Purpose: The purpose of this study was to evaluate the coordination between swallowing and respiration during noninvasive positive pressure ventilation (NPPV), and clarify the safe swallowing volume and method.
Methods: The subjects consisted of 28 nurses (11 males and 17 females) aged 36.0±5 years (mean). The independent variables were the swallowing volume (5 or 10 mL), NPPV (during or without), and the swallowing method (voluntary or according to instructions), and their combinations were analyzed. For swallowing according to instructions, the subjects were instructed to swallow after inspiration. The dependent variables were the incidences of respiration patterns during swallowing, respiratory cessation during preparation before and after swallowing, and inspiration after swallowing apnea, as well as respiratory cycle duration before swallowing, swallowing apnea duration, respiratory cycle duration related to swallowing during NPPV, and the presence of forced ventilation.
During swallowing, respiration data were obtained using a Piezo Respiratory Belt Transducer® with simultaneous surface electromyography of the suprahyoid muscles. For NPPV, Trilogy 100® and oronasal masks were used. The subjects were placed in the supine position with a 30°head-up tilt on the bed. Water was injected into the oral floor using an 8-Fr feeding catheter, and the subjects were asked to swallow it.
Water (5 and 10 mL) was swallowed three times under each of the following conditions: voluntary swallowing without NPPV, voluntary swallowing during NPPV, and swallowing according to instructions during NPPV (total number of swallows: 18 times).
Results: 1. In voluntary swallowing during NPPV compared with that without NPPV, the incidence of the inspiration-apnea-expiration (iae) pattern increased, and the respiration cycle duration before swallowing was significantly prolonged irrespective of the water volume.
2. In swallowing according to instructions during NPPV compared with voluntary swallowing during NPPV, the incidence of the iae pattern increased irrespective of the water volume. In addition, inspiration after swallowing as a respiration pattern was not observed. However, the incidence of respiratory cessation during preparation before swallowing was high.
3. In swallowing according to instructions during NPPV compared with voluntary swallowing without NPPV, the respiratory cycle duration before swallowing and that related to swallowing during NPPV were significantly prolonged.
Discussion: In voluntary swallowing during NPPV, the incidence of the iae pattern was high irrespective of the water volume. It may be important for safer swallowing to instruct patients to swallow just at the end of inspiration and then expire immediately during NPPV.
Objective: In this study, we devised and created tablets coated with a gel agent to facilitate their movement through the pharynx. Gel formulations have been marketed for this purpose; however, no studies have examined the ease of swallowing of these formulations in humans. Therefore, we used non-gel and gel formulations that lacked medicinal ingredients and compared the preference for swallowing by a sensory evaluation.
Methods: A total of 100 subjects (28 males and 72 females, average age 29.0±9.7 years old) were selected; the subjects were healthy adults with normal swallowing functions. Four types of samples were tested: non-gel-based deformed tablets and mini tablets (hereafter, mini tabs) and gel-based deformed tablets and mini tabs. Tablets were randomly assigned to subjects and evaluated for preference for swallowing as: easy, simple, hard, and unable to swallow. The subjects also made a direct comparison between non-gel and gel formulations for each dosage form.
Results: When the ease of swallowing of non-gel and gel formulations was compared for each dosage form using the Wilcoxon signed-rank test in three stages of “easy, simple, hard, or unable to swallow,” we found that both dosage forms of gel formulations were easier to swallow than the non-gel formulations (p＜0.05). The magnitude of the effect of the gel coating was moderate (r＝0.45) in deformed tablets and high (r＝ 0.60) in mini tabs. When directly compared using the χ2 goodness of fit test, “gel formulations are easy to swallow” in both dosage forms was significantly higher than the sum of “non-gel formulations are easy to swallow” and “no difference” (p＜0.05).
Conclusion: In healthy adults, both dosage forms of gel formulations were easier to swallow than nongel formulations. With the gel formulation, the tablets are in a state similar to being wrapped in jelly, which is believed to be the reason why they facilitate movement through the pharynx.
Purpose: The Seirei dysphagia screening questionnaire has 15 questions and three choices of: severe symptoms (A), mild symptoms (B), and no symptoms (C). The conventional assessment method of “a response of at least one severe symptom A suggests the presence of dysphagia” has high sensitivity and specificity. In this study, a new method for scoring and evaluating the answer choices was devised and compared with the conventional evaluation methods. In addition, this method was applied to healthy subjects to obtain basic data for the development of a screening tool for the condition of impaired swallowing function.
Methods: We used survey data from 50 patients with cerebrovascular disease who had dysphagia but were able to swallow orally, 145 patients with cerebrovascular disease who did not have dysphagia, and 170 healthy subjects. All those data were obtained during the development of the Seirei dysphagia screening questionnaire. The sensitivity and specificity of the cutoff values were calculated for each of the alternatives, A: 2 points, B: 1 point, C: 0 point, and A: 4 points, B: 1 point, C: 0 point. In addition, the data from 170 healthy subjects were analyzed for the total scores for each age group.
Results: The results of ROC analysis showed that the evaluation method with a score of A: 4 points and a cutoff value of 8 points was the most suitable. The sensitivity and specificity of this method were 90.0% and 89.8%, respectively, which were comparable to the sensitivity and specificity of the conventional method of 92.0% and 90.1%, respectively. A clear difference in scores was found between those under 75 years and those over 75 years when comparing the age groups in healthy subjects.
Conclusions: The sensitivity and specificity of the Seirei dysphagia screening questionnaire by scoring were almost the same as those of the conventional assessment method in which the presence of dysphagia was suspected if at least one answer in A was given. In the general elderly population, scores were found to be significantly higher after 75 years of age, providing basic data for the development of screening tools to assess impaired swallowing function.
Purpose: Few studies about the medium- to long-term survival of patients with aspiration pneumonia have been reported. The purpose of this study was to clarify the medium- to long-term survival of patients with aspiration pneumonia and the prognostic factors influencing survival.
Methods: This was an observational retrospective cohort study. Aspiration pneumonia inpatients who consulted the Department of Otorhinolaryngology for an evaluation of swallowing from April 2018 to March 2019 were surveyed. Inclusion criteria were that the chief cause of hospitalization was aspiration pneumonia and not secondary to acute cerebrovascular disease. Cases who died in the acute phase of pneumonia before swallowing evaluation were also excluded. We analyzed the factors related to the prognosis of aspiration pneumonia by multivariate analysis and calculated the hazard ratio (HR). Those were age (three groups: 74 years old or under, 75–89 years old, 90 years old or over), gender, dysphagia severity scale (two group: within normal limits to occasional aspiration, water aspiration to saliva aspiration), activities of daily living (two groups: non bedridden, bedridden), body mass index (three groups: BMI over 18.5, 18.5–16, under 16), induction of alternative nutrition and pre- and co-existing disease (past history of pneumonia, past history of cerebrovascular disease, Parkinson’s disease, dementia, hypertension, diabetes mellitus). Survival, days alive, and induction of alternative nutrition were investigated by telephone from January to April 2020.
Results: 109 patients with aspiration pneumonia (median age: 86 years old) were analyzed. Only five cases were 64 years old or under, 104 were geriatric patients over 65 years old. 67 cases died during the studied period and 42 remained alive. The median period of remaining alive was 254 days, the survival rate of 6th months was 54.8% and that of 1 year was 41.8%. The HR of prognostic factors were age: 1.76, male: 1.78, swallow under water aspiration: 2.01, bedridden: 2.39, low BMI: 1.60 and induction of alternative nutrition: 0.27. Only Parkinson’s disease mitigated the prognosis of aspiration pneumonia (HR 5.00) among pre- and co-existing diseases.
Conclusion: More than half of the aspiration pneumonia patients died within 1 year. Elderly, male, swallow under water aspiration, bedridden and low BMI were risk factors of survival. Induction of alternative nutrition had a good influence on the prognosis. Parkinson’s disease mitigated the prognosis.
Purpose: This study aimed to determine the tongue and palate contact time and areas during cup and straw drinking using electropalatography (EPG). The impact of viscosity on tongue and palate contact during cup and straw drinking was also investigated.
Methods: Six healthy adults participated in this study. All participants were tested by an EPG that was created with 124 touch sensors. Any contact while swallowing liquids was measured by each of the sensors on the palate floor. Single swallows of cup drinking and straw drinking were investigated. The participants were asked to drink 10 mL of liquid at once. All participants were able to swallow 1) thin liquid using a straw (straw condition), 2) thickened liquid using a straw (thickened condition), and 3) thin liquid using a cup (cup condition). The minimum contact point (MCP) and the uncontacted time (UT) were calculated.
Results: There were a significant number of MCPs and significantly shorter UT in a single swallow from a drinking straw.
Conclusions: The findings of this study suggest that when a small amount of liquid was ingested, the mouth easily opened for the drinking cup. As the drinking straw maximized tongue and palate contact while opening the mouth, the straw was different from a cup in terms of tongue-palate contact when drinking water. The movement of the oral cavity while drinking water varied according to the crockery or utensil used, so it is important to choose one while taking these characteristics into consideration.
Introduction: Swallowing training was performed for a case of hereditary fibrosing poikiloderma with tendon contractures, myopathy, and pulmonary fibrosis (POIKTMP). The course of dysphagia is reported.
Case: A 47-year-old man. At X－4 years, he presented with a variety of symptoms, including polymorphic skin atrophy on the face, muscle weakness in the proximal limbs, and dysphagia. He was diagnosed as POIKTMP by mutation of the FAM111B gene.
Course: At X years, the delay time of laryngeal elevation was prolonged, and the onset of swallowing reflex was significantly delayed compared to X－3 years. Laryngeal elevation failure worsened due to narrowing of the movement of the hyoid bone too.
Discussion: In this case, the disorder at the pharyngeal stage was stronger than that at the oral stage. It is suggested that nutritional status should be taken into consideration when performing swallowing training, and it is important to monitor nutritional status from an early stage. Conventionally, patients without neck muscle weakness have no dysphagia, while those with neck muscle weakness have dysphagia. In this case, the muscle strength of the limbs and neck was weakened, and dysphagia appeared too. The occurrence of dysphagia was most likely related to neck muscle weakness, suggesting the importance of focusing on neck muscle strength.
Patients who undergo wide removal of palatal tumor sometimes show dysphagia and speech disorder due to velopharyngeal incompetence, decreasing their quality of life. We report two cases of dysphagia and speech disorder resulting from palate resection, improved by a palatal and velopharyngeal obturator designed using a light-cure type rebase material.
One case was a 65-year-old male who underwent wide removal of a palatal tumor and reconstruction with a forearm flap at another hospital. In the surgery, he had lost a large part of the palate and the forearm flap covered only about half of the original palate. The oral cavity communicated with the nasal cavity on a broad scale. He complained of taking a long time to eat meals and difficulty in speaking.
To create a palate shape and improve the velopharyngeal function, we made a denture with an obturator using a light-cure type rebase material. The denture enabled him to chew foods, make a bolus of food, and transport the bolus to the pharynx naturally.
With this denture, his mealtimes were shortened and difficulty in speaking was improved, as confirmed by a speech clarity test from 30% (without the denture) to 67% (with the denture).
The other case was a 67-year-old female who underwent removal of the right side of the tongue, fauces and palatal tumor. After the surgery, a nasopalatal fistula and scar contracture was seen in the soft palate and she complained of regurgitation of foods to the nasal cavity and indistinct speech.
We made a denture with an obturator to obturate the defect of the palate, create the palatal shape and improve the velopharyngeal function. The obturator was made of a light-cure type rebase material to fill the space that the velum after surgery and pharyngeal constrictor were unable to close for velopharyngeal closure. The denture improved the shape of the palate and velopharyngeal closure. With the denture, no regurgitation was confirmed by videofluorography and improvement of indistinct speech was confirmed by a speech clarity test from 47% (without the denture) to 91% (with the denture).