Arquivo da tag: swallowing

Postextubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness

Macht M; Wimbish T; Clark BJ; Benson AB; Burnham EL; Williams A; Moss M
Crit Care; 15(5): R231, 2011.
INTRODUCTION: Dysphagia is common among survivors of critical illness who required mechanical ventilation during treatment. The risk factors associated with the development of postextubation dysphagia, and the effects of dysphagia on patient outcomes, have been relatively unexplored. METHODS: We conducted a retrospective, observational cohort study from 2008 to 2010 of all patients over 17 years of age admitted to a university hospital ICU who required mechanical ventilation and subsequently received a bedside swallow evaluation (BSE) by a speech pathologist. RESULTS: A BSE was performed after mechanical ventilation in 25% (630 of 2,484) of all patients. After we excluded patients with stroke and/or neuromuscular disease, our study sample size was 446 patients. We found that dysphagia was present in 84% of patients (n = 374) and classified dysphagia as absent, mild, moderate or severe in 16% (n = 72), 44% (n = 195), 23% (n = 103) and 17% (n = 76), respectively. In univariate analyses, we found that statistically significant risk factors for severe dysphagia included long duration of mechanical ventilation and reintubation. In multivariate analysis, after adjusting for age, gender and severity of illness, we found that mechanical ventilation for more than seven days remained independently associated with moderate or severe dysphagia (adjusted odds ratio (AOR) = 2.84 [interquartile range (IQR) = 1.78 to 4.56]; P < 0.01). The presence of severe postextubation dysphagia was significantly associated with poor patient outcomes, including pneumonia, reintubation, in-hospital mortality, hospital length of stay, discharge status and surgical placement of feeding tubes. In multivariate analysis, we found that the presence of moderate or severe dysphagia was independently associated with the composite outcome of pneumonia, reintubation and death (AOR = 3.31 [IQR = 1.89 to 5.90]; P < 0.01). CONCLUSIONS: In a large cohort of critically ill patients, long duration of mechanical ventilation was independently associated with postextubation dysphagia, and the development of postextubation dysphagia was independently associated with poor patient outcomes.

Assessing penetration and aspiration: how do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare?

Kelly AM, Drinnan MJ, Leslie P.

Laryngoscope. 2007 Oct;117(10):1723-7.



We aimed to investigate whether the type of dysphagia examination (fiberoptic endoscopic evaluation of swallowing [FEES] or videofluoroscopy) influences the scoring of penetration and aspiration.


Prospective, single-blind study.


Fifteen dysphagic participants were recruited and underwent one FEES and one videofluoroscopy examination, performed and recorded simultaneously. Fifteen independent raters from 12 centers scored penetration and aspiration from recordings using the Penetration Aspiration Scale. Raters were blind to participant details, the pairing of the FEES and videofluoroscopy recordings, and the other raters’ scores. Interrater and intrarater reliability were analyzed using weighted kappa.


The Penetration Aspiration Scale scores were significantly higher for the FEES recordings than for the videofluoroscopy recordings (ANOVA P < .001). The mean difference between the FEES and videofluoroscopy penetration aspiration scores for the same swallows was 1.15 points. Interrater and intrarater reliability ranged from 0.64 to 0.79 (weighted kappa).


Penetration aspiration is perceived to be greater (more severe) from FEES than videofluoroscopy images. The clinical implications are discussed.


Recovery of Swallowing After Dysphagic Stroke: An Analysis of Prognostic Factors

Kumar S, Doughty C, Doros G, Selim M, Lahoti S, Gokhale S, Schlaug G.

J Stroke Cerebrovasc Dis. 2012 Oct 23. doi:pii: S1052-3057(12)00314-X. 10.1016/j.jstrokecerebrovasdis.2012.09.005.




Dysphagia is a major complication of stroke, but factors influencing its recovery are incompletely understood. The goal of this study was to identify important prognostic variables affecting swallowing recovery after acute ischemic stroke.


We retrospectively reviewed our patient database to identify acute ischemic stroke patients who developed dysphagia after stroke but were free of other confounding conditions affecting swallowing. Of the 1774 patients screened, 323 met the study criteria. We assessed the effect of age, sex, baseline National Institutes of Health Stroke Scale (NIHSS) score, level of consciousness (LOC), facial weakness, dysarthria, neglect, bihemispheric infarcts, right hemispheric infarcts, brainstem infarcts, intubation, aspiration, acute stroke therapies, occurrence of symptomatic hemorrhagic transformation, seizures, pneumonia, and length of hospitalization (LOH) on persistence of dysphagia at hospital discharge in a logistic regression analysis.


The mean age and NIHSS scores (mean ± standard deviation) were 75.9 ± 13.6 years and 13.5 ± 6.9, respectively; 58.5% were women. In a multivariate analysis, aspiration detected on a clinical swallowing evaluation (odds ratio [OR] 21.83; 95% confidence interval [CI] 8.16-58.42; P < .0001), aspiration on videofluoroscopic swallowing study (OR 10.50; 95% CI 3.35-32.96; P < .0001), bihemispheric infarcts (OR 3.72; 95% CI 1.33-10.43; P = .0123), dysarthria (OR 3.4; 95% CI 1.57-7.35; P = .0019), intubation (OR 2.86; 95% CI 1.10-7.39; P = .0301), NIHSS score ≥12 (OR 2.51; 95% CI 1.19-5.23; P = .0157) were significant predictors of persistent dysphagia. The area under the curve and Somer’s D(xy) statistics of the model were 0.8918 and 0.78, respectively, indicating good calibration and discriminative power.


Prognostic factors affecting swallowing recovery identified in this study can help advance dysphagia research methodologies and the clinical care of stroke patients.


Analysis of a physician tool for evaluating dysphagia on an inpatient stroke unit: the modified Mann Assessment of Swallowing Ability

Antonios N, Carnaby-Mann G, Crary M, Miller L, Hubbard H, Hood K, Sambandam R, Xavier A, Silliman S.

J Stroke Cerebrovasc Dis. 2010 Jan;19(1):49-57.



Although many dysphagia screening protocols have been introduced in recent years, no validated, physician-administered dysphagia screening tool exists for acute stroke that can be performed at the bedside. Based on the psychometrically validated Mann Assessment of Swallowing Ability (MASA), we developed the Modified MASA (MMASA) as a physician-administered screening tool for dysphagia in acute stroke.


The purpose of this study was to complete initial validation of this new screening tool for dysphagia in acute ischemic stroke.


Two stroke neurologists independently performed the MMASA on 150 patients with ischemic stroke. Speech-language pathologists performed the standard MASA on all patients. All examiners were blinded to the results of the other assessments. Interjudge reliability was evaluated between the neurologists. Validity between the screening tool (MMASA) and the clinical evaluation (MASA) was assessed with sensitivity/specificity and predictive value assessment.


Interobserver agreement between the neurologists using the MMASA was good (k=0.76; SE=0.082). Based on the comprehensive clinical evaluation (MASA), 36.2% of patients demonstrated dysphagia. Screening results from the neurologists (N1 and N2) identified 38% and 36.7% prevalence of dysphagia, respectively. Sensitivity (N1: 92%, N2: 87%), specificity (N1: 86.3%, N2: 84.2%), positive predictive value (N1: 79.4%, N2: 75.8%), and negative predictive value (N1: 95.3%, N2: 92%) were high between the screen and the comprehensive clinical evaluation.


This preliminary study suggests that the MMASA is a potentially valid and reliable physician-administered screening tool for dysphagia in acute ischemic stroke. Use of this tool may facilitate earlier identification of dysphagia in patients with stroke prompting more rapid comprehensive evaluation and intervention.


Tracheotomy implication upon communication and swallowing: [review]

Barros, Ana Paula Brandão; Portas, Juliana Godoy; Queija, Débora dos Santos.

Rev. bras. cir. cabeça pescoço;38(3):202-207, jul.-set. 2009. ilus.


In the last two decades, researchers and clinicians have been concerned to the impact of tracheotomy upon the respiration, communication and swallowing. The tracheotomy is associated to the increased risk of aspiration, and the decanulization can improve the functions quality. In those cases with easy occlusion of the tracheotomy, it is necessary gradually increasing the occlusion time and to observe the respiratory clinical condition. The sequence will vary according to the basic disease and the respiratory situation. The impact of the tracheotomy on the swallowing physiology can be both mechanical and/or functional.(AU)

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.


Image-based Measurement of Post-Swallow Residue: The Normalized Residue Ratio Scale

William G. Pearson Jr., Sonja M. Molfenter, Zachary M. Smith and Catriona M. Steele

Online First™, 22 October 2012


Post-swallow residue is considered a sign of swallowing impairment. Existing methods for capturing post-swallow residue (perceptual and quantitative) have inherent limitations. We employed several different perceptual and quantitative (ratio) methods for measuring post-swallow residue on the same 40 swallows and addressed the following questions: (1) Do perceptual and quantitative methods demonstrate good agreement? (2) What differences in precision are apparent by measurement method (one-dimensional, two-dimensional, and circumscribed area ratios)? (3) Do residue ratios agree strongly with residue area measures that are anatomically normalized? Based on the findings of this series of questions, a new method for capturing residue is proposed: the Normalized Residue Ratio Scale (NRRS). The NRRS is a continuous measurement that incorporates both the ratio of residue relative to the available pharyngeal space and the residue proportionate to the size of the individual. A demonstration of this method is presented to illustrate the added precision of the NRRS measurement in comparison to other approaches for measuring residue severity.

Sensory stimulation activates both motor and sensory components of the swallowing system

Lowell SY, Poletto CJ, Knorr-Chung BR, Reynolds RC, Simonyan K, Ludlow CL.

Neuroimage. 2008 Aug 1;42(1):285-95. Epub 2008 Apr 26.


Volitional swallowing in humans involves the coordination of both brainstem and cerebral swallowing control regions. Peripheral sensory inputs are necessary for safe and efficient swallowing, and their importance to the patterned components of swallowing has been demonstrated. However, the role of sensory inputs to the cerebral system during volitional swallowing is less clear. We used four conditions applied during functional magnetic resonance imaging to differentiate between sensory, motor planning, and motor execution components for cerebral control of swallowing. Oral air pulse stimulation was used to examine the effect of sensory input, covert swallowing was used to engage motor planning for swallowing, and overt swallowing was used to activate the volitional swallowing system. Breath-holding was also included to determine whether its effects could account for the activation seen during overt swallowing. Oral air pulse stimulation, covert swallowing and overt swallowing all produced activation in the primary motor cortex, cingulate cortex, putamen and insula. Additional regions of the swallowing cerebral system that were activated by the oral air pulse stimulation condition included the primary and secondary somatosensory cortex and thalamus. Although air pulse stimulation was on the right side only, bilateral cerebral activation occurred. On the other hand, covert swallowing minimally activated sensory regions, but did activate the supplementary motor area and other motor regions. Breath-holding did not account for the activation during overt swallowing. The effectiveness of oral-sensory stimulation for engaging both sensory and motor components of the cerebral swallowing system demonstrates the importance of sensory input in cerebral swallowing control.