Characterizing the Validity of Using VASES to Derive DIGEST-FEES Grades.

INTRODUCTION: Visual Analysis of Swallowing Efficiency and Safety (VASES) and Dynamic Imaging Grade of Swallowing Toxicity for Flexible Endoscopic Evaluation of Swallowing (DIGEST-FEES) are two complimentary methods for assessing swallowing during FEES. Whereas VASES is intended to facilitate trial-level ratings of pharyngeal residue, penetration, and aspiration, DIGEST-FEES is intended to facilitate protocol-level impairment grades of swallowing safety and efficiency. The aim of this study was to assess the validity of using VASES to derive DIGEST-FEES impairment grades. METHODS: DIGEST-FEES grades were blindly analyzed from 50 FEES - first using the original DIGEST-FEES grading method (n = 50) and then again using a VASES-derived DIGEST-FEES grading method (n = 50). Weighted Kappa (κw) and absolute agreement (%) were used to assess the relationship between the original DIGEST-FEES grades and VASES-derived DIGEST-FEES grades. Spearman's correlations assessed the relationship between VASES-derived DIGEST-FEES grades with measures of construct validity. RESULTS: Substantial agreement (κw = 0.76-0.83) was observed between the original and VASES-derived grading methods, with 60-62% of all DIGEST-FEES grades matching exactly, and 92-100% of DIGEST-FEES grades within one grade of each other. Furthermore, the strength of the relationships between VASES-derived DIGEST-FEES grades and measures of construct validity (r = 0.34-0.78) were similar to the strength of the relationships between original DIGEST-FEES grades and the same measures of construct validity (r = 0.34-0.83). CONCLUSION: Findings from this study demonstrate substantial agreement between original and VASES-derived DIGEST-FEES grades. Using VASES to derive DIGEST-FEES also appears to maintain the same level of construct validity established with the original DIGEST-FEES. Therefore, clinicians and researchers may consider using VASES to increase the transparency and standardization of DIGEST-FEES ratings. Future research should seek to replicate these findings and explore the simultaneous use of VASES and DIGEST-FEES in a greater sampling of raters and across other patient populations.

Auditory-Perceptual Assessments of Cough: Characterizing Rater Reliability and the Effects of a Standardized Training Protocol.

INTRODUCTION: Auditory-perceptual assessments of cough are commonly used by speech-language pathologists working with people with swallowing disorders with emerging evidence beginning to demonstrate their validity; however, their reliability among novice clinicians is unknown. Therefore, the primary aim of this study was to characterize the reliability of auditory-perceptual assessments of cough among a group of novice clinicians. As a secondary aim, we assessed the effects of a standardized training protocol on the reliability of auditory-perceptual assessments of cough. METHODS: Twelve novice clinicians blindly rated ten auditory-perceptual cough descriptors for 120 cough audio clips. Standardized training was then completed by the group of clinicians. The same cough audio clips were then re-randomized and blindly rated. Reliability was analyzed pre- and post-training within each clinician (intra-rater), between each unique pair of raters (dyad-level inter-rater), and for the entire group of raters (group-level inter-rater) using intraclass correlation coefficients and Cohen's Kappa. RESULTS: Pre-training reliability was greatest for measures of strength, effectiveness, and normality and lowest when judging the type of expiratory maneuver (cough, throat clear, huff, other). The measures that improved the most with training were ratings of perceived crispness, amount of voicing, and type of expiratory maneuver. Intra-rater reliability coefficients ranged from 0.580 to 0.903 pre-training and 0.756-0.904 post-training. Dyad-level inter-rater reliability coefficients ranged from 0.295 to 0.745 pre-training and 0.450-0.804 post-training. Group-level inter-rater reliability coefficients ranged from 0.454 to 0.919 pre-training and 0.558-0.948 post-training. CONCLUSION: Reliability of auditory-perceptual assessments varied across perceptual cough descriptors, but all appeared within the range of what has been historically reported for auditory-perceptual assessments of voice and visual-perceptual assessments of swallowing and cough airflow. Reliability improved for most cough descriptors following 30-60 min of standardized training. Future research is needed to examine the validity of auditory-perceptual assessments of cough by assessing the relationship between perceptual cough descriptors and instrumental measures of cough effectiveness to better understand the role of perceptual assessments in clinical practice.

Cough and Swallowing Therapy and Their Effects on Vocal Fold Bowing and Laryngeal Lesions.

OBJECTIVE: Expiratory muscle strength training (EMST) and sensorimotor training of airway protection (smTAP) are two exercises intended to improve cough and swallowing in people with Parkinson's Disease (PwPD). The aims of this study were to (1) examine whether EMST or smTAP elicit changes to vocal fold bowing; and (2) describe the safety of EMST and smTAP as it relates to the development of vocal fold lesions. METHOD(S): This was a secondary analysis of data from PwPD who completed EMST or smTAP as part of a prospective randomized controlled trial. Vocal fold bowing (BI) and the presence of laryngeal lesions were blindly analyzed from flexible endoscopic evaluation of swallowing (FEES) using ImageJ software and operational definitions. Linear regression was used to examine the influence time (pre- vs. post-therapy) and therapy (EMST vs. smTAP) on vocal fold bowing. Descriptive statistics were used to describe the presence of laryngeal lesions. RESULT(S): Overall, 56 participants were included, 28 per group. The median BI scores pre- and post-therapy were 8.2% and 8.3% for the EMST group and 11.3% and 8.4% for the smTAP group, respectively. Statistical analyses revealed insufficient evidence to suggest an effect of time and treatment type on BI (p > 0.05) or on the presence of vocal fold lesions (p > 0.05). CONCLUSION: Based on these and previous findings, it appears that changes in vocal fold bowing do not drive treatment effects following EMST and smTAP. Also, this study further supports the safety of smTAP and EMST despite the required forceful exhalation and repetitive coughing. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1127-1132, 2024.

Virtual Reality for Pain Management During High-Resolution Manometry: A Randomized Clinical Trial.

OBJECTIVE: High-resolution esophageal manometry (HRM) is the gold standard for the diagnosis of esophageal motility disorders. HRM is typically performed in the office with local anesthesia only, and many patients find it unpleasant and painful. The aim of this study was to examine the effects of the use of a virtual reality (VR) headset on pain and anxiety outcomes in patients with dysphagia undergoing HRM. METHODS: Patients with dysphagia were prospectively recruited and randomized to undergo HRM with and without VR distraction. Data collected included the State-Trait Anxiety Inventory-6 (STAI-6), the Short-Form McGill Pain Questionnaire, heart rate, and galvanic skin response (GSR) tracings. RESULTS: Forty subjects completed the study, including 20 subjects in the intervention arm and 20 in the control arm. There was evidence of a significant positive effect of VR on calmness (p = 0.0095) STAI-6 rating, as well as on physiologic measures of pain with significantly decreased GSR rise time (p = 0.0137) and average rate of change of conductance change (p = 0.0035). CONCLUSION: The use of VR during HRM catheter insertion increased calmness compared to control. Change of skin conductance was also reduced in the VR group, suggesting decreased physiologic pain. This study supports the consideration of the use of VR as a distraction tool to improve patient comfort during HRM. LEVEL OF EVIDENCE: 2 Laryngoscope, 134:1118-1126, 2024.

Concurrent Validity of a Low-Cost Manometer for Objective Assessments of Respiratory Muscle Strength.

OBJECTIVE(S): This study examined the agreement in maximal expiratory (MEP) and inspiratory (MIP) pressure readings between two digital manometers: (1) the MicroRPM - the gold-standard manometer for respiratory muscle strength testing; and (2) the LDM - a low-cost, commercially available, alternative manometer. METHODS: Positive (MEP) and negative (MIP) pressures were simultaneously applied to the MicroRPM and LDM using a 3-liter syringe within a controlled laboratory setting. Pressure readings were compared, and agreement was analyzed using Lin's concordance correlation (ρc ). Agreement was interpreted as 'poor' if <0.90, 'moderate' if 0.90 - <0.95, 'substantial' if 0.95 - <0.99, and 'excellent' if ≥0.99. Twenty percent of the pressure trials were repeated by a second researcher to examine test-retest reliability. RESULTS: A total of 150 trials were completed, ranging from -167 to +208 cmH2 O. There was a median absolute difference of 0.3 cmH2 O in pressure readings between the MicroRPM and the LDM. Lin's concordance correlation revealed 'excellent' agreement between the LDM and MicroRPM devices, with test-retest reliability assessment revealing 'substantial-to-excellent' agreement between the LDM and MicroRPM devices, with a concordance correlation coefficient of ρc = 0.999 (95% CI: 0.999-0.999). CONCLUSIONS: There was a median difference of 1.0% in MEP and MIP pressure readings consistently observed between the LDM and MicroRPM. Despite these relatively small differences, excellent agreement between the two manometers was present. These data suggest the LDM may be a valid, lower cost alternative to the MicroRPM for objectively assessing respiratory strength in clinical practice; however, additional research is needed in healthy adults and in patient populations. LEVEL OF EVIDENCE: NA Laryngoscope, 134:1831-1836, 2024.

Normative Reference Values for FEES and VASES: Preliminary Data From 39 Nondysphagic, Community-Dwelling Adults.

PURPOSE: The aim of this study was to establish preliminary reference values for the Visual Analysis of Swallowing Efficiency and Safety (VASES)-a standardized rating methodology used to evaluate swallowing safety and efficiency for flexible endoscopic evaluation of swallowing (FEES). METHOD: FEES were completed in nondysphagic, community-dwelling adults using a standardized protocol of 15 swallowing trials that varied by bolus size, consistency, contrast agent, and swallowing instructions. FEES were blindly analyzed using VASES. Primary outcome measures included bolus location at swallow onset, Penetration-Aspiration Scale (PAS) scores, and percentage-based residue ratings for six anatomic landmarks. Secondary outcome measures included sip size, bite size, and number of swallows. RESULTS: Thirty-nine healthy adults completed the study, yielding an analysis of 584 swallows. Swallows were initiated with the bolus in the pharynx for 41.8% of trials. PAS 1 was the most common score, accounting for 75.3% of trials, followed by PAS 3, which accounted for 18.8% of trials. When residue was present (> 0%), the amount was relatively small across all anatomic landmarks, with median residue ratings of 2.0% (oropharynx), 1.5% (hypopharynx), 3.0% (epiglottis), 3.0% (laryngeal vestibule), and 3.5% (vocal folds). Five events of aspiration were observed, which were characterized by subglottic residue ratings of 1%, 3%, 10%, 24%, and 90%. The average sip size of self-selected volume cup sips of water was 19.8 ml, and the average bite size of a 3.0-g saltine cracker was 1.33 g. Moreover, 78% of the trials in this study protocol (except 90-ml trials) were completed in a single swallow. DISCUSSION: The results from this study provide preliminary norms for VASES that could be used as a reference when assessing functional swallowing outcomes during FEES. While this is an important first step in establishing norms for FEES and VASES, clinicians and researchers should be mindful that the normative reference values from this study are from a relatively small study sample (N = 39), with most people below the age of 60 years (n = 30). Future research should expand on these norms by including a greater number of people across the age continuum and with greater racial, ethnic, and gender diversity. Supplemental Material and Open Science Form: https://doi.org/10.23641/asha.23504325.

Concurrent Validity of the IOPI and Tongueometer Orofacial Strength Measurement Devices.

OBJECTIVE(S): This study examined the concurrent validity of two orofacial strength manometers: (1) the Iowa Oral Performance Instrument (IOPI) - the current, gold standard orofacial manometer; and (2) the Tongueometer - a newly-available, lower cost, orofacial manometer. METHODS: This study compared IOPI and Tongueometer pressure readings across three experimental conditions. Experiment 1 compared full setup (manometer + tongue bulb) pressure readings between the IOPI and Tongueometer. Experiment 2 compared IOPI tongue bulb and Tongueometer tongue bulb pressure readings, while controlling for manometer. Experiment 3 compared IOPI manometer and Tongueometer manometer pressure readings, while controlling for tongue bulb. Pressures were applied manually within a laboratory setting. Lin's concordance correlation (ρc ) was used to calculate level of agreement, with ρc interpreted as 'poor' if <0.90, 'moderate' if 0.90 to <0.95, 'substantial' if 0.95 to <0.99, and 'excellent' if ≥0.99. RESULTS: 539 trials were analyzed. There was a median absolute difference of 2.4 kPa in pressure readings between the IOPI and Tongueometer full setups (manometer + tongue bulb). Correlations revealed substantial agreement between IOPI and Tongueometer full setups (experiment 1: n = 292; ρc = 0.986), tongue bulbs (experiment 2: n = 146; ρc = 0.987-0.992), and manometers (experiment 3: n = 101; ρc = 0.970). CONCLUSIONS: Differences in pressures were consistently observed between the Tongueometer and IOPI. Despite these differences, substantial agreement was present. These data suggest the Tongueometer may be a valid, lower cost alternative to the IOPI for objectively assessing orofacial strength in clinical practice. LEVEL OF EVIDENCE: Level 2 Laryngoscope, 133:3123-3131, 2023.

Quantifying Impairments in Swallowing Safety and Efficiency in Progressive Supranuclear Palsy and Parkinson's Disease.

Dysphagia is a largely inevitable symptom in both progressive supranuclear palsy (PSP) and Parkinson's disease (PD). To date, comparative studies in these diseases have failed to detect differences in the severity of impairments in swallowing safety or efficiency, potentially due to small sample sizes and outcome measures with low sensitivity. Therefore, this study sought to address these limitations by using novel measurement methodology to comprehensively compare swallowing safety and efficiency impairments between these populations in order to better understand whether differences may exist and guide clinical management. Twenty-four participants with PSP and 24 with PD were matched for disease duration and completed flexible endoscopic evaluations of swallowing. A visual analog scale and penetration-aspiration scale quantified swallowing safety and efficiency. Bayesian multilevel models compared the frequency, severity, and variability of swallowing impairments. Individuals with PSP demonstrated greater impairments in swallowing safety, including deeper and more variable airway invasion and more frequent vocal fold and subglottic residue. Swallowing efficiency was also more impaired among individuals with PSP, including more frequent hypopharyngeal residue (with solids) and more severe residue in the oropharynx (with thin liquids and solids) and hypopharynx (with thin liquids). When airway or pharyngeal residue was present, similar within-subject variability of the amount of residue was appreciated across anatomic landmarks. This is the first study comparing the frequency, severity, and variability of swallowing impairments between PSP and PD populations. Our findings demonstrate more pronounced impairments in swallowing safety and efficiency for PSP compared to PD. These findings provide a clinically relevant characterization of swallowing measures using novel methodological and statistical approaches attempting to resolve some limitations of prior studies.

The Relationship Between Lingual Strength and Functional Swallowing Outcomes in Parkinson's Disease.

The purpose of this retrospective study was to determine whether reduced lingual strength was associated with functional swallowing outcomes in individuals with Parkinson's disease (PD). Participants (N = 42) completed evaluations of maximal lingual isometric pressure (MIP) and mean lingual swallowing pressure (MSP), and flexible endoscopic evaluations of swallowing. Regression models were used to determine the association between lingual strength and functional swallowing outcomes of airway invasion, the presence of post-swallow pharyngeal residue, and the amount of pharyngeal residue (when present). Results revealed that higher MIP (p = 0.002, OR 0.93) and higher MSP (p = 0.001 OR 0.88) were associated with less airway invasion of thin liquids. Both MIP and MSP were able to differentiate between those with and without dysphagia (MIP: AUC 0.7935, p = 0.001; MSP: AUC 0.75, p = 0.026). Neither MIP nor MSP was related to the presence of residue. However, when thin liquid oropharyngeal residue was present, both MIP (p < 0.001, OR 0.99) and MSP (p < 0.001; OR 0.98) were significantly associated with the amount of residue observed. Similarly, when thin liquid hypopharyngeal residue was present, MIP (p < 0.001, OR 0.99) and MSP (p < 0.001, OR 0.98) were associated with the amount of residue observed. These findings suggest a relationship between reduced lingual strength and worse thin liquid swallowing safety and efficiency; however, the magnitude of these effects was small. This indicates that lingual strength is one important contributing factor to functional swallowing impairments in PD and may identify those with unsafe swallowing. These findings have important clinical implications for including lingual strength in the screening, assessment, and management of dysphagia in PD.

The Role of Aspiration Amount on Airway Protective Responses in People with Neurogenic Dysphagia.

The aim of this study was to examine relationships between the presence vs. absence of an aspiration-related airway protective response (i.e., coughing or throat clearing) with aspiration amount, trial volume, disease diagnosis, and disease duration in people with neurologic disease. A secondary analysis was completed of flexible endoscopic evaluations of swallowing (FEES) in people with neurologic disease. Thin liquid boluses with endoscopically confirmed aspiration were included. Aspiration amount was measured for each trial using the visual analysis of swallowing efficiency and safety (VASES). Statistical analyses were used to (1) compare aspiration amount between swallows with vs. without an airway protective response and (2) examine if trial volume, disease duration, and disease diagnosis were related to the presence of airway protective responses when controlling for aspiration amount. 422 aspirated swallows across 86 FEES were analyzed. Of the 59 people who aspirated more than once, 66.1% exhibited variability in the presence vs. absence of an airway protective response. Statistical analyses revealed airway protective responses were significantly related to aspiration amount (p < 0.001; Marginal R2 = 0.46) and disease duration (p = 0.036, L.R. = 4.35) but not trial volume (p = 0.428) or disease diagnosis (p = 0.103). The participants in this study were less likely to cough or throat clear when having smaller amounts of aspiration or longer disease durations. Future research is needed to examine if aspiration amount is related to airway protective responses in healthy adults and across other patient populations.

Rehabilitating Cough Dysfunction in Parkinson's Disease: A Randomized Controlled Trial.

BACKGROUND: Disorders of airway protection (cough and swallowing) are pervasive in Parkinson's disease (PD) resulting in a high incidence of aspiration pneumonia and death. However, there are no randomized controlled trials comparing strength and skill-based approaches to improve airway protection in PD. OBJECTIVES: The aim of this study was to compare expiratory muscle strength training (EMST) and sensorimotor training for airway protection (smTAP) to improve cough-related outcomes in people with PD. METHODS: Participants with PD and dysphagia were recruited for this prospective phase II randomized-blinded controlled clinical trial. Participants completed baseline assessment, 5 weeks of EMST or smTAP, and a post-training assessment. Primary outcome measures included maximum expiratory pressure (MEP) and voluntary cough peak expiratory flow rate (PEFR). Mixed effects models were used to assess the effects of EMST and smTAP on outcomes. RESULTS: A total of 65 participants received either EMST (n = 34) or smTAP (n = 31). MEP improved from pre- to post-treatment for smTAP (P < 0.001, d = 0.19) and EMST (P < 0.001, d = 0.53). Voluntary PEFR increased from pre- to post-treatment for smTAP (P < 0.001, d = 0.19) and EMST (P < 0.001, d = 0.06). Moreover, reflex cough PEFR (P < 0.001, d = 0.64), reflex cough expired volume (P < 0.001, d = 0.74), and urge to cough (P = 0.018, OR = 2.70) improved for the smTAP group but not for the EMST group. CONCLUSIONS: This clinical trial confirmed the efficacy of smTAP to improve reflex and voluntary cough function, above and beyond EMST, the current gold standard. © 2022 International Parkinson and Movement Disorder Society.

Visual Analysis of Swallowing Efficiency and Safety (VASES): Establishing Criterion-Referenced Validity and Concurrent Validity.

PURPOSE: The primary aim of this study was to examine the criterion-referenced validity of the Visual Analysis of Swallowing Efficiency and Safety (VASES). As a secondary aim, we examined the concurrent validity of using verbal numerical ratings for VASES as a potential substitute for visual analog scale ratings. METHOD: Fifty-seven novice raters were prospectively recruited to rate 26 flexible endoscopic evaluations of swallowing (FEES) images (2 times each, randomized)-once using VASES and once using a criterion-referenced scale. Ratings were made for the valleculae, piriforms, epiglottis, laryngeal vestibule, vocal folds, and subglottis. Criterion validity was determined by examining the correlation between VASES and the criterion-referenced scales. The novice raters also provided visual analog scale ratings following verbal numerical ratings. Concurrent validity of using verbal numerical ratings as a potential substitute for visual analog scale ratings was determined by examining the correlation and absolute agreement between both rating methods. RESULTS: Three thousand five hundred eighty-seven ratings were analyzed. Spearman's correlation revealed strong correlations between VASES ratings and criterion-referenced ratings across all anatomic landmarks (ρ = .882-.915). Lin's concordance revealed substantial agreement between numerical ratings and visual analog scale ratings (ρc = .986). CONCLUSIONS: The strong correlations between VASES and the criterion-referenced scales suggest that VASES is a valid method for interpreting pharyngeal residue, penetration, and aspiration during FEES. Furthermore, numerical ratings exhibited substantial agreement with visual analog scales. This suggests that clinicians could provide verbal numerical ratings in lieu of visual analog scale ratings as a potential way to enhance the ease and feasibility of implementing VASES into clinical practice. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.18737072.

Visual Analysis of Swallowing Efficiency and Safety (VASES): A Standardized Approach to Rating Pharyngeal Residue, Penetration, and Aspiration During FEES.

The primary aim of this study was to describe the development of the Visual Analysis of Swallowing Efficiency and Safety (VASES)-a standardized method to rate pharyngeal residue, penetration, and aspiration during FEES. As a secondary aim, we explored the feasibility of training novices to interpret FEES using VASES. Literature review and consensus panel discussions were used to develop standardized rules for VASES. A training protocol was developed and criterion ratings were established. Twenty-five novice raters completed VASES training and pre-/post-training assessments. Statistical analyses were used to examine pre- to post-training differences in the accuracy, reliability, and time to rate each video clip using VASES. Four sets of VASES rules were developed, including 'what', 'where', 'when', and 'how' to rate FEES. Large, significant post-training improvements in rating accuracy were observed across all seven VASES outcome measures (Cohen's d range 0.74-1.59). Additionally, inter-rater reliability increased for four of the seven outcome measures, and the amount of time to rate each video clip decreased from 2.6 min pre-training to 1.5 min post-training. VASES is a standardized FEES rating method used to enhance the subjective analysis of pharyngeal residue, penetration, and aspiration. It can be feasibly taught to novice raters with a high level of success and may be an effective method to analyze swallowing safety and efficiency in clinical and research practices. Future research is needed to test the validity of VASES by examining its relationship with other validated FEES rating scales.

Immediate Effects of Sensorimotor Training in Airway Protection (smTAP) on Cough Outcomes in Progressive Supranuclear Palsy: A Feasibility Study.

Progressive supranuclear palsy (PSP) is a neurodegenerative disease characterized by a high prevalence of dysphagia, cough dysfunction, and resultant aspiration pneumonia. Sensorimotor cough function is important for airway clearance in people with dysphagia. Upregulation of cough has been demonstrated in healthy adults and Parkinson's disease; however, the feasibility of cough rehabilitation in PSP is unknown. We sought to assess feasibility by examining the immediate effects of a novel sensorimotor training in airway protection (smTAP) on upregulation of cough function in PSP. Fifteen individuals with PSP enrolled in this study. Baseline voluntary and reflex cough testing were completed. During smTAP, participants were presented with subthreshold capsaicin and instructed to cough with sufficient intensity to hit a target line (set 25% above baseline reflex peak cough flow) via cough airflow visual biofeedback. Twenty-five repetitions were targeted within a single session. Wilcoxon signed-rank tests compared cough airflow measures between baseline voluntary cough testing, the initial five trials of smTAP, and final five trials. Mean peak expiratory flow rate (PEFR) significantly increased from initial to final smTAP trials (p < 0.001). Fourteen participants increased PEFR, with gains of more than 10% in 11 participants. Variability of PEFR (p = 0.01) and cough expired volume (p = 0.01) significantly decreased across smTAP trials. This study is the first to demonstrate the ability of people with PSP to immediately upregulate cough function, providing preliminary support for the feasibility of cough rehabilitation in this population with this novel treatment approach. Future research examining the effects of multiple sessions of smTAP on cough outcomes is warranted.

Effects of Bolus Holding on Respiratory-Swallow Coordination in Parkinson's Disease.

PURPOSE: The aim of this study was to examine the effects of bolus holding on respiratory-swallow coordination (RSC) in people with Parkinson's disease (PD). METHOD: People with PD were prospectively recruited to undergo RSC assessment using simultaneous respiratory inductive plethysmography and flexible laryngoscopy. During RSC assessment, participants swallowed 5-ml thin liquid boluses during held and nonheld swallowing tasks. Measures of RSC were analyzed for each swallow, which included respiratory pause duration, lung volume at swallow initiation, respiratory phase patterning, and the presence of paradoxical respiratory movements. Multilevel statistical modeling was used to determine if differences in RSC were present between the held and nonheld tasks. RESULTS: Thirty-three participants were enrolled. When compared to the nonheld swallows, the held swallows exhibited shorter respiratory pauses (p = .001, R 2 = .019), lower lung volumes at swallow initiation (p < .001, R 2 = .116), more frequent exhale-swallow-exhale patterns (p < .001, OR = 4.30), and less frequent paradoxical respiratory movements (p = .001, OR = 0.43). CONCLUSIONS: Findings from this study revealed that bolus holding significantly influences RSC in people with PD. This demonstrates that bolus holding may be an efficacious strategy to immediately improve RSC in PD. However, clinicians and researchers should consider avoiding bolus holding during swallowing evaluations if attempting to assess RSC behaviors that are most typical for the examinee.

Sensorimotor Cough Dysfunction Is Prevalent and Pervasive in Progressive Supranuclear Palsy.

BACKGROUND: Pneumonia, a leading cause of death in progressive supranuclear palsy (PSP), results from progressive and pervasive deficits of airway protection, including both cough and swallowing dysfunction. Cough protects the airway by expelling aspirate and may be an important therapeutic target to protect against pneumonia in the presence of dysphagia. However, cough has not been objectively characterized in PSP or compared to other common forms of parkinsonism, such as Parkinson's disease (PD). OBJECTIVE: The purpose of this study was to examine voluntary and reflex cough function in PSP, as compared to patients with PD matched for disease duration. METHODS: Twenty-six patients with PSP and 26 with PD completed voluntary and reflex cough testing via spirometry. Linear mixed effects models examined comparisons between groups and within cough types across cough sensory and motor outcomes. RESULTS: Patients with PSP demonstrated significantly reduced cough motor function compared to PD, specifically reduced peak expiratory flow rate (P < 0.001), cough expiratory volume (P < 0.001), and cough inspiratory volume (P = 0.008). Both groups showed similar reflex cough thresholds (P = 0.694), but PSP demonstrated an increased perception of cough stimuli (P = 0.041). CONCLUSIONS: These findings suggest that sensorimotor cough dysfunction is prevalent in PSP, and cough motor deficits, in particular, are worse in PSP than in PD. These deficits likely contribute to the pathogenesis of pneumonia in PSP. Therefore, cough should be integrated into assessments of airway protection and considered as a therapeutic target to potentially reduce adverse health events and improve quality of life in this population. © 2021 International Parkinson and Movement Disorder Society.

Examining the Relationships Between Lingual Strength, Perihyoid Strength, and Swallowing Kinematics in Dysphagic Adults: A Retrospective Cross-Sectional Analysis.

Purpose The aim of this study was to examine the relationships of clinical measures of lingual and perihyoid strength with displacement swallowing kinematics and swallowing safety in a heterogenous group of dysphagic adults. Method A retrospective analysis was completed of videofluoroscopic swallow studies of consecutive dysphagic outpatient adults presenting to a tertiary swallowing center from January 1, 2015, to December 31, 2017. Videofluoroscopic swallow study records were included if containing displacement swallowing kinematics of a 20-ml single liquid swallow and clinical measures of anterior (L-MIPA) or posterior (L-MIPP) lingual maximal isometric press, saliva mean swallowing pressures (S-MSP), and/or open mouth-maximal isometric press (OM-MIP). Regression analyses were used to examine the relationships between clinical measures of lingual (L-MIPA, L-MIPP, S-MSP) and perihyoid (OM-MIP) strength and displacement swallowing kinematics, and binomial logistic regressions were used to examine the relationships between clinical measures of lingual and perihyoid strength and swallowing safety (Penetration-Aspiration Scale [PAS]). Results Multivariate regressions revealed significant relationships of L-MIPA, L-MIPP, S-MSP, and OM-MIP with group-level changes to the displacement swallowing kinematics. Univariate analyses revealed significant relationships of L-MIPA and L-MIPP with pharyngeal constriction ratio, maximal extent of upper esophageal segment opening, and PAS. Conclusions Weak relationships were identified of clinical measures of lingual and perihyoid strength with displacement swallowing kinematics. These findings suggest that clinical measures of lingual and perihyoid strength do not fully explain impairments in swallowing kinematics across a heterogenous group of dysphagic patients. Weak-to-moderate relationships were identified between clinical measures of lingual strength and PAS, suggesting that they may have value in predicting functional measures of swallowing safety. Further research is needed to examine how findings may differ between specific patient populations.

Detection of Aspiration, Penetration, and Pharyngeal Residue During Flexible Endoscopic Evaluation of Swallowing (FEES): Comparing the Effects of Color, Coating, and Opacity.

The aim of this study was to assess the effects of color, coating, and opacity on the detection of aspiration, penetration, and residue during flexible endoscopic evaluations of swallowing (FEES). Thirty dysphagic adults underwent FEES while swallowing five 5 mL thin liquid boluses (1 × each, randomized): white water, blue water, white milk, blue milk, and barium water. To assess the effects of color, blue milk was compared to white milk. To assess the effects of coating, barium, white water, and white milk were compared to each other. To assess the effects of opacity, blue milk was compared to blue water. Videos were blindly analyzed and judged for the presence of pharyngeal residue, penetration, and aspiration. Repeated measures analyses were used to assess differences in the frequency of detection across bolus types. Pharyngeal residue was detected more frequently for liquids that were blue, had a coating effect, or were opaque (p < 0.05) when compared to liquids that were white, did not have a coating effect, or were translucent, respectively. Penetration and aspiration were detected more frequently for liquids that had a coating effect (p < 0.05), but not for liquids that were colored blue or opaque (p > 0.05). Coating appears to be the most important factor detecting thin liquid residue, penetration, and aspiration during FEES. Given these findings, standardized use of boluses that possess a coating effect (e.g., white-dyed water or barium) is highly recommended to enhance the sensitivity of identifying impairments in swallowing safety and efficiency during FEES.

The Role of Vocal Fold Bowing on Cough and Swallowing Dysfunction in Progressive Supranuclear Palsy.

OBJECTIVES: Progressive supranuclear palsy (PSP) is a neurodegenerative disease which results in cough and swallowing dysfunction and aspiration pneumonia. Relationships among vocal fold atrophy, cough, and swallowing have been identified in related diseases, but remain unknown in PSP. This study examined: 1) the prevalence of vocal fold bowing in PSP, and 2) the influence of vocal fold bowing on cough and swallowing in PSP. STUDY DESIGN: Prospective Cohort Study. METHODS: Twenty-three participants with PSP completed instrumental assessments of cough and swallowing. Vocal fold bowing (BI) and swallowing safety (PAS) was assessed using flexible laryngoscopy. Measures of cough effectiveness were obtained using spirometry. Statistical analyses were used to determine the frequency of mild-moderate (BI > 0) and severe (BI > 12.2) bowing, and to assess the influence of BI on PAS and cough effectiveness in PSP. RESULTS: Fifty-two percent (n = 12) of participants exhibited severe bowing while 48% (n = 11) exhibited mild-to-moderate bowing. Voluntary cough peak expiratory flow rate (P = .01), as well as reflex (P = .02) and voluntary (P = .005) cough volume acceleration were lower for participants with severe BI when compared to mild-to-moderate BI. However, BI did not influence PAS (P > .05). CONCLUSIONS: Findings from this study suggest that vocal fold bowing is highly prevalent in PSP and associated with reduced reflex and voluntary cough effectiveness. These findings provide insight into the pathophysiology of compromised airway protection in this patient population. Future studies should examine vocal fold atrophy as a treatment target for behavioral and medical intervention in PSP. LEVEL OF EVIDENCE: 3 (Prospective Observational Study) Laryngoscope, 131:1217-1222, 2021.