The Criteria of Thickened Liquid for Dysphagia Management in Japan.

In Japan, the viscosity of thickened liquids is different among hospitals and nursing homes. In order to standardize viscosity of thickened liquids, the dysphagia diet committee of the Japanese Society of Dysphagia Rehabilitation developed the Japanese Dysphagia Diet 2013 (JDD2013). To decide on a definition of thickened liquids, the committee reviewed categories from other countries. Especially, the criteria of the USA and Australia were used as references. The definition had three levels: mildly thick, moderately thick, and extremely thick. Then a sensory evaluation by health care workers was carried out to decide the viscosity range of each level, and a draft document was made. After collecting public comments, follow-up experiments using thickened water with thickeners using xanthan gum were performed, and the JDD2013 (Thickened Liquid) was determined. The JDD2013 (Thickened Liquid) evaluated the drinking properties, visual properties, and viscosity values of each level. The shear rate of 50 s-1 was adopted to measure the viscosity with a cone and plate type viscometer to duplicate the measurement criteria used by the USA. We also set the values of the JDD2013 with the Line Spread Test to promote the use of guidelines in clinical practice. We believe the JDD2013 standards help hospitals and other settings that care for people with dysphagia to use the same thickness level and the same labels. In the future, the JDD2013 levels will be compared with new international guidelines to help with international understanding of the JDD2013 levels.

Inappropriate Timing of Swallow in the Respiratory Cycle Causes Breathing-Swallowing Discoordination.

Rationale: Swallowing during inspiration and swallowing immediately followed by inspiration increase the chances of aspiration and may cause disease exacerbation. However, the mechanisms by which such breathing-swallowing discoordination occurs are not well-understood. Objectives: We hypothesized that breathing-swallowing discoordination occurs when the timing of the swallow in the respiratory cycle is inappropriate. To test this hypothesis, we monitored respiration and swallowing activity in healthy subjects and in patients with dysphagia using a non-invasive swallowing monitoring system. Measurements and Main Results: The parameters measured included the timing of swallow in the respiratory cycle, swallowing latency (interval between the onset of respiratory pause and the onset of swallow), pause duration (duration of respiratory pause for swallowing), and the breathing-swallowing coordination pattern. We classified swallows that closely follow inspiration (I) as I-SW, whereas those that precede I as SW-I pattern. Patients with dysphagia had prolonged swallowing latency and pause duration, and tended to have I-SW or SW-I patterns reflecting breathing-swallows discoordination. Conclusions: We conclude that swallows at inappropriate timing in the respiratory cycle cause breathing-swallowing discoordination, and the prolongation of swallowing latency leads to delayed timing of the swallow, and results in an increase in the SW-I pattern in patients with dysphagia.

Breathing-swallowing discoordination is associated with frequent exacerbations of COPD.

INTRODUCTION: Impaired coordination between breathing and swallowing (breathing-swallowing discoordination) may be a significant risk factor for the exacerbation of chronic obstructive pulmonary disease (COPD). We examined breathing-swallowing discoordination in patients with COPD using a non-invasive and quantitative technique and determined its association with COPD exacerbation. METHODS: We recruited 65 stable outpatients with COPD who were enrolled in our prospective observational cohort study and did not manifest an apparent swallowing disorder. COPD exacerbation was monitored for 1 year before and 1 year after recruitment. Swallowing during inspiration (the I-SW pattern) and swallowing immediately followed by inspiration (the SW-I pattern) were identified. RESULTS: The mean frequency of the I-SW and/or SW-I patterns (I-SW/SW-I rate) was 21.5%±25.5%. During the 2-year observation period, 48 exacerbation incidents (25 patients) were identified. The I-SW/SW-I rate was significantly associated with the frequency of exacerbation. During the year following recruitment, patients with a higher I-SW/SW-I frequency using thicker test foods exhibited a significantly higher probability of future exacerbations (p=0.002, log-rank test). CONCLUSIONS: Breathing-swallowing discoordination is strongly associated with frequent exacerbations of COPD. Strategies that identify and improve breathing-swallowing coordination may be a new therapeutic treatment for patients with COPD.

Development of a simple and objective evaluation method for thickened liquids using funnels.

Some patients with dysphagia are prone to aspiration of low-viscosity liquids. Thickened liquids are often used in attempts to prevent aspiration. The patients should be given thickened liquids with suitable thickness, and the thickness should be constant at all time. While rotational and cone-and-plate viscometers are used for the evaluation of thickened liquids, they are high-precision and expensive equipment. To control the thickness of liquids, a simple and objective evaluation method is thus necessary. We developed a method to evaluate thickened liquids using funnels, and verified the appropriateness of this method. We measured the outflow times of five thickened liquids through funnels. One of the thickened liquids was a commercially available nutritional supplement, another was made with a thickening agent that contained guar gum, and all others were made with a thickening agent that contained xanthan gum. Four funnels with different stem sizes were tested. We found that the outflow time of thickened liquids through a funnel depended on their viscosities at a shear rate between 10 and 50 s-1 , when the average inner diameter of the stem was in the range of 5.3-9.0 mm, and the volume of the liquid poured into the funnel was 30 mL. The correlation coefficient between the value of the sensory evaluation and the outflow time of the funnel with an average stem ID of 5.3 mm was 0.946. Therefore, this method may be useful in hospital and nursing home kitchens for evaluating thickened liquids. PRACTICAL APPLICATIONS: The findings of this study will help develop a new method for the evaluation of thickened liquids. Funnels made from polypropylene, which are inexpensive and light, were used in this method. The process for measuring the outflow time of thickened liquids through a funnel is simple, and we can obtain quantitative data that are objective. Even though line spread test (LST) is well known as a simple measurement method, nutritional supplements and liquids thickened using a thickening agent containing guar gum have not been evaluated accurately. The funnel method was found to have a stronger correlation with sensory evaluation compared to LST. This method is useful in hospital and nursing home kitchens for evaluating thickened liquids.

Suitable Food Textures for Videofluoroscopic Studies of Swallowing in Esophageal Cancer Cases to Prevent Aspiration Pneumonia.

AIMS: To determine suitable food textures for videofluoroscopic study of swallowing (VFSS), in order to predict and prevent subsequent aspiration pneumonia in esophageal cancer patients with dysphagia after surgery. MATERIALS AND METHODS: We evaluated 45 hospitalized esophageal cancer patients who underwent surgery between January 2012 and December 2013. The control group consisted of 43 patients treatmed from January 2010 until December 2011 and were not examined by VFSS. Test foods, which were presented in order of increasing thickness, included thin barium sulfate (Ba) liquid (3 or 10 ml), slightly thickened Ba liquid (3 or 10 ml), a spoonful of Ba jelly, and a spoonful of Ba puree. RESULTS: Patients could most safely swallow puree, followed by jelly. The 3mL samples of both the thin and thick liquids put patients at risk for aspiration pneumonia, with incidence rates of 13% and 11%, respectively. While 64.4% of patients could swallow all test foods and liquids safely, 35.6% were at risk for aspiration pneumonia when swallowing liquids. Even though >30% of patients were at risk, only 1 (2.2%) in the VFSS group developed aspiration pneumonia, which occurred at the time of admission. Following VFSS, no incidence of aspiration pneumonia was observed. However, aspiration pneumonia occurred in 4 (9.3%) control patients during hospitalization. CONCLUSIONS: Postoperative esophageal cancer patients were more likely to aspirate any kind of liquid than solid foods, such as jellies. VFSS is very useful in determining suitable food textures for postoperative esophageal cancer patients.