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.

Exploring the scope of post-intensive care syndrome therapy and care: engagement of non-critical care providers and survivors in a second stakeholders meeting.

BACKGROUND: Increasing numbers of survivors of critical illness are at risk for physical, cognitive, and/or mental health impairments that may persist for months or years after hospital discharge. The post-intensive care syndrome framework encompassing these multidimensional morbidities was developed at the 2010 Society of Critical Care Medicine conference on improving long-term outcomes after critical illness for survivors and their families. OBJECTIVES: To report on engagement with non-critical care providers and survivors during the 2012 Society of Critical Care Medicine post-intensive care syndrome stakeholder conference. Task groups developed strategies and resources required for raising awareness and education, understanding and addressing barriers to clinical practice, and identifying research gaps and resources, aimed at improving patient and family outcomes. PARTICIPANTS: Representatives from 21 professional associations or health systems involved in the provision of both critical care and rehabilitation of ICU survivors in the United States and ICU survivors and family members. DESIGN: Stakeholder consensus meeting. Researchers presented summaries on morbidities for survivors and their families, whereas survivors presented their own experiences. MEETING OUTCOMES: Future steps were planned regarding 1) recognizing, preventing, and treating post-intensive care syndrome, 2) building strategies for institutional capacity to support and partner with survivors and families, and 3) understanding and addressing barriers to practice. There was recognition of the need for systematic and frequent assessment for post-intensive care syndrome across the continuum of care, including explicit "functional reconciliation" (assessing gaps between a patient's pre-ICU and current functional ability at all intra- and interinstitutional transitions of care). Future post-intensive care syndrome research topic areas were identified across the continuum of recovery: characterization of at-risk patients (including recognizing risk factors, mechanisms of injury, and optimal screening instruments), prevention and treatment interventions, and outcomes research for patients and families. CONCLUSIONS: Raising awareness of post-intensive care syndrome for the public and both critical care and non-critical care clinicians will inform a more coordinated approach to treatment and support during recovery after critical illness. Continued conceptual development and engagement with additional stakeholders is required.

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.

Supported Communication Video Training for the Nursing Department in an Inpatient Rehabilitation Hospital.

PURPOSE: The aim of this study was to develop a valid educational intervention to improve knowledge and confidence using communication strategies when interacting with a person with aphasia. DESIGN: A quantitative, nonrandomized pretest/posttest research study was performed. METHODS: Pre- and postcourse assessments were completed with learning participants. This educational intervention was developed using the underlying theoretical concepts of the integrated behavioral model. RESULTS: Forty-nine new employees from the nursing department participated in this study, with 61% reporting less than 1 year of experience. Pre- to posttraining assessments on the Test of Knowledge of Aphasia improved from 3.7 to 5.8 (p ≤ .0001) for direct knowledge, from 5.5 to 8.2 (p ≤ .0001) for confidence self-efficacy, and from 5.3 to 7.6 (p ≤ .0001) for knowledge self-efficacy. CONCLUSION: Results indicated this theory-driven educational training was effective in training employees from the nursing department working in an inpatient rehabilitation environment. CLINICAL RELEVANCY: Improving communication effectiveness is critical for overall quality of care and patient safety.

Predictors of returning to oral feedings after feeding tube placement for patients poststroke during inpatient rehabilitation.

OBJECTIVES: To identify the frequency and characteristics of patients admitted to inpatient rehabilitation (IPR) following a stroke who are able return to oral feedings and have their feeding tube (FT) removed prior to discharge from IPR, the timing of FT removal, and implications for outcomes. METHODS: Medical records were identified by admission rehabilitation impairment code (RIC) for stroke (RIC 01), and reviews were completed by two physiatrists and two speech language pathologists. At random, 25% of the charts were reviewed by a second rater for data quality control. Measures collected during the chart review included the following: age, gender, onset of stroke, rehabilitation length of stay (LOS), admission and discharge FIM, discharge destination, diet level, and feeding tube status. RESULTS: One hundred forty-three patients were identified as subjects for this investigation who had an FT and were NPO upon IPR admission. Overall, 46.9% (67/143) of the patients returned to three meals daily prior to discharge from IPR. The mean days post stroke onset until returning to three meals daily was 38.43 days (SD=26.36). Twenty percent (30/143) of the patients were able to have their FT tube removed prior to discharge from IPR. Factors associated with returning to three meals included gender (ie, female), longer IPR LOS, and higher admission FIM scores at IPR. Factors associated with removal of the feeding tube included a longer IPR LOS and younger age. Patients who were able to have their FT removed were more likely to be discharged to home. CONCLUSION: Individuals with longer IPR LOS were more likely to return to three meals daily and have their feeding tubes removed prior to discharge.

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.

Self-Reported Quality of Life Outcomes in Aphasia Using Life Participation Approach Values: 1-Year Outcomes.

OBJECTIVE: To evaluate the effectiveness of a newly initiated aphasia center program using Life Participation Approach to Aphasia (LPAA) values. DESIGN: Evidence-based practice quality improvement project. SETTING: Ambulatory care aphasia center part of a larger health care system. PARTICIPANTS: Participants included 41 clients with aphasia and 40 primary caregivers of clients with aphasia. Participants included all clients and caregivers that were enrolled in the aphasia center within the first year of opening. All participants were enrolled in 1-4 eleven-week sessions of the aphasia center program. Participants with aphasia included 19 women and 22 men with a mean age of 65.2 years (range, 33-84 years). INTERVENTIONS: Group therapy was provided using the LPAA statement of values with each client receiving 3 hours of treatment once per week for 11 weeks. Clients were provided with the opportunity to complete multiple 11-week enrollment sessions if they chose to do so. MAIN OUTCOME MEASURES: Client-reported outcomes included the Stroke and Aphasia Quality of Life Scale, and caregiver-reported outcomes included the Modified Caregiver Strain Index. Both measures are self-reported and scale based. Client satisfaction data were also collected via a self-reported program evaluation upon completion of each 11-week session. RESULTS: Results indicated statistically significant improvements in quality of life scores for clients with aphasia following initial participation of an 11-week aphasia center program (P≤.0001) and following 1-year participation (P≤.0001). Additionally, caregiver's level of burden decreased significantly following initial participation of the family member (P=.003) and following completion of three 11-week sessions (P≤.0001). Self-reported client satisfaction program evaluation results also demonstrated improved quality of life (100%) and improved language skills (average=89.75%). CONCLUSIONS: The project provided further evidence supporting the use of LPAA values with clients experiencing chronic aphasia.

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.

Secretions, occlusion status, and swallowing in patients with a tracheotomy tube: a descriptive study.

We conducted a prospective, descriptive study of 40O tracheotomized patients to investigate the relationships between (1) levels of accumulated oropharyngeal secretions and laryngealpenetration/aspiration status, (2) secretion levels and tube-occlusion status, and (3) tube-occlusion status and aspiration status. Assessments of secretion status were quantified with the use of a 5-point rating scale. All evaluations were made by fiberoptic endoscopic evaluation of swallowing. We found that patients with higher secretion levels were more likely to aspirate than were patients with lower secretion levels. Also, patients who tolerated placement of a tube cap had the lowest mean secretion level, and those who tolerated only light finger occlusion had the highest; likewise, most patients with normal secretion levels tolerated a capped tube, and a plurality of patients with profound secretion levels tolerated only light finger occlusion. Finally, no significant differences were observed with respect to occlusion status and aspiration rates.

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.

The inadequacy of Individual Educational Program (IEP) goals for high school students with word-level reading difficulties.

This investigation analyzed goals from the Individual Educational Programs (IEPs) of 54 high school students with diagnosed reading disabilities in basic skills (decoding and/or word identification). Results showed that for 73% of the students, the IEPs written when they were in high school failed to specify any objectives regarding their acute difficulties with basic skills. IEPs from earlier points in the students' educations were also reviewed, as available. For 23 of the students, IEPs were present in the students' files for three time points: elementary school (ES), middle school (MS), and high school (HS). Another 20 students from the sample of 54 had IEPs available for two time points (HS and either MS or ES). Comparisons with the IEPs from younger years showed a pattern of decline from ES to MS to HS in the percentage of IEPs that commented on or set goals pertaining to weaknesses in decoding. These findings suggest that basic skills deficits that persist into the upper grade levels are not being sufficiently targeted for remediation, and help explain why older students frequently fail to resolve their reading problems.

The effects of breath-holding on vocal fold adduction: implications for safe swallowing.

OBJECTIVE: To determine the effects, if any, of 3 different breath-holding techniques on a person's ability to attain vocal fold closure (VFC) to successfully complete swallowing maneuvers. DESIGN: Prospective, randomized study. SETTING: Private practice. PATIENTS: A total of 150 healthy volunteers recruited from private practice patients and community volunteers. Intervention Group 1 received the easy breath-hold instruction; group 2 received the inhale/easy breath-hold instruction; and group 3 received the hard breath-hold instruction. MAIN OUTCOME MEASURE: Closure of true and false vocal folds following the breath-hold instruction. RESULTS: In the easy breath-hold group, true VFC occurred in 82% of the subjects, and closure of both the true and false vocal folds occurred in 30%. In the inhale/easy breath-hold group, true VFC occurred in 62%, and closure of both folds occurred in 46%. In the hard breath-hold group, true VFC occurred in 86%, and closure of both folds occurred in 64%. The differences among the 3 groups were significant for true VFC (chi2=9.242; P=.01) and for closure of both folds (chi2=11.625; P=.003). CONCLUSIONS: The hard breath-hold instruction was the most effective method to attain full laryngeal closure, and the inhale/easy breath-hold instruction was the least effective method to attain true VFC for safe swallowing.

Sterilisations in girls and young women: is it still happening?

OBJECTIVE: To determine whether sterilising procedures - hysterectomies, endometrial ablations or tubal ligations - are being performed in minors for non-therapeutic reasons, without Family Law Court approval. METHODS: Victorian Admitted Episode Dataset 1996-99 was used to identify all young women < 18 who had a sterilising procedure. Associated codes for indications and pathology were reviewed to exclude malignancies, congenital anomalies, potential miscoding and misleading codes associated with endometriosis. RESULTS: Although 40 procedures were identified from the dataset, the majority of these can be excluded after review of the associated codes. In two cases sterilising procedures were performed without clear therapeutic indications and it is likely they were done in young women with disabilities. No Family Law Court applications were heard in this time period, thus it is likely they represent unlawful sterilisations. CONCLUSIONS: It would appear that sterilisations without Family Law Court approval are probably occurring at very low rates in Victoria.

Predictive value of accumulated oropharyngeal secretions for aspiration during video nasal endoscopic evaluation of the swallow.

The purpose of this prospective study was to investigate the predictive value of oropharyngeal secretions by use of 5-point and modified 3-point secretion scales for aspiration of food or liquid and diet recommendation outcomes. One hundred consecutive patients and 4 control subjects participated. The 5-point secretion severity scale correlated highly to aspiration (Spearman's rho = .516, p < .0001) and to diet recommendation outcomes (Spearman's rho = .72, p < .0001). Patients who received tube feedings were more likely to demonstrate a higher secretion level than patients who received oral feedings (Pearson chi squared analysis value = 25.461, p < .0001). Patients with a tracheotomy tube tended to demonstrate higher secretion levels than patients without a tracheotomy tube (Spearman's rho = .446, p < .0001). The relationship of the 3-point secretion severity scale level with aspiration was .488, p < .0001 (Spearman's rho), and that with diet recommendation outcomes was .746, p < .0001 (Spearman's rho).

The modified barium swallow and the functional endoscopic evaluation of swallowing.

This article reviews the current standard of care for the instrumental evaluation of swallow function using the modified barium swallow (MBS) and the functional endoscopic evaluation of swallowing (FEES). Both the MBS and FEES are valuable procedures for evaluating dysphagia and show good agreement with diagnostic findings as related to tracheal aspiration, laryngeal penetration, pharyngeal residue, diet level, and compensatory swallow safety strategies. The use of the MBS and FEES has advantages and disadvantages and both should be considered the gold standard for evaluating swallow function.

The effect of vocabulary knowledge on novel word identification.

The study investigated the relationship between vocabulary knowledge and novel word reading. Fourth-grade students were assessed on standardized measures of word identification, decoding, and receptive vocabulary, as well as on an experimental word identification measure using words that students in the fourth grade are unlikely to have seen before in print. In the experimental measure, pairs of words were matched on printed frequency and orthographic pattern (with a variety of spelling patterns represented), but differed in terms of the frequency of expected oral exposure for children (i.e., higher vs. lower). Results showed that students' receptive vocabulary knowledge was significantly related to performance on both the standardized and experimental measures of word identification, even after accounting for the substantial amount of variance explained by decoding ability. Students performed better reading the words with higher expected oral frequencies on the experimental task than on those items with lower expected oral frequencies. The results point to the benefits, albeit modest, of oral word familiarity for reading words when they are first encountered in print and suggest that this top-down effect is not limited to exception words, as has been suggested, but has a wider scope.

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.