The purpose of this study was to compare the differences of awareness of nursing related to dysphagia between certified nurses and registered nurses．
【Subjects】The subjects were 64 nurses (41.0%) who participated in one meeting of the national conference for professionals in 2007.
【Methods】The self-reported questionnaire was distributed before the meeting with voluntary informed consent for participation in the study, and was collected after the meeting. The contents of the questionnaire included characteristics of subjects, caring for patients with dysphagia, cooperation with other professionals, participating in a nutrition support team (NST), performance of oral care and clinical assessment related to dysphagia, necessity and desire for educational support, and so on. The relationship between the two groups (whether a license as a certified nurse of dysphagia was held or not) and each item of this study were analyzed by the chi-square test using SPSS ver14.0.
【Results】The subjects were 63 females (98.4%) and 1 male. Of the total members, the average age was 38.1 ± 8.2 years and average working duration was 13.6 ± 7.2 years. There were 14 (21.9%) who held a license as a certified nurse of dysphagia and 50 who did not (78.1%). Comparing the two groups, the answer rate among the former group was significantly higher than that in the latter group for the following items：young patients, dehydration and edema in constitutional symptoms, vision and hearing in cognitive phase, gustation and smell, opening and closing of lips, chewing, sialorrhea, tongue movement, pronunciation using lips, apex linguae of tongue and tongue base, facial nerve, temporomandibular, glossopharyngeal, findings of hypoglossal and vagus nerve, pronunciation [i:], adaptation of PAP and PLP in oral preparatory and oral phase, swallowing time, distance, time and pitch of thyrolaryngeal upward movement, and forward movement of the jaw in the pharyngeal phase. Over 95% answered that educational support was necessary.
【Conclusion】 Nursing related to dysphagia is a necessary skill for registered nurses at bedsides. The results suggested that the difference in performance of observation and evaluation was affected by educational background. Dysphagia training of nurses is a future task.
【Objective】Video-fluorographiec (VF) and endoscopic examinations are generally used te evaluate patients with dysphagia. However, the former examinations inevitably require substantial facilities and radiation hazards, and so their use in nursing homes or institutes is restricted. We have therefore developed an imaging analysis of swallowing sounds called video-sound imaging analysis (VS) and have examined the possibility of its clinical application.
【Subjects and methods】Image data were taken from healthy men through an accelerated transducer placed on the lateral border of the trachea immediately inferior to the cricoid cartilage on the neck. VS waveforms displayed on the universal ultrasonograph were recorded digitally on a hard disk recorder. VF images were also stored in another hard disk. VS and VF monitor images were simultaneously recorded by digital video camera during swallowing of diluted 30% barium sulfate solution, jelly, rice, and thickened water. Liquid swallowing and modified swallowing with holding up the laryngeal elevation by voluntarily manipulated maneuver, were compared, and the effect of food texture was examined. We reviewed the position of the bolus and wave onset by comparing VF images with VS waveforms. We compared the coefficients of variance to identify the value of the repand area divided by duration (A/t).
【Results】The VS waveforms consisted of three main complexes (Sa, Sb, Sc). VF images revealed that Sa waveforms were in the passage from the oral cavity to the vallecula, Sb from the vallecula to the orifice of the esophagus, and Sc in the upper esophagus. The origin of wave complexes is still being examined, however, larynx depression suggested one of the probable components of Sc wave complexes. Comparing A/t, it showed that Sb is larger than Sa/Sc, but regarding the coefficient of variance of A/t, Sb tended to be smaller than Sa/Sc.
【Discussion】VS wave complexes were significantly demonstrated in the whole process of swallowing movements and total deglutition dynamies, and although each component has not yet been defined, it is suggested that the calculated A/t can be used to.evaluate VS. In the near future, VS is expected to provide a new method for evaluating the swallowing mechanism and functional disabilities of patients with dysphagia without radiation hazards.
It is necessary to intake liquid for patients with dysphagia to prevent dehydration. However, liquid occur frequency aspiration in these patients. To drink liquid more safety, we use commercial thickening agents and are changed texture of liquid. But there are many number of thickening agents. Therefore, health care staffs have been dithered about select thickening agents. Additionally, there has been little information for suitable concentration of thickening agents. In this study, we compared the physical properties (hardness, adhesiveness, cohesiveness) of liquid addition 10 kinds of products in the xanthan-gum based thickening agents. These agents indicated various physical properties. Some agents influenced physical properties by cob. To decide of suitable physical properties, we researched by the sensory evaluation with university students and day service users. It was difficult to swallow sticky liquid, in case of increased the hardness and the adhesiveness. lt was suggested that suitable physical properties of liquid with thickening agents was 115–128N/m2 in hardness. On the other hand, it was suggested that no good physical properties of with thickening agents was over 197N/m2 in hardness.
We reviewed the influence of a change of posture on swallowing. The subjects were 21 normal adults (average age：30.6 ± 9.7 years old). We performed a survey and examination after obtaining informed consent. We took the sitting position without using a support for the back and set four postures making neck position free without limitation： ① Posture (a)：hip flexion 90 degrees, knee flexion 90 degrees, ② Posture (b)：crotch flexure 135 degrees, knee flexure 90 degrees, ③ Posture (c)：crotch flexure 90 degrees, knee flexure zero degree, and ④ posture (d)：elevation of both lower extremities. With the subjects in these postures, we performed videofluorography and the repetitive saliva swallowing test. In each posture, 15 ml of 70％ diluted barium solution were swallowed at a given signal, and we performed a Logemann assay, and measured the pharynx transit time by videofluorography. We performed RSST for similar postures and measured the number of deglutition times by palpation. In addition, we performed one-way analysis of variance in statistical processing and examined the results by Tukey's multiple comparison tests. As a result, we compared the pharynx transit time of postures (a) and (b), and no significant difference was observed. In comparison with the pharynx transit time of postures (c) (p＜0.05) and (d) (p＜0.01) by videofluorography, however, significantly lower values were shown. Also, the pharynx transit time of posture (b) was significantly lower than that of posture (c) (p＜0.05). The results obtained by RSST were similar to those by videofluorography. For dysphagia, there are few reports on the positioning of the lower limbs. It is assumed that a change of posture including the lower limbs had an influence on swallowing function. From the above, it is suggested that the posture is important when considering appendicular mutual relations of the neck and trunk.
【Purpose】The aim of this study was to establish an animal experimental model with tube feeding during the weaning period that achieves a level of growth and development equal to that of normal animal weaning. Therefore, a modified gastrostomoy method providing symptomatic relief and growth of rats reared through tube feeding was examined.
【Methods】Sprague-Dawley (SD) rats underwent gastrostomy at postnatal 7 days (P7), P9 and P11. Six rat pups were included in each group. The rat pups with operation were fed through the intragastric cannula exclusively, and then nursed until P21. Bodyweight of the rats was measured from P7 to P21, and length of body, maximum width of head and liver/body weight ratio were measured at P21 after euthanasia.
【Results】No significant difference was found in bodyweight, length of body and maximum width of head between the rat group with gastrostomy and the control. On the other hand, liver/bodyweight ratio of the operated rats in the P9 and P11 groups showed significantly larger values than the control rats. The operated rats were infused through a catheter early in the gastrostomy.
【Conclusion】These results suggested that the rats operated by the above method and nursed under this condition reached the same level of physical growth as rats weaned naturally. Consequently, this method might be useful for an experimental model of artificial tube feeding during the weaning period.
【Objectives】Various approaches for removing residual food on the pharynx in patients with dysphagia or eating dysfunction have been attempted in the clinical setting to reduce the risk of choking, aspiration pneumonia, and associated problems. However, few studies have confirmed the effectiveness of such approaches. The present study was conducted to investigate the effectiveness of alternate swallowing of a jelly food (Engelead® Apple Jelly) for removing residual food on the pharynx. Alternate swallowing was evaluated by videofluoroscopic swallowing study.
【Subjects and Methods】The subjects were patients with dysphagia or eating difficulties who were found to have residual food on the pharynx after they had consumed at least one of three barium-based test foods with different viscosities (viscosity similar to honey, yogurt, or liquid) and who performed alternate swallowing of the jelly food. The effectiveness of alternate swallowing for removing residual food on the pharynx was evaluated by measuring the amount of the test food remaining in the epiglottic vallecula and piriform sinus before and after the consumption of the jelly food, with the results scored using a 4-grade scale (a large amount, a small amount, surface adhesion, and no residual food).
【Results】The study included 28 subjects (average age: 73.2 years; primary medical condition: 15 patients with cerebral infarction, 7 with cerebral hemorrhage, 4 with aspiration pneumonia, and 2 with other conditions). One patient was dropped from the study because continued aspiration from the piriform sinus was observed due to the retention of large quantities of the consumed food. After alternate swallowing of the jelly food, the residual food score for the epiglottic vallecula was improved in 60%-72% of the patients and that for the piriform sinus was improved in 75%-100% of the patients, with a significant difference observed by the Wilcoxon signed-rank test. Adverse events such as coughing, hoarseness, decreased oxygen saturation, and fever were not observed, and no clinical problems were noted in any of the patients.
【Discussion】The alternate swallowing of Engelead® Apple Jelly was found to be effetctive for removing residual food in the epiglottic vallecula and piriform sinus for all three test foods with different viscosities. These results indicate that the alternate swallowing of the jelly food is an effective method for reducing the risk of retention of food on the pharynx in dysphagia patients.
Video Endoscopic evaluation of swallowing (VE) performed between April and October 2006 in a general hospital for acute disease was investigated. VE was performed 172 times on 133 patients with an average age of 75.3 years (26–96 years). Stroke was the most frequently observed condition 57 patients [42.8%], followed by pneumonia. The most frequent aim of the first VE (66.2%) was “to determine the indication for direct swallowing training.” Characteristics of the patients with stroke and pneumonia were analyzed based on the first VE findings.
In the stroke group (cerebral, infarction, intracerebral hemorrhage, subarachnoidal hemorrhage), the median period from the onset till the first VE was 23 days, and the aim of the first VE was “to determine the indication for direct swallowing training” in 78.9%, which was significantly higher than the rates in patients with other diseases. Patients frequently had no oral intake before VE and direct swallowing training after VE.
The pneumonia group comprised 38 cases (the main reason for hospitalization was pneumonia, or after hospitalization for disease other than pneumonia or stroke, pneumonia developed within two months before the first VE). The average age of this group was 80.4 years, which was significantly older than the patients with other diseases (p＜0.05). Stroke and pneumonia were found as past history in 52.6% and 28.9%, respectively. Patients frequently had no oral intake before and after the first VE.
Persistent fever after VE was found more frequently in the pneumonia group than in other cases, and it was particularly common in cases with no oral intake due to suspected saliva aspiration. In the pneumonia group, fever was frequently observed in those patients who were old and who had a past history of stroke and pneumonia. In the stroke group, fever was frequently observed after direct swallowing training. In these cases, reexamination by VE and combination with video fluorography were considered important.
When patients with a history of stroke and pneumonia were hospitalized due to pneumonia, severe dysphagia was frequently observed. Therefore, these cases should be followed-up carefully soon after the onset. Because VE does not require a specific examination room to confirm the safety of oral intake and advance direct swallowing training. It was markedly useful in the hospital for acute disease patients with difficulty in transferring.
【Purpose】We often experience elderly patients who have only mild dysphagia but are NPO. The purpose of this study was to investigate the relationship between problems that are specific to elderly patients with chronic CVA and the outcome of dysphagia rehabilitation for these elderly patients.
【Methods】Thirty tube- or IV-fed patients who were： 1) ＞65 years old (aged 66–96, 23 males), 2) chronic CVA (＞30 days from onset), 3） NPO, and 4) exhibiting mild dysphagia, were studied and treated by speech therapists. Two groups of patients were identified based on their responses to swallowing therapy: “good outcome” if all nutrition was oral； and “poor outcome” if nutrition was provided via tube or IV. General medical, activity, mental and motivational status during the first examination, and the number of times of fever and the development of amount intake per day during the therapeutic processes were determined and compared between the good outcome group and the poor outcome group.
【Results】Twenty patients, had good outcomes, while ten had poor outcomes. There were no significant differences between the two groups in general status, activity status or mental function at the first examination. Duration from the onset was significantly longer in good outcome patients. Most were bedridden and demented. Motivation was significantly lower in the poor outcome group. A half of patients with severe dementia and severe apathy could regain oral intake. Seventy-five percent of the good outcome patients increased their oral food intake by more than 50% within 10 days, while none in the poor outcome group showed an increase of more than 50%. There was no significant difference between the number of times of fever in the two groups.
【Discussion】In our study of elderly patients who had only mild dysphagia but who were NPO and bedridden and demented, 67% of the patients were tube-free by the end of treatment. So, dysphagia rehabilitation is important for these patients. As it is important but difficult to determine a feasible method of providing adequate nutrition and direction for dysphagia rehabilitation, clinicians should consider a trial of direct therapy for about 10 days for chronic disabled elderly patients.
Among 1258 pediatric patients who had newly attended the outpatient clinic in our Rehabilitation Center for Children during a period of two years and three months from September 2003 to December 2006, 72 children with eating disorders were eligible for the present survey based on their actual condition as an outpatient. The age at the first medical examination was one year old at most in 36 cases followed by two years old in 19 cases. The rate of referral from other departments in the Center to the outpatient clinic for eating disorders was 5.7%. The rate of referral from the Rehabilitation Department was as high as 44.9% of new pediatric patients, indicating the potentially high need during rehabilitation for functional therapy for eating.
As for primary disease, cerebral motor disorders such as cerebral palsy accounted for half or more of the patients enrolled in this survey. There were eight cases of mental retardation without motor disturbance. Unstable neck was the most common regarding the development of gross motor function, while mal-acquisition of swallowing function and/or capturing function was frequently observed when eating function was subsequently evaluated.
As for the development of gross motor function in relation to eating function in the present subjects, it was demonstrated that children with immature gross motor function tend to have an immature eating function as well. These findings suggest it is necessary not only to understand the patient's general condition accurately and to promote the development of gross motor function as far as possible, but also to devise an appropriate chair and/or caring approach in order to allow eating in a stable posture and to give adequate guidelines for attaining an improved eating function in children.
As for the eating function in relation to the shape of food daily taken by the subjects, there were many children who were eating food of a shape that was difficult for them to eat due to their eating function, suggesting that their parents need to understand the child's oral function and to be instructed concerning the shape of food suitable for their children's eating function.
The results of the present survey indicate that various approaches are necessary to promote the development of eating function in children. In rehabilitation centers, not only medical treatment but also training, attending manner at a kindergarten and rehabilitation are conducted in daily activities. In order to achieve a comprehensive eating function therapy, rehabilitation centers should coordinate the specialized abilities of various professionals through a team approach.