Diagnosis and Treatment of Dysphagia and its Adverse Outcomes

Transcription

1/29/2009
DIAGNOSIS AND MANAGEMENT OF DYSPHAGIA AND ITS ADVERSE OUTCOMES
Evidence Based Decision Making by SLP’s March 07, 2009
Ohio Speech Language and Hearing Association Convention
Columbus, OH
James L. Coyle, Ph.D., CCC‐SLP, BRS‐S
Department of Communication Science and Disorders
University of Pittsburgh
1
Why “Medical” SLP?
Our profession’s history
à Communication science: anatomy, physiology
à Psychological/social communicative mechanisms à Transmission of sound
T
i i f d
à Conditions impairing use of communication
à Environmental factors affecting communication
à Effects of communication and swallowing function on individuals and society
Johnson & Jacobson, 2007.
2
Medical Speech Language Pathology
Evolution of the Profession
Speed of medical technology change
Discovery of causes of preventable diseases
Our role has changed to include not only…
Restoration of functions after disease and trauma, but also…
Prevention of diseases that shorten lives
3
1
1/29/2009
Using Evidence in Practice
Research consumerism
à Clinicians are research consumers
If not, they’d better be…
Evidence is essential
E id
i ti l
à Buying a product Æ offering a clinical service
à Choosing a physician Æ offering competent service
à Agreeing to a treatment Æ choosing the best treatment for our patient
4
Topics
1. External Evidence: treatment, diagnosis
à Controversial methods, common methods
ES, DPNS, water protocols
VFG vs. FEES diagnosis
2. Pulmonary Issues: Aspiration Pneumonia
à Using evidence to differentiate among similar syndromes
à What is and what is not aspiration pneumonia
5
Evidence. What is Evidence?
Smith et al., 2003
6
2
1/29/2009
A Little Data Can Be a Dangerous Thing…
p<0.05!!!
“… significant inverse relationship between pirates and global temperature.” 7
What is Evidence‐Based Practice?
8
What is Evidence‐Based Practice?

1. See a patient
2. Ask a question
3. Seek the best evidence for that question
4. Appraise that evidence
5. Apply the evidence
6. Monitor the change
7. Continuously re‐evaluate ourselves
University of Oxford
Centre for Evidence Based Medicine
http://www.jr2.ox.ac.uk/bandolier
9
3
1/29/2009
1. See A Patient
Signs and Symptoms Medical Record, Interview
Examination‐Collect Data
Individual’s Characteristics
Form a list of what is known, what issues need resolution
10
2. Ask a Question
1. Therapy
à Best methods to achieve target outcome
2. Screening/Diagnostic tests à Predicting instrumental test results
à Predict long term consequences
11
2. Ask a Question
The “Answerable” Clinical Question has 4‐Parts PICO
1. Who is the Patient or what is the clinical Problem you are planning to treat?
y
p
g
2. What Intervention are you considering?
3. What alternative or Comparison treatment is available? 4. What clinical Outcomes are you targeting?
12
4
1/29/2009
3. Seek the BEST evidence for the question
13
4. Appraise the evidence
Read the article(s), evaluate them!
à Characteristics of good and not‐so‐good published research…
à Some “types” of articles are stronger than S
“
” f i l h others.
Which article “types” are stronger?
Which have better quality?
Which are more valid?
14
4 Characteristics to Evaluate a. Design
b. Sample Size
c. Internal Validity
d. External Validity
d External Validity
Baker & Tickle‐Degnen, (2001).
à
An explicit scoring mechanism – multidimensional and unambiguous
15
5
1/29/2009
a. Design
(Case-control study, cohort, case series)
RCT, quasi‐experiment, cohort, pre‐post, SSD
16
b. Sample Size
Persons per condition, observations (SSD)
“More is always better.” True or false?
17
Synthesis
•Average 1‐2 per day drinker has 1.19 times greater odds of outscoring teetotalers
•Average 1‐2 per day drinker scored 0.28 SD higher on MMSE than average teetotaler
18
6
1/29/2009
c & d: internal and external validity
Believability of research depends on how well authors controlled for sources of bias and error
c. Internal Validity:
à How well the study’s design controlled the for sources or error
Efficacy: outcome under controlled conditions
d. External Validity:
à How well the study matches reality
Effectiveness: outcome in typical practice
19
Therapy Studies–
judging validity
Patients/
Subjects Control
Group
Experimental (Tx) Group
Control Effects
Treatment Effects
Subjects Analyzed
20
Validity
1. Were all patients similar at start
1. Were all patients similar at start of trial?
2. Were patients 2. Were patients randomly
randomly assigned to the treatment groups? à And was randomization list concealed
And was randomization list concealed??
3. Were clinician/judges blinded/subjects masked?
4. Were all patients were treated 4. Were all patients were treated equally?
equally?
à except for the experimental method
except for the experimental method
21
7
1/29/2009
Validity
5. Was follow
5. Was follow‐‐up up sufficiently
sufficiently long and complete?
6. Were Were all all patients patients analyzed
analyzed as as randomized?
randomized?
à Attrition, intention to treat
7. Was treatment effect hypothesized at start of trial?
8. Effects of maturation/recovery, test learning?
9. Conflicts of interest ???
10. Is the treatment feasible?
22
Effects of Randomization
23
Effects of Blinding
24
8
1/29/2009
Evidence for common and controversial therapeutic interventions
Electrical Stimulation
Physiologic Principles
DPNS
“DPNS”
Evidence Summary
“Free Water Protocols”
Comments on Clinical Use
25
Electrical Stimulation
Evidence Summary for Electrical Stimulation for Oropharyngeal Dysphagia
26
Electrical Stimulation Principles
Facilitate laryngeal elevation
à 1. Necessary for airway closure
à 2. Essential to UES opening
2 Essential to UES opening
à 3. Contributes to bolus clearance
27
9
1/29/2009
Electrical Stimulation Principles
28
sternohyoid
thyrohyoid
geniohyoid
g
y
ant. digastric
mylohyoid
platysma
Images from Visible Human Project: http://www.nlm.nih.gov/research/visible/visible_human.html 29
Evidence for Electrical Stimulation
30
10
1/29/2009

Blumenfeld, L., Hahn, Y., LePage, A., Leonard, R., & Belafsky, P. C. (2006). Transcutaneous electrical stimulation versus traditional dysphagia therapy: a nonconcurrent cohort study. Otolaryngology ‐ Head & Neck Surgery.135(5):754‐7.

Burnett, T. A., Mann, E. A., Cornell, S. A., & Ludlow, C. L. (2003). Laryngeal elevation achieved by neuromuscular stimulation at rest. Journal of Applied Physiology., 94, 128‐134.

Carnaby‐Mann, G. D. & Crary, M. A. (2007). Examining the evidence on neuromuscular electrical stimulation for swallowing: A meta‐analysis. Archives of Otolaryngology‐‐Head & Neck Surgery, 133, 564‐571.

Crary, M. A., Carnaby‐Mann, G. D., & Faunce, A. (2007). Electrical stimulation therapy for dysphagia: descriptive results of two surveys. Dysphagia.22(3):165‐73.

Freed, M. L., Freed, L., Chatburn, R. L., & Christian, M. (2001). Electrical stimulation for swallowing disorders caused by stroke. Respiratory Care, 46, 466‐474.

Humbert, I. A., Poletto, C. J., Saxon, K. G., Kearney, P. R., Crujido, L., Wright‐Harp, W. et al. (2006). The effect of surface electrical stimulation on hyolaryngeal movement in normal individuals at rest and during swallowing. Journal of Applied Physiology, 101, 1657‐1663.

Kiger, M., Brown, C. S., & Watkins, L. (2006). Dysphagia management: an analysis of patient outcomes using VitalStim therapy compared to traditional swallow therapy. Dysphagia, 21, 243‐253.

Leelamanit, V., Limsakul, C., & Geater, A. (2002). Synchronized electrical stimulation in treating pharyngeal dysphagia. Laryngoscope., 112, 2204‐2210.

Ludlow, C. L., Humbert, I., Saxon, K., Poletto, C. J., Sonies, B., & Crujido, L. (2007). Effects of surface electrical stimulation both at rest and during swallowing in chronic pharyngeal dysphagia. Dysphagia, 22, 1‐
10.

Shaw, G. Y., Sechtem, P. R., Searl, J., Keller, K., Rawi, T. A., & Dowdy, E. (2007). Transcutaneous
neuromuscular electrical stimulation (VitalStim) curative therapy for severe dysphagia: myth or reality? Annals of Otology, Rhinology & Laryngology, 116, 36‐44.

Suiter, D. M., Leder, S. B., & Ruark, J. (2006). Effects of neuromuscular electrical stimulation on submental
muscle activity. Dysphagia, 21, 56‐60.
31
Article Citation
1. Freed, M.L., Freed, L., Chatburn, R.L., and Christian, M., (2001). Electrical stimulation
for swallowing disorders caused by stroke. Respiratory Care 46(5), 466‐74.
46(5) 466 74
32
Research Design
Recall…
Homogeneous Cohort Of Subjects Random Assignment
Control
Group
Treatment Effects
Equal
Treatment
Experimental Group
Blind judgment,
comparison
Treatment Effects
33
11
1/29/2009
Freed et al.
SLP (MLF) screens 125 CVA “with possible
swallow disorder”
3
Unknown
Reasons
11 “dropped out” during
study
(? Group)
110 consent, enrolled by SLP (MLF)
MBS; SLP (MLF) assigns SFS
TS 36
9
8
99 completed study
6
Drug
Toxicity
2
Transferred
ES group 63
3
6
Stroke Not
Documented
“most of these patients had already failed conventional therapy which is why they were referred for the study” Pg. 472
Comorbid
“cancer” 34
Flaws #1: Assignment
Heterogeneous cohort
à Stroke not documented in all enrollees
Selective assignment
à based on “failed conventional treatment”
Groups unequal at start of trial
G
l t t t f t i l
à Distribution of comorbidity
Attrition of 10% of subjects after assignment
Judge not blinded to patient assignment
35
Flaws #2: Blinding Radiologist Reads MBS
Dictates Report, Sends
Report to SLP (MLF)
SLP* reads radiologist report
SLP* assigns Swallow Function Score**
SLP* Assesses
Aspiration Daily Using
Bronchial Auscultation
SLP* Treats
ES and TS
Patients
SLP* assigns Patients to Treatment Groups
Inpatients: 1 hour/Daily
Until SFS Score >5
Or Discharged
Outpatients: 1 hour/TIW
Until SFS Score >6 Or “No More Progress Would be Made”
* First author
** “type of liquid that could be safely swallowed” (p. 468)
36
12
1/29/2009
Flaws #3 & 4: Unequal treatment, conflict of interest
Some patients terminated when “insurance constraints” caused discharge
P.I. owns patent to experimental product
37
Results
Both groups improved significantly from their own baselines
à ES: p<0.0001; TS: p<0.005
Table 1. Raw Data and Significance (p) of Comparisons
n
Mean + SD
(pre‐
treatment)
Mean + SD
(post‐
treatment)
p*
ES (treatment)
63
0.76 +1.04
4.52 +1.69
<0.0001*
TS (control)
36
0.75 +1.20
1.39 + 1.13
0.0048*
Swallow Function Score
Between Group Difference (post‐treatment scores)
<0.0001*
*as reported by authors
38
Conclusion: Freed et al.
Treatment effect sizes are high, BUT...
à Flawed methods, investigator bias (blinding), attrition without accounting, poor theoretical support for methods, selective assignment, support for methods
selective assignment unequal treatment, dissimilarity of groups at start of trial, conflict of interest...
à ...invalidate the results of this study Yet the method has been adopted by >10,000 SLP’s
39
13
1/29/2009
ES studies showing positive results
40
Studies showing + results

Blumenfeld et al., 2006. Significant improvement in swallow function scores @

Crary et al., 2007. Good treatment outcomes without complications, good patient satisfaction @

Leelamanit et al., 2002. 20/23 (87%) patients improved RLED #
à
à
à

Used Freed’s unsubstantiated SFS, unblinded, selective assignment, conflict of interest
Opinion survey of SLP’s that use and do not use ES, Funded by Chattanooga
Heterogeneous patients, 4 hrs/day treatment, subjective judgment, unblinded
Shaw et al., 2007. 11/18 (61) patients improved @
à
? Duration post onset, ? Judges, subjective
p
,
g ,
j
scoring methods, retrospective, unblinded
g
,
p
,

Chaudhuri et al., 2006. Significantly greater improvement in ES group @

Burnett et al., 2003. Hyoid elevation achieved with ES *
à
à
Outcome = ASHA NOMS scored by treating SLP? (no objective measures), unblinded
HLE with intramuscular stim at rest, good design

Ludlow et al., 2007. Improved PAS w/sensory stimulation only *

Carnaby‐Mann & Crary, 2007. Small, but significant treatment effect for NMES #
à
à
à
à
Very small sample; (see neg results next)
Included above studies that are flawed (authors mention this weakness in article)
Funded by manufacturer of product
Used very low cutoff for quality (4/13 on Pedro)
* = good design; # = fair design; @ = poor design
41
Shaw – subjective measures
42
14
1/29/2009
Carnaby Mann meta‐analysis
Meta‐analysis
à Determine construct of interest
à Establish research question
à Seek literature à Rate literature
à Discard poor quality studies
à Calculate indiv. effect sizes
à Calculate combined effect size
à Determine homogeneity of studies
43
Carnaby Mann meta‐analysis
Authors used a score of 4 or higher as cutoff for inclusion
Potential eligible study *
à Nonrandom, unconcealed à
à
à
à
à
à
assignment
Unblinded judges/ clinicians, Up to 15% attrition
Dissimilar subjects
One “key” outcome, subjective or objective
Not analyzed as randomized
No between groups results
*
*
*
*
44
ES studies showing negative results
45
15
1/29/2009
Ludlow et al., 2007. Depressed hyoid; increase asp risk *
à Well designed small study
Humbert et al., 2006. Significant reductions in pead
HLE ith ES *
HLE with ES *
à Well designed small study
Kiger et al., 2006. no difference between ES and traditional treatment #
à Well designed study however used composite scale
Suiter et al., 2008. No difference in submental
myelectric activity after 10 treatments *
à Well designed, small study, investigated normals not patients
* = good design; # = fair design; @ = poor design
46
Kiger et al., 2006, (pg. 250).
à A potential factor contributing to the negative outcome is the fact that “…when Vital Stim
when Vital Stim results produce no improvement as documented by a follow‐up VFSS or FEES, the Vital Stim protocol recommends referring patients to an otolaryngologist or gastroenterologist for cricopharyngeal dilatation.”
à Patients did NOT undergo dilatation
Which method produces the “change”?
47
What seems to be the evidence consensus?
Weak evidence that sensory stimulation may do something to some patients
But the notion that this method improves myoelectric
l t i activity is not supported
ti it i t t d
à Depth of musculature to stimulate too deep for low level stimulation to reach
May be counterproductive (reduces HLE, necessary for airway closure)
à No adverse reactions have been published
48
16
1/29/2009
DPNS
Evidence summary for “Deep Pharyngeal Neuromuscular Stimulation”
49
DPNS Principles
“…developed at a major hospital system in Florida during the period 11/91 through 11/93. “
g
y p g
q
“after finding ‘traditional’ … dysphagia techniques to be largely ineffective…”
Retrieved 01/23/09 from http://www.speechteam.com
50
Principles of “DPNS”
Assumptions
à Pharyngeal phase is reflexive
à Mouth and tongue receptors “elicit” swallow “reflex”
à Stimulating posterior receptors produces reflexes
Hypothesized
à Food in pharynx may occasionally trigger a swallow
à CN IX, X, and XII* mediate pharyngeal motor functions
à Pharyngeal reflexes input to brainstem
à Swallow is impaired when these reflexes are diminished
“DPNS … specific stimulation techniques within the oral/pharyngeal areas”.
*erroneous reference to innervation of hyolaryngeal elevators
51
17
1/29/2009
DPNS Evidence
“DPNS study results indicate DPNS improves and/or restores oral/pharyngeal muscle strength, endurance, and pharyngeal reflex functions… “The ongoing study of the results of DPNS strongly indicate a high efficacy rate for patients with varying neurological etiologies.”
Retrieved 01/23/09 from http://www.speechteam.com/
52
DPNS Evidence
Developer has not authored any published research
53
54
18
1/29/2009
55
“In swallowing there are currently several procedures being advocated for which there is no published evidence in peer‐reviewed journals: deep pharyngeal neuromuscular stimulation (DPNS), electrical stimulation (E‐
Stim), to the surface of the neck, and myofascial release.”

(Johnson & Jacobson, 2007; pg. 143)
56
“Free Water” Protocols
Evidence Summary for using Free Water Protocols
57
19
1/29/2009
“Free Water” Protocol Principles
The Frazier Rehab Institute Water Protocol
à Kathy Panther, M.S., CCC, Louisville, Kentucky Safety of Water
Hydration
Compliance
58
“Concern over patient and family non‐
compliance with thin liquid restrictions both within the facility and after discharge led us to alter our protocol in 1984. “Previously prohibited, oral intake of water became a major feature in both treatment and day to day hydration.”
Retrieved 01/20/09 from http://www.speech‐languagepathologist.org/archives/chat/SLP/April212003.html
59
According to its developers:
Water is relatively safe to aspirate
à Sterile, neutral pH, therefore safe to use in testing
Hydration is increased using this method
à “most patients”; should decrease IVF costs
à Patients indicate they drink more water
Compliance with interventions is higher
à Patients complain less and comply more, with water
à Burdon of thickening fluids is eliminated
60
20
1/29/2009
Free Water Protocols Evidence
Literature search
à “Free Water”, + Deglutition Disorders
à Panther, K.
One citation on semantic relations in the Journal of p
g
, 9 3
Speech & Hearing Disorders, 1983
Perspectives article in 03/05 describing protocol
“Currently there is no published evidence that will give dysphagia clinicians a definitive scientific basis for the safe delivery of water to patients with dysphagia”
ASHA journal (pre “Leader”) piece in 1998
Leonard, L. B., Steckol, K. F., & Panther, K. M. (1983). Returning meaning to semantic relations: some clinical applications. Journal of Speech and Hearing Disorders, 48, 25‐36.
61
Free Water Protocols Evidence
Bronchoalveolar lavage
Whelan et al. (2001) reduced fluid intake in patients prescribed thick liquids
Numerous citations on dehydration in dysphagia
Animal studies of water aspiration 62
“Free Water” Protocol Evidence
Garon et al., 1997
à 10 aspiration‐documented patients randomized to
Thick liquids only at all times
Thick liquids for diet, AND free access to water under specified rules
d ifi d l
à No patient in either group developed pneumonia, dehydration, complications (30 day follow‐up) 63
21
1/29/2009
Results Garon et al., 1997
Fluid intake
à Control (thick liquids): 1210mL/day
à Experimental (free water): 1318mL per day
855mL, 463mL water thick liquid
8
L 6 L t thi k li id
Satisfaction: only one patient was satisfied with thick liquid (among all control subjects)
Amount of water taken by experimental patients was considerably less than expected
64
Robbins et al. 2008. Protocol 201
à Thin liquids/chin‐down posture: 10% pneumonia
à Thick liquids: 11% pneumonia
Nectar: 8%, Honey: 15%
à Dehydration
Thin: 2%, Thick: 6%
à UTI
Thin: 3%, Thick: 6%
à 3 times longer hospital stay in honey‐thick who developed pneumonia
65
Two more recent studies
à One presented at ASHA 2008
Bronson‐Lowe, et al., 2008. Effects of a free water protocol for patients with dysphagia
protocol for patients with dysphagia.
à One in press and presented at ASHA 2008
Becker et al., 2008. An oral water protocol in rehabilitation patients with dysphagia for liquids.
66
22
1/29/2009
Free Water Protocols (#1)
Retrospective study comparing patients with historical controls (via chart review)
à 30 patients using the water protocol (experimental)
à 46 eligible but not treated patients (historical control)
à 25 eligible concurrent untreated patients
Dependent Variables (all objective measures)
à Pneumonia
à Hydration
à Fluid Intake
Bronson‐Lowe, et al., 2008
67
Results
Water (treatment) vs. Historical Control
à Significant differences (favoring treatment)
Avg. daily fluid intake (p=.03)
à No significant differences between groups:
Pneumonia, Dehydration
,
y
Water vs. concurrent control
à Significant differences (favoring treatment)
Pneumonia (p=.02), Fluid intake (p<.01)
à No significant differences
Dehydration
68
Authors’ discussion
Authors could not determine whether results were influenced by
à Increased oral hygiene in the treatment group
à Increased oral hydration in the treatment group
à More compliance with aspiration precautions in treated patients
à Hydration not affected by treatment/control assignment
This needs to be replicated prospectively
69
23
1/29/2009
Randomization to water protocol or prescribed dietary fluid (26 patients)
17 patients requiring feeding assistance
à 8 assigned to control, 9 to treatment
9 independent feeding patients
à 3 assigned to control, 6 to treatment All received oral care four times per day
Becker, et al., 2008
70
Dependent Variables
à Adverse events (pneumonia, UTI, death) Objective measures
à FIM
FIM, FCM scores FCM Subjective measures, not blinded
à Length of stay
?
71
Results
à No differences
Pneumonia: 1 patient in each group
UTI: 2 patients in each group
FIM, FCM: no significant differences
à Differences
Diff
Death: 2 treatment deaths, no control deaths
Length of stay*: 29.1 days (control) vs. 15.8 (tx)
Other findings:
à Independent‐feeding patients consumed significantly less fluid than dependent patients (p<.01), regardless of group
(opposite finding from study #1)
72
24
1/29/2009
73
Discussion
à The presence of two deaths in the treatment group cannot be ignored
…and may underscore the importance of clinical and may underscore the importance of clinical judgment in applying this and other treatments
Both patients that died had chronic pulmonary conditions
à Dependent patients drank more
Staff/caregiver influences?
End treatment
74
Diagnostic Methods
Research consumers have 2 questions:
à 1. Clinical test precision Which clinical testing method best predicts what an accepted instrumental test will find?
à 2. Which instrumental test is superior?
75
25
1/29/2009
1. Clinical Test Precision
76
Citation
Martino R, Pron G, Diamant N, (2000). Screening for oropharyngeal dysphagia in stroke: insufficient evidence for guidelines. Dysphagia 15: 19‐30.
a. How well do non‐instrumental tests predict aspiration?
b. How well do non‐instrumental tests predict health outcomes in dysphagics?
à Does screening affect length of stay, mortality, pneumonia incidence, etc.?
77
Methods
Systematic Review with calculation of Predictive Value of each clinical sign
End points/Outcomes
à (a). Physiology: aspiration, residue detection à (b). Health: pneumonia, mortality, PEG
78
26
1/29/2009
154 articles accepted
89 Accepted
n=24: (a) clinical exam and VFG
58 ineligible
14 eliminated
65 Rejected
10 reviewed
5: specific CVA types
3 reviewed
n=7: (b) clinical exam and outcomes
4 eliminated
5: generalizable to “stroke”
a. Do clinical tests predict aspiration or physiologic deficits?
b. Do clinical tests predict health outcomes?
79
Clinical Test precision
39 clinical signs predicted VFG findings
à 5 of them, when present, were 2‐5 times more likely than a coin toss, to predict aspiration.

Failed water swallow test (30mL)
Failed water swallow test (50mL)
Cranial nerve IX sensory abnormality
Abnormal pharyngeal sensation
Facial weakness
80
10 clinical examinations reveal signs that predict pneumonia, mortality, future PEG placement
à Only one had a weak (but clean) predictive value
O l h d k (b t l ) di ti l
50mL water swallow
81
27
1/29/2009
50mL H2O swallow
Pneumonia
“Acute Stroke Pathway”
2 years
Aspiration
pneumonia
Mortality
PEG tube
inserted
“Acute Stroke Pathway” ‐ 1 year
Aspiration
pneumonia
PEG tube
inserted
ARR
0.13
0.07
0.06
0.02
0.03
0.01
RRR
81.2%
85.1%
70%
18%
38.8%
6.7%
NNT
7.69 (8)
50
33.3 (34)
100
14.3 (15) 16.7 (17)
82
Clinical exams should include:
à Signs with strong predictive value for dysphagia
Failed water swallow test
Cranial nerve sensory/motor abnormalities
Facial Weakness
à These have weak predictive value; do not use solely:
Weak voluntary cough
Dysphonia
Abnormal motor exam (extremities)
83
2. Comparing Instrumental Tests
FEES and Videofluoroscopy
84
28
1/29/2009
Diagnosis: VFG vs. FEES
Characteristics of good diagnosis research
à New test compared to accepted gold standard
Simultaneous events using both test methods
Gold standard applied despite outcome
à Independent judges score the two tests I d
d t j d th t t t Blinded to one another’s judgments
à Appropriate spectrum of patients tested
à Can be replicated, large enough “N”, no conflict of interest
à New method is feasible
85
Three studies:
*Kelly, A. M., Drinnan, M. J., & Leslie, P. (2007). Assessing penetration and aspiration: how do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare? Laryngoscope, 117, 1723‐1727.
*Kelly, A. M., Leslie, P., Beale, T., Payten, C., & Drinnan, M. J. (2006). Fibreoptic endoscopic evaluation of swallowing and videofluoroscopy: yp
p
p
p y g
does examination type influence perception of pharyngeal residue severity? Clinical Otolaryngology, 31, 425‐432.
Aviv, J.E., (2000). Prospective, randomized outcome study of endoscopy versus modified barium swallow in patients with dysphagia. Laryngoscope, 110(4):563‐74.
* Same patients generated both data sets
86
Kelly, et al. (2006,2007)
Simultaneous FEES and VFG performed and recorded on 15 consecutive patients
Video clips numbered and randomly ordered
à 17 Judges viewed one liquid, one yogurt bolus
à Judges blinded to diagnosis, corresponding FEES/VFG
2007: Penetration Aspiration Scale score
2006: Residue ratings
Both studies: inter‐ and intra‐ rater reliability 87
29
1/29/2009
Results
FEES PA scores significantly higher than VFG
à p<.001
FEES residue scores significantly higher than VFG à p<.001
88
Results
Reliability: Higher (not significantly) for VFG
à Inter‐rater: .64 ‐ .67 (VFG, FEES)
à Intra‐rater: .73 ‐ .79 (VFG, FEES)
Overall: FEES scores more severe impairments, VFG reliability slightly higher
89
Aviv, 2000.
“Prospective, randomized outcome study...”
Outpatients with Dysphagia
FEES(ST)
pneumonia
No
pneumonia
MBS
pneumonia
No
pneumonia
Dependent Variable: Pneumonia
90
30
1/29/2009
Assignment to Test Method
126 Outpatients with Dysphagia
Monday, Thursday
Tuesday, Wednesday, Friday
FEES(ST)
n=50
MBS
n=76
“Patients whose consults were requested on Tuesday, Wednesday, or Friday were randomly assigned to MBS...”
91
Methods
FEESST
à “laryngeal adductor reflex”
à normal = <4 mm Hg à “Severe” deficit: absent response to >6 mm Hg. p
g
MBS
à Typical protocol
92
Blinding
Referring MD and patient unaware of assignment scheme
PI not involved in assignment
SLP screened and enrolled all patients
PI blinded to results until analysis completed
93
31
1/29/2009
Blinding
Blinding is not clear
à Same team of SLP’s carried out all testing in conjunction with the PI (Clinical, FEESST)
But PI was “blinded to results until study ended”??
à SLP performed MBS
f
d
à Same MD examined all patients in each diagnostic group
94
Groups similar at start of trial?
Mon., Thu.
Tue., Wed., Fri.
FEESST (50)
MBS (76)
à 6/50 (12%) chronic neurogenic
à 5
50 patients underwent p
61 FEESST tests
Repeated exams are not described
à ? Stroke patients
à 30/76 (39%) chronic neurogenic
Significantly more (X2 = 11.2, p<0.001)
à 76 patients underwent 78 MBS tests
à ? Stroke patients
95
Equal treatment?
<4mm 4‐6mm
>6mm
>6mm
96
32
1/29/2009
Equal treatment [?]
MBS (76)
à Silent asp Æ PEG/NPO
à Asp. not cleared Æ
PEG/NPO
FEESST (50)
à Pt. with normal, moderate, or unilateral severe sens. impairment
Treated like MBS patients
à Any patient with bilateral à All others: conservative management (diet + maneuvers)
severe sensory impairment and laryngeal penetration Æ PEG/NPO
à All others: conservative management (diet + maneuvers)
97
Equal treatment [?]
FEESST patients received 11 extra tests?
à 76 MBS patients, 50 FEESST patients
Unequal treatment in favor of FEESST guided management.
Aviv, 2000
98
Results: primary: no difference
Results: no significant difference in incidence of pneumonia;
à MBS: 14/76 (18.4%); FEESST: 6/50 (12%) (NS) Unfortunately since groups were unequal we don’t know whether the higher pneumonia in MBS group is associated with diagnosis.
No significant difference in pneumonia‐free interval
99
33
1/29/2009
Results‐ not reported
“...the recommendations for placing a PEG in the MBS group were too few to draw conclusions regarding differences in pneumonia outcome between patients who had a PEG placed or continued versus those who did not... However in the FEESST group, enough PEG recommendations were made to conduct analysis.” pg. 571
Caveat emptor
100
Do‐it‐yourself analysis…
MBS
FEESST
Pneumonia
14
6
No Pneumonia
62
44
% i % pneumonia (NS)
8 % 18.4% % 12% 2/76 (<3%) 16/50 (32%) Received PEG
Results
6.3% higher risk of 11X increased risk of PEG pneumonia with PEG
with FEESST
101
Bottom Line
Both endoscopic and MBS guided dysphagia management produce similar pneumonia outcomes
Patients guided by FEESST were 11 times more likely to receive a PEG
lik l t i PEG
Dysphagic patients with PEG had 6.3% higher pneumonia risk
102
34
1/29/2009
So what about testing?
1. Good clinical techniques bear fair to good predictive value (combining them increases value)
2. Both FEES and VFG have advantages and disadvantages
à As well as situations when one or the other is preferred, a better choice
3. Select your methods based on the clinical questions
à VFG: excellent evaluation; FEES is excellent at monitoring progress, biofeedback, adjusting plan, etc.
End diagnosis
103
Differential Diagnosis of Aspiration and other Pneumonias
104
Dysphagia is Not a Disease
Disease,
Condition:
Disease,
Condition:
D h i
Dysphagia
Neurologic
Traumatic
Neoplastic
Structural
Iatrogenic
“Deconditioning”
Pulmonary
Others
Pulmonary
Nutritional
Community -Acquired
Social
Psychological
Others
105
35
1/29/2009
Pneumonia
Most frequent infectious cause of death*
63,000 deaths in 2003**
à Incidence: 224** per 10,000 elderly adults
p
y
162*** per 10,000 persons over age 14
13%‐48% of all Nursing Home Infections
2nd most common nosocomial infection (UTI) in hospitals***
Marston, et al., 1997*; National Center for Health Statistics, 2003**; ***Niederman, et al., 2002
106
Pneumonia
Types
à Community Acquired Pneumonia (CAP)
Pneumonia not acquired in a health care facility
5.6 million cases per year*
5 6 million cases per year*
Typical: Streptococcus, Klebsciella
pneumoniae
Atypical **: H. influenzae, RSV, Legionella, E. coli, Staph. aureus, others
*Niederman, 2002; **El Solh, et al., 2001; ***CDC guidelines
107
Pneumonia
Types
à Nosocomial Pneumonias: Ventilator Associated, Nursing Home Acquired Pneumonia
Pseudomonas aeruginosa, Proteus species, staph. Aureus
108
36
1/29/2009
Community Acquired Pneumonia
Human Costs of Community Acquired Pneumonia
Pneumonia admissions: 743,000*
à Pneumonia in a 5% Medicare admissions sample* 30,000 30 000 – 37,000 per year x 20 = 600,000 37 000 per year x 20 = 600 000 – 740,000/year
740 000/year
Case fatality rate
55% (elderly)
Leading cause of mortality in children under 5***
*Baine, et al., 2001; ** Niederman, et al., 2001; ***Almirall, et al., 2000
109
Other pneumonias
à Pathogen isolated
à Patient’s residential environment
à Lack of underlying source of dysphagia/aspiration
Ventilator Associated Pneumonia
V il
A
i d P
i
à Exposure to mechanical ventilation
à Absence of oral intake at onset
à Gastroesophageal reflux common in Ventilation
110
Human Costs of Community Acquired Pneumonia
Pneumonia after stroke*
à 26.9% mortality, vs. 4.4% in stroke w/o pneumonia
Economic Costs of Community Acquired Pneumonia
Cost of pneumonia: $8 billion/year (1998)**
*Katzan, et al., 2003; ** Niederman, et al., 1998
111
37
1/29/2009
Aspiration Pneumonia (AP)
Typically associated with Dysphagia
à Can occur from other etiologies
Can occur in a health care facility (HCF)
à Nosocomial Aspiration Pneumonia
Can occur outside of the HCF
à Community Acquired Aspiration Pneumonia
*Baine, et al., 2001
112
Aspiration Pneumonia Incidence
15.5% of 1998 pneumonia admissions = AP*
Baine, et al., 2001
113
Aspiration Pneumonia
Pneumonia
40000
35000
AP
6000
+22.6
5000
30000
4000
25000
20000
15000
3000
+93.5%
2000
10000
1000
5000
0
0
91
92
93
Pneumonia
94
95
96
97
98
Baine, et al., 2001
114
38
1/29/2009
Human Costs of Aspiration Pneumonia
à 115,000 cases per year
AP admissions highest case‐fatality rate
à 23.1% during hospitalization*
23 1% during hospitalization*
Annual mortality (1998 numbers)
à 115,000 x 23.1% fatality = 26,603 annual AP deaths
*Baine et al, 2001; 115
Economic Costs of Aspiration Pneumonia
Cost of pneumonia: $8 billion (1998)*
à AP: 15.5% of all CAP**
à $8 billion x 15.5% = $1.3 billion (1998 dollars)
*Niederman, et al, 2001; **Baine et al., 2001.
116
Importance:
If we reduce the incidence of AP by a modest 20%
à 23,000 fewer cases each year
à 4,000‐5,000 saved lives each year
d li h If we reduce the admissions or length of stay for AP by a modest 10%
à $130 million saved (1998 dollars)
117
39
1/29/2009
What is Pneumonia?
An inflammation of the alveoli…
à Respiratory distress, failure must be treated
…that is caused by infectious pathogens
à Infection must be treated
118
What is Pneumonia?
Phase 1: Edema à Pathogen infiltrates, infects alveoli
O2
Draws nourishment from p
alveolar epithelium
Damaging alveolar epithelium
O2
CO2
Producing metabolic byproducts (toxins)
CO2
O2
Irritants to alveoli
O2
CO2
O2
CO2
Mandell & Wunderink, 2007
O2
Capillary – RBC, WBC
O2
119
What is Pneumonia?
Phase 2: Red O2
hepatization phase.
à Alveoli become excessively permeable
O2
Red blood cells “leak” from capillaries
CO2
O2
O2
à Immunological CO2
response
Inflammation of the lung = Pneumonitis
O2
O2
O2
CO2
CO2
Capillary – RBC, WBC
120
40
1/29/2009
What is Pneumonia?
à Alveoli fill with RBC, WBC, O2
serum, infectious debris
à Respiratory surface area is reduced by infiltrate
CO2
Dyspnea, hypoxemia
O2
O2
O2
O2
à Epithelium thickens
à Surfactant production is diminished
Reduces compliance of lung
…further source of dyspnea
à Can spread with cough
CO2
O2
CO2
O2
CO2
capillary
121
What is Pneumonia?
Phase 3: Gray hepatization phase
O2
à RBC’s destroyed
à Infection contained
Bacteria absent
O2
O2
à Infiltrates diminish
CO2
O2
Phase 4: Resolution
CO2
à Immunological “clean‐up”
à Epithelium “heals”, surfactant restored
O2
CO2
CO2
O2
O2
capillary
122
Aspiration Pneumonitis
Acute Lung Injury caused by aspiration of caustic or particulate matter
Inflammation of alveoli by effects of irritants
à No infection (sterile/non‐pathogenic material)
à Inflammatory response (edema) reduces surface area (as shown earlier)
No infectious spread from site of origin
May spread as volume increases
123
41
1/29/2009
O2
No Infectious agent
Chemical irritant
CO2
O2
O2
O2
O2
O2
CO2
CO2
O2
O2
O2
O2
CO2
O2
O2
CO2
O2
CO2
CO2
O2
O2
CO2
CO2
CO2
capillary
124
What is Aspiration Pneumonia?
Definition of Aspiration
à Foreign matter enters the respiratory system
Definition of Pneumonia
à Infectious acute inflammation
à Reaction to bacteria and byproducts
à Lung inflammation caused by pulmonary infection
due to aspiration of colonized matter
125
What is Dysphagia‐
Related Aspiration Pneumonia (AP)?
Aspirated Pathogens are Different
à O
Oral pharyngeal flora
l h
l fl
Eruption of teeth
à * pathogens Æ
à Others found in flora
à Opportunistic infection
Staphylococcus epidermidis
Staphylococcus aureus*
Streptococcus salivarius
Streptococcus mutans*
Enterococcus faecalis*
Streptococcus pneumoniae*
Streptococcus pyogenes*
Neisseria sp.
Neisseria meningitidis*
g
Enterobacteriaceae* (E. coli)
Proteus sp.
Pseudomonas aeruginosa* Haemophilus influenzae*
Lactobacillus sp. Clostridium sp.* Corynebacteria
Spirochetes Mycoplasmas
Todar's Online Textbook of Bacteriology
126
42
1/29/2009
Oral biofilm development
Bacteria enter the area (seconds)
Bacteria attach to underlying structures
à Epithelium, prior biofilm, other surfaces
à Seconds to minutes
Bacteria grow and multiply (hours – days)
An exopolymer forms and Biofilm is born
Other bacteria attach to biofilm
Todar's Online Textbook of Bacteriology
127
How Does AP Develop?

Oral/Pharyngeal Colonization Risk Factors

Medications*, Oral disease**
inadequate oral hygiene
Iatrogenic Risk Factors

Recent Extubation*
Tracheostomy***
Medication side effects*
Postoperative sensorimotor
impairment*
* CDC/MMWR 46, RR‐1, (1997); **Langmore et al, (1998);***Eibling and Gross, 1996; Gross et al, (2003).
128
How Does AP Develop?

Host Risk Factors (the patient)
Underlying disease

Immunocompromise* (infection)
Impaired mucociliary clearance** (resistance)
Pulmonary disease (resistance)
Sensorimotor impairments (dysphagia)
Obesity, neck malignancy * (dysphagia)
Impaired Mental Status (up to 70%)* (dysphagia)
Dementia* (dysphagia, feeding dependence)
* CDC/MMWR 46, RR‐1, (1997); **Langmore et al, (1998);***Eibling and Gross, 1996; Gross et al, (2003).
129
43
1/29/2009
Source of Colonization + Prandial Aspiration + Poor Host Resistance… Aspiration Pneumonia
130
Aspiration Pneumonitis
Gastric Contents: Massive Acute Inflammation
à Sterile, acidic Sterile acidic à Airways, respiratory membrane damage
Opportunistic secondary infection
à ARDS
131
Aggressive acid suppression may create conditions favoring pathogenesis of pneumonia*
à PPI: O.R. = 1.94 –
PPI O R 2.28 (over control)**
8 (
t l)**
à H2 receptor antagonist: O.R. = 1.36 – 1.64**
*Marik, 2001; Marik and Zaloga, 2002; **Laheij, et al., 2004
132
44
1/29/2009
Aspiration and Lung Damage
Idiopathic Pulmonary Fibrosis
IPF: 16/17 (94%) with abnormally low proximal or p
p
distal pH supine
Normals: 4/8 (50%) Tobin et al., 1998
133
Distinguishing AP, Aspiration Pneumonitis, Other Pneumonias
134
The Medical Record contains important clues
à HISTORY OF ONSET
à The course and progression of the disease
à Presence/absence of underlying source/cause of P
/ b
f d l i /
f aspiration
à Results of lab, radiographic tests
135
45
1/29/2009
Differential Diagnosis‐
history
Aspiration Aspiration pneumonia
pneumonitis
à History: predisposing disease
Dysphagia
esophageal dysmotility/paresis
witnessed choking at meal; may be unwitnessed.
à History: depressed LOC (anesthesia, sedation, coma)
may be witnessed (as in post‐operative)
Onset not at mealtime
Emesis preceded dyspnea
136
Differential Diagnosis
Radiographic Signs
pneumonitis
à Radiographic à Radiographic evidence of infiltrates in dependent lobes or segments
(position when aspirating…)
=
evidence of infiltrates in dependent lobes or segments
(position…)
137
Clinical, laboratory signs
pneumonitis
à Fever (+1C x 24h)
à Afebrile or short à Pathogen identified duration fever (“spike”)
à Sterile bacteriology
via protected culture
Oral, nosocomial
pathogen
à persistent leukocytosis
Normal oral flora
Opportunistic secondary infection
à brief leukocytosis
138
46
1/29/2009
Clinical, laboratory signs
Laboratory Values
à WBC: current overall immune activity (x1000/ml)
4.5 – 10.5 k cells/microliter
à Neutrophils: immunocompromise?
à If Neutropenic: WBC elevation absent/reduced
in infection
Wallach JW (2000). Interpretation of Diagnostic
Tests. Philadelphia, Lippincott Williams & Wilkins.
The Medical Record
139
Differential Diagnosis‐
clinical, laboratory signs
Aspiration pneumonia
à
à
à
à
à
à
à
à
Inflammation
Cough – productive
Bronchospasm Dyspnea
Hypoxemia Purulent sputum Tachypnea Malaise
Aspiration pneumonitis
à
à
à
à
à
à
à
à
Inflammation
Cough ‐ not productive
Bronchospasm Dyspnea Hypoxemia Frothy or bloody sputum
Tachypnea
Respiratory distress
minutes to hours after aspiration; may persist
140
Radiographic evidence
Chest x‐ray
à Infiltrates cause radiographic “shadows” at sites of infection‐induced inflammation
Advanced pneumonia may involve entire lobes
Infection can spread
Aspiration Pneumonitis ‐ Does not spread…
141
47
1/29/2009
Aspiration Related Infiltrates
(R) Basilar infiltrates
(R) Upper lobe infiltrates
Aspiration produces pneumonitis or pneumonia in gravity dependent portions of lung(s).
“Dependence” depends on posture when aspiration occurs,
occurs density & volume aspirated.
142
AP, vs. Non‐AP
***History
à History of dysphagia‐producing disease
à Position at onset of symptoms
Infiltrates in dependent segments
fl
d
d
à Position at onset of symptoms
Dependency for oral care/feeding, periodontal disease
143
AP, vs. Non‐AP
Bacteriology
à Non‐AP
Typical: Streptococcus, Klebsciella pneumoniae
Atypical **: H. influenzae, RSV, Legionella, E. coli, Staph aureus others
Staph. aureus, others
à AP
Oral pathogens
à Nosocomial (VAP, etc.)
Pseudomonas aeruginosa, Proteus species, staph. Aureus
144
48
1/29/2009
Summary
Determination of the etiology of respiratory disease, presumed to be aspiration related, is essential in mitigation of recurrence.
à Aspiration may not be related to a swallowing
disorder, but can result from a number of other sources.
à Aspiration is only one potential source of pneumonia
à All respiratory illnesses are NOT pneumonia
à ALL PNEUMONIAS ARE NOT ASPIRATION RELATED
145
Summary
A medical diagnosis of “aspiration pneumonia” should not lead the SLP to assume dysphagia is present
The SLP must use all available patient information and examination data, to determine the likelihood that dysphagia poses a risk to the patient
146
Thank you.
147
49
James L. Coyle, Ph.D.
OSLHA Convention, 03/07/09
Reference List
Almirall, J., Bolibar, I., Vidal, J., Sauca, G., Coll, P., Niklasson, B. et al. (2000). Epidemiology of communityacquired pneumonia in adults: a population-based study. European Respiratory Journal, 15, 757763.
Aviv, J. E. (2000). Prospective, randomized outcome study of endoscopy versus modified barium swallow
in patients with dysphagia. Laryngoscope, 110, 563-574.
Baine, W. B., Yu, W. M., & Summe, J. P. (2001). Epidemiologic trends in the hospitalization of elderly
medicare patients for pneumonia, 1991-1998. American Journal of Public Health, 91, 1121-1123.
Baker, N. A. & Tickle-Degnen, L. (2001). The effectiveness of physical, psychological, and functional
interventions in treating clients with multiple sclerosis: a meta-analysis. Journal of American
Occupational Therapy Association, 55, 324-331.
Becker, D. L., Tews, L. K., & Lemke, J. H. (2008). An oral water protocol in rehabilitation patients with
dysphagia for liquids. 11-21-2008.
Blumenfeld, L., Hahn, Y., LePage, A., Leonard, R., & Belafsky, P. C. (2006). Transcutaneous electrical
stimulation versus traditional dysphagia therapy: a nonconcurrent cohort study. Otolaryngology
- Head & Neck Surgery.135(5):754-7.
Bradley, L., Hart, B. B., Mandana, S., Flowers, K., Riches, M., & Sanderson, P. (1998). Electromyographic
biofeedback for gait training after stroke. Clinical Rehabilitation, 12, 11-22.
Bronson-Lowe, C. R., Leisling, K., Bronson-Lowe, D., Lanham, S., Hayes, S. M., Ronquillo, A. M. et al.
(2008). Effects of a free water protocol for patients with dysphagia. 11-21-2008.
Bryant, M. (1991). Biofeedback in the treatment of a selected dysphagic patient. Dysphagia, 6, 140-144.
Burnett, T. A., Mann, E. A., Cornell, S. A., & Ludlow, C. L. (2003). Laryngeal elevation achieved by
neuromuscular stimulation at rest. Journal of Applied Physiology., 94, 128-134.
Cameron, J. L., Reynolds, J., & Zuidema, G. D. (1973). Aspiration in patients with tracheotomies. Surgical
Gynecology and Obstetrics, 136, 68-70.
Carnaby-Mann, G. D. & Crary, M. A. (2007). Examining the evidence on neuromuscular electrical
stimulation for swallowing: A meta-analysis. Archives of Otolaryngology--Head & Neck Surgery,
133, 564-571.
Centers for Disease Control and Prevention (2003). Guidelines for preventing health-care associated
pneumonia, 2003 (Rep. No. MMWR, 53 (RR-3)).
Chao, N. S., Leung, M. W., Leung, A. K., Cho, J. S., Kwok, E. C., Chung, K. W. et al. (2004). The results of
pelvic muscle biofeedback exercise in children with severe fecal incontinence after surgery for
severe anorectal malformation. Abstracts of The 11th Scientific Meeting of the College of
Surgeons of Hong Kong, 2004.
Reference List
Charbonneau, I., Lund, J. P., & McFarland, D. H. (2005). Persistence of respiratory-swallowing
coordination after laryngectomy. Journal of Speech Language & Hearing Research, 48, 34-44.
Chaudhuri, G., Brady, S., & Caldwell, R. (2006). Electric stimulation for dysphagia following stroke: pilot
data. Archives of Physical Medicine and Rehabilitation, 87, e51.
Coyle, J. L. (2002). Critical appraisal of a treatment publication: electrical stimulation for the treatment
of dysphagia. Perspectives on Swallowing and Swallowing Disorders, 11, 12-15.
Crary, M. A., Carnaby Mann, G. D., Groher, M. E., & Helseth, E. (2004). Functional benefits of dysphagia
therapy using adjunctive sEMG biofeedback. Dysphagia, 19, 160-164.
Crary, M. A., Carnaby, G. D., & Groher, M. E. (2007). Identification of swallowing events from sEMG
signals obtained from healthy adults. Dysphagia, 22, 94-99.
Crary, M. A., Carnaby-Mann, G. D., & Faunce, A. (2007). Electrical stimulation therapy for dysphagia:
descriptive results of two surveys. Dysphagia.22(3):165-73.
Crary, M. A. & Groher, M. E. (2000). Basic concepts of surface electromyographic biofeedback in the
treatment of dysphagia: a tutorial. American Journal of Speech-Language Pathology, 9, 116-125.
Crider, A., Glaros, A. G., & Gevirtz, R. N. (2005). Efficacy of biofeedback-based treatments for
temporomandibular disorders. Applied Psychophysiology & Biofeedback, 30, 333-345.
Dannecker, C., Wolf, V., Raab, R., Hepp, H., & Anthuber, C. (2005). EMG-biofeedback assisted pelvic floor
muscle training is an effective therapy of stress urinary or mixed incontinence: a 7-year
experience with 390 patients. Archives of Gynecology and Obstetrics, 273, 93-97.
Donzelli, J., Brady, S., Wesling, M., & Craney, M. (2001). Simultaneous modified Evans blue dye
procedure and video nasal endoscopic evaluation of the swallow. Laryngoscope., 111, 17461750.
Dursun, E., Dursun, N., & Alican, D. (2004). Effects of biofeedback treatment on gait in children with
cerebral palsy. Disability & Rehabilitation, 26, 116-120.
Eibling, D. E. & Gross, R. D. (1996). Subglottic air pressure: a key component of swallowing efficiency.
Annals of Otology, Rhinology & Laryngology, 105, 253-258.
Eisenhuber, E., Schima, W., Schober, E., Pokieser, P., Stadler, A., Scharitzer, M. et al. (2002).
Videofluoroscopic assessment of patients with dysphagia: pharyngeal retention is a predictive
factor for aspiration. American Journal of Roentgenology, 178, 393-398.
El Solh, A., Okada, M., Bhat, A., & Pietrantoni, C. (2003). Swallowing disorders post orotracheal
intubation in the elderly. Intensive Care Medicine, 29, 1451-1455.
El Solh, A. A., Sikka, P., Ramadan, F., & Davies, J. (2001). Etiology of severe pneumonia in the very
elderly. American Journal of Respiratory & Critical Care Medicine., 163, 645-651.
Reference List
Ferdjallah, M., Wertsch, J. J., & Shaker, R. (2000). Spectral analysis of surface electromyography (EMG)
of upper esophageal sphincter-opening muscles during head lift exercise. Journal of
Rehabilitation Research & Development., 37, 335-340.
File, T. M., Tan, J. S., Thomson, R. B., Stephens, C., & Thompson, P. (1995). An outbreak of Pseudomonas
aeruginosa ventilator-associated respiratory infections due to contaminated food coloring dye-further evidence of the significance of gastric colonization preceding nosocomial pneumonia.
Infection Control & Hospital Epidemiology, 16, 417-418.
Freed, M. L., Freed, L., Chatburn, R. L., & Christian, M. (2001). Electrical stimulation for swallowing
disorders caused by stroke. Respiratory Care, 46, 466-474.
Garon, B. R., Engle, M., & Ormiston, C. (1997). A randomized control study to determine the effects of
unlimited oral intake of water in patients with identified aspiration. Journal of Neurologic
Rehabilitation, 11, 139-148.
Good-Fratturelli, M. D., Curlee, R. F., & Holle, J. L. (2000). Prevalence and nature of dysphagia in VA
patients with COPD referred for videofluoroscopic swallow examination. Journal of
Communication Disorders, 33, 93-110.
Griffiths, J., Barber, V. S., Morgan, L., & Young, J. D. (2005). Systematic review and meta-analysis of
studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ
[On-line]. Available: http://www.bmj.com/cgi/content/abstract/bmj.38467.485671.E0v1
Gross, R. D., Steinhauer, K. M., Zajac, D. J., & Weissler, M. C. (2006). Direct measurement of subglottic
air pressure while swallowing. Laryngoscope, 116, 753-761.
Heymen, S., Jones, K. R., Scarlett, Y., & Whitehead, W. E. (2003). Biofeedback treatment of constipation:
a critical review. Diseases of the Colon & Rectum, 46, 1208-1217.
Hiss, S. G., Strauss, M., Treole, K., Stuart, A., & Boutilier, S. (2003). Swallowing apnea as a function of
airway closure. Dysphagia, 18, 293-300.
Humbert, I. A., Poletto, C. J., Saxon, K. G., Kearney, P. R., Crujido, L., Wright-Harp, W. et al. (2006). The
effect of surface electrical stimulation on hyolaryngeal movement in normal individuals at rest
and during swallowing. Journal of Applied Physiology, 101, 1657-1663.
Intiso, D., Santilli, V., Grasso, M. G., Rossi, R., & Caruso, I. (1994). Rehabilitation of walking with
electromyographic biofeedback in foot-drop after stroke. Stroke, 25, 1189-1192.
Jerkins, G. R., Noe, H. N., Vaughn, W. R., & Roberts, E. (1987). Biofeedback training for children with
bladder sphincter incoordination. Journal of Urology, 138, 1113-1115.
Johnson, A. F. & Jacobson, B. H. (2007). Medical Speech Language Pathology: A Practitioner's Guide.
(2nd ed.) New York: Thieme.
Reference List
Katzan, I. L., Cebul, R. D., Husak, S. H., Dawson, N. V., & Baker, D. W. (2003). The effect of pneumonia on
mortality among patients hospitalized for acute stroke. Neurology, 60, 620-625.
Kelly, A. M., Drinnan, M. J., & Leslie, P. (2007). Assessing penetration and aspiration: how do
videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare? Laryngoscope,
117, 1723-1727.
Kelly, A. M., Leslie, P., Beale, T., Payten, C., & Drinnan, M. J. (2006). Fibreoptic endoscopic evaluation of
swallowing and videofluoroscopy: does examination type influence perception of pharyngeal
residue severity? Clinical Otolaryngology, 31, 425-432.
Kiger, M., Brown, C. S., & Watkins, L. (2006). Dysphagia management: an analysis of patient outcomes
using VitalStim therapy compared to traditional swallow therapy. Dysphagia, 21, 243-253.
Landis, J., Keselman, I., & Murphy, C. N. (2005). Comparison of electromyographic (EMG) activity of
selected forearm muscles during low grade resistance therapeutic exercises in individuals
diagnosed with lateral epicondylitis. Work, 24, 85-91.
Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in
nursing home residents. Dysphagia, 17, 298-307.
Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D. et al. (1998). Predictors
of aspiration pneumonia: how important is dysphagia? Dysphagia, 13, 69-81.
Leelamanit, V., Limsakul, C., & Geater, A. (2002). Synchronized electrical stimulation in treating
pharyngeal dysphagia. Laryngoscope., 112, 2204-2210.
Leslie, P., Drinnan, M. J., Ford, G. A., & Wilson, J. A. (2002). Resting respiration in dysphagic patients
following acute stroke. Dysphagia, 17, 208-213.
Leslie, P., Drinnan, M. J., Ford, G. A., & Wilson, J. A. (2005). Swallow respiratory patterns and aging:
presbyphagia or dysphagia? Journals of Gerontology Series A: Biological Sciences and Medical
Sciences, 60, 391-395.
Levee, J. R., Cohen, M. J., & Rickles, W. H. (1976). Electromyographic biofeedback for relief of tension in
the facial and throat muscles of a woodwind musician. Biofeedback & Self Regulation, 1, 113120.
Ludlow, C. L., Humbert, I., Saxon, K., Poletto, C. J., Sonies, B., & Crujido, L. (2007). Effects of surface
electrical stimulation both at rest and during swallowing in chronic pharyngeal dysphagia.
Dysphagia, 22, 1-10.
Mahony, R. T., Malone, P. A., Nalty, J., Behan, M., O'connell, P. R., & O'herlihy, C. (2004). Randomized
clinical trial of intra-anal electromyographic biofeedback physiotherapy with intra-anal
electromyographic biofeedback augmented with electrical stimulation of the anal sphincter in
the early treatment of postpartum fecal incontinence. American Journal of Obstetrics &
Gynecology, 191, 885-890.
Reference List
Marik, P. E. (2001). Aspiration pneumonitis and aspiration pneumonia. New England Journal of
Medicine, 344, 665-671.
Marik, P. E. & Kaplan, D. (2003). Aspiration pneumonia and dysphagia in the elderly. Chest, 124, 328336.
Marik, P. E. & Zaloga, G. P. (2003). Gastric versus post-pyloric feeding: a systematic review. Critical Care
(London)., 7, R46-R51.
Marston, B. J., Plouffe, J. F., File, T. M., Jr., Hackman, B. A., Salstrom, S. J., Lipman, H. B. et al. (1997).
Incidence of community-acquired pneumonia requiring hospitalization. Results of a populationbased active surveillance Study in Ohio. The Community-Based Pneumonia Incidence Study
Group. Archives of Internal Medicine, 157, 1709-1718.
McClurg, D., Ashe, R. G., Marshall, K., & Lowe-Strong, A. S. (2006). Comparison of pelvic floor muscle
training, electromyography biofeedback, and neuromuscular electrical stimulation for bladder
dysfunction in people with multiple sclerosis: a randomized pilot study. Neurourology &
Urodynamics, 25, 337-348.
Moreland, J. D., Thomson, M. A., & Fuoco, A. R. (1998). Electromyographic biofeedback to improve
lower extremity function after stroke: a meta-analysis. Archives of Physical Medicine &
Rehabilitation, 79, 134-140.
Niederman, M. & Fein, A. (1991). Community-acquired pneumonia in the elderly. In M.Niederman (Ed.),
Respiratory Infections in the Elderly (pp. 45-62). New York: Raven Press.
Niederman, M. S., McCombs, J. S., Unger, A. N., Kumar, A., & Popovian, R. (1998). The cost of treating
community-acquired pneumonia. Clinical Therapeutics, 20, 820-837.
O'Neil-Pirozzi, T. M., Lisiecki, D. J., Jack, M. K., Connors, J. J., & Milliner, M. P. (2003). Simultaneous
modified barium swallow and blue dye tests: a determination of the accuracy of blue dye test
aspiration findings. Dysphagia., 18, 32-38.
Perlman, A. L., He, X., Barkmeier, J., & Van Leer, E. (2005). Bolus location associated with
videofluoroscopic and respirodeglutometric events. Journal of Speech Language & Hearing
Research.48(1):21-33.
Petrofsky, J. S. (2001). The use of electromyogram biofeedback to reduce Trendelenburg gait. European
Journal of Applied Physiology, 85, 491-495.
Ritz, T., von Leupoldt, A., & Dahme, B. (2006). Evaluation of a respiratory muscle biofeedback procedureeffects on heart rate and dyspnea. Applied Psychophysiology & Biofeedback, 31, 253-261.
Robbins, J., Butler, S. G., Daniels, S. K., Diez, G. R., Langmore, S., Lazarus, C. L. et al. (2008). Swallowing
and dysphagia rehabilitation: translating principles of neural plasticity into clinically oriented
evidence. Journal of Speech, Language, and Hearing Research, 51, S276-S300.
Reference List
Rosenbek, J. C., Robbins, J. A., Roecker, E. B., Coyle, J. L., & Wood, J. L. (1996). A penetration-aspiration
scale. Dysphagia, 11, 93-98.
Samsa, G. P., Govert, J., Matchar, D. B., & McCrory, D. C. (2002). Use of data from nonrandomized trial
designs in evidence reports: an application to treatment of pulmonary disease following spinal
cord injury. Journal of Rehabilitation Research & Development, 39, 41-52.
Shaw, G. Y., Sechtem, P. R., Searl, J., Keller, K., Rawi, T. A., & Dowdy, E. (2007). Transcutaneous
neuromuscular electrical stimulation (VitalStim) curative therapy for severe dysphagia: myth or
reality? Annals of Otology, Rhinology & Laryngology, 116, 36-44.
Smith, G. C. S. & Pell, J. P. (2003). Parachute use to prevent death and major trauma related to
gravitational challenge: systematic review of randomised controlled trials. BMJ, 327, 1459-1461.
Suiter, D. M., Leder, S. B., & Ruark, J. (2006). Effects of neuromuscular electrical stimulation on
submental muscle activity. Dysphagia, 21, 56-60.
Thompson-Henry, S. & Braddock, B. (1995). The modified Evan's blue dye procedure fails to detect
aspiration in the tracheostomized patient: five case reports. Dysphagia.10(3):172-4.
Tobin, R. W., Pope, C. E., Pellegrini, C. A., Emond, M. J., Sillery, J., & Raghu, G. (1998). Increased
prevalence of gastroesophageal reflux in patients with idiopathic pulmonary fibrosis. American
Journal of Respiratory & Critical Care Medicine, 158, 1804-1808.
Vaiman, M., Shlamkovich, N., Kessler, A., Eviatar, E., & Segal, S. (2005). Biofeedback training of nasal
muscles using internal and external surface electromyography of the nose. American Journal of
Otolaryngology, 26, 302-307.
Wagner, D. R., Elmore, M. F., & Knoll, D. M. (1994). Bacterial contamination of enteral feeding
reservoirs. Journal of Parenteral & Enteral Nutrition, 18, 562-Dec.
Ware, L. B. & Matthay, M. A. (2000). The acute respiratory distress syndrome. The New England Journal
of Medicine, 342, 1334-1349.
Warnes, E. & Allen, K. D. (2005). Biofeedback treatment of paradoxical vocal fold motion and respiratory
distress in an adolescent girl. Journal of Applied Behavior Analysis, 38, 529-532.
Yamanishi, T., Yasuda, K., Murayama, N., Sakakibara, R., Uchiyama, T., & Ito, H. (2000). Biofeedback
training for detrusor overactivity in children. Journal of Urology, 164, 1686-1690.