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.     

Tracheotomy Tube Occlusion Status and Aspiration in Early Postsurgical Head and Neck Cancer Patients

The purpose of the present study was to investigate tracheotomy tube occlusion status and prevalence of aspiration utilizing videofluoroscopy. A prospective study was done of 16 consecutive, early, postsurgical head and neck cancer patients with tracheotomy. Selection criteria included the ability to tolerate tracheotomy tube occlusion prior to and during the modified barium swallow procedure, oral and/or pharyngeal surgical resection, no history of neurological disease or stroke, and medical clearance to begin oral feeding. There was 100% agreement among the independent reviewers on ratings of the presence or absence of aspiration. It was found that occlusion status of the tracheotomy tube did not influence the prevalence of aspiration in the immediate postoperative period. No trends were observed when comparing bolus consistency, type of tracheotomy tube, or presence/absence of a nasogastric tube and the ratings of aspiration.     

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.     

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.     

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.     

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.     

Fiberoptic Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) in Healthy Controls

The purpose of this study was to introduce a new method of bedside assessment of both the motor and sensory components of swallowing called fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST). This approach combines the established bedside endoscopic swallowing evaluation with a more recently described technique that allows objective determination of laryngopharyngeal (LP) sensory discrimination thresholds by delivering air pulse stimuli to the mucosa innervated by the superior laryngeal nerve via a flexible endoscope. A prospective study was conducted of FEESST in 20 healthy control subjects, mean age of 34 ± 11 years. LP sensory thresholds were defined as either normal (<4.0 mmHg air pulse pressure [APP]), moderate deficit (4.0–6.0 mmHg APP), or severe deficits (>6.0 mmHg APP). Subsequent to LP sensory testing, food of varying consistencies, mixed with green food coloring, was given and attention was paid to spillage, laryngeal penetration, pharyngeal residue, aspiration, and reflux. Therapeutic maneuvers such as postural changes and airway protection techniques were performed on each subject to determine if the assessed swallowing parameters were affected by maneuvers. All patients completed the study; all had normal LP sensory discrimination thresholds (2.9 ± 0.7 mmHg APP). There were no instances of spillage, laryngeal penetration, or aspiration. Two of 20 subjects had pharyngeal residue and 2 of 20 had reflux. Institution of therapeutic maneuvers resulted in a predictable change in the endoscopic view of the laryngopharyngeal anatomy. FEESST provides comprehensive, objective sensory and motor information about deglutition in the bedside setting and might have implications for the bedside diagnosis and management of patients with dysphagia.     

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.     

Effects of Cuff Deflation and One-Way Tracheostomy Speaking Valve Placement on Swallow Physiology

This study examined the effects of tracheostomy cuff deflation and one-way speaking valve placement on swallow physiology. Fourteen nonventilator-dependent patients completed videofluoroscopic swallow studies (VFSS) under three conditions: (1) cuff inflated, (2) cuff deflated, and (3) one-way valve in place. Four additional patients with cuffless tracheostomy tubes completed VFSS with and without the one-way valve in place. All swallows were analyzed for the severity of penetration/aspiration using an 8-point penetration–aspiration scale. Seven preselected swallow duration measures, extent of hyolaryngeal elevation and anterior excursion, and oropharyngeal residue were also determined. Scores on the penetration–aspiration scale were not significantly affected by cuff status, i.e., inflation or deflation. However, one-way valve placement significantly reduced scores on the penetration–aspiration scale for the liquid bolus. Patients who are unable to tolerate thin liquids may be able to safely take thin liquids when the valve is in place. However, one-way valve placement may not be beneficial for all patients. Clinicians who complete VFSS with tracheostomized patients should include several bolus presentations with a one-way speaking valve in place before making any decisions regarding the use of the valve as a means to reduce aspiration. Work was performed at The University of Tennessee Medical Center, Knoxville, Tennessee.     

Incidence and Patient Characteristics Associated with Silent Aspiration in the Acute Care Setting

Coughing is a physiologic response to aspiration in normal healthy individuals. However, there are published records that report no cough in response to aspiration (i.e., silent aspiration) in dysphagic patients. In this retrospective study, for more than 2 years in two acute care hospitals we examined frequency of the cough response in patients identified as aspirators by using videofluoroscopy. One thousand one hundred one patients underwent videofluorographic evaluation of their swallowing during this 2-year period; 469 aspirated; 276 were silently aspirating. Two hundred twenty-four of these silent aspirators aspirated once during a swallow and 52 silently aspirated more than once during a swallow. These two groups of patients were analyzed separately. Univariate (chi-square and Fisher's exact tests) and multivariate (logistic regression) analyses were conducted to assess the relationship of silent aspiration to age, gender, medical diagnosis, timing of aspiration, and etiology of aspiration. In univariate analysis, age (p < 0.001), gender (p < 0.004), and medical diagnosis (p= 0.05) were significantly associated with silent aspiration in the group who aspirated once during a swallow. No significant associations were seen in the group of patients who aspirated more than once during a swallow.     

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.     

The Safety of Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST): An Analysis of 500 Consecutive Evaluations

We assessed the safety of a new office or bedside method of evaluating both the motor and sensory components of swallowing called flexible endoscopic evaluation of swallowing with sensory testing (FEESST). FEESST combines the established endoscopic evaluation of swallowing with a technique that determines laryngopharyngeal sensory discrimination thresholds by endoscopically delivering air-pulse stimuli to the mucosa innervated by the superior laryngeal nerve. Endoscopic assessment of laryngopharyngeal sensory capacity followed by endoscopic visualization of deglutition was prospectively performed 500 times in 253 patients with dysphagia over a 2.5-year period in a tertiary care center. The patients had a variety of underlying diagnoses, with stroke and chronic neurological disease predominating (n= 155). To determine the safety of FEESST, the presence of epistaxis, airway compromise, and significant changes in heart rate before and after the evaluation were assessed. Patients were also asked to rate the level of discomfort of the examination; 498 evaluations were completed. There were three instances of epistaxis that were self-limited. There were no cases of airway compromise. There were no significant differences in heart rate between pre- and posttest measurements (p > 0.05). Eighty-one percent of patients noted either no discomfort or mild discomfort as a result of the examination. In conclusion, FEESST is a safe method of evaluating dysphagia in the tertiary care setting and may also have application for the chronic care setting.     

Swallowing Physiology of Toddlers with Long-Term Tracheostomies: A Preliminary Study

This study investigated the swallowing physiology of toddler-aged patients with long-term tracheostomies. Structural movements and motility of the pharyngeal stage of swallowing were studied in four toddlers ranging in age from 1:2 (years:months) to 2:9 with long-term tracheostomies. A patient aged 1:2 years with no tracheostomy served as a toddler model for comparison. Videofluoroscopic recordings of the patients' liquid and puree bolus swallows were analyzed for a) onset times for pharyngeal stage events, laryngeal vestibule closure, and tracheostomy tube movement; b) timeliness of swallow response initiation; and c) pharyngeal transport function. Results found differences in timing of pharyngeal stage movements between the tracheostomized patients and the patient with no tracheostomy. Laryngeal vestibule closure occurred before or within the same 0.033-s video frame as onset of upper esophageal sphincter (UES) opening in the patient with no tracheostomy, but occurred 0.033–.099 s after onset of UES opening in the tracheostomized patients. The time line required to close the laryngeal vestibule once the arytenoids began their anterior movement was longer in the tracheostomized patients than in the patient with no tracheostomy and was associated with laryngeal penetration. The patient with no tracheostomy displayed superior excursion of the arytenoid and epiglottis during the swallowing; the tracheostomized patients did not. No association was found between onset of tracheostomy tube movement and laryngeal vestibule closure. Delayed swallow response initiation was observed across tracheostomized patients at a mean frequency of 45% with associated penetration. Pharyngeal dysmotility was not observed. Findings supported the concept that long-term tracheostomy in toddler-aged patients affects swallowing physiology.     

The Natural History of Dysphagia following a Stroke

To assess the frequency and natural history of swallowing problems following an acute stroke, 121 consecutive patients admitted within 24 hours of the onset of their stroke were studied prospectively. The ability to swallow was assessed repeatedly by a physician, a speech and language therapist, and by videofluoroscopy. Clinically 51% (61/121) of patients were assessed as being at risk of aspiration on admission. Many swallowing problems resolved over the first 7 days, through 28/110 (27%) were still considered at risk by the physician. Over a 6-month period, most problems had resolved, but some patients had persistent difficulties (6, 8%), and a few (2, 3% at 6 months) had developed swallowing problems. Ninety-five patients underwent videofluoroscopic examination within a median time of 2 days; 21 (22%) were aspirating. At 1 month a repeat examination showed that 12 (15%) were aspirating. Only 4 of these were persistent; the remaining 8 had not been previously identified. This study has confirmed that swallowing problems following acute stroke are common, and it has been documented that the dysphagia may persist, recur in some patients, or develop in others later in the history of their stroke.     

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.     

Accuracy of Bedside Clinical Methods Compared with Fiberoptic Endoscopic Examination of Swallowing (FEES) in Determining the Risk of Aspiration in Acute Stroke Patients

This prospective study was undertaken to determine the accuracy of bedside clinical methods compared with fiberoptic endoscopic examination of swallowing (FEES) for detecting aspiration in acute stroke patients. Fifty patients underwent an examination of their ability to swallow 50 ml of water in 10-ml aliquots. Later their oxygen saturation levels before and after swallowing 10 ml of water were measured using a pulse oximeter. Oxygen desaturation of more than 2%, was considered to be clinically significant. All patients then underwent a FEES assessment by a speech therapist and were followed up during their inpatient stay for evidence of aspiration pneumonia. The oxygen desaturation test had a sensitivity of 76.9% and specificity of 83.3% (chi2 = 18.154, p = 0.00002), while the 50-ml water swallow test had a sensitivity of 84.6% and specificity of 75.0% (chi2 = 18.001, p = 0.00002). However, when these two tests were combined into one test called "bedside aspiration," the sensitivity rose to 100% with a specificity of 70.8% (chi2 = 27.9, p = 0.000001). Five (10%) patients developed pneumonia during their inpatient stay. The relative risk (RR) of developing pneumonia, if there was evidence of aspiration on FEES, was 1.24 (1.03 < RR < 1.49). We conclude that the oxygen desaturation test combined with the 50-ml water swallow test is suitable as a screening test to identify all acute stroke patients at risk of aspiration for further evaluation and management.     

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.     

The Interdependency of Protein-Energy Malnutrition, Aging, and Dysphagia

Advancing age is increasingly associated with confounding chronic and acute ailments, predisposing elderly individuals to conditions such as malnutrition and swallowing dysfunction. This enhanced susceptibility to malnutrition and dysphagia in this aging demographic lends itself to exacerbating, disabling conditions that may result in increased morbidity and mortality in the event of an aspiration episode. Early identification of substandard nutritional status and subsequent interventiion in the elderly dysphagic population may circumvent the deleterious effects of malnutrition.     

Effects of Nasogastric Tubes on the Young, Normal Swallowing Mechanism

The present study aimed to investigate the effects of different-sized nasogastric tubes on swallowing speed and function in 10 young normal volunteers. Using X-ray visualization, liquid barium swallows were recorded on video (videofluoroscopy) under three experimental conditions: no nasogastric tube, fine-bore nasogastric tube, and wide-bore nasogastric tube. Nasogastric tubes slowed swallowing but did not alter swallowing function, namely bolus transit and clearance, and airway protection. The presence of a wide-bore nasogastric tube caused significant duration changes in several swallowing measures, namely duration of stage transition, duration of pharyngeal response, duration of pharyngeal transit, and duration of upper esophageal sphincter opening. Similar trends were seen for the fine-bore tube. The implications for nonoral feeding of patients with swallowing disorders are discussed.     

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.