Arquivo da tag: Aspiration

Kinematic and Temporal Factors Associated with Penetration-Aspiration in Swallowing Liquids.

Dysphagia. 2014 Jan 21. [Epub ahead of print]

In this study we undertook careful analysis of 13 quantitative physiological variables related to oropharyngeal swallowing from a sample of 42 subacute patients referred for dysphagia assessment. Each patient underwent a videofluoroscopic swallowing examination in which they swallowed up to five boluses of 22 % w/v ultrathin liquid barium suspension administered by teaspoon. Our goal was to determine whether scores on 13 kinematic or temporal parameters of interest were independently associated with the presence of penetration-aspiration in the final compiled dataset of 178 swallows. Participants were classified as aspirators based on the presence of at least one swallow that demonstrated a Penetration-Aspiration Scale score of ≥3. The parameters of interest included six kinematic parameters for capturing hyoid position, three swallow durations [laryngeal closure duration, hyoid movement duration, and upper esophageal sphincter (UES) opening duration], and four swallow intervals (laryngeal closure to UES opening, bolus dwell time in the pharynx prior to laryngeal closure, stage transition duration, and pharyngeal transit time). Mixed-model repeated-measures ANOVAs were conducted to determine the association between each parameter and aspiration status. Only 1 of the 13 parameters tested distinguished aspirators from nonaspirators: aspirators demonstrated significantly shorter UES opening duration. In addition, a trend toward reduced maximum superior position of the hyoid was seen in aspirators. Limitations and future considerations are discussed.


Correlation Between Laryngeal Sensitivity and Penetration/Aspiration After Stroke.

Dysphagia. 2014 Jan 21. [Epub ahead of print]


Stroke is the most common neurological disease in adults that is associated with deglutition disorders. The presence of laryngeal sensitivity is very important in developing safe swallowing without risk of pulmonary complications. The aim of this study was to correlate laryngeal sensitivity with laryngeal penetration and tracheal aspiration after swallows of three food consistencies (puree, thickened liquid, and liquid) in poststroke individuals in the late phase. A cross-sectional clinical study was performed with 91 post-ischemic stroke individuals, with oropharyngeal dysphagia, who were in rehabilitation center treatment from 2009 to 2011. They had a mean age of 68.1 years and average time since injury was 22.6 months; 39 had injury to the right hemisphere and 52 had injury to the left hemisphere. All underwent fiberoptic endoscopic evaluation of swallowing and evaluation of laryngeal sensitivity by touching the tip of the endoscope to the arytenoids and aryepiglottic folds. The linear correlation coefficient of Spearman was applied to evaluate the correlation between laryngeal penetration and tracheal aspiration and the presence/absence of laryngeal sensitivity. There was a negative correlation between the observation of penetration and tracheal aspiration and laryngeal sensitivity, with all bolus consistencies (p < 0.001 for aspiration and p ≤ 0.01 for penetration). The absence of laryngeal sensitivity determines the more frequent findings of penetration and tracheal aspiration. This sensory stimulus in the mucosa of the pharynx and larynx is an essential element for safe swallowing and its deficiency associated with altered motor activity can cause laryngeal penetration and aspiration in poststroke individuals regardless of food consistency.


The influence of sour taste on Dysphagia in brain injury: blind study

Lee KL, Kim DY, Kim WH, Kim EJ, Lee WS, Hahn SJ, Kang MS, Ahn SY.

Ann Rehabil Med. 2012 Jun;36(3):365-70. doi: 10.5535/arm.2012.36.3.365. Epub 2012 Jun 30.



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.


The Relationship Between Residue and Aspiration on the Subsequent Swallow: An Application of the Normalized Residue Ratio Scale

Molfenter SM, Steele CM.

Dysphagia. 2013 Mar 5


Postswallow residue is widely considered to be a sign of swallowing impairment and is assumed to pose risk for aspiration on subsequent swallows. We undertook a preliminary retrospective study to investigate the link between postswallow residue and penetration-aspiration on the immediately occurring subsequent clearing swallow (i.e., without introduction of a new bolus). Videofluoroscopy clips for 156 thin-liquid single bolus swallows by patients with neurogenic dysphagia were selected for study because they displayed multiple swallows per bolus. Residue for each subswallow (n = 407) was analyzed using the Normalized Residue Ratio Scale for the valleculae (NRRSv) and piriform sinuses. The association between residue presence at the end of a swallow and penetration-aspiration on the next swallow was examined. Postswallow residue in one or both pharyngeal spaces was significantly associated with impaired swallowing safety on the subsequent clearing swallow for the same bolus. However, when analyzed separately by residue location, only vallecular residue was significantly associated with impaired swallowing safety on the next clearing swallow. The distribution of NRRSv scores by swallowing safety demonstrated an NRRSv cut-point of 0.09, above which there was a 2.07 times greater relative risk of penetration-aspiration. Postswallow vallecular residue, measured using the NRRS, is significantly associated with penetration-aspiration on subsequent clearing swallows. A clinically meaningful cut-point of 0.09 on the NRRSv scale demarcates this risk. Further research with different bolus consistencies is needed.


The semisolid bolus swallow test for clinical diagnosis of oropharyngeal dysphagia: a prospective randomised study

Schultheiss C; Nusser-Müller-Busch R; Seidl RO
Eur Arch Otorhinolaryngol; 268(12): 1837-44, 2011 Dec.
Contrary to clinical experience, clinical swallow tests are predominantly performed using water (water swallow tests, WST). In this study, we examine whether swallow tests performed using a bolus of semisolid food (bolus swallow test, BST) offer benefits. In a prospective, randomised, blind study, the results of a standardised saliva swallow test (SST), WST, BST, combinations of these tests and an endoscopic swallow test (FEES) in patients with oropharyngeal swallowing disorders of neurological (NEU) and non-neurological (NNEU) origin were compared. Sensitivity, specificity, test accuracy and inter-rater reliability were analysed. 62 patients (mean age = 64.68; range = 22–84) were included in the study (NEU = 40; NNEU = 22). A sensitivity of 70.7% (NEU = 70.3%, NNEU = 71.4%) and specificity of 82.5% (NEU = 92.3%; NNEU = 100%) were determined for the WST. The BST + SST was found to have a sensitivity of 89.6% (NEU = 66.7%; NNEU = 90.9%) and a specificity of 72.7% (NEU = 87.5%; NNEU = 90.9%). Analysis of test accuracy showed a statistically significant correlation between FEES and BST + SST. Only BST + SST exhibited statistically significant inter-rater reliability. BST in combination with SST was the sensitive clinical instrument for detecting aspiration both over the patient population as a whole and over the two sub-populations. Inter-rater reliability was found to be statistically significant. The results presented here demonstrate the benefit of semisolid food in investigating clinical dysphagia.

Functional lesions in dysphagia due to acute stroke: discordance between abnormal findings of bedside swallowing assessment and aspiration on videofluorography

Osawa A, Maeshima S, Matsuda H, Tanahashi N.

Neuroradiology. 2012 Nov 18. [Epub ahead of print]



Bedside swallowing assessments are often used to assess dysphagia. However, in some patients, aspiration pneumonia occurs without any problems on bedside swallowing assessments and some patients do not suffer aspiration pneumonia despite abnormal results of bedside swallowing assessments in acute stroke. To detect the differences of lesions related to bedside swallowing assessment abnormality and aspiration, we investigated swallowing-related functional lesions in terms of cerebral blood flow in patients with dysphagia after stroke.


The study included 50 acute stroke patients who underwent bedside swallowing assessments and videofluorography as well as single-photon emission computed tomography (CT) at approximately the same time. Bedside swallowing assessments included repetitive saliva swallowing test and modified water swallowing test as dry and wet swallowing tasks. The presence or absence of aspiration was assessed using videofluorography. We divided patients into three subgroups based on the outcomes of the bedside swallowing assessments and presence or absence of aspiration. Statistical image analysis was performed using single-photon emission CT to determine their relationship with bedside swallowing assessments and videofluorography results.


Twenty-seven (54.0 %) and 28 (56.0 %) patients had abnormal repetitive saliva swallowing test and modified water swallowing test results. Videofluorography indicated aspiration in 35 (70.0 %) patients. In comparing patients with and without abnormal results on each test, the groups with abnormal repetitive saliva swallowing test, abnormal modified water swallowing test, and aspiration demonstrated lower cerebral blood flow in the left precuneus, left insula, and anterior cingulate gyrus, respectively.


Based on the analysis of cerebral blood flow, functional lesions differed across abnormal repetitive saliva swallowing test and abnormal modified water swallowing test findings and aspiration on videofluorography, and each test may assess different functions among the many processes involved in swallowing.


Swallowing dysfunction after mechanical ventilation in trauma patients

Carlos V.R. Brown, Kelli Hejl, Amy D. Mandaville, Paul E. Chaney, et al.

Journal of Critical Care, February 2011, Vol. 26, Issue 1, Pages 108.e9-108.e13



Swallowing dysfunction can occur after mechanical ventilation, leading to complications such as aspiration and pneumonia. After mechanical ventilation, authors have recommended evaluating patients with contrast studies or endoscopy to identify patients at risk for swallowing dysfunction and aspiration. The purpose of the study was to determine if a bedside swallowing evaluation (BSE) can identify patients with swallowing dysfunction after mechanical ventilation.


This is a 1-year (2008) prospective study of all adult trauma patients admitted to the intensive care unit requiring mechanical ventilation. Upon separation from mechanical, all patients received a BSE. The BSE used mental status, facial symmetry, swallow reflex, and oral ice chips and water to identify swallowing dysfunction. Patients who passed the BSE were advanced to oral intake per physician orders, whereas patients who failed the BSE were allowed nothing by mouth.


A total of 345 patients were included; 54 died before separation from mechanical ventilation and were excluded. The remaining 291 patients underwent BSE after separation from mechanical ventilation, with 143 (49%) passing and 148 (51%) failing. Patients who failed the BSE required mechanical ventilation longer than those who passed (14 ± 13 vs 5 ± 20 days, P = .001). In addition, only 23% of patients extubated within 72 hours failed the BSE, whereas 78% of those intubated more than 72 hours failed the BSE (P < .001). All patients who passed the BSE were discharged from the hospital without a clinical aspiration event. Independent risk factors for failure of BSE included tracheostomy, older age, prolonged mechanical ventilation, delirium tremens, traumatic brain injury, and spine fracture. Three (2%) patients who failed the BSE had a clinical aspiration event despite taking nothing by mouth.


A simple BSE can be used to identify patients at risk for swallowing dysfunction after mechanical ventilation. More importantly, BSE can safely clear patients without swallowing dysfunction, avoiding costly and time-consuming contrast studies or endoscopic evaluation.