Answering Orientation Questions and Following Single-Step Verbal Commands: Effect on Aspiration Status

Bedside diagnosis of silent aspiration using mobile dynamic digital radiography: a preliminary study

PURPOSE

This study aimed to assess reliable options for bedside diagnosis of silent aspiration in the intensive care unit by examining the use of default grayscale images (DGI) obtained using a mobile, general-purpose, radiography system capable of dynamic digital radiography (M-DDR) and inverted grayscale images (IGI) of DGI.

METHODS

This cohort study (exploratory and preliminary) involved 18 adult patients (mean age, 89.0 years) for whom a swallowing assessment request was received from their primary physicians. Fifty-six IGI videoclips were evaluated by three specialists using the penetration-aspiration scale (PAS), with the gold standard being the consensus reading of all three specialists. Another three speech-language pathologists (SLPs) assessed 56 DGI and IGI videoclips using the PAS. PAS scores 1 and 2 were classified as normal range, PAS scores 3-5 as pathological laryngeal penetration, and PAS scores 6-8 as aspiration. The correct rates with IGI and DGI were then determined, and the level of agreement of IGI and DGI evaluations was evaluated.

RESULTS

The correct rate of all evaluators was 100% for normal range, 80-100% for pathological laryngeal penetration, and 83-100% for aspiration with IGI and 100% for normal range, 90% for pathological laryngeal penetration, and 83% for aspiration with DGI. The kappa coefficient for IGI and DGI showed almost complete agreement for abnormal conditions.

CONCLUSION

Dynamic imaging of swallowing 2-5 ml of liquid using M-DDR performed for elderly patients at the bedside showed that aspiration assessments by SLPs obtained from DGI videos immediately after imaging are acceptable.

Diagnostic Accuracy of the Yale Swallow Protocol in Moderate-to-Severe Traumatic Brain Injury: A Prospective Blinded Videofluoroscopic Investigation

OBJECTIVE

The study aimed to assess the accuracy of the Yale Swallow Protocol (YSP) in screening aspiration in adults with acute moderate-to-severe traumatic brain injury (TBI) by comparing the YSP with a videofluoroscopic swallow study (VFSS).

SETTING

Level 1 academic trauma center.

PARTICIPANTS

The study involved a cohort of 50 consecutive adults with a history of acute moderate-to-severe TBI.

DESIGN

The prospective cohort study was conducted between July 2020 and June 2021. Participants underwent the YSP to assess aspiration risk, followed by a VFSS within 5 to 10 minutes after the YSP, to assess the accuracy of the YSP compared with the VFSS.

MAIN MEASURE

The accuracy of the YSP in identifying aspiration in adults with acute moderate-to-severe TBI.

RESULTS

The interrater agreement for identifying aspiration on the VFSS and the YSP was excellent, as well as 100% agreement between the speech-language pathologists and the radiologist and between the 2 speech-language pathologists, respectively. Of the 50 participants, 16 passed the YSP, while 34 failed. Among those who failed, 30 were confirmed to have aspirated on the VFSS (true-positives) and 4 did not show aspiration on the VFSS (false-positives). The YSP demonstrated a high sensitivity of 96.8%, a specificity of 78.9%, a positive predictive value of 88.2%, and a negative predictive value of 93.8% in identification of aspiration in this cohort.

CONCLUSIONS

To date, no dedicated prospective studies have been conducted to assess the utility of the YSP as a screening tool for identifying aspiration risk in persons with moderate-to-severe TBI. The results of this study conclude that the YSP is an effective screening tool for prediction of aspiration in acute care patients with moderate-to-severe TBI due to its high sensitivity and negative predictive value. These factors aid in identification of individuals at risk for aspiration and facilitate timely interventions to prevent complications.

Best Practice Recommendations for Dysphagia Management in Intensive Care Unit (ICU): A Delphi Study from Multidisciplinary Experts in Turkey

There is no study about all aspects of oropharyngoesophageal (OPE) dysphagia from diagnosis to follow-up in a multidisciplinary manner in the world. In order to close this gap, we aimed to create a recommendation study that can be used in clinical practice, addressing all aspects of dysphagia in the ICU in detail with the opinion of experienced multidisciplinary experts. This recommendation paper was generated by a multidisciplinary team, using the seven-step process and a three-modified Delphi round via e-mail. Firstly, 15 open-ended questions were created, and then detailed recommendations including general principles, management, diagnosis, rehabilitation, and follow-up were created with the answers from these questions, Each recommendation item was voted on by the experts as overall consensus (strong recommendation), approaching consensus (weak recommendation), and divergent consensus (not recommended).In the first Delphi round, a questionnaire consisting of 413 items evaluated with a scale of 0-10 was prepared from the opinions and suggestions given to 15 open-ended questions. In the second Delphi round, 55.4% were accepted and revised suggestions were created. At the end of the third Delphi round, the revised suggestion form was approved again and the final proposals containing 133 items were created. This study includes comprehensive and detailed recommendations, including a broad perspective from diagnosis to treatment and follow-up, as detailed as possible, for management of dysphagia in patients with both oropharyngeal- and esophageal-dysphagia in ICU.

Chewing and Swallowing Abilities of Persons Living With Dementia: A Systematic Review of Psychometric Properties of Instruments

Background and Objectives

It is critical to use validated instruments to diagnose and manage chewing and swallowing problems of persons living with dementia. The study aimed to synthesize the characteristics and psychometric quality of instruments that assess the chewing and swallowing abilities of persons living with dementia.

Research Design and Methods

The systematic review was used to conduct this study. We searched 5 electric databases for records published from January 1, 1980, to July 8, 2022. Records were eligible if they included any instrument to assess chewing ability or swallowing ability in the dementia population. Eight characteristics of eligible instruments were extracted from the records: (1) development process, (2) operationalized concept/construct, (3) sample and setting, (4) administration method, (5) items, (6) scoring format/interpretation, (7) reliability, and (8) validity. The psychometric assessment for self-report and observational tool was used to evaluate 12 psychometric properties of eligible instruments.

Results

In total, 11,074 records were reviewed. Thirty-five eligible instruments, including observational tools, self-report questionnaires, and physiological instruments, were identified from 60 records. All 8 instruments assessing chewing ability were evaluated as having low psychometric quality, and only 3 out of 27 instruments assessing swallowing ability were evaluated as having moderate psychometric quality. Fifteen instruments were tested for only 1 type of psychometric property, limiting the overall evaluation of psychometric evidence.

Discussion and Implications

The study findings inform the use and adaptation of appropriate instruments for practice and research. All existing instruments warrant further validation in larger samples to expand use in diverse care settings. This review described and evaluated current instruments measuring chewing and swallowing abilities and potential use in research and clinical practice to plan for and evaluate the effectiveness of mealtime and oral care practice and reduce health-related negative outcomes of persons living with dementia.

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: [Formula: see text] person-years and [Formula: see text] person-years, respectively. NIHSD and seizure history consistently and significantly were associated with decline (ORNIHSD = 1.34-2.10, 95% CI 1.04-3.4, p = 0.001-0.026; ORSeizure = 3.26-18.22, 1.03-167.79; p = 0.001-0.046), while miglustat use revealed protection (ORMiglustat = 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.

The effect of taste on swallowing: A scoping and systematic review

Consuming foods and liquids for nutrition requires the coordination of several muscles. Swallowing is triggered and modified by sensory inputs from the aerodigestive tract. Taste has recently received attention as a potential modulator of swallowing physiology, function, and neural activation; additionally, taste impairment is a sequela of COVID-19. This review presents factors impacting taste and swallowing, systematically summarizes the existing literature, and assesses the quality of included studies. A search was conducted for original research including taste stimulation, deglutition-related measure(s), and human participants. Study design, independent and dependent variables, and participant characteristics were coded; included studies were assessed for quality and risk of bias. Forty-eight articles were included after abstract and full-text review. Synthesis was complicated by variable sensory components of stimuli (taste category and intensity, pure taste vs. flavor, chemesthesis, volume/amount, consistency, temperature), participant characteristics, confounding variables such as genetic taster status, and methods of measurement. Most studies had a high risk of at least one type of bias and were of fair or poor quality. Interpretation is limited by wide variability in methods, taste stimulation, confounding factors, and lower-quality evidence. Existing studies suggest that taste can modulate swallowing, but more rigorous and standardized research is needed.

Swallowing and laryngeal complications in lung and heart transplantation: Etiologies and diagnosis

Despite continued surgical advancements in the field of cardiothoracic transplantation, post-operative complications remain a burden for the patient and the multidisciplinary team. Lesser-known complications including swallowing disorders (dysphagia), and voice disorders (dysphonia), are now being reported. Such disorders are known to be associated with increased morbidity and mortality in other medical populations, however their etiology amongst the heart and lung transplant populations has received little attention in the literature. This paper explores the potential mechanisms of oropharyngeal dysphagia and dysphonia following transplantation and discusses optimal modalities of diagnostic evaluation and management. A greater understanding of the implications of swallowing and laryngeal dysfunction in the heart and lung transplant populations is important to expedite early diagnosis and management in order to optimize patient outcomes, minimize allograft injury and improve quality of life.

Association between swallowing function, malnutrition and frailty in community dwelling older people

BACKGROUND & AIMS

Swallowing function decreases with age and impacts nutritional state and frailty. The aim of the study was to test the relationship between swallowing function, dysphagia, frailty, malnutrition and depression in community dwelling older participants.

METHODS

Community dwelling older participants (n = 180), were enrolled (74 men aged 75.9 ± 7.8, 65-91 years, and 107 women aged 75.9 ± 8.0, 65-95 years). Swallowing function was assessed by the Test of Mastication and Swallowing Solids (TOMASS) and the Timed Water Swallow Test (TWST). Dysphagia was identified using Hebrew 10-Item Eating Assessment Tool (H-EAT-10). Frailty was assessed by grip strength and the FRAIL Questionnaire. The Mini Nutritional Assessment - Short Form (MNA-SF) was used to identify nutritional status. Depression was screened with the Geriatric Depression Scale - Short Form (GDS-SF).

RESULTS

18.3% of the participants had a score of 3 or above in H-EAT-10, indicating suspected dysphagia. 17.8% of the participants were malnourished or at risk of malnutrition, and 48.3% were defined as frail or pre-frail. The odds of being malnourished/at risk of malnutrition were 3 times greater in those with suspected dysphagia. The odds of being frail/pre-frail were also 3 times greater in those with suspected dysphagia. Moreover, suspected dysphagia and frail/pre-frail health status coincided in 69.7% of participants. Participants that were malnourished/at risk of malnutrition required more masticatory cycles (p < .05) and more time (p < .05) to eat a cracker and drink 150 mL of water (p < .05), and had reduced swallowing capacity (volume/sec) in the TWST (p < .05) than those who were at normal nutritional statues. Similar results were found for frail/pre-frail participants versus robust health status. A decrease in grip strength was associated with increased (worse) frailty score, decreased nutritional score, decreased chewing function in TOMASS and decreased water drinking function in TWST (p < .05). MNA-SF score, age, GDS-SF score and EAT-10 were the best predictors of FRAIL score.

CONCLUSION

A simple multi-dimensional screen should be employed by trained allied health professionals, nurses and their assistants to improve early identification and early referral to relevant health providers in order to provide preventive intervention for dysphagia, nutrition, frailty and depression.

Evaluation of Swallowing Function according to the Stage of Alzheimer's Disease

BACKGROUND

Alzheimer's disease (AD) is a progressive neurodegenerative disease, and swallowing difficulties may occur as the disease progresses. Dysphagia has many consequences, such as aspiration and pneumonia. In particular, in the advanced stage, approximately 70% of the causes of death in AD involve aspiration pneumonia. Therefore, it is vital to assess the presence or absence of dysphagia in AD.

OBJECTIVE

This study aims to describe swallowing difficulty across the stages of AD.

METHODS

Thirty-five AD patients were evaluated. The Mini-Mental State Examination was conducted. A bedside water swallow test (BWST) and the Eating Assessment Tool (EAT-10) were administered. Finally, fiberoptic endoscopic evaluation of swallowing was used to evaluate residual, aspiration and penetration conditions.

RESULTS

EAT-10 scores, BWST results, and penetration-aspiration status were statistically significantly different according to AD stage (p < 0.05). Among all patients, 74.3% had residue, 25.7% had penetration, and 2.9% had aspiration.

CONCLUSIONS

This study has demonstrated that swallowing dysfunction begins at a mild stage and progressively worsens toward the advanced stage in patients with AD. At all stages of AD, residue was observed, and this poses a risk for the development of penetration-aspiration. Therefore, it is necessary to evaluate the early dysphagia of individuals.

Oropharyngeal dysphagia frequency in older adults living in nursing homes: an integrative review

PURPOSE

To synthesize the scientific knowledge on the frequency of oropharyngeal dysphagia in older adults living in nursing homes.

RESEARCH STRATEGIES

The study question followed the PECO strategy and the search was performed in the Pubmed/Medline, Web of Science, Scopus, LILACS and SciELO databases, using keywords and specific free terms.

SELECTION CRITERIA

articles with no time or language restrictions that reported the frequency of oropharyngeal dysphagia in older adults living in nursing homes and the diagnostic criteria.

DATA ANALYSIS

it was analyzed the population characteristics, the concept of "oropharyngeal dysphagia", the methods for identifying the outcome and the frequency of oropharyngeal dysphagia. The evaluation of the methodological quality of the articles followed the criteria of Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

RESULTS

Fifteen articles were included. There was great variability in relation to the sample size, with a predominance of longevous old women. The concept of dysphagia, when mentioned, was heterogeneous. Diagnostic criteria were diverse and mostly comprised of questionnaires or clinical trials results. No studies used instrumental tests. The frequency of oropharyngeal dysphagia in the studied population ranged from 5.4% to 83.7%, being higher in studies that used clinical tests, but with greater precision of confidence intervals in studies that used questionnaires and large sample size.

CONCLUSION

The frequency of oropharyngeal dysphagia in older adults living in nursing homes has wide variability. Methodological discrepancies among studies compromise the reliability of frequency estimates and highlight the need for research with better defined and standardized methodological criteria.

Characterization of dysphagia and laryngeal findings in COVID-19 patients treated in the ICU-An observational clinical study

Background

Dysphagia appears to be common in patients with severe COVID-19. Information about the characteristics of dysphagia and laryngeal findings in COVID-19 patients treated in the intensive care unit (ICU) is still limited.

Objectives

The aim of this study was to evaluate oropharyngeal swallowing function and laryngeal appearance and function in patients with severe COVID-19.

Method

A series of 25 ICU patients with COVID-19 and signs of dysphagia were examined with fiberendoscopic evaluation of swallowing (FEES) during the latter stage of ICU care or after discharge from the ICU. Swallowing function and laryngeal findings were assessed with standard rating scales from video recordings.

Results

Pooling of secretions was found in 92% of patients. Eleven patients (44%) showed signs of silent aspiration to the trachea on at least one occasion. All patients showed residue after swallowing to some degree both in the vallecula and hypopharynx. Seventy-six percent of patients had impaired vocal cord movement. Erythema of the vocal folds was found in 60% of patients and edema in the arytenoid region in 60%.

Conclusion

Impairment of oropharyngeal swallowing function and abnormal laryngeal findings were common in this series of patients with severe COVID-19 treated in the ICU. To avoid complications related to dysphagia in this patient group, it seems to be of great importance to evaluate the swallowing function as a standard procedure, preferably at an early stage, before initiation of oral intake. Fiberendoscopic evaluation of swallowing is preferred due to the high incidence of pooling of secretion in the hypopharynx, silent aspiration, and residuals. Further studies of the impact on swallowing function in short- and long-term in patients with COVID-19 are warranted.

Preclinical Dysphagia in Community Dwelling Older Adults: What Should We Look For?

Purpose Traditionally, etiology of dysphagia is thought to be related to multiple medical diagnoses including stroke, head and neck cancer, degenerative neurological conditions, and so forth. However, community dwelling older adults (CDOA) can present with dysphagia in the absence of any specific etiology. The purpose of this research was to develop a multidimensional framework to help identify those CDOA at risk for dysphagia of nonspecific etiology. Method Pertinent literature was examined to identify support for the proposed framework and to explain how the various elements support the model. Results Several factors that are not traditionally thought to be associated with dysphagia can both initiate and exacerbate symptoms of swallowing difficulties. Swallowing difficulties may be subtle and underreported. Monitoring for symptoms related to preclinical dysphagia may be helpful for early identification. Conclusions Dysphagia in CDOA is complex and multidimensional. Clinicians working with older adults will benefit from considering elements described in this multidimensional framework to better understand the etiology of swallowing deficits and improve management. Supplemental Material https://doi.org/10.23641/asha.14150078.

Predictors of swallowing outcomes in patients with combat-injury related dysphagia

BACKGROUND

Traumatic injuries, such as those from combat-related activities, can lead to complicated clinical presentations that may include dysphagia.

METHODS

This retrospective observational database study captured dysphagia-related information for 215 US military service members admitted to the first stateside military treatment facility after sustaining combat-related or combat-like traumatic injuries. A multidimensional relational database was developed to document the nature, course, and management for dysphagia in this unique population and to explore variables predictive of swallowing recovery using Bayesian statistical modeling and inferential statistical methods.

RESULTS

Bayesian statistical modeling revealed the importance of maxillofacial fractures and soft tissue loss as primary predictors of poor swallowing outcomes. The presence of traumatic brain injury (TBI), though common, did not further complicate dysphagia outcomes. A more detailed examination and rating of videofluoroscopic swallow studies from a subset of 161 participants supported greater impairment for participants with maxillofacial trauma and no apparent relationship between having sustained a TBI and swallow functioning.

CONCLUSION

These analyses revealed that maxillofacial trauma is a stronger indicator than TBI of dysphagia severity and slower or incomplete recovery following combat-related injuries.

LEVEL OF EVIDENCE

Therapeutic/Care Management study, level IV.

Prevalence, Pathophysiology, Diagnostic Modalities, and Treatment Options for Dysphagia in Critically Ill Patients

Postextubation dysphagia may impose a substantial burden on intensive care unit patients and healthcare systems. Approximately 517,000 patients survive mechanical ventilation during critical care annually. Reports of postextubation dysphagia prevalence are highly variable ranging between 3% and 93%. Of great concern is aspiration leading to the development of aspiration pneumonia when patients resume oral feeding. Screening for aspiration with a water swallow test has been reported to be positive for 12% of patients in the intensive care unit after extubation. This review aims to increase awareness of postextubation dysphagia and provide an updated overview of the current knowledge regarding prevalence, pathophysiology, diagnostic modalities, and treatment options.

Translation and adaption of the Yale Swallow Protocol for a Danish intensive care setting

BACKGROUND

Dysphagia related to intubation affects almost one in five patients in the intensive care unit; it may vary due to fluctuations in cerebral status and fatigue and lead to pneumonia, re-intubation and increased mortality. Taking care of patients' nutritional needs is an integral part of nursing and nurses must therefore be able to assess risk of dysphagia at all hours. However, Danish validated methods for use in the critically ill patient population are lacking.

AIM

To translate and adapt the Yale Swallow Protocol method for implementation in a Danish intensive care unit setting.

METHODS

Translation and adaption followed WHO's recommendations for translation and adaption of instruments. Face validity of the Danish version was evaluated in four group interviews. These were digitally recorded, transcribed and analysed using deductive content analysis. All interviewees gave informed consent.

FINDINGS

The translated version of the Yale Swallow Protocol was easy to understand, although nurses needed to have the method explained and needed training in using the method. In addition, the Yale Swallow Protocol must be adapted to local practice in terms of identifying patients at risk of dysphagia and deciding where to document results of the screening.

CONCLUSION

The translated version of the Yale Swallow Protocol proved conceptually and culturally sound and acceptable to intensive care unit nurses. Implementation should be followed by theoretical and practical training to build a nursing vocabulary relating to dysphagia and strengthen nurses' sensitivity to clinical manifestations consistent with dysphagia.

Postintubation Dysphagia During COVID-19 Outbreak-Contemporary Review

The COVID-19 is a global pandemic. Its rapid dissemination and serious course require a novel approach to healthcare practices. Severe disease progression is often associated with the development of the Acute Respiratory Distress Syndrome and may require some form of respiratory support, including endotracheal intubation, mechanical ventilation, and enteral nutrition through a nasogastric tube. These conditions increase the risk of dysphagia, aspiration, and aspiration pneumonia. The data on the incidence and risks of dysphagia associated with COVID-19 are not yet available. However, it is assumed that these patients are at high risk, because of respiratory symptoms and reduced lung function. These findings may exacerbate swallowing deficits. The aim of this review is to summarize available information on possible mechanisms of postintubation dysphagia in COVID-19 patients. Recommendations regarding the diagnosis and management of postintubation dysphagia in COVID-19 patients are described in this contemporary review.

Assessment Across the Life Span: The Clinical Swallow Evaluation

Purpose This clinical focus article considers the roles of the clinical swallow examination (CSE) as a clinically meaningful assessment method used in both adult and pediatric populations. Method This clinical focus article explores the utility of the CSE across the life span. Specifically, components, reliability, standardized assessments, and limitations of the CSE within the adult and pediatric populations are highlighted. Conclusions The CSE remains a crucial assessment tool for the speech-language pathologist. The experienced clinician can make important judgments regarding patient safety and function. If the CSE is conducted mindfully and methodically, findings can help chart the course of care for individuals needing additional assessment and possibly intervention.

Efficacy of Mealtime Interventions for Malnutrition and Oral Intake in Persons With Dementia: A Systematic Review

Malnutrition and weight loss are highly prevalent in persons with Alzheimer's disease and related dementias. Oral intake is an important interventional target for addressing these nutritional consequences. However, the efficacy of interventions remains poorly understood as prior syntheses have failed to examine the impact of intervention approaches on malnutrition and hypothesized mechanisms of action in persons with dementia. This review aimed to determine the efficacy of mealtime interventions to improve oral intake and nutritional outcomes in persons with dementia. Four databases yielded 1712 studies, resulting in 32 studies that met inclusion criteria. Studies included education, environmental modifications, feeding, oral supplementation, and other pharmacologic/ecopsychological interventions. While the majority of studies reported statistically significant improvements in at least 1 nutritional outcome, study design and outcome measures were heterogenous with many lacking adequate statistical power or blinding. Collectively, we found moderate evidence to suggest the efficacy of oral supplementation, and preliminary evidence to suggest that feeding interventions, education, and environmental modifications may confer improvements. Findings clarify the state of existing evidence regarding various interventional strategies for improving malnutrition in persons with dementia. While some approaches are promising, adequately powered and rigorously designed multidimensional intervention trials are needed to inform clinical decision-making in real-world contexts.

Implementation of a Risk Assessment Tool to Reduce Aspiration Pneumonia in Nonstroke Patients

BACKGROUND

Aspiration pneumonia is one of the most common forms of pneumonia in hospitalized adults. Aspiration is potentially preventable when healthcare providers take action to decrease its occurrence. Standardized protocols can improve consistency with identification, assessment, and treatment of hospitalized patients at risk of aspiration pneumonia.

PROBLEM/PURPOSE

There was no process in place to identify patients at risk of aspiration who did not present with stroke symptoms. The aims of this project were to assess that action steps were taken in patients who assessed positive for aspiration risk and to determine the aspiration risk assessment tool's impact on the incidence of aspiration pneumonia.

METHODS

After implementing an adapted evidence-based aspiration risk assessment tool and aspiration precautions protocol, consistency of actions taken was assessed descriptively, and rates of aspiration pneumonia were compared from preimplementation to postimplementation using χ analysis.

INTERVENTIONS

An aspiration risk assessment tool was adapted to include local hospital findings and implemented.

RESULTS

All adult patients admitted (n = 10 973) during the initial evaluation period (July 2016 to December 2016) were screened using the adapted aspiration risk assessment tool. Three hundred twenty-six patients (19%) were identified at risk of aspiration and referred to speech therapy for evaluation, with 87.1% evaluated in less than 24 hours. Signs for aspiration risk and speech therapy recommendations were posted on 40% (n = 12). During the 18-month preintervention and postintervention period, hospital-acquired aspiration pneumonia decreased from preimplementation (n = 58 cases/26 738 admissions, 0.22%) to postimplementation (37/28 164, 0.13%), P = .018.

CONCLUSIONS

Implementation of an adapted aspiration risk assessment screening tool to document risk of hospital-acquired aspiration pneumonia and aspiration precautions protocol was associated with a decrease in aspiration pneumonia rates.

Dysphagia in the intensive care unit: epidemiology, mechanisms, and clinical management

Dysphagia may present in all critically ill patients and large-scale clinical data show that e.g. post-extubation dysphagia (PED) is commonly observed in intensive care unit (ICU) patients. Recent data demonstrate that dysphagia is mostly persisting and that its presence is independently associated with adverse patient-centered clinical outcomes. Although several risk factors possibly contributing to dysphagia development were proposed, the underlying exact mechanisms in ICU patients remain incompletely understood and no current consensus exists on how to best approach ICU patients at risk.From a clinical perspective, dysphagia is well-known to be associated with an increased risk of aspiration and aspiration-induced pneumonia, delayed resumption of oral intake/malnutrition, decreased quality of life, prolonged ICU and hospital length of stay, and increased morbidity and mortality. Moreover, the economic burden on public health care systems is high.In light of high mortality rates associated with the presence of dysphagia and the observation that dysphagia is not systematically screened for on most ICUs, this review describes epidemiology, terminology, and potential mechanisms of dysphagia on the ICU. Furthermore, the impact of dysphagia on affected individuals, health care systems, and society is discussed in addition to current and future potential therapeutic approaches.

Evaluation of Swallow Function Post-Extubation: Is It Necessary to Wait 24 Hours?

BACKGROUND

Post-extubation dysphagia is associated with an increased incidence of nosocomial pneumonias, longer hospitalizations, and higher re-intubation rates. The purpose of this study was to determine if it is necessary to delay swallow evaluation for 24 hours post-extubation.

METHODS

A prospective investigation of swallowing was conducted at 1, 4, and 24 hours post-extubation to determine if it is necessary to delay swallow evaluation following intubation. Participants were 202 adults from 5 different intensive care units (ICU).

RESULTS

A total of 166 of 202 (82.2%) passed the Yale Swallow Protocol at 1 hour post-extubation, with an additional 11 (177/202; 87.6%) at 4 hours, and 8 more (185/202; 91.6%) at 24 hours. Only intubation duration ≥4 days was significantly associated with nonfunctional swallowing.

CONCLUSIONS

We found it is not necessary to delay assessment of swallowing in individuals who are post-extubation. Specifically, the majority of patients in our study (82.2%) passed a swallow screening at 1 hour post-extubation.

Relationship Between Laryngeal Sensation, Length of Intubation, and Aspiration in Patients with Acute Respiratory Failure

Dysphagia is common in hospitalized patients post-extubation and associated with poor outcomes. Laryngeal sensation is critical for airway protection and safe swallowing. However, current understanding of the relationship between laryngeal sensation and aspiration in post-extubation populations is limited. Acute respiratory failure patients requiring intensive care unit admission and mechanical ventilation received a Flexible Endoscopic Evaluation of Swallowing (FEES) within 72 h of extubation. Univariate and multivariable analyses were performed to examine the relationship between laryngeal sensation, length of intubation, and aspiration. Secondary outcomes included pharyngolaryngeal secretions, pneumonia, and diet recommendations. One-hundred and three patients met inclusion criteria. Fifty-one patients demonstrated an absent laryngeal adductor reflex (LAR). Altered laryngeal sensation correlated with the presence of secretions (p = 0.004). There was a significant interaction between the LAR, aspiration, and duration of mechanical ventilation. Altered laryngeal sensation was significantly associated with aspiration on FEES only in patients with a shorter length of intubation (p = 0.008). Patients with altered laryngeal sensation were prescribed significantly more restricted liquid (p = 0.03) and solid (p = 0.001) diets. No relationship was found between laryngeal sensation and pneumonia. There is a high prevalence of laryngeal sensory deficits in mechanically ventilated patients post-extubation. Altered laryngeal sensation was associated with secretions, aspiration, and modified diet recommendations especially in those patients with a shorter length of mechanical ventilation. These results demonstrate that laryngeal sensory abnormalities impact the development of post-extubation dysphagia.

Laryngeal Injury and Upper Airway Symptoms After Oral Endotracheal Intubation With Mechanical Ventilation During Critical Care: A Systematic Review

OBJECTIVES

To systematically review the symptoms and types of laryngeal injuries resulting from endotracheal intubation in mechanically ventilated patients in the ICU.

DATA SOURCES

PubMed, Embase, CINAHL, and Cochrane Library from database inception to September 2017.

STUDY SELECTION

Studies of adult patients who were endotracheally intubated with mechanical ventilation in the ICU and completed postextubation laryngeal examinations with either direct or indirect visualization.

DATA EXTRACTION

Independent, double-data extraction and risk of bias assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias assessment followed the Cochrane Collaboration's criteria.

DATA SYNTHESIS

Nine studies (seven cohorts, two cross-sectional) representing 775 patients met eligibility criteria. The mean (SD; 95% CI) duration of intubation was 8.2 days (6.0 d; 7.7-8.7 d). A high prevalence (83%) of laryngeal injury was found. Many of these were mild injuries, although moderate to severe injuries occurred in 13-31% of patients across studies. The most frequently occurring clinical symptoms reported post extubation were dysphonia (76%), pain (76%), hoarseness (63%), and dysphagia (49%) across studies.

CONCLUSIONS

Laryngeal injury from intubation is common in the ICU setting. Guidelines for laryngeal assessment and postextubation surveillance do not exist. A systematic approach to more robust investigations could increase knowledge of the association between particular injuries and corresponding functional impairments, improving understanding of both time course and prognosis for resolution of injury. Our findings identify targets for future research and highlight the long-known, but understudied, clinical outcomes from endotracheal intubation with mechanical ventilation in ICU.

Association between executive and food functions in the acute phase after stroke

Purpose To investigate potential associations among executive, physical and food functions in the acute phase after stroke. Methods This is a cross-sectional study that evaluated 63 patients admitted to the stroke unit of a public hospital. The exclusion criteria were other neurological and/or psychiatric diagnoses. The tools for evaluation were: Mini-Mental State Examination and Frontal Assessment Battery for cognitive functions; Alberta Stroke Program Early CT Score for quantification of brain injury; National Institutes of Health Stroke Scale for neurological impairment; Modified Rankin Scale for functionality, and the Functional Oral Intake Scale for food function. Results The sample comprised 34 men (54%) and 29 women with a mean age of 63.6 years. The Frontal Assessment Battery was significantly associated with the other scales. In multivariate analysis, executive function was independently associated with the Functional Oral Intake Scale. Conclusion Most patients exhibited executive dysfunction that significantly compromised oral intake.

Temporal Associations between Caregiving Approach, Behavioral Symptoms and Observable Indicators of Aspiration in Nursing Home Residents with Dementia

OBJECTIVES

Dysphagia, or impaired swallowing, is common in nursing home (NH) residents with dementia and contributes to malnutrition and diminished quality of life. Dysphagia also commonly leads to aspiration or passage of food or fluids into the airway, which can result in aspiration pneumonia-a leading cause of death for people with dementia. Currently available interventions for dysphagia aim to modify the risk of aspiration events primarily by modifying diet and positioning to improve the safety of an individual's swallow. However other potentially modifiable contextual factors relevant to mealtime care within NH settings that may influence the occurrence of aspiration events, such as the nature of caregiving interactions or occurrence of dementia-related behavioral symptoms, have not been examined. To address this gap, we examined the temporal associations between caregiving approach and behavioral symptoms as antecedents to observable indicators of aspiration among nursing home (NH) residents with dementia.

DESIGN

Secondary analysis of coded, timed-event behavioral data from 33 video-recorded observations of mealtime interactions between NH residents with dementia and caregivers.

SETTING/PARTICIPANTS

Residents with dementia who required assistance with mealtime care (n=12) and nursing assistants (n=8) from Memory Care Units (MCU) in 2 Midwestern NHs.

RESULTS

Observable indicators of aspiration were significantly more likely to occur during or following task-centered caregiver actions than person-centered actions (12% likelihood; Yule's Q 0.89; OR 95% CI 12.70-23.75) and 15-30 seconds after a behavioral symptom (5% likelihood; Yule's Q 0.65; OR 95% CI 4.18-8.57).

CONCLUSIONS

These findings provide compelling preliminary evidence that caregiver approach may influence the occurrence of aspiration. Provided the urgent need for more approaches to mitigate the complications associated with dysphagia in people with dementia, even a moderate reduction in aspiration events may be clinically meaningful. Further, well-designed observational studies with individuals with well-characterized dysphagia are needed to better understand and characterize these relationships, their temporal structures and their impacts on other relevant outcomes such as eating performance and malnutrition.

Predictors of dysphagia in critically injured patients with neck trauma

PURPOSE

Trauma patients admitted to the intensive care unit (ICU) are at heightened risk for oropharyngeal dysphagia and pulmonary aspiration. Timely and appropriate referrals for dysphagia may reduce mortality rates and hospital readmissions. This study sought to identify predictors of dysphagia in a large cohort of patients with multiple traumatic injuries.

METHODS

The Trauma Registry Database was queried for admissions at a level 1 trauma center from 2012 to 2016 who underwent instrumental swallowing evaluations. Relevant demographics, injuries, and interventions known to be associated with dysphagia were collected. The Dysphagia Outcome and Severity Scale (DOSS) was utilized to define severity of dysphagia. Regression analyses were performed to identify predictors of dysphagia.

RESULTS

Two hundred and sixty two patients met criteria. Multivariate analyses found injury severity (p<0.01), tracheostomy (p<0.05), TBI (p<0.05), and cervical spinal bracing (p<0.001) to be predictors of dysphagia development. Furthermore, length of ICU stay (p<0.01) and cervical spinal bracing (p<0.01) were associated with a greater severity of dysphagia.

CONCLUSIONS

Oropharyngeal dysphagia is a common complication in trauma patients. Our results propose a set of predictors that should be considered when identifying critically injured patients at risk for dysphagia.

Diagnostic Assessment and Management of Dysphagia in Patients with Alzheimer's Disease

A growing concern in patients affected by Alzheimer's disease (AD) is dysphagia, or swallowing impairment, which leads to malnutrition, dehydration, weight loss, functional decline and fear of eating and drinking, as well as a decrease in the quality of life. Thus the diagnostic assessment of dysphagia in patients with AD is imperative to ensure that they receive effective management, avoiding complications, and reducing comorbidity and mortality in such a growing population. Dysphagia management requires a multidisciplinary approach considering that no single strategy is appropriate for all patients. However, evidence for clinical diagnostic assessment, interventions, and medical management of dysphagia in these patients are still limited: few studies are reporting the evaluation and the management among this group of patients. Here we analyzed the most recent findings in diagnostic assessment and management of swallowing impairment in patients affected by AD.

An Epidemiologic Study on Ageing and Dysphagia in the Acute Care Geriatric-Hospitalized Population: A Replication and Continuation Study

United States census data project dramatic increases in the geriatric population ageing demographics by 2060 with concomitant health-care consequences. The purpose of this replication and continuation study was to collect new 2014 demographic data relative to ageing, swallow evaluation referral rates, and oral feeding status in geriatric-hospitalized patients for comparison with published data from 2000 to 2007. This was a planned data acquisition study of consecutive hospitalized patients referred for swallow assessments. Swallow evaluation referral rates for 2014 were described according to inpatient discharges, age range 60-105 years grouped by decade, gender, admitting diagnostic category, results of swallow evaluations, and oral feeding status. Determination of aspiration risk status was made with the Yale Swallow Protocol and diagnosis of dysphagia made with fiberoptic endoscopic evaluation of swallowing (FEES). There were 1348 referrals and 961 patients ≥60 years of age participated. Overall swallow evaluation referral rates increased an average of 63 % between the comparison years 2007 and 2014 with consistent increases corresponding to the decades, i.e., 60-69 (46 %), 70-79 (68 %), 80-89 (53 %), and 90+ (222 %). A total of 75 % of participants resumed oral alimentation and oral medications. Swallow evaluation referral rates increased by 63 % for 60-90+ year-old acute care geriatric-hospitalized participants despite only a 23 % increase in inpatient discharges for the years 2007 versus 2014. This corroborated previously reported increases for individual years from 2000 to 2007. For timely, safe, and successful initiation of oral alimentation, it is important to perform a reliable swallow screen for aspiration risk assessment with the Yale Swallow Protocol and, if failed, instrumental testing with FEES. More dysphagia specialists are needed through 2060 and beyond due to projections of continued population ageing resulting in ever increasing referral rates for swallow assessments.

Clinical Swallow Examination (CSE): Can We Talk?

The clinical swallow examination (CSE) is widely used by clinicians evaluating patients with dysphagia, yet this method remains controversial among many. The composition and purpose of the CSE are highly variable by region, facility, age group and individual clinician. This article will review literature on the topic and present clinical practice suggestions to further its usefulness and ongoing investigation.

Postextubation Dysphagia

Postextubation dysphagia (PED) is a common problem in critically ill patients with recent intubation. Although several risk factors have been identified, most of them are nonmodifiable preexisting or concurrent conditions. Early extubation, small endotracheal tube size, and small bore of nasogastric tube potentially decrease the risk of PED. The majority of patients receive treatment based on only bedside swallow evaluations, which has an uncertain diagnostic accuracy as opposed to gold standard instrumental tests. Therefore, the treatment decision for patients may not be appropriately directed for each individual. Current treatments are mainly focused on dietary modifications and postural changes/compensatory maneuvers rather than interventions, but recent studies have shown limited proven benefits. Direct therapies in oromotor control, such as therapeutic exercises and neuromuscular stimulations, should be considered as potential effective treatments.

Development of a Safety protocol for Management Thirst in the Immediate Postoperative Period

Objective To develop a safety protocol for the management of thirst in the immediate postoperative period. Method Quantitative, methodological, and applied study conducted in April-August 2012. An extensive literature search and expert consultation was carried out to develop the protocol and its operating manual. Theoretical and semantic analyzes were carried out by experts. Results Assessment of level of consciousness, reflexes of protection of the airways (cough and swallowing), and absence of nausea and vomiting were selected as safety criteria. These criteria were grouped and formatted in a graph algorithm, which indicates the need to interrupt the procedure if a security criterion does not reach the expected standard. Conclusion The protocol was elaborated to fill in the gap in the literature of a specific model concerning nursing actions in the safe management of thirst in the immediate postoperative period.

Five Days of Successful Oral Alimentation for Hospitalized Patients Based Upon Passing the Yale Swallow Protocol

Objective:

This study aimed to determine the success of oral alimentation and patient retention rate 1 to 5 days after passing the Yale Swallow Protocol.

Methods:

Participants were 200 consecutive acute care inpatients referred for swallow assessment. Inclusion criteria were adequate cognitive abilities to participate safely, completing an oral mechanism examination, and passing the 3-ounce water swallow challenge. Exclusion criteria were altered mental status, failing the 3-ounce challenge, preadmission dysphagia, head-of-bed restrictions < 30°, and a tracheotomy tube. Electronic medical record monitoring post-protocol passing for 1 to 5 consecutive days determined success of oral alimentation and retention rate.

Results:

All patients who remained medically and neurologically stable drank thin liquids and ate successfully 1 to 5 days after passing the protocol. Mean (SD) volume of liquid ingested per day was 474.2 (435.5) cc. Patient retention declined steadily from day of testing (n = 200) through post-testing day 5 (n = 95).

Conclusion:

Passing the Yale Swallow Protocol allowed for initial determination of aspiration risk followed by successful oral alimentation for 1 to 5 days in medically and neurologically stable acute care hospitalized patients and without the need for instrumental dysphagia testing. The decline in patient retention was expected because of increasingly rapid transit through the acute care setting, which often renders longer follow-up problematic.

ICU-acquired swallowing disorders

OBJECTIVES

Patients hospitalized in the ICU can frequently develop swallowing disorders, resulting in an inability to effectively transfer food, liquids, and pills from their mouth to stomach. The complications of these disorders can be devastating, including aspiration, reintubation, pneumonia, and a prolonged hospital length of stay. As a result, critical care practitioners should understand the optimal diagnostic strategies, proposed mechanisms, and downstream complications of these ICU-acquired swallowing disorders.

DATA SOURCES

Database searches and a review of the relevant medical literature.

DATA SYNTHESIS

A significant portion of the estimated 400,000 patients who annually develop acute respiratory failure, require endotracheal intubation, and survive to be extubated are determined to have dysfunctional swallowing. This group of swallowing disorders has multiple etiologies, including local effects of endotracheal tubes, neuromuscular weakness, and an altered sensorium. The diagnosis of dysfunctional swallowing is usually made by a speech-language pathologist using a bedside swallowing evaluation. Major complications of swallowing disorders in hospitalized patients include aspiration, reintubation, pneumonia, and increased hospitalization. The national yearly cost of swallowing disorders in hospitalized patients is estimated to be over $500 million. Treatment modalities focus on changing the consistency of food, changing mealtime position, and/or placing feeding tubes to prevent aspiration.

CONCLUSIONS

Swallowing disorders are costly and clinically important in a large population of ICU patients. The development of effective screening strategies and national diagnostic standards will enable further studies aimed at understanding the precise mechanisms for these disorders. Further research should also concentrate on identifying modifiable risk factors and developing novel treatments aimed at reducing the significant burden of swallowing dysfunction in critical illness survivors.

Validation of the Yale Swallow Protocol: a prospective double-blinded videofluoroscopic study

The purpose of this prospective, double-blinded, multirater, systematic replication study was to investigate agreement for aspiration risk, in the same individual, between videofluoroscopic swallow studies (VFSS) and the Yale Swallow Protocol. Participants were 25 consecutive adults referred for dysphagia testing who met the inclusion criteria of completion of a brief cognitive assessment, oral mechanism examination, and no tracheotomy tube. First, all participants were administered the Yale Swallow Protocol by two experienced speech-language pathologists trained in protocol administration. Failure criteria were inability to drink the entire amount, interrupted drinking, or coughing during or immediately after drinking. Second, all participants completed a VFSS within 5-10 min of protocol administration. A speech-language pathologist, blinded to protocol results, reviewed the VFSS to determine aspiration status in a binary (yes/no) manner. Inter-rater agreement between two speech-language pathologists was 100 % for identification of aspiration risk with the Yale Swallow Protocol. Inter-rater agreement between the speech-language pathologist and the radiologist for identification of aspiration status with VFSS was 100 %. Twenty percent of VFSS recordings were viewed again 3-6 months after initial data collection, and intrarater agreement for identification of thin liquid aspiration was 100 %. Sensitivity for the Yale Swallow Protocol = 100 %, specificity = 64 %, positive predictive value = 78 %, and negative predictive value = 100 %. Importantly, all participants who passed the protocol did not aspirate during VFSS. Multiple, double-blinded raters and VFSS as the reference standard agreed with previous research with a single, nonblinded rater and FEES as the reference standard for identification of aspiration risk. The clinical usefulness and validity of the Yale Swallow Protocol for determining aspiration risk in a small sample size of male participants has been confirmed. Future research is needed with a larger and more heterogeneous population sample.

Avaliação clínica da deglutição em unidade de terapia intensiva

OBJETIVO: Relatar os resultados da avaliação clínica completa da deglutição em pacientes críticos de um hospital de ensino de grande porte na cidade de São Paulo. MÉTODOS: Foi realizado um estudo prospectivo, descritivo, no período de setembro a novembro de 2009, em uma unidade de terapia intensiva de emergências clínicas de trinta leitos, de um hospital terciário de grande porte do Brasil. Foram encaminhados 35 pacientes para a avaliação fonoaudiológica clínica da deglutição. Para a avaliação clínica completa da deglutição na unidade de terapia intensiva, foram preconizados os seguintes protocolos: Protocolo de Avaliação Preliminar (PAP), Protocolo de Avaliação do Risco para Disfagia (PARD) e Protocolo de Introdução e Transição da Alimentação por Via Oral (PITA). RESULTADOS: Neste estudo, foi constatada uma prevalência de 63% de disfagia orofaríngea (DO) na UTI, sendo a maioria destas classificadas como moderada e moderada-grave (39%). Entre os pacientes encaminhados para avaliação da deglutição, 74% apresentaram intubação orotraqueal prévia. A análise estatística revelou as variáveis que poderiam classificar corretamente os pacientes como tendo ou não DO nos testes clínicos. Esses indicadores clínicos incluíram: força da tosse, coordenação pneumofonoarticulatória, gravidade da disfonia e elevação laríngea. Vinte e seis pacientes (74%) completaram todos os protocolos. Desse total, 38% retornaram à dieta regular. CONCLUSÃO: A prática com protocolos padronizados mostra-se como uma importante opção no gerenciamento da disfagia orofaríngea na unidade de terapia intensiva.