Katlyn McGrattan

Respiratory-Swallow Training in Patients With Head and Neck Cancer

OBJECTIVE To test a novel intervention to train swallowing to occur in the midexpiratory to low expiratory phase of quiet breathing to improve swallowing safety and efficiency. DESIGN Safety and efficacy nonrandomized controlled trial with 1-month follow-up. SETTING Ambulatory clinics. PARTICIPANTS Patients (N=30) with head and neck cancer (HNC) and chronic dysphagia completed the intervention. Fifteen of these patients participated in a 1-month follow-up visit. INTERVENTIONS Training protocol based on hierarchy of motor skill acquisition to encourage autonomous and optimal respiratory-swallowing coordination. Visual feedback of respiratory phase and volume for swallowing initiation was provided by nasal airflow and rib cage/abdomen signals. MAIN OUTCOME MEASURES Respiratory-swallow phase pattern, Modified Barium Swallow Impairment Profile (MBSImP) scores, Penetration-Aspiration Scale (PAS) scores, and MD Anderson Dysphagia Inventory scores. RESULTS Using visual feedback, patients were trained to initiate swallows during the midexpiratory phase of quiet breathing and continue to expire after swallowing. This optimal phase patterning increased significantly after treatment (P<.0001). Changes in respiratory-swallowing coordination were associated with improvements in 3 MBSImP component scores: laryngeal vestibular closure (P=.0004), tongue base retraction (P<.0001), and pharyngeal residue (P=.01). Significant improvements were also seen in PAS scores (P<.0001). Relative to pretreatment values, patients participating in 1-month follow-up had increased optimal phase patterning (P<.0001), improved laryngeal vestibular closure (P=.01), tongue base retraction (P=.003), and pharyngeal residue (P=.006) MBSImP scores and improved PAS scores (P<.0001). CONCLUSIONS Improvements in respiratory-swallowing coordination can be trained using a systematic protocol and respiratory phase-lung volume-related biofeedback in patients with HNC and chronic dysphagia, with favorable effects on airway protection and bolus clearance.

Costs of pediatric stroke care in the United States: a systematic and contemporary review.

A substantial literature exists regarding cost-of-care outcomes in adult stroke, however less is known about pediatric stroke. The objective of this review of the literature was to examine studies of costs associated with pediatric stroke care. Six studies reporting data from individuals who experienced a pediatric stroke were included in the review. Cost data (charges and payments) were generally limited to one year and ranged from approximately US

Team-Oriented Care for Orofacial Clefts: A Review of the Literature

15,000–140,000 depending upon stroke type. Pediatric stroke is linked to substantial costs but studies primarily emphasize the direct cost of care during the first year post-stroke onset. However, since many pediatric stroke survivors experience normal lifespans, they can also accumulate a significantly greater long term cost of care than strokes that occur in adulthood. Future studies are needed to examine long term direct costs, short and long term indirect costs and other economic outcomes in this population.

Dysphagia in infants with single ventricle anatomy following stage 1 palliation: Physiologic correlates and response to treatment

Objective To examine the process of team-oriented care for children with orofacial clefts. Design Systematic review of available studies reporting team-oriented management of children and adults with orofacial clefts. We identified studies from OVID, PsychINFO, REHABDATA, PubMed, and The Cleft Palate–Craniofacial Journal to complete this review. Main Outcome Measures Process of team-oriented treatment, which included use of team-oriented care, continuity of team-oriented care, and approaches to team-oriented care. Results We identified nine studies including 1398 participants. We found that studies examining team-oriented approaches to orofacial clefts were limited. Studies of orofacial teams suggest that use of team-oriented approaches to care are highly variable. It is unclear how these inconsistencies in approaches to care influence long-term outcomes. Conclusions Although the literature suggests that the process of team-oriented care results in better outcomes in individuals with orofacial clefts, process of care as a measurable outcome has yet to be adequately examined. Future studies are needed to investigate the impact on clinical outcomes and their relationship to cost effectiveness and efficiency of care.

First Steps Towards Development of an Instrument for the Reproducible Quantification of Oropharyngeal Swallow Physiology in Bottle-Fed Children

BACKGROUND Deficits in swallowing physiology are a leading morbidity for infants with functional single ventricles and systemic outflow tract obstruction following stage 1 palliation. Despite the high prevalence of this condition, the underlying deficits that cause this post-operative impairment remain poorly understood. OBJECTIVE Identify the physiologic correlates of dysphagia in infants with functional single ventricles and systemic outflow tract obstruction following stage 1 palliative surgery. METHODS Postoperative fiberoptic laryngoscopies and videofluoroscopic swallow studies (VFSS) were conducted sequentially on infants with functional single ventricles following stage 1 palliative surgery. Infants were dichotomized as having normal or impaired laryngeal function based on laryngoscopy findings. VFSS were evaluated frame-by-frame using a scale that quantifies performance within 11 components of swallowing physiology. Physiologic attributes within each component were categorized as high functioning or low functioning based on their ability to support milk ingestion without bolus airway entry. RESULTS Thirty-six infants (25 male) were included in the investigation. Twenty-four underwent the Norwood procedure and twelve underwent the Hybrid procedure. Low function physiologic patterns were observed within multiple swallowing components during the ingestion of thin barium as characterized by ≥4 sucks per swallow (36%), initiation of pharyngeal swallow below the level of the valleculae (83%), and incomplete late laryngeal vestibular closure (56%) at the height of the swallow. Swallowing deficits contributed to aspiration in 50% of infants. Although nectar thick liquids reduced the rate of aspiration (P = .006), aspiration rates remained high (27%). No differences in rates of penetration or aspiration were observed between infants with normal and impaired laryngeal function. CONCLUSIONS Deficits in swallowing physiology contribute to penetration and aspiration following stage 1 palliation among infants with normal and impaired laryngeal function. Although thickened liquids may improve airway protection for select infants, they may inhibit their ability to extract the bolus and meet nutritional needs.

Effect of Single-Use, Laser-Cut, Slow-Flow Nipples on Respiration and Milk Ingestion in Preterm Infants

The incidence of feeding/swallowing impairments (deglutition disorders) in young children is rising and poses serious acute and long-term health consequences. Accurate detection and prompt intervention can lessen the impact of dysphagia-induced sequelae. Videofluoroscopic Swallow Studies (VFSSs) are used to make critical decisions for medically fragile children despite procedural variability and the lack of agreed upon measures for interpreting and reporting results. This investigation represents the first steps in the development of a novel tool for the quantification of oropharyngeal swallow physiology from full-length VFSS examinations in bottle-fed children. The Modified Barium Swallow Impairment Profile MBSImP™© served as the conceptual assessment model for development of components and operational score variants to characterize distinguishable VFSS observations. Twenty-four components of swallowing physiology were validated via expert consensus. Training materials included a library of 94 digitized video images comprised of distinct score variants for each component. Materials were disseminated to seven speech-language pathologists (SLPs) who participated in didactic and self-training sessions, and rated components. All SLPs achieved ≥80% reliability criterion after completing two or three training sessions. Agreement for 17 (71%) components was achieved after two sessions. Nutritive sucking/oral and airway-related components were most difficult to distinguish. Three sessions were required for 2 (33%) of the sucking/oral components and 4 (57%) of the airway-related components. These findings support the feasibility to standardize training and reliably score swallowing physiology using precise definitions and unambiguous visual images, and represent preliminary steps towards content validity and reliability of a standardized VFSS tool for bottle-fed children.

Efficacy of Six Tasks to Clear Laryngeal Mucus Aggregation

Purpose Single-use, laser-cut, slow-flow nipples were evaluated for their effect on respiration and milk ingestion in 13 healthy preterm infants (32.7-37.1 weeks postmenstrual age) under nonlaboratory, clinical conditions. Method The primary outcomes of minute ventilation and overall milk transfer were measured by using integrated nasal airflow and volume-calibrated bottles during suck bursts and suck burst breaks during slow-flow and standard-flow nipple bottle feedings. Wilcoxon signed-ranks tests were used to test the effect of nipple type on both outcomes. Results Prefeeding minute ventilation decreased significantly during suck bursts and returned to baseline values during suck burst breaks across both slow-flow and standard-flow nipples. No differences were found in minute ventilation (p > .40) or overall milk transfer (p = .58) between slow-flow and standard-flow nipples. Conclusions The lack of difference in primary outcomes between the single-use slow-flow and standard-flow nipples may reflect variability in nipple properties among nipples produced by the same manufacturer. Future investigations examining the effect of both single-use and reusable nipple products are warranted to better guide nipple selection during clinical care.

Are improved rater reliability results associated with faster reaction times after rater training for judgments of laryngeal mucus

PURPOSE Clinicians commonly teach patients alternative clearing behaviors to reduce coughing and hard throat clearing with the assumption that these behaviors clear mucus from the vocal folds. Yet there is limited evidence of the effectiveness of these alternative behaviors at clearing mucus. This studys purpose was to evaluate the efficacy of reducing laryngeal mucus aggregation using alternative approaches in comparison with hard coughing and hard throat clearing in people with and without voice disorders. METHOD Mucus aggregation of 46 participants, 22 with and 24 without voice disorders, was evaluated from stroboscopy recordings taken before and after each of six clearing behaviors: hard coughing, hard throat clearing, silent coughing, soft throat clearing, dry swallowing, and swallowing with a fluid bolus. Each participant performed each clearing behavior twice. Two trained raters evaluated mucus aggregation for type, thickness, and pooling. RESULTS Of the six clearing behaviors studied, only hard throat clearing changed vocal fold mucus aggregation. The features of mucus aggregation that were changed by hard throat clearing were the severity of mucus thickness and the presence of type 3 mucus. CONCLUSIONS Despite the widespread clinical use of alternative clearing behaviors, the results of this study indicate that hard throat clearing is the only clearing behavior to have a significant impact on removing mucus aggregation from the vocal folds. This finding should be further investigated in a larger scale study. If the results of this study are replicated, clinicians should consider changing their use and description of alternative clearing behaviors in clinical practice.

Radiation Exposure Time during MBSS: Influence of Swallowing Impairment Severity, Medical Diagnosis, Clinician Experience, and Standardized Protocol Use

Mucus aggregation on the vocal folds, a common complaint amongst persons with voice disorders, has been visually rated on four parameters: type, pooling, thickness, and location. Rater training is used to improve the reliability and accuracy of these ratings. The goal of this study was to evaluate the effect of training on rater reliability, accuracy and response time. Two raters scored mucus aggregation from 120 stroboscopic exams after a brief introductory session and again after a thorough training session. Reliability and accuracy were calculated in percent agreement. Two-tail paired t-tests were used to assess differences in reaction time for ratings before and after training. Inter-rater reliability improved from 79% pre-training to 92% post-training. Intra-rater reliability improved from 77% to 91% for Rater 1 and 80% to 88% for Rater 2 following training. Accuracy improved from 80% to 96% for Rater 1 and 76% to 95% for Rater 2 from pre- to post-training. Reaction time decreased for both raters (p=0.025). These findings further our understanding of observer performance on judgments of laryngeal mucus. These results suggest that rater training increases reliability and accuracy while decreasing reaction time. Future studies should assess the relationship of these judgments and voice changes.