Truth is Stranger than Fiction – in the Latest Dysphagia Research (Part 1)
By guest blogger: Amanda Warren, MS, CCC-SLP
Edited by Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com
Mark Twain once said, “Truth is stranger than fiction, but it is because fiction is obliged to stick to possibilities; truth isn’t.”
This certainly was the case for me as I attended the 2018 Dysphagia Research Society’s (DRS) Annual Meeting in Baltimore, MD. Many of us speech-language pathologists (SLPs) think of ourselves as “just” clinicians (and I could write a whole separate blog post about that, couldn’t I?); therefore, it is easy for us to see the name of this conference, skim the session titles, and decide that a conference like this is over our heads or that we are not the target audience. But, you know what? I learned so much! Additionally, much of it has already impacted my clinical practice just in these few weeks after the March conference. As such, I wanted to share some of that newfound knowledge with you. This is not because I obtained all the answers, but because sitting in a room with the foremost experts in our field (and listening intensely for 3 days), makes you question everything you know.
Those questions make us all better clinicians.
Similar to Karen Sheffler’s SwallowStudy.com post last year (please also see the second edition of 2017), I’ll start with a caveat that these are not the only topics that were covered at this year’s DRS. These were a few pieces of dysphagia research that really got me thinking. So, read on. You might just learn that even in the field of dysphagia, truth is stranger than fiction.
1. The diagnosis of dysphagia is correlated with higher costs and higher mortality than in those patients without dysphagia.
From session titled: Economic and Survival Burden of Dysphagia Among Inpatients in the United States presented by Dr. David Francis
Dr. David Francis from the University of Wisconsin presented published work by Patel, Krishnaswami, Steger, Conover, Vaezi, Ciucci and Francis titled: Economic and survival burden of dysphagia among inpatients in the United States. This was a study that pulled data from 2009-2013 from the Healthcare Cost & Utilization Project and the National Inpatient Sample. They looked at patients who were over 45 years old and had hospital stays of under 180 days. They learned that 2.7 of 88 million inpatients (3%) have dysphagia. Keep in mind, those are just the people who have been medically coded correctly. The actual numbers of people with difficulty swallowing are likely much higher, as dysphagia is often under-reported and under-diagnosed.
The mean length of stay for these patients was 8.8 days in comparison to 5.0 days for those without dysphagia. Their total inpatient costs were $6,243 higher, on average, and they were 33.2% more likely to be transferred to a nursing facility or rehabilitation center instead of going home at discharge. Most surprisingly (or maybe not?) patients with dysphagia were 1.7 times more likely to die in the hospital than those without.
Wow, right? So whenever someone asks you, why do you do what you do? Why do SLPs work with patients with dysphagia? You can come back to this article and start with this reason: Our patients are sicker, their hospital stays are longer, and their chance of morbidity is higher. We get the challenge to try to change those numbers and improve these people’s lives! What a gift.
2. Pyriform sinus pooling has a higher association with aspiration than vallecular pooling in patients with Head and Neck Cancer.
From session titled: Association between pharyngeal pool and aspiration using fiberoptic endoscopic evaluation of swallowing in head and neck cancer patients with dysphagia presented by Sorina Simon
Sorina Simon, from Maastricht University Medical Center in the Netherlands, shared her work studying residue and risk in patients with head and neck cancer. Her team studied about 100 participants (under 85 years old) who had received either chemotherapy, radiation, or a combination of chemotherapy and radiation. Using videofluoroscopic swallow studies/VFSS (aka, Modified Barium Swallow Studies or MBSS), they measured vallecular residue and pyriform sinus residue on a 3-point scale (absent, less than 50%, and more than 50%). They also assessed for the presence or absence of aspiration. They found that there was a statistically significant association between pyriform sinusresidue and aspiration, but not between vallecular residue and aspiration. Interestingly, the amountof pooling was not significant.
It made me start to think about the practice patterns at the hospitals that I work in. What restrictions do we place on our patients due to “risk” for aspiration, even if aspiration isn’t occurring?Do we really factor in where residue is in the pharynx when making our diet recommendations? Could we be less restrictive, if we factored this knowledge into our clinical practice?
3. Not all aspects of the swallow worsen over time in a degenerative disease, even in people with Parkinson’s disease.
From session titled: Relationship between reflex cough and swallow timing in Parkinson’s disease presented by Dr. Karen Hegland
One of the leading causes of death in the later stages of Parkinson’s disease (PD) is pneumonia, which may be due to dysphagia-related aspiration pneumonia. So it’s no surprise that SLPs are studying dysphagia in this patient population to see what we can do about it.
Dr. Karen Hegland and colleagues at the University of Florida recently studied 60 people with PD (ages 50-85 years old). Using the VFSS/MBSS, they collected data on the timing of the swallows and the Penetration/Aspiration Scale (PAS) scores. Her team also measured participants’ Urge to Cough using capsaicin in a nebulizer. They found that the longer someone had Parkinson’s, the more impaired their urge to cough would be. (In other words, the person would require a larger amount of a substance getting into his airway before he would sense the need to cough.) They also found that the worse the urge to cough, the more delayed laryngeal vestibule closure (slow to fully close the airway) would be. However, the fascinating part of the study comes when they learned that reduced urge to cough was associated with longer duration of laryngeal vestibule closure AND that penetration/aspiration scale scores were not impacted!
Hmmm… what could this possibly mean? We don’t know for sure, but Dr. Hegland made us all wonder. When cough sensitivity decreases, there may be delays in onset of laryngeal vestibule closure, which puts our patients with Parkinson’s at higher risk for airway compromise during swallowing. However, are there signs of natural compensation? Is it possible that the longer duration of laryngeal vestibule closure may be a natural compensation method to protect the airway, reducing the amount or frequency of penetration and aspiration?
If that hypothesis is possible… I wonder, are there times when a diagnosis alone makes me overly cautious about someone’s risk for aspiration? Do I have a confirmation bias in that I’m looking for certain deficits in certain patient populations?
If this makes you want to learn more, check out Dr. Hegland’s lab and her other work. She’s changing the way we all think about airway protection, especially in people with neuromuscular disorders!
Editor’s Note: For more information on Parkinson’s Disease as presented during #DRS2016, please see last year’s Dysphagia Digest on Parkinson’s.
4. Lower lingual pressures in people with Parkinson’s disease are associated with higher PAS scores.
From session titled: The influence of tongue strength on oral bolus preparation, swallowing effiency, and airway invasion in Parkinson’s disease presented by Dr. Sarah Perry
So if Dr. Hegland’s work in fact #3 above intrigues you, you must also check out the amazing work being done at Columbia University in Dr. Michelle Troche’s lab. Dr. Sarah Perry presented her recent work with 35 people with Parkinson’s disease. She used the IOPI to test both maximum strength and endurance of lingual muscles, as well as assessing the participants’ swallow function on Fiberoptic Endoscopic Evaluation of Swallowing (FEES) with the Yale Pharyngeal Residue Severity Rating Scale and the Penetration/Aspiration Scale (PAS). Dr. Perry and her colleagues found that lower lingual pressures on a swallow specific task were, in fact, associated with a higher or worse PAS score.
(Editor’s Note: the PAS scale is from 1-8, with 1 being no penetration/aspiration and 8 being aspiration without any patient reaction of coughing to eject the aspirate, aka, silent aspiration. See: Rosenbek, J.C., Robbins, J.A., Roecker, E.B., Coyle, J.L., Wood, J.L. (1996). A penetration-aspiration scale. Dysphagia, 11, 93–8.
So sure… for anyone who studies oropharyngeal dysphagia, that truth may not actually be stranger than fiction as a stand-alone. However, I have a question for clinicians out there: What objective measures are you collecting at the bedside? Do you incorporate testing like what Drs. Perry and Troche are using with the IOPI in your clinical evaluations? Maybe these objective measures could better predict who needs further instrumental assessment and who may not. In this day-and-age when time and resources are finite, and your productivity is being challenged, could a simple tool help you prioritize the needs of your patients?
Editor’s note: As someone with an extremely high palate with a decreased ability to achieve high maximum isometric tongue pressures (MIP), I urge you to use caution due to the likelihood for unexpected variability in your patients. Check out those oral cavities and palates. For a literature example that studied these variabilities: See this article by Pitts, L.L., Stierwalt, J.A.G., Hageman, C.F. & LaPointe, L.L. (2017) from the Dysphagia journal, Volume 32, Issue 6: The Influence of Oropalatal Dimensions on the Measurement of Tongue Strength. https://link.springer.com/article/10.1007/s00455-017-9820-4
5. Digital palpation of swallow elevation at bedside is minimally correlated with actual hyolaryngeal excursion on VFSS/MBSS.
From session titled: Clinical Utility of Perceptual Methods for Assessing Hyolaryngeal Movement presented by Danielle Brates
Danielle Brates, a PhD student who has had the opportunity over the years to work with both the University of Wisconsin and now New York University (with Dr. Sonja Molfenter), presented her work exploring our perceptual ability to assess laryngeal elevation of the swallow at the bedside. Danielle explained that 62% of SLPs report using palpation of the swallow as part of their clinical swallow evaluation. However, she studied 87 heterogeneous participants who underwent both clinical swallowing evaluations and videofluoroscopic swallow studies, and there was minimal correlation between the SLP’s assessment of hyolaryngeal excursion and whether or not hyolaryngeal excursion was actually present on the VFSS/MBSS. In addition, and possibly even more fascinatingly, the experience level of the SLP in question did not actually make them more accurate in this measure.
Intense, right? How many larynges have you palpated during your bedside evaluations? What information do you think you are gaining? And more importantly, what exactly are you documenting based on what you feel? It is time to think twice. Do you trust your palpation of the swallow in evaluation? What about during your therapeutic sessions?
This post is part 1 of a 3 part series. Stay tuned for the next installment of the DRS Dysphagia Digest 2018 for news from the Dysphagia Research Society’s Annual Meeting. Keep in mind; many of these studies are still in process. Where possible, we will point you to citations and primary literature to read. But in many cases, you will need to wait months (if not up to a year) for final results to be published on this data. This gives you all the more reason to regularly attend the Dysphagia Research Society’s Annual Meetings. The next one is in sunny San Diego from March 7-9, 2019! In the meantime, we encourage you to read other work on related topics by these authors. Links provided to their research where possible.
But never hesitate to trot on over to https://pubmed.ncbi.nlm.nih.gov to take a peek around for yourself!
You can even use the “Open Access[filter]” in Pubmed to find the free-open-access articles available. See also: https://www.ncbi.nlm.nih.gov/pmc/tools/openftlist/
Thank you to my guest blogger:
Amanda Warren, MS, CCC-SLP, is a medical Speech-Language Pathologist practicing in the city of Boston, MA. She has extensive experience in outpatient, acute care, rehabilitative care, skilled nursing and home care environments. Amanda teaches in Speech-Language Pathology at the undergraduate level at Gordon College and at the graduate level at Boston University. She is an author of continuing education courses at Northern Speech Services. She has a special interest in palliative dysphagia management, augmentative communication at the end of life, and patient-family advocacy and education.
By Karen Sheffler