Pulmonary Rehabilitation in Patients with Dysphagia

( Sang Hun Kim ) 대한결핵 및 호흡기학회 2021 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.129 No.0

The function of swallowing is very complex in humans. Swallowing not only plays an important role in food digestion, but also plays a critical role in preventing the aspiration of food and/or other substances into the lower respiratory tract. To achieve this, precise coordination between breathing and swallowing is required as the pharynx acts as a common pathway for breathing and digestion. The swallowing reflex consists of afferent pathways, central integration, and efferent pathways. Any defects along the reflex arc can cause swallow dysfunction. Among these, timing of swallows may be the most important factor that determines the occurrence of pulmonary aspiration, since phases of inspiration and the expiration-inspiration transition are the most vulnerable for pulmonary aspiration. Dysphagia has a Greek etymology, and it means the state of being unable (dys-) to swallow (phagia). Dysphagia is one of the main complications associated with aspiration pneumonia. With increases in older adult populations, dysphagia causing aspiration pneumonia and nutritional impairment is a growing problem. Dysphagia can be caused by a wide variety of diseases. In general, it is divided into the disease group that involves the nervous system and the group that does not. Dysphagia that do not involves the nervous system are most often caused by anatomical structural changes, and head and neck tumors such as laryngeal or oral cancer are representative. In addition, dysphagia in respiratory diseases including COPD is reported with varying frequencies of 20-92%. In COPD patients, food aspiration is recognized as a risk factor for repeated acute exacerbations, pneumonia, and pulmonary fibrosis. Patients with COPD have impaired coordination between respiration and swallowing and are more likely to commence swallowing and resume respiration in the inspiratory phase, both in the chronic state as well as during exacerbations of the disease. Reported characteristics of dysphagia in people with COPD include oral and pharyngeal stasis, delayed swallow reflex, reduced laryngeal elevation during swallowing, cricopharyngeal dysfunction, laryngeal penetration and aspiration. Postextubation dysphagia (PED) is a common problem in critically ill patients with recent intubation. Although several risk factors have been identified, most of them are non-modifiable preexisting or concurrent conditions. Advanced age, prolonged mechanical ventilation, preexisting congestive heart failure, forced supine position, the presence of tracheostomy, nasogastric tube placement have been associated with a higher risk of developing PED. These conditions may also be experienced in acute exacerbation of COPD or severe postoperative pulmonary complications in lung cancer. In addition, acute dysphagia is occurred frequently during concurrent chemo-radiation or high-dose radiotherapy for lung cancer. With greater focus in modern medicine on quality of life, the importance of accurate swallowing assessment with appropriate evaluation tools is drawing greater attention. Videofluoroscopic swallowing study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) are well known and widely used diagnostic tools for dysphagia. VFSS provides a real-time view of oral, pharyngeal, and cervical esophageal phases of swallowing, and FEES is useful for direct visualization of the anatomy of the nasopharynx and supraglottic structures. Dysphagia treatment is focused on nutritional status, hydration, and reducing morbidity from pneumonia. There are several major therapeutic options for Dysphagia: dietary texture modifications, postural changes/compensatory maneuvers, and interventions to improve swallow function, therapeutic exercises, and neuromuscular stimulation. Dysphagia education, screening, and management in a pulmonary rehabilitation program can improve participants’ swallowing related quality of life and overall self-management of chronic respiratory disease and dysphagia.

뇌졸중으로 인한 연하 곤란에서 전기 자극의 효과

김대열,고은실,강보성,한태륜,이시욱 대한재활의학회 2008 Annals of Rehabilitation Medicine Vol.32 No.1

Objective: To investigate the benefit of electrical stimulation for dysphagia caused by stroke. Method: Ten consecutive stroke patients with dysphagia for 3 months or more were enrolled in this study and assigned to one of the two group (electrical stimulation group or sham group) according to randomization table. Five patients were allocated to electrical stimulation group and 5 patients to sham group. One patient in the sham group dropped out because of transfer to other hospital. Electrical stimulation with a maximal tolerable intensity was applied on both digastric muscles and both thyrohyoid muscles for 1 hour, 5 days a week for 4weeks in electrical stimulation group. Sham group received electrical stimulation in same condition except stimulation intensity of 1 mA. Clinical dysphagia scale, functional dysphagia scale and kinematic analysis of hyoid bone movement were assessed at baseline (before treatment), 2 weeks later (during treatment), 4 weeks later (after treatment). Results: The clinical dysphagia scale decreased in both group, of which the difference was not statistically significant. The functional dysphagia scale decreased significantly in the electrical stimulation group. The electrical stimulation group revealed greater improvement in clinical dysphagia scale and functional dysphagia scale compared to sham group. Conclusion: Electrical stimulation therapy with a maximally tolerable intensity to digastric and thyroid muscles might be effective in chronic stroke patients with dysphagia. Objective: To investigate the benefit of electrical stimulation for dysphagia caused by stroke. Method: Ten consecutive stroke patients with dysphagia for 3 months or more were enrolled in this study and assigned to one of the two group (electrical stimulation group or sham group) according to randomization table. Five patients were allocated to electrical stimulation group and 5 patients to sham group. One patient in the sham group dropped out because of transfer to other hospital. Electrical stimulation with a maximal tolerable intensity was applied on both digastric muscles and both thyrohyoid muscles for 1 hour, 5 days a week for 4weeks in electrical stimulation group. Sham group received electrical stimulation in same condition except stimulation intensity of 1 mA. Clinical dysphagia scale, functional dysphagia scale and kinematic analysis of hyoid bone movement were assessed at baseline (before treatment), 2 weeks later (during treatment), 4 weeks later (after treatment). Results: The clinical dysphagia scale decreased in both group, of which the difference was not statistically significant. The functional dysphagia scale decreased significantly in the electrical stimulation group. The electrical stimulation group revealed greater improvement in clinical dysphagia scale and functional dysphagia scale compared to sham group. Conclusion: Electrical stimulation therapy with a maximally tolerable intensity to digastric and thyroid muscles might be effective in chronic stroke patients with dysphagia.

치과위생사의 연하장애 지식 및 예방 태도가 노인구강건강 관련 교육요구도에 미치는 영향

노우정,김선영 한국치위생학회 2023 한국치위생학회지 Vol.23 No.4

Objectives: In this study, we aimed to examine the dysphagia knowledge, preventive attitudes toward dysphagia, and educational needs concerning geriatric oral health, of dental hygienists, and to provide fundamental information for recognizing the necessity of knowledge and education concerning geriatric oral health and for increasing educational needs. Methods: From April 1 to June 30, 2022, a questionnaire survey was administered to 198 dental hygienists via an online link. SPSS Statistics ver. 22.0 was used to conduct the frequency analysis, t-test, one-way ANOVA, Pearson’s correlation coefficient, and multiple regression analysis. Results: Regarding the difference in knowledge of dysphagia depending on general characteristics, the study participants had more knowledge of dysphagia when they were more interested in dysphagia and had a higher geriatric treatment frequency. The preventive attitudes toward dysphagia were strong in those who graduated from graduate school or higher, had more prevention and education at work, became more interested in dysphagia, received more education about dysphagia, had intention to receive additional education on dysphagia, and had a higher geriatric treatment frequency. Positive correlations were observed between knowledge of dysphagia, preventive attitudes toward dysphagia, and educational needs related to geriatric oral health. The educational needs related to geriatric oral health were found to be, significantly and positively influenced by preventive attitudes toward dysphagia, having master’s degree or higher, knowledge of dysphagia, and intention to receive additional education on dysphagia. Conclusions: It is necessary to improve the quality of oral health services offered to older patients by having accurate knowledge of dysphagia implementing appropriate prevention practices for dysphagia, and understanding the educational content needed by the oral hygienists and developing an effective education program to enhance their professionalism.

전국 병원의 연하장애 환자식 및 영양관리 서비스 제공 현황 조사

Ji-Soo Lee,Hee-Sook Lim,Aram Kim,Tae-Lim Kim,Weon-Sun Shin,Dal Lae Ju,Byung-Mo Oh 대한연하장애학회 2023 대한연하장애학회지 Vol.13 No.1

Objective: This study enrolls diverse hospitals and analyzes the differences in meal provision and nutrition management services for patients with dysphagia. Methods: A nationwide survey was conducted by mail and mobile for 850 medical institutions, and data were collected from 217 hospitals. We analyzed the status of the dysphagia diet and nutrition management by considering the type of hospital. Results: Among the hospitals surveyed, 167 (77%) provided texture-modified diets for dysphagia patients. The status of providing dysphagia diets and nutrition management for dysphagia differed depending on the institution. In particular, nutrition services for dysphagia patients in long-term care hospitals were poor. Difficulties in providing a dysphagia diet included the complexity of the cooking process, difficulty maintaining constant viscosity, difficulty in hygiene management, and low meal bills. Using commercial thickeners in cooking accounted for 72.5%, and only 41.9% of hospitals provided a commercial thickener with meals. Compared to the regular diet, the additional food cost to provide a single dysphagia diet meal was estimated to be 500-1,000 won. Based on a 5-point scale, we determined that the average scores for the importance and performance of nutrition management in patients with dysphagia were 4.29 and 3.19 points, respectively. Regardless of the type of hospital, performances of all the steps in the nutrition care process were significantly lower than their importance. Conclusion: Several difficulties are encountered in meal provision and nutrition management for patients with dysphagia, including the burden of expenses and human resources. Thus, the medical fees for a dysphagia diet need to be reasonably increased. Moreover, national health insurance should additionally cover nutrition education for dysphagia patients.

라이프케어를 위한 간호 인력의 연하곤란 관련 지식, 태도 및 간호수행과의 관계

이정미,장미영 한국엔터테인먼트산업학회 2019 한국엔터테인먼트산업학회논문지 Vol.13 No.4

This study was intended to understand the status of dysphagia related knowledge, attitude and nursing performance of nursing staff`s in geriatric hospitals, to confirm the correlation among these, and to provide basic resources for dysphagia nursing intervention programs. The 220 subjects were nursing staff`s who worked in geriatric hospitals located in G city and N city. For data analysis, The descriptive statistic was used to analyze the subjects' general characteristics, and dysphagia related characteristics, knowledge, attitude and nursing performance degree. For the differences of dysphagia related knowledge, attitude and nursing performance according to the subjects' general characteristics, t-test and ANOVA were used. The correlation of the subjects' knowledge, attitude and nursing performance degree was analyzed with Pearson's correlation coefficient. The score of the subjects' dysphagia related knowledge was average 14.07±2.94, the subjects' dysphagia related attitude was average 3.59±0.39, the subjects' dysphagia nursing performance was 3.10±0.43. dysphagia nursing performance had a significantly positive correlation with dysphagia related knowledge(r=0.295, p=.000) and dysphagia related attitude(r=0.392, p=.000). The above result of the study indicated positive attitude based on accurate knowledge is needed for nursing staff`s in geriatric hospitals to improve nursing performance for dysphagia. When education programs for dysphagia are planned in geriatric hospitals, it is necessary to consider knowledge level and attitude simultaneously.

K-EAT-10으로 확인한 지역사회 거주 노인의 연하장애 유병률 및 특성

민경철,김은희,우희순 대한작업치료학회 2023 대한작업치료학회지 Vol.31 No.1

목적 : 본 연구는 한국어판 Eating Assessment Tool-10(K-EAT-10) 연하장애 선별 검사를 활용하여 지역사회 거주 노인의 연하장애 유병률 및 특성을 확인하기 위해 진행하였다. 연구방법 : 경기도 내 일개 보건소에 내소하는 정상 인지 수준의 지역사회 거주 노인 89명을 K-EAT-10과 연하장애 설문지를 통해 연하장애 증상을 평가하였다. K-EAT-10로 유병률을 확인하였으며, K-EAT-10 3점을 기준으로 연하장애 정상군과 위험군을 나누어 두 그룹 간 차이 및 특성을 Mann-Whitney U로 분석하 였다. 결과 : K-EAT-10 총점 3점 이상의 연하장애 유병률은 24.7%(22명)이었다. 연하장애 증상이 있다고 자각하는 대상자 12명 중 7명은 실제로 연하장애 위험군에 속하였다. 정상군과 위험군 사이에는 연하장 애 증상 및 심리적 요소에서 유의미한 차이가 나타났다. K-EAT-10 항목 별로는 먹을 때 사레 걸림, 목에 음식물이 걸린 느낌, 알약 삼킬 때의 어려움이 주요한 증상으로 나타났다. 결론 : 본 연구를 통하여 일반 노화 과정의 연하장애 증상이 없거나 문제를 호소하지 않는 지역사회 거주 노인들도 내재되어 있는 연하장애 증상 확인을 위한 선제적 검사와 관리가 필요함을 알 수 있었다. 이에 지역사회 전문가들은 지역사회 거주 노인의 연하장애에 대한 관심을 갖고 그에 맞는 종합적인 관리 및 중재를 통한 질 향상 노력을 기울여야 할 것이다. Objective: The purpose of this study was to investigate the prevalence and symptoms of dysphagia in community dwelling elderly people using the Korean-Eating Assessment Tool-10 (K-EAT-10). Methods: A total of 89 K-EAT-10 results of community dwelling elderly individuals from 1 public health center were analyzed. Results: A total of 22 (24.7%) out of 89 respondents were screened as the dysphagia risk group (≥3 in K-EAT-10). Seven people in the dysphagia risk group felt that they have problems with dysphagia. The symptoms and psychologic issues of dysphagia were significantly different between the normal and dysphagia risk groups. The main symptoms were “I cough when I eat,” “When I swallow, food sticks in my throat,” and “Swallowing pills takes extra effort.” There was no significant relationship between age and gender. Conclusion: Community dwelling elderly people tend to underestimate their dysphagia symptoms and cognition as aspects of aging. Through this study, it was found that a preemptive examination and management are necessary to confirm the underlying symptoms of dysphagia even in subjects living in the community who do not have dysphagia symptoms. Therefore, experts of a community service organization such as a public health center should pay attention to the dysphagia of community dwelling elderly individuals and strive to improve the quality through comprehensive management and intervention. In the future, it will be important to establish a system for the management and linkage of dysphagia for the elderly in a community environment.

National Trends and Correlates of Dysphagia After Anterior Cervical Discectomy and Fusion Surgery

Roberto J. Perez-Roman,Evan M. Luther,David McCarthy,Julian G. Lugo-Pico,Roberto Leon-Correa,Steven Vanni,Michael Y. Wang 대한척추신경외과학회 2021 Neurospine Vol.18 No.1

Objective: Anterior cervical discectomy and fusion (ACDF) is the most common performed surgery in the cervical spine. Dysphagia is one of the most frequent complications following ACDF. Several studies have identified certain demographic and perioperative risk factors associated with increased dysphagia rates, but few have reported recent trends. Our study aims to report current trends and factors associated with the development of inpatient postoperative dysphagia after ACDF. Methods: The National Inpatient Sample was evaluated from 2004 to 2014 and discharges with International Classification of Diseases procedure codes indicating ACDF were selected. Time trend series plots were created for the yearly treatment trends for each fusion level by dysphagia outcome. Separate univariable followed by multivariable logistic regression analyses were performed to evaluate predictors of dysphagia. Results: A total of 1,212,475 ACDFs were identified in which 3.3% experienced postoperative dysphagia. A significant increase in annual dysphagia rates was observed from 2004–2014. Frailty, intraoperative neuromonitoring, 4 or more level fusions, African American race, fluid/electrolyte disorders, blood loss, and coagulopathy were all identified as significant independent risk factors for the development of postoperative dysphagia following ACDF. Conclusion: Postoperative dysphagia is a well-known postsurgical complication associated with ACDF. Our cohort showed a significant increase in the annual dysphagia rates independent of levels fused. We identified several risk factors associated with the development of postoperative dysphagia after ACDF.

Swallowing Status Comparison between Primary Dysphagia and Post-stroke Dysphagia in Inpatient Rehabilitation Facilities

Ickpyo Hong,Kimberly P. Hreha 대한연하재활학회 2020 Swallowing Rehabilitation Vol.3 No.1

Objectives: To examine the improvement of discharge swallowing status between patients with a primary dysphagia diagnosis and those with post-stroke dysphagia discharged from inpatient rehabilitation facilities (IRFs). Methods: A retrospective cohort design used data from the United States Uniform Data System for Medical Rehabilitation (UDSMR) during 2016 and 2017. Ordinal logistic regression model compared the swallowing status at discharge between the two comparison groups, accounting for baseline patient and clinical characteristics. Multiple imputations with the fully conditional specification method was used to deal with the missing observations for the discharge swallowing status variable. Results: The mean age of the sample was 71.4 years (SD = 12.8). A total of 992 patients were retrieved from the study data, including 64 patients with a primary dysphagia diagnosis and 928 patients with post-stroke dysphagia. Adjusted ordinal logistic regression model revealed that patients with primary dysphagia had lower odds of improving their swallowing status (odds ratio [OR] 0.300; 95% Confidence Interval [CI] 0.142, 0.636) than those with post-stroke dysphagia at discharge from IRFs. Similarly, the multiple imputations method revealed that patients with primary dysphagia had lower odds of swallowing status improvement at discharge from IRFs (OR 0.563; 95% CI 0.342, 0.925). Discussion: Patients with a primary dysphagia diagnosis receiving rehabilitation services in IRFs demonstrated substantially worse swallowing status compared to those with post-stroke dysphagia in a large national sample. This finding suggests that healthcare providers should be aware of the differences occurring in swallowing improvement across dysphagia diagnosis groups.

Relationship between Generalized Sarcopenia and the Severity of Dysphagia after a Stroke

Kim Gyu Seong,Moon Hyun Im,Ham Jeong A,Ma Min Kyeong 대한연하장애학회 2022 대한연하장애학회지 Vol.12 No.1

Objective: Patients who have suffered a stroke may experience dysphagia, which could raise the risk of aspiration pneumonia and death. This is also a complication prevalent in older adults with various comorbidities. This study aimed at investigating the association between head lifting strength and dysphagia, particularly in each of the two phases of dysphagia, namely the oral and the pharyngeal phase, in stroke patients. Methods: We prospectively recruited 64 patients within six months of their first-ever stroke. Head lifting strength, handgrip strength, and calf circumference were measured. The severity of dysphagia was evaluated using the video-fluoroscopic dysphagia scale (VDS). Partial correlation and multiple linear regression analyses were applied to ex-amine the association between head lifting strength and dysphagia. Results: The subjects were comprised of 31 men and 33 women with a mean age of 63 years. The median National Institute of Health Stroke Scale (NIHSS) score was 5.5 (interquartile range 4.0-8.0). Based on the penetration-aspira-tion scale, 46 participants had dysphagia without aspiration and 18 had dysphagia with aspiration. The head lifting strength in the non-aspiration group was higher compared with the aspiration group. The head lifting strength was significantly correlated with the VDS-pharyngeal phase (r=−0.715) and the penetration-aspiration scale (r=−0.662). In the multiple linear regression analysis, head lifting strength was independently associated with pharyngeal-phase dysphagia (P<0.001). Conclusion: Head lifting strength is significantly associated with the severity of dysphagia in the pharyngeal phase.

Dysphagia Requiring Medical Attention in Parkinson’s Disease: A Korean Population-Based Study

Cha Seungwoo,Chang Won Kee,Cho Hee-Mun,한경도,백남종,권소현,Kim Won-Seok 대한의학회 2023 Journal of Korean medical science Vol.38 No.15

Background: Patients with Parkinson’s disease (PD) experience both motor and non-motor symptoms, including dysphagia. Although PD is closely associated with dysphagia, the prevalence or risk of dysphagia in PD is unclear, especially in Asian countries. Methods: The prevalence of PD and dysphagia with PD in the general population was analyzed using the Korean National Health Insurance Service (NHIS) database. The prevalence per 100,000 persons of PD and dysphagia with PD from 2006 to 2015 was analyzed in the general population aged ≥ 40 years. Patients newly diagnosed with PD between 2010 and 2015 were compared with those without PD. Results: The prevalence of PD and dysphagia in patients with PD increased continuously during the study period and was highest in the ninth decade of life. The percentage of patients with dysphagia in patients with PD increased with age. Patients with PD showed an adjusted hazard ratio of 3.132 (2.955–3.320) for dysphagia compared to those without PD. Conclusion: This nationwide study showed increasing trends in the prevalence of PD and dysphagia among patients with PD in Korea between 2006 and 2015. The risk of dysphagia was three times higher in patients with PD than that in those without PD, highlighting the importance of providing particular attention.