The Modified Volume-Viscosity Swallow Test as a Predictor of Aspiration Pneumonia after Acute Ischemic Stroke

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.

Dysphagia after stroke: research advances in treatment interventions

After a stroke, most patients have dysphagia, which can lead to aspiration pneumonia, malnutrition, and adverse functional outcomes. Protective interventions aimed at reducing these complications remain the cornerstone of treatment. Dietary adjustments and oral hygiene help mitigate the risk of aspiration pneumonia, and nutritional supplementation, including tube feeding, might be needed to prevent malnutrition. Rehabilitative interventions aim to enhance swallowing function, with different behavioural strategies showing promise in small studies. Investigations have explored the use of pharmaceutical agents such as capsaicin and other Transient-Receptor-Potential-Vanilloid-1 (TRPV-1) sensory receptor agonists, which alter sensory perception in the pharynx. Neurostimulation techniques, such as transcranial direct current stimulation, repetitive transcranial magnetic stimulation, and pharyngeal electrical stimulation, might promote neuroplasticity within the sensorimotor swallowing network. Further advancements in the understanding of central and peripheral sensorimotor mechanisms in patients with dysphagia after a stroke, and during their recovery, will contribute to optimising treatment protocols.

Clinical signs to predict the severity of dysphagia in Acute Ischemic Stroke patients

OBJECTIVES

In the current era, clinicians working in areas with limited and/or without facilities are only able to manage their patients based on clinical signs to detect dysphagia. This study assesses the performance of 5 simple clinical signs for predicting the severity of dysphagia.

METHODS

We systematically documented 5 targeted bedside clinical signs within 24 h after admission in 737 consecutive patients with acute stroke. We examined the median onset of each sign and calculated their ratios associated with severe dysphagia. The performance and significance of these special clinical signs were evaluated by further computation.

RESULTS

In total, 184 of 737 AIS patients were screened positive dysphagia by the modified V-VST. The 5 targeted bedside clinical signs were differed among the patients with and without dysphagia. Patients with serious dysphagia (n = 61,33.15%) showed higher positive percentages of larynx movement disorders than those classified as moderate (73.77% [60.99%-83.50%] vs 29.27% [21.82%-38.03%], p < 0.001). Logistic regression analyses conducted in the subsets confirmed larynx movement disorders as an independent predictor of dysphagia severity.

CONCLUSIONS

Larynx movement disorders is correlated with a higher probability of severe dysphagia as measured by the modified V-VST in AIS patients.

[Diagnostics and treatment of post-stroke dysphagia]

BACKGROUND

Post-stroke dysphagia is highly prevalent and leads to severe complications, such as aspiration pneumonia and malnutrition. Despite the high clinical relevance dysphagia management is heterogeneous and often inadequate.

OBJECTIVE

The aim of this review article is to provide an overview of the diagnostic and treatment strategies for post-stroke dysphagia based on recent studies.

MATERIAL AND METHODS

Narrative literature review.

RESULTS

Dysphagia screening should be performed as early as possible in every stroke patient, e.g., with a simple water swallowing test or a multiconsistency protocol. Subsequently, flexible endoscopic evaluation of swallowing (FEES) is indicated in patients with abnormal screening results or existing risk factors for dysphagia. Dietary modifications, oral hygiene measures, and nutritional therapy can help reduce complications. Behavioral swallowing therapy or experimental therapies, such as neurostimulation procedures and pharmacological approaches aim to improve swallowing function and have shown promising results in studies.

CONCLUSION

Timely management of dysphagia is necessary to reduce complications.

Utility of the modified Volume-Viscosity Swallow Test for bedside screening of dysphagia in critically ill patients

BACKGROUND AND AIM

Aspiration and dysphagia are frequent in critically ill patients, and evidence of the validity of bedside screening tests is lacking. This study evaluated the modified Volume-Viscosity Swallow Test (mV-VST) as a screening tool for aspiration and dysphagia in intensive care unit patients.

METHODS

An observational, prospective longitudinal cohort single-center study included patients older than 18 years old, on mechanical ventilation for at least 48 h, conscious and cooperative. Patients had been admitted in intensive care between March 2016 and August 2019 at a university hospital in Spain. Data from the mV-VST and the flexible endoscopic evaluation of swallowing (FEES) test in extubated and tracheostomized patients were collected; the ROC curve was obtained for each group, and the sensitivity (Se), specificity (Sp), positive (pPV) and negative (nPV) predictive values of mV-VST were calculated and compared with the FEES results. We calculated percentages and 95% confidence intervals (CI) for qualitative variables and means or medians for quantitative variables according to the Shapiro-Wilk test. A univariate analysis identified dysphagia risk factors in each group.

RESULTS

The study included 87 patients: 44 extubated and 43 tracheostomized with similar age, body mass index, Sequential Organ Failure Assessment, Charlson comorbidity index, type and reason for admission. Aspiration with FEES was significantly higher in extubated patients than in tracheostomized patients, 43.2% vs. 23.2%, respectively, p = 0.04. With the mV-VST, aspiration was detected in 54.5% of extubated patients and in 39.5% of tracheostomized patients. In the extubated group, the Se of mV-VST to detect aspiration was 89.5%, Sp was 72%, and nPV was 90%. In the tracheostomized group, Se was 100%, Sp was 78.8%, and nPV was 100%. The ROC curve showed that mV-VST similarly identifies aspiration in extubated and tracheostomized patients.

CONCLUSIONS

Dysphagia and aspiration are frequent amongst patients in intensive care after mechanical ventilation. The mV-VST is a valid screening tool to detect aspiration and dysphagia in extubated and tracheostomized patients.

Assessment and treatment of neurogenic dysphagia in stroke and Parkinson's disease

PURPOSE OF REVIEW

Neurogenic dysphagia worsens quality of life and prognosis of patients with different neurological disorders. Management of neurogenic dysphagia can be challenging. This review provides a comprehensive overview of current evidence on screening, diagnosis, and treatment of neurogenic dysphagia in stroke and Parkinson's disease, suggesting clues for clinical practice.

RECENT FINDINGS

The pros and cons of diagnostic techniques are discussed in the light of updated evidence. Findings from recent meta-analyses of different treatment approaches, including traditional dysphagia therapy, peripheral and central neurostimulation techniques, and treatment with botulinum toxin, are critically discussed, emphasizing inconsistencies and controversial issues.

SUMMARY

Screening tests and clinical swallow examination should be routinely performed in neurological patients at risk for dysphagia. In patients testing positive for dysphagia, first-line instrumental investigations, represented by fiberoptic endoscopic evaluation of swallowing or videofluoroscopic swallow study, should be performed to confirm the presence of dysphagia, to assess its severity, and to inform the treatment. Second-line and third-line instrumental methods can be used in selected patients to clarify specific pathophysiological aspects of oropharyngeal dysphagia. Treatment strategies should be personalized, and combination of traditional dysphagia therapy with innovative treatment approaches may increase the chance of restoring effective and safe swallowing.

Dysphagia and mechanical ventilation in SARS-COV-2 pneumonia: It's real

BACKGROUND & AIMS

Dysphagia can be a consequence of prolonged hospitalization in intensive care units (ICUs) due to severe SARS-CoV-2 pneumonia. This study aims at Identifying the risk factors for dysphagia in ICU patients with COVID-19 pneumonia requiring invasive mechanical ventilation, and at determining the frequency of postextubation dysphagia in this population.

METHODS

Observational, descriptive, retrospective, cohort study of SARS-CoV-2 pneumonia patients admitted into the ICUs from March to May 2020. The Modified Viscosity Volume Swallowing Test (mV-VST) was used to screening for dysphagia during the first 48 h of extubation in patients requiring mechanical ventilation. Descriptive statistics, univariate and multivariate analyses were conducted. A logistic regression was applied to construct a predictive model of dysphagia.

RESULTS

A total of 232 patients were admitted into the ICUs (age [median 60.5 years (95% CI: 58.5 to 61.9)]; male [74.1% (95% CI: 68.1 to 79.4)]; APACHE II score [median 17.7 (95% CI: 13.3 to 23.2)]; length of mechanical ventilation [median 14 days (95% CI: 11 to 16)]; prone position [79% (95% CI: 72.1 to 84.6)]; respiratory infection [34.5% (95% CI: 28.6 to 40.9)], renal failure [38.5% (95% CI: 30 to 50)])). 72% (167) of patients required intubation; 65.9% (110) survived; and in 84.5% (93) the mV-VST was performed. Postextubation dysphagia was diagnosed in 26.9% (25) of patients. APACHE II, prone position, length of ICU and hospital stay, length of mechanical ventilation, tracheostomy, respiratory infection and kidney failure developed during admission were significantly associated (p < 0.05) with dysphagia. Dysphagia was independently explained by the APACHE II score (OR: 1.1; 95% CI: 1.01 to 1.3; p = 0.04) and tracheostomy (OR: 10.2; 95% CI: 3.2 to 32.1) p < 0.001). The predictive model forecasted dysphagia with a good ROC curve (AUC: 0.8; 95% CI: 0.7 to 0.9).

CONCLUSIONS

Dysphagia affects almost one-third of patients with SARS-COV-2 pneumonia requiring intubation in the ICU. The risk of developing dysphagia increases with prolonged mechanical ventilation, tracheostomy, and poorer prognosis on admission (worst APACHE II score).

Single Nucleotide Polymorphisms May Increase the Risk of Aspiration Pneumonia in Post-Stroke Patients with Dysphagia

This study aimed to evaluate whether genetic polymorphism is associated with an increased risk of infection, specifically post-stroke aspiration pneumonia. Blood samples were obtained from a total of 206 post-stroke participants (males, n = 136; mean age, 63.8 years). Genotyping was performed for catechol-O-methyltransferase (rs4680, rs165599), dopamine receptors (DRD1; rs4532, DRD2; rs1800497, DRD3; rs6280), brain-derived neurotrophic factor (rs6265), apolipoprotein E (rs429358, rs7412), and the interleukin-1 receptor antagonist gene (rs4251961). The subjects were stratified into two groups, aged < 65 (young) and ≥ 65 (elderly). Functional parameters and swallowing outcomes were measured at enrollment and at 3 months post-onset. The primary outcome was the incidence of aspiration pneumonia. Analysis of the association between genetic polymorphisms and aspiration pneumonia history showed that a minor C rs429358 allele was associated with the occurrence of aspiration pneumonia in the young group, both in the additive and the dominant models (odds ratio: 4.53; 95% CI: 1.60−12.84, p = 0.004). In the multivariable analysis, the minor C rs429358 allele increased the risk of post-stroke aspiration pneumonia in young stroke patients by 5.35 (95% CI: 1.64−20.88). In contrast, no such association was observed in the elderly group. Apolipoprotein E polymorphism may affect the risk of post-stroke aspiration pneumonia.

Predictors of complete oral feeding resumption after feeding tube placement in patients with stroke and dysphagia: A systematic review

AIMS

The aim was to synthesise and discuss predictors of complete oral feeding resumption after feeding tube placement in stroke patients with dysphagia.

DESIGN

This was a systematic review, following the PRISMA 2020 checklist.

DATA SOURCES

Eight databases (PubMed, Web of Science, Embase, Cochrane, CINAHL, CNKI, WanFang and Vip) were searched for eligible studies from inception up to June 2021.

REVIEW METHODS

The JBI Manual for Evidence Synthesis was used to guide this systematic review. Any cross-sectional survey, longitudinal study, cohort study or case-control study that explored the recovery from tube feeding to complete oral feeding in patients with dysphagia after stroke was included. Qualitative studies, review articles, case reports and conference abstracts were excluded. Two reviewers independently screened and appraised the studies. The Newcastle-Ottawa scale was used for quality assessment. Content analysis was used to categorise factors predicting feeding tube removal in stroke patients with dysphagia.

RESULTS

This review included a total of 15 studies consisting of 1746 participants, of which 2 were case-control studies and 13 were cohort studies. Four studies were rated as having low risk of bias, and the other 11 had high risk of bias. The factors examined in the studies were categorised into demographic characteristics (age and sex), swallowing function (instrumental assessments and non-instrumental assessments), stroke characteristics (stroke severity, past stroke history and location of the stroke), functional status (cognitive function and physical function) and clinical measures (body mass index, geriatric nutritional risk index, white blood cell count and C-reactive protein level).

CONCLUSIONS

The major limitation of this review is the failure to identify predictors of different tube feeding types. Although the current evidence is insufficient to support or oppose the predictive effect of any single factor, these factors are still valuable data for clinical staff that provide information that researchers can use in developing prognostic models. Rigorously designed and high-quality research is needed to further explore the predictive value of these factors.

REGISTRATION

This review was registered prospectively with PROSPERO [CRD42021272552].

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers should strengthen the monitoring of swallowing function in patients with stroke to promote complete oral feeding resumption. As the predictive value of the identified factors is still uncertain, large, well-designed, studies are needed to better clarify the importance of these predictors.

NO PATIENT OR PUBLIC CONTRIBUTION

No patient or public was involved in the design, analysis, preparation or writing of this review.