensory input, voluntary swallow maneuvers, and exercises. Evidence to support the efficacy of these procedures is variable. An instrumental study of a patient's oropharyngeal swallow forms the basis for treatment selection.
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Standard Values of Maximum Tongue Pressure Taken Using Newly Developed Disposable Tongue Pressure Measurement Device. Dysphagia 2008; 23:286-90. [DOI: 10.1007/s00455-007-9142-z] [Citation(s) in RCA: 256] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Accepted: 11/16/2007] [Indexed: 11/26/2022]
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Robbins J, Hind J. Overview of Results From the Largest Clinical Trial for Dysphagia Treatment Efficacy. ACTA ACUST UNITED AC 2008. [DOI: 10.1044/sasd17.2.59] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Information presented herein provides an overview of the largest randomized clinical trial ever completed in dysphagia. The two-part sequential randomized clinical trial studied the effect of two common dysphagia interventions (chin tuck and thickened liquids) for immediate prevention of aspiration during videofluorographic assessment and also for the incidence of pneumonia at 3-months for patients with Parkinson's disease and/or dementia. Results indicated that thickened liquids (nectar-thick or honey-thick) prevented aspiration during the radiographic study more frequently than chin-down posture; however, both interventions were equally successful at preventing pneumonia. Adverse events such as urinary tract infection and dehydration were more common with thickened liquids. Median length of hospital stay due to pneumonia was three times longer for patients drinking honey-thick liquids compared to nectar-thick and chin-tuck arms of the study. Several important secondary outcomes are discussed as well as implications for clinical practice. The reader is encouraged to refer to other published works for detailed information that is highlighted in this overview.
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Affiliation(s)
- JoAnne Robbins
- Department of Medicine, Department of Radiology, Interdepartmental Nutritional Sciences Graduate Program and Biomedical Engineering at University of Wisconsin; and Geriatric Research, Education and Clinical Center at the William S. Middleton Memorial Veterans Hospital Madison, WI
| | - Jacqueline Hind
- Department of Medicine, University of Wisconsin Hospitals and Clinics; and Geriatric Research, Education and Clinical Center at the William S. Middleton Memorial Veterans Hospital Madison, WI
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Robbins J, Gensler G, Hind J, Logemann JA, Lindblad AS, Brandt D, Baum H, Lilienfeld D, Kosek S, Lundy D, Dikeman K, Kazandjian M, Gramigna GD, McGarvey-Toler S, Miller Gardner PJ. Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial. Ann Intern Med 2008; 148:509-18. [PMID: 18378947 PMCID: PMC2364726 DOI: 10.7326/0003-4819-148-7-200804010-00007] [Citation(s) in RCA: 185] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Aspiration pneumonia is common among frail elderly persons with dysphagia. Although interventions to prevent aspiration are routinely used in these patients, little is known about the effectiveness of those interventions. OBJECTIVE To compare the effectiveness of chin-down posture and 2 consistencies (nectar or honey) of thickened liquids on the 3-month cumulative incidence of pneumonia in patients with dementia or Parkinson disease. DESIGN Randomized, controlled, parallel-design trial in which patients were enrolled for 3-month periods from 9 June 1998 to 19 September 2005. SETTING 47 hospitals and 79 subacute care facilities. PATIENTS 515 patients age 50 years or older with dementia or Parkinson disease who aspirated thin liquids (demonstrated videofluoroscopically). Of these, 504 were followed until death or for 3 months. INTERVENTION Participants were randomly assigned to drink all liquids in a chin-down posture (n = 259) or to drink nectar-thick (n = 133) or honey-thick (n = 123) liquids in a head-neutral position. MEASUREMENTS The primary outcome was pneumonia diagnosed by chest radiography or by the presence of 3 respiratory indicators. RESULTS 52 participants had pneumonia, yielding an overall estimated 3-month cumulative incidence of 11%. The 3-month cumulative incidence of pneumonia was 0.098 and 0.116 in the chin-down posture and thickened-liquid groups, respectively (hazard ratio, 0.84 [95% CI, 0.49 to 1.45]; P = 0.53). The 3-month cumulative incidence of pneumonia was 0.084 in the nectar-thick liquid group compared with 0.150 in the honey-thick liquid group (hazard ratio, 0.50 [CI, 0.23 to 1.09]; P = 0.083). More patients assigned to thickened liquids than those assigned to the chin-down posture intervention had dehydration (6% vs. 2%), urinary tract infection (6% vs. 3%), and fever (4% vs. 2%). LIMITATIONS A no-treatment control group was not included. Follow-up was limited to 3 months. Care providers were not blinded, and differences in cumulative pneumonia incidence between interventions had wide CIs. CONCLUSION No definitive conclusions about the superiority of any of the tested interventions can be made. The 3-month cumulative incidence of pneumonia was much lower than expected in this frail elderly population. Future investigation of chin-down posture combined with nectar-thick liquid may be warranted to determine whether this combination better prevents pneumonia than either intervention independently.
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Affiliation(s)
- JoAnne Robbins
- William S. Middleton Memorial Veterans Hospital, Geriatric Research Education and Clinical Center, and University of Wisconsin, Madison, Wisconsin 53705, USA
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Brandt DK, Hind JA, Robbins J, Lindblad AS, Gensler G, Gill G, Baum H, Lilienfeld D, Logemann JA. Challenges in the design and conduct of a randomized study of two interventions for liquid aspiration. Clin Trials 2008; 3:457-68. [PMID: 17060219 DOI: 10.1177/1740774506070731] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Liquid aspiration during swallowing has been linked to pneumonia, the most common cause of infectious death in the elderly. This paper examines the key issues in the design and implementation of the first multisite, randomized behavioral trial in dysphagia in an aging population. The study evaluated two commonly used treatments with respect to short-term and long-term management of liquid aspiration and subsequent pneumonia in dysphagic geriatric participants with dementia and/or Parkinson's disease. METHODS Discussed are lessons learned during the conduct of this trial and include (1) ethical and methodological design issues, (2) pragmatic implementation of procedures and forms, (3) importance of multiple communication and monitoring strategies, (4) response to funding issues, and (5) changes in staff and facilities. RESULTS In order to complete this trial the researchers were required to provide more support than anticipated in tasks such as completion of regulatory requirements by sites, supplementing site staff to identify potential study participants using a 'circuit rider' approach, continued recruitment of new sites and staff throughout the course of the trial, adapting forms and procedures and managing within economic constraints in a changing trial environment. LIMITATIONS Many of the challenges faced by the researchers were not anticipated when the study began. Successful strategies are described for these unanticipated difficulties, based on retrospective evaluation. CONCLUSIONS Successful conduct of clinical trials in long-term care environments that are heavily impacted by changes extraneous to the trial design and with staff typically new to clinical trials is possible but success depends on logistical flexibility.
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Abstract
BACKGROUND Aspiration pneumonia is a common cause of morbidity and mortality. Several approaches, including bed positioning, dietary changes, and oral hygiene, have been proposed to prevent aspiration pneumonia, yet few data are available on the efficacy of pharmacologic interventions in reducing the rate of aspiration. OBJECTIVE This study was a systematic literature review of the pharmacologic prevention of aspiration pneumonia. METHODS We searched MEDLINE (1996-2006); EMBASE (1974-2006); Cumulative Index to Nursing & Allied Health Literature (CINAHL) (1982-2006); Health Services Technology, Administration, and Research (HealthSTAR) (1975-2006); and the Cochrane Library for relevant articles. References of all included articles were reviewed. Studies were included if they had a prospective, controlled design with a primary outcome of prevention of aspiration pneumonia. Surrogate outcomes that had a direct link to decreasing the incidence of aspiration pneumonia were considered. Selected articles were reviewed independently by 2 authors. RESULTS Of 1108 studies reviewed, 20 were analyzed. Angiotensin-converting enzyme inhibitors may be beneficial in selected patients at high risk for aspiration. Capsaicin may be a low-risk approach to stimulate swallowing and cough reflexes. Amantadine, cabergoline, and theophylline may cause serious adverse events, and their routine use for prevention of aspiration pneumonia is not recommended. Cilostazol should not be used because of the increased risk for bleeding. CONCLUSIONS Limited information is available on benefits and risks to guide an evidence-based approach to the pharmacologic prevention of aspiration pneumonia. Considering the high incidence of aspiration pneumonia in older adults, large randomized clinical trials on the effectiveness of pharmacologic interventions are warranted.
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Lunghar L, D'Ambrosio CM. Noninvasive ventilation in the older patient who has acute respiratory failure. Clin Chest Med 2008; 28:793-800, vii. [PMID: 17967295 DOI: 10.1016/j.ccm.2007.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Older patients are at significantly increased risk of acute respiratory failure from multiple causes. Noninvasive positive pressure ventilation has been shown to dramatically improve care of patients with acute respiratory failure. Patient selection is important in all patients being treated with noninvasive positive pressure ventilation but is especially important in older patients. Delirium, confusion, and dementia can lead to difficulty for patients in tolerating this procedure and lead to a worsening respiratory status. The presence of a do-not-intubate order does not necessarily preclude the use of noninvasive positive pressure ventilation, and some patients may derive significant benefit from its use. Overall, noninvasive positive pressure ventilation is a reasonable and justifiable option in the treatment of acute respiratory failure in older patients.
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Affiliation(s)
- Layola Lunghar
- Pulmonary, Critical Care and Sleep Medicine Division, The Center for Sleep Medicine, Tufts University School of Medicine, Tufts-New England Medical Center, 750 Washington Street #257, Boston, MA 02111, USA
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Contribution of Tracheotomy Tubes and One-way Speaking Valves to Swallowing Success. TOPICS IN GERIATRIC REHABILITATION 2007. [DOI: 10.1097/01.tgr.0000299162.52493.6f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nicosia MA. A planar finite element model of bolus containment in the oral cavity. Comput Biol Med 2007; 37:1472-8. [PMID: 17374530 DOI: 10.1016/j.compbiomed.2007.01.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2006] [Accepted: 01/08/2007] [Indexed: 11/20/2022]
Abstract
As individuals age, one of the objective changes that occurs in the oropharyngeal swallow is the development of a delay between bolus entry into the pharynx and the initiation of airway protection mechanisms. For longer delays, this phenomenon is sometimes referred to as "premature spillage," and it has been suggested that such spillage, which is a risk factor for dysphagia, may be associated with pre-swallow lingual gestures, or "tongue pumping." The goal of the current study was to develop a simplified two-dimensional computational model of the oropharynx to simulate the containment of a Newtonian fluid bolus within the oral cavity in response to a given pattern of lingual gestures for different viscosities. An arbitrary Lagrangian-Eulerian simulation was performed using the commercial finite element software package, LS-Dyna. It was found that for a given lingual motion, higher viscosity Newtonian boluses, consistent with those offered therapeutically, were able to be contained within the simulated oral cavity while a lower viscosity bolus would be "spilled," suggesting a potential mechanisim by which thickened liquids may reduce aspiration. Although the current data must be validated with more realistic, three-dimensional geometric information and for a wider range of bolus rheologies, they represent an exciting first step towards realistic modeling of oropharyngeal bolus flow.
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Affiliation(s)
- Mark A Nicosia
- Department of Mechanical Engineering, Widener University, One University Place, Chester, PA 19013, USA.
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Affiliation(s)
- Linda Nazarko
- older people at Richmond and Twickenham Primary Care Trust. Teddington Memorial Hospital, Teddington TW11 OJL
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Abstract
Older adults comprise 48% of the critically ill population in intensive care units and will continue to represent a substantial proportion of patients requiring intensive care for decades to come. Aging both decreases the reserve capacity of vital organs and increases the risk of concurrent illnesses that challenge the respiratory system, such as pneumonia, renal failure, or heart diseases. Because respiratory failure is one of the leading causes of death in intensive care units, implementation of strategies to prevent the need for reintubation should be considered early in the course of respiratory decompensation. For those who require mechanical ventilation, protocols to identify patients who are ready to wean should facilitate liberation from respiratory support and reduce complications of mechanical ventilation. Finally, allocation of potentially limited health care resources necessitates knowing about the risk-benefit of mechanical ventilation and other treatment for respiratory failure in this population.
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Affiliation(s)
- Ali A El Solh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY 14215, USA.
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Abstract
Dysphagia can negatively affect quality of life, nutritional status, and pulmonary status of individuals. The most common intervention for dysphagia is the use of thickening agents for liquids. This group study (n = 43) investigated the taste preference, taste ratings, and ranking for nectar-thick hot and cold beverages using three types of thickeners: SimplyThick, Thick-It, and noncommercially prepared natural thickeners. Results demonstrated a significant difference between the taste ratings of two commercial thickeners and between one commercial and the natural thickener for the ranking of taste with hot beverages. Every participant rated at least one of the thickener beverages as having an acceptable taste for the hot chocolate and fruit juice beverages. Exploring individual preferences is critical to selecting a beverage that increases compliance to clinical recommendations.
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Robbins J, Gangnon RE, Theis SM, Kays SA, Hewitt AL, Hind JA. The Effects of Lingual Exercise on Swallowing in Older Adults. J Am Geriatr Soc 2005; 53:1483-9. [PMID: 16137276 DOI: 10.1111/j.1532-5415.2005.53467.x] [Citation(s) in RCA: 317] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the effects of an 8-week progressive lingual resistance exercise program on swallowing in older individuals, the most "at risk" group for dysphagia. DESIGN Prospective cohort intervention study. SETTING Subjects were recruited from the community at large. PARTICIPANTS Ten healthy men and women aged 70 to 89. INTERVENTION Each subject performed an 8-week lingual resistance exercise program consisting of compressing an air-filled bulb between the tongue and hard palate. MEASUREMENTS At baseline and Week 8, each subject completed a videofluoroscopic swallowing evaluation for kinematic and bolus flow assessment of swallowing. Swallowing pressures and isometric pressures were collected at baseline and Weeks 2, 4, and 6. Four of the subjects also underwent oral magnetic resonance imaging (MRI) to measure lingual volume. RESULTS All subjects significantly increased their isometric and swallowing pressures. All subjects who had the MRI demonstrated increased lingual volume of an average of 5.1%. CONCLUSION The findings indicate that lingual resistance exercise is promising not only for preventing dysphagia due to sarcopenia, but also as a treatment strategy for patients with lingual weakness and swallowing disability due to frailty or other age-related conditions. The potential effect of lingual exercise on reducing dysphagia-related comorbidities (pneumonia, malnutrition, and dehydration) and healthcare costs while improving quality of life is encouraging.
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Affiliation(s)
- JoAnne Robbins
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA.
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Iwamoto T, Fukuda S, Kikawada M, Takasaki M, Imamura T. Prognostic Implications of Swallowing Ability in Elderly Patients After Initial Recovery From Stroke. J Gerontol A Biol Sci Med Sci 2005; 60:120-4. [PMID: 15741294 DOI: 10.1093/gerona/60.1.120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND It remains unclear how swallowing assessment can help clinicians to predict the risk for pneumonia in elderly persons after ischemic stroke. A prospective case-control study was conducted to evaluate the prognostic utility of swallowing ability assessments. METHODS Participants were 136 elderly persons who had an acute ischemic stroke 3-12 months previously. They were separated into four groups based on their history of repeated episodes of pneumonia in combination with swallowing ability: Group 1 had neither repeated pneumonia nor swallowing abnormality (n = 69); group 2 had repeated pneumonia but no swallowing abnormality (n = 0); group 3 had swallowing abnormality but no repeated pneumonia (n = 54); and group 4 had both swallowing abnormality and repeated pneumonia (n = 13). The follow-up period was as long as 2.2 years. Outcomes and causes of death were compared among the groups. RESULTS During the study, the overall mortality rate was higher in group 3 (24 deaths, 44.4%) and group 4 (9 deaths, 69.2%) than in group 1 (3 deaths, 4.3%, both p <.05). The annual mortality rate from pneumonia was also significantly higher in group 3 (21.2%) and group 4 (38.2%) than in group 1 (0.8%, p <.0001). The odds ratio for patients who subsequently died of pneumonia was 46.8 between groups 1 and 3. CONCLUSIONS The high sensitivity (.96) and specificity (.68) of swallowing ability indicate that the method is useful for identifying those persons at greatest risk for pneumonia and death after ischemic stroke.
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Affiliation(s)
- Toshihiko Iwamoto
- Department of Geriatric Medicine, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
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Eisenhuber E, Schima W, Stadler A, Schober E, Schibany N, Denk DM. Evaluation of swallowing disorders with videofluoroscopy in Austria: a survey. Eur J Radiol 2005; 53:120-4. [PMID: 15607862 DOI: 10.1016/j.ejrad.2004.03.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2003] [Revised: 03/22/2004] [Accepted: 03/26/2004] [Indexed: 11/26/2022]
Abstract
AIM The aim of our study was to assess the availability of videofluoroscopy to examine patients with swallowing disorders in Austria. MATERIALS AND METHODS A questionnaire was sent to the department heads of the radiology departments of all hospitals (n=143) and to all non-hospital-based radiologic practices (n=226) throughout Austria. The survey focused on the availability of videofluoroscopic swallowing studies and on the studies performed in patients with deglutition disorders. RESULTS The questionnaire was completed and returned by 134 of 143 radiology departments (94%) and 65 of 226 non-hospital-based radiologists (29%). Videofluoroscopic swallowing studies were performed in 38 of 134 radiology departments (28%) and in 21 of 65 practices (32%). The method is available in all nine Austrian states (100%) and 27 of 99 districts (27%). The number of examinations performed in different states ranged from 0.7 to 19 studies/10,000 population per year. The number of videofluoroscopic examinations per department or practice in the year 2001 ranged between 5 and 690 (median, 100 examinations). To 85% of videofluoroscopy units patients were referred from otorhinolaryngology/phoniatrics-logopedics, to 69% of videofluoroscopy units referrals were also from internal medicine, from neurology in 54%, and from pediatrics in 20%. CONCLUSION Despite the widespread availability of videofluoroscopy throughout Austria, its use still varies largely between different states. The data show that in general there is a wide-spread demand for videofluoroscopic swallowing studies.
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Affiliation(s)
- Edith Eisenhuber
- Department of Radiology, University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
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Abstract
Pneumonia is the fourth leading cause of death despite the availability of potent new antimicrobials in Japan. Aspiration of oropharyngeal bacterial pathogens to the lower respiratory tract is one of the most important risk factors for pneumonia. Impairments in swallowing and cough reflexes among disabled older persons, e.g., related to cerebrovascular disease, increase the risk of pneumonia. Thus, strategies to reduce the volumes and pathogenicity of aspirated material should be pursued. Since both swallowing and cough reflexes are mediated by endogenous substance P contained in the vagal and glossopharyngeal nerves, pharmacologic therapy using angiotensin-converting enzyme inhibitors, which decrease substance P catabolism, can improve both reflexes and result in the lowering of the risk of pneumonia. Similarly, since the production of substance P is regulated by dopaminergic neurons in the cerebral basal ganglia, treatment with dopamine analogs or potentiating drugs such as amantadine can reduce the incidence of pneumonia. Furthermore, since mortality from infections correlates with cutaneous anergy, interventions that reverse these age-associated changes in the immune system are also effective. The main theme of this review is to discuss how pneumonia develops in disabled older people and to suggest preventive strategies that may reduce the incidence of pneumonia among these subjects.
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Affiliation(s)
- Takashi Ohrui
- Department of Geriatric and Respiratory Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
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West JF. Oral Sensory Influences on Eating and Swallowing in the Neurogenic Population. TOPICS IN GERIATRIC REHABILITATION 2004. [DOI: 10.1097/00013614-200404000-00009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
The purpose of this study was to explore eating, feeding and nutrition among stroke patients in nursing homes as described by their nurses and by assessments. Registered Nurses were interviewed about an individual stroke patient's state of health, care needs and nursing care received and nursing records were reviewed. Information on eating, feeding and nutrition was extracted from the interviews and nursing records. A comprehensive instrument, the Resident Assessment Instrument, was also used to assess these patients' state of health. The domains of eating, feeding and nutrition were focused on in this study. Manifest content analysis was used. The results showed that more than 80% of the stroke patients in nursing homes were assessed as having some sort of dependence in eating. According to the Registered Nurses, 22 out of 40 patients demonstrated different eating disabilities. The number of eating disabilities in individual patients ranged from 1 to 7, which emphasized the complexity of eating disabilities in stroke patients. Dysphagia was reported in almost one-fourth of the patients and 30% were described and/or assessed as having a poor food intake or poor appetite. The Registered Nurses' descriptions of the eating disabilities, nutritional problems and their care were often vague and unspecific. Only six weights were documented in the nursing records and there were no nutritional records. The findings highlight the importance of making careful observations and assessments, and of maintaining documentation about eating and nutrition early after a patient's arrival in the nursing home to enable appropriate care and promotion of health.
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Affiliation(s)
- Suzanne Kumlien
- Department of Clinical Neuroscience, Occupational Therapy and Elderly Care Research, Karolinska Institutet, Stockholm, Sweden.
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Robbins J, Nicosia M, Hind JA, Gill GD, Blanco R, Logemann J. Defining Physical Properties of Fluids for Dysphagia Evaluation and Treatment. ACTA ACUST UNITED AC 2002. [DOI: 10.1044/sasd11.2.16] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- JoAnne Robbins
- Department of Medicine, University of Wisconsin, Madison and Wm. S. Middleton Memorial Veterans Hospital
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Nakayama K, Jia YX, Hirai H, Shinkawa M, Yamaya M, Sekizawa K, Sasaki H. Acid stimulation reduces bactericidal activity of surface liquid in cultured human airway epithelial cells. Am J Respir Cell Mol Biol 2002; 26:105-13. [PMID: 11751210 DOI: 10.1165/ajrcmb.26.1.4425] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
To examine the effects of acid exposure with moderate acidity (pH 3.0-5.0) on bactericidal activity of airway surface liquid (ASL), ASL was collected by washing the surface of primary cultures of human tracheal epithelial cells 24 h after treatment with phosphate-buffered saline (PBS) adjusted to a pH of 3.0, 4.0, or 5.0. In all ASL, bactericidal activity was sensitive to sodium concentration. Escherichia coli (500 colony forming units [CFU]) was incubated in ASL, and the number of surviving bacteria was examined. The number of surviving bacteria in ASL from cultured cells with acid exposure at pH 3.0-5.0 was significantly higher than that in control ASL. The minimum inhibitory dilution ratio of ASL against 500 CFU of E. coli was also examined by microdilution assays. According to this assay, the bactericidal activity in ASL with acid challenge at a pH of 3.0 was less than half of that in control ASL. Reverse transcription-polymerase chain reaction and Western blot analysis showed that the production of mRNA and protein of human beta-defensin (HBD)-1 were significantly decreased by acid exposure at pH 3.0-5.0. In contrast, acid exposure did not change the production of mRNA and protein of HBD-2 and beta-actin mRNA. These results indicate that acid exposure, even with moderate acidity, may inhibit the production of bactericidal molecules, including HBD-1, in airway epithelial cells. Acid exposure may reduce bactericidal activity of ASL in human airway epithelial cells and may increase susceptibility of the airway to bacterial infection.
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Affiliation(s)
- Katsutoshi Nakayama
- Department of Geriatric and Respiratory Medicine, Tohoku University School of Medicine, Sendai, Japan
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Miyazaki Y, Arakawa M, Kizu J. Introduction of simple swallowing ability test for prevention of aspiration pneumonia in the elderly and investigation of factors of swallowing disorders. YAKUGAKU ZASSHI 2002; 122:97-105. [PMID: 11828754 DOI: 10.1248/yakushi.122.97] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Aspiration pneumonia is a major cause of death in the elderly. In this study, a water swallowing test was introduced as a method of evaluating the swallowing ability of patients, and a swallowing ability evaluation team investigated an appropriate procedure and evaluation method for the situation of our hospital. We also investigated the relationship between the swallowing ability of patients examined by the water swallowing test and underlying diseases, complications, and medicated drugs. In the water swallowing test, the water-drinking method was fixed, and evaluation was made based on the time required for drinking, profile, and episodes, by which patients suspected of swallowing disorder were detected, confirming the usefulness of this method. The frequency of developing swallowing disorder was significantly higher in patients with cerebrovascular disorders, Parkinson's syndrome (p < 0.01, respectively) and symptomatic epilepsy, hypertension (p < 0.05, respectively) as underlying disease/complication. Regarding medicated drugs, H2 blockers were related to swallowing disorder (p < 0.05). It was confirmed that patients who were judged as having swallowing disorder (including suspected cases) by the water swallowing test, and patients with underlying diseases and complication that may cause the disorder, and patients medicated with drugs that may affect the swallowing ability require appropriate management by medical care staff.
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Affiliation(s)
- Yoshiko Miyazaki
- Sakamoto Dai-2 Hospital, 1-3438 Osoki, Ohme, Tokyo 198-0003, Japan
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