Christina Hamacher

The Safety of Fiberoptic Endoscopic Evaluation of Swallowing in Acute Stroke Patients

Background and Purpose— Fiberoptic endoscopic evaluation of swallowing (FEES) is an excellent method for the accurate examination of swallowing function in the acute phase of stroke. The present study investigates the safety of FEES related to patients characteristics in a setting of acute stroke care. Methods— A prospective study of FEES-associated complications was carried out in 300 acute stroke patients over a 1-year period. A neurologist and a speech-language pathologist of the stroke unit team performed FEES within a mean time interval of 1.9±0.8 days after stroke onset. A closely meshed monitoring of cardiovascular parameters was done during each examination. A discomfort rating was obtained from the patients. Results— In none of the 300 subjects any airway comprise, decrease in the level of consciousness, symptomatic bradycardia/tachycardia, laryngospasm, or epistaxis requiring special treatment was observed. The incidence of self-limiting nosebleeds was 6% and did not significantly differ in relation to major stroke types (ischemic versus hemorrhagic), acute treatment strategy (thrombolysis versus no thrombolysis), or secondary prevention regime (anticoagulant therapy versus antiplatelet drugs). Whereas no alterations in diastolic blood pressure were noted, statistically significant changes in systolic blood pressure, heart rate, and oxygen saturation occurred. However, these alterations did not cause any severe adverse event and were clinically judged as being mild. The assessment of comfort revealed an excellent tolerance of FEES in >80% of patients. Conclusion— This study demonstrates that FEES is a well-tolerated and safe method to assess swallowing function when performed by a speech-language pathologist and a neurologist in a stroke unit setting.

Do nasogastric tubes worsen dysphagia in patients with acute stroke

BackgroundEarly feeding via a nasogastric tube (NGT) is recommended as safe way of supplying nutrition in patients with acute dysphagic stroke. However, preliminary evidence suggests that NGTs themselves may interfere with swallowing physiology. In the present study we therefore investigated the impact of NGTs on swallowing function in acute stroke patients.MethodsIn the first part of the study the incidence and consequences of pharyngeal misplacement of NGTs were examined in 100 stroke patients by fiberoptic endoscopic evaluation of swallowing (FEES). In the second part, the effect of correctly placed NGTs on swallowing function was evaluated by serially examining 25 individual patients with and without a NGT in place.ResultsA correctly placed NGT did not cause a worsening of stroke-related dysphagia. Except for two cases, in which swallowing material got stuck to the NGT and penetrated into the laryngeal vestibule after the swallow, no changes of the amount of penetration and aspiration were noted with the NGT in place as compared to the no-tube condition. Pharyngeal misplacement of the NGT was identified in 5 of 100 patients. All these patients showed worsening of dysphagia caused by the malpositioned NGT with an increase of pre-, intra-, and postdeglutitive penetration.ConclusionBased on these findings, there are no principle obstacles to start limited and supervised oral feeding in stroke patients with a NGT in place.

Endoscopic characteristics and levodopa responsiveness of swallowing function in progressive supranuclear palsy.

Dysphagia is a frequent and early symptom in progressive supranuclear palsy (PSP) predisposing patients to aspiration pneumonia. Fiberoptic endoscopic evaluation of swallowing (FEES®) has emerged as a valuable apparative tool for objective evaluation of neurogenic dysphagia. This is the first study using FEES® to investigate the nature of swallowing impairment in PSP. Eighteen consecutive PSP patients (mean age 69.7 ± 9.0 years) were included. The salient findings of FEES® in PSP patients were compared with those of 15 patients with Parkinsons disease (PD). In 7 PSP patients, a standardized FEES® protocol was performed to explore levodopa (L‐dopa) responsiveness of dysphagia. Most frequent abnormalities detected by FEES® were bolus leakage, delayed swallowing reflex, and residues in valleculae and piriformes. Aspiration events with at least one food consistency occurred in nearly 30% of PSP patients. Significant pharyngeal saliva pooling was observed in 4 PSP patients. We found no difference of salient endoscopic findings between PSP and PD patients. Endoscopic dysphagia severity in PSP correlated positively with disease duration, clinical disability, and cognitive impairment. No correlation was found with dysarthria severity. In early PSP patients, swallowing dysfunction was solely characterized by liquid leakage with the risk of predeglutitive aspiration during the oral phase of swallowing. Two PSP patients showed relevant improvement of swallowing function after L‐dopa challenge. Chin tuck—maneuver, hard swallow, and modification of food consistency were identified as the most effective therapeutic interventions. In conclusion, FEES® assessment can deliver important findings for the diagnosis and refined therapy of dysphagia in PSP patients.

Standardized endoscopic swallowing evaluation for tracheostomy decannulation in critically ill neurologic patients.

Objectives:Decisions regarding tracheostomy tube removal after mechanical ventilation often depend on the physician’s individual experience because evidence-based practice guidelines are still scarce, especially for critically ill neurologic patients. In these patients, the prevalence of aspiration is high and regarded as an important contributor to decannulation failure. The presence of severe neurological deficits may, however, give clinicians the subjective impression that a tracheostomy tube is still necessary although decannulation may actually be safe. It is therefore crucial to test swallowing function reliably prior to decannulation in this patient population. Design:Prospective observational study. Setting:University hospital, neurological ICU. Patients:One hundred tracheostomized patients with acute neurologic disease completely weaned from mechanical ventilation. Interventions:An endoscopic protocol evaluating readiness for decannulation and a conventional clinical swallowing examination were carried out by separate, experienced practitioners blinded to each other’s decisions. Patient management always followed the decision made with endoscopy. Measurements and Main Results:Practitioners’ decannulation decisions (yes/no) reached with both assessments were compared. Decannulated patients were monitored throughout their stay for complications related to tube removal. Endoscopy was performed successfully in all subjects without any complications. Following the protocol, the tracheostomy tube was successfully removed in 54 patients, whereas according to the clinical swallowing examination, only 29 patients would have been decannulated at that point. Only one patient needed recannulation due to respiratory problems, resulting in a failure rate of 1.9%. Conclusions:In neurologic patients, speech-language pathologists’ impressions about the patient’s state when clinically assessing indirect variables of swallowing function often lead to the unnecessary prolongation of cannulation time. Endoscopic evaluation has the advantage of objectively visualizing the patient’s ability to manage secretions directly and allows for faster but, nonetheless, safe decannulation. The endoscopic protocol proposed here is a safe, efficient, and objective bedside tool to guide decannulation decisions.

The impact of lesion location on dysphagia incidence, pattern and complications in acute stroke. Part 1: dysphagia incidence, severity and aspiration.

Although early identification of patients at risk for dysphagia is crucial in acute stroke care, predicting whether a particular patient is likely to have swallowing problems based on the brain scan is difficult because a comprehensive model of swallowing control is missing. In this study whether stroke location is associated with dysphagia incidence, severity and the occurrence of penetration or aspiration was systematically evaluated relying on a voxel‐based imaging analysis approach.

Dysphagia in X-linked bulbospinal muscular atrophy (Kennedy disease)

Dysphagia in X-linked bulbospinal muscular atrophy (Kennedy disease) has never been characterized in detail by objective swallowing studies. We assessed the nature of swallowing impairment in Kennedy disease by undertaking fiberoptic endoscopic evaluation of swallowing examinations of 10 genetically confirmed patients with Kennedy disease who were scored according to an ordinal rating scale including 25 different items. The results were compared to an age-matched control group of 10 healthy volunteers. Swallowing dysfunction was found in 80% of patients with Kennedy disease. The main pattern of dysphagia was an incomplete food bolus clearance through the pharynx with residues left in the valleculae overflowing into the laryngeal vestibule after the swallow. Total duration of the pharyngeal swallow was significantly shorter in patients with Kennedy disease compared to the control group. These findings suggest that dysphagia in Kennedy disease is predominantly characterized by an impairment of the pharyngeal phase of swallowing resulting from reduced base-of-tongue movement and bilateral paresis of pharyngeal and laryngeal muscles.

Aspiration and dysphagia screening in acute stroke – the Gugging Swallowing Screen revisited

The Gugging Swallowing Screen (GUSS) is a tool to screen aspiration risk in acute stroke. We aimed to replicate its validity in a larger second cohort of patients with acute stroke, including the more severe with a National Institutes of Health Stroke Scale (NIHSS) ≥ 15.

The impact of lesion location on dysphagia incidence, pattern and complications in acute stroke. Part 2: Oropharyngeal residue, swallow and cough response, and pneumonia

Dysphagia is a well‐known complication of acute stroke. Given the complexity of cerebral swallowing control it is still difficult to predict which patients are likely to develop swallowing dysfunction based on their neuroimaging. In Part 2 of a comprehensive voxel‐based imaging study, whether the location of a stroke lesion can be correlated with further dysfunctional swallowing patterns, pulmonary protective reflexes and pneumonia was evaluated.

Measurement of Oxygen Desaturation Is Not Useful for the Detection of Aspiration in Dysphagic Stroke Patients

Background: Dysphagia is one of the most dangerous symptoms of acute stroke. Various screening tools have been suggested for the early detection of this condition. In spite of conflicting results, measurement of oxygen saturation (SpO2) during clinical swallowing assessment is still recommended by different national guidelines as a screening tool with a decline in SpO2 ≥2% usually being regarded as a marker of aspiration. This paper assesses the sensitivity of SpO2 measurements for the evaluation of aspiration risk in acute stroke patients. Methods: Fifty acute stroke patients with moderate to severe dysphagia were included in this study. In all patients, fiberoptic endoscopic evaluation of swallowing (FEES) was performed according to a standardised protocol. Blinded to the results of FEES, SpO2 was monitored simultaneously. The degree of desaturation during/after swallows with aspiration was compared to the degree of desaturation during/after swallows without aspiration in a swallow-to-swallow analysis of each patient. To minimise potential confounders, every patient served as their control. Results: In each subject, a swallow with and a swallow without aspiration were analysed. Overall, aspiration seen in FEES was related to a minor decline in SpO2 (mean SpO2 without aspiration 95.54 ± 2.7% vs. mean SpO2 with aspiration 95.28 ± 2.7%). However, a significant desaturation ≥2% occurred only in 5 patients during/after aspiration. There was no correlation between aspiration/dysphagia severity or the amount of aspirated material and SpO2 levels. Conclusions: According to this study, measurement of oxygen desaturation is not a suitable screening tool for the detection of aspiration in stroke patients.