Japanese clinical practice guidelines for aspiration and pharyngeal residual assessment during eating and swallowing for nursing care.

AIM: This clinical practice guideline aims to provide and recommend methods of assessing aspiration and pharyngeal residue during eating and swallowing and methods of selecting and implementing nursing care for adults to prevent the development of aspiration pneumonia through early and appropriate management of oropharyngeal dysphagia. METHODS: In April 2018, the Japan Academy of Nursing Science established the Supervisory Committee in Nursing Care Development/Standardization Committee to develop clinical practice guidelines for aspiration and pharyngeal residual assessment during eating and swallowing for nursing care. This clinical practice guideline was developed according to the Minds Manual for Guideline Development 2017, with the aim of providing a specific pathway for nurses to determine the policy for selecting management for oropharyngeal dysphagia based on research evidence and multifaceted factors including the balance of benefits and harms and patients' values. RESULTS: Based on the 10 clinical questions related to assessment by physical assessment, the Repetitive Saliva Swallowing Test, Modified Water Swallowing Test, Food Test, cervical auscultation, observation using an ultrasound diagnostic device, and an endoscope, 10 recommendations have been developed. Eight recommendations have been evaluated as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) 2C, and the other two have been evaluated as no GRADE. CONCLUSION: The first reliable clinical practice guideline has been produced from an academic nursing organization that focuses on assessment for nursing care and incorporates the latest findings.

Objective assessment of leg edema using ultrasonography with a gel pad.

Ultrasonography (US) is useful for visual detection of edematous tissues to assess subcutaneous echogenicity. However, visualization of subcutaneous echogenicity is interpreted differently among operators because the evaluation is subjective and individual operators have unique knowledge. This study objectively assessed leg edema using US with a gel pad including fat for normalization of echogenicity in subcutaneous tissue. Five younger adults and four elderly people with leg edema were recruited. We compared assessments of US and limb circumference before and after the intervention of vibration to decrease edema in younger adults, and edema prior to going to sleep and reduced edema in the early morning in elderly people. These assessments were performed twice in elderly people by three operators and reliability, interrater differences, and bias were assessed. For US assessment, echogenicity in subcutaneous tissue was normalized to that of the gel pad by dividing the mean echogenicity of subcutaneous tissue by the mean echogenicity of the gel pad. In younger adults, the normalized subcutaneous echogenicity before the intervention was significantly higher than that after the intervention. In elderly people, echogenicity indicating edema was significantly higher than that after edema reduction. Edema was detected with accuracy rates of 76.9% in younger adults and 75.0% in elderly people. Meanwhile, limb circumference could be used to detect edema in 50.0% of healthy adults and 87.8% of elderly people. The intra-reliability was excellent (intraclass correlation coefficient > 0.9, p < 0.01), and the inter-reliability was good (intraclass correlation coefficient > 0.7, p < 0.01) for normalized subcutaneous echogenicity. Bland-Altman plots revealed that inter-rater differences and systematic bias were small. Normalized subcutaneous echogenicity with the pad can sensitively and objectively assess leg edema with high reliability. Therefore, this method has the potential to become a new gold standard for objective assessment of leg edema in clinical practice.

Assessment of the interstitial fluid in the subcutaneous tissue of healthy adults using ultrasonography.

OBJECTIVE: Lymphoedema involves swelling, especially in the subcutaneous tissues. For lymphoedema management to be successful, it is necessary to remove the interstitial fluid. Subcutaneous echogenicity may be associated with interstitial fluid, but echogenicity is not an indicator for the evaluation of management because we do not directly compare echogenicity with the interstitial fluid. We aimed to identify an outcome indicator for the evaluation of interstitial fluid using ultrasonography. We assessed the correlation between echogenicity and transverse relaxation rate (R2) on magnetic resonance imaging. METHODS: This was an observational study. Healthy adults with leg swelling after activity for >8 h were recruited. The legs of 13 women were evaluated using ultrasonography, magnetic resonance imaging and measurements of the limb circumference before and after an intervention to reduce the swelling. RESULTS: Echogenicity in the oedema group was greater than that of the controls. Echogenicity decreased with reductions in oedema. The range of the strongest correlations with the changes in R2 occurred at echogenicity values of 48-144 (Pearson's correlation coefficient: r = -0.63 and p < 0.01). Thus, it was possible to evaluate the interstitial fluid using echogenicity. CONCLUSION: The outcome indicators for the evaluation of interstitial fluid using ultrasonography were echogenicities in the range of 48-144, and these values were valid for assessing the interstitial fluid in the subcutaneous tissue.