Respiratory function and cough flow intensity are thought to be influenced by posture. During swallowing training or eating a meal, the postures of the head, neck and trunk are adjusted in a complex manner, but aspiration may still happen even when the posture is suitable. It is important to find the posture that can exhaust aspiration effectively or that allows breathing to be performed easily during a meal.
This study examined posture-related alterations of respiratory function and cough flow intensity in healthy subjects.
The subjects were asked to take four postures in random order: (1) reclining 90 degrees ＋ head and neck facing straight forward (R90HN0), (2) reclining 90 degrees ＋ head and neck tilted 30 degrees in the flexor direction (R90HN30), (3) reclining 30 degrees ＋ head and neck facing straight forward (R30HN0), and (4) reclining 30 degrees ＋ head and neck tilted 30 degrees in the flexor direction (R30HN30). Respiratory function and cough flow intensity parameters included Tidal Volume (TV), Inspiratory Reserve Volume (IRV), Expiratory Reserve Volume (ERV), Vital Capacity (VC), Peak Expiratory Flow (PEF) and Peak Cough Flow (PCF).
As a result, there were no significant differences in TV among the four postures. On the other hand, the measurement items related to labored respiration (IRV, ERV, IC, VC, PCF, PEF) were influenced by posture change. ERV and PCF were significantly greater in the R90 posture than in the R30 posture, and ERV was significantly greater in the HN0 posture than in the HN30 posture.
The R90HN0 posture allowed expiration to be performed most effectively. In other words, it was shown that the R90HN0 posture is the most effective for discharging aspiration.
Objective: Several reports have measured the physical properties of a modified diet for patients with dysphagia at individual facilities, but few multicenter reports have been published. We measured the physical properties of modified diets for patients with dysphagia at many facilities and judged whether these properties are in accordance with the standards for “Foods for the elderly with difficulty in swallowing” of “Food for Special Dietary Uses.”
Method: We sampled 903 diets for dysphagic persons provided by 176 facilities. We measured physical properties of each sample in 2 temperature zones according to the standard regulation of “Foods for the elderly with difficulty in swallowing.”
Result and Discussion: Meats, fishes and seafood, potatoes, and test foods for videofluoroscopic examination of swallowing showed that more than half of the samples did not conform to the standard regulations. Meats, fishes, and seafood are easily affected by temperature and factor of not conforming to the standard regulations of potatoes are adhesiveness and test foods are hardness. It was found that the physical properties of meats and potatoes can be adjusted by adding water during cooking.
Conclusion: We measured the physical properties of the modified diet for dysphagic persons and found that it is difficult to prepare meats, fishes and seafood, potatoes, and test foods.
The Repetitive Saliva Swallowing Test (RSST) is in widespread clinical use as a highly sensitive, low-risk method of screening for dysphagia. During evocation of the swallowing reflex, movement is observable in both the suprahyoid and infrahyoid muscles. However, conducting the RSST is challenging when laryngeal elevation cannot be confirmed due to thick cervical subcutaneous fat or high positioning of the thyroid cartilage. In this study, we investigated a possibility of improvement for the accuracy of RSST by concurrent palpation of the thyroid cartilage and the inferior aspect of the mandible. This hypothesis was verified by videofluorographic (VF) assessment of swallowing in addition to simultaneous measurement of surface electromyography (SEMG) and swallowing sounds. Methods included simultaneous measurement of SEMG, palpation of the thyroid cartilage, palpation of the inferior aspect of the mandible, and swallowing sounds in 23 healthy elderly subjects and 21 dysphagic patients. When the reflex was detected by palpation, a corresponding mark was made by the investigator on the SEMG. Muscle activity was calculated using integration after absolute value processing. SEMG was recorded from the suprahyoid and infrahyoid muscles. Comparison of the swallowing reflex marks made for swallowing sounds and during palpation revealed that the swallowing reflex detection rate was significantly increased by palpation of the suprahyoid muscles compared with thyroid cartilage palpation alone in healthy elderly subjects (97.5% vs 87.0%, respectively) and dysphagic patients (91.9% vs 81.0%, respectively). Furthermore, activation of the suprahyoid muscle group was significantly greater during evocation than during failed attempts. The effect of muscle fatigue over 30 seconds was not significant in this study. These findings suggest that the accuracy of RSST can be improved by concurrent palpation of the inferior aspect of the mandible in patients in whom confirmation of the swallowing reflex is difficult using thyroid cartilage palpation alone.
Using various thick foods as an index for the thickness of foods for dysphagia, when adjusting thickness by instant food thickeners (IFTs), is beneficial for clarifying the thickness easily, but may not be an appropriate means because of lack of objectivity. However, hospitals or institutions for the elderly do not usually use any instruments to measure the physical properties of thick foods such as a viscometer or rheometer because such instruments are expensive and require space. The Line Spread Test (LST) has been suggested to be a simple, inexpensive, and useful tool for measuring the rheological properties of thick foods. We measured physical properties of nine foods with various consistencies and those of thickened liquids prepared by nine commercial IFTs, and evaluated the suitability of the thick foods as indexes for the IFTthickening solutions. With data from thickened liquids and seven thick foods that were measurable by the LST, we performed cluster analysis and principal component analysis. They were roughly classified into three groups, and one of the clusters did not include IFT-thickening solutions. The other two groups could be further classified into six small groups. On the basis of these categorizations, the thickness standard could fall into three groups, and each group could be defined with the range of physical properties. We then performed multiple linear regression analysis on data from five index foods and IFT-thickening solutions made by one IFT, using the LST value as an objective variable, and the other physical properties as explanatory variables. A good multiple regression model was obtained when using viscosity and adhesive energy as explanatory variables, and all IFT solutions matched well in this model. These results indicate that the five thick foods in this study were suitable as index foods for IFT-thickening solutions on the basis of the physical properties including LST. In conclusion, using the LST standard for thickness will contribute to practical and useful standardization of diets for dysphagia, though it should be noted that some foods are not suitable for LST, which has some limitations on applicability.
The purpose of this study was to investigate the usability of tongue pressure measurement made by JMS Co., Ltd. as a method of quantitative evaluation of tongue motor function in oral functional evaluation, using a newly developed tongue pressure measurement device approved as the first medical device for tongue pressure measurement in Japan.
The subjects were divided into a “disorder group” and a “control group”. The former group consisted of 115 patients having dysphagia or dysarthria resulting from cerebrovascular or neuromuscular disease, and the latter group consisted of 29 people without such disorders.
The underlying disease, presence of dysphagia or dysarthria, repetitive saliva swallowing test, and so on were evaluated along with tongue pressure. The tongue pressure measurement was performed by compressing the balloon against the palate for 5 to 7 seconds with maximum voluntary effort, and repeating three times. The mean value of the three measurements was defined as the “tongue pressure value” for each subject.
To evaluate the usability of tongue pressure measurement, the reproducibility of the tongue pressure value and the correlations between tongue pressure value and other functional evaluation items was analyzed statistically.
The reproducibility of the tongue pressure value evaluated from the standard deviation of the tongue pressure values in each subject was comparable with the results of previous studies. In the correlations between the tongue pressure values and the conventional functional items, we obtained the following findings. The tongue pressure value of the disorder group was lower than that of the control group. The tongue pressure value of the patients with low swallowing ability was lower than that of the patients having no swallowing problem. The tongue pressure value of patients with dysphagia in the mastication phase and in the oral phase was lower than that of the control group. The tongue pressure value of the patients who were suspected of dysphagia from the repetitive saliva swallowing test was lower than that of normal people.
It was confirmed that the reproducibility of the tongue pressure values using the new device was accurate and useful without any clinical problem. The correlations between the tongue pressure value and other functional evaluation items were estimated by objective statistical analyses.
It is suggested that the tongue pressure value could be a useful quantitative indicator in the usual qualitative functional evaluation. Furthermore, this device (JMS TPM-01) is a useful measuring tool in the oral functional evaluation.
We conducted a questionnaire targeting 338 children who utilized the Regional Care and Guidance Center and were diagnosed as autistic spectrum disorder (ASD) and their parents to survey the actual conditions of unbalanced diets and to study the factors affecting those diets.
The number of foodstuffs never taken was strongly correlated with the development level rather than age. Types of foodstuffs not taken were not significantly different between ages and development levels. Many of them were foodstuffs that are difficult to eat such as “squid and octopus” and vegetables. Accordingly, it was considered necessary to investigate the relationship with eating function.
The number of foodstuffs not taken and sensory bias were strongly correlated with “tactile sense” and “visual sense”. These overlapped with “eating texture” and “visual appearance” cited by parents as reasons for not eating. Processing of foodstuffs improves “tactile sense” and “visual sense” and is considered to be an effective approach. Furthermore, it was suggested that, in addition to eating situations, it is necessary to improve the development level and to reduce sensory bias throughout everyday life.
[Purpose] The purpose of this study was to develop a new paste food suitable for the dysphagia characteristics of dysphagic patients with severe motor and intellectual disabilities.
[Subjects] Of the dysphagic patients with severe motor and intellectual disabilities who came to our hospital as an outpatient with a chief complaint of dysphagia, a total of 20 who were confirmed as having clinical aspiration symptoms while eating conventional paste food were enrolled in the study.
1. The findings of a total of 14 patients who were confirmed as showing aspiration of solid examination diet (jelly, gel, conventional paste) by videofluoroscopic swallow study were examined to analyze the dysphagia.
2. A new paste food, “Fluffy paste food”, the physical properties of which were designed to compensate for the shortcomings of each examination diet confirmed with aspiration by videofluoroscopic swallow study, was developed.
3. A clinical assessment of eating scenes was conducted by continuously using the cervical auscultation method and monitoring the percutaneous arterial blood oxygen saturation (SpO2).
4. The physical properties of each examination diet, traditional paste food, and the new paste food were measured.
5. A hearing survey on the clinical condition and outcome at one year later was conducted for the 20 patients.
1. The following findings were observed as a result of analyzing the aspiration patterns of solid examination diet. The whole or a portion of a separated bolus of food ran into the trachea. A portion of the bolus of food was broken into pieces during swallowing and ran into the trachea. The bolus of food remaining at the pharynx got mixed with saliva and induced aspiration.
2. The new paste food, the physical properties of which were designed to compensate for the shortcomings of each examination diet confirmed with aspiration by videofluoroscopic swallow study, was developed with two kinds of thickeners and water mixed into the foodstuff.
3. A clinical assessment using the cervical auscultation method and SpO2 monitoring revealed that aspiration symptoms while eating the new paste food were reduced in all cases and thus the food was judged to be safer than the previous paste food.
4. As a result of physical property measurements, the new paste food showed a hardness of 3,500-8,500
N/m2, stickiness of 500-1,500 J/m3, cohesiveness of 0.55-0.6, and higher hardness and stickiness than
the previous paste food.
5. The outcome at one year later proved to be effective in terms of either fever frequency or absorption frequency based on the fact that 16 patients were able to continue oral eating.
[Conclusion] A new paste food, “Fluffy paste food”, which was developed by analyzing the findings of a videofluoroscopic swallow study of patients with severe motor and intellectual disabilities, was found by clinical evaluation to be safer for dysphagic patients with severe motor and intellectual disabilities.
[Purpose] To investigate the relationship between the questionnaire for screening dysphagia and 30 ml water swallowing test.
[Subjects] In total, 310 outpatients of the rehabilitation department, consisting of 197 males and 113 females with age ranging from 25-93 (mean age of 66), were studied. Major disorders included cerebral vascular accidents, head injury, and neurogenic and muscular disorders.
[Method] The questionnaire contained 15 items reflecting factors such as history of pneumonia, nutritional state, oral, pharyngeal and esophageal functions and airway protective function, with three levels of severity as possible answers to be chosen. All subjects were assessed with the questionnaire as well as the water swallowing test (drinking 30 ml of water from a cup; Kubota, 1982). After univariate analysis on the relationship between the response of each item on the questionnaire and the profile of the water swallowing test with the chi square test, logistic regression analysis (stepwise: forward selection method) was performed. In the analyses, “responding A to any item” was considered abnormal on the questionnaire, and on the water swallowing test profiles 1 and 2 were considered normal and 3-5 were considered abnormal.
[Results] The chi square test revealed a significant relationship between the items reflecting pharyngeal function and airway protective function on the questionnaire and the water swallowing test. No relationship was indicated on the items reflecting oral and esophageal functions. Logistic regression analysis revealed that the following three items, “Do you cough when you drink tea?,” “Have you lost weight?,” “Does your throat sound gurgly during or after meals?,” were significant factors, and that the odds ratio of each was 11.96, 10.75, 3.80, respectively.
[Discussion] The questionnaire contains an item that is highly correlated to the results of the water swallowing test, which checks if “patient coughs when drinking liquid.” Thus, the questionnaire items are considered to be valid to some extent. If the questionnaire is used effectively, it is possible to screen dysphagia as well as the 30 ml water swallowing test with a low risk of aspiration.
To care patients with dysphagia, which causes aspiration pneumonia, a department of dysphagia rehabilitation of dental clinic was established 3 years ago in a local hospital. For patients of cerebrovascular accident (CVA) with dysphagia, early intervention and long-term observation in the disorder are important, as well as preventing from complications such as dehydration, malnutrition, and deterioration of dysphagia. On the other hand, some patients experience aspiration after leaving hospital, and there are many patients whose nutrition does not match their present swallowing function, and they are overestimated or underestimated. We assess the swallowing function of patients upon hospitalization using an interdisciplinary team approach and train, yet many patients need continuous follow-up after discharged from hospital. We examined those patients whom we could continuously follow up, and found that many of them improved the way of nutrition intake, and some stopped using PEG after discharged from hospital. In particular, no one showed deterioration of dysphagia. The better the patients could improve their ADL level, the better they could improve the way of nutrition intake after discharge from hospital. Therefore, continuous follow-up after discharge from hospital is thought to be important. It is also important to build a community system to follow up patients who leave or change hospital frequently.