Quantifying swallowing function after stroke: A functional dysphagia scale based on videofluoroscopic studies

OBJECTIVE: To develop a sensitive, specific scale for quantifying functional dysphagia in stroke patients, using results obtained from videofluoroscopic swallowing studies. DESIGN: Data collected from a serial oral and pharyngeal videofluoroscopic swallowing study. SETTING: A dysphagia clinic in a department of rehabilitation medicine at a tertiary care university hospital. PARTICIPANTS: One hundred three consecutively admitted stroke patients. INTERVENTIONS: Videoflurorscopy to measure a scale of 11 variables: lip closure score, bolus formation, residue in oral cavity, oral transit time, triggering of pharyngeal swallow, laryngeal elevation and epiglottic closure, nasal penetration, residue in valleculae, coating of pharyngeal wall after swallow, and pharyngeal transit time. MAIN OUTCOME MEASURES: Polychotomous linear logistic regression analysis of videofluoroscopic and aspiration results. Scale sensitivity and specificity, and the correlation between the total score of the scale and aspiration grade were analyzed. RESULTS: The scale's sensitivity and specificity for detecting supraglottic penetration and subglottic aspiration were 81%, 70.7%, and 78.1%, 77.9%, respectively. A significant positive correlation was found between the scale's total score and the severity of aspiration (Spearman's r =.58943, p =.00001). CONCLUSION: This functional dysphagia scale, which was based on a videofluoroscopic swallowing study in stroke patients, is a sensitive and specific method for quantifying the severity of dysphagia.     

Prediction of laryngeal aspiration using voice analysis

OBJECTIVE: To determine the diagnostic value of voice analysis to screen for patients with high risk of clinically significant aspiration. DESIGN: A total of 93 patients referred for a videofluoroscopic swallowing study were included in the study. Voice analyses were performed before and after videofluoroscopic swallowing study, and five acoustic variables were measured, including average fundamental frequency, relative average perturbation, shimmer percentage, noise-to-harmonic ratio, and voice turbulence index. The patients were divided into two groups based on the results of the videofluoroscopic swallowing study: a high-risk group with patients who had the ingested materials on or below the vocal cords and a low-risk group with patients who did not have the ingested materials on or below the vocal cords. The changes of each acoustic variable before and after the videofluoroscopic swallowing study were compared between the two groups. RESULTS: Relative average perturbation, shimmer percentage, noise-to-harmonic ratio, and voice turbulence index were significantly increased after videofluoroscopic swallowing study in the high-risk group as compared with the low-risk group (P < 0.05). The change of average fundamental frequency, however, was not significantly different between the two groups (P > 0.05). According to the receiver operating characteristics curve, the sensitivity of these acoustic variables in detecting aspiration or penetration ranged from 68.9% to 91.1% and specificity ranged from 68.8% to 97.9%. Relative average perturbation was the most accurate variable, with a sensitivity of 91.1% and a specificity of 97.9% in predicting aspiration or penetration. The combination of relative average perturbation and noise-to-harmonic ratio increased the sensitivity to 100% but reduced the specificity to 77.1%. CONCLUSION: Voice analysis is a safe, noninvasive, and reliable screening tool for patients with dysphagia and can detect patients at high risk of clinically significant aspiration, thereby augmenting clinical bedside examination.     

球囊扩张术对脑卒中后吞咽障碍康复疗效及不良并发症研究

目的:研究球囊扩张术对脑卒中后吞咽障碍的康复疗效及不良并发症的影响。方法:选取我院经吞咽造影检查确诊为脑卒中后环咽肌失弛缓导致的吞咽障碍患者50例,随机分为2组各25例。对照组接受常规吞咽功能训练、Vitalstim神经肌肉低频电刺激,观察组另外给予球囊扩张术治疗。比较2组患者的总有效率、吞咽功能、并发症发生率,同时比较治疗前和治疗后的咽通过时间、吞咽造影检查(VFSS)评分及功能性经口摄食评估(FOIS)评分。结果:观察组的可进水、可进食流质物、可进食糊状物、可进食固体食物比例均明显高于对照组(均P0.01);观察组的吸入性肺炎发生率明显低于对照组(P0.05);治疗后,观察组的咽通过时间明显低于对照组(P0.01),VFSS和FOIS评分均明显高于对照组(均P0.01);观察组的康复总有效率明显高于对照组(96.0%,72.0%,P0.05)。结论:球囊扩张术对脑卒中后吞咽障碍具有显著疗效,缩短患者康复时间,降低误吸等并发症的发生。     

Bedside screening tests vs. videofluoroscopy or fibreoptic endoscopic evaluation of swallowing to detect dysphagia in patients with neurological disorders: systematic review

Title. Bedside screening tests vs. videofluoroscopy or fibreoptic endoscopic evaluation of swallowing to detect dysphagia in patients with neurological disorders: systematic review. Aim. This paper is a report of a systematic review conducted to determine the effectiveness and feasibility of bedside screening methods for detecting dysphagia in patients with neurological disorders. Background. Dyspaghia affects 22–65% of patients with neurological conditions. Although there is a large variety of bedside tests to detect dysphagia, it is unknown which have the best psychometric properties and are feasible for nurses to use. Data sources and review methods. An electronic database search was carried out using Medline (PubMed), Embase, CINAHL, and PsychLit, including all hits up to July 2008. The search terms were dysphagia, sensitivity, specificity, diagnosis, and screening. The methodological quality of included studies was assessed. Results. Thirty‐five out of 407 studies were included in the review. Eleven studies with sufficient methodological quality revealed that trial swallow tests using water had sensitivities between 27% and 85% and specificities between 63% and 88%. Trial swallow tests with different viscosities led to sensitivities ranging from 41% to 100% and specificities of 57% to 82%. Combining water tests with oxygen desaturation led to sensitivities between 73% and 98% and specificities between 63% and 76%. Single clinical features, such as abnormal gag, generally had low sensitivity and specificity. Conclusion. A water test combined with pulse oximetry using coughing, choking and voice alteration as endpoints is currently the best method to screen patients with neurological disorders for dysphagia. Further research is needed to establish the most effective standardized administration procedure for such a water test, and to assess the value of pulse oximetry, in addition to a trial swallow to detect silent aspiration.     

Dysphagia in patients with brainstem stroke: incidence and outcome

OBJECTIVE: This study was conducted to delineate the incidence and outcome of dysphagia among hospitalized patients who were referred for rehabilitation because of brainstem stroke. DESIGN: We retrospectively reviewed the medical records of 36 patients who were admitted because of brainstem stroke. Information on the patients' clinical features, feeding status, and the results of clinical and videofluoroscopic swallowing examinations were obtained through chart review. Follow-up interviews were conducted via telephone to learn the general medical condition and feeding status of the patients 7-43 mo after hospital discharge. RESULTS: A total of 81% of the patients had dysphagia at the time of initial clinical swallowing evaluation, which was performed 10-75 days after the onset of stroke. A total of 79% of the dysphagic individuals depended on tube feeding at the initial evaluation; 22% of all individuals could not resume oral intake at discharge. Statistical analyses revealed a significant association between poor outcome and disease involving the medulla, the presence of a wet voice during the initial swallowing test, and a delay or absence of the swallowing reflex. The incidence of aspiration pneumonia was 11%. There was a correlation between the detection of aspiration by modified barium meal videofluoroscopy and the development of aspiration pneumonia. Follow-up interviews showed that 88% of the 27 patients who were contacted had resumed full oral intake 4 mo after the onset of stroke. CONCLUSIONS: The incidence of dysphagia was relatively high in our study population. The long-term outcome was favorable.     

Predictors of dysphagia after spinal cord injury.

OBJECTIVE: To quantify the incidence of swallowing deficits (dysphagia) and to identify factors that predict risk for dysphagia in the rehabilitation setting following acute traumatic spinal cord injury. DESIGN: Retrospective case-control study. SETTING: Freestanding rehabilitation hospital. PATIENTS: Data were collected on 187 patients with acute traumatic spinal cord injury admitted for rehabilitation over a 4-year period who underwent a swallowing screen, in which 42 underwent a videofluoroscopic swallowing study (VFSS). MAIN OUTCOME MEASURES: VFSS was performed on patients with suspected swallowing problems. Possible antecedents of dysphagia were recorded from the medical record including previous history of spine surgery, surgical approach and technique, tracheostomy and ventilator status, neurologic level of injury, ASIA Impairment Classification, orthosis, etiology of injury, age, and gender. RESULTS: On admission to rehabilitation 22.5% (n = 42) of spinal cord injury patients had symptoms suggesting dysphagia. In 73.8% (n = 31) of these cases, testing confirmed dysphagia (aspiration or requiring a modified diet), while VFSS ruled out dysphagia in 26.2% (n = 11) cases. Logistic regression and other analyses revealed three significant predictors of risk for dysphagia: age (p < .028), tracheostomy and mechanical ventilation (p < .001), and spinal surgery via an anterior cervical approach (p < .016). Other variables analyzed had no relation or at best a slight relation to dysphagia. Tracheostomy at admission was the strongest predictor of dysphagia. The combination of tracheostomy at rehabilitation admission and anterior surgical approach had an extremely high rate of dysphagia (48%). CONCLUSION: Swallowing abnormalities are present in a significant percentage of patients presenting to rehabilitation with acute traumatic cervical spinal cord injury. Patients with a tracheostomy appear to have a substantially increased risk of development of dysphagia, although other factors are also relevant. Risk of dysphagia should be evaluated to decrease the potential for morbidity related to swallowing abnormalities.     

脑卒中吞咽障碍患者吸入性肺炎的危险评估与护理干预

目的 使用吞水试验评估脑卒中吞咽障碍患者吸入性肺炎的危险度,并探讨护理干预对改善吞咽功能及减少吸入性肺炎的作用。方法 180例经吞水试验证实的脑卒中吞咽障碍患者随机分为两组:干预组90例在常规护理基础上,采取体位、饮食、吞咽基础功能训练;对照组90例仅给予常规护理。1个月后观察两组患者吞咽功能的改善情况及吸入性肺炎发生率。结果 干预组吞咽康复的总有效率为92.2%,明显高于对照组的57.8%(P＜0.05);吸入性肺炎发生率为12.2%,明显低于对照组的42.2%(P＜0.05)。结论 针对性护理干预能改善脑卒中患者吞咽功能,减少吸入性肺炎的发生。     

Can the aspiration detected by videofluoroscopic swallowing studies predict long-term survival in stroke patients with dysphagia?

Purpose: This study aimed to evaluate whether the aspiration detected by videofluoroscopic swallowing study (VSS) could predict the long-term survival in stroke patients with dysphagia in the post-acute phase of stroke. Methods: A cohort of 182 consecutive patients with stroke-related dysphagia referred for VSS from July 1994 to April 1999 was retrospectively constructed. VSS findings and clinical features in the post-acute phase of stroke were recorded. The records thus obtained were then linked to the National Death Register to track the occurrence of patient deaths until December 31, 2000. Results: Of the 182 patients, 91 (50%) showed aspiration during VSS performed for a median duration of 8.4 weeks after stroke, and 76 (42%) had silent aspiration. In the post-acute phase of stroke (14.7?±?8.7 weeks after stroke, mean?±?standard deviation), 56 (31%) were tube-fed, and 88 (48%) were wheelchair-confined. A total of 65 patients died in a median follow-up duration of 30.8 months after VSS. Patients were classified into three groups based on the findings of VSS-detected aspiration or penetration, but no difference was noted in their survival curves. In the Cox stepwise regression analysis, only advanced age, recurrent stroke (hazard ratio 1.74, 95% CI 1.06?-?2.85), the need of tube-feeding (hazard ratio 2.07, 95% CI 1.19?-?3.59), and being wheelchair-confined (hazard ratio 2.83, 95% CI 1.54?-?5.19) during follow-up were independent predictors of long-term survival. Conclusions: VSS-detected aspiration during the post-acute phase of stroke was not predictive for the long-term survival in stroke patients with dysphagia.     

Dysphagia in stroke: Development of a standard method to examine swallowing recovery

This study began development of a standard method that uses the videofluoroscopic swallow study for evaluation of swallowing recovery after stroke based on a definition of dysphagia derived from three domains: bolus timing, bolus direction, and bolus clearance. Two experiments were conducted: one that defined normal versus disordered swallowing based on the range of scores in a sample of healthy adults (n = 13), and one that applied these thresholds to nine stroke patients to identify the presence of dysphagia. Results indicate that acute and protracted dysphagia may be more accurately detected by identifying abnormalities on multiple objective measures of swallowing rather than on laryngeal penetration or aspiration alone. Results indicate that our selected measures and use of healthy control subjects to establish normal thresholds may eventually contribute to the definition and differentiation of dysphagic and nondysphagic patients. Further research with a broader sample of healthy controls and stroke patients is mandatory.     

Implementing a systematic care pathway for management of dysphagia after cardiothoracic surgery

ObjectivesThis longitudinal quality improvement study explored the impact of a new multidisciplinary dysphagia care pathway on swallow screening referrals, patient journeys and swallow outcomes in patients after cardiac surgery.Research methodologyThe new dysphagia care pathway consisted of i) nurse chart review triaging using established risk factors, ii) nurse swallow screening (including a cough reflex test and water swallow test) and iii) rapid referral routes to speech pathology. All patients referred for swallow screening in 2020 after the commencement of the new dysphagia care pathway were included (n = 114). Data was compared to two historical, published data sets at the research site (n-41 in 2012–2013 and n = 121 in 2013–2016).SettingCardiovascular intensive care unit.Results52% failed chart review and 29% failed cough reflex test. All patients who passed chart review and cough reflex test returned to a normal diet without need for speech pathology referral. Silent aspiration rates were high in those who failed chart review and the cough reflex test (42%, 43% respectively). For those who received a swallow screen, enteral feeding rates were 70% on first assessment and 27% by discharge from the unit in historical data (2013–2016). In comparison, in 2020, enteral feeding rates were 44% and 8% respectively.ConclusionsReferrals for nurse swallow screening and speech pathology increased following the introduction of the care pathway. There has been a reduction in enteral feeding rates and length of enteral feeding at discharge. High rates of silent aspiration in those who fail screening suggests stepwise nurse dysphagia screening successfully picks up at-risk patients.     

Triaging dysphagia: nurse screening for dysphagia in an acute hospital

Aims and objectives. To (1) develop a dysphagia screening tool to triage all patients at risk of aspiration/dysphagia on admission to acute hospital wards, (2) evaluate tool reliability, (3) evaluate nursing compliance and (4) develop a robust dysphagia training programme. Background. Failure to diagnose dysphagia has significant medical and economic costs. Dysphagia screening reduces pneumonia threefold. Most nurse‐screening tools have focused on stroke. However, many other conditions are associated with dysphagia. A multidisciplinary team developed a nurse‐administered, evidence‐based swallow screening tool for generic acute hospital use. Design. Prospective, quasi‐experimental. Methods. Nurses were assessed for knowledge pre‐ and post‐training. All patients were nurse‐screened for dysphagia on admission. All patients were reviewed by speech pathologists to determine screening accuracy. Results were not blinded. The one page tool encompassed (1) diagnostic categories, (2) patient/carer interview, (3) dysphagia indicators and (4) if applicable, water swallow test. Results. Thirty‐eight nurses participated in a seven‐week study; 442 patients were screened on two general medical wards. Three speech pathologists counter‐assessed each patient by clinical examination or chart review. Sensitivity was 95%; specificity was 97%. Positive predictive value was 92%; negative predictive value was 98%. 3·4% of clinical screening decisions were incorrect. Compliance rate was 85%. Conclusions. Caution is advised in interpretation of the results due to lack of blinding. Initial results suggest that the dysphagia screening tool is a quick and robust tool for triaging individuals with dysphagia. Training is critical to successful screening. Relevance to clinical practice. Twenty‐five to 30% of acute hospitalised individuals have dysphagia. All adult acute patients are screened for dysphagia using the Royal Brisbane and Women’s Hospital dysphagia screening tool. Patients are triaged into categories of ‘those requiring additional specialist intervention’ and ‘those who can proceed directly to regular diets and liquids’. Improved quality of care and cost savings is likely.     

家庭参与式口咽操训练在卒中后吞咽困难患者中的应用及效果评价

目的 探讨家庭参与式口咽操训练在卒中后吞咽困难患者的吞咽功能康复及营养状态改善中的应用及效果评价。方法 选取经洼田饮水试验评估为吞咽困难的脑卒中患者160例,按照随机数字法分为试验组与对照组,每组80例。对照组患者给予常规的吞咽功能训练,试验组给予常规的吞咽功能训练和家庭参与式口咽操训练。2组患者接受30d干预后,对其吞咽功能、吸入性肺炎发生率及营养状态进行评定与分析。结果 干预后,试验组吞咽困难改善情况好于对照组,差异具有统计学意义(P＜0.05);干预期间试验组吸入性肺炎发生率为11.25%,明显低于对照组(31.25%),差异具有统计学意义(P＜0.05);干预后,试验组营养风险评分为(2.74±0.69),明显低于对照组[(3.04±1.02)],差异具有统计学意义(P＜0.05)。结论 针对吞咽功能障碍的卒中患者,在常规吞咽功能训练的基础上加用家庭参与式口咽操可有效改善患者吞咽功能,降低吸入性肺炎的发生率,改善营养状态。     

Clinical predictors of dysphagia and aspiration risk: outcome measures in acute stroke patients

OBJECTIVE: To use an established dysphagia clinical screening system to evaluate outcomes in acute stroke patients. DESIGN: Case-control study. SETTING: Tertiary care center. PARTICIPANTS: Acute stroke patients (n = 56) consecutively referred to a speech pathology service. MAIN OUTCOME MEASURES: Outcomes (ie, pneumonia, dietary status at discharge) in patients who were referred for a videofluoroscopic swallow study (VSS) based on results of a previously validated clinical screening system were compared with outcomes in patients who were not referred for VSS based on the clinical evaluation. RESULTS: Thirty-eight of 56 patients (68%) presented with 2 or more clinical predictors of moderate to severe dysphagia and were further evaluated with VSS, whereas 18 patients (32%) had fewer than 2 clinical features and were not evaluated radiographically. Based on patient outcomes and VSS results, identification of at least 2 clinical predictors significantly distinguished patients with moderate to severe dysphagia from patients with mild dysphagia or normal swallowing. None of the patients in either group developed pneumonia while following recommendations of the clinical or dynamic swallowing evaluation, and 93% of the patients returned to a regular diet. CONCLUSIONS: These data demonstrate that clinical use of this screening system can objectively identify acute stroke patients who warrant further diagnostic studies and can safely determine which patients need no further deglutitive evaluation.     

多伦多床旁吞咽筛查试验在急性期脑卒中后吞咽障碍筛查中的筛检效果评价

目的:探讨多伦多床旁吞咽筛查试验(TOR-BSST)在急性期脑卒中后吞咽障碍筛查中的筛检效果。方法:采用TOR-BSST对148例急性期脑卒中后住院患者进行筛查评估,筛查当天或24小时之内行吞咽障碍诊断金标准——视频透视检查(VFSS),以金标准为参考标准,用灵敏度、特异度、阳性预测值、阴性预测值、阳性似然比、阴性似然比进行筛检效果评价。结果:TOR-BSST(+)共46例(31.08%),TOR-BSST(-)共102例(68.92%),结果显示TOR-BSST判断吞咽障碍的灵敏度为61.8%,特异度为87.1%,阳性预测值为73.9%,阴性预测值79.4%,阳性似然比为4.7907,阴性似然比0.4386。结论:与TOR-BSST研发原作者的研究相比较,此研究结果显示筛检效果不够理想,两者的研究环境与使用环境均有差距,未来需要更严谨的研究方法学设计、更多的吞咽障碍评估方法的引进或开发,且加强VFSS评价的准确性是关键。     

Videofluoroscopic evaluation of HIV/AIDS patients with swallowing dysfunction

Background: We investigated the association of abnormalities of the swallowing mechanism in the oral and pharyngeal phases of swallowing with symptoms of dysphagia and painful swallowing in patients with human immunodeficiency virus (HIV). Methods: Seventeen patients, two with HIV and 15 with acquired immunodeficiency syndrome (AIDS), with symptoms of dysphagia or pain on swallowing for routine barium esophagograms were studied prospectively by videofluoroscopic examination of the oropharynx in addition to a routine biphasic esophagogram. The videofluoroscopic studies were performed in conjunction with a speech pathologist. Results: All 17 patients demonstrated abnormalities in the oral, pharyngeal, or esophageal phase of swallowing. Eight patients aspirated, six of whom did not exhibit a cough reflex and were classified as silent aspirators. Seven of the eight patients who aspirated had chest radiographs consistent with aspiration pneumonia. Conclusion: A significant number of HIV-positive and AIDS patients with dysphagia or pain on swallowing have dysfunction of the swallowing mechanism and are at risk for aspiration.     

The effect of nasogastric tubes on swallowing function in persons with dysphagia following stroke

OBJECTIVE: To determine whether the use of a nasogastric tube influences swallowing function in stroke patients with dysphagia. DESIGN: Before-after trial. SETTING: Primary care center. PARTICIPANTS: A total of 22 patients with stroke (12 men, 10 women; mean age, 69.7 y; range, 19-85 y) participated in the study. Time from onset of stroke to time of assessment averaged 20.3 days (range, 14-38 d). All participants continued to use a nasogastric tube for nutrition supply and had either minor or no aspiration of barium on videofluoroscopic examination of swallowing (VFES). INTERVENTION: The swallowing function was evaluated by VFES with thin and thick bariums (5 mL each) as a contrast medium. MAIN OUTCOME MEASURES: The oral transit, swallowing trigger, and pharyngeal transit times were measured and compared before and after the removal of the nasogastric tube. The patients were also observed for changes in velopharyngeal closure, pharyngeal contraction, epiglottic tilt, valleculae stasis, pyriform sinus stasis, penetration, and aspiration. RESULTS: Transit times were reduced by 0.2 to 0.6 seconds after removal of the nasogastric tube, but the reduction was not statistically significant. These transit times were slightly longer with thick barium than with thin barium, but were without statistical significance. Similarly, most of the patients had no change in nontemporal assessment of swallowing function after the tube was removed. CONCLUSIONS: The placement of a nasogastric tube did not affect temporal and nontemporal measurement of swallowing in stroke patients with dysphagia with or without minor aspiration.     

神经肌肉电刺激疗法与电针治疗脑卒中后吞咽障碍的疗效对比研究

摘要 目的：探讨神经肌肉电刺激疗法与电针治疗脑卒中所致吞咽障碍的临床疗效。 方法：　45例脑卒中后吞咽障碍患者随机分为电刺激组、电针组及对照组各15例,前两组在接受常规药物治疗及康复训练基础上分别加用电刺激和电针治疗。3组治疗前和治疗3周后进行洼田饮水试验和吞咽X线电视透视检查（VFSS）。 结果：3组治疗后洼田氏饮水试验和VFSS评分均明显高于治疗前,电刺激组和电针组疗效更明显,电刺激组和电针组相比较,洼田氏饮水试验评分无明显差异,但VFSS评分电刺激组治疗后明显高于电针组。 结论：电刺激疗法和电针均可明显改善脑卒中所致吞咽障碍,电刺激疗法作用更佳。 关键词　 电刺激;电针;吞咽障碍;脑卒中 中图分类号：R454.1,R245,R743.3 文献标识码：A 文章编号：1001-1242（2010）-02-0135-04     

针刺“吞咽点”治疗脑卒中后吞咽障碍的临床效果

目的观察针刺"吞咽点"治疗脑卒中后吞咽障碍的临床效果。方法选取2014年3月至2017年6月陕西中医药大学第二附属医院针灸康复科及殷克敬工作室收治的60例脑卒中后吞咽障碍患者为研究对象,将其随机分为对照组和观察组,每组30例。对照组给予康复训练,观察组给予针刺"吞咽点"治疗。比较两组患者的洼田饮水试验评分、标准吞咽功能评价量表(SSA)评分以及临床疗效。结果治疗前,两组患者的洼田饮水试验评分比较,差异不具有统计学意义(P>0.05);治疗后,两组患者的洼田饮水试验评分均较治疗前降低,且观察组低于对照组,差异具有统计学意义(P<0.05)。治疗前,两组患者的SSA评分比较,差异无统计学意义(P>0.05);治疗后,两组患者的SSA评分均较治疗前降低,且观察组低于对照组,差异具有统计学意义(P<0.05)。观察组患者的治疗总有效率为96.67%,高于对照组患者的73.33%,差异具有统计学意义(P<0.05)。结论针刺"吞咽点"可显著改善脑卒中患者吞咽功能障碍,值得临床应用和推广。     

Electrical stimulation for swallowing disorders caused by stroke

BACKGROUND: An estimated 15 million adults in the United States are affected by dysphagia (difficulty swallowing). Severe dysphagia predisposes to medical complications such as aspiration pneumonia, bronchospasm, dehydration, malnutrition, and asphyxia. These can cause death or increased health care costs from increased severity of illness and prolonged length of stay. Existing modalities for treating dysphagia are generally ineffective, and at best it may take weeks to months to show improvement. One common conventional therapy, application of cold stimulus to the base of the anterior faucial arch, has been reported to be somewhat effective. We describe an alternative treatment consisting of transcutaneous electrical stimulation (ES) applied through electrodes placed on the neck. OBJECTIVE: Compare the effectiveness of ES treatment to thermal-tactile stimulation (TS) treatment in patients with dysphagia caused by stroke and assess the safety of the technique. METHODS: In this controlled study, stroke patients with swallowing disorder were alternately assigned to one of the two treatment groups (TS or ES). Entry criteria included a primary diagnosis of stroke and confirmation of swallowing disorder by modified barium swallow (MBS). TS consisted of touching the base of the anterior faucial arch with a metal probe chilled by immersion in ice. ES was administered with a modified hand-held battery-powered electrical stimulator connected to a pair of electrodes positioned on the neck. Daily treatments of TS or ES lasted 1 hour. Swallow function before and after the treatment regimen was scored from 0 (aspirates own saliva) to 6 (normal swallow) based on substances the patients could swallow during a modified barium swallow. Demographic data were compared with the test and Fisher exact test. Swallow scores were compared with the Mann-Whitney U test and Wilcoxon signed-rank test. RESULTS: The treatment groups were of similar age and gender (p > 0.27), co-morbid conditions (p = 0.0044), and initial swallow score (p = 0.74). Both treatment groups showed improvement in swallow score, but the final swallow scores were higher in the ES group (p > 0.0001). In addition, 98% of ES patients showed some improvement, whereas 27% of TS patients remained at initial swallow score and 11% got worse. These results are based on similar numbers of treatments (average of 5.5 for ES and 6.0 for TS, p = 0.36). CONCLUSIONS: ES appears to be a safe and effective treatment for dysphagia due to stroke and results in better swallow function than conventional TS treatment.     

Assessment of aspiration in patients with tracheostomies: comparison of the bedside colored dye assessment with videofluoroscopic examination

BACKGROUND: Aspiration is a serious clinical concern in patients with long-term artificial airways. The purpose of this study was to determine the reliability of a bedside colored dye assessment of aspiration in tracheostomized patients and to determine its comparability to a more sophisticated videofluoroscopic study. METHODS: This was a prospective, blinded comparison study conducted in a large, urban, university teaching hospital. We studied 20 consecutive patients who underwent tracheostomy for bronchial hygiene needs and who were referred for videofluorographic evaluation for suspected oropharyngeal dysphagia and possible aspiration. Excluded were patients unable to follow verbal commands and those requiring mechanical ventilatory support. All patients were brought to the videofluorography suite for colored dye assessment for aspiration and videofluorographic assessment of oropharyngeal swallow. A nurse, blinded to the results of videofluorographic swallow study, performed colored dye assessments for aspiration. Speech-language pathologists, blinded to the results of the colored dye assessments, interpreted simultaneous (preliminary) and subsequent complete (final) videofluorographic evaluations of swallow. RESULTS: The colored dye aspiration assessments and the videofluoroscopic studies were compared for the frequency of aspiration detection. Sensitivity and specificity were determined using standard methods. Seven patients showed no aspiration on either the colored dye test or videofluoroscopic examination. Eight patients were judged to aspirate by videofluorography but not by the colored dye test. Five patients were judged to aspirate by both the colored dye test and videofluorography. The data indicate that the colored dye test for aspiration carries a low sensitivity of 38% (95% confidence interval = +/- 7%), but a high specificity of 100%. The videofluoroscopic study detected a significantly greater frequency of aspiration than did the colored dye test (p < 0.01). CONCLUSIONS: The colored dye test for aspiration can provide useful information when positive, but because there is a significant false negative rate, decisions made on the basis of a negative test must be made with caution.