Development of an Accurate Bedside Swallowing Evaluation Decision Tree Algorithm for Detecting Aspiration in Acute Respiratory Failure Survivors.

BACKGROUND: The bedside swallowing evaluation (BSE) is an assessment of swallowing function and airway safety during swallowing. After extubation, the BSE often is used to identify the risk of aspiration in acute respiratory failure (ARF) survivors. RESEARCH QUESTION: We conducted a multicenter prospective study of ARF survivors to determine the accuracy of the BSE and to develop a decision tree algorithm to identify aspiration risk. STUDY DESIGN AND METHODS: Patients extubated after ≥ 48 hours of mechanical ventilation were eligible. Study procedures included the BSE followed by a gold standard evaluation, the flexible endoscopic evaluation of swallowing (FEES). RESULTS: Overall, 213 patients were included in the final analysis. Median time from extubation to BSE was 25 hours (interquartile range, 21-45 hours). The FEES was completed 1 hour after the BSE (interquartile range, 0.5-2 hours). A total of 33% (70/213; 95% CI, 26.6%-39.2%) of patients aspirated on at least one FEES bolus consistency test. Thin liquids were the most commonly aspirated consistency: 27% (54/197; 95% CI, 21%-34%). The BSE detected any aspiration with an accuracy of 52% (95% CI, 45%-58%), a sensitivity of 83% (95% CI, 74%-92%), and negative predictive value (NPV) of 81% (95% CI, 72%-91%). Using recursive partitioning analyses, a five-variable BSE-based decision tree algorithm was developed that improved the detection of aspiration with an accuracy of 81% (95% CI, 75%-87%), sensitivity of 95% (95% CI, 90%-98%), and NPV of 97% (95% CI, 95%-99%). INTERPRETATION: The BSE demonstrates variable accuracy to identify patients at high risk for aspiration. Our decision tree algorithm may enhance the BSE and may be used to identify patients at high risk for aspiration, yet requires further validation. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT02363686; URL: www.clinicaltrials.gov.

Early Injection Laryngoplasty After Surgery: 30 Cases and Proposed Aspiration Assessment Protocol.

Vocal fold movement impairment may significantly compromise postoperative recovery and quality of life of patients following thoracic or cardiothoracic surgery or prolonged intubation. The literature is limited and there is no standard screening protocol for the optimal postoperative swallowing and aspiration evaluations. We performed retrospective review of adult patients undergoing early vocal fold (VF) injection laryngoplasty for acute postoperative Vocal fold movement impairment (<30 days) that had both pre- and postinjection speech language pathologist (SLP) performed swallowing/aspiration evaluations. Records were reviewed for demographics, clinical characteristics, procedural details, and short-term outcome measures of oral intake. In total, 30 patients were included, and had data on swallowing/aspiration studies before and after the VF injection laryngoplasty. Most of the patients were injected within 5 days following the laryngologist evaluation and within 14 days following the iatrogenic recurrent laryngeal nerve injury (23/30, 76.7%). The majority of patients were injected at the bedside by awake transcutaneous injection (22/30, 73.3%), six patients were injected in the operating room under general anesthesia, and two at the outpatient clinic. Pre- and postinjection SLP evaluations included clinical bedside assessment or instrumental evaluation. Following VF injection laryngoplasty, oral diet advancement was noted in 81.8% of the patients that were nil per os before the injection (18/22). No complications were noted. In conclusions, acute VFMI following surgery requires immediate diagnosis and therapeutic strategy to minimize postoperative complications and to overcome impairments in the voice, swallow, and cough. Otolaryngology-SLP interdisciplinary aspiration and swallowing assessment protocol is proposed based on our experience and an extensive literature review.

Ultrasound assessment of gastric antrum in term pregnant women before elective cesarean section / Ultrassom de antro gástrico em gestantes a termo antes de cesariana eletiva

Abstract Background and objectives: Pregnant women are considered patients at risk for pulmonary aspiration of gastric contents. The study aim was to evaluate the gastric antral cross-sectional area using ultrasound. Method: In this prospective study, 85 scheduled term pregnant women underwent gastric ultrasound. The outcomes were the measurement of the gastric antral cross-sectional area (main outcome), the estimated gastric volume, the incidence of pregnant women at risk for pulmonary aspiration, and the association between gastric antral cross-sectional area and clinical-demographic characteristics. Gastric antral cross-sectional area and gastric volume were compared according to body mass index <30 or ≥30. Results: The median (IIQ) for gastric antral cross-sectional area was 4 cm2 (2.8-6.3), for the estimated gastric volume it was 49.8 mL (33.7-87.2), and for the gastric volume estimated in mL.kg-1 it was 0.62 mL.kg-1 (0.39-0.95). The 95th percentile [95% confidence interval (CI)] of the gastric antral cross-sectional area and the estimated gastric volume were ≤10.3 cm2 (95% CI: 7.6-15.6) and 1.42 mL.kg-1 (95% CI: 1.20-2.64), respectively. The incidence of pregnant women at risk for pulmonary aspiration was 3.5% (CI: 3.5 (1.2-9.8)). There was a positive correlation between gastric antral cross-sectional area and weight, p < 0.001 and body mass index <0.001. Patients with a body mass index ≥30 had a gastric antral cross-sectional area and an estimated gastric volume greater than those with a body mass index <30, respectively, p < 0.01 and p < 0.02. Conclusion: Measuring the gastric antral cross-sectional area of pregnant women is feasible and easy. There was positive correlation between gastric antral cross-sectional area, body weight and body mass index. The estimation of gastric volume by measuring the gastric antral cross-sectional area can identify patients at risk for pulmonary aspiration. Obese patients had a gastric antral cross-sectional area and an estimated gastric volume greater than non-obese patients.

Resumo Justificativa e objetivos: As gestantes são consideradas pacientes de risco para aspiração pulmonar do conteúdo gástrico. O objetivo foi avaliar a área transversal do antro gástrico por meio de ultrassonografia. Método: Neste estudo prospectivo, 85 gestantes a termo agendadas foram submetidas à ultrassonografia do antro gástrico. Os desfechos foram a mensuração da área transversal do antro gástrico (desfecho principal), a estimativa do volume gástrico, a incidência de gestantes sob risco de aspiração pulmonar, a associação entre a área transversal do antro gástrico e características clínico-demográficas. A área transversal do antro gástrico e do volume gástrico foi comparada de acordo com o índice de massa corporal < 30 ou ≥ 30. Resultados: A mediana (IIQ) da área transversal do antro gástrico foi 4 cm2 (2,8-6,3), do volume gástrico estimado 49,8 mL (33,7-87,2) e do volume gástrico estimado em mL.kg-1 de 0,62 mL.kg-1 (0,39-0,95). O percentil 95 [intervalo de confiança (IC) 95%] da área transversal do antro gástrico e do volume gástrico estimado foi ≤ 10,3 cm2 (IC 95%: 7,6-15,6) e 1,42 mL.kg-1 (IC 95%: 1,20-2,64), respectivamente. A incidência de gestantes sob risco de aspiração pulmonar foi de 3,5% (IC: 3,5 (1,2-9,8). Houve correlação positiva entre a área transversal do antro gástrico e peso, p < 0,001 e índice de massa corporal p < 0,001. As pacientes com índice de massa corporal ≥ 30 apresentaram maior área transversal do antro gástrico, e do volume gástrico estimado, do que as com índice de massa corporal < 30, respectivamente p < 0,01 e p < 0,02. Conclusão: A mensuração da área transversal do antro gástrico de gestantes é factível e fácil. A área transversal do antro gástrico correlacionou-se positivamente com peso e índice de massa corporal. A estimativa do volume gástrico através da mensuração da área transversal do antro gástrico pode identificar pacientes sob risco de aspiração pulmonar. As pacientes obesas apresentaram área transversal do antro gástrico e volume gástrico estimado maior do que as não obesas.

[Ultrasound assessment of gastric antrum in term pregnant women before elective cesarean section]. / Ultrassom de antro gástrico em gestantes a termo antes de cesariana eletiva.

BACKGROUND AND OBJECTIVES: Pregnant women are considered patients at risk for pulmonary aspiration of gastric contents. The study aim was to evaluate the gastric antral cross-sectional area using ultrasound. METHOD: In this prospective study, 85 scheduled term pregnant women underwent gastric ultrasound. The outcomes were the measurement of the gastric antral cross-sectional area (main outcome), the estimated gastric volume, the incidence of pregnant women at risk for pulmonary aspiration, and the association between gastric antral cross-sectional area and clinical-demographic characteristics. Gastric antral cross-sectional area and gastric volume were compared according to body mass index <30 or ≥ 30. RESULTS: The median (IIQ) for gastric antral cross-sectional area was 4cm2 (2.8-6.3), for the estimated gastric volume it was 49.8mL (33.7-87.2), and for the gastric volume estimated in mL.kg-1 it was 0.62mL.kg-1 (0.39-0.95). The 95th percentile [95% confidence interval (CI)] of the gastric antral cross-sectional area and the estimated gastric volume were ≤ 10.3cm2 (95% CI: 7.6-15.6) and 1.42mL.kg-1 (95% CI: 1.20-2.64), respectively. The incidence of pregnant women at risk for pulmonary aspiration was 3.5% (CI: 3.5 (1.2-9.8). There was a positive correlation between gastric antral cross-sectional area and weight, p <0.001 and body mass index <0.001. Patients with a body mass index ≥ 30 had a gastric antral cross-sectional area and an estimated gastric volume greater than those with a body mass index <30, respectively, p <0.01 and p <0.02. CONCLUSION: Measuring the gastric antral cross-sectional area of pregnant women is feasible and easy. There was positive correlation between gastric antral cross-sectional area, body weight and body mass index. The estimation of gastric volume by measuring the gastric antral cross-sectional area can identify patients at risk for pulmonary aspiration. Obese patients had a gastric antral cross-sectional area and an estimated gastric volume greater than non-obese patients.

Periprocedural pulmonary aspiration: An analysis of medical malpractice cases and alleged causative factors.

RATIONALE AIMS AND OBJECTIVES: Pulmonary aspiration is a feared complication of anaesthesia that is associated with significant morbidity and mortality. Within the small existing body of literature on medical malpractice claims related to periprocedural aspiration, very little information is available regarding the case-specific factors that were alleged to contribute to each aspiration event. METHODS: This study searched an extensive nationwide database of medical malpractice claims and identified 43 relating to periprocedural pulmonary aspiration. RESULTS: The most common mechanism of causation cited in these claims (37%) was the failure to secure the airway with an endotracheal tube (ETT) when an elevated aspiration risk existed, most commonly because endotracheal intubation was not originally selected as part of the anaesthetic plan. The second most common alleged category of causation (33%) was the failure to perform a proper rapid-sequence induction and/or place a nasogastric tube (NGT) for decompression prior to induction. An equal amount of cases resulted in defendant versus plaintiff verdicts (44.2% each), while a settlement was reached in the remaining 11.6% of cases. CONCLUSION: These findings are generalizable to clinical practice improvement on a broader scale. They demonstrate the need to develop reliable, high-sensitivity tests for detecting elevated risk before clinicians can be expected to take special steps to protect susceptible patients, and they also show that medical malpractice can be alleged because of failure to uphold currently accepted standards of care even when the published evidence for those standards is weak. This study demonstrates that careful review of medical malpractice litigation can elucidate common contributory factors and facilitate improvements in clinical practice and decision-making.

Collecting Nursing Research Data 24 Hours a Day: Challenges, Lessons, and Recommendations.

BACKGROUND: Research on many routine nursing interventions requires data collection around the clock each day (24/7). Strategies for implementing and coordinating a study 24/7 are not discussed in the literature, and best practices are needed. OBJECTIVE: To identify strategies incorporated into implementing a nursing intervention trial 24/7, including key lessons learned. METHODS: Strategies to facilitate implementation of a clinical trial of a nursing intervention with patients undergoing mechanical ventilation are shared. Challenges and changes for future studies also are discussed. RESULTS: Adequate planning, including a detailed operations manual, guides study implementation. Staffing is the most challenging and costly part of a study but is essential to a study's success. Other important strategies include communication among the study personnel and with collaborators and direct care staff. An electronic method of recording study-related data also is essential. CONCLUSIONS: A nursing clinical trial that requires interventions on a 24/7 basis can be done with thorough planning, staffing, and continuous quality improvement activities.

The Pediatric Version of the Eating Assessment Tool: a caregiver administered dyphagia-specific outcome instrument for children.

PURPOSE: To develop and evaluate the psychometric properties of the Pediatric version of the caregiver administered Eating Assessment Tool. METHODS: The study included developmental phase and reported content, criterion validity, internal consistency and test-retest reliability of the Pediatric Eating Assessment Tool. Literature review and the original Eating Assessment Tool were used for line-item generation. Expert consensus assessed the items for content validity over two Delphi rounds. Fifty-one healthy children to obtain normative data and 138 children with cerebral palsy to evaluate test-retest reliability, internal consistency, and criterion validity were included. The Penetration-Aspiration Scale was used to assess criterion validity. RESULTS: All items were found to be necessary. Content validity index was 0.91. The mean score of Pediatric Eating Assessment Tool for healthy children and children with cerebral palsy was 0.26 ± 1.83 and 19.5 ± 11, respectively. The internal consistency was high with Cronbach's alpha =0.87 for test and retest. An excellent correlation between the Pediatric Eating Assessment Tool and Penetration-Aspiration score for liquid and pudding swallowing was found (p < 0.001, r = 0.77; p < 0.001, r = 0.83, respectively). A score >4 demonstrated a sensitivity of 91.3% and specificity of 98.8% to predict penetration/aspiration. CONCLUSIONS: The Pediatric Eating Assessment Tool was shown to be a valid and reliable tool to determine penetration/aspiration risk in children. Implications for rehabilitation The pediatric eating assessment tool: a new dyphagia-specific outcome survey for children. The Pediatric Version of the Eating Assessment Tool is a dysphagia specific, parent report outcome instrument to determine penetration/aspiration risk in children. The Pediatric Version of the Eating Assessment Tool has good internal consistency, test-retest reliability and criterion-based validity. The Pediatric Version of the Eating Assessment Tool may be utilized as a clinical instrument to assess the need for further instrumental evaluation of swallowing function in children.

Point-of-care gastric ultrasound and aspiration risk assessment: a narrative review.

This narrative review summarizes the current knowledge on point-of-care ultrasound (POCUS) of gastric contents in order to inform an assessment of aspiration risk and guide anesthetic management at the bedside. An I-AIM framework (Indication, Acquisition, Interpretation, and Medical decision-making) is used to summarize and organize the content areas. This narrative review spans the breadth of the literature on pediatric and adult subjects as well as on special patient populations such as obstetric and severely obese individuals. Areas that need further investigation include the diagnostic accuracy of gastric POCUS from a Bayesian perspective and the impact of POCUS on patient outcomes, healthcare economics, and educational curricula.

Cost-Effectiveness Analysis of Interventions to Reduce Risk of Aspiration in Elderly Cancer Survivors Residing in Skilled Nursing Facilities.

BACKGROUND: Aspiration can occur in patients of any age group, but it can be prevented. The primary population at risk is made up of survivors of cancer because of their increased risk of mucositis, mucosal atrophy, and dysphagia associated with chemotherapy, radiotherapy, and the disease process itself. The rate of incidence of aspiration cannot be quantified, because minor cases of aspiration often go unreported. Sequelae ensuing from aspirations can include pneumonia, end-stage kidney disease, dialysis, and death. METHODS: Analyses of cost, decision-tree modeling, and cost effectiveness were performed to compare a hypothetical, interventional model based on best practices with usual (standard) care. A societal perspective was used as the economic view point. Direct costs, caregiver time, and market values for wages were estimated for the 2 interventions. Effectiveness values for the cost-effectiveness and decision-tree analyses were obtained from the literature. The incremental-cost-effectiveness ratio was calculated and used to compare the intervention with usual care. RESULTS: The interventional method was more costly but more effective than usual care. A sensitivity analysis considered the uncertainty of event probability (aspiration vs no aspiration). The interventional protocol for aspiration reduction continued to be more cost effective than usual care. CONCLUSIONS: Aspiration takes a financial toll on all facets of health care, including on nurses, skilled nursing facilities, patients, their families, and insurers, among others. Implementing guidelines that describe best practices for aspiration appears to be a cost-effective strategy for reducing aspirations among cancer survivors - especially elderly patients - who live in skilled nursing facilities.

Incident management guidelines for an ingested orthodontic object.

Dental materials or components of orthodontics devices can fall into a patient's oropharynx, and be swallowed or inhaled. In this paper a short review of accidental foreign body ingestion/aspiration prevention, evaluation, and relevant incident management guidelines are presented. In addition, a case of an accidentally swallowed piece of archwire during a chair side procedure is reported.

A novel method for the nonradiological assessment of ineffective swallowing.

OBJECTIVES: This validation study evaluates a new manometry impedance-based approach for the objective assessment of pharyngeal function relevant to postswallow bolus residue. METHODS: We studied 23 adult and pediatric dysphagic patients who were all referred for a videofluoroscopy, and compared these patients with 10 adult controls. The pharyngeal phase of swallowing of semisolid boluses was recorded with manometry and impedance. Fluoroscopic evidence of postswallow bolus residue was scored. Pharyngeal pressure impedance profiles were analyzed. Computational algorithms measured peak pressure (Peak P), pressure at nadir impedance (PNadImp), time from nadir impedance to PeakP (PNadImp-PeakP), the duration of impedance drop in the distal pharynx (flow interval), upper esophaghageal sphincter (UES) relaxation interval (UES-RI), nadir UES pressure (NadUESP), UES intrabolus pressure (UES-IBP), and UES resistance. A swallow risk index (SRI) was derived by the formula: SRI=(FI × PNadImp)/(PeakP × (TNadImp-PeakP+1)) × 100. RESULTS: In all, 76 patient swallows (35 with residue) and 39 control swallows (12 with residue) were analyzed. Different functional variables were found to be altered in relation to residue. In both controls and patients, flow interval was longer in relation to residue. In controls, but not patients, residue was associated with an increased PNadImp (suggestive of increased pharyngeal IBP). Controls with residue had increased UES-IBP, NadUESP, and UES resistance compared with patients with residue. Residue in patients was related to a prolonged UES-RI. The SRI was elevated in relation to residue in both controls and patients and an average SRI of 9 was optimally predictive of residue (sensitivity 75% and specificity 80%). CONCLUSIONS: We present novel findings in control subjects and dysphagic patients showing that combined manometry and impedance recordings can be objectively analyzed to derive pressure-flow variables that are altered in relation to the bolus residual and can be combined to predict ineffective pharyngeal swallowing.

Risk and safety of anesthesia outside the operating room.

More and more frequently anaesthetists must be able to provide complete, integrated anaesthetic care outside the traditional environment of the operating room. Providing non-operating room anaesthesia (NORA) has gained widespread popularity. Both the number and the complexity of these therapeutic and diagnostic procedures is increasing. Performing NORA cannot, in most cases, be compared with traditional anaesthesia care inside the operating room. NORA might carry a higher risk as opposed to anaesthesia inside the operating room. It has its specific logistical problems resulting in specific patient selection, pre-operative patient assessment, per-operative morbidity and mortality and post-operative patient follow-up and treatment. From what is available in the literature paediatric patients carry a high risk of complications; monitored anaesthesia care is associated with more complications and substandard care is often present. Despite these potential risks, the mortality and morbidity related to NORA is infrequently studied and poorly described. Most authors agree that improvements in monitoring are essential to decrease the complication rate.

Knowledge, attitude, and practice regarding cricoid pressure of ED personnel at a large U.S. teaching hospital.

INTRODUCTION: Application of cricoid pressure (CP) is an important step during rapid sequence intubation. Previous surveys of anesthesia personnel showed a knowledge deficiency in the recommended level of cricoid force. There has been no previous attempt to assess the adequacy of knowledge of ED personnel in the application of CP. The objective of this study was to assess the theoretic knowledge of ED personnel about CP. METHODS: We carried out a convenience sample of all ED personnel present at the morbidity and mortality meeting of a major US teaching hospital. A questionnaire-based survey was distributed; respondents were unaware of the questions or the nature of the survey before participating. RESULTS: In total, 83 completed questionnaires were returned by 38 residents, 25 attending physicians, and 20 nurses. Many of the respondents knew the anatomic structure to which CP is applied. However, 24 respondents (14 nurses and 10 residents) thought that CP is applied to both the cricoid and thyroid cartilage. Interestingly, 70% of the nurses in this survey gave an incorrect response to the question on the anatomic localization of CP. Many of the participants in this survey either were unsure of the recommended amount of cricoid force in the asleep patient or quoted values that were too low. The majority of respondents rated their training in CP application as either poor or nonexistent. Most were able to name 2 contraindications to the application of CP. DISCUSSION: The theoretic knowledge about CP is poor in this survey from staff at a major US teaching hospital. Poor theoretic knowledge could lead to poor technique in the application of CP. More specific education and training are needed to improve the clinical use of CP and possibly increase patient safety.