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BACKGROUND/RATIONALE:
Statement of problem:
Oral pharyngeal dysphagia - a common complication in patients typically seen for rehabilitation - may affect the success of recovery. The ability to identify veterans at-risk for dysphagia is important to preventing associated complications including aspiration pneumonia, malnutrition and hospital re-admission. Current clinical screening tests for dysphagia have poor sensitivity and specificity; however recent evidence shows objective characteristics of voluntary cough (sound pressure level and aerodynamics) are highly predictive of aspiration in patients with acute stroke. The validity of screening tests in other patient groups at-risk for oral pharyngeal dysphagia is uncertain. The goal of this study is to determine the ability of objective airflow measures of voluntary cough to predict dysphagia and aspiration in other, non-stroke patient groups at-risk for swallowing problems. A secondary goal is to determine the validity of commonly used clinical signs associated with risk for dysphagia and aspiration to detect these problems. The gold standard will be the videofluoroscopic (VSE) or fiberoptic endoscopic (FEES) evaluation of swallow to determine presence or absence of dysphagia. Clinical signs will be assessed at bedside by an experienced speech language pathologist. Cough characteristics will be assessed at bedside with the PERCI SARS system (Microtronics, Chapel Hill, NC). Test performance will be measured by sensitivity, specificity, predictive value, and ROC curve. At-risk patient groups include patients referred from the Medicine, Neurology and Surgical services. We will recruit approximately 15 patients from each group. The VSE/FEE, clinical assessment and objective cough measurement will be done independently by individuals who will be blinded to the findings on the other tests.
OBJECTIVE(S):
The purpose of this project is to assess the sensitivity and specificity of objective measures of voluntary cough to identify dysphagia in other patient groups at high risk for oral pharyngeal dysphagia.
METHODS:
Methods and Study Design: We are proposing a 6-month pilot study using a prospective observational design to be conducted at the Durham and Gainesville VAMCs. Study population will include patients referred to the Speech Pathology Services at both sites who have conditions placing them at high risk for dysphagia such as stroke, traumatic brain injury, COPD, and surgical patients including neurosurgical, cardiac, head and neck cancer and the recently extubated elderly. These types of patients are often referred for rehabilitation. Patients from these diagnostic groups will be enrolled as they are referred and are appropriate for evaluation during the acute hospital stay at either of the two sites. We will enroll 80 patients from these groups: 40 at each site. Patients will be consented then enrolled to achieve a 80:20 ratio of those screened positive to those screened negative. We anticipate that up to a third of subjects will not demonstrate dysphagia by radiological or endoscopic evaluation. All patients will undergo a videofluoroscopic or endoscopic evaluation of swallow (gold standard) to determine swallowing status, an oral/facial motor and sensory examination, and patient/caregiver interview regarding swallowing function. A screening will be performed to assess cognitive function and the medical record will be abstracted for nutritional status including lab values that index hydration status and body mass index.
Aerodynamic measures of voluntary cough will be obtained on all subjects. Subjective measure of cough and the instrumental evaluation will be performed independently by speech pathology clinicians who are blinded to the other test results. A sub-set of subjects will be seen for a stadardized weight assessment and patient/caretaker interview regarding swallow function during their anticipated follow-up outpatient appointments at 4-6 weeks post-discharge. A follow-up radiological or endoscopic swallow evaluation will be performed when indicated. For the primary analysis, the data will be analyzed with receiver-operator curves (ROC), sensitivity, specificity, and positive and negative predictive value. Our hypothesis is that the objectively-obtained measures of voluntary cough will improve clinical tests to screen for oral/pharyngeal dysphagia. With our sample size of 40 patients per site, we will have 80% or better statistical power to detect differences in test sensitivity and specificity. Initial and short term nutritional and hyrdration status will be compared between those veterans with and without dysphagia.
FINDINGS/RESULTS:
None to date.
IMPACT:
The current policy of the Veteran's Health Administration is that all patients will be screened for oral/pharyngeal dysphagia on admission or at any time during continuation of care to determine those patients who should be referred to the Speech Pathology Service for further evaluation. Many aspects to implementing this policy remain uncertain including the screening method. The results of the proposed project will help inform implementation by identifying an effective screening protocol which could be tailored to the patient population which are frequently referred for rehabilitation
PUBLICATIONS:
None at this time.
DRA:
Chronic Diseases
DRE:
Rehabilitation, Prevention, Diagnosis and Prognosis
Keywords:
Nursing, Quality assessment, Screening
MeSH Terms:
none
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