Development of a Non-invasive Device for Swallow Screening in Patients at Risk of Oropharyngeal Dysphagia: Results from a Prospective Exploratory Study.

Oropharyngeal dysphagia is prevalent in several at-risk populations, including post-stroke patients, patients in intensive care and the elderly. Dysphagia contributes to longer hospital stays and poor outcomes, including pneumonia. Early identification of dysphagia is recommended as part of the evaluation of at-risk patients, but available bedside screening tools perform inconsistently. In this study, we developed algorithms to detect swallowing impairment using a novel accelerometer-based dysphagia detection system (DDS). A sample of 344 individuals was enrolled across seven sites in the United States. Dual-axis accelerometry signals were collected prospectively with simultaneous videofluoroscopy (VFSS) during swallows of liquid barium stimuli in thin, mildly, moderately and extremely thick consistencies. Signal processing classifiers were trained using linear discriminant analysis and 10,000 random training-test data splits. The primary objective was to develop an algorithm to detect impaired swallowing safety with thin liquids with an area under receiver operating characteristic curve (AUC) > 80% compared to the VFSS reference standard. Impaired swallowing safety was identified in 7.2% of the thin liquid boluses collected. At least one unsafe thin liquid bolus was found in 19.7% of participants, but participants did not exhibit impaired safety consistently. The DDS classifier algorithms identified participants with impaired thin liquid swallowing safety with a mean AUC of 81.5%, (sensitivity 90.4%, specificity 60.0%). Thicker consistencies were effective for reducing the frequency of penetration-aspiration. This DDS reached targeted performance goals in detecting impaired swallowing safety with thin liquids. Simultaneous measures by DDS and VFSS, as performed here, will be used for future validation studies.

Face-to-face versus online training for the interpretation of findings in the fiberoptic endoscopic exam of the swallow procedure.

OBJECTIVE: The aim of this study was to evaluate the comparative effectiveness of an online, interdisciplinary, interactive course designed to increase the ability to accurately interpret the fiberoptic endoscopic exam of the swallow (FEES) procedure to traditional, face-to-face (F2F) lectures for both graduate medical education (GME) and graduate speech language pathology (GSLP) programs. DESIGN: This was a prospective, quantitative, nonrandomized study. Participants were medical residents in physical medicine and rehabilitation from two affiliated programs and graduate students in speech language pathology from two instructional cohorts at a single institution. Group 1, traditional group (n=51), participated in F2F lectures using an audience response system, whereas Group 2, online group (n=57), participated in an online, interactive course. The main outcome measure was pre- and post-course FEES knowledge test scores. RESULTS: For Group 1, the mean pre-course score was 26.94 (SD=3.24) and the post-course score was 34.96 (SD=2.51). Differences between pre- and post-course scores for Group 1 were significant (t=-16.38, P≤0.0001). For Group 2, the mean pre-course score was 27.05 (SD=2.74) and the post-course score was 34.05 (SD=2.84). Differences between pre- and post-course scores for Group 2 were significant (t=-13.5, P≤0.0001). The mean knowledge change score for Group 1 and Group 2 was 8.01 (SD=3.50) and 7.04 (SD=3.91), respectively (nonsignificant, t=1.372, P=0.173), suggesting groups made similar gains. CONCLUSION: Incorporating technology into GME and GSLP programs yielded comparable gains to traditional lectures. Findings support the use of online education as a viable alternative to the traditional F2F classroom format for the instruction of the cognitive component of the FEES procedure.

Swallowing frequency: Impact of accumulated oropharyngeal secretion levels and gustatory stimulation.

We conducted a prospective, descriptive study of 27 individuals with known or suspected dysphagia to investigate the relationship between swallowing frequency, accumulated oropharyngeal secretion levels, and gustatory stimulation. Assessment of the secretion level was quantified with the use of a previously published 5-point rating scale using endoscopy. Overall, we found a moderate relationship between the baseline swallowing frequency at rest and the accumulated oropharyngeal secretion level (Pearson correlation 0.470; p = 0.01). The study sample was divided into two groups based on their secretion level. Group 1 (n = 19; mean age 59.7 ± 21.5 years) included patients whose accumulated oropharyngeal secretion level was rated as 1 (normal) or 2 (mild). Group 2 (n = 8; mean age 69.78 ± 8.35 years) included patients whose accumulated oropharyngeal secretion level was rated as 4 (severe) or 5 (profound). For Group 1, swallowing frequency increased from a baseline of 1.05 to 5.26 swallows over 2 minutes, following gustatory stimulation; for Group 2 it increased from a baseline of 0.125 swallows to 3.5 swallows. These results indicate that individuals with a lower baseline swallowing frequency at rest demonstrated a higher accumulated oropharyngeal secretion level as viewed by nasal endoscopy and that, regardless of secretion level, gustatory stimulation was effective at increasing swallowing frequency. Increasing swallowing frequency may be a functional dysphagia treatment objective in efforts to improve the efficiency of the swallow and may offer better management of accumulated oropharyngeal secretions.

Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference.

BACKGROUND: Millions of patients are discharged from intensive care units annually. These intensive care survivors and their families frequently report a wide range of impairments in their health status which may last for months and years after hospital discharge. OBJECTIVES: To report on a 2-day Society of Critical Care Medicine conference aimed at improving the long-term outcomes after critical illness for patients and their families. PARTICIPANTS: Thirty-one invited stakeholders participated in the conference. Stakeholders represented key professional organizations and groups, predominantly from North America, which are involved in the care of intensive care survivors after hospital discharge. DESIGN: Invited experts and Society of Critical Care Medicine members presented a summary of existing data regarding the potential long-term physical, cognitive and mental health problems after intensive care and the results from studies of postintensive care unit interventions to address these problems. Stakeholders provided reactions, perspectives, concerns and strategies aimed at improving care and mitigating these long-term health problems. MEASUREMENTS AND MAIN RESULTS: Three major themes emerged from the conference regarding: (1) raising awareness and education, (2) understanding and addressing barriers to practice, and (3) identifying research gaps and resources. Postintensive care syndrome was agreed upon as the recommended term to describe new or worsening problems in physical, cognitive, or mental health status arising after a critical illness and persisting beyond acute care hospitalization. The term could be applied to either a survivor or family member. CONCLUSIONS: Improving care for intensive care survivors and their families requires collaboration between practitioners and researchers in both the inpatient and outpatient settings. Strategies were developed to address the major themes arising from the conference to improve outcomes for survivors and families.

Feasibility of instrumental swallowing assessments in patients with prolonged disordered consciousness while undergoing inpatient rehabilitation.

OBJECTIVE: To evaluate the feasibility, safety, and potential benefit of instrumental swallowing assessments for patients with prolonged disordered consciousness participating in rehabilitation. DESIGN: Case-control, retrospective. PARTICIPANTS: Thirty-five participants divided into 2 cohorts according to cognitive level at the time of baseline instrumental swallowing assessment. Group 1 (n = 17) participants were at Rancho Los Amigo (RLA) level II/III or RLA level III, while Group 2 (n = 18) participants were rated better than RLA level III. RESULTS: Aspiration and laryngeal penetration rates for both groups were similar (aspiration rate Group 1 = 41%, Group 2 = 39%; laryngeal penetration rate Group 1 = 59%, Group 2 = 61%). Overall, 76% (13/17) of Group 1 and 72% (13/18) of Group 2 were able to receive some type of oral feedings following baseline video fluoroscopic swallow study (VFSS) or endoscopic exam of the swallow (FEES). CONCLUSION: The majority of participants who underwent an instrumental swallowing examination while still functioning at RLA level II/III or RLA level III were able to return to some form of oral feedings immediately following their baseline examination. Swallowing as a treatment modality can be considered a part of the overall plan to facilitate neurobehavioral recovery for patients with prolonged disordered consciousness participating in rehabilitation.

Pilot date on swallow function in nondysphagic patients requiring a tracheotomy tube.

Objective. To evaluate the effects of occlusion status (i.e., open, finger, capped) of the tracheotomy tube and removal of the tracheotomy tube that may have upon bolus flow and durational measurements in nondysphagic persons requiring a tracheotomy tube. Study Design. Prospective, single subject, repeated measure design. Methods. Participants had their swallow evaluated with 5 mL pureed boluses using nasal endoscopy with the tracheotomy tube in place, removed, and under the following occlusion conditions: open, finger, and capped. The order of occlusion condition was randomized. Results. Aspiration was never observed but laryngeal penetration was a common finding. Durational measurements for swallow initiation and duration of white out were not significantly different by occlusion status or after removal of the tracheotomy tube. Conclusion. This study provides corroborating evidence demonstrating the lack of a relationship between a tracheotomy tube and swallowing dysfunction.

Persons with disorders of consciousness: are oral feedings safe/effective?

PRIMARY OBJECTIVE: Evaluate the safety and efficacy of providing oral feedings to persons early in coma recovery following a severe brain injury. RESEARCH DESIGN: Descriptive, retrospective study. METHODS AND PROCEDURES: Medical chart reviews of all patients admitted to a rehabilitation hospital following severe brain injury. MAIN OUTCOMES AND RESULTS: Twenty-five patients met the inclusion criteria, 22 had a tracheostomy, and all were NPO. Subjects were divided into two cohorts. Group 1, n=10, mean age 43.5 years, received oral feedings early in coma recovery. Group 2, n=15, mean age 45.2 years, did not. Group 1, 30% returned to an oral diet of three meals daily at discharge from inpatient rehabilitation as compared to 40% in group 2 (chi2 = 0.260, p = 0.610). Average cost of care for group 1 = US$45 759 and group 2 = US$41 056 (p = 0.634). CONCLUSION: Safe therapeutic oral feedings, in accordance with findings from instrumental swallowing examinations, are possible for patients with disordered consciousness. The therapeutic oral feedings do not significantly increase the cost of care, but the effectiveness of oral feedings early in coma recovery requires further investigation.