Choking Episodes Research Articles

A rare presentation of myasthenia gravis

Background and aims Myasthenia gravis (MG) is a heterogeneous disorder in which antibodies are directed at the postsynaptic membrane of the neuromuscular junction, leading to varying degrees of muscle weakness and fatigability. Ptosis, dysphagia, dysphonia and proximal weakness are common presenting symptoms in children. We report a case of 14 months old male child presenting with inspiratory stridor resembling group. Methods and results A 14 months old child presented to accident and emergency (A&E) of a district general hospital for the third time in a week, with barking cough, noisy breathing and stridor. His symptoms had worsened over the last 24 hours resulting in a choking episode and difficulty in feeding. This was preceded by a week9s history of cough, cold, diarrhoea and vomiting. He was treated as croup on first two attendances in A&E. He was born at term by normal vaginal delivery to unrelated Caucasian parents. He was diagnosed with laryngomalacia at two months of age, when he presented to paediatric outpatients for noisy breathing. This improved by 6 months of age. There was no family history of neuromuscular disorders. Examination revealed tachycardia, signs of respiratory distress, stridor, drooling from mouth and drooping eyelids. He was transferred to tertiary centre for intensive monitoring and further investigations. His initial treatment based on a presumptive diagnosis of croup did not show any response. Further investigations included MRI brain which was normal. After a failed extubation, he was subjected to tensilon test to which a partial response was noted. He was commenced on pyridostigmine and prednisolone. Repetitive nerve stimulation and stimulated single fibre electromyography confirmed the diagnosis of MG. Acetyl choline receptor antibodies were undetectable. Results of genetic screening are still awaited. Prednisolone was weaned in next 4- 6 months. He remains well on pyridostigmine. Conclusion Myasthenia gravis can present with involvement of any muscle innervated by cranial nerves and the diagnosis should be entertained when muscular weakness or fatigability is demonstrated. Although an uncommon cause Myasthenia gravis should be included in differential diagnosis of stridor.

All that wheezes is not asthma: a case report of a child with a concealed upper airways foreign body

The authors report the case of a previously fit and well six-year-old girl who presented to paediatric outpatients with a four month history of wheezing associated with intermittent cough. During her first clinic appointment, she was given a trial of salbutamol via a spacer, which appeared to reduce the wheeze and few crepitations which had been heard prior to administration of the drug. She was diagnosed with asthma and prescribed Beclomethasone and Salbutamol at this time. This apparent initial response to salbutamol was later disputed as spirometry showed no reversibility. Also, she did not report any interval symptoms or increased wheezing with exercise or upper respiratory tract infections. Her mother did not feel that the inhalers had made any difference to her symptoms so her medications were stopped. She developed a number of chest infections and was investigated for possible underlying conditions including cystic fibrosis and structural defects, none of which were found to be present. IgE and RAST for specific allergens were negative and a chest X-ray was completely normal. Full blood count and immunoglobulins were also normal. She was found to have low Hib and tetanus antibodies but these returned to normal after she was re-vaccinated. The doctors treating her began to suspect tracheobronchomalacia was responsible for her symptoms and at this point, the wheeze was noted to be musical in character. At this point, she was referred for a bronchoscopy and a small piece of plastic tubing was found in her airway. It was removed successfully and she has been completely well since, with no further episodes of wheeze or cough. In retrospect she could not remember a choking episode or inhaling a foreign body. This case demonstrates that all that wheezes is not asthma. It is important to re-evaluate and re-consider differential diagnoses when the clinical picture does not completely fit. Airway foreign bodies should be considered even with a long history of cough and no signs of respiratory distress and absence of a history of inhalation of a foreign body does not rule it out, even in older children.

Application of Digital Accelerometry for Swallow Imaging (DASI) for Dysphagia Evaluation and Treatment in a Series of Myotonic Dystrophy Type 1 (DM1) Patients (P05.189)

Objective: To use digital accelerometry for swallow imaging (DASI) for evaluation and treatment of dysphagia in DM1 patients. Background Dysphagia is a potentially life threatening complication of DM1 patients. Design/Methods: Patients with DM1 and history of aspiration or dysphagia underwent a formal swallow evaluation +/- modified barium swallow (MBS). We used noninvasive DASI technology with software designed for swallow imaging and calculation of key parameters of swallow biomechanics. Trials included spontaneous and instructed dry and wet swallows with different consistencies. We analyzed shape, amplitude, timing, frequency and jitter looking for swallow movement dysfunction. DASI biofeedback: Patients observed swallow traces on the computer screen and were coached in improving strength, duration and timing of swallow. Results: Case 1: A 24-year old man with congenital DM1, dysphagia, and repeated hospitalizations for aspiration pneumonia had a MBS showing aspiration of pyriform sinus residue. DASI evaluation showed excessive pre/post-swallow laryngeal movement, decreased pharyngeal phase control with multiple small amplitude peaks. DASI Treatment: Patient improved swallow strenght and control of pharyngeal movement. Case 2: A 46 year-old man with adult-onset DM1 and choking episodes was hospitalized with pneumonia and placed on a ventilator. MBS showed aspiration during/after the swallow with delayed cough. DASI evaluation showed low amplitude and frequency of swallow with increased jitter and frequent coughing. DASI Treatment: Patient improved swallow strength. Case 3: A 33 year-old female with adult-onset DM1 reported dysphagia. Clinical swallow evaluation showed oral residue, reduced hyolaryngeal excursion, and throat clearing. DASI evaluation showed reduced amplitude and increased jitter, with extraneous, inefficient lingual/hyolaryngeal movements. DASI Treatment: Reduced extraneous laryngeal movements and improved control of swallow. Conclusions: DASI is an adjunct in dysphagia evaluation in DM1. DASI biofeedback is helpful in gaining increased swallow function through Active Repetitive Motion Therapy which is instructive for reducing extraneous, inefficient laryngeal movements and can be personalized according to the patient physical and mental status. Supported by: DASI equipment on loan from Elixir Therapeutics. Disclosure: Dr. Farkas has nothing to disclose. Dr. Entrekin has nothing to disclose. Dr. Milstead has nothing to disclose. Dr. Mosman has nothing to disclose. Dr. Berggren has nothing to disclose. Dr. Sampson has received personal compensation for activities with PTC Therapeutics and Myotonic Dystrophy Foundation.

Binge Eating Disorder May Be Added toDSM-5

The DSM-5 Feeding and Eating Disorders Work Group is proposing a number of diagnostic changes. Here’s an overview.

The sweet lung: Chewing gummi bear aspiration

Inhalation of foreign bodies, a leading cause of accidental death, is most common in preschool children. In this article we report our experience with a 5-year-old Greek girl who presented with a 24-hour history of sore throat, chest pain, and shortness of breath. Emergency bronchoscopy was performed and multiple small chewing gummi bear (HARIBO) particles impacted in the orifices of the right main bronchus and right lobar and segmentalinic bronchi were successfully removed and aspirated. Aspiration of gummi bears, which is for the first time reported, may cause a silent choking episode leading to life-threatening bronchi obstruction at multiple sites, even in children older than 4 years.

Subglottic Airway Foreign Body

THIS image was obtained during a di-rect laryngoscopy of a 4-yr-old boy. He experienced a choking episode after a witnessed aspiration of a sunflower seed. The seed is lodged at the level of the cricoid. On arrival in the emergency department, the patient was alert with an oxygen saturation of 96%, tachypneic with inspiratory stridor, nasal flaring, subcostal retractions, and accessory muscle use.In the operating room, an induction of midazolam and ketamine was followed by sevoflurane inhalation and maintenance. After an adequate depth of anesthesia was achieved, direct laryngoscopy and rigid bronchoscopy was performed with removal of the sunflower seed. Spontaneous ventilation was maintained throughout the procedure. The child continued to have mild stridor in the postanesthesia care unit, but responded to a single postoperative dose of racemic epinephrine. He was discharged home less than 24 h later.This image indicates how a foreign body can potentially result in complete airway obstruction. The seed traversed the more distensible glottis and lodged at the rigid cricoid ring.1,2The image indicates the potential for complete airway obstruction leading to asphyxia. The subglottic location reinforces two management principles related to airway foreign bodies in children. First, spontaneous ventilation is recommended to prevent the seed from completely obstructing the airway at the level of the cricoid. The second, an observation from the American Heart Association (Dallas, TX), because of the cricoid location of foreign bodies in children, a cricothyrotomy may not relieve complete airway obstruction unless the catheter is passed beyond the foreign body.3In the United States alone, approximately 150 children die each year because of foreign body aspiration.4

The hypothetical role of congenital hypotonia in the development of early coronoid hyperplasia

BackgroundCoronoid hyperplasia (CH) is an abnormal bony elongation of a histologically normal coronoid process. Its definitive cause remains unknown. ObjectivesTo analyze the possible implication of congenital hypotonia in the pathogenesis of early coronoid overgrowth. Patients and methodsTwo infants with congenital hypotonia were evaluated for limited mouth aperture. Bilateral CH was diagnosed. Transoral coronoidectomy was followed by an early dynamic physiotherapy program. ResultsSignificant improvement of maximum interincisal opening was achieved. The review of the scientific literature proved the diagnosis of CH in the infant age group is extremely unusual and the etiology of the condition is still uncertain. ConclusionsBesides mouth opening restriction, clinical features of coronoid hyperplasia in infants can include suction or deglutition anomalies, failure to thrive and recurrent episodes of choking or aspiration pneumonia. The authors hypothesize reduced fetal mandibular movements and deglutition as a result of congenital hypotonia may lead to relative hyperactivity of the temporalis muscle that is not counterbalanced by the infra and suprahyoid muscles, thereby facilitating coronoid overgrowth.

Asthma and Foreign Body Aspiration

Objective: Determine the prevalence of asthma in children who underwent rigid bronchoscopy (RB) for a suspected foreign body aspiration (sFBA) in the tracheobronchial tree, and to identify characteristics of patients who could benefit from a trial of anti-asthma treatment prior to undergoing a diagnostic bronchoscopy. Method: Retrospective chart review of children with sFBA in the tracheobronchial tree who underwent RB at the Montreal Children’s Hospital (2001-2009). Patient characteristics such as delay between initial choking episode and first otolaryngology evaluation, clinical findings, radiologic findings, bronchoscopic findings, and history of asthma were analyzed. Results: A total of 55 children underwent a RB for sFBA. Foreign bodies (FB) were found in 36 of these, one of which was asthmatic (2.78%, P < .05). In the 19 children who had a negative bronchoscopy (no FB), four were asthmatics (21.1%, P < .05). The mean time from the suspected initial choking event to the first otolaryngology evaluation was 27 days in asthmatics (range, 5 hours-90 days; median, 14 days), whereas it was 7.2 days in nonasthmatics (range, 0.5 hours-120 days; median, 16 hours). Otherwise, clinical and radiological findings were not significantly different in the asthmatic and non-asthmatic groups. Conclusion: Asthmatic children with sFBA are significantly more likely to have a negative bronchoscopy than non-asthmatics, especially when there is a delay between the suspected choking episode and the first otolaryngology evaluation. Therefore, a trial of anti-asthma treatment prior to performing a diagnostic bronchoscopy in this subgroup of patients is justified.

Clinical features and respiratory complications in Myhre syndrome

We describe the clinical characteristics of 4 singleton cases, 3 males and 1 female, with Myhre Syndrome (OMIM 139210), who were born to non-consanguineous parents. Three cases had no family history of similarly affected individuals but 1 male’s mother had short stature, some facial features suggestive of Myhre syndrome and evidence of skewed X-chromosome inactivation in her blood DNA. Short stature, deafness, learning difficulties, skeletal anomalies and facial dysmorphisms were evident in all cases. Arthralgia and stiff joints with limited movement were also present. The facial appearance, thickened skin, a ‘muscular’ habitus are memorable features. The female patient was least affected: this patient and one affected male displayed streaky skin with areas of patchy thickening, suggestive of genetic mosaicism. One patient developed sleep apnoea, a restrictive ventilatory defect and died following a choking episode. Another affected male developed recurrent, progressive, proximal, tracheal stenosis requiring partial tracheal resection, laser treatment and eventually tracheotomy. Review of Myhre syndrome patients in the literature and syndromes in the differential diagnosis, suggests heterogeneity in Myhre syndrome and clinical overlap with Laryngotracheal stenosis, Arthropathy, Prognathism and Short stature syndrome.

Gels and Jellies as a Dosage Form for Dysphagia Patients: A Review

Patient compliance and safety is now prominent on the agenda of healthcare companies. Dysphagia (swallowing dysfunction) is common in general populations and more common in elderly institutionalized patients and persons in long-term care facilities due to significant primary illnesses, including cerebrovascular accidents, neurodegenerative disorders, head and neck cancer, or head injury. To ensure safety during oral medication administration, patients with dysphagia require an appropriate oral dosage form or modification of the dosage form. However inappropriate drug administration in patients with dysphagia (i.e., the crushing of sustained-release or enteric-coated tablets or the administration of oral medications with water) is undesirable and may be associated with adverse events (e.g. choking episodes, adverse drug reactions resulting from the immediate release of drug from a sustained-release product, refusal to take medications). Hence, there is a need of alternative novel oral dosage form like gels and jellies to deliver drugs having a viscosity that can be easily swallowed without any discomfort to the patient preventing choking and suffocation. Hence, today the potential for such dosage form is promising because of patient compliance and improved quality of life. This review briefly describes the role of gels and jellies in dysphagia patients, its advantages and disadvantages, formulation considerations, evaluation parameters and reviews of gels and jellies for dysphagia patients which have been carried out. Keywords: Dysphagia, elderly patients, gels, jellies, patient compliance, semi-solid, dosage form, formulation of drugs, drug delivery, novel oral dosage

Two cases of aspiration of calcium tablets

Two clinical cases of aspiration are reported in elderly ladies with differing presentations following inhalation of the same brand of calcium tablet. One of the patients distinctly recalled the choking episode, whereas the other failed to do so making the diagnosis of aspiration difficult. One of the aspirated tablets was successfully retrieved during rigid bronchoscopy after the patient reported several months of cough requiring multiple courses of antibiotics. The other aspirated tablet was coughed up by the patient after the successful treatment of a pneumonia complicated by a parapneumonic effusion.

Nocturnal Choking Episodes: Under-Recognized and Misdiagnosed

Causes of nocturnal paroxysmal events include a variety of disorders such as epileptic seizures, parasomnias, sleep-related movement disorders, and psychiatric disturbances. Timing and semiology of the events, simultaneous video-electroencephalographic observation, presence of any daytime events, and relevant psychiatric and medical history may help in sorting out various possibilities considered in the differential diagnosis of such events. Timely diagnosis of these events is crucial for appropriate management; under-recognition and misdiagnosis of nonepileptic events is not uncommon. Described here are two cases within the spectrum of nocturnal paroxysmal events, one with nocturnal panic attacks and the other with frontal lobe epilepsy, each presenting with choking episodes.

A Doctor, a Son, a Medicare Catch-22

A Doctor, a Son, a Medicare Catch-22

Gastric Ascariasis Presenting as Unique Dyspeptic Symptoms in an Endemic Area

Khuroo, Naira Sultan MD1; Khuroo, Mehnaaz Sultan MD2; Khuroo, Mohammad Sultan MD1 Author Information

Paediatric myasthenia: A moving target

A two-and-a-half-year-old boy presented to the emergency department with an upper respiratory tract infection and increasing breathing difficulties over the past 24 h. His health was normal until two months before presentation. Since then, his parents noticed progressive (although fluctuating) motor weakness, trouble chewing and swallowing as well as episodes of choking on his secretions. His speech deteriorated to monosyllables, and he had trouble walking and getting up off the floor. The boy’s ‘tired-ness’ seemed substantially more noticeable in the evenings. A physical examination of the boy revealed moderate respiratory distress. Otherwise, the only remarkable physical signs included bilateral asymmetrical ptosis (his right eye appeared to be more affected than his left eye), and decreased facial movements with the inability to close his eyes and with his mouth hanging open. He was generally weak, hypotonic and could not rise from a lying position. His deep tendon reflexes were preserved. On admission, his respiratory status deteriorated to the point of requiring intubation for five days. A diagnosis of respiratory syncytial virus pneumonia was confirmed. Although his respiratory status improved, his weakness remained. Diagnostic evaluations included high acetyl-cholinesterase antibodies and a positive edrophonium test, resulting in transient reversal of the ptosis. During the next six months, the patient was treated with various combinations of pyridostigmine, intravenous immunoglobulin and corticosteroids, with only partial improvement. At three years of age, he underwent a thymectomy. Within one year, he was weaned off all medications (pyridostigmine and prednisone). Four years later, he remains in complete remission. LEARNING POINTS Juvenile myasthenia gravis (JMG) is a rare autoimmune-mediated disorder acquired in childhood, representing 10% to 15% of all cases of myasthenia gravis. It is generally characterized by muscle weakness secondary to antibodies that bind acetylcholine receptors at the neuromuscular junction, preventing transmission of the nerve impulse to the muscle. The majority of patients with JMG present with fluctuating ocular symptoms, such as ptosis, diplopia and strabismus. Many patients with JMG will develop variable fatigability, proximal limb weakness and bulbar problems, such as altered chewing and swallowing, drooling, nasal or weak voice, and poor pronunciation. If the condition is left untreated, there is a risk of respiratory muscle paralysis leading to respiratory failure and death. A high index of suspicion is required because ptosis and diplopia may only become apparent with sustained upgaze for 2 min. Similarly, weakness of deltoids and hips may be elicited only after strength has been repeatedly tested. Diagnostic tests include edrophonium administration, nerve conduction studies (with repetitive stimulation) and antibody titres against acetylcholine receptors at the neuromuscular junction. A significant percentage of patients are seronegative for the acetylcholine receptor antibodies, particularly prepubertal children and those with exclusively ocular presentations. JMG is generally a treatable disease. Symptomatic patients are initially treated with an acetylcholinesterase inhibitor that increases acetylcholine levels at synaptic junctions. If symptoms persist, immunomodulatory drugs are added, typically prednisone followed by other immunosuppressants. Intravenous immunoglobulin or plasmapheresis can be used for severe breakthrough symptoms. If significant bulbar or limb weakness persists despite a reasonable medication trial, a thymectomy is often recommended. To determine the national incidence of JMG, a Canadian Paediatric Surveillance Program study was initiated in January 2010. The study is also designed to increase awareness, document the burden of illness and inform on best treatment practices. Early recognition and management of JMG helps to avoid unnecessary testing, prevents the progression of symptoms, and results in low morbidity and mortality.

Erosion of Anterior Cervical Plate into Pharynx with Pharyngotracheal Fistula

We report a 58-year-old woman who presented with dysphagia and recurrent episodes of coughing and choking during swallowing 10years after anterior cervical discectomy and fusion with implantation of an anterior cervical plate. Barium esophagography revealed erosion of the cervical plate through the posterior wall of the pharyngoesophageal junction with an extraluminal collection that extended inferiorly as a track through the posterior wall of the trachea, producing a pharyngotracheal fistula. The pharyngeal perforation was repaired and the cervical hardware removed at surgery. This rare complication of anterior cervical discectomy and fusion should be recognized as a potentially serious but treatable long-term sequela of an anterior cervical plate.

Surgical management of refractory gastro-oesophageal reflux

Surgery in the management of gastrooesophageal reflux disease (GORD) is controversial; its availability and frequency show variability between, and even within, countries. GORD is a common chronic condition, with some 20 per cent of the population in Western countries experiencing symptoms of reflux at least once a week1. When gastric juice flows back into the oesophagus, it causes heartburn and acid regurgitation (so-called ‘typical’ symptoms) and/or a variety of symptoms often referred to as ‘atypical’. Atypical symptoms include cough, hoarseness, dental erosions and angina-like chest pain.The regurgitated gastric contents may damage the oesophageal mucosa, inducing erosions, ulcers and even metaplastic change (Barrett’s oesophagus). Most patients with GORD are treated effectively by non-prescription medication or acid-suppressing drugs (proton pump inhibitors (PPIs)), or a combination of the two. Although effective2, surgery has a relatively marginal role. It is generally reserved for those few patients who are unwilling to take drugs or whose condition is considered ‘refractory’ to such treatments (patients whose symptoms or mucosal damage persist or are cured only partially by PPIs)3. When faced with a patientwith refractory disease it falls to the surgeon to decide whether or not an antireflux procedure will confer benefit. As will be shown below, the present difficulty in defining the role of surgery in the management of refractory GORD stems partly from the currently accepted Montreal definition of GORD as ‘a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or syndromes’4. According to this symptom-focused definition, all patients with typical or atypical symptoms related to acid or nonacid reflux have the disease. These patients may be prescribed a trial of medical therapy, even if their overall oesophageal exposure to gastric contents is normal. Four groups of refractory patients who might request surgery can be identified. The first group consists of poorly compliant patients, or those having an inappropriate PPI consumption because of poor timing and/or frequency of dosing. This is probably the largest group and these patients are the simplest to treat, either by correcting themedical treatment (enforcing compliance, modifying the timing and/or frequency of dosage) or, if necessary, by antireflux surgery. The second group contains patients whose refractory symptoms are different to their initial symptoms. PPIs often resolve the severe heartburn felt in the initial stages of GORD but fail to reduce volume reflux and regurgitation while stooping or straining. Cough (especially at night), episodes of wakening and choking, and poor sleep pattern are common refractory symptoms that prompt a patient to seek surgical intervention. The third group of patients have symptoms that are unresponsive to PPIs. Themain reason is a persistence of alkaline or weakly acidic reflux of duodenal contents (bile and pancreatic juice). In this situation PPIs have reduced gastric acid output, but are ineffective with respect to the alkaline component of the refluxate. The final group comprises those whose refractory symptoms are due to an altered sensitivity of the oesophageal mucosa. This results in an abnormal perception of otherwise normal events, often described as ‘acid-sensitive oesophagus’ or ‘functional heartburn’. Although no exact figure is available, it has been estimated that these last two groups account for 10–20 per cent of refractory GORD. Without refractory symptoms, there is little evidence to promote antireflux surgery, except for Barrett’s oesophagus with severe reflux requiring progressively increasing doses of PPI, or when there is an associated large paraoesophageal hernia (to prevent future strangulation or respiratory complications). For a surgeon to operate, something more than a purely symptombased definition ofGORDis required; a trial of treatment by operation is not acceptable if the chance of successful outcome is minimal. An accurate definition of disease before surgery requires the measurement of acid reflux (by 24-h pH monitoring after suspension of PPI therapy) and exclusion of dysmotility disorders (achalasia, diffuse oesophageal spasm). If acid exposure is abnormal, GORD may be regarded as present and surgery as justified, if symptoms warrant it. This diagnostic approach, however, does not deal satisfactorily with the last two of the four groups described above. In

Identification and nursing management of dysphagia in individuals with acute neurological impairment (update)

Background Dysphagia, or difficulty in swallowing, is a serious and life threatening medical condition that affects a significant number of individuals with neurological impairment. Nurses, who are available to patients 24 hours a day, are in the ideal position to identify individuals with swallowing difficulties and initiate interventions that may prevent further complications until a formal assessment can be undertaken1. Appropriate assessment of swallowing function is essential to the accurate identification and diagnosis of deficits in swallowing and to the effective management of dysphagia. Objectives What is the nursing role in the recognition and management of dysphagia in adults with neurological impairment? Is there evidence on the effectiveness of nursing interventions in the recognition and management of dysphagia? Inclusion criteria Types of participants Adult patients over the age of 18 years with neurogenic dysphagia secondary to acute neurological impairment were the chief population of interest; studies of nurses caring for these patients were also included. Types of interventions This review included studies which used various interventions which focussed on the nursing role in recognition and nursing management of dysphagia; any formal observation of ability to swallow undertaken / documented by nurses; Clinical / Bedside Swallowing Assessment undertaken by nurses; and/or pulse oximetry monitoring. Types of outcomes Early recognition by nurses of those with difficulty swallowing Clinical screening by nurses of any patient with suspected swallowing difficulties Timely referral by nurses to speech language pathology for formal assessment Any outcome measures from interventions that aimed to prevent aspiration, choking episodes and/or associated morbidity were of interest. Time spent prior to the initiation of appropriate nutrition and hydration by patients with neurological impairment Types of studies Original quantitative research studies with a range of study designs such as randomised controlled trials, quasi-randomised trials, observational and descriptive studies. Exclusion criteria Studies focussing solely on diagnostic procedures ordered or undertaken by either medical professionals or speech-language pathologist (such as videofluoroscopy/VFSS) were not of interest to this review. Search strategy A comprehensive search of a wide variety of published and unpublished sources was undertaken for the period between January 1998 and January 2008 using as main keywords: dysphagia (text word and MH) or gag reflex or swallow or deglutition disorder (text word and MH); problem or impair or difficult; neurological and impair or stroke or bedside swallowing assessment; MH Brain Diseases+ or neurological and impair* or disorder* disease* or malfunction. Methodological quality Quantitative papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review. Any disagreements that arose between the reviewers were resolved through discussion, or with a third reviewer. Data extraction The data extracted included specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Due to significant variability in study methodology, populations and interventions, no statistical meta-analysis was possible. Results are presented in narrative and tabular form instead. Results Forty-two quantitative studies were retrieved and, of these, 17 met the inclusion and quality criteria, representing a wide range of quantitative research methodologies. Conclusions The evidence from this updated review indicates that nurses are well-placed to conduct dysphagia assessments and that there are several tools available that may be suitable for them to use. It is important that formal dysphagia screening protocols are in place and that nurses are trained to use them. If nurses screen patients with an acute neurological impairment within 24 hours of admission, it may reduce the time that patients spend without appropriate methods of nutrition and hydration and improve clinical outcomes. Dysphagia screening by nurses does not replace assessment by other health professionals; instead it enhances the provision of care to patients at risk allowing for early recognition and intervention to occur.

A 62-Year-Old Woman With Chronic Cough and Bronchospasm

62-year-old woman presented with chronic productive cough, intermittent wheezing, and shortness of breath over a 5-year period. She was a nonsmoker and had no history of environmental exposure to chemicals or dust. Her medical history was notable for nasopharyngeal cancer (NPC) treated with radiation therapy 26 years previously that resulted in mild dry mouth and hoarseness, nasal polyp, and chronic sinusitis. During the past 5 years, she underwent a series of examinations that revealed positive bronchodilator test and mild hyperinfl ation of lung parenchyma on chest radiograph. She received maintenance therapy with inhaled bronchodilator and corticosteroids, antihistaminics, and xanthine under the impression of chronic asthma and sinusitis, and antibiotics and oral corticosteroids during episodes of acute exacerbation. However, the clinical course fl uctuated, with deterioration of symptoms on climatic changes or following upper respiratory tract infection. Even though the patient denied being aware of any episodes of aspiration, she was hospitalized and treated as having aspiration pneumonia on four occasions. Yet, no advanced study was performed to evaluate her swallowing function. Tracing back her history, she experienced occasional choking episodes while drinking, but did not pay attention to them. Over the past year, her symptoms of productive

An unusual complication of an attempt to open the airway in a choking child

The use of a blind finger sweep to clear the upper airway can cause subsequent problems when used in paediatric practice. This case report adds support to recommendations that this procedure should not be used, while simultaneously describing a complication the authors have not come across in the published literature.