Categories
Dysphagia Professional Issues Research

December Research Tuesday

To Eat or Not to Eat: What Information do Clinicians Use in Recommending an Oral Diet?
I LOVE the holiday season.  I love the decorations, the spirit in the air, and spending time with friends and family.  And if you are at my house, that means food – lots of food.  Our family loves to cook and eat together, and I cannot imagine a time of year when it would be more difficult to not be able to eat. Making the recommendation for oral versus nonoral feeding is pretty much the most important decision we make as swallowing therapists.  There are very few things that more dramatically change a patient’s life than taking away their PO status.  We should not take these recommendations lightly.  With great power comes great responsibility, and we should constantly be assessing why we make certain decisions.  Back in 2008, Dr. Logemann and 24 colleagues investigated this topic – they wanted to know how and why clinicians make their oral or nonoral feeding recommendations – and luckily they published this information for us to use!
Logemann, J. A. et al. (2008). What information do clinicians use in recommending oral versus nonoral feeding on oropharyngeal dysphagia patient? Dysphagia, 23. (Full Text Here)
This study was comprised of two phases.  In the initial phase, a group of 23 experienced dysphagia clinicians identified the variables they might use in making NPO vs PO decisions.  Those variables were then rated by the clinicians to determine the most important of the identified variables.  The chart below describes the 13 most influential variables identified.
chart 12142
In the second phase of the investigation, 20 modified barium swallow studies with patient histories were sent to the SLPs for analysis.  For each patient, clinicians were asked whether they would recommend an oral diet, partially oral diet, or nonoral feeding.  They were then asked what diet consistency they would recommend if they gave a partially oral feeding, whether dental status affected their decision, and if they would recommend postures or maneuvers.
The decision for a full oral feeding was made 57% of the time, whereas the decision for limited oral comprised 15% of the recommendations and nonoral 26%. A Kappa statistic was used to determine the agreement between the clinicians.  A low Kappa statistic would signify low agreement between the clinicians whereas a high Kappa statistic would signify high agreement between the clinicians.  There was a statistically substantial Kappa statistic (meaning that the agreement was above chance happening) for the full oral decision (.72) and the nonoral decision (.66).  There was little agreement amongst the clinicians on the type of oral diet recommended. A lot of data was collected – see the full text to go through it.
The Results:
The four most influential variables for the PO versus NPO decision were
  1. amount of aspiration (by far the most frequently used variable – and a very subjective variable, as well – what is ‘a lot’ of aspiration?)
  2. frequency of aspiration
  3. diagnosis
  4. history of pneumonia (best agreement amongst the clinicians)
The most frequently recommended postures/maneuvers were
  1. effortful swallow
  2. head turn
  3. chin tuck
  4. super supraglottic swallow
  5. supraglottic swallow
  6. repeat swallow
Some thoughts:
While the frequency of recommendations for full oral feeding was the same amongst clinicians, the amount of experience was found to be an important factor in determining if limited oral feeding was allowed.  Those clinicians with fewer years of clinical experience were more conservative and recommended nonoral feeding more frequently than those with more experience.  They also recommended more maneuvers than the clinicians with more years of experience.
As I have grown in my career, I have become much more liberal with my diet recommendations and learned to trust my postures/maneuvers more.  In my earlier years I was so terrified to allow a patient to leave an evaluation without a strategy (or multiple strategies) to completely eliminate all aspiration.  While this is certainly an admirable goal, I now know so many other factors determine whether a patient actually gets pneumonia (like dependence on others for feeding/oral care, pulmonary status, etc – see my July Research Tuesday post on The Most Important Aspiration Pneumonia Article Ever for more details on this!).  I have witnessed many patients who aspirate buckets who never get pneumonia, and I have seen how well certain maneuvers/postures dramatically improve the swallow.  I don’t feel the need to have the patient use a supraglottic swallow with a head turn & chin tuck – especially if a head turn will suffice.  And how do I know all this?  I have seen it.  I have completed a MBS or FEES on the patient and determined the safest swallowing situation for them by visualizing them complete the strategy or swallow the consistency.
In our practice we have spoken with many younger clinicians who rely on bedside assessments because their facility will not allow them to get an instrumental and they are too afraid to rock the boat to demand one.  We see their patients with multiple strategies and limited diets based on the best “guess” the clinician could make from the bedside.  Is that really fair to the patient – to manipulate or forbid their mealtime  based off of a guess?  Know for sure – don’t let a bean counter take away your ability to properly determine a diet.
I really appreciate Dr. Logemann and colleagues for giving us this opportunity to glance into the radiology suites of 23 skilled clinicians.  We can learn so much from our colleagues.  I hope this article gives you new insights into your own clinical decision making, and don’t forget to share this information with some newbies!
Have a very happy holiday season from the SASS family!!

sass2sass

 

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out sasspllc.com or connect with Kelley on Twitter or LinkedIn.

Photo credit flikr for creative commons

 

Categories
Dysphagia FEES Research

November Research Tuesday

 The Gamble of Blue Dye Testing
First I want to start off with what this post isn’t:
-The purpose of this post is not to bash the way many therapists have been practicing for years.
-The purpose of this post is not to convince therapists that they should never use blue dye ever again.
-The purpose of this post IS to objectively evaluate the reliability data behind the Modified Evans Blue Dye Test to best determine what we are actually observing when we do a blue dye tracheostomy swallowing exam.
So what is a Modified Evans Blue Dye Test (MEBDT)?  This clinical swallowing test was developed to identify aspiration in patients with tracheostomies with the help of suctioning by the respiratory therapist.  In the original Evans Blue Dye Test, the clinician would place a few drops of dye on a patient’s tongue and the respiratory therapist would suction the patient every few hours and report back as to whether blue dye was present in suctioned secretions.  Speech pathologists modified this to add blue dye to food and drinks to further evaluate aspiration with trials of certain consistencies. The Modified Evans Blue Dye Test was formally introduced in Dysphagia Journal in 1995.
It all makes sense.  If the patient is aspirating secretions or food consistencies, the blue dye will go into the trachea/lungs and the respiratory therapist will suction it out.  If the respiratory therapist doesn’t suction any blue out, then the patient must not be aspirating.  Bingo bango, our job is done!
Unfortunately life just isn’t that simple.  Less than 5 years after the introduction of the MEBDT, clinicians performing instrumental swallow exams began reporting on patients who had no blue dye return on MEBDT but who were found to be aspirating on instrumental exam.  Bummer.  Big bummer.
As SLPs we must critically look at any test we perform to ensure that the test is
  1. Reliable enough to produce the same results under consistent conditions
  2. Sensitive enough to identify those who do have the searched for criteria
  3. Specific enough that those who do not have the searched for criteria are not identified
There have a been many different studies looking at reliability, sensitivity and specificity of the MEBDT.  Because we are depending on pretty specific circumstances to obtain our outcome – the patient must aspirate, the respiratory therapist must suction enough and in the right spots to pull out the aspirated material, the dye must be dark enough to perceive in the secretions – many have claimed that the MEBDT may not be sensitive enough to identify everyone who aspirates.  The biggest concern with MEBDT is a false negative – this would occur if the MEBDT does not show aspiration but the patient actually is aspirating. This study, from Dysphagia Journal waaaay back in 1999,  was one of the first to identify the high likelihood of false negative results with MEBDTs.
Brady SL, Hildner CD, Hutchins BF.  1999. Simultaneous video- fluoroscopic swallow study and modified Evans blue dye procedure: an evaluation of blue dye visualization in cases of known aspiration. Dysphagia 14:146–149.  Full Text Here
This investigation analyzed 20 simultaneous MBS exams and MEBDTs to determine if the MEBDT correctly identified each aspiration event that occurred. Before the MBS, the investigators dyed thin, nectar and puree consistency barium blue.  During the MBS, if aspiration was observed, the respiratory therapist would suction the patient to identify if blue dye was present in their tracheal secretions.  The respiratory therapist also suctioned the patients at the termination of the study.  Two SLPs reviewed the MBS exams and identified the quantity of aspiration for the exam as either trace or greater than trace.  The investigators then compared the results of the MBS exams and the MEBDTs.
Results:
Aspiration occurred in 8/20 of the exams, however, suctioning after the aspiration event only identified aspiration in 4/20 exams.  Of those exams that were determined to have greater than trace amounts of aspiration, tracheal suctioning identified the aspiration in 100% of patients.  Of those exams which showed only trace amounts of aspiration, tracheal suctioning identified the aspiration in 0% of patients.  There were no charts or graphs in this study, so I made my own because I am a visual learner:

mebdt chart

In this study, the Modified Evans Blue Dye Test was shown to have a false-negative error rate of 50% in cases of observed aspiration on MBS.  Donzelli and colleagues replicated this study in 2001using FEES and found the exact same 50% false-negative error rate and only a 67% identification of aspiration in patients with large amounts of aspiration.
These are grim statistics.  Ultimately what we can take from this information is that the MEBDT is not sensitive enough to identify all aspiration events, especially when only trace amounts of aspiration occur.  This means that for every two MEBDTs performed that do not identify aspiration, one of the patients likely could be aspirating.  That is a gamble – a huge gamble – and a gamble that I don’t want to take with my patients.
So what can a MEBDT be used for?  It can be used as a screening device to positively identify aspiration.  That’s it.  If a test is performed and aspiration is identified, you can be pretty darn sure that aspiration is occurring.
Failure to consistently identify aspiration isn’t the only negative to the MEBDT.  Last time I checked, aspiration wasn’t the only indicator of dysphagia.  The MEBDT doesn’t identify penetration or significant residue- both of which constitute dysphagia.  It doesn’t identify the quantity and consistencies of penetration, aspiration or residue nor does it identify the actual physiological impairments that are causing the dysphagia or give us indications on how to treat them.
So how do we identify if a patient with a tracheostomy has dysphagia?  I think you know my answer…
GET AN INSTRUMENTAL SWALLOWING EVALUATION!!
This is the only way to objectively identify aspiration in a patient with a trach or without one.  Both MBS and FEES have generally good reliability, sensitivity and specificity.  They both will identify on which consistencies penetration, aspiration or residue occur, and they both will provide insight on the physiological deficits causing the dysphagia.
Don’t gamble with aspiration.  Get an instrumental exam and know for sure.

Works cited:

Donzelli J, Brady S, Wesling M, Craney M. Simultaneous modified Evans blue dye procedure and video nasal endoscopic evaluation of the swallow. 2001.  Laryngoscope;111:1746 –1750.

Peruzzi WT, Logemann JA, Currie D, Moen SG. 2001. Assessment of aspiration in patients with tracheostomies: comparison of the bedside colored dye assessment with videofluoroscopic examination. Respir Care 46:243–247.

Thompson-Henry, S., & Braddock, B. 1995. The modified Evan’s blue dye procedure fails to detect aspiration in tracheostomized patient: Five case reports. Dysphagia,10, 172–174.

O’Neil-Pirozzi TM, Lisieeki DJ, Monsek J, Connors JJ, Milliner MP. 2003. Simultaneous modified barium swallow and blue dye tests: a determination of the accuracy of blue dye test aspiration findings. Dysphagia;18:32-8.

 

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out sasspllc.com or connect with Kelley on Twitter or LinkedIn.

Photo credit flikr for creative commons

Categories
Dysphagia FEES Professional Issues Research

October Research Tuesday

Ode to the Bean Counter: The Price of Dysphagia
In every medical facility there is always a bean counter, and in most, more than one.  They are the people who deny your ten thousandth request for a new Hausted chair for modified barium swallow studies because the old one “works just fine,” even when it doesn’t.  They are the folks who won’t purchase prethickened liquids because dietary can mix it up from powder, even though cups of glue keep showing up on patient trays.  And they are the ones who don’t understand why you need an instrumental exam to determine a patient’s diet status – no one has ever needed one before you came along.  So we, the ever faithful army of passionate dysphagia professionals, start collecting our own special data – we document the delayed or impossible studies, present facts about our patient’s hydration status and outline how the changes we are begging for will improve the quality of care we provide.  I’m not sure about you, but this kind of research was not covered in my graduate program…
Having been the one addressing the bean counters on many of occasions, I get waaay too excited when I find an article like this – one that speaks the bean counter’s language.  Dollars and cents!  Complex statistical analyses!  Facts and figures!  Historically speech pathologists haven’t spent a lot of time researching cost/benefit analyses and the impact on our services to hospitals, but in the last few months I have seen some promising studies coming out on this very topic (here’s looking at you, London Health Sciences Center in Ontario, Canada and the University of South Carolina).  With the changing landscape of healthcare and insurance, justification of our services will become even more crucial.  This article, which comes from our ENT colleagues at Mount Sinai School of Medicine and New York Eye & Ear, is just a small snapshot of the incidence and financial impact of dysphagia, but the information it provides could be invaluable to you the next time you have to email your bean counter.  Enjoy!
Altman KW, Yu GP, Schaefer SD. 2010. Consequence of dysphagia in the hospitalized patient: impact on prognosis and hospital resources. Archives of Otolaryngology Head Neck Surgery 136(8):784-9. Full Text Here
This study looked at the National Hospital Discharge Survey (NHDS) data from 2005-2006 to identify the incidence of dysphagia and its most common comorbid medical diagnoses as well as to further quantify the length of stay, morbidity and mortality of dysphagia.
To obtain their data, the investigators searched for the dysphagia ICD-9 code (ICD-9-CM 787.2) in the first 7 diagnosis codes of each patient abstract from the 2005-2006 NHDS data (the NHDS lists the most important diagnoses first).  They then searched for dysphagia symptoms and other major accompanying disorders listed in the first 7 diagnoses.  There were 20 major diseases identified as most frequently occurring with dysphagia.  Using some very fancy software and complex statistical analysis, the authors found the mortality rates as well as the standard errors, confidence intervals and rate ratios of the disease and mortality rates among patients with and without dysphagia.
Findings:
During the years 2005-2006, there were over 77 million estimated hospital admissions and 271,983 of these were associated with dysphagia (.35% of all hospital admissions).  See the chart below for further details regarding rate of dysphagia by sex, age and race.

oct data

The authors note that the most significant findings from the demographic section of the investigation were that the percent of hospitalizations increase with age and that those with dysphagia older than 75 had twice the national average of hospital admissions than the average of all other groups.
When the authors looked at major diseases and symptoms associated with dysphagia, they noted that half of the admissions had at least one comorbid diagnosis of fluid & electrolyte disorder, disease of the esophagus, ischemic stroke, or aspiration pneumonia.  Those patients who had a diagnosis of dysphagia had an increased number of diagnoses at discharge compared to those without dysphagia – 88.9% vs 57.7% with 5 or more comorbid diagnoses, respectively.
The mortality rate of patients with dysphagia undergoing rehabilitation and those with coronary atherosclerosis was significantly elevated compared to those who did not have dysphagia.
The most notable (and bean-counter important) part of the study looked at the median number of hospital days for diseases associated with dysphagia compared to those not associated with dysphagia.  They found that the median number of hospitalization days for patients without dysphagia was 2.4 days compared to 4.04 days for those with dysphagia – that’s a 40.6% increase!!!!  Hospital stay was increased by 30% or more for patients with congestive heart failure, Parkinson disease and ischemic stroke and for patients with hemorrhagic stroke, the median hospital stay increased to 10.55 days.
To summarize their findings the author noted these three important take-aways:
  1. age older than 75 years was associated with double the risk of dysphagia associated with hospitalization
  2. the presence of dysphagia was associated with a 40% increase in length of hospital stay in all age groups
  3. patients undergoing rehabilitation had a greater than 13-fold increased risk of mortality during their hospitalization when they had dysphagia.
The aim of the study was to find statistically significant associations of variables.  The authors concede that cause and effect relationships cannot be determined from this type of data, but that important conclusions can be made.
The investigators then presented more data supporting the additional costs and the likely underestimated number of patients diagnosed with dysphagia. One of the figures was an established formula that was created to determine the actual increased cost for a one-day stay with community-acquired pneumonia.  The total daily cost was found to be $2,454 which they believe is less than the actual daily cost of a patient with dysphagia/aspiration pneumonia (alternative means of nutrition/hydration, additional diagnostic testing and more care from more providers would raise the price). They extrapolate the additional number of hospitalization days per year and the estimated additional cost per year of the extra days of hospitalization to yield an economic burden of approximately $547,307,964.
Whew.  That was a lot of math, but it is important math that helps us help the bean counters understand why we are fighting so hard to help people with dysphagia.
As a speech pathologist I most often enjoy looking at the little picture – helping the individual patient get better and eat.  While that is my mission and the joy of my heart, I must remember that the bean counter’s mission is to look at the big picture – to make sure that the hospital has enough money to stay open.  The authors conclude that the best ways to save money in dysphagia care are to identify the dysphagia early, especially in those patients with high-risk comorbid conditions such as old age, stroke, neurodegenerative disease, and pneumonia, and to provide proper intervention including evaluation, treatment and diet modification.  So, armed with all of your data, documentation, and published research, let’s work with those bean counters to get patients properly (and objectively) evaluated and treated to help improve both the big and little picture.

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out sasspllc.com or connect with Kelley on Twitter or LinkedIn.

Photo credit flikr for creative commons

Categories
Dysphagia Research

September Research Tuesday

Which Came First – the Dysphagia or the PEG?
Early in my career as a speech-language pathologist, a close family friend was diagnosed with tonsillar cancer.  The cancer was caught early and the prescribed treatment was surgical removal of the tumor as well as radiation treatment of the area.  It was a tough diagnosis for him and his family, but I, as the all-knowing swallowing therapist, was there to sweep in to offer my opinions and recommendations.  He was receiving no management from an SLP, so I provided him with prophylactic swallowing exercises and encouraged him to talk to his physician about a feeding tube to be there as a support if swallowing became too difficult for him.  His physician offered him a feeding tube, but, as the strong Southern gentleman that he was and still is, he declined.  I, frankly, was annoyed.  He didn’t listen to my opinion.  He declined something that I thought would really help him through this battle.  I was baffled.
It is amazing how much I have learned in my career from people who declined the well-researched, thoughtful, and loudly provided advice I have given them.  Though swallowing during the treatment became very difficult for him, he did manage to go through the entire treatment and recovery without using a feeding tube.  He drank a lot of milkshakes, but now, many years out from his cancer, he is regaining weight and eating most anything he wants.
Since that time I have worked in a comprehensive head and neck (H&N) cancer clinic and had the opportunity to walk through the chemo/radiation process with hundreds of patients.  I was lucky to be a part of a clinic that provided SLP services to patients throughout their treatment and that encouraged patients to remain eating as much as they could until it became unsafe to do so.  This article came out while I was working in the H&N cancer clinic and I have passed it on to many therapists who have asked me about PEG tubes during H&N treatment.  It poses an interesting question about PEG tubes during treatment: does the use of the PEG and the decreased use of swallowing muscles actually contribute to the swallowing dysfunction during H&N cancer treatment?
Langmore S, Krisciunas GP, Miloro KV, et al. Does PEG Use Cause Dysphagia in Head and Neck Cancer Patients? Dysphagia. 2012;27:251-259.  Full text here
This retrospective study from Dr. Langmore’s lab  looked at weight and diet outcome differences in patients treated with radiation for H&N cancer who used a PEG tube versus those who did not use a PEG tube.  They also looked at differences between those who maintained a full PO diet, those who had some PO intake and those who were NPO.  Outcomes were reviewed after completion of radiation treatment and at 3, 6, and 12 months post-treatment.
The article begins with a brief review of the use of feeding tubes in management of dysphagia in head and neck cancer.  There are two common approaches to PEG use in H&N cancer: prophylactic placement, where the PEG is placed prior to treatment in preparation for dysphagia to come, and therapeutic placement, where the PEG is placed after a diagnosed dysphagia or significant weight loss occurs.  The authors acknowledge the lack of evidence supporting and refuting both PEG placement options and note that the decision is facility-dependent.  A literature review looking for studies about the topic yielded very little and those studies that were found rarely looked at swallowing outcomes on instrumental exams (FEES, MBSS).  Studies looking at weight loss found variable outcomes between the prophylactic PEG, therapeutic PEG and total oral intake.  Two studies (Chen et al., 2010 & Morton et al., 2009) found that a greater number of patients given PEGs had dysphagia at 3-12 months post-treatment compared to those who were not given PEGs.  These were two of the first studies that identified PEG tube placement as potentially detrimental to swallowing.
To identify subjects for the study, the authors completed a chart review of eligible H&N cancer patients looking at their weight, diet level, and PEG status at start of radiation,  completion of radiation and 3, 6, and 12 months post-radiation.  As instrumental swallowing evaluations were not available for most patients, the two major indicators for swallowing function were percent weight loss and diet level.  Diet levels were ranked from 1-6 based on the chart below.

sept diet levels

Fifty-nine patients with different cancer types and at different disease stages were selected. Some did and some did not receive surgical and/or chemo treatment. Twenty-seven patients received prophylactic PEGs, 6 received therapeutic PEGS and 26 did not receive PEGs.
Two analyses were completed with the first comparing prophylactic PEG with no/therapeutic PEGS.   No significant differences were found in percent weight change between the two groups, but the prophylactic PEG groups had significantly worse diet outcomes than than the no/therapeutic PEG group.
The second analysis compared patients with 100% PEG, partial PEG/partial oral diet, and 100% oral diet.  No statistically significant differences in percent weight change between the groups was found, but the partial PEG/partial oral and the 100% oral group had significantly higher mean diet scores than the 100% PEG group.  See the chart below for the data on diet scores. (click on the photo to make it larger)

sept diet outcome

Both analyses showed no significant weight loss differences between the groups, but they did show that those who had some or full oral intake had improved diet levels up to one year post radiation treatment.  In the chart above, you can see that the 12 month mean diet scores for the 100% oral diet & partial PEG groups were puree/wet soft or above, whereas the PEG group were almost all still on the PEG.  That’s some pretty good data for those wanting to maintain PO intake during treatment.
The implications for patients with H&N cancer receiving radiation are twofold:
1. we “should reconsider recommending prophylactic PEG placements in patients who are likely to depend entirely on the PEG for nutrition unless it is absolutely necessary” and
2. “when a patient is given a PEG, this study suggests that they should be strongly encouraged to continue to swallow something orally on a regular basis”
While this is a small study, the implications are big.  This study encourages us to help patients maintain PO intake as long as possible before, during and after radiation.  Our role as swallowing therapists now becomes a coach through the treatment, helping patients maintain what musculature they have and prevent loss of strength & coordination.  Because of the individualized nature of H&N cancer treatment, each patient will experience different swallowing impairments which may change throughout the course of their treatment and recovery. We want our patients to be as safe as possible during meal times, so determining whether patients NEED alternative means of nutrition/hydration is still very important – this is where our instrumental evaluations of swallowing are invaluable.  Instrumental evaluations allow us to determine what foods a patient can tolerate safely and if any compensatory strategies might help a patient. I was amazed at how many patients with H&N cancer were profoundly helped by simple strategies. Some went from not eating any solids to taking soft solids with a head turn, or went from aspirating all thin liquids to taking thin liquids with a supraglottic swallow.  Working closely with patients to customize therapy and swallowing strategies will help not only prevent the PEG, but help patients maintain swallowing strength as they recover.
So when working with your H&N cancer patients, here are a few things you can do to help them through their treatment:
  1. Prepare patients for the possible dysphagia that could come, encourage swallowing & if you are able, teach prophylactic swallowing exercises (see Hutcheson et al., 2013 for more details on this)
  2. Teach patients to identify signs/symptoms of dysphagia
  3. Teach patients how to prevent pneumonia (ORAL CARE!)
  4. Evaluate patients to find out what they can eat to help them to continue eating as much as they can!

Works cited:

Chen AM, Li B, Lau DH, Farwell DG, Lu Q, Stuart K, et al. Evaluating the role of prophylactic gastrostomy tube placement prior to definitive chemoradiotherapy for head and neck cancer. Int J Radiat Oncol Biol Phys. 2010;78(4):1026–32.

Morton RP, Crowder VL, Mawdsley R, Ong E, Izzard M. Elective gastrostomy, nutritional status and quality of life in advanced head and neck cancer patients receiving chemoradiotherapy. ANZ J Surg. 2009;79(10):713–8.

Hutcheson KA; Bhayani MK; Beadle BM; Gold KA; Shinn EH; Lai SY; Lewin J.  Eat and exercise during radiotherapy or chemoradiotherapy for pharyngeal cancers: Use it or lose it.  JAMA Otolaryngology – Head and Neck Surgery. 2013;139(11):1127-1134.

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out sasspllc.com or connect with Kelley on Twitter or LinkedIn.

Photo Credit: Unsplash

Categories
Dysphagia Research

August Research Tuesday

Is Thicker Better for Dysphagia Treatment?
We have all seen the sad, mostly full cups sitting on tables from hospitals to nursing homes to home health.   I have even had patients tell me that they would rather dehydrate themselves and die than drink it.  Honey.  I hate honey.  I don’t put it in my tea, and I find it a huge pain to cook or bake with it.  Most of all, I really hate it when patients are subjected to “drink” honey-thickened liquids.  I mean, really, as Dr. Ashford asks us all the time, what naturally occurring liquid is honey-thick?!?  Umm…honey?
I have found over the last few years many SLPs have started to shy away from it, but, in 2005 Garcia et al. (1), found that 18.5% of SLPs still used honey-thickened liquid as their most commonly prescribed liquid modification (yes, over nectar-thick). Thankfully, this month’s Research Tuesday article gives us some evidence to avoid the goop.
But first, here’s a little history. A lot of the press on honey-thickened liquids came about in 2008 when  2 large, multi-institutional studies on the compensatory strategies of thickening liquids and chin tuck were published.  The first study from Dr. Logemann’s lab (2) involved 742 patients with Parkinson Disease.  One finding (of many) was that aspiration was most successfully eliminated with honey-thickened liquid, compared to nectar-thickened liquids and chin tuck.  The second study from Dr. Robbins’ lab (3) found that of those patients who aspirated despite all three trialed interventions (nectar-thick, honey-thick, and chin tuck), honey-thickened liquids resulted in “more than a two-fold pneumonia risk after adjustment of risk factors.”
Yikes.
So the frustrating paradox of honey-thickened liquids presenting from these studies is that a patient is less likely to aspirate on honey-thickened liquids, but more likely to develop pneumonia from aspirating honey-thickened liquids.
Want to prevent aspiration?  Make it thick.
Want a patient to develop pneumonia?  Make it thick.
NOOOOOOOOOOOOOO.  My head can’t handle that!
The Robbins study and many other studies in the nutrition literature also note that dehydration is more common with thicker liquids than thin.  Its not that thickened liquids are less hydrating, per say, but patients refuse it more often – hence our sad, mostly full cups.  Unfortunately, we so often find that thickening liquids requires less training and oversight – they are easier for us, family and nursing to implement.  But is thicker really better for our patients?
Leder, S., Judson, B., Sliwinski, E., Madson, L. (2013). Promoting Safe Swallowing When Puree is Swallowed Without Aspiration but Thin Liquid is Aspirated: Nectar is Enough. Dysphagia 28: 58-62. (Full text here)
This prospective study from Dr. Leder’s lab at Yale sought to determine the most appropriate liquid recommendations for patients who aspirated on thin liquids but not on puree.  Each of the 84 patients who met the inclusion criteria (aspirated on thins but not puree, stable medical condition) were evaluated with FEES.  The evaluation consisted of 3 trials of puree followed by 1-3 trials of thin liquid, on which at least one aspiration event must occur, followed by 3 boluses each of nectar-thickened and honey-thickened liquid, presented in random order.  A safe swallow was defined as no aspiration on nectar, honey or puree.  Patients were then placed on diets containing both nectar-thickened and honey-thickened liquids and nursing was asked to monitor patients for signs/symptoms of aspiration during meals for 24 hours.  Diets were considered a success if the patient did not have increased cough, increased temperature, or signs/symptoms of an upper respiratory infection for the next 24 hours.
Of the 84 participants, 100% showed no signs/symptoms of aspiration on either the nectar or honey-thickened liquids on FEES or on the diets in the following 24 hours.  See the chart below.
results august
From this data the authors concluded that nectar IS enough (emphasis mine):
“All participants who swallowed pureed food without aspiration but exhibited aspiration with thin liquid ingested both nectar-like and honey-like thickened liquid consistencies with 100% success at the time of testing and 24 h after testing. Therefore, in a specific subset of dysphagic patients who swallowed puree without aspiration but aspirated thin liquid, the data indicate that there does not appear to be a need to either test with or recommend a diet containing honey-like thickened liquid, i.e., nectar is enough. Importantly, the widespread practice-based intervention of using a thickened liquid (in the present case, nectar-like consistency) to improve patient care has been supported by empirical, research-based evidence.”
I LOVE the results, but I’m not going to lie, I really wish there were long-term outcomes as well as the 24 hour results.  Oh well.  Not every research study is designed to please my curiosity, and in medicine we very rarely get long-term data like the Robbins study.
I also thought this statement tucked into the introduction was incredibly profound:
“Although clinically intuitive, compensatory diet modification using either nectar-like or honey-like thickened liquids needs to be hypothesis-driven, accepted by the patient, and shown to be beneficial prior to their implementation in patient care.”
Clinicians should set these criteria as a standard and ask themselves the following questions prior to writing any recommendations for diet modification.
Is my recommendation:
  1. Hypothesis-driven?
  2. Accepted by the patient?
  3. Shown to be beneficial prior to implementation?
If the clinician cannot answer those three things in the affirmative, then they are subjecting a patient to a diet that may not be required or beneficial.  These questions also highlight the importance of both accepting patient autonomy in decision making (see my June Research Tuesday on this topic) and having an instrumental evaluation to prove that the diet modification is actually beneficial.  At SASS we are so privileged to provide clinicians with this objective information via FEES evaluations at their facilities.  If you as a clinician do not currently have any access to instrumental evaluations for patients, consider speaking with you DON or rehab director to see if a mobile company could provide these services for you.  It will profoundly impact your practice and your patient’s quality of life.
As for the goop?  At SASS we almost never test it and almost never recommend it.  I can’t actually remember the last time I recommended honey-thickened liquids.  In my humble opinion, if the patient is not safe on nectar, then there really isn’t a safe liquid for them to ingest.  It may be easier to recommend making the liquid super thick so that the patient does not have a chance of aspirating, but we have to remember that part of our job is ensuring the patient’s quality of life – this includes proper hydration and mealtime pleasure – and drinking glue just doesn’t do that.

1. Garcia, J., Chambers, E., Molander, M. (2005) Thickened Liquids: Practice Patterns of Speech-Language Pathologists. American Journal of Speech-Language Pathology. Vol. 14.

2. Logemann JA, Gensler G, Robbins J. (2008). A randomized study of three interventions for aspiration of thin liquids in dementia or Parkinson’s disease. J Speech Lang Hear Res. 51:173–83.

3. Robbins J, Gensler G, Hind J. (2008). Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial. Ann Intern Med. 148:509–18.

4. Logemann, J.  & Robbins, J. (2007). Landmark Clinical Trial in Swallowing Results Released : Study Tests Aspiration Risk and Related Health Outcomes. The ASHA Leader.

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out sasspllc.com or connect with Kelley on Twitter or LinkedIn.

(Photo credit: Hillary Stein for Creative Commons)

Categories
Dysphagia Research

July Research Tuesday

The Most Important Aspiration Pneumonia Article…Ever
This month I am going old school.  Waaay old school.  I’m talking 1998 old school, which in the world of research is basically primitive and never encouraged by professors or important research-reading people. Oh well.  Sometimes we need to go back to the basics – to the seminal articles which help us understand why we do what we do, and that which has been shown time and again to be truth in our practice.  My trip to the past was motivated by my selection of this 2014 article as my original Research Tuesday post.  Its a lovely article showing how NPO status and presence of a NG tube were significant predictors of aspiration pneumonia in acute stroke management, but as I read it and attempted to write about it, I kept thinking about this beauty.  I had to share.  I couldn’t resist the antique, and I love that the shiny new article I was attempting to write about was another article that supported a lot of the information from this old faithful.  Whether its news to you or old hat, I hope you enjoy it!
Langmore SE, Terpenning MS, Schork A, Chen YL, Murray JT, Lopatin D, Loesche WJ. Predictors of Aspiration Pneumonia: How Important is Dysphagia? Dysphagia. 1998;13:69–81.
This prospective outcome study, brought to us by Dr. Langmore, Dr. Terpenning and a before-he-completed-his-PhD Joseph Murray, looked at a variety of possible predictors for aspiration pneumonia.  The authors followed 189 subjects for 4 years (!!!) to determine who got aspiration pneumonia and what predictive factors the patients had in common.  The subjects were all male and had a variety of medical diagnoses (CVA, neurologic disease, COPD) and were followed in acute care, nursing homes and as outpatients.  Each participant was given a clinical swallowing evaluation, a FEES, a MBSS, three scintigraphy exams to assess esophageal clearance and reflux, a dental exam, saliva & throat samples, a thorough chart review and an interview to gather pertinent information.  The exams and interview were repeated annually unless a status change occurred, and the patients were followed until death, an occurrence of pneumonia or till they failed to return.  A panel of physicians was established to create a consensus as to when pneumonia was present.  The features used to diagnose pneumonia were “elevated white blood cell count (12,000 or above); fever (temperature >100.5 F); and new infiltrate on the chest radiograph, with the most weight given to the radiographic evidence.”   Risk factors for aspiration pneumonia were identified in the following categories: functional status, medical/health status, oral/dental status, and swallowing/feeding status.  Here are some of the most interesting results from each category:
  1. Functional status: Dependence for feeding and oral care were associated with a high level of pneumonia.
  2. Medical/Health Status: The highest incidence of pneumonia was found in nursing home patients (44%).  Patients with COPD, GI disease, and CHF experienced pneumonia at a similarly high rate as those with neurological diagnoses, and patients with both COPD & GI disease had the highest rate of pneumonia (50%).
  3. Oral/Dental Status: Number of decayed teeth, frequency of brushing teeth, and dependence for oral care were significantly associated with pneumonia.
  4. Swallowing/Feeding Status: Aspiration of food was found to have a higher association with aspiration pneumonia than aspiration of liquids.  Pharyngeal delay, premature spillage, and excess pharyngeal residue were the physiologic swallowing parameters most linked with aspiration pneumonia. Aspiration of secretions and excess secretions in the mouth were both significantly associated with pneumonia in dentate subjects, as was reduced esophageal motility.  And of the upmost importance was this quote, one that we all shake our heads at in dismay and disbelief: “In our study, tube feeding was significantly associated with aspiration pneumonia, which is consistent with the findings of others [19,28,31–34,38,40]. Because our patients were usually not taking any food or liquid by mouth, aspiration presumably occurred with secretions.”
The authors found that the best predictors of pneumonia were:
  1. dependent for feeding
  2. dependent for oral care
  3. number of decayed teeth
  4. tube feeding
  5. more than one medical diagnosis
  6. number of medications
  7. smoking status
And then they created this awesome flow chart to show how all of the factors are linked to result in aspiration pneumonia. (click on the image to make it bigger)
predictors of pneu
WOW.  Just wow.  Its almost an entire dysphagia course in one single journal article.  I reference it at least once a week, and it is on my mind during every chart review and every evaluation I complete.  At SASS, we have taken this article to heart so much that our FEES report and oral mechanism templates cover almost all of those 7 predictors (we don’t actually sit down and count decayed teeth, but we do note oral condition). SLPs will never truly be able to identify every single patient who will get aspiration pneumonia, but with a good instrumental evaluation and these factors in mind, we can provide the patient and staff some good information as to their risk.
May I take a quick moment on my soap box?…Please?… How often do we harp about oral care only to get brushed off by family or the patient or nursing staff?  A lot.  This is the article to show directors of nursing everywhere when patients aren’t getting their teeth cleaned or are getting food administered too quickly.  Those dinky green spongy things and mouthwash don’t cut it.  Patients need friction and abrasion to get plaque off teeth and they need a toothbrush to do it.  If teeth aren’t present, gums should be brushed and dentures appropriately cleaned.  Bacteria lives in those places, too.  Dr. Ashford always says the best tools to combat pneumonia are a teaspoon, a toothbrush and a thermometer – use them! SASS has created an amazing oral care presentation designed for CNA inservices that should be available soon.  If you need help in this battle, please let us know!  Phew, ok, rant over.
There are many other articles out there that elaborate on the findings of this article in single studies (such as the one I started to write about for this post), but this one is so thorough and covers so much information about the multifactorial nature of aspiration pneumonia – it should be in everyone’s “dysphagia” file.  At the end, the authors note “ a major conclusion was that dysphagia and aspiration are necessary but not sufficient conditions for development of pneumonia.”  That is such an important take-away from this study.  There is no cookbook for dysphagia evaluation and treatment.  We have to lean on our training, experience, and articles like this one to help us best treat our patients. Never stop reading and never stop learning, and, occasionally, go back and look at some of these ancient artifacts of dysphagia research…there is much to gain from it!

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out sasspllc.com or connect with Kelley on Twitter or LinkedIn.

Categories
Dysphagia Research

March Research Tuesday

 
ResearchTuesdayBooksSA Swallowing Services is joining Gray Matter Therapy again for this month’s Research Tuesday!  Research Tuesday was created to “increase accountability for reading research, advocate for reading research, and improving exposure to research.” Every second Tuesday of each month, speech-language pathologists from all settings across the world join together at Gray Matter Therapy to share current literature reviews so that we may all benefit from the most up-to-date research.
This month, Kelley Babcock, MS, CCC-SLP, BCS-S, shares a few of her favorite research studies presented at the 2014 Dysphagia Research Society in Nashville, TN.

 

Barium on Sushi & MBSS on Dogs: A Roundup of Studies from the 22nd Annual Meeting of the Dysphagia Research Society.  
This past week I attended my first Dysphagia Research Society Annual Meeting, and I am still exhausted.   Each day was packed with back-to-back 15 minute oral presentations and poster sessions of the most current dysphagia research from scholars in a variety of disciplines from across the world.  It was thrilling to hear from some of the greatest researchers in the field of speech-language pathology and enlightening to learn from radiologists, otolaryngologists, gastroenterologists, pediatricians, dentists and even engineers!  I highly encourage you to attend if you ever have the opportunity – I learned a lot, gained some perspective, and met a lot of talented clinicians and researchers.  Pictures weren’t allowed during the presentations, so here is a great shot of my name tag : ).
nametag
I could not pick just one study to discuss for Research Tuesday as there were so many that absolutely knocked me off my feet, so below are quick reviews of a few of my favorites.  As an aside, much of this is unpublished and therefore not vetted entirely through the peer-review process.  It is false to assume that because one research study showed a result that this should become standard of care or brought into your practice.
My main takeaway from the whole week was that there is so much more to consider when determining patient swallowing safety, pneumonia risk, and patient outcome than just the presence or absence of aspiration on an instrumental evaluation.  The following studies exemplify this.
Domer, A., Adams, B., Traslavina, R., Plowman, E.K., Kuhn, M., Belafsky, P. (2014, March). Effects of Aspirated Thickened Water on Pulmonary Health and Survival in a Lagomorph Model.  Oral presentation at the 22nd Annual Meeting of the Dysphagia Research Society, Nashville, TN.
This study from the University of South Florida and UC Davis addressed the impact of aspirated thickened water on lung tissue.  The researches compared survival of rabbits after “aspiration” of water thickened with xanthan-gum and water thickened with cornstarch.  (I put aspiration in quotes there because the thickened water was actually inserted into the trachea rather than an aspiration event occurring).
They found that survival rate for the rabbits who received xanthan-gum was 100% whereas survival rate of the rabbits who received cornstarch was only 12.5%.
Takeaway: This study caused quite a stir and also motivated my favorite quote from the week.  During the question and answer portion, a very famous SLP researcher got up to the microphone to make the comment that “now we know that xanthan-gum won’t thicken the liquids as much as starch-based thickener and also won’t kill you as much either.”  Now remember, this is bench science with large quantities of thickened water inserted directly in the trachea of rabbits.  We CANNOT translate this to humans.  This study does not mean that we should never ever ever use starch-based thickeners ever again or that you contributed to the death of a patient by giving him starch-based thickeners, but it does give us some good information to consider.  I personally hate starch-based thickeners and do not use them due to how they change consistencies over time, but if you don’t know much about your thickeners, I hope this study will encourage you to investigate them further – see Dr. Russell Mills research on the topic.  I look forward to the publication of this study and further investigations from these labs.
Troche, M.S., Brandimore, A.E., Okun, M.S, Davenport, P.W., & Hegland, K.  (2014, March).  Reflex Cough Sensitivity in Parkinson’s Disease and Dysphagia.  Oral presentation at the 22nd Annual Meeting of the Dysphagia Research Society, Nashville, TN.
Troche and colleagues from the University of Florida looked at reflex cough thresholds and urge to cough in patients with Parkinson’s Disease (with and without dysphagia) and healthy adults.  Participants in the study were stimulated with capsaicin – the chemical that gives hot peppers their heat – in increasing concentrations to determine the participant’s cough sensitivity and to see which concentration would stimulate a two cough response.
They found that most of their PD participants (with and without dysphagia) did not have a reliable cough at the highest concentration tested.  They also found that in those patients with PD who did have dysphagia, cough reflex thresholds were higher and cough sensitivity was lower.
Takeaway: We frequently see silent aspiration in the PD population, but this term “dystussia,” or impaired cough, was new to me. It was interesting that the PD patients both with and without dysphagia showed decreased sensitivity. It makes perfect sense given the reduced laryngeal function that occurs in PD, but I wonder if cough is something that we could be training/helping to maintain very early in the disease process.  The researchers noted that aspiration pneumonia is the leading cause of death in PD, so I believe these findings are of huge clinical significance.
Ishman, S.L., Sidell, D., Westhoff, T.M., Benke, J.R., Vigilar, M.V., Anderson, R.M., Lefton-Greinf, M.A. (2014, March). Impact of FEES on Feeding Status in Children with and without Neurologic Impairment.  Oral presentation at the 22nd Annual Meeting of the Dysphagia Research Society, Nashville, TN.
Cincinnati Children’s Hospital worked with Johns Hopkins School of Medicine for this retrospective analysis of feeding outcomes after FEES evaluation in children.  The purpose of the study was to determine whether a FEES exam more often resulted in upgrading or downgrading a patient’s diet and whether neurologic or other patient variables would impact feeding status.
The researchers found NPO status changed from 43% prior to evaluation to 21% after evaluation and thus that FEES “liberalized oral feeding status in 52% of children who were NPO.”  Neurologic status and other patient variables did not significantly contribute to feeding status, though the speaker noted that there were more incidences of abnormalities (penetration/aspiration/residue) in patients with neurologic status.
Takeaway: Often patients and families assume that instrumental evaluation will result in a more restrictive diet, but this study found the opposite.  I find the instrumental evaluation to be liberating in that it allows us to truly know what is occurring rather than making guesses or assumptions.  Sometimes the instrumental exam results in a more restrictive diet, sometimes in compensatory strategies, and sometimes in a less restrictive diet, but we won’t know if we don’t look.
I hope you enjoyed this tiny taste of the studies presented at this year’s DRS Meeting.  I plan to follow a few of the other studies, and hopefully when they get published I can do a Research Tuesday write up on them!  Thanks for stopping by SA Swallowing Services webpage for this month’s installment of Research Tuesday – see you next month!

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out sasspllc.com or follow Kelley on twitter @kelleybabcock.

Categories
Dysphagia Research

February Research Tuesday

ResearchTuesdayBooksSA Swallowing Services is thrilled to join Gray Matter therapy for this month’s Research Tuesday!  Research Tuesday was created to “increase accountability for reading the research, advocate for reading the research, and improving exposure to research.” Every second Tuesday of each month, speech-language pathologists from all settings across the nation join together to share current literature reviews so that we may all benefit from the most up-to-date research.
This month, Kelley Babcock, MS, CCC-SLP, BCS-S shares a new study looking at the relationship between residue and aspiration.
Much Ado About Residue: The Relationship Between Residue & Aspiration
Molfenter, S.M. & Steele, C.M.  The Relationship Between Residue and Aspiration on the Subsequent Swallow: An Application of the Normalized Residue Ratio Scale.  Dysphagia. 2013; 28:494–500.
I recently joined the Dysphagia Research Society which gave me unlimited access to the Dysphagia Journal and its years of literature on swallowing and swallowing disorders.  Needless to say there was a lot to choose from for my first Research Tuesday blog!  There were so many articles, all with such important implications on swallowing, but this one stood out to me like a beacon in the night.  It stopped me in my tracks and made me think.  My first thought was slightly dismissive: “residue is residue – it’s bad, and can result in penetration/aspiration – but what of it?” Then I really began to ponder more deeply about the issue of residue – its timing, location, the consistencies with which it occurs and the physiologic reasons behind its occurrence – and I realized that residue is often what makes or breaks my swallow studies.  All of our physician and allied health colleagues focus on the A-word.  All they care about is if aspiration occurred.  That’s when a swallowing evaluation becomes a pass or fail proposition, the answer to a yes or no question.  But we all know that a swallowing evaluation is not meant to be a pass/fail venture, but rather a descriptive analysis of what’s going on when someone swallows.  So I read more.  And here is what I learned.
This was a retrospective study of neurogenic patients utilizing a relatively new tool, the Normalized Residue Ratio Scale on modified barium swallow studies.  I had never heard of this scale & hoped it would be a new scale for describing residue, something to add to my swallow study tool kit that might be a little more specific than the “trace, collection, majority, or no clearance” from MBSImP or my basic old “thin coating, partial filling, or near/complete filling” that I use in FEES. I found the scale online (http://www.steeleswallowinglab.ca/media/NRRS_Rating_Instructions.pdf) and learned that though it is a nifty tool, an “image-based measurement of post-swallow residue,”  it appears to be designed more for research than clinical use.  From the seminal article on this scale (1), “The NRRS is a continuous measurement that incorporates both the ratio of residue relative to the available pharyngeal space and the residue proportionate to the size of the individual.”  It utilizes imaging software and spreadsheets which may not be a viable option for most speech pathologists.  Below you can see an image from the original article with vallecular residue outlined in white.

residue scale

The purpose of the study was to determine the influence of post-swallow vallecular & pyriform sinus residue on penetration and aspiration on the clearing swallow immediately following the residue.   The article began with a quick review of the literature on post-swallow residue and its influence on aspiration.  As there is very limited research on this subject matter, only five studies were identified and most of those that were found had limits in reliability and study design.  The study focused on 156 thin liquid swallows that resulted in secondary, tertiary or 4+ clearing swallows of residue after the initial swallow.  The first author scored each swallow utilizing the Penetration-Aspiration Scale (2) as well as the NRRSv (for vallecular residue) and the NRRSp (for pyriform sinus residue) and 20% of the ratings were scored by the second author for interrater reliability.   A clinically significant level of residue was considered to be that with a NRRS score >0.06.  The author set a cut-point to determine a significant or “unsafe” swallow for penetration/aspiration at a a PA Scale score of 3 or higher (“Material enters the airway, remains above the vocal folds, and is not ejected from the airway”).
The authors found that 43.5% of swallows which contained preswallow residue of concern were found to have a cleansing swallow with a PA Scale score greater than 3.  When they looked at the scores based on location, they found that only residue in the valleculae was found to have a significant relationship with subsequent swallow safety.  Of those swallows with preswallow vallecular residue, 53% were found to be unsafe compared to 37.3% for pyriform sinus residue.  A threshold of NRRSv >0.09 with thin liquids was determined to double the risk of PA Scale score greater than 3 on the following swallow and deemed to be a clinically significant threshold, but this was introduced with caution, as other consistencies and cup sips were not studied.    See the chart below for a great visual of this.

graph

This study surprised me.  If I had placed a bet on the outcome prior to reading it, I would have absolutely chosen pyriform sinus residue to be more significant on second-swallow penetration/aspiration.  The proximity of the pyriforms to the laryngeal vestibule just seems to be the right positioning for material to fill up and spill into the larynx, and my experience with head and neck cancer and FEES may influence that thinking.  This brings me to the limitations of this study.  Though I think the outcome is quite interesting and has certainly changed the way I look at residue in swallowing evaluations, the study only contained thin liquid trials on neurogenic patients.  I suspect that if we looked at increased viscosities with a greater variety of diagnoses (especially with head and neck cancer) we may have a different outcomes.  I also wonder how this study would compare on FEES.  Often post-swallow penetration/aspiration is missed on the MBSS secondary to turning the fluro off to reduce radiation exposure.  With FEES, the swallow is continuously monitored from the start, so no instance of penetration/aspiration is missed.
One of the really exciting things about this study is that the NRRS allows us to make quantitative, rather than just subjective, measurements of vallecular  and pyriform sinus residue.  There are so many studies that can come from this tool and I believe that we can learn and quantify a lot from using it.  Now if only there were a way to bring it easily into the hospital radiology suite!

Works Cited:

1.  Pearson, W.G., Molfenter, S.M., Smith, Z.M., and Steele, C.M.  Image-based Measurement of Post-Swallow Residue: The Normalized Residue Ratio Scale.  Dysphagia. 2013; 28:167–177
2. Rosenbek, JC, Robbins, J, Roecker EV, Coyle, JL, & Woods, JL.  A Penetration-Aspiration Scale.  Dysphagia  11:93-98, 1996.
Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out sasspllc.com or follow Kelley on twitter @kelleybabcock.