Silent Aspiration: What Do We Know?

A systematic review and meta-analysis of acupuncture in aspiration caused by post-stroke dysphagia

Objective

This systematic review and meta-analysis aims to systematically evaluate the effectiveness and safety of acupuncture in the treatment of aspiration caused by post-stroke dysphagia.

Methods

A computer search was conducted in nine databases, including the China National Knowledge Infrastructure (CNKI), China Science and Technology Journal (VIP), Wan-fang Database, China Biomedical Literature Database (CBM), PubMed, Web of Science, Cochrane Library, Embase, and Chinese Clinical Trial Registry (ChiCTR), from their inception until April 2024. Clinical randomized controlled trials comparing acupuncture combined therapy or single therapy with control interventions for the treatment of aspiration caused by post-stroke dysphagia were included. The primary outcome measure was the Penetration Aspiration Scale (PAS), and secondary outcome measures included the overall effective rate, video fluoroscopic swallowing study (VFSS), and hyoid bone displacement. The statistical analysis was performed using RevMan 5.3 and Stata 16.0.

Results

A total of 16 articles involving 1,284 patients were included. The meta-analysis results showed that acupuncture combined therapy or single therapy was more effective in improving PAS scores compared to conventional rehabilitation therapy or balloon dilation of the catheter [WMD = -1.05, 95% CI (-1.30, -0.80), Z = 0.82, p = 0.00 < 0.05]. It was also more effective in improving VFSS scores [WMD = 1.32, 95% CI (0.08, 2.55), Z = 2.09, p = 0.04 < 0.05] and hyoid bone displacement [WMD = 2.02, 95% CI (0.86, 3.18), Z = 3.41, p = 0.00 < 0.05]. Additionally, acupuncture had a higher overall effective rate [WMD = 1.21, 95% CI (1.14, 1.29), Z = 5.76, p = 0.00 < 0.05] and a lower incidence of adverse events. Sensitivity analysis indicated that the literature had minimal impact on the results, and bias tests showed no publication bias.

Conclusion

Acupuncture combined therapy and acupuncture single therapy can effectively improve aspiration caused by post-stroke dysphagia with a low incidence of adverse events. However, due to the low quality of the included literature, more high-quality randomized controlled trials are still needed to confirm the effectiveness and safety of acupuncture in the treatment of aspiration caused by post-stroke dysphagia.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023462707, identifier CRD42023462707.

Well-Established and Traditional Use of Vegetal Extracts as an Approach to the "Deep Roots" of Cough

Cough is a common presenting symptom for patients in a primary care setting and significantly impacts a patient's quality of life. Cough involves a complex reflex arc beginning with the stimulation of sensory nerves that function as cough receptors that stimulate the cough center in the brain. This "cough center" functions to receive these impulses and produce a cough by activating efferent nervous pathways to the diaphragm and laryngeal, thoracic, and abdominal musculature. Drugs that suppress the neural activity of cough are non-specific as those treatments are not directed toward pathogenic causes such as inflammation and oxidative stress. Moreover, they block a reflex called the watchdog of the lung and have a defense mechanism. Acute respiratory infections of the upper and lower airways most commonly cause acute cough. In contrast, the most common causes of chronic cough are upper airway cough syndrome, asthma, and gastroesophageal reflux disease, all associated with an inflammatory reaction at the level of the cough receptors. The use of natural compounds or herbal drugs such as carob syrup, dry blackcurrant extract, dry extract of caraway fruit, dry extract of ginger rhizome, dry extract of marshmallow root, and dry extract of ivy leaves, to name a few, not only have anti-inflammatory and antioxidant activity, but also act as antimicrobials, bronchial muscle relaxants, and increase gastric motility and empty. For these reasons, these natural substances are widely used to control cough at its deep roots (i.e., contrasting its causes and not inhibiting the arch reflex). With this approach, the lung watchdog is not put to sleep, as with peripheral or central inhibition of the cough reflex, and by contrasting the causes, we may control cough that viruses use at self-advantage to increase transmission.

Screening of aspiration pneumonia using the modified Mallampati classification tool in older adults

Pneumonia is a major cause of morbidity and mortality in older adults. In the aging society, screening methods for predicting aspiration pneumonia are crucial for its prevention. Changes in the oropharyngeal morphology and hyoid bone position may increase the risk of aspiration pneumonia. This multicenter study aimed to investigate a simple and effective screening method for predicting dysphagia and aspiration pneumonia. Overall, 191 older adults (aged 65 years or older) were randomly sampled using the simple random sampling technique. Oropharyngeal morphology was assessed using the modified Mallampati classification, which reflects the size of the tongue in the oropharyngeal cavity. The hyoid position was measured as the distance between the menton and laryngeal prominence to evaluate aging-related changes in the muscles of the laryngopharynx. Dysphagia was assessed using the repetitive saliva swallowing test (RSST), which measures the number of swallowing movements in 30 seconds; dysphasia is defined as less than 3 swallowing movements in 30 seconds. The aspiration signs were assessed based on history of choking or coughing reflex during eating or drinking and medical history of pneumonia. The study findings revealed that the modified Mallampati classification was significantly correlated with a medical history of pneumonia. A higher incidence of pneumonia was evident in the lower Mallampati classification, which shows the smaller size of the tongue base in the oropharyngeal cavity. The results of this study suggest that the modified Mallampati classification may be a possible screening method to predict the occurrence of pneumonia.

Incidence and characteristics of aspiration pneumonia in the Nagasaki Prefecture from 2005 to 2019

BACKGROUND

Aspiration pneumoniae remains a major health concern, particularly in the older population and has poor prognosis; however, the concept itself remains vague worldwide. This study aimed to determine the actual situation and characteristics of aspiration pneumonia from 2005 to 2019 in Nagasaki Prefecture, Japan.

METHODS

Cases of aspiration pneumonia that occurred in the Nagasaki Prefecture between 2005 and 2019 were analyzed using emergency transportation records. The number of occurrences and incidence were analyzed according to age, sex, month, day of the week, and recognition time to clarify the actual situation of aspiration pneumonia.

RESULTS

The total number of new aspiration pneumonia cases was 8,321, and the mean age of the patients was 83.0 years. Annual incidence per 100,000 population increased from 12.4 in 2005 to 65.1 in 2019, with the most prominent increase in the ≥ 80-year-old stratum. Males (55.1%) were more commonly affected than females (44.9%), and 82.2% of the cases involved patients aged ≥ 70 years. No significant correlations were observed between the incidence of aspiration pneumonia and season, month, or day of the week. Aspiration pneumonia occurred frequently in houses (39.8%) and facilities for elderly individuals (40.8%). At 7 days after admission, 80.9% of patients were still hospitalized and 6.5% had died.

CONCLUSIONS

The incidence of aspiration pneumonia with risks of severity and mortality is increasing among elderly individuals. Valid preventive measures are urgently needed based on the findings that the disease occurs in both household and elderly care facility settings, regardless of the season.

Dysphagia is associated with increased mortality risk after hip fracture surgery

PURPOSE

This study aims to explore the prevalence of dysphagia, as well as mortality associated with dysphagia in the elderly population receiving surgical treatment for a hip fracture.

METHODS

A retrospective cohort study was completed at an academic level 1 tertiary care center. Patients older than or equal to 65 admitted with a hip fracture diagnosis from January 2015 to December 2020 (n = 617) were included. The main outcome was the prevalence of dysphagia and association with mortality. Secondary analysis included timing of dysphagia and contributions to mortality.

RESULTS

Fifty-six percent of patients had dysphagia, and the mortality rates were higher in patients with dysphagia (8.9%) versus those without dysphagia (2.6%), chi-square p = 0.001, and odds ratio 3.69 (CI 1.6-8.5). Mortality rates in patients with acute dysphagia were also higher (12.4%) than those with chronic dysphagia (5%) and chi-squared p = 0.02. Mortality rates in patients with a perioperative dysphagic event (13.9%) were higher than those with non-perioperative dysphagia (4%) and chi-squared p = 0.001. Mortality rates in patients who had acute perioperative dysphagia (21.2%) were higher than those with chronic dysphagia that presented perioperatively (6.8%) and chi-squared p = 0.006.

CONCLUSIONS

This study demonstrates high rates of dysphagia in the elderly hip fracture population and a significant association between dysphagia and mortality. Timing and chronicity of dysphagia were relevant, as patients with acute perioperative dysphagia had the highest mortality rate. Unlike other identified risk factors, dysphagia may be at least partially modifiable. More research is needed to determine whether formal evaluation and treatment of dysphagia lowers mortality risk.

Clinical Features and Voxel-Based-Symptom-Lesion Mapping of Silent Aspiration in Acute Infratentorial Stroke

Post-stroke dysphagia (PSD) is a severe and common complication after ischemic stroke. The role of silent aspiration as an important contributing factor in the development of a dysphagia-associated complications, in particular aspiration-associated pneumonia has been insufficiently understood. The aim of this study was to investigate the characteristics and risk factors of silent aspiration in patients with acute infratentorial stroke by FEES and to identify culprit lesions in stroke patient with a high risk of silent aspiration via voxel-based-symptom-lesion mapping (VBS/ML). This study is a retrospective observational study based on a prospectively collected FEES and stroke database. Consecutive patient cases with acute ischemic infratentorial stroke and FEES examination between 2017 and 2022 were identified. Group allocation was performed based on PAS scores. Imaging analysis was performed by manual assignment and by VBS/ML. Group comparisons were performed to assess silent aspiration characteristics. Binary logistic regression analysis was performed to determine if baseline clinical, demographic, and imaging parameters were helpful in predicting silent aspiration in patients. In this study 84 patient cases with acute infratentorial stroke who underwent FEES examination were included. Patients were moderately affected at admission (mean NIH-SS score at admission 5.7 SD ± 4.7). Most lesions were found pontine. Overall 40.5% of patients suffered from silent aspiration, most frequently in case of bilateral lesions. Patients with silent aspiration had higher NIH-SS scores at admission (p < 0.05), had a more severe swallowing disorder (p < 0.05) and were 4.7 times more likely to develop post-stroke pneumonia. Patients who underwent FEES examination later than 72 h after symptom onset were significantly more likely to suffer from silent aspiration and to develop pneumonia compared to patients who underwent FEES examination within the first 72 h (p < 0.05). A binary logistic regression model identified NIH-SS at admission as a weak predictor of silent aspiration. Neither in manual assignment of the lesions to brain regions nor in voxel-wise statistic regression any specific region was useful in prediction of silent aspiration. Silent aspiration is common in patients with infratentorial stroke and contributes to the risk for pneumonia. Patients with silent aspiration are more severely affected by stroke, but cannot reliably be identified by NIH-SS at admission or lesion location. Patients suffering from acute infratentorial stroke should been screened and examined for PSD and silent aspiration.

Predictive Value of Laryngeal Penetration to Aspiration in a Cohort of Pediatric Patients

Videofluoroscopic swallow studies (VFSS) provide dynamic assessment of the phases of swallowing under fluoroscopic visualization and allow for identification of abnormalities in the process, such as laryngeal penetration and aspiration. While penetration and aspiration both reflect degrees of swallowing dysfunction, the predictive potential of penetration for subsequent aspiration is not fully elucidated in the pediatric population. As a result, management strategies for penetration vary widely. Some providers may interpret any depth or frequency of penetration as a proxy for aspiration and implement various therapeutic interventions (e.g., modification of liquid viscosity) to eliminate penetration episodes. Some may recommend enteral feeding given the presumed risk of aspiration with penetration, even when aspiration is not identified during the study. In contrast, other providers may advise continued oral feeding without modification even when some degree of laryngeal penetration is identified. We hypothesized that the depth of penetration is associated with the likelihood of aspiration. Identification of predictive factors for aspiration following laryngeal penetration events has significant implications for selection of appropriate interventions. We performed a retrospective cross-sectional analysis of a random sample of 97 patients who underwent VFSS in a single tertiary care center over a 6 month period. Demographic variables including primary diagnosis and comorbidities were analyzed. We examined the association between aspiration and degrees of laryngeal penetration (presence or absence, depth, frequency) across diagnostic categories. Infrequent and shallow penetration events of any type of viscosity were less likely to be associated with aspiration event(s) during the same clinical encounter regardless of diagnosis. In contrast, children with consistent deep penetration of thickened liquids invariably demonstrated aspiration during the same study. Our findings show that shallow, intermittent laryngeal penetration of any viscosity type on VFSS was not consistent with clinical aspiration. These results provide further evidence that penetration-aspiration is not a uniform clinical entity and that nuanced interpretation of videofluoroscopic swallowing findings is necessary to guide appropriate therapeutic interventions.

A multicenter cross-sectional survey of the knowledge, attitude, and behaviour of nurses regarding dysphagia after anterior cervical spine surgery: a prospective multicentre study

BACKGROUND

The incidence of dysphagia after anterior cervical spine surgery is high, which directly affects the quality of life of patients after surgery. The knowledge, attitude, and behavior of nurses can affect the identification and management of patients after anterior cervical spine surgery. Therefore, we need a survey to understand the current status of nurses' knowledge, attitude, and behavior towards dysphagia after anterior cervical spine surgery.

OBJECTIVE

To investigate the knowledge, attitude, and behaviour of orthopaedic nurses towards patients with dysphagia after anterior cervical spine surgery and provide recommendations for management and intervention.

METHOD

An online cross-sectional survey was conducted between March and June 2023, which among 894 orthopaedic nurses from 36 tertiary hospitals in Chongqing using a questionnaire. The questionnaire included general information and knowledge, attitudes, and behaviours related to the management of dysphagia after anterior cervical surgery.

RESULTS

The orthopaedic nurses' mean score for dysphagia-related knowledge was 16.1 ± 3.640 (out of a total score of 30). The orthopaedic nurses' mean score for dysphagia-related attitude was 32.5 ± 4.623 (out of a total score of 40). The orthopaedic nurses' mean score for dysphagia-related behaviour was 43.6 ± 11.513 (out of a total score of 60). The results of statistical analysis showed that the dysphagia after anterior cervical spine surgery -related knowledge scores differed significantly among the nurses according to, education level, and training (P < 0.05). Correlation analysis showed that there was a positive correlation between the knowledge, attitude, and behaviour scores of neurological nurses and swallowing disorders after anterior cervical surgery (P < 0.05).

CONCLUSION

Targeted knowledge and skills training should be carried out to improve the rules and regulations for dysphagia after anterior cervical spine surgery. Multidisciplinary team cooperation is needed, and dietary service processes and management standards should be improved to improve the management ability of orthopaedic nurses for dysphagia after anterior cervical spine surgery.

Diagnostic accuracy of the 'Dysphagia Screening Tool for Geriatric Patients' (DSTG) compared to Flexible Endoscopic Evaluation of Swallowing (FEES) for assessing dysphagia in hospitalized geriatric patients - a diagnostic study

BACKGROUND

Oropharyngeal dysphagia is highly prevalent among hospitalized geriatric patients. The screening instruments used to date have been evaluated primarily in stroke patients. This diagnostic study aimed to validate a new screening instrument for oropharyngeal dysphagia, the 'Dysphagia Screening Tool for Geriatric Patients' (DSTG), as compared to one of the gold standards, flexible endoscopic evaluation of swallowing (FEES).

MATERIALS AND METHODS

Geriatric inpatients admitted to five geriatric hospitals in Germany were consecutively evaluated using both DSTG and FEES in random order and by different evaluators blinded to the results of the other evaluation. In the FEES examination, a score of more than 3 on Rosenbek's Penetration Aspiration Scale was considered evidence of clinically relevant oropharyngeal dysphagia. Sensitivity, specificity and further measures of test performance were calculated for DSTG.

RESULTS

The 53 volunteers recruited were on average 85 years of age, 56.6% were women. Twenty patients (37.7%) were diagnosed with dysphagia using FEES. Of these, 12 were screened as positive on DSTG. Of the 33 FEES negative patients, 4 tested positive on DSTG. The following test parameters were calculated for DSTG: sensitivity: 0.60, 95% confidence interval [0.39 ; 0.78], specificity 0.88 [0.73 ; 0.95], positive predictive value 0.75 [0.51 ; 0.90], negative predictive value 0.78 [0.63 ; 0.89], positive likelihood ratio 4.95 [1.85 ; 13.27], negative likelihood ratio 0.46 [0.26 ; 0.79]. In a receiver-operator characteristic (ROC) curve analysis, the area under the curve (AUC) was 0.77 [0.62 ; 0.91]. No adverse events occurred.

CONCLUSION

The DSTG appears to be a valid instrument for screening of oropharyngeal dysphagia in geriatric inpatients.

Impacts of body positions on the geniohyoid muscle contraction and swallowing difficulty in healthy adults

BACKGROUND

Body positions affect swallowing and gastroesophageal reflux. Swallowing impairment is one of the main causes of aspiration pneumonia. To prevent pneumonia, evaluation of body positions on gastroesophageal reflux recommended 30 degrees or higher semi-recumbent positions. The geniohypoid muscle and tongue play central roles in swallowing. However, the effects of body positions on contracting rates in the geniohyoid muscle and tongue pressure are unclear. Moreover, correlations between geniohyoid muscle contracting rates and subjective swallowing difficulties are unclear.

AIMS

This study aimed to identify the proper body positions on contracting rates in the geniohyoid muscle, tongue pressure, and subjective swallowing difficulties.

MATERIALS & METHODS

Twenty healthy adults swallowed 15- or 50 ml of water at 90 degrees sitting, 60- and 30 degrees semi-recumbent, and 0 degrees supine positions. We scored the subjective swallowing difficulties and measured the tongue pressure and the number of swallows. An ultrasound evaluated the geniohyoid muscle size and contracting rates.

RESULTS

At sitting and 60 degrees semi-recumbent positions, the geniohyoid muscle showed greter contracting rates than at 30 degrees semi-recumbent and supine postions (P < 0.05), which resulted in easier swalloiwng. Greater tongue pressure was weakly correlated with fewer swallows (r = -0.339, P = 0.002), whereas the body positions did not affect.

CONCLUSION

Considering swallowing and gastroesophageal reflux together, a trunk angle of 60 degrees or more might be beneficial for reducing the risk of aspiration.

Incidence and characteristics of aspiration pneumonia in adults in Beijing, China, 2011-2017

OBJECTIVES

This study aimed to estimate aspiration pneumonia (AP) incidence and describe comorbid characteristics and mortality in Beijing, China.

STUDY DESIGN

A historical cohort study was conducted based on medical claim records.

METHODS

Patients admitted with a primary diagnosis of AP were identified from approximately 12 million adults who enrolled in the Urban Employee Basic Medical Insurance program in Beijing, China, from January 2011 to December 2017. The incidences of AP and pneumonia with risk factors for aspiration (PRFA) were estimated by a Poisson distribution. The estimated annual percentage change was reported to represent the average percentage change in incidence per year. Characteristics and 6-month and 1-year all-cause mortality rates for AP and suspected AP patients were described and compared with community-acquired pneumonia (CAP).

RESULTS

The incidence rates of hospitalized AP and PRFA were 9.4 (95% confidence interval [CI]: 7.6, 11.3) and 102.9 (95% CI: 95.8, 110.3) per 100,000 person-years, respectively. The incidences increased rapidly with age and were stable across the observed years. Patients with AP and PRFA possessed a greater burden of comorbidities than CAP (mean age-adjusted Charlson comorbidity indices for AP: 7.72, PRFA: 7.83, and CAP: 2.84). The 6-month and 1-year all-cause mortality rates for those with AP and PRFA were higher than those for patients with CAP (6-month mortality, AP: 35.2%, PRFA: 21.8%, CAP: 11.1%; 1-year mortality, AP: 42.7%, PRFA: 26.6%, CAP: 13.2%).

CONCLUSIONS

The incidence of AP and PRFA in Beijing was reported, presenting a full picture of the disease burden. The results provide baseline information for AP prevention.

Poor Oral Health in the Etiology and Prevention of Aspiration Pneumonia

Aspiration pneumonia (AP), inflammation of the lung parenchyma initiated by aspirated microorganisms into the lower airways from proximal sites, including the oral cavity, is prevalent in, and problematic for, the elderly, especially those in institutions, and for those with several important risk factors. Many factors influence the pathogenesis of AP, including dysphagia, poor oral hygiene, diminished host defense, and underlying medical conditions. This article reviews the epidemiology, microbiology, pathogenesis, and prevention of AP, focusing on the role of poor oral health as a risk factor for, and on dental care for the prevention and management of, this important infection.

Prevalence of dysphagia following posterior fossa tumour resection in children: the Alder Hey experience

BACKGROUND

Surgery for posterior fossa tumours (PFTs) in children is associated with bulbar palsy and swallowing difficulties although this risk is not well defined in the literature and issues contributing to dysphagia following surgery are not fully understood.

AIMS

This study aims to study the eating, drinking and swallowing function of children following PFT resection in a specialist paediatric neurosurgery centre. This included the frequency and duration of dysphagia, the risk of aspiration and the link between tumour type and dysphagia.

MATERIALS AND METHODS

This is a retrospective review of children undergoing surgery for PFT between 2014 and 2019. Information was obtained from the patients' hospital and speech and language therapy (SLT) notes, oncology database and clinical letters. The International Dysphagia Diet Standardisation Initiative (IDDSI) Framework was used to describe food and fluid modifications.

RESULTS

Seventy children had surgery to resect a posterior fossa tumour at Alder Hey from 2014 to 2019. Thirty-one children were included in the study following referral to SLT. Videofluoroscopy (VF) was undertaken at our institution in 68% (21/31) of cases. Fifty-two percent (11/21) of children aspirated or were considered at risk, and 55% (6/11) of those who aspirated showed silent aspiration. After 3 months, 43% (13/30) still required modified food and/or fluid textures, with this proportion reducing as time progressed. By tumour type, VF was performed in 5/7 medulloblastoma patients with 3/5 showing aspiration and 3/3 silently aspirating; in 8/9 patients with ependymoma with 4/8 patients aspirating with 2/4 showing silent aspiration; and 6/12 glioma patients with 4/6 aspirating with 1/4 showing silent aspiration.

CONCLUSION

Swallowing difficulties, including silent aspiration, are an important complication of PFT resection. A proportion of children will need ongoing food and/or fluid modification. Further study into dysphagia following PFT resection is indicated.

Food-Grade Activated Charcoal for Contrast-Enhanced Photoacoustic Imaging of Aspiration: A Phantom Study

Aspiration pneumonia has the highest attributable mortality of all medical complications post-stroke, or in individuals with progressive neurological diseases. For optimum health outcomes for individuals with dysphagia, a non-invasive and convenient method for objectively detecting aspiration is needed. This study introduces a potential new aspiration screening method based on photoacoustic imaging (PAI), a medical imaging technology that measures the optical contrast of tissue rather than mechanical or elastic properties. In this preliminary study, a tissue-mimicking neck phantom was designed to test the performance of PAI for aspiration screening with a charcoal solution as a contrast agent. A 1064 nm wavelength light source was illuminated on the anterior of the neck phantom to induce the photoacoustic effect. The resulting photoacoustic signal of the charcoal contrast in the mock trachea was detected by a linear transducer array with a 2.25 MHz central ultrasound frequency. The phantom results showed that charcoal solution at 10 mg/ml exhibited strong photoacoustic signals when flowing into the phantom trachea. By overlaying the photoacoustic signals of the charcoal contrast on top of the ultrasound image, we were able to simultaneously visualize the movement of food contrast and a cross-section of tissue structures during mock swallowing. Moreover, we confirmed the ability to detect the flow of charcoal contrast at a small bolus volume of ~ 7 μl through the phantom, suggesting high sensitivity to detect small aspiration events. The study suggests that PAI holds promise to be developed as an aspiration detection tool with charcoal powder as a contrast agent.

Difficult intubation and postoperative aspiration pneumonia associated with Moebius syndrome: a case report

Background

Moebius syndrome is a rare congenital disorder characterized by non-progressive palsy of the abducens (VI) and facial (VII) cranial nerves. Its common features include dysfunctions associated with other cranial nerves, orofacial abnormalities, skeletal muscle hypotonia, and other systemic disorders of differing severities. There are several concerns in the perioperative management of patients with Moebius syndrome.

Case presentation

We present a report on the management of general anesthesia of a 14-year-old male patient with Moebius syndrome who was scheduled for mandibular cystectomy. The patient was diagnosed with Moebius syndrome at the age of 7 years based on his clinical manifestations of nerve palsy since birth and cranial nerve palsy of the trigeminal (V), facial (VII), glossopharyngeal (IX), vagus (X), and sublingual nerves (XII). The patient’s oral morphological abnormalities made intubation difficult. He also experienced dysphagia and aspiration pneumonia on a daily basis. Oral secretions were frequently suctioned postoperatively. However, after discharge, the patient developed aspiration pneumonia and was readmitted to the hospital.

Conclusions

The main problem arising when administering general anesthesia to patients with this syndrome is difficult airway management. The oral abnormalities in these patients, such as small jaw and extreme dental stenosis, make mask ventilation and intubation difficult. Furthermore, this syndrome often involves respiratory impairment and dysphagia due to cerebral nerve palsy, so there is a high risk of postoperative respiratory complications. Since multiple organs are affected in patients with Moebius syndrome, appropriate perioperative management strategies must be prepared for these patients.

Atypical Presentation of Pill Aspiration in Older Adults with Dysphagia: A Picture Not To Be Forgotten

Nonconventional clinical presentations of diseases are common in older adults. Even dramatic events, such as foreign body (FB) inhalation, can occur in a subtle and non-specific manner. Pill aspiration is a rare yet overlooked cause of airway injury. It accounts for approximately 7% of all FB aspirations. In contrast, oral dysphagia and polypharmacology, mainly administrated in solid oral dosage forms (SDOF), like tablets and pills, are common conditions in older adults. Herein, we present a case of SDOF aspiration in a 78-year-old man. FB inhalation developed with general clinical deterioration and neurological impairment (delirium) rather than overt respiratory symptoms. Bronchoscopy provided remarkable images of this unexpected finding. Caregivers and healthcare workers must be aware of the risk of SDOF aspiration and adopt proper safety measures. Early recognition and bronchoscopy for diagnostic and therapeutic purposes can be lifesaving in such cases.

Phenotypic expression of swallowing function in Niemann-Pick disease type C1

Background

Niemann–Pick disease type C1 (NPC1) is a rare autosomal recessive disease characterized by endolysosomal accumulation of unesterified cholesterol with progressive deterioration in swallowing, often leading to premature death. Although documented, the natural history of NPC1 swallowing dysfunction has yet to be delineated systematically. This manuscript aims to provide a comprehensive characterization of the phenotypic spectrum and progression of swallowing dysfunction in NPC1.

Methodology

The National Institutes of Health (NIH) NPC1 natural history study (NCT00344331) enrolled 120 patients, who underwent comprehensive interpretative swallow assessments for swallowing safety, dietary modifications, and aspiration risk. Longitudinal statistical modeling accounted for all outcomes with NPC1 disease covariates (first symptom onset, age at neurological symptom onset, seizure history, duration of neurological symptoms) as well as miglustat use (a glucosylceramide synthase inhibitor) and NIH study duration (NIHSD; the length of time an individual participated in the NIH study). Probabilities for disease progression and time to swallowing decline were conducted for the entire cohort.

Results

Time to swallowing decline with American Speech-Language-Hearing Association National Outcome Measure (ASHA-NOMS) and the NIH-adapted Penetration Aspiration Scale (NIH-PAS) were identified: \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\frac{7.7}{100}$$\end{document}7.7100 person-years and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\frac{9.8}{100}$$\end{document}9.8100 person-years, respectively. NIHSD and seizure history consistently and significantly were associated with decline (OR_NIHSD = 1.34–2.10, 95% CI 1.04–3.4, p = 0.001–0.026; OR_Seizure = 3.26–18.22, 1.03–167.79; p = 0.001–0.046), while miglustat use revealed protection (OR_Miglustat = 0.01–0.43, 0.007–0.98; p = 0.001–0.044). The probability of decline with NPC1 neurological severity scale and annual severity increment scale were established with the aforementioned covariates, varying amongst subgroups.

Conclusion

This study represents the most extensive collection of prospective, instrumental swallowing assessments in NPC1 to date with an interpretive analysis providing an improved understanding of NPC1 disease progression with swallowing function—serving as a foundation for clinical management and future NPC1 therapeutics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-022-02472-w.

Swallowing and aspiration during sleep in patients with obstructive sleep apnea versus control individuals

Study Objectives

There are only a few reports on voluntary swallowing during sleep; therefore, this study aimed to propose a method for observing voluntary swallowing during sleep using polysomnography. The frequency of voluntary swallowing during sleep and the factors related to swallowing and aspiration during sleep were investigated.

Methods

Polysomnography records of 20 control subjects and 60 patients with obstructive sleep apnea (OSA) (mild, moderate, and severe groups; n = 20 each) were collected. Simultaneous increases in the electromyographic potentials of the submental and masseter muscles, termed coactivation, and declining oronasal airflow (SA) were extracted as “swallowing.” The cough reflex that occurred during sleep was extracted as “aspiration.” The frequency of swallowing events was compared among the different OSA severity groups. Subsequently, a multivariate regression analysis was performed.

Results

The average frequency of coactivation with SA in control subjects was 4.1 events/h and that without SA was 1.7 events/h. These frequencies increased with the severity of OSA during non-REM sleep. The distance of the hyoid to the Frankfurt plane was associated with the frequency of coactivation with (β = 0.298, p = 0.017) as well as without SA (β = 0.271, p = 0.038). The frequency of coactivation without SA was associated with aspiration (B = 0.192, p = 0.042).

Conclusions

Our data provide new insights into the relationship between swallowing and aspiration during sleep. We found that the longer the distance from the hyoid bone to the Frankfurt plane, the higher the coactivation without SA, which could lead to aspiration during sleep.

Clinical Trials

Retrospective observational study of swallowing during sleep in obstructive sleep apnea patients using polysomnography, https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000050460, UMIN000044187.

A Preliminary Investigation of Similarities of High Resolution Cervical Auscultation Signals Between Thin Liquid Barium and Water Swallows

Dysphagia, commonly referred to as abnormal swallowing, affects millions of people annually. If not diagnosed expeditiously, dysphagia can lead to more severe complications, such as pneumonia, nutritional deficiency, and dehydration. Bedside screening is the first step of dysphagia characterization and is usually based on pass/fail tests in which a nurse observes the patient performing water swallows to look for dysphagia overt signs such as coughing. Though quick and convenient, bedside screening only provides low-level judgment of impairment, lacks standardization, and suffers from subjectivity. Recently, high resolution cervical auscultation (HRCA) has been investigated as a less expensive and non-invasive method to diagnose dysphagia. It has shown strong preliminary evidence of its effectiveness in penetration-aspiration detection as well as multiple swallow kinematics. HRCA signals have traditionally been collected and investigated in conjunction with videofluoroscopy exams which are performed using barium boluses including thin liquid. An HRCA-based bedside screening is highly desirable to expedite the initial dysphagia diagnosis and overcome all the drawbacks of the current pass/fail screening tests. However, all research conducted for using HRCA in dysphagia is based on thin liquid barium boluses and thus not guaranteed to provide valid results for water boluses used in bedside screening. If HRCA signals show no significant differences between water and thin liquid barium boluses, then the same algorithms developed on thin liquid barium boluses used in diagnostic imaging studies, it can be then directly used with water boluses. This study investigates the similarities and differences between HRCA signals from thin liquid barium swallows compared to those signals from water swallows. Multiple features from the time, frequency, time-frequency, and information-theoretic domain were extracted from each type of swallow and a group of linear mixed models was tested to determine the significance of differences. Machine learning classifiers were fit to the data as well to determine if the swallowed material (thin liquid barium or water) can be correctly predicted from an unlabeled set of HRCA signals. The results demonstrated that there is no systematic difference between the HRCA signals of thin liquid barium swallows and water swallows. While no systematic difference was discovered, the evidence of complete conformity between HRCA signals of both materials was inconclusive. These results must be validated further to confirm conformity between the HRCA signals of thin liquid barium swallows and water swallows.

Predicting feeding-tube dependence in patients following endotracheal extubation: a two-item swallowing screen

BACKGROUND

To meet the surging demands for intubation and invasive ventilation as more COVID-19 patients begin their recovery, clinicians are challenged to find an ultra-brief and minimally invasive screen for postextubation dysphagia predicting feeding-tube dependence persisting for 72 h after extubation.

METHODS

This study examined the predictive validity of a two-item swallowing screen on feeding-tube dependence over 72 h in patients following endotracheal extubation. Intensive-care-unit (ICU) patients (≥ 20 years) successfully extubated after ≥ 48 h endotracheal intubation were screened by trained nurses using the swallowing screen (comprising oral stereognosis and cough-reflex tests) 24 h postextubation. Feeding-tube dependence persisting for 72 h postextubation was abstracted from the medical record by an independent rater. To verify the results and cross-check whether the screen predicted penetration and/or aspiration during fiberoptic endoscopic evaluation of swallowing (FEES), participants agreeing to receive FEES were analyzed within 30 min of screening.

RESULTS

The results showed that 95/123 participants (77.2%) failed the screen, which predicted ICU patients' prolonged (> 72 h) feeding-tube dependence, yielding sensitivity of 0.83, specificity of 0.35, and accuracy of 0.68. Failed-screen participants had 2.96-fold higher odds of feeding-tube dependence (95% CI, 1.13-7.76). For the 38 participants receiving FEES, the swallowing screen had 0.89 sensitivity to detect feeding-tube dependence and 0.86 sensitivity to predict penetration/aspiration, although specificity had room for improvement (0.36 and 0.21, respectively).

CONCLUSION

This ultra-brief swallowing screen is sufficiently sensitive to identify high-risk patients for feeding-tube dependence persisting over 72 h after extubation. Once identified, a further assessment and care are indicated to ensure the prompt return of patients' oral feeding.

TRIAL REGISTRATION

NCT03284892, registered on September 15, 2017.

Laryngeal sensation and its association with aspiration and cough in children with neurological impairment

BACKGROUND

Aspirations are frequent in children with neurological impairment. They significantly increase the risk for acute and chronic respiratory insufficiencies leading to high morbidity and mortality. Laryngeal sensation deficits have been linked to aspirations in adults and are a suspected cause for dysphagia in children. In a similar neurological circuit as swallowing, laryngeal receptors trigger coughing as a protective airway reflex. The aim of this study was to examine the association between impaired laryngeal sensation (ILS), aspiration, and coughing in neurologically impaired children.

DESIGN AND METHODS

In a retrospective study, 110 children with suspected dysphagia underwent a clinical evaluation of swallowing and a flexible endoscopic evaluation of swallowing (FEES) between 2013 and 2019 in the children's university clinic Düsseldorf were analyzed. Laryngeal sensation was tested by the endoscopic touch method. Associations were computed using χ² -test.

RESULTS

Fifty-four patients (49.1%) had a neurological impairment, 56 patients (50.9%) had no or other comorbidities and served as a control cohort. Children with neurological impairment suffered from ILS significantly more often than children with no or other comorbidities (χ²(1) = 4.63, p = .031). ILS was associated with all other FEES variables but did not correlate with coughing. The symptom coughing correlated with aspiration in the group of neurologically impaired children and in children ILS.

CONCLUSION

ILS is a potential cause of aspirations in children with neurological impairment. Physicians need to pay special attention to the occurrence of coughing in children with neurological impairment and/or ILS since it signals aspirations that took place.

Advanced Machine Learning Tools to Monitor Biomarkers of Dysphagia: A Wearable Sensor Proof-of-Concept Study

Introduction

Difficulty swallowing (dysphagia) occurs frequently in patients with neurological disorders and can lead to aspiration, choking, and malnutrition. Dysphagia is typically diagnosed using costly, invasive imaging procedures or subjective, qualitative bedside examinations. Wearable sensors are a promising alternative to noninvasively and objectively measure physiological signals relevant to swallowing. An ongoing challenge with this approach is consolidating these complex signals into sensitive, clinically meaningful metrics of swallowing performance. To address this gap, we propose 2 novel, digital monitoring tools to evaluate swallows using wearable sensor data and machine learning.

Methods

Biometric swallowing and respiration signals from wearable, mechano-acoustic sensors were compared between patients with poststroke dysphagia and nondysphagic controls while swallowing foods and liquids of different consistencies, in accordance with the Mann Assessment of Swallowing Ability (MASA). Two machine learning approaches were developed to (1) classify the severity of impairment for each swallow, with model confidence ratings for transparent clinical decision support, and (2) compute a similarity measure of each swallow to nondysphagic performance. Task-specific models were trained using swallow kinematics and respiratory features from 505 swallows (321 from patients and 184 from controls).

Results

These models provide sensitive metrics to gauge impairment on a per-swallow basis. Both approaches demonstrate intrasubject swallow variability and patient-specific changes which were not captured by the MASA alone. Sensor measures encoding respiratory-swallow coordination were important features relating to dysphagia presence and severity. Puree swallows exhibited greater differences from controls than saliva swallows or liquid sips (p < 0.037).

Discussion

Developing interpretable tools is critical to optimize the clinical utility of novel, sensor-based measurement techniques. The proof-of-concept models proposed here provide concrete, communicable evidence to track dysphagia recovery over time. With refined training schemes and real-world validation, these tools can be deployed to automatically measure and monitor swallowing in the clinic and community for patients across the impairment spectrum.

The role of the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke (GLOBE-3S) in the prevention of stroke-associated pneumonia (SAP)

Background and purpose

Stroke-associated pneumonia (SAP) affects 10 to 38% of patients in the acute phase of stroke. Stroke patients diagnosed with dysphagia have an 11-fold higher risk of developing SAP. Thus, identifying dysphagic patients through a highly accurate screening tool might be crucial in reducing the incidence of SAP. We present a case–control study designed to evaluate efficacy in reducing the risk of SAP between two swallowing screening tools, the classic water swallow test (WST) and a recently validated tool such as the GLOBE-3S (the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke), which is a highly sensitive swallowing screening tool particularly accurate in detecting silent aspiration as well.

Methods

We analyzed the occurrence of dysphagia in 100 acute stroke patients distributed in two groups: half were screened with WST and the other half with GLOBE-3S.

Results

Dysphagia was diagnosed in 28 patients. The main result is that, among patients who passed the dysphagia screenings, none of those screened with the GLOBE-3S method developed pneumonia compared to 31.82% in the WST group. Discriminant function analysis (DFA) showed that NIH Stroke Scale (NIHSS) score and the dysphagia screening method (i.e., GLOBE-3S vs. WST) were the two main factors in the SAP’s predicting model and the only significant ones per se.

Conclusions

The new GLOBE-3S screening test can reduce the risk of SAP compared to WST.

Cough-Inducing Method Using a Tartaric Acid Nebulizer for Patients with Silent Aspiration

The tartaric acid nebulizer is a well-known cough test to evaluate cough function. This study aimed to evaluate the effectiveness of a cough-inducing method using tartaric acid (CiTA). Patients with dysphagia examined by videofluoroscopic examination of swallowing (VF) at a single institution from May 2017 to August 2017 were included in this retrospective observational study. Although undergoing VF, patients who had aspirated without reflexively coughing or who had coughed insufficiently, were instructed to cough voluntarily. Patients who could not cough voluntarily or had expectorated insufficiently underwent the CiTA method. The rate of cough induction and the effectiveness of expectoration using the CiTA method were evaluated. One hundred fifty-four patients (mean age 69.2 ± 16.8 years) were evaluated. Eighty-seven patients aspirated during VF. Of those patients, 15 were able to expectorate via the cough reflex, 18 were able to expectorate with a voluntary cough, and 12 required suctioning for removal of aspirated material. The remaining 42 patients underwent the CiTA method. Thirty-eight patients (90.4%) could reflexively cough, and 30 (71.4%) could expectorate the aspirated material. This novel method, CiTA, was effective for cough induction in patients with dysphagia, especially for those with silent aspiration.

Gold Standard? Method of Citric Acid Solution Swallowing Test as a Screening Test for Patients with Tracheostomy

This study aimed to apply various ranges of citric acid levels in the mouth and T-cannula to compare the validity with instrumental aspiration measures in patients with tracheostomy. Sixty-one patients underwent the citric acid cough reflex test (CRT) and videofluoroscopic swallowing study (VFSS). Citric acid was delivered via facemask and T-cannula at concentrations of 0.4 mol/L, 0.6 mol/L, and 0.8 mol/L. Further, we recorded the coughing count and presence of ≥ 2 (C2) and ≥ 5 (C5) coughs. CRT via facemask at 0.4 mol/L C2, 0.6 mol/L C5, and 0.8 mol/L C2 and C5 were significantly associated with the presence of tracheal aspiration during VFSS. The sensitivity and specificity were optimized at 0.8 mol/L C2 for mouth inhalation and at 0.8 mol/L C5 for T-cannula inhalation. There was a significant difference in the coughing count during CRT at 0.4 mol/L and 0.8 mol/L via mouth inhalation between patients with or without tracheal aspiration, but not via T-cannula. The AUC for 0.8 mol/L facemask inhalation was 0.701. The optimal cut-off value of coughing count was thrice with 84.62% sensitivity and 50.00% specificity on the ROC curve. Afferent sensory nerve desensitization around and below the tracheostomy site could affect coughing reflex initiation and decrease the sensitivity of detecting aspiration in tracheotomized patients. The citric acid CRT via facemask can reliably detect tracheal aspiration and presence of coughing reflex compared to that via T-cannula in patients with tracheostomy.

Best Practice Recommendations for Stroke Patients with Dysphagia: A Delphi-Based Consensus Study of Experts in Turkey-Part I: Management, Diagnosis, and Follow-up

Dysphagia is one of the most common and important complications of stroke. It is an independent marker of poor outcome after acute stroke and may become chronic after the acute period and continues to affect all aspects of the patient's life. Patients with stroke may encounter any of the medical branches in the emergency room or outpatient clinic, and as in our country, there may not be specialists specific for dysphagia, such as speech-language pathologists (SLP), in every hospital. This study aimed to raise awareness and create a common opinion of medical specialists for stroke patients with dysphagia. This recommendation paper has been written by a multidisciplinary team and offers 45 recommendations for stroke patients with dysphagia. It was created using the eight-step Delphi round via e-mail. This study is mostly specific to Turkey. However, since it contains detailed recommendations from the perspective of various disciplines associated with stroke, this consensus-based recommendation paper is not only a useful guide to address clinical questions in practice for the clinical management of dysphagia in terms of management, diagnosis, and follow-up, but also includes detailed comments for these topics.

Poor Oral Health in the Etiology and Prevention of Aspiration Pneumonia

Aspiration pneumonia (AP), inflammation of the lung parenchyma initiated by aspirated microorganisms into the lower airways from proximal sites, including the oral cavity, is prevalent in, and problematic for, the elderly, especially those in institutions, and for those with several important risk factors. Many factors influence the pathogenesis of AP, including dysphagia, poor oral hygiene, diminished host defense, and underlying medical conditions. This article reviews the epidemiology, microbiology, pathogenesis, and prevention of AP, focusing on the role of poor oral health as a risk factor for, and on dental care for the prevention and management of, this important infection.

Correlation Between EAT-10 and Aspiration Risk Differs by Dysphagia Etiology

Agreement between self-reported dysphagic symptoms and actual swallowing physiology can vary widely across individuals. The Eating Assessment Tool-10 (EAT-10) is a self-report questionnaire commonly used to identify individuals with oropharyngeal dysphagia, but its interpretation for highly prevalent populations is poorly defined. Our primary objective was to determine if correlation strength between EAT-10 and Penetration-Aspiration Scale (PAS) scores differed by dysphagia etiology. Our secondary objective was to identify clinical factors that were associated with a mismatch between EAT-10 scores and videofluoroscopic findings. Outpatients with Parkinson disease (PD), stroke, and/or head and neck cancer (HNC) who completed EAT-10 and underwent videofluoroscopy were included (n = 203). EAT-10/PAS correlations were calculated by dysphagia etiology. We found that across the sample, higher EAT-10 scores were significantly correlated to higher PAS scores (r_s = 0.31, p < 0.001). EAT-10 and PAS were moderately correlated in the HNC group (r_s = 0.41, p < 0.001, n = 87), but correlations were modest in the PD (r_s = 0.18, n = 41) and stroke groups (r_s = 0.12, n = 59). Clinical characteristics of individuals with a "matched" profile (normal EAT-10 score and normal swallow physiology) and a "mismatched" profile (normal EAT-10 score and abnormal swallow physiology) were also compared. Individuals with a "mismatched" EAT-10/PAS profile appeared to be significantly older and had a worse Charlson Comorbidity Index than individuals with a "matched" profile. Within the HNC subgroup, EAT-10/PAS correlations for specific tumor sites, treatment types, and time since treatment are reported. Clinicians may consider these aspiration risk profiles when making recommendations for instrumented swallowing assessment.

Effect of cognitive and motor dual-task on oropharyngeal swallowing in Parkinson's disease

BACKGROUND

Dysphagia frequently occurs in patients with Parkinson's disease (PD) and is associated with severe complications. However, the underlying pathology is poorly understood at present. This study investigated the effect of cognitive and motor dual-task interference on oropharyngeal swallowing in PD.

METHODS

Thirty PD patients (23 men, mean age 65.90 ± 9.32 years, mean Hoehn and Yahr stage 2.62 ± 0.81, mean UPDRS 18.00 ± 7.18) were examined using flexible endoscopic evaluation of swallowing (FEES). FEES was performed during three paradigms: at baseline without interference, during a cognitive dual-task, and during a motor dual-task. Oropharyngeal swallowing function was rated using a score which was validated to detect changes in PD related dysphagia. The three paradigms were compared using a two-way-repetitive-measures-ANOVA and a post-hoc-analysis.

RESULTS

Mean swallowing score in baseline FEES was 10.67 ± 5.89. It significantly increased (worsened) to 15.97 ± 7.62 (p < 0.001) in the motor dual-task and to 14.55 ± 7.49 (p < 0.001) in the cognitive dual-task. Premature bolus spillage and pharyngeal residue both significantly increased during both of the dual-task conditions whereas penetration/aspiration events did not change.

CONCLUSION

Oropharyngeal swallowing in patients with PD is not purely reflexive but requires mental capacity. Additional allocation of attentional resources in the central control of swallowing seems to be an effective compensatory mechanism in PD-related dysphagia: The proposed dual-task protocol may be useful to challenge swallowing functional reserve. Conversely, as a therapeutic strategy, it could be beneficial to focus attention on swallowing and to avoid dual-task situations.

Tough Pill to Swallow: Postextubation Dysphagia and Nutrition Impact in the Intensive Care Unit

More than 5 million patients are admitted to US intensive care units (ICUs) each year. Many of these patients have risk factors for dysphagia. Dysphagia must be promptly addressed and appropriately treated to avoid the deleterious impacts of aspiration and malnutrition. Therefore, clinicians must be aware of ways to identify and treat dysphagia. This review will highlight the risk factors, mechanisms, and impact of dysphagia in the ICU as well as provide screening, diagnostic, and management options.

Effects of cognitive and motor dual-tasks on oropharyngeal swallowing assessed with FEES in healthy individuals

Dysphagia is frequent in many neurological diseases and gives rise to severe complications such as malnutrition, dehydration and aspiration pneumonia. Therefore, early detection and management of dysphagia is essential and can reduce mortality. This study investigated the effect of cognitive and motor dual-task interference on swallowing in healthy participants, as dual-task effects are reported for other motor tasks such as gait and speech. 27 participants (17 females; 29.2 ± 4.1 years) were included in this prospective study and examined using flexible endoscopic evaluation of swallowing (FEES). Using a previously established FEES-based score, the paradigms "baseline swallowing", "cognitive dual-task" and "motor dual-task" were assessed. Scores of the three paradigms were compared using a repetitive measures ANOVA and post-hoc analysis. Mean baseline swallowing score in single task was 5 ± 3. It worsened to 6 ± 5 in the cognitive (p = 0.118), and to 8 ± 5 in the motor dual-task condition (p < 0.001). This change was driven by subclinical worsening of premature bolus spillage and pharyngeal residue. Oropharyngeal swallowing is not exclusively reflexive in nature but requires attention, which leads to motor dual-task interference. This has potential diagnostic and therapeutic implications, e.g. in the early screening for dysphagia or in avoiding dual-task situations while eating.

Professional dental cleaning in dogs: clinical routines among Swedish veterinarians and veterinary nurses

BACKGROUND

Dental disease is very common in dogs and veterinary professional dental cleaning and examination, together with daily dental home care, is the foundation for good dental health. To our knowledge, no previous study has investigated professional dental cleaning routines in small animal veterinary practice. A validated questionnaire survey was distributed to all veterinarians and veterinary nurses with registered e-mail addresses in the Swedish national registry (veterinarians; n = 3657, veterinary nurses; n = 1650). Response rates were 32% for veterinarians (V) and 38% for veterinary nurses (VN).

RESULTS

In total, 73% (V)/96% (VN) of respondents reported that professional dental cleaning was performed at their work place under general anesthesia, and 27% (V)/18% (VN) that dental cleaning was performed under sedation. Of the respondents, 43% (V)/96% (VN) considered regular dental cleaning under general anesthesia fairly or very important, and 49% (V)/47% (VN) stated that it was sometimes important for good dental health in dogs. A majority of respondents, 84% (V)/97% (VN), reported that dental extractions were performed at their clinic, and 72% (V)/90% (VN) had access to dental radiography equipment.

CONCLUSION

A majority of Swedish veterinarians and veterinary nurses perform professional dental cleaning under general anesthesia with access to dental radiography equipment, in accordance with national and international recommendations. However, a considerable proportion of professional dental cleanings were performed under sedation only, and extractions performed without access to dental radiography equipment were common, suggesting several areas of improvement in the routines in Swedish veterinary clinics and hospitals. Our results clearly indicate the need for improved educational efforts to increase the awareness among veterinary health professionals regarding guidelines and official recommendations in canine dental care.

Fiberoptic endoscopic evaluation of swallowing in early-to-advanced stage Huntington's disease

Huntington's disease (HD) is a neurodegenerative disorder characterized by motor disturbances, cognitive decline, and behaviour changes. A well-recognized feature of advanced HD is dysphagia, which leads to malnutrition and aspiration pneumonia, the latter being the primary cause of death in HD. Previous studies have underscored the importance of dysphagia in HD patients with moderate-to-advanced stage disease, but it is unclear whether dysphagia affects patients already at an early stage of disease and whether genetic or clinical factors can predict its severity. We performed fiberoptic endoscopic evaluation of swallowing (FEES) in 61 patients with various stages of HD. Dysphagia was found in 35% of early-stage, 94% of moderate-stage, and 100% of advanced-stage HD. Silent aspiration was found in 7.7% of early-stage, 11.8% of moderate-stage, and 27.8% of advanced-stage HD. A strong correlation was observed between disease progression and dysphagia severity: worse dysphagia was associated with worsening of motor symptoms. Dysphagia severity as assessed by FEES correlated with Huntington’s Disease Dysphagia Scale scores (a self-report questionnaire specific for evaluating swallowing in HD). The present findings add to our understanding of dysphagia onset and progression in HD. A better understanding of dysphagia onset and progression in HD may inform guidelines for standard clinical care in dysphagia, its recognition, and management.

Prevalence of Swallowing and Eating Difficulties in an Elderly Postoperative Hip Fracture Population-A Multi-Center-Based Pilot Study

Elderly patients operated for hip fracture are characterized by high age and high degree of comorbidity and need of care, factors previously found to be associated with swallowing and eating difficulties. The aim of this study was to investigate the prevalence of swallowing and eating difficulties in an elderly postoperative hip fracture population and to identify factors associated with swallowing and eating difficulties. A cross-sectional multi-center pilot study was performed, including patients ≥65 years, operated for hip fracture, and able to participate in a swallowing and eating assessment. A clinical assessment was conducted using Danish versions of the standardized tools Volume-Viscosity Swallow Test and Minimal Eating Observation Form-version II. Demographic data and clinical characteristics were examined. A total of 78 patients (mean age 81.4 years (SD 7.8), 30.8% male) were included. Swallowing and eating difficulties were present in 60 patients (77%). Swallowing and eating difficulties were significantly associated with living in a nursing home before hospital admission (p = 0.014), low habitual New Mobility Score (p = 0.018), and absence of cardiac comorbidity (p = 0.023). The results underline the importance of focusing on swallowing and eating difficulties in elderly patients operated for hip fracture to ensure effectivity and safety and optimize the prognosis for the patient.

Visuoperceptual Analysis of the Videofluoroscopic Study of Swallowing: An International Delphi Study

INTRODUCTION

The Videofluoroscopic Swallow Study (VFSS) is a commonly used dysphagia assessment that is routinely analysed visuoperceptually. However, no consensus exists regarding which visuoperceptual measures should be used to analyse VFSSs. Current visuoperceptual measures for VFSSs are limited by poor quality and incomplete or indeterminate psychometric properties.

OBJECTIVE

This study aimed to establish the content validity for a new visuoperceptual VFSS measure for oropharyngeal dysphagia in adults, by identifying relevant domains of the construct and generating items and corresponding response scales.

METHODS

Consensus among experts in dysphagia and VFSS from over 20 countries was achieved across three rounds of anonymous online surveys, using the Delphi technique. Participants judged relevance and comprehensiveness of definitions of visuoperceptual domains of VFSS and the relevance of various domains to the overall construct. After reaching consensus on definitions of relevant domains, consensus on items were established using the same process.

RESULTS

Participants achieved consensus on definitions of 32 domains recommended for analysis, and at least one item per domain (range 1-4). Domains selected by participants included both those which occur in existing measures and domains which have not been included in any measures to date. This study will form the basis for content validity of a new measure for VFSS.

CONCLUSIONS

This first phase of developing a visuoperceptual measure of VFSS resulted in the identification of 32 domains and 60 items for oropharyngeal dysphagia. Developers can now advance to the next phase of measure construction; prototype development and psychometric testing.

The assessment of the peak of reflex cough in subjects with acquired brain injury and tracheostomy and healthy controls

INTRODUCTION

There is no standard procedure to evaluated the peak of reflex cough flow (PCF-reflex) in the literature, which is important assessment in subjects with acquired brain injury and tracheostomy cannula. The present study aims to investigate the PCF of the reflex cough in a broad sample of healthy controls and, furthermore, the presence and the strength of voluntary and reflex cough in subjects with ABI with tracheostomy cannula.

MATERIALS AND METHODS

We recruited 147 participants including the healthy subjects (n = 105) and acquired brain injury subjects (n = 43), who underwent respiratory assessment: the Tidal Volume, Forced Vital Capacity, PCF of voluntary cough (PCF-voluntary) and PCF-reflex (using a spirometer connected with a nebulizer by a bidirectional).

RESULTS

The PCF-reflex of controls and subjects was significant lower than the PCF-voluntary (P < 0.01). The PCF-voluntary was not assessed in 26 (60.5 %) subjects due to severe cognitive deficit. In subjects without cognitive deficits (n = 17; 39.5 %), it was significantly lower than in healthy controls (p < 0.01). In contrast, the PCF-reflex was completed in all subjects and it was not significantly different from healthy controls. Furthermore, the strength of the PCF-reflex decreased with increasing inhalation numbers of nebulised air.

CONCLUSION

Reflex cough behaviour differs largely from voluntary cough and the PCF results reflect this great discrepancy. PCF-reflex could be useful parameter for assessing the airway protection whereas PCF-voluntary for measuring airway clearance.

Incidental finding of tracheobronchial foreign body during double lumen tube placement-lessons learned

Tracheobronchial foreign bodies are common in pediatric patients, but also seen in adult patients. Most of these patients present with history of foreign body inhalation, or with the symptoms like cough, respiratory distress. In this paper, we would like to report an incidental finding of a tablet in tracheobronchial tree during double lumen tube placement with fiberoptic bronchoscopy in a middle-aged patient scheduled for right lung decortication for hemothorax. We also learned that delay in removing the tablet would make the removal of foreign body complicated. The patient did not report any history of aspiration or have any signs and symptoms consistent with aspiration. We also discussed the difficult in diagnosing foreign-body aspiration in adults with nonspecific symptoms.

Clinical swallowing assessment in the diagnosis of silent aspiration

ABSTRACT Purpose: to identify, in the clinical assessment of swallowing, signs indicating silent aspiration in ischemic stroke patients. Methods: forty-six patients were assessed, 17 days being the mean time elapsed from the stroke to the swallowing assessment. The clinical assessment encompassed structural and functional aspects, oximetry monitoring, and cervical auscultation. During the videofluoroscopy examination, the patients were also monitored with pulse oximetry. In both assessments, the patients were given 100 ml of liquid. In the statistical analysis, the exact logistic regression test and odds ratio calculation were used, with a 0.05 significance level. Results: seven, out of the 46 patients, presented aspiration, which was silent in six of them. Change in the cervical auscultation, in the clinical assessment (OR: 18.8; 95% CI: 1.2 - 1000, p = 0.03), was associated with silent aspiration, as detected in the videofluoroscopy. The hawking present in the analysis of the recording (OR: 12.2; 95% CI: 1.23 - ∞, p = 0.03), was associated with possible non-silent laryngotracheal penetrations and aspirations. No change was identified regarding oxygen saturation in patients presented with silent aspiration. Conclusion: the change in cervical auscultation observed in the clinical assessment can indicate silent aspiration in patients affected by an ischemic stroke.

Aerodigestive disorders in dogs evaluated for cough using respiratory fluoroscopy and videofluoroscopic swallow studies

Aerodigestive diseases, hybrid disorders representing a pathologic link between respiratory and alimentary tracts, may manifest with respiratory signs without gastrointestinal signs. These are underdiagnosed in dogs due to poor clinical recognition and diagnostic limitations. We hypothesize that a subset of dogs presenting for cough without gastrointestinal signs would have occult aerodigestive disorders identified using videofluoroscopic swallow study (VFSS). Data were retrospectively obtained from 31 client-owned dogs presenting for cough, with thoracic radiographs, and a VFSS between April 2015 and December 2017. Exclusion criteria were cough of cardiac origin or gastrointestinal signs within 6 months. Swallow study parameters included pharyngeal/esophageal motility, laryngeal obstruction/defects, penetration-aspiration, reflux, excessive aerophagia, megaesophagus (ME), lower-esophageal sphincter achalasia-like syndrome (LES-AS), and sliding hiatal hernia (HH). The median (interquartile range) duration of cough was 4 (2-8) months. Thoracic radiographs were unremarkable in 11 dogs, with aspiration pneumonia suspected in seven. In 25/31 dogs (81%), VFSS abnormalities were detected and some dogs had more than one defect: pharyngeal (n=10) or esophageal hypomotility (n=10), reflux (n=9), penetration-aspiration (n=8), excessive aerophagia (n=6), laryngeal obstruction (n=3), ME (n=3), HH (n=2), and LES-AS (n=1). A respiratory disorder causing cough was identified in 17 dogs with VFSS abnormalities (laryngeal obstruction/defect and airway disease including chronic or eosinophilic bronchitis, tracheal/mainstem bronchial collapse, bronchiectasis, and bronchomalacia). An alimentary disorder identified on VFSS in absence of a discrete respiratory disorder causing cough was diagnosed in eight dogs. In conclusion, canine aerodigestive disorders can manifest as cough without alimentary signs. VFSS is a useful diagnostic to determine the contribution of esophageal/gastrointestinal pathology in dogs with cough.

[Guideline conform diagnostics for dysphagia : A representative survey of speech therapists at certified stroke units in Germany]

BACKGROUND

Almost 260,000 people in Germany suffer from a stroke each year. As a consequence, for more than 60% this leads to dysphagia. In order to prevent secondary diseases, such as pneumonia, malnutrition and dehydration, a differentiated diagnosis by a multiprofessional team in a stroke unit is required. The guidelines in 2015 for diagnosing neurologic dysphagia by the German Society of Neurology recommend a detailed anamnesis, a standardized screening, a clinical swallowing examination and additional instrumental diagnostics.

OBJECTIVE

This study examined whether dysphagia is diagnosed by speech therapists at certified stroke units according to the recommended guidelines.

MATERIAL AND METHODS

An online questionnaire was compiled and sent to 1 speech therapist at each of the 195 certified stoke units and 112 participants responded to the questionnaire. The questionnaire consisted of questions about anamnesis, clinical swallowing diagnostics and the instrumental diagnostics. Of the speech therapists working on a stroke unit 57% participated in this study.

RESULTS

The results show that 50% of the participants elaborated a detailed and differentiated anamnesis, 64% used a standardized screening (Daniels test) and 66% implemented a guideline conform swallowing test. As technical instruments, 35% of the respondents used video fluoroscopy and 71% of the respondents a fiber endoscopy.

CONCLUSION

The implementation of a detailed and differentiated anamnesis, standardized screening, and a clinical swallowing examination with testing of different food consistencies suggests a high quality of the dysphagia diagnostics at stroke units in Germany. The increasing availability of technical instruments, especially fiber endoscopy, substantiates this view.

[Microbiology of Aspiration Pneumonia]

The number of patients with pneumonia has been increasing as the population ages, and most fatal pneumonia cases are the elderly with aspiration pneumonia. Although aspiration pneumonia leads to poor short- and long-term prognosis, there have been no practical ways to diagnose it precisely. Persistent subclinical aspiration without any subjective symptoms is problematic in clinical practice in patients with aspiration pneumonia, and physicians can only use aspiration risks such as brain infarction to diagnose aspiration pneumonia. Anaerobes have been believed to be major causative pathogens in aspiration pneumonia, based on data from the 1970's. In relation to these data, Marik insisted that there is a possible overestimation of anaerobes because 1) the sampling of microbiologic specimens was in the late phase in the course of the illness, especially frequently after developing complications such as abscesses, necrotizing pneumonia, or empyema thoracis; 2) the organisms recovered by percutaneous transtracheal aspiration (PTA) sampling could have been contaminated by the aspiration of oropharyngeal flora during the PTA procedure or colonized in the trachea; and 3) many of the patients had chronic alcoholism or were under general anesthesia. In addition, 4) oral care was not common in the 1970s, and 5) the patients in these reports were relatively young. Molecular biological approaches using the 16S ribosomal RNA (rRNA) gene have recently been used, and have enabled us to detect more exact pathogens compared to conventional bacterial culture. Using the method with the detection of the 16S rRNA gene, we evaluated the bacterial phylotypes in bronchoalveolar lavage fluid in patients with aspiration pneumonia and found that oral streptococci were the most detected phylotypes (31.0%), while anaerobes were only 6.0%. Our results suggest that oral streptococci are important, and anaerobes may have been overestimated as causative pathogens in patients with aspiration pneumonia.

Sapienza Global Bedside Evaluation of Swallowing after Stroke: the GLOBE-3S study

BACKGROUND AND PURPOSE

Dysphagia occurs in up to 50% of all patients with acute stroke. There is debate regarding which is the most effective screening tool in identifying aspiration in patients with acute stroke. We assessed the accuracy of the Sapienza Global Bedside Evaluation of Swallowing after Stroke (GLOBE-3S), which combines the Toronto Bedside Swallowing Screening Test (TOR-BSST©) with oxygen desaturation and laryngeal elevation measurement during swallowing.

METHODS

We prospectively enrolled consecutive patients with stroke within 72 h of symptom onset. All patients with stroke firstly underwent a standard neurological examination, then the GLOBE-3S evaluation and finally the fiberoptic endoscopic evaluation of swallowing (FEES). Two different assessors, a neurologist and a speech pathologist, blind to both the clinical data and each other's evaluation, administered the GLOBE-3S and FEES examination. We assessed the accuracy of the GLOBE-3S in detecting post-stroke swallow impairment with aspiration using the FEES as the standard.

RESULTS

We enrolled 50 patients with acute stroke, 28 of whom (56%) had swallowing impairment with aspiration at FEES evaluation. A total of 33 patients (66%) failed the GLOBE-3S evaluation. The GLOBE-3S reached a sensitivity of 100% and a specificity of 77.3% (negative predictive value, 100%; positive likelihood ratio, 4.34). The median time required for the GLOBE-3S to be performed was 297 s.

CONCLUSIONS

GLOBE-3S is quick to perform at the bedside and can accurately identify aspiration in patients with acute stroke. By including the measurement of laryngeal elevation and monitoring of oxygen desaturation, it could represent a highly sensitive instrument to avoid the misdiagnosis of silent aspirators.

Development of the Decannulation Prediction Tool in Patients With Dysphagia After Acquired Brain Injury

OBJECTIVES

Patients with acquired brain injuries (ABIs) often need tracheostomy because of dysphagia. However, many of them may recover over time and be eventually decannulated during post-acute rehabilitation. We developed the Decannulation Prediction Tool (DecaPreT) to identify, early in the post-acute course, patients with ABIs who can be safely decannulated.

DESIGN

Nonconcurrent cohort study.

SETTING AND PARTICIPANTS

Patients with ABI, as well as with dysphagia and tracheostomy, were retrospectively selected from the database of a neurorehabilitation unit in Correggio, Reggio Emilia, Italy.

MEASURES

Potential bivariate predictors of decannulation were screened from variables collected on admission during clinical examination, conducted by an expert speech therapist. Multivariable prediction was then obtained in 2 separate random subsamples to develop and validate the logistic regression model of the DecaPreT.

RESULTS

Of 463 patients with ABI (mean age 52.2 years) selected, 73.0% could be safely decannulated before discharge. After bivariate screening, multivariable predictors of decannulation were identified in the development subsample and confirmed in the validation subsample, each with its odds ratio and 95% confidence interval as follows: age tertile (1.77, 1.08-2.89; P = .024), no saliva aspiration (3.89, 1.73-8.64; P = .001), pathogenesis of ABI (trauma vs other causes vs stroke vs anoxia: 2.23, 1.41-3.54; P = .001), no vegetative status (8.47; 2.91-24.63; P < .001), and coughing score (voluntary and reflex vs voluntary vs reflex vs neither voluntary nor reflex cough: 2.62, 1.70-4.05; P < .001). In the validation subsample, the predicting equation obtained an area under the receiver operating characteristics curve of 0.836.

IMPLICATIONS

The DecaPreT predicts safe decannulation in patients with dysphagia and tracheostomy, using simple clinical variables detected early in the post-acute phase of ABI. The tool can help clinicians choose timing and intensity of rehabilitation interventions and plan discharge.

Examining the relationship between sepsis and oropharyngeal dysphagia in hospitalised elderly patients: a retrospective cohort study

INTRODUCTION

Elderly people are recognised to be at increased risk of oropharyngeal dysphagia (OPD), the causes of which are multifactorial. Our aim was to identify if sepsis is associated with OPD in the elderly during hospitalisation in the absence of known other risk factors for OPD.

METHODS

A hospital electronic database was searched for elderly patients (≥65 years) referred for assessment for suspected dysphagia between March 2013 and 2014. Exclusion criteria were age <65 years, pre-existing OPD or acute OPD secondary to acute intracranial event, space-occupying lesion or trauma. Data were collected on factors including age, sex, comorbidities, existing OPD, sepsis, microbiology, recovery of OPD and medication. Sepsis was defined as evidence of a systemic inflammatory response syndrome with a clinical suspicion of infection.

RESULTS

A total of 301 of 1761 screened patients referred for dysphagia assessment met the inclusion criteria. The prevalence of sepsis and subsequent OPD was 16% (51/301). The mean age was 83 years (median 81 years). The most common comorbidity was dementia (31%). The majority (84%) failed to recover swallowing during their hospital stay, 12% had complications of aspiration and 35% died. The most common source of sepsis was from the chest (55%). Other factors contributing to the risk for dysphagia included delirium (22%) and neuroactive medication (41%). However, 10% of patients had sepsis and subsequent OPD without other identified risk factors.

CONCLUSION

The prevalence of sepsis and subsequent dysphagia is significant and should be taken into account in any elderly person in hospital with new-onset OPD without other predisposing risk factors.