Temporal and Sequential Analysis of the Pharyngeal Phase of Swallowing in Poststroke Patients.

The purpose of this study was to conduct a quantitative analysis of the temporal and sequential events of the pharyngeal phase of swallowing in 45 poststroke patients who presented or did not present with supraglottic penetration and/or laryngotracheal aspiration and to compare the groups with each other and to a group of 46 patients with normal swallowing. All individuals were assessed by videofluoroscopy and the temporal and sequential measures for the swallowing of 3 mL and 5 mL of thickened liquid, 3 mL of liquid, and 3 mL and 5 mL of pasty were obtained by analyzing the recorded exams on Virtual Dub software. The following events were measured: time of maximal displacement and sustaining of the hyoid and larynx, duration of velopharyngeal sphincter (VS) and supraglottic closure, total inversion time of the epiglottis, duration of pharyngeal constriction, and duration of upper esophageal sphincter (UES) opening. For the analysis of the temporal sequence, the initial time of larynx and hyoid elevation, VS closure, epiglottic inversion, supraglottic closure, pharyngeal constriction, and opening of the UES were obtained. For 5 mL of thickened liquid, the maximum hyoid elevation time was greater for patients with normal swallowing and the time the supraglottis remained closed was higher in the aspirators group. The time of pharyngeal constriction during swallowing of 3 mL of thickened liquid was lower in the aspirators group. During the swallowing of 3 mL of thin liquid, it was observed that in the aspirators group, the larynx took longer to reach its maximum elevation and the epiglottis took longer to complete its total inversion. The analysis of the temporal sequence showed that patients in the aspirators group presented greater disorganization with significant alteration of the time interval between the events.

Algoritmo para el manejo de la aspiración pulmonar crónica en pediatría / Algorithm for the management of chronic pulmonary aspiration in pediatrics

La aspiración pulmonar es el pasaje de alimentos, reflujo gastroesofágico y/o saliva a la vía aérea de manera suficiente que ocasione síntomas respiratorios crónicos o recurrentes. Es una ausa importante de neumonía recurrente, enfermedad pulmonar progresiva, bronquiectasias e, incluso, muerte. La aspiración es intermitente y, con frecuencia, ocurre en niños con anomalías médicas subyacentes o síndromes que ocasionan síntomas respiratorios similares a la aspiración pulmonar crónica, por lo que, muchas veces, el diagnóstico de aspiración se demora hasta que haya una lesión pulmonar significativa. Se describen los métodos diagnósticos disponibles y sus limitaciones, y las opciones de tratamiento de la aspiración pulmonar crónica en la población pediátrica.

Pulmonary aspiration is the passage of food, gastroesophageal reflux and/or saliva to the airway in a manner sufficient to cause chronic or recurrent respiratory symptoms. It is an important cause of recurrent pneumonia, progressive lung disease, bronchiectasis and even death.Aspiration is intermittent and often occurs in children with underlying medical conditions or syndromes that cause respiratory symptoms similar to chronic pulmonary aspiration, so diagnosis of aspiration is often delayed until there is a significant lung injury. The available diagnostic methods and their limitations, and treatment options of chronic pulmonary aspiration in the pediatric population are described.

Acoustic signal of silent tracheal aspiration in children with oropharyngeal dysphagia.

Objetive: The aim of this study was to characterize the acoustic signal of silent tracheal aspiration in children with oropharyngeal dysphagia (OPD). METHOD: Thirty-two children with OPD were examined with combined digital cervical auscultation (DCA) and videofluoroscopic swallow study (VFSS). Power spectral density (PSD, in 1/√Hz) of the acoustic signal from a sequential series of five liquid swallows was used for comparisons between children who silently aspirated and children who did not aspirate on VFSS. Fourteen children were excluded due to either DCA/VFSS artifact or non-silent aspiration (cough, choking). RESULTS: The remaining 18 participants (median age 6 years, range 2-12.8) were classified based on VFSS as aspirators (n = 8) and non-aspirators (n = 10). The PSD curve of aspirators presented an ascending pattern (1st vs. 5th deglutition: 695.2 vs. 4421.9 1/√Hz), while the curve of non-aspirators was flat (1st vs. 5th deglutition: 509 vs. 463.4 1/√Hz), with marked differences being observed from the 3rd measure onwards (p < .001). In this study, DCA was able to identify silent tracheal aspiration in children with OPD. CONCLUSION: This non-invasive technique identified aspiration by an increase in the PSD curve in aspiration sounds.

Presenting Signs and Symptoms do not Predict Aspiration Risk in Children.

OBJECTIVES: To determine if any presenting symptoms are associated with aspiration risk, and to evaluate the reliability of clinical feeding evaluation (CFE) in diagnosing aspiration compared with videofluoroscopic swallow study (VFSS). STUDY DESIGN: We retrospectively reviewed records of children under 2 years of age who had evaluation for oropharyngeal dysphagia by CFE and VFSS at Boston Children's Hospital and compared presenting symptoms, symptom timing, and CFE and VFSS results. We investigated the relationship between symptom presence and aspiration using the Fisher exact test and stepwise logistic regression with adjustment for comorbidities. CFE and VFSS results were compared using the McNemar test. Intervals from CFE to VFSS were compared using the Student t test. RESULTS: A total of 412 subjects with mean (±SD) age 8.9 ± 6.9 months were evaluated. No symptom, including timing relative to meals, predicted aspiration on VFSS. This lack of association between symptoms and VFSS results persisted even in the adjusted multivariate model. The sensitivity of CFE for predicting aspiration by VFSS was 44%. Patients with a reassuring CFE waited 28.2 ± 8.5 days longer for confirmatory VFSS compared with those with a concerning CFE (P < .05). CONCLUSIONS: Presenting symptoms are varied in patients with aspiration and cannot be relied upon to determine which patients have aspiration on VFSS. The CFE does not have the sensitivity to consistently diagnose aspiration so a VFSS should be performed in persistently symptomatic patients.

Pulmonary computed tomography findings in patients with chronic aspiration detected by videofluoroscopic swallowing study.

OBJECTIVE: To demonstrate CT findings in patients with chronic aspiration compared with a control group without aspiration, as detected by the videofluoroscopic swallowing study (VFSS). METHODS: This retrospective, observational study included patients with and without diagnoses of aspiration confirmed by VFSS, who underwent CT examination of the lungs between 2010 and 2014. Two radiologists blinded to the presence of aspiration reviewed the images to detect the presence of any abnormality. Consensus was reached with a third radiologist. CT pulmonary findings (bronchial thickening, bronchiolectasis, centrilobular nodules, ground-glass opacities, atelectasis, consolidation and air trapping) were compared between the groups using the χ(2) test, with a significance level of 0.05. RESULTS: A total of 56 patients (28 patients with diagnoses of aspiration; 52% male, mean age 65 ± 15 years) were included in the study. Patients with aspiration were more likely to than those in the control group to demonstrate atelectasis, centrilobular nodules, bronchiolectasis, consolidation and ground-glass opacities (all p < 0.05), with a significant predilection for the lower lobes (p < 0.001). Bronchial wall thickening and air trapping did not differ between groups. CONCLUSION: Atelectasis, centrilobular nodules, bronchiolectasis, consolidation and ground-glass opacities occurred more frequently in patients with aspiration than in those without aspiration, with a pronounced tendency for distribution in the lower lobes. ADVANCES IN KNOWLEDGE: CT findings of aspiration are very important, as pulmonary symptoms may be the first manifestation of this disorder. Knowledge of these findings is essential to enable the early diagnosis of aspiration disorders and prevent lung damage.

Swallowing disorders in Parkinson's disease: impact of lingual pumping.

BACKGROUND: Lingual pumping (LP) is a repetitive, involuntary, anteroposterior movement of the tongue on the soft palate that is executed prior to transferring the food bolus to the pharynx, but we also observed LP when multiple swallows were taken. LP may be associated with rigidity and bradykinesia in patients with Parkinson's disease (PD). This phenomenon tends to be more prevalent in dysphagic PD patients, and its impact on swallowing dynamics remains poorly understood. OBJECTIVE: To evaluate how LP interferes with the oral and pharyngeal phases of the swallowing of foods of different consistencies and volumes. METHODS: We used videofluoroscopy to study the swallowing of 69 PD patients performing 10 swallows of barium mixed with foods of different consistencies and volumes. RESULTS: LP was associated with the unstable intra-oral organization of the bolus, the loss of bolus control, the pharyngeal retention of food and food entering the airway. This abnormal movement was also associated with a shorter oral transit time and was found to be more prevalent with food of thicker consistencies. CONCLUSIONS: LP is associated with swallowing incoordination and with food entering the airway. Preventive measures to minimise the pulmonary or nutritional consequences of this behaviour are necessary.

An Index to Objectively Score Supraglottic Abnormalities in Refractory Asthma.

BACKGROUND: Patients with refractory asthma frequently have elements of laryngopharyngeal reflux (LPR) with potential aspiration contributing to their poor control. We previously reported on a supraglottic index (SGI) scoring system that helps in the evaluation of LPR with potential aspiration. However, to further the usefulness of this SGI scoring system for bronchoscopists, a teaching system was developed that included both interobserver and intraobserver reproducibility. METHODS: Five pulmonologists with expertise in fiber-optic bronchoscopy but novice to the SGI participated. A training system was developed that could be used via Internet interaction to make this learning technique widely available. RESULTS: By the final testing, there was excellent interreader agreement (κ of at least 0.81), thus documenting reproducibility in scoring the SGI. For the measure of intrareader consistency, one reader was arbitrarily selected to rescore the final test 4 weeks later and had a κ value of 0.93, with a 95% CI of 0.79 to 1.00. CONCLUSIONS: In this study, we demonstrate that with an organized educational approach, bronchoscopists can develop skills to have highly reproducible assessment and scoring of supraglottic abnormalities. The SGI can be used to determine which patients need additional intervention to determine causes of LPR and gastroesophageal reflux. Identification of this problem in patients with refractory asthma allows for personal, individual directed therapy to improve asthma control.

Patología respiratoria y alteraciones funcionales respiratorias y deglutorias / Respiratory disease and respiratory and swallowing functional impairment

In daily clinical practice pediatricians, pneumonologists and phonoaudiologists deal with children’s complex respiratory pathologies. This has generated the necessity of interrelating us to analyze deglutition function alterations that could lead to respiratory pathology and vice versa, establishing an interdisciplinary way of doing anamnesis, organic and functional physical examination, diagnosis and treatment. In this paper we analyze deglutition, its alterations, respiratory-deglutition disruptions, aspiration’s pathophysiology, videofluoroscopy diagnosis and treatment.

En la práctica clínica diaria pediatras, neumonólogos y fonoaudiólogos nos enfrentamos a niños con patologías respiratorias complejas. Esto generó la necesidad de interrelacionarnos para analizar alteraciones en la función deglutoria que pudieran llevar a patología respiratoria y viceversa, estableciendo anamnesis, examen físico orgánico y funcional, diagnóstico y tratamiento en forma interdisciplinarias. En este artículo analizamos la deglución, sus alteraciones, las disrupciones respiración-deglución, la fisiopatología de la aspiración, el diagnóstico videofluoroscópico así como su tratamiento.

Silent aspiration in Parkinson's disease patients with diurnal sialorrhea.

OBJECTIVE: We studied the frequency of silent laryngeal penetration or silent aspiration (SLP/SA) in Parkinson's disease (PD) patients with diurnal sialorrhea. PATIENTS AND METHODS: In 19 consecutive PD patients with diurnal sialorrhea, swallow was evaluated using the videofluoroscopy analysis. Data were analysed to determine the frequency of aspiration and its relationship with the severity of sialorrhea. RESULTS: All patients were classified in the Hoehn and Yahr stages between 2 and 5. SLP/SA was observed in 21% of patients and the score of sialorrhea in the group with SLP/SA was 8.0+/-0.81, while in the group with no SLP/SA was 6.46+/-1.06 (p=0.02). CONCLUSION: SLP/SA is a frequent morbidity in PD patients, its risk is higher in later stages of disease and in those patients with severe sialorrhea. However, prospective and controlled studies of follow up will be necessary to determine the prognosis and management in this group of patients.

Laryngeal lesion in leprosy and the risk of aspiration.

Leprosy affects the larynx, damaging its mucosa and sensory nerves and loss of sensation may result in aspiration of food and secretions. The laryngeal lesion may be insidious. Post-mortem studies showed bronchopneumonia that could have originated from aspiration. In patients with laryngeal symptoms, dysphagia or aspiration pneumonia loss of laryngeal sensation should be looked for.