Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial.

BACKGROUND: Aspiration pneumonia is common among frail elderly persons with dysphagia. Although interventions to prevent aspiration are routinely used in these patients, little is known about the effectiveness of those interventions. OBJECTIVE: To compare the effectiveness of chin-down posture and 2 consistencies (nectar or honey) of thickened liquids on the 3-month cumulative incidence of pneumonia in patients with dementia or Parkinson disease. DESIGN: Randomized, controlled, parallel-design trial in which patients were enrolled for 3-month periods from 9 June 1998 to 19 September 2005. SETTING: 47 hospitals and 79 subacute care facilities. PATIENTS: 515 patients age 50 years or older with dementia or Parkinson disease who aspirated thin liquids (demonstrated videofluoroscopically). Of these, 504 were followed until death or for 3 months. INTERVENTION: Participants were randomly assigned to drink all liquids in a chin-down posture (n = 259) or to drink nectar-thick (n = 133) or honey-thick (n = 123) liquids in a head-neutral position. MEASUREMENTS: The primary outcome was pneumonia diagnosed by chest radiography or by the presence of 3 respiratory indicators. RESULTS: 52 participants had pneumonia, yielding an overall estimated 3-month cumulative incidence of 11%. The 3-month cumulative incidence of pneumonia was 0.098 and 0.116 in the chin-down posture and thickened-liquid groups, respectively (hazard ratio, 0.84 [95% CI, 0.49 to 1.45]; P = 0.53). The 3-month cumulative incidence of pneumonia was 0.084 in the nectar-thick liquid group compared with 0.150 in the honey-thick liquid group (hazard ratio, 0.50 [CI, 0.23 to 1.09]; P = 0.083). More patients assigned to thickened liquids than those assigned to the chin-down posture intervention had dehydration (6% vs. 2%), urinary tract infection (6% vs. 3%), and fever (4% vs. 2%). LIMITATIONS: A no-treatment control group was not included. Follow-up was limited to 3 months. Care providers were not blinded, and differences in cumulative pneumonia incidence between interventions had wide CIs. CONCLUSION: No definitive conclusions about the superiority of any of the tested interventions can be made. The 3-month cumulative incidence of pneumonia was much lower than expected in this frail elderly population. Future investigation of chin-down posture combined with nectar-thick liquid may be warranted to determine whether this combination better prevents pneumonia than either intervention independently.

Comparison of trained clinician ratings with expert ratings of aspiration on videofluoroscopic images from a randomized clinical trial.

Accurate detection and classification of aspiration is a critical component of videofluoroscopic swallowing evaluation, the most commonly utilized instrumental method for dysphagia diagnosis and treatment. Currently published literature indicates that interjudge reliability for the identification of aspiration ranges from poor to fairly good depending on the amount of training provided to clinicians. The majority of extant studies compared judgments among clinicians. No studies included judgments made during the use of a postural compensatory strategy. The purpose of this study was to examine the accuracy of judgments made by speech-language pathologists (SLPs) practicing in hospitals compared with unblinded expert judges when identifying aspiration and using the 8-point Penetration/Aspiration Scale. Clinicians received extensive training for the detection of aspiration and minimal training on use of the Penetration/Aspiration Scale. Videofluoroscopic data were collected from 669 patients as part of a large, randomized clinical trial and include judgments of 10,200 swallows made by 76 clinicians from 44 hospitals in 11 states. Judgments were made on swallows during use of dysphagia compensatory strategies: chin-down posture with thin liquids and head-neutral posture with thickened liquids (nectar-thick and honey-thick consistencies). The subject population included patients with Parkinson's disease and/or dementia. Kappa statistics indicate high accuracy for all interventions by SLPs for identification of aspiration (all kappa > 0.86) and variable accuracy (range = 69-76%) using the Penetration/Aspiration Scale when compared to expert judges. It is concluded that while the accuracy of identifying the presence of aspiration by SLPs is excellent, more extensive training and/or image enhancement is recommended for precise use of the Penetration/Aspiration Scale.

A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson's disease.

PURPOSE: This study was designed to identify which of 3 treatments for aspiration on thin liquids-chin-down posture, nectar-thickened liquids, or honey-thickened liquids-results in the most successful immediate elimination of aspiration on thin liquids during the videofluorographic swallow study in patients with dementia and/or Parkinson's disease. METHOD: This randomized clinical trial included 711 patients ages 50 to 95 years who aspirated on thin liquids as assessed videofluorographically. All patients received all 3 interventions in a randomly assigned order during the videofluorographic swallow study. RESULTS: Immediate elimination of aspiration on thin liquids occurred most often with honey-thickened liquids for patients in each diagnostic category, followed by nectar-thickened liquids and chin-down posture. Patients with most severe dementia exhibited least effectiveness on all interventions. Patient preference was best for chin-down posture followed closely by nectar-thickened liquids. CONCLUSION: To identify best short-term intervention to prevent aspiration of thin liquid in patients with dementia and/or Parkinson's disease, a videofluorographic swallow assessment is needed. Evidence-based practice requires taking patient preference into account when designing a dysphagic patient's management plan. The longer-term impact of short-term prevention of aspiration requires further study.

Timing of events during deglutition after chemoradiation therapy for oropharyngeal carcinoma.

BACKGROUND: The purpose of this study was to determine if persistent changes in the duration of bolus movement through the pharynx and bolus movement coordination with pharyngeal swallowing gestures occur after treatment of oropharyngeal carcinoma with chemoradiation therapy. METHODS: The timing of bolus movement and coordination with swallowing gestures was evaluated in 30 patients using a modified barium swallowing study at least 1 year after completion of treatment. Patients were recruited irrespective of any swallowing complaints. The mean of each measure from the study subjects was compared to those from a group of age-matched controls. RESULTS: Bolus transit duration in the study population was unchanged compared with normal controls. Unlike normal controls, the patients were found to allow the bolus to arrive in the vallecula before the initiation of swallowing gestures that resulted in a swallow. Earlier opening of the upper esophageal sphincter was found for a 1-cc bolus (p = .004). For the 20 cc bolus size, the onset of hyoid and aryepiglottic fold elevation was delayed (p = .029 and .037, respectively). Gesture timing did not change to accommodate larger bolus sizes, as it normally does, resulting in a delay in airway protection for the 20-cc bolus. CONCLUSION: Patients are able to move a liquid bolus through the pharynx in a timely manner. However, patients are unable to modify swallowing gestures to safely protect the airway.

Quality-of-life scores compared to objective measures of swallowing after oropharyngeal chemoradiation.

OBJECTIVES/HYPOTHESIS: To compare objective measures of swallowing function with patient reports of swallowing-related quality of life 1 year after treatment of oropharyngeal cancer with chemoradiation therapy. STUDY DESIGN: Patients seen for follow-up at least 1 year after treatment of oropharyngeal carcinoma with chemoradiation therapy were sequentially approached and asked to participate in the study. METHODS: Maximum pharyngeal constriction, hyoid elevation, upper esophageal sphincter opening size, and bolus pharyngeal transit time were measured from modified barium swallowing studies in a group of 31 patients at least 1 year after chemoradiation therapy for the treatment of oropharyngeal carcinoma. Measures were made for a liquid 1-mL, 3-mL, and 20-mL bolus. Objective measure results were compared to scores from the MD Anderson Dysphagia Inventory and The University of Washington Swallowing Quality of Life Questionnaire results from the same patients. RESULTS: No strong correlation was identified between any of the objective measures of swallowing physiology and quality-of-life scores. CONCLUSIONS: Patient perception of the impact of swallowing function on quality of life does not correlate well with actual physiologic functioning.