Pilot study of 12-month outcomes of nursing home patients with aspiration on videofluoroscopy

Association between Dysphagia and Frailty in Older Adults: A Systematic Review and Meta-Analysis

Background: Increasing bodies of epidemiological evidence indicate potential associations between dysphagia and the risk of frailty in older adults. We hypothesized that older adults with symptoms of dysphagia might have a higher prevalence of frailty or prefrailty than those without dysphagia. Methods: We systematically searched the PubMed, Embase, and Cochrane Library databases for relevant studies published through 20 April 2022. Cross-sectional and longitudinal studies that examined the associations between dysphagia and the existence of frailty or prefrailty in community-dwelling, facility-dwelling, or hospitalized adults aged 50 years or older were synthesized. The Newcastle–Ottawa Scale was used to evaluate study quality. Results: The meta-analysis comprised 12 cohorts, including 5,503,543 non-frailty participants and 735,303 cases of frailty or prefrailty. Random-effect meta-analysis demonstrated a significant association between dysphagia and the risk of frailty and prefrailty (OR, 3.24; 95% CI, 2.51–4.20). In addition, we observed consistent results across the subgroups and heterogeneity assessments. Conclusions: We propose including dysphagia assessment as a critical factor in the cumulative deficit model for identifying frailty in older adults. Understanding dysphagia and the potential role of nutritional supplements in older adults may lead to improved strategies for preventing, delaying, or mitigating frailty.

Episodic Aspiration with Oral Commensals Induces a MyD88-dependent, Pulmonary T-Helper Cell Type 17 Response that Mitigates Susceptibility to Streptococcus pneumoniae

Rationale: Cross-sectional human data suggest that enrichment of oral anaerobic bacteria in the lung is associated with an increased T-helper cell type 17 (Th17) inflammatory phenotype.Objectives: In this study, we evaluated the microbial and host immune-response dynamics after aspiration with oral commensals using a preclinical mouse model.Methods: Aspiration with a mixture of human oral commensals (MOC; Prevotella melaninogenica, Veillonella parvula, and Streptococcus mitis) was modeled in mice followed by variable time of killing. The genetic backgrounds of mice included wild-type, MyD88-knockout, and STAT3C backgrounds.Measurements and Main Results: 16S-rRNA gene sequencing characterized changes in microbiota. Flow cytometry, cytokine measurement via Luminex and RNA host-transcriptome sequencing was used to characterize the host immune phenotype. Although MOC aspiration correlated with lower-airway dysbiosis that resolved within 5 days, it induced an extended inflammatory response associated with IL-17-producing T cells lasting at least 14 days. MyD88 expression was required for the IL-17 response to MOC aspiration, but not for T-cell activation or IFN-γ expression. MOC aspiration before a respiratory challenge with S. pneumoniae led to a decrease in hosts' susceptibility to this pathogen.Conclusions: Thus, in otherwise healthy mice, a single aspiration event with oral commensals is rapidly cleared from the lower airways but induces a prolonged Th17 response that secondarily decreases susceptibility to S. pneumoniae. Translationally, these data implicate an immunoprotective role of episodic microaspiration of oral microbes in the regulation of the lung immune phenotype and mitigation of host susceptibility to infection with lower-airway pathogens.

Fiberoptic endoscopic evaluation of swallowing and videofluoroscopy swallowing assessment in adults in residential care facilities: a scoping review protocol

OBJECTIVE

This scoping review will identify and explore existing evidence on the use of instrumental swallowing assessment in the diagnosis and management of dysphagia in adults living in residential care facilities.

INTRODUCTION

Oropharyngeal dysphagia is prevalent among adults living in residential care facilities. Videofluoroscopy and fiberoptic endoscopic evaluation of swallowing are instrumental assessment procedures commonly utilized in the evaluation of oropharyngeal dysphagia in hospital and community settings. However, little is known about the use of these procedures in residential care facilities. To ensure evidence-based assessment of oropharyngeal dysphagia and to guide future research, exploration of the current use and clinical utility of videofluoroscopy and fiberoptic endoscopic evaluation of swallowing in residential care facilities is needed.

INCLUSION CRITERIA

Published and gray literature written in English from 2000 onward that discusses instrumental swallowing assessment of adults in residential care facilities will be included in the review.

METHODS

A three-step search strategy will be used to explore relevant literature. All citations and articles retrieved during the searches will be imported into a software application for systematic reviews. Once duplicates are removed, two reviewers will screen the titles and abstracts against predefined inclusion criteria. Information will be extracted from literature that meets the selection criteria using a purposefully developed charting form. The search strategy and results will be illustrated through a Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram. Key findings and their relationship to the research questions will be summarized in a chart and discussed in interpretive narrative form.

Correlation of Videofluoroscopic Swallowing Study Findings With Radionuclide Salivagram in Chronic Brain-Injured Patients

Objective

To investigate the correlation between videofluoroscopic swallowing study (VFSS) and radionuclide salivagram findings in chronic brain-injured patients with dysphagia.

Methods

Medical records of chronic brain-injured patients who underwent radionuclide salivagram and VFSS were retrospectively analyzed. Patients were divided into two groups according to salivagram findings. Differences in patient characteristics and clinical factors, including Mini-Mental State Examination (MMSE), Modified Barthel Index (MBI), Functional Ambulatory Category (FAC), feeding method, tracheostomy state, and VFSS findings between the two groups were investigated.

Results

A total of 124 patients were included in this study. There were no significant differences in MMSE, MBI, FAC, feeding method, and presence of tracheostomy between the two groups. However, the incidence of aspiration pneumonia history was significantly higher in the positive salivagram group. The Functional Dysphagia Scale (FDS) was significantly associated with positive salivagram findings, especially in the pharyngeal phase. A multivariate logistic regression analysis showed that laryngeal elevation and epiglottic closure was statistically significant FDS parameter in predicting salivary aspiration on a salivagram (odds ratio=1.100; 95% confidence interval, 1.017–1.190; p=0.018). The receiver operating characteristic (ROC) curve of FDS in the pharyngeal phase showed that an optimum sensitivity and specificity of 55.1% and 65.4%, respectively, when the cut-off value was 39.

Conclusion

In chronic brain-injured patients, inappropriate laryngeal elevation and epiglottic closure is predictive variable for salivary aspiration. Therefore, performing a radionuclide salivagram in patients with FDS of 39 or less in the pharyngeal phase for prevents aspiration pneumonia from salivary aspiration.

Transoral closure of the supraglottic larynx for intractable aspiration

The aim of this paper is to describe a novel, safe, and effective surgical technique to eliminate aspiration, that is performed entirely by reconstructive transoral laser microsurgery (R-TLM). Eleven tracheostomy-dependent patients with recurrent pneumonia secondary to intractable aspiration treated with transoral laryngeal closure were included in our study. In all cases, the supraglottic mucosa is incised in a circumferential manner. The distal tissues are sutured side-to-side longitudinally, and the superficial tissues are sutured back-to-front transversally. All patients successfully underwent transoral laryngeal closure without significant perioperative complication. Four patients resumed oral feeding for effective nutrition and two patients for pleasure. One patient developed a small fistula with a leak that warranted secondary closure by a follow-up R-TLM procedure and subsequently held to protect his airway. Complete supraglottic laryngeal closure can be performed safely and effectively using R-TLM techniques. They provide a natural-orifice alternative to open surgery in patients with intractable aspiration.

Effectiveness of Conventional Swallowing Therapy in Acute Stroke Patients with Dysphagia

Background

Dysphagia is a common problem in acute stroke patient. Aspiration pneumonia increases in this group. Swallowing therapy is immediately conducted in a stable stroke patient. An effectiveness of our program has not been determined.

Objective

To determine an effectiveness of conventional swallowing therapy in acute stroke patients with dysphagia.

Methods

We retrospectively reviewed data from medical records of acute stroke patients with dysphagia who participated a swallowing therapy from January 2017 to June 2017. Fifty-seven acute stroke patients with dysphagia (26 males and 31 females) were participating in a conventional swallowing therapy (50 minutes a day for 3 days per week). A functional oral intake scale (FOIS) and swallow function scoring system (SFSS) were used to determine an effectiveness of the swallowing therapy. FOIS and SFSS scores before the first therapy session and after the last therapy session were compared using a paired t-test.

Results

The mean age of the patient was 69.5 ± 15.35 years. The period from stroke onset to the first swallowing therapy session was 7.5 ± 6.69 days. The number of therapy was 5.6 ± 2.83 sessions. Participants showed a significant improvement of the FOIS (mean score increased from 1.74 to 3.30 points, P = 0.001) and SFSS (mean score increased from 2.51 to 3.68 points, P = 0.001). Forty-two percent of patients with tube dependent change to total oral intake.

Conclusion

Conventional swallowing therapy is an effective treatment in acute stroke with dysphagia.

Swallowing Disorders in the Older Population

Swallowing problems, or dysphagia, are common as people age, and are associated with significant negative outcomes, including weight loss, pneumonia, dehydration, shortened life expectancy, reduced quality of life, and increased caregiver burden. In this article, we will discuss the complex process of swallowing in normal circumstances and with healthy aging, then review etiologies that contribute to dysphagia. We will discuss approaches to evaluating and treating dysphagia, providing relevant data where they are available. We highlight the desperate need for high-quality research to guide best practices in treating dysphagia in older adults. J Am Geriatr Soc 67:2643-2649, 2019.

Aspiration in the Fiberoptic Endoscopic Evaluation of Swallowing Associated with an Increased Risk of Mortality in a Cohort of Patients Suspected of Oropharyngeal Dysphagia

There is a general lack of published studies on the risk of mortality due to alterations in the safety of swallowing detected during the fiberoptic endoscopic evaluation of swallowing (FEES). We aimed at assessing the risk of mortality of the detection of aspiration, penetration, and pharyngeal residues by FEES. A cohort of consecutively evaluated patients suspected of experiencing oropharyngeal dysphagia undergoing FEES at a tertiary care university hospital were prospectively followed up on to assess mortality. The FEES findings, comorbidities, and potential confounders were studied as predictors of death using a Cox multivariate regression analysis. A total of 148 patients were included, 85 of whom were male (57.4%). The mean age (± standard deviation) was 52.7 years (± 22.1). The median of the follow-up time was 4.5 years. The most frequent conditions were stroke in 50 patients (33.8%), brain and spine traumas in 27 (18.2%), and neurodegenerative diseases in 19 (12.8%). Variables associated with mortality in bivariate analyses were age > 65 years (p < 0.001), pneumonia (p = 0.046), aspiration of any consistency (p < 0.001), and pharyngeal residues (p = 0.017). Variables independently associated with mortality in the Cox multivariate model were age (> 65 years) [adjusted hazard ratio (HR) 5.76; 95% CI 2.72 to 17.19; p = 0.001] and aspiration (adjusted HR: 3.96; 95% CI 1.82 to 14.64; p = 0.003). Aspiration detected by FEES and an age > 65 years are independent predictors of mortality in patients with oropharyngeal dysphagia.

Clinical characteristics of dysphagic stroke patients with salivary aspiration: A STROBE-compliant retrospective study

The aim of this study was to evaluate the correlation between radionuclide salivagram findings and clinical characteristics in stroke patient with swallowing difficulty.In this study, dysphagic stroke patients who had undergone both a radionuclide salivagram and videofluoroscopic swallowing study (VFSS) were included retrospectively. To evaluate the correlations between clinical parameters and salivary aspiration, clinical parameters, such as stroke lesion, the degree of paralysis, sex, age, onset duration of stroke, the score of the Mini-Mental State Examination (MMSE), the score of the Global Deterioration Scale (GDS), the total score of the Modified Barthel Index (MBI), and each sub-score of the MBI were collected and analyzed.In the results of this study, the MMSE score was the only significant parameter for predicting positive findings in a salivagram in a multivariate logistic regression analysis in patients with supratentorial stroke. In patients with infratentorial stroke, however, the transfer sub-score of MBI was the only significant parameter for predicting positive findings in a salivagram in a multivariate logistic regression analysis.In conclusion, care should be taken to prevent salivary aspiration when the MMSE score is less than eight in patients with supratentorial stroke, and the transfer sub-score of MBI score is less than three in patients with infratentorial stroke.

Clinical Effects and Differences in Neural Function Connectivity Revealed by MRI in Subacute Hemispheric and Brainstem Infarction Patients With Dysphagia After Swallowing Therapy

Background: Early detection and intervention for post-stroke dysphagia could reduce the incidence of pulmonary complications and mortality. The aims of this study were to investigate the benefits of swallowing therapy in swallowing function and brain neuro-plasticity and to explore the relationship between swallowing function recovery and neuroplasticity after swallowing therapy in cerebral and brainstem stroke patients with dysphagia.

Methods: We collected 17 subacute stroke patients with dysphagia (11 cerebral stroke patients with a median age of 76 years and 6 brainstem stroke patients with a median age of 70 years). Each patient received swallowing therapies during hospitalization. For each patient, functional oral intake scale (FOIS), functional dysphagia scale (FDS) and 8-point penetration-aspiration scale (PAS) in videofluoroscopy swallowing study (VFSS), and brain functional magnetic resonance imaging (fMRI) were evaluated before and after treatment.

Results: FOIS (p = 0.003 in hemispheric group and p = 0.039 in brainstem group) and FDS (p = 0.006 in hemispheric group and p = 0.028 in brainstem group) were both significantly improved after treatment in hemispheric and brainstem stroke patients. In hemispheric stroke patients, changes in FOIS were related to changes of functional brain connectivity in the ventral default mode network (vDMN) of the precuneus in brain functional MRI (fMRI). In brainstem stroke patients, changes in FOIS were related to changes of functional brain connectivity in the left sensorimotor network (LSMN) of the left postcentral region characterized by brain fMRI.

Conclusion: Both hemispheric and brainstem stroke patients with different swallowing difficulties showed improvements after swallowing training. For these two dysphagic stroke groups with corresponding etiologies, swallowing therapy could contribute to different functional neuroplasticity.

The Correlation Between Clinical Characteristics and Radionuclide Salivagram Findings in Patients With Brain Lesions: A Preliminary Study

Objective

To evaluate the correlation between radionuclide salivagram findings and clinical characteristics in dysphagic patients with brain lesions.

Methods

The medical records of 35 dysphagic patients with brain lesions who simultaneously underwent both a videofluoroscopic swallowing study (VFSS) and radionuclide salivagram were analyzed retrospectively. The subjects were divided into two groups according to the presence of aspiration on a salivagram (group A, patients with aspiration on the salivagram; group B, patients with no aspiration on the salivagram). The differences between clinical characteristics and VFSS findings (penetration-aspiration scale [PAS]) between the two groups were analyzed.

Results

Eleven out of 35 patients displayed salivary aspiration on the radionuclide salivagram. There were no significant differences between the two groups according to age, sex, disease duration, PAS on VFSS and feeding methods (p≥0.05). The incidence of aspiration pneumonia was significantly higher in group A. In a multivariate logistic regression analysis with forward stepwise method, the Mini-Mental State Examination (MMSE) score was the only significant parameter in predicting positive findings in salivagrams (odds ratio=0.760; 95% confidence interval [CI], 0.625–0.923; p=0.006). The area under the receiver operating characteristic curve (AUC) of the MMSE score for positive detection in salivagrams was 0.855 (95% CI, 0.689–0.953; p<0.0001). The optimal cut-off value was 7 for the MMSE score (sensitivity 72.73%, specificity 100%).

Conclusion

In patients with brain lesions who complain of dysphagia, the MMSE score was correlated with salivary aspiration. If patients present with a score of 7 or less on the MMSE, performing a radionuclide salivagram may helpful for early detection of patients at high risk of aspiration pneumonia induced from salivary aspiration.

Gastrointestinal Dysmotility in the Elderly

The number of persons 60 years and older has increased 3-fold between 1950 and 2000. Aging alone does not greatly impact the gastrointestinal (GI) tract. Digestive dysfunction, including esophageal reflux, achalasia, dysphagia, dyspepsia, delayed gastric emptying, constipation, fecal incontinence, and fecal impaction, is a result of the highly prevalent comorbid conditions and the medications with which those conditions are treated. A multidisciplinary approach with the expertise of a geriatrician, gastroenterologist, neurologist, speech pathologist, and physical therapist ensures a comprehensive functional and neurological assessment of the older patient. Radiographic and endoscopic evaluation may be warranted in the evaluation of the symptomatic older patient with consideration given to the risks and benefits of the test being used. Treatment of the digestive dysfunction is aimed at improving health-related quality of life if cure cannot be achieved. Promotion of healthy aging, treatment of comorbid conditions, and avoidance of polypharmacy may prevent some of these digestive disorders. The age-related changes in GI motility, clinical presentation of GI dysmotility, and therapeutic principles in the symptomatic older patient are reviewed here.

Neumonía aguda extrahospitalaria

La neumonía aguda extrahospitalaria sigue estando asociada a una elevada morbimortalidad. Durante estos últimos años, y gracias al desarrollo de técnicas de biología molecular, se han realizado importantes progresos en los métodos diagnósticos. Estas técnicas permiten mejorar la detección de bacterias atípicas y de virus respiratorios estacionales. Han permitido asimismo subrayar el lugar de los virus respiratorios en su aparición. El protocolo terapéutico se basa siempre en la instauración precoz de una antibioticoterapia que casi siempre es empírica. Las recomendaciones europeas para el tratamiento de las neumonías extrahospitalarias han sido puestas al día en 2011, como también lo han sido recientemente las pautas vacunales frente al neumococo. En este artículo, se resumen las etiologías de las neumonías, su diagnóstico, las escalas que permiten evaluar su gravedad y orientar el tratamiento del paciente, los datos sobre la sensibilidad a los antibióticos y las recomendaciones terapéuticas resultantes, así como las estrategias de prevención.

Functional outcome in acute stroke patients with oropharyngeal Dysphagia after swallowing therapy

Dysphagia after stroke is associated with mortality and increased pulmonary complications. Swallowing therapies may decrease pulmonary complications and improve patients' quality of life after stroke. This study used clinical swallowing assessments and videofluoroscopy (VFS) to assess the functional recovery of acute stroke patients with dysphagia after different swallowing therapies. We enrolled 29 acute stroke patients with dysphagia and randomly divided them into 3 therapy groups: traditional swallowing (TS), oropharyngeal neuromuscular electrical stimulation (NMES), and combined NMES/TS. All patients were assessed using the clinical functional oral intake scale (FOIS), 8-point penetration-aspiration scale (PAS), and functional dysphagia scale (FDS) of VFS before and after treatment. There were no differences in the clinical parameters and swallowing results of the FOIS and VFS before swallowing treatment among the 3 groups (P > .05). TS therapy and combined therapy both had significant swallowing improvement after therapy according to the FOIS and 8-point PAS (P < .05). When comparing the results of the VFS among the 3 groups, we found significant improvements in patients eating cookies and thick liquid after combined NMES/TS therapy (P < .05). In acute stroke patients with dysphagia, combined NMES/TS therapy is the most effective swallowing therapy in taking solid diets and thick liquids.

Objective assessment of swallow function in children with suspected aspiration using pharyngeal automated impedance manometry

OBJECTIVES

The purpose of the present study was to apply a new method, pharyngeal automated impedance manometry (AIM), as an objective assessment tool of swallow function relevant to aspiration, in a cohort of paediatric patients with dysphagia.

METHODS

We studied 20 children (mean age 6 years [5 months to 13.4 years]) referred for videofluoroscopy to assess aspiration risk with simultaneous manometry-impedance. Fluoroscopic evidence of aspiration was scored using a validated aspiration-penetration score. Pressure-flow profiles were analysed using AIM analysis measuring peak pressure, pressure at nadir impedance, time from nadir impedance to peak pressure, and flow interval. These variables were combined into a swallow risk index (SRI).

RESULTS

Six of 20 children presented with deglutitive aspiration during videofluoroscopic assessment of swallowing. Of 58 liquid swallows analysed, in 9 aspiration was observed. Multiple logistic regression identified longer flow interval (P < 0.05), higher SRI (P < 0.05) and increased pressure in the upper oesophageal sphincter during maximal bolus flow (P < 0.05) to be the dominant risk variables predictive of aspiration in children. Each of these nonradiologically derived pressure-flow variables correlated with higher aspiration scores on videofluoroscopy (P < 0.01).

CONCLUSIONS

We present novel, preliminary findings in children with deglutitive aspiration, suggesting that pharyngeal AIM can detect alterations in pressure-flow characteristics of swallowing that predispose to aspiration risk.

Dysphagia in old-old women: prevalence as determined according to self-report and the 3-ounce water swallowing test

OBJECTIVES

To determine whether symptoms and clinical signs of swallowing dysfunction could be easily identified in community-dwelling elderly adults and to examine the association between self-report and direct observation of symptoms and signs of swallowing dysfunction.

DESIGN

Physiological substudy conducted as a home visit within an observational cohort study.

SETTING

Baltimore City and County, Maryland.

PARTICIPANTS

Community-dwelling elderly women without history of dysphagia or neurological disease aged 85 to 94 enrolled in the Women's Health and Aging Study II (N = 47).

MEASUREMENTS

Three trials of the 3-ounce water swallowing test, swallowing function questionnaire, and frailty status.

RESULTS

Thirty-four (72%) subjects demonstrated swallowing dysfunction in at least one swallowing trial and 16 (34%) in all three trials. The most common signs of dysfunction were throat clear and wet voice. Conversely, participants reported few symptoms of dysphagia on a swallowing function questionnaire. The most common symptom, reported by approximately 15% of participants, was the sensation of the food going "down the wrong way," 8.5% or fewer participants reported other symptoms.

CONCLUSION

Signs of swallowing dysfunction were present in a large majority of community-dwelling old-old women, but they were largely unrecognized and reported. Formal evaluation of swallowing function in community-dwelling elderly adults is necessary to determine the clinical consequences of these findings.

Classification of high-resolution manometry data according to videofluoroscopic parameters using pattern recognition

OBJECTIVE

To determine if pattern recognition techniques applied to high-resolution manometry (HRM) spatiotemporal plots of the pharyngeal swallow can identify features of disordered swallowing reported on the Modified Barium Swallow Impairment Profile (MBSImP).

STUDY DESIGN

Case series evaluating new method of data analysis.

SETTING

University hospital.

SUBJECTS AND METHODS

Simultaneous HRM and videofluoroscopy was performed on 30 subjects (335 swallows) with dysphagia. Videofluoroscopic studies were scored according to the MBSImP guidelines while HRM plots were analyzed using a novel program. Pattern recognition using a multilayer perceptron artificial neural network (ANN) was performed to determine if 7 pharyngeal components of the MBSImP as well as penetration/aspiration status could be identified from the HRM plot alone. Receiver operating characteristic (ROC) analysis was also performed.

RESULTS

MBSImP parameters were identified correctly as normal or disordered at an average rate of approximately 91% (area under the ROC curve ranged from 0.902 to 0.981). Classifications incorporating two MBSImP parameters resulted in classification accuracies over 93% (area under the ROC curve ranged from 0.963 to 0.989).

CONCLUSION

Pattern recognition coupled with multiparameter quantitative analysis of HRM spatiotemporal plots can be used to identify swallowing abnormalities, which are currently assessed using videofluoroscopy. The ability to provide quantitative, functional data at the bedside while avoiding radiation exposure makes HRM an appealing tool to supplement and, at times, replace traditional videofluoroscopic studies.

Comparison between the radionuclide salivagram and videofluoroscopic swallowing study methods for evaluating patients with aspiration pneumonia

OBJECTIVE

A videofluoroscopic swallowing study (VFSS) is generally used to assess dysphagia and aspiration, although false-negative results may be obtained. Saliva aspiration may cause false-negative VFSS findings in elderly people. A radionuclide salivagram can be useful in detecting saliva aspiration. We therefore compared these two methods for the evaluation of patients with aspiration pneumonia.

METHODS

We prospectively enrolled 50 patients with aspiration pneumonia into this study. All patients underwent VFSS, and were evaluated on the Penetration-Aspiration Scale. A salivagram was performed on the day after VFSS and each patient received 1 mL Tc-99 m DTPA sublingually. Both dynamic and delayed images were obtained.

RESULTS

Aspiration was observed in 34% of patients by salivagram and in 42% by VFSS. The frequency of tests that were positive for aspiration pneumonia using a combination of the two methods was 52%. Five patients with positive aspiration findings on salivagram were negative on VFSS. The association between VFSS and salivagram findings was significant but the total agreement was 72%. The frequency of aspiration pneumonia was significantly associated with an abnormal salivagram finding.

CONCLUSIONS

A salivagram may be a useful method for the evaluation of aspiration in elderly people, and a combination of the VFSS and salivagram methods could enable a more effective investigation of aspiration pneumonia.

Artificial neural network classification of pharyngeal high-resolution manometry with impedance data

OBJECTIVES/HYPOTHESIS

To use classification algorithms to classify swallows as safe, penetration, or aspiration based on measurements obtained from pharyngeal high-resolution manometry (HRM) with impedance.

STUDY DESIGN

Case series evaluating new method of data analysis.

METHODS

Multilayer perceptron, an artificial neural network (ANN), was evaluated for its ability to classify swallows as safe, penetration, or aspiration. Data were collected from 25 disordered subjects swallowing 5- or 10-mL boluses. Following extraction of relevant parameters, a subset of the data was used to train the models, and the remaining swallows were then independently classified by the ANN.

RESULTS

A classification accuracy of 89.4 ± 2.4% was achieved when including all parameters. Including only manometry-related parameters yielded a classification accuracy of 85.0 ± 6.0%, whereas including only impedance-related parameters yielded a classification accuracy of 76.0 ± 4.9%. Receiver operating characteristic analysis yielded areas under the curve of 0.8912 for safe, 0.8187 for aspiration, and 0.8014 for penetration.

CONCLUSIONS

Classification models show high accuracy in classifying swallows from dysphagic patients as safe or unsafe. HRM-impedance with ANN represents one method that could be used clinically to screen for patients at risk for penetration or aspiration.

[Pneumonia Severity Index (PSI), CURB-65, and mortality in hospitalized elderly patients with aspiration pneumonia]

BACKGROUND

Aspiration pneumonia is associated with a high morbidity and mortality in elderly patients. In order to provide risk-adapted medical care, it is necessary to establish valid prognostic tools for these patients.

OBJECTIVE

The value of two well-established scores to assess prognosis in community-acquired pneumonia (CAP), i.e., CURB-65 and the Pneumonia Severity Index (PSI), was evaluated in elderly patients hospitalized for aspiration pneumonia.

MATERIAL AND METHODS

A total of 209 patients hospitalized with aspiration pneumonia between 2001 and 2005 in a single center were evaluated using PSI and CURB-65. For comparison of morbidity and mortality, an equally large group of inpatients with CAP was analyzed.

RESULTS

The mean age of patients with aspiration pneumonia was 76.7 ± 13.4 years, and 104 (49.8 %) were female. Patients with aspiration pneumonia more frequently showed a history of cancer, hypotension, and hyponatriemia on admission. Mortality was clearly higher in comparison to patients with CAP (39.2% vs. 16.3%). The Odds Ratio (OR) for mortality was 1.03 (95% CI 0.59; 1.79) for a CURB-65 score of 3-5 points compared to 0-2 points. In cases of CAP, OR showed a statistically significant increase of risk (OR 2.50; 95% CI 1.04; 6.06), for CURB-65 scores of 3-5 points vs. 0-2 points). In aspiration pneumonia, the PSI showed a trend towards increasing mortality within higher risk class.

CONCLUSIONS

In geriatric patients hospitalized with aspiration pneumonia, CURB-65 and PSI have no prognostic value.

Pneumonia in the long-term resident

Pneumonia in the long-term resident is common. It is associated with high morbidity and mortality. However, diagnosis and management of pneumonia in long-term care residents is challenging. This article provides an overview of the epidemiology, pathophysiology, diagnostic challenges, and management recommendations for pneumonia in this setting.

Pharyngeal flow interval: a novel impedance-based parameter correlating with aspiration

BACKGROUND

The role of pharyngeal impedance recording for assessing pharyngeal function is yet to be established. The aim of this study was to evaluate impedance flow interval, a novel parameter, in relation to bolus residue and the occurrence of aspiration. The effect of catheter configuration was also assessed.

METHODS

We studied 12 children (1.8-13.5years) with cerebral palsy, who were all referred for a videofluoroscopy due to suspected aspiration risk. Pharyngeal impedance patterns during bolus swallowing were recorded simultaneously with fluoroscopy. Two different catheter configurations were used: Catheter 1, 1.9mm diameter with 1cm electrodes and Catheter 2, 3.2mm diameter with 2cm electrodes. The flow interval was based on the objective assessment of impedance drop and recovery across multiple impedance segments and was correlated with fluoroscopic evidence of postswallow bolus residue and deglutitive aspiration.

KEY RESULTS

One hundred and thirty two liquid swallows were evaluated. Patient swallows with aspiration compared to those without aspiration had a longer flow interval (Cath 1 P=0.005; Cath 2 P<0.001). Patient swallows with residue had a longer flow interval, however this was only significant for swallows recorded using Catheter 2 (P=0.004). Multiple logistic regressions showed that higher flow interval was a better marker of the presence of aspiration [odds ratio (OR) 13.4 (3.0, 59.2); P<0.001] than the presence of residue [OR 3.8 (1.4, 10.3); P=0.01].

CONCLUSIONS & INFERENCES

We present novel findings suggesting that impedance measurement can detect alterations in flow characteristics of pharyngeal swallow that have the potential to predict to deglutitive aspiration risk.

A method to objectively assess swallow function in adults with suspected aspiration

BACKGROUND & AIMS

Pharyngeal manometry and impedance provide information on swallow function. We developed a new analysis approach for assessment of aspiration risk.

METHODS

We studied 20 patients (30-95 years old) with suspected aspiration who were referred for videofluoroscopy, along with controls (ages 24-47 years). The pharyngeal phase of liquid bolus swallowing was recorded with manometry and impedance. Data from the first swallow of a bolus and subsequent clearing swallows were analyzed. We scored fluoroscopic evidence of aspiration and investigated a range of computationally derived functional variables. Of these, 4 stood out as having high diagnostic value: peak pressure (PeakP), pressure at nadir impedance (PNadImp), time from nadir impedance to peak pressure (TNadImp-PeakP), and the interval of impedance drop in the distal pharynx (flow interval).

RESULTS

During 54 liquid, first swallows and 40 clearing swallows, aspiration was observed in 35 (13 patients). Compared to those of controls, patient swallows were characterized by a lower PeakP, higher PNadImp, longer flow interval, and shorter TNadImp-PeakP. A Swallow Risk Index (SRI), designed to identify dysfunctions associated with aspiration, was developed from iterative evaluations of variables. The average first swallow SRI correlated with the average aspiration score (r = 0.846, P < .00001 for Spearman Rank Correlation). An average SRI of 15, when used as a cutoff, predicted aspiration during fluoroscopy for this cohort (κ = 1.0).

CONCLUSIONS

Pressure-flow variables derived from automated analysis of combined manometric/impedance measurements provide valuable diagnostic information. When combined into an SRI, these measurements are a robust predictor of aspiration.

Effects of chronic aspirations on breathing pattern and ventilatory drive in vagatomized rats

The aim of this study was to test the hypothesis that aspirations induced by unilateral vagotomy destabilise ventilatory pattern during swallowing. The study was carried out on 15 Wistar rats (2-3 months, 290-350 g) using whole-body plethysmography and video recordings, before and after unilateral vagotomy. The rats were given water ad libitum via a baby bottle fitted with a nipple. The experiment was continued until rest ventilation and swallowing periods were identified on the video recordings. Following the sectioning of the right vagus nerve, all the rats presented bronchial aspirations and unilateral vocal cord paralysis in the aperture position. After the vagotomy there were no changes at rest of the ventilatory variables compared to healthy controls. In healthy animals during swallowing, we observed a decrease in total ventilatory time (TTOT), a decrease in inspiratory time (TI) (p < 0.001), a decrease in expiratory time (TE) (p < 0.001), no change in tidal volume (VT) and an increase in mean inspiratory time (VT/TI) (p < 0.001) compared to the rest period. Animals with chronic aspiration presented during swallowing an increase in TTOT (p < 0.001), TI (p < 0.01), and TE (p < 0.001), no change in VT and a decrease of VT/TI (p < 0.001) and a modification of ventilatory pattern. In conclusion, our results confirmed that swallowing modifies ventilation in healthy animals and that chronic aspiration decreases ventilatory drive and modifies ventilatory pattern during swallowing.

Aspiration syndromes: aspiration pneumonia and pneumonitis

Aspiration pneumonia and pneumonitis are common clinical syndromes that occur in hospitalized patients. Aspiration pneumonia occurs in patients with dysphagia and usually presents as a community-acquired pneumonia with a focal infiltrate in a dependent bronchopulmonary segment. Patients with aspiration pneumonia require treatment with broad-spectrum antibiotics and management of the underlying dysphagia. Aspiration pneumonitis follows the aspiration of gastric contents, usually in patients with a marked decreased level of consciousness. Treatment of aspiration pneumonitis is essentially supportive; however, corticosteroids and other immunomodulating agents may have a role in these patients.

Dysphagia in children with infantile cerebral palsy

PURPOSE

Dysphagia is a significant health problem in children with infantile cerebral palsy (ICP), but not frequently discussed in the literature. The study objective was to analyse dysphagia symptoms in children with a pyramidal form of ICP, including the oral and pharyngeal phases of deglutition and dysarthria severity. We searched for a correlation between dysphagia severity and ICP type, mental development and occurrence of epilepsy.

MATERIAL AND METHODS

A total of 67 children with a pyramidal form of infantile cerebral palsy were studied. Data were obtained based on case history elicited from the mothers, analysis of medical and psychological documentation, and logopaedic examination, including an examination of the action of swallowing.

RESULTS

Dysphagia symptoms were found in 41 (61%) studied children, most frequently referring only to the oral phase (25 children), with concomitant mild and moderate dysarthria. Oral and pharyngeal dysfunctions were observed in 14 children and coexisted with more pronounced dysarthria symptoms. The most severe disorders were mainly found in the pharyngeal phase in 2 children. A statistically significant correlation was noted between the severity of dysphagia symptoms and the ICP type (p<0.044) and mental development (p<0.00002).

CONCLUSIONS

Swallowing dysfunctions occur in the majority of children (>50%) with ICP. More serious disorders involving the oral and pharyngeal phases mainly affect children with tetraplegia and profound mental impairment. These disorders continue from early infancy through childhood and adolescence and improvement has been mainly observed when only the oral phase of swallowing is affected. These are always accompanied by dysarthria symptoms, which are especially severe when dysphagia involves the oral and pharyngeal phases. Early assessment and stimulation of the swallowing function should be a common element in the rehabilitation and care of children with ICP.

Closure of laryngotracheal cavity and tracheostomy for intractable aspiration secondary to radiation encephalopathy or radiation damage of cranial nerve after radiotherapy of nasopharyngeal carcinoma

CONCLUSIONS

Closure of the laryngotracheal cavity and tracheostomy is especially suitable for intractable aspiration secondary to radiation encephalopathy or damage of cranial nerve after radiation for nasopharyngeal carcinoma (NPC).

OBJECTIVE

To investigate the clinical value, technique, indications and contraindications of closure of the laryngotracheal cavity and tracheostomy for intractable aspiration secondary to radiation encephalopathy (REP) or radiation damage of cranial nerve after radiotherapy of NPC.

PATIENTS AND METHODS

Thirty patients, suffering from intractable aspiration secondary to radiotherapy for nasopharyngeal carcinoma, were treated with closure of the laryngotracheal cavity and tracheostomy and were observed for at least 1 year.

RESULTS

Intractable aspiration and dyspnea were completely eradicated in all patients. The quality of their life was greatly improved.

Tube Feeding in Advanced Dementia: An Exploratory Survey of Physician Knowledge

The administration of artificial nutrition by means of a percutaneous endoscopic gastrostomy (PEG) tube in older persons in the advanced stages of dementia is commonplace, yet the treatment is associated with significant treatment burdens and unclear benefits in this population. In addition, there is wide and unexplained geographic variability in the use of PEG in advanced dementia, which may stem partly from physicians’ lack of understanding about its indications, risks, benefits, and effect on quality of life in advanced dementia. This study was a mail survey undertaken to assess physician knowledge regarding tube feeding in advanced dementia and explore whether certification in geriatrics or other physician characteristics are associated with physician knowledge. To assess knowledge about tube feeding, we asked participants to rate the importance of commonly cited, but non–evidence based, indications for tube feeding in advanced dementia, including recurrent aspiration pneumonia, abnormal swallowing evaluations, abnormal nutritional parameters, preventing an uncomfortable death, and others. Discrepancies between physician knowledge and current evidence regarding tube feeding in advanced dementia were found, indicating a need for improved education of primary care physicians in order to ultimately provide better end-of-life care for patients with advanced dementia.

ESPEN Guidelines on Enteral Nutrition: Geriatrics

Nutritional intake is often compromised in elderly, multimorbid patients. Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake. The present guideline is intended to give evidence-based recommendations for the use of ONS and TF in geriatric patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. EN by means of ONS is recommended for geriatric patients at nutritional risk, in case of multimorbidity and frailty, and following orthopaedic-surgical procedures. In elderly people at risk of undernutrition ONS improve nutritional status and reduce mortality. After orthopaedic-surgery ONS reduce unfavourable outcome. TF is clearly indicated in patients with neurologic dysphagia. In contrast, TF is not indicated in final disease states, including final dementia, and in order to facilitate patient care. Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.