Management Of Dysphagia In Patients Research Articles

Development of Evidence-Based Care Guidelines for the Management of Dysphagia in Patients with Stroke

Amaç: Bu çalışmanın amacı, inme sonrası disfaji yönetiminde hemşirelere yönelik kanıta dayalı bakım rehberi geliştirmektir. Yöntem: İnme sonrası disfaji yönetiminde hemşirelere yönelik kanıta dayalı De Novo rehber, 1 Ocak -30 Aralık 2017 tarihleri arasında kanıta dayalı rehber süreç geliştirme yaklaşımı kullanılarak geliştirildi. Bulgular: Literatür incelenerek 2000-2017 tarihleri arasında yayınlanan çalışmalar derlendikten sonra, bunların kanıtla ilişkileri yönünden araştırmalar sınıflandırıldı. Kanıt kalitesinin değerlendirilmesi ve analizi yapılarak kanıt tabloları oluşturuldu. Rehberde yer alan kanıta dayalı öneriler 17 çalışmanın ve 10 rehberin gözden geçirilmesinden elde edildi. Elde edilen kanıtlar belirlenen altı alana (Tarama, Değerlendirme, İzlem, Tedavi, Konsültasyon ve Eğitim) ayrıldı. Sonuç: İnme sonrası gelişen disfajinin erken dönemde saptanması ve komplikasyonlarının azaltılmasında, geliştirdiğimiz rehberin hasta bakım kalitesini artırmaya ve komplikasyonların önlenmesine önemli katkı sağlanması beklenmektedir.

Isometric tongue endurance and incomplete laryngeal vestibule closure in Parkinson's disease.

Dysphagia is a common symptom of Parkinson's disease (PD). A delay in laryngeal vestibule closure (LVC) and a reduction in tongue pressure, may affect swallowing safety and increase the risk of pulmonary aspiration. To verify the relationship between tongue pressure and airway protection in PD patients: (1) comparing tongue pressure measures and physiological events in the pharyngeal phase of swallowing between PD and controls and (2) analysing the association between tongue pressure and LVC in the PD group. Twenty-three patients with idiopathic PD (64.9 years) and 24 healthy controls (64.1 years) participated in this study. All participants underwent the following procedures to verify tongue pressure measurements using the Iowa Oral Performance Instrument: maximum anterior and posterior pressure, isotonic and isometric tongue endurance and anterior and posterior tongue pressure during saliva swallowing. To verify swallowing safety, videofluoroscopic swallowing studies focusing on the pharyngeal phase were performed based on the MBSImP protocol. Compared to healthy controls, PD exhibited a statistically significant decline in tongue pressure tasks: posterior maximum pressure, isotonic endurance, anterior and posterior isometric endurance and tongue pressure during posterior swallowing. Patients with PD had worse pharyngeal scores, including LVC scores, than controls. PD and incomplete LVC had lower anterior isometric endurance scores when compared to those with complete LVC. PD with incomplete LVC scored lower in the anterior isometric endurance task. We observed a potential clinical use of this task for the assessment and management of dysphagia in patients with PD.

Best Practice Recommendations for Dysphagia Management in Intensive Care Unit (ICU): A Delphi Study from Multidisciplinary Experts in Turkey.

There is no study about all aspects of oropharyngoesophageal (OPE) dysphagia from diagnosis to follow-up in a multidisciplinary manner in the world. In order to close this gap, we aimed to create a recommendation study that can be used in clinical practice, addressing all aspects of dysphagia in the ICU in detail with the opinion of experienced multidisciplinary experts. This recommendation paper was generated by a multidisciplinary team, using the seven-step process and a three-modified Delphi round via e-mail. Firstly, 15 open-ended questions were created, and then detailed recommendations including general principles, management, diagnosis, rehabilitation, and follow-up were created with the answers from these questions, Each recommendation item was voted on by the experts as overall consensus (strong recommendation), approaching consensus (weak recommendation), and divergent consensus (not recommended).In the first Delphi round, a questionnaire consisting of 413 items evaluated with a scale of 0-10 was prepared from the opinions and suggestions given to 15 open-ended questions. In the second Delphi round, 55.4% were accepted and revised suggestions were created. At the end of the third Delphi round, the revised suggestion form was approved again and the final proposals containing 133 items were created. This study includes comprehensive and detailed recommendations, including a broad perspective from diagnosis to treatment and follow-up, as detailed as possible, for management of dysphagia in patients with both oropharyngeal- and esophageal-dysphagia in ICU.

Optimal Management of Dysphagia in Patients with Inoperable Esophageal Cancer: Current Perspectives.

The majority of patients with esophageal cancer are diagnosed at an advanced, incurable stage. Palliation of symptoms, specifically dysphagia, is a crucial component to improve quality of life and optimize nutritional status. Despite multiple available treatment modalities, there is not one accepted or recommended to be the preferred treatment option. Palliative management is often decided by a multidisciplinary team considering factors including local availability, preference, patient life expectancy, and symptom severity. Systemic therapies such as chemotherapy are the most commonly used palliative modalities. Oncologists are most familiar with radiation for dysphagia palliation, especially for advanced metastatic cancer patients with good performance status. One common approach used by endoscopist is self-expandable metal stents. This is preferred for patients with short-term survival and poor functional status as it provides rapid relief of dysphagia. Cryotherapy is a relatively new endoscopic ablative modality and appears to be a promising option for dysphagia palliation, but more data is needed for wider adoption. This review summarizes the current literature on endoscopic and non-endoscopic treatment options for malignant dysphagia.

Pharmacological Management of Dysphagia in Patients with Alzheimer's Disease: A Narrative Review.

Alzheimer's disease (AD) and dysphagia are important health and socioeconomic problems in the aging population. Currently, the medical treatment of dysphagia in AD patients remains insufficient, and there are significant gaps in the management and clinical needs to postpone tube feeding. Literatures published over the last 30 years were searched in the PubMed and Embase databases. All relevant and promising pharmacological management studies were included. Because of the heterogeneity in design and methodology, only narrative reports were mentioned. Nine studies were included with two case reports, two case series, and two observational and three randomized controlled trials. The key approaches and clinical problems related to dysphagia include onset pattern, dementia stage, review of offending drugs and polypharmacy, and comorbidities (cerebrovascular disease, hypertension, parkinsonism, depression, and anorexia). The corresponding strategies of pharmacological treatments are further proposed and discussed comprehensively, with transient receptor potential channel modulators as promising treatment. With the integration of adequate and potential pharmacomanagement, AD patients with dysphagia can achieve a good prognosis and postpone tube feeding to maintain a better quality of life. More rigorous studies are needed to verify the effectiveness of innovative strategies and develop targets for neurostimulation.

Considerations for speech and language therapy management of dysphagia in patients who are critically ill with COVID-19: a single centre case series

Background/Aims Patients treated with intubation and tracheostomy for COVID-19 infection are at risk of increased incidence of laryngeal injury, dysphagia and dysphonia. Because of the novelty of the SARS-CoV-2 virus, little is known about the type of dysphagia patients experience as a result of infection and critical illness. The aim of this case series report was to progress understanding of COVID-19 and dysphagia following admission to an intensive care unit and to guide speech and language therapy clinical practice in the ongoing pandemic. Methods A retrospective case review was conducted of all patients at Imperial College Healthcare NHS Trust, London who underwent a tracheostomy because of COVID-19 and received an instrumental assessment of swallowing in the early stages of the pandemic. Results A total of 11 patients were identified, and descriptive statistics were used to present demographic data, with a narrative account of their dysphagia profile used to describe presentation. Causes and presentation of dysphagia were heterogenous, with each patient requiring individualised clinical management to maximise outcome. A positive trend was seen in terms of recovery trajectory and progressing to oral intake. Conclusions This study reports on early experience of the presentation of dysphagia in patients with COVID-19 and demonstrates the value of instrumental assessment. It indicates the need for further research to consolidate knowledge and guide clinical practice.

Parkinsonova choroba a postihnutie GITu

Involvement of the upper part of the gastrointestinal tract in patients with Parkinson disease is reported less frequently than the involvement of the lower part. Its clinical impact is, however, substantial because dysphagic symptoms considerably decrease the quality of life and may lead to life threatening complications. Even though the clinical symptoms related to esophageal motility disorders as a result of Parkinson disease are more common in the advanced stages of the disease, these could be dia­gnosed much earlier using high resolution manometry. The authors describe the basic principles of dia­gnostic management of dysphagia in patients with Parkinson disease and in the clinical part they present an analysis of their patient cohort. They found out that nonspecific and diverse motility disorders are present in most patients, even without dysphagic symptoms. In the experimental part, we outlined new possibilities for dia­gnostic procedures using the most up-to-date methods for the detection of pathological forms of alpha-synuclein and advanced microscopic methods. Key words: esophageal motility disorders – manometry – Parkinson disease – alpha-synuclein – FLIM analysis – immunohistochemistry

A Novel Method for Triggering the Swallowing Reflex in Patients with Amyotrophic Lateral Sclerosis: the Ishizaki Press Method.

This study describes the identification of specific maxillofacial points triggering the swallowing reflex by finger pressure in a patient with severe amyotrophic lateral sclerosis. This method has been named as the "Ishizaki Press Method." The first point was identified in a serendipitous encounter during training sessions to aid communication. This led to the search for such additional points, after obtaining informed consent from the patient and his relatives. Seven effective points were identified: the depressions in front of the left and right tragus (Ting gong points), bilateral points over the parotid and submandibular glands, and a point over the mentum in the midline of the face. The efficacy of these trigger points was noted to be ≥ 70%. The mean time taken for swallowing to occur in response to the stimulation at each of these points was less than 10s, and the induction of a rapid swallowing reflex was recognized. Alternating left and right stimulations of the Ting gong points and the parotid points triggered the swallowing reflex significantly faster than unilateral stimulations alone. The Ishizaki Press Method may improve the management of dysphagia in patients with amyotrophic lateral sclerosis.

Estratégias fonoaudiológicas para o manejo da disfagia em pacientes acometidos por Covid-19: revisão integrativa

Este artigo buscou apresentar as estratégias de atuação fonoaudiológica e os cuidados descritos na literatura para o manejo da disfagia em pacientes acometidos de COVID-19. Trata-se de uma revisão integrativa da literatura realizada em setembro de 2020 nas bases de dados PubMed/Medline, Lilacs, Scopus e Web of Science, utilizando os descritores “COVID-19”, “SARS-Cov-2”, “therapy”, “speech therapy” e “deglutition disorders”, combinados por meio dos operadores AND e OR. Foram inseridos estudos que abordavam a temática de interesse, pesquisas em humanos com COVID-19; publicações disponíveis em português, inglês ou espanhol, estudos do tipo artigos originais, caso controle, transversais e estudos de caso. Foi realizada leitura dos títulos e resumos, excluindo aqueles que não se encaixavam na pesquisa. Foram selecionados 3 artigos, cujo resultados mostraram relação do surgimento da disfagia com a COVID-19, em decorrência da intubação orotraqueal e dos danos neurológicos causados. Os cuidados com os atendimentos e a necessidade de acompanhamento também foram abordados. Verificou-se literatura escassa em relação aos procedimentos de avaliação e estratégias de intervenção fonoaudiológicas, mas sugerem atividades de estimulação sensorial e que promovam o fortalecimento dos músculos envolvidos na deglutição, além de estratégias de cuidado que visem proteger o paciente e os profissionais.

Shifting Tides Toward a Proactive Patient-Centered Approach in Dysphagia Management of Neurodegenerative Disease.

Purpose Persons with neurodegenerative disease frequently develop comorbid dysphagia as part of their disease process. Current "reactive" approaches to dysphagia management address dysphagia once it manifests clinically and consist of compensatory approaches. The purpose of this article is to propose a paradigm shift in dysphagia management of patients with neurodegenerative disease from a "reactive to proactive" approach by highlighting amyotrophic lateral sclerosis (ALS) and dementia as case examples. Method The authors present several areas of special consideration for speech-language pathologists (SLPs) treating dysphagia in patients with neurodegenerative disease. The drawbacks of historical "reactive" approaches to dysphagia management are described. Concepts of functional reserve for swallowing and homeostenosis are discussed. A "proactive" patient-centered paradigm of care for these patients is proposed with evidence to support its importance. A rationale for use of this approach in patients with ALS and dementia is provided with strategies for implementation. Results When treating dysphagia in patients with neurodegenerative disease, SLPs must balance a variety of factors in their decision making, including disease severity and expected progression, cultural considerations, goals of care, patient empowerment, and caregiver support. Reactive approaches to dysphagia management in these populations are problematic in that they disempower patients by focusing on use of compensatory techniques (e.g., diet modification, postural changes, feeding tube placement). Proactive approaches that employ rehabilitative interventions to increase functional reserve, such as resistance training, may result in improvement or maintenance of swallowing function longer into disease progression. An interdisciplinary team with early SLP involvement is necessary. Conclusions SLPs play a critical role in the management of dysphagia in patients with neurodegenerative disease and should be integrated early in the care of these patients. By focusing on a proactive patient-centered approach, patients with neurodegenerative conditions, such as ALS and dementia, will experience improved quality of life and health outcomes for a longer time.

Translating Dysphagia Evidence into Practice While Avoiding Pitfalls: Assessing Bias Risk in Tracheostomy Literature.

Critically ill patients who require a tracheostomy often have dysphagia. Widespread practice guidelines have yet to be developed regarding the acute assessment and management of dysphagia in patients with tracheostomy. In order for clinicians to base their practice on the best available evidence, they must first assess the applicable literature and determine its quality. To inform guideline development, our objective was to assess literature quality concerning swallowing following tracheostomy in acute stages of critical illness in adults. Our systematic literature search (published previously) included eight databases, nine gray literature repositories and citation chasing. Using inclusion criteria determined a priori, two reviewers, blinded to each other, conducted an eligibility review of identified citations. Patients with chronic tracheostomy and etiologies including head and/or neck cancer diagnoses were excluded. Four teams of two reviewers each, blinded to each other, assessed quality of included studies using a modified Cochrane Risk of Bias tool (RoB). Disagreements were resolved by consensus. Data were summarized descriptively according to study design and RoB domain. Of 6,396 identified citations, 74 studies met our inclusion criteria. Of those, 71 were observational and three were randomized controlled trials. Across all studies, the majority (> 75%) had low bias risk with: participant blinding, outcome reporting, and operationally defined outcomes. Areas requiring improvement included assessor and study personnel blinding. Prior to translating the literature into practice guidelines, we recommend attention to study quality limitations and its potential impact on study outcomes. For future work, we suggest an iterative approach to knowledge translation.

Management of Dysphagia in Patients with Parkinson's Disease and Related Disorders.

Various methods of rehabilitation for dysphagia have been suggested through the experience of treating stroke patients. Although most of these patients recover their swallowing function in a short period, dysphagia in Parkinson's disease (PD) and Parkinson-related disorder (PRD) degenerates with disease progression. Muscle rigidity and bradykinesia are recognized as causes of swallowing dysfunction, and it is difficult to easily apply the strategies for stroke to the rehabilitation of dysphagia in PD patients. Disease severity, weight loss, drooling, and dementia are important clinical predictors. Silent aspiration is a pathognomonic sign that may lead to aspiration pneumonia. Severe PD patients need routine video fluoroscopy or video endoscopy to adjust their food and liquid consistency. Patients with PRD experience rapid progression of swallowing dysfunction. Nutrition combined with nasogastric tube feeding or percutaneous endoscopic gastrostomy feeding should be considered owing to the increased risk of aspiration and difficulty administrating oral nutrition.

Editors' note: High frequency of gastrointestinal manifestations in myotonic dystrophy type 1 and type 2

In “High frequency of gastrointestinal manifestations in myotonic dystrophy type 1 and type 2,” Hilbert et al. studied gastrointestinal (GI) manifestations, their progression over time, and medications being used to treat GI symptoms in a large cohort of patients with myotonic dystrophy types 1 (DM1) and 2 (DM2). They found that GI manifestations were common in both DM1 and DM2, with a relatively high frequency of gallbladder removal in DM1 and DM2 occurring at a younger age compared to normative data in the literature. Commenting on the article, Silvestri et al. suggest that oropharyngoesophageal scintigraphy (OPES) can be a sensitive test to assess and follow-up swallowing function in DM. They share data from their own study where OPES documented a higher prevalence of swallowing dysfunction. In response, Hilbert et al. conclude that more research is needed to determine the most appropriate patient-reported outcomes and functional tests for the clinical assessment and management of dysphagia in patients with DM1. In “High frequency of gastrointestinal manifestations in myotonic dystrophy type 1 and type 2,” Hilbert et al. studied gastrointestinal (GI) manifestations, their progression over time, and medications being used to treat GI symptoms in a large cohort of patients with myotonic dystrophy types 1 (DM1) and 2 (DM2). They found that GI manifestations were common in both DM1 and DM2, with a relatively high frequency of gallbladder removal in DM1 and DM2 occurring at a younger age compared to normative data in the literature.

A practical guide to the management of dysphagia in patients with metastatic esophageal cancer

In patients with esophageal cancer, dysphagia can be a distressing symptom, subsequently resulting in weight loss and malnutrition. While luminal obstruction is a common complication, the optimal management approach remains undefined. Given the high morbidity and mortality of esophagectomy and esophageal bypass, surgical palliation has long fallen out of favor. Instead, various other palliative approaches are available, all of which are relatively effective, but differ in regards to time to benefit, durability and toxicity. The available literature is relatively limited, and decisions regarding how to manage dysphagia, and when to appropriately employ these various therapies, are left to individual judgment. Using a tertiary center experience and a review of the current literature, we would typically recommend either systemic chemotherapy or palliative external beam radiotherapy (EBRT) as initial measures. The benefits of chemotherapy include the high likelihood of symptomatic improvement, avoidance of delays in systemic therapy, and minimal loco-regional toxicity. Radiotherapy would similarly be an effective initial approach and may be best suited for patients with low volume (oligo-metastatic) disease. For patients who develop progressive dysphagia later in their disease course, radiotherapy or SEMS placement are the main therapy options. We recommend against “double palliation,” in which patients receive two palliative therapies simultaneously. Overall, decisions regarding management of malignant dysphagia should be individualized to consider the severity of the obstruction, the need for systemic therapy, prior therapy received, and finally the patient’s life expectancy and personal wishes.

Laryngeal Sensitivity in Patients with Amyotrophic Lateral Sclerosis.

Recent studies have shown the involvement of the sensory nervous system in patients with amyotrophic lateral sclerosis (ALS). The aim of our study was to investigate the correlation between the laryngeal sensitivity deficit and the type of ALS onset (bulbar or spinal) in a large series of 114 consecutive ALS patients. Participants were subdivided into two groups, bulbar and spinal ALS, according to the clinical onset of disease and submitted to a clinical and instrumental evaluation of swallowing, including a fiber-optic endoscopic evaluation of swallowing with sensory testing. Dysphagia severity was scored using the Penetration–Aspiration Scale (PAS) and the Pooling score (P-score). In addition, three patients with laryngeal sensitivity deficit were submitted to a laryngeal biopsy to assess the status of the sensory innervation. All patients showed a normal glottal closure during phonation and volitional cough. Fifty-six subjects (49%), 14 spinal- and 42 bulbar-onset ALS, showed dysphagia at the first clinical observation (PAS score >1; P-score >5). Dysphagia resulted more frequently in bulbar-onset ALS (P < 0.01). Thirty-eight (33%) patients had a sensory deficit of the larynx. The sensory deficit of the larynx was significantly more frequent in bulbar-onset ALS (P < 0.01). The sensory deficit of the larynx among dysphagic patients was also significantly more frequent in bulbar-onset ALS (P = 0.02). Several abnormalities were found in all three subjects who underwent a laryngeal biopsy: in one patient, no intraepidermal fiber was found; in the other two, the fibers showed morphological changes. Our observations are important to consider for assessment and management of dysphagia in patients with ALS.

Diagnostic Assessment and Management of Dysphagia in Patients with Alzheimer's Disease.

A growing concern in patients affected by Alzheimer's disease (AD) is dysphagia, or swallowing impairment, which leads to malnutrition, dehydration, weight loss, functional decline and fear of eating and drinking, as well as a decrease in the quality of life. Thus the diagnostic assessment of dysphagia in patients with AD is imperative to ensure that they receive effective management, avoiding complications, and reducing comorbidity and mortality in such a growing population. Dysphagia management requires a multidisciplinary approach considering that no single strategy is appropriate for all patients. However, evidence for clinical diagnostic assessment, interventions, and medical management of dysphagia in these patients are still limited: few studies are reporting the evaluation and the management among this group of patients. Here we analyzed the most recent findings in diagnostic assessment and management of swallowing impairment in patients affected by AD.

Diagnosis and management of dysphagia in patients with tracheostomy tube after cardiac surgery: an early screening protocol

Patients with tracheostomy tube after major cardiac surgery undergoing Cardiac Rehabilitation Program often present swallowing disorders that need a specific evaluation. This study aimed at validating the usefulness of a swallowing screen protocol in order to obtain an early assessment of dysphagia and to prevent aspiration, malnutrition and dehydration risks. The protocol has been applied to 38 consecutive patients with tracheostomy tube after cardiac surgery between September 2007 and December 2009. The average age of patients was 73 +/- 6 years; the average value of left ventricular ejection fraction was 41 +/- 4%. The protocol included a water swallowing test and a specific swallowing test with blue dye. During tests, the presence of signs of swallowing dysfunction was evaluated and oxygen saturation levels were monitored. Out of 38 patients, 2 did not show any swallowing deficits; 18 showed deficits in the water swallowing test even though they presented a preserved swallowing function during specific swallowing test. All these 20 patients (53%), before discharge, restarted an oral feeding and obtained an adequate body mass index and effective coughing, so they were soon decannulated. Twelve patients (31%) showed deficits during the water swallowing test, confirmed by the specific swallowing test with blue dye: the tracheostomy tube was not removed and a specific program of swallowing rehabilitation was performed. Before discharge all patients restarted an oral feeding, recovered an effective coughing and were decannulated. Six patients (16%), because of persistent dysphagia, underwent percutaneous endoscopic gastrostomy. None of these 38 patients developed ab ingestis pneumonia, dehydration or malnutrition. An early assessment of swallowing in patients with tracheostomy tube after cardiac surgery allows the selection of patients with higher aspiration risk, preventing possible severe complications.

Management of Dysphagia in Patients With Head and Neck Cancer

Dysphagia is one of the most common symptoms affecting patients with head and neck cancer. It can lead to several complications and affect patients' quality of life. The advanced practice nurse can play an important role in the plan of care for managing this condition in patients with head and neck cancer.

Assessment and management of dysphagia in patients with head and neck cancer who receive radiotherapy in the United Kingdom – A web-based survey

We undertook a service evaluation to establish how oropharyngeal dysphagia is managed in head and neck cancer patients receiving radiotherapy in the United Kingdom. A web-based survey including 23 open and closed questions was distributed to Speech and Language Therapy (SLT) teams via a national network of Royal College of Speech and Language Therapists (RCSLT) special interest groups with members involved in head and neck cancer care. Forty-six teams responded to the survey and 89% completed the questionnaire fully. Fifty percent (n=21/42) of the SLT teams reported routinely seeing patients prior to commencing radiotherapy. Baseline oromotor assessment (85.7% (n=36/42)), clinical dysphagia assessment (90.5% (n=38/42)) and information provision on the potential treatment effects on swallowing (97.6% (n=41/42)) and communication ability (85.7% (n=36/42)) were the most common components of initial evaluation. In keeping with expert opinion and emerging evidence, prophylactic swallowing exercises were administered by 71.4% (n=30/42) of teams targeting specific aspects of swallowing, although the nature, intensity and duration of programmes varied. A range of measures are used to monitor progress during treatment. Our survey highlighted that resource limitations affect service provision with some teams managing the consequences of treatment rather than proactive multidisciplinary intervention prior to and during treatment. Cancer- and treatment-related dysphagia can impact significantly on a broad range of outcomes following radiotherapy. There is variability in dysphagia service provision to patients before, during and following treatment. Comprehensive evaluation of swallowing function prior to treatment and proactive management can yield benefits for patients, inform multidisciplinary case management and support those involved in clinical trials to accurately determine treatment effects.

Dysphagia in Parkinson’s disease: a therapeutic challenge?

This article focuses on the current status and research directions on swallowing disorders (dysphagia) in patients with Parkinson’s disease (PD). Although epidemiological data are scarce, increased incidence of dysphagia in patients with PD leads to increased risk of mortality, secondary to aspiration pneumonia. Although studies show that aspiration pneumonia is a common cause of death in this group of patients, clinical practice lacks an evidence base and there is an increased need for randomized clinical trials. Importantly, the underlying mechanisms accounting for the progression of dysphagia in PD are still unclear. Furthermore, evidence shows that dopaminergic medication does not affect swallowing performance. Future research in the field is urgently needed and may result in improved management of dysphagia in patients with PD.