Showing papers in "Dysphagia in 1990"

Aspiration and the elderly.

Abstract: Aspiration is prevalent in the elderly but its association with impairment of oral intake and gastroesophageal reflux is often misunderstood. This paper describes the causes, pathophysiology, and consequences of aspiration and their unique features in aged persons. It also explains how videofluoroscopic evaluation can assess current function while limiting factors that result in misinformation. The management of aspiration is discussed, emphasizing the importance and difficulties in maintaining functional well-being and possible complications of therapy.

Test-retest variability in normal swallowing.

Abstract: The test-retest variability of the modified barium swallow study using videofluoroscopy was analyzed. Sixteen normal subjects (8 men, 8 women) were organized into 2 age groups: middle-aged group (mean, 45 years) and old-age group (mean, 66 years). Nine durational measures of the swallow were evaluated. There were no statistically significant differences for any of the measures between the initial test and a retest conducted days later. The findings suggest that, on the whole, normal subjects perform similarly on test and a retest. However, the variability displayed by these normal subjects may be clinically significant, indicating that test-retest swallowing duration measures require careful interpretation.

Central neural control of esophageal motility: A review

Abstract: We review recent studies on the central neural control of esophageal motility, emphasizing the anatomy and chemical coding of esophageal pathways in the spinal cord and medulla. Sympathetic innervation of the proximal esophagus is derived primarily from cervical and upper thoracic paravertebral ganglia, whereas that of the lower esophageal sphincter and proximal stomach is derived from the celiac ganglion. In addition to noradrenaline, many sympathetic fibers in the esophagus contain neuropeptide Y (NPY), and both noradrenaline and NPY appear to decrease blood flow and motility. Preganglionic neurons innervating the cervical and upper thoracic ganglia are located at lower cervical and upper thoracic spinal levels. The preganglionic innervation of the celiac ganglion arises from lower thoracic spinal levels. Both acetylcholine (ACh) and enkephalin (ENK) have been localized in sympathetic preganglionic neurons, and it has been suggested that ENK acts to pre-synaptically inhibit ganglionic transmission. Spinal afferents from the esophagus are few, but have been described in lower cervical and thoracic dorsal root ganglia. A significant percentage contain calcitonin gene-related peptide (CGRP) and substance P (SP). The central distribution of spinal afferents, as well as their subsequent processing within the spinal cord, have not been addressed.

The Exeter Dysphagia Assessment Technique.

Abstract: The Exeter Dysphagia Assessment Technique (EDAT) uses noninvasive equipment to record, simultaneously, "feeding respiratory patterns," the time drink entered the mouth, and associated swallow sounds during feeding. The easily portable equipment enabled patients' swallowing ability to be tested, at the bedside if necessary, using a small amount of fruit-flavored drink. The results appear in chart form. EDAT findings from groups of normal subjects aged 2-90 years were compared with those from patients with dysphagia of neurologic origin and normal subjects under experimental feeding conditions. The results revealed maturation of the feeding respiratory pattern in the teenage years and remarkable consistency thereafter. Differences in the recordings between the normal and abnormal subjects were sufficiently marked to allow the findings to be used in the diagnosis of other patients with dysphagia of doubtful neurologic cause. Interpretation of the charts and recorded timings of the oral and pharyngeal stages of swallowing permitted a more accurate identification of sensory nerve, motor nerve, and functional involvement causing dysphagia of neurologic origin and may be used as a guide to the origin of the sensory deficit.

Development and dissemination of an aspiration risk reduction diet.

Abstract: Patients with oropharyngeal swallowing disorders secondary to neurologic impairments benefit from diets that minimize the risk of aspiration. An aspiration risk reduction diet was developed from our hospital's regular menu cycle. Examples of the diet's preparation, dissemination, and use in a 600-bed acute medical/surgical teaching hospital are discussed.

Effects of body position and bolus consistency on the manometric parameters and coordination of the upper esophageal sphincter and pharynx.

Abstract: The development of a solid-state intraluminal sphincter transducer has alleviated many of the problems associated with manometric studies of the upper esophageal sphincter (UES) and pharynx (P) We used this technology to study the effect of position (upright vs supine) on resting UES pressures and the pressure dynamics of the UES/P complex during both wet and dry swallows in 11 normal volunteers and the effects of foods of different consistencies on the UES/P swallow dynamics in 10 normal volunteers The UES/P coordination parameters were defined as the 15 time intervals that can be measured between any 2 of 6 pertinent points: the beginning, peak, and end of the pharyngeal contraction and the beginning, nadir, and end of the UES relaxation Data from both the circumferential transducer used to measure sphincter pressures and a standard microtransducer used to measure pharyngeal pressures were collected on-line by an Apple IIe microcomputer and analyzed by programs written in our laboratory Significant changes in swallow coordination were measured between upright and supine swallows of the same bolus size, between wet and dry swallows in the same position, and among foods of varying consistencies Resting UES pressure was unchanged by position and pharyngeal contraction pressure was unchanged by bolus size or consistency

Effects of a multidisciplinary management program on neurologically impaired patients with dysphagia.

Abstract: Dysphagia is a major problem in patients with neurologic disorders. Aspiration pneumonia and impaired nutritional status are consequences of dysphagia that result in high morbidity and mortality rates. Assessment and treatment of the dysphagic patient by a multidisciplinary team have been advocated but to date the effects of such an approach have not been demonstrated quantitatively. This prospective study was conducted to determine if a dysphagia program would improve patients' caloric intake and body weight, decrease the instances of aspiration pneumonia, or improve patients' feeding ability. Patients were referred from a 26 bed neurology/neurosurgery unit. A time series design was utilized. The control group consisted of 15 patients (mean age = 46.1 years), managed according to the existing ward routine. Subsequently, nursing staff attended a dysphagia training program. Following this, the treated group of 16 patients, (mean age = 49.3 years) was assessed by the dysphagia team, using bedside and videofluoroscopic examinations to determine the specific swallowing disorder. An individualized treatment program was designed for each patient. The groups were compared on the basis of deviation from their baseline weight, deviation from ideal energy intake, and the incidence of aspiration pneumonia. Statistical analysis revealed that the groups were comparable in age, number of days on the study, and Glasgow Coma Scale score; and that a significant weight gain and increase in caloric intake occurred in the treated group. No incidence of aspiration pneumonia was reported in either group. We speculate that this may have been influenced by the meticulousness of the care delivered in an acute unit as well as greater attention to prevention given in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Nature, nurture, nutrition: interdisciplinary programs to address the prevention of malnutrition and dehydration.

Abstract: Malnutrition and dehydration are common problems in nursing home patients. One explanation for this may be the large number of patients requiring feeding assistance. The Dysphagia Team at the Department of Veterans Affairs Medical Center in Miami, Florida served as the primary source in the expansion of a nutritionally supportive environment to assist in the prevention of malnutrition and dehydration in patients with feeding/swallowing disorders. “Silver Spoons,” a program in which volunteers provide supervised feeding, “Happy Hour,” a time each day during which an atmosphere is provided that encourages socialization and hydration, and “Second Seating,” during which lunch is provided for patients who require modification of eating style, food texture, or timing are described. Analysis of the program's outcomes show it to be timely, pleasing to patients, and cost-effective.

Surgical therapy of Zenker's diverticulum: low risk and high efficiency.

Abstract: Surgery for the treatment of Zenker's diverticulum was performed at our institution in a total of 43 patients over 6 1/2 years. Cervical myotomy with diverticulectomy was performed in 32 of the patients and myotomy alone in 11. Mortality totaled 0%, with a reversible lesion of the recurrent nerve occurring in 7%. In 60% of the cases investigated preoperatively (N = 40), motility disorders of the upper esophageal sphincter (UES) could be demonstrated using manometry as well as with cineradiography in 92% of the patients. Follow-up studies in 39 of the cases 25 months (mean) postprocedure indicated 82% of the patients to be symptom-free, with the remaining 18% demonstrating a marked improvement. Postoperative manometry as well as cineradiography carried out in 12 patients revealed the presence of UES motility dyscoordination in 8% and 25%, respectively. There were, however, no signs of recurrence of the diverticulum. The high number of patients in our study group demonstrating motility disorders of the UES emphasizes the need for cervical myotomy as part of the surgical therapy for Zenker's diverticulum.

Developing a dysphagia program in an acute care hospital: a needs assessment.

Abstract: A needs assessment for a hospital-based dysphagia program was conducted to determine incidence, management procedures, and outcome for stroke patients with swallowing disorders. Using a chart review of 225 patients, it was found that 28% had documented evidence of dysphagia. When dysphagia co-occurred with stroke, significantly more functional problems and medical complications were reported, as well as increased need for dietary modifications and alternative feeding methods. The dysphagic patients were more often aphasic and dysarthric and less able to communicate. Mental status was more likely to be reduced and the need for staff supervision during mealtime was increased. Dysphagic patients had significantly longer hospital stays, thus increasing the cost of their care. At discharge, almost half of them continued to need feeding modifications, which may have delayed rehabilitation or transfer to facilities with other levels of care. The dysphagia group clearly displayed a wide range of clinical symptoms that would alert staff to their risk for medical complications because of swallowing problems. We believe that this needs assessment clearly showed that a multidisciplinary dysphagia management program has the potential to enhance patient care while decreasing the cost of health care delivery for the hospital.

Dietary adjustments and nutritional therapy during treatment for Oral-Pharyngeal Dysphagia

Abstract: Dietary adjustments are an important part of the therapy for dysphagia. Once dysphagia is diagnosed, the patient must be nourished safely while being taught therapeutic and compensatory strategies for dealing with the swallowing disorder. The patient's nutritional status must be maintained despite any limitations on oral intake. Liquids may be thickened and the consistency of solid foods may be adjusted to ensure an adequate diet that is safe for the patient. When the patient cannot eat safely or take adequate amounts of food orally, an alternative feeding method should be instituted.

Image quality and radiation levels in videofluoroscopy for swallowing studies: a review.

Abstract: Inexpensive video recording equipment coupled to conventional x-ray fluoroscopes is now in widespread use by clinicians for the evaluation of patients with swallowing disorders The prevalence and simplicity of this apparatus have encouraged its use by clinical specialists who are often not specifically trained in the safe use of x-ray equipment, and this may not be in the best interest of either the patient or the examiner This has prompted an overview of the operating principles of videofluorescopy equipment The factors governing image quality are discussed as well as potential hazards and protective measures for both patients and operator A method of estimating the radiation dose to sensitive tissues from a typical swallowing study is included

Approaches to the patient with aspiration and swallowing disabilities.

Abstract: Aspiration, or soiling of the tracheobronchial tree, can produce life-threatening pulmonary disease. Intermittent or persistent aspiration may cause symptoms including cough, intermittent fever, recurrent tracheobronchitis, atelectasis, pneumonia, and/or empyema. The pulmonary disease may be associated with weight loss, cachexia, and dehydration. In many cases the aspiration is caused by laryngeal dysfunction, allowing pulmonary contamination by swallowed material. In other cases the aspiration is caused by a dysfunction of the oral, pharyngeal, or esophageal phases of swallowing. In some cases the aspiration is caused by a combination of laryngeal and swallowing dysfunction. Geriatric patients are more likely to experience aspiration, since muscle weakness causing mechanical disability and neurologic impairment are more common in this age group. Therefore, with the ever-increasing aging of our population, these disabilities will be on the rise, with an associated increase in pulmonary disease and death. The approach to evaluation and management of these disorders must be based on an understanding of the underlying functional impairment.

Factors affecting ability to resume oral nutrition in the oropharyngeal dysphagic individual

Abstract: Successful oral intake of nutrition depends not only on the patient's ability to swallow efficiently and safely but also a number of cognitive, neurolinguistic, and behavioral variables. This paper reviews these competencies as they are integrated into the act of oral feeding and describes the types of disorders that affect these abilities. Methods of evaluating and treating the abilities needed for successful oral intake are described.

Feeding strategies for the dysphagic patient: a nursing perspective.

Abstract: The goal of treatment for the dysphagic patient is to maintain safe oral feeding. Achieving this goal requires an individualized care plan using selected feeding strategies. This care plan will need to be altered as changes in the patient's condition occur.

Indications for tube feedings in elderly patients.

Abstract: Tube feedings are utilized in elderly patients with acute and chronic problems. Inadequate oral intake with malnutrition, comatose state, neurologic disorders with severe dysphagia, extensive burns, massive gastrointestinal resection, and oropharyngeal and upper gastrointestinal malignancies are the commonly encountered conditions requiring tube alimentation. Dysphagia with frequent aspiration is the most common indication for use of tube feedings in the elderly. Nasogastric tube is preferred for short-term feeding, while gastrostomy or jejunostomy is indicated for long-term or permanent nutritional support. Nutritional assessment should be done initially and on a regular basis. Specific formulas are available to calculate height, weight, and caloric needs of bedbound elderly patients. Various enteral feeding formulas are available for a specific clinical condition and are preferably administered by continuous drip using a pump. Parenteral nutrition is also indicated for certain situations in which enteral feeding cannot meet the patient's nutritional requirement, and in particular situations where enteral feeding is contraindicated and not feasible. Optimal patient care is dependent on adequate nutritional support.

Adapting the mealtime environment: setting the stage for eating.

Abstract: In long-term care facilities, mealtime should be an important and exciting event that residents and staff look forward to three times a day Providing residents with a homelike, pleasant dining atmosphere should promote socialization, enhance awareness, and increase appetities, thereby improving the residents' quality of life This paper discusses the subtle but strong influence that the environment has in preparing residents for eating Environmental factors that promote a positive mealtime experience are discussed

Radiographic techniques and efficacy in evaluating esophageal dysphagia

Abstract: The radiographic examination of the esophagus to determine structural and/or functional causes of dysphagia is best performed with multiple techniques. These include full-column studies to produce distended films with or without the use of a solid bolus, mucosal relief films to identify mucosal defects such as esophagitis or the presence of varices, double-contrast films, and motion recording (fluoroscopy). The efficacy of each technique depends on the quality of the study and the specific disorder to be detected. Esophageal lesions producing dysphagia are classified into extrinsic structural lesions, intrinsic structural lesions, and esophageal motility disorders. Radiographic studies are the preferred screening techniques for patients with dysphagia. Although not as sensitive for the evaluation of mucosal lesions, radiographic studies are superior to endoscopy for the detection of abnormal motility, esophageal rings, and strictures.

Symptoms of achalasia in young women mistaken as indicating primary anorexia nervosa.

Abstract: The case of a young women with dysphagia, regurgitation, and weight loss, who was diagnosed as having anorexia nervosa but in whom reevaluation showed that achalasia was causing the symptoms, is presented together with related observations. Misinterpretation of esophageal symptoms may occur not only as a consequence of inadequate history taking and of being biased by a patient's emaciation, age, and gender, which leads to view certain aspects of the patient's history and behavior as suggesting a pathologic attitude towards eating and body weight, but also as a consequence of a misinterpretation of the symptoms as indicative of an eating disorder by the patients themselves. In some cases a disordered attitude toward eating and body weight may develop together or coexist with achalasia. The clinical evaluation of patients with symptoms suggestive of anorexia nervosa but also of bulimia nervosa should include the taking of a thorough history regarding swallowing and vomiting in order to recognize a possible esophageal motor disorder.

Volunteer participation in feeding residents: Training and supervision in a long-term care facility

Abstract: The increasing number of residents in long-term care facilities who require full and partial assistance during meals has created a need for volunteer support to enhance the quality of life for residents. The correlation between dependence in eating and the existence of swallowing disorders and the risk of aspiration in persons with swallowing disorders suggests that training must be given to volunteers who feed residents. A formalized program for volunteer training and supervision was implemented at Coler Memorial Hospital, a long-term care facility. The program's development and benefits are outlined. Implementation of this program resulted in better training of volunteers, increased socialization, communication, and safety for patients during meals.

Ethical dilemmas in providing nutrition.

Abstract: The decisions involved in the institution of artificial feeding in patients with chronic and/or terminal illness are difficult. They are more complex when one is deciding if nutrition and hydration are to be withdrawn. In both instances the decision must be based on a combination of factors: the patient's right to self-determination; documented medical evidence demonstrating the need for artificial feeding, combined with a risk/benefit analysis if alternative alimentation is recommended; and an appreciation of prior legal decisions as they relate to the implementation of alternative forms of nutrients to sustain life.

Dysphagia after laryngeal surgery: radiologic assessment.

Abstract: In the past three decades, we have witnessed the emergence and perfection of surgical techniques designed to treat carcinoma of the larynx and pharynx. Extensive cancers are treated with what is conceptually the simplest procedure: total laryngectomy (TL) [1]. For patients with well-circumscribed neoplasms, voice-conserving surgical procedures are available; subtotal supraglottic laryngectomy (SSL) [2-8], for example, has been widely used to treat patients with primary cancers of the epiglottis, false vocal cords, or aryepiglottic folds. Considering the fact that normal swallowing depends on the coordinated action of at least a dozen intrinsic laryngeal muscles innervated by three cranial nerves [9], it is remarkable that the majority of patients undergoing head and neck surgery recover normal swallowing function. When dysphagia arises, however, it is a serious, frequently debilitating problem; moreover, standard clinical evaluation may be unsatisfactory in evaluating the cause. For example, submucosal recurrence of tumor cannot be reliably detected by direct visualization and blind biopsy may be too superficial to sample it [10]. In patients who have undergone subtotal surgery, biopsy of suspiciouslooking mucosa overlying remaining portions of the laryngeal skeleton often leads to chondronecrosis, and, ultimately, total laryngectomy. Assessment of a specific cause for dysphagia in postoperative patients is therefore a problem often referred to the radiologist. If we are to be helpful to our clinical colleagues, we need some fundamental idea of the likely causes of dysphagia in a given clinical setting, the variable appearances

Esophageal perforation during pneumatic dilatation for achalasia: A possible association with malnutrition

Abstract: Pneumatic balloon dilatation of the lower esophageal sphincter is commonly utilized as primary therapy for achalasia. Perforation related to pneumatic dilatation is uncommon (2–6%) but may result in severe morbidity. Factors associated with risk of perforation are not well defined. We noted perforation in three patients undergoing forceful balloon dilatation. All these patients had clinical evidence of significant malnutrition (recent marked weight loss and severe hypoalbuminemia). Malnutrition may be a causal factor for perforation in patients with achalasia undergoing dilatation.

Neuropeptide-containing nerve fibers in the pharynx of the rabbit.

Abstract: The distribution of peptide-containing nerve fibers in the pharyngeal region of rabbits was studied by immunocytochemistry. Neuropeptide Y (NPY)-containing fibers were numerous around blood vessels and moderate in number among bundles of striated muscle fibers. A few NPY-containing fibers were seen around seromucous glands and beneath the epithelium. Nerve fibers containing vasoactive intestinal peptide (VIP) were numerous around seromucous glands and moderate in number around blood vessels, bundles of muscle, and in the subepithelial layer. A few nerve fibers containing substance P (SP) were seen around blood vessels, seromucous glands, among bundles of muscle, and in the subepithelial layer. Nerve fibers containing calcitonin gene-related peptide (CGRP) were numerous. They were distributed close to blood vessels, among bundles of muscle, in the subepithelial layer, and within the epithelium. A conspicuous finding was the occurrence of CGRP within motor end plates of striated muscle.

Acoustic technique for determining timing of velopharyngeal closure in swallowing.

Abstract: A pure tone sound source was introduced at a nostril and monitored by a miniature accelerometer on the throat. During velopharyngeal closure in a swallow, the pure tone component in the accelerometer signal was attenuated. Throat accelerometer recordings were made simultaneously with videofluoroscopy of a modified barium swallow in adults with normal velopharyngeal mechanisms. It was verified that the period of sound attenuation corresponded to the period of velar closure. This noninvasive method of monitoring otherwise silent velopharyngeal closure holds promise for normative studies on swallowing function, as an adjunct method in longitudinal assessment, and as a training aid.

Swallowing disorders and nutritional support.

Abstract: Evaluation of nutritional needs in patients with swallowing disorders should include a global assessment. This includes a nutritional assessment, a determination of the metabolic state, and a separation of the causes of nutrient deficits due to the patient's underlying disease(s) from diminished nutrient intake related to the dysphagia. Techniques for intense nutritional support are surveyed, and the complications of each are discussed.

Nutrition and the older adult.

Abstract: The surge in interest in aging research has led to a growing awareness of the importance of adequate nutritional status in the elderly. This paper highlights the current state of our knowledge of nutrition in the older adult with regard to age-related alterations in nutritional status, the effects of altered nutritional status on the general well-being of the elderly, and the contributions of alcohol and drugs to altered nutritional status. Nutritional assessment techniques used for the elderly and directions for future research are discussed.

Esophageal motility, heartburn, and gastroesophageal reflux: variations in clinical presentation of esophageal dysphagia.

Abstract: Dysphagia is a potentially important symptom, often leading to the finding of an anatomical or motility disorder of the esophagus. Dysphagia and heartburn represent two of the most common symptoms associated with esophageal motility disorders. To explore the relationship of symptomatic esophageal dysphagia and heartburn and their association with primary esophageal motor disorders, we have performed a retrospective assessment of 1035 patient evaluations performed at our gastrointestinal laboratory. A clear statistical association of symptomatic dysphagia and heartburn was established; however, no pattern diagnostic of a specific motility disorder was discernible. A sizable fraction of our patient population with dysphagia demonstrated normal esophageal motility. A significant portion of dyspeptic patients exhibited both normal motility and acid exposure. The differences observed between the incidence of subjective symptoms and objective dysfunction may be explained in part by an altered or increased esophageal sensitivity of these patients.

Overview of geriatric nutrition.

Abstract: Restoration and maintenance of optimal nutritional status in the long-term care setting may enhance the quality of life for geriatric patients. The elderly are at increased risk for poor nutrition due to age-related physiological and psychosocial changes, as well as the added toll of chronic disease. All of these may have a negative impact on adequate food intake. Health care providers must identify and address nutrition-related problems in a timely manner to correct nutrient imbalances and restore nutritional well-being in this population.

Nutritional assessment and requirements.

Abstract: Nutrition plays an important role in health and disease, both in prevention and treatment. Increasing emphasis is being placed upon nutrition as a therapeutic tool to decrease the morbidity and mortality associated with obesity, hypertension, coronary artery disease, and cancer. Adequate nutrition should be a concern for all health care workers because of its impact on the overall health of patients. Health care professionals should be familiar with the essentials of nutritional assessment and basic nutritional requirements and be able to improve their patients' care in the face of nutritional deficiencies or excesses.