Videofluoroscopy of swallowing abnormalities in 22 symptomatic patients after cardiovascular surgery

Long-Lasting Dysphagia Developing After Thoracotomy for Pulmonary Resection: a Case Series

The purpose of this study was to retrospectively evaluate the severity and the characteristics of dysphagia using videofluoroscopic swallowing studies (VFSS) in long-lasting dysphagia patients developing after thoracotomy performed for pulmonary resection. Eleven patients (10 men and 1 woman, average age 67 ± 6.6 years; the average operation time in the patients was 507 min) were selected from among patients who developed dysphagia after undergoing thoracotomy for pulmonary resection between January 2009 and December 2012. The videofluoroscopic dysphagia scale (VDS) at 1 month postoperatively was used as a representative of parameters examined by the VFSS. The score on the functional oral intake scale (FOIS) was determined to evaluate the swallowing capacity at 1 and 3 months postoperatively. Most of the patients showed improvement of FOIS score at 3 months postoperatively. The patients showed mainly pharyngeal dysfunction. In spite of preserving the swallowing reflex, abnormalities of the residue in the vallecula and pyriform sinus and penetration were relatively frequent. Perioperative factors (age, %VC, FEV_1.0 %, operation time, length of ICU stay) and FOIS were investigated to determine their relationships with the VDS score. While it showed no relationship with the age, lung function, operation time, and length of ICU stay, the VDS score was found to be significantly associated with the FOIS score at 3 months postoperatively. Evaluation by VFSS after lung surgery is useful to predict the prognosis of swallowing difficulty.

The feasibility of assessing swallowing physiology following prolonged intubation after cardiovascular surgery

Background

Dysphagia following prolonged intubation after cardiovascular (CV) surgery is common occurring in 67% of patients; however, this population’s swallowing physiology has never been prospectively evaluated using standardized methods. Hence, prior to conducting a larger study, our primary objective was to determine the feasibility of assessing swallowing physiology using instrumentation and validated interpretation methods in cardiovascular surgical patients following prolonged intubation.

Method

From July to October 2011, we approached adults undergoing CV surgery at our institution who were intubated > 48 h. Those with a tracheostomy were excluded. Videofluoroscopic swallowing study (VFS) and nasendoscopy were completed within 48 h after extubation. Feasibility measurements included recruitment rate, patient participation, task completion durations, and the inter-rater reliability of VFS measures using the intraclass correlation coefficient (ICC). VFSs were interpreted using perceptual rating tools (Modified Barium Swallow Measurement Tool for Swallow Impairment™^© and Penetration Aspiration Scale) and objective displacement measurements (hyoid displacement and pharyngeal constriction ratio).

Results

Of the 39 patients intubated > 48 h, 16 met inclusion criteria with three enrolled and completing the VFS. All refused nasendoscopy. Across all VFSs, rating completion time ranged from 14.6 to 51.7 min per patient with ICCs for VFS scales ranging from 0.25 (95% CI − 0.10 to 0.59) to 0.99 (95% CI 0.98 to 0.99).

Conclusions

This study design was not feasible as recruitment was slow, few patients participated, and no patient agreed to all procedures. We discuss necessary methodological changes and lessons learned that would generalize to future research.

Dysphagia and associated risk factors following extubation in cardiovascular surgical patients

Following cardiovascular (CV) surgery, prolonged mechanical ventilation of >48 h increases dysphagia frequency over tenfold: 51 % compared to 3-4 % across all durations. Our primary objective was to identify dysphagia frequency following CV surgery with respect to intubation duration. Our secondary objective was to explore characteristics associated with dysphagia across the entire sample. Using a retrospective design, we stratified all consecutive patients who underwent CV surgery in 2009 at our institution into intubation duration groups defined a priori: I (≤ 12 h), II (>12 to ≤ 24 h), III (>24 to ≤ 48 h), and IV (>48 h). Eligible patients were >18 years old who survived extubation following coronary artery bypass alone or cardiac valve surgery. Patients who underwent tracheotomy were excluded. Pre-, peri-, and postoperative patient variables were extracted from a pre-existing database and medical charts by two blinded reviewers. Disagreements were resolved by consensus. Across the entire sample, multivariable logistic regression analysis determined independent predictors of dysphagia. Across the entire sample, dysphagia frequency was 5.6 % (51/909) but varied by group: I, 1 % (7/699); II, 8.2 % (11/134); III, 16.7 % (6/36); and IV, 67.5 % (27/40). Across the entire sample, the independent predictors of dysphagia included intubation duration in 12-h increments (p < 0.001; odds ratio [OR] 1.93, 95 % confidence interval [CI] 1.63-2.29) and age in 10-year increments (p = 0.004; OR 2.12, 95 % CI 1.27-3.52). Patients had a twofold increase in their odds of developing dysphagia for every additional 12 h with endotracheal intubation and for every additional decade in age. These patients should undergo post-extubation swallow assessments to minimize complications.

Digital cineradiographic study of swallowing in patients with amyotrophic lateral sclerosis

PURPOSE

This study was performed to evaluate the usefulness of digital cineradiography in detecting swallowing disorders in dysphagic patients affected by amyotrophic lateral sclerosis (ALS) with a view to planning an adequate therapeutic approach.

MATERIAL AND METHODS

From January 2005 to September 2006, 23 patients (10 men and 13 women; mean age 41.3+/-8.6 years) affected by ALS were evaluated with digital cineradiography to assess the grade of dysphagia. All patients were classified using the Hillel ALS Severity Scale (ALSSS). All examinations were performed with radiocontrolled equipment provided with a digital C-arm.

RESULTS

The cineradiographic technique enabled us to differentiate patients with disorders of the oral (17/23) and/or pharyngeal (19/23) swallowing phase from those without swallowing dysfunction (4/23). In 14/23 patients, passage of contrast medium into the upper airways was observed during swallowing, whereas in 5/23 cases, aspiration of contrast medium into the lower airways was recorded.

CONCLUSIONS

The videofluoroscopic swallowing study has high diagnostic capabilities in the evaluation of swallowing disorders, as it is able to identify the degree and causes of impairment. In addition, the study proved useful for planning speech therapy and for follow-up in patients with ALS.