Comparative analysis of videofluoroscopy and pulse oximetry for aspiration identification in patients with dysphagia after stroke and non-dysphagics

PURPOSE

Dysphagia is a prevalent symptom observed in acute stroke. Several bedside screening tests are employed for the early detection of dysphagia. Pulse oximetry emerges as a practical and supportive method to augment the existing techniques utilized during bedside swallowing assessments. Desaturation levels, as measured by pulse oximetry, are acknowledged as indicative of aspiration by certain screening tests. However, the predictive capability of pulse oximetry in determining aspiration remains a subject of controversy. The objective of this study was to compare aspiration and oxygen desaturation levels by time and aspiration severity in dysphagic patients compared to healthy controls. It also aimed to evaluate the accuracy of pulse oximetry by comparing it with VFSS findings in detecting aspiration in both liquid (IDDSI-0) and semi-solid (IDDSI-4) consistencies.

MATERIALS AND METHODS

Eighty subjects (40 healthy and 40 acute stroke patients) participated. Patients suspected of dysphagia underwent videofluoroscopy as part of the stroke unit's routine procedure. Baseline SpO2 was measured before VFSS, and stabilized values were recorded. Sequential IDDSI-0 and IDDSI-4 barium tests were conducted with 5 ml boluses. Stabilized SPO2 values were recorded during swallowing and 3-min post-feeding. Patients with non-dysphagia received equal bolus monitoring. Changes in SPO2 during, before, and after swallowing were analyzed for each consistency in both groups.

RESULTS

The study revealed a statistically significant difference in SPO2 between patients with dysphagia and controls for IDDSI-4 and IDSSI-0. In IDDSI-4, 20% of patients experienced SpO2 decrease compared to 2.5% in control group (p = 0.013). For IDDSI-0, 35% of patients showed SpO2 decrease, while none in the control group did (p = 0.0001). Aspiration rates were 2.5% in IDDSI-4 and 57.5% in IDDSI-0. In IDDSI-0, SpO2 decrease significantly correlated with aspiration (p = 0.0001). In IDDSI-4, 20.5% had SpO2 decrease without aspiration, and showing no significant difference (p = 0.613). Penetration-Aspiration Scale scores had no significant association with SpO2 decrease (p = 0.602). Pulse oximetry in IDDSI-4 had limited sensitivity (0%) and positive predictive value, (0%) while in IDDSI-0, it demonstrated acceptable sensitivity (60.9%) and specificity (100%) with good discrimination capability (AUC = 0.83).

CONCLUSIONS

A decrease in SPO2 may indicate potential aspiration but is insufficient alone for detection. This study proposes pulse oximetry as a valuable complementary tool in assessing dysphagia but emphasizes that aspiration cannot be reliably predicted based solely on SpO2 decrease.

Asymptomatic Dysphagia and Aspiration in Patients with Idiopathic Bronchiectasis

PURPOSE

Although considered contributors to idiopathic bronchiectasis (IB), neither dysphagia nor silent aspiration have been systematically evaluated in IB patients. We aimed to explore the prevalence of asymptomatic dysphagia and silent aspiration in IB patients and to identify parameters predictive of their presence.

METHODS

This prospective cohort study included IB patients from our Pulmonary Institute without prior history of dysphagia and without prior dysphagia workup. Swallowing function was assessed by the Eating Assessment Tool (EAT-10) questionnaire and by the Fiberoptic Endoscopic Evaluation of Swallowing (FEES) test.

RESULTS

Forty-seven patients (31 females, mean age 67 ± 16 years) were recruited. An EAT-10 score ≥ 3 (risk for swallowing problems) was present in 21 patients (44.6%). Forty-two patients (89.3%) had at least one abnormal swallowing parameter in the FEES test. Six patients (12.7%) had a penetration aspiration score (PAS) in the FEES of at least 6, indicating aspiration. An EAT-10 score of 3 was found to be the ideal cutoff to predict aspiration in the FEES, with a good level of accuracy (area under the curve = 0.78, 95% CI 0.629-0.932, p = 0.03) and sensitivity of 83%. This cutoff also showed a trend towards a more severe disease using the FACED (forced expiratory volume, age, colonization with pseudomonas, extension of lung involvement, dyspnea) score (p = 0.05).

CONCLUSION

Dysphagia is prevalent in IB and may be undiagnosed if not specifically sought. We recommend screening all patients with IB for dysphagia by the EAT-10 questionnaire and referring all those with a score of ≥ 3 to formal swallowing assessment.

Prediction of dysphagia aspiration through machine learning-based analysis of patients' postprandial voices

BACKGROUND

Conventional diagnostic methods for dysphagia have limitations such as long wait times, radiation risks, and restricted evaluation. Therefore, voice-based diagnostic and monitoring technologies are required to overcome these limitations. Based on our hypothesis regarding the impact of weakened muscle strength and the presence of aspiration on vocal characteristics, this single-center, prospective study aimed to develop a machine-learning algorithm for predicting dysphagia status (normal, and aspiration) by analyzing postprandial voice limiting intake to 3 cc.

METHODS

Conducted from September 2021 to February 2023 at Seoul National University Bundang Hospital, this single center, prospective cohort study included 198 participants aged 40 or older, with 128 without suspected dysphagia and 70 with dysphagia-aspiration. Voice data from participants were collected and used to develop dysphagia prediction models using the Multi-Layer Perceptron (MLP) with MobileNet V3. Male-only, female-only, and combined models were constructed using 10-fold cross-validation. Through the inference process, we established a model capable of probabilistically categorizing a new patient's voice as either normal or indicating the possibility of aspiration.

RESULTS

The pre-trained models (mn40_as and mn30_as) exhibited superior performance compared to the non-pre-trained models (mn4.0 and mn3.0). Overall, the best-performing model, mn30_as, which is a pre-trained model, demonstrated an average AUC across 10 folds as follows: combined model 0.8361 (95% CI 0.7667-0.9056; max 0.9541), male model 0.8010 (95% CI 0.6589-0.9432; max 1.000), and female model 0.7572 (95% CI 0.6578-0.8567; max 0.9779). However, for the female model, a slightly higher result was observed with the mn4.0, which scored 0.7679 (95% CI 0.6426-0.8931; max 0.9722). Additionally, the other models (pre-trained; mn40_as, non-pre-trained; mn4.0 and mn3.0) also achieved performance above 0.7 in most cases, and the highest fold-level performance for most models was approximately around 0.9. The 'mn' in model names refers to MobileNet and the following number indicates the 'width_mult' parameter.

CONCLUSIONS

In this study, we used mel-spectrogram analysis and a MobileNetV3 model for predicting dysphagia aspiration. Our research highlights voice analysis potential in dysphagia screening, diagnosis, and monitoring, aiming for non-invasive safer, and more effective interventions.

TRIAL REGISTRATION

This study was approved by the IRB (No. B-2109-707-303) and registered on clinicaltrials.gov (ID: NCT05149976).

Foreign body aspiration in children: our pediatric tertiary care experience

PURPOSE

Inhalation of a foreign body is a real emergency in pediatric age and requires prompt diagnosis and treatment to reduce mortality. The objective of this study is to analyze clinical and radiological details, types, and localization of foreign bodies in patients conducted or to our hospital with suspected inhalation.

METHODS

We conducted a retrospective analysis of all cases of foreign body inhalation admitted to our Pediatric Emergency Room between January 2009 and June 2022.

RESULTS

171 patients were included in the study. In 83 patients, the FB was detected. The mean age of presentation was 2.3 years (SD: ± 2). Cough (73%) and unilateral reduced breath sound (51%) were the most common clinical symptom and clinical sign. The most frequent localization was the right main bronchus (43%). The foreign bodies retrieved were vegetable (83%), of which peanut was the most common. Chest radiographs were normal in 25%. The mean duration of hospitalization was 5 days (± 2.9). Complications such as pneumothorax were seen in two cases.

CONCLUSIONS

Foreign body inhalation represents a true pediatric emergency and still a challenge in clinical practice. The best way to manage it is an early diagnosis and removal by fully trained staff.

The Water Swallow Test and EAT-10 as Screening Tools for Referral to Videofluoroscopy

BACKGROUND

Videofluoroscopy (VFS) is the gold standard in evaluating dysphagia. Water swallow tests (WST) and the Eating Assessment Tool (EAT-10) are commonly used in dysphagia screening. We aimed to determine the feasibility of WST and EAT-10 as screening tools for referral to VFS.

METHODS

Patients (n = 150, median age: 70.0 years, range: 19-92 years, 58.7% female) referred to VFS completed the WST and EAT-10 before the examination. In the WST, we evaluated both the qualitative parameters (coughing, possible change in voice) and quantitative parameters (average drinking bolus size, swallowing speed). Correlations of EAT-10 total scores and WST parameters to the VFS findings were analyzed both individually and combined.

RESULTS

In the WST, the most specific (89.7%) predictor of normal VFS findings was the absence of coughing, and the most sensitive (79.1%) parameter to predict abnormal findings was a bolus size of ≤20 mL. Using a combination of coughing and a bolus size ≤20 mL (simplified WST), the sensitivity of predicting abnormal findings increased to 83.5%. The most sensitive (84.6%) predictor of penetration/aspiration was failing any parameter in the WST. Lack of coughing indicated an absence of penetration/aspiration with an 82.5% specificity. Swallowing speed or combining the EAT-10 results with the WST results did not enhance the sensitivity or specificity of the WST for predicting the VFS results.

CONCLUSIONS

Coughing and average drinking bolus size are the most important parameters in WST when screening for referral to VFS, whereas the swallowing speed does not seem to be useful. The WST is superior to EAT-10 in predicting VFS findings.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1349-1355, 2024.

Late Diagnosis of Foreign Body Aspiration in Adults: Case Series and Review of the Literature

BACKGROUND

Tracheobronchial foreign body (FB) aspiration (FBA) is a life-threatening emergency mostly observed in childhood and advanced age. With early diagnosis, the FB can be removed using bronchoscopic methods without causing irreversible damage.

METHODS

This was a single-center, retrospective observational study. Subjects diagnosed with FBA via either bronchoscopic methods and/or radiological findings, having no medical history of aspirated FB, and who were detected to have aspirated FB for longer than 30 days were included in the study. Medical records and radiological and bronchoscopic findings of the subjects were investigated from the hospital information database system.

RESULTS

Of the 255 patients with FBA, 17.6% (N = 45) were diagnosed late. The mean age was 53 y; 28% were female, and 60% of the subjects had a history of ever smoking. The estimated residence time of the FB in the bronchial system was 22.8 months. The most common complaints were cough and shortness of breath. Forty-two percent of the aspirated FBs were organic material. FB artifact could be observed in 6.7% of posteroanterior chest radiographs and 65% of thorax computed tomography (CT) scans. Rigid bronchoscopy had been primarily preferred as therapeutic interventional procedure. It was also found that the artifact most frequently resided in the right bronchial system and was most commonly found in the right lower lobe, while granulation tissue was formed in 85% of the subjects.

CONCLUSIONS

The findings of the present study demonstrate that subjects tended to forget the FBA, leading to insidious respiratory system symptoms, with recurrent infections. In cases with an endobronchial mass lesion image on thorax CT, clinicians should consider the possibility of FBA. Delayed diagnosis of both organic and inorganic FB may cause granulation tissue.

Foreign body aspiration score (FOBAS)-a prospectively validated algorithm for the management and prediction of foreign body aspiration in children

Foreign body aspiration (FBA) is a common cause of pediatric morbidity, but a standardized protocol to guide decision-making about bronchoscopy is lacking. We aimed to validate a new Foreign body aspiration score (FOBAS) for the pediatric emergency department (ED). Patients aged 0-18 years referred to the ED for suspected FBA were prospectively enrolled. FOBAS was calculated according to clinical features of a choking episode, sudden cough, exposure to nuts, absence of fever and rhinitis, stridor, and unilateral auscultatory and radiological findings. FBA risk was evaluated based on the total score (low, 1-3; moderate, 4-6; high, 7-10). Low-risk children were discharged from the ED and followed clinically. Moderate-risk children were hospitalized and evaluated by a pediatric pulmonologist, and high-risk children were referred directly for therapeutic bronchoscopy. Among the 100 enrolled children (59% males; median age 20 [interquartile range 11-39] months), a foreign body was diagnosed in 1/49 (2%), 14/41 (34.1%), and 9/10 (90%) with low, moderate, and high FOBAS, respectively (P < .001). Logistic regression indicated a higher risk for FBA with higher scores. The odds ratio for each additional point was 2.75 (95% confidence interval 1.78-4.24), and FOBAS showed a high predictive value for FBA (area under the curve 0.89). FOBAS implementation significantly reduced the rate of negative bronchoscopies, from 67.4% annually during 2016-2019 to 50% in 2020 (P = .042).

CONCLUSION

FOBAS reliably predicts FBA in cases of suspected FBA and improves management and in-hospital decision-making.

WHAT IS KNOWN

• Foreign body aspiration is a major cause of pediatric morbidity and mortality. • Currently, there is no unified protocol for children referred to the emergency department for suspected FBA, therefore, a well-defined algorithm is needed to improve the decision-making process.

WHAT IS NEW

• The pediatric Foreign body aspiration score (FOBAS) is a new, prospectively validated clinical score that shows high sensitivity and specificity for the presence of FBA in children. • FOBAS reduces unnecessary admissions and invasive procedures and leads to better clinical outcomes.

Predictive Value of Laryngeal Penetration to Aspiration in a Cohort of Pediatric Patients

Videofluoroscopic swallow studies (VFSS) provide dynamic assessment of the phases of swallowing under fluoroscopic visualization and allow for identification of abnormalities in the process, such as laryngeal penetration and aspiration. While penetration and aspiration both reflect degrees of swallowing dysfunction, the predictive potential of penetration for subsequent aspiration is not fully elucidated in the pediatric population. As a result, management strategies for penetration vary widely. Some providers may interpret any depth or frequency of penetration as a proxy for aspiration and implement various therapeutic interventions (e.g., modification of liquid viscosity) to eliminate penetration episodes. Some may recommend enteral feeding given the presumed risk of aspiration with penetration, even when aspiration is not identified during the study. In contrast, other providers may advise continued oral feeding without modification even when some degree of laryngeal penetration is identified. We hypothesized that the depth of penetration is associated with the likelihood of aspiration. Identification of predictive factors for aspiration following laryngeal penetration events has significant implications for selection of appropriate interventions. We performed a retrospective cross-sectional analysis of a random sample of 97 patients who underwent VFSS in a single tertiary care center over a 6 month period. Demographic variables including primary diagnosis and comorbidities were analyzed. We examined the association between aspiration and degrees of laryngeal penetration (presence or absence, depth, frequency) across diagnostic categories. Infrequent and shallow penetration events of any type of viscosity were less likely to be associated with aspiration event(s) during the same clinical encounter regardless of diagnosis. In contrast, children with consistent deep penetration of thickened liquids invariably demonstrated aspiration during the same study. Our findings show that shallow, intermittent laryngeal penetration of any viscosity type on VFSS was not consistent with clinical aspiration. These results provide further evidence that penetration-aspiration is not a uniform clinical entity and that nuanced interpretation of videofluoroscopic swallowing findings is necessary to guide appropriate therapeutic interventions.

Type 3 Laryngeal Clefts Presenting with Upper Airway Obstruction without Aspiration

Traditionally, otolaryngologists are taught that the defining clinical feature of a laryngeal cleft is aspiration. However, in a small subset of patients-even those with extensive clefts-the sole presenting feature may be airway obstruction. Here, we report two cases of type III laryngeal clefts that presented with upper airway obstruction without aspiration. The first patient was a 6-month-old male with history of tracheoesophageal fistula (TEF) who presented with noisy breathing, initially thought to be related to tracheomalacia. Polysomnogram (PSG) demonstrated moderate OSA and modified barium swallow (MBS) was negative for aspiration. In-office laryngoscopy was notable for a mismatch of tissue in the interarytenoid region. A type III laryngeal cleft was identified on bronchoscopy, and airway symptoms resolved after endoscopic repair. The second patient was a 4-year-old male with a diagnosis of asthma who presented with progressive exercise-induced stridor and airway obstruction. In-office flexible laryngoscopy revealed redundant tissue in the posterior glottis and MBS was negative for aspiration. He was found to have a type III laryngeal cleft on bronchoscopy and his stridor and upper airway obstruction resolved after endoscopic repair. While aspiration is the most common presenting symptom of a laryngeal cleft, it is important to consider that patients can have a cleft in the absence of dysphagia. Laryngeal cleft should be included in the differential diagnosis for patients with obstructive symptoms not explained by other etiologies and in those with suspicious features on flexible laryngoscopy. Laryngeal cleft repair is recommended to restore normal anatomy and relieve obstructive symptoms. Laryngoscope, 134:977-980, 2024.

[Inflammatory Polyp due to Peanut Aspiration, Needed to Differentiate from Malignant Tumor: Report of a Case]

The patient was in his 70s. He was addmitted to our hospital because of obstructive pneumonia for 3 months. Chest computed tomography( CT) showed a nodule at the base of the right B8, obstructing the basal branch, with consolidation of the peripheral lung. Bronchoscopy revealed the right basal trunk obstruction by a tumorous lesion. FDG-PET showed heterogeneous FDG uptake at the right hilum and the lower lobe suggesting malignancy, and a thoracoscopic right lower lobectomy was performed. Pathology showed a granulation-like nodule and a brown oval foreign body incarcerated in the peripheral bronchus, which was later revealed to be a peanut, and no obvious malignant findings were observed.

Scoring the Penetration-Aspiration Scale (PAS) in Two Conditions: A Reliability Study

A widely applied metric for identifying airway invasion events is the Penetration-Aspiration Scale (PAS). PAS scores are often included as primary outcome measures in clinical interventional studies, applied to characterize airway protection in a particular disease, used to establish a normal referent for control group comparisons without dysphagia, and as determinants or predictors of clinical outcomes. Despite the widespread use of the PAS, there is variability in scoring condition. One common method used in research studies includes rater scores applied to each single swallow that occurred during a modified barium swallow study (MBSS) of the same patient. A second common method includes raters scoring single swallow segments that have been spliced from full MBSS from different patients. These single swallow segments are then randomly distributed and the rater is blinded to all swallows that occurred during that patient MBSS. The potential effects of different scoring conditions on rater reliability and score accuracy have not been studied and may have high relevance for the conclusion drawn from the result. The primary aim of this investigation is to determine the impact of two scoring conditions on rater reliability and score accuracy: 1. Contextual, unblinded scoring condition and 2. Randomized, blinded condition. Results of the present study show that no statistically significant differences in PAS rater reliability and score accuracy were found between the two scoring conditions. If findings from this pilot study are reproduced in larger sample sizes, the time and intensity involved in splicing and randomizing MBSS for scoring may not be necessary.

Predictive Utility of the Penetration-Aspiration Scale in Inter-Arytenoid Injection Augmentation

OBJECTIVES/HYPOTHESIS

To determine the utility of preoperative penetration-aspiration scale (PAS) scores and clinical findings on modified barium swallow (MBS) in predicting advancement of diet after interarytenoid injection augmentation (IAIA).

STUDY DESIGN

Retrospective review.

METHODS

In this retrospective cohort study, 372 consecutive patients who underwent IAIA for pharyngeal dysphagia between 2009 and 2019 were initially identified. Patients were excluded from the study if they had insufficient preop MBS, no postop MBS within 3 months of injection, supraglottoplasty, or underlying neurological condition. Ninety-three patients were included in the study. Pre- and postoperative PAS scores were recorded, as were pre and postop diets. PAS scores were calculated by a single pediatric speech and language pathologist.

RESULTS

Average PAS score on MBS was 5.87 (standard deviation [SD] 2.74); median (range) = 8 (1-8). Postop average was 4.29 (SD 3.02); median (range) = 2 (1-8), P < .001. Those with worse preop PAS scores had increased odds of improvement in diet (odds ratio 1.24, 95% confidence interval [CI] 1.02-1.49, P = .029). An improvement in PAS score of 3.0 or greater predicted an improvement in diet with a sensitivity of 76.7% and a specificity of 85.7%.

CONCLUSIONS

PAS score on MBS can be a useful tool when assessing pediatric patients who may be candidates for IAIA. Prospectively comparing PAS score in patients post-IAIA to patients solely undergoing diet modification can help to better objectively assess differences in outcomes and understand the full utility of PAS score.

LEVEL OF EVIDENCE

Level III (Individual Cohort Study) Laryngoscope, 131:E1707-E1713, 2021.

Predictors of reflux aspiration and laryngo-pharyngeal reflux

BACKGROUND

Gastro-esophageal reflux disease (GERD) can present with typical or atypical or laryngo-pharyngeal reflux (LPR) symptoms. Pulmonary aspiration of gastric refluxate is one of the most serious variants of reflux disease as its complications are difficult to diagnose and treat. The aim of this study was to establish predictors of pulmonary aspiration and LPR symptoms.

METHODS

Records of 361 consecutive patient from a prospectively populated database were analyzed. Patients were categorized by symptom profile as predominantly LPR or GERD (98 GER and 263 LPR). Presenting symptom profile, pH studies, esophageal manometry and scintigraphy and the relationships were analyzed.

RESULTS

Severe esophageal dysmotility was significantly more common in the LPR group (p = 0.037). Severe esophageal dysmotility was strongly associated with isotope aspiration in all patients (p = 0.001). Pulmonary aspiration on scintigraphy was present in 24% of patients. Significant correlation was established between total proximal acid on 24-h pH monitoring and isotope aspiration in both groups (p < 0.01). Rising pharyngeal curves on scintigraphy were the strongest predictors of isotope aspiration (p < 0.01).

CONCLUSIONS

Severe esophageal dysmotility correlates with LPR symptoms and reflux aspiration in LPR and GERD. Abnormal proximal acid score on 24-h pH monitoring associated with pulmonary aspiration in reflux patients. Pharyngeal contamination on scintigraphy was the strongest predictor of pulmonary aspiration.

Tracheobronchial foreign body aspiration in children: A retrospective single-center cross-sectional study

Foreign body (FB) aspiration is a common and serious problem in childhood as it requires early recognition and treatment to avoid potentially lethal consequences. This study aimed to characterize the clinical and epidemiological features of airway FBs in a pediatric Chinese population.A retrospective review of medical records of children aged 0 to 14 years who attended with a diagnosis of FB aspiration the Shanghai Children's Hospital between January 2013 and December 2017 was carried out. Descriptive analysis was used to assess patient's demographics, clinical, radiographic, bronchoscopic findings, time to presentation, and characteristics of the FBs.Among the 200 patients included in the study, 92% were under 3 years of age, with a peak incidence of FB aspiration occurring between 1 and 2 years old. The male to female ratio was about 2.6:1. Twenty-three percent of the patients were admitted within 24 hours of the event, 40% within 1 week, 30% within 1 month, and 7% more than 1 month after aspiration. The most common presenting symptoms of laryngotracheal FBs were cough, dyspnea, and wheezing; those of bronchial FBs were cough, decreased air entry, and wheezing. Chest X-ray was normal in four-fifths of the children with laryngotracheal FBs, whereas most common abnormal X-ray findings in children with bronchial FBs were mediastinal shift, obstructive emphysema, and pneumonia. There was a trend that in children younger than 2 years FBs were more frequently found in the left bronchus, whereas in older children FBs were more frequently found in the right bronchus. Ninety-three percent of the removed FBs were organic materials such as food items and the most frequently aspirated FBs were peanuts. Flexible bronchoscopy was performed in 82.5% of the patients, while rigid bronchoscopy or direct laryngoscopy in 17.5% of the patients. Four patients were subjected to thoracic surgery and 1 died during rigid bronchoscopy due to acute respiratory failure.FBs is a frequent pathology among Chinese children. Tracheobronchial FBs should be strongly suspected in young children who have sudden onset of cough and wheezing episode, even when physical and radiographic evidence is absent.

Tracheal Irrigation Without Bronchoscopy as an Alternative Emergent Treatment of Blood Aspiration

BACKGROUND

Tracheobronchial foreign body aspiration can cause mild symptoms but may also become dangerous enough to cause death. Bronchoscopy is the first choice for the diagnosis and the removal of aspirated foreign bodies. So, when bronchoscopy is not available, the situation might get challenging.

CASE REPORT

A 62-year-old man was waiting for emergent surgery for traumatic epidural hematoma in the Emergency Department (ED). Endotracheal intubation was performed for surgery and airway maintenance. However, oxygen saturation dropped and respiratory arrest was expected. As emergent bronchoscopy could not be performed, the emergency physician decided to irrigate the trachea by using 0.9% normal saline in the ED. After three rounds of irrigation, vital signs including oxygen saturation improved and the patient could undergo neurosurgical surgery. The patient was subsequently discharged with improved health. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Bronchoscopy is the first choice for the treatment and diagnosis in cases of bronchial aspiration of blood, such as that caused by epistaxis. However, in emergency situations, such as deteriorating vital signs due to aspiration of life-threatening amounts of blood from epistaxis, using blind tracheal irrigation as an alternative tool when bronchoscopy is not available can help in achieving clinically acceptable results.

Gastroesophageal Reflux and Microaspiration in Lung Transplant Recipients: The Utility of a Single Esophageal Manometry and pH Probe Monitoring Study

BACKGROUND

Gastroesophageal reflux (GER) in recipients of lung transplant (LTX) is associated with chronic allograft rejection, presumably via microaspiration that damages airway epithelium. Most LTX programs perform a single post-LTX esophageal study to evaluate for GER; the efficacy of this test is unclear.

METHODS

Patients with 1 year of post-LTX follow-up, including routine bronchoscopies with bronchoalveolar lavage fluid (BALF) samples as well as high-resolution esophageal manometry and pH probe monitoring (HREMpH), were evaluated. BALF samples were analyzed with competitive enzyme-linked immunosorbent assay to detect bile salts, which are indicative of aspiration. These results were compared to results of HREMpH studies post LTX.

RESULTS

Ninety BALF samples were analyzed for bile salts and acted as disease positive for this evaluation. Of the 13 HREMpH cases, 8 were positive for GER, but only 3 were positive for bile salts via assay. Of the 5 HREMpH-negative cases, 2 experienced aspiration. A solitary HREMpH study had 60.0% sensitivity and 37.5% specificity with positive and negative likelihood ratios: 0.96 and 1.07, respectively.

CONCLUSION

Microaspiration appears to be an intermittent phenomenon, and HREMpH screening poorly correlates with BALF evidence of aspiration; which may not be adequate. As aspiration detection is crucial in this population, further analysis is warranted.

BaByVFSSImP© A Novel Measurement Tool for Videofluoroscopic Assessment of Swallowing Impairment in Bottle-Fed Babies: Establishing a Standard

AIM

This investigation tested the construct validity of the first standardized assessment tool, the BaByVFSS Impairment Profile, (BaByVFSSImP©), developed for the quantification of swallowing observations made from videofluoroscopic swallow studies (VFSS) in bottle-fed babies.

METHOD

Construct validity of the measures was tested using descriptive methods and confirmatory factor analysis (CFA) of swallowing scores obtained from a cohort of bottle-fed babies (median age 3 months 1 day, interquartile range 1 month 4 days-7 months 4 days) sequentially referred for VFSS based on clinical signs, symptoms, or risk factors associated with dysphagia and/or aspiration. Main outcome measures were emergence of functional domains derived from swallowing component impairment scores.

RESULTS

Confirmatory factor analysis resulted in 21 significant components (factor loadings ≥ 0.5) grouping into five functional domains labeled for common contribution to overall swallowing function. The tool was organized into the BaByVFSSImP. Clinical relevance was explored using correlational analyses between domain scores, maximum penetration/aspiration scores, feeding status, and caregiver burden.

INTERPRETATION

Quantification of physiologic swallowing impairment captured by BaByVFSSImP holds promise for identification of physiologically based targets for intervention, clinical decisions regarding enteral feeding, and tracking the trajectory of swallowing impairment throughout development in young children.

Prediction of aspiration in dysphagia using logistic regression: oral intake and self-evaluation

OBJECTIVES

Oropharyngeal dysphagia (OD) has a major influence on health in general and health-related quality of life (HR-QoL) in particular. The gold standard assessments for OD, especially for aspiration in OD, are fiberoptic endoscopic evaluation of swallowing (FEES) and videofluoroscopy (VFSS), but not all patients have access to such procedures. Therefore, the current study built a prediction model to forecast aspiration in patients with OD on the basis of common self-evaluation questionnaires and oral intake status.

METHODS

A consecutive series of 111 patients with confirmed diagnosis of OD was measured according to a standardised protocol using the following tools: the Swallowing Quality of Life Questionnaire (SWAL-QOL), the Dysphagia Handicap Index (DHI), two self-report visual analogue scales which measure the Severity and the Impairment of the swallowing problem on everyday social life as experienced by the patient, the Eating Assessment Tool 10 (EAT-10), the Functional Oral Intake Scale (FOIS) and subsequently FEES (the gold standard). Penalised logistic regression was carried out to predict aspiration. The performance of the resulting models was evaluated by constructing receiver operating characteristics (ROC) curves and computing areas under the curve (AUC).

RESULTS

The final model showed an AUC of 0.92, indicating excellent performance.

CONCLUSION

This study shows that it may be possible to accurately predict aspiration in oropharyngeal dysphagia by a non-invasive and non-instrumental assessment protocol including oral intake status and self-report questionnaires on functional health status and HR-QoL.

Deglutition disorders as a consequence of head and neck cancer therapies: a systematic review and meta-analysis

PURPOSE

In this study, we aimed to estimate the frequency of deglutition disorders in patients pre- and post-treatment for head and neck cancer (HNC).

METHODS

Search strategies were developed for the following databases: LILACS, PubMed, SpeechBITE, LIVIVO, Web of Science, and Scopus. Additionally, the gray literature was searched using Google Scholar, OpenGrey, and ProQuest. Only studies that conducted an evaluation of deglutition before and after cancer treatment and had sufficient quantitative data were included. We conducted a proportion of random effects meta-analysis using R statistical software.

RESULTS

Seventeen studies were included. Aspiration showed a high frequency in the period less than 3 months post-treatment, with 28.6% (total sample = 229). Penetration of fluids above the vocal folds and reduced laryngeal elevation were more frequent in the period less than 6 months post-treatment.

CONCLUSION

The frequency of deglutition disorders and its complications, such as aspiration, appears to be higher in the immediate to 6-month post-treatment period in patients with HNC. The parameter pharyngeal residue continued to increase through the period analyzed.

The Penetration-Aspiration Scale: Adaptation to Open Partial Laryngectomy and Reliability Analysis

A standard for assessing swallowing function after open partial horizontal laryngectomy (OPHL) is still not established. The variability in the measures used to investigate swallowing functional outcomes after OPHL limits the communication among clinicians and the possibility to compare and combine results from different studies. The study aims to adapt the PAS to the altered anatomy after OPHLs using fiberoptic endoscopic evaluation of swallowing (FEES) and to test its reliability. To adapt the PAS, two landmarks were identified: the entry of the laryngeal vestibule and the neoglottis. Ninety patients who underwent an OPHL were recruited (27 type I, 31 type II and 32 type III). FEES was performed and video-recorded. Two speech and language therapists (SLTs) independently rated each FEES using the PAS adapted for OPHL (OPHL-PAS). FEES recordings were rated for a second time by both SLTs at least 15 days from the first video analysis. Inter- and intra-rater agreement was assessed using unweighted Cohen's kappa. Overall, inter-rater agreement of the OPHL-PAS was k = 0.863, while intra-rater agreement was k = 0.854. Concerning different OPHL types, inter- and intra-rater agreement were k = 0.924 and k = 0.914 for type I, k = 0.865 and k = 0.790 for type II, and k = 0.808 and k = 0.858 for type III, respectively. The OPHL-PAS is a reliable scale to assess the invasion of lower airway during swallowing in patients with OPHL using FEES. The study represents the first attempt to define standard tools to assess swallowing functional outcome in this population.

Eating and drinking with an inflated tracheostomy cuff: a systematic review of the aspiration risk

BACKGROUND

Speech and language therapists (SLT) lack consensus with regard to assessing the swallow function of a patient with a cuff-inflated tracheostomy. In the UK, one-third would not accept such a referral due to perceived negative effects on swallow safety. Patients may be spending longer hospitalized and fed enterally as a result.

AIMS

To establish the evidence base for aspiration risk in the adult population when eating/drinking with a cuff-inflated tracheostomy.

METHODS & PROCEDURES

Systematic searches of seven key electronic databases, grey literature and reference lists of full-text articles were conducted until January 2017. Two researchers independently identified eligible studies according to inclusion criteria (studies written in English, reporting aspiration rates in adult humans with inflated cuff tracheostomies). Methodological quality was assessed using the Downs and Black checklist. Owing to the heterogeneity of included studies in their design, population and measured outcomes, a narrative synthesis was employed.

OUTCOMES & RESULTS

In total, 454 titles, 168 abstracts and 37 full papers were retrieved with 10 studies included in the final review. Methodological flaws and risk of bias were identified in all studies. Meta-analysis was not feasible. Narrative synthesis found no study identified a statistically significantly higher incidence of aspiration in cuff-inflated patients.

CONCLUSIONS & IMPLICATIONS

Evidence regarding aspiration risk is inconclusive. These results imply SLT services need to review policy to consider accepting referrals on a case-by-case basis, regardless of cuff status. Further research, though challenging to conduct, would inform best-practice and policy/guideline development, allowing a consistent clinical approach.

Poor compliance with antimicrobial guidelines for childhood pneumonia

INTRODUCTION

Antimicrobial stewardship programmes recommend use of narrow-spectrum antibiotics as first-line treatment of childhood pneumonia in secondary care. The primary aim of the present study was to assess whether current guidelines are followed. A secondary aim was to assess if tracheal aspiration is a useful tool in the diagnostic process of suspected childhood pneumonia.

METHODS

This was a retrospective descriptive single-centre cohort study. Children between three months and 17 years with a pneumonia diagnosis were included. The children were divided into two groups based on whether or not they had been treated with antibiotics (TWA) by their general practitioner. We obtained information on blood samples, treatment and microbial findings. Finally, we compared the use of antibiotics and the microbiological diagnosis of children TWA prior to admittance with those of drug-naïve children (DN).

RESULTS

Guidelines were followed in 55% (n = 78) of the cases, which is comparable to results reported by other studies. Tracheal aspiration culture identified a bacterial pathogen in 54% (n = 77) of the cases; Haemophilus influenzae was the most prevalent. A larger percentage of tracheal aspirations was positive in the TWA group than in the DN group (66%; n = 31 versus 48%; n = 46).

CONCLUSIONS

Compliance with local guidelines was comparable to findings reported in similar single-centre studies. Airway aspiration may be a useful supplement to other investigations.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

Fiberoptic bronchoscopic treatment of blood aspiration and use of sugammadex in a patient with epistaxis: A case report

RATIONALE

In patients with oropharyngeal and nasopharyngeal bleeding, blood aspiration can make airway management difficult and lead to severe pulmonary complications.

PATIENT CONCERNS

A 44-year-old male patient with recurrent epistaxis underwent surgery for hemostasis. The patient aspirated blood through the endotracheal tube when he hiccupped during the surgery.

DIAGNOSIS

The patient was diagnosed with blood aspiration after intraoperative fiberoptic bronchoscopy revealed a blood clot and viscous mucus in the airways, but no sign of active bleeding.

INTERVENTIONS

Tracheobronchial suctioning and irrigation with normal saline was performed through the bronchoscope to remove the aspirated blood clot. Prior to emergence from anesthesia, sugammadex was administered to induce complete neuromuscular recovery and enable the patient to cough up any blood remaining in the airways.

OUTCOMES

The patient was successfully extubated and fully recovered with no complications.

LESSONS

Blood aspiration due to oropharyngeal or nasopharyngeal bleeding can be diagnosed and treated by tracheobronchial suctioning via fiberoptic bronchoscopy. In addition, sugammadex can enable patients to recover spontaneous breathing, facilitate extubation, and enable patients to cough up any blood remaining in the airways.

Aspiration of Nasopore nasal packing

We present a case of postoperative Nasopore aspiration in an otherwise fit and well 11-year-old. An endoscopic adenoidectomy had been performed without incident and Nasopore packing placed into each nasal cavity. Immediately after extubation, there was marked hypoxia, tachypnoea and high clinical suspicion of pack aspiration. The patient returned to theatre for emergency rigid bronchoscopy and retrieval of nasal packing.

Ivacaftor and symptoms of extra-oesophageal reflux in patients with cystic fibrosis and G551D mutation

BACKGROUND

Extra-oesophageal reflux (EOR) may lead to microaspiration in patients with cystic fibrosis (CF), a probable cause of deteriorating lung function. Successful clinical trials of ivacaftor highlight opportunities to understand EOR in a real world study.

METHODS

Data from 12 patients with CF and the G551D mutation prescribed ivacaftor (150mg bd) was collected at baseline, 6, 26 and 52weeks. The changes in symptoms of EOR were assessed by questionnaire (reflux symptom index (RSI) and Hull airway reflux questionnaire (HARQ)).

RESULTS

Six patients presented EOR at baseline (RSI >13; median 13; range 2-29) and 5 presented airway reflux (HARQ >13; median 12; range 3 to 33). Treatment with ivacaftor was associated with a significant reduction of EOR symptoms (P<0∙04 versus baseline) denoted by the reflux symptom index and Hull airway reflux questionnaire.

CONCLUSION

Ivacaftor treatment was beneficial for patients with symptoms of EOR, thought to be a precursor to microaspiration.

Identifying the Risk of Swallowing-Related Pulmonary Complications in Older Patients With Hip Fracture

To identify and potentially modify the risk of pulmonary complications in a group of older patients with hip fracture, the authors obtained speech and language pathology consultations for these patients. Then they performed a retrospective chart review of all patients 65 years and older who were admitted to their institution between June 2011 and July 2013 with acute hip fracture, were treated surgically, and had a speech and language pathology evaluation in the immediate perioperative period. The authors identified 52 patients who met the study criteria. According to the American Society of Anesthesiologists (ASA) classification system, at the time of surgery, 1 patient (2%) was classified as ASA I, 12 patients (23%) were ASA II, 26 (50%) were ASA III, and 12 (23%) were ASA IV. Based on a speech and language pathology evaluation, 22 patients (42%) were diagnosed with dysphagia. Statistical analysis showed that ASA III status and ASA IV status were meaningful predictors of dysphagia and that dysphagia itself was a strong risk factor for pulmonary aspiration, pneumonia, and aspiration pneumonitis. Evaluation by a speech and language pathologist, particularly of patients classified as ASA III or ASA IV, may be an efficient means of averting pulmonary morbidity that is common in older patients with hip fracture.

[Incidence, pathomorphism and outcomes of the bronchopulmonary dysplasia associated with microaspiration of gastric contents]

Today the influence of the digestive tract functional violations followed by microaspiration of gastric contents (MAGC) on the incidence, features and outcomes of bronchopulmonary dysplasia BPD) remains little studied. Focusing on this aspect makes the research actual.

OBJECTIVE

determination of the nature of influence of MAGC on the progress and course of BPD.

METHODS

373 newborns exposed to artificial pulmonary ventilation (APV) in the neonatal period were examined. In a tracheobronchial aspirate (TBA) the marker of MAGC-pepsin--was determined. Its activity was measured by extinction value with subsequent analysis of the incidence and nature of the course of bronchopulmonary dysplasia (BPD) in patients against MAGC and without it. During the three years follow-up period outcomes of BPD and features of combined pathology were established.

RESULTS

it was revealed that in children suffered from MAGC the incidence of BPD was higher and grew in proportion to the increase of pepsin activity in TBA and the reduction of gestational age. The extinction increase in TBA values was followed by the increase in duration of APV and the subsequent oxygen therapy, and also the severity of BPD clinical course. By the end of 3 years clinical recovery was detected in 55.2% of children suffering from BPD without MAGC whereas in patients with BPD against MAGC this outcome occured only in 0.9% of cases.

CONCLUSION

MAGC is clinically significant for the etiology, pathogenesis and pathomorphism of BPD. The proposed method of early detection of MAGC and algorithm of complex therapy can reduce its severity and improve the forecast accuracy of neonatal adaptation.

American Cancer Society Head and Neck Cancer Survivorship Care Guideline

Answer questions and earn CME/CNE The American Cancer Society Head and Neck Cancer Survivorship Care Guideline was developed to assist primary care clinicians and other health practitioners with the care of head and neck cancer survivors, including monitoring for recurrence, screening for second primary cancers, assessment and management of long-term and late effects, health promotion, and care coordination. A systematic review of the literature was conducted using PubMed through April 2015, and a multidisciplinary expert workgroup with expertise in primary care, dentistry, surgical oncology, medical oncology, radiation oncology, clinical psychology, speech-language pathology, physical medicine and rehabilitation, the patient perspective, and nursing was assembled. While the guideline is based on a systematic review of the current literature, most evidence is not sufficient to warrant a strong recommendation. Therefore, recommendations should be viewed as consensus-based management strategies for assisting patients with physical and psychosocial effects of head and neck cancer and its treatment. CA Cancer J Clin 2016;66:203-239. © 2016 American Cancer Society.

Screening adult patients with a tracheostomy tube for dysphagia: a mixed-methods study of practice in the UK

BACKGROUND

Patients with tracheostomy tubes are at risk of aspiration and swallowing problems (dysphagia), and because of their medical acuity, complications in this patient population can be severe. It is well recognized that swallow screening in stroke significantly reduces potential complications by allowing early identification and appropriate management of patients at risk (by health professionals), thereby reducing delays in commencing oral intake and preventing unnecessary, costly interventions by speech and language therapists (SLTs). However, there is no standardized swallow screen for the tracheostomised population and there is a paucity of literature regarding either current or best practice in this area.

AIMS

To investigate current UK practice for dysphagia screening in adult patients with tracheostomy tubes and to explore and describe health professionals' perceptions of their current practice or current systems used.

METHODS & PROCEDURES

A mixed-methods approach was adopted comprising a semi-structured online questionnaire and recorded follow-up telephone interviews. Participants were SLTs, nurses and physiotherapists working with patients with tracheostomies. Responses were analysed to determine current practice with regard to swallow screening. Thematic analysis of interviews allowed further exploration and clarification of the questionnaire findings.

OUTCOMES & RESULTS

A total of 221 questionnaires were completed. Approximately half (45%) the participants worked in trusts with formal swallow screens, whilst the remainder used a variety of other approaches to identify patients at risk, often relying on informal links with multidisciplinary teams (MDT). In line with current evidence, patients with neurological diagnoses and a tracheostomy were consistently referred directly to speech and language therapy (SLT). Only one-quarter of questionnaire participants thought their current system was effective at identifying patients at risk of swallowing problems. Eleven questionnaire participants were interviewed. They highlighted the important role of MDT team working here, emphasizing both its strengths and weaknesses when working with these patients.

CONCLUSIONS & IMPLICATIONS

Current practice in the UK for screening patients with a tracheostomy for swallow problems is varied and often suboptimal. Despite the evidence for enhancing outcomes, MDT working is still perceived as problematic. A swallow screening tool for use with this population, to enhance MDT working whilst also ensuring that practice fits in line with current evidence, may improve patient safety and care.

Objective Measures of Swallowing Function Applied to the Dysphagia Population: A One Year Experience

Quantitative, reliable measures of swallowing physiology can be made from an modified barium swallowing study. These quantitative measures have not been previously employed to study large dysphagic patient populations. The present retrospective study of 139 consecutive patients with dysphagia seen in a university tertiary voice and swallowing clinic sought to use objective measures of swallowing physiology to (1) quantify the most prevalent deficits seen in the patient population, (2) identify commonly associated diagnoses and describe the most prevalent swallowing deficits, and (3) determine any correlation between objective deficits and Eating Assessment Tool (EAT-10) scores and body mass index. Poor pharyngeal constriction (34.5 %) and airway protection deficits (65.5 %) were the most common swallowing abnormalities. Reflux-related dysphagia (36 %), nonspecific pharyngeal dysphagia (24 %), Parkinson disease (16 %), esophageal abnormality (13 %), and brain insult (10 %) were the most common diagnoses. Poor pharyngeal constriction was significantly associated with an esophageal motility abnormality (p < 0.001) and central neurologic insult. In general, dysphagia symptoms as determined by the EAT-10 did not correlate with swallowing function abnormalities. This preliminary study indicates that reflux disease is common in patients with dysphagia and that associated esophageal abnormalities are common in dysphagic populations and may be associated with specific pharyngeal swallowing abnormalities. However, symptom scores from the EAT-10 did not correspond to swallowing pathophysiology.

Screening Accuracy for Aspiration Using Bedside Water Swallow Tests: A Systematic Review and Meta-Analysis

BACKGROUND

Hospitalizations for aspiration pneumonia have doubled among older adults. Using a bedside water swallow test (WST) to screen for swallowing-related aspiration can be efficient and cost-effective for preventing additional comorbidities and mortality. We evaluated screening accuracy of bedside WSTs used to identify patients at risk for dysphagia-associated aspiration.

METHODS

Sixteen online databases, Google Scholar, and known content experts through May 2015 were searched. Only prospective studies with patients ≥ 18 years of age given WST screenings validated against nasoendoscopy or videofluoroscopy were included. Data extraction used dual masked extraction and quality assessment following Meta-analysis of Observational Studies in Epidemiology guidelines.

RESULTS

Airway response (eg, coughing/choking) with or without voice changes (eg, wet/gurgly voice quality) was used to identify aspiration during three different bedside WSTs. Pooled estimates for single sip volumes (1-5 mL) were 71% sensitive (95% CI, 63%-78%) and 90% specific (95% CI, 86%-93%). Consecutive sips of 90 to 100 mL trials were 91% sensitive (95% CI, 89%-93%) and 53% specific (95% CI, 51%-55%). Trials of progressively increasing volumes of water were 86% sensitive (95% CI, 76%-93%) and 65% specific (95% CI, 57%-73%). Airway response with voice change improved overall accuracy in identifying aspiration.

CONCLUSIONS

Currently used bedside WSTs offer sufficient, although not ideal, utility in screening for aspiration. Consecutive sips with large volumes in patients who did not present with overt airway responses or voice changes appropriately ruled out risk of aspiration. Small volumes with single sips appropriately ruled in aspiration when clinical signs were present. Combining these bedside approaches may offer improved screening accuracy, but further research is warranted.

CVAS: A Rapid Dysphagia Evaluation Tool

A simple-to-administer test for dysphagia was developed at our institution. The test can be administered rapidly and easily in the Emergency Department (ED) by a nurse or other qualified medical person, making formal consultation with a speech pathologist for rapid determination of dysphagia unnecessary. Our study shows that the use of the test does not increase the incidence of aspiration pneumonia.

[Aspiration of water during underwater birth]

BACKGROUND

Underwater birth is becoming increasingly popular because of the advantages for the mother. Women who deliver in this way feel less pain and therefore pain relief is less frequently needed during the delivery. But what seems to be forgotten is the fact that aspiration of water by the neonate could take place during an underwater birth, resulting in respiratory distress.

CASE DESCRIPTION

A one-day-old neonate was admitted because of tachypnoea following underwater delivery at home. The respiratory rate of the neonate was one hundred breaths per minute without evident signs of dyspnoea. Chest radiography showed bilateral patches on the lungs consistent with aspiration of bathwater. After seven days of intravenous antibiotic treatment, the neonate recovered and could be discharged home.

CONCLUSION

An underwater birth may cause respiratory problems in the neonate. If a pregnant woman wants to deliver under water, she should also be advised of the potential detrimental consequences for the neonate.

Foreign Body Aspiration in Children with Focus on the Role of Flexible Bronchoscopy: A 5 Year Experience

BACKGROUND

Foreign body aspiration (FBA) is common in the pediatric population and if not diagnosed and treated properly can lead to major complications.

OBJECTIVES

To define the clinical and radiological features of aspirated foreign bodies, characterize the incidence of FBA among the Israeli-Arab population, and evaluate flexible bronchoscopy as a diagnostic tool prior to performing rigid bronchoscopy.

METHODS

We reviewed the e-files of 115 children who underwent bronchoscopy for suspected FBA between January 2006 and December 2010 in the pediatric department of the St. Vincent French Hospital, Nazareth.

RESULTS

We identified 44 patients (38.3%) who had foreign body aspiration (mean age 31.2 ± 29 months, males 64%). Organic-type foreign body was seen in 70% of cases and location was equally distributed. Statistically significant correlations were found between the presence of a foreign body and a history of choking, abnormal lung auscultation, and abnormal chest X-ray (P < 0.05). The rate of negative finding in rigid bronchoscopy in our study was as low as 15% (in only 8 of 52 rigid bronchoscopies was the finding negative for FBA). Compared with other centers in our region where rigid bronchoscopy was performed without the preceding flexible procedure, we found that our protocol reduced the rate of negative rigid bronchoscopies.

CONCLUSIONS

Introducing flexible bronchoscopy initially in FBA management reduced the rate of negative rigid bronchoscopies.

Analysis of Dysphagia Patterns Using a Modified Barium Swallowing Test Following Treatment of Head and Neck Cancer

PURPOSE

The purposes of this study were to evaluate specific dysphagia patterns and to identify the factors affecting dysphagia, especially aspiration, following treatment of head and neck cancer.

MATERIALS AND METHODS

A retrospective analysis of 57 patients was performed. Dysphagia was evaluated using a modified barium swallow (MBS) test. The MBS results were rated on the 8-point penetration-aspiration scale (PAS) and swallowing performance status (SPS) score.

RESULTS

Reduced base of the tongue (BOT) retraction (64.9%), reduced laryngeal elevation (57.9%), and cricopharyngeus (CP) dysfunction (47.4%) were found. Reduced BOT retraction was correlated with clinical stage (p=0.011) and treatment modality (p=0.001). Aspiration in 42.1% and penetration in 33.3% of patients were observed. Twenty-four patients had PAS values over 6, implying aspiration. Forty-one patients had a SPS score of more than 3, 25 patients had a score greater than 5, and 13 patients had a SPS score of more than 7. Aspiration was found more often in patients with penetration (p=0.002) and in older patients (p=0.026). In older patients, abnormal swallowing caused aspiration even in those with a SPS score of more than 3, irrespective of stage or treatment, contrary to younger patients. Tube feeders (n=20) exhibited older age (65.0%), dysphagia/aspiration related structures (DARS) primaries (75.0%), higher stage disease (66.7%), and a history of radiotherapy (68.8%).

CONCLUSION

Reduced BOT retraction was the most common dysphagia pattern and was correlated with clinical stage and treatment regimens including radiotherapy. Aspiration was more frequent in patients who had penetration and in older patients. In contrast to younger patients, older patients showed greater risk of aspiration even with a single abnormal swallowing irrespective of stage or treatment.

Retrieving difficult aspirated pen caps by balloon catheter with short working-length flexible endoscopy and noninvasive ventilation support in intensive care unit

OBJECTIVES

Aspirated pen cap (APC) is a clinical challenging issue in children because of the difficulty in both making diagnosis and performing extraction. In case of failed retrieval by rigid endoscopy (RE), more invasive surgical approaches are recommended. The objective of this study is to introduce a new retrieval technique of APC by using laser and balloon catheter (BC) guided with flexible endoscopy (FE) and supported by a novel non-invasive ventilation (NIV) in the intensive care unit (ICU) setting.

METHODS

We retrospectively review the charts and FE video records of our pediatric cases with the diagnosis of APC in the past decade, 2004-2014.

RESULTS

Four consecutive cases with bronchial APC which had failed extraction with RE were transferred to our hospital. All of them were under procedural sedation, topical anesthesia, NIV support and ICU monitoring. After FE confirmed the diagnosis and location, a BC parallel to the endoscope was manipulated to pass through the cap hole of the APC. Two APCs required laser pretreatment before retrieval: one debulked the entrenched granulation whereas another enlarged the size of cap hole. Guide wires also were required in three cases to assist the BC to pass through the cap hole. All four APCs were successfully retrieved on their first attempts with no significant complications.

CONCLUSIONS

FE assisted by laser, guide wire and BC, with this NIV support and ICU monitoring is a feasible, safe and effective modality for retrieving those difficult bronchial APCs in pediatric cases.

Swallowing disorders in Parkinson's disease: impact of lingual pumping

BACKGROUND

Lingual pumping (LP) is a repetitive, involuntary, anteroposterior movement of the tongue on the soft palate that is executed prior to transferring the food bolus to the pharynx, but we also observed LP when multiple swallows were taken. LP may be associated with rigidity and bradykinesia in patients with Parkinson's disease (PD). This phenomenon tends to be more prevalent in dysphagic PD patients, and its impact on swallowing dynamics remains poorly understood.

OBJECTIVE

To evaluate how LP interferes with the oral and pharyngeal phases of the swallowing of foods of different consistencies and volumes.

METHODS

We used videofluoroscopy to study the swallowing of 69 PD patients performing 10 swallows of barium mixed with foods of different consistencies and volumes.

RESULTS

LP was associated with the unstable intra-oral organization of the bolus, the loss of bolus control, the pharyngeal retention of food and food entering the airway. This abnormal movement was also associated with a shorter oral transit time and was found to be more prevalent with food of thicker consistencies.

CONCLUSIONS

LP is associated with swallowing incoordination and with food entering the airway. Preventive measures to minimise the pulmonary or nutritional consequences of this behaviour are necessary.

Mimics of child abuse: Can choking explain abusive head trauma?

Choking is one of the alternative explanations of abusive head trauma in children that have been offered in courtroom testimony and in the media. Most of these explanations - including choking - are not scientifically supported. This article highlights four points. (1) The origins of choking as an explanation for intracranial and retinal hemorrhages are speculative. (2) Choking has been used in high profile court testimony as an explanation for the death of a child thought to have been abused. (3) A case report that proposes choking as an alternative explanation for the death of a child diagnosed with abusive head trauma includes omissions and misrepresentations of facts. (4) There was a decision by the editor of the journal that published the case report that it was not necessary to include all the facts of the case; moreover, the editor indicated that facts are not required when presenting an alternative explanation. The use of scientifically unsupported alternative explanations for abusive head trauma based on inaccurate and biased information constitutes further victimization of the abused child and represents a travesty of justice.

Type I-II laryngeal cleft: clinical course and outcome

BACKGROUND

Laryngeal cleft (LC) is a rare congenital anomaly manifesting in a variety of symptoms, including swallowing disorders and aspirations, dyspnea, stridor and hoarseness. The mild forms (types I-II) may be underdiagnosed, leading to protracted symptomatology and morbidity.

OBJECTIVES

To evaluate the diagnostic process, clinical course, management and outcome in children with type I-II laryngeal clefts.

METHODS

We conducted a retrospective case analysis for the years 2005-2012 in a tertiary referral center.

RESULTS

Seven children were reviewed: five boys and two girls ranging in age from birth to 5 years. The most common presenting symptoms were cough, aspirations and pneumonia. Evaluation procedures included fiber-optic laryngoscopy (FOL), direct laryngoscopy (DL) and videofluoroscopy. Other pathologies were seen in three children. Six children underwent successful endoscopic surgery and one child was treated conservatively. The postoperative clinical course was uneventful in most of the cases.

CONCLUSIONS

Types I-II LC should be considered in the differential diagnosis of children presenting with protracted cough and aspirations. DL is crucial for establishing the diagnosis. Endoscopic surgery is safe and should be applied promptly when conservative measures fail.

FEES protocol derived estimates of sensitivity: aspiration in dysphagic patients

Aspiration is a common phenomenon in patients with oropharyngeal dysphagia. It can be studied using fiberoptic endoscopic evaluation of swallowing (FEES). FEES is well known and widely used in the diagnosis and treatment of swallowing disorders. However, various protocols exist, and there is no consensus on the examination protocol. The objective of this prospective study was to determine the FEES protocol derived estimates of sensitivity (Se') to detection of aspiration in dysphagic patients. The study estimated the probability of aspiration as a function of the number of swallow trials in dysphagic patients using FEES. The derived sensitivity was calculated based on presence or absence of aspiration in a ten-swallow trial protocol as arbitrary 'gold standard'. Eighty-four persons were included, comprising two patient populations with oropharyngeal dysphagia. Dysphagia in one group was due to head and neck cancer and possible oncological treatment effects on swallowing; in the other it was a result of neurological disease. All patients underwent a standardized FEES examination using ten swallows of thin liquid followed by ten swallows of thick liquid, all in boluses of 10 cc each. FEES recordings were rated for aspiration by an expert panel blinded to patients' identity and clinical history. Descriptive statistics, Kaplan-Meier survival analysis techniques, and Log Rank/Mantel-Cox tests were used. In both patient populations the aspiration risk was underestimated when using a limited number (three or four) of swallow trials. The oncology and neurology patients differed significantly in the number of swallow trials required to determine aspiration for thin liquids (median values 2 and 7 respectively, P = 0.006). FEES protocols using a limited number of swallow trials can underestimate the aspiration risk in both oncological and neurological patients suffering from oropharyngeal dysphagia, especially when using boluses with a thin liquid consistency.

Accuracy of alpha amylase in diagnosing microaspiration in intubated critically-ill patients

OBJECTIVES

Amylase concentration in respiratory secretions was reported to be a potentially useful marker for aspiration and pneumonia. The aim of this study was to determine accuracy of α-amylase in diagnosing microaspiration in critically ill patients.

METHODS

Retrospective analysis of prospectively collected data collected in a medical ICU. All patients requiring mechanical ventilation for at least 48 h, and included in a previous randomized controlled trial were eligible for this study, provided that at least one tracheal aspirate was available for α-amylase measurement. As part of the initial trial, pepsin was quantitatively measured in all tracheal aspirates during a 48-h period. All tracheal aspirates were frozen, allowing subsequent measurement of α-amylase for the purpose of the current study. Microaspiration was defined as the presence of at least one positive tracheal aspirate for pepsin (>200 ng.mL-1). Abundant microaspiration was defined as the presence of pepsin at significant level in >74% of tracheal aspirates.

RESULTS

Amylase was measured in 1055 tracheal aspirates, collected from 109 patients. Using mean α-amylase level per patient, accuracy of α-amylase in diagnosing microaspiration was moderate (area under the receiver operator curve 0.72±0.05 [95%CI 0.61-0.83], for an α-amylase value of 1685 UI.L-1). However, when α-amylase levels, coming from all samples, were taken into account, area under the receiver operator curve was 0.56±0.05 [0.53-0.60]. Mean α-amylase level, and percentage of tracheal aspirates positive for α-amylase were significantly higher in patients with microaspiration, and in patients with abundant microaspiration compared with those with no microaspiration; and similar in patients with microaspiration compared with those with abundant microaspiration. α-amylase and pepsin were significantly correlated (r2 = 0.305, p = 0.001).

CONCLUSION

Accuracy of mean α-amylase in diagnosing microaspiration is moderate. Further, when all α-amylase levels were taken into account, α-amylase was inaccurate in diagnosing microaspiration, compared with pepsin.

The effect of the training given to the child development students about foreign body aspiration upon their knowledge levels

OBJECTIVE

This study was semi-experimentally conducted in order to determine knowledge levels of child development students about foreign body aspiration and to explore the effect of the training given to these students about foreign body aspiration upon their knowledge levels.

METHODS

The research was conducted with a total of 231 students who studied at the department of child development of two high schools and one vocational higher school in Erzincan Province located in the east of Turkiye between May 2011 and February 2012. The data were gathered using a questionnaire form of 38 questions. The training on foreign body aspiration (Power point presentation, video presentation and practice on a dummy) was provided in three phases. For the data evaluation; percentages, chi-square test and Mc Nemar test were used.

RESULTS

It was found out in the study that 91.8% of the students did not take any training/course about foreign body aspiration and 55% confronted situations of foreign body aspirations (ear, nose, airway). After the training about foreign body aspiration; it was noted that the number of the students who knew risky behaviors for foreign body aspiration increased and the increase in the number of the students was at the highest level among high schools (p<0.05). It was seen that the training was most effective among the university students in terms of knowing first-aid intervention in case a foreign body would obstruct airway among the children aged<1 year (p<0.05).

CONCLUSION

It was noted that the training which was applied on the dummy by using visual aids about foreign body aspiration increased the knowledge level of the students. Based on this finding, it may be recommended that nurses should perform their counseling and educator roles more actively for the families and those who are responsible for the baby care about foreign body aspiration by playing a more active role in the health care team.

The modified barium swallow and the functional endoscopic evaluation of swallowing

This article reviews the current standard of care for the instrumental evaluation of swallow function using the modified barium swallow (MBS) and the functional endoscopic evaluation of swallowing (FEES). Both the MBS and FEES are valuable procedures for evaluating dysphagia and show good agreement with diagnostic findings as related to tracheal aspiration, laryngeal penetration, pharyngeal residue, diet level, and compensatory swallow safety strategies. The use of the MBS and FEES has advantages and disadvantages and both should be considered the gold standard for evaluating swallow function.

[Foreign body aspiration in Kigali University Teaching Hospital, Rwanda]

We present the case of a 12-year-old girl referred to Kigali University Teaching Hospital (KUTH) for persistent cough, fever and haemoptysis. Respiratory symptoms started acutely with a stridor at age 4. Thereafter she developed a chronic cough with intermittent fever. She was treated ambulatory in the health care centre with oral antibiotics and finally referred to the district hospital at age 7. The chest X-ray then suggested tuberculosis for which a 6 month treatment was given with no improvement. The cough persisted and haemoptysis appeared so the patient was referred to the reference hospital (KUTH). Chest X-ray showed diffuse lesions of the left lung with bronchiectasis. Bronchoscopy revealed the presence of a foreign body in the left intermediary bronchus and a piece of plastic was extracted. Symptoms rapidly disappeared with antibiotic treatment. This case illustrates how important it is to include foreign body inhalation in the differential diagnosis of respiratory disease in children. Bronchoscopy plays a key role in diagnosis and treatment. The authors point out the advantages of the joint efforts of the Belgian Development Aid Agency (BTC) and the Université libre de Bruxelles (ULB) in the development of this activity in the Rwandese context.