Dysphagia after stroke: research advances in treatment interventions.

After a stroke, most patients have dysphagia, which can lead to aspiration pneumonia, malnutrition, and adverse functional outcomes. Protective interventions aimed at reducing these complications remain the cornerstone of treatment. Dietary adjustments and oral hygiene help mitigate the risk of aspiration pneumonia, and nutritional supplementation, including tube feeding, might be needed to prevent malnutrition. Rehabilitative interventions aim to enhance swallowing function, with different behavioural strategies showing promise in small studies. Investigations have explored the use of pharmaceutical agents such as capsaicin and other Transient-Receptor-Potential-Vanilloid-1 (TRPV-1) sensory receptor agonists, which alter sensory perception in the pharynx. Neurostimulation techniques, such as transcranial direct current stimulation, repetitive transcranial magnetic stimulation, and pharyngeal electrical stimulation, might promote neuroplasticity within the sensorimotor swallowing network. Further advancements in the understanding of central and peripheral sensorimotor mechanisms in patients with dysphagia after a stroke, and during their recovery, will contribute to optimising treatment protocols.

Aspiration Pneumonia.

Aspiration pneumonia is a lower respiratory tract infection that results from inhalation of foreign material, often gastric and oropharyngeal contents. It is important to distinguish this from a similar entity, aspiration with chemical pneumonitis, as treatment approaches may differ. An evolving understanding of the human microbiome has shed light on the pathogenesis of aspiration pneumonia, suggesting that dysbiosis, repetitive injury, and inflammatory responses play a role in its development. Risk factors for aspiration events involve a complex interplay of anatomical and physiological dysfunctions in the nervous, gastrointestinal, and pulmonary systems. Current treatment strategies have shifted away from anaerobic organisms as leading pathogens. Prevention of aspiration pneumonia primarily involves addressing oropharyngeal dysphagia, a significant risk factor for aspiration pneumonia, particularly among elderly individuals and those with cognitive and neurodegenerative disorders.

Differences in residual volume above different tracheostomy tube cuffs depending on tube structure, tube tilt angle, and liquid viscosity.

INTRODUCTION: Proper management of aspirated material above the tracheostomy tube cuff is crucial to prevent complications, such as aspiration pneumonia. This study aimed to thoroughly examine the effects of aspirated liquid viscosity, suction port positioning, and tube tilt angle on residual volume above the cuff (RVAC). METHODS: Five types of tracheostomy tubes (approximately 9 mm outer diameter) were placed through a transparent cylinder with an inner diameter of 18 mm. The cuff was inflated to completely seal the interior of the cylinder. Four liquids with different viscosities were poured onto the cuff, and the liquid above the cuff was suctioned from the side port. The cylinder was angled at 90° and 20°, and each test was performed thrice to determine the average RVAC. RESULTS: After side-port suctioning, some liquid residue was observed on the cuff of all tracheostomy tubes. The RVAC increased with higher liquid viscosity. The tubes with a longer distance from the suction port opening to the cuff top exhibited more RVAC. Moreover, the RVAC was almost the same regardless of the cylinder angle for tubes with a suction port on the lateral side. However, tubes with backside ports showed a decreased RVAC with cylinder tilt. CONCLUSIONS: This study underscores the persistence of residual material on cuffed tracheostomy tubes even with regular subglottic secretion drainage. This emphasizes the need for specialized tracheostomy tube development aimed at reducing post-suction RVAC. Improved designs can potentially minimize complications associated with residue accumulation.

Saturation of Percutaneous Oxygen Decreases with Meal Consumption in Patients with Acute Pneumonia.

OBJECTIVE: This study aimed to investigate how respiratory status may be affected during meal consumption in patients with acute pneumonia, mainly aspiration pneumonia, using percutaneous oxygen saturation (SpO2) and pulse rate (PR) measurements. METHODS: We recruited 44 inpatients at the Towada City Hospital and divided them into 'pneumonia' and 'control' groups. Generalized linear mixed effects model was used for analysis. The pneumonia group comprised 22 patients (mean age 81.2 ± 7.0 years, body mass index [BMI] 21.1 ± 4.0 kg/m2) with 1-3 points A-DROP scores. The control group comprised 22 patients (mean age 80.5 ± 4.9 years, BMI 20.9 ± 2.9 kg/m2) with no obvious respiratory diseases. SpO2 and PR were measured 30 min before, during, and 30 min after meals. RESULTS: SpO2 was significantly lower during meals in the pneumonia group (-1.60%; 95% confidence interval = -2.76 to -0.44). There were no significant changes in PR during or after meals in the pneumonia group. CONCLUSIONS: This study suggests pneumonia may worsen respiratory status during meal intake. Patients with pneumonia may be unable to eat adequately due to worsened oxygenation during meals, even in the absence of aspiration. Therefore, it is important to observe whether there is a decrease in respiratory status during meals.

Association between successful weaning from nasogastric tube feeding and thoracic muscle mass in patients with aspiration pneumonia.

Nasogastric tube feeding is often used to provide optimal nutrition and hydration in patients with aspiration pneumonia. However, evidence regarding radiologic indicators for successful nasogastric tube weaning is lacking. We investigated whether thoracic skeletal muscle assessment can be useful for predicting successful weaning from nasogastric tube feeding in patients with aspiration pneumonia. This longitudinal, observational study included subjects with aspiration pneumonia who underwent a videofluoroscopic swallowing study (VFSS) and chest computed tomography (CT) in Boramae Medical Center, from January 2012 to December 2019. We estimated the area under the receiver operating characteristics curve (AUC) to evaluate the predictive performance of skeletal muscle and visceral fat parameters and VFSS results for successful weaning from nasogastric tube feeding. A board-certified radiologist measured muscle and fat areas. Muscle and fat volumes were segmented and measured using an externally validated convolutional neural network model. Among the 146 included patients, nasogastric tube feeding was successfully transitioned to oral feeding in 46.6%. After adjusting for covariables related to successful weaning, skeletal muscle areas, indices, and volume indices were positively associated with successful nasogastric tube weaning. Although VFSS results and skeletal muscle parameters alone showed suboptimal performance for predicting successful weaning, a prediction model combining skeletal muscle index at the T4 level and VFSS results improved the prediction performance to an acceptable level (AUC ≥ 0.7). Skeletal muscle index measured at the T4 level may be a useful supplementary indicator for predicting successful weaning from nasogastric tube feeding in patients with aspiration pneumonia.

[Diagnostics and treatment of post-stroke dysphagia]. / Diagnostik und Therapie der Dysphagie nach einem Schlaganfall.

BACKGROUND: Post-stroke dysphagia is highly prevalent and leads to severe complications, such as aspiration pneumonia and malnutrition. Despite the high clinical relevance dysphagia management is heterogeneous and often inadequate. OBJECTIVE: The aim of this review article is to provide an overview of the diagnostic and treatment strategies for post-stroke dysphagia based on recent studies. MATERIAL AND METHODS: Narrative literature review. RESULTS: Dysphagia screening should be performed as early as possible in every stroke patient, e.g., with a simple water swallowing test or a multiconsistency protocol. Subsequently, flexible endoscopic evaluation of swallowing (FEES) is indicated in patients with abnormal screening results or existing risk factors for dysphagia. Dietary modifications, oral hygiene measures, and nutritional therapy can help reduce complications. Behavioral swallowing therapy or experimental therapies, such as neurostimulation procedures and pharmacological approaches aim to improve swallowing function and have shown promising results in studies. CONCLUSION: Timely management of dysphagia is necessary to reduce complications.

Aspiration pneumonia in enteral feeding: A review on risks and prevention.

Enteral feeding plays a critical role in the management of hospitalized patients, especially in intensive care units. In addition to delivering important nutrients, it also maintains the integrity of the gut and microbiota. Enteral feeding is also associated with complications and adverse events, some are related to access placement, metabolic and electrolytes disturbances, and aspiration pneumonia. In tube-fed patients, aspiration pneumonia has a prevalence ranging from 4% to 95% with a mortality rate of 17%-62%. Our review has not showed any significant difference in the incidence of aspiration pneumonia between gastric and postpyloric feeding and, given the ease of gastric access, we therefore suggest using gastric feeding as an initial strategy for the delivery of nutrition unless postpyloric access is otherwise indicated for other clinical reasons.

[Is oral care for dysphagic patients wasted time? A narrative review on the effects of oral care on pneumonia risk and guidelines for an effective and structured approach]. / Ist die therapeutische Mundpflege bei Dysphagiepatient*innen verschwendete Zeit? Ein narrativer Review zu Effekten der Mundpflege auf die Pneumoniehäufigkeit und Ableitung einer Handlungsempfehlung.

Aspiration pneumonia is a common cause of death in dysphagia patients. In this review, we investigate whether a structured oral care approach can help to reduce pneumonia risk in dysphagic patients. In addition, guidelines for the implementation of oral care on the basis of the analyzed studies are presented. Oral care has positive effects on the risk of pneumonia in dysphagia patients. Oral care should be based on the principles of simplicity, safety, efficiency and effectiveness, universality and economy and it should include all parts of the oral cavity. Effective oral care takes less than five minutes a day. The tactile stimulation prepares the patient for dysphagia therapy and can be considered wisely-invested time.

Poor Oral Health in the Etiology and Prevention of Aspiration Pneumonia.

Aspiration pneumonia (AP), inflammation of the lung parenchyma initiated by aspirated microorganisms into the lower airways from proximal sites, including the oral cavity, is prevalent in, and problematic for, the elderly, especially those in institutions, and for those with several important risk factors. Many factors influence the pathogenesis of AP, including dysphagia, poor oral hygiene, diminished host defense, and underlying medical conditions. This article reviews the epidemiology, microbiology, pathogenesis, and prevention of AP, focusing on the role of poor oral health as a risk factor for, and on dental care for the prevention and management of, this important infection.

Management of Aspiration Risk in Stroke.

Managing risk for aspiration in the stroke patient will assist to decrease one of the major complications that these patients experience, which is poststroke pneumonia. Using an evidenced-based dysphagia protocol is shown to reduce mortality, morbidity, and length of stay caused by poststroke pneumonia. Physicians, nurses, speech pathologists, and dieticians will be instrumental in performing ongoing assessments and aspiration-prevention strategies to improve stroke patient outcome and reduce complications. Education, and measurement of comprehension, of the care team, patient, and family concerning dysphagia management and prevention of aspiration pneumonia will assist in achieving the aforementioned goals.

Does oral intake of thin fluids increase aspiration pneumonia for dysphagia after head and neck cancer surgery? A retrospective study for a total of 654 cases.

OBJECTIVE: Head and neck cancer (HNC) treatment causes dysphagia, which may lead to aspiration pneumonia (AP). Thickened fluids are widely used to prevent aspiration in patients with dysphagia; however, there is little evidence that they can prevent AP. This study aimed to clarify the differences between restriction of oral intake of fluids (R), only thickened fluids (TF), and no restriction of fluids (NR) for AP in patients with dysphagia after HNC treatment. METHODS: We retrospectively studied 654 patients with dysphagia after HNC surgery between 2012 and 2021. Of these, 255 had some restriction of fluids. The development of possible AP and administration of antibacterial drugs were used as outcomes. Multivariate linear regression and propensity score matching analyses were performed. RESULTS: The mean patient age was 64 ± 13, 67 ± 11, and 68 ± 10 years, while the Dynamic Imaging Grade of Swallowing Toxicity score 3-4 was 2.8%, 27.5, and 53.3%% water in NR, TF, and R groups, respectively. AP was diagnosed or suspected after starting oral intake in 37 (9.3%), 11 patients (15.9%), and 45 (17.6%) and antibacterial drugs were administered in 11 (2.8%), 7 patients (10.1%), and 25 (9.8%) in NR, TF, and R groups, respectively. R and TF had significant negative impacts on AP. CONCLUSIONS: Fluid restrictions may not reduce the risk of AP or affect the administration of antibacterial drugs. Medical staff should bear in mind that fluid restrictions do not necessarily prevent AP in patients with HNC.

Press needle for aspiration pneumonia prevention in older adults: Study protocol for a randomized double-blind placebo-controlled trial.

BACKGROUND: Pneumonia is the fifth most common cause of death among the Japanese population, with 97% of the deaths occurring among older adults aged ≥65 years. The incidence ratio of aspiration pneumonia is high among the older adults. Therefore, its prophylaxis is important in geriatric medicine. In our previous studies, we reported that stimulation of acupoints at stomach meridian 36 and kidney meridian 3 of the lower limbs with a press needle improved the swallowing function of patients with dysphagia. Improvements in swallowing function may prevent aspiration pneumonia. This study aims to investigate the protective efficacy of press needle stimulation in the lower limbs for aspiration pneumonia. METHODS/DESIGN: This is a multicenter, randomized, double-blind, placebo-controlled trial. A total of 140 patients with cerebrovascular disorder and a history of aspiration pneumonia will be recruited from 6 centers and randomly assigned to either the real or sham press needle group in a 1:1 ratio. The press needle will be replaced twice a week. The treatment will be administered bilaterally at acupoints stomach meridian 36 and kidney meridian 3. The primary outcome is the frequency of aspiration pneumonia onset. The secondary outcome is the improvement of the latent time of the swallowing reflex. The study period is of 12-month. The primary outcome will be evaluated throughout the study period, while the secondary outcomes will be assessed at baseline, 1st month, 6th month, and at the end of the investigation period. DISCUSSION: This study will evaluate the effects of press needle on the prevention of aspiration pneumonia and the improvement of swallowing function in patients. The results of this study will help support the prophylaxis of aspiration pneumonia.

Aspiration prevention surgeries: a review.

BACKGROUND: Severe dysphagia can cause intractable pneumonia and lead to life-threatening conditions. Intractable aspiration can occur despite medical management for aspiration prevention. Surgical intervention is indicated for intractable aspiration to prevent potentially life-threatening complications. Since the 1970s, several surgical treatments to prevent aspiration have been reported, and various aspiration prevention surgeries have been introduced, but little is known about them or their benefits. This is a review of the types of aspiration prevention surgery, with the aim of increasing aspiration prevention surgery awareness and their clinical outcomes among medical professionals, which will guide the choices of aspiration prevention surgeries for patients with intractable aspiration. MAIN BODY: Aspiration prevention surgeries can be categorized into three according to their approaches: removal of the larynx, altering the structure of the trachea, and closure of the larynx. Aspiration prevention surgeries to remove the larynx include total and central-part laryngectomy. Aspiration prevention surgeries to alter the structure of the trachea include tracheoesophageal diversion, laryngotracheal separation, and the tracheal flap method. Surgeries to close the larynx can be divided into supraglottic laryngeal closure, glottic laryngeal closure, and subglottic laryngeal closure. Aspiration prevention surgeries prevent aspiration and increase oral intake in 50-80% of patients. Most patients lose vocal function after aspiration prevention surgeries; however, some patients who have undergone total laryngectomy or laryngotracheal separation restored their speech function through tracheoesophageal puncture and use of voice prosthesis. Postoperative suture failure is frequent after epiglottic flap closure and total laryngectomy but rare after central-part laryngectomy, laryngotracheal separation, glottic closure, and subglottic closure. Furthermore, aspiration prevention surgeries improve the quality of life of patients and their caregivers by decreasing suctioning frequency. CONCLUSIONS: In this review, we described the history and development of aspiration prevention surgeries. Medical professionals need to continually improve their knowledge and skills to facilitate appropriate aspiration prevention surgeries according to patient condition.

Dysphagia.

Dysphagia, or difficult swallowing, can result in malnutrition, dehydration, aspiration pneumonia, and airway obstruction. Some primary etiologies of dysphagia include neurological disorders, traumatic brain injury, Parkinson's disease, chronic obstructive pulmonary disease, head and neck cancer, cervical spine injury, and stroke. Home care clinicians are often the first healthcare professionals to encounter patients exhibiting signs of dysphagia and can play an important role in identifying, referring, and educating patients with dysphagia. This article will discuss the broad types of dysphagia, the signs and symptoms that suggest dysphagia, and the possible etiology and treatment.

Oropharyngeal dysphagia in head and neck cancer: how to reduce aspiration pneumonia.

OBJECTIVE: Oropharyngeal dysphagia is caused by difficulty in bolus preparation and transport from the mouth to the oesophagus; this may result in malnutrition and aspiration pneumonia. It has a high prevalence in head and neck cancer patients. The objective of this study is to reduce these complications using a new protocol of diagnosis and evaluation of oropharyngeal dysphagia. METHOD: This is a prospective study developed in a secondary hospital. All patients diagnosed with head and neck cancer in 2021 and 2022 are subjected to this protocol: an oropharyngeal dysphagia screening test, a swallowing-related quality of life questionnaire and a flexible endoscopic evaluation of swallow. RESULTS: A total of 72 evaluations are reported using this protocol, before and after cancer treatment, and only 1 presents with aspiration pneumonia. CONCLUSION: Using this protocol, the incidence of aspiration pneumonia can be reduced, and diet recommendations can be given earlier in order to maintain a patient's nutritional requirements.

Development and implementation of an aspiration pneumonia cause investigation algorithm.

The diagnostic criteria of aspiration pneumonia have not been established, and it remains an underdiagnosed entity. Diagnosis and cause investigation is essential in improving the management of aspiration pneumonia. The Japanese Respiratory Society Guidelines for the Management of Pneumonia in Adults (JRS Guidelines) show a list of risk factors for aspiration pneumonia. We developed an algorithm to aid physicians in evaluating these possible underlying factors and guide their management with a focus on aspiration pneumonia. The algorithm was developed based on the JRS Guidelines. The algorithm suggested dysphagia screening, pneumococcal and influenza vaccination, and other preventative measures for pneumonia. The algorithm was implemented in the acute setting of a general hospital among older patients admitted with pneumonia. Their outcomes were compared with a historical control group constituting similar patients from the previous year. Forty patients with pneumonia were assessed with the algorithm group, and 44 patients were included in the control group. In the algorithm group, significantly more cases (95.0% vs. 15.9%, p < 0.01) underwent early screening for a swallowing disorder. Two patients in the algorithm group were diagnosed with a new condition causing aspiration pneumonia, as opposed to none in the control group. Drugs with a potential risk for aspiration were identified and discontinued in 27.5% of the patients in the algorithm group and 4.5% in the control group. In conclusion, an aspiration pneumonia cause investigation algorithm translating the JRS guideline approach into practice enhanced the rate of swallow screening and preventative measures for aspiration.

Complete Lateral Positioning Enabled Feeding in a Patient with Aspiration Pneumonia.

The complete lateral position can be used to widen the lateral pharynx in a direction that facilitates swallowing and reduces the risk of aspiration, even if the patient is unable to eat in the sitting position. Here, we report a case of aspiration pneumonia in a patient who was unable to eat in the sitting position after swallowing endoscopy, but was able to eat in the complete lateral position. By employing complete lateral positioning, more patients may be able to continue oral intake.

Evaluation of antimicrobial activity of chlorhexidine-containing oral gels against aspiration pneumonia-inducing bacteria: An In Vitro study.

Aim: Hospitalised patients have a high risk of developing aspiration pneumonia because of poor oral care and oral microbial flora changes. Chlorhexidine (CHX) solution has been used to reduce inflammation and prevent infections in oral cavity, but it is difficult to use in inpatients. Gel-type antimicrobial agents rather than the liquid form may be effective for the oral management of hospitalised patients. Therefore, we evaluated the in vitro antimicrobial effects of CHX-containing oral gels on aspiration pneumonia-inducing bacteria compared to the CHX solution. Materials and Methods: The experimental products of two oral gel types containing 1% and 0.1% CHX, respectively, were selected. Hexamedine, a 0.12% CHX solution, was used as a positive control. The antimicrobial activity of CHX agents against six pneumonia-causing bacteria and Streptococcus mutans, one of the most common oral bacteria, was comparatively analysed using the agar disk diffusion method. Results: In the disk diffusion assay, the 1% CHX gels showed the highest inhibitory effect on all bacteria. All CHX agents including gels and solution had the highest antibacterial activity against Staphylococcus aureus compared with other bacteria. Conclusions: We confirmed the significant antimicrobial effects of the 1% CHX oral gels on aspiration pneumonia-inducing bacteria. These results suggest that CHX gels may be an effective oral care method for preventing infection in inpatients who have difficulty using the solution.