Identification of risk groups for oropharyngeal dysphagia in hospitalized patients in a university hospital

Profile of oropharyngeal dysphagia patients in a teaching hospital in Northern Brazil: a descriptive cross-sectional study

OBJECTIVE

The aim of this study was to describe the profile of patients with oropharyngeal dysphagia in a teaching hospital in the public health system in northern Brazil.

METHODS

This is a descriptive cross-sectional study. All procedures of this study were approved by the ethics committee. A convenience sample composed of participants aged >18 years, of both sexes, with any underlying pathology admitted to the medical clinic on exclusive oral feeding, alternatively enteral or gastric tube feeding (Gastrostomy), or associated by both routes, whose swallowing assessment was performed by a Speech-Language Pathologist. Data from the database/medical records were investigated from March 2020 to September 2021.

RESULTS

The sample consisted of 44 patients diagnosed with oropharyngeal dysphagia, with a higher frequency of males (63.64%) aged over 60 years (70.45%). Almost half of the evaluated patients were diagnosed with neurological disorders (47.73%) and had dysphagia associated with other underlying diseases (31.82%). Excluding patients with neurological disorders, trauma/polytrauma, and respiratory disorders from the last group, some patients (11.36%) had two concomitant underlying diseases.

CONCLUSION

According to the sample of this study, the profile of oropharyngeal dysphagia patients includes pneumonia, respiratory failure, bronchoaspiration, and the consequent need for ventilatory support.

Effects of Sequential Bilateral Cochlear Implantation in Children: Evidence from Speech-Evoked Cortical Potentials and Tests of Speech Perception

INTRODUCTION

Benefits of bilateral cochlear implants (CI) may be compromised by delays to implantation of either ear. This study aimed to evaluate the effects of sequential bilateral CI use in children who received their first CI at young ages, using a clinical set-up.

METHODS

One-channel cortical auditory evoked potentials and speech perception in quiet and noise were evoked at repeated times (0, 3, 6, 12 months of bilateral CI use) by unilateral and bilateral stimulation in 28 children with early-onset deafness. These children were unilaterally implanted before 3.69 years of age (mean ± SD of 1.98 ± 0.73 years) and received a second CI after 5.13 ± 2.37 years of unilateral CI use. Comparisons between unilaterally evoked responses were used to measure asymmetric function between the ears and comparisons between bilateral responses and each unilateral response were used to measure the bilateral benefit.

RESULTS

Chronic bilateral CI promoted changes in cortical auditory responses and speech perception performance; however, large asymmetries were present between the two unilateral responses despite ongoing bilateral CI use. Persistent cortical differences between the two sides at 1 year of bilateral stimulation were predicted by increasing age at the first surgery and inter-implant delay. Larger asymmetries in speech perception occurred with longer inter-implant delays. Bilateral responses were more similar to the unilateral responses from the first rather than the second CI.

CONCLUSION

These findings are consistent with the development of the aural preference syndrome and reinforce the importance of providing bilateral CIs simultaneously or sequentially with very short delays.

Quality-of-life self-assessment, risk of dysphagia, and swallowing disorders in COVID-19 inpatients

ABSTRACT Purpose: to identify the impact of swallowing changes and dysphagia complaints on quality-of-life and eating self-assessments of COVID-19 inpatients. Methods: the study comprised 54 COVID-19 inpatients above 18 years old, whose swallowing was clinically assessed by a speech-language-hearing therapist. They were classified regarding food intake (with the FOIS scale) and degree of dysphagia. They also filled out a sample characterization questionnaire and the SWAL-QOL and EAT-10 protocols. Results: the respiratory condition led to worse quality-of-life self-assessment Fatigue results, oral food intake and dysphagia severity classifications. Females had worse quality-of-life self-assessment Burden and Food selection scores. Swallowing complaints were associated with worse eating self-assessments. Patients at risk of dysphagia had worse quality-of-life self-assessments in five out of the 11 domains, worse oral food intake levels, and worse dysphagia severity. Conclusion: COVID-19 inpatients commonly have swallowing complaints and are at risk of dysphagia, with worse quality-of-life self-assessment, lower oral food intake classification, and worse dysphagia severity rating.

Autoavaliação da qualidade de vida, risco para disfagia e alteração de deglutição em pacientes internados com COVID-19

RESUMO Objetivos: identificar o impacto de alterações na deglutição e queixa de disfagia na autoavaliação da qualidade de vida e na autoavaliação da alimentação de pacientes internados com COVID-19. Métodos: participaram do estudo 54 indivíduos acima de 18 anos com COVID-19 internados, submetidos à avaliação clínica da deglutição por fonoaudiólogo, classificados em relação à ingestão alimentar pela escala FOIS e grau da disfagia, que preencheram um questionário de caracterização da amostra e os protocolos SWAL-QOL e EAT-10. Resultados: a condição respiratória determinou piores resultados na autoavaliação da qualidade de vida no domínio Fadiga, na definição da ingesta de alimentos via oral e na classificação da gravidade da disfagia. Indivíduos do gênero feminino apresentaram pior autoavaliação da qualidade de vida nos domínios Deglutição como um fardo e Seleção do alimento. Houve associação entre queixa de deglutição e pior autoavaliação da alimentação. Pacientes em risco para disfagia apresentaram pior autoavaliação da qualidade de vida em cinco dos 11 domínios, pior nível de ingesta de alimentos via oral e pior gravidade da disfagia. Conclusão: pacientes internados com COVID-19 comumente apresentam queixas de deglutição e encontram-se em risco para disfagia, apresentando pior autoavaliação da qualidade de vida, menor nível em classificação da escala de ingesta de alimentos via oral e pior classificação da gravidade da disfagia.

Relationship of pharyngeal transition time and presence of residue with dyspnea and lung function in chronic obstructive pulmonary disease

PURPOSE

To relate pharyngeal transit time and the presence of residues with dyspnea and lung function in individuals with Chronic Obstructive Pulmonary Disease COPD.

METHODS

Study conducted with 19 adults (11 men, 8 women) with a clinical and spirometric diagnosis of COPD and a mean age of 63.8 years (SD = 9.3). Data collection was performed using the COPD Assessment Test (CAT) questionnaire, the modified Medical Research Council scale (mMRC) and a digital manovacuometer, to characterize the impact of the disease on the individual, dyspnea and lung function. The data related to pharyngeal transit time and pharyngeal residue were collected through the analysis of videofluoroscopic images performed by three blinded judges.

RESULTS

No significant relationship was found between pharyngeal transit time (PTT) with lung function (r = -0.71), pharyngeal residue and dyspnea (r = -0.06). PTT, when compared to normality, was increased.

CONCLUSION

Individuals with COPD, regardless of the severity of the disease, showed no association between PTT and pharyngeal residue and dyspnea and lung function.

Outcomes of manual therapy on the biomechanics of swallowing in individuals with COPD

PURPOSE

Several swallowing disorders have been reported in chronic obstructive pulmonary disease (COPD) patients due to the mechanical disadvantage of the respiratory muscles caused by hyperinflation. To date, no reports have been found in the literature among the therapeutic strategies on the use of manual therapy (MT) to manage swallowing disorders in COPD. The aim of the study was to verify the outcomes of a TM program on the biomechanics of swallowing of individuals with COPD.

METHODS

18 individuals with a mean age of 66.06 ± 8.86 years, 61.1% (11) men, and a FEV1% mean of 40.28 ± 16.73 were evaluated before and after TM. The measures analyzed were: oral transit time, pharyngeal transit time (PTT), number of swallows, vallecular (VL) residue and pyriform sinuses, penetration/aspiration and hyolaryngeal excursion in liquid and pasty consistencies.

RESULTS

A significant difference was found in PTT (p=0.04), VL residue (p=0.03), maximal hyoid elevation (p=0.003), and displacement of hyoid (p=0.02) in the pasty consistency. In the liquid consistency, we found a decrease in VL residue (p=0.001).

CONCLUSION

The MT program influenced the swallowing biomechanics of COPD patients demonstrated by a reduction in PTT and VL residue and increased hyoid elevation and displacement in the pasty consistency. In the liquid consistency, a decrease in VL residue was found.

Tube feeding predictors after ischemic hemispheric stroke during hospitalization

PURPOSE

To verify the factors associated with the need of tube feeding (TF) during patients post-ischemic stroke hospitalization.

METHOD

This is a retrospective study with 70 adult post-ischemic hemispheric stroke adult patients hospitalized in the Neurology department at a tertiary public hospital in Santa Catarina, Brazil. We investigated associations between the need of a feeding tube during hospitalization and the variables age, gender, admission and discharge NIHSS and FOIS, length of hospital stay in days, presence of thrombolytic therapy, extensive stroke, hemisphere affected, prior stroke, pneumonia during hospitalization, presence of signs of laryngeal penetration and laryngotracheal aspiration and dysphagia in the first and last swallowing clinical evaluation.

RESULTS

A total of 33 participants used tube feeding. There was a significant relationship among tube feeding and the following parameters: NIHSS (p value .001), FOIS (p value .001), extensive stroke (p value .034), left hemisphere involvement (p value .035), pneumonia during hospitalization (p value .001), length of hospital stay in days (p value .001), signs of laryngotracheal penetration/aspiration (p value .001) and dysphagia in speech-language assessment (p value .001).

CONCLUSION

Tube feeding during patients hospitalization after ischemic hemispheric stroke was predicted by the severity of stroke and signs of airway permeation.Key pointsSwallowing difficulty is one of the most common post-stroke consequences.There are few studies on the characterization of post-stroke patients with tube feeding.Tube feeding after ischemic stroke predictors were severity of stroke and signs of airway permeation.

Better Medicines for Older Patients: Considerations between Patient Characteristics and Solid Oral Dosage Form Designs to Improve Swallowing Experience

Oral drug administration provided as solid oral dosage forms (SODF) remains the major route of drug therapy in primary and secondary care. There is clear evidence for a growing number of clinically relevant swallowing issues (e.g., dysphagia) in the older patient population, especially when considering the multimorbid, frail, and polymedicated patients. Swallowing impairments have a negative impact on SODF administration, which leads to poor adherence and inappropriate alterations (e.g., crushing, splitting). Different strategies have been proposed over the years in order to enhance the swallowing experience with SODF, by using conventional administration techniques or applying swallowing aids and devices. Nevertheless, new formulation designs must be considered by implementing a patient centric approach in order to efficiently improve SODF administration by older patient populations. Together with appropriate SODF size reductions, innovative film coating materials that can be applied to SODF and provide swallowing safety and efficacy with little effort being required by the patients are still needed. With that in mind, a literature review was conducted in order to identify the availability of patient centric coating materials claiming to shorten esophageal transit times and improve the overall SODF swallowing experience for older patients. The majority of coating technologies were identified in patent applications, and they mainly included well-known water soluble polymers that are commonly applied into pharmaceutical coatings. Nevertheless, scientific evidence demonstrating the benefits of given SODF coating materials in the concerned patient populations are still very limited. Consequently, the availability for safe, effective, and clinically proven solutions to address the increasing prevalence of swallowing issues in the older patient population is still limited.

Sensitivity and Specificity of Bedside Screening Tests for Detection of Aspiration in Patients Admitted to a Public Rehabilitation Hospital

Early detection of dysphagia and specifically aspiration is essential to prevent and reduce complications of hospitalized patients in rehabilitation centers. Bedside screening test are often used to evaluate swallowing disorders, but their results may be questionable due to insufficient and inconsistent sensitivity and specificity. To compare the sensitivity and specificity of various bedside screening tests for detecting aspiration in hospitalized rehabilitation patients. A prospective observational study was performed in 150 consecutive patients of a tertiary rehabilitation hospital. Patients were evaluated regarding clinical predictors for aspiration, maximum phonation time (MPT), Eating Assessment Tool 10 (EAT-10) questionnaire, tongue strength and endurance (Iowa Oral Performance Instrument [IOPI]) and a swallowing test (Volume-Viscosity Swallow Test [V-VST]). Flexible Endoscopic Evaluation of Swallowing (FEES) was the reference test. Of the 144 patients included, 22% aspirated on FEES. Previous history of pneumonia, dysarthria, wet voice, and abnormal cough reflex were significantly associated with aspiration. The sensitivity, specificity and accuracy for V-VST (83.3%, 72.6%, 74.8%, respectively) and EAT-10 (82.8%, 57.7%, 62.8%, respectively) to detect aspiration were superior than those of other methods. Maximum tongue strength on IOPI and MPT presented high sensitivity but low specificity to detect aspiration. Clinical predictors of aspiration (previous history of pneumonia, dysarthria, wet voice, and abnormal cough reflex) associated with either V-VST or EAT-10 may be good screening methods to detect aspiration in patients hospitalized in a rehabilitation center.

Changes in P1 latencies of children with normal hearing and those with cochlear implants

Background/aim

The aim of this study was to determine the age-related latency interval of P1 latencies of children with normal hearing, and to evaluate the P1 latency changes after surgery in children who underwent cochlear implantation.

Materials and methods

We evaluated 60 children with normal hearing and 16 children with cochlear implants aged 0–6 years using cortical auditory evoked potentials. P1 latencies were measured only once in the children with normal hearing, and on the postoperative first day, and the first, third, and sixth postoperative months in the children with cochlear implants.

Results

There was a statistically significant decrease in the P1 latencies as the age increased in children with normal hearing (P < 0.001). It was determined that when the external partof the cochlear implant was applied, the P1 latencies of children with cochlear implants were significantly longer than those of age-matched children with normal hearing (P < 0.001). This difference disappeared in 10 children with implants at the third and sixth months, but significant differences remained in 6 children.

Conclusion

P1 latency could be used as an objective tool to evaluate the normal development of auditory pathways, and may be helpful in the effective programming of children undergoing cochlear implantation.

Cortical Auditory Evoked Potentials in 2-Year-Old Subjects

Introduction  Cortical auditory evoked potentials (CAEPs) can be used to evaluate both peripheral and cortical components of auditory function, and contribute to the assessment of functional sensitivity and auditory thresholds, especially in neonates and infants. Auditory evoked potentials reflect auditory maturity and precede the acquisition of more complex auditory and cognitive skills, and are therefore crucial for speech and language development.

Objective  The aim of the present study was to determine the presence, latency and amplitude of CAEP components in response to verbal stimuli in children aged 2 years old.

Methods  The sample consisted of 19 subjects, 10 of whom were male while 9 were female. All of the participants were 24 months old at the time of assessment.

Results  A total of 17 of the participants displayed all components of the CAEP. Additionally, no significant differences were observed between genders or ears in the present sample. The presence of all components of the CAEP in subjects aged 2 years old confirms the existence of a critical period for the maturation of auditory pathways in the first 2 years of life.

Conclusion  In the present study, in addition to the P1/N1 components, it was possible to observe the presence of the CAEP P2/N2 components in individuals aged 24 months, confirming the existence of a critical period for the maturation of the auditory pathways in the first 2 years of life.

The importance of dysphagia screening and nutritional assessment in hospitalized patients

OBJECTIVE

To determine frequency of dysphagia risk and associated factors in hospitalized patients as well as to evaluate nutritional status by using different methods and correlate the status with scores of the Eating Assessment Tool (EAT-10).

METHODS

This was a cross-sectional study including 909 inpatients of a philanthropic hospital. For the diagnosis of dysphagia we used an adapted and validated Brazilian version of the Eating Assessment Tool (EAT-10). The nutritional status was evaluated through the subjective global assessment, and anthropometric measurements included weight, calf and arm circumference, and knee height. The Mann-Whitney test, associations using the Pearson's χ2 and Spearman's correlation were used to verify differences between the groups.

RESULTS

The prevalence of dysphagia risk was 10.5%, and aging was the associated factor with this condition. Patients at risk presented lower values of arm and calf circumference, variables that correlated inversely with the Eating Assessment Tool (EAT-10) score. Malnutrition was observed in 13.2% of patients based on the subjective global assessment and in 15.2% based on the Body Mass Index.

CONCLUSION

Screening for dysphagia and malnutrition should be introduced in hospitals routine to avoid or minimize damages caused by dysphagia or malnutrition, especially among older people.

Cortical maturation in children with cochlear implants: Correlation between electrophysiological and behavioral measurement

Central auditory pathway maturation in children depends on auditory sensory stimulation. The objective of the present study was to monitor the cortical maturation of children with cochlear implants using electrophysiological and auditory skills measurements. The study was longitudinal and consisted of 30 subjects, 15 (8 girls and 7 boys) of whom had a cochlear implant, with a mean age at activation time of 36.4 months (minimum, 17 months; maximum, 66 months), and 15 of whom were normal-hearing children who were matched based on gender and chronological age. The auditory and speech skills of the children with cochlear implants were evaluated using GASP, IT-MAIS and MUSS measures. Both groups underwent electrophysiological evaluation using long-latency auditory evoked potentials. Each child was evaluated at three and nine months after cochlear implant activation, with the same time interval adopted for the hearing children. The results showed improvements in auditory and speech skills as measured by IT-MAIS and MUSS. Similarly, the long-latency auditory evoked potential evaluation revealed a decrease in P1 component latency; however, the latency remained significantly longer than that of the hearing children, even after nine months of cochlear implant use. It was observed that a shorter P1 latency corresponded to more evident development of auditory skills. Regarding auditory behavior, it was observed that children who could master the auditory skill of discrimination showed better results in other evaluations, both behavioral and electrophysiological, than those who had mastered only the speech-detection skill. Therefore, cochlear implant auditory stimulation facilitated auditory pathway maturation, which decreased the latency of the P1 component and advanced the development of auditory and speech skills. The analysis of the long-latency auditory evoked potentials revealed that the P1 component was an important biomarker of auditory development during the rehabilitation process.

Pharyngeal Residue and Aspiration and the Relationship with Clinical/Nutritional Status of Patients with Oropharyngeal Dysphagia Submitted to Videofluoroscopy

OBJECTIVES

The aim of this study was to investigate the association between the videofluoroscopic (VFS) signs of impaired efficacy (pharyngeal residue) and safety (aspiration) swallowing and the clinical/nutritional status of patients with suspect of dysphagia.

DESIGN

A cross-sectional study was conducted with patients submitted to videofluoroscopy.

SETTING AND PARTICIPANTS

Data of 76 patients were analyzed between March 2011 and December 2014.

MEASUREMENTS

The clinical history and VFS exams of patients ≥ 38 years were retrospectively analyzed.

RESULTS

88% patients presented Oropharyngeal Dysphagia (OD), 44.7% presented laryngeal penetration and 32% presented aspiration. 78% patients presented pharyngeal residue. Aspiration was associated with Head Neck Cancer (HNC) [Prevalence Ratio (PR): 2.27, p = 0.028] and cardiovascular disease (PR 1.96, p = 0.027). Underweight [Body Mass Index < 18.5 kg/m2] was not associated with the presence of aspiration. Underweight patients with OD had a higher prevalence rate of pharyngeal residue than those normally nourished (100% vs. 78%) (PR 1.34, p = 0.011). Pharyngeal residue was associated with male sex (PR 1.32, p = 0.040), neurodegenerative disease (PR 1.57, p = 0.021), stroke (PR 1.62, p = 0.009), cerebral palsy (PR 1.76, p = 0.006) and HNC (PR 1.73, p = 0.002).

CONCLUSION

In the present study, neurologic diseases, HNC, male sex and underweight were associated to impaired swallowing efficacy. Underweight, independently of the other variables, was not associated with impaired swallowing safety.

Cognitive Dysfunction and Malnutrition Are Independent Predictor of Dysphagia in Patients with Acute Exacerbation of Congestive Heart Failure

Early detection and intervention for dysphagia is important in patients with congestive heart failure (CHF). However, previous studies have focused on how many patients with dysphagia develop CHF. Studies focusing on the comorbidity of dysphagia in patients with CHF are rare. Additionally, risk factors for dysphagia in patients with CHF are unclear. Thus, the aim of this study was to clarify risk factors for dysphagia in patients with acute exacerbation of CHF. A total of 105 patients, who were admitted with acute exacerbation of CHF, were enrolled. Clinical interviews, blood chemistry analysis, electrocardiography, echocardiography, Mini-Mental State Examination (MMSE), exercise tolerance tests, phonatory function tests, and evaluation of activities of daily living (ADL) and nutrition were conducted on admission. After attending physicians permitted the drinking of water, swallowing screening tests were performed. Patients were divided into a dysphagia group (DG) or a non-dysphagia group (non-DG) based on Functional Oral Intake Scale level. Among the 105 patients, 38 had dysphagia. A greater number of patients had history of aspiration pneumonia and dementia, and there was a higher age, N-terminal pro-B-type natriuretic peptide level in the DG compared with the non-DG. MMSE scores, exercise tolerance, phonatory function, status of ADL, nutrition, albumin, and transthyretin were lower in the DG compared with the non-DG. In multivariate analysis, after adjusting for age and sex, MMSE, BI score, and transthyretin was independently associated with dysphagia. Comorbidity of dysphagia was 36.1% in patients with acute exacerbation of CHF, and cognitive dysfunction and malnutrition may be an independent predictor of dysphagia.

Swallowing function and chronic respiratory diseases: Systematic review

BACKGROUND

The precise coordination between breathing and swallowing is an important mechanism to prevent pulmonary aspiration. Factors that alter breathing patterns and ventilation, such as chronic respiratory diseases, may influence that precise coordination of breathing and swallowing.

PURPOSE

The purpose of this systematic literature review is to examine the effects of chronic respiratory diseases on swallowing function.

METHOD

Literature searches were performed using the electronic databases PubMed and Embase. All articles meeting the eligibility criteria up to March 2016 were included.

RESULTS

All articles included studied Chronic Obstructive Pulmonary Diseases (COPD) or Obstructive Sleep Apnea (OSA); no studies involving other respiratory diseases were found. A total of 1069 abstracts were retrieved, of which twenty-six studies met the inclusion criteria; eleven studies dealt with OSA and fifteen studies dealt with COPD.

CONCLUSION

The outcome data indicate that chronic respiratory diseases increase the prevalence of oropharyngeal dysphagia (OD) in patients. However, the relative small number of studies, differences in selection criteria, definitions and assessment techniques used for diagnosing OSA, COPD, and OD point to the need for further research.

Auditory Cortical Maturation in a Child with Cochlear Implant: Analysis of Electrophysiological and Behavioral Measures

The purpose of this study was to longitudinally assess the behavioral and electrophysiological hearing changes of a girl inserted in a CI program, who had bilateral profound sensorineural hearing loss and underwent surgery of cochlear implantation with electrode activation at 21 months of age. She was evaluated using the P1 component of Long Latency Auditory Evoked Potential (LLAEP); speech perception tests of the Glendonald Auditory Screening Procedure (GASP); Infant Toddler Meaningful Auditory Integration Scale (IT-MAIS); and Meaningful Use of Speech Scales (MUSS). The study was conducted prior to activation and after three, nine, and 18 months of cochlear implant activation. The results of the LLAEP were compared with data from a hearing child matched by gender and chronological age. The results of the LLAEP of the child with cochlear implant showed gradual decrease in latency of the P1 component after auditory stimulation (172 ms–134 ms). In the GASP, IT-MAIS, and MUSS, gradual development of listening skills and oral language was observed. The values of the LLAEP of the hearing child were expected for chronological age (132 ms–128 ms). The use of different clinical instruments allow a better understanding of the auditory habilitation and rehabilitation process via CI.

Speech processing in children with cochlear implant

Cochlear implants (CIs) can be used effectively in the profoundly impaired children individuals.

OBJECTIVES

This work was designed to assess speech processing at brainstem and cortical level in children fitted with CIs to investigate the possible influence of brainstem processing of speech on the cortical processing in those children.

METHOD

Twenty children fitted with CIs underwent aided sound-field audiologic evaluation, speech evoked cortical auditory evoked potentials (S-CAEPs) and according to the results, children were classified into two groups: group I with good cortical response and group II with poor cortical response. This was followed by speech evoked ABR (S-ABR) recoding.

RESULTS

P1 component of CAEPs was recorded in all children while other component showed variable results. S-ABR was recorded in all children even those with poor S-CAEPs response who showed delayed D, E, F and O latencies. However, S-ABR amplitudes did not show any significant difference between both groups.

CONCLUSIONS

Children fitted with CI showed immediate cortical activation following device programming and this activity depends on the age of implantation as well as the child's age. S-ABR provides a new clinical tool that showed an important role of brainstem in complex sound processing that contribute to cortical processing.