Aspiration In Dysphagic Patients Research Articles

Thicker is better? Impact of food consistencies on aspiration detection using IDDSI levels

Background/purposeWater is the most commonly, and often the only tested material in swallow screening. Our objective is to assess the impact of food consistencies on the reliability of trial swallows in predicting aspiration in dysphagic patients, utilizing the International Dysphagia Diet Standardisation Initiative (IDDSI) levels. MethodsAll trial swallows were evaluated using 5 ml of standardized test food with IDDSI levels of 0, 2, 4, 5. The flexible endoscopic evaluation of swallowing was used as the basis for comparison. The sensitivity, specificity, and predictive values of commonly used direct clinical signs for the detection of aspiration were analyzed, including cough with swallow (choking) and post-swallow voice change (wet voice). ResultsIDDSI 2 test food demonstrated the highest accuracy for detecting aspiration when using both clinical signs of cough (91%) and wet voice (83%). Despite reduced risk of aspiration, the percentage of silent aspiration among aspirators was significantly higher when tested with higher IDDSI levels of test food. ConclusionThe diagnostic accuracy of commonly-used clinical signs for the indication of aspiration is significantly affected by food consistency. Test foods with varying consistencies, particularly those at IDDSI level 2, should be considered during clinical swallow examinations, especially for screening purposes.

Effects of neuromuscular electrical stimulation in patients with Parkinson's disease and dysphagia: A randomized, single-blind, placebo-controlled trial.

Neuromuscular electrical stimulation has been used to improve swallowing function in neurologic patients with dysphagia, but its effect on patients with dysphagia and Parkinson's disease remains unclear. This study aimed to identify the effect of effortful swallowing combined with neuromuscular electrical stimulation as a novel treatment approach in dysphagic patients with Parkinson's disease. Participants were randomly allocated to an experimental group (n = 9) or a placebo group (n = 9). The experimental group simultaneously received neuromuscular electrical stimulation with effortful swallowing, while the placebo group received sham neuromuscular electrical stimulation with effortful swallowing. All participants received the treatment for 30 min/day at five sessions per week for 4 weeks. Both groups also received the same conventional dysphagia therapy. The experimental group showed significant differences in horizontal movement (p = 0.038) and vertical movement (p = 0.042) compared to the placebo group, but showed no significant differences in the oral (p = 0.648) or pharyngeal phase (p = 0.329) of the Videofluoroscopic Dysphagia Scale compared to the placebo group, except for the Penetration-Aspiration Scale (p = 0.039). We demonstrated that neuromuscular electrical stimulation applied to the infrahyoid region combined with effortful swallowing effectively increased hyoid bone movement and reduced aspiration in dysphagic patients with Parkinson's disease.

Murray secretion scale and fiberoptic endoscopic evaluation of swallowing in predicting aspiration in dysphagic patients.

The objective of this retrospective review is to evaluate the ability of the Murray secretion scale to predict aspiration as determined by fiberoptic endoscopic evaluation of swallowing. Patients with dysphagia undergoing a fiberoptic endoscopic evaluation of swallowing study between January 2013 and November 2015 from a single, tertiary care institution were retrospectively reviewed. The Murray secretion scale and penetration aspiration scale on fiberoptic endoscopic evaluation of swallowing examination were determined. Spearman's correlation analysis, sensitivity, specificity, predictive values, and relative risk evaluating the relationship between the Murray secretion scale and aspiration on fiberoptic endoscopic evaluation of swallowing were calculated. Subgroups of head and neck cancer patients, penetration group, and aspiration group were also analyzed. The mean age of the cases (N = 212) was 62.4years. Eighty percent were male. There was a strong correlation between Murray secretion scale grade and penetration aspiration scale score (r = 0.785, p < 0.001). The sensitivity and specificity of a Murray secretion scale grade 2 or higher in predicting aspiration were 74 and 90%, respectively. Individuals with a Murray secretion scale grade of 2 or higher were 13.6 times more likely to aspirate than patients with a lower Murray secretion scale grade. All subgroups showed similar trend. Determination of a Murray secretion scale grade, determined by flexible nasopharyngoscopy, may predict patients at high risk for aspiration. In clinical scenarios where more complete assessments of aspiration risk are immediately impossible or impractical, the Murray secretion scale grade may add valuable information to assist in clinical decision-making in patients with dysphagia.

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 10cc 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.

PTU-132 Carbonated Solutions are Superior to Sour Solutions in Modifying Human Swallowing Reaction time Performance

Introduction Background/AimsClinical evidence supports a role for carbonated liquids in reducing aspiration in dysphagic patients compared to simple water (Bulow et al Acta Radiologica, 2003). However, there are limited data...

Dysphagia Screening and Intensified Oral Hygiene Reduce Pneumonia After Stroke

Dysphagia occurs in approximately 51%-78% of patients with acute stroke. The incidence of pneumonia caused by aspiration in dysphagic patients increases both mortality and the need for hospitalization. The aim of this study was to investigate whether the incidence of aspiration pneumonia could be reduced in such patients by an early screening for dysphagia and intensified oral hygiene. In this controlled trial, 146 hospitalized acute stroke patients with moderate or severe dysphagia were included in three groups: an intervention group (n = 58), one internal control group (n = 58, retrospectively selected from same clinic), and one external control group (n = 30) from a comparable stroke unit in a neighboring hospital. The intervention consisted of early screening with a clinical method of dysphagia screening, the Gugging Swallowing Screen, and intensified oral hygiene. The incidence of x-ray verified pneumonia was 4 of 58 (7%) in the intervention group compared with 16 of 58 (28%) in the internal control group (p < .01) and with 8 of 30 (27%) in the external control group (p < .05). Early and systematic dysphagia screening by the Gugging Swallowing Screen method and intensified oral hygiene reduced the incidence of x-ray verified pneumonia.

PWE-057 Bilateral reversal of a virtual lesion to human pharyngeal motor cortex by carbonated water swallowing

IntroductionAnecdotal clinical evidence supports the use of carbonated liquids in reducing the likelihood of aspiration in dysphagic patients (Bulow et al. Acta Radiol 2003; Sdravou et al. Dysphagia 2011). Repetitive...

Su1974 Classification of Cyclic Vomiting Syndrome Patients in Inter-Episodic Phase From Healthy Controls Using Cortical Resting State Functional Connectivity

Background/Aims: Anecdotal clinical evidence supports the use of carbonated liquids in reducing the likelihood of aspiration in dysphagic patients (Bulow et al,Acta Radiol 2003; Sdravou et al, Dysphagia 2011). Repetitive transcranial magnetic stimulation (rTMS) delivered at 1-Hz can induce transient focal suppression of pharyngeal motor cortex (Mistry S., et al. J Physiol, 2007). Here we investigated whether swallowing of carbonated water can reverse the inhibitory effects of a virtual lesion to pharyngeal motor cortex, compared to still water and saliva swallowing. Methods: In 9 healthy subjects (5 male, mean age 33.7 ± 14.34(SD)) pharyngeal electromyographic responses were recorded using an intraluminal catheter after the application of Transcranial Magnetic Stimulation (TMS) over pharyngeal motor cortex, as a measure of cortico-bulbar excitability. On 3 randomised visits, subjects were cued by a visual feedback software to perform a total of 40 swallows over 10 minutes (swallows every 15 s) of either carbonated water or still water vs. 10 minutes of saliva swallowing ad libitum (control), before and after an unilateral 1-Hz virtual lesion of the pharyngeal motor cortex. Cortical excitability (presented as mean ± SEM) was then reassessed bilaterally for 60 minutes post-interventions and analysed with two-way ANOVA (SPSS 14). Results: Compared to saliva swallowing (control), swallowing of carbonated water appeared to increase cortical excitability bilaterally (lesioned pharyngeal motor cortex: 68 ± 38% at 30 minutes post intervention, and to the unlesioned: 60 ± 24%, at 15 minutes post), not seen with still water swallowing. However, using a 2-way ANOVA, only the effects over the ipsilateral (lesioned) pharyngeal motor projection were statistical significant for carbonation (F1,8=6.2, p=0.037, Figure 1). Conclusion: Carbonation reverses the effects of a unilateral virtual lesion with significant increases in cortical excitability limited to the lesioned hemisphere. These data support the notion that chemesthetic solutions of carbonation may provide the required peripheral sensory information that can influence greater neuronal activity compared to still water swallowing. These data provides the platform for considering the use of carbonation as facilitating stimuli in dysphagic patients who aspirate thin liquids.

Su1975 Molecular Alteration in Anterior Cingulate Cortex Following Esophageal Acid Challenge and Rechallenge in Adult Rats

Background/Aims: Anecdotal clinical evidence supports the use of carbonated liquids in reducing the likelihood of aspiration in dysphagic patients (Bulow et al,Acta Radiol 2003; Sdravou et al, Dysphagia 2011). Repetitive transcranial magnetic stimulation (rTMS) delivered at 1-Hz can induce transient focal suppression of pharyngeal motor cortex (Mistry S., et al. J Physiol, 2007). Here we investigated whether swallowing of carbonated water can reverse the inhibitory effects of a virtual lesion to pharyngeal motor cortex, compared to still water and saliva swallowing. Methods: In 9 healthy subjects (5 male, mean age 33.7 ± 14.34(SD)) pharyngeal electromyographic responses were recorded using an intraluminal catheter after the application of Transcranial Magnetic Stimulation (TMS) over pharyngeal motor cortex, as a measure of cortico-bulbar excitability. On 3 randomised visits, subjects were cued by a visual feedback software to perform a total of 40 swallows over 10 minutes (swallows every 15 s) of either carbonated water or still water vs. 10 minutes of saliva swallowing ad libitum (control), before and after an unilateral 1-Hz virtual lesion of the pharyngeal motor cortex. Cortical excitability (presented as mean ± SEM) was then reassessed bilaterally for 60 minutes post-interventions and analysed with two-way ANOVA (SPSS 14). Results: Compared to saliva swallowing (control), swallowing of carbonated water appeared to increase cortical excitability bilaterally (lesioned pharyngeal motor cortex: 68 ± 38% at 30 minutes post intervention, and to the unlesioned: 60 ± 24%, at 15 minutes post), not seen with still water swallowing. However, using a 2-way ANOVA, only the effects over the ipsilateral (lesioned) pharyngeal motor projection were statistical significant for carbonation (F1,8=6.2, p=0.037, Figure 1). Conclusion: Carbonation reverses the effects of a unilateral virtual lesion with significant increases in cortical excitability limited to the lesioned hemisphere. These data support the notion that chemesthetic solutions of carbonation may provide the required peripheral sensory information that can influence greater neuronal activity compared to still water swallowing. These data provides the platform for considering the use of carbonation as facilitating stimuli in dysphagic patients who aspirate thin liquids.

Effect of shear thinning on aspiration – Toward making solutions for judging the risk of aspiration

Polysaccharide solutions containing a contrast medium were prepared so that their viscosity at 50 s −1, which was reported as a shear rate in the oral cavity, is the same but different at other shear rates. Preparation procedure of such solutions based on heat treatment using widely used polysaccharides in foods is described, and the rheological properties of these solutions are discussed in relation with flow behaviours in the swallowing process. Videofluorographic observation was performed for healthy persons and patients and compared with rheological characteristics of these solutions to understand the mechanism of aspiration. It was shown that the degree of aspiration depended on the degree of shear thinning of polysaccharide solutions. This study showed the possibility to find what kind of fluid induces the aspiration and to reduce the risk of aspiration in dysphagic patients by controlling the food rheology.

Evidence for an enhancing effect of carbonated liquids on complex human swallowing behaviour

IntroductionAnecdotal clinical evidence supports the use of carbonated liquids for reducing pharyngeal transit time and the likelihood of aspiration in dysphagic patients compared to non-carbonated liquids.1 However, there is limited...

Inter- and intra-rater reliability of cervical auscultation to detect aspiration in patients with dysphagia.

To measure the inter- and intra-rater reliability of cervical auscultation used alone to detect aspiration in dysphagic patients. A university teaching hospital. Comparison of the detection of aspiration in 16 recorded swallow sounds by five speech and language therapists on two occasions. Swallow sounds were recorded simultaneously with videofluoroscopy. Sixteen patients referred for assessment of dysphagia with videofluoroscopy. The kappa statistic for multiple raters showed fair agreement between raters (kappa = 0.28). There was high agreement when aspiration occurred but in non-aspirating swallows there was significant overdetection of aspiration (p < 0.001 McNemar's test). The intra-rater reliability within different individuals was widely variable (kappa = 0.55 (range 0.31-0.85)). Presented with the swallowing sounds in isolation speech and language therapists cannot reliably classify swallows into those with accompanying aspiration and those without. There appears to be a problem of over detection of aspiration. Even in this small study, however, some individual therapists achieve such high reliability (kappa = 0.85) that they must be using successful internal criteria to interpret the swallow sounds correctly and further qualitative research may identify these.

The relationship between the shape of the pyriform sinus and the risk of aspiration in dysphagic patients

The relationship between the shape of the pyriform sinus and the risk of aspiration in dysphagic patients

A preliminary comparison of videofluoroscopy of swallow and pulse oximetry in the identification of aspiration in dysphagic patients

ABSTRACT Pulse oximetry has recently received attention in the dysphagia literature on account of its possible contribution to the management of neurogenic dysphagia. The present study was devised to examine whether pulse oximetry could be exploited to determine episodes of aspiration in patients with known dysphagia of neurological origin. To this end, pulse oximetry was undertaken in six patients undergoing videofluoroscopic study of swallow. Normal controls also underwent pulse oximetry during feeding. The results indicate that there is no clear‐cut relationship between changes in arterial oxygenation and aspiration. Some support, however, is found for altered arterial oxygenation being associated with oral feeding in dysphagic individuals. Further research in both normal subjects and compromised individuals is required.

Chin-down posture effect on aspiration in dysphagic patients.

Use of the chin-down posture during swallowing has been reported to reduce the occurrence of aspiration in some dysphagic patients. This study measured four pharyngeal dimensions in 30 neurologically impaired patients who aspirated before the swallow because of a delay in triggering the pharyngeal swallow, 15 for whom the posture eliminated aspiration and 15 who aspirated despite the chin-down position. Patients who did not benefit from the posture were significantly younger and aspirated material from the pyriform sinus rather than the valleculae when the pharyngeal swallow was triggered. Changes in pharyngeal dimensions with the chin down were not significantly different for both patient groups, except for epiglottic angle, which increased significantly more in the group who continued to aspirate. Changes in pharyngeal dimensions with chin-neutral versus chin-down differed somewhat from those reported in a previous publication. Possible reasons for these differences are discussed.