Evaluation of Swallow Function Post-Extubation: Is It Necessary to Wait 24 Hours?

BACKGROUND: Post-extubation dysphagia is associated with an increased incidence of nosocomial pneumonias, longer hospitalizations, and higher re-intubation rates. The purpose of this study was to determine if it is necessary to delay swallow evaluation for 24 hours post-extubation. METHODS: A prospective investigation of swallowing was conducted at 1, 4, and 24 hours post-extubation to determine if it is necessary to delay swallow evaluation following intubation. Participants were 202 adults from 5 different intensive care units (ICU). RESULTS: A total of 166 of 202 (82.2%) passed the Yale Swallow Protocol at 1 hour post-extubation, with an additional 11 (177/202; 87.6%) at 4 hours, and 8 more (185/202; 91.6%) at 24 hours. Only intubation duration ≥4 days was significantly associated with nonfunctional swallowing. CONCLUSIONS: We found it is not necessary to delay assessment of swallowing in individuals who are post-extubation. Specifically, the majority of patients in our study (82.2%) passed a swallow screening at 1 hour post-extubation.

An Epidemiologic Study on Ageing and Dysphagia in the Acute Care Geriatric-Hospitalized Population: A Replication and Continuation Study.

United States census data project dramatic increases in the geriatric population ageing demographics by 2060 with concomitant health-care consequences. The purpose of this replication and continuation study was to collect new 2014 demographic data relative to ageing, swallow evaluation referral rates, and oral feeding status in geriatric-hospitalized patients for comparison with published data from 2000 to 2007. This was a planned data acquisition study of consecutive hospitalized patients referred for swallow assessments. Swallow evaluation referral rates for 2014 were described according to inpatient discharges, age range 60-105 years grouped by decade, gender, admitting diagnostic category, results of swallow evaluations, and oral feeding status. Determination of aspiration risk status was made with the Yale Swallow Protocol and diagnosis of dysphagia made with fiberoptic endoscopic evaluation of swallowing (FEES). There were 1348 referrals and 961 patients ≥60 years of age participated. Overall swallow evaluation referral rates increased an average of 63 % between the comparison years 2007 and 2014 with consistent increases corresponding to the decades, i.e., 60-69 (46 %), 70-79 (68 %), 80-89 (53 %), and 90+ (222 %). A total of 75 % of participants resumed oral alimentation and oral medications. Swallow evaluation referral rates increased by 63 % for 60-90+ year-old acute care geriatric-hospitalized participants despite only a 23 % increase in inpatient discharges for the years 2007 versus 2014. This corroborated previously reported increases for individual years from 2000 to 2007. For timely, safe, and successful initiation of oral alimentation, it is important to perform a reliable swallow screen for aspiration risk assessment with the Yale Swallow Protocol and, if failed, instrumental testing with FEES. More dysphagia specialists are needed through 2060 and beyond due to projections of continued population ageing resulting in ever increasing referral rates for swallow assessments.

Pharyngeal Residue Severity Rating Scales Based on Fiberoptic Endoscopic Evaluation of Swallowing: A Systematic Review.

Identification of pharyngeal residue severity located in the valleculae and pyriform sinuses has always been a primary goal during fiberoptic endoscopic evaluation of swallowing (FEES). Pharyngeal residue is a clinical sign of potential prandial aspiration making an accurate description of its severity an important but difficult challenge. A reliable, validated, and generalizable pharyngeal residue severity rating scale for FEES would be beneficial. A systematic review of the published English language literature since 1995 was conducted to determine the quality of existing pharyngeal residue severity rating scales based on FEES. Databases were searched using controlled vocabulary words and synonymous free text words for topics of interest (deglutition disorders, pharyngeal residue, endoscopy, videofluoroscopy, fiberoptic technology, aspiration, etc.) and outcomes of interest (scores, scales, grades, tests, FEES, etc.). Search strategies were adjusted for syntax appropriate for each database/platform. Data sources included MEDLINE (OvidSP 1946-April Week 3 2015), Embase (OvidSP 1974-2015 April 20), Scopus (Elsevier), and the unindexed material in PubMed (NLM/NIH) were searched for relevant articles. Supplementary efforts to identify studies included checking reference lists of articles retrieved. Scales were compared using qualitative properties (sample size, severity definitions, number of raters, and raters' experience and training) and psychometric analyses (randomization, intra- and inter-rater reliability, and construct validity). Seven articles describing pharyngeal residue severity rating scales met inclusion criteria. Six of seven scales had insufficient data to support their use as evidenced by methodological weaknesses with both qualitative properties and psychometric analyses. There is a need for qualitative and psychometrically reliable, validated, and generalizable pharyngeal residue severity rating scales that are anatomically specific, image-based, and easily learned by both novice and experienced clinicians. Only the Yale Pharyngeal Residue Severity Rating Scale, an anatomically defined and image-based tool, met all qualitative and psychometric criteria necessary for a valid, reliable, and generalizable vallecula and pyriform sinus severity rating scale based on FEES.

Oral Alimentation in Neonatal and Adult Populations Requiring High-Flow Oxygen via Nasal Cannula.

Use of high-flow oxygen via nasal cannula (HFO2-NC) is increasingly common in intensive care unit (ICU) settings. Despite the critical interface between respiration and swallowing, and the high acuity of patients in ICUs, the impact of HFO2-NC on feeding and swallowing is unknown. The present prospective, single-center, cohort study investigated the impact of HFO2-NC use on oral alimentation in neonatal and adult ICU patients. Oral alimentation status was evaluated in 100 consecutive ICU inpatients (50 neonatal and 50 adult) requiring HFO2-NC. Participant characteristics, respiratory support, successful initiation of oral feeding in neonates, and successful resumption of oral feeding in adults were recorded. Seventeen of 50 (34 %) neonates requiring HFO2-NC were deemed developmentally and medically appropriate by the neonatologist and nursing to begin oral alimentation. All 17 (100 %) were successful with initiation of oral feedings. Thirty-three of 50 (66 %) continued nil per os due to prematurity or medical conditions precluding oral alimentation at time of data collection. Thirty-nine of 50 (78 %) adults requiring HFO2-NC were deemed medically appropriate by the intensivist and nursing to resume oral alimentation (n = 34) or with a functional swallow without aspiration on FEES (n = 5). All 39 (100 %) resumed oral alimentation successfully. Eleven of 50 (22 %) continued nil per os due to severe respiratory issues precluding both swallow testing and oral alimentation at time of data collection. All developmentally and medically appropriate neonatal and adult patients requiring HFO2-NC were successful with either the introduction or resumption of oral alimentation. Patients requiring HFO2-NC who are identified as having feeding or swallowing issues should be referred for swallowing evaluations using the same criteria as patients who do not require HFO2-NC, as it is not the use of HFO2-NC but rather patient-specific determinants of feeding and swallowing readiness and their underlying medical conditions that impact readiness for oral alimentation status.

A Biomechanical Study of Hyoid Bone and Laryngeal Movements During Swallowing Comparing the Blom Low Profile Voice Inner Cannula and Passy-Muir One Way Tracheotomy Tube Speaking Valves.

The aim of this prospective, consecutive, cohort study was to investigate the biomechanical effects, if any, of the Blom low profile voice inner cannula and Passy-Muir one-way tracheotomy tube speaking valves on movement of the hyoid bone and larynx during swallowing. Ten adult patients (8 male, 2 female) with an age range of 61-89 years (mean 71 years) participated. Criteria for inclusion were ≥18 years of age, English speaking, and ability to tolerate both changing to a Blom tracheotomy tube and placement of a one-way tracheotomy tube speaking valve with a fully deflated tracheotomy tube cuff. Digitized videofluoroscopic swallow studies were performed at 30 frames/s and with each patient seated upright in the lateral plane. A total of 18 swallows (three each with 5 cc bolus volumes of single contrast barium and puree + barium × 3 conditions) were analyzed for each participant. Variables evaluated included larynx-to-hyoid bone excursion (mm), maximum hyoid bone displacement (mm), and aspiration status under three randomized conditions: 1. Tracheotomy tube open with no inner cannula; 2. Tracheotomy tube with Blom valve; and 3. Tracheotomy tube with Passy-Muir valve. Blinded reliability testing with a Pearson product moment correlation was performed on 20 % of the data. Intra- and inter-rater reliability for combined measurements of larynx-to-hyoid bone excursion and maximum hyoid bone displacement was r = 0.98. Intra- and inter-rater reliability for aspiration status was 100 %. No significant differences (p > 0.05) were found for larynx-to-hyoid bone excursion and maximum hyoid bone displacement during swallowing based upon an open tracheotomy tube, Blom valve, or Passy-Muir valve. Aspiration status was identical for all three randomized conditions. The presence of a one-way tracheotomy tube speaking valve did not significantly alter two important components of normal pharyngeal swallow biomechanics, i.e., hyoid bone and laryngeal movements. Aspiration status was similarly unaffected by valve use. Clinicians should be aware that the data do not support placement of a one-way tracheotomy tube speaking valve to reduce prandial aspiration.

Verbal communication with the Blom low profile and Passy-Muir one-way tracheotomy tube speaking valves.

OBJECTIVE: To investigate physiologic parameters, voice production abilities, and functional verbal communication ratings of the Blom low profile voice inner cannula and Passy-Muir one-way tracheotomy tube speaking valves. STUDY DESIGN: Case series with planned data collection. SETTING: Large, urban, tertiary care teaching hospital. SUBJECTS AND METHODS: Referred sample of 30 consecutively enrolled adults requiring a tracheotomy tube and tested with Blom and Passy-Muir valves. Physiologic parameters recorded were oxygen saturation, respiration rate, and heart rate. Voice production abilities included maximum voice intensity in relation to ambient room noise and maximum phonation duration of the vowel/a/. Functional verbal communication was determined from randomized and blinded listener ratings of counting 1-10, saying the days of the week, and reading aloud the sentence, "There is according to legend a boiling pot of gold at one end." RESULTS: There were no significant differences (p>0.05) between the Blom and Passy-Muir valves for the physiologic parameters of oxygen saturation, respiration rate, and heart rate; voice production abilities of both maximum intensity and duration of/a/; and functional verbal communication ratings. Both valves allowed for significantly greater maximum voice intensity over ambient room noise (p<0.001). CONCLUSIONS: The Blom low profile voice inner cannula and Passy-Muir one-way speaking valves exhibited equipoise regarding patient physiologic parameters, voice production abilities, and functional verbal communication ratings. LEARNING OUTCOMES: Readers will understand the importance of verbal communication for patients who require a tracheotomy tube; will be able to determine the differences between the Blom low profile voice inner cannula and Passy-Muir one-way tracheotomy tube speaking valves; and will be confident in knowing that both the Blom and Passy-Muir one-way tracheotomy tube speaking valves are equivalent regarding physiological functioning and speech production abilities.

The Yale Pharyngeal Residue Severity Rating Scale: An Anatomically Defined and Image-Based Tool.

The Yale Pharyngeal Residue Severity Rating Scale was developed, standardized, and validated to provide reliable, anatomically defined, and image-based assessment of post-swallow pharyngeal residue severity as observed during fiberoptic endoscopic evaluation of swallowing (FEES). It is a five-point ordinal rating scale based on residue location (vallecula and pyriform sinus) and amount (none, trace, mild, moderate, and severe). Two expert judges reviewed a total of 261 FEES evaluations and selected a no residue exemplar and three exemplars each of trace, mild, moderate, and severe vallecula and pyriform sinus residue. Hard-copy color images of the no residue, 12 vallecula, and 12 pyriform sinus exemplars were randomized by residue location for hierarchical categorization by 20 raters with a mean of 8.3 years of experience (range 2-27 years) performing and interpreting FEES. Severity ratings for all images were performed by the same 20 raters, 2 weeks apart, and with the order of image presentations randomized. Intra-rater test-retest reliability, inter-rater reliability, and construct validity were determined by pooled multi-category multi-rater kappa statistics. Residue ratings were excellent for intra-rater reliability for vallecula (kappa = 0.957 ± 0.014) and pyriform sinus (kappa = 0.854 ± 0.021); very good to excellent for inter-rater reliability for vallecula (kappa = 0.868 ± 0.011) and pyriform sinus (kappa = 0.751 ± 0.011); and excellent for validity for vallecula (kappa = 0.951 ± 0.014) and pyriform sinus (kappa = 0.908 ± 0.017). Clinical uses include accurate classification of vallecula and pyriform sinus residue severity patterns as none, trace, mild, moderate, or severe for diagnostic purposes, determination of functional therapeutic change, and precise dissemination of shared information. Scientific uses include tracking outcome measures, demonstrating efficacy of interventions to reduce pharyngeal residue, investigating morbidity and mortality in relation to pharyngeal residue severity, and improving training and accuracy of FEES interpretation by students and clinicians. The Yale Pharyngeal Residue Severity Rating Scale is a reliable, validated, anatomically defined, and image-based tool to determine residue location and severity based on FEES.

Use of the Blom Tracheotomy Tube with Suction Inner Cannula to Decontaminate Microorganisms from the Subglottic Space. A Proof of Concept.

RATIONALE: Preventing pulmonary complications during mechanical ventilation via tracheotomy is a high priority. OBJECTIVES: To investigate if the Blom tracheotomy tube with suction-above-the-cuff inner cannula reduced the quantity of normal flora and pathogens in supra- versus subglottic spaces. METHODS: We enrolled 20 consecutive medical ICU adults requiring tracheostomy for mechanical ventilation in this proof-of-concept, prospective, single-center study. All participants received a Blom tracheotomy tube with suction-above-the-cuff inner cannula to decontaminate microorganisms from the supra- and subglottic spaces. Supra- and subglottic sputum samples were obtained for microbiologic analysis while an endotracheal tube was in place before tracheotomy and once per week for up to 4 weeks of mechanical ventilation after tracheotomy. MEASUREMENTS AND MAIN RESULTS: Demographics, duration of endotracheal tube intubation, and duration of mechanical ventilation post-tracheotomy were recorded. There was a significant reduction for supraglottic (2.86 ± 1.11 [mean ± SD]) versus subglottic suction samples (2.48 ± 1.07) (paired t test, P = 0.048; Wilcoxon test, P = 0.045) when all data pairs for normal flora and pathogens were combined across times. There was a significant reduction of normal flora pooled across times in 19 data pairs for supraglottic (3.00 ± 1.05) versus subglottic suction samples (2.00 ± 0.94) (paired t test, P = 0.0004; Wilcoxon test, P = 0.0007). There was no significant reduction of pathogens pooled across times in 25 data pairs for supraglottic (2.76 ± 1.16) versus subglottic suction samples (2.84 ± 1.03) (paired t test, P = 0.75; Wilcoxon test, P = 0.83). CONCLUSIONS: Proof-of-concept was confirmed. The Blom tracheotomy tube with disposable suction-above-the-cuff inner cannula decontaminated microorganisms from the subglottic space when normal flora and pathogens were combined. Future research should investigate if decreased quantity of normal flora and pathogens in the subglottic space reduces the incidence of ventilator-associated pulmonary complications in critically ill patients requiring ongoing mechanical ventilation via tracheotomy.

Is partial laryngectomy safe forever?

OBJECTIVES: Over past decades, function-preserving surgery has been oncologically effective for specific types of laryngeal cancer. Although safe short-term swallow function has been reported, swallow safety during long-term survival has received less attention. The purpose of this report is to highlight potential consequences of late dysphagia and chronic aspiration after partial laryngectomy. METHODS: A retrospective case series was performed. The head and neck cancer database from Yale-New Haven Hospital identified 3 patients requiring completion laryngectomy due to chronic aspiration 11-15 years after oncologically successful partial laryngectomy. Demographics, presentation, treatment, and course are included. RESULTS: Primary treatment was open supraglottic laryngectomy with adjuvant radiation therapy (n=2) and vertical hemilaryngectomy (n=1). All patients demonstrated locoregional control and preservation of swallow function for >10 years postoperatively. Due to late dysphagia and chronic aspiration, two patients required completion laryngectomy 11 and 15 years postoperatively and the third patient will require this 14 years postoperatively. CONCLUSIONS: Successful swallowing after function-preserving laryngeal surgery may not last forever despite adequate control of cancer. Three patients presented with aspiration 11-15 years after partial laryngectomy and required definitive completion laryngectomy. This observation may affect preoperative counseling and consideration for longer post-operative follow-up. The data encourage a larger sample size.

Five days of successful oral alimentation for hospitalized patients based upon passing the Yale Swallow Protocol.

OBJECTIVE: This study aimed to determine the success of oral alimentation and patient retention rate 1 to 5 days after passing the Yale Swallow Protocol. METHODS: Participants were 200 consecutive acute care inpatients referred for swallow assessment. Inclusion criteria were adequate cognitive abilities to participate safely, completing an oral mechanism examination, and passing the 3-ounce water swallow challenge. Exclusion criteria were altered mental status, failing the 3-ounce challenge, preadmission dysphagia, head-of-bed restrictions < 30°, and a tracheotomy tube. Electronic medical record monitoring post-protocol passing for 1 to 5 consecutive days determined success of oral alimentation and retention rate. RESULTS: All patients who remained medically and neurologically stable drank thin liquids and ate successfully 1 to 5 days after passing the protocol. Mean (SD) volume of liquid ingested per day was 474.2 (435.5) cc. Patient retention declined steadily from day of testing (n = 200) through post-testing day 5 (n = 95). CONCLUSION: Passing the Yale Swallow Protocol allowed for initial determination of aspiration risk followed by successful oral alimentation for 1 to 5 days in medically and neurologically stable acute care hospitalized patients and without the need for instrumental dysphagia testing. The decline in patient retention was expected because of increasingly rapid transit through the acute care setting, which often renders longer follow-up problematic.

Validation of the Yale Swallow Protocol: a prospective double-blinded videofluoroscopic study.

The purpose of this prospective, double-blinded, multirater, systematic replication study was to investigate agreement for aspiration risk, in the same individual, between videofluoroscopic swallow studies (VFSS) and the Yale Swallow Protocol. Participants were 25 consecutive adults referred for dysphagia testing who met the inclusion criteria of completion of a brief cognitive assessment, oral mechanism examination, and no tracheotomy tube. First, all participants were administered the Yale Swallow Protocol by two experienced speech-language pathologists trained in protocol administration. Failure criteria were inability to drink the entire amount, interrupted drinking, or coughing during or immediately after drinking. Second, all participants completed a VFSS within 5-10 min of protocol administration. A speech-language pathologist, blinded to protocol results, reviewed the VFSS to determine aspiration status in a binary (yes/no) manner. Inter-rater agreement between two speech-language pathologists was 100 % for identification of aspiration risk with the Yale Swallow Protocol. Inter-rater agreement between the speech-language pathologist and the radiologist for identification of aspiration status with VFSS was 100 %. Twenty percent of VFSS recordings were viewed again 3-6 months after initial data collection, and intrarater agreement for identification of thin liquid aspiration was 100 %. Sensitivity for the Yale Swallow Protocol = 100 %, specificity = 64 %, positive predictive value = 78 %, and negative predictive value = 100 %. Importantly, all participants who passed the protocol did not aspirate during VFSS. Multiple, double-blinded raters and VFSS as the reference standard agreed with previous research with a single, nonblinded rater and FEES as the reference standard for identification of aspiration risk. The clinical usefulness and validity of the Yale Swallow Protocol for determining aspiration risk in a small sample size of male participants has been confirmed. Future research is needed with a larger and more heterogeneous population sample.

Comparing accuracy of the Yale swallow protocol when administered by registered nurses and speech-language pathologists.

AIMS AND OBJECTIVES: (1) To describe the results of a web-based teaching module used by registered nurses to identify patients at risk of aspiration and (2) to determine accuracy of the registered nurse-administered 3-ounce water swallow challenge protocol, that is, drinking three ounces of water, a basic cognitive screen and oral mechanism evaluation, when compared with blinded ratings from speech-language pathology. BACKGROUND: Early identification of potential swallowing problems is important prior to ingestion of food, fluid and medications. Unfortunately, current nurse-administered screens use a variety of non-evidence-based assessments. It would be beneficial to use a valid, reliable and evidence-based screen, that is, the Yale swallow protocol. DESIGN: Prospective, blinded, referral-based. METHODS: Fifty-two registered nurses and 101 inpatients participated. First, each participant was administered the 3-ounce water swallow challenge protocol by a speech-language pathologist. Second, a nurse administered the protocol to the same patient within one hour and independently recorded results and diet recommendations. The nurse was blinded to the study's purpose and results of the speech-language pathologist's initial screening. Out of view, but simultaneous with the nurse-administered protocol, a speech-language pathologist rerated the patient's challenge for comparison with initial results and determined the accuracy of the nurse-administered protocol. RESULTS: Intra- and inter-rater protocol agreements for the two speech-language pathologists were 100%. Inter-rater protocol agreement between registered nurses and speech-language pathologists was 98·01%. CONCLUSIONS: Results confirm the reliability and accuracy of a registered nurse-administered Yale swallow protocol. The consequence of 98% accuracy combined with previously reported 96·5% sensitivity, 97·9% negative predictive value and <2% false negative rate allowed for adoption of the protocol for the entire general hospital population. RELEVANCE TO CLINICAL PRACTICE: Avoidance of preventable prandial pulmonary aspiration as a cause of nosocomial infection is an important goal for all acute care hospitalised patients deemed at risk of aspiration.

Laryngeal physiology and voice acoustics are maintained after minimally invasive parathyroidectomy.

OBJECTIVES: This prospective single-arm study investigated both laryngeal physiology and voice acoustic measures in patients undergoing minimally invasive parathyroidectomy (MIP) due to primary hyperparathyroidism (primary HPTH). BACKGROUND: Avoidance of recurrent or superior laryngeal nerve injury and maintenance of normal laryngeal physiology and vocal function are key goals in the treatment of primary HPTH. No data are available comparing pre- and postoperative MIP laryngeal physiology and voice acoustics. METHODS: Patients served as their own controls and underwent identical pre- and postoperative assessment. True vocal fold mobility was assessed and recorded using transnasal fiber-optic laryngoscopy. Vocal capacity was recorded with maximum phonation time and vocal stability by frequency-based voice measures, that is, mean fundamental frequency (F0), standard deviation of the fundamental frequency (F0SD), and jitter and shimmer as measured by relative average perturbation and mean shimmer in decibels, respectively. RESULTS: A total of 104 patients were enrolled [26 men, mean age = 53 years, range 29-79 years; 78 women, mean age = 56 years, range 16-83 years). All completed the protocol and were analyzed according to intent to treat. MIP was accomplished in 95 patients, and 9 were converted to general anesthesia. The cure rate was 100%, as evidenced by normalization of serum calcium levels. Both real-time agreement and blinded inter- and intrarater reliability testing for laryngeal physiology ratings were 100%. One patient (<1%) exhibited a recurrent laryngeal nerve injury. No significant differences (P > 0.05) were found for any voice acoustic parameter between pre- and postoperative MIP (ie, maximum phonation time, F0, F0SD, relative average perturbation, or shimmer in decibels). CONCLUSIONS: MIP can be performed with exquisite disease control and without significant effects on laryngeal physiology or voice acoustic measures. For the first time, both physiologic and acoustic data support the use of MIP.

Can an oral mechanism examination contribute to the assessment of odds of aspiration?

Use of an oral mechanism examination is ubiquitous and long-standing despite a paucity of research supporting its clinical utility in dysphagia diagnostics. The purpose of this study was to investigate whether components of an oral mechanism examination, i.e., binary judgments (complete/incomplete) of labial closure, lingual range of motion, and facial symmetry, were associated with increased odds of aspiration as confirmed by subsequent instrumental testing. Study design was a single-group consecutively referred case series with a single judge. A total of 4,102 consecutive inpatients from a large, urban, tertiary-care teaching hospital were accrued, with 3,919 meeting the inclusion criterion of adequate cognitive ability to participate in an oral mechanism examination followed immediately by a fiberoptic endoscopic evaluation of swallowing. Stepwise multiple logistic regression analysis indicated that participants with incomplete lingual range of motion had an odds of aspiration that was 2.72 times the odds of aspiration of those with complete lingual range of motion (95% confidence interval [CI] = 1.96-3.79, p < 0.0001), and incomplete lingual range of motion was an independent risk factor for aspiration regardless of labial closure and facial symmetry. Participants with incomplete facial symmetry had an odds of aspiration that was 0.76 times the odds of aspiration of those with complete facial symmetry (95% CI = 0.61-0.95, p = 0.017). Isolated incomplete labial closure did not affect the odds of aspiration (p > 0.05). New and clinically relevant information was found for lingual range of motion and facial symmetry, i.e., when incomplete, the clinician should be alerted to potential increased odds of aspiration during subsequent instrumental dysphagia testing.

Verbal communication for the ventilator-dependent patient requiring an inflated tracheotomy tube cuff: A prospective, multicenter study on the Blom tracheotomy tube with speech inner cannula.

BACKGROUND: The purpose of this study was to present our findings on the impact of the Blom tracheotomy tube with speech inner cannula on voice production abilities and speech intelligibility scores of ventilator-dependent patients requiring a fully inflated tracheotomy tube cuff. METHODS: Prospective single group case-series design permitted consecutive accrual of 23 adult inpatients from acute care and rehabilitation settings. Maximum ambient room noise, voice intensity, phonation duration of vowel /a/, and speech intelligibility scores were determined over 3 sessions. RESULTS: All participants achieved audible voicing with the Blom tracheotomy tube. Voice intensity was significantly greater than ambient room noise by >10 dB SPL (p = .003). Speech intelligibility scores improved significantly from 80% to 85% (p = .03). Phonation duration averaged from 3.30 to 3.45 seconds. There were no significant changes in oxygen saturation (p > .05), and no significant complications occurred. CONCLUSION: The Blom tracheotomy tube with speech inner cannula permitted individuals requiring mechanical ventilation with a fully inflated tracheotomy tube cuff to produce excellent speech intelligibility for verbal communication. © 2012 Wiley Periodicals, Inc. Head Neck, 2013.

A bibliometric review of published abstracts presented at the Dysphagia Research Society: 2001-2011.

The purpose of this investigation was to perform a comprehensive bibliometric review of published abstracts presented at the Dysphagia Research Society between 2001 and 2011 in order to delineate research trends, identify knowledge gaps, and recommend areas for future dysphagia research. All 972 research abstracts, both oral and poster presentations, were included. Study designs included cross-sectional (n = 333, 34.4 %), cohort (n = 279, 28.8 %), and case series (n = 210, 21.7 %), while randomized controlled trials constituted only 3.3 % (n = 32) of all research presentations. Levels of evidence were assigned based on analysis of abstract details, as level 1 (n = 29, 3.0 %), level 2 (n = 639, 65.7 %), level 3 (n = 53, 5.5 %), level 4 (n = 243, 25.0 %), and level 5 (n = 8, 0.8 %). Research topics included normal swallowing pathophysiology (n = 279, 28.7 %), swallowing physiology (n = 266, 27.4 %), swallowing diagnosis (n = 192, 19.7 %), swallowing treatment (n = 165, 17.0 %), clinical policy and practice (n = 36, 3.7 %), and basic science (n = 34, 3.5 %). Research occurred in adults (n = 861, 88.6 %), pediatrics (n = 76, 7.8 %), animals (n = 29, 3.0 %), cadavers (n = 3, 0.3 %), and mechanical models (n = 3, 0.3 %). Presenting authors represented 14 different disciplines, with the majority in speech-language pathology, dentistry, basic science, and otolaryngology. Research was performed in 14 different countries with increased geographical diversity during the decade of analysis. Research recommendations derived from our findings call for increased (1) randomized controlled clinical trials consistent with level 1 evidence, (2) focus on pediatric feeding and swallowing, (3) use of animal models to study swallowing dysfunction and novel treatments, and (4) investigations from additional medical specialties. In addition, we applaud current trends and encourage continued support of interdisciplinary, international, and trainee representation.

Promoting safe swallowing when puree is swallowed without aspiration but thin liquid is aspirated: nectar is enough.

The use of thickened liquids is a common compensatory strategy to improve swallow safety. The purpose of this study was to determine the optimal liquid viscosity to use to promote successful swallowing in a specific subset of dysphagic patients who swallow puree without aspiration but thin liquid with aspiration. A referral-based sample of 84 consecutive inpatients from a large, urban, tertiary-care teaching hospital who met the study criteria was analyzed prospectively. Inclusion criteria were no preexisting dysphagia, a successful pharyngeal swallow without aspiration with puree consistency but pharyngeal dysphagia with aspiration of thin liquid consistency, and stable medical, surgical, and neurological status at the time of transnasal fiberoptic swallow testing and up to 24 h after recommendations for oral alimentation with a modified diet consisting of nectar-like and honey-like thickened liquids. Success with ingesting both nectar-like and honey-like thickened liquids and clinically evident aspiration events were recorded. Care providers were blinded to the study's purpose. All 84 patients were successfully ingesting nectar-like and honey-like thickened liquids at the time of swallow testing and up to 24 h after testing. A specific subset of dysphagic patients who swallowed puree without aspiration but aspirated thin liquid demonstrated 100 % successful swallowing of both nectar-like and honey-like thickened liquids. Therefore, a nectar-like thickened liquid appears to be adequate to promote safe swallowing in these patients and, because of patient preference for the least thick liquid, may enhance compliance and potentially contribute to maintenance of adequate hydration requirements.

Success of recommending oral diets in acute stroke patients based on passing a 90-cc water swallow challenge protocol.

PURPOSE: This study investigated the success of recommending specific oral diets following an acute stroke based on passing a 90-cc water swallow challenge protocol. METHOD: The study was a single group consecutively referred case series design. The study took place in a large, urban, tertiary care teaching hospital and involved 75 acute adult stroke inpatients in a 90-cc water swallow challenge. The volume (in cc) of liquid ingested, percent of meal eaten, and specific diet recommendations made 12 to 24 hours after passing a 90-cc water swallow challenge were accessed electronically from routine oral intake information entered by nursing staff on each participant's daily flow sheets. Nurses were blinded to the study's purpose. RESULTS: All 75 participants were drinking thin liquids and eating food successfully 12 to 24 hours after passing a 90-cc water swallow challenge. The mean volume of liquid ingested was 385.4 cc and percent of diet eaten ranged from 10% to 100%. Flow sheets indicated that specific diet recommendations were followed with 100% accuracy. CONCLUSIONS: Successfully recommending specific oral diets to acute stroke patients based on passing a 90-cc water swallow challenge protocol was supported. A 90-cc challenge is an easily administered, highly reliable, cost-effective, and validated clinical assessment that can be used by a variety of qualified health care professionals to identify aspiration risk. When a 90-cc challenge protocol is passed, specific diet recommendations can be made safely and confidently without the need for further objective dysphagia testing.

Vocal fold immobility and aspiration status: a direct replication study.

The purpose of this direct replication study was to confirm the incidence of vocal fold immobility (VFI) and its relationship to pharyngeal dysphagia and aspiration. Using a single-group consecutively referred case series, a total of 2,650 participants underwent fiberoptic endoscopic evaluation of swallowing between August 2003 and December 2007. Main outcome measures included overall incidence of VFI and aspiration status, with specific emphasis on age, gender, etiology and pharyngeal phase bolus flow characteristics, and side of VFI (right, left, or bilateral). These data were compared to and then combined with the original study (n = 1,452) for a total of 4,102 participants. Results indicated that the incidence of VFI was 4.3% (112/2,650), i.e., 27% (31/112) unilateral right, 58% (65/112) unilateral left, and 14% (16/112) bilateral. Incidence of aspiration was 22% (580/2,650). Of those with VFI, 40% (45/112) aspirated, i.e., 42% (13/31) unilateral right, 37% (24/65) unilateral left, and 50% (8/16) bilateral. An individual with VFI had 2.50 times the odds of aspirating as someone without VFI (95% CI = 1.86-3.37). For liquid aspiration, the odds ratio (OR) = 2.41 (95% CI = 1.77-3.28), and for puree aspiration, OR = 2.08 (95% CI = 1.47-2.93). Left VFI occurred most frequently due to surgical trauma. Liquid was aspirated more often than a puree. Males exhibited VFI more often than females. Side of VFI and age were not factors that increased the incidence of aspiration significantly. It was confirmed that VFI is not an uncommon finding during dysphagia testing and, when present, increased the odds of aspiration compared to a population already being evaluated for dysphagia.

Effect of presence/absence of a nasogastric tube in the same person on incidence of aspiration.

OBJECTIVE: To determine what effect, if any, the presence or absence of a nasogastric (NG) tube in the same person had on the incidence of anterograde aspiration. DESIGN: Case series with planned data collection. SETTING: Large, urban, tertiary care teaching hospital. SUBJECTS AND METHODS: Referred sample of 62 consecutively enrolled adult inpatients for fiber-optic endoscopic evaluation of swallowing (FEES). Group 1 (n = 21) had either small-bore (n = 13) or large-bore (n = 8) NG tubes already in place and had a FEES first with the NG tube in place and a second FEES after NG tube removal. Group 2 (n = 41) did not have an NG tube and had a FEES first without an NG tube and a second FEES after placement of a small-bore NG tube. Time between FEES was approximately 5 minutes. Patients were tested with thin liquid and puree food consistencies. Occurrence of aspiration for each consistency dependent on the presence or absence of an NG tube was recorded. RESULTS: There were no significant differences (P > .05) in aspiration status for both liquid and puree consistencies in the same person dependent on presence or absence of either a small-bore or large-bore NG tube. CONCLUSIONS: Since objective swallowing evaluation (eg, FEES) can be performed with an NG tube in place, it is not necessary to remove an NG tube to evaluate for aspiration. Similarly, there is no contraindication to leaving an NG tube in place to supplement oral alimentation until nutritional requirements are achieved.