Evaluation of the natural history of patients who aspirate

Oropharyngeal dysphagia management and informed consent: a survey of speech-language pathologists' practice patterns when recommending modified texture diets

Purpose

The modification of diet textures and liquid viscosity represents the primary form of management of oropharyngeal dysphagia (OD) by speech-language pathologists (SLPs). Despite the ubiquitous use of modified texture diets (MTDs) to prevent aspiration in an attempt to prevent pneumonia, there is no convincing evidence that consumption of MTDs protects individuals with dysphagia from developing pneumonia. Furthermore, informed consent is required for the prescription of MTDs. To date, no study has investigated if practicing SLPs know the risks associated with MTDs, consider the risks when making clinical decisions, and disclose those risks to their patients.

Method

Thirteen negative health outcomes associated with MTDs were identified in the research literature. A web-based survey was created and distributed. Participants were asked to identify known risks associated with MTDs, how often they considered the risks associated with MTDs before recommending them, and how often they informed patients with OD of the known risks associated with MTDs.

Results

Only 6.3% of the SLPs surveyed identified all thirteen listed health risks associated with MTDs, and greater than one in five respondents (n = 55; 21.7%) were unable to select even one known risk. Seventy percent (n = 140) of participants indicated that they "almost always" weigh the risks associated with drinking thickened liquids, and fifty-four percent of respondents (n = 108) specified that they "almost always" weigh the risks associated with consuming modified texture solids. Less than half of the participants (n = 99; 49.7%) stated that they "almost always" inform the patient of the risks associated with thickened liquids and 39.9% (n = 79) indicated that they "almost always" inform patients of the risks associated with altered texture solids.

Conclusions

Participants demonstrated poor overall knowledge of the hazards associated with MTDs, limited consideration of known risks of MTDs, and suboptimal levels of disclosure of the risks associated with MTDs to patients with OD.

Predictors of Pneumonia in Patients With Penetration-Aspirations Detected on Fiberoptic Endoscopic Evaluation of Swallowing

Aspiration pneumonia is a serious condition resulting from swallowing dysfunction. However, predicting high risk patients remains challenging. This study aimed to assess the incidence and risk factors for pneumonia in oropharyngeal dysphagia patients exhibiting episodes of penetration or aspiration during fiberoptic endoscopic swallowing evaluation (FEES). A retrospective analysis was performed on patients who visited a dysphagia clinic between 2016 and 2022, and demonstrated at least one episode of penetration or aspiration during the FEES (Penetration Aspiration Scale [PAS] score ≥ 3). Data collected included demographics, comorbidities and FEES findings. Outcomes included mortality, hospital admissions to treat pneumonia events, and incidents of pneumonia managed by primary care providers or outpatient medical facilities. Statistical analyses included descriptive statistics, chi-squared tests, t-tests, logistic regression and Kaplan-Meier survival analysis. Among 73 patients (mean follow-up: 3.87 ± 1.5 years), 33 (45.2%) exhibited penetration, and 40 (54.8%) aspiration. Pneumonia developed in 41 patients (56%), with 33 (45%) hospitalized. A total of 28 patients (38.4%) died during follow-up. A history of prior pneumonia (OR: 1.374, p = 0.02) and Murray Secretion Scale score (OR: 1.121, p = 0.022) were associated with subsequent pneumonia events. Reduced laryngeal sensation showed a near-significant trend toward association with pneumonia-related hospitalizations in the penetration group (58.3% vs. 19%, P = 0.052). No significant association was found between PAS and pneumonia or mortality. Prior pneumonia and secretions accumulation during FEES significantly predict pneumonia in patients presenting with penetration-aspiration during FEES. Reduced laryngeal sensation showed a nearly-significant trend toward pneumonia-related hospitalizations.

Linking the impact of aspiration to host variables using the BOLUS framework: support from a rapid review

Purpose

The purpose of this rapid review was to identify the level of evidence for a previously proposed theoretical framework to assess risks associated with prandial aspiration using the host as a central theme.

Methods

Covidence software was used to search two databases (PubMed and Web of Science). PEDro scale was utilized to determine the quality of individual studies. Data points were evaluated for level of support and determined to be either conclusive, suggestive, unclear, or not supportive. Within each component of the framework, data points were clustered to determine the level of evidence as strong, moderate, insufficient, or negative.

Results

The rapid review process resulted in a limited number of publications investigating host variables impact on outcomes for patients with swallowing disorders. Overall, it yielded 937 articles, of which, upon review, 16 articles were selected for data extraction. There was a strong level of evidence to support that (a) as viscosity and density of aspirate increased, so did the likelihood of general medical complications, (b) poor oral care and oral health increase the risk of a pulmonary or general medical complication, and (c) the presence of oropharyngeal or laryngeal tubes increases the risk of a pulmonary consequence. There was moderate evidence to support the impact of amount and frequency of aspiration on outcomes. There was insufficient evidence to determine relationships for all other aspects of the BOLUS framework.

Conclusion

Additional evidence to support the BOLUS framework was obtained; however, the number of studies was limited. A more thorough review such as a systematic review should be employed.

Clinical outcomes before and after videofluoroscopic swallow study in children 24 months of age or younger

OBJECTIVE

To evaluate the combined impact of videofluoroscopic swallow study (VFSS) and therapeutic feeding and swallowing interventions on clinical outcomes in children with oropharyngeal dysphagia (OPD).

METHODS

This was an uncontrolled longitudinal analytical study in which OPD patients were evaluated before and after VFSS. Children ≤ 24 months of age diagnosed with OPD in a clinical setting and undergoing VFSS for investigation and management of OPD were included in the study. The study participants received therapeutic feeding and swallowing interventions after having undergone VFSS, being followed at an outpatient clinic for pediatric dysphagia in order to monitor feeding and swallowing difficulties. Respiratory and feeding outcomes were compared before and after VFSS.

RESULTS

Penetration/aspiration events were observed in 61% of the VFSSs (n = 72), and therapeutic feeding and swallowing interventions were recommended for 97% of the study participants. After the VFSS, there was a reduction in the odds of receiving antibiotic therapy (OR = 0.007) and in the duration of antibiotic therapy (p = 0.014), as well as in the odds of being admitted to hospital (p = 0.024) and in the length of hospital stay (p = 0.025). A combination of oral and enteral feeding became more common than oral or enteral feeding alone (p = 0.002).

CONCLUSIONS

A high proportion of participants exhibited penetration/aspiration on VFSS. Therapeutic feeding and swallowing interventions following a VFSS appear to be associated with reduced respiratory morbidity in this population.

Laryngeal Penetration and Risk of Aspiration Pneumonia in Children with Dysphagia-A Systematic Review

This study was a systematic review and meta-analysis that assessed the risk of aspiration pneumonia in children with laryngeal penetration or tracheal aspiration via a video-fluoroscopic study (VFSS) and compared the results to those for children with neither condition. Systematic searches were conducted using databases, including PubMed, Cochrane Library, and Web of Science. Meta-analysis was used to obtain summary odds ratios (OR) and 95% confidence intervals (CI). The overall quality of evidence was assessed using the grading of recommendations, assessment, development, and evaluation (GRADE) criteria. In total, 13 studies were conducted with 3159 participants. Combined results from six studies showed that laryngeal penetration on VFSS may be associated with aspiration pneumonia compared to no laryngeal penetration; however, the summary estimate was imprecise and included the possibility of no association (OR 1.44, 95% CI 0.94, 2.19, evidence certainty: low). Data from seven studies showed that tracheal aspiration might be associated with aspiration pneumonia compared to no tracheal aspiration (OR 2.72, 95% CI 1.86, 3.98, evidence certainty: moderate). The association between aspiration pneumonia and laryngeal penetration through VFSS seems to be weaker than that for tracheal aspiration. Prospective cohort studies with clear definitions of laryngeal penetration and that measure clinical and patient reported outcomes are needed to further define the association between laryngeal penetration and aspiration pneumonia.

Impact of anxiety and depression on the swallowing process among patients with neurological disorders and head and neck neoplasia: systemic review

Background

Dysphagia is associated with depression and anxiety due to the severity, impact of symptoms itself or secondary to the underlying cause. This is more recognizable to brain diseases that has consequences common to the neural supply of the swallowing act and the cognition and behavior. Limited data are available to explore, quantitate and monitor these neurological outcomes. Our aim of this research to review the literature pertinent to depressive disorders, anxiety, and/or the quality of life (QoL) and psychological well-being. Search of Medline and Google Scholar databases for relevant articles had revealed a total of 1568 citations; 30 articles met the inclusion and exclusion criteria.

Results

Data about the direct effect of dysphagia on psychiatric aspects are limited. Studies of the relationship between severity of dysphagia and depressive symptoms demonstrated that several evaluation tools are available for objective and subjective assessment. The severity and progression of dysphagia was significantly associated with increased depressive symptoms.

Conclusion

Dysphagia is associated with and positively correlated to depression and anxiety scores observed in Parkinson disease (PD), multiple sclerosis (MS) and stroke. Similar association is observed in patients with head and neck cancer, tongue cancer and oral cancer. A bidirectional positive correlation exists with a vicious circle that loops between dysphagia and psychological disease. Moreover, the severity of dysphagia shows correlation with depression and/or anxiety scores (Fig. 1, Graphical abstract).

Graphical Abstract

Expert Consensus Statement: Management of Dysphagia in Head and Neck Cancer Patients

OBJECTIVE

To develop an expert consensus statement (ECS) on the management of dysphagia in head and neck cancer (HNC) patients to address controversies and offer opportunities for quality improvement. Dysphagia in HNC was defined as swallowing impairment in patients with cancers of the nasal cavity, paranasal sinuses, nasopharynx, oral cavity, oropharynx, larynx, or hypopharynx.

METHODS

Development group members with expertise in dysphagia followed established guidelines for developing ECS. A professional search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements targeted at providers managing dysphagia in adult HNC populations. The development group prioritized topics where there was significant practice variation and topics that would improve the quality of HNC patient care if consensus were possible.

RESULTS

The development group identified 60 candidate consensus statements, based on 75 initial proposed topics and questions, that focused on addressing the following high yield topics: (1) risk factors, (2) screening, (3) evaluation, (4) prevention, (5) interventions, and (6) surveillance. After 2 iterations of the Delphi survey and the removal of duplicative statements, 48 statements met the standardized definition for consensus; 12 statements were designated as no consensus.

CONCLUSION

Expert consensus was achieved for 48 statements pertaining to risk factors, screening, evaluation, prevention, intervention, and surveillance for dysphagia in HNC patients. Clinicians can use these statements to improve quality of care, inform policy and protocols, and appreciate areas where there is no consensus. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to dysphagia in HNC patients.

Respiratory aspiration during treatment with clozapine and other antipsychotics: a literature search and a pharmacovigilance study in VigiBase

INTRODUCTION

Antipsychotics (APs), during treatment or overdose, may be associated with respiratory aspiration.

AREAS COVERED

A PubMed search on September 30, 2022, provided 3 cases of respiratory aspiration during clozapine therapy and 1 case during an AP overdose. VigiBase records of respiratory aspiration associated with APs from inception until September 5, 2021, were reviewed. VigiBase, the World Health Organization's global pharmacovigilance database, uses a statistical signal for associations called the information component (IC).

EXPERT OPINION

The ICs (and IC₀₂₅) were 2.1 (and 2.0) for APs, 3.2 (and 3.0) for clozapine, 2.6 (and 2.4) for quetiapine, and 2.5 (and 2.2) for olanzapine. Cases of respiratory aspiration associated with APs included: 137 overdose/suicide cases (64 fatal) and 609 cases during treatment (385 fatal) including 333 taking clozapine (238 fatal). In logistic regression models of fatal outcomes, the odds ratios, OR, and (95% confidence intervals, CI) of significant independent variables were: a) 2.3 - 2.6 for clozapine in 3 samples of AP treatment of varying size, b) 1.9 (CI 1.0 to 3.5) for geriatric age in 284 patients on clozapine treatment, and c) 1.8 (CI 1.1 - 3.2) for antidepressant co-medication in 276 patients on non-clozapine APs. Multiple AP pharmacological mechanisms may explain respiratory aspiration.

Respiratory aspiration during treatment with benzodiazepines, antiepileptic and antidepressant drugs in the pharmacovigilance database from VigiBase

INTRODUCTION

Three psychotropic drug classes, benzodiazepines, antiepileptic drugs (AEDs) and antidepressants (ADs), whether used in treatment or overdose, may be associated with respiratory aspiration. Polypharmacy was defined by counting suspected drugs from these classes or two others, antipsychotics and opioids. The confounding effects of polypharmacy were considered in this study.

AREAS COVERED

VigiBase records of respiratory aspiration associated with benzodiazepines, AEDs, and/or ADs from inception until September 5, 2021, were reviewed. VigiBase, the World Health Organization's global pharmacovigilance database, uses a statistical signal for associations called the information component (IC).

EXPERT OPINION

The ICs (and IC₀₂₅) were benzodiazepines 2.8 (and 2.6), AEDs 1.6 (and 1.5), and ADs 1.4 (and 1.3). The cases of respiratory aspiration associated with at least one drug from these 3 classes included: 1) 553 cases absent any known overdose (2.8±1.7 drugs) and 2) 347 overdose cases (2.9±1.8 drugs). Little support for the association of respiratory aspiration and benzodiazepine, AED or AD monotherapy in therapeutic dosages was found. Studies of the association between benzodiazepine monotherapy and respiration aspiration are needed in geriatric patients. ADs added to other medications increased lethality in all cases of respiratory aspiration including those associated with overdose, polypharmacy and/or major medical problems.

Shared decision making in dysphagia

The term 'risk feeding' usually applies where a person continues to eat and drink despite aspiration. This term has been increasingly challenged. Risk feeding has connotations of risk-taking behaviour and may conflict with healthcare values of keeping people safe. 'Risk' is difficult to quantify in dysphagia and interventions to reduce risk are not risk-free. The relationship between aspiration and pneumonia is complex, as are the success of the interventions designed to prevent them. Attempts to eliminate risk may lead to heavy restriction with unsatisfactory evidence, at a cost to quality of life. The Royal College of Speech and Language Therapists (RCSLT) has introduced a framework for multidisciplinary, person-centered decision making: Eating and Drinking with Acknowledged Risk. Every decision we make carries risk and as humans we balance these based on our personal values and goals. This is supported by the Mental Capacity Act 2005 and it is our role to achieve this for our patients. This article discusses these complexities and describes the RCSLT framework, with particular focus on the role of the nurse.

[Tasteless thickening agents? A competitive comparison]

Hintergrund

Das Andicken von Flüssigkeiten gehört zu den Standardverfahren der Dysphagietherapie. Diese adaptive Methode soll u. a. einem posterioren Leaking entgegenwirken und die Anforderung an verlangsamte Schutzreflexe durch eine reduzierte Fließgeschwindigkeit des Bolus senken. Bisherige Erhebungen zeigen jedoch aufgrund der Geschmacksperzeption eine ablehnende Haltung von Patienten gegenüber angedickten Flüssigkeiten. Diese Studie untersucht, ob zwischen verschiedenen Andickungsmitteln Geschmacksunterschiede bestehen.

Methoden

An der Studie haben 37 gesunde Probanden Teil genommen und 8 auf dem deutschen Markt erhältliche Andickungsmittel untereinander verglichen. Zur Testung wurden jeweils 2 mit Wasser angerührte Andickungsmittel einander gegenübergestellt. Die Probanden sollten dann entscheiden, welches sie geschmacklich präferierten. Bis zu 7 dieser Paarvergleiche wurden von jedem Probanden vorgenommen. Insgesamt wurden 224 Paarvergleiche durchgeführt. Aus diesen wurde mittels eines probabilistischen Modells eine relative Geschmacksgüte bestimmt und eine Signifikanztestung der Unterschiede durchgeführt.

Ergebnisse und Schlussfolgerung

Zwischen den verschiedenen Andickungsmitteln zeigten sich signifikante Geschmacksunterschiede. Es kann vermutet werden, dass sich die Geschmacksunterschiede auf die Inhaltsstoffe der jeweiligen Andickungsmittel zurückführen lassen. Im therapeutischen Setting sollte für eine höhere Akzeptanz von Kostanpassungen nach Möglichkeit die Ausprobe unterschiedlicher Andickungsmittel erfolgen. Unklar bleibt, ob die hier gezeigten Geschmacksunterschiede sich auch zeigen, wenn anstelle von Wasser andere Flüssigkeiten wie Kaffee, Tee oder Säfte angedickt werden.

Deterioration of the Corticobulbar Tract in Older Dysphagic Patients Without Neurologic Diseases

OBJECTIVES

Less is known how dysphagia affects older patients without neurologic diseases and whether the symptoms of dysphagia have any association with impaired central control of swallowing. This study investigated the state of the corticobulbar tract, the surrogate marker for the central control of swallowing, in older dysphagic patients without any neurologic diseases, using diffusion tensor tractography.

DESIGN

This retrospective observational study was conducted at a tertiary university hospital including 10 patients 60 yrs or older with oropharyngeal dysphagia without neurological disease and 11 age- and sex-matched control participants. The corticobulbar tract was reconstructed, and the fractional anisotropy and tract volume were measured using diffusion tensor tractography.

RESULTS

The corticobulbar tracts of the dysphagia group were narrowed and not reconstructed by their configurations and had lower fractional anisotropy and tract volume values when compared with those of control group. Significant asymmetry between the left and the right corticobulbar tract hemispheres was found in the dysphagia group, whereas no asymmetry was found in the control group.

CONCLUSIONS

A deteriorated corticobulbar tract could be associated with the development of dysphagia in older adults without neurological diseases. Our findings might help establish more appropriate treatment strategies, such as targeted neuromodulation therapies in the future.

Scoring the Penetration-Aspiration Scale (PAS) in Two Conditions: A Reliability Study

A widely applied metric for identifying airway invasion events is the Penetration-Aspiration Scale (PAS). PAS scores are often included as primary outcome measures in clinical interventional studies, applied to characterize airway protection in a particular disease, used to establish a normal referent for control group comparisons without dysphagia, and as determinants or predictors of clinical outcomes. Despite the widespread use of the PAS, there is variability in scoring condition. One common method used in research studies includes rater scores applied to each single swallow that occurred during a modified barium swallow study (MBSS) of the same patient. A second common method includes raters scoring single swallow segments that have been spliced from full MBSS from different patients. These single swallow segments are then randomly distributed and the rater is blinded to all swallows that occurred during that patient MBSS. The potential effects of different scoring conditions on rater reliability and score accuracy have not been studied and may have high relevance for the conclusion drawn from the result. The primary aim of this investigation is to determine the impact of two scoring conditions on rater reliability and score accuracy: 1. Contextual, unblinded scoring condition and 2. Randomized, blinded condition. Results of the present study show that no statistically significant differences in PAS rater reliability and score accuracy were found between the two scoring conditions. If findings from this pilot study are reproduced in larger sample sizes, the time and intensity involved in splicing and randomizing MBSS for scoring may not be necessary.

Residue localization and risk for aspiration in partial laryngectomy: the relevance of assertive therapeutic strategies and resources

Objective:

To describe the correlation between the residues, their anatomical location and the presence of laryngotracheal penetration and aspiration in patients after supracricoid laryngectomy undergoing cricohyoidoepiglotopexy reconstruction.

Methods:

This study included 70 patients treated by supracricoid laryngectomy with cricohyoidoepiglotopexy reconstruction in a referral national cancer hospital. The patients were submitted to swallowing videofluoroscopy, and the findings were classified by the penetration and aspiration scale. The images were described observing the presence or absence of residues and their anatomical location.

Results:

The prevalence of penetration in this study was 68.6% and aspiration was 34.3%. An association was found between the presence of residue on the tongue (p=0.005), posterior pharyngeal wall (p=0.013), pyriform recesses (p=0.002), valecula (p=0.061), and laryngeal penetration. The residue in the upper esophageal sphincter (p=0.039) was associated with the occurrence of laryngotracheal aspiration.

Conclusion:

Patients undergoing supracricoid laryngectomy with cricohioidoepiglotopexy reconstruction have food residues in different anatomical regions after swallowing. Penetration was associated with the presence of residues on the base of the tongue and posterior pharyngeal wall. Aspiration was associated with the presence of residues in the upper esophageal sphincter.

Predictive value of the videofluoroscopic swallowing study for long-term mortality in patients with subacute stroke

To investigate the usefulness of the videofluoroscopic swallowing study (VFSS) for subacute stroke in predicting long-term all-cause mortality, including not only simple parameters obtained from VFSS results, but also recommended dietary type as an integrated parameter.This was a retrospective study of patients with subacute (<1 month) stroke at a university hospital between February 2014 and September 2019. The independent risk factors were investigated using stepwise Cox regression analysis, which increased the all-cause mortality of patients with stroke among VFSS parameters.A total of 242 patients with subacute stroke were enrolled. The significant mortality-associated factors were age, history of cancer, recommended dietary type (modified dysphagia diet; adjusted hazard ratio [HR], 6.971; P = .014; tube diet, adjusted HR: 10.169; P = .019), and Modified Barthel Index. In the subgroup survival analysis of the modified dysphagia diet group (n = 173), the parameters for fluid penetration (adjusted HR: 1.911; 95% confidence interval, 1.086-3.363; P = .025) and fluid aspiration (adjusted HR: 2.236; 95% confidence interval, 1.274-3.927; P = .005) were significantly associated with mortality.The recommended dietary type determined after VFSS in subacute stroke was a significant risk factor for all-cause mortality as an integrated parameter for dysphagia. Among the VFSS parameters, fluid penetration and aspiration were important risk factors for all-cause mortality in patients with moderate dysphagia after stroke. Therefore, it is important to classify the degree of dysphagia by performing the VFSS test in the subacute period of stroke and to determine the appropriate diet and rehabilitation intervention for mortality-related prognosis.

Risk of an Adverse Event in Individuals Who Aspirate: A Review of Current Literature on Host Defenses and Individual Differences

PURPOSE

The presence of oropharyngeal dysphagia increases the likelihood of prandial aspiration, and aspiration increases the likelihood of a dysphagia-related pulmonary sequelae such as aspiration pneumonia, acute respiratory distress syndrome, pulmonary fibrosis, and even death. Although these outcomes are unfortunate, it is important to point out that these consequences are not solely determined by the presence of aspiration. The purpose of this tutorial is to provide current information on pulmonary defenses and the variables that increase risk of an adverse outcome in individuals who aspirate.

METHOD

This tutorial reviews the basics of lung defenses and summarizes the literature to make the case that the host is a central theme in dysphagia management. Case studies are employed to highlight the key variables.

RESULTS

Based on a literature review, a series of questions are proposed for consideration in dysphagia management. These questions, which take the focus away from the presence of aspiration and toward the associated risks within an individual, are then applied to two case studies.

CONCLUSIONS

A guiding framework is proposed to encourage clinicians to assess more than the presence of aspiration and consider the individual's ability to cope with the aspirated material. In the presence of aspiration, clinicians are urged to focus on the risk factors that can lead to a negative consequence, identify which factors are modifiable, and determine when a level of risk is acceptable.

Predictors of Aspiration Pneumonia and Mortality in Patients with Dysphagia

OBJECTIVES/HYPOTHESIS

To identify risk factors for pneumonia incidence in patients with dysphagia undergoing a videofluoroscopic swallow study (VFSS) in an outpatient tertiary-care center.

STUDY DESIGN

Historical cohort study.

METHODS

All individuals undergoing a VFSS between 10/02/13 and 07/30/15 were identified and followed historically for 2 years. Demographic information, medical history, and fluoroscopic data were collected. The 2-year incidence of pneumonia was obtained from the medical records and telephone interview. The incidence of pneumonia and death were calculated and risk factors for pneumonia and mortality were ascertained.

RESULTS

689 patients were followed for 2 years. The mean age (±standard deviation) of the cohort was 65 (±15.5) years. 49% (338/689) were female. The most common causes of dysphagia were cricopharyngeus muscle dysfunction (270/689), head and neck cancer (175/689), and neurodegenerative disease (56/689). The incidence of pneumonia was 22% (153/689). The incidence of death was 11%. Multivariable logistic regression revealed that chronic obstructive pulmonary disorder [COPD] (odds ratio [OR] = 2.36, 95% confidence interval [CI]: 1.33-4.19), hypertension (OR = 1.82, 95% CI: 1.23-2.73), tracheotomy status (OR = 2.96, 95% CI: 1.09-7.99), and vallecular residue (OR = 1.88, 95% CI: 1.24-2.85) were all significantly associated with an elevated risk of pneumonia. Kidney disease (OR = 1.27, 95% CI: 1.02-9.9), COPD (OR = 3.27, 95% CI: 1.65-6.49), vallecular residue (OR = 2.35, 95% CI: 1.35-4.1), male gender (OR = 2.21, 95% CI: 1.25-3.92), and low body mass index (OR: 1.12, 95% CI: 1.06-1.19) were independent adjusted risk factors for death.

CONCLUSIONS

The incidence of aspiration pneumonia (22%) and death (11%) within 2-years of a VFSS was high. The greatest adjusted risk factors for incident pneumonia were tracheotomy (OR = 3.0), COPD (OR = 2.4) and vallecular residue (OR = 1.9). The greatest adjusted risk factors for death were COPD (OR = 3.3), vallecular residue (OR = 2.3), and male gender (OR = 2.2).

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Videofluoroscopic Swallowing Study Findings Associated With Subsequent Pneumonia in Patients With Dysphagia Due to Frailty

Dysphagia in frailty or deconditioning without specific diagnosis that may cause dysphagia such as stroke, traumatic brain injury, or laryngeal pathology, has been reported in previous studies; however, little is known about which findings of the videofluoroscopic swallowing study (VFSS) are associated with subsequent pneumonia and how many patients actually develop subsequent pneumonia in this population. In this study, we followed 190 patients with dysphagia due to frailty or deconditioning without specific diagnosis that may cause dysphagia for 3 months after VFSS and analyzed VFSS findings for the risk of developing pneumonia. During the study period, the incidence of subsequent pneumonia was 24.74%; regarding the VFSS findings, (1) airway penetration (PAS 3) and aspiration (PAS 7 and 8) were associated with increased risk of developing pneumonia, and (2) the functional dysphagia scale (FDS) scores of the patients who developed subsequent pneumonia were higher than those of the patients who did not develop subsequent pneumonia. Our study findings might assist clinicians in making clinical decisions based on the VFSS findings in this population.

Effects of a food preparation program on dietary well-being for stroke patients with dysphagia: A pilot study

BACKGROUND

Dysphagia is one of the common issues observed in patients with stroke. Stroke patients with dysphagia have to eat blended food or similar types of food for each meal, resulting in dietary dissatisfaction. The purpose of this study was to investigate the effects of a food preparation program on dietary well-being for stroke patients with dysphagia.

METHODS

This study was a pilot randomized clinical trial. Twenty-two patients were assigned randomly into the food preparation group (n = 11) and control group (n = 11). The food preparation group received oral motor exercises, recognition of food texture and thickener, and hands-on food preparation for 6 weeks. Outcome measures included the Dietary Well-Being Scale, brief version of the World Health Organization Quality of life, Swallowing Quality of Life Questionnaire, and Mini Nutritional Assessment.

RESULTS

Patients in the food preparation group showed significant improvements in the Dietary Well-Being Scale, psychological and environmental domains of the brief version of the World Health Organization Quality of life (P = .001-.024) with small to large effect sizes (success rate difference = 0.23-0.46). The Swallowing Quality of Life Questionnaire and Mini Nutritional Assessment displayed non-significant differences (P = .053-.092) and revealed small to moderate effect sizes (success rate difference = 0.23-0.32).

CONCLUSIONS

The food preparation program showed a positive impact on dietary well-being and a potential improvement in the health-related quality of life, quality of life related to the process of swallowing, and nutritional status for stroke patients with dysphagia. We recommend that stroke patients with dysphagia receive adequate knowledge and hands-on food preparation training to increase their dietary intake and well-being.

Progression of swallowing dysfunction and associated complications of dysphagia in a cohort of patients with serial videofluoroscopic swallow examinations

OBJECTIVE

Dysphagia is a common symptom with associated complications ranging from mild discomfort to life-threatening pulmonary compromise. Videofluoroscopic swallow is the 'gold standard' evaluation for oropharyngeal dysphagia, but little is known about how patients' performance changes over time.

METHOD

This was a retrospective cohort study evaluating dysphagia patients' clinical course by serial videofluoroscopic swallow study. Univariate analysis followed by multivariate analysis were used to identify correlations between pneumonia outcomes, diet allocation, aetiology and comorbidities.

RESULTS

This study identified 104 patients (53 per cent male) stratified into risk groups by penetration-aspiration scale scores. Mean penetration-aspiration scale worsened over time (p < 0.05), but development of pneumonia was not associated with worsened penetration-aspiration scale score over time (p = 0.57) or severity of dysphagia (p = 0.88).

CONCLUSION

Our dataset identified a large cohort of patients with oropharyngeal dysphagia and demonstrated mean penetration-aspiration scale tendency to worsen. Identifying prognostic factors associated with worsening radiological findings and applying this to patients at risk of clinical swallowing difficulty is needed.

Association between Dysphagia and Surgical Outcomes across the Continuum of Frailty

This study examined the relationship between dysphagia and adverse outcomes across frailty conditions among surgical patients ≥50 years of age. A retrospective cohort analysis of surgical hospitalizations in the Healthcare Cost and Utilization Project's National Inpatient Sample among patients ≥50 years of age undergoing intermediate/high risk surgery not involving the larynx, pharynx, or esophagus. Of 3,298,835 weighted surgical hospitalizations, dysphagia occurred in 1.2% of all hospitalizations and was higher in frail patients ranging from 5.4% to 11.7%. Dysphagia was associated with greater length of stay, higher total costs, increased non-routine discharges, and increased medical/surgical complications among both frail and non-frail patients. Dysphagia may be an independent risk factor for poor postoperative outcomes among surgical patients ≥50 years of age across frailty conditions and is an important consideration for providers seeking to reduce risk in vulnerable surgical populations.

Development of an Oral Care Multidisciplinary Initiative in an Acute Care Community Hospital: Framework, Timeline, and Outcomes

Purpose Published literature universally supports the provision of oral care in acute care settings to decrease hospital-acquired aspiration pneumonia (HAAP) events. This evidence-based practice project aimed to implement a comprehensive oral care initiative to reduce a problematic HAAP rate. Method Through a comprehensive, multidisciplinary approach, the project scope included an assessment of the current state of oral care delivery, development of an Oral Care Task Force, creation of risk stratification criteria with recommended oral care products, and robust education for the clinical staff. Data were gathered using a small convenience sample of inpatients and hospital-wide HAAP rates. Results Over the 1 year of implementation and education associated with this multidisciplinary project, the organization saw an increase in oral care tools being available to patients and staff at the bedside, an increase in patients' awareness of oral care tools in their rooms, and a decrease in the overall HAAP rate. Conclusions Creating a multidisciplinary team within an acute care organization with a focus on oral care delivery can be substantially advantageous to patients and hospitals alike. Although this project was limited in its analysis, the demonstrated results are nonetheless interesting and may be applicable to other acute care settings. Ultimately, attention to the importance of oral care and consistent care delivery can provide improved patient outcomes.

[Intraoperative Aspiration]

术中误吸是外科手术中常见的肺部并发症，麻醉和体位是导致术中误吸的主要因素。近年来，围手术期肺保护已受到外科和麻醉医师的广泛关注，如何加速术后康复进程，减少相关并发症发生，显著改善患者预后已成为当前外科治疗的主要目标。本文将以术中误吸为重点，从解剖、病理生理、表现、诊断、处理和预防等方面展开综述。

Thickened liquids: do they still have a place in the dysphagia toolkit?

PURPOSE OF REVIEW

The use of commercially or naturally thickened liquids is a well-established treatment for patients with dysphagia to fluids, the aim of which is to improve swallow safety by minimizing risk of aspiration. Although the most recent systematic reviews conclude that this treatment lacks evidential support and leads to patient-reported worsening health and quality of life, thickened liquids continue to be used with patients with dysphagia across clinical settings. This review briefly summarizes the evidence and considers potential reasons for the apparent mismatch between the evidence and clinical practice.

RECENT FINDINGS

Continuing practice with thickened liquids is influenced by a range of factors, including gaps in clinical knowledge, inadequate patient involvement, a culture of common practice and a reliance on invalid surrogate studies or research lacking a credible association between thickened liquids and clinically meaningful endpoints.

SUMMARY

While awaiting further research, clinical decision-making about thickened liquids can be improved by considering the evidence of clinically meaningful endpoints, promoting shared decision-making with patients and underpinning practice with knowledge about the complex relationship between dysphagia, aspiration and pneumonia.

Asphyxia risk factors in adult psychiatric wards

PURPOSE

To identify factors for choking in psychiatric wards that can be easily screened.

DESIGN AND METHODS

Data were collected from patients admitted to the acute phase psychiatric wards who were assessed for swallowing function by dentists. We defined 47 and 102 patients of choking in the high- and low-risk groups, respectively.

FINDINGS

Through multivariate analysis, we identified basal metabolic index and two Drug-induced Extra-pyramidal Symptoms Scale items, bradykinesia and tremor, as independent choking factors.

PRACTICE IMPLICATIONS

Choking risk is related to patient tolerability rather than to the absolute severity of psychiatric symptoms or psychotropic dose.

Profiling of Oropharyngeal Dysphagia in an Acute Care Hospital Setting

PURPOSE

To identify the main complaints, diagnostic tools, as well as the treatment plan in patients presenting with oropharyngeal dysphagia in the acute care settings.

METHODS

The electronic medical chart of 100 consecutive hospitalized patients who presented an oropharyngeal dysphagia were retrospectively reviewed from January 2017 to January 2019.

RESULTS

The mean age of patients was 76.03 (standard deviation = 16.06) years old with 71% of patients being males. The most common admission diagnosis was pneumonia (30%), followed by stroke (28%). The swallowing evaluation was performed on the regular floor in 85% of patients and in the intensive care unit in 15% of patients. The main reasons for the swallowing evaluation are suspicion of aspiration by the medical or nursing teams (60%), systematic evaluation (20%), ear, nose and throat (ENT) complaints by the patient (14%), and aspiration pneumonia (6%). Fiberoptic endoscopic evaluation of swallowing with sensitivity testing was the most common diagnostic tool used alone in 88% of patients. Diet and postural modifications were prescribed to 71% and 62% of the patients, respectively. Swallowing exercises were performed in 43% of patients. Overall, otolaryngologist interventions resulted in an increased rate of patients getting oral intake compared to nonoral feeding routes (P = .05).

CONCLUSIONS

This study adds knowledge about the causes and characteristics of oropharyngeal dysphagia in an acute tertiary medical setting. It also provides insights regarding the role, and the consequences of a swallowing intervention led by an ENT specialist in collaboration with the members of the health team.

Association Between Dysphagia and Inpatient Outcomes Across Frailty Level Among Patients ≥ 50 Years of Age

Frail patients may have heightened risk of dysphagia, a potentially modifiable health factor. Our aim is to examine whether the relationship between dysphagia and adverse health outcomes differs by frailty conditions among inpatients ≥ 50 years of age. Medical or surgical hospitalizations among patients ≥ 50 years of age in the Healthcare Cost and Utilization Project's National Inpatient Sample from 2014 through the first three quarters of 2015 were included. Adverse outcomes included length of stay (LOS), hospital costs, in-hospital mortality, discharge status, and medical complications. Dysphagia was determined by ICD-9-CM codes. Frailty was defined as (a) ≥ 1 condition in the10-item Johns Hopkins Adjusted Clinical Groups (ACG) frailty measure and a frailty index for the (b) ACG and (c) a 19-item Frailty Risk Score (FRS) categorized as non-frail, pre-frail, and frail. Weighted generalized linear models for complex survey designs using generalized estimating equations were performed. Of 6,230,114 unweighted hospitalizations, 4.0% had a dysphagia diagnosis. Dysphagia presented in 3.1% and 11.0% of non-frail and frail hospitalizations using the binary ACG (p < 0.001) and in 2.9%, 7.9%, and 16.0% of non-frail, pre-frail, and frail hospitalizations using the indexed FRS (p < 0.001). Dysphagia was associated with greater LOS, higher total costs, increased non-routine discharges, and more medical complications among both frail and non-frail patients using the three frailty definitions. Dysphagia was associated with adverse outcomes in both frail and non-frail medical or surgical hospitalizations. Dysphagia management is an important consideration for providers seeking to reduce risk in vulnerable populations.

Long-term Swallowing Function, Pulmonary Complications, and Quality of Life after Supracricoid Laryngectomy

Objectives

Long-term effects of supracricoid laryngectomies are nowadays under discussion. The purpose of this study was to detect the prevalence of chronic aspiration and incidence of pulmonary complications, to investigate possible influencing factors, and to analyze dysphagia-related quality of life in a cohort of patients who recovered swallowing function after undergoing supracricoid laryngectomies.

Study Design

Retrospective observational study.

Setting

San Raffaele Hospital, Vita-Salute University, Milan, Italy.

Methods

A cohort of 39 patients who recovered swallowing function free of disease after a minimum 3-year follow-up period was retrospectively investigated between October and December 2017—clinically with the Pearson’s Scale and M. D. Anderson Dysphagia Inventory and instrumentally with fiberoptic endoscopic evaluation of swallowing.

Results

Chronic aspiration was demonstrated in a significant portion of patients (clinically in 33.3% and instrumentally in 35.9%). Aspiration was influenced by advanced age at surgery ( P = .020). Type of surgical procedure, resection of 1 arytenoid cartilage, postoperative rehabilitation with a speech-language therapist, radiotherapy, age at consultation, and length of follow-up did not influence the prevalence of aspiration. Pulmonary complications affected 5 patients; incidence of pulmonary complications was related to aspiration and was favored by poor laryngeal sensation/cough reflex. Aspiration significantly affected quality of life.

Conclusions

Chronic aspiration is frequent and affects patients’ quality of life. However, incidence of pulmonary complications is low; therefore, oral feeding should not be contraindicated for aspirating patients. Preservation of laryngeal sensation and cough reflex is mandatory to prevent pulmonary complications.

Aspiration in the otherwise healthy Infant-Is there a natural course for improvement?

OBJECTIVES/HYPOTHESIS

Timing and indication for surgical intervention is a major challenge in managing pediatric oropharyngeal dysphagia. No study has evaluated a natural course of swallowing dysfunction in otherwise healthy infants. Our objective was to review the outcomes and time to resolution of abnormal swallow in infants with aspiration.

STUDY DESIGN

Retrospective case series at a tertiary children's hospital.

METHODS

Fifty patients under 1 year old with aspiration on a modified barium swallow study were included. Patients born <34 weeks, with medical or genetic comorbidities, or who underwent surgical intervention for aspiration were excluded. Patients were followed until aspiration resolved on a swallow study. Kaplan-Meier survival analysis was performed.

RESULTS

Forty patients (25 patients [50%] by 6 months, 10 [20%] by 1 year, three [6%] by 2 years, and two [4%] at the end of the follow-up interval) were recommended a normal diet, and 10 patients (20%) were still aspirating by the end of the follow-up interval. Median time to resolution was 202 ± 7 days (range, 19-842 days), probability 48% (95% confidence interval [CI]: 0.34-0.62). The probability of resolution at 6 months was 46% (95% CI: 0.4-0.68), at 1 year was 64% (95% CI: 0.51-0.77), at 2 years was 76% (95% CI: 0.64-0.88), and at the end of the follow-up interval 81.3% (95% CI: 0.7-0.92).

CONCLUSIONS

The majority of infants with aspiration and without any other major comorbidities improved within 1 year. Future research should be directed toward better understanding swallowing dysfunction in neurologically normal infants.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:514-520, 2020.

A comprehensive review of swallowing difficulties and dysphagia associated with antipsychotics in adults

INTRODUCTION

This is a comprehensive review of antipsychotic (AP)-induced dysphagia and its complications: choking and pneumonia. Areas covered: Four PubMed searches were completed in 2018. The limited literature includes: 1) 45 case reports of AP-induced dysphagia with pharmacological mechanisms, 2) a systematic review of APs as a risk factor for dysphagia, 3) reviews suggesting adult patients with intellectual disability (ID) and dementia are prone to dysphagia (APs are a risk factor among multiple others), 4) studies of the increased risk of choking in patients with mental illness (APs are a contributing factor), 5) naturalistic pneumonia studies suggesting that pneumonia may contribute to AP-increased death in dementia, and 6) naturalistic studies suggesting that pneumonia may be a major cause of morbidity and mortality in clozapine patients. Expert commentary: The 2005 Food and Drug Administration requirement that package inserts warn of AP-induced dysphagia jumpstarted this area, but current studies are limited by: 1) its naturalistic nature, 2) the lack of dysphagia studies of patients with IDs and dementia on APs, and 3) the assumed indirect association between dysphagia with choking and pneumonia. Future clozapine studies on pneumonia, if they lead to a package insert warning, may have high potential to save lives.

The Prevalence and Prognosis of Sarcopenic Dysphagia in Patients Who Require Dysphagia Rehabilitation

OBJECTIVES

The purpose of this study was to assess the prevalence and prognosis of sarcopenic dysphagia in patients who require dysphagia rehabilitation.

DESIGN

Prospective cohort study.

SETTING

Tertiary-care acute general hospital.

PARTICIPANTS

One hundred and eight patients referred to the Department of Rehabilitation Medicine for dysphagia rehabilitation.

MEASUREMENTS

The Food Intake Level Scale (FILS), a 5-step diagnostic algorithm for sarcopenic dysphagia.

RESULTS

The study included 72 males and 36 females (mean age, 76±7 years). Comorbid diseases included brain and nervous system disease (36%), cardiovascular disease (25%), respiratory disease (14%), and cancer (11%). Median energy intake was 1159 kcal (interquartile range: 648, 1502). Median FILS at admission and discharge was 4 (interquartile range: 2, 7) and 8 (interquartile range: 5, 8), respectively. Sarcopenic dysphagia was observed in 35 patients (32%). Sarcopenic dysphagia was associated with lower FILS at referral and discharge, lower calf circumference, lower handgrip strength, lower body mass index, lower serum albumin, and higher C-reactive protein at referral. Tongue pressure, energy intake, and Barthel index did not differ significantly between patients with or without sarcopenic dysphagia. Ordered logistic regression analysis of the FILS at discharge adjusted for presence of sarcopenic dysphagia, age, sex, and the FILS at admission revealed that presence of sarcopenic dysphagia (β=-1.603, 95% confidence intervals= -2.609, -0.597, p=0.002), sex, and the FILS at admission were independently associated with the FILS at discharge.

CONCLUSIONS

The prevalence of sarcopenic dysphagia in patients who require dysphagia rehabilitation was quite high. Sarcopenic dysphagia was independently associated with poor swallowing function at discharge.

Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified?

BACKGROUND

Although modifying diets, by thickening liquids and modifying the texture of foods, to reduce the risk of aspiration has become central to the current management of dysphagia, the effectiveness of this intervention has been questioned. This narrative review examines, and discusses possible reasons for, the apparent discrepancy between the widespread use of modified diets in current clinical practice and the limited evidence base regarding the benefits and risks of this approach.

DISCUSSION

There is no good evidence to date that thickening liquids reduces pneumonia in dysphagia and this intervention may be associated with reduced fluid intake. Texture-modified foods may contribute to undernutrition in those with dysphagia. Modified diets worsen the quality of life of those with dysphagia, and non-compliance is common. There is substantial variability in terminology and standards for modified diets, in the recommendations of individual therapists, and in the consistency of diets prepared by healthcare staff for consumption. Although use of modified diets might appear to have a rational pathophysiological basis in dysphagia, the relationship between aspiration and pneumonia is not clear-cut. Clinical experience may be a more important determinant of everyday practice than research evidence and patient preferences. There are situations in the management of dysphagia where common sense and the necessity of intervention will clearly outweigh any lack of evidence or when application of evidence-based principles can enable good decision making despite the absence of robust evidence. Nevertheless, there is a significant discrepancy between the paucity of the evidence base supporting use of modified diets and the beliefs and practices of practitioners.

CONCLUSION

The disconnect between the limited evidence base and the widespread use of modified diets suggests the need for more careful consideration as to when modified diets might be recommended to patients. Patients (or their representatives) have a choice whether or not to accept a modified diet and must receive adequate information, about the potential risks and impact on quality of life as well as the possible benefits, to make that choice. There is an urgent need for better quality evidence regarding this intervention.