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

A Scoping Review on the Intersection Between Voice and Swallowing Measures in Healthy and Disordered Populations

PURPOSE

Voice and swallowing are distinct functions that share anatomical and physiological properties; however, research investigating their intersection is limited. The purpose of this scoping review was to explore the literature surrounding the relationship between voice and swallowing measures in healthy adults and those with non-degenerative disorders. Specifically, we aimed to elucidate whether objective voice measures could be used as correlates of swallowing function.

METHOD

We systematically searched four databases (Embase, PubMed, CINAHL, and Web of Science) for relevant literature using a combination of key words and controlled vocabulary generated from the Yale Mesh Analyzer. The inclusion criteria consisted of peer-reviewed studies in the English language that reported on healthy adults and/or patients with non-degenerative neurological disorders and pulmonary diseases and contained instrumental and/or objective voice and swallowing measures. Two raters completed the abstract screening process followed by independent full-text reviews. Case studies, review studies, gray literature, or abstract-only studies were excluded.

RESULTS

Among 5,485 screened studies, 182 were fully reviewed, with only 11 studies meeting the inclusion criteria. Eight studies found an association between voice and swallowing objective measures, whereas the other three did not. Significant voice measures that were related to swallowing safety and/or physiology included maximum fundamental frequency (F0), F0 range, maximum phonation time, biomechanics of effortful pitch glides, and voice onset time.

CONCLUSIONS

Although there was heterogeneity in the measures used, specific objective voice measures showed promise in clinical practice as a screening tool for dysphagia. Further investigations are needed to validate the clinical utility of these measures across diverse patient populations.

Role of fiberoptic endoscopic evaluation of swallowing (FEES) in children with suspected dysphagia

OBJECTIVE

To assess FEES findings in defining oral feeding safety in children with suspected dysphagia, comparing them with clinical feeding evaluation results.

METHODS

This study comprised a case series involving children with suspected dysphagia, referred for evaluation by otolaryngologists and speech-language pathologists (SLPs) at a Brazilian quaternary public university hospital. These children underwent both clinical evaluations and fiberoptic endoscopic evaluation of swallowing (FEES), with a comprehensive collection of demographic and clinical data. Subsequently, the authors performed a comparative analysis of findings from both assessments.

RESULTS

Most patients successfully completed the FEES procedure (93.7%), resulting in a final number of 60 cases included in the study. The prevalence of dysphagia was confirmed in a significant 88% of these cases. Suspected aspiration on clinical SLP evaluation was present in 34 patients. Of these, FEES confirmed aspiration or penetration in 28 patients. Among the 35 patients with aspiration or penetration on FEES, 7 (20%) had no suspicion on SLP clinical assessment. All seven patients in whom clinical SLP evaluation failed to predict penetration/aspiration had neurological disorders. The median age of the children was 2.8 years, and 49 (81.6%) had neurological disorders, while 35 (58.3%) had chronic pulmonary disease. The most prevalent complaints were choking (41.6%) and sialorrhea (23.3%).

CONCLUSION

FEES can diagnose structural anomalies of the upper aerodigestive tract and significantly contribute to the detection of aspiration and penetration in this group of patients with suspected dysphagia, identifying moderate and severe dysphagia even in cases where clinical assessment had no suspicion.

Analysis of Patients' Dietary Status/Restrictions Following Instrumental Swallow Evaluations in Skilled Nursing Facilities

Many residents in Skilled Nursing Facilities (SNFs) present with dysphagia and receive altered diets or liquids to minimize the risk of complications. Limited access to timely instrumental evaluations of swallow may impede the best management of these dysphagic residents. De-identified FEES reports completed by a mobile FEES company during a single month, January 2019, were reviewed. Descriptive statistics were used to summarize the pre-study diet/liquid levels and the post-study diet/liquid recommendations. FEES reports (n = 952) were reviewed. Before the FEES evaluation, 209 residents were receiving only non-oral nutrition. After the FEES evaluation, 76% of these residents were recommended to receive oral nutrition. Before the FEES evaluation, 442 (46%) residents were receiving thickened liquids, after the FEES evaluation, 244 (26%) were recommended to have a less restrictive liquid level. Before the FEES evaluation, 576 (60%) residents were receiving altered food texture, after the FEES evaluation, 413 (43%) were recommended to have a less restrictive food texture. The percentage of residents recommended to receive thin liquids increased from 32 to 68% and those recommended to receive a regular diet increased from 18 to 34%. These data indicate that access to instrumental swallow evaluations in the SNF setting generally resulted in lifting liquid and diet restrictions for many residents in the cohort reviewed and potentially improved their quality of life.

Advancing stroke patient care: a network meta-analysis of dysphagia screening efficacy and personalization

Introduction

The increasing incidence of stroke globally has led to dysphagia becoming one of the most common complications in stroke patients, with significant impacts on patient outcomes. Accurate early screening for dysphagia is crucial to avoid complications and improve patient quality of life.

Methods

Included studies involved stroke-diagnosed patients assessed for dysphagia using bedside screening tools. Data was sourced from Embase, PubMed, Web of Science, Scopus, and CINAHL, including publications up to 10 December 2023. The study employed both fixed-effect and random-effects models to analyze sensitivity, specificity, positive predictive value (PPV), and Negative Predictive Value (NPV), each with 95% confidence intervals. The random-effects model was particularly utilized due to observed heterogeneity in study data.

Results

From 6,979 records, 21 studies met the inclusion criteria, involving 3,314 participants from 10 countries. The analysis included six assessment tools: GUSS, MASA, V-VST, BSST, WST, and DNTA, compared against gold-standard methods VFSS and FEES. GUSS, MASA, and V-VST showed the highest reliability, with sensitivity and specificity rates of 92% and 85% for GUSS, 89% and 83% for MASA, respectively. Heterogeneity among studies was minimal, and publication bias was low, enhancing the credibility of the findings.

Conclusion

Our network meta-analysis underscores the effectiveness of GUSS, MASA, and V-VST in dysphagia screening for stroke patients, with high sensitivity and specificity making them suitable for diverse clinical settings. BSST and WST, with lower diagnostic accuracy, require more selective use. Future research should integrate patient-specific outcomes and standardize methodologies to enhance dysphagia screening tools, ultimately improving patient care and reducing complications.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/#recordDetails.

A deep learning approach to dysphagia-aspiration detecting algorithm through pre- and post-swallowing voice changes

Introduction

This study aimed to identify differences in voice characteristics and changes between patients with dysphagia-aspiration and healthy individuals using a deep learning model, with a focus on under-researched areas of pre- and post-swallowing voice changes in patients with dysphagia. We hypothesized that these variations may be due to weakened muscles and blocked airways in patients with dysphagia.

Methods

A prospective cohort study was conducted on 198 participants aged >40 years at the Seoul National University Bundang Hospital from October 2021 to February 2023. Pre- and post-swallowing voice data of the participants were converted to a 64-kbps mp3 format, and all voice data were trimmed to a length of 2 s. The data were divided for 10-fold cross-validation and stored in HDF5 format with anonymized IDs and labels for the normal and aspiration groups. During preprocessing, the data were converted to Mel spectrograms, and the EfficientAT model was modified using the final layer of MobileNetV3 to effectively detect voice changes and analyze pre- and post-swallowing voices. This enabled the model to probabilistically categorize new patient voices as normal or aspirated.

Results

In a study of the machine-learning model for aspiration detection, area under the receiver operating characteristic curve (AUC) values were analyzed across sexes under different configurations. The average AUC values for males ranged from 0.8117 to 0.8319, with the best performance achieved at a learning rate of 3.00e-5 and a batch size of 16. The average AUC values for females improved from 0.6975 to 0.7331, with the best performance observed at a learning rate of 5.00e-5 and a batch size of 32. As there were fewer female participants, a combined model was developed to maintain the sex balance. In the combined model, the average AUC values ranged from 0.7746 to 0.7997, and optimal performance was achieved at a learning rate of 3.00e-5 and a batch size of 16.

Conclusion

This study evaluated a voice analysis-based program to detect pre- and post-swallowing changes in patients with dysphagia, potentially aiding in real-time monitoring. Such a system can provide healthcare professionals with daily insights into the conditions of patients, allowing for personalized interventions.

Clinical Trial Registration

ClinicalTrials.gov, identifier NCT05149976.

Association of early oral intake after extubation and independent activities of daily living at discharge among intensive care unit patients: A single centre retrospective cohort study

PURPOSE

We investigated the association between the time to first post-extubation oral intake, barriers to oral intake, and the rate of activities of daily living (ADL) independence at discharge (Barthel Index score <70).

METHOD

Consecutive patients admitted to the intensive care unit, aged ≥18 years, and mechanically ventilated for ≥48 hr were retrospectively enrolled. The time to first oral intake, barriers to oral intake, daily changes, and clinical outcomes were assessed. Multiple logistic regression analysis adjusted for baseline characteristics was used to determine the association between time to first post-extubation oral intake and ADL independence.

RESULT

Among the 136 patients, 74 were assigned to the ADL independence group and 62 to the dependence group. The time to first post-extubation oral intake was significantly associated with ADL independence (adjusted p = < 0.001) and was a predictor of ADL independence at discharge. Respiratory and dysphagia-related factors (odds ratio [OR] 0.35; 95% confidence interval [CI] 0.15-0.82, p = 0.015 and OR 0.07; CI 0.01-0.68, p = 0.021, respectively) were significantly associated with the ADL independence at discharge.

CONCLUSION

Respiratory and dysphagia-related factors, as barriers to the initiation of oral intake after extubation, were significantly associated with ADL independence at discharge.

Swallowing during provision of helmet ventilation: Review and provisional multidisciplinary guidance

Use of noninvasive ventilation provided by a helmet increased globally during and after the COVID-19 pandemic. This approach may reduce need for intubation and its associated clinical complications in critically ill patients. Use of helmet interface minimizes virus aerosolization while enabling verbal communication, oral feeding and coughing/expectoration of secretions during its administration. Although improved oral hydration is a recognized benefit of helmet NIV, relatively little is known about the safety and efficiency of swallowing during helmet NIV. Risk of aspiration is a key consideration given the fragile pulmonary status of critically ill patients requiring respiratory support, and therefore the decision to initiate oral intake is best made based on multidisciplinary input. We reviewed the current published evidence on NIV and its effects on upper airway physiology and swallowing function. We then presented a case example demonstrating preservation of swallowing performance with helmet NIV. Last, we offer provisional multidisciplinary guidance for clinical practice, and provide directions for future research.

Assessing Dysphagia in the Adult

This article explores the landscape of dysphagia assessment in adults. Dysphagia, a complex condition affecting the lifespan and many health conditions, significantly compromises individuals' quality of life. Dysphagia is often underdiagnosed, emphasizing the need for comprehensive assessment methods to ensure timely and accurate intervention. It encompasses clinical history, physical examination, clinical and instrumental swallow evaluations. Procedures within each of these modalities are reviewed, highlighting strengths, limitations, and contribution toward a complete understanding of dysphagia, ultimately guiding effective intervention strategies for improved patient outcomes.

A qualitative study on the life experiences and discharge planning of family caregivers for the elderly with nasal feeding

OBJECTIVE

To understand the discharge planning needs of family caregivers for the elderly with nasal feeding.

METHODS

From May to August in 2021, in-depth interviews were conducted with eleven family caregivers for elderly patients with nasal feeding at a tertiary hospital in Shenzhen. The interviews were analyzed using phenomenological research methods and the Knowledge, Awareness, and Practice (KAP) theory to identify and refine key themes.

RESULTS

The discharge planning needs of family caregivers for elderly with nasal feeding can be summarized into three themes: ① Learning needs related to nasal feeding knowledge and discharge planning (Knowledge), ② Factors affecting the family caregivers of elderly with nasal feeding (Awareness), and ③ Practical needs in caregiving (Practice).

CONCLUSION

Discharge planning for family caregivers of elderly individuals receiving nasal feeding should focus on the accurate assessment of tube placement and patient condition, operational skills, emergency response, and complication management. Medical professionals should evaluate these needs to develop personalized discharge readiness service plans, ensuring the quality of care for elderly patients with nasal feeding at home.

Effects of Huoxue Qufeng Decoction combined with Tongguan Liquefying Acupoint Penetration therapy on swallowing function and quality of life in patients with ischemic stroke

OBJECTIVE

To analyze the effects of Huoxue Qufeng Decoction combined with Tongguan Liquefying Acupoint Penetration therapy on swallowing function and quality of life in patients with ischemic stroke.

METHODS

A total of 145 patients with post-stroke dysphagia admitted to Dingxi People's Hospital from January 2019 to May 2022 were selected with 65 patients in the control group and 80 patients in the observation group. The control group received Huoxue Qufeng Decoction alone, while the observation group received additional Tongguan Liquefying Acupoint Penetration therapy. Clinical efficacy, NIH Stroke Scale (NIHSS) score, Water Swallow Test, Swallowing Function Assessment (SSA) score, MD Anderson Dysphagia Inventory (MDADI) score, overall incidence of adverse events, and Swallowing Quality of Life (SWAL-QOL) score were compared between the two groups.

RESULTS

The total response rate in the observation group was higher than that in the control group, with a statistically significant difference (P<0.01). After treatment, the SSA score and NIHSS score were statistically lower in the observation group than in the control group (P<0.01). The MDADI and SWAL-QOL scores were higher in the observation group than in the control group, with a statistically significant difference (both P<0.01). The total effective rate reflected by the Water Swallow Test was significantly higher in the observation group than in the control group (P<0.05). There was no significant difference in the incidence of adverse events between the two groups (P>0.05). Univariate analysis revealed that age and treatment plan were factors influencing the recovery of swallowing function. Logistic multivariate regression analysis further identified age and treatment plan as independent risk factors affecting patient prognosis (P<0.05).

CONCLUSION

Huoxue Qufeng Decoction combined with Tongguan Liquefying Acupoint Penetration has a significant effect on post-stroke dysphagia, effectively improving swallowing function and enhancing quality of life.

Dysphagia management by nurses in Spanish intensive care units

INTRODUCTION/PURPOSE

Dysphagia is a disorder that presents with specific signs and symptoms in critically ill patients. Intensive care unit (ICU) nurses are responsible for monitoring and detecting abnormalities in critically ill patients, so they must be trained to assess swallowing and the complications that may arise. The aim of this research is to analyse the dynamics of the detection and assessment of dysphagia by ICU nurses.

METHOD

Cross-sectional descriptive study using an electronic questionnaire to nurses from different Spanish ICUs. The survey was adapted from previous research and consisted of 6 sections with 30 items of qualitative questions. The collection period was between December 2022 and March 2023. Statistical analysis was performed using frequencies and percentages, and the Chi-Square test was used for bivariate analysis.

OUTCOMES

43 nurses were recruited. Dysphagia is considered an important problem (90,7%) but in 50,3% of the units there is no standard or care protocol for this disorder. The most common technique is the swallowing test (32,6%). There is a consensus in our sample that aspiration pneumonia is the main problem; however, nurses in the busiest care units consider sepsis to be a frequent complication (p = ,029). The most common treatment is modification of food consistency (86,0%).

CONCLUSION

The findings of this research show a low systematisation of dysphagia screening in the units included. There is a need for greater implementation of interventions and clinical protocols for monitoring complications as well as for compensatory and rehabilitative management.

Mapping research trends regarding the mechanism of dysphagia from 1993 to 2023: a bibliometrics study and visualization analysis

As a common consequence of various neurogenic disorders, dysphagia has a significant impact on the quality of life for patients. To promote the development the field of swallowing, it will be helpful to clarify the pathological and therapeutic mechanisms of dysphagia. Through visual analysis of related papers from 1993 to 2023 in the Web of Science Core Collection (WoSCC) database, the research status and development trend of the pathogenesis of dysphagia were discussed. The co-occurrence study was finished using CiteSpace 6.2 R4 software, including keywords, countries, institutions, and authors. Finally, 1,184 studies satisfied the inclusion requirements. The findings of the visualization analysis suggested that aspiration and gastroesophageal reflux disease would be the areas of greatest interest for researchers studying the mechanism of dysphagia. As for the latest occurred research trends, fMRI, signals and machine learning emerging into the field of view of researchers. Based on an analysis of country co-occurrence, United States, Japan and China rank the top three, in terms of the number of publications on dysphagia. University System of Ohio is the organization that has published the most amount of articles regarding the mechanism of dysphagia. Other highly published schools in the top three include State University System of Florida and Northwestern University. For the prolific authors, German, Rebecca Z published the most articles at present, whose own research team working closely together. Several closely cooperating research teams have been formed at present, including the teams centered around German, Rebecca Z, Warnecke, Tobias and Hamdy Shaheen. This study intuitively analyzed the current research status of the mechanism of dysphagia, provided researchers with research hotspots in this field.

Association between swallowing dynamics, tongue pressure and pulmonary function in patients with idiopathic pulmonary fibrosis

BACKGROUND

Swallowing is a complex process that requires the coordination of muscles in the mouth, pharynx, larynx, and esophagus. Dysphagia occurs when a person has difficulty swallowing. In the case of subjects with respiratory diseases, the presence of oropharyngeal dysphagia potentially increases lung disease exacerbations, which can lead to a rapid decline in lung function. This study aimed to analyze the swallowing of patients with idiopathic pulmonary fibrosis (IPF).

METHODS

Patients with IPF were evaluated using the Eating Assessment Tool (EAT-10), tongue pressure, the Timed Water Swallow Test (TWST), and the Test of Mastication and Swallowing Solids (TOMASS). The findings were related to dyspnea severity assessed by the modified Medical Research Counsil (mMRC) score; the nutritional status screened with Mini Nutritional Assessment (MNA) tool; and pulmonary function tests, specifically spirometry and measurement of the diffusing capacity for carbon monoxide (DLCO), the maximal inspiratory pressure (PImax), and the maximal expiratory pressure (PEmax).

RESULTS

The sample consisted of 34 individuals with IPF. Those who exhibited swallowing modifications scored lower on the MNA than those who did not (9.6 ± 0.76 vs. 11.64 ± 0.41 points; mean difference 1.98 ± 0.81 points; p = 0.02). They also showed poorer lung function when considering the predicted force vital capacity (FVC; 81.5% ± 4.61% vs. 61.87% ± 8.48%; mean difference 19.63% ± 9.02%; p = 0.03). The speed of liquid swallowing was altered in 31of 34 of the evaluated subjects (91.1%). The number of liquid swallows correlated significantly with the forced expiratory volume in 1 s (FEV1)/FVC ratio (r = 0.3; p = 0.02). Solid eating and swallowing assessed with the TOMASS score correlated with lung function. The number of chewing cycles correlated negatively with PImax% predicted (r = -0.4; p = 0.0008) and PEmax% predicted (r = -0.3; p = 0.02). FVC% predicted correlated with increased solid swallowing time (r = -0.3; p = 0.02; power = 0.6). Swallowing solids was also impacted by dyspnea.

CONCLUSION

Patients with mild-to-moderate IPF can present feeding adaptations, which can be related to the nutritional status, lung function, and the severity of dyspnea.

Thick Liquids and Clinical Outcomes in Hospitalized Patients With Alzheimer Disease and Related Dementias and Dysphagia

Importance

Oropharyngeal dysphagia is common in hospitalized patients with Alzheimer disease and related dementias (ADRD). Although the use of thick liquids in patients with dysphagia has been shown to reduce aspiration on direct visualization, there is no clear evidence that this practice translates into improved clinical outcomes.

Objectives

To determine whether a diet of thick liquids compared with thin liquids is associated with improved outcomes in hospitalized patients with ADRD and dysphagia.

Design, Setting, and Participants

This cohort study included adults aged 65 years and older with ADRD who were admitted to the medicine service across 11 diverse hospitals in New York between January 1, 2017, and September 20, 2022, with clinical suspicion of dysphagia during hospitalization and survival for at least 24 hours after hospital arrival. Patients were grouped according to whether at least 75% of their hospital diet consisted of a thick liquid diet or a thin liquid diet. Propensity score matching was used to balance covariates across the 2 groups for the following covariates: demographics (eg, age, sex), baseline clinical characteristics (eg, Charlson Comorbidity Index), and acute presentation (eg, respiratory diagnosis, illness severity, delirium).

Main Outcomes and Measures

Hospital outcomes included mortality (primary outcome), respiratory complications (eg, pneumonia), intubation, and hospital length of stay (LOS).

Results

Of 8916 patients with ADRD and dysphagia included in the propensity score matched analysis, the mean (SD) age was 85.7 (8.0) years and 4829 were female (54.2%). A total of 4458 patients receiving a thick liquid diet were matched with 4458 patients receiving a thin liquid diet. There was no significant difference in hospital mortality between the thick liquids and thin liquids groups (hazard ratio, 0.92; 95% CI, 0.75-1.14]; P = .46). Compared with patients receiving thin liquids, patients receiving thick liquids were less likely to be intubated (odds ratio [OR], 0.66; 95% CI, 0.54-0.80), but they were more likely to have respiratory complications (OR, 1.73; 95% CI, 1.56-1.91).

Conclusions and Relevance

This cohort study emphasizes the need for prospective studies that evaluate whether thick liquids are associated with improved clinical outcomes in hospitalized patients with ADRD and dysphagia.

Exploring the diagnostic accuracy and applicability of the Gugging Swallowing Screen in children with feeding and/or swallowing disorders

BACKGROUND

The Gugging Swallowing Screen (GUSS) is a bedside dysphagia screening tool that has been designed to determine the risk of aspiration in acute stroke patients. There is no evidence in the literature for the GUSS for the pediatric population. The present study aimed to determine the diagnostic accuracy of GUSS as a screening tool in the Greek language for children with dysphagia.

METHODS

Eighty-Greek-Cypriot children aged 3-12 years who had dysphagia participated in this retrospective study. The translated into Greek GUSS was administered twice (pre- and post-therapy) to each patient throughout 24 sessions of dysphagia therapy.

KEY RESULTS

The GUSS showed a high internal consistency (Cronbach's α = 0.826), good test-retest reliability (rs = 0.767), convergent validity compared to the Greek Pediatric Eating Assessment tool-10 (PEDI-EAT-10) total score (rs = -0.365), and inter-rater reliability (κ = 0.863). A total cutoff points equal to 13.00 was also calculated. Aspiration was identified by the GUSS with low sensitivity and high specificity (PPV 100%, NPV 57%, LR+ NA, LR- 0.79); dysphagia/penetration was identified with high sensitivity and low specificity (PPV 33%, NPV 100%, LR+ 0.102, LR- NA).

CONCLUSIONS & INFERENCES

The pediatric version of GUSS has been found to be a valuable tool in identifying the risk of aspiration as that of adults. It proved to be used as a good screening guide for selecting and confirming the existence of dysphagia from instrumental assessments. This is the first study of the pediatric version of GUSS, and future studies on this topic are needed.

A simple nomogram for predicting aspiration associated with dysphagia in hospitalized patients after stroke

BACKGROUND

Aspiration is a common complication of poststroke dysphagia (PSD) and is associated with poor prognosis and mortality. There is no uniform criterion for determining aspiration associated with dysphagia. The aim of this study was to identify early predictors of aspiration, leading to the development of a simple nomogram for identifying aspiration risk associated with dysphagia in hospitalized patients after stroke.

METHODS

Demographic information and clinical characteristics of 330 patients with PSD in the training cohort were utilized to develop a nomogram. The LASSO regression method was used to screen variables, and logistic regression was used to construct the nomogram. Internal validation was performed with bootstrap in the training cohort, and external validation was performed in the validation cohort of another 82 patients. The area under the curve (AUC), calibration curves, and decision curve analysis (DCA) were used to evaluate the performance of the nomogram.

RESULTS

Seven variables were selected based on LASSO and multivariate logistic regression. The AUC of the nomogram was 0.834 (95% CI, 0.790-0.878) in the training cohort, 0.806 (95% CI, 0.791-0.880) in the internal validation cohort, and 0.882 (95% CI, 0.810-0.954) in the external validation cohort, which indicated that the model had good discrimination. The calibration and DCA curves showed that the nomogram had good accuracy and clinical utility.

CONCLUSIONS

In this study, we established a nomogram that can be used to identify the risk of aspiration associated with dysphagia after stroke, and patients may benefit from early screening and preventive care.

Dysphagia Is an Underrecognized Risk Factor for Viral Pneumonia Severity

The aim of this study was to examine the role of pre-existing dysphagia as a risk factor for COVID-19 severity among adults ≥50 years of age presenting to the emergency department (ED). This was a retrospective cohort study that used electronic health record data from two Midwestern EDs in the same health care system. The sample included patients ≥50 years of age who tested positive for SARS-COV-2 during an ED visit between March 15, 2020 and November 19, 2020. Patients were dichotomized based on documented history of dysphagia. The primary outcome was the highest World Health Organization COVID-19 clinical severity score within 30-days of ED arrival. Patients with a score of <4 were classified as non-severe whereas a score ≥4 was considered severe. Chi-square tests were used to assess differences in clinical severity scores between patients with and without dysphagia. A logistic regression model was created to estimate the odds of a severe COVID-19 clinical score. The sample included 126 patients without dysphagia and 40 patients with dysphagia. Patients with a history of dysphagia were more likely to develop severe COVID-19 disease compared to patients without (65.0% vs. 41.3%, p = 0.015). In multivariable analysis, patients with preexisting dysphagia (OR 2.38, 95% CI: 1.05-5.42; p = 0.038) and diabetes (OR 2.42 95% CI: 1.15-5.30; p = 0.021) had significantly increased odds of developing severe COVID-19. This study showed that a pre-existing diagnosis of dysphagia was independently associated with COVID-19 severity in adults ≥50 years of age.

Prediction of Oral Intake at Discharge with Early Assessment of Swallowing Function within 24 h after Admission: A Retrospective Cohort Study

Dysphagia is one of the most common symptoms of stroke and can lead to other complications such as pneumonia, dehydration, and malnutrition. This retrospective cohort study evaluated the predictive value of a comprehensive swallowing assessment tool, the Mann Assessment of Swallowing Ability (MASA), in the acute phase of stroke for oral intake status at discharge. Among 1,133 consecutive patients with acute stroke, 512 patients whose swallowing function was assessed using the MASA within 24 h of admission were included. Data including demographic information, stroke severity, MASA, Oral Health Assessment Tool, body mass index, and serum albumin level were collected. Predictive factors for oral intake were analyzed using a multiple logistic regression model, and the receiver operating characteristic (ROC) curve analysis was used to determine the cutoff values of the MASA score for determining oral intake at discharge. Oral intake at discharge was established in 69.1% of the cohort (354/512). The multiple logistic regression analysis identified a higher MASA score, younger age, and higher serum albumin level as significant predictors of oral intake at discharge. The cutoff value of the MASA score for oral intake was 136.5 points, with an area under the ROC curve of 0.87. These findings suggest that the MASA is a valid tool for predicting oral intake in patients with dysphagia during the acute phase of stroke.

Prediction of dysphagia aspiration through machine learning-based analysis of patients' postprandial voices

BACKGROUND

Conventional diagnostic methods for dysphagia have limitations such as long wait times, radiation risks, and restricted evaluation. Therefore, voice-based diagnostic and monitoring technologies are required to overcome these limitations. Based on our hypothesis regarding the impact of weakened muscle strength and the presence of aspiration on vocal characteristics, this single-center, prospective study aimed to develop a machine-learning algorithm for predicting dysphagia status (normal, and aspiration) by analyzing postprandial voice limiting intake to 3 cc.

METHODS

Conducted from September 2021 to February 2023 at Seoul National University Bundang Hospital, this single center, prospective cohort study included 198 participants aged 40 or older, with 128 without suspected dysphagia and 70 with dysphagia-aspiration. Voice data from participants were collected and used to develop dysphagia prediction models using the Multi-Layer Perceptron (MLP) with MobileNet V3. Male-only, female-only, and combined models were constructed using 10-fold cross-validation. Through the inference process, we established a model capable of probabilistically categorizing a new patient's voice as either normal or indicating the possibility of aspiration.

RESULTS

The pre-trained models (mn40_as and mn30_as) exhibited superior performance compared to the non-pre-trained models (mn4.0 and mn3.0). Overall, the best-performing model, mn30_as, which is a pre-trained model, demonstrated an average AUC across 10 folds as follows: combined model 0.8361 (95% CI 0.7667-0.9056; max 0.9541), male model 0.8010 (95% CI 0.6589-0.9432; max 1.000), and female model 0.7572 (95% CI 0.6578-0.8567; max 0.9779). However, for the female model, a slightly higher result was observed with the mn4.0, which scored 0.7679 (95% CI 0.6426-0.8931; max 0.9722). Additionally, the other models (pre-trained; mn40_as, non-pre-trained; mn4.0 and mn3.0) also achieved performance above 0.7 in most cases, and the highest fold-level performance for most models was approximately around 0.9. The 'mn' in model names refers to MobileNet and the following number indicates the 'width_mult' parameter.

CONCLUSIONS

In this study, we used mel-spectrogram analysis and a MobileNetV3 model for predicting dysphagia aspiration. Our research highlights voice analysis potential in dysphagia screening, diagnosis, and monitoring, aiming for non-invasive safer, and more effective interventions.

TRIAL REGISTRATION

This study was approved by the IRB (No. B-2109-707-303) and registered on clinicaltrials.gov (ID: NCT05149976).

Dysphagia Prevalence in Progressive Supranuclear Palsy: A Systematic Review and Meta-Analysis

The objective of this systematic review was to determine the prevalence of dysphagia and aspiration in people with progressive supranuclear palsy (PSP). A search of six electronic databases was performed from inception to April 2022. No context restrictions were set. All primary research comprising figures to derive a prevalence rate were included. Two independent reviewers screened search results. Data were extracted by one reviewer. Conflicts were resolved by discussion with a third reviewer. The quality of included studies was assessed using the JBI Checklist for Prevalence Studies. From 877 studies, 12 were eligible for inclusion. Dysphagia had to be confirmed using instrumental assessments, clinical swallowing evaluation, screening, and patient-reported outcome measures (PROM). A random-effects meta-analysis calculated a pooled dysphagia prevalence in 78-89% (95% CI [60.6, 89.1], [78.9, 95.0]). depending on the chosen assessment method, and a pooled aspiration prevalence of 23.5% (95% CI [14.5, 33.7]). The included studies were of moderate quality, with high risk of selection and coverage bias and low to moderate risk of measurement bias. Dysphagia is highly prevalent in a sample of participants with mostly moderately severe PSP. Aspiration occurs in a quarter of this sample and is likely to increase as the disease progresses. Given the low general prevalence of PSP, studies remain at high risk for selection bias. Prospective research should focus on the development of dysphagia in the course of PSP and its subcategories using instrumental assessment and consider all phases of swallowing. REGISTRATION: The protocol of this systematic review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) in April 2021 (registration number: CRD42021245204).

Significant enhancement of swallowing function and oral hygiene following multidisciplinary team nursing in tongue cancer patients after radical resection

OBJECTIVE

To determine the effects of multidisciplinary team (MDT) nursing mode on the swallowing function and oral hygiene in patients after radical resection of tongue cancer (TC).

METHODS

The data of 88 patients with TC treated in West China School/Hospital of Stomatology, Sichuan University were analyzed retrospectively. Among them, 42 patients who received routine nursing between February 2019 and February 2020 were assigned to a control group, and 46 patients who received MDT nursing between March 2020 and February 2022 were assigned to an observation group. The two groups were compared in the changes of postoperative swallowing function and oral hygiene, postoperative swallowing-related quality of life (QoL), and the survival rate for myocutaneous flap. The risk factors affecting swallowing function were analyzed through Logistic regression.

RESULTS

After one month of nursing, the score of swallowing function decreased notably in both groups, with notably lower score in the observation group than that in the control group (P < 0.05). The control group exhibited notably lower oral cleanliness than the observation group after nursing (P < 0.05). Additionally, a notably lower survival rate of myocutaneous flap was found in the control group than that in the observation group (P < 0.05). The QoL scores of the two groups increased notably after nursing, and the observation group had notably higher QoL score than the control group (P < 0.05). The extent of glossectomy and nursing plan were independent risk factors impacting the recovery of swallowing function (P < 0.05).

CONCLUSION

MDT nursing have a positive impact on oral hygiene as well as the swallowing function of patients after radical resection of TC, and MDT is a protective factor for swallowing function in the patients after radical resection.

Contribution of Wireless Wi-Fi Intraoral Cameras to the Assessment of Swallowing Safety and Efficiency

BACKGROUND

Clinical evaluation of swallowing provides important clinical information but is limited in detecting penetration, aspiration, and pharyngeal residue in patients with suspected dysphagia. Although this is an old problem, there remains limited access to low-cost methods to evaluate swallowing safety and efficiency.

PURPOSE

The purpose of this technical report is to describe the experience of a single center that recently began using a wireless Wi-Fi intraoral camera for transoral endoscopic procedures as an adjunct to clinical swallowing evaluation. We describe the theoretical structure of this new clinical evaluation proposal. We present descriptive findings on its diagnostic performance in relation to videofluoroscopic swallowing study as the gold standard in a cohort of seven patients with dysphagia following head and neck cancer. We provide quantitative data on intra- and interrater reliability. Furthermore, this report discusses how this technology can be applied in the clinical practice of professionals who treat patients with dysphagia and provides directions for future research.

CONCLUSIONS

This preliminary retrospective study suggests that intraoral cameras can reveal the accumulated oropharyngeal secretions and postswallow pharyngolaryngeal residue in patients with suspected dysphagia. Future large-scale studies focusing on validating and exploring this contemporary low-cost technology as part of a clinical swallowing evaluation are warranted.

The Water Swallow Test and EAT-10 as Screening Tools for Referral to Videofluoroscopy

BACKGROUND

Videofluoroscopy (VFS) is the gold standard in evaluating dysphagia. Water swallow tests (WST) and the Eating Assessment Tool (EAT-10) are commonly used in dysphagia screening. We aimed to determine the feasibility of WST and EAT-10 as screening tools for referral to VFS.

METHODS

Patients (n = 150, median age: 70.0 years, range: 19-92 years, 58.7% female) referred to VFS completed the WST and EAT-10 before the examination. In the WST, we evaluated both the qualitative parameters (coughing, possible change in voice) and quantitative parameters (average drinking bolus size, swallowing speed). Correlations of EAT-10 total scores and WST parameters to the VFS findings were analyzed both individually and combined.

RESULTS

In the WST, the most specific (89.7%) predictor of normal VFS findings was the absence of coughing, and the most sensitive (79.1%) parameter to predict abnormal findings was a bolus size of ≤20 mL. Using a combination of coughing and a bolus size ≤20 mL (simplified WST), the sensitivity of predicting abnormal findings increased to 83.5%. The most sensitive (84.6%) predictor of penetration/aspiration was failing any parameter in the WST. Lack of coughing indicated an absence of penetration/aspiration with an 82.5% specificity. Swallowing speed or combining the EAT-10 results with the WST results did not enhance the sensitivity or specificity of the WST for predicting the VFS results.

CONCLUSIONS

Coughing and average drinking bolus size are the most important parameters in WST when screening for referral to VFS, whereas the swallowing speed does not seem to be useful. The WST is superior to EAT-10 in predicting VFS findings.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1349-1355, 2024.

Management of swallowing disorders in ICU patients - A multinational expert opinion

BACKGROUND

Dysphagia is common in intensive care unit (ICU) patients, yet it remains underrecognized and often unmanaged despite being associated with life-threatening complications, prolonged ICU stays and hospitalization.

PURPOSE

To propose an expert opinion for the diagnosis and management of dysphagia developed from evidence-based clinical recommendations and practitioner insights.

METHODS

A multinational group of dysphagia and critical care experts conducted a literature review using a modified ACCORD methodology. Based on a fusion of the available evidence and the panel's clinical experience, an expert opinion on best practice management was developed.

RESULTS

The panel recommends adopting clinical algorithms intended to promote standardized, high-quality care that triggers timely systematic dysphagia screening, assessment, and treatment of extubated and tracheostomized patients in the ICU.

CONCLUSIONS

Given the lack of robust scientific evidence, two clinical management algorithms are proposed for use by multidisciplinary teams to improve early systematic detection and effective management of dysphagia in ICU patients. Additionally, emerging therapeutic options such as neurostimulation have the potential to improve the quality of ICU dysphagia care.

Evaluation and Treatment of Dysphagia in Public and Private Intensive Care Units (ICUs) in Greece

Introduction  Dysphagia is a significant but underrecognized clinical issue in the intensive care unit (ICU), and it is associated with various complications. Despite its clinical importance, there is limited research and no Greek ICU-specific guidelines for managing dysphagic patients. Additionally, only a few ICUs in Greece have dysphagia specialists, specifically speech-language pathologists (SLPs) providing their expertise. Objective  Τo identify the current practices for dysphagia management (screening, assessment, treatment) and gain insight into ICU directors' awareness/perceptions of the prevalence, complications, and risk of dysphagia. Materials and Methods  We identified 138 Greek ICUs. Data were collected from ICU (including pediatric and neonatal) directors, working in public and private hospitals, via a 24-item, anonymous online questionnaire, within a 4-month period. Results  Our survey was completed by 45 ICU directors. Most participants (84.4%) reported that dysphagia is a relevant clinical problem in their ICU, and 51.1% estimated a frequency rate < 20%. Non-instrumental approaches are mainly utilized to screen and diagnose dysphagia, whereas enteral nutrition and diet modifications are used to manage dysphagia. Additionally, 64.4% of ICU directors agreed that SLPs are essential for the management of dysphagic patients, and 66.7%, that awareness of dysphagia in their ICU could be increased. Conclusion  The current study documented the methods and approaches used to manage dysphagic patients in Greek ICUs. The ICU directors seem to recognize the clinical significance of dysphagia and its complications. According to our findings, the employment of SLPs could result in a more comprehensive and intensive approach and improve the quality of care for these patients.

Research trends and hotspots of post-stroke dysphagia rehabilitation: a bibliometric study and visualization analysis

Background

Post-stroke dysphagia (PSD) is one of the most prevalent stroke sequelae, affecting stroke patients' prognosis, rehabilitation results, and quality of life while posing a significant cost burden. Although studies have been undertaken to characterize the pathophysiology, epidemiology, and risk factors of post-stroke dysphagia, there is still a paucity of research trends and hotspots on this subject. The purpose of this study was to create a visual knowledge map based on bibliometric analysis that identifies research hotspots and predicts future research trends.

Methods

We searched the Web of Science Core Collection for material on PSD rehabilitation research from its inception until July 27, 2023. We used CiteSpace, VOSviewer, and Bibliometrix R software packages to evaluate the annual number of publications, nations, institutions, journals, authors, references, and keywords to describe present research hotspots and prospective research orientations.

Results

This analysis comprised 1,097 articles from 3,706 institutions, 374 journals, and 239 countries or regions. The United States had the most publications (215 articles), and it is the most influential country on the subject. "Dysphagia" was the most published journal (100 articles) and the most referenced journal (4,606 citations). Highly cited references focused on the pathophysiology and neuroplasticity mechanisms of PSD, therapeutic modalities, rehabilitation tactics, and complications prevention. There was a strong correlation between the terms "validity" and "noninvasive," which were the strongest terms in PSD rehabilitation research. The most significant words in PSD rehabilitation research were "validity" and "noninvasive brain stimulation," which are considered two of the most relevant hotspots in the field.

Conclusion

We reviewed the research in the field of PSD rehabilitation using bibliometrics to identify research hotspots and cutting-edge trends in the field, primarily including the pathogenesis and neurological plasticity mechanisms of PSD, complications, swallowing screening and assessment methods, and swallowing rehabilitation modalities, and this paper can provide in the follow-up research in the field of PSD rehabilitation. The results of this study can provide insightful data for subsequent studies in the field of PSD rehabilitation.

Dysphonia Outperforms Voice Change as a Clinical Predictor of Dysphagia

PURPOSE

Changes in voice quality after consuming food or drink have been used as a clinical indicator of dysphagia during the clinical swallowing evaluation (CSE); however, there is conflicting evidence of its efficacy. This study investigated if dysphonia and/or voice change after swallowing are valid predictors of penetration, aspiration, or pharyngeal residue. Our approach aimed to improve current methodologies by collecting voice samples in the fluoroscopy suite, implementing rater training to improve interrater reliability and utilizing continuous measurement scales, allowing for regression analyses.

METHOD

In this prospective study, 30 adults (aged 49-97 years) referred for a videofluoroscopic swallowing study (VFSS) were audio-recorded completing a sustained /i/ prior to VFSS and again after swallowing each bolus during the VFSS. Swallowing function was measured using the reorganized Penetration-Aspiration Scale and the Normalized Residue Ratio Scale. Following listener training, 84 voice samples were perceptually rated using the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). Ordinal and logistic regression were used to determine whether voice quality and voice quality change after swallowing were predictors of airway invasion and pharyngeal clearance.

RESULTS

Results indicated that the presence of dysphonia at baseline during a sustained /i/ task as measured by the CAPE-V predicted airway invasion but not pharyngeal residue. Voice change after swallowing associated with vowel /i/ production as measured by the CAPE-V did not predict either dysphagia measure.

CONCLUSION

These results indicate that voice change during a sustained /i/ after swallowing appears unrelated to airway invasion or pharyngeal residue; however, in the absence of known laryngeal pathology, dysphonia prior to a CSE should alert speech-language pathologists of a possible comorbid dysphagia.

Construction and evaluation of a nomogram prediction model for aspiration pneumonia in patients with acute ischemic stroke

Background

Aspiration Pneumonia (AP) is a leading cause of death in patients with Acute Ischemic Stroke (AIS). Early detection, diagnosis and effective prevention measures are crucial for improving patient prognosis. However, there is a lack of research predicting AP occurrence after AIS. This study aimed to identify risk factors and develop a nomogram model to determine the probability of developing AP after AIS.

Method

A total of 3258 AIS patients admitted to Jinshan Hospital of Fudan University between January 1, 2016, and August 20, 2022, were included. Among them, 307 patients were diagnosed with AP (AP group), while 2951 patients formed the control group (NAP group). Univariate and multivariate logistic regression analyses were conducted to identify relevant risk factors for AP after AIS. These factors were used to establish a scoring system and develop a nomogram model using R software.

Results

Univariate analysis revealed 20 factors significantly associated (P < 0.05) with the development of AP after AIS. These factors underwent multivariate logistic regression analysis, which identified age (elderly), National Institute of Health Stroke Scale (NIHSS) score, dysphagia, atrial fibrillation, cardiac insufficiency, renal insufficiency, hepatic insufficiency, elevated Fasting Blood Glucose (FBG), elevated C-Reactive Protein (CRP), elevated Neutrophil percentage (NEUT%), and decreased prealbumin as independent risk factors. A nomogram model incorporating these 11 risk factors was constructed, with a C-index of 0.872 (95 % CI: 0.845-0.899), indicating high accuracy. Calibration and clinical decision analyses demonstrated the model's reliability and clinical value.

Conclusion

A nomogram model incorporating age, NIHSS score, dysphagia, atrial fibrillation, cardiac insufficiency, renal insufficiency, hepatic insufficiency, FBG, CRP, NEUT%, and prealbumin effectively predicts AP risk in AIS patients. This model provides guidance for early intervention strategies, enabling the identification of high-risk individuals for timely preventive measures.

Clinical practice patterns of speech-language pathologists for screening and identifying dysphagia

PURPOSE

To identify how speech-language pathologists (SLPs) in the United States are screening for and identifying dysphagia. To do this, we examined the approaches most often used to screen for dysphagia and the influence of contextual factors such as setting, continuing education and means of staying up to date with the most current literature on screening approaches.

METHOD

A web-based survey composed of 32 questions was developed and field tested for content, relevance and workflow. The survey was distributed online, via social media, online SLP forums and through the American Speech-Language-Hearing Association's Special Interest Group 13 (swallowing disorders). One hundred and thirty-seven clinicians from the United States completed the survey and were included for analysis using descriptive statistics and linear regression modelling to assess associations of continuing education and years practicing with screening protocols and consumption of evidence.

RESULTS

Respondents worked in a variety of settings, including acute care, skilled nursing facilities, and inpatient rehabilitation. Most respondents worked with adult populations (88%). The most common screening protocols reported were a volume-dependent water swallow test (74%), subjective patient report (66%), and trials of solids/liquids (49%). Twenty-four percent (24%) reported using a questionnaire, the Eating Assessment Tool (80%) being most common. How clinicians consume their evidence was significantly associated with the types of screening approaches used. Continuing education hours were significantly associated with dysphagia screening protocol choice (p < 0.001) and how clinicians stayed up to date with evidence (p < 0.001).

CONCLUSIONS

Results from this study provide an in-depth look at the choices clinicians are making in the field regarding how to effectively screen patients for the presence of dysphagia. Contextual factors such as evidence base consumption patterns should serve researchers to continue seeking alternative ways to share evidence with clinicians, accessibly. Associations between continuing education and protocol choice show the need for continued evidence-based and high-quality continuing education opportunities.

WHAT THIS PAPER ADDS

This study provides an in-depth look at the choices clinicians are making in the field regarding effective dysphagia screening practices. Clinician screening choices are examined with contextual factors such as evidence base consumption patterns and continuing education. This paper increases knowledge of the most used dysphagia screening practices and context for clinicians and researchers to improve use, evidence and dissemination of best practices.

The Association Between Dysphagia Symptoms, DIGEST Scores, and Severity Ratings in Individuals with Parkinson's Disease

The Swallow Disturbance Questionnaire (SDQ) is a screening tool developed to identify patients with Parkinson's Disease (PD) in need of objective swallowing evaluation. In a previous investigation, the SDQ did not predict abnormal airway protection on a videofluoroscopic swallowing study (VFSS). This investigation was undertaken to determine whether SDQ scores were more accurate when a global measure was used. The Dynamic Imaging Grade for Swallowing Toxicity (DIGEST) is a validated measure that provides a safety, efficiency, and total severity grade based on VFSS. A secondary analysis was performed using data from 20 patients with PD who had participated in a standardized VFSS protocol. The study sample was predominantly male (80%) with an average age of 71 years, and an average PD duration of 9 years. Using an established cut-off score, participants were subdivided into those with "normal" (n = 10) and "abnormal" SDQ scores (n = 10). Recordings were scored using the DIGEST protocol by two blinded raters who also rated overall dysphagia severity from the VFSS. There was good agreement between the two raters on the DIGEST and strong correlations between DIGEST scores and clinician perceptions of dysphagia severity. Higher SDQ scores were associated with poorer Efficiency on the DIGEST but not Safety or Total scores. Consistent with other PD studies, subjective perceptions of dysphagia were poorly predictive of objective findings on VFSS. There is little information about the validity of the DIGEST for rating neurogenic dysphagia. Our study provides preliminary support for the use of the DIGEST in the PD population.

Acoustic Screening of the "Wet voice": Proof of Concept in an ex vivo Canine Laryngeal Model

BACKGROUND

Current protocols for bedside swallow evaluation have high rates of false negative results. Though experts are not consistently able to screen for aspiration risk by assessing vocal quality, there is emerging evidence that vocal acoustic parameters are significantly different in patients at risk of aspiration. Herein, we aimed to determine whether the presence of material on the vocal folds in an excised canine laryngeal model may have an impact on acoustic and aerodynamic measures.

METHODS

Two ex vivo canine larynges were tested. Three liquids of different viscosities (1:100 diluted glycerin, pure glycerin, and honey-thick Varibar) were placed on the vocal folds at a constant volume. Acoustic and aerodynamic measures were obtained in both adducted and abducted vocal fold configurations. Intraglottal high-speed imaging was used to approximate the maximum divergence angle of the larynges in the studied conditions and examine its relationship to vocal efficiency (VE) and acoustic measures.

RESULTS

In glottic insufficiency conditions only, we found that several acoustic parameters could predict the presence of material on the vocal folds. Based on the combination of the aerodynamic and acoustic data, we found that decreased spectral energy in the higher harmonics was associated with decreased VE in the presence of material on the vocal folds and/or glottic insufficiency.

CONCLUSION

Decreased spectral energy in the higher harmonics of the voice was found to be a potential biomarker of swallowing dysfunction, as it correlates with decreased vocal efficiency due to material on the vocal folds and/or glottic insufficiency, both of which are known risk factors for aspiration.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:2517-2524, 2023.

Strategies of Screening and Treating Post-Extubation Dysphagia: An Overview of the Situation in Greek-Cypriot ICUs

Post-extubation dysphagia (PED) can lead to serious health problems in critically ill patients. Contrasting its high incidence rate of 12.4% reported in a recent observational study, many ICUs lack routine bedside screening, likely due to limited awareness. This study aimed to establish baseline data on the current approaches and the status of perceived best practices in PED screening and treatment, as well as to assess awareness of PED. A nationwide cross-sectional, online survey was conducted in all fourteen adult ICUs in the Republic of Cyprus in June 2018, with a 100% response rate. Over 85% of ICUs lacked a standard screening protocol for PED. The most commonly reported assessment methods were cough reflex testing and the water swallow test. Treatment approaches included muscle strengthening exercises without swallowing and swallowing exercises. Only 28.6% of ICUs acknowledged PED as a common issue. The study identified significant gaps in awareness and knowledge regarding PED screening and treatment in Greek-Cypriot ICUs. Urgent implementation of comprehensive dysphagia education programs within the units is necessary, and interdisciplinary collaboration among nurses, intensivists, and speech and language therapists is crucial to improve the quality of care provided.

Does Dysphagia Predict Inpatient Morbidity and Mortality in Geriatric Patients Admitted for Aspiration Pneumonia?

Background Aspiration pneumonia is common in older adults admitted for community-acquired pneumonia and is associated with significant morbidity and mortality. Factors that put this population at higher risk of aspiration include cognitive impairment, neuromuscular dysfunction, and dysphagia. This study aimed to determine whether a concurrent diagnosis of dysphagia conferred a higher risk of complications in the elderly admitted for aspiration pneumonia. Methods The National Inpatient Sample 2001-2013 database was queried for patients, aged 65 or older, with a diagnosis of aspiration pneumonia using International Classification of Diseases, Ninth Revision (ICD-9) codes. Sepsis, respiratory failure, and intubation were identified with their respective ICD-9 codes. A chi-square test and binary logistic regression analysis were used to examine socio-demographic and complication variables, with a significance level of α <0.001. Results A total of 1,097,325 patients were admitted for aspiration pneumonia, of which 349,861 (24.2%) had dysphagia. After incorporating socio-demographic variables, the dysphagia group had a significantly lower likelihood of having sepsis (OR=0.72), respiratory failure (OR=0.92), intubation (OR=0.52), and inpatient mortality (OR = 0.59). Patients with dysphagia had a significantly higher likelihood of increased length of stay (OR=1.24). Conclusions Elderly patients admitted with aspiration pneumonia with a co-diagnosis of dysphagia were less likely to have inpatient morbidity and mortality compared to their counterparts. This may be due to improved speech evaluation and treatment in patients with dysphagia allowing for better control of macro and micro aspiration. Future research is needed to examine if universal speech therapy can reduce hospitalization and long-term mortality for such patients.

Optimal time point for neutrophil-to-lymphocyte ratio to predict stroke-associated pneumonia

PURPOSE

This study aimed at the population receiving thrombolytic therapy and to explore the optimal time point for neutrophil-to-lymphocyte ratio (NLR) in predicting stroke-associated pneumonia (SAP).

METHODS

We assessed patients undergoing intravenous thrombolysis (IVT) for acute ischemic stroke. Blood parameters were sampled before thrombolysis (within 30 min after admission) and within 24-36 h after thrombolysis, respectively. The primary outcome measure was the occurrence of SAP. Multivariate logistic regression analysis was performed to analyze the association between admission blood parameters and the event of SAP. We also used receiver operating characteristic (ROC) curve analysis to assess the discriminative ability of blood parameters measured at different times in predicting SAP.

RESULTS

Among the 388 patients, SAP occurred in 60 (15%) patients. Multivariate logistic regression analysis showed that NLR was significantly associated with SAP (NLR before IVT: aOR = 1.288; 95%CI = 1.123-1.476; p < 0.001; NLR after IVT: (aOR = 1.127, 95%CI = 1.017-1.249; p = 0.023). The ROC curve showed that the predictive ability of NLR after IVT was better than NLR before IVT, not only in predicting the occurrence of SAP but also in predicting short-term and long-term functional outcomes, hemorrhagic transformation, and 1-year mortality.

CONCLUSION

Increased NLR measured within 24-36 h after IVT has a significant predictive effect on the occurrence of SAP and can be used to predict short-term and long-term poor functional outcomes, hemorrhagic transformation, and 1-year mortality.

A Decision Guide for Assessing the Recently Extubated Patient's Readiness for Safe Oral Intake

BACKGROUND

Postextubation dysphagia is a known consequence of endotracheal intubation. Several risk factors for postextubation dysphagia have been identified that could be used to help determine which patients should undergo swallowing assessment by an appropriate professional.

LOCAL PROBLEM

At the authors' institution, critical care nurses, health care providers, and speech-language pathology professionals lacked a clear process for referring patients for swallowing assessment after extubation, resulting in inefficiency and confusion. Information to guide their decision-making in this area was needed. To address this need, a multidisciplinary group convened and developed a guide with specific indicators.

METHODS

A review of the literature on postextubation dysphagia was conducted to determine the most appropriate indicators for the guide, which was piloted in the medical intensive care unit. The utilization rate was calculated. Referrals to speech-language pathology professionals were tabulated before and after the project.

RESULTS

During the 11 months before implementation of the project, there were 994 speech-language pathology consultations for postextubation evaluation of swallowing. During the 11 months after implementation, there were 831 consultations, representing a 16.4% reduction. The decline in consultations resulted in cost savings in addition to preventing unnecessary testing before patients' resumption of oral intake. The utilization rate for the guide during the project was 58%.

CONCLUSION

The decision guide was an effective tool to help nurses and health care providers determine which patients should be referred to speech-language pathology professionals for swallowing assessment after extubation, facilitating the appropriate use of limited health care resources.

Reliability and Validity of Non-Instrumental Clinical Assessments for Adults with Oropharyngeal Dysphagia: A Systematic Review

This systematic review on non-instrumental clinical assessment in adult oropharyngeal dysphagia (OD) provides an overview of published measures with reported reliability and validity. In alignment with PRISMA, four databases (CINAHL, Embase, PsycINFO, and PubMed) were searched, resulting in a total of 16 measures and 32 psychometric studies included. The included measures assessed any aspect of swallowing, consisted of at least one specific subscale relating to swallowing, were developed by clinical observation, targeted adults, and were developed in English. The included psychometric studies focused on adults, reported on measures for OD-related conditions, described non-instrumental clinical assessments, reported on validity or reliability, and were published in English. Methodological quality was assessed using the standard quality assessment QualSyst. Most measures targeted only restricted subdomains within the conceptual framework of non-instrumental clinical assessments. Across the 16 measures, hypothesis testing and reliability were the most reported psychometrics, whilst structural validity and content validity were the least reported. Overall, data on the reliability and validity of the included measures proved incomplete and frequently did not meet current psychometric standards. Future research should focus on the development of comprehensive non-instrumental clinical assessments for adults with OD using contemporary psychometric research methods.

Dysphagia in Intensive Care Evaluation (DICE): An International Cross-Sectional Survey

Dysphagia occurs commonly in the intensive care unit (ICU). Despite the clinical relevance, there is little worldwide research on prevention, assessment, evaluation, and/or treatment of dysphagia for ICU patients. We aimed to gain insight into this international knowledge gap. We conducted a multi-center, international online cross-sectional survey of adult ICUs. Local survey distribution champions were recruited through professional and personal networks. The survey was administered from November 2017 to June 2019 with three emails and a final telephone reminder. Responses were received from 746 ICUs (26 countries). In patients intubated > 48 h, 17% expected a > 50% chance that dysphagia would develop. This proportion increased to 43% in patients intubated > 7 days, and to 52% in tracheotomized patients. Speech-language pathologist (SLP) consultation was available in 66% of ICUs, only 4% reported a dedicated SLP. Although 66% considered a routine post-extubation dysphagia protocol important, most (67%) did not have a protocol. Few ICUs routinely assessed for dysphagia after 48 h of intubation (30%) or tracheostomy (41%). A large proportion (46%) used water swallow screening tests to determine aspiration, few (8%) used instrumental assessments (i.e., flexible endoscopic evaluation of swallowing). Swallowing exercises were used for dysphagia management by 30% of ICUs. There seems to be limited awareness among ICU practitioners that patients are at risk of dysphagia, particularly as ventilation persists, protocols, routine assessment, and instrumental assessments are generally not used. We recommend the development of a research agenda to increase the quality of evidence and ameliorate the implementation of evidence-based dysphagia protocols by dedicated SLPs.

A Prospective Validation Study of the Functional Bedside Aspiration Screen with Endoscopy: Is It Clinically Applicable in Acute Stroke?

The purpose of this study was to investigate the reliability of the novel Functional Bedside Aspiration Screen (FBAS) to predict aspiration risk in acute stroke and to guide initial therapy needs. We conducted a prospective validation study of the FBAS 10-point scale in 101 acute ischemic stroke patients. Outcome measures were compared with the Penetration Aspiration Scale (PAS) via the Flexible Endoscopic Swallowing Study. Correlations with the Functional Oral Intake Scale (FOIS) and the Therapy Requirement Scale (TRS) were analyzed. We observed a 65.8% sensitivity and 70.2% specificity (p = 0.004) for predicting penetration risk (for PAS score ≥ 3) and a 73% sensitivity and 62% specificity for predicting aspiration risk (PAS score ≥ 6). For patients with a modified ranking scale 0-2 (n = 44) on admission, the predictive measurements of the FBAS yielded sensitivity and specificity values of 66.7% and 88.6% (p = 0.011). A significant negative correlation was found with PAS measurements, whereas a positive correlation was observed regarding FOIS. Significantly lower FBAS scores were observed in patients with high requirements for therapeutic interventions and dietary modification. FBAS may be regarded as an alternative time-efficient clinical support tool in settings in which instrumentation is not directly accessible. Further studies including a larger cohort of acute stroke patients with more severe neurological deficits are necessary.

Effect of Chin Tuck against Resistance Exercise in Citizens with Oropharyngeal Dysphagia-A Randomised Controlled Study

Oropharyngeal dysphagia (OD) impacts the safety and efficacy of the swallowing function. The aim was to uncover the effect of chin tuck against resistance (CTAR) exercises compared to standard care in relation to the swallowing function in citizens with OD. Ninety-two citizens (46% male, median age 78 years (IQR 71, 84)) with OD confirmed by the Volume-Viscosity Swallow Test and/or Minimal Eating Observation Form version II were randomised to standard care with the addition of CTAR daily for six weeks or standard care only. The participants were included from seven Danish municipalities from March 2019 to October 2020. A nonsignificant effect on dysphagia of CTAR training combined with standard care versus standard care alone was documented. Both CTAR training combined with standard care and standard care alone had a significant effect on the swallowing function in citizens with OD, with the best effect in the group receiving CTAR training combined with standard care. A significant effect compared to baseline was observed in all participants (p = 0.03) after 12 weeks. Participants in both groups had a significant reduction in problems with manipulating food in the mouth (p = 0.005), swallowing (p = 0.005), and chewing (p = 0.03) but an increased appetite (p = 0.01). The reported quality of life scored with DHI-DK was significantly improved in both groups.

Quantification of the Swallowing Mechanism Through Muscle Synergy Analysis

Decreased swallowing function increases the risk of choking and aspiration pneumonia. Videofluoroscopy and computed tomography allow for detailed observation of the swallowing movements but have radiation risks. Therefore, we developed a method using surface electromyography (sEMG) to noninvasively assess swallowing function without radiation exposure. A 44-channel flexible sEMG sensor was used to measure the sEMG signals of the hyoid muscles during swallowing in 14 healthy young adult and 14 elderly subjects. Muscle synergy analysis was performed to extract the muscle synergies from the sEMG signals, and the three synergies were extracted from the hyoid muscle activities during the swallowing experiments. The experimental results showed that the three synergies represent the oral, early pharyngeal, and late pharyngeal swallowing phases and that swallowing strength is tuned by the strength of the muscle activities, whereas swallowing volume is controlled by adjusting muscle activation timing. In addition, the timing of the swallowing reflex is slower in elderly individuals. The results confirm that the proposed approach successfully quantifies swallowing function from sEMG signals, mapping the signals to the swallowing phases.

Japanese clinical practice guidelines for aspiration and pharyngeal residual assessment during eating and swallowing for nursing care

AIM

This clinical practice guideline aims to provide and recommend methods of assessing aspiration and pharyngeal residue during eating and swallowing and methods of selecting and implementing nursing care for adults to prevent the development of aspiration pneumonia through early and appropriate management of oropharyngeal dysphagia.

METHODS

In April 2018, the Japan Academy of Nursing Science established the Supervisory Committee in Nursing Care Development/Standardization Committee to develop clinical practice guidelines for aspiration and pharyngeal residual assessment during eating and swallowing for nursing care. This clinical practice guideline was developed according to the Minds Manual for Guideline Development 2017, with the aim of providing a specific pathway for nurses to determine the policy for selecting management for oropharyngeal dysphagia based on research evidence and multifaceted factors including the balance of benefits and harms and patients' values.

RESULTS

Based on the 10 clinical questions related to assessment by physical assessment, the Repetitive Saliva Swallowing Test, Modified Water Swallowing Test, Food Test, cervical auscultation, observation using an ultrasound diagnostic device, and an endoscope, 10 recommendations have been developed. Eight recommendations have been evaluated as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) 2C, and the other two have been evaluated as no GRADE.

CONCLUSION

The first reliable clinical practice guideline has been produced from an academic nursing organization that focuses on assessment for nursing care and incorporates the latest findings.

Longitudinal dysphagia assessment in adult patients with nephropathic cystinosis using the Modified Barium Swallow Impairment Profile

INTRODUCTION/AIMS

Nephropathic cystinosis is a lysosomal storage disorder with known myopathic features, including dysphagia. Evaluation of oropharyngeal swallowing physiology can be standardized using the Modified Barium Swallow Impairment Profile (MBSImP), a validated assessment tool used to analyze and rate swallowing across 17 distinct physiologic domains. Our objective was to better characterize swallowing impairments in nephropathic cystinosis using MBSImP analysis.

METHODS

We retrospectively evaluated 40 video fluoroscopic swallowing studies performed at two time points over 1 y in patients with nephropathic cystinosis with various levels of oral and pharyngeal stage dysphagia. Patients completed two self-administered dysphagia outcome measures (the M. D. Anderson Dysphagia Inventory [MDADI] and the 10-item Eating Assessment Tool [EAT-10]).

RESULTS

We demonstrated oral stage and pharyngeal stage dysphagia across domains that impacted bolus control, transit, and clearance through both the oral cavity and pharyngeal lumen. Also captured were deficits related to onset and completeness of laryngeal closure that impact airway protection during swallow. There were significant correlations between pharyngeal total score and EAT-10 (r = 0.5, p < 0.001) and between oral total score and EAT-10 (r = 0.7, p < 0.001), MDADI-e (r = -0.6, p < 0.001), MDADI-p (r = -0.5, p < 0.001) and MDADI-c (r = -0.6, p < 0.001). There were no differences in oral or pharyngeal total scores across the 1-y time span.

DISCUSSION

This study identifies oral and pharyngeal stage dysphagia as crucial to patients with nephropathic cystinosis and paves the path for future studies of treatment targets.

Cognitive Impairment and Mild to Moderate Dysphagia in Elderly Patients: A Retrospective Controlled Study

Background: To investigate whether cognitive impairment in elderly patients could correlate with the severity of swallowing disorders detectable through the endoscopic fiber optic evaluation. Methods: Elderly patients (≥65 years) performing a swallowing evaluation were included and divided according to the Dysphagia outcome and severity scale (DOSS). Neurological evaluation and Mini-Mental test examination (MMET) were administered to detect cognitive impairment. Results: Significantly worse swallowing function was reported in the cognitive impairment group than the control one (40% vs 19%; P = .001). A different significant distribution of swallowing performance was detected according to the patient's MMET score (P < .001; P < .001; P = .01). At the ANOVA test among dependent variables assessed, only age>65 and MMET<10 were significantly correlated with swallowing function (F = 3.862, P = .028; F = 17.49, P = .000). Conclusions: The elderly patient has an increased risk for unrecognized swallowing disorders, with a prevalence of mild to moderate forms. Assessment of cognitive performance could facilitate the identification of swallowing disorders by providing a higher level of suspicion for silent aspiration in subjects with poor MMET scores.

High Fibrinogen to Albumin Ratio: A Novel Marker for Risk of Stroke-Associated Pneumonia?

Background: Stroke-associated pneumonia (SAP) is associated with poor prognosis after acute ischemic stroke (AIS).

Purpose: This study aimed to describe the parameters of coagulation function and evaluate the association between the fibrinogen-to-albumin ratio (FAR) and SAP in patients with AIS.

Patients and methods: A total of 932 consecutive patients with AIS were included. Coagulation parameters were measured at admission. All patients were classified into two groups according to the optimal cutoff FAR point at which the sum of the specificity and sensitivity was highest. Propensity score matching (PSM) was performed to balance potential confounding factors. Univariate and multivariate logistic regression analyses were applied to identify predictors of SAP.

Results: A total of 100 (10.7%) patients were diagnosed with SAP. The data showed that fibrinogen, FAR, and D-dimer, prothrombin time (PT), activated partial thromboplastin time (aPTT) were higher in patients with SAP, while albumin was much lower. Patients with SAP showed a significantly increased FAR when compared with non-SAP (P < 0.001). Patients were assigned to groups of high FAR (≥0.0977) and low FAR (<0.0977) based on the optimal cut-off value. Propensity score matching analysis further confirmed the association between FAR and SAP. After adjusting for confounding and risk factors, multivariate regression analysis showed that the high FAR (≥0.0977) was an independent variable predicting the occurrence of SAP (odds ratio =2.830, 95% CI = 1.654–4.840, P < 0.001). In addition, the FAR was higher in the severe pneumonia group when it was assessed by pneumonia severity index (P = 0.008).

Conclusions: High FAR is an independent potential risk factor of SAP, which can help clinicians identify high-risk patients with SAP after AIS.

Are Oropharyngeal Dysphagia Screening Tests Effective in Preventing Pneumonia?

Oropharyngeal dysphagia, a clinical condition that indicates difficulty in moving food and liquid from the oral cavity to the esophagus, has a markedly high prevalence in the elderly. The number of elderly people with oropharyngeal dysphagia is expected to increase due to the aging of the world's population. Understanding the current situation of dysphagia screening is crucial when considering future countermeasures. We report findings from a literature review including citations on current objective dysphagia screening tests: the Water Swallowing Test, Mann Assessment of Swallowing Ability, and the Gugging Swallowing Screen. Pneumonia can be predicted using the results of the screening tests discussed in this review, and the response after the screening tests is important for prevention. In addition, although interdisciplinary team approaches prevent and reduce aspiration, optimal treatment is a challenging. Intervention studies with multiple factors focusing on the elderly are needed.

Factors and Outcomes Associated With Dysphagia in Hospitalized Persons With Dementia

OBJECTIVES

Dysphagia is prevalent in older adults with dementia, particularly in the acute care setting. The objective of this study was to use an innovative approach to extract a more representative sample of patients with dysphagia from the electronic health record (EHR) to determine patient characteristics, hospital practices, and outcomes associated with dysphagia in hospitalized persons with dementia.

DESIGN

A retrospective study of hospitalized adults (aged ≥65 years) with dementia was conducted in 7 hospitals across the greater New York metropolitan area.

SETTING AND PARTICIPANTS

Data were obtained from the inpatient EHR with the following inclusion criteria: age ≥65 years; admitted to one of 7 health system hospitals between January 1, 2019, and December 31, 2019; and documented past medical diagnosis of dementia (based on International Classification of Diseases, Ninth Revision).

METHODS

A diagnosis of dysphagia was defined as nurse documentation of a positive bedside swallow screening, nurse documentation of "difficulty swallowing" as reason for not performing bedside swallow screening, and physician documentation of a dysphagia diagnosis.

RESULTS

Of adults with dementia (N = 8637), the average age was 84.5 years, 61.6% were female, and 18.1% were Black and 9.3% Hispanic. Dysphagia was identified in 41.8% (n = 3610). In multivariable models, dysphagia was associated with invasive mechanical ventilation [odds ratio (OR) 4.53, 95% CI 3.55-5.78], delirium (OR 1.53, 95% CI 1.40-1.68), increased length of stay (B = 3.29, 95% CI 2.98-3.60), and mortality (OR 4.44, 95% CI 3.54-5.55).

CONCLUSIONS AND IMPLICATIONS

Given its high prevalence, underrecognition, and associated poor outcomes, improving large-scale dysphagia identification can impact clinical care and advance research in hospitalized persons with dementia.

Aspiration syndromes and associated lung injury: incidence, pathophysiology and management

Aspiration is a common condition affecting healthy or sick patients which could create an acute or chronic inflammatory reaction in the lungs. Aspiration syndromes could be categorized according to a content entering the respiratory system into bacterial aspiration pneumonia with the gastric or oropharyngeal bacteria entering, aspiration chemical pneumonitis with bacteria-freegastric acid aspiration, or aspiration of a foreign body which causes an acute pulmonary emergency. There are differences in the clinical presentation of volume-dependent aspirations (microaspiration and macroaspiration): the higher is the volume of aspiration, the greater is the injury to the patient and more serious are the health consequences (with 70 % mortality rate for hospitalized patients). Aspiration syndromes can affect both the airways and pulmonary parenchyma, leading to acute lung injury, increased hospitalization rate and worse outcomes in critically ill patients. Impaired alveolar-capillary permeability, oedema formation, neutrophilic inflammatory response and pulmonary surfactant inactivation lead to reduced lung compliance and loss of aerated lung tissue and give rise to hypoxemia and respiratory failure. This review discusses the effect of aspiration events on the pulmonary tissue. The main focus is to distinguish the differences between bacterial and chemical pneumonia, their clinical presentation and symptoms, risk factors of developing the changes, possibilities of diagnostics and management as well as prevention of aspirations. Because of a risk of serious lung damage after the aspiration, pathophysiology and processes leading to lung tissue injury are discussed in detail. Data sources represent a systematic literature search using relevant medical subject headings.

A Machine Learning-Based Screening Test for Sarcopenic Dysphagia Using Image Recognition

Background: Sarcopenic dysphagia, a swallowing disorder caused by sarcopenia, is prevalent in older patients and can cause malnutrition and aspiration pneumonia. This study aimed to develop a simple screening test using image recognition with a low risk of droplet transmission for sarcopenic dysphagia. Methods: Older patients admitted to a post-acute care hospital were enrolled in this cross-sectional study. As a main variable for the development of a screening test, we photographed the anterior neck to analyze the image features of sarcopenic dysphagia. The studied image features included the pixel values and the number of feature points. We constructed screening models using the image features, age, sex, and body mass index. The prediction performance of each model was investigated. Results: A total of 308 patients participated, including 175 (56.82%) patients without dysphagia and 133 (43.18%) with sarcopenic dysphagia. The area under the receiver operating characteristic curve (ROC-AUC), sensitivity, specificity, positive predictive value, negative predictive value, and area under the precision-recall curve (PR-AUC) values of the best model were 0.877, 87.50%, 76.67%, 66.67%, 92.00%, and 0.838, respectively. The model with image features alone showed an ROC-AUC of 0.814 and PR-AUC of 0.726. Conclusions: The screening test for sarcopenic dysphagia using image recognition of neck appearance had high prediction performance.

Aspiration Screening in Motor Neuron Disease: Preliminary Results From Utilization of the Yale Swallow Protocol

Purpose Dysphagia is a common symptom experienced by patients with motor neuron disease (MND). The Yale Swallow Protocol (YSP) is a validated screening instrument for identifying patients at risk for aspiration. The purpose of this exploratory cross-sectional, multicenter study was to investigate how the YSP results in identifying aspiration risk in patients with MND in comparison with aspiration observed during a videofluoroscopic swallow study (VFSS). Method Participants referred for VFSS as part of clinical management were recruited from four specialized MND clinics. All participants were administered the YSP immediately prior to the VFSS by a speech-language pathologist, with results recorded as pass or fail. Aspiration on VFSS was determined using the Penetration-Aspiration Scale (scores 6-8). A 2 × 2 contingency table was constructed to compare results of YSP with those on VFSS. Results Thirty-one patients with MND (13 males, 18 females; M _age = 64 ± 12 years) referred for VFSS participated in this study. Of the 22 patients who failed the YSP, interrupted drinking was the most frequent reason (65%). Compared to the VFSS, the YSP yielded a sensitivity of 80%, a specificity of 33%, positive predictive value of 36%, and negative predictive value of 78%. Conclusions The YSP is a simple tool and easy to utilize and has a high sensitivity in identifying aspiration risk in amyotrophic lateral sclerosis. A future investigation with a larger sample size is needed to better investigate the utility of YSP as a screening tool for this population.