[Most evidence favors a relationship between pneumonia incidence and VFSS findings, and positive effects of targeted therapy.]





Screening, diagnosis, and management of neurogenic dysphagia.

Semin Neurol 1996 ;16:319-27, Logemann JA

Patients with dysphagia as a result of neurologic disease can be effectively evaluated and managed, particularly if the dysphagia is recognized before any medical complications such as aspiration pneumonia appear. Management can be cost-effective and efficient when assessment not only defines symptoms but their underlying anatomic or physiologic cause and treatment is designed to eradicate the abnormalities in structure or function. The specific nature of the oropharyngeal dysphagia may also point to the nature of the underlying neurologic damage or disease process. Involvement of a speech-language pathologist early in the neurogenic patient's dysphagia care can speed recovery and reduce cost. Medications, Side Effects, Eating, and Dysphagia

Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening - Reza Shaker et.al. ["Shaker Excercises"]

Background & Aims: We evaluated the effect of a novel rehabilitative exercise on restoration of deglutition in a group of patients with deglutitive failure caused by abnormal upper esophageal sphincter (UES) opening manifested by postswallow residue and aspiration necessitating percutaneous tube feeding.

Methods: We studied a total of 27 patients by videofluoroscopy and functional assessment of swallowing scores before and after 6 weeks of a head-raising exercise program. Seven of 27 patients, assigned randomly, participated in a sham exercise before entering the tested exercise program. Eleven of 27 were randomized to the real exercise program.

Results: Although there was no change in swallow function and biomechanics after the sham exercise, following 6 weeks of real exercise, all 11 patients exhibited a significant improvement in their UES opening, anterior laryngeal excursion (P < 0.01), as well as resolution of postdeglutitive aspiration and were able to resume oral feeding. Similar results were found when the 7 patients in the sham group were crossed over to the real exercise group. Comparison of before and after exercise values for anteroposterior UES opening (P < 0.01) and laryngeal anterior excursion (P < 0.05), as well as functional outcome assessment of swallowing (P < 0.05) in the entire group of 27 patients also showed significant improvement. Etiology and duration of dysphagia did not affect the outcome.

Conclusions: The proposed suprahyoid muscle strengthening exercise program is effective in restoring oral feeding in some patients with deglutitive failure because of abnormal UES opening.

This is the quote from an article by Langmore et al which was published in Dysphagia 1998;13:69-81 "of the patients who were documented aspirators, only about 38% developed pneumonia".

Predictors of aspiration pneumonia: how important is dysphagia? Langmore SE, Terpenning MS, Schork A, Chen Y, Murray JT, Lopatin D, Loesche WJ.

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.

Gerodontology. 2004 Jun;21(2):108-11. Related Articles, Links

Effects of functional training of dysphagia to prevent pneumonia for patients on tube feeding. Ueda K, Yamada Y, Toyosato A, Nomura S, Saitho E., Division of Dysphagia Rehabilitation, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan. ueda@dent.niigata-u.ac.jp

OBJECTIVE: The purpose of this study was to evaluate the effects of functional training on outbreak frequency of pneumonia for the elderly dysphagia patients who were being tube fed. METHODS: Subjects were divided into two groups; one group (n = 10) received oral care (i.e. non-training group) and the other group (n = 11) received functional training of dysphagia in addition to oral care (i.e. training group). The dental health team treated subjects once a week for 3 years (1999-2001). The frequency of pneumonia outbreaks and changes in activities of daily living scale (ADL) were evaluated for each year. RESULT: It was recognised that the frequency of pneumonia in the training group decreased year by year (p < 0.05). Cognitive items in ADL improved in two subjects of the training group. No statistical differences were recognised in the non-training group. CONCLUSION: It was suggested that once-a-week functional training of dysphagia with professional oral care might be effective in preventing pneumonia for elderly people who were being tube fed.

J Intern Med. 2000 Jan;247(1):39-42

Relation between incidence of pneumonia and protective reflexes in post-stroke patients with oral or tube feeding. Nakajoh K, Nakagawa T, Sekizawa K, Matsui T, Arai H, Sasaki H. Department of Geriatric Medicine, Tohoku University School of Medicine, Sendai, Japan.

OBJECTIVES: Although attenuated protective reflexes have been implicated in the development of aspiration pneumonia, the relation between the incidence of pneumonia and the state of these reflexes has not been investigated. Furthermore, the role of feeding tube placement in preventing pneumonia in patients with attenuated protective reflexes is unknown. We studied the relationship between the incidence of pneumonia and the state of cough and swallowing reflexes in post-stroke patients with oral or tube feeding. DESIGN: The incidence of pneumonia was prospectively analysed for 1 year in three groups of post-stroke patients on the basis of the following clinical conditions: oral feeding without dysphagia (n = 43); oral feeding with dysphagia (n = 48); and nasogastric tube feeding with dysphagia (n = 52). We also studied the incidence of pneumonia in bedridden patients with nasogastric tube feeding (n = 14). Before the start of the study, the swallowing and cough reflexes of each patient were measured. The swallowing reflex was evaluated according to latency of response, which was timed from the injection of 1 mL of distilled water into the pharynx through a nasal catheter to the onset of swallowing. The cough threshold of citric acid aerosols was defined as the concentration at which the patient coughed five times. RESULTS.;: The incidence of pneumonia was observed in patients having both a latency of response longer than 5 s and a cough threshold for citric acid higher than a concentration of 1.35 (log mg mL-1). The incidence of pneumonia was significantly higher in patients with oral feeding than in those with tube feeding (54.3 vs. 13.2%, P < 0.001). In bedridden patients with tube feeding, the latency of response was longer than 20 s and no patient coughed at the highest concentration of citric acid. The incidence of pneumonia was 64.3% in such patients. CONCLUSIONS: The state of protective reflexes had a significant relation to the incidence of pneumonia. Feeding tube placement may have a beneficial role in preventing aspiration pneumonia in mildly or moderately disabled post-stroke patients with attenuated protective reflexes. Bedridden patients who were tube-fed had the highest incidence of pneumonia.

Dysphagia. 1990;5(3):147-51. Related Articles, Links

Effects of a multidisciplinary management program on neurologically impaired patients with dysphagia. Martens L, Cameron T, Simonsen M. Health Sciences Centre, Winnipeg, Manitoba, Canada.

Dysphagia is a major problem in patients with neurologic disorders. Aspiration pneumonia and impaired nutritional status are consequences of dysphagia that result in high morbidity and mortality rates. Assessment and treatment of the dysphagic patient by a multidisciplinary team have been advocated but to date the effects of such an approach have not been demonstrated quantitatively. This prospective study was conducted to determine if a dysphagia program would improve patients' caloric intake and body weight, decrease the instances of aspiration pneumonia, or improve patients' feeding ability. Patients were referred from a 26 bed neurology/neurosurgery unit. A time series design was utilized. The control group consisted of 15 patients (mean age = 46.1 years), managed according to the existing ward routine. Subsequently, nursing staff attended a dysphagia training program. Following this, the treated group of 16 patients, (mean age = 49.3 years) was assessed by the dysphagia team, using bedside and videofluoroscopic examinations to determine the specific swallowing disorder. An individualized treatment program was designed for each patient. The groups were compared on the basis of deviation from their baseline weight, deviation from ideal energy intake, and the incidence of aspiration pneumonia. Statistical analysis revealed that the groups were comparable in age, number of days on the study, and Glasgow Coma Scale score; and that a significant weight gain and increase in caloric intake occurred in the treated group. No incidence of aspiration pneumonia was reported in either group. We speculate that this may have been influenced by the meticulousness of the care delivered in an acute unit as well as greater attention to prevention given in both groups.