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Abstract

The incidence and the prevalence of aspiration pneumonia (AP) in the community is poorly defined. It increases in direct relation with age and underlying diseases. The pathogenesis of AP presumes the contribution of risk factors that alter swallowing funtion and predispose the orofaringe and gastric region to bacterial colonization. The microbial etiology of AP involves Staphylococcus aureus, Haemophilus influenzae and Streptococcus pneumoniae for community-acquired aspiration pneumonia and Gram-negative aerobic bacilli in nosocomial pneumonia. It is worth bearing in mind the relative unimportance of anaerobic bacterias in AP. When we choose the empirical antibiotic treatmentant we have to consider some pathogens identified in orofaríngea flora. Empirical treatment with antianaerobics should only be used in certain patients. Videofluoroscopic swallowing studies should be used to determine the nature and extent of any swallow disorder and to rule out silent aspiration. Assesment of swallowing disorders is cost-efective and results in a significant reduction in overall morbidity and mortality.

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... Most of these respiratory infections are not related to OD. AP occurs when there is radiological evidence of pulmonary condensation caused by the entry of oropharyngeal secretions contaminated by pathogenic bacteria into the bronchial tree in patients with swallow dysfunction [67]. It has been estimated that up to 50% of older patients with OD will present an oropharyngeal aspiration, and from those, 50% will develop an AP with an associated mortality of up to 50% [68]. The EAT-10 developed and validated by Belafsky et al. suggests that with this screening tool for OD, a score equal to or higher than 3 points can be considered a positive result [13]. ...
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Oropharyngeal dysphagia (OD) is underdiagnosed and current screening is costly. We aimed: (a) to develop an expert system (ES) based on machine learning that calculates the risk of OD from the electronic health records (EHR) of all hospitalized older patients during admission, and (b) to implement the ES in a general hospital. In an observational, retrospective study, EHR and swallowing assessment using the volume-viscosity swallow test for OD were captured over 24 months in patients > 70 yr admitted to Mataró Hospital. We studied the predictive power for OD of 25,000 variables. ES was obtained using feature selection, the final prediction model was built with non-linear methods (Random Forest). The database included 2809 older patients (mean age 82.47 ± 9.33 yr), severely dependent (Barthel Index 47.68 ± 31.90), with multiple readmissions (4.06 ± 7.52); 75.76% had OD. The psychometrics of the ES built with a non-linear model were: Area under the ROC Curve of 0.840; sensitivity 0.940; specificity, 0.416; Positive Predictive Value 0.834; Negative Predictive Value 0.690; positive likelihood ratio (LH), 1.61 and negative LH, 0.146. The ES screens in 6 s all patients admitted to a 419-bed hospital, identifies patients at greater risk of OD, and shows the risk for OD in the clinician’s workstation. It is currently in use at our institution. Our ES provides accurate, systematic and universal screening for OD in real time during hospital admission of older patients, allowing the most appropriate diagnostic and therapeutic strategies to be selected for each patient.
... Dysphagia impairs swallowing safety and efficiency, causing pneumonia and damaging the nutritional and water needs of the elderly, respectively (26) . Thus, understanding the frequency of oropharyngeal dysphagia frequency in older adults living in nursing homes allows to knowing the impact of this condition in the health of the elderly, enabling the management of the feeding and swallowing problems of this population in order to determine individual and collective interventions, both by speech therapy and interdisciplinary, aimed to the well-being of each older adult and to the reduction of health costs (27) . ...
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Purpose: To synthesize the scientific knowledge on the frequency of oropharyngeal dysphagia in older adults living in nursing homes. Research strategies: The study question followed the PECO strategy and the search was performed in the Pubmed/Medline, Web of Science, Scopus, LILACS and SciELO databases, using keywords and specific free terms. Selection criteria: articles with no time or language restrictions that reported the frequency of oropharyngeal dysphagia in older adults living in nursing homes and the diagnostic criteria. Data analysis: it was analyzed the population characteristics, the concept of "oropharyngeal dysphagia", the methods for identifying the outcome and the frequency of oropharyngeal dysphagia. The evaluation of the methodological quality of the articles followed the criteria of Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Results: Fifteen articles were included. There was great variability in relation to the sample size, with a predominance of longevous old women. The concept of dysphagia, when mentioned, was heterogeneous. Diagnostic criteria were diverse and mostly comprised of questionnaires or clinical trials results. No studies used instrumental tests. The frequency of oropharyngeal dysphagia in the studied population ranged from 5.4% to 83.7%, being higher in studies that used clinical tests, but with greater precision of confidence intervals in studies that used questionnaires and large sample size. Conclusion: The frequency of oropharyngeal dysphagia in older adults living in nursing homes has wide variability. Methodological discrepancies among studies compromise the reliability of frequency estimates and highlight the need for research with better defined and standardized methodological criteria.
... Up to 50 % of neurological patients and the elderly have alterations in swallowing safety (penetrations and aspirations), with a high proportion of silent aspirations (not accompanied by cough), during videofluoroscopy, and a 50 % risk of developing aspirative pneumonia, which is associated with an increase in mortality for 50 % of these patients. These respiratory infections represent the main cause of mortality in patients with oropharyngeal dysphagia, and have also been associated with an increase in hospital stay and hospital readmissions (11). ...
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Introduction: Introduction: the objective was to assess the utility of the Eating Assessment Tool (EAT-10) in hospitalisation units with patients at high risk of dysphagia. Patients and methods: a cross-sectional study was conducted in the Neurology and Internal Medicine wards; patients with admission < 24 hours and in a terminal stage of disease were excluded. In the first 24-48 hours of admission the presence of dysphagia as assessed with the EAT-10, the risk of malnutrition as assessed with the Malnutrition Universal Screening Tools (MUST), and comorbidities using the Charlson index were screened. Results: a total of 169 patients were recruited (76.0 years, 52 % women); 19.5 % were at risk of malnutrition. The EAT-10 instrument could be administered in 80.6 % of the patients, and was positive in 26.6 % (women 34.1 % vs. men 18.4 %; p = 0.025). When comparing patients with higher comorbidity with those with a lower Charlson index, a lower response rate to EAT-10 was observed (78.4 % vs. 93.9 %; p = 0.038), without differences in screening positivity (28.3 % vs. 19.4 %; p = 0.310). The prevalence of dysphagia risk was higher in the Internal Medicine unit than in the Neurology unit (30.4 % vs. 19.6 %; p = 0.133), as was the percentage of cases in which screening could not be performed (21.1 % vs. 11.1 %; p = 0.011). There were no significant differences in risk of malnutrition, mortality, hospital stay, or readmission according to the EAT-10. Conclusions: The EAT-10 has limited utility in the studied hospitalisation units due to a high rate of unfeasible tests, especially among patients at higher risk of dysphagia.
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Introducción: La disfagia tiene una morbimortalidad importante en pacientes hospitalizados. Objetivos: principal; describir las características de los pacientes con disfagia hospitalizados y, secundarios; cuantificar y analizar la prevalencia de mortalidad y de reingresos. Metodología: Estudio transversal descriptivo de las hospitalizaciones por disfagia durante el año 2015 en un Hospital General Universitario. Resultados: Se evaluaron 431 historias clínicas. La edad de los pacientes fue de 83,21 (DE 11,4) años, el 52,5% fueron mujeres y el 47,2% varones; la estancia media fue de 11,1 (DE 7,99) días. En el 71,2 % de los casos la disfagia fue por afectación de la fase orofaríngea. En el 80,51% de los casos se diagnosticaron complicaciones respiratorias: 48,12% neumonía aspirativa por líquidos, 40,05 % neumonitis química por aspiración y 11,81% neumonía aspirativa por sólidos. La mortalidad general asociada a las complicaciones respiratorias respecto del total de los casos de disfagia fue del 24,49%. El 50,48% de los pacientes con neumonía aspirativa fallecieron. La principal causa de la disfagia fue las enfermedades neurológicas (un 77,25%). La mortalidad fue significativamente mayor en las mujeres - 42,3% frente al 7,8% - (p < 0,01) y esta diferencia se mantuvo tras ajustar el resultado por edad: OR 9,937, IC95%: 5,446; 18,131. El 13,10% de los pacientes reingresaron al menos en una ocasión. Los pacientes de geriatría presentaron un mayor número de reingresos por número de ingresos. Discusión: las enfermedades neurológicas fueron la principal causa de disfagia. La mortalidad fue significativamente mayor en las mujeres.
Article
Introduction: Aspiration pneumonia is a subclass of community-acquired pneumonia that is expected to have an increasing contribution in mortality and morbidity, particularly in the elderly population over the next coming decades. While studies have revealed significant progress in identifying risk factors for aspiration pneumonia, the clinical presentation and diagnosis remains challenging to healthcare providers. Areas Covered: We conducted a broad literature review using the MeSH heading in PubMed/MEDLINE of “aspiration pneumonia” from January 1970 to July 2019. The understanding of the microbiology of aspiration pneumonia has evolved from a possible shift in the causative organisms away from anaerobes to traditional community-acquired pneumonia organisms. The importance of this shift is not yet known, but it has questioned the pathogenic role of anaerobes, appropriate anaerobic testing and the role of these pathogens in the pulmonary microbiome in patients with pneumonia. The identification of risk factors led to strategies to prevent or minimize the risk of aspiration pneumonia with moderate success. Expert Opinion: Our expert opinion is that further research is needed to determine the role of the microbiome with aspiration pneumonia and patient risk factors. There is also a great need to develop clinical tools to help providers diagnose, treat, and prevent aspiration pneumonia.
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Background/objectives: Oropharyngeal dysphagia (OD) is a common problem in elderly population that negatively affects the oral intake and body composition resulting in clinical complications as malnutrition and dehydration. The aim of this study was to design, implement, and evaluate the effect of texture-modified foods and thickened drinks diet, with nectar or pudding viscosity and controlled bolus volume in older adults with OD on body composition and oral intake. Subjects/methods: Randomized clinical trial, simple blind. Patients ≥ 65 years, admitted at a national institute, who had a confirmed diagnosis of OD were included. A texture-modified foods and thickened drinks diet, with nectar or pudding viscosity and controlled bolus volume, was compared to isocaloric standard treatment for 12 weeks. Body composition was evaluated by bioelectrical impedance, muscular functionality was evaluated by handgrip strength, and daily energy and protein intake by 24-h recall and evaluated by Food Processor Nutrition Analysis® software. Results: Twenty participants were included per group, with mean age 76 years. After 12 weeks, the consumption of energy (29 ± 10 to 40 ± 15 kcal/kg, p = 0.009) and protein (1.3 ± 0.6 to 1.8 ± 0.7 g/kg, p = 0.03), as well as phase angle (4.4 ± 1.8 to 5.5 ± 2.5°, p = 0.05), body weight (56 ± 10 to 60 ± 10 kg, p < 0.001), and handgrip strength (18 ± 11 to 21 ± 13 kg, p = 0.004) increased in the intervention group. In control group there were no changes. Conclusions: The dietary intervention improved oral intake, weight, handgrip strength, and phase angle, which can prevent or limit the nutritional complications associated with the OD.
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Dietary adaptations are adaptive compensation strategies that are used to optimize safety and swallowing efficacy on people who have dysphagia. The aim of the article is to propose an instrument to improve the continuum of care in clinical practice in people with swallowing disorders that require dietary adaptations, given that in the literature there is no instrument of these characteristics. In the design, different methodologies are combined, in which the qualitative and quantitative research approaches are mixed in a single mixed research procedure. The procedure of the Delphi Method is performed to search for consensus in the search for validation evidences based on the content of the items. A total of 13 experts through two rounds arrive at a CVI-I equal to 1 in 100% of the questions presented on the content of the Adherence Questionnaire. The originally proposed instrument is modified and improved thanks to the opinions of the experts. The final result is an Adherence Questionnaire to be used in clinical practice with people suffering from dysphagia and who need adaptations in the diet, agreed by a group of experts.
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Oropharyngeal dysphagia (OD) is a condition recognized by the World Health Organization and defined as the difficulty or inability to move a bolus safely and effectively from the oral cavity to the esophagus, and can include aspirations, choking, and residue. OD is pandemic among different phenotypes of older people, affecting between 27% and 91% of the population 70 years or older. Although OD can be diagnosed by well-defined clinical methods and complementary explorations, in the clinical setting OD is seldom systematically screened and treated, and awareness among the medical/geriatric community is scarce. The etiology of OD in this population includes many concomitant risk factors with neurogenic and neurodegenerative processes, muscular weakness, and sarcopenia. The pathophysiology includes mechanical deficits in the swallow response (mainly delayed laryngeal vestibule closure time and weak tongue thrust), reduced pharyngeal sensitivity, and sensory/motor central nervous system impairments. Recently, OD has been recognized as a geriatric syndrome due to its high prevalence and its relationship with many comorbidities and their poor outcomes, including malnutrition, respiratory infections and aspiration pneumonia, functional disability and frailty, institutionalization and increased readmissions, and mortality. There is an evidence-based and effective treatment for OD in the elderly mainly oriented to compensating swallow impairments through adaptation of fluid viscosity and solid food textures to avoid aspiration and choking, and improving nutritional status and oral health to avoid respiratory infections. This has been defined as the minimal effective treatment to be provided to this population. New treatments aiming at recovering the swallowing function are under research with promising results, and the near future will provide us with methods to stimulate the swallow response with pharmacological or physical stimuli.
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Introduction Parkinson's disease is a type of chronic neurodegenerative pathology with a typical movement pattern, as well as different, less studied symptoms such as dysphagia. Disease-related disorders in efficacy or safety in the process of swallowing usually lead to malnutrition, dehydration or pneumonias. The aim of this study was identifying and analyzing swallowing disorders in Parkinson's disease. Subjects and methods The initial sample consisted of 52 subjects with Parkinson's disease to whom the specific test for dysphagia SDQ was applied. Nineteen participants (36.5%) with some degree of dysphagia in the SDQ test were selected to be evaluated by volume-viscosity clinical exploration method and fibreoptic endoscopic evaluation of swallowing. Results Disorders in swallowing efficiency and safety were detected in 94.7% of the selected sample. With regards to efficiency, disorders were found in food transport (89.5%), insufficient labial closing (68.4%) and oral residues (47.4%), relating to duration of ingestion. Alterations in security were also observed: pharynx residues (52.7%), coughing (47.4%), penetration (31.64%), aspiration and decrease of SaO2 (5.3%), relating to the diagnosis of respiratory pathology in the previous year. Conclusion The SDQ test detected swallowing disorders in 36.5% of the subjects with Parkinson's disease. Disorders in swallowing efficiency and safety were demonstrated in 94.7% of this subset. Disorders of efficiency were more frequent than those of safety, establishing a relationship with greater time in ingestion and the appearance of respiratory pathology and pneumonias.
Chapter
This chapter describes the nutritional aspects of dysphagia management by starting with the definition of these two conditions (dysphagia and malnutrition) that share three main clinical characteristics: (a) their prevalence is very high, (b) they can lead to severe complications, and (c) they are frequently underrecognized and neglected conditions. From an anatomical standpoint, dysphagia can result from oropharyngeal and/or esophageal causes; from a pathophysiological perspective, dysphagia can be caused by organic or structural diseases (either benign or malignant) or diseases causing impaired physiology (mainly motility and/or perception disorders). This chapter gathers up-to-date information on the screening and diagnosis of oropharyngeal dysphagia, the consequences of dysphagia (aspiration pneumonia, malnutrition, and dehydration), and on the nutritional management of dysphagic patients. Concerning this last topic, this chapter reviews the rheological aspects of swallowing and dysphagia (including shear and elongational flows) and its influence on the characteristics of the enteral nutrition for dysphagia management (solid/semisolid foods and thickened liquids; ready-to-use oral nutritional supplements and thickening powders), with special focus on the real characteristics of the bolus after mixing with human saliva.
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This position document has been developed by the Dysphagia Working Group, a committee of members from the European Society for Swallowing Disorders and the European Union Geriatric Medicine Society, and invited experts. It consists of 12 sections that cover all aspects of clinical management of oropharyngeal dysphagia (OD) related to geriatric medicine and discusses prevalence, quality of life, and legal and ethical issues, as well as health economics and social burden. OD constitutes impaired or uncomfortable transit of food or liquids from the oral cavity to the esophagus, and it is included in the World Health Organization’s classification of diseases. It can cause severe complications such as malnutrition, dehydration, respiratory infections, aspiration pneumonia, and increased readmissions, institutionalization, and morbimortality. OD is a prevalent and serious problem among all phenotypes of older patients as oropharyngeal swallow response is impaired in older people and can cause aspiration. Despite its prevalence and severity, OD is still underdiagnosed and untreated in many medical centers. There are several validated clinical and instrumental methods (videofluoroscopy and fiberoptic endoscopic evaluation of swallowing) to diagnose OD, and treatment is mainly based on compensatory measures, although new treatments to stimulate the oropharyngeal swallow response are under research. OD matches the definition of a geriatric syndrome as it is highly prevalent among older people, is caused by multiple factors, is associated with several comorbidities and poor prognosis, and needs a multidimensional approach to be treated. OD should be given more importance and attention and thus be included in all standard screening protocols, treated, and regularly monitored to prevent its main complications. More research is needed to develop and standardize new treatments and management protocols for older patients with OD, which is a challenging mission for our societies.
Article
Introduction: Parkinson's disease is a type of chronic neurodegenerative pathology with a typical movement pattern, as well as different, less studied symptoms such as dysphagia. Disease-related disorders in efficacy or safety in the process of swallowing usually lead to malnutrition, dehydration or pneumonias. The aim of this study was identifying and analyzing swallowing disorders in Parkinson's disease. Subjects and methods: The initial sample consisted of 52 subjects with Parkinson's disease to whom the specific test for dysphagia SDQ was applied. Nineteen participants (36.5%) with some degree of dysphagia in the SDQ test were selected to be evaluated by volume-viscosity clinical exploration method and fiberoptic endoscopic evaluation of swallowing. Results: Disorders in swallowing efficiency and safety were detected in 94.7% of the selected sample. With regards to efficiency, disorders were found in food transport (89.5%), insufficient labial closing (68.4%) and oral residues (47.4%), relating to duration of ingestion. Alterations in security were also observed: pharynx residues (52.7%), coughing (47.4%), penetration (31.64%), aspiration and decrease of SaO2 (5.3%), relating to the diagnosis of respiratory pathology in the previous year. Conclusion: The SDQ test detected swallowing disorders in 36.5% of the subjects with Parkinson's disease. Disorders in swallowing efficiency and safety were demonstrated in 94.7% of this subset. Disorders of efficiency were more frequent than those of safety, establishing a relationship with greater time in ingestion and the appearance of respiratory pathology and pneumonias.
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Oropharyngeal dysphagia (OD) is a very prevalent condition in patients with neurological disorders and in the elderly, and has been shown to play a key role in the pathophysiology of aspiration pneumonia (AP), a frequent and severe complication in patients with OD. The pathophysiology of AP includes three main elements: (1) OD with impaired safety of swallow, aspirations, and frequently, impaired cough reflex; (2) poor oral health and oropharyngeal colonization by respiratory pathogens; and (3) frailty with malnutrition and poor immunity. Respiratory infections and AP lead to readmissions and high mortality among patients at risk, and appropriate management is important to avoid these complications. We have developed a therapeutic intervention including early screening, assessment, and treatment of patients at risk of OD. Those with OD are further assessed and treated for nutritional deficiency, oral hygiene, and oral diseases. This will reduce complications and morbidity and mortality among these patients.
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Prevalence of oropharyngeal dysphagia among the elderly is high, but underestimated and underdiagnosed. It may give raise to relevant complications impacting on morbidity, hospital length of stay and health care costs. Dysphagia evaluation and management is a multidisciplinary task; it includes a detailed history taking, clinical and instrumental exams, and identification of the risk of aspiration. Long-standing individual abilities and impairments determine the goals of an ad hoc rehabilitation program. Currently there are no standard algorithmic approaches for the management of dysphagia in the elderly. Education of health professionals on early diagnosis and improvement of therapeutic strategies are mainstays to allow maximal recovery potential in this population. This narrative review summarizes the current rehabilitation approaches for dysphagia in the elderly. The aim is to inform the treating health care professionals, whether caring physician, physical medicine doctor, speech/swallowing therapist or nurse, on the state-of-the-art and stimulate discussion in the scientific community.
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Objectives: To describe the initial results of the implementation of a dysphagia assessment and intervention programme and to know which variables showed significant differences between patients with and without dysphagia detected by this way at an intermediate and long stay hospital. Methods: Descriptive and retrospective study on the assessment performed to patients suspected of having dysphagia and of the subsequent intervention done on those in whom it was confirmed. A standardized clinical method using different viscosities and volumes was used. After confirming the condition, different dietary, postural, and educational cares were undertaken. Demographical, clinical, and analytical variables were registered. Results: 146 patients were included, 110 of them presenting dysphagia of whom the corresponding assessments and interventions were described. This represented a dysphagia prevalence of 14.8% among all admitted patients. The univariate analysis between patients with and without dysphagia showed that the former presented at the time of admission a higher prevalence of a feeding tube (p = 0.011) and a lower proportion of mild cognitive impairment (p = 0.048); and at the time of hospital discharge, lower functional recovery (p < 0.01) and higher presence of a feeding tube (p = 0.028), hyponutrition(p < 0,01), and mortality (p = 0.02). Conclusions: Given its frequent presentation and important clinical repercussion, and in order to improve health care quality at ILSH, the implementation of a dysphagia care programme is advisable. The dysphagia detected was correlated with the presence of a feeding tube and had clear implications on the clinical course at a functional and nutritional level and vital prognosis.
Article
Introduction Oropharyngeal dysphagia is very common in neurological diseases. It is a serious symptom with nutritional and respiratory complications that may lead to the death. Objectives To determine the prevalence of oropharyngeal dysphagia in Neurological Rehabilitation Units of the Fundación Instituto San José (FISJ), Madrid, as well as to determine the functional status and diseases that may lead to the possible occurrence of oropharyngeal dysphagia in these patients. Method A descriptive cross-sectional study was conducted on all patients admitted from 1 January to 30 September 2012, in the Moderate Neurological Disorders (UTNM) and Severe Neurological Disorders Units (UTNS) of the FISJ. Results A total of 109 patients were admitted to the UTNM and 31 patients to the UTNS during the study period. There was a 31.2% prevalence of oropharyngeal dysphagia in the UTNM, with a very high prevalence of 64.5% in UTNS. A total of 14 new cases were diagnosed In the UTNM, and 6 new cases in the UTNS. Patients with oropharyngeal dysphagia have been admitted with a primary diagnosis of stroke (63%) and 18.5% with cerebral hemorrhage/hematoma. It was also determined that of the 85.2% of patients diagnosed with dysphagia, 11.1% presented levels of total dependence, whilst 3.7% presented severe/moderate dependence. Conclusions The prevalence of dysphagia in Neurological Disorders Units in Madrid is very high, especially in patients with cerebrovascular disease and total/severe dependency level.
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The development of postextubation swallowing dysfunction is well documented in the literature with high prevalence in most studies. However, there are relatively few studies with specific outcomes that focus on the follow-up of these patients until hospital discharge. The purpose of our study was to determine prognostic indicators of dysphagia in ICU patients submitted to prolonged orotracheal intubation (OTI). We conducted a retrospective, observational cohort study from 2010 to 2012 of all patients over 18 years of age admitted to a university hospital ICU who were submitted to prolonged OTI and subsequently received a bedside swallow evaluation (BSE) by a speech pathologist. The prognostic factors analyzed included dysphagia severity rate at the initial swallowing assessment and at hospital discharge, age, time to initiate oral feeding, amount of individual treatment, number of orotracheal intubations, intubation time and length of hospital stay. After we excluded patients with neurologic diseases, tracheostomy, esophageal dysphagia and those who were submitted to surgical procedures involving the head and neck, our study sample size was 148 patients. The logistic regression model was used to examine the relationships between independent variables. In the univariate analyses, we found that statistically significant prognostic indicators of dysphagia included dysphagia severity rate at the initial swallowing assessment, time to initiate oral feeding and amount of individual treatment. In the multivariate analysis, we found that dysphagia severity rate at the initial swallowing assessment remained associated with good treatment outcomes. Studies of prognostic indicators in different populations with dysphagia can contribute to the design of more effective procedures when evaluating, treating, and monitoring individuals with this type of disorder. Additionally, this study stresses the importance of the initial assessment ratings.
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La disfagia de origen neurologico se asocia, con mucha frecuencia, a las enfermedades neurodegenerativas y al accidente vascular cerebral. Su deteccion precoz evita complicaciones graves y ayuda a poner en marcha tecnicas de deglucion seguras y estrategias dieteticas adecuadas. La optimizacion en el diagnostico y el tratamiento de la disfagia orofaringea se consiguen con un equipo multidisciplinar.
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Objective To determine the prevalence of dysphagia in a population of institutionalised elderly people, and the effectiveness of a clinical method for its detection.
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Oropharyngeal dysphagia, or inability to swallow liquids and/or solids, is one of the less well known geriatric syndromes, despite its enormous impact on functional ability, quality of life and health in affected individuals. The origin of oropharyngeal dysphagia can be structural or functional. Patients with neurodegenerative or cerebrovascular diseases and the frail elderly are the most vulnerable. The complications of oropharyngeal dysphagia are malnutrition, dehydration and aspiration, all of which are serious and provoke high morbidity and mortality. Oropharyngeal aspiration causes frequent respiratory infections and aspiration pneumonias. Antibiotic therapy must cover the usual microorganisms of the oropharyngeal flora. Oropharyngeal dysphagia should be identified early in risk groups through the use of screening methods involving clinical examination of swallowing and diagnostic confirmation methods. The simplest and most effective therapeutic intervention is adaptation of the texture of the solid and the viscosity of the liquid.
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Digestive surgeons should form part of the multidisciplinary team managing patients with oropharyngeal dysphagia. These patients can be diagnosed through clinical methods and complementary investigations such as videofluoroscopy and pharyngoesophageal manometry. These techniques also allow specific treatment to be selected. Up to one-third of patients with dysphagia suffer from malnutrition as a result of alterations in food bolus transport. Furthermore, up to two-thirds show alterations in swallowing safety (penetrations and aspirations, especially when swallowing liquids), as well as a high risk of respiratory infections and aspiration pneumonia. Increasing food bolus viscosity to 3500-4000 mPas (pudding viscosity) improves the effectiveness of swallowing and reduces the risk of aspirations. Botulinic toxin injection in the upper esophageal sphincter is indicated in patients with spasticity of neuromuscular origin. Cricopharyngeal myotomy is the basis of treatment for Zenker's diverticulum and is also indicated in patients with alterations in the upper esophageal sphincter and preserved oropharyngeal motor response.
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Main objective: To describe the prevalence of oropha-ryngeal dysphagia at hospital discharge in elderly patients admitted to a Subacute Care Unit (SACU) using the Volume-Viscosity Swalow Test (V-VST) and an adapted version for severe dementia (V-VST-G). Methodology and design: Descriptive cross-sectional study; duration; 50 days. Data gathered from the clinical chart at hospital discharge: demographical, clinical, risk factors, and complications of dysphagia, functional course, and V-VCAM and V-VCAM-G outcomes. The results are described comparing the data of the groups with and without dysphagia. Results: 86 patients (60% women), mean age 83.8 ± 6.7 years. The specific clinical history detected previous oropharyngeal dysphagia in 23 patients (26%). The V-VCAM detected oropharyngeal dysphagia in 46 patients (53.5%). Of them, 30 patients (65.21%) had mixed swal-lowing disorder, 15 (32.6%) had isolated efficacy disor-der, and 1 (2.17%) had isolated safety disorder. Those patients with a positive dysphagia test had a statistically significant higher prevalence of cognitive disorder, higher age, and more positive history of previous dyspha-gia, worse functional course and mobility impairment, and more complications during their staying at the SACU. Conclusions: dysphagia is highly prevalent among this group of elderly patients. Only half of the cases are diag-nosed through the specific anamnesis. The V-VCAM detected a high prevalence of dysphagia so that its routine use is recommended specially in patients at risk taking into account the peculiarities of using it in the elderly. This at-risk population would be defined by characteris-tics such as higher age, cognitive and/or functional impairment.
Article
To describe the prevalence of oropharyngeal dysphagia at hospital discharge in elderly patients admitted to a Subacute Care Unit (SACU) using the Volume-Viscosity Swalow Test (V-VST) and an adapted version for severe dementia (V-VST-G). METHODOLOGY AND DESIGN: Descriptive cross-sectional study; duration; 50 days. Data gathered from the clinical chart at hospital discharge: demographical, clinical, risk factors, and complications of dysphagia, functional course, and V-VCAM and V-VCAM-G outcomes. The results are described comparing the data of the groups with and without dysphagia. 86 Patients (60% women), mean age 83.8 ± 6.7 years. The specific clinical history detected previous oropharyngeal dysphagia in 23 patients (26%). The V-VCAM detected oropharyngeal dysphagia in 46 patients (53.5%). Of them, 30 patients (65.21%) had mixed swallowing disorder, 15 (32.6%) had isolated efficacy disorder, and 1 (2.17%) had isolated safety disorder. Those patients with a positive dysphagia test had a statistically significant higher prevalence of cognitive disorder, higher age, and more positive history of previous dysphagia, worse functional course and mobility impairment, and more complications during their staying at the SACU. Dysphagia is highly prevalent among this group of elderly patients. Only half of the cases are diagnosed through the specific anamnesis. The V-VCAM detected a high prevalence of dysphagia so that its routine use is recommended specially in patients at risk taking into account the peculiarities of using it in the elderly. This at-risk population would be defined by characteristics such as higher age, cognitive and/or functional impairment.
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AP is a major cause of morbidity and mortality in elderly patients, especially frail elderly patients. The aim of this article is to review effect of oral care, including oral hygiene and improvement of oral function, on the prevention of AP among elderly people in hospitals and nursing homes. There is now a substantial body of work studying the effect of oral care on the prevention of respiratory diseases. Oral hygiene, consisting of oral decontamination and mechanical cleaning by dental professionals, has resulted in significant clinical effects (decreased incidence of pneumonia and decreased mortality from respiratory diseases) in clinical randomized trials. Moreover, studies examining oral colonization by pneumonia pathogens have shown the effect of oral hygiene on eliminating these pathogens. In addition, swallowing training has been shown to improve the movement and function of swallowing-related muscles, also resulting in decreased incidence of pneumonia. These findings support the contention that oral care is effective in the prevention of AP.
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Oropharyngeal dysphagia is a major complaint among older people. Dysphagia may cause two types of complications in these patients: (a) a decrease in the efficacy of deglutition leading to malnutrition and dehydration, (b) a decrease in deglutition safety, leading to tracheobronchial aspiration which results in aspiration pneumonia and can lead to death. Clinical screening methods should be used to identify older people with oropharyngeal dysphagia and to identify those patients who are at risk of aspiration. Videofluoroscopy (VFS) is the gold standard to study the oral and pharyngeal mechanisms of dysphagia in older patients. Up to 30% of older patients with dysphagia present aspiration-half of them without cough, and 45%, oropharyngeal residue; and 55% older patients with dysphagia are at risk of malnutrition. Treatment with dietetic changes in bolus volume and viscosity, as well as rehabilitation procedures can improve deglutition and prevent nutritional and respiratory complications in older patients. Diagnosis and management of oropharyngeal dysphagia need a multidisciplinary approach.
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The oral cavity of the hospitalized or bedridden elderly is often a reservoir for opportunistic pathogens associated with respiratory diseases. Commensal flora and the host interact in a balanced fashion and oral infections are considered to appear following an imbalance in the oral resident microbiota, leading to the emergence of potentially pathogenic bacteria. The definition of the process involved in colonization by opportunistic respiratory pathogens needs to elucidate the factors responsible for the transition of the microbiota from commensal to pathogenic flora. The regulatory factors influencing the oral ecosystem can be divided into three major categories: the host defense system, commensal bacteria, and external pathogens. In this article, we review the profile of these categories including the intricate cellular interaction between immune factors and commensal bacteria and the disturbance in homeostasis in the oral cavity of hospitalized or bedridden elderly, which facilitates oral colonization by opportunistic respiratory pathogens.
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Oropharyngeal dysphagia is a major complaint among the elderly. Our aim was to assess the pathophysiology of oropharyngeal dysphagia in frail elderly patients (FEP). A total of 45 FEP (81.5 +/- 1.1 years) with oropharyngeal dysphagia and 12 healthy volunteers (HV, 40 +/- 2.4 years) were studied using videofluoroscopy. Each subject's clinical records, signs of safety and efficacy of swallow, timing of swallow response, hyoid motion and tongue bolus propulsion forces were assessed. Healthy volunteers presented a safe and efficacious swallow, faster laryngeal closure (0.157 +/- 0.013 s) upper esophageal sphincter opening (0.200 +/- 0.011 s), and maximal vertical hyoid motion (0.310 +/- 0.048 s), and stronger tongue propulsion forces (22.16 +/- 2.54 mN) than FEP. By contrast, 63.63% of FEP presented oropharyngeal residue, 57.10%, laryngeal penetration and 17.14%, tracheobronchial aspiration. Frail elderly patients with impaired swallow safety showed delayed laryngeal vestibule (LV) closure (0.476 +/- 0.047 s), similar bolus propulsion forces, poor functional capacity and higher 1-year mortality rates (51.7%vs 13.3%, P = 0.021) than FEP with safe swallow. Frail elderly patients with oropharyngeal residue showed impaired tongue propulsion (9.00 +/- 0.10 mN), delayed maximal vertical hyoid motion (0.612 +/- 0.071 s) and higher (56.0%vs 15.8%, P = 0.012) 1-year mortality rates than those with efficient swallow. Frail elderly patients with oropharyngeal dysphagia presented poor outcome and high mortality rates. Impaired safety of deglutition and aspirations are mainly caused by delayed LV closure. Impaired efficacy and residue are mainly related to weak tongue bolus propulsion forces and slow hyoid motion. Treatment of dysphagia in FEP should be targeted to improve these critical events.
Article
To describe the initial results of the implementation of a dysphagia assessment and intervention programme and to know which variables showed significant differences between patients with and without dysphagia detected by this way at an intermediate and long stay hospital. Descriptive and retrospective study on the assessment performed to patients suspected of having dysphagia and of the subsequent intervention done on those in whom it was confirmed. A standardized clinical method using different viscosities and volumes was used. After confirming the condition, different dietary, postural, and educational cares were undertaken. Demographical, clinical, and analytical variables were registered. 146 patients were included, 110 of them presenting dysphagia of whom the corresponding assessments and interventions were described. This represented a dysphagia prevalence of 14.8% among all admitted patients. The univariate analysis between patients with and without dysphagia showed that the former presented at the time of admission a higher prevalence of a feeding tube (p = 0.011) and a lower proportion of mild cognitive impairment (p = 0.048); and at the time of hospital discharge, lower functional recovery (p < 0.01) and higher presence of a feeding tube (p = 0.028), hyponutrition(p < 0,01), and mortality (p = 0.02). Given its frequent presentation and important clinical repercussion, and in order to improve health care quality at ILSH, the implementation of a dysphagia care programme is advisable. The dysphagia detected was correlated with the presence of a feeding tube and had clear implications on the clinical course at a functional and nutritional level and vital prognosis.
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oropharyngeal dysphagia is a common condition among the elderly but not systematically explored. to assess the prevalence and the prognostic significance of oropharyngeal dysphagia among elderly patients with pneumonia. a prospective cohort study. an acute geriatric unit in a general hospital. a total of 134 elderly patients (>70 years) consecutively admitted with pneumonia. clinical bedside assessment of oropharyngeal dysphagia and aspiration with the water swallow test were performed. Demographic and clinical data, Barthel Index, Mini Nutritional Assessment, Charlson Comorbidity Index, Fine's Pneumonia Severity Index and mortality at 30 days and 1 year after admission were registered. of the 134 patients, 53% were over 84 years and 55% presented clinical signs of oropharyngeal dysphagia; the mean Barthel score was 61 points indicating a frail population. Patients with dysphagia were older, showed lower functional status, higher prevalence of malnutrition and comorbidities and higher Fine's pneumonia severity scores. They had a higher mortality at 30 days (22.9% vs. 8.3%, P = 0.033) and at 1 year of follow-up (55.4% vs. 26.7%, P = 0.001). oropharyngeal dysphagia is a highly prevalent clinical finding in elderly patients with pneumonia and is an indicator of disease severity in older patients with pneumonia.
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The aim is to describe recent advances concerning pneumonia in older patients in relation to epidemiology, microbiology, and factors related to severity, treatment, and prevention. This article is a review of recent studies (2007 and 2008) on pneumonia in older people. The incidence of oropharyngeal dysphagia is increasing among older people. Biological markers of prognosis and severity do not normally offer additional relevant information to clinical data. Viral cause is increasingly relevant, and mixed infections are more severe and affect more old people. A new index has been developed (SMART-COP), which complements the existing Pneumonia Severity Index (PSI) and CURB-65 by improving identification of patients who require intensive care and vasopressor drugs. Reduction in antibiotic treatment duration is not associated with greater mortality or more readmissions. New developments regarding prevention of aspiration pneumonia and the utility of influenza and pneumococcal vaccines are discussed. Pneumonia is increasingly caused by viral pathogens, and the pneumococcal and influenza vaccines may not be as effective as was first published. Recent studies have shown that aspiration is an increasing risk factor for pneumonia among older people.
Article
To determine the accuracy of the bedside volume-viscosity swallow test (V-VST) for clinical screening of impaired safety and efficacy of deglutition. We studied 85 patients with dysphagia and 12 healthy subjects. Series of 5-20 mL nectar (295.02 mPa.s), liquid (21.61 mPa.s) and pudding (3682.21 mPa.s) bolus were administered during the V-VST and videofluoroscopy. Cough, fall in oxygen saturation > or =3%, and voice changes were considered signs of impaired safety, and piecemeal deglutition and oropharyngeal residue, signs of impaired efficacy. Videofluoroscopy showed patients had prolonged swallow response (> or =1064 ms); 52.1% had safe swallow at nectar, 32.9%, at liquid (p<0.05), and 80.6% at pudding viscosity (p<0.05); 29.4% had aspirations, and 45.8% oropharyngeal residue. The V-VST showed 83.7% sensitivity and 64.7% specificity for bolus penetration into the larynx and 100% sensitivity and 28.8% specificity for aspiration. Sensitivity of V-VST was 69.2% for residue, 88.4% for piecemeal deglutition, and 84.6% for identifying patients whose deglutition improved by enhancing bolus viscosity. Specificity was 80.6%, 87.5%, and 73.7%, respectively. The V-VST is a sensitive clinical method to identify patients with dysphagia at risk for respiratory and nutritional complications, and patients whose deglutition could be improved by enhancing bolus viscosity. Patients with a positive test should undergo videofluoroscopy.
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Community-acquired pneumonia (CAP) in the elderly has a different clinical presentation than CAP in other age groups. Confusion, alteration of functional physical capacity, and decompensation of underlying illnesses may appear as unique manifestations. Malnutrition is also an associated feature of CAP in this population. We undertook a study to assess the clinical and nutritional aspects of CAP requiring hospitalization in elderly patients (over 65 yr of age). One hundred and one patients with pneumonia, consecutively admitted to a 1,000-bed teaching hospital over an 8-mo period, were studied (age: 78 ± 8 yr, mean ± SD). Nutritional aspects and the mental status of patients with pneumonia were compared with those of a control population (n = 101) matched for gender, age, and date of hospitalization. The main symptoms were dyspnea (n = 71), cough (n = 67), and fever (n = 64). The association of these symptoms with CAP was observed in only 32 patients. The most common associated conditions were cardiac dise...
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We prospectively studied the impact of an antibiotic prophylaxis regimen on the incidence of infections, organ dysfunctions, and mortality in a predominantly surgical and trauma intensive care unit (ICU) population. A total of 546 patients were enrolled and stratified according to Acute Physiology and Chronic Health Evaluation (APACHE)-II scores. They were then randomized to receive either 2 400 mg of intravenous ciprofloxacin for 4 days, together with a mixture of topical gentamicin and polymyxin applied to the nostrils, mouth, and stomach throughout their ICU stay or to receive intravenous and topical placebo. When receiving prophylaxis, significantly fewer patients acquired infections (p 0.001, risk ratio [RR], 0.477; 95% confidence interval [CI], 0.367–0.620), especially pneumonias (6 versus 29, p 0.007), other lower respiratory tract infections (39 versus 70, p 0.007), bloodstream infections (14 versus 36, p 0.007), or urinary tract infections (36 versus 60, p 0.042). Also, significantly fewer patients acquired severe organ dysfunctions (63 versus 96 patients, p 0.0051; RR, 0.636; 95% CI, 0.463–0.874), especially renal dysfunctions (17 versus 38; p 0.018). Within 5 days after admission, 24 patients died in each group, whereas 28 patients receiving prophylaxis and 51 receiving placebo died in the ICU thereafter (p 0.0589; RR, 0.640; 95% CI, 0.402–1.017). The overall ICU mortality was not statistically different (52 versus 75 fatalities), but the mortality was significantly reduced for 237 patients of the midrange stratum with APACHE-II scores of 20–29 on admission (20 versus 38 fatalities, p 0.0147; RR, 0.508; 95% CI, 0.295–0.875); there was still a favorable trend after 1 year (51 versus 60 fatalities; p 0.0844; RR, 0.720; 95% CI, 0.496–1.046). Surveillance cultures from tracheobronchial, oropharyngeal, and gastric secretions and from rectal swabs did not show any evidence for the selection of resistant microorganisms in the patients receiving prophylaxis.
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Poor dental hygiene has been linked to respiratory pathogen colonization in residents of long-term care facilities. We sought to investigate the association between dental plaque (DP) colonization and lower respiratory tract infection in hospitalized institutionalized elders using molecular genotyping. We assessed the dental status of 49 critically ill residents of long-term care facilities requiring intensive care treatment. Plaque index scores and quantitative cultures of DPs were obtained on ICU admission. Protected BAL (PBAL) was performed on 14 patients who developed hospital-acquired pneumonia (HAP). Respiratory pathogens recovered from the PBAL fluid were compared genetically to those isolated from DPs by pulsed-field gel electrophoresis. Twenty-eight subjects (57%) had colonization of their DPs with aerobic pathogens. Staphylococcus aureus (45%) accounted for the majority of the isolates, followed by enteric Gram-negative bacilli (42%) and Pseudomonas aeruginosa (13%). The etiology of HAP was documented in 10 patients. Of the 13 isolates recovered from PBAL fluid, nine respiratory pathogens matched genetically those recovered from the corresponding DPs of eight patients. These findings suggest that aerobic respiratory pathogens colonizing DPs may be an important reservoir for HAP in institutionalized elders. Future studies are needed to delineate whether daily oral hygiene in hospitalized elderly would reduce the risk of nosocomial pneumonia in this frail population.
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Two patients with attacks of choking caused by aspiration of gastric contents in the laryngotracheal tube are presented. One had such severe attacks of respiratory arrest, that tracheostomy was done. The common symptoms of gastro-oesophageal reflux such as pirosis, acid regurgitation, or retrosternal burning were absent in both patients and upper gut radiological and endoscopic examinations were negative. Histology of the oesophageal mucosa showed a deep chronic eosophagitis, and the 24-hour pH-monitoring of the upper oesophagus showed frequent gastro-oesophageal refluxes. Manometry showed hypotonic lower oesophageal sphincter with marked alterations of peristalsis. In the patient with tracheostomy a 24 pH monitoring of the hypolaryngeal zone showed decreased pH at the time of choking attacks. In the other patient further investigations showed that amyotrophic lateral sclerosis was the cause of the oesophageal motility disorder. An intense antireflux treatment abolished the respiratory attacks in both patients.
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This study examines the effects of a sour bolus (50% lemon juice, 50% barium liquid) on pharyngeal swallow measures in two groups of patients with neurogenic dysphagia. Group 1 consisted of 19 patients who had suffered at least one stroke. Group 2 consisted of 8 patients with dysphagia related to other neurogenic etiologies. All patients were selected because they exhibited delays in the onset of the oral swallow and delays in triggering the pharyngeal swallow on boluses of 1 ml and 3 ml liquid barium during videofluoroscopy. Results showed significant improvement in oral onset of the swallow in both groups of patients and a significant reduction in pharyngeal swallow delay in Group 1 patients and in frequency of aspiration in Group 2 patients with the sour as compared to the non-sour boluses. Other selected swallow measures in both subject groups also improved with the sour bolus. Volume effects were present but not as consistently as in prior studies. Implications for swallow therapy are discussed.
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To study the relationship between complaints of xerostomia and salivary performance and food avoidances in four geriatric groups chosen to reflect a broad spectrum of individuals along the health-disease continuum. To determine whether xerogenic medications taken by these individuals could be associated with either complaints of xerostomia or with food avoidances. Cross-sectional survey. Clinical examinations and interview. A VA dental clinic and a retirement home. Subjects were 529 individuals older than 56 years of age, living both in institutions and in the community (average age 70 years). Two hundred eight persons were recruited from a VA Dental Clinic, 114 from a residential retirement home, and 132 from a nursing/long-term-care facility; 75 were from an acute care ward and had a diagnosis of a cerebral vascular accident or other neurological condition. Prevalence of xerostomia, dental morbidity, salivary flow, and food avoidances. About 72% of the subjects experienced xerostomia sometime during the day. Stimulated salivary flow was found to be significantly lower in individuals who complained of xerostomia than in those who did not. Fifty-five percent of participants reported using one or more xerogenic medications, with an 86% prevalence in the nursing/long-term-care facility. Individuals with xerostomia had difficulty in chewing and in starting a swallow and were significantly more likely to avoid crunchy foods such as vegetables, dry foods such as bread, and sticky foods such as peanut butter in their diets. Specific medications such as the inhalants ipratropium and triamcinolone and the systemic agents oxybutynin and triazolam could be statistically associated with xerostomia and/or low salivary flow, and/or specific food avoidances. Xerostomia apparently affects the ability to chew and start a swallow. This leads to avoidance of certain foods, which raises the possibility that xerostomia could contribute to undernutrition in older persons. The topically applied ipratropium and triamcinolone and the systemic agents amitriptyline, oxybutynin and triazolam could be statistically associated with one or more complaints of xerostomia.
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The study of Streptococcus pneumoniae has led to many insights into the pathogenesis of bacterial infections. The importance of the polysaccharide capsule of the organism in determining its virulence was indicated by studies of the protective role of anticapsular antibodies.1–3 Of comparable importance was the observation that noncapsulated pneumococci caused progressive disease in rabbits with agranulocytosis, demonstrating thereby the pathogenic properties of the pneumococcal soma.4 Investigation of the pathologic events in pneumococcal infection led to the discovery of DNA,2,3 the development of the first bacterial polysaccharide vaccine,5 and insights into the mechanism of action of penicillin,6 antibiotic tolerance, . . .
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The objective of this study was to validate a dysphagia screening test to identify patients in the rehabilitation phase post stroke at risk for pneumonia, recurrent upper airway obstruction, and death. The setting was an inpatient stroke rehabilitation unit. One hundred thirty-nine consecutive patients met the following criteria: stroke confirmed by clinical history and neurological exam with compatible computed tomography (CT) or magnetic resonance imaging (MRI) scan; ages 20 to 90 years inclusive; and no known history of significant oral or pharyngeal anomaly. The main outcome measures were pneumonia, recurrent upper airway obstruction, and death. The Burke Dysphagia Screening Test (BDST) identified 11 of 12 patients who subsequently developed pneumonia, recurrent upper airway obstruction, or death (Fisher's exact test: p = .03). The relative risk for the occurrence of any of these complications was 7.65 times greater for those failing versus passing the BDST. The BDST identified 9 of 9 patients who developed pneumonia (Fisher's exact test: p = .01). We concluded that the BDST is of value in identifying patients in the rehabilitation phase poststroke at risk for pneumonia, recurrent upper airway obstruction, and death.
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We investigated the frequency with which changes in the position of a patient's head or body eliminated aspiration of liquid barium during videofluoroscopic swallowing studies in patients with oropharyngeal dysphagia. We also studied factors that influenced the effect of posture on aspiration. The study group comprised 165 patients consecutively referred for videofluoroscopic examination of the oropharyngeal stages of swallowing in whom aspiration of barium occurred while swallowing 1, 3, 5, or 10 ml of thin liquid barium or drinking barium from a cup. When aspiration occurred, the patient changed to one of five postures (chin down, chin up, head rotated, head tilted, and lying down), selected on the basis of the specific swallowing abnormality causing the aspiration. Changes in head or body position eliminated aspiration of at least one bolus of barium in 127 (77%) of the 165 patients, and of all four boluses plus drinking barium from a cup in 41 patients (25%). Postural changes were less beneficial in preventing aspiration in patients with substantial language or cognitive defects or restricted head movement. Postural techniques can eliminate aspiration of barium of at least small volumes in most patients. Expansion of the oropharyngeal swallowing study to include the effect of various postures can be done with minimal risk of increased aspiration.
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Bacterial pneumonia is a prevalent and costly infection that is a significant cause of morbidity and mortality in patients of all ages. The continuing emergence of antibiotic-resistant bacteria (e.g., penicillin-resistant pneumococci) suggests that bacterial pneumonia will assume increasing importance in the coming years. Thus, knowledge of the pathogenesis of, and risk factors for, bacterial pneumonia is critical to the development of strategies for prevention and treatment of these infections. Bacterial pneumonia in adults is the result of aspiration of oropharyngeal flora into the lower respiratory tract and failure of host defense mechanisms to eliminate the contaminating bacteria, which multiply in the lung and cause infection. It is recognized that community-acquired pneumonia and lung abscesses can be the result of infection by anaerobic bacteria; dental plaque would seem to be a logical source of these bacteria, especially in patients with periodontal disease. It is also possible that patients with high risk for pneumonia, such as hospitalized patients and nursing home residents, are likely to pay less attention to personal hygiene than healthy patients. One important dimension of this personal neglect may be diminished attention to oral hygiene. Poor oral hygiene and periodontal disease may promote oropharyngeal colonization by potential respiratory pathogens (PRPs) including Enterobacteriaceae (Klebsiella pneumoniae, Escherichia coli, Enterobacter species, etc.), Pseudomonas aeruginosa, and Staphylococcus aureus. This paper provides the rationale for the development of this hypothesis especially as it pertains to mechanically ventilated intensive care unit patients and nursing home residents, two patient groups with a high risk for bacterial pneumonia.
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Upper airway inflammation is present in patients with obstructive sleep apnea (OSA). To determine whether exhaled pentane and nitric oxide (NO) levels, two nonspecific markers of inflammation, are increased in patients with OSA. Exhaled nasal and oral pentane and NO levels were determined before and after sleep in 20 patients with OSA (apnea-hypopnea index, 48+/-7; mean+/-SEM) and eight healthy control subjects. In patients with OSA, exhaled nasal and oral pentane levels after sleep were significantly higher than presleep values (6.1+/-1.2 nM vs 3.4+/-0.4 nM, and 7.0+/-1.3 nM vs 4.2+/-0.4 nM, respectively; p<0.05). Likewise, exhaled nasal and oral NO levels after sleep were significantly higher than presleep values in patients with OSA (39.7+/-3.8 ppb vs 28.4+/-2.9 ppb and 10.9+/-1.5 ppb vs 6.6+/-0.8 ppb, respectively; p<0.05). By contrast, there were no significant differences in exhaled nasal and oral pentane, and nasal NO levels before and after sleep in control subjects. Exhaled oral NO levels were significantly increased after sleep in comparison to presleep values in control subjects (p<0.05). Exhaled nasal pentane and NO levels are increased after sleep in patients with moderate-severe OSA. These data suggest that upper airway inflammation is present in these patients after sleep.
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Community-acquired pneumonia (CAP) in the elderly has a different clinical presentation than CAP in other age groups. Confusion, alteration of functional physical capacity, and decompensation of underlying illnesses may appear as unique manifestations. Malnutrition is also an associated feature of CAP in this population. We undertook a study to assess the clinical and nutritional aspects of CAP requiring hospitalization in elderly patients (over 65 yr of age). One hundred and one patients with pneumonia, consecutively admitted to a 1,000-bed teaching hospital over an 8-mo period, were studied (age: 78 +/- 8 yr, mean +/- SD). Nutritional aspects and the mental status of patients with pneumonia were compared with those of a control population (n = 101) matched for gender, age, and date of hospitalization. The main symptoms were dyspnea (n = 71), cough (n = 67), and fever (n = 64). The association of these symptoms with CAP was observed in only 32 patients. The most common associated conditions were cardiac disease (n = 38) and chronic obstructive pulmonary disease (COPD) (n = 30). Seventy-seven (76%) episodes of pneumonia were clinically classified as typical and 24 as atypical. There was no association between the type of isolated microorganism and the clinical presentation of CAP, except for pleuritic chest pain, which was more common in pneumonia episodes caused by classical microorganisms (p = 0.02). This was confirmed by a multivariate analysis (relative risk [RR] = 11; 95% confidence interval [CI]: 1.7 to 65; p = 0.0099). The prevalence of chronic dementia was similar in the pneumonia cohort (n = 25) and control group (n = 18) (p = 0.22). However, delirium or acute confusion were significantly more frequent in the pneumonia cohort than in controls (45 versus 29 episodes; p = 0.019). Only 16 patients with pneumonia were considered to be well nourished, as compared with 47 control patients (p = 0.001). Kwashiorkor-like malnutrition was the predominant type of malnutrition (n = 65; 70%) in the pneumonia patients as compared with the control patients (n = 31; 31%) (p = 0.001). The observed mortality was 26% (n = 26). Pleuritic chest pain is the only clinical symptom that can guide an empiric therapeutic strategy in CAP (typical versus atypical pneumonia). Both delirium and malnutrition were very common clinical manifestations of CAP in our study population.
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A sensitive technic using indium111 chloride was devised to investigate the occurrence of pharyngeal aspiration. Twenty normal subjects and 10 patients with depressed consciousness were studied. Forty-five per cent of the normal subjects aspirated during deep sleep. Normal subjects who did not aspirate were noted to sleep poorly. Seventy per cent of the patients with depressed consciousness aspirated. Aspiration of pharyngeal secretions occurs frequently in patients with depressed sensorium and also in normal adults during deep sleep. Bacterial pneumonia may result when aspirated bacteria are not effectively cleared. This may result when clearance mechanisms are impaired or when they are overwhelmed by large volumes of aspirated secretions.
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The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission ofpathogenic microorganisms to patients and personnel in health-care settings. This report reviews studies published since the 1985 CDC guideline (Garner JS, Favero MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986;7:231-43) and the 1995 APIC guideline (Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251-69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levels of adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the in vivo efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studies demonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubs in improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical hand antiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.
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Aspiration pneumonitis and aspiration pneumonia are common entities that occur more frequently in populations that are susceptible to aspiration. In aspiration pneumonitis, the degree of lung injury caused by the aspiration of gastric contents is influenced by the pH and to a lesser extent volume of the aspirate. In aspiration pneumonia, the key precipitating event is the inhalation of colonized oropharyngeal material. While anaerobic bacteria are the classic organisms associated with aspiration pneumonia, gram-negative bacteria also play an important role in its pathogenesis. Although there is enormous potential for the investigation of strategies aiming the prevention of aspiration pneumonia, most studies have failed to show a benefit of these strategies. Recently published clinical trials have evaluated the efficacy of different antibiotic regimens for the treatment of aspiration pneumonia. Importantly, new and simplified antibiotic regimens have emerged as an option for the treatment of aspiration pneumonia.
Article
Background Aspiration pneumonia (AP) represents about 5-24% of community-acquired pneumonias. This condition mainly affects elderly patients and causes a high mortality. Our objective was to quantify the AP mortality rate and to identify prognostic factors upon patients admission. Patients and method We underwent a retrospective observational study of a cohort of AP patients admitted to a tertiary care hospital during a 29 months period. The in-hospital mortality rate was calculated. To identify prognostic factors, basal characteristics of patients as well as their clinical presentation and complementary tests performed on admission were studied and analyzed by univariate and multivariate techniques. Odds ratios and 95% confidence intervals were estimated. Results Thirty six out of 105 admitted patients with AP died (cumulative mortality incidence rate 34%, 95% CI 25-44%). In the univariate analysis, demographic, clinical and complementary test variables were associated with mortality. Final logistic model revealed the following independent variables: living in a nursing home (OR = 3.4; 95% CI 1.1–10.9), high degree of dependence (OR = 0.3; 95% CI, 0.1–0.9), body temperature (OR = 0.5 per Celsius degree; 95% CI, 0.3-1.0), serum creatinine levels (OR = 2.2 per mg/100 ml; 95% CI, 1.2–4.1) and LDH serum concentrations (OR = 1.5 per 100 IU/L; 95% CI, 1.1–2.0). Conclusions The mortality of community-acquired AP is very high. In addition to clinical and biological parameters on admission such as body temperature and LDH and creatinine serum concentrations, living in a nursing home and having a high degree of dependence for the basic daily activities were identified as independent prognostic factors. An in-depth knowledge of prognostic factors related to pre-admission care and assistance is needed to decrease the mortality in these patients.
Article
The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care settings. This report reviews studies published since the 1985 CDC guideline (Garner JS, Favero MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986;7:231-43) and the 1995 APIC guideline (Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251-69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levels of adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the in vivo efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studies demonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubs in improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical hand antiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.
Article
• Xerostomia, the subjective feeling of dry mouth caused by a severe reduction in the flow of saliva, is a common problem that is particularly prevalent among the aged. It has become increasingly evident that dry mouth is associated with a number of serious systemic conditions and diseases. Among these are the intake of commonly prescribed medications, autoimmune diseases, and irradiation to the head and neck. The diminution in the flow of saliva may profoundly affect oral health, disturb digestion and speech, and seriously impair the patient's quality of life. Food avoidance, nonabsorption of sublingually placed drugs, and noncompliance with medication may also result. Sialometry can be used to confirm the presence of dry mouth. Treatment is aimed at increasing the flow of saliva, when possible, or providing oral moisture by other means. (Arch Intern Med 1987;147:1333-1337)
Article
Although community-acquired pneumonia (CAP) remains a major cause of hospitalization and death, few studies on risk factors have been performed. A population-based case–control study of risk factors for CAP was carried out in a mixed residential–industrial urban area of 74,610 adult inhabitants in the Maresme (Barcelona, Spain) between 1993 and 1995.All patients living in the area and clinically suspected of having CAP at primary care facilities and hospitals were registered. In total, 205 patients with symptoms, signs and radiographic infiltrate compatible with acute CAP participated in the study. They were matched by municipality, sex and age with 475 controls randomly selected from the municipal census. Risk factors relating the subject′s characteristics and habits, housing conditions, medical history and treatments were investigated by means of a questionnaire.In the univariate analysis, an increased risk of CAP was associated with low body mass index, smoking, respiratory infection, previous pneumonia, chronic lung disease, lung tuberculosis, asthma, treated diabetes, chronic liver disease, and treatments with aminophiline, aerosols and plastic pear-spacers. In multivariate models, the only statistically significant risk factors were current smoking of >20 cigarettes·day-1 (odds ratio (OR)=2.77; 95% confidence interval (CI) 1.14–6.70 compared with never-smokers), previous respiratory infection (OR=2.73; 95% CI 1.75–4.26), and chronic bronchitis (OR=2.22; 95% CI 1.13–4.37). Benzodiazepines were found to be protective in univariate and multivariate analysis (OR=0.46; 95% CI 0.23–0.94).This population-based study provides new and better established evidence on the factors associated with the occurrence of pneumonia in the adult community.
Article
To assess the factors responsible for oropharyngeal colonization with gram-negative bacilli among elderly persons in institutions, we performed a cross-sectional survey of 407 volunteers, 65 years of age and older, who had not received antimicrobials in the previous four weeks. Colonization increased with level of care: from 9 per cent in independent residents of apartments to 60 per cent in patients on an acute hospital ward (P less than 0.0001). Klebsiella species was found in 41 per cent of those with colonization, Escherichia coli in 24 per cent and enterobacter species in 14 per cent. There was no association between numbers of normal flora and numbers of gram-negative bacilli. Associated with colonization were bladder incontinence, deteriorating or terminal clinical status, inability to walk or perform activities of daily living and incapacitation due to neoplastic, respiratory and cardiac disease (P less than 0.05). Multivariate analysis indicated that respiratory disease and being bedridden contributed most to colonization.
Article
A sensitive technic using indium111 chloride was devised to investigate the occurrence of pharyngeal aspiration. Twenty normal subjects and 10 patients with depressed consciousness were studied. Forty-five per cent of the normal subjects aspirated during deep sleep. Normal subjects who did not aspirate were noted to sleep poorly. Seventy per cent of the patients with depressed consciousness aspirated. Aspiration of pharyngeal secretions occurs frequently in patients with depressed sensorium and also in normal adults during deep sleep. Bacterial pneumonia may result when aspirated bacteria are not effectively cleared. This may result when clearance mechanisms are impaired or when they are overwhelmed by large volumes of aspirated secretions.
Article
Elderly patients have a disproportionate incidence of nosocomial pneumonia (NP) and a higher mortality rate, yet few studies have focused on this high-risk population. We undertook a study to examine risk factors for NP in elderly inpatients and to describe how these patients differ from younger patients with NP. In a public teaching hospital, all cases of NP in patients aged 65+ were ascertained by prospective surveillance during a 2-year period (n = 59). These elderly cases were compared with 59 cases of NP in patients aged 25 to 50 to describe differences in risk factors and outcomes. Elderly cases were then matched to elderly control subjects who were admitted to the same hospital service but did not develop NP. Data were collected on known risk factors and on the potential risk factors of poor nutrition, neuromuscular disease, and dementia. Significant differences in risk factors were analyzed using univariate and multivariate comparisons of cases and controls. Elderly patients had twice the incidence of NP (RR = 2.1) as younger patients. Onset of infection was earlier for young than for older cases (6 versus 11 days, p less than or equal to 0.02), but mortality following NP was equal for the two age groups (42% versus 44%). No significant differences in risk factors were found for old and young cases, although older cases tended to have higher rates of poor nutrition, neuromuscular disease, and aspiration preceding their pneumonias. Comparison of elderly cases and elderly controls revealed significantly increased frequencies of poor nutrition, neuromuscular disease, pharyngeal colonization, aspiration, depressed level of alertness, intubation, intensive care unit admission, nasogastric tube use, and antacid use among cases. Cases were more severely ill on admission and had more pre-existing risk factors (2.8 versus 1.3, p less than or equal to 0.001) and more in-hospital risk factors (4.7 versus 1.6, p less than or equal to 0.001). Logistic regression analysis revealed low albumin, diagnosis of neuromuscular disease, and tracheal intubation to be strong independent predictors of risk for NP among elderly inpatients. We conclude that the specific risk factors of poor nutrition, neuromuscular disease, and tracheal intubation may prove useful to target future clinical interventions to prevent NP in the elderly.
Article
This study examined the effect of head rotation on the mechanics of swallowing in healthy subjects, as well as the effects of this postural change on the oropharyngeal swallow of five patients with lateral medullary syndrome (LMS). Videofluoroscopic studies of swallowing in the normal subjects revealed that head rotation to either side increased upper esophageal sphincter (UES) opening diameter by an average of 2mm without affecting the period of UES opening or the oropharyngeal transit time. Maximal rotation of the head to the right or left caused the bolus to lateralize away from the direction of rotation, and also caused a significant (18mmHg or 35%) fall in UES pressure. In the face forward position, the LMS patients exhibited barium residue in the pharynx and pyriform sinuses, as well as diminished UES opening diameter. The fraction of the bolus swallowed and the UES opening diameter increased significantly with the head turned toward the paretic side in the LMS patients. We conclude that head rotation can improve swallowing in patients with unilateral oropharyngeal dysphagia. Two potentially beneficial effects were observed: (1) functional exclusion of the relatively flaccid, weakened pharyngeal wall, and (2) reduced UES tone. Which of these mechanisms is operative probably depends on the dominant mechanisms of dysphagia. In individuals with substantial impairment of UES opening, head turning reduces the resistance of the sphincter that must be overcome by pharyngeal contraction. In individuals with a flaccid hemipharynx, which dissipates pharyngeal pressure, head rotation excludes these structures from the bolus path and allows pharyngeal pressure to be directed at the UES.
Article
Xerostomia, the subjective feeling of dry mouth caused by a severe reduction in the flow of saliva, is a common problem that is particularly prevalent among the aged. It has become increasingly evident that dry mouth is associated with a number of serious systemic conditions and diseases. Among these are the intake of commonly prescribed medications, autoimmune diseases, and irradiation to the head and neck. The diminution in the flow of saliva may profoundly affect oral health, disturb digestion and speech, and seriously impair the patient's quality of life. Food avoidance, nonabsorption of sublingually placed drugs, and noncompliance with medication may also result. Sialometry can be used to confirm the presence of dry mouth. Treatment is aimed at increasing the flow of saliva, when possible, or providing oral moisture by other means.
Article
Although not conclusive, several lines of evidence suggest that cigarette smoking alters the respiratory tract’s ability to defend itself from infection. Some subjects with chronic bronchitis have colonization of the lower respiratory tract with bacteria. Both patients with chronic respiratory disease and healthy smokers appear to have a higher frequency of respiratory infections and an increased severity of symptoms when infected. Children exposed passively to cigarette smoke have higher rates of respiratory illnesses. Yet the marked variability in the incidence of infection in the smoking population suggests that there are subtle factors that predispose some smokers to more risk of infection than others. Cigarette smoking is associated with alterations in mechanisms of the host defense system, even in asymptomatic individuals (summarized in Table 3). Ciliary function is impaired, mucous volume is increased, humoral response to antigens altered, and quantitative and qualitative changes in cellular components occur. Some of these alterations in host defense mechanisms are dose related; others revert to normal after smoking cessation. Yet, it is unknown if one or all of these alterations cause any significant compromise of host defense or if other factors, as yet unidentified, may be important. Answers to these questions await a more thorough elucidation of normal host defense function.
Article
The elderly are at risk for an increased incidence and severity of certain infections. The contribution of age-related immunologic impairment to the pathogenesis of these infections has been difficult to determine because of a number of confounding variables associated with aging. Nevertheless, studies in vitro and in animals support the hypothesis that immunodeficiency accompanies the aging process. Multiple factors may be responsible for altered cell-mediated immunity in the elderly, including thymic involution, reduced levels of thymic hormones, and an increase in the number of immature T lymphocytes. While studies of T cell subpopulations have yielded conflicting results, it appears that T cell proliferative responses are diminished. Aging is also associated with abnormalities of humoral immunity. Although the number and functional activities of neutrophils from healthy elderly persons are relatively intact, diminished bactericidal activity and altered oxygen metabolism have been reported in extremely old individuals. While the relative importance and clinical impact of these immunologic abnormalities remain unclear, future studies may provide new strategies for the prevention and treatment of infections in this rapidly growing segment of the population.
Article
Nosocomial pneumonia accounts for 10% to 20% of all nosocomial infections and represents one of the most serious complications of hospitalization. This review focuses on the etiology, pathogenesis, and prevention of nosocomial pneumonia, with emphasis on infection control procedures to prevent and minimize its occurrence.
Article
A prospective study of 54 cases of pulmonary infection following aspiration was performed. Specimens utilized for bacteriologic study were either transtracheal aspirates, empyema fluid or blood. Appropriate anaerobic bacteriologie methods were employed. Anaerobic bacteria were recovered in 50 patients (93 per cent) and were the only pathogens in 25 (46 per cent). The predominant species were Bacteroides melanino-genicus, Fusobacterium nucleatum and anaerobic or microaerophilic gram-positive cocci. Bacteroides fragilis, which is resistant to many commonly used antibiotics, was recovered in nine patients (17 per cent). Aerobic and facultative bacteria were present in 29 patients (54 per cent), but anaerobes were present concurrently in all but 4. Enteric gram-negative bacilli and pseudomonads were particularly common in patients whose disease developed in the hospital. Eleven patients with mixed aerobic and anaerobic infections were treated successfully with antibiotics which were active only against the anaerobic isolates, thereby further implicating the pathogenic role of these microorganisms. The results indicate that anaerobes play a key role in most cases of infection following aspiration.
Article
Two indices of alveolar epithelial permeability were derived in man by a non-invasive method. The rate of transfer of 99mTc DTPA (diethylenetriamine penta-acetate) from the lung into the blood was measured and a significantly greater (P less than 0.001) transfer rate was found in symptomless cigarette smokers compared with non-smokers.
Patients with respiratory disease commonly report that their sleep is disrupted by nocturnal cough. We have recorded cough during the night in 10 patients with severe chronic bronchitis and emphysema (forced expiratory volume in one second, 1.0 +/- SEM 0.1/L) who complained of nocturnal cough and correlated cough with electroencephalographic sleep stage and arterial oxygenation. Cough was recorded using a directional microphone and an auto-editing tape recorder system. Each cough was subsequently verified by a listener. There was a mean of 14.6 +/- 4.5 bouts of coughing per patient per night, each bout lasting on average 3.9 +/- 0.2 s. Eighty-five percent of coughing bouts occurred during electroencephalographically confirmed wakefulness (p less than 0.02 versus sleep), and coughs during true sleep were rare, with only 1 patient coughing during rapid eye movement sleep and none during Stages 3 and 4 sleep. Cough was only once followed by arousal. There was no correlation between cough and either apneas or hypoxemia during sleep. We conclude that spontaneous cough is suppressed during sleep and only rarely awakens patients.
Article
In order to confirm that re-intubation can be a risk factor of nosocomial pneumonia in mechanically ventilated patients, a case-control study was performed. Forty consecutive patients needing re-intubation were selected as cases. Each case was paired with a matched control for the previous duration of mechanical ventilation (+/- 2 d). Nineteen (47%) of the cases developed pneumonia after re-intubation compared with 4 (10%) of the controls (odds ratio [OR] = 8.5; 95% confidence interval [CI] 1.7 to 105.9; p = 0.0007). After adjusting for age, sex, and presence of prior bronchoscopy, the conditional logistic regression analysis demonstrated that re-intubation was the only significant factor related to the development of pneumonia (OR: 5.94; 95% CI 1.27 to 22.71; p = 0.023). Sixteen (73%) of the 22 patients lying semirecumbent during the interval between extubation and re-intubation developed nosocomial pneumonia versus three (16%) of the 18 in supine position (p = 0.001). These results indicate that semirecumbency during the period between extubation and re-intubation may play a role in nosocomial pneumonia development in patients who need re-intubation. Total intensive care unit stay (19.4 +/- 10 versus 13.9 +/- 11.9 days, p = 0.0008) and crude mortality (35 versus 20%, p = 0.14) were also higher in re-intubated patients when compared with controls. We conclude that re-intubation is a risk factor for ventilator-associated pneumonia and might be avoided in a substantial number of cases.
Article
Normal swallowing consists of a set of physiologic behaviors which result in food, liquid or other substances moving safely and efficiently from the mouth to the stomach. Dysphagic patients may have difficulty with any one or more of the anatomic or physiologic components of the oral, pharyngeal or esophageal stages of the swallow. Evaluation of the dysphagic patient should identify the anatomic or physiologic abnormalities characterizing the patient's swallow and include introduction and assessment of the efficacy of treatment strategies. Treatment may involve compensatory management, such as postural changes or enhancing sensory input, or active muscle exercise with or without the introduction of food. Speech-language pathologists have taken the lead in research on normal swallow and evaluation and treatment strategies for dysphagia.
Article
Severe pneumonia can be acquired by previously healthy patients, those with pre-existing illness, or those hospitalized for an unrelated illness. Because diagnosis is frequently difficult or delayed, treatment is usually empirically tailored to the most probable offending organisms and the patient's condition. This article reviews the pathogenesis of community- and hospital-acquired pneumonia, clinical features, and diagnostic techniques. An approach to selecting an antibiotic regimen is suggested.
Article
Pneumonia is a major cause of death in the elderly. To investigate the role of silent aspiration in community-acquired pneumonia, we examined the occurrence of silent aspiration during sleep in 14 elderly patients with acute episode of pneumonia and 10 age-matched control subjects by a new technique using indium111 chloride. Scanning of the thorax demonstrated that 71% of patients aspirated, whereas aspiration was observed in only 10% of control subjects. The percentage of positive scans was significantly higher in patients with acute episode of pneumonia than in control subjects (p < 0.02). The results may indicate an important role of silent aspiration in the development of community-acquired pneumonia in the elderly.
Article
The source of ventilator-associated pneumonia (gastric or oropharyngeal flora) remains controversial. We investigated the source of bacterial colonisation of the ventilated lung in 100 consecutive intensive-care patients. Gram-negative bacilli were isolated from the lower respiratory tract in 19 patients. Bacteria isolated from the stomach contents either previously or at the same time were identical to lower respiratory isolates in 11 patients. No gram-negative oropharyngeal isolate was identical to a lower respiratory tract isolate. Gastric bacterial overgrowth with gram-negative bacilli was associated with the presence of bilirubin in the stomach contents. Detectable bilirubin was also associated with subsequent acquisition of gram-negative bacilli in the lower respiratory tract. Only 5 gastric aspirate specimens with pH < 3.5 contained gram-negative bacilli. These results establish a relation between duodenal reflux and subsequent bacterial colonisation of the lower respiratory tract. Restoration of normal gastroduodenal motility might help prevent pneumonia in intensive-care patients.
Article
Oral-pharyngeal dysphagia in Parkinson's disease is well recognized. The aim of this study was to establish the mechanisms of oral-pharyngeal dysphagia in these patients. Using simultaneous videoradiography and pharyngeal manometry, we studied 19 patients with Parkinson's disease (12 with oral-pharyngeal dysphagia and 7 without oral-pharyngeal dysphagia) and compared them with 23 healthy controls. the clinical severity of Parkinson's disease predicted neither the presence nor the severity of dysphagia. Minor alterations in oral function were common in controls and patients, but pharyngeal dysfunction was significantly more prevalent in patients. Incomplete upper esophageal sphincter (UES) relaxation was present in 4 patients (21%), all of whom showed increased hypopharyngeal intrabolus pressure, but not all of whom had a diminished UES opening. The patients had a reduced UES diameter (P = 0.004) and a higher intrabolus pressure compared with the controls (P = 0.007). Pharyngeal contraction pressures were lower in patients, but 6 patients with dysphagia and an abnormal pharyngeal wall motion had normal peak pressures. An incomplete UES relaxation and a reduced UES opening, both associated with high intrabolus pressure, are prevalent in Parkinson's disease. Oral-pharyngeal dysphagia in Parkinson's disease is multifactorial, with the majority of patients showing oral and pharyngeal dysfunction, even before the clinical expression of dysphagia. Impaired pharyngeal bolus transport is the major determinant of dysphagia.
The purpose in this paper is to consider the importance of early nutrition for critically ill patients, briefly reviewing the effects of malnutrition, and the metabolic response to starvation and sepsis. Discussion includes assessment of nutritional status and nutritional requirements, with a suggested enteral feeding regime; and also the combined effect of enteral nutrition and glutamine on gut integrity and its relevance to nosocomial pneumonia, and the ability of the gut to accept food during critical illness.
Article
To determine the within-subject variability and to estimate the quantity of occult aspiration of nasopharyngeal secretions during sleep in normal humans. Prospective duplicate full-night sleep studies. Pulmonary sleep laboratory, university hospital. Ten normal male volunteers aged 22 to 55 years. Two full-night polysomnographic recordings with infusion of 2 mL/h radioactive 99mTc tracer into the nasopharynx through a small catheter during EEG-documented sleep. Standard lung scans were conducted immediately following final awakening. Aspiration was defined as the presence of radioactivity in the pulmonary parenchyma on two separate views. A mean sleep efficiency of 85.7 +/- 2.6% was found with no difference between the two study nights. A total of 5 of the 10 subjects studied had tracer evident in the pulmonary parenchyma following final awakening. Three had the tracer apparent following the first-night study and four had tracer apparent following the second-night study. Thus, two subjects aspirated on both nights. Comparing the subjects who aspirated with those who did not, no significant difference could be found for age, time spent in bed, sleep efficiency, apnea-hypopnea index, arousal plus awakening index, or percent of sleep time spent in a supine position. The quantities of tracer aspirated were on the order of magnitude of 0.01 to 0.2 mL. Aspiration measured by this technique occurs commonly in healthy young men during sleep, is unrelated to sleep quality, and is variable within subjects studied on more than one occasion. The quantity aspirated is of an order of magnitude likely to contain bacterial organisms in physiologically significant quantities.
Article
Laryngeal vestibule penetration is a prerequisite for deglutitive aspiration. This study aimed to analyze the mechanism and model the risk of laryngeal penetration before or during the pharyngeal swallow. Videofluoroscopic swallowing studies of 29 patients with neurogenic dysphagia with penetration before or during the pharyngeal swallow were compared with 12 controls. A stepwise regression analysis was used to define the coordinative defects leading to bolus penetration into the laryngeal vestibule. The mechanism was biomechanically analyzed. The stepwise regression modeled a laryngeal penetration index from the coordination between laryngeal vestibule closure and bolus release at the glossopalatal junction and the timing of upper esophageal sphincter opening relative to glossopalatal junction opening. The model accounted for 86% of the observed variance in severity of laryngeal penetration among the dysphagics. The observed incoordination resulted from both delayed initiation and slowed enactment of deglutitive laryngeal elevation. A dysphagic individual's risk of incurring laryngeal penetration before or during 1-, 3-, or 5-mL swallows is proportional to two temporal measures of coordination made from 1-mL swallows. The severity of the relevant defects (delayed and slowed laryngeal elevation) is proportional to the severity of swallow dysfunction.