Donna S. Lundy

Comparison of 2 Interventions for Liquid Aspiration on Pneumonia Incidence A Randomized Trial

Context Patients with dysphagia are at increased risk for aspiration pneumonia. Contribution This trial involved 515 adults with dementia or Parkinson disease and videofluoroscopically demonstrated aspiration. Participants were randomly assigned to drink thin liquids with a chin-down posture or to drink nectar- or honey-thick liquids in a head-neutral position. At 3 months, the cumulative incidence of pneumonia was about 10%, 8%, and 15% in the thin, nectar-thick, and honey-thick liquid groups. Dehydration was more common with thick than thin liquids. Caution Findings were inconclusive. The incidence of pneumonia was lower than expected, and confidence bounds around differences between groups were wide. The Editors Swallowing disorders are associated with increased morbidity and mortality. An estimated 18 million adults will require care for dysphagia-related malnutrition, dehydration, pneumonia, and reductions in quality of life by 2010 (13). Patients with dysphagia have an increased incidence of aspiration pneumonia because the aspirated material is heavily colonized with bacteria. Pneumonia is the fifth leading cause of infectious death in the United States among persons age 65 years or older and the third leading cause of death for persons age 85 years or older (4). One hospital admission for pneumonia is estimated to cost

Aspiration: Cause and Implications:

7166 (5). Rates of hospital discharge for Medicare beneficiaries with pneumonia as a primary diagnosis have increased by 93.5% in the past decade (6), along with length of stay and death rates (4). Liquid aspiration is the most common type of aspiration in elderly persons (1). Relative risk for pneumonia is highest in patients with dementia, followed by those who are institutionalized (7). As many as 50% of patients with parkinsonism are estimated to have dysphagia (8), and one third aspirate silentlythat is, with no external sign (such as coughing) to eject material or alert caregivers (9). Many short- and long-term care facilities use thickened liquid diets to treat aspiration (10). In these diets, thin liquids (for example, water, tea, and coffee) are eliminated, even in the absence of efficacy data, at a substantial cost in financial and quality-of-life terms. It costs approximately

Longitudinal Evaluation of Vocal Function After Thyroplasty Type I in the Treatment of Unilateral Vocal Paralysis

200 per month for an individual to drink thickened liquids (11, 12). A common alternative to thickened liquids is use of a chin-down posture (1317). Welch and coworkers (13) noted that posterior shift of anterior pharyngeal structures with the chin-down posture improved airway protection. Whereas previous studies have provided a basis for the widespread clinical use of chin-down posture, none has provided long-term health outcome data. Results from a previously reported portion of this study (18) demonstrated that short-term elimination of aspiration during the videofluorographic swallowing evaluation occurred most often with honey-thick liquids, followed by nectar-thick liquids and chin-down position. We sought to compare the effectiveness of chin-down posture and thickened liquids (nectar thick and honey thick) on the incidence of pneumonia in participants with dementia or Parkinson disease during 3 months of treatment. Methods Design The study design and methods are described in detail elsewhere (19). In brief, between enrollment initiation on 9 June 1998 and closure on 16 September 2005, 47 acute-care hospitals and 79 subacute residential facilities combined their patients to enroll 515 participants, a total that was 65 participants short of the recruitment goal. Follow-up was completed on 9 December 2005. The Data and Safety Monitoring Committee recommended discontinuing enrollment, on the basis of a futility analysis suggesting that enrolling additional participants would not change the findings. Participants were enrolled in this 3-month follow-up study if they were observed to aspirate when swallowing 3 mL of thin liquids from a spoon or when drinking from a cup without an intervention during videofluoroscopy of swallowing. Aspiration was defined as barium observed below the vocal folds. Participants who qualified were then given boluses to perform 3 conditions in random order: thin liquid (15 centipoise) swallowed in a chin-down posture, nectar-thick liquid (300 centipoise) swallowed in a head-neutral position, and honey-thick liquid (3000 centipoise) swallowed in a head-neutral position. Participants who did equally well (all conditions eliminated aspiration) or equally poorly (no conditions eliminated aspiration) but wished to continue oral intake, despite being warned about risk for pneumonia, were randomly assigned to 1 of the conditions as an intervention and followed for 3 months. Participants who aspirated during 1 or 2 of the conditions were not randomly assigned. On-site speech-language pathologists, nurses, and direct care and dietary staff who completed rigorous training about facilitation of the chin-down posture and proper techniques to thicken liquids supervised administration of the interventions. The number of participants under supervision by a speech-language pathologist ranged from 1 to 93 (median, 4 participants). Clinicians were instructed to refrain from using concomitant active or compensatory interventions with participants during the study period. Research staff made monthly site visits to monitor protocol adherence. All participants or their representatives provided written informed consent. Each facilitys institutional review board of record, as approved by the Office for Human Research Protections, Department of Health and Human Services, approved the study. Setting and Participants Inclusion criteria were a physician-identified diagnosis of dementia (Alzheimer type, single or multistroke type, or other nonresolving types) or Parkinson disease and patient age (50 to 95 years). Exclusion criteria were tobacco use in the past year, current alcohol abuse, history of head or neck cancer, insulin-dependent diabetes for 20 years or more, nasogastric tube, other progressive or infectious neurologic diseases, or pneumonia within 6 weeks of enrollment. Outpatients and inpatients from participating acute and subacute care facilities who were suspected of aspirating liquids by their physicians and speech-language pathologists during standard clinical care were referred for a videofluoroscopic swallowing study at a participating acute-care facility. The speech-language pathologist or research personnel completed the informed consent process with the patient and care provider before the swallowing study. After the swallowing study, participants returned to their living situation (acute care, subacute care, or home) while the videofluoroscopic images were analyzed. Participants were randomly assigned to an intervention group within 24 hours. Randomization and Interventions The primary interventions were chin-down posture while consuming thin liquids versus consuming thickened liquids (nectar thick or honey thick; Resource ThickenUp, Nestl HealthCare Nutrition [formerly Novartis Medical Nutrition], St. Louis Park, Minnesota) in a head-neutral position. The thin, nectar-thick, and honey-thick barium solutions (Varibar, E-Z-EM, Lake Success, New York) were manufactured in a standardized formulation for this study. Standardized recipes matching the viscosities of the barium products were developed for a wide variety of thickened beverages. Participants were randomly assigned centrally by a telephone system controlled by the Statistical and Data Center at the EMMES Corporation (Rockville, Maryland). A study speech-language pathologist called a central telephone number and entered participant criteria when prompted to, by using the telephone keys. If the patient was eligible, an intervention was assigned and a summary page that included intervention assignment and meal-monitoring was faxed to the speech-language pathologist. Randomization sequences for primary assignment (chin-down posture vs. thickened liquids) were developed by a statistician at the Statistical and Data Center. The sequences were stratified by participant age (50 to 79 years or 80 to 95 years) and diagnosis (Parkinson disease with or without dementia, or dementia only) and included randomly assigned block sizes of 32, 40, or 48 within each of the 4 strata. If a participant was assigned to thickened liquids, a second randomization was done to assign the participant to nectar-thick liquids or honey-thick liquids with equal probability. Neither the participants nor direct caregivers were blinded to intervention assignment, but neither group made outcome judgments. We expected that all liquids, regardless of amount or frequency of administration, would be provided to participants consistent with the intervention to which the participant was randomly assigned. All participants continued nonliquid nutritional intake in the same manner as before enrollment. Eight percent received nutrition by means of a gastrostomy tube. Measurements and Outcomes Primary Outcome The primary outcome for the study was definite pneumonia. Definite pneumonia was defined as evidence of pneumonia on chest radiography or 3 or more of the following: sustained fever (temperature >100F [38C]), rales or rhonchi on chest auscultation, sputum Gram stain showing substantial leukocytes, or sputum culture showing a respiratory pathogen. Suspected pneumonia was defined as at least 2 of the 4 features of definite pneumonia (except evidence of pneumonia on a chest radiograph). The primary care physician determined the need for chest radiography or sputum culture as part of standard clinical care. Chest radiography was done in all 52 patients with pneumonia; 2 of these patients did not have evidence of pneumonia on chest radiography but had 3 or 4 of the features of definite pneumonia. Secondary Outcomes and Comparisons A secondary outcome of interest was definite pneumonia or death. Secondary comparisons of interest were relative effectiveness of the 2 degre

Laser cordectomy for T1 glottic carcinoma: a 10-year experience and videostroboscopic findings.

The purpose of this investigation was to determine the overall prevalence of aspiration in dysphagic individuals referred for a modified barium swallow and the underlying anatomic and/or physiologic causes. A total of 166 patients were seen during a 1-month period at 5 participating institutions. Aspiration was detected in 51.2% of the patients. The most common causes were decreased laryngeal elevation and delayed triggering of the pharyngeal motor response. A history of aspiration pneumonia was significantly associated with the presence of aspiration on modified barium swallow study. The presence of a protective cough was present in only 53% of patients who aspirated, reinforcing the need for appropriate radiologic assessment in patients with suspected dysphagia.

Efficacy of Videostroboscopy in the Diagnosis of Voice Disorders

This study investigated longitudinal changes of vocal efficiency and stability after primary thyroplasty type I. Fifty‐three patients with unilateral vocal‐fold paralysis underwent vocal‐function evaluation preoperatively and at periodic intervals of 1, 3, and 6 months postoperatively. Vocal‐function assessment included videostrobolaryngoscopic examination, acoustical and aerodynamic analysis, and perceptual judgment of voice characteristics. Parameters that included glottic‐gap size, maximum phonation time, glottic‐flow rate, jitter, harmonic/noise ratio, breathiness, hoarseness, loudness, and phrasing showed significant improvement after thyroplasty and remained stable as early as 1 month postoperatively, with only slight fluctuations over a 6‐month period. Postoperative voice outcome was not affected by age, sex, duration of vocal symptoms, cause of paralysis, or preoperative pulmonary function.

Speech restoration and complications of primary versus secondary tracheoesophageal puncture following total laryngectomy.

Fifty-three patients underwent laser cordectomy for T1 glottic squamous cell carcinoma between January 1980 and December 1989—sixteen after having undergone unsuccessful radiation and thirty-seven who had no previous treatment. There was a 51% five-year cure rate in the irradiated group vs. 62% in the nonirradiated group. Extension of tumor to the anterior commissure resulted in a higher failure rate. Patients experienced an overall 5-year cure rate of 98% after surgical or radiation salvage of unsuccessful laser cordectomies. Six patients had preoperative and postoperative videostrobolaryngoscopy. The most common postoperative problem with voice was a breathiness that did not resolve in any of the patients. All patients had absent or moderately reduced amplitude and mucosal wave patterns and imcomplete glottic closure proportional to the amount of cordal tissue removed. Despite its seemingly poor results in carefully selected patients, laser cordectomy is still indicated without compromising the ultimate oncologic results. Advantages over radiation therapy or conservation laryngeal surgery include a short treatment time, requiring only an outpatient surgical procedure at the time of the initial diagnostic and/or staging laryngoscopy, and the avoidance of potential radiation side effects or surgical complications. However, patients should be advised the possibility of persistent postoperative breathy dysphonia, in addition to the possibility of further treatment to effect a long-term cure.

PRIORITIZING TREATMENT OUTCOMES: HEAD AND NECK CANCER PATIENTS VERSUS NONPATIENTS

While videostrobolaryngoscopy is not a new technique, its acceptance as a routine part of the voice evaluation has not been as forthcoming. Many are in agreement that the rigid fiberoptic telescopes in combination with standard VHS equipment provide a clear, magnified image that can be recorded and used for pretreatment and post-treatment comparisons, documentation, teaching, and research. Yet, some skepticism persists with regard to the ability of videolaryngoscopy and/or videostrobolaryngoscopy in changing the diagnosis and treatment outcome of patients with voice disorders as compared to indirect laryngoscopy. Two hundred ninety-two dysphonic patients were identified who underwent indirect as well as videolaryngoscopy with and without stroboscopic examination. Videostrobolaryngoscopy was found to alter the diagnosis and treatment outcome in 14% of the patients. It is most useful in patients with a diagnosis of functional dysphonia and vocal fold paralysis by indirect laryngoscopy. The increased illumination and magnification afforded by rigid fiberoptic telescopes during videolaryngoscopy, combined with the detailed assessment of glottic closure, mucosal wave, and amplitude characteristics provided by stroboscopic examination, allowed detection of subtle vocal fold pathology, otherwise missed by indirect laryngoscopy.

Acoustic analysis of the singing and speaking voice in singing students.

The tracheoesophageal (TE) fistula with a speech prosthesis has become the method of choice for vocal rehabilitation in many postlaryngectomy patients. Several modifications of the procedure have been described including primary TE puncture at the time of laryngectomy. Fear of increased risk of complications has kept the primary procedure from widespread usage. Our series of 95 TE fistula procedures from 1980 to 1988 revealed 33 to be primary and 62 secondary. Eighty‐five percent (85%) (28 of 33) patients in the primary group achieved long‐term satisfactory speech (1 year or more of follow‐up). Complications occurred in 36% of this group of patients. The success rate for the secondary group was 69% (43 of 62), while the complication rate was 21%. There were no instances of death, sepsis, or media‐stinitis associated with either primary or secondary TE fistula patients. It appears that the primary TE fistula can be performed as safely and effectively as the secondary procedure.

Complete hypopharyngeal obstruction by mucosal adhesions: a complication of intensive chemoradiation for advanced head and neck cancer.

Treatment decisions in head and neck cancer (HNC) might involve consideration of uncertain tradeoffs of one late effect against another or increasing toxicity or residual impairment for increased chance of survival. Understanding how patients prioritize potential outcomes, as well as whether these preferences are similar to those of nonpatients, is important to informed decision making and treatment planning.

Effects of vagal nerve stimulation on laryngeal function

The singing power ratio (SPR) is an objective means of quantifying the singers formant. SPR has been shown to differentiate trained singers from nonsingers and sung from spoken tones. This study was designed to evaluate SPR and acoustic parameters in singing students to determine if the singer-in-training has an identifiable difference between sung and spoken voices. Digital audio recordings were made of both sung and spoken vowel sounds in 55 singing students for acoustic analysis. SPR values were not significantly different between the sung and spoken samples. Shimmer and noise-to-harmonic ratio were significantly higher in spoken samples. SPR analysis may provide an objective tool for monitoring the students progress.