Effect of occlusion of a tracheotomy tube on aspiration

The purpose of the present study was to investigate the effect of occlusion of a tracheotomy tube on aspiration utilizing fluoroscopy. Twenty consecutive tracheotomized patients referred for a modified barium swallow were included. Selection criteria were ability to tolerate tracheotomy tube occlusion during the modified barium swallow procedure, no surgery of the upper aerodigestive tract except tracheotomy, and no history of oropharyngeal cancer or stroke. These was 100% agreement among 3 independent reviewers on ratings of the presence or absence of aspiration. It was found that the occlusion status of the tracheotomy tube did not influence the prevalence of aspiration. Nine of 10 (90%) subjects who exhibited aspiration were over 65 years of age ( X=72 years 2 months). No trends were observed for bolus consistency, type of tracheotomy tube, or presence/absence of a nasogastric tube and ratings of aspiration.     

Effect of a One-Way Tracheotomy Speaking Valve on the Incidence of Aspiration in Previously Aspirating Patients with Tracheotomy

The purpose of the present study was to investigate the incidence of aspiration in previously aspirating patients with tracheotomy after use of a one-way tracheotomy tube speaking valve. Twenty consecutive inpatients from the acute care setting of a large urban tertiary care teaching hospital were included. All subjects had objective documentation of aspiration by a fiberoptic endoscopic evaluation of swallowing prior to placement of a one-way tracheotomy speaking valve, from 2 to 7 days of valve use with intelligible speech production, and no surgery to the upper aerodigestive tract except tracheotomy. Results indicated that incidence of aspiration was not affected by use of a one-way tracheotomy speaking valve. These results are in agreement with previous observations that subjects either aspirated or swallowed successfully regardless of tracheotomy tube occlusion status. Also, no significant differences were found between aspiration status and time since tracheotomy, time off ventilator, or duration of valve use. It was concluded that use of a one-way speaking valve provided mostly nondeglutitive benefits and should not be considered to promote successful swallowing for patients with tracheotomy in the acute care setting.     

Videofluoroscopic Evaluation of Aspiration with Visual Examination of the Gag Reflex and Velar Movement

The purpose of the present study was to investigate the relationship between prevalence of aspiration as determined by videofluoroscopic evaluation and prevalence of the gag reflex and velar movement as determined by direct visual examination. One hundred adult patients underwent a videofluoroscopic evaluation of aspiration with either an esophagram (n = 31), upper gastrointestinal series (n = 18), small bowel series (n = 23), or modified barium swallow procedure (n = 28), and concomitant evaluation of the gag reflex and velar movement on phonation. All studies were performed using the lateral, upright position, and all patients drank at least 5 cc of single contrast barium. Aspiration was defined as penetration of material below the level of the true vocal folds. A normal gag reflex and normal velar movement on phonation were observed in 14 of 15 (93%) patients who exhibited objective documentation of aspiration with videofluoroscopy. Conversely, 19 of 20 (95%) patients without a gag reflex were observed with videofluoroscopy to be without aspiration. Normal velar movement on phonation was observed in 99 of 100 (99%) patients. There was no significant age difference between patients with or without a gag reflex. No relationship was found between the prevalence of aspiration and the gag reflex or velar movement on phonation. It was concluded that the presence of a gag reflex does not protect against aspiration, and the absence of a gag reflex does not predict aspiration.     

Predictors of Aspiration Pneumonia: How Important Is Dysphagia?

Aspiration pneumonia is a major cause of morbidity and mortality among the elderly who are hospitalized or in nursing homes. Multiple risk factors for pneumonia have been identified, but no study has effectively compared the relative risk of factors in several different categories, including dysphagia. In this prospective outcomes study, 189 elderly subjects were recruited from the outpatient clinics, inpatient acute care wards, and the nursing home care center at the VA Medical Center in Ann Arbor, Michigan. They were given a variety of assessments to determine oropharyngeal and esophageal swallowing and feeding status, functional status, medical status, and oral/dental status. The subjects were followed for up to 4 years for an outcome of verified aspiration pneumonia. Bivariate analyses identified several factors as significantly associated with pneumonia. Logistic regression analyses then identified the significant predictors of aspiration pneumonia. The best predictors, in one or more groups of subjects, were dependent for feeding, dependent for oral care, number of decayed teeth, tube feeding, more than one medical diagnosis, number of medications, and smoking. The role that each of the significant predictors might play was described in relation to the pathogenesis of aspiration pneumonia. Dysphagia was concluded to be an important risk for aspiration pneumonia, but generally not sufficient to cause pneumonia unless other risk factors are present as well. A dependency upon others for feeding emerged as the dominant risk factor, with an odds ratio of 19.98 in a logistic regression model that excluded tube-fed patients.     

Hyoid Bone and Laryngeal Movement Dependent Upon Presence of a Tracheotomy Tube

The aim of this prospective, consecutive study was to investigate the biomechanical effects, if any, of the presence of a tracheotomy tube and tube cuff status, tube capping status, and aspiration status on movement of the hyoid bone and larynx during normal swallowing. Seven adult patients (5 male, 2 female) with an age range of 46–82 years (mean = 63 years) participated. Criteria for inclusion were no history of cancer of or surgery to the head and neck (except tracheotomy), normal cognition, normal swallowing, and ability to tolerate decannulation. Digital videofluoroscopic swallowing studies were performed at 30 frames/s and with each patient seated upright in the lateral plane. Variables evaluated included maximum hyoid bone displacement and larynx-to-hyoid bone approximation under three randomized conditions: tracheotomy tube in and open with a 5-cc air-inflated cuff; tracheotomy tube in and capped with deflated cuff; and tracheotomy tube out (decannulated). Differences between maximum hyoid bone displacement and larynx-to-hyoid approximation (cm) based on presence/absence of a tracheotomy tube, tube cuff status, and tube capping status were analyzed with the Student’s t test. Reliability testing with a Pearson product moment correlation was performed on 21% of the data. No significant differences (p > 0.05) were found for both maximum hyoid bone displacement and larynx-to-hyoid bone approximation during normal swallowing based on tracheotomy tube presence, tube cuff status, or tube capping status. Intraobserver reliability for combined measurements of maximum hyoid displacement and larynx-to-hyoid approximation was r = 0.97 and interobserver reliability for the absence of aspiration was 100%. For the first time with objective data it was shown that the presence of a tracheotomy tube did not significantly alter two important components of normal pharyngeal swallow biomechanics, i.e., hyoid bone movement and laryngeal excursion. The hypothesis that a tracheotomy tube tethers the larynx thereby preventing hyoid bone and laryngeal movement during normal swallowing is not supported.     

Effects of the Removal of the Tracheotomy Tube on Swallowing During the Fiberoptic Endoscopic Exam of the Swallow (FEES)

This study investigated the effects, if any, that the presence of a tracheotomy tube has on the incidence of laryngeal penetration and aspiration in patients with a known or suspected dysphagia. This was a prospective, repeated-measure design study. A total of 37 consecutive patients with a tracheotomy tube underwent a fiberoptic endoscopic evaluation of swallowing (FEES). Patients were first provided with pureed food boluses with the tracheotomy tube in place. The tracheotomy tube was then removed and the tracheostoma site was covered with gauze and gentle hand pressure was applied. The patients were then evaluated without the tracheotomy tube in place with additional puree. Aspiration status was in agreement with and without the tracheotomy tube in place in 95% (35/37) of the patients. The two patients who demonstrated a different swallowing pattern with regard to aspiration demonstrated aspiration only when the tracheotomy tube was removed. Laryngeal penetration status was in agreement with and without the tracheotomy tube in place in 78% (29/37) of the patients. For the majority of the patients, the removal of the tracheotomy tube made no difference in the incidence of aspiration and/or laryngeal penetration. Results of this study do not support the clinical notion that the patient’s swallowing function will improve once the tracheotomy tube has been removed. Work for this project was completed at Marianjoy Rehabilitation Hospital, Wheaton, Illinois.     

Fiberoptic Endoscopic Documentation of the High Incidence of Aspiration following Extubation in Critically Ill Trauma Patients

The purpose of this study was to investigate the incidence of aspiration following extubation in critically ill trauma patients. This prospective pilot study included 20 consecutive trauma patients who required orotracheal intubation for at least 48 hours. All subjects underwent a bedside transnasal fiberoptic endoscopic evaluation of swallowing at 24 ± 2 hr after extubation to determine objectively aspiration status. Aspiration was defined as the entry of a blue dyed material into the airway below the level of the true vocal folds, with silent aspiration occurring in the absence of any external behavioral signs such as coughing or choking. Aspiration was identified in 9 of 20 (45%) subjects and 4 of these 9 (44%) were silent aspirators. Therefore, silent aspiration occurred in 20% of the study population. Eight of the 9 (89%) aspirating subjects resumed an oral diet from 2–10 days (mean, 5 days) following extubation. All subjects had no evidence of pulmonary complications. It was concluded that trauma patients after orotracheal intubation and prolonged mechanical ventilation have an increased risk of aspiration. An objective assessment of dysphagia to identify aspiration may reduce the likelihood of pulmonary complications after extubation.     

Outcomes of Swallowing Rehabilitation in Chronic Brainstem Dysphagia: A Retrospective Evaluation

This study examines the functional and physiologic outcomes of treatment in a group of 10 patients with chronic dysphagia subsequent to a single brainstem injury. All patients participated in a structured swallowing treatment program at a metropolitan teaching hospital. This program differs from more traditional swallowing treatment by the inclusion of surface electromyography biofeedback as a treatment modality and the completion of 10 hr of direct treatment in the first week of intervention. A retrospective analysis of medical records and patient questionnaires was used to gain information regarding medical history, site of lesion, prior interventions, and patient perception of swallowing recovery. Physiologic change in swallowing treatment, as measured by severity ratings of videofluoroscopic swallowing studies, was demonstrated in nine of 10 patients after 1 week or 10 sessions of treatment. Functional change was measured by diet level tolerance after 1 week of treatment, at 6 months, and again at 1 year posttreatment. Eight of the 10 patients were able to return to full oral intake with termination of gastrostomy tube feedings, whereas two demonstrated no long-term change in functional swallowing. Of the eight who returned to full oral intake, the average duration of tube feedings following treatment until discontinuation was 5.3 months, with a range of 1–12 months. Six patients who returned to oral intake maintained gains in swallowing function, and two patients returned to nonoral nutrition as the result of a new unrelated medical condition.     

Approaches to the patient with aspiration and swallowing disabilities

Aspiration, or soiling of the tracheobronchial tree, can produce life-threatening pulmonary disease. Intermittent or persistent aspiration may cause symptoms including cough, intermittent fever, recurrent tracheobronchitis, atelectasis, pneumonia, and/or empyema. The pulmonary disease may be associated with weight loss, cachexia, and dehydration. In many cases the aspiration is caused by laryngeal dysfunction, allowing pulmonary contamination by swallowed material. In other cases the aspiration is caused by a dysfunction of the oral, pharyngeal, or esophageal phases of swallowing. In some cases the aspiration is caused by a combination of laryngeal and swallowing dysfunction. Geriatric patients are more likely to experience aspiration, since muscle weakness causing mechanical disability and neurologic impairment are more common in this age group. Therefore, with the ever-increasing aging of our population, these disabilities will be on the rise, with an associated increase in pulmonary disease and death. The approach to evaluation and management of these disorders must be based on an understanding of the underlying functional impairment.     

Intra- and Interrater Variation in the Evaluation of Videofluorographic Swallowing Studies

The objective of this study was to determine the inter- and intrarater reliability in evaluating videofluoroscopic swallowing studies (VFSS). Participants included 4 physicians (3 physiatrists and 1 internist) and 5 speech-language pathologists with at least 5 years experience in evaluating VFSS. The main outcomes of the study were reliability ratios of positive and negative tests in inter- and intrarater evaluations. Raters independently rated each of 20 VFSS on two separate occasions. Traits evaluated included oral stage impairment, aspiration, pharyngeal retention, and several functional components: timing of swallow onset, adequacy of velopharyngeal apposition, laryngeal elevation, epiglottic tilt, pharyngeal contraction, and pharyngoesophageal (PE) segment opening. Reliability varied widely depending on food type and the trait under evaluation. Inter- and intrarater reliability ratios did not differ widely. Reliability ratios values typically were highest (greater than 90%) for aspiration, especially with solid food, and lowest for the functional components. It was concluded that inter- and intrarater reliability in VFSS are adequate for evaluating oral stage, laryngeal penetration, and aspiration and pharyngeal retention, but questionable for functional components.     

Effect of Tracheotomy Tube Occlusion on Upper Esophageal Sphincter and Pharyngeal Pressures in Aspirating and Nonaspirating Patients

The biomechanics of the pharyngeal swallow in patients with a tracheotomy tube were investigated with manometry. Upper esophageal sphincter (UES) and pharyngeal pressure recordings were made with and without occlusion of the tracheotomy tube. Criteria for selection were ability to tolerate tracheotomy tube occlusion for both 5 minutes prior to and during the first manometric analysis, absence of surgery to the upper aerodigestive tract other than tracheotomy, and no history of oropharyngeal cancer or stroke. Aspiration was determined objectively by fiberoptic endoscopic evaluation of swallowing (FEES) immediately prior to manometric recording. Eleven adult individuals with tracheotomy participated; 7 swallowed successfully and 4 exhibited aspiration on FEES. The results indicated no significant effect of tracheotomy tube occlusion on UES or pharngeal pressures in either aspirating or nonaspirating patients. It was concluded that the biomechanics of the swallow as determined by UES and pharyngeal manometric pressure measurements were not changed significantly by tracheotomy tube occlusion in aspirating or nonaspirating patients. These results support previous observations that subjects either aspirated or swallowed successfully regardless of tracheotomy tube occlusion status.     

Inter- and Intrajudge Reliability of a Clinical Examination of Swallowing in Adults

This study investigates inter- and intrajudge reliability of a clinical examination of swallowing in adults. Several investigations have sought correlations between clinical indicators of dysphagia and the actual presence of dysphagia as determined by videofluoroscopy. Whereas some investigations have reported interjudge reliability for the videofluoroscopic measures employed, none have reported reliability for clinical measures. Without established reliability for rating clinical measures, conclusions drawn regarding the utility of a measure for detecting aspiration can be called into question. Results of the present study indicate that fewer than 50% of the measures clinicians typically employ are rated with sufficient inter- and intrajudge reliability. Measures of vocal quality and oral motor function were rated more reliably than were history measures or measures taken during trial swallows. There is a need to define more clearly the measures employed in clinical examinations and to be consistent in reporting reliability for clinical measures of swallowing function in future research.     

A Preliminary Comparison of Videofluoroscopy of Swallow and Pulse Oximetry in the Identification of Aspiration in Dysphagic Patients

Pulse oximetry has recently received attention in the dysphagia literature because of its possible contribution to the management of neurogenic dysphagia. The present study was devised to examine whether pulse oximetry could be exploited to determine episodes of aspiration in patients with known dysphagia of neurologic origin. To this end, pulse oximetry was undertaken in six patients undergoing videofluoroscopic study of swallow. Normal controls also underwent pulse oximetry during feeding. The results indicate that there is no clear-cut relationship between changes in arterial oxygenation and aspiration. However, some support is found for the association between altered arterial oxygenation and oral feeding in dysphagic individuals. Further research in both normals and compromised individuals is needed.     

Fiberoptic Endoscopic Evaluation of Dysphagia to Identify Silent Aspiration

The traditional bedside dysphagia evaluation has not been able to identify silent aspiration because the pharyngeal phase of swallowing could not be objectively assessed. To date, only videofluoroscopy has been used to detect silent aspiration. This investigation assessed the aspiration status of 400 consecutive, at risk subjects by fiberoptic endoscopic evaluation of swallowing (FEES). Our study demonstrated that 175 of 400 (44%) subjects were without aspiration, 115 of 400 (29%) exhibited aspiration with a cough reflex, and 110 of 400 (28%) aspirated silently. No significant differences were observed for age or gender and aspiration status. The FEES, done at bedside, avoids irradiation exposure, is repeatable as often as necessary, uses regular food, can be videotaped for review, and is a patient-friendly method of identifying silent aspiration.     

Prevalence of Aspiration and Laryngeal Penetration in Patients with Unilateral Vocal Fold Motion Impairment

The adverse consequences of aspiration in regard to patient health and quality of life are well documented. It is generally accepted that the probability of aspiration is increased in patients with unilateral vocal fold motion impairment, however, the incidence and proposed mechanism of aspiration vary depending on the reported series. We reviewed the cine or video pharyngoesophagographic findings in patients with documented unilateral vocal fold motion impairment, identified through the Johns Hopkins Hospital Swallowing Center database, to determine the prevalence and cause of aspiration and laryngeal penetration. Aspiration and laryngeal penetration were identified in 38% and 12% of patients, respectively. Aspiration resulted from impaired airway protection, not from esophageal obstruction with laryngeal ``spill-over.' The number and degree of impairments directly correlated with probability of aspiration. Obstruction potentiated the likelihood of aspiration. Video pharyngoesophagography accurately identifies patients at risk for aspiration.     

Dysphagia following Anterior Cervical Spine Surgery

Although previous reports have identified dysphagia as a potential complication of anterior cervical spine surgery (ACSS), current understanding of the nature and etiologies of ACSS-related dysphagia remains limited. The present study was undertaken to describe the patterns of dysphagia that may occur following ACSS. Thirteen patients who exhibited new-onset dysphagia following ACSS were studied retrospectively by means of chart review and videofluoroscopic swallow study analysis. Results indicated that a variety of swallowing impairments occurred following ACSS. In 2 patients, prevertebral soft tissue swelling near the surgical site, deficient posterior pharyngeal wall movement, and impaired upper esophageal sphincter opening were the most salient videofluoroscopic findings. In another 5 patients, the pharyngeal phase of swallowing was absent or very weak, with resulting aspiration in 3 cases. In contrast, an additional 4 patients exhibited deficits primarily of the oral preparatory and oral stages of swallowing including deficient bolus formation and reduced tongue propulsive action. Finally, 2 patients exhibited impaired oral preparatory and oral phases, a weak pharyngeal swallow, as well as prevertebral swelling. Thus, a variety of swallowing deficits, due possibly to neurological and/or soft tissue injuries, may occur following ACSS.     

Use of Arterial Oxygen Saturation, Heart Rate, and Blood Pressure as Indirect Objective Physiologic Markers to Predict Aspiration

If an indirect bedside variable can reliably predict whether an objective instrumental dysphagia evaluation is needed, time and money can be saved without compromising patient care. To date, the search for a reliable indirect subjective marker of aspiration has not been successful. However, research on indirect objective markers of aspiration is alluring. The purpose of the present study was to investigate changes, if any, in the physiologic parameters of arterial oxygen saturation (SpO(2)), heart rate, and blood pressure during simultaneous objective confirmation of aspiration status with Fiberoptic Endoscopic Evaluation of Swallowing (FEES). Sixty adult subjects were divided into 4 groups of 15. Group 1 did not require supplemental oxygen and did not aspirate. Group 2 did not require supplemental oxygen and exhibited aspiration. Group 3 required supplemental oxygen and did not aspirate. Group 4 required supplemental oxygen and exhibited aspiration. Simultaneous SpO(2), heart rate, and blood pressure measurements were collected at 1-min intervals, i.e., pre-FEES baseline for 5 min; during FEES; and post-FEES for 5 min. Results indicated no significant differences in SpO(2) levels based on aspiration status or oxygen requirements for any of the 4 groups. A consistent pattern of higher heart rate values during FEES and continuing for 5 min post-FEES was observed for all 4 groups. A consistent pattern of higher blood pressure values during FEES and then lower blood pressure values post-FEES was observed for all 4 groups. It was concluded that the use of changes in SpO(2), heart rate, or blood pressure values as indirect objective markers of aspiration was not supported.     

Videofluorographic Study of Swallowing in Parkinson's Disease

We studied 16 patients with Parkinson's disease (PD) with dysphagia and 8 young and 7 elderly normal controls videofluorographically to evaluate the nature of swallowing disorders in PD patients. In 13 patients, abnormal findings in the oral phase were residue on the tongue or residue in the anterior and lateral sulci, repeated pumping tongue motion, uncontrolled bolus or premature loss of liquid, and piecemeal deglutition. Thirteen patients showed abnormal findings in the pharyngeal phase, including vallecular residue after swallow, residue in pyriform sinuses, and delayed onset of laryngeal elevation. Ten of these patients also showed abnormal findings in both the oral and pharyngeal phases. Aspiration was seen in 9 patients. The oral transit duration was significantly longer in the patients with and without aspiration than in the control subjects. The stage transition duration, pharyngeal transit duration, duration of the upper esophageal sphincter (UES) opening, and total swallow duration were significantly longer in the patients with and without aspiration than in the young controls, but were not longer than in the elderly controls. These durational changes in the pharyngeal phase of swallowing were similar to those in the elderly controls. The findings suggest that the disturbed motility in the oral phase of swallowing may be due to bradykinesia. Although PD patients with dysphagia evince a variety of swallowing abnormalities, the duration of pharyngeal swallowing may remain within the age-related range until the symptoms worsen.     

Pneumonia in Stroke Patients: A Retrospective Study

This is a retrospective study of 378 consecutive stroke patients who were referred between June 1994 and June 1997 for videofluorographic study of oropharyngeal swallow. Patients who had radiation therapy, brain tumor, brain surgery, head and/or spinal cord trauma, oral–pharyngeal disease or surgery, or other neurologic diseases in addition to the stroke were excluded from the study. Patients were assigned to two groups: one with pneumonia and one without pneumonia. One hundred one patients were included in the pneumonia group, and 277 patients were included in the nonpneumonia group. Within the pneumonia group, patients were assigned to an acute pneumonia group (pneumonia within 6 months poststroke) and a chronic pneumonia group (pneumonia more than 6 months poststroke). Variables examined in the study included patients' medical history and the findings from the videofluorographic studies. Pearson chi-square analysis was used to identify those variables that were significantly different between the pneumonia and nonpneumonia patient groups and between the acute and chronic pneumonia groups. Results showed that stroke patients who developed pneumonia had a significantly higher incidence of multiple-location and unspecified lesion strokes, chronic airway disease in their medical history, and aspiration during the videofluorographic studies when compared with patients who did not develop pneumonia. Within the pneumonia group, the acute pneumonia group was found to have a significantly higher incidence of hypertension and diabetes in their medical history and a significantly higher incidence of aspiration and reduced laryngeal elevation during the videofluorographic studies. Between 48% and 55% of all stroke patients in the study aspirated. Patients who suffered multiple strokes, brainstem stroke, or subcortical stroke had the greatest frequency of aspiration.     

A Screening Procedure for Oropharyngeal Dysphagia

The present study was designed to examine the sensitivity and specificity of a 28-item screening test in identifying patients who aspirate, have an oral stage disorder, a pharyngeal delay, or a pharyngeal stage disorder. The screening test includes 28 items divided into 5 categories: (1) 4 medical history variables; (2) 6 behavioral variables; (3) 2 gross motor variables; (4) 9 observations from oromotor testing; and (5) 7 observations during trial swallows. Results identified variables that were able to classify patients correctly as having or not having aspiration 71% of the time, an oral stage disorder 69% of the time, a pharyngeal delay 72% of the time, and a pharyngeal stage swallowing problem 70% of the time. Sensitivity and specificity for each of these judgments and all 28 items on the test are also provided. Results are discussed relative to statistical, clinical, and third-party perspectives on the goals of screening, data from other screening tests, and the role of screening versus diagnostic testing in care of dysphagic patients.