Feasibility of high-resolution manometry for decision of feeding methods in patients with amyotrophic lateral sclerosis

Dysphagia Assessments as Criteria in the 'Decision-Making Process' for Percutaneous Endoscopic Gastrostomy Placement in People with Amyotrophic Lateral Sclerosis: A Systematic Review

To review the assessment methods of dysphagia as a criterion for the decision-making process for Percutaneous Endoscopic Gastrostomy (PEG) placement in patients with Amyotrophic Lateral Sclerosis (ALS). Systematic review. A search was conducted in three databases (EMBASE, CINAHL, PUBMED) in December 2022 and updated in July 2023. Two reviewers independently screened, selected, and extracted data. Study quality was appraised using the Joanna Briggs Institute Critical Appraisal Tools. Systematic review registration number in the International Prospective Register of Systematic Reviews (PROSPERO): CRD42022385461. The searches identified 240 records. The 10 eligible studies included 2 case reports, 4 retrospective studies, 3 prospective studies, and 1 cohort observational study. Study quality was low, with most studies having moderate to high risk of bias. Dysphagia is a common criterion for decision-making. Dysphagia assessment is usually in the form of either self-reports, objective instrumental assessments, or both. Dysphagia is a common criterion for the decision-making process, yet is missing in clinical guidelines. Establishing the optimal means of dysphagia assessment is important for timely decision-making procedures, so that life-threatening consequences of dysphagia are minimized.

Design and validation of a questionnaire for monitoring neurological dysphagia and respiratory deterioration in patients with amyotrophic lateral sclerosis (DEREDELA)

INTRODUCTION

Amyotrophic lateral sclerosis (ALS) is a degenerative disease of unknown origin that affects the motor neurons. It has a rapid, fatal course.

METHOD

For this study, an initial questionnaire of eleven items was developed by experts in the field, who evaluated the suitability and relevance of the items.

RESULTS

The questionnaire was then applied to a pilot group of 22 patients diagnosed with ALS. Confirmatory factor analysis, based on estimating maximum likelihood, confirmed the three domains detected in the exploratory factor analysis. The reliability of the scale was tested using Cronbach's α (0.801) and the Kaiser-Meyer-Olkin test (0.770) confirmed the construct validity.

CONCLUSIONS

The DEREDELA questionnaire is valid, in terms of its content, for monitoring the neurological dysphagia and respiratory deterioration suffered by patients diagnosed with ALS.

A Knowledge-based Decision Support System for recommending safe recipes to individuals with dysphagia

BACKGROUND

Dysphagia is a disorder that can be associated to several pathological conditions, including neuromuscular diseases, with significant impact on quality of life. Dysphagia often leads to malnutrition, as a consequence of the dietary changes made by patients or their caregivers, who may deliberately decide to reduce or avoid specific food consistencies (because they are not perceived as safe), and the lack of knowledge in how to process foods are critics. Such dietary changes often result in unbalanced nutrients intake, which can have significant consequences for frail patients. This paper presents the development of a prototypical novel ontology-based Decision Support System (DSS) to support neuromuscular patients with dysphagia (following a per-oral nutrition) and their caregivers in preparing nutritionally balanced and safe meals.

METHOD

After reviewing scientific literature, we developed in collaboration with Ear-Nose-Throat (ENT) specialists, neurologists, and dieticians the DSS formalizes expert knowledge to suggest recipes that are considered safe according to patient's consistency limitations and dysphagia severity and also nutritionally well-balanced.

RESULTS

The prototype can be accessed via digital applications both by physicians to generate and verify the recommendations, and by the patients and their caregivers to follow the step-by-step procedures to autonomously prepare and process one or more recipe. The system is evaluated with 9 clinicians to assess the quality of the DSS's suggested recipes and its acceptance in clinical practice.

CONCLUSIONS

Preliminary results suggest a global positive outcome for the recipes inferred by the DSS and a good usability of the system.

Swallowing biomechanics in tracheostomised critically ill patients compared to age- and gender-matched healthy controls

Objective

The mechanistic effects of a tracheostomy on swallowing are unclear. Pharyngeal high-resolution manometry with impedance (P-HRM-I) is a novel swallow assessment tool providing quantifiable metrics. This study aimed to characterise swallowing biomechanics in tracheostomised critically ill (non-neurological) patients.

Design

Cohort study.

Setting

Australian tertiary hospital intensive care unit.

Participants

Tracheostomised adults, planned for decannulation.

Main outcome measures

Swallowing assessment using P-HRM-I, compared to healthy age- and gender-matched controls.

Results

In this tracheostomised cohort (n = 10), the Swallow Risk Index, a global measure of swallow function, was significantly elevated (p < 0.001). At the upper oesophageal sphincter (UOS), hypopharyngeal intrabolus pressure and UOS integrated relaxation pressure were significantly elevated (control 0.65 mmHg [-1.02, 2.33] v tracheostomy 13.7 mmHg [10.4, 16.9], P < 0.001; control -4.28 mmHg [-5.87, 2.69] v tracheostomy 12.2 mmHg [8.83, 15.6], P < 0.001, respectively). Furthermore, UOS opening extent and relaxation time were reduced (control 4.83 mS [4.60, 5.07] v tracheostomy 4.33 mS [3.97, 4.69], P = 0.002; control 0.52 s [0.49, 0.55] v tracheostomy 0.41 s [0.37, 0.45], P < 0.001, respectively). Total pharyngeal contractility (PhCI) measuring pharyngeal pressure generation was significantly elevated (control 199.5 mmHg cm.s [177.4, 221.6] v tracheostomy 326.5 mmHg cm.s [253.3, 399.7]; P = 0.001).

Conclusion

In a critically ill tracheostomised cohort, UOS dysfunction was the prevalent biomechanical feature, with elevated pharyngeal pressures. Pharyngeal weakness is not contributing to dysphagia in this cohort. Instead, elevated pharyngeal pressures may represent a compensatory mechanism to overcome the UOS dysfunction. Further studies to extend these findings may inform the development of timely and targeted rehabilitation.

Use of Pharyngeal High-Resolution Manometry to Evaluate Dysphagia in Adults with Motor Neurone Disease: A Scoping Review

There has been a recent shift towards proactive dysphagia intervention in motor neurone disease (MND) to maintain physiological reserve. Pharyngeal high-resolution manometry (PHRM) can quantify swallowing pathophysiology to inform and evaluate proactive dysphagia intervention. This study aims to explore the current use of PHRM as a dysphagia evaluation in adults with MND. A scoping review based on the Joanna Briggs Framework was completed. Four electronic databases (PubMed, EMBASE, CINAHL and Web of Science core) were searched (inception to March 2021) by two independent researchers. Data were analysed according to (i) PHRM protocol and analysis methods and the feasibility of same, (ii) swallow biomechanics data and (iii) dysphagia intervention effects as measured by PHRM. Six studies with 78 people with MND (PwMND) were included. There was considerable variation in PHRM protocol and analysis methods. Five studies reported a 100% completion rate and three studies reported no adverse events. Swallow biomechanics data were reported across all studies. The effects of sensory stimulation, increased bolus consistency, effortful swallow and cricopharyngeal myotomy were evaluated using PHRM with 20 PwMND across four studies with varying effects. Literature on the use of PHRM in PwMND is limited. Variability in PHRM methods restricts comparison of metrics. PHRM appears to be a feasible tool for PwMND. PHRM can provide novel swallow physiology data in PwMND and quantify discrete effects of compensatory and surgical dysphagia interventions not detectable by videofluoroscopy or FEES. Further research on the effects of proactive dysphagia intervention as measured by PHRM is required.

Usefulness of the Modified Videofluoroscopic Dysphagia Scale in Evaluating Swallowing Function among Patients with Amyotrophic Lateral Sclerosis and Dysphagia

INTRODUCTION

The videofluoroscopic dysphagia scale (VDS) is used to predict the long-term prognosis of dysphagia among patients with the condition. Previously, a modified version of the VDS (mVDS) was established to overcome the relatively low inter-rater reliability of VDS, and was verified in patients with dysphagia, such as stroke patients. However, the validity of mVDS in patients with amyotrophic lateral sclerosis (ALS) has never been proved. Therefore, in this study, we attempted to seek the validity of the mVDS score in patients with ALS suffering from dysphagia.

METHOD

Data from the videofluoroscopic swallowing study (VFSS) of 34 patients with ALS and dysphagia were retrospectively collected. We investigated the presence of aspiration pneumonia and the selected feeding method based on the VFSS. We also evaluated the correlations between the mVDS and the selected feeding method, and between the mVDS and the presence of aspiration pneumonia. Multivariate logistic regression and receiver operating characteristic (ROC) analyses were performed during the data analysis.

RESULTS

In patients with ALS and dysphagia, the mVDS scores were statistically correlated with the selected feeding method (p < 0.05) and the presence of aspiration pneumonia (p < 0.05). In the ROC curve analysis, the area under the ROC curve values for the selected feeding method and the presence of aspiration pneumonia were 0.886 (95% confidence interval (CI), 0.730-0.969; p < 0.0001) and 0.886 (95% CI, 0.730-0.969; p < 0.0001), respectively.

CONCLUSION

The mVDS can be a useful tool for quantifying the severity of dysphagia and interpreting the VFSS findings in patients with ALS and dysphagia. However, further studies involving a more general population of patients with ALS are needed to elucidate a more accurate cut-off value for the allowance of oral feeding and the presence of aspiration pneumonia.

Relationship between statins and the risk of amyotrophic lateral sclerosis: A PRISMA-compliant meta-analysis

OBJECTIVE

Previous studies on overlapping surveillance databases have suggested that statin use was associated with the development of amyotrophic lateral sclerosis (ALS)-like syndrome. However, the association between statin use and ALS incidence has not been clearly elucidated. To further explore this issue, we performed a systemic review and meta-analysis of all available clinical studies on the association between statin use and ALS incidence.

METHODS

A comprehensive database search on PubMed, Embase, Cochrane Library, and SCOPUS was conducted. We included studies up to January 31, 2020 that fulfilled our inclusion and exclusion criteria. Statin use between the ALS and control groups was collected for the meta-analysis.

RESULTS

Three case-control studies and 1 cohort study, that related the risk of ALS to statin use, satisfied the inclusion criteria for the meta-analysis. There was no statistically significant difference in statin use between the ALS and control groups (odds ratio, 0.75 [95% confidence interval, 0.53-1.08]).

CONCLUSION

No definite association was found between statin use and the development of ALS. Further large-scale prospective randomized control studies are necessary to draw definite conclusions.

Adequate Number of Swallows for Pharyngeal Pressure Measurement of a Subject using High-resolution Manometry

Introduction  The number of pressure measurements that need to be recorded using high-resolution manometry (HRM) for the accurate evaluation of pharyngeal function is not well established.

Objective  The purpose of this study is to clarify the number of swallows required to obtain an accurate pharyngeal manometric profile of a person.

Methods  Forty healthy adults performed a dry swallow and bolus swallows using 3-, 5-, or 10 ml of water and underwent measurements using the Starlet HRM system. Each subject underwent 10 swallows for each of the four bolus volume conditions.

Results  The mean of up to seven measurements of maximum pre-swallow upper esophageal sphincter pressure with 10 ml of swallow was close to the mean of up to eight measurements in 95% of the subjects. Similarly, the rate of change of the average for the eighth and ninth measurements and the rate of change for the average of the ninth and tenth measurements were less than 5%. When the other parameters were similarly measured up to the sixth measurement, no major change in the average value was observed even if more measurements were taken.

Conclusion  A minimum of six measurements are required, and seven swallows are sufficient for evaluating the pharyngeal manometric profile of a single person. This number of measurements can be a useful criterion when performing HRM measurements on individual subjects.

Esophageal Peristalsis Disorders in ALS Patients with Dysphagia

To detect the variations of esophageal peristalsis in amyotrophic lateral sclerosis (ALS) patients with predominantly bulbar or predominantly pseudobulbar clinical presentation by using esophageal manometry (EM). Fifteen ALS patients with pseudobulbar clinical presentation (PBP) and 13 patients with bulbar presentation (BP), fulfilling WFN Criteria, were studied. EM was performed in all subjects using a flexible catheter with solid-state transducers. Swallowing was initiated with 5 to 10 mL of water (wet swallows) and saliva (dry swallows) and repeated at 30 s intervals. The manometric parameters were measured automatically and visualized by the computer system. The tracings were analyzed using Synectics software. In PBP patients, an increase of resting pressure value in the upper esophageal sphincter (UES) >45 mmHg, a wave-like course of resting pressure, and toothed peristaltic waves were observed. In BP patients, a low amplitude of peristaltic waves <30 mmHg (mean: 17 ± 5) was recorded, without signs of esophageal motility disturbance at onset or during progression. EM procedure allows objectively distinguishing dysphagia in ALS patients due to bulbar syndrome from the dysphagia due to pseudobulbar syndrome. It is important to identify PBP patients because of their high risk of aspiration.

Perceived Professional and Institutional Factors Influencing Clinical Adoption of Pharyngeal High-Resolution Manometry

Purpose We assessed experienced clinicians' perceptions of benefits and drawbacks to the clinical adoption of pharyngeal high-resolution manometry (HRM). This article focuses on the professional and institutional factors that influence the clinical adoption of pharyngeal HRM by speech-language pathologists (SLPs). Method Two surveys (closed- and open-ended questions) and a series of focus groups were completed with SLP members of both the American Speech-Language-Hearing Association and the Dysphagia Research Society (DRS). Transcripts were inductively coded for emergent themes. Results Thirteen SLPs were recruited to attend focus group sessions at the American Speech-Language-Hearing Association. Eighty-seven SLPs responded to the DRS open-set response survey. Two additional focus groups of 11 SLPs were convened at the DRS meeting. Conventional content analysis revealed overall SLP enthusiasm for the clinical use of HRM, with some concerns about the technology adoption process. The following themes related to the professional and institutional factors influencing clinical adoption were identified: (a) scope of practice, (b) access, (c) clinical workflow, and (d) reimbursement. Conclusion These data serve to elucidate the most salient factors relating to the clinical adoption of pharyngeal HRM into routine speech-language pathology clinical practice. While enthusiasm exists, a variety of systems-level issues must be addressed to support this process.

Shifting Tides Toward a Proactive Patient-Centered Approach in Dysphagia Management of Neurodegenerative Disease

Purpose Persons with neurodegenerative disease frequently develop comorbid dysphagia as part of their disease process. Current "reactive" approaches to dysphagia management address dysphagia once it manifests clinically and consist of compensatory approaches. The purpose of this article is to propose a paradigm shift in dysphagia management of patients with neurodegenerative disease from a "reactive to proactive" approach by highlighting amyotrophic lateral sclerosis (ALS) and dementia as case examples. Method The authors present several areas of special consideration for speech-language pathologists (SLPs) treating dysphagia in patients with neurodegenerative disease. The drawbacks of historical "reactive" approaches to dysphagia management are described. Concepts of functional reserve for swallowing and homeostenosis are discussed. A "proactive" patient-centered paradigm of care for these patients is proposed with evidence to support its importance. A rationale for use of this approach in patients with ALS and dementia is provided with strategies for implementation. Results When treating dysphagia in patients with neurodegenerative disease, SLPs must balance a variety of factors in their decision making, including disease severity and expected progression, cultural considerations, goals of care, patient empowerment, and caregiver support. Reactive approaches to dysphagia management in these populations are problematic in that they disempower patients by focusing on use of compensatory techniques (e.g., diet modification, postural changes, feeding tube placement). Proactive approaches that employ rehabilitative interventions to increase functional reserve, such as resistance training, may result in improvement or maintenance of swallowing function longer into disease progression. An interdisciplinary team with early SLP involvement is necessary. Conclusions SLPs play a critical role in the management of dysphagia in patients with neurodegenerative disease and should be integrated early in the care of these patients. By focusing on a proactive patient-centered approach, patients with neurodegenerative conditions, such as ALS and dementia, will experience improved quality of life and health outcomes for a longer time.

Choice of Aspiration Prevention Surgery for Patients With Neuromuscular Disorders: Report of Three Cases

Dysphagia, one of the major complications of neuromuscular diseases such as Parkinson's disease and amyotrophic lateral sclerosis (ALS), decreases quality of life and may lead to malnutrition or aspiration pneumonia. Although recent reports have suggested that surgical aspiration prevention improves quality of life and enables oral intake, the selection of appropriate aspiration prevention techniques has rarely been discussed. In this report, we present the cases of three patients with neuromuscular diseases who underwent surgical aspiration prevention; we selected the surgical techniques based on analysis of the dysphagia mechanisms, disease progression, and general condition in each case. Case 1 was a 55-year-old man with multiple system atrophy (MSA) and presented with dysphagia associated with insufficient upper esophageal sphincter (UES) relaxation. We performed central-part laryngectomy, which was able to improve UES relaxation. Case 2 was a 79-year-old man with progressive supranuclear palsy who presented with respiratory disorder and dysphagia. Glottic closure under local anesthesia was selected because he also had acute hepatobiliary dysfunction and methicillin-resistant Staphylococcus aureus pneumonia with pleural effusion. Case 3 was a 75-year-old man with ALS and presented with respiratory disorder and mild dysphagia. Subglottic closure with total cricoidectomy was selected because his dysphagia was expected to worsen due to tracheostomy and disease progression. We also summarize the characteristics of the aspiration prevention surgical techniques based on our cases and on literature review. The causes of dysphagia, including insufficient UES opening during swallowing, weak pharyngeal constriction, velopharyngeal insufficiency, and inadequate laryngeal elevation, should be assessed by detailed examination before surgery, and the type of aspiration prevention surgery should be selected based on patient swallowing function and general condition.