Stroke is a major etiological factor in dysphagia. The purpose of this study was to investigate the factors affecting difficulty of oral intake in patients with acute cerebrovascular disorder.
Two hundred and fourteen stroke patients with stroke-related dysphagia who entered an emergency hospital between March 2009 and March 2010 were recruited. Multivariate analyses were performed to identify variables significantly associated with the possibility of oral intake.
The mean age of the patients was 76.8 (SD 12.7) years old. A total of 158 patients suffered from ischemic stroke while 56 suffered from hemorrhagic stroke. At the point of discharge from the hospital, 107 patients (50.0%) resumed a regular diet. Logistic regression analysis identified four factors that significantly predicted the resumption of oral intake: a lesion limited to the right hemisphere; a score＞0 on the Barthel Index; normal swallowing sound in cervical auscultation; a profile score of 4 or above in the food test. The sensitivity and specificity of the type for forecasting oral intake were 89.7% and 78.5%, respectively. The probability of successful oral intake was 99.7% when all five factors were excellent values, but was 9.6% when all five factors were poor values.
These findings may be used to predict which patients with stroke-related dysphagia can remove the feeding tube and achieve oral intake before being discharged from an emergency hospital.
Purpose: The purpose of this study was to create adaptational criteria for palatal lift prosthesis (PLP) and to examine the effects of PLP as a device for dysphagic patients.
Methods: A group in whom PLP was attached in addition to function training (PLP group, N＝57) was compared with the group which underwent function training (non-PLP group, N＝49). Analysis of the PLP group was performed based on the initial evaluation (articulation test, examination of velopharyngeal function, maximum phonation time (MPT), food test (FT), modified water swallowing test (MWST), videofluoroscopy (VF), video-endoscopy (VE), nutrition state, and subjective health investigation) after making the PLP. Both groups were examined every 3 months (about 3, 6, 12 months and more than 12 months) after the initial evaluation.
Results: We needed to define the clinical state of subjects rather than their disease itself because almost all subjects had cerebrovascular disease. Especially, more than 80% of subjects suffered from inability to elevate their tongue and soft palate, rhinolalia aperta, articulatory disorder, dysfunction of oral stage and pharyngeal stage.
In the PLP group, the subjects who were suspected of aspiration on FT and MWST when the initial evaluation was showed decreased aspiration after using the PLP. In addition, improvement of velopharyngeal function and nasal regurgitation was observed in VF. Our finding suggested that the PLP caused a build-up of pressure in the oral cavity during swallowing, and helped to reduce residues of materials in the oral cavity and pharynx. Moreover, there was no difference in the state of mastication for rice and soft solids in VE. Therefore, this finding suggested that the PLP helped to improve the swallowing function although it had an insignificant effect on the mastication. Regarding the period of service of the PLP, it was more effective to use the PLP for more than 6 months.
Conclusion: To identify adaptation to using the PLP, it is important to perceive not only the disease of patients but also the clinical state. Our findings suggest that the PLP is effective for inability to elevate the tongue and soft palate, rhinolalia aperta, articulatory disorder, dysfunction of oral stage and pharyngeal stage. In addition, regarding the period of service of the PLP, it was more effective to use the PLP for more than 6 months.
Purpose: During the oral preparatory stage, semi-solid foods are usually mashed by the tongue against the hard palate. However, some normal subjects chew semi-solid foods as well as solid foods. This study examined whether the palatal height influences the pattern of chewing semi-solid foods.
Materials and Methods: Fifty young females participated in the study. ① Their maxillary impressions were used to measure from the occlusal plane to the palatal base at 5-millimeter intervals. ② Maximum tongue pressure was measured three times for each subject and the mean value was used for analysis. ③ Their food processing method was classified into chewing or mashing pattern through observation and interview without giving instructions when swallowing 5 grams of jelly. ④ An imitation palatal augmentation prosthesis (PAP) using soft wax was applied to 9 subjects who were classified as chewing pattern, and the alterations in food processing method and tongue pressure were tested. ⑤ A videofluoroscopic study was done on 3 subjects to observe the swallowing pattern with and without the imitation PAP.
Results: A value of more than 20 mm obtained from statistical analysis between chewing and compressed pattern was defined as high arch. Among the subjects with high arch, chewing pattern was significant and the tongue pressure was significantly low. When applying the imitation PAP to the 9 subjects with high arch, the chewing pattern changed to the compressed pattern and the tongue pressure increased by 5 kPa on average. The position of the bolus head at the time of triggering of pharyngeal swallowing was 100% below the vallecular for the chewing pattern, however the position changed to the oral/upper pharyngeal area by 87.5% of the time, and the vallecular aggregation time was shortened for the compressed pattern.
Discussion: It was suggested that the subjects with high arch might chew semi-solid food because they could easily triturate and automatically propel food into the pharynx using Stage II Transport. It is hypothesized that a client with dysphagia may be able to chew semi-solid food if he/she has a high arched palate. It is proposed that observation of palatal height and chewing pattern should be added to dysphagia screening. Application of PAP might be effective for some dysphagia clients with a high arched palate.
Purpose: It has been reported that larger bolus volumes tend to increase the risk of aspiration. The hyoid bone moves during swallowing due to contraction of the suprahyoid muscles, which are critical components of normal swallowing function. Hyoid movement is important for epiglottic closure for airway protection and opening of the upper esophageal sphincter. It has been reported that the muscle force and shortening velocity decline gradually with age. Reduced hyoid velocity may delay the sealing of the laryngeal vestibule and opening of the cricopharyngeal muscle. We hypothesized that the displacement and velocity of hyoid movement could be factors influencing aspiration during swallowing. This study evaluated the effects of bolus volume changes on the displacement and velocity of hyoid movement in normal swallowing.
Method(s): The subjects were 21 healthy young adults. Lateral projection videofluorography was recorded twice while each subject swallowed 2.5 ml, 5 ml, 10 ml and 20 ml of thin liquid barium in one gulp. The movements were measured in two directions, vertical and horizontal. The horizontal axis was defined by Camper’s plane. We evaluated the maximum displacement (Max d), upward displacement (Max ud), and forward displacement (Max fd) of hyoid movement during swallowing. We also evaluated the maximum velocity (Max v), upward velocity (Max uv), and forward velocity (Max fv) of hyoid movement during swallowing.
Results: The two-way ANOVA test revealed that Max d, Max ud and Max fd for different bolus volumes are not significant different (Max d: 2.5 ml 20.3±3.6, 5 ml 20.3±3.4, 10 ml 20.4±3.8, 20 ml 20.3±3.8 (mm), Max ud: 2.5 ml 16.9±3.8, 5 ml 16.8±4.2, 10 ml 16.4±4.2, 20 ml 16.1±3.9 (mm), Max fd: 2.5 ml 15.5±3.6, 5 ml 15.4±2.8, 10 ml 15.9±3.3, 20 ml 14.6±4.5 (mm)). The two-way ANOVA test showed statistical significance in Max v, Max uv and Max fv among the different bolus volumes (p＜0.01) (Max v: 2.5 ml 49.9±9.3, 5 ml 51.6±9.0, 10 ml 55.0±12.1, 20 ml 63.4±12.8 (mm/s), Max uv: 2.5 ml 28.1±13.6, 5 ml 29.2±14.5, 10 ml 31.8±13.8, 20 ml 38.3±14.0 (mm/s), Max fv: 2.5 ml 44.5±9.5, 5 ml 47.5±9.5, 10 ml 48.7±9.8, 20 ml 53.4±10.9 (mm/s)). Tukey’s test showed significant differences in Max v between 2.5 and 20 ml, 5.0 and 20 ml, 10 and 20 ml, and 2.5 and 10 ml swallowing. Tukey’s test also showed significant differences in Max uv and fv between 2.5 and 20 ml, 5.0 and 20 ml, 10 and 20 ml swallowing.
Conclusion: It is possible that a larger bolus volume requires greater maximum velocity of the hyoid movement. We plan to study the maximum velocity of hyoid movement in elderly subjects and in those with dysphagia.
Lethal factors of food suffocation were analyzed by comparing 62 (57.9%) patients who died with 45 (42.1%) cases who survived. The results found no significant correlation between lethal rate and patients’ background including age, sex, medical history, functional impairments, smoking or drinking habits, food texture, or independence during eating. Therefore, it is difficult to predict accidents of food suffocation based on these factors. The most important point is to notice the accident, administer emergency first aid and prevent suffocation. For prevention, database management by accumulating cases is necessary to analyze the risks from various viewpoints of patients, food, and circumstances.
Objective: The aim of this study was to investigate the risk factors for aspiration pneumonia among patients with schizophrenia suffering from dysphagia.
Patients: This study included 232 patients with schizophrenia who were referred to the Department of Dentistry and Oral Surgery of our hospital because of swallowing impairment, and the risk factors for aspiration pneumonia were retrospectively investigated. The numbers of males and females were 126 and 106, respectively, and the mean age of cases was 70.1 years (standard deviation: 11.8 years). Doses of neuroleptics were converted to milligram equivalents of chlorpromazine (CP equivalent dose), and the mean CP equivalent dose at the time of assessment of swallowing ability was 458 mg/day (standard deviation: 633 mg). The activity of daily living (ADL) was evaluated by the assessment of independence level in daily living established by the Ministry of Health, Labour and Welfare of Japan.
Results: Eighty (34.5%) cases developed aspiration pneumonia and the other 152 (65.5%) cases did not develop aspiration pneumonia within 3 months before the first visit to the Department of Dentistry and Oral Surgery. Functional Oral Intake Scale (FOIS) (p＝1.6×10－12), serum albumin (p＝9.0×10－6) and ADL (p＝5.7×10－7) were significantly lower in patients with aspiration pneumonia than in those without aspiration pneumonia. However, there were no significant differences in age (p＝0.111) and body mass index (BMI) (p＝0.509) between cases with and without the occurrence of aspiration pneumonia. In addition, there were no significant differences in the rates of males and females (p＝0.069) as well as in the rate of patients developing orofacial dyskinesia (p＝0.679) between cases with and without the occurrence of aspiration pneumonia. CP equivalent dose at the time of assessment of swallowing ability was significantly lower (p＝0.001) in patients with aspiration pneumonia than in those without aspiration pneumonia.
Conclusion: Impaired swallowing function as well as lowered ADL and ALB levels were strongly correlated to the occurrence of aspiration pneumonia.
Elderly patients often require continuous medication with a number of drugs to treat basal diseases, and there is the potential for these drugs to affect swallowing function. In order to preserve swallowing function and prevent diseases such as aspiration pneumonia, we must support drug choices for which the effects upon swallowing function is considered. We conducted a retrospective study on the status of administration of drugs that affect swallowing function and the influences of these effects in the acute stroke patients with dysphagia that were undergoing swallowing rehabilitation at Kochi University Hospital. We found that out of 55 such patients, 37 (67.3%) were taking drugs that affected swallowing function. The breakdown by drug type was 14 patients (25.5%) taking drugs that improved swallowing function, 16 (29.1%) taking drugs that reduced swallowing function, and 7 patients (12.7%) taking both kinds of drugs. We also confirmed that there are cases in which drug selection needs to take into account the effects of the regimen on swallowing function, such as when the existing regimen has a 1:4.6 ratio of ACE inhibitors to ARB, where drugs that reduce the risk of aspiration pneumonia will be outweighed by those that lack such action. Since many patients have also been found to develop dysphagia because of a lowered consciousness level, it is necessary to consider drug selection and dose levels for antipsychotics and anticholinergic drugs. We investigated the effect of drugs that influence swallowing function in patients. We found that the patients in the group who took drugs that improved swallowing function were able to maintain a higher degree of swallowing function at the start of swallowing rehabilitation, compared to other groups. The group of patients taking drugs that reduced swallowing function ended the swallowing rehabilitation program with a lower level of swallowing function than others. Based on the above results, we think that pharmacists should proactively involve themselves in drug selection and methods of use tailored to the specific pathological condition of each individual patient with dysphagia, with the goal of improving patient QOL.
Introduction: Creutzfeldt-Jakob disease (CJD) is a prion disease in which the function of brain neurons is impaired by the accumulation of abnormal prion proteins in the brain, causing spongiform degeneration. We herein report a patient with sporadic CJD for whom we provided oral care until death.
Case: A man in his 50s developed movement disorder and cognitive impairment in the summer of 2009 that gradually impaired his ability to work. He was admitted to the Department of Neurology at our hospital for a detailed examination in January 2010. A definitive diagnosis of sporadic CJD was reached based on the results of a prion protein gene analysis. Ten days after admission, the patient’s ataxia rapidly worsened, it became difficult for him to communicate, and he became bedridden. Oral ingestion was difficult, and enteral nutrition was initiated.
Course: Our department received a request for oral care in February 2010. Patient symptoms included trismus, bleeding of the lips, oral malodor, oral dryness, a large amount of sputum, and adhesion of phlegm. Although it was difficult to provide oral care due to the trismus, we provided conventional care using tools such as a mouth gag, tongue cleaner, sponge brush, end-tufted brush, and moisturizer. Oral care resulted in healing of the bleeding of the lips and improvement of oral malodor and dryness. In addition, the number of days with fever decreased, albeit temporarily. During provision of oral care, disposable caps, face guards, gloves, and protective gear were worn, and these items were disposed of after completion of care.
Discussion: Patients with CJD experience a period of ataxia and aphagia before succumbing to the disease, and onset of trismus and pneumonia is considered unavoidable in these patients. Oral care is therefore essential, and its provision may improve the oral condition and contribute, to some extent, to the prevention of pneumonia. Because prion proteins remain infectious even with regular disinfection and sterilization methods, it is necessary to avoid sustaining injuries as well as droplet infection during oral care for CJD patients. It is also desirable to use disposable items when possible, and to dispose of them after use.
Congenital choanal atresia (CCA) is a rare congenital disease, and there are still fewer cases of bilaterality. For such cases, there are no detailed reports on the progress of suckling and sucking training or swallowing training focusing on bottle-feeding disorder which occurs immediately after birth. In this paper, we report the progress for about 1 year from beginning of sucking training in the Neonatal Intensive Care Unit (NICU) to the oral feeding stage.
The patient was a 3-month-old girl with bilateral complete CCA (atresia by bones), stricture palpebral fissure (left eye), anophthalmos, and left incomplete cleft lip. For the first 3 months, her SpO2 often dropped to about 30–80% irregularly. Head CT revealed a bone defect of the frontal cranial bone and the connection of intracranial and intranasal regions.
When she was 3 months old, she was in danger of choking caused by temporary apnea while sucking, lowering of SpO2, aspiration caused by subordination between sucking, swallowing and respiration, and lack of experience caused by no formal training of oral bottle-feeding. Since developing the ability to perform oral respiration she has been better and could drink milk from a feeding bottle at age 6 months old, and could take baby food once a day at age 7 months. Finally, when she was 1 year and 1 month old, she could have three meals a day the same as children with normal development.
Because newborn infants live by only nasal respiration for a few weeks and it takes a few weeks to learn how to perform oral respiration, it is fatal if they cannot perform nasal respiration. So, when faced with a case which has a risk of dying by dyspnea or cyanosis by nature such as reported here, it is important to carry out suckling and sucking training or swallowing training carefully with continuous assessment of coordination between sucking, swallowing, and respiration, danger of choking, and SpO2 value. In addition, this case reveals that in cases of bottle-feeding disorder or dysphagia requiring intervention in the NICU, a team approach with close cooperation among many specialists is very important, because there are many points and trends to be checked