Risk Of Aspiration In Patients Research Articles

An analysis of enhanced recovery pathways for bariatric surgery-preoperative fasting, carbohydrate loading, and aspiration risk: a position statement from the International Society for the Perioperative Care of Patients with Obesity.

Enhanced recovery pathways (ERPs) and recommendations have become widely accepted for metabolic and bariatric surgery, including recommendations for preoperative carbohydrate loading and duration of fasting status. There is still a lack of consensus regarding such protocols and the underlying issues of gastric emptying time, resting gastric volume and pH, and risk of aspiration in patients with severe obesity and in patients undergoing bariatric surgery. The goal of this position statement by the International Society for the Perioperative Care of Patients with Obesity (ISPCOP) is to provide an analysis of available data on preoperative fasting and loading with oral complex clear carbohydrate drinks as well its potential effects on perioperative risk of aspiration in the context of Enhanced Recovery Pathways for Metabolic and Bariatric Surgery (ERAMBS).

Ultrasound assessment of gastric contents and volume in patients undergoing endoscopic endonasal transsphenoidal surgery: a prospective observational study

Intraoperative ingestion of blood, cerebrospinal fluid, and irrigation fluid can lead to an increase in gastric volume, resulting in the potential risk of aspiration in patients after endoscopic endonasal transsphenoidal surgery (EETS). In this prospective observational study, we aimed to assess the volume of gastric contents in patients undergoing this neurosurgical procedure using ultrasound, and to determine the factors associated with volume change. Eighty-two patients diagnosed with pituitary adenoma were recruited consecutively. Semi-quantitative (Perlas scores: 0, 1 and 2) and quantitative (cross-sectional area, CSA) ultrasound assessments of the gastric antrum were performed immediately before and after surgery in the semi-recumbent and semi-recumbent right-lateral positions. Seven (8.5%) patients had antrum scores from preoperative grade 0 to postoperative grade 2; nine (11%) patients had antrum scores from preoperative grade 0 to postoperative grade 1. The mean ± standard deviation (SD) of increased gastric volume was 71.0 ± 33.1 mL and 236.5 ± 32.4 mL in postoperative grade 1 and 2 groups, respectively. Subgroup analysis showed that 11 (13.4%) patients (4 in grade 1 and all in grade 2) had postoperative estimated gastric volume > 1.5 mL kg−1 (mean ± SD 3.08 ± 1.67, range 1.51–5.01 mL kg−1). Logistic regression analysis revealed that older age, diabetes mellitus, and long surgical duration were independent risk factors for significant volume change (all P < 0.05). Our results showed a significant increase in gastric volume in some patients who underwent EETS. Bedside ultrasound measurements of gastric volume can be used to assess the postoperative aspiration risk, particularly in older diabetic patients with a longer surgical duration.

Validity &amp; Reliability of a Korean-version of Eating Assessment Tool (K-EAT-10): Predicting the Risk of Aspiration in Stroke Patients

Objectives: This study aims to investigate the reliability and validity of a Korean version of the Eating Assessment Tool (EAT-10) as a clinical evaluation tool for dysphagia with stroke patients and determine its clinical usefulness as a screening tool. Methods: A total of 50 patients with stroke (15 without dysphagia, and 35 with dysphagia, identified through a videofluoroscopic swallowing study (VFSS) participated in this study. The internal consistency, test-retest reliability, and concurrent validity of the adapted Korean version of EAT-10(K-EAT-10) were evaluated. In addition, the K- EAT-10 scores were compared between two groups according to demographic characteristics, post-stroke conditions, and swallowing function. Moreover, K-EAT-10 scores were compared with the VFSS findings to estimate the sensitivity, specificity, and positive and negative predictions of aspiration. Results: The internal consistency of the K-EAT-10 questionnaire showed a Cronbach α coefficient of .091, and the correlation coefficient of the test- retest reliability was .988. In addition, when correlation analysis was performed between the total score of K-EAT-10 and the K-DHI, the correlation coefficient was .904. In the receiver operating characteristic (ROC) curve analysis of K-EAT-10, a cut-off point for the K-EAT-10 questionnaire was set at 10 points with a sensitivity of 86.7% and specificity of 77.1%, and the area under the curve was shown to be 0.86. In addition, the positive predictive value (PPV) for the K-EAT-10 was 91%, and the negative predictive value (NPV) was 60%. Conclusion: Korean version of EAT-10 revealed excellent internal consistency, test-retest reliability, concurrent validity and positive predictive value for aspiration. The results suggest that the Korean adaptation of EAT-10 can be useful as a clinical screening test for dysphagia, especially predicting aspiration risk in patients with stroke.

Establishment of a Multi-parameter Evaluation Model for Risk of Aspiration in Dysphagia: A Pilot Study.

It's difficult for clinical bedside evaluations to accurately determine the occurrence of aspiration in patients. Although VFSS and FEES are the gold standards for clinical diagnosis of dysphagia, which are mainly used to evaluate people at high risk of dysphagia found by bedside screening, the operation is complicated and time-consuming. The aim of this pilot study was to present an objective measure based on a multi-parameter approach to screen for aspiration risk in patients with dysphagia. Objective evaluation techniques based on speech parameters were used to assess the oral motor function, vocal cord function, and voice changes before and after swallowing in 32 patients with dysphagia (16 low-risk aspiration group, 16 high-risk aspiration group). Student's t test combined with stepwise logistic regression were used to determine the optimal index. The best model consists of three parameters, and the equation is: logit(P) = -3.824-(0.504 × maximum phonation time) + (0.008 × second formant frequency of /u/)-0.085 × (fundamental frequency difference before and after swallowing). An additional eight patients with dysphagia were randomly selected as the validation group of the model. When applied to validation, this model can accurately identify the risk of aspiration in 87.5% of patients, and the sensitivity is as high as 100%. Therefore, it has certain clinical practical value that may help clinicians to assess the risk of aspiration in patients with dysphagia, especially for silent aspiration.

Pulmonary Aspiration Albeit Rapid Sequence Induction in Achalasia CardiaDo We Have an Infallible Technique?

Achalasia cardia is among the conditions that pose a high risk of aspiration during induction of anaesthesia. This report is about a case of 23-year-old male patient, where regurgitation and pulmonary aspiration occurred in a patient with achalasia cardia despite Rapid Sequence Induction (RSI). The risk of aspiration in conditions that cause stasis in the oesophagus is much higher due to the anaesthetic induced relaxation of the upper oesophageal sphincter and the proximity of the pooled contents to the oropharynx. The lower oesophageal sphincter being pathological in achalasia cardia does not relax. In this article, even though it is a case report of such an incidence, the various techniques that can be adopted to negate the risk have been explored. Preinduction oesophagoscopy and suctioning, video-laryngoscope guided intubation and ultrasound confirmation of Tracheal Tube (TT) position before initiating ventilation can be adopted in addition to head up positioning and RSI as an infallible technique to abolish the aspiration risk in patients with achalasia cardia. The case report is highlighted in the way to focus on describing safe ways of induction of anaesthesia where there is a high risk of aspiration.

Aspiration Screening in Motor Neuron Disease: Preliminary Results From Utilization of the Yale Swallow Protocol.

Purpose Dysphagia is a common symptom experienced by patients with motor neuron disease (MND). The Yale Swallow Protocol (YSP) is a validated screening instrument for identifying patients at risk for aspiration. The purpose of this exploratory cross-sectional, multicenter study was to investigate how the YSP results in identifying aspiration risk in patients with MND in comparison with aspiration observed during a videofluoroscopic swallow study (VFSS). Method Participants referred for VFSS as part of clinical management were recruited from four specialized MND clinics. All participants were administered the YSP immediately prior to the VFSS by a speech-language pathologist, with results recorded as pass or fail. Aspiration on VFSS was determined using the Penetration-Aspiration Scale (scores 6-8). A 2 × 2 contingency table was constructed to compare results of YSP with those on VFSS. Results Thirty-one patients with MND (13 males, 18 females; M age = 64 ± 12 years) referred for VFSS participated in this study. Of the 22 patients who failed the YSP, interrupted drinking was the most frequent reason (65%). Compared to the VFSS, the YSP yielded a sensitivity of 80%, a specificity of 33%, positive predictive value of 36%, and negative predictive value of 78%. Conclusions The YSP is a simple tool and easy to utilize and has a high sensitivity in identifying aspiration risk in amyotrophic lateral sclerosis. A future investigation with a larger sample size is needed to better investigate the utility of YSP as a screening tool for this population.

A protocol implementation to determine aspiration risk in patients with multiple risk factors for gastroparesis.

Patients with risk factors for gastroparesis are at increased risk for aspiration into the tracheobronchial tree. Current American Society of Anesthesiologists fasting guidelines use subjective measures to determine aspiration risk. A gastric ultrasound protocol can identify patients with risk factors for gastroparesis and determine the need to perform a point-of-care gastric ultrasound to objectively assess gastric antral contents. This enables the anaesthesia provider to assess patients at increased risk for aspiration. Additionally, many patients who present for surgery with risk factors for gastroparesis have an empty gastric antrum. Thus, the gastric ultrasound protocol checklist saves time and manpower requirements of anaesthesia staff without impacting patient safety or perioperative efficiency. A convenience sample of 40 patients consented for surgery was assessed using a screening tool to identify those at risk for gastroparesis and possible aspiration. Patients deemed at risk received a gastric ultrasound examination to evaluate for the presence of gastric contents. Over 12% of these patients had solid food gastric contents on exam. All patients with solid food gastric contents had an American Society of Anesthesiologists Physical Status Classification of 3 or higher, and two or more risk factors for gastroparesis.

The Effects of Fasting Status on the Relative Risk of Pulmonary Aspiration in Acute Care Surgery Patients

Acute care surgery patients are often unfasted at the time of surgery, presenting a unique opportunity to study the effects of fasting on the risk of pulmonary aspiration. We aimed to determine the relative risk of aspiration in patients who were fasted at the time of surgery according to guidelines versus those in an unfasted state. A retrospective chart review of 100 patients who underwent appendectomy (n = 76) or exploratory laparotomy (n = 24) was conducted at a single institution in 2016-2017. Using the American Society of Anesthesiologists (ASA) Practice Guidelines for Preoperative Fasting, patients were stratified into study and control groups according to whether they were unfasted (nothing by mouth for <8 hours prior to surgery) or fasted (nothing by mouth for >8 hours prior to surgery). Data controlled for patients' age, sex, body mass index (BMI), most recent hemoglobin A1c, presence of gastroesophageal reflux disease (GERD), and presence of hiatal hernia. Of the 76 patients who underwent appendectomy, 15% were unfasted with a total of 0 aspiration events (P < .001). Of the 24 patients who underwent exploratory laparotomy, 42% were unfasted with a total of 0 aspiration events (P < .001). This yields a relative risk of pulmonary aspiration of 1.0 (absolute risk of 0) in both the study and control groups. In an acute care surgery population including patients who were not fasted according to guidelines, there was no increase in the risk of pulmonary aspiration. Epidemiological study; Level III.

Does Point-of-Care Gastric Ultrasound Correlate With Reported Fasting Time?

Traditionally, patient-reported fasting time has been the primary objective presedation measure of aspiration risk. Recently, gastric ultrasound has been used to assess gastric volume for the determination of aspiration risk in patients undergoing anesthesia in the operative setting. We sought to determine the correlation of gastric volume estimated by point-of-care ultrasound (POCUS) to reported fasting time. We included children 4 to 18 years of age who presented with an acute traumatic injury. Enrolled children underwent POCUS to calculate gastric volume, which was calculated using a validated formula: Volume (mL) = -7.8 + (3.5 × Cross-sectional Area [CSA]) + (0.127 × Age in months). The CSA was measured (CSA = (anterior-posterior diameter × craniocaudal diameter × π)/4). We analyzed the relationship between time since last reported oral intake and measured gastric volume using Spearman rank correlation (ρ). A total of 103 patients with a median age of 10.5 years (interquartile range, 7.3-13.7 years) were enrolled. The gastric antrum was identified and measured in 88 (85%) patients; air obstructing the posterior surface of the gastric antrum prevented measurement in 14 of the 15 remaining patients. We observed a weak inverse correlation between fasting time (either liquid or solid) and estimated gastric volume (ρ = -0.33), with no significant difference based on type of intake (solids, ρ = 0.28; liquids, ρ = 0.22). Gastric volume can be estimated by POCUS and is not strongly correlated with fasting time in children in the emergency department setting.

Multilingual Validation of the First French Version of Munich Dysphagia Test-Parkinson's Disease (MDT-PD) in the Luxembourg Parkinson's Study.

Introduction: The Munich Dysphagia Test for Parkinson's disease (MDT-PD) was initially developed and validated in the German population as a highly sensitive and specific self-reported screening questionnaire to detect early oropharyngeal symptoms and aspiration risk in patients with idiopathic Parkinson's disease (iPD). In order to make this tool accessible for prevention in the French speaking populations worldwide, we performed the first French translation and provide a linguistic and psychometric validation in the unique multilingual environment of the Luxembourg Parkinson's Study.Methods: We performed the translation of the MDT-PD into French according to WHO guidelines and subsequently performed the linguistic validation including native speakers. For psychometric validation, 46 patients with parkinsonism from Luxembourg and the Greater Region without severe cognitive impairment were recruited in the frame of the Luxembourg Parkinson's Study. All patients were fluent in French and German completed the MDT-PD in both languages (three times in total).Results: Linguistic and psychometric validation of the French MDT-PD was reflected by a high test-retest (10/26 questions with K > 0.6 and 10/26 with 0.4 < K ≤ 0.6) and language reliability (12/26 K > 0.6 and 8/26 0.4 < K ≤ 0.6), with an internal consistency for the French (Cronbach's alpha 0.84) and German version (0.87); strong item collinerarity strengthens the internal consistency. No significant differences between MDT-PD score distribution and clinical parameters assessing, for example, disease progression, motor state, or cognition has been observed.Conclusion: Based on a multilingual approach in the Luxembourg Parkinson Study, we validated the translation of the first French MDT-PD as a non-invasive tool for early detection of dysphagia in patients with parkinsonism. The unexpectedly high number of positively screened patients at earlier disease stages indicate options for new prevention strategies in large French speaking populations worldwide. Diagnostic validation using clinical and endoscopic swallowing evaluation will be continued soon.

Effects of noninvasive ventilation on the coordination between breathing and swallowing in patients with chronic obstructive pulmonary disease.

PurposeAs shown in our previous study, inspiration after swallowing (SW-I) increases during the bi-level positive airway pressure ventilation (BiPAP) in healthy subjects because swallowing-associated non-inspiratory flow (SNIF) triggers inspiratory support, while SW-I during continuous positive pressure ventilation (CPAP) is rare. In the present study, we evaluated the coordination between breathing and swallowing during spontaneous breathing, BiPAP, and CPAP in patients with chronic obstructive pulmonary disease (COPD).Patients and methodsThis study is a prospective intervention study at the Hoshigaoka Medical Center (November 01, 2015–April 30, 2018). We simultaneously recorded the respiratory flow, laryngeal motion, and swallowing sounds during saliva swallowing in patients with COPD. We estimated the respiratory phase after swallowing, frequency of SNIF, the duration of the respiratory pause during swallowing, and timing of swallowing in the respiratory cycle and compared these parameters among control, CPAP, and BiPAP conditions.ResultsThe expiration after swallowing (SW-E) frequency was associated with the occurrence of SNIF (p<0.01), pause duration ≤0.8 s (p<0.01), and timing of swallowing at the intermediate respiratory phase (50–80% of the respiratory cycle from the onset of inspiration) (p<0.01). In particular, the occurrence of SNIF most substantially affected the SW-E frequency. The SW-I frequencies under the control, CPAP, and BiPAP conditions were 35.0%, 3.0%, and 37.7%, respectively. The pause durations were shorter during CPAP and BiPAP than under the control condition (p<0.01). During CPAP, the occurrence rates of SW-E. Residual denotes the percentage difference between observed and expected values (residual =10.8: p<0.01) and SNIF (residual =9.1: p<0.01) were significantly increased, and timing of swallowing shifted toward the intermediate respiratory phase (residual=3.5: p<0.01).ConclusionCPAP decreases the SW-I frequency, increases the SNIF occurrence, and normalizes the timing of swallowing, all of which suggest that CPAP alleviates the risk of aspiration in patients with COPD.

Predicting aspiration risk in patients with dysphagia: Evidence from fluoroscopy.

ObjectiveTo investigate the potential of timing and displacement measures from fluoroscopic swallow studies for predicting aspiration in dysphagic patients.MethodsTiming and displacement variables for a 20‐ml liquid bolus were extracted from fluoroscopic swallow studies of 5923 patients reflecting a variety of dysphagia etiologies. Patients were divided into aspirators and non‐aspirators, and variables were compared between groups, and to a group of 148 normal control subjects. The relationship of each variable to aspiration was determined. Odds ratios for aspiration were calculated for measures deviating more than two standard deviations from normal. Associations of variables with time of aspiration relative to airway closure were also examined.ResultsRegression analyses revealed that the pharyngeal constriction ratio (PCR) was the measure most predictive of aspiration (74.6%), with percentage of accuracy improving to 76.5% when all measures were considered. Odds Ratios ranging from two times to more than five times were identified for variables deviating more than two standard deviations from normal. Aspiration relative to maximum airway closure, ie, before, during, and after, was also investigated. In the current study, 53% of aspiration events occurred after maximum airway closure, on residue that remained after swallow. Some mechanical impairments appeared specific to timing of aspiration and provide further evidence of the utility of mechanical analysis.ConclusionsResults of the review provide substantial support for the value of quantitative assessment of swallow mechanics, and for the role of such data in predicting aspiration risk in dysphagic patients.Level of Evidence3b (retrospective, individual case‐control)

Utility of Eating Assessment Tool-10 in Predicting Aspiration in Patients with Unilateral Vocal Fold Paralysis.

Objective Examine the incidence of penetration/aspiration in patients with unilateral vocal fold immobility and investigate the relationship with self-reported perception of dysphagia. Study Design Case series with chart review. Setting Academic cancer center. Subjects and Methods Adult patients with unilateral vocal fold immobility diagnosed between 2014 and 2016 were reviewed. Patients were stratified into an aspiration group and a nonaspiration group using objective findings on flexible endoscopic evaluation of swallowing, as scored using Rosenbek's Penetration Aspiration Scale. Objective findings were compared to patient perception of dysphagia. Bivariate linear correlation analysis was performed to evaluate correlation between Eating Assessment Tool-10 scores and presence of aspiration. Tests of diagnostic accuracy were calculated to investigate the predictive value of Eating Assessment Tool-10 scores >9 on aspiration risk. Results Of the 35 patients with new-onset unilateral vocal fold immobility were evaluated, 25.7% (9/35) demonstrated tracheal aspiration. Mean ± SD Eating Assessment Tool-10 scores were 19.2 ± 13.7 for aspirators and 7.0 ± 7.8 for nonaspirators ( P = .016). A statistically significant correlation was demonstrated between increasing Eating Assessment Tool-10 scores and Penetration Aspiration Scale scores ( r = 0.511, P = .002). Diagnostic accuracy analysis for aspiration risk in patients with an Eating Assessment Tool-10 score >9 revealed a sensitivity of 77.8% and a specificity of 73.1%. Conclusion Patient perception of swallowing difficulty may have utility in predicting aspiration risk. An EAT-10 of >9 in patients with unilateral vocal fold immobility may portend up to a 5 times greater risk of aspiration. Routine swallow testing to assess for penetration/aspiration may be indicated in patients with unilateral vocal fold immobility.

Predictive factors for oropharyngeal dysphagia after prolonged orotracheal intubation.

IntroductionLesions in the oral cavity, pharynx and larynx due to endotracheal intubation can cause reduction in the local motility and sensitivity, impairing the swallowing process, resulting in oropharyngeal dysphagia.ObjectiveTo verify the predictive factors for the development of oropharyngeal dysphagia and the risk of aspiration in patients with prolonged orotracheal intubation admitted to an intensive care unit.MethodsThis is an observational, analytical, cross-sectional and retrospective data collection study of 181 electronic medical records of patients submitted to prolonged orotracheal intubation. Data on age; gender; underlying disease; associated comorbidities; time and reason for orotracheal intubation; Glasgow scale on the day of the Speech Therapist assessment; comprehension; vocal quality; presence and severity of dysphagia; risk of bronchoaspiration; and the suggested oral route were collected. The data were analyzed through logistic regression. The level of significance was set at 5%, with a 95% Confidence Interval.ResultsThe prevalence of dysphagia in this study was 35.9% and the risk of aspiration was 24.9%. As the age increased, the altered vocal quality and the degree of voice impairment increased the risk of the presence of dysphagia by 5-; 45.4- and 6.7-fold, respectively, and of aspiration by 6-; 36.4- and 4.8-fold. The increase in the time of orotracheal intubation increased the risk of aspiration by 5.5-fold.ConclusionPatients submitted to prolonged intubation who have risk factors associated with dysphagia and aspiration should be submitted to an early speech-language/audiology assessment and receive appropriate and timely treatment. The recognition of these predictive factors by the entire multidisciplinary team can minimize the possibility of clinical complications inherent to the risk of dysphagia and aspiration in extubated patients.

Rapid Aspiration Screening for Suspected Stroke: Part 1: Development and Validation

ObjectiveTo develop and validate a nurse-administered screening tool to identify aspiration risk in patients with suspected stroke. DesignValidity study comparing evidence-based swallowing screening items with the videofluoroscopic swallowing study (VFSS) results. SettingA certified primary stroke center in a major metropolitan medical facility. ParticipantsConsecutive patients (N=250) admitted with suspected stroke. InterventionsPatients were administered evidence-based swallowing screening items by nurses. A VFSS was completed within 2 hours of swallowing screening. Main Outcome MeasuresValidity relative to identifying VFSS-determined aspiration for each screening item and for various combinations of items. ResultsAspiration was identified in 29 of 250 participants (12%). Logistic regression revealed that age (P=.012), dysarthria (P=.001), abnormal volitional cough (P=.030), and signs related to the water swallow trial (P=.021) were significantly associated with aspiration. Validity was then determined on the basis of the best combination of significant items for predicting aspiration. The results revealed that age >70 years, dysarthria, or signs related to the water swallow trial (ie, cough, throat clear, wet vocal quality, and inability to continuously drink 90mL water) yielded 93% sensitivity and 98% negative predictive value. ConclusionsThe final validated tool, Rapid Aspiration Screening for Suspected Stroke, is a valid nurse-administered tool to detect risk of aspiration in patients presenting with suspected stroke.

Swallowing Kinematics and Factors Associated with Laryngeal Penetration and Aspiration in Stroke Survivors with Dysphagia.

The purpose of this study was to investigate swallowing kinematics and explore kinematic factors related with penetration-aspiration in patients with post-stroke dysphagia. Videofluoroscopic images of 68 patients with post-stroke dysphagia and 34 sex- and age-matched healthy controls swallowing a thin liquid were quantitatively analyzed using two-dimensional motion digitization. The measurements included the movement distances and velocities of the hyoid and larynx, and the maximal tilt angles and angular velocities of the epiglottis. All velocity variables were significantly decreased in the stroke patients compared to the controls. There was a significant difference in the maximal horizontal displacement of the larynx, but there were no significant differences in other displacements of the larynx, the maximal displacements of the hyoid bone, and the maximum tilt angle of the epiglottis between the two groups. The maximal tilt angle of the epiglottis was lower in the aspiration subgroup than in the no penetration/aspiration and penetration subgroups as well as the controls. The maximal tilt angle from the y axis showed a dichotomous pattern at 90° of the angle, and all 11 patients with an angle <90° showed either penetration or aspiration. In the ROC curve of the angle for prediction of aspiration, the area under the curve was 0.725 (95% CI 0.557-0.892, P=0.008). This study suggested that sluggish rather than decreased hyolaryngeal movements during swallowing are a remarkable feature of post-stroke dysphagia. The association of reduced epiglottic movement with the risk of aspiration in patients with post-stroke dysphagia was supported by the quantitative analysis.

Speech Pathology Reliability for Stroke Swallowing Screening Items.

Swallowing screening is critical in rapid identification of risk of aspiration in patients presenting with acute stroke symptoms. Accuracy in judgments is vital for the success of the screening. This study examined speech-language pathologists' (SLPs) reliability in interpreting screening items. Swallowing screening was completed in 75 individuals admitted with stroke symptoms. Screening items evaluated were lethargy, dysarthria, wet voice unrelated to swallowing, abnormal volitional cough, and cough, throat clear, wet voice after swallowing, and inability to continuously drink with ingestion of 5 and 90 ml water. Two SLPs, each with more than 10 years of experience, made simultaneous independent judgments of the same observations obtained from the screening. Overall, generally high agreement was identified between the SLPs (k[SE] = 0.83[0.03]). Individual kappas ranged from 0.38 (fair) for non-swallowing wet voice to 0.95 (almost perfect) for cough after swallow, with one item omitted due to minimal variation. SLPs demonstrate high reliability in swallowing screening. Results, however, indicate some potential variability. Items associated with trial swallows had the highest reliability, whereas items related to judgments of speech and voice quality had the lowest. Although SLPs have dedicated training and ample opportunity to practice, differences in agreement are evident. Routine practice in hospital departments is recommended to establish and maintain sensitive perceptual discrimination. If other professionals are to provide swallowing screening, knowledge of SLPs' reliability levels must be considered when identifying screening items, creating education modules, and determining acceptable levels of agreement.

Full Implementation of Screening for Nutritional Risk and Dysphagia in an Acute Stroke Unit: A Clinical Audit.

In patients with acute stroke, undernutrition and aspiration pneumonia are associated with increased mortality and length of hospital stay. Formal screening for nutritional risk and dysphagia helps to ensure optimal nutritional management in all patients with stroke and to reduce the risk of aspiration in patients with dysphagia. We developed a national guideline for nutritional and dysphagia screening in acute stroke, which was introduced in our stroke unit on June 1, 2012. The primary objective was to audit adherence to the guideline and to achieve full implementation. Second, we assessed the prevalence of nutritional risk and dysphagia. We performed a chart review to assess performance of screening for nutritional risk and dysphagia in all patients with stroke hospitalized for ≥48 hours between June 1, 2012, and May 31, 2013. Next we applied a "clinical microsystems approach" with rapid improvement cycles and audits over a 6-month period to achieve full implementation. The chart review showed that nutritional risk screening was performed in 65% and swallow testing in 91% of eligible patients (n = 185). Proactive implementation resulted in >95% patients screened (n = 79). The overall prevalence of nutritional risk was 29%, and 23% of the patients failed the initial swallow test. Proactive implementation is required to obtain high screening rates for nutritional risk and swallowing difficulties using validated screening tools. The proportion of patients at nutritional risk and the prevalence of dysphagia at initial swallow test were in the lower range of previous reports.

A validation study of the Facial-Oral Tract Therapy Swallowing Assessment of Saliva

Objective: To investigate the validity and reliability of the Swallowing Assessment of Saliva in detection of aspiration risk. Design: Validation study. Setting: Inpatient neurorehabilitation centre. Subjects: Adult patients with acquired brain injury. A total of 43 patients for concurrent validity and 33 other patients for inter-rater reliability. Interventions: Concurrent validity was established with blinded Swallowing Assessment of Saliva and endoscopic evaluation within a 24-hour time interval. Inter-rater reliability was established with two blinded Swallowing Assessments of Saliva within a one-hour time interval. Main measures: The Swallowing Assessment of Saliva is a seven-item scale with a combination of swallowing and non-swallowing items. It is based on the Facial-Oral Tract Therapy approach. Results: The Swallowing Assessment of Saliva had a sensitivity of 91%, 95% confidence interval (CI) (59; 100), a specificity of 88% %, 95% CI (71; 97) and a kappa coefficient of 0.87 ±0.17 in detection of aspiration risk. Furthermore, analyses showed that experienced and inexperienced occupational therapists performed equally in detection of aspiration risk. Conclusion: The Swallowing Assessment of Saliva is a simple, sensitive and reliable assessment for detecting aspiration risk in patients with acquired brain injury.

Role of laryngeal mask airway in laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is one of the most commonly performed surgical procedures and the laryngeal mask airway (LMA) is the most common supraglottic airway device used by the anesthesiologists to manage airway during general anesthesia. Use of LMA has some advantages when compared to endotracheal intubation, such as quick and ease of placement, a lesser requirement for neuromuscular blockade and a lower incidence of postoperative morbididy. However, the use of the LMA in laparoscopy is controversial, based on a concern about increased risk of regurgitation and pulmonary aspiration. The ability of these devices to provide optimal ventilation during laparoscopic procedures has been also questioned. The most important parameter to secure an adequate ventilation and oxygenation for the LMA under pneumoperitoneum condition is its seal pressure of airway. A good sealing pressure, not only state correct patient ventilation, but it reduces the potential risk of aspiration due to the better seal of airway. In addition, the LMAs incorporating a gastric access, permitting a safe anesthesia based on these commented points. We did a literature search to clarify if the use of LMA in preference to intubation provides inadequate ventilation or increase the risk of aspiration in patients undergoing laparoscopic cholecystectomy. We found evidence stating that LMA with drain channel achieves adequate ventilation for these procedures. Limited evidence was found to consider these devices completely safe against aspiration. However, we observed that the incidence of regurgitation and aspiration associated with the use of the LMA in laparoscopic surgery is very low.