Weak Cough Research Articles

Swallowing difficulties and Parkinson's disease

Parkinson's disease impacts the lives of thousands of people across the world. Chest infection is a significant health risk for people with Parkinson's disease and is often caused by swallowing difficulties, saliva management and weak cough. There is promising research on various treatments for swallowing and cough impairments. If swallowing and cough function can improve with rehabilitation, this will potentially improve the health and quality of life of people with Parkinson's disease worldwide.

Voluntary Cough and Swallowing Function Characteristics of Acute Stroke Patients Based on Lesion Type

ObjectiveTo investigate the relation between voluntary cough and swallowing functions according to the type of lesion in patients with acute stroke. DesignCross-sectional study. SettingUniversity rehabilitation hospital. ParticipantsAcute stroke patients with dysphagia symptoms (N=397). InterventionsNot applicable. Main Outcome MeasuresA peak cough flow meter was used to measure voluntary coughing ability. Swallowing function was evaluated using the functional dysphagia scale and the penetration-aspiration scale based on the results of a videofluoroscopic swallowing study. Stroke lesions were divided into one of the following 3 categories: cortical, subcortical, and brainstem. These evaluations were performed within 2 weeks after stroke onset. ResultsOf the enrolled 397 patients, 207 patients were classified as cortical stroke, 106 patients were classified as subcortical stroke, and 84 patients were classified as brainstem stroke. Among the subscores of the functional dysphagia scale, the amount of pharyngeal residue negatively correlated with peak cough flow meter results across all stroke lesion types. In the brainstem lesion, peak cough flow and penetration-aspiration scale scores were high compared with other lesions, but these 2 functions did not show a correlation. ConclusionsThis study revealed that large amounts of pharyngeal residue correlated with weak voluntary cough ability in all stroke lesion groups. We also showed a discrepancy between 2 functions in the brainstem lesion group. Our results suggest that voluntary coughing exercises could be a helpful therapeutic option for dysphagia to prevent pulmonary complications in some types of patients with stroke.

167 Evaluation of the oscillatory Cough Assist E70 in adults with cystic fibrosis (CF)

Oscillatory devices used in airway clearance create variable resistances generating controlled oscillating positive pressure which mobilises mucus. Mechanical insufflation-exsufflation provides a non-invasive therapy to aid secretion clearance in patients with weak cough. The Cough Assist E70 combines these concepts. Methods We compared standard airway clearance with the E70 in 5 patients (2M, 3F, age 19–35). All had a diagnosis of CF and a typical cough (FEV 1 range 0.8–1.59 L). Implementation of this device was in response to chest wall discomfort on coughing, respiratory exacerbation or fatigue with standard therapy. Ease of expectoration, cough effort, sputum weight and patient preference were considered on initialisation and were the basis for continued use. Days of use ranged from 1 to 21. E70 pressure settings were titrated for comfort. Oscillation frequency was set at 13–15 Hz on insufflation and/or exsufflation. Results Average sputum weight for standard therapy was 9 (4–11 g) and for E70 17 g (4–28 g). 4 patients described reduced cough effort and increased ease of expectoration using the E70. 3 patients preferred the E70 to their standard therapy. 1 patient preferred standard therapy and 1 patient felt that the E70 supported standard therapy and would be advantageous during an exacerbation. Conclusion Despite the small sample size we identified that the E70 is a useful adjunct in managing secretions. In particular, patients who experience fatigue or chest wall discomfort on coughing benefited from the implementation of this device and sputum yield improved noticeably. Use of the E70 should be considered when patient participation in routine airway clearance is compromised.

Diagnostic accuracy of methods used to verify nasogastric tube position in mechanically ventilated adult patients: a systematic review.

Nasogastric tubes are widely used in hospitals, e.g. for the administration of nutrients. However, nasogastric tubes can be inserted accidently into the airways leading to complications like pneumonia, pneumothorax and even death. Mechanically ventilated patients are at high risk of having a nasogastric tube misplaced, since they often have reduced consciousness and weak cough reflex. A variety of methods have been used for determination of nasogastric tube placement, but with varying success. The present systematic review was carried out to evaluate the diagnostic accuracy of methods used to determine nasogastric tube placement in mechanically ventilated adult patients. Studies including mechanically ventilated adult patients with a nasogastric tube were considered for inclusion, regardless of the type of nasogastric tube.All methods (index tests) used to verify nasogastric tubes placed in the airways and in the gastrointestinal tract were included. As a reference standard, X-ray was used to verify the accuracy of each index test.The studies that were included in the present systematic review were designed based on diagnostic test accuracy studies.The outcome was the accuracy (sensitivity and specificity) of the methods to discriminate between respiratory and gastrointestinal placement of the nasogastric tube. The search strategy aimed to find both published and unpublished studies before September 2013. Eleven electronic databases were searched including CINAHL, PubMed, Scopus and Embase. Methodological quality was assessed independently by two reviewers using QUADAS as a critical appraisal tool. Data were extracted by two reviewers independently using a modified Joanna Briggs Institute data extraction form including specific details such as: population, setting, index test, sensitivity and specificity. Sensitivity and specificity were extracted from the studies and presented in tables. When these were not written in the studies, calculations were performed based on data presented in the studies. Five relevant papers describing two different methods for determining nasogastric tube position were identified: colorimetric capnography (four studies) and capnography (one study).In all four studies examining colorimetric capnography the sensitivity was 100% when nasogastric tubes were inserted intentionally into the airways through an already existing tracheal tube, thereby imitating misplaced nasogastric tubes. When inserted through the nose, the sensitivity was 88-100% and specificity was 99-100%.Capnography obtained a specificity of 100% but sensitivity for when the nasogastric tube was inserted through the nose could not be calculated based on available data. We found evidence (Level 2b) for colorimetric capnography to be a valid method for verifying nasogastric tube placement.Capnography also detected nasogastric tube position with very high accuracy. However, since these methods were tested in only a single study with a limited sample size, further research is required before clinical recommendations can be made.Despite the impressive results obtained by using colorimetric capnography, implication for practice is not straightforward. A concern is that the colorimetric capnograph is not produced by the manufacture to fit a NG tube and therefore has to be connected to the NG tube by an adaptor-system. Practical issues therefore have to be resolved if the method is supposed to become a standard procedure in a clinical setting.The execution of the procedure using colorimetric capnography differs between the studies. This systematic review therefore recommends that further research should be done to optimize the execution of the procedure.We also recommend that further research be done to reproduce the results obtained using capnography, since this method was tested only in a single study with a limited sample size.

Semiquantitative cough strength score and associated outcomes in noninvasive positive pressure ventilation patients with acute exacerbation of chronic obstructive pulmonary disease

Weak cough may result in the failure of noninvasive positive pressure ventilation (NPPV) in patients with AECOPD. However, no detailed descriptions have yet been published for the measurement of cough strength and associated outcomes in AECOPD patients. This study prospectively enrolled 261 AECOPD patients who received NPPV. Semiquantitative cough strength score (SCSS, ranging from 0 = weak to 5 = strong) was recorded before NPPV. Patients who required intubation were defined as NPPV failures. NPPV failed in 55 patients (21.1%). Weak cough (SCSS ≤3, OR = 8.1), high disease severity (APACHE II score >19, OR = 3.8), and malnutrition (total proteins ≤58 g/L, OR = 2.8) were independent risk factors for NPPV failure. Patients with 1, 2, and 3 risk factors were 4.7, 13.6, and 21.6 times more likely, respectively, to experience NPPV failure compared with patients with no risk factors. The NPPV failure rates were 80%, 40%, and 10.2% in patients with SCSS of 0–1, 2–3, and 4–5, respectively (p < 0.001). Compared with NPPV success patients, NPPV failure patients stayed longer in ICU (10.1 ± 7.9 days vs. 6.5 ± 4.6 days, p < 0.001), and they had higher ICU costs (€2986 ± 1906 vs. €5680 ± 3,604, p < 0.001), higher hospital costs (€ 6714 ± 7025 vs. €10,399 ± 9,509, p = 0.009), and higher hospital mortality (72.7% vs. 4.4%, p < 0.001). Moderate accuracy to distinguish NPPV failure by APACHE II score, SCSS, and total proteins was evidenced by ROC curves, with areas under the curve of 0.71, 0.78, and 0.67, respectively. A combination of all three factors reached good accuracy, with an area under the curve of 0.86. AECOPD patients with weak cough had a high risk of NPPV failure. SCSS, APACHE II scores, and total proteins were predictors of NPPV failure. Combined, these factors increased the power to predict NPPV failure.

Concordance and Discriminatory Power of Cough Measurement Devices for Individuals With Parkinson Disease

Dysphagia and aspiration pneumonia are two causes of morbidity in Parkinson disease (PD). In PD, impaired airway clearance can lead to penetration of foreign material, resulting in a high prevalence of aspiration pneumonia and death. This study examines three different devices for measurement of peak airflow during voluntary cough in healthy control subjects and those with PD. Two simple and low-cost devices for measuring peak cough airflow were compared with the "gold standard" pneumotachograph. Thirty-five healthy control subjects and 35 individuals with PD produced voluntary cough at three perceived strengths (weak, moderate, and strong cough) for each of the three devices. A significant difference in mean peak cough airflow was demonstrated for disease (F[1,56] = 4.0, P &lt; .05) and sex (F[1,56] = 9.59, P &lt; .003) across devices. The digital and analog meters were comparable to the gold standard demonstrating no significant difference (statistical) by device (digital vs analog) in receiver operating characteristic curve analysis. Both devices were discriminative of the presence of PD. The analog and digital peak airflow meters are suitable alternatives to the gold standard pneumotachograph due to their low cost, portability, ease of use, and high sensitivity relative to normative peak cough airflows. Voluntary cough airflow measures may serve as a noninvasive means of screening for aspiration risk in target populations. Additionally, quantification of cough strength through use of predetermined limens for weak, moderate, and strong cough may assist clinicians in better describing and tracking cough strength as a contributing factor to aspiration risk.

Timing of noninvasive ventilation failure: causes, risk factors, and potential remedies

BackgroundIdentifying the predictors of noninvasive ventilation (NIV) failure has attracted significant interest because of the strong link between failure and poor outcomes. However, very little attention has been paid to the timing of the failure. This narrative review focuses on the causes of NIV failure and risk factors and potential remedies for NIV failure, based on the timing factor.ResultsThe possible causes of immediate failure (within minutes to <1 h) are a weak cough reflex, excessive secretions, hypercapnic encephalopathy, intolerance, agitation, and patient-ventilator asynchrony. The major potential interventions include chest physiotherapeutic techniques, early fiberoptic bronchoscopy, changing ventilator settings, and judicious sedation. The risk factors for early failure (within 1 to 48 h) may differ for hypercapnic and hypoxemic respiratory failure. However, most cases of early failure are due to poor arterial blood gas (ABGs) and an inability to promptly correct them, increased severity of illness, and the persistence of a high respiratory rate. Despite a satisfactory initial response, late failure (48 h after NIV) can occur and may be related to sleep disturbance.ConclusionsEvery clinician dealing with NIV should be aware of these risk factors and the predicted parameters of NIV failure that may change during the application of NIV. Close monitoring is required to detect early and late signs of deterioration, thereby preventing unavoidable delays in intubation.

Noninvasive ventilation success: Combining knowledge and experience.

Noninvasive ventilation success: Combining knowledge and experience.

Pain-associated Respiratory Failure in Chest Trauma

Pain-associated Respiratory Failure in Chest Trauma

Neuroborreliosis Presenting as Acute Disseminated Encephalomyelitis

We report a case of a 5-year-old boy with acute disseminated encephalomyelitis as the initial presentation of neuroborreliosis. Parents report an upper-airway infection a few days before the development of acute encephalopathy, mild facial palsy, and seizures. The patient needed mechanical ventilation for 10 days, and after extubation, he presented hypotonia, ataxia, dysarthria, as well as weak gag and cough reflexes. Brain magnetic resonance imaging showed hyperintense lesions on T2- and fluid-attenuated inversion recovery sequences on the right subcortical occipital and parietal region, left posterior arm of the internal capsule, and in the medulla oblongata. Borrelia burgdorferi was identified in the plasma and cerebrospinal fluid by polymerase chain reaction and in the plasma by Western blotting. He was treated with ceftriaxone, methylprednisolone, and human immunoglobulin. Recovery was partial.

Cough - another important factor in extubation readiness in critically ill patients

Ling Liu and colleagues [1] found that critically ill patients who fail weaning have impaired ability to convert neuromuscular activity into tidal ventilation, highlighting the eff ect of diaphragm weakness on weaning and extubation from mechanical ventilation. However, it is noteworthy that the insuffi cient cough strength greatly contributes to failed extubation in clinical practice as well, particularly in patients with acute cervical cord injury, or who have undergone major thoracic or abdominal surgery. Some intubated patients with inadequate cough strength can successfully pass the spontaneous breathing trial, but nevertheless might still experience extubation failure afterwards. It is diffi cult for them to clear secretions in airways due to the inability to cough, which leads to increased risk of atelectasis and respiratory infection. Weak cough can be attributable to expiratory muscle dysfunction, inspiratory muscle weakness, and so on; however, expiratory muscle function is crucial for eff ective cough [2]. Th e major expiratory muscles include the muscles of the anterolateral wall of the abdomen, the expiratory intercostal muscle, and the triangularis sterni [3]. Th e neuro-ventilatory effi ciency of these muscles, however, cannot be assessed by diaphragm electrical activity. Expiratory muscle strength became a focus of interest for estimating cough strength. Cough peak expiratory fl ow was used to evaluate cough refl ex, which was considered an indicator for predicting successful extubation of

Abstract 2395: Respiratory Muscle Weakness in Acute Stroke Patients

Background: Increased frequency of chest infections in acute stroke patients may be the result of respiratory muscle weakness contributing to a weak cough and poor airway clearance. We undertook a systematic review of studies comparing respiratory muscle strength in acute stroke patients with age-matched controls. Method: A systematic review of literature was performed using the electronic databases Medline, EMBASE, ISI web of knowledge and the Scopus. The key words searched were stroke or cerebrovascular accident in combination with cough, inspiratory, expiratory or respiratory and strength or weakness. Studies were included if they compared stroke patients with age matched controls and measured maximum inspiratory or expiratory mouth pressure (PImax and PEmax) for inspiratory and expiratory muscle strength respectively. Results: The initial search identified 136 articles, 14 of which remained after screening for pre-defined inclusion criteria and removal of duplicates. Eleven were excluded after reviewing abstracts (5 did not assess muscle strength, 5 did not include healthy control group, 1 absolute values could not be obtained). A further study was identified from the reference lists of screened articles. The 4 studies that met inclusion criteria included 121 subjects. Mean PImax ranged from 75-99 cmH 2 O in controls and 37-74 cmH 2 O in stroke patients. (mean difference 41 cmH 2 O, 95% CI 54 to 29 cm H 2 O; P&lt;0.0001). Mean PEmax ranged from 52-89 cm H 2 O in stroke patients and was also reduced compared with age matched controls (mean difference 55 cmH 2 O, 95% CI 61 to 48 cmH 2 O; P&lt;0.0001). ( Fig 1 ). Conclusion: Individual studies and pooled data suggest that respiratory muscle strength is impaired in acute stroke patients. However, these studies are limited by small samples and design heterogeneity. Larger studies are needed to assess the relationship of respiratory muscle weakness with chest infections and clinical outcomes in the acute phase.

So You Think You Can Safely Extubate Your Patient?

Intubation and mechanical ventilation are necessary in onethird of patients who are critically ill. While life-saving, these interventions are coupled with increased acid–base disturbances, infections and organ failure [1]. In addition, both early extubation leading to reintubation and deferred extubation correlate with higher morbidity and morality and longer stays in the intensive care unit (ICU) [2, 3]. Physicians strive to determine the most appropriate time to extubate a patient with efforts to predict this dating to the earliest research in critical care [4]; however, patients still have a significant extubation failure rate, now estimated to be 13–18% of the time [5, 6]. Extubation and discontinuation of mechanical ventilation should be considered once the cause of the respiratory failure has been remedied if the patient is oxygenating without difficulty and not hemodynamically compromised. The patient should also be evaluated for ability to tolerate a spontaneous breathing trial [7]. While these recommendations guide the physician in liberating a patient from the ventilator, they do not assess if the patient’s airway is adequate to tolerate extubation. A weak cough and copious secretions are associated with an unsatisfactory airway and extubation failure [6]. Accurately judging ability to protect the airway is paramount in patients intubated solely for neurologic reasons. This unique population of critically ill patients frequently does not have respiratory failure and otherwise meet criteria for extubation. Uncertainty of a brain-injured patient’s airway can delay extubation, perhaps unnecessarily. Coplin et al. [3] followed a prospective observational cohort of 136 brain-injured patients. Twenty-seven percent of patients experienced extubation delay after meeting criteria for extubation readiness. These patients had worse neurologic status as measured by the Glasgow Coma Scale (GCS) and increased airway care requirements. Extubation delay was not necessarily associated with improvement in neurologic status. In fact, 43% of the patients who had a delayed extubation had no change or a worsening of their neurologic condition at time of extubation. A physician may choose to keep a comatose patient intubated for airway protection and prevention of pneumonia. However, 54% of pneumonias occurred after patients met criteria for extubation delay (P = 0.05). Coplin and colleagues also underscored the costs associated with extubation delay, including increased lengths of ICU and hospital stays and increased mortality. Given physicians’ trepidation in safely extubating braininjured patients, several studies have attempted to identify predictors of extubation outcome in these patients. Weaning parameters (including respiratory rate, tidal volume, rapid shallow breathing index, minute ventilation, negative inspiratory force, and the PaO2/FiO2 ratio) are not prognostic of extubation failure in patients intubated for neurologic reasons [8]. These findings are not unsurprising given these parameters evaluate pulmonary status in patients without primary pulmonary dysfunction. Neurologic status as a predictor of extubation failure has produced contradictory results. Coplin et al. [3] demonstrated that comatose patients could be extubated successfully (80 and 91% of patients with GCS B 8 and B4, respectively). Ko L. C. Wendell (&) Department of Neurology and Neurosurgery, Rhode Island Hospital/Warren Alpert School of Medicine at Brown University, Providence, RI 02906, USA e-mail: linda_wendell@brown.edu

Tracheal Aspiration of Capsule Endoscopes: Completing a Cases Compilation

We read with great interest the report and compilation of cases of capsule endoscope (CE) aspiration by Lucendo et al. [1]. We would like to add two more cases to complete the compilation of reported cases. We had described the case of a 76-year-old man who underwent an inpatient CE with PillCam" SB1 and experienced a short-lived (15 s), by and large asymptomatic aspiration [2]. Depriest et al. [3] reported the case of a 90-year-old man, with multiple comorbidities, who aspirated the CE into the left main bronchus and eventually underwent flexible bronchoscopy for retrieval of the device with a Roth net. As in the Lucendo et al. case, CE aspiration in the aforementioned cases precipitated the cough reflex, which (albeit weak) in our case, led to dislodgment of the capsule and uneventful completion of the test. Lucendo et al. [1] point out that in case of CE aspiration, the relative size of the CE (11 9 26 mm) compared with the average antero-posterior and transverse diameter of an adult trachea (16 and 14 mm, respectively), allows enough space for adequate patient oxygenation; therefore, no fatalities have been described until now. Although four companies are competing in the market for the production of capsule endoscopy systems, the PillCam"SB remains the most widely used capsule worldwide for the study of the small bowel [4]. The sum total of CE aspirations reports are with PillCam"SB; interestingly, EndoCapsule" (Olympus Medical Systems, Tokyo Japan) is of exactly the same dimensions, while Intromedic Co. Ltd., Seoul, Korea produces the smaller and lighter MiroCam" (11 9 24 mm, 3.4 g), while Jinshan Science and Technology Company, Chongqing, China provides the bigger and heavier OMOM"CE. It is tempting to hypothesize that, although the possibility of a rare complication is more likely with the more commonly used system, the CE size might play a role in the response. Since a number of CE aspiration cases present with no or very weak cough (as in our case), we believe that patients with increased aspiration risk should swallow the CE while connected with real-time viewers, available for each system at the point of capsule ingestion. However, despite the theoretical advantage of a smaller and lighter shape, the image transmission mode of the Mirocam"CE does not generally allow acquisition of useful images of the oropharynx/upper esophagus during the ingestion phase. Finally, we would like once more to note that a potential serious complication as this should be included in the consent form for the procedure [2] and that for certain patient cohorts (elderly, patients with dysphagia or multiple co-morbidities) CE administration should take place in a controlled environment with oxygen and resuscitation facilities at close proximity. In our practice, we always confirm CE position with a real-time viewer in the immediate post-ingestion period, and prior to allowing patient discharge. Moreover, if endoscopy capsule placement is considered necessary we prefer to use for this the AdvanCE" delivery device and not the Roth net as we found that the floppiness of the last and its pointy end prevent a comfortable esophageal intubation. A. Koulaouzidis (&) ! S. Douglas ! J. N. Plevris Endoscopy Unit, Centre for Liver & Digestive Diseases, The Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK e-mail: akoulaouzidis@hotmail.com

The GlideScope for tracheal intubation in patients with grade IV modified Cormack and Lehane

The GlideScope for tracheal intubation in patients with grade IV modified Cormack and Lehane

Cepstral Analysis of Voice in Unilateral Adductor Vocal Fold Palsy

Unilateral vocal fold paralysis (UVFP) occurs because of the dysfunction of the vagus nerve innervating the larynx. It causes a characteristic breathy voice often accompanied by swallowing disability, a weak cough, and the sensation of shortness of breath. Clinical evaluation of voice is generally based on perceptive criteria and the acoustic analysis of voice. In the present study, it is hypothesized that there would be an abnormal reduction of the cepstral peak in speakers with UVFP relative to the normal controls, as they are characterized by a breathy voice because of inadequate closure of vocal folds. Phonation of sustained vowel /a/ sample was subjected to acoustic analysis using Computerized Speech Lab (CSL model 4150; Kay Pentax, Lincoln Park, NJ) software. The vowels were analyzed acoustically by the measurement of cepstral peak prominence (CPP). The results of 2 × 2 analysis of variance revealed the main effects of the groups (clinical vs control group), indicating reduced cepstral peak value in the clinical group in comparison with controls. The main effect of gender was also significant, indicating a decrease in the CPP value in the female group in comparison with the male group. The results obtained were discussed with respect to the underlying pathophysiology. The present study investigated the CPP in subjects with UVFP. Cepstral deviations in the clinical group are explained to be the result of the presence of phonatory gap, leading to the lower values of CPP.

Lower Thoracic Spinal Cord Stimulation to Restore Cough in Patients With Spinal Cord Injury: Results of a National Institutes of Health–Sponsored Clinical Trial. Part I: Methodology and Effectiveness of Expiratory Muscle Activation

DiMarco AF, Kowalski KE, Geertman RT, Hromyak DR. Lower thoracic spinal cord stimulation to restore cough in patients with spinal cord injury: results of a National Institutes of Health–sponsored clinical trial. Part I: methodology and effectiveness of expiratory muscle activation. Objective Evaluation of the capacity of lower thoracic spinal cord stimulation (SCS) to activate the expiratory muscles and generate large airway pressures and high peak airflows characteristic of cough, in subjects with tetraplegia. Design Clinical trial. Setting Inpatient hospital setting for electrode insertion; outpatient setting for measurement of respiratory pressures; home setting for application of SCS. Participants Subjects (N=9; 8 men, 1 woman) with cervical spinal cord injury and weak cough. Interventions A fully implantable electrical stimulation system was surgically placed in each subject. Partial hemilaminectomies were made to place single-disk electrodes in the epidural space at the T9, T11, and L1 spinal levels. A radiofrequency receiver was placed in a subcutaneous pocket over the anterior portion of the chest wall. Electrode wires were tunneled subcutaneously and connected to the receiver. Stimulation was applied by activating a small portable external stimulus controller box powered by a rechargeable battery to each electrode lead alone and in combination. Main Outcome Measures Peak airflow and airway pressure generation achieved with SCS. Results Supramaximal SCS resulted in high peak airflow rates and large airway pressures during stimulation at each electrode lead. Maximum peak airflow rates and airway pressures were achieved with combined stimulation of any 2 leads. At total lung capacity, mean maximum peak airflow rates and airway pressure generation were 8.6±1.8 (mean ± SE) L/s and 137±30 cmH 2O (mean ± SE), respectively. Conclusions Lower thoracic SCS results in near maximum activation of the expiratory muscles and the generation of high peak airflow rates and positive airway pressures in the range of those observed with maximum cough efforts in healthy persons.

Bedside Assessment of Swallowing in Stroke: Water Tests Are Not Enough

Objective: The clinical functional evaluation is the usual method for dysphagia screening in patients with acute stroke. This study compared two methods of evaluation — with liquid and semisolid viscosities. Method: Twenty-six patients with stroke onset within 7 days — with a mean age of 63.5 ± 12.4 years — were prospectively evaluated for deficit severity, swallowing mechanisms, chest X-ray studies, and late (30 days after discharge) assessment of disability with the modified Rankin Scale. Results: Tests using water and pudding correlated poorly (p < .001). The water test exhibited higher sensitivity for detection of problems in laryngeal protection, and the test with pudding was more sensitive for the functional analysis of dysphagia itself. Abnormalities in the water test were associated with weak spontaneous cough, while a normal pudding test correlated well with oral feeding 30 days after hospital discharge. The initial neurological severity correlated with results from both tests. No patient had pulmonary infiltrates 72 hours after testing or pneumonia up to 30 days after hospital discharge. Conclusion: The two evaluation methods should be used to both decrease the risk of aspiration and increase the likelihood of a safe and early reintroduction of oral feeding.

Malpositioning of a nasogastric tube: a pitfall in the emergency department

A 57-year-old man had a past history of diabetes mellitus controlled by oral hypoglycaemic agents. He was brought into the emergency department one day by paramedics after ingesting over 200 ml of synthetic pyrethroid insecticide (alpha-cypermethrin). The patient was vomiting and agitated; therefore, a nasogastric tube was immediately inserted in order to perform gastric lavage. Routine chest X-ray was also done before admission (Fig. 1). Fig. 1 Chest X-ray revealed nasogastric tube inserted into right main stem bronchus Placement of a nasogastric tube is indicated to decompress the stomach by aspiration of gastric contents, to introduce fluids and to assist in the clinical diagnosis of the ingested contents or gastric contents. Accidental misplacement of a nasogastric tube can occur in high-risk patients such as sedated patients, patients with weak cough reflex, endotracheally intubated patients and agitated patients [1]. Various methods to verify nasogastric tube placement in the stomach include the use of chest X-ray, aspiration of gastric content with the irrigating syringe, audible sounds of air entering the stomach while a 30 cc air bolus is injected with the syringe, and able to talk without coughing, choking or cyanosis. It is important to verify nasogastric tube placement in the stomach because the result of misplacement can be fatal such as aspiration pneumonitis or aspiration pneumonia.

Disturbed Sleep in a Patient with Duchenne Muscular Dystrophy

Disturbed Sleep in a Patient with Duchenne Muscular Dystrophy