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To determine whether the use of both videofluoroscopic swallowing study (VFSS) and radionuclide salivagram was beneficial for detecting aspiration-induced pneumonia in children with swallowing difficulty.
From 2001 to 2016, children who underwent both VFSS and salivagram consecutively for suspected aspiration or dysphagia were included in the study. Demographic data, findings of VFSS and salivagram, and medical records were reviewed.
Aspiration pneumonia (AP) was present in 34 out of 110 children; 48 showed positive aspiration findings in VFSS and 33 showed positive aspiration findings in salivagram. Among the 62 children who were negative of aspiration in VFSS, 12 (19.4%) showed positive aspiration findings in salivagram. Four out of 12 children were diagnosed with AP. The aspiration findings in both VFSS and salivagram were significantly related to AP. However, the aspiration findings in the two tests were weakly consistent. Even if one test showed negative aspiration, it was helpful to additionally detect AP using another test, which showed positive aspiration finding. If aspiration findings were positive in only one of the two tests, the probability of AP was 38.5%, whereas if they were positive in both tests, the probability increased to 66.7%. If the aspiration findings were negative in both tests, AP did not occur with a probability of 90%.
Salivagram is a valuable tool for monitoring of aspiration in children with swallowing difficulties. It could be helpful in assessment of children at a high risk of AP, even if the VFSS showed negative aspiration findings. Thus, testing for AP using both VFSS and salivagram is desirable.
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To prospectively assess the association between impoverished sensorimotor integration of the tongue and lips and post-extubation dysphagia (PED).
This cross-sectional study included non-neurologic critically ill adult patients who required endotracheal intubation and underwent videofluoroscopic swallowing study (VFSS) between October and December 2016. Participants underwent evaluation for tongue and lip performance, and oral somatosensory function. Demographic and clinical data were retrieved from medical records.
Nineteen patients without a definite cause of dysphagia were divided into the non-dysphagia (n=6) and the PED (n=13) groups based on VFSS findings. Patients with PED exhibited greater mean duration of intubation (11.85±3.72 days) and length of stay in the intensive care unit (LOS-ICU; 13.69±3.40 days) than those without PED (6.83±5.12 days and 9.50±5.96 days; p=0.02 and p=0.04, respectively). The PED group exhibited greater incidence of pneumonia, higher videofluoroscopy swallow study dysphagia scale score, higher oral transit time, and lower tongue power and endurance and lip strength than the non-dysphagia groups. The differences in two-point discrimination and sensations of light touch and taste among the two groups were insignificant. Patients intubated for more than 7 days exhibited lower maximal tongue power and tongue endurance than those intubated for less than a week.
Duration of endotracheal intubation, LOS-ICU, and oromotor degradation were associated with PED development. Oromotor degradation was associated with the severity of dysphagia. Bedside oral performance evaluation might help identify patients who might experience post-extubation swallowing difficulty.
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To evaluate the correlation between radionuclide salivagram findings and clinical characteristics in dysphagic patients with brain lesions.
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.
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%).
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.
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To explore both the early prediction and diagnosis of dysphagia in preterm infants as an important developmental aspect as well as the prevention of respiratory complications, we developed the simple and-easy-to-apply Dysphagia Screening Test for Preterm Infants (DST-PI) to predict supraglottic penetration and subglottic aspiration.
Fifty-two infants were enrolled in a videofluoroscopic swallowing study (VFSS) due to clinical suspicions of dysphagia. Thirteen items related to supraglottic penetration or subglottic aspiration were initially selected from previous studies for the DST-PI. Finally, 7 items were determined by linear logistic regression analysis. Cutoff values, sensitivity, specificity, and the area under the ROC curve (AUC) of the DST-PI for predicting supraglottic penetration or subglottic aspiration were calculated using a ROC curve. For inter-rater reliability, the kappa coefficient was calculated.
Seven items were selected: ‘gestational age,’ ‘history of apnea,’ ‘history of cyanosis during feeding,’ ‘swallowing pattern,’ ‘coughs during or after feeding,’ ‘decreased oxygen saturation within 3 minutes of feeding,’ and ‘voice change after feeding.’ The Spearman correlation coefficient between the DST-PI and the penetration-aspiration scale (PAS) was 0.807 (p<0.001). The sensitivity and specificity at different cutoff values for detecting supraglottic penetration and subglottic aspiration were 96.6% and 76.9% at 3.25, and 88.9% and 75.8% at 6.25, respectively.
The DST-PI is a valid and reliable dysphagia screening test for supraglottic penetration or subglottic aspiration in preterm infants that is easy to apply in a clinical context.
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To evaluate the safety of nasogastric tube (NGT) removal and change to oral feeding with a food thickener for acute stroke patients in whom a videofluoroscopic swallow study (VFSS) confirmed thin liquid aspiration.
We retrospectively examined data of 199 patients with first stroke who were diagnosed with dysphagia from 2011 to 2015. Swallowing function was evaluated using VFSS. Patients included in this study were monitored for 4 weeks to identify the occurrence of aspiration pneumonia. The penetration-aspiration scale (PAS) was used to assess VFSS findings. The patients were divided into thin-liquid aspiration group (group 1, n=104) and no thin-liquid aspiration group (group 2, n=95).
The feeding method was changed from NGT feeding to oral feeding with food thickener (group 1) and without food thickener (group 2). The PAS scores of thin and thick liquids were 6.46±0.65 and 1.92±0.73, respectively, in group 1 and 2.65±0.74 and 1.53±0.58, respectively, in group 2. Aspiration pneumonia developed in 1.9% of group 1 and 3.2% of group 2 (p=0.578), with no significant difference between the groups.
We concluded that removing the NGT and changing to oral feeding with a food thickener is a safe food modification for acute stroke patients with thin liquid aspiration. Therefore, we recommend that VFSS should be conducted promptly in acute stroke patients to avoid unnecessary prolonged NGT feeding.
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To confirm a relationship between the pharyngeal response and bolus volume, and examine whether increasing the fluid bolus volume can improve penetration and aspiration for stroke dysphagic patients.
Ten stroke patients with a delayed pharyngeal response problem confirmed by a videofluoroscopic swallowing study (VFSS) were enrolled. Each subject completed two swallows each of 2 mL, 5 mL, and 10 mL of barium liquid thinned with water. The pharyngeal delay time (PDT) and penetration-aspiration scale (PAS) were measured and the changes among the different volumes were analyzed.
PDTs were shortened significantly when 5 mL and 10 mL of thin barium were swallowed compared to 2 mL. However, there was no significant difference in PAS as the bolus volume increased.
The increased fluid bolus volume reduced the pharyngeal delay time, but did not affect the penetration and aspiration status.
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To determine the effects of cervical kyphosis on the recovery of swallowing function in subacute stroke patients.
Baseline and 1-month follow-up videofluoroscopic swallowing studies (VFSSs) of 51 stroke patients were retrospectively analyzed. The patients were divided into the cervical kyphosis (Cobb's angle <20°, n=27) and control (n=24) groups. The penetration-aspiration scale (PAS), American Speech-Language-Hearing Association National Outcomes Measurement System swallowing scale (ASHA NOMS), and videofluoroscopic dysphagia scale (VDS) were used to determine the severity of dysphagia. Finally, the prevalence of abnormal VFSS findings was compared between the two groups.
There were no significant differences in baseline PAS, ASHA NOMS, and VDS scores between the two groups. However, the follow-up VDS scores in the cervical kyphosis group were significantly higher than those in the control group (p=0.04), and a follow-up study showed a tendency towards worse ASHA NOMS scores (p=0.07) in the cervical kyphosis group. In addition, the cervical kyphosis group had a higher occurrence of pharyngeal wall coating in both baseline and follow-up studies, as well as increased aspiration in follow-up studies (p<0.05).
This study showed that stroke patients who had cervical kyphosis at the time of stroke might have impaired recovery from dysphagia after stroke.
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To examine the relation between the presence of penetration or aspiration and the occurrence of the clinical indicators of dysphagia. The presence of penetration or aspiration is closely related to the clinical indicators of dysphagia. It is essential to understand these relationships in order to implement proper diagnosis and treatment of dysphagia.
Fifty-eight poststroke survivors were divided into two groups: patients with or without penetration or aspiration. Medical records and videofluoroscopic swallowing examinations were reviewed. The occurrence of clinical indicators of dysphagia between two groups was analyzed with Cross Tabulation and the Pearson chi-square test (p<0.05).
Poststroke survivors with penetration or aspiration had significantly high occurrences of delayed initiation of the swallow (p=0.04) and reduced hyolaryngeal elevation (p<0.01) than those without penetration or aspiration.
The results of this study indicate that delayed initiation of the swallow is a strong physiological indicator of penetration or aspiration during the oral stage of swallowing in poststroke survivors. For the pharyngeal stage of swallowing, hyoid and laryngeal elevation is a key event related to occurrence of penetration or aspiration. Clinical indicators should be investigated further to allow appropriate implementation of treatment strategies for stroke survivors.
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To develop a quantitative and organ-specific practical test for the diagnosis and treatment of dysphagia based on assessment of stroke patients.
An initial test composed of 24 items was designed to evaluate the function of the organs involved in swallowing. The grading system of the initial test was based on the analysis of 50 normal adults. The initial test was performed in 52 stroke patients with clinical symptoms of dysphagia. Aspiration was measured via a videofluoroscopic swallowing study (VFSS). The odds ratio was obtained to evaluate the correlation between each item in the initial test and the VFSS. A polychotomous linear logistic model was used to select the final test items.
Eighteen of 24 initial items were selected as significant for the final tests. These 18 showed high initial validity and reliability. The Spearman correlation coefficient for the total score of the test and functional dysphagia scale was 0.96 (p<0.001), indicating a statistically significant positive correlation.
This study was carried out to design a quantitative and organ-specific test that assesses the causes of dysphagia in stroke patients; therefore, this test is considered very useful and highly applicable to the diagnosis and treatment of dysphagia.
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To identify the associations between the duration of endotracheal intubation and developing post-extubational supraglottic and infraglottic aspiration (PEA) and subsequent aspiration pneumonia.
This was a retrospective observational study from January 2009 to November 2014 of all adult patients who had non-neurologic critical illness, required endotracheal intubation and were referred for videofluoroscopic swallowing study. Demographic information, intensive care unit (ICU) admission diagnosis, severity of critical illness, duration of endotracheal intubation, length of stay in ICU, presence of PEA and severity of dysphagia were reviewed.
Seventy-four patients were enrolled and their PEA frequency was 59%. Patients with PEA had significantly longer endotracheal intubation durations than did those without (median [interquartile range]: 15 [9-21] vs. 10 [6-15] days; p=0.02). In multivariate logistic regression analysis, the endotracheal intubation duration was significantly associated with PEA (odds ratio, 1.09; 95% confidence interval [CI], 1.01-1.18; p=0.04). Spearman correlation analysis of intubation duration and dysphagia severity showed a positive linear association (r=0.282, p=0.02). The areas under the receiver operating characteristic curves (AUCs) of endotracheal intubation duration for developing PEA and aspiration pneumonia were 0.665 (95% CI, 0.542-0.788; p=0.02) and 0.727 (95% CI, 0.614-0.840; p=0.001), respectively.
In non-neurologic critically ill patients, the duration of endotracheal intubation was independently associated with PEA development. Additionally, the duration was positively correlated with dysphagia severity and may be helpful for identifying patients who require a swallowing evaluation after extubation.
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To investigate the prevalence of chronic obstructive pulmonary disease (COPD) in stroke patients, and to assess the difference in swallowing function between stroke patients with COPD (COPD group) and stroke patients without COPD (control group).
The subjects included 103 stroke patients. They underwent the pulmonary function test and were assigned to either the COPD group or the control group. Their penetration-aspiration scale (PAS) scores and functional dysphagia scale scores were compared by performing a videofluoroscopic swallowing study. The intergroup differences in lip closure, bolus formation, mastication, and the oral transit time, laryngeal elevation, cricopharyngeal dysfunction, oronasal regurgitation, residue in pyriform sinus and vallecula, pharyngeal transit time, aspiration, and esophageal relaxation were also compared.
Thirty patients were diagnosed with COPD. The COPD group showed statistically higher PAS scores (4.67±2.15) compared to the control group (2.89±1.71). Moreover, aspiration occurred more frequently in the COPD group with statistical significance (p<0.05). The COPD group also showed higher occurrence of cricopharyngeal dysfunction, albeit without statistical significance.
This study shows that a considerable number of stroke patients had COPD, and stroke patients with COPD had higher risk of aspiration than stroke patients without COPD.
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To identify risk factors for dysphagia in tongue cancer patients. Dysphagia is a common complication of surgery, radiotherapy, and chemotherapy in tongue cancer patients. Previous studies have attempted to identify risk factors for dysphagia in patients with head and neck cancer, but no studies have focused specifically on tongue cancer patients.
This study was conducted on 133 patients who were diagnosed with tongue cancer and who underwent a videofluoroscopy swallowing study (VFSS) between January 2007 and June 2012 at the Asan Medical Center. Data collected from the VFSS were analyzed retrospectively. Patients with aspiration were identified.
Patients showed a higher incidence of inadequate tongue control, inadequate chewing, delayed oral transit time, aspiration or penetration, vallecular pouch and pyriform residue, and inadequate laryngeal elevation after surgery. Moreover, male gender, extensive tumor resection, a higher node stage, and more extensive lymph node dissection were major risk factors for aspiration in tongue cancer patients.
Tongue cancer patients have difficulties in the pharyngeal phase as well as the oral phase of swallowing. These difficulties can worsen after tongue cancer surgery. Gender, the extent of tumor resection, and lymph node metastasis affect swallowing in tongue cancer patients. Physicians should take these risk factors into account when administering swallowing therapy to tongue cancer patients.
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To evaluate demographic characteristics of children with suspected dysphagia who underwent videofluoroscopic swallowing study (VFSS) and to identify factors related to penetration or aspiration.
Medical records of 352 children (197 boys, 155 girls) with suspected dysphagia who were referred for VFSS were reviewed retrospectively. Clinical characteristics and VFSS findings were analyzed using univariate and multivariate analyses.
Almost half of the subjects (n=175, 49%) were under 24 months of age with 62 subjects (18%) born prematurely. The most common condition associated with suspected dysphagia was central nervous system (CNS) disease. Seizure was the most common CNS disorder in children of 6 months old or younger. Brain tumor was the most important one for school-age children. Aspiration symptoms or signs were the major cause of referral for VFSS in children except for infants of 6 months old or where half of the subjects showed poor oral intake. Penetration or aspiration was observed in 206 of 352 children (59%). Subjects under two years of age who were born prematurely at less than 34 weeks of gestation were significantly (p=0.026) more likely to show penetration or aspiration. Subjects with congenital disorder with swallow-related anatomical abnormalities had a higher percentage of penetration or aspiration with marginal statistical significance (p=0.074). Multivariate logistic regression analysis revealed that age under 24 months and an unclear etiology for dysphagia were factors associated with penetration or aspiration.
Subjects with dysphagia in age group under 24 months with preterm history and unclear etiology for dysphagia may require VFSS. The most common condition associated with dysphagia in children was CNS disease.
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To assess cough reflex sensitivity using the simplified cough test (SCT) and to evaluate the usefulness of SCT to screen for silent aspiration.
The healthy control group was divided into two subgroups: the young (n=29, 33.44±9.99 years) and the elderly (n=30, 63.66±4.37 years). The dysphagic elderly group (n=101, 72.95±9.19 years) consisted of patients with dysphagia, who suffered from a disease involving central nervous system (ischemic stroke 47, intracerebral hemorrhage 27, traumatic brain injury 11, encephalitis 5, hypoxic brain damage 3, and Parkinson disease 8). The SCT was performed using the mist of a 1% citric acid from a portable nebulizer. The time from the start of the inhalation to the first cough was measured as the cough latency. All the dysphagic patients underwent the videofluoroscopic swallowing study.
The cough latency was more significantly prolonged in the healthy elderly group than in the healthy young group (p<0.001), and in the dysphagic elderly group than in the healthy elderly group (p<0.001). The sensitivity and specificity of SCT were 73.8% and 72.5% for detecting aspiration in the dysphagic patients, and 87.1% and 66.7% for detecting silent aspiration in the aspirated patients.
Cough latency measured with the SCT reflects the impairment of cough reflex in healthy elderly and dysphasic subjects. The results of this study show that the SCT test can be a valuable method of screening aspiration with or without cough in dysphasic patients.
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To determine the useful tool for evaluating salivary aspiration in brain-injured patients with tracheostomy.
Radionuclide salivagram and laryngoscopy was done in 27 brain-injured patients with tracheostomy. During salivagram, 99mTc sulfur colloid was placed sublingually in the supine position, and 50-minute dynamic images and 2-hour delayed images were obtained. Salivary aspiration was detected when the tracer was entered into the major airways or lung parenchyma. Laryngoscopy was done by otolaryngologists, and saliva aspiration, saliva pooling, and vocal cord palsy were evaluated. Videofluoroscopic swallowing study was done in patients who were able to undergo the test.
The detection rate of salivary aspiration was 44.4% with salivagram, and 29.6% with laryngoscopy. The correlation of the two tests was 70.4%. Of the laryngoscopy findings, salivary pooling had significant correlation with positive salivagram results (p=0.04). Frequent need of suction correlated with salivary aspiration in both salivagram (p=0.01) and laryngoscopy (p=0.01). Patients with negative results in salivagram or laryngoscopy had higher rates of progressing to oral feeding or tapering tracheostomy. Two patients developed aspiration pneumonia, and both patients only showed aspiration in salivagram.
Brain-injured patients with tracheostomy have a high risk of salivary aspiration. Evaluation of salivary aspiration is important, as it may predict aspiration pneumonia and aids in clinical decisions of oral feeding or tracheostomy removal. Salivagram is more sensitive than laryngoscopy, but laryngoscopy may be useful for evaluating structural abnormalities or for follow-up examinations to assess the changes.
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To investigate the clinical characteristics of dysphagic elderly Korean patients diagnosed with aspiration pneumonia as well as to examine the necessity of performing a videofluoroscopic swallowing study (VFSS) in order to confirm the presence of dysphagia in such patients.
The medical records of dysphagic elderly Korean subjects diagnosed with aspiration pneumonia were retrospectively reviewed for demographic and clinical characteristics as well as for VFSS findings.
In total, medical records of 105 elderly patients (81 men and 24 women) were reviewed in this study. Of the 105 patients, 82.9% (n=87) were admitted via the emergency department, and 41.0% (n=43) were confined to a bed. Eighty percent (n=84) of the 105 patients were diagnosed with brain disorders, and 68.6% (n=72) involved more than one systemic disease, such as diabetes mellitus, cancers, chronic cardiopulmonary disorders, chronic renal disorders, and chronic liver disorders. Only 66.7% (n=70) of the 105 patients underwent VFSS, all of which showed abnormal findings during the oral or pharyngeal phase, or both.
In this study, among 105 dysphagic elderly patients with aspiration pneumonia, only 66.7% (n=70) underwent VFSS in order to confirm the presence of dysphagia. As observed in this study, the evaluation of dysphagia is essential in order to consider elderly patients with aspiration pneumonia, particularly in patients with poor functional status, brain disorders, or more than one systemic disease. A greater awareness of dysphagia in the elderly, as well as the diagnostic procedures thereof, particularly VFSS, is needed among medical professionals in Korea.
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To verify the influence of sour taste on swallowing and the presence of reflex cough when sour material was swallowed in patients with dysphagia secondary to brain injury.
Fifty dysphagic brain injury patients who underwent videofluoroscopic swallowing study (VFSS) were recruited. The patients who had shown severe aspiration at 2 ml of liquid were excluded. The dysphagic patients were given 5 ml each of a sour tasting liquid (SOUR) and a thin liquid barium (LIQUID) in random order. An expert analyzed the result of VFSS by reviewing recorded videotapes. Analysis components consisted of the Penetration-Aspiration-Scale (PAS) score, oral transit time (OTT), pharyngeal transit time (PTT), pharyngeal delay time (PDT) and the reflex cough presence.
The PAS score for SOUR was significantly lower than the one for LIQUID (p=0.03). The mean OTT for SOUR was significantly shortened compared to that for LIQUID (p=0.03). The mean PTT and PDT were also shortened in SOUR, although the differences were not statistically significant (p=0.26 and p=0.32, respectively). There was no significant difference between SOUR and LIQUID regarding the presence of reflex cough (p=1.00).
The sour taste could enhance sensorimotor feedback in the oropharynx, thus lowering the chances of penetration-aspiration caused by shortening of the oropharyngeal passage times. There was no significant difference in the presence of reflex cough produced between LIQUID and SOUR.
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To determine the major risk factors and abnormal videofluoroscopic swallowing study (VFSS) findings associated with aspiration in patients with head and neck cancer (HNC).
Risk factors associated with aspiration were investigated retrospectively in 241 patients with HNC using medical records and pre-recorded VFSS. Age, gender, lesion location and stage, treatment factors, and swallowing stage abnormalities were included.
Aspiration occurred in 50.2% of patients. A univariate analysis revealed that advanced age, increased duration from disease onset to VFSS, higher tumor stage, increased lymph node stage, increased American Joint Committee on Cancer (AJCC) stage, operation history, chemotherapy history, and radiotherapy history were significantly associated with aspiration (p<0.05). Among them, advanced age, increase AJCC stage, operation history, and chemotherapy history were significantly associated with aspiration in the multivariate analysis (p<0.05). Delayed swallowing reflex and reduced elevation of the larynx were significantly associated with aspiration in the multivariate analysis (p<0.05).
The major risk factors associated with aspiration in patients with HNC were advanced age, higher AJCC stage, operation history, and chemotherapy history. A VFSS to evaluate aspiration is needed in patients with NHC who have these risk factors. Delayed swallowing reflex and reduced elevation of the larynx were major abnormal findings associated with aspiration. Dysphagia rehabilitation should focus on these results.
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Method: The patient population consisted of 93 patients undergoing video fluoroscopic swallowing study (VFSS) to evaluate the risk of aspiration. The voice analyses were performed before and after VFSS using a portable recorder and voice analysis. The parameters included Average Fundamental Frequency (Fo), Relative Average Perturbation (RAP), Shimmer Percent, Noise to Harmonic Ratio (NHR), and Voice Turbulence Index.
Results: The patients were divided into two groups according to VFSS findings, non-aspiration group (including patients without vocal cord contact) and aspiration group (including patients with vocal cord contact). In comparing the differences of acoustic parameters before and after VFSS, all parameters except Fo were significantly different (p＜0.05). When the cut-off point was set to 0.3, the RAP was the most significant parameter given that the sensitivity was 0.911 and the specificity was 0.979. Combining RAP and NHR, the sensitivity was 1.000 and the specificity was 0.771.
Conclusion: Voice analysis is a very convenient and effective diagnostic tool in clinically evaluating the risk of aspiration. (J Korean Acad Rehab Med 2003; 27: 984-989)
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