Dysphagia and pulmonary complications in acute cerebrovascular disease: A retrospective observational study

INTRODUCTION

Dysphagia is a common post-stroke complication, which may result in serious pulmonary sequelae. Early detection of dysphagia and aspiration risk can reduce morbidity, mortality and length of hospitalization.

OBJECTIVES

This study aims to identify association between dysphagia and acute cerebrovascular disease, and evaluate the prevalence and impact of pulmonary complications on readmissions and mortality.

MATERIAL AND METHODS

Retrospective observational study based on 250 clinical records of patients with acute cerebrovascular disease: clinical history, neurological examination, imaging and Gugging Swallowing Screen in the first 48h. Patients were followed for 3 months via medical records to estimate 3-month mortality and readmissions.

RESULTS

Out of 250 clinical records analyzed, 102 (40.8%) were evaluated for dysphagia. The prevalence of dysphagia was 32.4%. The risk was higher in older patients (p<0.001), in severe stroke (p<0.001) and in the hemorrhagic subtype (p=0.008). An association was found with dysarthria and aphasia (p=0.003; p=0.017). Respiratory tract infections occurred in 14.4% of all patients (GUSS group 11.8% versus no GUSS group 16.2%), and in 75% of those with severe dysphagia (p<0.001). Mortality at 3 months was 24.2% in dysphagic patients, especially high in the severe dysphagia group (75%, p<0.001).

CONCLUSIONS

The type of cerebrovascular disease, NIHSS and GCS scores, age, dysarthria, and aphasia were significant associated factors to dysphagia. The prevalence of respiratory tract infections was higher in patients with no GUSS record, and no statistical significance was observed in related readmissions. Mortality at 3 months was superior in the severe dysphagia group.

Clinical Practice Guidelines for Oropharyngeal Dysphagia

OBJECTIVE

Dysphagia is a common clinical condition characterized by difficulty in swallowing. It is sub-classified into oropharyngeal dysphagia, which refers to problems in the mouth and pharynx, and esophageal dysphagia, which refers to problems in the esophageal body and esophagogastric junction. Dysphagia can have a significant negative impact one's physical health and quality of life as its severity increases. Therefore, proper assessment and management of dysphagia are critical for improving swallowing function and preventing complications. Thus a guideline was developed to provide evidence-based recommendations for assessment and management in patients with dysphagia.

METHODS

Nineteen key questions on dysphagia were developed. These questions dealt with various aspects of problems related to dysphagia, including assessment, management, and complications. A literature search for relevant articles was conducted using Pubmed, Embase, the Cochrane Library, and one domestic database of KoreaMed, until April 2021. The level of evidence and recommendation grade were established according to the Grading of Recommendation Assessment, Development and Evaluation methodology.

RESULTS

Early screening and assessment of videofluoroscopic swallowing were recommended for assessing the presence of dysphagia. Therapeutic methods, such as tongue and pharyngeal muscle strengthening exercises and neuromuscular electrical stimulation with swallowing therapy, were effective in improving swallowing function and quality of life in patients with dysphagia. Nutritional intervention and an oral care program were also recommended.

CONCLUSION

This guideline presents recommendations for the assessment and management of patients with oropharyngeal dysphagia, including rehabilitative strategies.

Advances in 3D printing of food and nutritional products

The main advantage of both 3D printing (3DP) and 3D food printing (3DFP) over other technologies is the enormous capacity of both techniques for customization. Its use makes it possible to obtain products without planning and implementing a complex and costly manufacturing process. This makes 3DFP a technology of choice for the preparation of food products that meet specific needs, such as controlled nutritional or rheological properties. However, further technological developments are still needed before 3DFP can be considered fully useful for innovative and demanding applications. If both preparation and post-processing of materials based on 3D printing are optimized, aiming to reduce production time and/or complication for non-expert users, this would open a whole new range of possibilities. It is in this sense that the development of advanced 3DFP systems becomes a must. This chapter reviews current advances in extrusion-based 3D food printing systems, with in situ gelation and mixing as key aspects to better exploit the potential of 3DFP. On one hand, 3DFP systems based on in situ gelation (G3DFP) provide greater control over the final properties of the printed products, as the selection of adequate printing parameters gives the possibility of influencing the gelation process. On the other hand, mixing is indispensable for true 3DFP automation, so that the formulations do not have to be prepared by the user. Different innovative 3DFP systems based on gelling and/or mixing are presented in this chapter. Finally, the status and future of extrusion-based 3DFP, and its application in the production of customized foods for specific needs, are also overviewed.

European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia

Post-stroke dysphagia (PSD) is present in more than 50% of acute stroke patients, increases the risk of complications, in particular aspiration pneumonia, malnutrition and dehydration, and is linked to poor outcome and mortality. The aim of this guideline is to assist all members of the multidisciplinary team in their management of patients with PSD. These guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. An interdisciplinary working group identified 20 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence and wrote evidence-based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found moderate quality of evidence to recommend dysphagia screening in all stroke patients to prevent post-stroke pneumonia and to early mortality and low quality of evidence to suggest dysphagia assessment in stroke patients having been identified at being at risk of PSD. We found low to moderate quality of evidence for a variety of treatment options to improve swallowing physiology and swallowing safety. These options include dietary interventions, behavioural swallowing treatment including acupuncture, nutritional interventions, oral health care, different pharmacological agents and different types of neurostimulation treatment. Some of the studied interventions also had an impact on other clinical endpoints such as feedings status or pneumonia. Overall, further randomized trials are needed to improve the quality of evidence for the treatment of PSD.

Free from Dysphagia? A Test Battery to Differentiate Between Mild and No Dysphagia

Assessing mild oropharyngeal dysphagia (OD) raises the question where to draw the line between normal and pathological swallowing. There is a lack of clinical test methods appropriate in the subacute phase of recovery from dysphagia following stroke and other brain injuries. The aim of this pilot study was to investigate the diagnostic accuracy of a new test battery, called the Swallow Battery (SwaB), in relation to Fiberoptic Endoscopic Evaluation of Swallowing (FEES). SwaB consists of the validated tests Repetitive Saliva Swallowing Test (RSST), Timed Water Swallowing Test (TWST) and parts of the Test of Masticating and Swallowing Solids (ToMaSS). Nineteen adult patients with acquired brain injury who were enrolled in a rehabilitation programme underwent the SwaB and a FEES, both resulting in a pass or fail outcome. The pass or fail results were based on RSST's and TWST's suggested cutoffs, normative values of ToMaSS and on established rating scales used for FEES. The SwaB's ability to predict FEES results was 74% according to a binary logistic regression analysis, with a 92% correct prediction of fail results and 33% correct prediction of pass results. The ToMaSS was sensitive to small changes in eating ability, failing 13 out of 19 patients using 95% CI normative values as cutoff, including patients with a passed FEES. Alternative cutoffs were therefore suggested, depending on purpose of dysphagia assessment. The results of this study indicate that the SwaB may be a useful tool when assessing mild dysphagia following brain injury. Further studies of SwaB's validity and clinical utility are suggested.

Are Medication Swallowing Lubricants Suitable for Use in Dysphagia? Consistency, Viscosity, Texture, and Application of the International Dysphagia Diet Standardization Initiative (IDDSI) Framework

Medication lubricants are thick liquids or gels that are designed to aid swallowing of solid oral dosage forms. Tablets and capsules are placed within a spoonful of the product for swallowing. The aim of this study was to describe and compare commercially available medication lubricants in terms of textural suitability for patients with dysphagia. Twelve medication lubricants were characterised according to the International Dysphagia Diet Standardisation Initiative (IDDSI) framework. Apparent viscosity, yield stress, thickness consistency, and various texture features were compared. Gloup Forte was the only medication lubricant classified as IDDSI level 4 (pureed/extremely thick) at room (24 °C) temperature. Four other Gloup products were IDDSI level 3 (liquidised/moderately thick) at room temperature but testing at 4 °C or pouring from the container instead of using the pump dispenser resulted in classification as IDDSI level 4. The IDDSI Flow test would have classified MediSpend and Slo Tablets as IDDSI level 3, but their very low yield stress led to these fluids flowing too quickly through the prongs of a fork and so these were classified as <3. Severo was IDDSI level 2. Heyaxon and the two versions of Magic Jelly tested contained lumps, and Swallow Aid had exceptionally high viscosity, hardness, adhesiveness, and gumminess, classifying them as IDDSI Level 7 (“regular textures”) and therefore as unsuitable for people with dysphagia according to IDDSI. This study provides valuable information to help with the selection of a safe medication lubricant with appropriate thickness level suited to each individual with dysphagia.

Dysphagia and Associated Pneumonia in Stroke Patients from Brazil: A Systematic Review

Dysphagia and its associated complications are expected to be relatively more frequent in stroke patients in Brazil than in similar patients treated in developed countries due to the suboptimal stroke care in many Brazilians medical services. However, there is no estimate of dysphagia and pneumonia incidence for the overall stroke population in Brazil. We conducted a systematic review of the recent literature to address this knowledge gap, first screening citations for relevance and then rating full articles of accepted citations. At both levels, judgements were made by two independent raters according to a priori criteria. Fourteen accepted articles underwent critical appraisal and data extraction. The frequency of dysphagia in stroke patients was high (59% to 76%). Few studies assessed pneumonia and only one study stratified patients by both dysphagia and pneumonia, with an increased Relative Risk for pneumonia in patients with stroke and dysphagia of 8.4 (95% CI 2.1, 34.4). Across all articles, we identified bias related to: heterogeneity in number and type of stroke; no rater blinding; and, assessments that were not reproducible, reliable or validated. Despite the high frequency of dysphagia and associated pneumonia in stroke patients in Brazil, the quality of the available literature is low and that there is little research focused on these epidemiologic data. Future rigorously designed studies are in dire need to accurately determine dysphagia incidence and its impact on stroke patients in Brazil. These data will be critical to properly allocate limited national resources that maximize the quality of stroke care.

Nutritional Aspects of Dysphagia Management

This chapter describes the nutritional aspects of dysphagia management by starting with the definition of these two conditions (dysphagia and malnutrition) that share three main clinical characteristics: (a) their prevalence is very high, (b) they can lead to severe complications, and (c) they are frequently underrecognized and neglected conditions. From an anatomical standpoint, dysphagia can result from oropharyngeal and/or esophageal causes; from a pathophysiological perspective, dysphagia can be caused by organic or structural diseases (either benign or malignant) or diseases causing impaired physiology (mainly motility and/or perception disorders). This chapter gathers up-to-date information on the screening and diagnosis of oropharyngeal dysphagia, the consequences of dysphagia (aspiration pneumonia, malnutrition, and dehydration), and on the nutritional management of dysphagic patients. Concerning this last topic, this chapter reviews the rheological aspects of swallowing and dysphagia (including shear and elongational flows) and its influence on the characteristics of the enteral nutrition for dysphagia management (solid/semisolid foods and thickened liquids; ready-to-use oral nutritional supplements and thickening powders), with special focus on the real characteristics of the bolus after mixing with human saliva.

Effect of Bolus Viscosity on the Safety and Efficacy of Swallowing and the Kinematics of the Swallow Response in Patients with Oropharyngeal Dysphagia: White Paper by the European Society for Swallowing Disorders (ESSD)

BACKGROUND

Fluid thickening is a well-established management strategy for oropharyngeal dysphagia (OD). However, the effects of thickening agents on the physiology of impaired swallow responses are not fully understood, and there is no agreement on the degree of bolus thickening.

AIM

To review the literature and to produce a white paper of the European Society for Swallowing Disorders (ESSD) describing the evidence in the literature on the effect that bolus modification has upon the physiology, efficacy and safety of swallowing in adults with OD.

METHODS

A systematic search was performed using the electronic Pubmed and Embase databases. Articles in English available up to July 2015 were considered. The inclusion criteria swallowing studies on adults over 18 years of age; healthy people or patients with oropharyngeal dysphagia; bolus modification; effects of bolus modification on swallow safety (penetration/aspiration) and efficacy; and/or physiology and original articles written in English. The exclusion criteria consisted of oesophageal dysphagia and conference abstracts or presentations. The quality of the selected papers and the level of research evidence were assessed by standard quality assessments.

RESULTS

At the end of the selection process, 33 articles were considered. The quality of all included studies was assessed using systematic, reproducible, and quantitative tools (Kmet and NHMRC) concluding that all the selected articles reached a valid level of evidence. The literature search gathered data from various sources, ranging from double-blind randomised control trials to systematic reviews focused on changes occurring in swallowing physiology caused by thickened fluids. Main results suggest that increasing bolus viscosity (a) results in increased safety of swallowing, (b) also results in increased amounts of oral and/or pharyngeal residue which may result in post-swallow airway invasion, (c) impacts the physiology with increased lingual pressure patterns, no major changes in impaired airway protection mechanisms, and controversial effects on oral and pharyngeal transit time, hyoid displacements, onset of UOS opening and bolus velocity-with several articles suggesting the therapeutic effect of thickeners is also due to intrinsic bolus properties, (d) reduces palatability of thickened fluids and (e) correlates with increased risk of dehydration and decreased quality of life although the severity of dysphagia may be an confounding factor.

CONCLUSIONS

The ESSD concludes that there is evidence for increasing viscosity to reduce the risk of airway invasion and that it is a valid management strategy for OD. However, new thickening agents should be developed to avoid the negative effects of increasing viscosity on residue, palatability, and treatment compliance. New randomised controlled trials should establish the optimal viscosity level for each phenotype of dysphagic patients and descriptors, terminology and viscosity measurements must be standardised. This white paper is the first step towards the development of a clinical guideline on bolus modification for patients with oropharyngeal dysphagia.

Effect of human saliva on the consistency of thickened drinks for individuals with dysphagia

BACKGROUND

Thickening of foods and fluids is commonly used in the management of dysphagia to reduce the risk of aspiration. The use of starch-based thickeners is established. However, the use of gums in thickeners is gaining interest as they are resistant to salivary amylase, which may promote safer swallowing.

AIMS

To compare the effect of human saliva on the consistency of drinks thickened with a gum-containing (GC) thickener with that of drinks thickened with four starch-based (SB) thickeners.

METHODS & PROCEDURES

Three drinks (artificial tap water, hot coffee and full-fat milk) were thickened to custard consistency with the different thickeners. Compression force and amount of thin liquid formed were determined after 10 and 50 min of contact with human saliva with standardized amylase activity and compared with a control inoculated with water.

OUTCOMES & RESULTS

Drinks thickened with GC thickener were significantly less sensitive to thinning by human saliva compared with drinks thickened with all four SB thickeners (p < 0.05). Moreover, incubation of SB-thickened drinks with human saliva resulted in the formation of at least 10 g of decantable liquid, while for GC-thickened drinks, almost no liquid was formed.

CONCLUSIONS & IMPLICATIONS

These results show that GC thickeners contain their consistency better in contact with human saliva than SD thickeners. This may enhance the swallowing safety of people with dysphagia.

Cutoff value of pharyngeal residue in prognosis prediction after neuromuscular electrical stimulation therapy for Dysphagia in subacute stroke patients

OBJECTIVE

To determine the cutoff value of the pharyngeal residue for predicting reduction of aspiration, by measuring the residue of valleculae and pyriformis sinuses through videofluoroscopic swallowing studies (VFSS) after treatment with neuromuscular electrical stimulator (VitalStim) in stroke patients with dysphagia.

METHODS

VFSS was conducted on first-time stroke patients before and after the VitalStim therapy. The results were analyzed for comparison of the pharyngeal residue in the improved group and the non-improved group.

RESULTS

A total of 59 patients concluded the test, in which 42 patients improved well enough to change the dietary methods while 17 did not improve sufficiently. Remnant area to total area (R/T) ratios of the valleculae before treatment in the improved group were 0.120, 0.177, and 0.101 for solid, soft, and liquid foods, respectively, whereas the ratios for the non-improved group were 0.365, 0.396, and 0.281, respectively. The ratios of the pyriformis sinuses were 0.126, 0.159, and 0.121 for the improved group and 0.315, 0.338, and 0.244 for the non-improved group. The R/T ratios of valleculae and pyriformis sinus were significantly lower in the improved group than the non-improved group in all food types before treatment. The R/T ratio cutoff values were 0.267, 0.250, and 0.185 at valleculae and 0.228, 0.218, and 0.185 at pyriformis sinuses.

CONCLUSION

In dysphagia after stroke, less pharyngeal residue before treatment serves as a factor for predicting greater improvement after VitalStim treatment.

Comparison of different gum-based thickeners using a viscometer and line spread test: a preliminary study

Objective

To compare fluid thickeners composed of starch polysaccharide (STA), guar gum-based polysaccharide (GUA), and xanthan gum-based polysaccharide (XAN) with the use of a viscometer and a line spread test (LST) under various measurement conditions.

Methods

The viscosity of thickened fluid with various concentrations (range, GUA 1%-4%, XAN 1%-6%, STA 1%-7%, at intervals of 1%) was measured with a rotational viscometer with various shear rates (1.29 s^-1, 5.16 s^-1, 51.6 s^-1, and 103 s^-1) at a temperature of 35℃, representing body temperature. The viscosity of STA showed time dependent alteration. So STA was excluded. Viscosities of GUA and XAN (range of concentration, GUA 1%-3%, XAN 1%-6%, at intervals of 1%) were measured at a room temperature of 20℃. LST was conducted to compare GUA and XAN (concentration, 1.5%, 2.0%, and 3.0%) at temperatures of 20℃ and 35℃.

Results

The viscosities of 1% GUA and XAN were similar. However, viscosity differences between GUA and XAN were gradually larger as concentration increased. The shear thinning effect, the inverse relationship between the viscosity and the shear rate, was more predominant in XAN than in GUA. The results of LST were not substantially different from GUA and XAN, in spite of the difference in viscosity. However manufacturers' instructions do not demonstrate the rheological properties of thickeners.

Conclusion

The viscosities of thickened fluid were different when the measurement conditions changed. Any single measurement might not be sufficient to determine comparable viscosity with different thickeners. Clinical decision for the use of a specific thickener seems to necessitate cautious consideration of results from a viscometer, LST, and an expert's opinion.

Guideline clinical nutrition in patients with stroke

Stroke is regularly accompanied by dysphagia and other factors associated with decreased nutritional intake. Dysphagia with aspiration pneumonia and insufficient nutritional intake lead to worse outcome after stroke.

This guideline is the first chapter of the guideline “Clinical Nutrition in Neurology” of the German Society for Clinical Nutrition (DGEM) which itself is one part of a comprehensive guideline about all areas of Clinical Nutrition. The thirty-one recommendations of the guideline are based on a systematic literature search and review, last updated December 31, 2011. All recommendations were discussed and consented at several consensus conferences with the entire DGEM guideline group. The recommendations underline the importance of an early screening and assessment of dysphagia and give advice for an evidence based and comprehensive nutritional management to avoid aspiration, malnutrition and dehydration.

Interventions for dysphagia and nutritional support in acute and subacute stroke

BACKGROUND

Dysphagia (swallowing problems) are common after stroke and can cause chest infection and malnutrition. Dysphagic, and malnourished, stroke patients have a poorer outcome.

OBJECTIVES

To assess the effectiveness of interventions for the treatment of dysphagia (swallowing therapy), and nutritional and fluid supplementation, in patients with acute and subacute (within six months from onset) stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (February 2012), MEDLINE (1966 to July 2011), EMBASE (1980 to July 2011), CINAHL (1982 to July 2011) and Conference Proceedings Citation Index- Science (CPCI-S) (1990 to July 2011). We also searched the reference lists of relevant trials and review articles, searched Current Controlled Trials and contacted researchers (July 2011). For the previous version of this review we contacted the Royal College of Speech and Language Therapists and equipment manufacturers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in dysphagic stroke patients, and nutritional supplementation in all stroke patients, where the stroke occurred within six months of enrolment.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the inclusion criteria, assessed trial quality, and extracted data, and resolved any disagreements through discussion with a third review author. We used random-effects models to calculate odds ratios (OR), 95% confidence intervals (95% CI), and mean differences (MD). The primary outcome was functional outcome (death or dependency, or death or disability) at the end of the trial.

MAIN RESULTS

We included 33 studies involving 6779 participants.Swallowing therapy: acupuncture, drug therapy, neuromuscular electrical stimulation, pharyngeal electrical stimulation, physical stimulation (thermal, tactile), transcranial direct current stimulation, and transcranial magnetic stimulation each had no significant effect on case fatality or combined death or dependency. Dysphagia at end-of-trial was reduced by acupuncture (number of studies (t) = 4, numbers of participants (n) = 256; OR 0.24; 95% CI 0.13 to 0.46; P < 0.0001; I(2) = 0%) and behavioural interventions (t = 5; n = 423; OR 0.52; 95% CI 0.30 to 0.88; P = 0.01; I(2) = 22%). Route of feeding: percutaneous endoscopic gastrostomy (PEG) and nasogastric tube (NGT) feeding did not differ for case fatality or the composite outcome of death or dependency, but PEG was associated with fewer treatment failures (t = 3; n = 72; OR 0.09; 95% CI 0.01 to 0.51; P = 0.007; I(2) = 0%) and gastrointestinal bleeding (t = 1; n = 321; OR 0.25; 95% CI 0.09 to 0.69; P = 0.007), and higher feed delivery (t = 1; n = 30; MD 22.00; 95% CI 16.15 to 27.85; P < 0.00001) and albumin concentration (t = 3; n = 63; MD 4.92 g/L; 95% CI 0.19 to 9.65; P = 0.04; I(2) = 58%). Although looped NGT versus conventional NGT feeding did not differ for end-of-trial case fatality or death or dependency, feed delivery was higher with looped NGT (t = 1; n = 104; MD 18.00%; 95% CI 6.66 to 29.34; P = 0.002). Timing of feeding: there was no difference for case fatality, or death or dependency, with early feeding as compared to late feeding. Fluid supplementation: there was no difference for case fatality, or death or dependency, with fluid supplementation. Nutritional supplementation: there was no difference for case fatality, or death or dependency, with nutritional supplementation. However, nutritional supplementation was associated with reduced pressure sores (t = 2; n = 4125; OR 0.56; 95% CI 0.32 to 0.96; P = 0.03; I(2) = 0%), and, by definition, increased energy intake (t = 3; n = 174; MD 430.18 kcal/day; 95% CI 141.61 to 718.75; P = 0.003; I(2) = 91%) and protein intake (t = 3; n = 174; MD 17.28 g/day; 95% CI 1.99 to 32.56; P = 0.03; I(2) = 92%).

AUTHORS' CONCLUSIONS

There remains insufficient data on the effect of swallowing therapy, feeding, and nutritional and fluid supplementation on functional outcome and death in dysphagic patients with acute or subacute stroke. Behavioural interventions and acupuncture reduced dysphagia, and pharyngeal electrical stimulation reduced pharyngeal transit time. Compared with NGT feeding, PEG reduced treatment failures and gastrointestinal bleeding, and had higher feed delivery and albumin concentration. Nutritional supplementation was associated with reduced pressure sores, and increased energy and protein intake.

Evaluation of the uptake of the Australian standardized terminology and definitions for texture modified foods and fluids

This paper discusses the uptake of standardized terminology and definitions for texture modified foods and fluids. The Australian dietetic and speech-language pathology associations endorsed national standards in 2007. This project sought to determine the barriers and enablers for use of the national standards in clinical practice. Cross-sectional online surveys were developed, including open- and closed-response questions. The surveys targeted different professional groups in Australia including speech-language pathologists, dietitians, nurses, and food service personnel. Australian accredited universities were contacted to determine penetration of the standards. A total of 574 surveys were received. Sixty-five per cent of respondents indicated full implementation, 23% partial implementation, and 10% no implementation of the standards in their workplace. Speech-language pathologists and dietitians were most likely to have championed implementation of the standards. Barriers to implementation included: lack of knowledge about the standards, time, and resistance to change. Enablers included: encouragement to use the standards and 'buy-in' from stakeholders. Benefits of implementation included: consistent terminology and perceived improvements in patient safety. It was concluded that the standards have been successfully implemented in a majority of facilities and Australian universities. This study provides insight into the complexity of introducing and managing change in healthcare environments.