Managing dysphagia. Special problems in patients with neurologic disease

Effect of nasogastric tube on salivagram result in paediatric patients

OBJECTIVE

The aim of this study was to analyse the potential effect of indwelling nasogastric tubes (NGTs) on the positive rate of pulmonary aspiration in the salivagram of paediatric patients.

METHODS

This retrospective study evaluated 290 children suffering from respiratory tract infection with clinical suspicion of pulmonary aspiration (104 cases with NGT and 186 cases without NGT). Among them, 216 had good past health, while 74 had history of oropharyngeal diseases or brain injuries. Tc-DTPA salivagrams were performed to determine whether the risk of pulmonary aspiration was different between patients with and without NGT.

RESULTS

The positive rates of aspiration in salivagram were 32.3% (60/186) and 29.8% (31/104) in the patients without and with NGT, respectively. The positive rates of the two groups had not statistically significant difference [risk ratio (RR) = 0.924; 95% confidence interval (CI): 0.644-1.326; P = 0.666]. Subgroup analyses showed that the patients with good past health had the positive rates of 24.4% (19/78) with NGT and 25.4 % (35/138) without NGT. The two groups had no statistically significant difference (RR = 0.960; 95% CI: 0.592-1.559; P = 0.870). For the patients with underlying diseases, the positive rates were 46.2% (12/26) with NGT and 52.1% (25/48) without NGT. These two groups also demonstrated no statistically significant difference (RR = 0.886; 95% CI: 0.540-1.455; P = 0.626).

CONCLUSION

The positive rate of pulmonary aspiration was relatively high in patients with respiratory tract infection who have underlying diseases but NGT feeding did not affect salivagram accuracy.

Recommendation of Nasogastric Tube Removal in Acute Stroke Patients Based on Videofluoroscopic Swallow Study

Objective

To evaluate the safety of nasogastric tube (NGT) removal and change to oral feeding with a food thickener for acute stroke patients in whom a videofluoroscopic swallow study (VFSS) confirmed thin liquid aspiration.

Methods

We retrospectively examined data of 199 patients with first stroke who were diagnosed with dysphagia from 2011 to 2015. Swallowing function was evaluated using VFSS. Patients included in this study were monitored for 4 weeks to identify the occurrence of aspiration pneumonia. The penetration-aspiration scale (PAS) was used to assess VFSS findings. The patients were divided into thin-liquid aspiration group (group 1, n=104) and no thin-liquid aspiration group (group 2, n=95).

Results

The feeding method was changed from NGT feeding to oral feeding with food thickener (group 1) and without food thickener (group 2). The PAS scores of thin and thick liquids were 6.46±0.65 and 1.92±0.73, respectively, in group 1 and 2.65±0.74 and 1.53±0.58, respectively, in group 2. Aspiration pneumonia developed in 1.9% of group 1 and 3.2% of group 2 (p=0.578), with no significant difference between the groups.

Conclusion

We concluded that removing the NGT and changing to oral feeding with a food thickener is a safe food modification for acute stroke patients with thin liquid aspiration. Therefore, we recommend that VFSS should be conducted promptly in acute stroke patients to avoid unnecessary prolonged NGT feeding.

The neurobiology of swallowing and dysphagia

The neurobiological study of swallowing and its dysfunction, defined as dysphagia, has evolved over two centuries beginning with electrical stimulation applied directly to the central nervous system, and then followed by systematic investigations that have used lesioning, transmagnetic stimulation, magnetoencephalography, and functional magnetic resonance imaging. The field has evolved from mapping the central neural pathway and peripheral nerves, to defining the importance of specific regions of the lower brain stem in terms of interneurons that provide sequential control for multiple muscles in the most complex reflex elicited by the nervous system, the pharyngeal phase of swallowing. The field is now emerging into defining how the higher cortical regions interact with this brain stem control and is providing a broader perspective of how the intact nervous system functions to control the three phases of swallowing (i.e., oral, pharyngeal, and esophageal). Much of the present interest focuses on how to retrain a damaged nervous system using a variety of stimulus techniques, which follow fundamentals in rehabilitation of the nervous system.

Improving nursing practice with staff education: the challenges of dysphagia

The 15 million Americans who experience some degree of dysphagia risk choking, airway obstruction, aspiration-related pulmonary disease, and/or death. These complications increase mortality, morbidity, length of hospitalization, and healthcare costs, but may be preventable through nursing intervention. Fifty-four nursing care workers (NCWs) from medical/surgical units in two acute care hospitals were assigned by convenience to two experimental groups and a control group. Experimental groups A and B participated in an educational program on dysphagia designed to increase their knowledge of dysphagia, knowledge attention, and the number of dysphagic patients identified and referred. Group B received deliberate reinforcement of program content over a 1-month period. The educational intervention had a significant effect on knowledge level and knowledge retention, immediately and at 1-month posttest in both experimental groups. NCWs applied what they learned to clinical practice as evidenced by an increase in the number of patients identified as being at risk for or experiencing dysphagia. Reinforcement of program content did not affect the outcomes. The study has implications for staff educators and nursing personnel who care for persons at risk for dysphagia.