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Background: Dysphagia is a frequent finding on intensive care units (ICUs) and is associated with increased reintubation rates, pneumonia, and prolonged ICU-stay. Only a limited numbers of ICUs have access to a Speech and Language Pathologist (SLP). Hence, it falls upon the critical care team to estimate dysphagia risk and define the safest feeding route. Therefore, the aim of this study was to evaluate if the feeding route established by the ICU-team is changed after a standardized dysphagia assessment (DA) by an SLP. Furthermore, we tried to identify predictors for the need of a SLP assessment looking at the change in feeding route (CIFR) after DA. Methods: We performed a retrospective analysis of patients consecutively admitted for at least 48 h in 2018, to the ICU of the Department of Neurology and Neurosurgery. Following variables were assessed: Referral to an SLP, feeding route before and after DA by an SLP, main diagnosis, and ventilation parameters. Results: From 497 included patients (65 years, IQR 51–77), 148 received a DA, confirming dysphagia in 125 subjects. DA by the SLP resulted in a significant CIFR, with 32 (21.6%) subjects receiving stricter diets, and in 29 (19.6%) cases a reduction of dietary recommendations. 50 patients lacked readiness for oral intake due to severely affected oral phase or reduced consciousness. Conclusion: Dysphagia is a frequent finding in the Neuro-ICU. Assessment of dysphagia-risk and safest feeding route differ significantly between the SLP and the critical care team. Besides implementation of standardized operating procedures for DA, the presence of ICU-specific trained SLP should be mandatory. [ABSTRACT FROM AUTHOR]

Swallowing is a complex process that involves over 50 muscles and nerves and has two critical roles: passing food from the oral cavity through the pharynx and into the esophagus and preventing contents from entering the airway. If a patient's swallowing physiology or airway protective mechanisms are disturbed, the airways and the lungs have innate defense systems to protect against injury and infection. However, critically ill patients are more likely to develop dysphagia, which is an impairment or malfunction in any aspect of the swallowing mechanism, due to the numerous interventions they undergo. When airway reflexes fail, commonly in the presence of dysphagia, aspiration can occur, which is the entry of a fluid or solid below the level of the true vocal cords. If left unmanaged, dysphagia has been associated with aspiration pneumonia, pneumonitis, airway obstruction, delayed enteral nutrition, prolonged length of intensive care unit (ICU) and hospital stay, reduced quality of life, and even death; in some cases, dysphagia is an independent risk factor for mortality. It is important to routinely assess dysphagia in all critically ill patients using a multimodal approach, including systematic assessments, scoring indices, trained specialists, and ICU nurses. Several interventions are crucial for preventing and managing dysphagia and its associated problems. Further research is necessary to help determine the best ways to prevent and manage pulmonary aspiration in critically ill patients. Several interventions are essential in preventing and managing dysphagia and the sequelae of swallowing dysfunction. Further research is needed to help elucidate the best way to avoid and manage pulmonary aspiration in critically ill patients. [ABSTRACT FROM AUTHOR]

The aim of this study was to examine the role of pre-existing dysphagia as a risk factor for COVID-19 severity among adults ≥50 years of age presenting to the emergency department (ED). This was a retrospective cohort study that used electronic health record data from two Midwestern EDs in the same health care system. The sample included patients ≥50 years of age who tested positive for SARS-COV-2 during an ED visit between March 15, 2020 and November 19, 2020. Patients were dichotomized based on documented history of dysphagia. The primary outcome was the highest World Health Organization COVID-19 clinical severity score within 30-days of ED arrival. Patients with a score of <4 were classified as non-severe whereas a score ≥4 was considered severe. Chi-square tests were used to assess differences in clinical severity scores between patients with and without dysphagia. A logistic regression model was created to estimate the odds of a severe COVID-19 clinical score. The sample included 126 patients without dysphagia and 40 patients with dysphagia. Patients with a history of dysphagia were more likely to develop severe COVID-19 disease compared to patients without (65.0% vs. 41.3%, p = 0.015). In multivariable analysis, patients with preexisting dysphagia (OR 2.38, 95% CI: 1.05–5.42; p = 0.038) and diabetes (OR 2.42 95% CI: 1.15–5.30; p = 0.021) had significantly increased odds of developing severe COVID-19. This study showed that a pre-existing diagnosis of dysphagia was independently associated with COVID-19 severity in adults ≥50 years of age. [ABSTRACT FROM AUTHOR]

Prevalence and characteristics of dysphagia (including aspiration) in patients with parkinsonism is variable, depending on type of assessment, diagnosis, disease stage and duration. The aim of this study was to further evaluate dysphagia characteristics in patients with different types of parkinsonism with both instrumental (Flexible Endoscopic Evaluation of Swallowing, FEES) and non-instrumental (Timed Water Swallow Test, TWST) assessments. Swallowing characteristics in 74 patients with parkinsonism were prospectively assessed using FEES and TWST. Statistics employed were (a) Spearman rank correlation to measure correlation between dysphagia results and Parkinson subtypes, disease severity and duration and (b) the non-parametric tests Mann Whitney U and Kruskal Wallis to measure difference between groups. Dysphagia was common, with 50 (67.6%) of the patients demonstrating a mild-severe Dysphagia Outcome Severity Scale (DOSS, level 1–5). During FEES, 42% aspirated and 68% of these had silent aspiration. Aspiration was seen more frequently with increased disease severity as per Hoehn and Yahr (H&Y) (r =.459, p = < 0.001) and disease duration (r =.269, p =.021). Thin liquid (IDDSI level 0) was the most common consistency to aspirate, and the frequency of aspiration decreased with thicker liquids. Dysphagia and aspiration are common in all subgroups of parkinsonism and seen in early stages of H&Y and within the first year of disease duration. Hence, it is recommended that these patients are evaluated early for optimal management and to avoid aspiration-related complications. [ABSTRACT FROM AUTHOR]

The objective of this systematic review was to determine the prevalence of dysphagia and aspiration in people with progressive supranuclear palsy (PSP). A search of six electronic databases was performed from inception to April 2022. No context restrictions were set. All primary research comprising figures to derive a prevalence rate were included. Two independent reviewers screened search results. Data were extracted by one reviewer. Conflicts were resolved by discussion with a third reviewer. The quality of included studies was assessed using the JBI Checklist for Prevalence Studies. From 877 studies, 12 were eligible for inclusion. Dysphagia had to be confirmed using instrumental assessments, clinical swallowing evaluation, screening, and patient-reported outcome measures (PROM). A random-effects meta-analysis calculated a pooled dysphagia prevalence in 78–89% (95% CI [60.6, 89.1], [78.9, 95.0]). depending on the chosen assessment method, and a pooled aspiration prevalence of 23.5% (95% CI [14.5, 33.7]). The included studies were of moderate quality, with high risk of selection and coverage bias and low to moderate risk of measurement bias. Dysphagia is highly prevalent in a sample of participants with mostly moderately severe PSP. Aspiration occurs in a quarter of this sample and is likely to increase as the disease progresses. Given the low general prevalence of PSP, studies remain at high risk for selection bias. Prospective research should focus on the development of dysphagia in the course of PSP and its subcategories using instrumental assessment and consider all phases of swallowing. Registration: The protocol of this systematic review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) in April 2021 (registration number: CRD42021245204). [ABSTRACT FROM AUTHOR]

Background: Cervical auscultation (CA) involves listening to swallowing and respiratory sounds and/or vibrations to detect oropharyngeal aspiration (OPA). CA has shown promising diagnostic test accuracy when used with the clinical swallowing examination and is gaining popularity in clinical practise. There has not been a review to date analysing the accuracy of CA in paediatric and adult populations with meta‐analyses. Objectives: To determine the accuracy of CA in detecting OPA in paediatric and adult populations, when compared to instrumental assessments. Search Methods: Databases searched included MEDLINE, PubMed, Embase, CINAHL, AustHealth, Cochrane and Web of Science. The search was restricted between 01 October 2012 and 01 October 2022. Selection Criteria: Inclusion criteria included (a) all clinical populations of all ages, (b) who have had an instrumental assessment and (c) CA. All study types were included. Data Collection and Analysis: Studies were reviewed independently by two authors. The methodological quality of the studies was analysed using the QUADAS‐2. Main Results: Ten studies met the inclusion criteria for this review and meta‐analyses. The pooled diagnostic performance of CA in detecting OPA was 0.91 for sensitivity and 0.79 for specificity. The area under the curve summary receiver operating curve (sROC) was estimated to be 0.86, thereby indicating good discrimination of OPA. Most studies scored high for risk of bias in at least one domain in the QUADAS‐2, likely attributed to a lack of high‐quality prospectively designed studies. Conclusions: There are promising diagnostic test accuracies for the use of CA in detection of OPA. Future research could include using CA in specific clinical populations and settings, and identifying standardised criteria for CA. [ABSTRACT FROM AUTHOR]

To validate the Manipal Bedside Swallowing Screening Test (MBSST) for assessing aspiration in individuals with tracheostomy using Video Fluoroscopic Swallow Study (VFSS). A total of 53 tracheostomized participants were screened for aspiration at bedside and VFSS across different consistencies. Penetration Aspiration Scale (PAS) was used to substantiate the severity of aspiration if present. The test demonstrated both high sensitivity (91%; 95% confidence interval = 70.8–98.9) and diagnostic accuracy (96%; 95% confidence interval = 87.0-99.5) for detecting aspiration in individuals with tracheostomy. The Manipal Bedside Swallowing Screening Test is an easy to administer tool that has sufficient sensitivity to detect aspiration in individuals with tracheostomy. The MBSST will be an easy to administer tool and will help in screening for aspiration at bedside without any instrumental examination. [ABSTRACT FROM AUTHOR]

To evaluate the whiteout duration (WOd) and intensity (WOi) during Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and examine their correlation with each other and age, gender, bolus consistencies, residue, and aspiration. Retrospective review of 75 videorecorded FEES. The first swallow of each of the following were scored: "Empty" swallow, semisolids, solids, and liquids (International dysphagia diet standardization initiative (IDDSI) 4, 7, 0, respectively). Data scored for each swallow included WOd, WOi, Penetration and aspiration scale (PAS), Pharyngeal residue (Yale Pharyngeal Residue Severity Rating Scale, YPR-SRS), and saliva pooling (Murray Secretion scale, MSS). The highest PAS and YPR-SRS for each consistency during the entire examination were also collected. WOd was significantly longer for stronger WOi in IDDSI4 swallows (p = 0.019). WOi was weaker for IDDSI0 swallows compared to IDDSI7, IDDSI4, and empty swallows (p < 0.05). Patients with saliva pooling had significantly shorter WOd (0.81 ± 0.3 s for MSS = 0 vs. 0.62 ± 0.24 for MSS = 3, p = 0.04). Lower WOi was associated with higher mean age for IDDSI0 (mean ages of 73 ± 12, 64 ± 14, 73 ± 7, 59 ± 16 years for intensity levels 1–4 respectively, p = 0.019). Swallows with weaker WOi and longer WOd had significantly more aspirations in IDDSI7 (28.8% of PAS ≥ 6 for intensity 2 vs 0% for intensity 4, p = 0.003 and 0.77 ± 0.4 s for PAS 1–2 vs. 1.02 ± 0.08 for PAS 6–8, p = 0.049). WOi and WOd are significantly associated with each other. WOi may vary for different bolus consistencies and decreases with age. Longer WOd and weaker WOi are associated with penetration–aspiration. Shorter WOd is associated with saliva pooling. [ABSTRACT FROM AUTHOR]

Abstract Background: Dysphagia is a frequent finding on intensive care units (ICUs) and is associated with increased reintubation rates, pneumonia, and prolonged ICU-stay. Only a limited numbers of ICUs have access to a Speech and Language Pathologist (SLP). Hence, it falls upon the critical care team to estimate dysphagia risk and define the safest feeding route. Therefore, the aim of this study was to evaluate if the feeding route established by the ICU-team is changed after a standardized dysphagia assessment (DA) by an SLP. Furthermore, we tried to identify predictors for the need of a SLP assessment looking at the change in feeding route (CIFR) after DA. Methods: We performed a retrospective analysis of patients consecutively admitted for at least 48 h in 2018, to the ICU of the Department of Neurology and Neurosurgery. Following variables were assessed: Referral to an SLP, feeding route before and after DA by an SLP, main diagnosis, and ventilation parameters. Results: From 497 included patients (65 years, IQR 51–77), 148 received a DA, confirming dysphagia in 125 subjects. DA by the SLP resulted in a significant CIFR, with 32 (21.6%) subjects receiving stricter diets, and in 29 (19.6%) cases a reduction of dietary recommendations. 50 patients lacked readiness for oral intake due to severely affected oral phase or reduced consciousness. Conclusion: Dysphagia is a frequent finding in the Neuro-ICU. Assessment of dysphagia-risk and safest feeding route differ significantly between the SLP and the critical care team. Besides implementation of standardized operating procedures for DA, the presence of ICU-specific trained SLP should be mandatory.

Purpose: The purpose of this rapid review was to identify the level of evidence for a previously proposed theoretical framework to assess risks associated with prandial aspiration using the host as a central theme. Methods: Covidence software was used to search two databases (PubMed and Web of Science). PEDro scale was utilized to determine the quality of individual studies. Data points were evaluated for level of support and determined to be either conclusive, suggestive, unclear, or not supportive. Within each component of the framework, data points were clustered to determine the level of evidence as strong, moderate, insufficient, or negative. Results: The rapid review process resulted in a limited number of publications investigating host variables impact on outcomes for patients with swallowing disorders. Overall, it yielded 937 articles, of which, upon review, 16 articles were selected for data extraction. There was a strong level of evidence to support that (a) as viscosity and density of aspirate increased, so did the likelihood of general medical complications, (b) poor oral care and oral health increase the risk of a pulmonary or general medical complication, and (c) the presence of oropharyngeal or laryngeal tubes increases the risk of a pulmonary consequence. There was moderate evidence to support the impact of amount and frequency of aspiration on outcomes. There was insufficient evidence to determine relationships for all other aspects of the BOLUS framework. Conclusion: Additional evidence to support the BOLUS framework was obtained; however, the number of studies was limited. A more thorough review such as a systematic review should be employed. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the feasibility of sparing the dysphagia-aspiration-related structures (DARS) in various head and neck cancer sites treated with definitive DARS-optimized intensity modulated radiation therapy (IMRT) and concurrent chemotherapy. Materials and Methods: Target volumes, organs at risk, and in addition, individual DARS were delineated, including the superior, middle, and inferior pharyngeal constrictor muscles, supraglottic and glottic larynx, the base of the tongue, esophageal inlet muscles and cervical esophagus in 35 patients with head and neck squamous cell carcinoma. Volume-based dose constraints were applied to the DARS outside the planning target volume (PTV). An IMRT plan was then generated to limit doses to DARS without compromising PTV dose coverage. Results: Twelve (34.3%) patients had an oropharyngeal primary (OPX), 18 (51.4%) had a laryngeal, and 5 (14.3%) patients had hypopharyngeal primary. The mean dose to the DARS was 47.93 Gy for the entire group, while it was 54.6 Gy in oropharyngeal primaries and 44.4 Gy in laryngopharyngeal primaries. DARS mean dose of ≤45 Gy could be achieved in a significantly lesser number of patients with oropharyngeal primaries (P < 0.02). Similarly, DARS mean dose was 42.25 Gy in patients with N0 disease, 49.6 Gy with ipsilateral involved nodes, and 55 Gy with bilateral disease. Sparing of DARS was feasible when the volume of PTV was ≤150 cc (P < 0.025). Conclusion: Sparing of DARS structures appears to be challenging in patients with oropharyngeal cancers without compromising the dose to the PTVs while it is feasible in laryngopharyngeal cancers. DARS sparing is feasible when the PTV volume is < 150 cc and in patients with negative or unilateral nodal disease. [ABSTRACT FROM AUTHOR]

Background and purpose: Swallowing is a complex task, moderated by a sophisticated bilateral network including multiple supratentorial regions, the brainstem and the cerebellum. To date, conflicting data exist about whether focal lesions to the cerebellum are associated with dysphagia. Therefore, the aim of the study was to evaluate dysphagia prevalence, recovery and dysphagia pattern in patients with ischaemic cerebellar stroke. Methods: A retrospective analysis of patients consecutively admitted to an academic stroke centre with ischaemic stroke found only in the cerebellum was performed. The presence of dysphagia was the primary end‐point and was assessed by a speech‐language pathologist, according to defined criteria. Dysphagia pattern was evaluated by analysing the videos of the flexible endoscopic evaluation of swallowing. Brain imaging was used to identify lesion size and location associated with dysphagia. Results: Between January 2016 and December 2021, 102 patients (35.3% female) with a mean age of 52.8 ± 17.3 years were included. Thirteen (12.7%) patients presented with dysphagia. The most frequently observed flexible endoscopic evaluation of swallowing phenotype was premature spillage (n = 7; 58.3%), whilst significant residues or aspiration did not occur. One patient died (7.7%); the other patients showed improvement of dysphagia and one patient (7.7%) was discharged with dietary restrictions. Conclusions: Although the involvement of the cerebellum in deglutition has become increasingly evident, isolated lesions to the cerebellum are less likely to cause clinically relevant and persisting dysphagia compared to other brain regions. The observed dysphagia pattern shows a lack of coordination and control, resulting in premature spillage or fragmented bolus transfer in some patients. [ABSTRACT FROM AUTHOR]

Nil per os (NPO), also referred to as Nil by Mouth (NBM), is a health-related intervention of withholding food and fluids. When implemented in the context of a person with dysphagia, NPO aims to mitigate risks of aspiration. However, evidence demonstrating that NPO is beneficial as an intervention for people with dysphagia is lacking. This paper explores the theoretical and empirical evidence relating to the potential benefits and adverse effects of NPO and asserts that NPO is not a benign intervention. This paper argues for applying an ethics framework when making decisions relating to the use of NPO as an intervention for dysphagia, in particular addressing informed consent and a person's right to self-determination. [ABSTRACT FROM AUTHOR]

Impaired swallowing, or dysphagia, significantly affects patients' well-being and health. Nearly half of the patients with head and neck cancers experience dysphagia or aspiration following radiation therapy or surgery. However, current dysphagia management approaches are primarily symptom-based rather than etiology-specific, owing to a lack of clear understanding of aspiration mechanisms. This study aimed to understand the mechanisms of aspiration in an anatomically accurate pharyngolaryngeal model at different epiglottis angles. A biomechanical swallowing model was developed using transparent casts, and liquid flow dynamics were visualized using fluorescent dye from side and back views. Two liquids and two dispensing conditions were evaluated for their roles in aspiration. The results demonstrated distinct flow dynamics between water and a 1 ​% w/v methylcellulose aqueous solution and, to a lesser extent, between fast and slow dispensing for the same liquid. Three frequent aspiration sites were identified, including the interarytenoid notch, the cuneiform tubercular recess, and the vallecula, corresponding to aspiration mechanisms of notch overflow, recess overflow, and creeping flow, respectively. The angle of the epiglottis influenced flow dynamics in at least three ways: by facilitating gravity-assisted fluid movement, redistributing flow through the gap between the epiglottis tip and pharyngeal wall, and affecting creeping flow via the angle between the epiglottis base and hypopharynx. Slow dispensing of water to the anterior oropharynx resulted in a significantly high aspiration rate with a downward tilted epiglottis due to concurrent tubercle-recess overflow and vallecular creeping flow. The biomechanical model can serve as a testing platform for better understanding aspiration mechanisms and developing etiology-based strategies before and after treatments for head and neck cancers.

Cough is a powerful, protective expulsive behavior that assists in maintaining respiratory health by clearing foreign material, pathogens, and mucus from the airways. Therefore, cough is critical to survival in both health and disease. Importantly, cough protects the airways and lungs from both antegrade (e.g., food, liquid, saliva) and retrograde (e.g., bile, gastric acid) aspirate contents. Aspiration is often the result of impaired swallowing (dysphagia), which allows oral and/or gastric contents to enter the lung, especially in individuals who also have cough dysfunction (dystussia). Cough hyposensitivity, downregulation, or desensitization- collectively referred to as hypotussia- is common in individuals with dysphagia, and increases the likelihood that aspirated material will reach the lung. The consequence of hypotussia with reduced airway clearance can include respiratory tract infection, chronic inflammation, and long-term damage to the lung parenchyma. Despite the clear implications for health, the problem of managing hypotussia in individuals with dysphagia is frequently overlooked. Here, we provide an overview of the current interventions and treatment approaches for hypotussic cough. We synthesize the available literature to summarize research findings that advance our understanding of these interventions, as well as current gaps in knowledge. Further, we highlight pragmatic resources to increase awareness of hypotussic cough interventions and provide support for the clinical implementation of evidence-based treatments. In culmination, we discuss potential innovations and future directions for hypotussic cough research. [ABSTRACT FROM AUTHOR]

Objective: This systematic review and meta-analysis aims to systematically evaluate the effectiveness and safety of acupuncture in the treatment of aspiration caused by post-stroke dysphagia. Methods: A computer search was conducted in nine databases, including the China National Knowledge Infrastructure (CNKI), China Science and Technology Journal (VIP), Wan-fang Database, China Biomedical Literature Database (CBM), PubMed, Web of Science, Cochrane Library, Embase, and Chinese Clinical Trial Registry (ChiCTR), from their inception until April 2024. Clinical randomized controlled trials comparing acupuncture combined therapy or single therapy with control interventions for the treatment of aspiration caused by post-stroke dysphagia were included. The primary outcome measure was the Penetration Aspiration Scale (PAS), and secondary outcome measures included the overall effective rate, video fluoroscopic swallowing study (VFSS), and hyoid bone displacement. The statistical analysis was performed using RevMan 5.3 and Stata 16.0. Results: A total of 16 articles involving 1,284 patients were included. The meta-analysis results showed that acupuncture combined therapy or single therapy was more effective in improving PAS scores compared to conventional rehabilitation therapy or balloon dilation of the catheter [WMD = -1.05, 95% CI (-1.30, -0.80), Z = 0.82, p = 0.00 < 0.05]. It was also more effective in improving VFSS scores [WMD = 1.32, 95% CI (0.08, 2.55), Z = 2.09, p = 0.04 < 0.05] and hyoid bone displacement [WMD = 2.02, 95% CI (0.86, 3.18), Z = 3.41, p = 0.00 < 0.05]. Additionally, acupuncture had a higher overall effective rate [WMD = 1.21, 95% CI (1.14, 1.29), Z = 5.76, p = 0.00 < 0.05] and a lower incidence of adverse events. Sensitivity analysis indicated that the literature had minimal impact on the results, and bias tests showed no publication bias. Conclusion: Acupuncture combined therapy and acupuncture single therapy can effectively improve aspiration caused by post-stroke dysphagia with a low incidence of adverse events. However, due to the low quality of the included literature, more high-quality randomized controlled trials are still needed to confirm the effectiveness and safety of acupuncture in the treatment of aspiration caused by post-stroke dysphagia. [ABSTRACT FROM AUTHOR]

Background: The Gugging Swallowing Screen (GUSS) is a bedside dysphagia screening tool that has been designed to determine the risk of aspiration in acute stroke patients. There is no evidence in the literature for the GUSS for the pediatric population. The present study aimed to determine the diagnostic accuracy of GUSS as a screening tool in the Greek language for children with dysphagia. Methods: Eighty‐Greek‐Cypriot children aged 3–12 years who had dysphagia participated in this retrospective study. The translated into Greek GUSS was administered twice (pre‐ and post‐therapy) to each patient throughout 24 sessions of dysphagia therapy. Key Results: The GUSS showed a high internal consistency (Cronbach's α = 0.826), good test–retest reliability (rs = 0.767), convergent validity compared to the Greek Pediatric Eating Assessment tool‐10 (PEDI‐EAT‐10) total score (rs = −0.365), and inter‐rater reliability (κ = 0.863). A total cutoff points equal to 13.00 was also calculated. Aspiration was identified by the GUSS with low sensitivity and high specificity (PPV 100%, NPV 57%, LR+ NA, LR− 0.79); dysphagia/penetration was identified with high sensitivity and low specificity (PPV 33%, NPV 100%, LR+ 0.102, LR− NA). Conclusions & Inferences: The pediatric version of GUSS has been found to be a valuable tool in identifying the risk of aspiration as that of adults. It proved to be used as a good screening guide for selecting and confirming the existence of dysphagia from instrumental assessments. This is the first study of the pediatric version of GUSS, and future studies on this topic are needed. [ABSTRACT FROM AUTHOR]

Purpose: Dysphagia is a prevalent symptom observed in acute stroke. Several bedside screening tests are employed for the early detection of dysphagia. Pulse oximetry emerges as a practical and supportive method to augment the existing techniques utilized during bedside swallowing assessments. Desaturation levels, as measured by pulse oximetry, are acknowledged as indicative of aspiration by certain screening tests. However, the predictive capability of pulse oximetry in determining aspiration remains a subject of controversy. The objective of this study was to compare aspiration and oxygen desaturation levels by time and aspiration severity in dysphagic patients compared to healthy controls. It also aimed to evaluate the accuracy of pulse oximetry by comparing it with VFSS findings in detecting aspiration in both liquid (IDDSI-0) and semi-solid (IDDSI-4) consistencies. Materials and methods: Eighty subjects (40 healthy and 40 acute stroke patients) participated. Patients suspected of dysphagia underwent videofluoroscopy as part of the stroke unit's routine procedure. Baseline SpO2 was measured before VFSS, and stabilized values were recorded. Sequential IDDSI-0 and IDDSI-4 barium tests were conducted with 5 ml boluses. Stabilized SPO2 values were recorded during swallowing and 3-min post-feeding. Patients with non-dysphagia received equal bolus monitoring. Changes in SPO2 during, before, and after swallowing were analyzed for each consistency in both groups. Results: The study revealed a statistically significant difference in SPO2 between patients with dysphagia and controls for IDDSI-4 and IDSSI-0. In IDDSI-4, 20% of patients experienced SpO2 decrease compared to 2.5% in control group (p = 0.013). For IDDSI-0, 35% of patients showed SpO2 decrease, while none in the control group did (p = 0.0001). Aspiration rates were 2.5% in IDDSI-4 and 57.5% in IDDSI-0. In IDDSI-0, SpO2 decrease significantly correlated with aspiration (p = 0.0001). In IDDSI-4, 20.5% had SpO2 decrease without aspiration, and showing no significant difference (p = 0.613). Penetration-Aspiration Scale scores had no significant association with SpO2 decrease (p = 0.602). Pulse oximetry in IDDSI-4 had limited sensitivity (0%) and positive predictive value, (0%) while in IDDSI-0, it demonstrated acceptable sensitivity (60.9%) and specificity (100%) with good discrimination capability (AUC = 0.83). Conclusions: A decrease in SPO2 may indicate potential aspiration but is insufficient alone for detection. This study proposes pulse oximetry as a valuable complementary tool in assessing dysphagia but emphasizes that aspiration cannot be reliably predicted based solely on SpO2 decrease. [ABSTRACT FROM AUTHOR]

Although gastrointestinal (GI) comorbidities are experienced by over 90% of individuals with Rett syndrome (RTT), a neurodevelopmental disorder associated with mutations in the MECP2 gene, many neurologists and pediatricians do not rank the management of these comorbidities among the most important treatment goals for RTT. Trofinetide, the first approved pharmacologic treatment for RTT, confers improvements in RTT symptoms but is associated with adverse GI events, primarily diarrhea and vomiting. Treatment strategies for GI comorbidities and drug-associated symptoms in RTT represent an unmet clinical need. This perspective covers GI comorbidities experienced by those with RTT, either with or without trofinetide treatment. PubMed literature searches were undertaken on treatment recommendations for the following conditions: constipation, diarrhea, vomiting, aspiration, dysphagia, gastroesophageal reflux, nausea, gastroparesis, gastritis, and abdominal bloating. The authors recommend a proactive approach to management of symptomatic GI comorbidities and drug-associated symptoms in RTT to enhance drug tolerance and improve the quality of life of affected individuals. Management strategies for common GI comorbidities associated with RTT are reviewed based on authors' clinical experience and augmented by recommendations from the literature. [ABSTRACT FROM AUTHOR]

Objective: Despite widespread use of high flow nasal cannula (HFNC) for respiratory support, the effect of HFNC on swallowing physiology is poorly understood. Flow rates that permit safe swallowing have not been established. We aim to assess if healthy individuals have diminished swallowing function and safety at high flow rates. Study Design: Repeated measures with planned data collection. Setting: Outpatient dysphagia clinic. Methods: Swallowing function in a cohort of healthy individuals was assessed using Flexible Endoscopic Evaluation of Swallowing (FEES). Participants' safety of swallowing was assessed with different textures under randomized rates of HFNC (0, 30, 40, 50, and 60 LPM). Swallowing trials included quantities of thin liquids, mildly‐thick liquids, and purees. Trials were scored using the Penetration‐Aspiration Scale (PAS). Pearson chi‐square tests were used to test for correlation between PAS result, flow rate, and consistency across each quantity of material. Results: Twenty‐seven subjects were enrolled. Forty‐one percent were male with mean age of 34 years (11 standard deviation). Ninety‐nine percent (267/270), 97% (n = 263/270), and 99% (399/405) of 1 sip swallows, 3 sip swallows, and 5 mL swallows, respectively, were safe. There was no significant correlation between swallow safety and flow rate using Pearson Chi‐Square test across all consistencies and across all quantities of materials (P > 0.05). Of note, out of all subtrials, the thin liquid, 3 sips trial at 60 LPM, had the largest percent of unsafe swallows (14%). Conclusion: Our results suggest rate of aspiration is not significantly affected by high flow nasal cannula in healthy individuals. [ABSTRACT FROM AUTHOR]

Objective: Sarcopenia, characterized by decreased skeletal muscle mass, is associated with poorer oncologic outcomes in head and neck cancer (HNC) patients. The effect of sarcopenia on swallowing following HNC treatment is unknown. This study aims to investigate the association of sarcopenia and swallowing dysfunction in patients treated for HNC. Study Design: Retrospective cohort study. Setting: Academic medical center. Methods: Pretreatment sarcopenia was assessed using the skeletal muscle index calculated from cross‐sectional imaging at the third cervical vertebra. Feeding tube dependence, patient‐reported dysphagia, and swallowing safety were assessed before and after treatment with the Functional Oral Intake Scale, Eating Assessment Tool‐10, and Penetration Aspiration Scale, respectively. The association between sarcopenia and swallowing dysfunction was evaluated. Results: A total of 112 patients were included, 84 males (75%) and 28 females (25%). A total of 69 (61.6%) had sarcopenia prior to initiating HNC therapy. Sarcopenia was significantly associated with an elevated risk of patient‐reported dysphagia (odds ratio [OR] = 2.71 [95% confidence interval, CI, 1.12‐6.79]; P <.05). Multivariate logistic regression demonstrated that sarcopenia (OR = 15.18 [95% CI, 1.50‐453.53]; P <.05) is an independent predictor for aspiration following treatment for HNC. Conclusion: Patients with pretreatment sarcopenia had higher rates of dysphagia before treatment and were more likely to develop aspiration after completion of HNC therapy. Sarcopenia is readily measured using cross‐sectional imaging and may be useful for identifying patients at risk of swallowing dysfunction and those most likely to benefit from prehabilitation efforts. [ABSTRACT FROM AUTHOR]

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Individuals with communication and swallowing disorders often exhibit poor oral health and hygiene (OHH), that can lead to further complications. OHH assessment and management is a part of scope of practice of Speech-Language Pathologists (SLPs). The study aims to determine the level of awareness, knowledge and practice patterns of OHH amongst the SLPs in India. A questionnaire with 20-item and three sections was developed to assess the awareness and knowledge regarding OHH among SLPs. A total of 162 participants responded to the survey. 93.2% participants were aware of the importance of OHH, however 42.6% participants did not feel confident enough to assess the same. A majority (82.7%) agreed that poor OHH can lead to different health complications. 38.8% of the participants responded that they assessed oral health only sometimes and 54.3% reported that they never used any standard screening/assessment tools to assess oral health. Only a very small percentage of participants (28.65%) counselled the patients for maintenance of oral hygiene and more than 40% never recommended appropriate OHH practices during management. Though a vast majority were aware of the importance of OHH and consequences of poor OHH, they did not feel confident and consequently did not incorporate OHH during clinical practice. Though the scope of SLP includes oral care assessment and management, Indian SLPs were not practicing this. Hence, the clinical and academic curriculum should focus on topics pertaining to oral health assessment and management, which will improve the quality-of-service delivery of the SLPs. [ABSTRACT FROM AUTHOR]

Purpose: Postoperative pneumonia remains a common complication of surgery, despite increased attention. The purpose of our study was to determine the effects of routine surgery and post-surgical opioid administration on airway protection risk. Methods: Eight healthy adult cats were evaluated to determine changes in airway protection status and for evidence of dysphagia in two experiments. (1) In four female cats, airway protection status was tracked following routine abdominal surgery (spay surgery) plus low-dose opioid administration (buprenorphine 0.015 mg/kg, IM, q8-12 h; n = 5). (2) Using a cross-over design, four naive cats (2 male, 2 female) were treated with moderate-dose (0.02 mg/kg) or high-dose (0.04 mg/kg) buprenorphine (IM, q8-12 h; n = 5). Results: Airway protection was significantly affected in both experiments, but the most severe deficits occurred post-surgically as 75% of the animals exhibited silent aspiration. Conclusion: Oropharyngeal swallow is impaired by the partial mu-opioid receptor agonist buprenorphine, most remarkably in the postoperative setting. These findings have implications for the prevention and management of aspiration pneumonia in vulnerable populations. [ABSTRACT FROM AUTHOR]

Aim: The chin‐down posture is a widely used compensatory manoeuvre for patients with dysphagia. The aim of this study was designed to systematically measure the effectiveness of chin‐down manoeuvre application. Methodology: We retrieved the PubMed, Web of Science, Embase, Cochrane Library, EBSCO, Medline, CNKI, WANFANG, VIP and SinoMed databases from inception to 30 August 2022. Raters independently screened literature according to inclusion and exclusion criteria. The quality of the included literature was evaluated, and data were extracted. The software Review Manager software 5.3 was used for statistical analysis. Results: Fourteen studies with a total of 571 patients were included in this meta‐analysis. The meta‐analysis indicated that chin‐down manoeuvre could significantly reduce the risk of aspiration (MD = −1.35, 95% CI [−2.25, −0.44], Z = 2.92, p <.01), decrease the chin angle (MD = −12.20, 95% CI [−14.61, −9.79], Z = 9.91, p <.001), shorten oral transit time (MD = −0.81, 95% CI [−1.20, −0.43], Z = 4.17, p <.001), reduce the maximum swallowing pressure at upper oesophageal sphincter (MD = −82.07, 95% CI [−112.77, −51.37], Z = 5.24, p <.001) and decrease pharyngeal residue. Conclusions: Existing evidence indicated that chin‐down manoeuvre could reduce the risk of aspiration and pharyngeal residue, decrease the maximum swallowing pressure at UES. More large‐sample, high‐quality clinical trials are still needed in the future to further ascertain the results of this research. [ABSTRACT FROM AUTHOR]

Introduction: Vocal fold motion impairment (VFMI) is a known consequence after high‐risk cardiac surgery. We implemented a universal laryngeal ultrasound (LUS) screening protocol for VFMI after the Norwood and aortic arch surgery. We hypothesized that LUS would accurately identify VFMI and predict postoperative aspiration. Methods: We implemented a screening algorithm with LUS for patients undergoing high‐risk cardiac surgery at a tertiary care pediatric hospital. Positively screened patients underwent flexible nasolaryngoscopy (FNL). Patients with an abnormal FNL underwent a video‐fluoroscopic swallow study (VFSS). Patient demographics, length of stay, and swallowing outcomes were assessed. Two‐tailed chi square and Wilcoxon rank sum tests were used to assess for differences. Results: Sixty‐seven patients underwent either Norwood or arch reconstruction over a 16‐month period and underwent universal LUS. The average birth weight was 3.24 kg (SD 0.57). Of the 67 patients, VFMI was identified by LUS and 100% confirmed on FNL in 58.21% (n = 39/67) of patients. Aspiration and penetration on VFSS were higher in the group with VFMI as compared with those without VFMI (53.8% vs. 21.4%, p = 0.008). There was no difference in length of stay between patients who did not have a diagnosis of VFMI and those found to have VFMI (41.0 days vs 45.3 days p = 0.73). Conclusions: Universal LUS screening for patients following high‐risk cardiac surgery may lead to earlier identification of postoperative VFMI and aspiration. Recognition of VFMI through this universal screening program could lead to earlier interventions and possibly improved swallowing outcomes. Level of Evidence: 3 Laryngoscope, 134:1939–1944, 2024 [ABSTRACT FROM AUTHOR]

PurposeThe purpose of this rapid review was to identify the level of evidence for a previously proposed theoretical framework to assess risks associated with prandial aspiration using the host as a central theme.MethodsCovidence software was used to search two databases (PubMed and Web of Science). PEDro scale was utilized to determine the quality of individual studies. Data points were evaluated for level of support and determined to be either conclusive, suggestive, unclear, or not supportive. Within each component of the framework, data points were clustered to determine the level of evidence as strong, moderate, insufficient, or negative.ResultsThe rapid review process resulted in a limited number of publications investigating host variables impact on outcomes for patients with swallowing disorders. Overall, it yielded 937 articles, of which, upon review, 16 articles were selected for data extraction. There was a strong level of evidence to support that (a) as viscosity and density of aspirate increased, so did the likelihood of general medical complications, (b) poor oral care and oral health increase the risk of a pulmonary or general medical complication, and (c) the presence of oropharyngeal or laryngeal tubes increases the risk of a pulmonary consequence. There was moderate evidence to support the impact of amount and frequency of aspiration on outcomes. There was insufficient evidence to determine relationships for all other aspects of the BOLUS framework.ConclusionAdditional evidence to support the BOLUS framework was obtained; however, the number of studies was limited. A more thorough review such as a systematic review should be employed.

Abstract Background Dysphagia, with its negative impact on life expectancy and quality of life, is a major side effect of head and neck squamous cell carcinoma (HNSCC). In a typical Head and Neck Cancer Center, more than half of patients are affected. Improving treatment, and ideally prevention respectively prehabilitation, therefore seems more than desirable. Methods The study is planned as a monocentric, prospective, outcome-blinded, randomized interventional study comparing an advanced phoniatric-logopedic prehabilitation with a control (standard of care). Seventy patients (30 control group, 30 intervention group, 10 drop-out rate of 15%) with an initial diagnosis of invasive HNSCC and curative treatment intention will be included over a period of 17 months. In addition to the previous standard, both groups will undergo both detailed subjective assessment of swallowing function and quality of life by means of various questionnaires and objective analyses by bioelectrical impedance measurements and phoniatric endoscopic swallowing examinations. In the intervention group, risk-related nutritional counseling (face-to-face) and phoniatric-logopedic prehabilitation are provided: detailed counseling with video demonstration and exercises to strengthen and improve the range of motion of the oral, pharyngeal, and laryngeal muscles (guided by exercise diary). Controls are performed at 6 weeks, 3 and 6 months, and 9 or 12 months after the end of therapy during the regular tumor follow-up. Primary study endpoints are swallowing function and emotional distress at 6 weeks of control visit. Discussion Prehabilitation measures have already proven successful in other patient groups, e.g., transplant patients. In the field of head and neck oncology, interest in such concepts has increased significantly in recent years. However, usually, only subgroups, e.g., patients with swallowing problems after radiochemotherapy alone, are in focus. Our study aims to investigate the general benefit of prehabilitation with regard to swallowing function, which is so important for protection of aspiration and quality of life. Trial registration German Clinical Trials Register DRKS00029676 . International Clinical Trials Registry Platform DRKS00029676 . Registered on 19 July 2022.

Introduction: Thickened liquids are commonly recommended to reduce the risk of penetration-aspiration. However, questions persist regarding the impact of bolus consistency on swallowing safety. The common practice of summarizing Penetration-Aspiration Scale (PAS) scores based on worst scores is a bias in prior analyses. The aim of this study was to examine the impact of liquid consistency on PAS scores using a Bayesian multilevel ordinal regression model approach, considering all scores across repeated bolus trials. A second aim was to determine whether PAS scores differed across thickener type within consistency. Methods: We analyzed two prior datasets (D1; D2). D1 involved 678 adults with suspected dysphagia (289 female; mean age 69 years, range 20-100). D2 involved 177 adults (94 female; mean age 54 years, range 21-85), of whom 106 were nominally healthy and 71 had suspected dysphagia. All participants underwent videofluoroscopy involving ≥3 boluses of 20% w/v thin liquid barium and of xanthan-gum thickened barium in mildly, moderately and extremely thick consistencies. D2 participants also swallowed trials of slightly thick liquid barium, and starch-thickened stimuli for each thickened consistency. Duplicate blinded rating yielded PAS scores per bolus, with discrepancies resolved by consensus. PAS ratings for a total of 8,185 and 3,407 boluses were available from D1 and D2, respectively. Bayesian models examined PAS patterns across consistencies. We defined meaningful differences as non-overlapping 95% credible intervals (CIs). Results: Across D1 and D2, penetration occurred on 10.87% of trials compared to sensate (0.68%) and silent aspiration (1.54%), with higher rates of penetration (13.47%) and aspiration (3.07%) on thin liquids. For D1, the probability of a PAS score > 2 was higher for thin liquids with weighted PAS scores of 1.57 (CI: 1.48, 1.66) versus mildly (1.26; CI: 1.2, 1.33), moderately (1.1; CI: 1.07, 1.13), and extremely thick liquids (1.04; CI: 1.02, 1.08). D2 results were similar. Weighted PAS scores did not meaningfully differ between thin and slightly thick liquids, or between starch and xanthan gum thickened liquids. Discussion: These results confirm that the probability of penetration-aspiration is greatest on thin liquids compared to thick liquids, with significant reductions in PAS severity emerging with mildly thick liquids. [ABSTRACT FROM AUTHOR]

Background: There exists a lacuna in the structured reporting of swallowing dysfunction and quality of life (QoL) outcome following major glossectomy. Methods: Prospective cohort study to assess the swallowing dysfunction and QoL following STG (subtotal glossectomy) or NTG (near total glossectomy) over a 6‐month period using FEES and PAS scale, MDADI, and FACT‐HN. Results: Twenty‐four patients were available for analysis. The pre‐ and post‐adjuvant evaluation revealed a statistically significant improvement in the composite MDADI and FACT‐HN scores. Subscale analysis of FACT‐HN scores revealed maximum deficit in the head and neck cancer‐specific score domain followed by functional domain and social well‐being domain, with serial improvement noted in the post‐adjuvant setting. Conclusion: This study showed serial improvement in terms of swallowing dysfunction although social and functional well‐being domains related to QoL continued to reveal major deficits. Better outcomes were seen with preservation of bilateral base of tongue and mandible. [ABSTRACT FROM AUTHOR]

Objective: To assess the risk of aspiration associated with post‐swallow residue subsites in Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in bottle‐fed infants <1 year of age. Methods: This is a retrospective matched‐pairs cohort study at an academic tertiary children's hospital. FEES and Videofluoroscopic Swallowing Study (VFSS) trials performed within the same infant <5 days apart were paired by matching bolus consistency and bottle flow rate. Positive aspiration was defined by the "or rule" in which aspiration is positive when either FEES or VFSS within a matched pair is positive. Results: Eighty‐seven FEES‐VFSS matched pairs from 29 patients (16 males; mean [SD] age, 2.9 [2.8] months) were included. The rate of positive aspiration, as defined by the "or rule", was 59% (51/87). In FEES, post‐swallow pyriform sinus residue was present in 16% (14/87) and anterior commissure residue 27% (31/87). Risk of positive aspiration was increased by pyriform sinus residue (odds ratio [OR] 5.4, 95% confidence interval [CI] 1.9–19.3, p < 0.01) and anterior commissure residue in FEES (OR 2.5, 95% CI 1.1–6.1, p = 0.03). In the neonate subgroup, <1 month of age, multivariate‐adjusted analysis showed that anterior commissure residue had better diagnostic accuracy for aspiration than in older infants (overall 70% vs. 42%, p < 0.01; sensitivity 60% vs. 10%, p < 0.01), whereas pyriform sinus residue had worse accuracy (overall 41% vs. 70%, p = 0.02; sensitivity 13% vs. 43%, p = 0.02). Conclusion: This study demonstrates that pyriform sinus and anterior commissure residue during infant FEES were associated with fivefold and twofold increased risk of aspiration, respectively. Level of Evidence: 3. Using a retrospective matched‐pairs cohort, this study assesses the diagnostic accuracy of post‐swallow residue in FEES for predicting aspiration. Laryngoscope, 134:1431–1436, 2024 [ABSTRACT FROM AUTHOR]

Key summary points: Aim: We performed a scoping review to investigate the necessary clinical competencies for the management of AP in older adults, to serve as a baseline for multidisciplinary healthcare professionals to improve how they work with AP in the clinical, educational, and research settings. Findings: The clinical competencies for the management of aspiration pneumonia in older adults that were identified are summarized in the phrase 'Diagnose, Treat, and SUPPORT', where SUPPORT is an acronym for Swallow and nutrition intervention, Underlying condition management, Prognosis evaluation and decision making, Prevention and palliation, Oral management, Rehabilitation, and Team approach. Message: There is a particular demand for research and education in the area of supportive therapy for AP. Background: Aspiration pneumonia in older adults is increasingly common, with a high care burden and morbidity. However, clinical competencies in its management have not been developed, and healthcare professionals struggle on how to care for these patients with multimodal treatment needs. Therefore, we conducted a scoping review to investigate what is known about the desired clinical competencies for the management of older adults with aspiration pneumonia, to utilise in clinical practice, education, and future research. Methods: First, we defined aspiration pneumonia according to a preliminary search. We then searched the literature on MEDLINE and CINAHL, focusing on studies involving patients aged 65 years old and older diagnosed with aspiration pneumonia. All settings were included, with the exception of intensive care units. Publication dates were limited to January 2011 to July 2022 and languages to English and Japanese. The extracted data were used to refine the preliminary competency framework developed by the Japan Aspiration pneumonia inter-Professional team Educational Program (JAPEP) in preparation of this study. Results: Ninety-nine studies were included. Following data extraction from these studies, 3 competencies were renamed, and 3 new competencies were added, to create a list of 12 competencies. These were Diagnosis, Treatment, Swallow Assessment, Underlying condition management, Nutrition, Oral management, Rehabilitation, Multidisciplinary team, Decision making, Prevention, Prognosis, and Palliative care. Conclusions: Our scoping review identified 12 clinical competencies required in the management of older adults with aspiration pneumonia, outlined in the phrase 'Diagnose, Treat and SUPPORT'. We encourage healthcare professionals to share these competencies as a team to identify areas of unmet need and improve their patient care, with an emphasis on supportive care. [ABSTRACT FROM AUTHOR]

Dysphagia is very common among hospitalized patients and is associated with increased length of hospital stay, morbidity, and mortality. Diet restrictions for dysphagia cause dehydration and discontent. The Frazier Free Water Protocol (FFWP) was developed to improve hydration and quality of life in dysphagia patients by establishing the safety of allowing sips of water between meals. Despite these potential benefits, we hypothesized that the FFWP is not widely utilized. We sought to determine barriers to utilization by assessing the familiarity, usage, and perceptions of the FFWP among health-care providers at our institution. We distributed an anonymous questionnaire to a convenience sample of nurses in the hospital during daily huddles. The questionnaire was adapted from a validated framework to assess provider acceptability of health-care interventions. Of the 66 surveys distributed, we had 58 completed (88%). Only 10 nurses (17%) had heard of the "FFWP" by name. For those that were familiar with the indications, benefits, and risks of giving free water to patients with dysphagia (n = 18), less than half (39%) reported doing so. No nurses that had less than 10 y of patient care experience gave water to dysphagia patients, even if they knew the indications, benefits, and risks. Similarly, less than a fifth (19%) of all nurses surveyed were comfortable giving water to dysphagia patients, but comfort increased for some if the protocol was recommended by a speech-language pathologist (33%) or physician (13%). Nursing experience of >10 y or in intensive care settings did not yield significant differences in knowledge, usage, or comfort level than those with less years or nonintensive care experience, respectively. Nurses are essential to the implementation of the FFWP, yet many are unfamiliar and uncomfortable with utilizing it. Education about the protocol is necessary to improve patient outcomes and quality of life. We plan to provide targeted education about the FFWP as well as assess other members of the health-care team, in an attempt to increase utilization of the protocol and improve dysphagia management. [ABSTRACT FROM AUTHOR]

Nil per os (NPO), also referred to as Nil by Mouth (NBM), is a health-related intervention of withholding food and fluids. When implemented in the context of a person with dysphagia, NPO aims to mitigate risks of aspiration. However, evidence demonstrating that NPO is beneficial as an intervention for people with dysphagia is lacking. This paper explores the theoretical and empirical evidence relating to the potential benefits and adverse effects of NPO and asserts that NPO is not a benign intervention. This paper argues for applying an ethics framework when making decisions relating to the use of NPO as an intervention for dysphagia, in particular addressing informed consent and a person's right to self-determination.

Cough is a powerful, protective expulsive behavior that assists in maintaining respiratory health by clearing foreign material, pathogens, and mucus from the airways. Therefore, cough is critical to survival in both health and disease. Importantly, cough protects the airways and lungs from both antegrade (e.g., food, liquid, saliva) and retrograde (e.g., bile, gastric acid) aspirate contents. Aspiration is often the result of impaired swallowing (dysphagia), which allows oral and/or gastric contents to enter the lung, especially in individuals who also have cough dysfunction (dystussia). Cough hyposensitivity, downregulation, or desensitization- collectively referred to as hypotussia- is common in individuals with dysphagia, and increases the likelihood that aspirated material will reach the lung. The consequence of hypotussia with reduced airway clearance can include respiratory tract infection, chronic inflammation, and long-term damage to the lung parenchyma. Despite the clear implications for health, the problem of managing hypotussia in individuals with dysphagia is frequently overlooked. Here, we provide an overview of the current interventions and treatment approaches for hypotussic cough. We synthesize the available literature to summarize research findings that advance our understanding of these interventions, as well as current gaps in knowledge. Further, we highlight pragmatic resources to increase awareness of hypotussic cough interventions and provide support for the clinical implementation of evidence-based treatments. In culmination, we discuss potential innovations and future directions for hypotussic cough research.

Abstract Oropharyngeal dysphagia is a swallowing disorder characterized by difficulty in transferring foods and/or liquids from the oral cavity to the stomach, affecting safe oral feeding. The main complications caused by dysphagia are tracheobronchial aspiration, pneumonia, malnutrition, and dehydration. Fibre-optic endoscopic evaluation of swallowing (FEES) is the first choice for studying swallowing disorders, it is easy to use, very well tolerated, allows bedside examination, and is economic. The dysphagia handicap index (DHI) is a 25-item self-administered questionnaire. It is a noninvasive tool measuring the handicapping effect of dysphagia in three aspects: the physical, functional, and emotional aspects of life, so a patient can rate the impact of his swallowing problem. The aim of this study is to test the correlation between DHI scores and fibre-optic endoscopic examination of swallowing and the ability of DHI to predict penetration and aspiration. For all patients, FEES examination was done as an assessment tool for dysphagia and DHI. Testing the correlation between DHI scores and penetration and aspiration on FEES results in a positive significant correlation, so we can apply DHI as a predictor of aspiration and penetration at medical centres where FEES examination is not accessible.

Although swallowing disorders are quite common in psychiatric patients and especially in patients with schizophrenia, they have not been adequately studied. Swallowing disorders are an important source of morbidity and mortality in patients with schizophrenia as a result of acute asphyxia resulting from airway obstruction or an insidious aspiration and pneumonia. Most swallowing disorders in schizophrenia are attributed to two main causes: The changes in eating and swallowing due to the disease itself and the effects of psychotropic drugs. Behavioral changes related to the illness include eating too fast or taking in inappropriately large amounts of food. Treatment-related problems are most often associated with drug-induced extrapyramidal side effects, including drug-induced parkinsonism, dystonia, and tardive dyskinesia. Also include dry mouth, sialorrhea, and sedation-related changes. In this case report, it is aimed to share the psychotropic drugs detected in a schizophrenic patient who developed mechanical asphyxia due to food aspiration and to examine their possible effects on food aspiration.

IntroductionThickened liquids are commonly recommended to reduce the risk of penetration-aspiration. However, questions persist regarding the impact of bolus consistency on swallowing safety. The common practice of summarizing Penetration-Aspiration Scale (PAS) scores based on worst scores is a bias in prior analyses. The aim of this study was to examine the impact of liquid consistency on PAS scores using a Bayesian multilevel ordinal regression model approach, considering all scores across repeated bolus trials. A second aim was to determine whether PAS scores differed across thickener type within consistency.MethodsWe analyzed two prior datasets (D1; D2). D1 involved 678 adults with suspected dysphagia (289 female; mean age 69 years, range 20-100). D2 involved 177 adults (94 female; mean age 54 years, range 21-85), of whom 106 were nominally healthy and 71 had suspected dysphagia. All participants underwent videofluoroscopy involving ≥3 boluses of 20% w/v thin liquid barium and of xanthan-gum thickened barium in mildly, moderately and extremely thick consistencies. D2 participants also swallowed trials of slightly thick liquid barium, and starch-thickened stimuli for each thickened consistency. Duplicate blinded rating yielded PAS scores per bolus, with discrepancies resolved by consensus. PAS ratings for a total of 8,185 and 3,407 boluses were available from D1 and D2, respectively. Bayesian models examined PAS patterns across consistencies. We defined meaningful differences as non-overlapping 95% credible intervals (CIs).ResultsAcross D1 and D2, penetration occurred on 10.87% of trials compared to sensate (0.68%) and silent aspiration (1.54%), with higher rates of penetration (13.47%) and aspiration (3.07%) on thin liquids. For D1, the probability of a PAS score > 2 was higher for thin liquids with weighted PAS scores of 1.57 (CI: 1.48, 1.66) versus mildly (1.26; CI: 1.2, 1.33), moderately (1.1; CI: 1.07, 1.13), and extremely thick liquids (1.04; CI: 1.02, 1.08). D2 results were similar. Weighted PAS scores did not meaningfully differ between thin and slightly thick liquids, or between starch and xanthan gum thickened liquids.DiscussionThese results confirm that the probability of penetration-aspiration is greatest on thin liquids compared to thick liquids, with significant reductions in PAS severity emerging with mildly thick liquids.

This cross-sectional study investigated the knowledge, attitude and practice (KAP) of community general practice (GP) team members on dysphagia complicated with aspiration pneumonia after stroke in Shanghai between October 2022 and November 2022 using a self-administered questionnaire. A total of 551 questionnaires were collected (mean age: 37.59 ± 8.86 years, 443 (80.40%) females), including 383 (69.51%) physicians. The mean KAP scores were 6.30 ± 1.54 (possible range: 0–12), 40.32 ± 5.11 (possible range: 9–45), and 72.54 ± 13.99 (possible range: 18–90), respectively. Multivariable linear regression analyses suggested that attitude (Coef = 1.29, 95%CI: 1.09–1.50), and holding research funding (Coef = −2.70, 95%CI: −5.00–−0.50) were significantly associated with practice toward dysphagia complicated with aspiration pneumonia after stroke of community GP team members. The structural equation model (SEM) indicated that knowledge had a direct influence on attitude (β = 2.029, p < 0.001) and attitude had a direct impact on practice (β = 0.710, p < 0.001). Additionally, knowledge exerted both direct (β = 0.935, p = 0.016) and indirect effects (β = 1.442, p < 0.001) on practice. In conclusion, this study showed that the community GP team members had poor knowledge, favorable attitudes, and proactive practices. Education and training on the management of dysphagia complicated with aspiration pneumonia after stroke are urgently needed. [ABSTRACT FROM AUTHOR]

Cough efficacy is considered a reliable predictor of the aspiration risk in head and neck cancer patients with radiation-associated dysphagia. Currently, coughing is assessed perceptually or aerodynamically. The goal of our research is to develop methods of acoustic cough analysis. In this study, we examined in a healthy population the acoustical differences between three protective maneuvers: voluntary cough, voluntary throat clearing, and induced reflexive cough. Forty healthy participants were included in this study. Voluntary cough, voluntary throat clearing, and reflexive cough samples were recorded and analyzed acoustically. Temporal acoustic features were the following: the slope and curvature of the amplitude contour, as well as the average, slope, and curvature of the sample entropy and kurtosis contours of the recorded signal. Spectral features were the relative energy in the frequency bands (0–400 Hz, 400–800 Hz, 800–1600 Hz, 1600 Hz-3200 Hz, > 3200 Hz) as well as the weighted spectral energy. Results showed that, compared to a voluntary cough, a throat clearing starts with a weaker onset pulse and involves oscillations from the onset to the offset (concave curvature of the amplitude contour, p < 0.05), lower average (p < 0.05), and slope (p < 0.05) as well as lower convex curvature (p < 0.05) of the kurtosis contour. An induced reflexive cough starts with a higher and briefer onset burst and includes higher frication noise (larger convexity of the curvature of the amplitude and kurtosis contours (p < 0.05)) compared to a voluntary cough. The conclusion is that voluntary coughs are acoustically significantly different from voluntary throat clearings and induced reflexive coughs. [ABSTRACT FROM AUTHOR]

Objective: Dysphagia is a common and serious clinical symptom of amyotrophic lateral sclerosis (ALS). The study aimed to evaluate the diagnostic utility of four dysphagia screening tools in ALS, including the ALS Functional Rating Scale-Revised (ALSFRS-R) bulbar subscale, water-swallowing test (WST), Eating Assessment Tool-10 (EAT-10) and Sydney Swallow Questionnaire (SSQ). Methods: A total of 68 individuals from First Hospital, Shanxi medical university, were recruited in the study. The ALSFRS-R, WST, EAT-10, SSQ and the gold standard video fluoroscopic swallowing study (VFSS) were performed. The Penetration Aspiration Scale (PAS) during VFSS was assessed to identify unsafe swallowing (PAS ≥ 3) and aspiration (PAS ≥ 6). Receiver operator characteristic curve (ROC) analyses were performed to evaluate the accuracy of the 4 tools. Youden index was used to determine the ideal cut-off value for each tool. Results: Of the patients, 20.59% (14/68) presented unsafety swallowing and 16.18% (11/68) had aspiration. The four tools could effectively identify patients with unsafe swallowing and aspiration. The EAT-10 had the maximum AUC (0.873 and 0.963, respectively) among the tools in the diagnosis of unsafe swallowing and aspiration. To detect unsafe swallowing and aspiration, an EAT-10 score of 6 (sensitivity: 78.6%, specificity: 87.0%) and an EAT-10 score of 8 (sensitivity: 90.9%, specificity: 91.2%), were the most appropriate cut-off points, respectively. Conclusions: The ALSFRS-R bulbar subscale, WST, EAT-10, and SSQ could effectively identify unsafe swallowing and aspiration in patients with ALS. Of the four tools, the EAT-10 was relatively accurate, safe, and convenient. Further studies including more patients should be conducted to verify the conclusions. [ABSTRACT FROM AUTHOR]

Introduction: The contributing factors of aspiration pneumonia have been well documented. However, there are gaps in the literature regarding identifying the weight associated with each factor and the relationship between factors. Method: In this study, 20 potential predictors of aspiration pneumonia (with four additional variables) have been applied to historic Speech and Language Therapy records to greater understand the significance of each contributor of aspiration pneumonia. 152 cases with an oropharyngeal dysphagia, and a Speech and Language Therapy recommendation of eating and drinking with known aspiration and the associated potential risk of developing an aspiration pneumonia, were included in the data. These were inpatients and outpatients, and had various diagnoses but all had had a videofluoroscopy. Results: Logistic regression analysis found seven factors that were individually significant in predicting the development of aspiration pneumonia with 84.93% sensitivity and 91.03% specificity Discussion: Logistic regression and random forest analyses led to the proposal of a new matrix of predictors of aspiration pneumonia with respective scoring weights for individual and cumulative contributors (a direction for future research). [ABSTRACT FROM AUTHOR]

Between 30% and 50% of infants and children with pediatric feeding disorders demonstrate oropharyngeal aspiration. Thickening fluids are a compensatory strategy that is commonly recommended by speech pathologists for the management of oropharyngeal aspiration. Ongoing variability in the preparation of thickened fluids across infant formulas and healthcare facilities continue to limit the standardization of the preparation of thickened infant and pediatric formulas. No studies exist which examine the influence of nutritional properties of different infant formula types on IDDSI thickness levels. Our study aimed to describe the impact of standardized resting times; and understand the influence of nutritional properties on a variety of ready‐to‐feed liquid and powder‐based Australian thickened formulae. A total of 27 ready‐to‐feed liquid and powder‐based formulas were tested for viscosity level at baseline and when thickener was added on at least two trials. Frequency counts and percentages were used to describe categorical data. Logistic regression was used to model the binary outcome and calculate the odds ratios and their 95% confidence intervals. A total of 18 formulas proceeded to IDDSI flow testing of at least two trials because 7 formulae tested as slightly or mildly thick at baseline; while 2 formulae only had one trial of IDDSI flow testing completed. Of the 18 formulae tested, 72.22% (13/18) of commonly used powder‐based and ready‐to‐feed formulas in Australia thickened to IDDSI slightly thick (level 1) were prepared in a standardized manner and allowed to rest for 5 min. Formulas with higher protein totals were more likely to thicken sufficiently (AOR: 7.45; 95% CI: 2.06–26.89), while formulas with higher sugar totals or those used for enteral feeds were less likely to thicken sufficiently (AOR: 0.02; 95% CI: 0.01–0.29). There was good test–retest reliability (ICC: 0.76; 95% CI: 0.22–0.97), indicating that standardizing the preparation of thickened fluids was consistently achievable. Given that not all formulae were observed to thicken to the intended consistency using standardized preparation and resting time, this study highlights the importance of using the IDDSI Flow Testing Method regularly in practice when recommending thickened infant formula recipes for managing aspiration in infants and children. [ABSTRACT FROM AUTHOR]

ObjectiveLiquid thickeners are commonly recommended in individuals with dysphagia and recurrent aspiration as a strategy for pneumonia prevention. The goal of this study was to examine the effects of small amounts of aspirated liquid thickener on the lungs.Study designAnimal model. Prospective small animal clinical trial.MethodsAdult Sprague Dawley rats (n = 19) were divided into two groups and underwent three intratracheal instillations of either xanthan gum-based nectar-thick water (0.1-0.25 mL/kg) or water-only control over the course of 8 days. Blood was collected from a peripheral vein on days 1 and 8 and submitted for complete blood count (CBC) analysis. Rats were euthanized 10 days after the last instillation, and the lungs were harvested. Histopathology was conducted on lung specimens by a blinded licensed veterinary pathologist and scored for evidence of lung injury and pneumonia.ResultsFifteen animals (8 nectar-thickener group, 7 control group) survived until the endpoint of the study (day 18). Serum CBC did not show abnormalities at any timepoint in either group. Histological evidence of lung inflammation and edema were significantly greater in the nectar-thick group compared to controls (P