Dysphagia and respiratory care in individuals with tetraplegia: incidence, associated factors, and preventable complications

Evaluation of clinical factors predicting dysphagia in patients with traumatic and non-traumatic cervical spinal cord injury: a retrospective study

Introduction

Dysphagia is a common complication in patients with cervical spinal cord injury (C-SCI) and can cause various pulmonary complications, such as aspiration pneumonia and mechanical airway obstruction increasing mortality and morbidity. This study evaluated the clinical factors that predict dysphagia in patients with traumatic and non-traumatic C-SCI.

Methods

Ninety-eight patients with C-SCI were retrospectively enrolled in this study and were divided into those with and without dysphagia. Clinical factors such as age, sex, tracheostomy, spinal cord independence measure, pulmonary function test (PFT) including forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1) and FVC/FEV1, American Spinal Cord Injury Association score, Berg Balance Scale, and surgical approach were investigated retrospectively.

Results

Multivariate logistic regression analysis revealed that FVC and the presence of tracheostomy were significantly correlated with dysphagia in patients with C-SCI (p < 0.05). FVC and the presence of tracheostomy are useful tools for detecting dysphagia in patients with C-SCI.

Conclusion

Considering the results of our study, early PFTs, especially FVC, in patients with C-SCI and early initiation of dysphagia management and treatment in patients with C-SCI and tracheostomy will be advantageous in lowering the mortality and morbidity due to pulmonary aspiration in these patients.

Incidence and risk factors of pneumonia following acute traumatic cervical spinal cord Injury

OBJECTIVES

To elucidate the incidence and risk factors for pneumonia after acute traumatic cervical spinal cord injury (CSCI).

DESIGN

Retrospective cohort study.Setting: Spinal injuries center in Japan.Participants: Of 184 individuals who were admitted within 2 weeks after acute traumatic cervical spinal injuries, 167 individuals who met the criteria were included in this study.Interventions: The occurrence of pneumonia, degree of dysphagia using the Dysphagia Severity Scale, patient age, history of smoking, presence of tracheostomy, vital capacity, level of injury, and the American Spinal Injury Association Impairment Scale (AIS) 2 weeks after injury were assessed.Outcomes: Incidence of pneumonia were analyzed. Moreover, the risk factors of pneumonia were evaluated using logistic regression analysis.

RESULTS

From the 167 individuals who met the criteria, 30 individuals (18%) had pneumonia; in 26 (87%) of these individuals, pneumonia was aspiration related, defined as Dysphagia Severity Scale ≤ 4. The median occurrence of aspiration pneumonia was 11.5 days after injury. A logistic regression analysis revealed that severe AIS and severe Dysphagia Severity Scale scores were significant risk factors of pneumonia after CSCI.

CONCLUSIONS

It was highly likely that the pneumonias following CSCI were related to aspiration based on the Dysphagia Severity Scale. In addition, most of the patients developed aspiration pneumonia within 1 month after injury. Aspiration and severe paralysis were significant risk factors for pneumonia. The treatment of dysphagia in the acute phase should be considered an important indicator to prevent pneumonia.

Cervical Collars and Dysphagia Among Geriatric TBIs and Cervical Spine Injuries: A Retrospective Cohort Study

INTRODUCTION

Dysphagia, a complication of traumatic brain injuries (TBIs), can lead to death. Cervical collar (c-collar) restriction may increase the risk for dysphagia. The objective was to determine how c-collars affect dysphagia rates.

METHODS

This retrospective cohort study included geriatric TBIs or cervical spine injuries (January 2016 to December 2018) at a Level 1 trauma center. Outcomes (dysphagia, aspiration, and respiratory failure) were compared by c-collar placement.

RESULTS

There were 684 patients: 21.5% had a c-collar and 78.5% did not. Demographics, injury severity score, and Glasgow Coma Scale were comparable. Dysphagia (53.7% vs. 39.3%, p = .002) and respiratory failure (17.0% vs. 6.9%, p = .0002) were more common among patients with c-collars. Aspiration rates (p = .11) were similar. After adjustment, patients with a c-collar had a significantly higher odds of dysphagia and respiratory failure. Among patients who did not receive swallow therapy, aspiration (p = .02) and respiratory failure (p < .0001) were more common for those with c-collars.

CONCLUSIONS

C-collar placement increased the risk for dysphagia and respiratory failure. There was evidence that swallow therapy may modify the effect of c-collar placement. For patients who did not receive swallow therapy, aspiration was more common among those with a c-collar. Dysphagia screening among patients with a c-collar may improve patient quality.

Oropharyngeal Dysphagia in Acute Cervical Spinal Cord Injury: A Literature Review

Dysphagia (swallowing impairment) is a frequent complication of cervical spinal cord injury (cSCI). Recently published national guidance in the UK on rehabilitation after traumatic injury confirmed that people with cSCI are at risk for dysphagia and require early evaluation while remaining nil by mouth [National Institute for Health and Care Excellence. Rehabilitation after traumatic injury (NG211), 2022, https://www.nice.org.uk/guidance/ng21]. While the pathogenesis and pathophysiology of dysphagia in cSCI remains unclear, numerous risk factors have been identified in the literature. This review aims to summarize the literature on the risk factors, presentation, assessment, and management of dysphagia in patients with cSCI. A bespoke approach to dysphagia management, that accounts for the multiple system impairment in cSCI, is presented; the overarching aim of which is to support effective management of dysphagia in patients with cSCI to prevent adverse clinical consequences.

Laryngeal and swallow dysregulation following acute cervical spinal cord injury

Laryngeal function is vital to airway protection. While swallow is mediated by the brainstem, mechanisms underlying increased risk of dysphagia after cervical spinal cord injury (SCI) are unknown. We hypothesized that loss of descending phrenic drive affects swallow and breathing differently, and loss of ascending spinal afferent information alters swallow regulation. We recorded electromyograms from upper airway and chest wall muscles in freely breathing pentobarbital-anesthetized cats and rats. Inspiratory laryngeal activity increased ~two-fold following C2 lateral-hemisection. Ipsilateral to the injury, crural diaphragm EMG amplitude was reduced during breathing (62 ± 25% change post-injury), but no animal had complete termination of activity; 75% of animals increased contralateral diaphragm recruitment, but this did not reach significance. During swallow, laryngeal adductor and pharyngeal constrictor muscles increased activity, and diaphragm activity was bilaterally suppressed. This was unexpected because of the ipsilateral-specific response during breathing. Swallow-breathing coordination was also disrupted and more swallows occurred during early expiration. Finally, to determine if the chest wall is a major source of feedback for laryngeal regulation, we performed T1 total transections in rats. As in the C2 lateral-hemisection, inspiratory laryngeal recruitment was the first feature noted. In contrast to the C2 lateral-hemisection, diaphragmatic drive increased after T1 transection. Overall, we found that SCI alters laryngeal drive during swallow and breathing, and reduced swallow-related diaphragm activity. Our results show behavior-specific effects, suggesting SCI affects swallow more than breathing, and emphasizes the need for additional studies on the effects of ascending afferents from the spinal cord on laryngeal function.

Systematic Review of Incidence Studies of Pneumonia in Persons with Spinal Cord Injury

Pneumonia continues to complicate the course of spinal cord injury (SCI). Currently, clinicians and policy-makers are faced with only limited numbers of pneumonia incidence in the literature. A systematic review of the literature was undertaken to provide an objective synthesis of the evidence about the incidence of pneumonia in persons with SCI. Incidence was calculated per 100 person-days, and meta-regression was used to evaluate the influence of the clinical setting, the level of injury, the use of mechanical ventilation, the presence of tracheostomy, and dysphagia. For the meta-regression we included 19 studies. The incidence ranged from 0.03 to 7.21 patients with pneumonia per 100 days. The main finding of this review is that we found large heterogeneity in the reporting of the incidence, and we therefore should be cautious with interpreting the results. In the multivariable meta-regression, the incidence rate ratios showed very wide confidence intervals, which does not allow a clear conclusion concerning the risk of pneumonia in the different stages after a SCI. Large longitudinal studies with a standardized reporting on risk factors, pneumonia, and detailed time under observation are needed. Nevertheless, this review showed that pneumonia is still a clinically relevant complication and pneumonia prevention should focus on the ICU setting and patients with complete tetraplegia.

Isolated traumatic occipital condyle fractures: Is external cervical orthosis even necessary?

Background:

Occipital condyle fractures (OCFs) have been reported in up to 4–16% of individuals suffering cervical spine trauma. The current management of OCF fractures relies on a rigid cervical collar for 6 weeks or longer. Here, we calculated the rate of acute and delayed surgical intervention (occipitocervical fusion) for patients with isolated OCF who were managed with a cervical collar over a 10-year period at a single institution.

Methods:

This was a retrospective analysis performed on all patients admitted to a Level 1 Trauma Center between 2008 and 2018 who suffered traumatic isolated OCF managed with an external rigid cervical orthosis. Radiographic imaging was reviewed by several board-certified neuroradiologists. Demographic and clinical data were collected including need for occipitocervical fusion within 12 months after trauma.

Results:

The incidence of isolated OCF was 4% (60/1536) for those patients admitted with cervical spine fractures. They averaged 49 years of age, and 58% were male falls accounted for the mechanism of injury in 47% of patients. Classification of OCF was most commonly classified in 47% as type I Anderson and Montesano fractures. Of the 60 patients who suffered isolated OCF that was managed with external cervical orthosis, 0% required occipitocervical fusion within 12 months posttrauma. About 90% were discharged, while the remaining 10% sustained traumatic brain/orthopedic injury that limited an accurate neurological assessment.

Conclusion:

Here, we documented a 4% incidence of isolated OCF in our cervical trauma population, a rate which is comparable to that found in the literature year. Most notably, we documented a 0% incidence for requiring delayed occipital-cervical fusions.

Dysphagia in cervical spinal cord injury: How international literature trends can guide South African practice patterns - A scoping review

Background

The limited data regarding dysphagia in high-level spinal cord injuries (SCIs) stem from economically developed countries. Dysphagia is prevalent in patients with cervical SCI; however, in a South African context, speech-language pathologists (SLPs) are not seen as key when managing this population. This may result in patients not being screened or identified early, leading to possible complications. The literature could provide useful insight on how best to address this clinical gap.

Objectives

The aim of my study was to conduct a scoping review on the description of dysphagia, the risk factors for developing dysphagia post-SCI and the practice patterns of team members working with dysphagia in cervical SCIs.

Methods

A five-step scoping review was undertaken. Data were analysed by using descriptive statistics as well as a thematic analysis by using a top-down approach.

Results

Through the process of screening according to the inclusion and exclusion criteria, 25 articles were included. Primarily, the pharyngeal phase was affected, which can lead to an aspiration pneumonia. The key risk factors were the presence of a tracheostomy tube, the use of ventilation and anterior spinal cord surgery. There was little mention regarding specific practice patterns, but an interdisciplinary approach was suggested as the most efficient model.

Conclusions

Specific guidelines and management options need to be considered for a South African context, given the high incidence of trauma-related injuries. There needs to be locally produced research, providing suggestions on how different team members can screen and identify dysphagia within this population. Solutions need to be unique, and contextually responsive and appropriate.

Clinical implications

The team members and the roles of these different team members need to be re-examined in order to ensure the early identification and management of cervical SCI patients who are at risk of developing a dysphagia.

Translating Dysphagia Evidence into Practice While Avoiding Pitfalls: Assessing Bias Risk in Tracheostomy Literature

Critically ill patients who require a tracheostomy often have dysphagia. Widespread practice guidelines have yet to be developed regarding the acute assessment and management of dysphagia in patients with tracheostomy. In order for clinicians to base their practice on the best available evidence, they must first assess the applicable literature and determine its quality. To inform guideline development, our objective was to assess literature quality concerning swallowing following tracheostomy in acute stages of critical illness in adults. Our systematic literature search (published previously) included eight databases, nine gray literature repositories and citation chasing. Using inclusion criteria determined a priori, two reviewers, blinded to each other, conducted an eligibility review of identified citations. Patients with chronic tracheostomy and etiologies including head and/or neck cancer diagnoses were excluded. Four teams of two reviewers each, blinded to each other, assessed quality of included studies using a modified Cochrane Risk of Bias tool (RoB). Disagreements were resolved by consensus. Data were summarized descriptively according to study design and RoB domain. Of 6,396 identified citations, 74 studies met our inclusion criteria. Of those, 71 were observational and three were randomized controlled trials. Across all studies, the majority (> 75%) had low bias risk with: participant blinding, outcome reporting, and operationally defined outcomes. Areas requiring improvement included assessor and study personnel blinding. Prior to translating the literature into practice guidelines, we recommend attention to study quality limitations and its potential impact on study outcomes. For future work, we suggest an iterative approach to knowledge translation.

Pharyngeal Dysphagia in Individuals With Cervical Spinal Cord Injury: A Prospective Observational Cohort Study

Objectives: To identify and describe the types and time course of dysphagia following cervical spinal cord injury (SCI). Methods: This was a prospective cohort study conducted in an SCI inpatient rehabilitation unit. Seventy-six individuals with SCI were enrolled. Inclusion criteria were age 18 years or older, admitted into SCI inpatient rehabilitation unit, and medically stable for participation in bedside swallow evaluation (BSE) and videofluoroscopic swallow study (VFSS). All participants first underwent a BSE, of whom 33 completed a VFSS. A follow-up BSE was conducted on individuals who tested positive on the initial BSE and continued to show signs of dysphagia. Diagnosis and type of dysphagia as well risk factors were collected. Results: Twenty-three out of 76 individuals with cervical SCI were diagnosed with dysphagia using the BSE. All participants with positive BSE and VFSS had pharyngeal dysfunction. For participants with a positive initial BSE and persisting dysphagia (n = 14), a follow-up BSE demonstrated resolution within 34 days. Risk factors associated with dysphagia were older age, nasogastric tube, invasive mechanical ventilation, tracheostomy, and pneumonia. Posterior spinal surgery was associated with a decreased risk of dysphagia. Conclusion: Dysphagia was present in 30% of individuals based on the initial BSE. All individuals with dysphagia demonstrated pharyngeal phase dysfunction on the VFSS. No participants experiencing dysphagia were missed on the BSE as confirmed by VFSS. In the subset of individuals who received a follow-up BSE, the time course of resolution of dysphagia was at most 34 days from initial BSE.

Investigating Swallowing and Tracheostomy Following Critical Illness: A Scoping Review

OBJECTIVES

Tracheostomy and dysphagia often coexist during critical illness; however, given the patient's medical complexity, understanding the evidence to optimize swallowing assessment and intervention is challenging. The objective of this scoping review is to describe and explore the literature surrounding swallowing and tracheostomy in the acute care setting.

DATA SOURCES

Eight electronic databases were searched from inception to May 2017 inclusive, using a search strategy designed by an information scientist. We conducted manual searching of 10 journals, nine gray literature repositories, and forward and backward citation chasing.

STUDY SELECTION

Two blinded reviewers determined eligibility according to inclusion criteria: English-language studies reporting on swallowing or dysphagia in adults (≥ 17 yr old) who had undergone tracheostomy placement while in acute care. Patients with head and/or neck cancer diagnoses were excluded.

DATA EXTRACTION

We extracted data using a form designed a priori and conducted descriptive analyses.

DATA SYNTHESIS

We identified 6,396 citations, of which 725 articles were reviewed and 85 (N) met inclusion criteria. We stratified studies according to content domains with some featuring in multiple categories: dysphagia frequency (n = 38), swallowing physiology (n = 27), risk factors (n = 31), interventions (n = 21), and assessment comparisons (n = 12) and by patient etiology. Sample sizes (with tracheostomy) ranged from 10 to 3,320, and dysphagia frequency ranged from 11% to 93% in studies with consecutive sampling. Study design, sampling method, assessment methods, and interpretation approach varied significantly across studies.

CONCLUSIONS

The evidence base surrounding this subject is diverse, complicated by heterogeneous patient selection methods, design, and reporting. We suggest ways the evidence base may be developed.

Speech and language therapy for management of chronic cough

BACKGROUND

Cough both protects and clears the airway. Cough has three phases: breathing in (inspiration), closure of the glottis, and a forced expiratory effort. Chronic cough has a negative, far-reaching impact on quality of life. Few effective medical treatments for individuals with unexplained (idiopathic/refractory) chronic cough (UCC) are known. For this group, current guidelines advocate the use of gabapentin. Speech and language therapy (SLT) has been considered as a non-pharmacological option for managing UCC without the risks and side effects associated with pharmacological agents, and this review considers the evidence from randomised controlled trials (RCTs) evaluating the effectiveness of SLT in this context.

OBJECTIVES

To evaluate the effectiveness of speech and language therapy for treatment of people with unexplained (idiopathic/refractory) chronic cough.

SEARCH METHODS

We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, trials registries, and reference lists of included studies. Our most recent search was 8 February 2019.

SELECTION CRITERIA

We included RCTs in which participants had a diagnosis of UCC having undergone a full diagnostic workup to exclude an underlying cause, as per published guidelines or local protocols, and where the intervention included speech and language therapy techniques for UCC.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of 94 records. Two clinical trials, represented in 10 study reports, met our predefined inclusion criteria. Two review authors independently assessed risk of bias for each study and extracted outcome data. We analysed dichotomous data as odds ratios (ORs), and continuous data as mean differences (MDs) or geometric mean differences. We used standard methods recommended by Cochrane. Our primary outcomes were health-related quality of life (HRQoL) and serious adverse events (SAEs).

MAIN RESULTS

We found two studies involving 162 adults that met our inclusion criteria. Neither of the two studies included children. The duration of treatment and length of sessions varied between studies from four sessions delivered weekly, to four sessions over two months. Similarly, length of sessions varied slightly from one 60-minute session and three 45-minute sessions to four 30-minute sessions. The control interventions were healthy lifestyle advice in both studies.One study contributed HRQoL data, using the Leicester Cough Questionnaire (LCQ), and we judged the quality of the evidence to be low using the GRADE approach. Data were reported as between-group difference from baseline to four weeks (MD 1.53, 95% confidence interval (CI) 0.21 to 2.85; participants = 71), revealing a statistically significant benefit for people receiving a physiotherapy and speech and language therapy intervention (PSALTI) versus control. However, the difference between PSALTI and control was not observed between week four and three months. The same study provided information on SAEs, and there were no SAEs in either the PSALTI or control arms. Using the GRADE approach we judged the quality of evidence for this outcome to be low.Data were also available for our prespecified secondary outcomes. In each case data were provided by only one study, therefore there were no opportunities for aggregation; we judged the quality of this evidence to be low for each outcome. A significant difference favouring therapy was demonstrated for: objective cough counts (ratio for mean coughs per hour on treatment was 59% (95% CI 37% to 95%) relative to control; participants = 71); symptom score (MD 9.80, 95% CI 4.50 to 15.10; participants = 87); and clinical improvement as defined by trialists (OR 48.13, 95% CI 13.53 to 171.25; participants = 87). There was no significant difference between therapy and control regarding subjective measures of cough (MD on visual analogue scale of cough severity: -9.72, 95% CI -20.80 to 1.36; participants = 71) and cough reflex sensitivity (capsaicin concentration to induce five coughs: 1.11 (95% CI 0.80 to 1.54; participants = 49) times higher on treatment than on control). One study reported data on adverse events, and there were no adverse events reported in either the therapy or control arms of the study.

AUTHORS' CONCLUSIONS

The paucity of data in this review highlights the need for more controlled trial data examining the efficacy of SLT interventions in the management of UCC. Although a large number of studies were found in the initial search as per protocol, we could include only two studies in the review. In addition, this review highlights that endpoints vary between published studies.The improvements in HRQoL (LCQ) and reduction in 24-hour cough frequency seen with the PSALTI intervention were statistically significant but short-lived, with the between-group difference lasting up to four weeks only. Further studies are required to replicate these findings and to investigate the effects of SLT interventions over time. It is clear that SLT interventions vary between studies. Further research is needed to understand which aspects of SLT interventions are most effective in reducing cough (both objective cough frequency and subjective measures of cough) and improving HRQoL. We consider these endpoints to be clinically important. It is also important for future studies to report information on adverse events.Because of the paucity of data, we can draw no robust conclusions regarding the efficacy of SLT interventions for improving outcomes in unexplained chronic cough. Our review identifies the need for further high-quality research, with comparable endpoints to inform robust conclusions.

Oropharyngeal dysphagia management in cervical spinal cord injury patients: an exploratory survey of variations to care across specialised and non-specialised units

Study design

A multi-centre online survey to staff working in specialised and non-specialised acute units.

Objectives

To identify clinical decisions and practices made for acute cervical spinal cord injury (CSCI) patients with respiratory impairments and oropharyngeal dysphagia.

Settings

All hospital intensive care units in the UK that admit acute cervical spinal cord injury patients.

Methods

Online distribution of a 35-question multiple-choice survey on the clinical management of ventilation, swallowing, nutrition, oral hygiene and communication for CSCI patients, to multi-disciplinary staff based in specialised and non-specialised intensive care units across UK.

Results

Responses were received from 219 staff members based in 92 hospitals. Of the 77 units that admitted CSCI patients, 152 participants worked in non-specialised and 30 in specialised units. Non-specialised unit staff showed variations in clinical decisions for respiratory management compared to specialised units with limited use of vital capacity measures and graduated weaning programme, reliance on coughing to indicate aspiration, inconsistent manipulation of tracheostomy cuffs for speech and swallowing and limited use of instrumental assessments of swallowing. Those in specialised units employed a multi-discplinary approach to clinical management of nutritional needs.

Conclusions

Variation in the clinical management of respiratory impairments and oropharyngeal dysphagia between specialised and non-specialised units have implications for patient outcomes and increase the risk of respiratory complications that impact mortality. The future development of clinical guidance is required to ensure best practice and consistent care across all units.

Long-term experience with diaphragm pacing for traumatic spinal cord injury: Early implantation should be considered

BACKGROUND

Cervical spinal cord injury can result in catastrophic respiratory failure requiring mechanical ventilation with high morbidity, mortality, and cost. Diaphragm pacing was developed to replace/decrease mechanical ventilation. We report the largest long-term results in traumatic cervical spinal cord injury.

METHODS

In this retrospective review of prospective institutional review board protocols, all patients underwent laparoscopic diaphragm mapping and implantation of electrodes for diaphragm strengthening and ventilator weaning.

RESULTS

From 2000 to 2017, 92 patients out of 486 diaphragm pacing implants met the criteria. The age at time of injury ranged from birth to 74 years (average: 27 years). Time on mechanical ventilation was an average of 47.5 months (range, 6 days to 25 years, median = 1.58 years). Eighty-eight percent of patients achieved the minimum of 4 hours of pacing. Fifty-six patients (60.8%) used diaphragm pacing 24 hours a day. Five patients had full recovery of breathing with subsequent diaphragm pacing removal. Median survival was 22.2 years (95% confidence interval: 14.0-not reached) with only 31 deaths. Subgroup analysis revealed that earlier diaphragm pacing implantation leads to greater 24-hour use of diaphragm pacing and no need for any mechanical ventilation.

CONCLUSION

Diaphragm pacing can successfully decrease the need for mechanical ventilation in traumatic cervical spinal cord injury. Earlier implantation should be considered.

Risk factors for dysphagia after a spinal cord injury: a systematic review and meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To determine the risk factors predictive of dysphagia after a spinal cord injury (SCI).

SETTING

None.

METHODS

A comprehensive literature search was performed in five scientific databases for English articles that identified risk factors for dysphagia after a SCI in adult (≥19 years) individuals. Data extracted included: author name, year and country of publication, participant demographics, sample size, study design, method of dysphagia diagnosis, and risk factor percentages. Methodological quality of studies was assessed using the Newcastle-Ottawa Scale. For identified risk factors, risk percentages were transformed into risk ratios (RR) with 95% confidence intervals. Quantitative synthesis was performed for risk factors reported in two or more studies using restricted maximum-likelihood estimator random effects models.

RESULTS

Eleven studies met inclusion criteria of which ten studies were of moderate quality (n = 10). Significant risk factors included: age, injury severity, level of injury, presence of tracheostomy, coughing, voice quality, bronchoscopy need, pneumonia, mechanical ventilation, nasogastric tubes, comorbid injury, and a cervical surgery. Results of the quantitative synthesis indicated that the presence of a tracheostomy posed a threefold greater risk of the development of dysphagia (RR: 3.67); while, cervical surgery posed a 1.3 times greater risk of the development of dysphagia (RR: 1.30).

CONCLUSIONS

Knowledge of these risk factors can be a resource for clinicians in the early diagnosis and appropriate medical management of dysphagia post SCI.

Traumatic cervical spinal cord injury: recovery of penetration/aspiration and functional feeding outcome

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

This prospective cohort study aims to evaluate the recovery of penetration/aspiration and functional feeding outcome in patients with acute TCSCI.

SETTING

Tampere University Hospital, Tampere, Finland METHODS: Forty-six patients with TCSCI were enrolled. All the patients received speech therapeutic interventions based on their clinical needs and were examined with a videofluoroscopic swallowing study (VFSS) at enrollment. The incidence of VFSS-verified laryngeal penetration/aspiration according to Rosenbek's Penetration-Aspiration Scale (PAS) served as the primary outcome. The secondary outcome was the level of functional oral intake (as per the Functional Oral Intake Scale; FOIS). Based on the PAS results, the patients were divided into two groups: (i) penetrator/aspirators (PAS score ≥3) and (ii) non-penetrator/aspirators (PAS score ≤2). Follow-up VFS studies were primarily conducted on the patients with penetration/aspiration in prior VFS studies. The follow-up VFS studies were scheduled on the basis of clinical demand.

RESULTS

Of the 46 patients, 48% had penetration/aspiration in the first VFSS. The second VFSS was conducted on 20 patients, of whom 6 patients (30%) had penetration/aspiration. The third VFSS was conducted on 9 patients. Of these, only two (22%) patients were still penetrator/aspirators. The majority (n = 37, 88%) of the patients presented a total oral intake without restrictions at the time of the final follow-up. Only one patient (2%) was still tube-dependent with consistent oral intake.

CONCLUSION

Swallowing physiology in patients with TCSCI improved during the first months after injury, and the number of penetrator/aspirators decreased progressively.

Risk factors for laryngeal penetration-aspiration in patients with acute traumatic cervical spinal cord injury

BACKGROUND CONTEXT

Laryngeal penetration-aspiration, the entry of material into the airways, is considered the most severe subtype of dysphagia and is common among patients with acute cervical spinal cord injury (SCI).

PURPOSE

The aim of this study was to investigate risk factors for penetration-aspiration in patients with acute traumatic cervical spinal cord injury (TCSCI).

STUDY DESIGN

This is a prospective cohort study.

PATIENT SAMPLE

Thirty-seven patients with TCSCI were included in the study.

OUTCOME MEASURES

The highest Rosenbek penetration-aspiration scale (PAS; range 1-8) score of each patient was the primary outcome measure. The risk factors consisted of patient characteristics, demographics, and clinical signs observed during a clinical swallowing trial.

MATERIALS AND METHODS

A clinical swallowing trial and videofluoroscopic swallowing study (VFSS) was performed on all patients within 28 days post injury. For group comparisons, the patients were divided into two groups: (1) penetrator-aspirators (PAS score ≥3) and (2) non-penetrator-aspirators (PAS score ≤2).

RESULTS

Of the 37 patients, 83.8% were male. The mean age at the time of the injury was 61.2 years. Most patients had an incomplete TCSCI (78.4%) caused by a fall (75.7%). In the VFSS, 51.4% of the patients were penetrator-aspirators, and 71.4% had silent aspiration. The risk factors for predicting penetration-aspiration were (1) necessity of bronchoscopies, (2) lower level of anterior cervical operation, (3) coughing, throat clearing, choking related to swallowing, and (4) changes in voice quality related to swallowing. Binary logistic regression identified coughing, throat clearing, choking, and changes in voice quality related to swallowing as independent risk factors for penetration-aspiration.

CONCLUSIONS

The necessity of bronchoscopies, postinjury lower cervical spine anterior surgery, coughing, throat clearing, choking, and changes in voice quality related to swallowing was a markedrisk factor for aspiration and penetration following a cervical SCI. These factors and signs should be used to suspect injury-related pharyngeal dysfunction and to initiate preventive measures to avoid complications. The clinical swallowing evaluation is a relevant adjunct in the management of these patients and can improve the detection of penetration and aspiration.

Traumatic cervical spinal cord injury: a prospective clinical study of laryngeal penetration and aspiration

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

Dysphagia is a relatively common secondary complication in patients with traumatic cervical spinal cord injuries (TCSCI). The purpose of this study was to determine the incidence of aspiration and penetration in patients with acute TCSCI.

SETTING

Tampere University Hospital, Tampere, Finland.

METHODS

A total of 46 patients with TCSCI were evaluated with a videofluoroscopic swallowing study (VFSS). Rosenbek's penetration-aspiration scale (PAS) was used to classify the degree of penetration or aspiration. The medical records of each patient were systematically reviewed.

RESULTS

Of the 46 patients, 85% were male. The mean age at the time of the injury was 62.1 years. Most patients had an incomplete injury (78%), and most of them due to a fall (78%). In the VFSS 19 (41%) patients penetrated and 15 (33%) aspirated. Only 12 (26%) of the patients had a PAS score of 1 indicating that swallowed material did not enter the airway. Of the patients who aspirated, 73% had silent aspiration.

CONCLUSION

The incidence of penetration or aspiration according to VFSS is high in this cohort of patients with TCSCI. Therefore, the swallowing function of patients with acute TCSCI should be routinely evaluated before initiating oral feeding. VFSS is highly recommended, particularly to rule out the possibility of silent aspiration and to achieve information on safe nutrition consistency.

Respiratory problems and management in people with spinal cord injury

Spinal cord injury (SCI) is characterised by profound respiratory compromise secondary to the level of loss of motor, sensory and autonomic control associated with the injury. This review aims to detail these anatomical and physiological changes after SCI, and outline their impact on respiratory function. Injury-related impairments in strength substantially alter pulmonary mechanics, which in turn affect respiratory management and care. Options for treatments must therefore be considered in light of these limitations.

KEY POINTS

Respiratory impairment following spinal cord injury (SCI) is more severe in high cervical injuries, and is characterised by low lung volumes and a weak cough secondary to respiratory muscle weakness.Autonomic dysfunction and early-onset sleep disordered breathing compound this respiratory compromise.The mainstays of management following acute high cervical SCI are tracheostomy and ventilation, with noninvasive ventilation and assisted coughing techniques being important in lower cervical and thoracic level injuries.Prompt investigation to ascertain the extent of the SCI and associated injuries, and appropriate subsequent management are important to improve outcomes.

EDUCATIONAL AIMS

To describe the anatomical and physiological changes after SCI and their impact on respiratory function.To describe the changes in respiratory mechanics seen in cervical SCI and how these changes affect treatments.To discuss the relationship between injury level and respiratory compromise following SCI, and describe those at increased risk of respiratory complications.To present the current treatment options available and their supporting evidence.

Respiratory Function Under Intrathecal Baclofen Therapy in Patients With Spastic Tetraplegia

OBJECTIVES

Intrathecal baclofen (ITB) therapy is an effective treatment for patients with severe spasticity. However, the effect of ITB therapy on respiratory function has not been reported in detail. In this study we quantitatively analyzed the effects of ITB on the respiratory function of patients with spastic tetraplegia.

METHODS

We retrospectively reviewed 23 patients who were administrated ITB therapy from January 2009 to December 2012. Six of these 23 patients, who had spastic tetraplegia and were able to undergo spirometric testing, were included this study. The spasticity derived from cervical spinal cord injury in four patients and cerebral palsy (CP) in two patients. Patients' Ashworth Scale scores and spirometer measurements obtained before and 1-6 months after the start of ITB therapy were evaluated and compared.

RESULTS

Before ITB therapy, %FVC of all six patients was below 80%, and a restrictive respiratory disorder was diagnosed in five patients and a combined respiratory disorder in one patient. Ashworth Scale scores for both the lower and upper extremities improved significantly with ITB therapy. Forced vital capacity (FVC), %FVC, and forced expiratory volume at one sec also improved significantly with ITB therapy.

CONCLUSIONS

Respiratory disorders were indeed present in our SCI and CP patients with spastic tetraplegia, and the respiratory function of these patients improved with ITB therapy. Our results suggest that ITB therapy is safe and efficacious in patients with spastic tetraplegia and respiratory dysfunction.

A bitter pill to swallow: dysphagia in cervical spine injury

BACKGROUND

Dysphagia is a common complication after cervical spine trauma with spinal cord injury. We sought to characterize the prevalence of dysphagia within a total cervical spinal injury (CSI) population, considering the implications of spinal cord injury status and age on dysphagia development. We hypothesized that while greater rates of dysphagia would be found in geriatric and spinal cord-injured subgroups, all patients presenting with CSI would be at heightened risk for swallowing dysfunction.

METHODS

All trauma admissions to a level II trauma center from January 2010 to April 2014 with CSI were retrospectively reviewed. CSI was classified as any ligamentous or cervical spinous fracture with or without cord injury. Patients failing a formal swallow evaluation were considered dysphagic. The implications of dysphagia development on age and spinal cord injury status were assessed in univariate and multivariate analyses.

RESULTS

A total of 481 patients met study inclusion criteria, of which 123 (26%) developed dysphagia. Within the dysphagic subpopulation, 90 patients (73%) were geriatric, and 23 (19%) sustained spinal cord injury. The dysphagic subpopulation was predominantly free from spinal cord injury (81%). Multivariate analyses found age (adjusted odds ratio: 1.06; 95% confidence interval 1.04-1.07; P < 0.001) and spinal cord injury (adjusted odds ratio: 2.69; 95% confidence interval 1.30-5.56; P = 0.008) to be significant predictors of dysphagia development.

CONCLUSIONS

Despite spinal cord-injured patients being at increased risk for dysphagia, most of the dysphagic subpopulation was free from spinal cord injury. Geriatric and CSI patients with or without cord injury should be at heightened suspicion for dysphagia development.

Dysphagia and associated respiratory considerations in cervical spinal cord injury

BACKGROUND

Dysphagia is a relatively common secondary complication that occurs after acute cervical spinal cord injury (SCI). The detrimental consequences of dysphagia in SCI include transient hypoxemia, chemical pneumonitis, atelectasis, bronchospasm, and pneumonia. The expedient diagnosis of dysphagia is imperative to reduce the risk of the development of life-threatening complications.

OBJECTIVE

The objective of this study was to identify risk factors for dysphagia after SCI and associated respiratory considerations in acute cervical SCI.

METHODS

Bedside swallow evaluation (BSE) was conducted in 68 individuals with acute cervical SCI who were admitted to an SCI specialty unit. Videofluroscopy swallow study was conducted within 72 hours of BSE when possible.

RESULTS

This prospective study found dysphagia in 30.9% (21 out of 68) of individuals with acute cervical SCI. Tracheostomy (P = .028), ventilator use (P = .012), and nasogastric tube (P = .049) were found to be significant associated factors for dysphagia. Furthermore, individuals with dysphagia had statistically higher occurrences of pneumonia when compared with persons without dysphagia (P < .001). There was also a trend for individuals with dysphagia to have longer length of stay (P = .087).

CONCLUSION

The role of respiratory care practitioners in the care of individuals with SCI who have dysphagia needs to be recognized. Aggressive respiratory care enables individuals with potential dysphagia to be evaluated by a speech pathologist in a timely manner. Early evaluation and intervention for dysphagia could decrease morbidity and improve overall clinical outcomes.

Specialized respiratory management for acute cervical spinal cord injury:: a retrospective analysis

BACKGROUND

In individuals with cervical spinal cord injury (SCI), respiratory complications arise within hours to days of injury. Paralysis of the respiratory muscles predisposes the patient toward respiratory failure. Respiratory complications after cervical SCI include hypoventilation, hypercapnea, reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Ultimately, the patient must use increased work to breathe, which results in respiratory fatigue and may eventually require intubation for mechanical ventilation. Without specialized respiratory management for individuals with tetraplegia, recurrent pneumonias, bronchoscopies, and difficulty in maintaining a stable respiratory status will persist.

OBJECTIVE

This retrospective analysis examined the effectiveness of specialized respiratory management utilized in a regional SCI center.

METHODS

Individuals with C1-C4 SCI (N = 24) were the focus of this study as these neurological levels present with the most complicated respiratory status.

RESULTS

All of the study patients' respiratory status improved with the specialized respiratory management administered in the SCI specialty unit. For a majority of these patients, respiratory improvements were noted within 1 week of admission to our SCI unit.

CONCLUSION

Utilization of high tidal volume ventilation, high frequency percussive ventilation, and mechanical insufflation- exsufflation have demonstrated efficacy in stabilizing the respiratory status of these individuals. Optimizing respiratory status enables the patients to participate in rehabilitation therapies, allows for the opportunity to vocalize, and results in fewer days on mechanical ventilation for patients who are weanable.