Dysphagia Grand Rounds 9

Can respiratory-swallowing coordination be trained and sustained? Does it have a beneficial impact on swallowing physiology and airway protection? What effects does it have in the head and neck cancer population with chronic dysphagia? Read the open-access paper in the link below to learn more. Then watch the Dysphagia Grand Rounds 9 webinar to learn about the clinical implications of this research.   

Article: Respiratory-Swallow Training in Patients with Head and Neck Cancer
Authors: Bonnie Martin-Harris, David McFarland, Elizabeth G. Hill, Charlton B. Strange, Kendrea L. Focht, Zhuang Wan, Julie Blair, and Katlyn McGrattan
Journal: Archives of physical medicine and rehabilitation. 2015;96(5):885-893

Read DGR 9 article here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4410058/

Watch DGR 9 webinar: Releasing on September 30, 2017

Abstract: 
Objective

To test a novel intervention to train swallowing to occur in the mid-to-low expiratory phase of quiet breathing to improve swallowing safety and efficiency.

Design
Safety and efficacy non-randomized clinical trial with one-month follow-up.

Setting
Head and neck cancer (HNC) ambulatory clinics.

Participants
Thirty patients with HNC and chronic dysphagia completed the intervention. Fifteen of these patients participated in a one-month follow-up visit.

Interventions
Training protocol based on hierarchy of motor skill acquisition to encourage autonomous and optimal respiratory-swallowing coordination. Visual feedback of respiratory phase and volume for swallowing initiation was provided by nasal airflow and rib cage/abdomen signals.

Main Outcome Measures
Respiratory-swallow phase pattern, Modified Barium Swallow Impairment Profile™© (MBSImP) scores, Penetration Aspiration Scale (PAS) scores, M.D. Anderson Dysphagia Inventory scores

Results
Using visual feedback, patients were trained to initiate swallows during the mid-expiratory phase of quiet breathing and to continue to expire after swallowing. This optimal phase patterning increased significantly after treatment (p <0.0001). Changes in respiratory-swallowing coordination were associated with improvements in three MBSImP component scores: laryngeal vestibular closure (p = 0.0004), tongue base retraction (p <0.0001), and pharyngeal residue (p = 0.01). Significant improvements were also seen in PAS scores (p <0.0001). Relative to pre-treatment values, patients participating in one-month follow-up had increased optimal phase patterning (p <0.0001), improved laryngeal vestibular closure (p = 0.01), tongue base retraction (p = 0.003), and pharyngeal residue (p = 0.006) MBSImP scores, and improved PAS scores (p <0.0001).

Conclusions
Improvements in respiratory-swallowing coordination can be trained using a systematic protocol and respiratory phase-lung volume related biofeedback in patients with HNC and chronic dysphagia, with favorable effects on airway protection and bolus clearance.

Dysphagia Grand Rounds 8

Although the Modified Barium Swallow Study (MBSS) is an important diagnostic tool for the evaluation of swallowing function, it requires caution related to the use of ionizing radiation. One strategy that is popularly used to decrease radiation exposure is reducing the pulse rate of the radiation beam emitted during MBSS. Although temporal resolution appears to be critical for viewing the swallow in its entirety, it is not known if decreasing fluoroscopy pulse rates negatively affects the ability to make judgments regarding swallowing impairment.

Dysphagia Grand Rounds 8 reviews a research study aimed at improving our understanding of the clinical implications of pulse rate, on diagnostic yield and dysphagia treatment recommendations. Read the paper below first and then watch the DGR 8 webinar to learn why these findings are important for your clinical practice. 

Article: Preliminary Investigation of the Effect of Pulse Rate on Judgments of Swallowing Impairment and Treatment Recommendations
Authors: Heather Shaw Bonilha, Julie Blair, Brittni Carnes, Walter Huda, Kate Humphries, Katlyn McGrattan, Yvonne Michel and Bonnie Martin-Harris
Journal: Dysphagia. 2013;28(4):10.1007/s00455-013-9463-z

Read DGR 8 article here:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3762944/

Watch DGR 8 webinar here: http://dysphagiagrandrounds.yondo.com/playlist/dgr-8-august-2017/403

Abstract: 
Reducing fluoroscopic pulse rate, a method used to reduce radiation exposure from Modified Barium Swallow Studies (MBSSs), decreases the number of images available from which to judge swallowing impairment. It is necessary to understand the impact of pulse rate reduction on judgments of swallowing impairment and, consequentially, treatment recommendations. This preliminary study explored differences in standardized MBSS measurements (Modified Barium Swallow Impairment Profile (MBSImP™©) and Penetration Aspiration Scale (PAS) scores) between two pulse rates: 30 and simulated 15 pulses per second (pps). Two reliable speech-language pathologists (SLPs) scored all 5 MBSSs. Five SLPs reported treatment recommendations based on those scores. Differences in judgments of swallowing impairment were found between 30 and simulated 15pps in all 5 MBSSs. These differences were in six physiological swallowing components: initiation of pharyngeal swallow, anterior hyoid excursion, epiglottic movement, pharyngeal contraction, pharyngeal-esophageal segment opening and tongue base retraction. Differences in treatment recommendations were found between 30 and simulated 15pps in all 5 MBSSs. These findings suggest that there are differences in both judgment of swallowing impairment and treatment recommendations when pulse rates are reduced from 30pps to 15pps to minimize radiation exposure.