Videofluoroscopic Modified Barium Swallow Research Articles

Characteristics and clinical assessment of deglutition disorders and oral movement function in children with cerebral palsy

Objective To investigate the symptom characteristis as well as the clinical assessment methods of dysphagia and oral motor function in children with cerebral palsy(CP).Methods A total of 116 children with CP,aged 18 months to 96 months(66 boys and 50 girls),treated in Qingdao Rehabilitation Center for Disabled Children from June 2009 to September 2010,were included in the study.Diagnosis and subtype of CP were determined by neuropaediatrician,the dysphagia disorders survey(DDS)as well as oral motor assessment were conducted by the speech therapists.Results Of the 116 cases,22.4％ of the cases were with mild dysphagia and 34.5％ with moderate to severe dysphagia,resulting in a prevalence of dysphagia of 56.9％.The main problems of these cases occurred during oral phase and pharyngeal phase,including inadequate feeding skills(involving sucking,biting,chewing or/and swallowing),coughing,vomiting and choking during feeding,cry/overextension of neck and head during feeding,drooling,hypertonic tongue and inadequate tongue lateralization.The severe dysphagia was encountered frequently in children with spastic quadriplegic,dyskinetic or mixed type CP children.Of the 116 cases,90 cases(77.59％)were with oral motor dysfunction(including all spastic quadriplegic,dyskinetic or mixed type children).The oral motor scores of CP children were significantly lower than those of the controls(P ＜ 0.01).Conclusions Oral phase dysphagia and oral motor disorder might be considered as the common clinical problems among the patients with CP,and could be assessed by using DDS combined with oral motor assessment,but for dysphagia during pharyngeal or esophagus phase,the videofluoroscopic modified barium swallow should be used for further evaluation. Key words: Cerebral palsy; Deglutition disorder; Oral movement disorder; Clinical assessment

Videofluoroscopic Modified Barium Swallow Study for Premature Ventricular Complexes–Associated Dysphagia

An 18-year-old white female with a body mass index of 28 kg/m2 presented with a 6-month history of intermittent esophageal dysphagia, dizziness, and heavy vomiting associated with frequent premature ventricular complexes (PVCs). Her echocardiogram was normal, and serial 24-hour ambulatory Holter monitoring documented between 100 and 5000 monomorphic PVCs. A 12-lead ECG obtained during an emergency department visit revealed monomorphic single PVC, as well as pairs and triplets with inferior axis and left bundle-branch block pattern. Upper endoscopy and chest x-ray did not reveal any pathologies. Videofluoroscopic modified barium swallow study with simultaneous ECG monitoring …

Tracking clinical improvement of swallowing disorders after stroke

Goal: The goal of this study was to determine recovery rates from swallowing disorders, or dysphagia, at 3 weeks and 3 months poststroke by tracking changes in nutritional management. Materials and Methods: Ninety-one newly diagnosed stroke patients were studied. Patients with suspected dysphagia were referred for bedside swallowing assessment, performed by a speech-language pathologist, and, where indicated, a videofluoroscopic modified barium swallow. Patients with confirmed dysphagia were initiated on either an oral dysphagia diet or enteral feeding, and they continued to receive swallowing treatment as both inpatients and out-patients. Recovery from dysphagia, based on the patient's type of diet, was assessed at days 21 and 90 poststroke. Findings: On admission, 48 of 91 (53%) newly diagnosed stroke patients presented with clinical evidence of a swallowing abnormality. Forty-two percent of these patients were managed by enteral tube feedings, and 58% received a dysphagia diet. By day 21 poststoke, 13 (27%) of the initially dysphagic patients were consuming a regular diet. By day 90, 36 (75%) of these patients were consuming a regular diet; 5 patients (10%) remained dysphagic and were nutritionally managed either with a dysphagia diet or enteral feeding. A total of 7 (15%) of the 48 patients were lost to follow-up. Conclusions: Three quarters of stroke patients initially presenting with dysphagia were consuming their prestroke diet by 3 months. Using assessment-based diet type as a proxy for the ongoing identification of dysphagia poststroke, this study found a substantial recovery rate in patients presenting with swallowing disorders. Copyright © 2002 by National Stroke Association

Use of percutaneous gastrojejunostomy feeding tubes in the rehabilitation of stroke patients

Teasell RW, Foley N, McRae M, Finestone H. Use of percutaneous gastrojejunostomy feeding tubes in the rehabilitation of stroke patients. Arch Phys Med Rehabil 2001;82:1412-5. Objective: To determine the characteristics of and complications in the rehabilitation of stroke patients in whom percutaneous gastrojejunostomy (PGJ) feeding tubes have been placed. Design: Retrospective cohort study. Setting: A rehabilitation unit in a tertiary care hospital. Participants: Stroke patients (n = 563) admitted to a tertiary care hospital over a 10-year period. Intervention: PGJ feeding tubes. Main Outcome Measures: Evidence of aspiration in all videofluoroscopic modified barium swallow (VMBS) studies was noted. For patients with a PGJ feeding tube, the following were recorded: stroke location; results of subsequent VMBS reports; length of time from stroke onset to PGJ feeding tube insertion; total time the PGJ feeding tube remained in situ; discharge disposition; and concurrent feeding status. Follow-up was at 1-year poststroke. Complications during the inpatient stay attributable to the PGJ feeding tube were recorded. Results: Thirty-two of all 563 (5.7%) stroke patients admitted and 28 of the 115 (24.3%) proven aspirators, as shown on VMBS studies, had a PGJ feeding tube inserted. Twenty-one of the 563 (3.7%) stroke patients were discharged to the community with PGJ feeding tubes in place. The tubes were inserted on average 37 days after stroke onset. Seventeen of all 88 (19.3%) brainstem stroke patients and 15 of all 29 (51.7%) brainstem stroke patients with documented aspiration had feeding tubes inserted, whereas only 15 of 475 (3.2%) hemispheric stroke rehabilitation patients received a tube. Eleven of 32 (34.3%) patients with a feeding tube were able to resume oral feedings at discharge; within 1 year of discharge, 24 of 32 (75%) had done so. Although there were no serious complications resulting from tube insertions, minor complications were documented in more than 50% of the cases. The tubes were associated with prolonged institutionalization in only 1 case; most patients were discharged on a home tube-feeding program. Conclusions: PGJ feeding tubes were placed in approximately 1 of every 20 of our stroke rehabilitation patients. One third of the tubes were removed before the patients were discharged from rehabilitation and 75% were removed within 1 year. Insertion of the tubes was most common in patients with evidence of aspiration and in patients with brainstem strokes. Complications caused by the tube were minor and all patients but 1 who were discharged with feeding tubes were able to manage the home tube-feeding program. © 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Management of Aspiration and Pneumonia Following Stroke

Aspiration has been associated with pneumonia following stroke and its detection and prevention are considered important in the management of stroke patients. Initially, a bedside assessment is conducted, especially in high-risk patients. However, clinical assessment may miss a substantial number of “silent” aspirators and therefore the videofluoroscopic modified barium swallow (VMBS) study is considered the “gold standard” for confirming the presence and extent of aspiration. Clinical indications for use of VMBS studies remain empirical and have never been scientifically validated. Treatment of known aspiration involves specialized diets and in more severe cases, nonoral feedings. Only a little quality scientific research demonstrates whether such treatments are effective or ineffective in preventing aspiration. An obvious need exists for further research into this area.

The Relationship between Aspiration and Pneumonia Following Stroke

Aspiration is defined as entry of oral material into the airway below the level of the true vocal cords. Aspiration is common following stroke, particularly in the initial acute phase. Because a significant number of these aspirators are “silent aspirators,” videofluoroscopic modified barium swallow (VMBS) studies are regarded as necessary to definitively diagnose aspiration in stroke patients. Pneumonia or chest infections occur relatively frequently more following stroke; they are most common shortly after stroke onset. The incidence of pneumonia varies according to clinical criteria and the populations studied. Nevertheless, a strong association between aspiration and pneumonia has been established with a 7-fold or greater risk of pneumonia among aspirators when compared with non-aspirators. Factors associated with aspiration pneumonia are the degree of severity of aspiration and—to a lesser extent—the underlying susceptibility of the stroke patient’s lungs.

Frequency of videofluoroscopic modified barium swallow studies and pneumonia in stroke rehabilitation patients: A comparative study

Objective: To study the association between the frequency of videofluoroscopic modified barium swallow (VMBS) studies and the incidence of pneumonia in stroke rehabilitation patients. Design: Retrospective comparative study. Subjects and Setting: Five hundred sixty-three consecutive stroke patients admitted to one hospital rehabilitation unit in London, Ontario, Canada were compared with 461 consecutive stroke patients admitted to another hospital rehabilitation unit in the same city. Interventions: The number of initial and total VMBS studies and the timing from stroke onset to initial VMBS studies. Main Outcome Measure: Incidence of pneumonia. Results: At the first hospital, 146 patients (25.9%) had 232 total VMBS studies performed, whereas at the second hospital 57 patients (12.4%) had 73 total studies ( p < .001). For the first 15 days there was no significant difference in the number of initial VMBS studies performed (8.2% vs 9.2%). There was a marked difference in the number of initial VMBS studies performed after 15 days (17.2% vs 2.0%, p < .0001). The difference between the hospitals in the number of VMBS studies in patients with brain stem strokes was not statistically significant, but for patients with hemispheric stroke, the difference was statistically significant. Pneumonia developed in 12 patients at the first hospital (2.1%) and 10 patients at the second hospital (2.2%), a difference that was not significant. Conclusions: The more frequent use of VMBS beyond 15 days after stroke was not associated with a change in the incidence of pneumonia among hemispheric stroke rehabilitation patients, assuming the two units were otherwise similar.

Pneumonia in Dysphagic Stroke Patients: Effect on Outcomes and Identification of High Risk Patients

Objectives : To identify variables associated with the development of pneumonia in patients with ischemic stroke and to assess the utility of both the clinical swallowing examination and the videofluoroscopic modified barium swallow (VMBS) to identify stroke patients at risk for aspiration and subsequent pneumonia and to measure the effect of pneumonia on hospital outcomes.Design/Methods: Bedside clinical evaluation and VMBS were performed on 102 patients admitted with acute ischemic stroke who were referred for swallowing eval uation because of clinical suspicion of dysphagia. The clinical features, stroke loca tion and severity, pneumonia, length of stay (LOS), mortality, and costs were evalu ated retrospectively.Results: Pneumonia occurred in 21 of 102 patients (20.6%) and was more fre quent in those with aspiration on VMBS (p < 0.01). Those with pneumonia had longer median LOS (29 days vs. 10 days), higher total costs ($27,764 vs. $9,753, p < 0.0001), higher mortality (24 percent vs. 3.7 percent, p < ...

Pneumonia associated with aspiration following stroke.

To determine the association between demonstrated aspiration and pneumonia in stroke patients. Chart review of 441 consecutive stroke patients admitted to a stroke rehabilitation unit within 4 months of their stroke over an 8-year period. Videofluoroscopic modified barium swallow (VMBS) was performed on all patients suspected of aspirating. In all patients, the presence or absence of pneumonia was noted. Eighty-four of the 441 (19.0%) stroke patients transferred for rehabilitation demonstrated aspiration of thin liquids on VMBS. Twelve of the 441 (2.7%) developed pneumonia while in hospital, either in the acute or rehabilitation phases. The incidence of pneumonia among proven aspirators on VMBS was 10 of 84 (11.9%) patients. Two of the 357 (0.6%) patients who were presumed nonaspirators developed pneumonia. Brain stem and right hemispheric stroke patients had a higher incidence of pneumonia. Pneumonia is an uncommon complication of stroke. However, approximately 12% of stroke rehabilitation patients diagnosed as aspirators on VMBS developed pneumonia, a 20-fold increase over presumed nonaspirators. VMBS is a potentially valuable tool in determining those patients at risk of aspiration pneumonia.

Prevalence and recovery of aspiration poststroke: a retrospective analysis.

This retrospective study was undertaken to review aspiration documented by videofluoroscopic modified barium swallow (VMBS) examination in a group of patients admitted to a stroke rehabilitation unit. Forty-two of 54 patients tested demonstrated evidence of aspiration of thin liquids on VMBS performed an average of over 5 weeks following the onset of stroke. However, only patients in whom there was clinical concern of aspiration (54 of 255 stroke patients admitted to the rehab unit) were tested with VMBS evaluation. With this limitation in mind, aspiration was demonstrated in at least 9.9% of all unilateral right hemispheric patients, 12.1% of unilateral left hemispheric, 24% of bilateral hemispheric, and 39.5% of brainstem stroke patients. Of the 42 patients in whom aspiration of thin liquids was demonstrated, 31 underwent repeat VMBS studies an average of 6 weeks after the initial VMBS. 7 of these 31 (22.6%) no longer showed aspiration on VMBS. Eighteen of the 42 patients (43%) clinically stopped aspirating over this 6-week period.

Characteristics of dysphagia in children with cerebral palsy.

Videofluoroscopic modified barium swallow (VMBS) examinations may provide clinically relevant information regarding deglutition in children with cerebral palsy and dysphagia. A retrospective review of clinical evaluations and VMBS studies on 90 consecutive children with cerebral palsy and dysphagia was completed. Most children were referred because of concerns regarding airway protection during oral feedings. Most children had multiple disabilities and 93% were nonambulatory. The majority of children were totally dependent for oral feedings (80%). Oral and pharyngeal phase abnormalities were present in almost all patients. Abnormalities of deglutition were observed only while swallowing specific food textures in the majority of patients. Aspiration of specific food textures was significantly more common than aspiration of all food textures (p < 0.0001). Finally, aspiration was silent in 97% of the patients. VMBS studies can provide clinicians with valuable information regarding the most appropriate food textures and rates of oral feeding for children with cerebral palsy and dysphagia.

Videofluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke

In order to assess the risk of pneumonia, dehydration, and death associated with videofluoroscopic evidence of aspiration following stroke, the clinical records of 26 patients with aspiration and 33 randomly selected, case-matched, dysphagic controls without videofluoroscopic evidence of aspiration were reviewed. The videofluoroscopic modified barium swallow technique included 5 ml-thin and thick liquid barium, 5 ml barium pudding, and 1/4 cookie coated with barium, plus additional 20 and 30 ml of thin liquid barium. Patients were assessed a mean of 2 +/- 1 SD months poststroke and were followed for a mean of 16 +/- 8 SD months poststroke. The odds ratio for developing pneumonia was 7.6 times greater for those who aspirated any amount of barium irrespective of its consistency (p = 0.05). The odds ratio for developing pneumonia was 5.6 times greater for those who aspirated thickened liquids or more solid consistencies compared with those who did not aspirate, or who aspirated thin liquids only (p = 0.06). Dehydration was unrelated to the presence or absence of aspiration. The odds ratio for death was 9.2 times greater for those aspirating thickened liquids or more solid consistencies compared with those who did not aspirate or who aspirated thin liquids only (p = 0.01). Aspiration documented by modified videofluoroscopic barium swallow technique is associated with a significant increase in risk of pneumonia and death but not dehydration following stroke.

Silent aspiration prominent in children with dysphagia

Children with neurologically-based dysphagia are at high risk for silent aspiration. Aspiration can lead to complications such as acute pneumonia and chronic lung disease. Thorough evaluation of the oral, pharyngeal, and esophageal phases of swallowing is crucial for patients with dysphagia. The videofluoroscopic modified barium swallow study (MBS) is the procedure of choice for children to delineate the pharyngeal and upper esophageal phases of the swallow that can only be inferred by bedside clinical assessment. This study describes attributes of aspiration and pharyngeal motility in a large sample of infants and children assessed with MBS. Aspiration was observed in 48 (26%) of 186 children, primarily on liquid before or during swallows. Aspiration was trace (less than 10% of a bolus) and silent in 94%. Relationships to clinical history and implications for management are discussed. Given the lack of objective clinical information to identify children at risk for aspiration, MBS should be considered in all children with severe dysphagia to rule out or confirm aspiration.

Validation of the 3-oz water swallow test for aspiration following stroke.

A 3-oz water swallow test identified 80% (16/20) of patients aspirating during a subsequent videofluoroscopic modified barium swallow examination (sensitivity, 76%; specificity, 59%). It also identified patients with more severe dysphagia aspirating larger amounts (sensitivity, 94%; specificity, 26%) or thicker consistencies (sensitivity, 94%; specificity, 30%) of test material. The 3-oz water swallow test is a sensitive screening tool for identifying patients at risk for clinically significant aspiration who need referral for more definitive modified barium swallow evaluation.