Oropharyngeal dysphagia after the acute phase of stroke: predictors of aspiration

Clinical Features and Voxel-Based-Symptom-Lesion Mapping of Silent Aspiration in Acute Infratentorial Stroke

Post-stroke dysphagia (PSD) is a severe and common complication after ischemic stroke. The role of silent aspiration as an important contributing factor in the development of a dysphagia-associated complications, in particular aspiration-associated pneumonia has been insufficiently understood. The aim of this study was to investigate the characteristics and risk factors of silent aspiration in patients with acute infratentorial stroke by FEES and to identify culprit lesions in stroke patient with a high risk of silent aspiration via voxel-based-symptom-lesion mapping (VBS/ML). This study is a retrospective observational study based on a prospectively collected FEES and stroke database. Consecutive patient cases with acute ischemic infratentorial stroke and FEES examination between 2017 and 2022 were identified. Group allocation was performed based on PAS scores. Imaging analysis was performed by manual assignment and by VBS/ML. Group comparisons were performed to assess silent aspiration characteristics. Binary logistic regression analysis was performed to determine if baseline clinical, demographic, and imaging parameters were helpful in predicting silent aspiration in patients. In this study 84 patient cases with acute infratentorial stroke who underwent FEES examination were included. Patients were moderately affected at admission (mean NIH-SS score at admission 5.7 SD ± 4.7). Most lesions were found pontine. Overall 40.5% of patients suffered from silent aspiration, most frequently in case of bilateral lesions. Patients with silent aspiration had higher NIH-SS scores at admission (p < 0.05), had a more severe swallowing disorder (p < 0.05) and were 4.7 times more likely to develop post-stroke pneumonia. Patients who underwent FEES examination later than 72 h after symptom onset were significantly more likely to suffer from silent aspiration and to develop pneumonia compared to patients who underwent FEES examination within the first 72 h (p < 0.05). A binary logistic regression model identified NIH-SS at admission as a weak predictor of silent aspiration. Neither in manual assignment of the lesions to brain regions nor in voxel-wise statistic regression any specific region was useful in prediction of silent aspiration. Silent aspiration is common in patients with infratentorial stroke and contributes to the risk for pneumonia. Patients with silent aspiration are more severely affected by stroke, but cannot reliably be identified by NIH-SS at admission or lesion location. Patients suffering from acute infratentorial stroke should been screened and examined for PSD and silent aspiration.

[Introduction of fiberoptic endoscopic evaluation of swallowing and increase of the range of indications in our department]

Dysphagia is a disease resulting from preparatory or transport disorder of the swallowing process and it is divided into oropharyngeal and esophageal phases according to the site of the lesion. The ear, nose and throat assessment focuses on the oropharyngeal phase, but differential diagnosis, investigation, and treatment of the cause of dysphagia is often a complex task requiring multidisciplinary approach and collaboration. The method of fiberoptic endoscopic evaluation of swallowing (FEES) has been introduced at the Department of Ear, Nose and Throat and Head-Neck Surgery, University of Szeged, enabling the examination of otorhinolaryngological and neurological disorders of swallowing as well as objective analysis of patients' swallowing quality. The fiberoptic endoscopic evaluation of swallowing is a minimally invasive procedure that allows visualization of the oropharyngeal phase of swallowing. It can identify anatomical abnormalities or neurological disorders causing dysphagia, thus playing a significant role in later patient rehabilitation. We hereby present our experiences in examinations of patients who underwent partial laryngectomy and/or pharyngectomy due to head and neck tumors as well as of those who underwent airway surgery duo to upper airway stenosis. Thanks to our collaboration with the Neurology Department, we also share our experiences gained during the examinations of patients struggling with oropharyngeal swallowing problems of various neurological origins. Orv Hetil. 2023; 164(46): 1817-1823.

Detection of poststroke oropharyngeal dysphagia with swallowing screening by ultrasonography

There are currently no standard evaluation tools for poststroke neurogenic oropharyngeal dysphagia. We previously suggested calculating the relative movements of the hyoid bone and larynx by ultrasonography to evaluate swallowing movement. Swallowing movement is altered in neurogenic oropharyngeal dysphagia. Therefore, the present study aimed to verify whether an ultrasonographic evaluation of swallowing movement facilitates the detection of neurogenic oropharyngeal dysphagia. Eighteen healthy male elderly participants (the healthy group) and 18 male stroke patients diagnosed with neurogenic oropharyngeal dysphagia (the dysphagia group) were enrolled. Participants swallowed 5 mL of liquid and water with an adjusted viscosity and the movements of the hyoid bone and larynx were visualized by ultrasonography. The results obtained revealed significant differences in laryngeal duration (static phase), laryngeal displacement (elevation phase), and the hyoid bone–laryngeal motion ratio (HL motion ratio) between the two groups. A multiple regression analysis was performed to adjust for confounding factors, and laryngeal duration (static phase) and the HL motion ratios were identified as factors affecting dysphagia. In the receiver operation characteristic curve of the two variations, the area under the curve for laryngeal duration (static phase) was 0.744 and the cut-off was 0.26 sec with 72.2% sensitivity and 88.9% specificity; the area under the curve for the HL motion ratio was 0.951 and the cut-off was 0.56 with 88.9% sensitivity and 88.9% specificity. Therefore, the objective evaluation of hyoid bone and larynx movements during swallowing by ultrasonography facilitated the detection of neurogenic oropharyngeal dysphagia.

Reduced tongue force and functional swallowing changes in a rat model of post stroke dysphagia

PURPOSE

Dysphagia is a common problem after stroke that is often associated with tongue weakness. However, the physiological mechanisms of post-stroke tongue muscle weakness and optimal treatments have not been established. To advance understanding of physiological mechanisms of post stroke dysphagia, we sought to validate the unilateral transient middle cerebral artery occlusion (MCAO) rat model of ischemic stroke as a translational model of post stroke dysphagia. Our goal was to establish clinically relevant measures and chronicity of functional deficits; criteria that increase the likelihood that findings will translate to the clinic. We hypothesized that MCAO would cause tongue weakness and functional swallowing changes.

METHODS

Maximum voluntary tongue forces and videofluoroscopic swallowing studies were collected in 8-week old male Sprague-Dawley rats prior to receiving either a left MCAO (N = 10) or sham (N = 10) surgery. Tongue forces and VFSS were reassessed at 1 and 8 weeks post-surgery.

RESULTS

Maximum voluntary tongue force, bolus area, and bolus speed were significantly reduced in the MCAO group at the 1 and 8-week timepoints.

CONCLUSION

Clinically relevant changes to swallowing and tongue force support the use of the MCAO rat model as a translational model of post stroke dysphagia. This model will allow for future studies to improve our understanding of the physiology contributing to these functional changes as well as the impact of therapeutic interventions on physiological targets and function.

Cohort Study on Laryngeal Cough Reflex, Respiratory Disease, and Death: A Mediation Analysis

OBJECTIVE

To estimate quantitatively whether the presence of cough associated with dysphagia (laryngeal cough reflex) increased mortality through respiratory disease among community-dwelling older Japanese.

DESIGN

A 6-year follow-up prospective cohort study (from 2010 to 2017).

SETTING

Thirteen municipalities in Japan.

PARTICIPANTS

Community-dwelling individuals aged 65 years or older (N = 32,682).

MEASURES

The baseline survey was conducted through self-reported questionnaire. Exposure was experience of laryngeal cough reflex while drinking. The outcome was all-cause mortality. All covariates were selected from demographic, socioeconomic variables, baseline health and functional status, smoking, alcohol drinking, number of remaining teeth, and stroke. The mediator variable was respiratory disease. Cox proportional hazards regression was used to estimate hazard ratios (HRs) for mortality. Parametric mediation analysis was conducted to estimate the effect of laryngeal cough reflex on the mean residual time to death mediated through respiratory disease.

RESULTS

Among the 32,682 participants (mean age = 74.1 years, standard deviation = 5.9 years), 5550 (17.0%) experienced laryngeal cough reflex at baseline. A total of 4037 deaths occurred. Crude mortality rates of the participants with or without laryngeal cough reflex were 16.3% and 11.6%, respectively. After adjusting for covariates, laryngeal cough reflex [HR = 1.10; 95% confidence interval (CI) = 1.02 to 1.19] and respiratory disease (HR = 1.80; 95% CI = 1.62 to 2.00) were associated with mortality. The mediation analysis showed that respiratory disease significantly (P < .001) and partially mediated the association between laryngeal cough reflex, an indicator of 1 or more conditions such as chronic aspiration and mortality.

CONCLUSIONS/IMPLICATIONS

Laryngeal cough reflex was a prevalent condition, and it was associated with all-cause mortality in community-dwelling older Japanese individuals. Clinicians could contribute to reduce mortality risk by addressing swallowing function problems using their interprofessional collaboration team (speech-language pathologist, dentist, rehabilitation doctor, otolaryngologist, respiratory physician, and gerontologist).

Efficacy of Myofunctional Therapy Associated with Voice Therapy in the Rehabilitation of Neurogenic Oropharyngeal Dysphagia: a pilot study

Introduction  Dysphagia causes changes in the laryngeal and stomatognathic structures; however, the use of vocal exercises is poorly described. Objective  To verify whether the therapy consisting of myofunctional exercises associated with vocal exercises is more effective in rehabilitating deglutition in stroke patients. Methods  This is a pilot study made up of two distinct groups: a control group, which performed only myofunctional exercises, and an experimental group, which performed myofunctional and vocal exercises. The assessment used for oral intake was the functional oral intake scale (FOIS). Results  The FOIS levels reveal that the pre-therapy median of the experimental group was 4, and increased to 7 after therapy, while in the control group the values were 5 and 6 respectively. Thus, the experimental group had a statistically significant difference between the pre- and post-therapy assessments ( p  = 0.039), which indicates that the combination of myofunctional and vocal exercises was more effective in improving the oral intake levels than the myofunctional exercises alone ( p  = 0.059). On the other hand, the control group also improved, albeit at a lower rate compared with the experimental group; hence, there was no statistically significant difference between the groups post-therapy ( p  = 0.126). Conclusion  This pilot study showed indications that using vocal exercises in swallowing rehabilitation in stroke patients was able to yield a greater increase in the oral intake levels. Nevertheless, further controlled blind clinical trials with larger samples are required to confirm such evidence, as this study points to the feasibility of conducting this type of research.

Fiberoptic Endoscopic Evaluation of Swallow (FEES) in Intensive Care Unit Patients Post Extubation

Intensive care unit patients frequently require prolonged intubation and ventilator support. Swallowing dysfunction often occurs in patients who receive prolonged mechanical ventilation. Intubation can cause transient injury to the larynx with a subsequent reduction in protective mechanism and increased incidence of oropharyngeal secretions once patient is extubated. Aim of this study was to evaluate the anatomical damage caused by intubation and the occurrence of aspiration/silent aspiration in patients following extubation, using fiberoptic endoscopic evaluation of swallow (FEES) as diagnostic and therapeutic tool. Participants in the study included all adult ICU patients who were intubated for ≥ 48 h. Head injury patients, patients with abnormal neurological status, completely disoriented patients were excluded. We performed FEES in 41 patients. Duration of intubation was in the range of 2-9 days. We studied 41 patients, among them 19(44%) patients had laryngeal injury and 6 (14%) had aspiration. we noticed that all patients who had aspiration had some laryngeal injury. All 6 patients who had aspiration initially recovered their swallowing function fully as noticed during repeat FEES done after swallow therapy. There is a significant impact of intubation on occurrence of aspiration (14%) and laryngeal abnormality (44%). We found in our study that there is a significant correlation to duration of intubation and occurrence of laryngeal injury.

Laryngeal Closure during Swallowing in Stroke Survivors with Cortical or Subcortical Lesion

BACKGROUND

One of the major, and most harmful, symptoms of dysphagia in stroke survivors is aspiration. Survivors of unilateral cortical strokes with dysphagia and resulting aspiration have been reported to have greater initiation delays in laryngeal closure than those who did not aspirate. Few studies have reported such data in survivors of subcortical stroke.

METHODS

This study measured initiation of laryngeal closure (ILC) and laryngeal closure duration (LCD) in 2 groups of subjects: 15 stroke survivors with cortical lesions and 15 stroke survivors with subcortical lesions. Means and standard deviations of ILC and LCD were analyzed on 5-mL thin liquid and 5-mL puree boluses using a 100-ms timer during subsequent analysis of videofluoroscopic swallowing examinations. Statistical comparisons were used by repeated measures analysis of variance. Significance level was set at P < .05.

RESULTS

ILC was significantly longer in stroke survivors with a subcortical lesion than in those with a cortical lesion for both bolus consistencies. However, there were no significant differences between the 2 groups in LCD. Stroke survivors with a subcortical lesion had a greater incidence of penetration or aspiration and silent aspiration than those with a cortical lesion and a longer delay in the ILC.

CONCLUSIONS

Subcortical lesions may put these survivors at greater risk of aspiration due to delayed initial laryngeal closure and reduced oral and laryngeal sensation. The subcortical damage, which occurs at the basal ganglia, may interrupt the ILC.

Effects of laryngeal restriction on pharyngeal peristalsis and biomechanics: Clinical implications

To date, rehabilitative exercises aimed at strengthening the pharyngeal muscles have not been developed due to the inability to successfully overload and fatigue these muscles during their contraction, a necessary requirement for strength training. The purpose of this study was to test the hypothesis that applying resistance against anterosuperior movement of the hyolaryngeal complex will overload the pharyngeal muscles and by repetitive swallowing will result in their fatigue manifested by a reduction in pharyngeal peristaltic amplitude. Studies were done in two groups. In group 1 studies 15 healthy subjects (age: 42 ± 14 yr, 11 females) were studied to determine whether imposing resistance to swallowing using a handmade device can affect the swallow-induced hyolaryngeal excursion and related upper esophageal sphincter (UES) opening. In group 2, an additional 15 healthy subjects (age 56 ± 25 yr, 7 females) were studied to determine whether imposing resistance to the anterosuperior excursion of the hyolaryngeal complex induces fatigue manifested as reduction in pharyngeal contractile pressure during repeated swallowing. Analysis of the video recordings showed significant decrease in maximum deglutitive superior laryngeal excursion and UES opening diameter (P < 0.01) due to resistive load. Consecutive swallows against the resistive load showed significant decrease in pharyngeal contractile integral (PhCI) values (P < 0.01). Correlation analysis showed a significant negative correlation between PhCI and successive swallows, suggesting "fatigue" (P < 0.001). In conclusion, repeated swallows against a resistive load induced by restricting the anterosuperior excursion of the larynx safely induces fatigue in pharyngeal peristalsis and thus has the potential to strengthen the pharyngeal contractile function.

Adaptation and Assessment of Reliability and Validity of the Greek Version of the Ohkuma Questionnaire for Dysphagia Screening

Introduction The Ohkuma questionnaire is a validated screening tool originally used to detect dysphagia among patients hospitalized in Japanese nursing facilities.

Objective The purpose of this study is to evaluate the reliability and validity of the adapted Greek version of the Ohkuma questionnaire.

Methods Following the steps for cross-cultural adaptation, we delivered the validated Ohkuma questionnaire to 70 patients (53 men, 17 women) who were either suffering from dysphagia or not. All of them completed the questionnaire a second time within a month. For all of them, we performed a bedside and VFSS study of dysphagia and asked participants to undergo a second VFSS screening, with the exception of nine individuals. Statistical analysis included measurement of internal consistency with Cronbach's α coefficient, reliability with Cohen's Kappa, Pearson's correlation coefficient and construct validity with categorical components, and One-Way Anova test.

Results According to Cronbach's α coefficient (0.976) for total score, there was high internal consistency for the Ohkuma Dysphagia questionnaire. Test-retest reliability (Cohen's Kappa) ranged from 0.586 to 1.00, exhibiting acceptable stability. We also estimated the Pearson's correlation coefficient for the test-retest total score, which reached high levels (0.952; p = 0.000). The One-Way Anova test in the two measurement times showed statistically significant correlation in both measurements (p = 0.02 and p = 0.016).

Conclusion The adapted Greek version of the questionnaire is valid and reliable and can be used for the screening of dysphagia in the Greek-speaking patients.

Pharyngeal Electrical Stimulation in Dysphagia Poststroke: A Prospective, Randomized Single-Blinded Interventional Study

Background Pharyngeal electrical stimulation (PES) appears to promote cortical plasticity and swallowing recovery poststroke. Objective We aimed to assess clinical effectiveness with longer follow-up. Methods Dysphagic patients (n = 36; median = 71 years; 61% male) recruited from 3 trial centers within 6 weeks of stroke, received active or sham PES in a single-blinded randomized design via an intraluminal pharyngeal catheter (10 minutes, for 3days). The primary outcome measure was the Dysphagia Severity Rating (DSR) scale (<4, no-mild; ≥4, moderate-severe). Secondary outcomes included unsafe swallows on the Penetration-Aspiration Scale (PAS ≥ 3), times to hospital discharge, and nasogastric tube (NGT) removal. Data were analyzed using logistic regression. Odds/hazard ratios (ORs/HRs) >1 for DSR <4, hospital discharge, and NGT removal and OR <1 for PAS ≥3, indicated favorable outcomes for active PES. Results Two weeks post-active PES, 11/18 (61%) had DSR <4: OR (95% CI) = 2.5 (0.52, 14). Effects of active versus sham for secondary outcomes included the following: PAS ≥3 at 2 weeks, OR (95% CI) = 0.61 (0.27, 1.4); times to hospital discharge, 39 days versus 52 days, HR (95% CI) = 1.2 (0.55, 2.5); NGT removal 8 versus 14 days, HR (95% CI) = 2.0 (0.51, 7.9); and DSR <4 at 3 months, OR (95% CI) = 0.97 (0.13, 7.0). PES was well tolerated, without adverse effects or associations with serious complications (chest infections/death). Conclusions Although the direction of observed differences were consistent with PES accelerating swallowing recovery over the first 2 weeks postintervention, suboptimal recruitment prevents definitive conclusions. Our study design experience and outcome data are essential to inform a definitive, multicenter randomized trial.

The Relation Between the Presence of Aspiration or Penetration and the Clinical Indicators of Dysphagia in Poststroke Survivors

Objective

To examine the relation between the presence of penetration or aspiration and the occurrence of the clinical indicators of dysphagia. The presence of penetration or aspiration is closely related to the clinical indicators of dysphagia. It is essential to understand these relationships in order to implement proper diagnosis and treatment of dysphagia.

Methods

Fifty-eight poststroke survivors were divided into two groups: patients with or without penetration or aspiration. Medical records and videofluoroscopic swallowing examinations were reviewed. The occurrence of clinical indicators of dysphagia between two groups was analyzed with Cross Tabulation and the Pearson chi-square test (p<0.05).

Results

Poststroke survivors with penetration or aspiration had significantly high occurrences of delayed initiation of the swallow (p=0.04) and reduced hyolaryngeal elevation (p<0.01) than those without penetration or aspiration.

Conclusion

The results of this study indicate that delayed initiation of the swallow is a strong physiological indicator of penetration or aspiration during the oral stage of swallowing in poststroke survivors. For the pharyngeal stage of swallowing, hyoid and laryngeal elevation is a key event related to occurrence of penetration or aspiration. Clinical indicators should be investigated further to allow appropriate implementation of treatment strategies for stroke survivors.

Effectiveness of Rehabilitative Balloon Swallowing Treatment on Upper Esophageal Sphincter Relaxation and Pharyngeal Motility for Neurogenic Dysphagia

OBJECTIVE

To investigate the relationship between dysphagia severity and opening of the upper esophageal sphincter (UES), and to assess the effect of balloon size on functional improvement after rehabilitative balloon swallowing treatment in patients with severe dysphagia with cricopharyngeus muscle dysfunction (CPD).

METHODS

We reviewed videofluoroscopic swallowing studies (VFSS) conducted in the Department of Physical Medicine and Rehabilitation, Myongji Hospital from January through December in 2012. All subjects diagnosed with CPD by VFSS further swallowed a 16-Fr Foley catheter filled with barium sulfate suspension for three to five minutes. We measured the maximum diameter of the balloon that a patient could swallow into the esophagus and subsequently conducted a second VFSS. Then, we applied a statistical technique to correlate the balloon diameter with functional improvement after the balloon treatment.

RESULTS

Among 283 inpatients who received VFSS, 21 subjects were diagnosed with CPD. It was observed that the degree of UES opening evaluated by swallowing a catheter balloon had inverse linear correlations with pharyngeal transit time and post-swallow pharyngeal remnant. Videofluoroscopy guided iterative balloon swallowing treatment for three to five minutes, significantly improved the swallowing ability in terms of pharyngeal transit time and pharyngeal remnant (p<0.005 and p<0.001, respectively). Correlation was seen between balloon size and reduction in pharyngeal remnants after balloon treatment (Pearson correlation coefficient R=-0.729, p<0.001), whereas there was no definite relationship between balloon size and improvement in pharyngeal transit time (R=-0.078, p=0.738).

CONCLUSION

The maximum size of the balloon that a patient with CPD can swallow possibly indicates the maximum UES opening. The iterative balloon swallowing treatment is safe without the risk of aspiration, and it can be an effective technique to improve both pharyngeal motility and UES relaxation.

Relationship between Dysphagia, National Institutes of Health Stroke Scale Score, and Predictors of Pneumonia after Ischemic Stroke

BACKGROUND

The present study aimed to evaluate the relation between the National Institutes of Health Stroke Scale (NIHSS) score and the presence of laryngeal penetration and/or laryngotracheal aspiration in ischemic stroke patients and to verify what factors are predictors of the occurrence of pneumonia in the evaluated patients.

METHODS

This was an observational study of ischemic stroke in the acute or subacute phases. Neurologic examination included anamnesis, Bamford classification, and application of the NIHSS. Speech therapy evaluation was carried out after clinical stabilization of the patient, and all individuals who were considered dysphagic were sent for examination by means of videofluoroscopic recordings. The parameters observed in the objective examination were the presence of laryngeal penetration and/or laryngotracheal aspiration. The pneumonia data were obtained in accordance with local protocols, which were based on international guidelines. The relation of laryngeal penetration and laryngotracheal aspiration with the NIHSS score was assessed by the Mann-Whitney U test, and predictors for the occurrence of pneumonia were analyzed by multiple logistic regression using semiautomatic backward selection. Significance was set at P less than .05.

RESULTS

The relations between laryngeal penetration and the NIHSS score and between laryngotracheal aspiration and the NIHSS score were not statistically significant. The predictors for pneumonia occurrence in the ischemic stroke patients with a clinical diagnosis of dysphagia were age (P = .002; odds ratio [OR], 1.12) and NIHSS score (P = .04; OR, 1.17), whereas laryngeal penetration of liquid (P = .065; OR, 3.70) tended to correlate with pneumonia but not significantly.

CONCLUSIONS

There was no relation between the NIHSS score and laryngeal penetration or laryngotracheal aspiration, and the principal predictors of pneumonia in dysphagic patients after ischemic stroke were advanced age and neurologic severity.

Differences in videofluoroscopic swallowing study (VFSS) findings according to the vascular territory involved in stroke

Dysphagia affects up to half of stroke patients and increases the risk of pneumonia and fatal outcomes. In order to assess swallowing difficulty, videofluoroscopic swallowing study (VFSS) has traditionally been the gold standard. The purpose of this study was to compare the patterns of post-stroke swallowing difficulties according to the vascular territories involved in the stroke. One hundred and three patients who were diagnosed with first ischemic stroke by brain magnetic resonance imaging and had swallowing difficulty were included in this study. Location of the stroke was classified into three groups: territorial anterior infarcts (TAI) (n = 62), territorial posterior infarcts (TPI) (n = 19) and white matter disease (WMD) (n = 22). Oral cavity residue existed significantly in the TAI group more than in any other groups (P = 0.017). The WMD group showed more residue in the valleculae (P = 0.002) and the TPI group showed more residue in the pyriform sinuses (P = 0.001). The oral transit time, pharyngeal delay time and pharyngeal transit time did not show significant differences among the groups with swallowing of both thick and thin liquids. Penetration and aspiration were more frequent in the TPI group (P < 0.05) with swallowing of both thick and thin liquids. The results suggest that TAI is more related to oral phase dysfunction and TPI is more related to pharyngeal dysfunction. In ischemic stroke, patterns of swallowing difficulty may differ according to the vascular territory involved and this should be considered in the management of post-stroke dysphagia.

Correlation between laryngeal sensitivity and penetration/aspiration after stroke

Stroke is the most common neurological disease in adults that is associated with deglutition disorders. The presence of laryngeal sensitivity is very important in developing safe swallowing without risk of pulmonary complications. The aim of this study was to correlate laryngeal sensitivity with laryngeal penetration and tracheal aspiration after swallows of three food consistencies (puree, thickened liquid, and liquid) in poststroke individuals in the late phase. A cross-sectional clinical study was performed with 91 post-ischemic stroke individuals, with oropharyngeal dysphagia, who were in rehabilitation center treatment from 2009 to 2011. They had a mean age of 68.1 years and average time since injury was 22.6 months; 39 had injury to the right hemisphere and 52 had injury to the left hemisphere. All underwent fiberoptic endoscopic evaluation of swallowing and evaluation of laryngeal sensitivity by touching the tip of the endoscope to the arytenoids and aryepiglottic folds. The linear correlation coefficient of Spearman was applied to evaluate the correlation between laryngeal penetration and tracheal aspiration and the presence/absence of laryngeal sensitivity. There was a negative correlation between the observation of penetration and tracheal aspiration and laryngeal sensitivity, with all bolus consistencies (p < 0.001 for aspiration and p ≤ 0.01 for penetration). The absence of laryngeal sensitivity determines the more frequent findings of penetration and tracheal aspiration. This sensory stimulus in the mucosa of the pharynx and larynx is an essential element for safe swallowing and its deficiency associated with altered motor activity can cause laryngeal penetration and aspiration in poststroke individuals regardless of food consistency.

Botulinum toxin treatment for oropharyngeal dysphagia in patients with stroke

BACKGROUND

In a previous pilot study, we demonstrated that a single injection of botulinum toxin A (BTX-A) in the cricopharyngeus muscle is effective in patients with neurologic dysphagia with upper esophageal sphincter (UES) opening dysfunction and presence of some pharyngeal contraction (>25 mmHg). The aim of this study was to confirm the long-lasting efficacy of this procedure after stroke.

METHODS

We prospectively studied 23 patients with stroke for at least 6 months before administration of a BTX-A injection. Baseline diagnosis of UES opening dysfunction and presence of some pharyngeal contraction were assessed by videofluoroscopy (VFS) and esophageal manometry (EM). Clinical and VFS follow-up was made at 3 weeks and 3, 6, and 12 months postinjection.

KEY RESULTS

Eighteen patients (78%) were fed by gastrostomy tube prior to treatment. Videofluoroscopy showed UES relaxation impairment, residue in pyriform sinuses, and aspiration in all cases. After BTX-A, the number of patients with aspiration and pharyngeal residue decreased to 52% and 70%, respectively (p < 0.05 for both); residue was severe in only 4%. Esophageal manometry showed a mean pharyngeal amplitude 66.8 mmHg (range: 25-120 mmHg). We observed a significant improvement in feeding mode during follow-up: after 3 months, 70% of patients were eating exclusively by mouth. Lower residual pressure and minor pharyngeal delay time at baseline were all predictive factors for treatment effectiveness.

CONCLUSIONS & INFERENCES

A single injection of BTX-A is efficacious for a period of at least 12 months in improving oropharyngeal dysphagia in stroke patients with UES opening dysfunction and some pharyngeal contraction (>25 mmHg).

Clinical prognostic indicators of dysphagia following prolonged orotracheal intubation in ICU patients

Introduction

The development of postextubation swallowing dysfunction is well documented in the literature with high prevalence in most studies. However, there are relatively few studies with specific outcomes that focus on the follow-up of these patients until hospital discharge. The purpose of our study was to determine prognostic indicators of dysphagia in ICU patients submitted to prolonged orotracheal intubation (OTI).

Methods

We conducted a retrospective, observational cohort study from 2010 to 2012 of all patients over 18 years of age admitted to a university hospital ICU who were submitted to prolonged OTI and subsequently received a bedside swallow evaluation (BSE) by a speech pathologist. The prognostic factors analyzed included dysphagia severity rate at the initial swallowing assessment and at hospital discharge, age, time to initiate oral feeding, amount of individual treatment, number of orotracheal intubations, intubation time and length of hospital stay.

Results

After we excluded patients with neurologic diseases, tracheostomy, esophageal dysphagia and those who were submitted to surgical procedures involving the head and neck, our study sample size was 148 patients. The logistic regression model was used to examine the relationships between independent variables. In the univariate analyses, we found that statistically significant prognostic indicators of dysphagia included dysphagia severity rate at the initial swallowing assessment, time to initiate oral feeding and amount of individual treatment. In the multivariate analysis, we found that dysphagia severity rate at the initial swallowing assessment remained associated with good treatment outcomes.

Conclusions

Studies of prognostic indicators in different populations with dysphagia can contribute to the design of more effective procedures when evaluating, treating, and monitoring individuals with this type of disorder. Additionally, this study stresses the importance of the initial assessment ratings.

Evaluation of dysphagia in early stroke patients by bedside, endoscopic, and electrophysiological methods

We aimed in this study to evaluate dysphagia in early stroke patients using a bedside screening test and flexible fiberoptic endoscopic evaluation of swallowing (FFEES) and electrophysiological evaluation (EE) methods and to compare the effectiveness of these methods. Twenty-four patients who were hospitalized in our clinic within the first 3 months after stroke were included in this study. Patients were evaluated using a bedside screening test [including bedside dysphagia score (BDS), neurological examination dysphagia score (NEDS), and total dysphagia score (TDS)] and FFEES and EE methods. Patients were divided into normal-swallowing and dysphagia groups according to the results of the evaluation methods. Patients with dysphagia as determined by any of these methods were compared to the patients with normal swallowing based on the results of the other two methods. Based on the results of our study, a high BDS was positively correlated with dysphagia identified by FFEES and EE methods. Moreover, the FFEES and EE methods were positively correlated. There was no significant correlation between NEDS and TDS levels and either EE or FFEES method. Bedside screening tests should be used mainly as an initial screening test; then FFEES and EE methods should be combined in patients who show risks. This diagnostic algorithm may provide a practical and fast solution for selected stroke patients.

Risk factors for swallowing dysfunction in stroke patients

CONTEXT: Stroke is a frequent cause of dysphagia. OBJECTIVE: To evaluate in a tertiary care hospital the prevalence of swallowing dysfunction in stroke patients, to analyze factors associated with the dysfunction and to relate swallowing dysfunction to mortality 3 months after the stroke. METHODS: Clinical evaluation of deglutition was performed in 212 consecutive patients with a medical and radiologic diagnosis of stroke. The occurrence of death was determined 3 months after the stroke. RESULTS: It was observed that 63% of the patients had swallowing dysfunction. The variables gender and specific location of the lesion were not associated with the presence or absence of swallowing dysfunction. The patients with swallowing dysfunction had more frequently a previous stroke, had a stroke in the left hemisphere, motor and/or sensitivity alterations, difficulty in oral comprehension, alteration of oral expression, alteration of the level of consciousness, complications such as fever and pneumonia, high indexes on the Rankin scale, and low indexes on the Barthel scale. These patients had a higher mortality rate. CONCLUSIONS: Swallowing evaluation should be done in all patients with stroke, since swallowing dysfunction is associated with complications and an increased risk of death.

Effectiveness of chin-down posture to prevent tracheal aspiration in dysphagia secondary to acquired brain injury. A videofluoroscopy study

BACKGROUND

The chin-down posture is generally recommended in patients with neurogenic dysphagia to prevent tracheal aspiration; however, its effectiveness has not been demonstrated.

AIM

To videofluoroscopically (VDF) assess the effectiveness of chin-down posture to prevent aspiration in patients with neurogenic dysphagia secondary to acquired brain injury.

METHODS

Randomized, alternating, cross-over study (with and without the chin-down posture) in 47 patients with a VDF diagnosis of aspiration [31 stroke, 16 traumatic brain injury (TBI)] and 25 controls without aspiration (14 stroke, 11 TBI).

KEY RESULTS

During the chin-down posture, 55% of patients avoided aspiration (40% preswallow aspiration and 60% aspiration during swallow). The percentage was similar in both etiologies (58% stroke and 50% TBI). Fifty-one percent of patients had silent aspiration; of these, 48% persisted with aspiration while in the chin-down posture. A statistically significant relationship was found between the existence of pharyngeal residue, cricopharyngeal dysfunction, pharyngeal delay time and bolus volume with the persistence of aspiration. The chin-down posture did not change swallow biomechanics in patients without aspiration.

CONCLUSIONS & INFERENCES

Only half the patients with acquired brain injury avoided aspiration during cervical flexion; 48% of silent aspirators continued to aspire during the maneuver. Several videofluoroscopic parameters were related to inefficiency of the maneuver. Therefore, the indication for chin-down posture should be evaluated by videofluoroscopic examination.

Using the National Institute of Health Stroke Scale to predict dysphagia in acute ischemic stroke

BACKGROUND AND PURPOSE

Oropharyngeal dysphagia is a common manifestation in acute stroke. Aspiration resulting from difficulties in swallowing is a symptom that should be considered due to the frequent occurrence of aspiration pneumonia that could influence the patient's recovery as it causes clinical complications and could even lead to the patient's death. The early clinical evaluation of swallowing disorders can help define approaches and avoid oral feeding, which may be detrimental to the patient. This study aimed to create an algorithm to identify patients at risk of developing dysphagia following acute ischemic stroke in order to be able to decide on the safest way of feeding and minimize the complications of stroke using the National Institutes of Health Stroke Scale (NHISS).

METHODS

Clinical assessment of swallowing was performed in 50 patients admitted to the emergency unit of the University Hospital, Faculty of Medicine of Ribeirão Preto, São Paulo, Brazil, with a diagnosis of ischemic stroke, within 48 h after the beginning of symptoms. Patients, 25 females and 25 males with a mean age of 64.90 years (range 26-91 years), were evaluated consecutively. An anamnesis was taken before the patient's participation in the study in order to exclude a prior history of deglutition difficulties. For the functional assessment of swallowing, three food consistencies were used, i.e. pasty, liquid and solid. After clinical evaluation, we concluded whether there was dysphagia. For statistical analysis we used the Fisher exact test, verifying the association between the variables. To assess whether the NIHSS score characterizes a risk factor for dysphagia, a receiver operational characteristics curve was constructed to obtain characteristics for sensitivity and specificity.

RESULTS

Dysphagia was present in 32% of the patients. The clinical evaluation is a reliable method of detection of swallowing difficulties. However, the predictors of risk for the swallowing function must be balanced, and the level of consciousness and the presence of preexisting comorbidities should be considered. Gender, age and cerebral hemisphere involved were not significantly associated with the presence of dysphagia. NIHSS, Glasgow Coma Scale, and speech and language changes had a statistically significant predictive value for the presence of dysphagia.

CONCLUSIONS

The NIHSS is highly sensitive (88%) and specific (85%) in detecting dysphagia; a score of 12 may be considered as the cutoff value. The creation of an algorithm to detect dysphagia in acute ischemic stroke appears to be useful in selecting the optimal feeding route while awaiting a specialized evaluation.

Clinical features and the role of atypical pathogens in nursing and healthcare-associated pneumonia (NHCAP): differences between a teaching university hospital and a community hospital

OBJECTIVE

The Japan Respiratory Society documented a new category of guidelines for nursing and healthcare-associated pneumonia (NHCAP), which is distinct from community acquired pneumonia (CAP). The objective of this study was to determine the epidemiological differences between NHCAP patients in a teaching university hospital and a community hospital. In addition, to clarify the strategy for treatment of NHCAP, we investigated the role of atypical pathogens.

METHODS

We analyzed 250 NHCAP and 421 CAP cases in a university hospital and 349 NHCAP and 374 CAP cases in a community hospital.

RESULTS

Patient age and the incidences of poor general condition were significantly higher in the community hospital compared with those in the university hospital. The distribution and frequency of pathogens, especially multidrug-resistant (MDR) pathogens, were significantly different between the two hospitals. Central nervous system disorders, dementia and poor performance status, which was possibility related to aspiration pneumonia, were significantly more frequent in patients with NHCAP compared with those with CAP in both hospitals. Atypical pathogens were detected in a few cases in patients with NHCAP.

CONCLUSION

There were many differences in the clinical characteristics between NHCAP patients in a university hospital and a community hospital even for hospitals located in the same area. Aspiration pneumonia was thought to be the main characteristic of NHCAP in both hospitals. Thus, all NHCAP patients did not need the same empiric therapy with a multidrug regimen directed against MDR pathogens. In addition, physicians rarely need to consider atypical pathogens in NHCAP treatment.

A cost-effectiveness analysis of screening methods for dysphagia after stroke

OBJECTIVE

To provide a cost-effectiveness analysis of dysphagia screening in the acute poststroke period with use of a videofluoroscopic swallowing study, a clinical bedside swallowing evaluation, or a combined approach.

DESIGN

Decision-analysis model.

METHODS

A decision-analysis model was used with information derived from multiple data sources, including meta-analyses and other relevant clinical studies. Univariate and probabilistic sensitivity analyses were performed.

MAIN OUTCOME MEASURES

The analysis assessed direct medical costs of pneumonia. Strategies were compared on the basis of an incremental cost-effectiveness analysis, with effectiveness measured in quality-adjusted life-years.

RESULTS

The strategy of having each patient undergo a videofluoroscopic swallowing study for dysphagia was more effective and less costly than the strategies of clinical bedside swallowing evaluation alone or a combined approach. The model was most influenced by the reduction in the risk of pneumonia attributable to the treatment of mild/moderate and severe dysphagia, the effectiveness of treatment with clinical bedside swallowing evaluation, the baseline probability of pneumonia, and the cost of a videofluoroscopic swallowing study.

CONCLUSIONS

A videofluoroscopic swallowing study is cost-effective and often saves costs compared with a clinical bedside swallowing evaluation alone or a combined approach. Research aimed at improving the understanding of the effectiveness of treatment for dysphagia in the prevention of aspiration pneumonia and resulting mortality would improve the model.

Identification and nursing management of dysphagia in individuals with acute neurological impairment (update)

AIM

Dysphagia, or difficulty in swallowing, is a serious and life-threatening medical condition that affects a significant number of individuals with neurological impairment. We conducted an update of a previous systematic review to examine the evidence regarding the nursing role in the recognition and management of dysphagia in adults with neurological impairment and the effectiveness of nursing interventions in the recognition and management of dysphagia.

METHODS

We conducted extensive database and internet searches and retrieved original quantitative research studies published between January 1998 and January 2008. Quantitative papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review. Any disagreements that arose between the reviewers were resolved through discussion, or with a third reviewer. The data extracted included specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Due to significant variability in study methodology, populations and interventions, no statistical meta-analysis was possible.

RESULTS

Forty-two quantitative studies were retrieved and, of these, 17 met the inclusion and quality criteria, representing a wide range of quantitative research methodologies. The evidence from this updated review indicates that nurses are well placed to conduct dysphagia screening and that there are several tools available that may be suitable for them to use. It is important that formal dysphagia screening protocols are in place and that nurses are trained to use them. If nurses screen patients with an acute neurological impairment within 24 h of admission, it may reduce the time that patients spend without appropriate methods of nutrition and hydration and improve clinical outcomes. Dysphagia screening by nurses does not replace assessment by other health professionals; instead it enhances the provision of care to patients at risk by allowing for early recognition and intervention to occur. Dysphagia screening by nurses is an important initial step in the care of patients with acute neurological impairment, but in order to achieve the best outcomes, it needs to be followed up with careful, consistent management of food and fluid intake.

Does a 3-sip test detect dysphagia in acute stroke rehabilitation patients?

OBJECTIVES

(1) Evaluate sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a 3-sip test within 24 hours of acute stroke as a screening for clinically relevant dysphagia during acute rehabilitation. (2) For those patients who pass the 3-sip test, identify factors predictive of later detection of clinically relevant dysphagia.

DESIGN

A retrospective review.

SETTING

Acute stroke rehabilitation unit of a tertiary academic medical center.

PATIENTS

223 patients undergoing dysphagia screening after stroke.

MAIN OUTCOME MEASURE

Development of clinically relevant dysphagia.

RESULTS

Seventeen of 223 patients (7.6%) failed the 3-sip test. Of the 206 patients who passed the 3-sip test, 57 (27.7%) manifested clinically relevant dysphagia. Sensitivity and specificity of the 3-sip test were 20.8% and 98.7%, respectively. PPV and NPV were 88.2% and 72.3%, respectively. Among those who passed the 3-sip test, logistic regression identified the Functional Independence Measure (FIM) total score as the only independent predictor (B = -0.066, P < .001) of clinically relevant dysphagia. Of those patients who passed the 3-sip test, 54.6% with an FIM total score <60 had clinically relevant dysphagia compared with 11.9% with an FIM total score >60.

CONCLUSIONS

The sensitivity of the 3-sip test was poor for stroke rehabilitation patients. For those who passed the 3-sip test, a low FIM total score was predictive of development of clinically relevant dysphagia. A high degree of clinical suspicion for dysphagia should remain after passing a 3-sip screening test, especially for those with FIM total score <60.

Influence of lip force on swallowing capacity in stroke patients and in healthy subjects

CONCLUSION

In spite of no clinical signs of facial paresis, a pathological lip force (LF) will strongly influence swallowing capacity (SC). Stroke patients with impaired SC suffer a subclinical facial paresis. The results support earlier findings that LF training can be used to treat dysphagia.

OBJECTIVES

Lip muscle training with an oral screen can improve both LF and SC in stroke patients, irrespective of the presence or absence of facial palsy. The aim was therefore to study the influence of LF on SC.

METHODS

This prospective study included 22 stroke patients, aged 38–90 years, with dysphagia, 12 with initial unilateral facial paresis and 45 healthy subjects, aged 25–87 years. All were investigated with a Lip Force Meter (LF100), and with an SC test.

RESULTS

A significant correlation was found between LF/SC (p = 0.012) in stroke patients but not in healthy subjects. LF/SC was not age-related in stroke patients. LF was not age-dependent in healthy subjects, but SC decreased with increasing age (p < 0.0001). However, SC did not reach a pathological value and a regression analysis showed that 73% of the variation in SC is attributable to LF and age.

Malnutrition in elder care: qualitative analysis of ethical perceptions of politicians and civil servants

BACKGROUND

Few studies have paid attention to ethical responsibility related to malnutrition in elder care. The aim was to illuminate whether politicians and civil servants reason about malnutrition in elder care in relation to ethical responsibility, and further about possible causes and how to address them.

METHOD

Eighteen elected politicians and appointed civil servants at the municipality and county council level from two counties in Sweden were interviewed. They worked at a planning, control and executive level, with responsibility for both the elder care budget and quality of care. Qualitative method was used for the data analysis.

RESULTS

Two themes emerged from their reasoning about malnutrition related to ethical responsibility. The theme assumed role involves the subthemes quality of care and costs, competent staff and govern at a distance. Old and ill patients were mentioned as being at risk for malnutrition. Caregivers were expected to be knowledgeable and stated primary responsible for providing adequate nutritional care. Extended physician responsibility was requested owing to patients' illnesses. Little was reported on the local management's role or on their own follow-up routines. The theme moral perception includes the subthemes discomfort, trust and distrust. Feelings of discomfort concerned caregivers having to work in a hurried, task-oriented manner. Trust meant that they believed for the most part that caregivers had the competence to deal appropriately with nutritional care, but they felt distrust when nutritional problems reappeared on their agenda. No differences could be seen between the politicians and civil servants.

CONCLUSION

New knowledge about malnutrition in elder care related to ethical responsibility was illuminated by persons holding top positions. Malnutrition was stressed as an important dimension of the elder care quality. Governing at a distance meant having trust in the staff, on the one hand, and discomfort and distrust when confronted with reports of malnutrition, on the other. Distrust was directed at caregivers, because despite the fact that education had been provided, problems reappeared. Discomfort was felt when confronted with examples of poor nutritional care and indicates that the participants experienced failure in their ethical responsibility because the quality of nutritional care was at risk.

Aspiration pneumonia

Aspiration pneumonia is diagnosed upon confirmation of inflammatory findings in the lungs and overt aspiration (apparent aspiration) or a condition in which aspiration is strongly suspected (abnormal swallowing function and dysphagia). In hospital-acquired pneumonia, this occurs as one consequence of frequent silent aspiration. In the diagnosis of aspiration pneumonia, evaluation of the risk of silent aspiration during the night and evaluation of swallowing function are important. The causative microorganisms in aspiration pneumonia, similar to community-acquired pneumonia, are basically thought to be bacteria residing in the oral cavity, such as pneumococcus, Haemophilus influenzae, Staphylococcus aureus and anaerobes. Hospital-acquired aspiration pneumonia often occurs with no distinction between apparent and silent aspiration, and in many cases, aspiration of foreign substances is serious when dysphagia itself is severe. In the treatment of aspiration pneumonia, use of antimicrobials for the pneumonia itself and early measures to prevent aspiration are important.

Oropharyngeal dysphagia after stroke: incidence, diagnosis, and clinical predictors in patients admitted to a neurorehabilitation unit

OBJECTIVE

We analyzed patients with stroke in a neurorehabilitation unit to define incidence of dysphagia, compare clinical bedside assessment and videofluoroscopy (VFS), and define any correlation between dysphagia and clinical characteristic of patients.

METHODS

In all, 151 consecutive inpatients with recent ischemic or hemorrhagic stroke were enrolled.

RESULTS

Dysphagia was clinically diagnosed in 62 of 151 patients (41%). A total of 49 patients (79% of clinically dysphagic patients) underwent VFS. Six patients clinically suggested to be dysphagic had a normal VFS finding. The correlation between clinical and VFS diagnosis of dysphagia was significant (r = 0.6505). Penetrations and aspirations were observed, respectively, in 42.8% and 26.5% of patients with dysphagia, with 12.2% classified as silent. Lower respiratory tract infections were observed in 5.9%, more frequently in patients with dysphagia (30%). Dysphagia was not influenced by type of stroke. Cortical stroke of nondominant side was associated with dysphagia (P = .0322) and subcortical nondominant stroke showed a reduced frequency of dysphagia (P = .0008). Previous cerebrovascular disease resulted associated to dysphagia (P = .0399). Patients with dysphagia had significantly lower functional independence measurement (FIM) and level of cognitive functioning on admission and lower FIM on discharge, longer hospital stay, and more frequent malnutrition, and they were more frequently aphasic and dysarthric. Percutaneous endoscopic gastrostomy was used in 18 of 151 patients (11.9%) (41.8% of patients with VFS-proved dysphagia).

CONCLUSIONS

Dysphagia occurs in more than a third of patients with stroke admitted to rehabilitation. Clinical assessment demonstrates good correlation with VFS. The grade of dysphagia correlates with dysarthria, aphasia, low FIM, and level of cognitive functioning. Large cortical strokes of nondominant side are associated with dysphagia.

Accuracy of clinical judgment of the chin-down posture for dysphagia during the clinical/bedside assessment as corroborated by videofluoroscopy in adults with acute stroke

Speech-language pathologists tend to rely on the noninstrumental swallowing evaluation in making recommendations about a patient's diet and management plan. The present study was designed to examine the sensitivity and specificity of the accuracy of using the chin-down posture during the clinical/bedside swallowing assessment. In 15 patients with acute stroke and clinically suspected oropharyngeal dysphagia, the correlation between clinical and videofluoroscopic findings was examined. Results identified that there is a difference in outcome prediction using the chin-down posture during the clinical/bedside assessment of swallowing compared to assessment by videofluoroscopy. Results are discussed relative to statistical and clinical perspectives, including site of lesion and factors to be considered in the design of an overall treatment plan for a patient with disordered swallowing.

Evolution of tracheal aspiration in severe traumatic brain injury-related oropharyngeal dysphagia: 1-year longitudinal follow-up study

The aims of the article were to ascertain the clinical evolution and prognostic factors of aspiration recovery and feeding outcome in patients with severe traumatic brain injury (TBI) and a videofluoroscopic (VFS) diagnosis of tracheal aspiration. Twenty-six patients with severe TBI and VFS diagnosis of tracheal aspiration were prospectively evaluated. Clinical evaluation of oropharyngeal dysphagia and VFS examination were performed at admission and repeated at 1, 3, 6 and 12 months of follow-up. At admission, all patients had VFS aspiration. During follow-up, an improvement was observed in both oral and pharyngeal function, with the number of patients with aspiration decreasing progressively. The most significant change occurred in the examination made at 3 months. At 1 year, only 23% of patients had aspiration. No patient had clinically significant respiratory infections during the follow-up period. Persistent aspiration at 1 year of follow-up correlated with baseline variables: Rancho Los Amigos Level Cognitive Function Scale score, Disability Rating Scale score, tongue control alteration, velopharyngeal reflex abolition and delay in triggering swallowing reflex. Swallowing physiology in severe TBI greatly improved during follow-up and the number of aspirations decreased progressively, with the most significant reduction at between 3 and 6 months of evolution. This study revealed several prognostic factors for persisting aspiration: neurological involvement (evaluated with the Rancho Los Amigos Level Cognitive Function Scale and Disability Rating Scale), tongue control alteration, oropharyngeal reflex abolition and delay in triggering swallowing reflex at baseline.

Resolution of tracheal aspiration after the acute phase of stroke-related oropharyngeal Dysphagia

OBJECTIVES

We set out to ascertain the evolution and the clinical and videofluoroscopic (VFS) prognostic factors of aspiration recovery and return to oral intake in patients with stroke and VFS diagnosis of tracheal aspiration.

METHODS

Twenty patients with stroke and VFS diagnosis of tracheal aspiration were prospectively evaluated. Clinical evaluation of oropharyngeal dysphagia and VFS examination were performed at admission and repeated at 1, 3, 6 and 12 months of follow-up.

RESULTS

At admission, videofluoroscopy showed 40% of patients to have an increase in oral transit time and 65% impaired tongue control; in the pharyngeal phase, mean pharyngeal transit time was increased in 70% of patients and the time required to trigger the swallowing reflex was delayed in 70%. During follow-up, an improvement was observed, and the number of patients with aspiration decreased progressively (the most significant change occurred at 6 months). Evolution was related to the vascular territory affected: at 1 year, aspiration persisted in 12% of anterior territory lesions vs. 58% of posterior territory lesions. Also, the number of silent aspirators decreased from 35% at baseline to no patients after 3 months. Persistent aspiration at 1 year of follow-up significantly correlated with the following baseline variables: vascular territory, gag reflex abolition, palatoglossal seal alteration and pharyngeal delay time.

CONCLUSIONS

Swallowing physiology in stroke greatly improved during follow-up, mainly between 3 and 6 months, and the number of aspirations decreased progressively. Prognostic factors for persisting aspiration are posterior vascular territory lesions, oropharyngeal reflex abolition, palatoglossal seal alteration and pharyngeal delay time at baseline.

Pneumonia in stroke patients with oropharyngeal dysphagia: a six-month follow-up study

The aim of the study was to estimate the frequency of pneumonia and to determine the risk factors for this complication in poststroke patients with oropharyngeal dysphagia (OD). We prospectively followed up 67 patients (mean age 72.9+/-12.2 years) in the first 6 months after stroke, during which time we recorded gender, stroke side, type of lesion, diabetes, history of chronic obstructive pulmonary disease (COPD), smoking, level of consciousness, functional outcome, dietary history, occurrence of chest infection, and death. Degree of OD and presence/absence of reflex cough was assessed by Fiberoptic Endoscopic Evaluation of Swallowing. Sixty patients showed complete recovery of prestroke swallowing; 9 (13.4% IC 95%=5-20%) developed pneumonia, two of whom died. The first episode of pneumonia occurred in all nine patients within the first month after stroke onset. The pneumonia was associated with absence of reflex cough after swallow, COPD, and severe impairment of consciousness and poor functional outcome.

Aspiration pneumonias: under-diagnosed and under-treated

PURPOSE OF REVIEW

To examine recent advancements of the epidemiology, risk factors, bacteriology, diagnostic measures, and treatment for aspiration pneumonia.

RECENT FINDINGS

In a large prospective study, 10.3% of community-acquired pneumonia requiring hospitalization was associated with aspiration pneumonia, as opposed to 30% when patients were admitted from long-term facilities. A murine stroke model showed increased apoptosis of cell-mediated immune cells due to overactivation of the sympathetic nervous system. Subsequent nasal inoculum of low-dose Streptococcus pneumoniae caused severe pneumonia. Another murine study showed intratracheal administration of hydrochloric acid-primed lungs more susceptible to infection with Klebsiella pneumoniae. Tracheal pH monitoring demonstrated acidification of trachea in 28% of patients with acute stroke deemed to be safe for oral feeding. Various antimicrobial agents used to treat aspiration pneumonia have comparable success rates. However, clindamycin was the only agent that did not propagate emergence of methicillin-resistant Staphylococcus aureus.

SUMMARY

Aspiration pneumonia is prevalent in community-acquired pneumonia. Further studies are needed to elucidate the effects of sympathetic nervous system and aspiration pneumonitis as primers for lung infection. Predicting aspiration risk is difficult and newer diagnostic tools are necessary. Antimicrobials used in aspiration pneumonia have similar success rates although the development of resistant organisms must be monitored.

Routine Evaluation for Aspiration After Thoracotomy for Pulmonary Resection

BACKGROUND

The purpose of this study was to evaluate the role of a routine protocol for evaluation of oropharyngeal aspiration after thoracotomy for pulmonary resection.

METHODS

Demographic, operative, and outcomes data were collected prospectively for consecutive patients undergoing thoracotomy for pulmonary resection starting in April 2005. Starting on postoperative day one, patients underwent evaluation by a licensed speech therapist before per os intake. Patients failing clinical examination were referred for radiographic evaluation. Diets were advanced on the basis of results from both clinical and radiographic evaluation. Data analysis included descriptive statistics, Student's t test, and chi2 test when appropriate.

RESULTS

One hundred forty patients were prospectively evaluated during this period. Thirty-two patients (22.9%) failed initial clinical swallowing evaluation and were referred for dynamic videofluoroscopic esophagram. Twenty-five patients (17.8%) had evidence of potential oropharyngeal aspiration on videofluoroscopic esophagram. Only 1 patient (0.7%) aspirated after a negative clinical evaluation. Univariate risk factor analysis revealed that patients demonstrating aspiration were older (67.7 +/- 1.6 years versus 64.4 +/- 1.1 years; p = 0.10) and had a higher incidence of head and neck malignancy (p < 0.001). Patients without radiographic aspiration had a shorter median hospital stay when compared with those who did (6 days versus 5 days).

CONCLUSIONS

Aspiration after thoracotomy for pulmonary resection may affect nearly 20% of patients and is likely underrepresented in the surgical literature. The institution of a protocol to evaluate risk of aspiration has characterized patients at high risk and led to an increased awareness of the potential for aspiration after thoracotomy.