Gary H. McCullough

Sensitivity and specificity of clinical/bedside examination signs for detecting aspiration in adults subsequent to stroke

UNLABELLED While detecting the presence of aspiration is only one aspect of a noninstrumented examination of swallowing function, it is an important component due to its potential health status consequences. The purpose of this investigation was to investigate the sensitivity and specificity of clinical/bedside examination signs for predicting aspiration on videofluoroscopic examination of swallowing. Sixty consecutive, acute stroke patients were investigated with clinical/bedside and videofluoroscopic exams. Clinical signs consisted of history, oral motor/speech praxis, voice, and trial swallow ratings. Results confirm that more work needs to be done if data collected from noninstrumented examinations are to be strongly predictive of aspiration on VFSE. However, comparisons of the current results with previous investigations provides a promising framework for future research. EDUCATIONAL OBJECTIVES (1) To understand the use of sensitivity and specificity in detecting disease; (2) To understand the current evidence regarding clinical signs of aspiration.

The association between oral microorgansims and aspiration pneumonia in the institutionalized elderly: review and recommendations.

Aspiration pneumonia is a leading cause of illness and death in persons who reside in long-term-care facilities and, combined with the lack of proper oral health care and services, the risk of aspiration pneumonia rises. The purpose of this article is to review recent literature on oral hygiene and oral care in long-term-care facilities and report new findings regarding associated risks for aspiration pneumonia, as well as research on oral care and health outcomes. The PubMed MeSH database was utilized to direct a specific search by entering terms “aspiration pneumonia” and “oral hygiene” from 1970 to 2009, which yielded 34 articles. The Ovid and Google Scholar databases were utilized as well and provided no additional references for the two terms. A manual search of references from other articles, including three systematic reviews published over the past decade, provided additional information regarding oral microorganisms and respiratory pathogens, as well as investigations of oral care. Finally, a brief but comprehensive introductory review was organized regarding oral microorganisms, biofilm, periodontal disease, and pneumonia to establish a framework for discussion. Overall, studies suggest (1) an association between poor oral hygiene and respiratory pathogens, (2) a decrease in the incidence of respiratory complications when patients are provided chemical or mechanical interventions for improved oral care, (3) the complex nature of periodontal disease and aspiration pneumonia make direct connections between the two challenging, and (4) additional studies are warranted to determine adequate oral hygiene protocols for nursing home patients to further reduce the incidence of aspiration pneumonia.

Inter- and Intrajudge Reliability for Videofluoroscopic Swallowing Evaluation Measures

Abstract Interjudge reliability for videofluoroscopic (VFS) swallowing evaluations has been investigated, and results have, for the most part, indicated that reliability is poor. While previous studies are well-designed investigations of interjudge reliability, few reports of intrajudge reliability are available for VFS measures derived from frame-by-frame analysis that clinicians typically employ. The purpose of this study was to examine the inter- and intrajudge reliability of VFS examination measures commonly used to assess swallowing functions. No training to criteria occurred. VFS examinations were conducted on 20 patients who had suffered a stroke within six weeks and had no structural abnormalities or tracheostomies. Three clinical judges served as subjects and rated the VFS examinations from videotape using frame-by-frame analysis. A clinicians repeated review of measures employed in the 20 examinations indicated high intrajudge reliability for a number of measures, suggesting that an experienced clinician may employ consistent standards for rating certain VFS measures across patients and time. These standards appear to vary among clinicians and yield unacceptable interjudge reliability. The need to train clinicians to criteria to improve interjudge reliability is discussed.

Effects of Cuff Deflation and One-Way Tracheostomy Speaking Valve Placement on Swallow Physiology

This study examined the effects of tracheostomy cuff deflation and one-way speaking valve placement on swallow physiology. Fourteen nonventilator-dependent patients completed videofluoroscopic swallow studies (VFSS) under three conditions: (1) cuff inflated, (2) cuff deflated, and (3) one-way valve in place. Four additional patients with cuffless tracheostomy tubes completed VFSS with and without the one-way valve in place. All swallows were analyzed for the severity of penetration/aspiration using an 8-point penetration–aspiration scale. Seven preselected swallow duration measures, extent of hyolaryngeal elevation and anterior excursion, and oropharyngeal residue were also determined. Scores on the penetration–aspiration scale were not significantly affected by cuff status, i.e., inflation or deflation. However, one-way valve placement significantly reduced scores on the penetration–aspiration scale for the liquid bolus. Patients who are unable to tolerate thin liquids may be able to safely take thin liquids when the valve is in place. However, one-way valve placement may not be beneficial for all patients. Clinicians who complete VFSS with tracheostomized patients should include several bolus presentations with a one-way speaking valve in place before making any decisions regarding the use of the valve as a means to reduce aspiration.

Utility Of Clinical Swallowing Examination Measures For Detecting Aspiration Post-Stroke

The purpose of this investigation was to determine the utility of clinical swallowing examination (CSE) measures for detecting aspiration as defined by videofluoroscopic swallowing examination (VFSE). This study, involving 165 participants, is a follow-up to a previously published investigation of 60 participants. Findings are compared with that investigation as well as with other research on CSEs. The results suggest that clinicians can make an accurate judgment of the occurrence of aspiration in most post-stroke patients. However, ruling out aspiration when it is absent appears more problematic. More work needs to be done if data collected from non-instrumented examinations are to be strongly predictive of the presence and absence of aspiration on VFSE. At present, there are no data to suggest that CSEs can be used to quantify aspiration or make adequate recommendations regarding patient care.

Maximum Hyoid Displacement in Normal Swallowing

Vertical and anterior displacement of the hyoid bone is a critical biomechanical component of normal swallowing function. The purpose of this study was to evaluate the maximal vertical and anterior displacement of the hyoid bone during oropharyngeal swallowing. A retrospective review of video-fluoroscopic swallowing exams in 40 normal subjects varying by age and gender was performed. Means and standard deviations for both vertical and anterior displacement were analyzed on both 5-ml and 10-ml thin liquids using an ImageJ program. Age and gender differences were submitted to a repeated-measures one-way analysis of variance. There was a significant difference between younger and older subjects for anterior displacement of the hyoid bone during the swallow but not for vertical displacement. No significant differences between male and female subjects were observed. Anterior displacement of the hyoid bone decreased with increasing age. This reduction may be related to muscle weakness. However, older people may adapt to preserve airway protection.

Inter-And Intrajudge Reliability Of A Clinical Examination Of Swallowing In Adults

This study investigates inter- and intrajudge reliability of a clinical examination of swallowing in adults. Several investigations have sought correlations between clinical indicators of dysphagia and the actual presence of dysphagia as determined by videofluoroscopy. Whereas some investigations have reported interjudge reliability for the videofluoroscopic measures employed, none have reported reliability for clinical measures. Without established reliability for rating clinical measures, conclusions drawn regarding the utility of a measure for detecting aspiration can be called into question. Results of the present study indicate that fewer than 50% of the measures clinicians typically employ are rated with sufficient inter- and intrajudge reliability. Measures of vocal quality and oral motor function were rated more reliably than were history measures or measures taken during trial swallows. There is a need to define more clearly the measures employed in clinical examinations and to be consistent in reporting reliability for clinical measures of swallowing function in future research.

Temporal Measurements Of Pharyngeal Swallowing In Normal Populations

The purpose of this investigation was to examine the temporal differences among three measures of pharyngeal stage transition in 40 normal subjects. The measures were (1) Pharyngeal Delay Time (PDT), (2) Stage Transition Duration (STD), and (3) Delayed Pharyngeal Swallow (DPS). Results showed a significant difference between younger and older subjects for PDT and STD but not for DPS. No gender differences were observed. These data on normal subjects will be used for comparisons with stroke patients in future research.

Clinicians’ Preferences and Practices in Conducting Clinical/Bedside and Videofluoroscopic Swallowing Examinations in an Adult, Neurogenic Population

The purposes of this investigation were: (a) to determine which clinical/bedside and videofluoroscopic (VFS) examination methods and measures clinicians believe should be employed to assess swallow...

Bolus Consistency and Swallowing in Children and Adults

Research has shown that swallowing in adults is affected by bolus consistency. Little is known, however, regarding the effect of bolus consistency on swallowing in children. Electromyographic (EMG) data from typically developing five- and eight-year-old-children and adults were obtained from the following muscles as they swallowed boluses of different consistencies: (1) right upper lip, (2) right lower lip, (3) submental, and (4) laryngeal strap. Signal analyses included calculating EMG onset and offset and average EMG amplitude of muscle activity during swallowing. Findings revealed that by five years of age, children employ adultlike control strategies during swallowing: significant differences in duration and magnitude of muscle activity resulted as a function of bolus consistency. General observations revealed, however, that swallowing in children is characterized by muscle activity that is shorter in duration. Similarities and differences in the biomechanics of swallowing between children and adults are important to consider during clinical evaluations and treatment of children with dysphagia.