Preliminary Normative Reference Values of Validated FEES Scales in Healthy Young Adults.

OBJECTIVES: Limited normative reference data are available for validated outcomes of flexible endoscopic evaluation of swallowing (FEES). We aimed to examine healthy swallowing via FEES in community-dwelling healthy adults to derive a preliminary reference dataset of normative validated FEES outcomes to guide clinical interpretation and diagnostic decision-making. METHODS: Adults with no history of dysphagia-related disease underwent simultaneous videofluoroscopy and FEES imaging using a standardized 11-item bolus protocol. Trained raters performed duplicate, independent, blinded ratings of the New Zealand Secretion Scale (NZSS), Penetration-Aspiration Scale (PAS), and Dynamic Imaging Grade of Swallowing Toxicity-FEES (DIGEST-FEES) validated scales. Descriptive statistics were performed at the bolus (PAS) and participant level (NZSS, DIGEST-FEES). RESULTS: 361 swallows from 33 community-dwelling adults (36.6 ± 14.7 years old) were analyzed. In rank order, distribution profiles were: (1) NZSS: 95% normal (NZSS = 0), 5% abnormal (NZSS = 4); (2) Worst PAS: 73% safe (PAS 1-2, n = 24), 21% penetration above the true vocal folds (PAS 3, n = 7), 6% deep penetration to the true vocal folds (PAS = 5, n = 2); (3) DIGEST-FEES Safety Grades: 91% Grade 0 (normal, n = 30), 9% Grade 1 (mild impairment, n = 3); (4) DIGEST-FEES Efficiency Grades: 73% Grade 0 (normal, n = 24), 24% Grade 1 (mild impairment, n = 8), 3% Grade 2 (moderate impairment, n = 1). CONCLUSION: This preliminary healthy FEES dataset highlights variation in swallowing safety and efficiency and suggests careful interpretation of FEES outcomes to avoid over-pathologizing impairment. Future studies are warranted to obtain additional normative data in diverse populations to further understand normal variation in FEES outcomes to guide clinically meaningful diagnostic cut-points. LEVEL OF EVIDENCE: Level 3 Laryngoscope, 2024.

Provision of Oral Care in the Cardiothoracic Intensive Care Unit: Survey of Nursing Staff Training, Confidence, Methods, Attitudes, and Perceived Barriers.

BACKGROUND: Poor oral health is associated with adverse outcomes in critical care settings. Although provision of oral care is a fundamental aspect of nursing practice, both formal training and practice among nursing staff remain unclear. METHOD: Cardiothoracic intensive care unit nurses were recruited to complete a 16-item survey regarding training, confidence, methods, prioritization, and barriers to provision of oral care. RESULTS: A total of 108 nurses participated (70% response rate). Formal training in oral care was reported by 38%, most frequently reported as less than 1 hour (53%) in duration. Of the respondents, 70% reported confidence in providing oral care. Nine methods and 16 products were identified, with variability in the frequency of provision. Prioritization of oral care was rated most frequently as moderate (53%), with 28% reporting barriers. CONCLUSION: Despite limited formal training, surveyed nurses reported confidence in providing oral care. Methods, frequency, and prioritization were variable. Both development of formal curricula and evaluation of adherence to standardized protocols for oral care are warranted. [J Contin Educ Nurs. 2023;54(7):313-321.].

A prospective examination of swallow and cough dysfunction after lung transplantation.

OBJECTIVES: Swallow and cough dysfunction are possible surgical complications of lung transplantation (LT). We examined voluntary cough strength, sensorimotor reflexive cough integrity, and swallow-related respiratory rate (RR) across swallowing safety and aspiration response groups in recovering LT recipients. METHODS: Forty-five LT recipients underwent flexible endoscopic evaluation of swallowing indexed by the validated Penetration Aspiration Scale. RR before and after a 3-ounce water drinking task was measured. Voluntary and reflexive cough screening were performed to index motor and sensory outcomes. T-tests, one-way ANOVAs, and chi-square (odds ratios) were used. RESULTS: 60% of patients exhibited laryngeal penetration (n = 27) and 40% demonstrated tracheal aspiration (n = 18); 72% (n = 13) demonstrated silent aspiration. Baseline RR was higher in aspirators versus non-aspirators (26.5 vs. 22.6, p = 0.04) and in silent aspirators compared to non-silent aspirators (27.9 vs. 20.7, p = 0.01). RR change post-swallowing did not differ between aspiration response groups; however, it was significantly higher in aspirators compared to non-aspirators (3 vs. -2, p = 0.02). Compared to non-silent aspirators, silent aspirators demonstrated reduced voluntary cough peak expiratory flow (PEF; 166 vs. 324 L/min, p = 0.01). PEF, motor and urge to cough reflex cough ratings did not differ between aspirators and non-aspirators. Silent aspirators demonstrated a 7.5 times higher odds of failing reflex cough screening compared to non-silent aspirators (p = 0.07). CONCLUSIONS: During the acute recovery period, all LT participants demonstrated some degree of unsafe swallowing and reduced voluntary cough strength. Silent aspirators exhibited elevated RR, reduced voluntary cough physiologic capacity to defend the airway, and a clinically distinguishable blunted motor response to reflex cough screening.

Incidence, risk factors, and sequelae of dysphagia mediated aspiration following lung transplantation.

BACKGROUND: We aimed to determine dysphagia profiles before and after lung transplantation (prevalence, incidence) and to examine predictors and health-related outcomes of aspiration in individuals undergoing lung transplantation. METHODS: A retrospective single-center study of consecutive adults undergoing lung transplantation and completing a postoperative videofluoroscopic swallowing study between 2017 and 2020 was conducted. The validated penetration aspiration scale indexed swallowing safety and clinical outcomes were extracted from electronic medical records. T-tests, chi square with odds ratios, and multivariable logistic regression were conducted. RESULTS: Two hundred five participants were identified who underwent lung transplantation and a postoperative swallowing exam. Of those who underwent both a pre- and postoperative swallowing exam (n = 170), preoperatively 83% demonstrated safe swallowing and 17% unsafe swallowing. Following lung transplantation, 16% demonstrated safe swallowing and 84% demonstrated unsafe swallowing (39% penetration, 45% aspiration). Independent predictors of postoperative aspiration were venous-venous extracorporeal membrane oxygenation (odds ratio [OR]: 6.7, confidence interval [CI]: 2.0-81.5) and reintubation (OR: 4.5, CI: 1.0-60.3), p < .05. Compared to non-aspirators, aspirators demonstrated higher odds of being discharged to a dependent care setting (OR: 2.3, CI: 1.2-4.5), p < .05. Aspirators spent significantly longer NPO (median = 138.0 hours, 25th percentile, 75th percentile = 75.7, 348.3) compared to non-aspirators (median = 85.0 hours, 25th percentile, 75th percentile = 48.0, 131.6, p < .001). CONCLUSIONS: Pre-existing dysphagia was low in this cohort of patients undergoing lung transplantation, however increased approximately 5-fold following lung transplantation and was associated with increased morbidity.