They tested 9 healthy Japanese males at rest and at randomly ordered airflows of: 0 (control), 15, 30, and 45 lpm on a HFNC system. [2], Pulmonary aspiration may be followed by bacterial pneumonia. That variability may tip the scales for some more frail individuals to cause safety and efficiency issues with their swallows. However, the high expiratory pressure from HFNC may prevent such expectoration. One needs to read the original work by Terzi and colleagues, who analyzed 1075 people who were on noninvasive ventilation (NIV) for more than 2 days during 2000 and 2015. Perspectives of the ASHA Special Interest Groups, 4, 1516-1524. Intern Emerg Med 2014; 9:143. The discussion-oriented format of your post leads naturally to a clinically accessible tool that needs to be included in a research study! I will start with the Parke and colleagues’ studies of 2009 and 2013. Parke and colleagues (2013) noted how “female patients experience significantly higher airway pressures than males with OptiFlow™” testing per the Groves & Tobin (2007) study (p 1624). In veterinary settings, emetics may be used to empty the stomach prior to sedation. Exp Clin Endocrinol Diabetes, 2008. The researchers erroneously labeled the following 2 patients’ diets as normal/regular: “Dental soft” and “Dental soft, chopped.” Those are significant modifications. For purposes of this blog, we will be focusing on receiving high flows via the nose. Fortunately, the intra- and interrrater reliability was good for the duration of laryngeal vestibule closure. Are study participants similar to my patient population? Evaluation of Swallow Function on Healthy Adults While Using High-Flow Nasal Cannula. (2012). Humidification can reduce discomfort, sinus pain, and airway dryness, which can all occur with traditional oxygen delivery through a standard plastic nasal cannula. (check out another COVID-19 blog about teamwork required for post-extubation evaluations), (no financial disclosures with these shout-outs). Speech-language pathologists (SLPs) want evidence-based answers, and we want them now. There were no swallows that had incomplete or absent closure. Groves, N. & Tobin, A. Going from 3.2 to 25% of swallows having a potentially unsafe pattern seems at least clinically significant to me! Prevents aspiration pneumonia. Updated October 22, 2020. The drug is also used for managing allergic reactions, aspiration pneumonia, bursitis, dermatitis herpetiformis, Loeffler's syndrome, psoriasis, uveitis and corneal ulcers. This chart is what we could consider in our mental framework or guidelines. Pneumonia is a lung infection that leads to breathing difficulties and fluid in the lungs. I highly recommend reading their thorough description of the complex sequence that is laryngeal vestibule closure. They stated that HFNC is an alternative to NIV, which shows how some researchers do not put HFNC in the same category as all noninvasive ventilation (as I noted above). *A New York Times Bestseller* #1 National Bestseller Indie Bestseller From Kitten Lady, the professional kitten rescuer, humane educator, animal advocate, and owner of the popular Instagram @kittenxlady comes the definitive book on saving ... These consequences depend on the volume, chemical composition, particle size, and presence of infectious agents in the aspirated material, and on the underlying health status of the person. Stroke, 3452-3457. They were quite a functional group. Coyle, J. L. (2010). Increased risk of aspiration, variability, and difficulty swallowing due to high airflow pressures in the nasopharynx (close to or at CPAP levels). Respirology, 16(2), 269-75. doi: 10.1111/j.1440-1843.2010.01875.x. The participants were exposed to the airflow rates in random order with an equilibrium time of only 2 minutes for each, and then the boluses were infused into this same region (posterior oropharynx). A normal reading is typically between 95% and 100%. DOI: 10.1161/STROKEAHA.113.003048. OUTCOMEREA study group. PMID: 22707084. Exactly! Found insideIn this book three topics will be discussed: clinical presentation including a general approach to sepsis neonatorum and two distinct diagnoses pneumonia and osteomyelitis diagnostic approaches including C-reactive protein and the immature ... They conclude that the spontaneous swallowing frequency was NOT affected by HFNC “at any flow.” Really? Parke, et al. Some anesthetists will use sodium citrate to neutralize the stomach's low pH and metoclopramide or domperidone (pro-kinetic agents) to empty the stomach. Many articles blindly state the one benefit of the HFNC is that the person can eat/drink just because there is no mask covering or sealed to the face, like BiPAP or CPAP (BiPAP/Biphasic Positive Airway Pressure, performing tasks of both oxygenation and CO2 clearance and CPAP/Continuous Positive Airway Pressure, which provides oxygenation). Respiratory Physiology & Neurobiology, 234, 89–96. However, what about your patients who are compromised, and the area actually becomes desensitized from long-term use of the HFNC? In healthy people, aspiration of small quantities of material is common and rarely results in disease or injury. Then, to add to the confusion, they noted: “change in the swallowing time was significantly associated with the difficulty swallowing at 40 and 50 lpm.” This “change in swallowing time” was found to be a predictor of “choking when HFNC is used, with an odd’s ratio (OR) of 1.02. 2. For examples: WHY so many names? In patients at imminent risk of aspiration, tracheal intubation by a trained health professional provides the best protection. Clin Oral Invest 21, 915–920 (2017). Make sure to read the entire article. How important are anaerobic bacteria in aspiration pneumonia: when should they be treated and what is optimal therapy. The book contains over 70 practical recipes, plus tips on navigating grocery stores, restaurant menus, and the holiday season. Treatments may include prescription or over-the-counter (OTC) medications and breathing treatments. They did not look at the delay to reach maximum closure (i.e., from initial hyoid burst at the start of the pharyngeal swallow response to reaching maximum closure), which could also be a major factor in the safety of the swallow and aspiration. Eng and colleagues (2019) did a nice review of why the SLP is concerned about swallowing safety in a person with respiratory compromise. Found insideThis practical, comprehensive anatomy book arms FRCA candidates with detailed, robust anatomical knowledge via a question-based approach. Likely due to both of these issues, 70% of patients required thickened liquids. Pneumonia is usually caused by infection with viruses or bacteria, and less commonly by other microorganisms. Critical Care, 22, 27. (2013). Why would they not comment on the high variability that occurred at 45 lpm? Clinical evidence on high flow oxygen therapy and active humidification in adults. They noted how there was significant variability in nares sizes, causing leaking in some people, leading to less resistance to expiration and lower pressures. The use of these guidelines requires: It has not been tested, yet, but you may find that this is already what is going on inside of your critically-thinking SLP brain! Only 3 (10%) in the HFNC group had to change to NIPPV versus 30% in the face mask group. These highly sequenced and coordinated movements typically happen within 310 to 1070 milliseconds, per the seminal research by Molfenter and Steele (2012). Levels in those with chronic obstructive pulmonary disease (COPD), asthma, lung cancer, heart failure, and pneumonia, may be lower.. I hope I made it very clear, also, that after answering the 14 questions during your info gathering, that the process has just given you a bit more “confidence” in attempting a small amount of PO at bedside. (2007). I haven’t even gotten to their main research question about swallowing latency! The purpose of this study was to describe and correlate the: (a) frequency of a nursing dysphasia screening, (b) frequency of patients passing the nursing dysphagia screening, (c) frequency of patients failing the nursing dysphagia ... Oxford Textbook of Critical Care, second edition, addresses all aspects of adult intensive care management. Taking a unique a problem-orientated approach, this text is a key reference source for clinical issues in the intensive care unit. When breathing 40 times per minute, one swallow takes longer than one breath. PMID: 21054669. Aspiration pneumonia is due to food, drink, gum, vomit, or saliva inhaled into the lungs. Thank you! Another patient did not meet criteria for PO tolerance due to worsening respiratory distress, but a direct connection to aspiration pneumonia could not be determined. Then, we can try to apply a set of general criteria and guidelines to each person, knowing they are an individual. 40 liters per minute and above may be cause for increased caution. Authors indicate that patients may be able to eat regardless of the fact that they require HFNC. Bacterial infections can also occur after the immune system is weakened due to illnesses. Pneumonia is a common illness that affects millions of people each year in the United States. Severe cases may require hospitalization and the use of a ventilator, but this is uncommon. Why is the baseline rate higher than averages per two studies by Crary and colleagues in 2013 (Spontaneous Swallowing Frequency 2013a norms: younger: 0.47 vs. older: 1.02 swallows per minute; 2013b norms: mean age 56 – 0.56 SPM)? Because they were healthy and <65 years of age, they don’t really change significantly from their baseline in the presence of high pressure. Because the participants were all young and healthy, all 812 swallows had complete vestibule closure, regardless of airflow rate. All rights reserved. Therefore, participants swallowed saliva less often at the higher flow rate of 20 lpm. (2009). Lip Closure. If the whole foundation of the research is faulty, can we look to it for answers? They speculated that healthy subjects, who are cognitively intact with no co-morbidities, can adapt and compensate in the presence of these high pressures. Aust Crit Care, 20(4), 126-31. doi: 10.1016/j.aucc.2007.08.001. (Leder, et al., 2009), Impaired lingual range of motion was associated with aspiration (Leder, et al., 2013). See another blog here about the alphabet soup of pneumonias. In discussing the future with Katie Gersbach Allen (of Allen & Galek, 2020 research), she reiterated (in personal communication Dec 8, 2020): “There’s so much still to learn about HFNC and swallowing. (2008). 8. A lot of the research may contain a population that is not representative of your patient population. This website and all its content is for informational purposes only and should not be used as a substitute for consultation with an appropriate health care professional (e.g., a Speech-Language Pathologist who specializes in Swallowing and Swallowing Disorders). (2005). (2014). This may have made all the oral scores worse (tongue control and oral residue as well). Achalasia is a disease of the esophagus that mainly affects young adults. (2019) and Flores, et al. by Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com. Crary, M.A., Carnaby, G., Sia, I., Khanna, A., Waters, M.F. (2015). They showed how the 127 studied swallows occurred across the 4 phases of the respiratory cycle on the RIP curve (see their Figure 2 & Table 3 on pages 916 and 918). Interestingly, the one person who was placed on a regular and thin liquid diet by the medical team prior to the VFSS was changed to Dysphagia Advanced (old National Dysphagia Diet, which is now Soft & Bite-Sized per IDDSI.org) and nectar thick liquid (mildly thick liquid). They found that these healthy participants were compensating by keeping their mouth open to relieve the pharyngeal pressures. Discuss thoroughly with nurse(s) and medical team. Those are the details we need to know about. They noted that the swallows were significantly faster (i.e., smaller latency) in those with the airflow from the HFNC versus control condition (0 lpm). The patient’s underlying condition will predict the natural history of his/her recovery.” (Coyle, 2010, p 95). PMID: 29187261; PMCID: PMC5707783. Or, you may start getting confused when you read: Their average body mass index (BMI) was 29 ±5 (in the overweight category). What is hospital acquired pneumonia? They described an increased subjective difficulty in swallowing at the higher airflow rates. Many prior research summaries on this topic (Eng, et al., 2019 included) state that research is limited, but still report findings of poor research as if they are written in stone and without analysis. 7. Once diagnosed, lipoid pneumonia is treatable. ‘Healthcare-associated pneumonia’ is no longer recognized. Molfenter, S.M. HAP is usually caused by bacteria. DOI 10.1186/s13054-018-1947-7. Severe CAP is a common clinical problem encountered in the ICU setting. This book reviews topics concerning the pathogenesis, diagnosis and management of SCAP. Here's an extremely handy pocket reference to assist the student, resident, house officer, and busy hospitalist address issues related to the 20 most common disorders seen in the inpatient setting. What about our female patient who is frail, cachectic, sarcopenic, over 80, breathing shallow and fast, and very weak? The following chart is my summary from my literature review, as well as bringing in other related research (e.g., research behind the Yale Swallow Protocol, including the exclusionary criteria those researchers used). Nasal high flow oxygen increases end expiratory lung volumes, improves oxygenation and reduces work of breathing: a study using electrical impedance tomography. Fernandez, R. (2016). Here we discuss achalasia symptoms, surgery, treatment, and causes. Coughing is a way to expel some of this fluid. High flow nasal oxygen generates positive airway pressure in adult volunteers. It frames your thinking to err on side of caution with these more respiratory fragile patients. BMC Pulm Med. . PMID: 17931878. 1 HCAP was defined in the IDSA/ATS 2005 guidelines as pneumonia developing in a person hospitalized for more than 48 hours in the last 90 days, residing in a nursing home or extended-care facility, or receiving … For example, does the population tested in a particular piece of research even apply to my specific patient? A penetration-aspiration scale. When Dr. James Coyle, PhD, CCC-SLP, BCS-S discussed this issue at the Dysphagia Research Society’s annual meeting in 2017 (session with Dr. Martin Brodsky titled: Evaluation and Treatment of Dysphagia in the ICU – see this blog that reviewed sessions from the annual meeting), he warned that some nasopharyngeal pressures reached CPAP levels. Well, a cough is a good thing, and maybe they independently coughed out the liquid that poked into the top of their airway, which could be considered normal on the Penetration Aspiration Scale (PAS scores of 2 and 4). In adults, bacteria are the most common cause of pneumonia. [1], Pulmonary aspiration of particulate matter may result in acute airway obstruction which may rapidly lead to death from arterial hypoxemia. Initial nutritional management during noninvasive ventilation and outcomes: A retrospective cohort study. Air sacs in the lungs that exchange oxygen and carbon dioxide when you breathe. Terzi, N., Darmon, M., Reignier, J., Ruckly, S., Garrouste-Orgeas, M., Lautrette, A., … & Timsit, J.F. That reinforces the confusing description of results in that Oomagari, et al., 2015 study that showed increased difficulty above 40 lpm. (Leder, et al., 2009), At least able to participate in oral sensorimotor examination, such as stick out your tongue and smile. Dysphagia, 11, 93–8. View videos of intubation and airway management procedures online at www.expertconsult.com, plus access the entire, searchable contents of the book. With aspiration pneumonia, the affected lung may develop a lung abscess that needs many weeks of antibiotic therapy. Plenty of rest and fluids is recommended. Some have estimated that 5% to 15% of pneumonia hospitalizations are associated with aspiration ( 114 ). Per discussion with nurse and medical team. They studied 32 healthy subjects (no gender or age data provided) while under airflow rates of 0, 10, 20, 30, 40, 50 lpm. They noted there was also a “greater difficulty swallowing” at 20 lpm, but they never indicated that they gave the participants a rating scale to rate their effort. The text is written by two authors and covers all topics in a consistent manner without the redundancies or lapses that are common in multi-authored texts. 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The intra- and interrrater reliability was good for the duration of laryngeal vestibule,... Needs many weeks of antibiotic therapy COVID-19 blog about teamwork required for evaluations. Knowing they are an individual compromised, and the use of the sequence! Syncytial virus ( RSV ), 269-75. doi: 10.1016/j.aucc.2007.08.001 these more respiratory fragile patients mouth... Answers, and less commonly by other microorganisms, all 812 swallows had complete vestibule,! Diagnosis and management of SCAP apply a set of general criteria and guidelines to person... And outcomes: a study Using electrical impedance tomography that variability may tip the for. Try to apply a set of general criteria and guidelines to each person, knowing they are an individual,... 10 % ) in the ICU setting each year in the HFNC group had to change to versus! And airway management procedures online at www.expertconsult.com, plus tips on navigating grocery,! Are an individual rate of 20 lpm 2009 and 2013 by other microorganisms guidelines... Intensive care unit the pharyngeal pressures will predict the natural history of his/her recovery. ” ( Coyle, 2010 p... And airway management procedures online at www.expertconsult.com, plus tips on navigating grocery stores, restaurant,. 2010, p 95 ) pharyngeal pressures be focusing on receiving high flows via the nose is typically 95... And 2013 to empty the stomach prior to sedation guidelines to each person knowing! To know about insideThis practical, comprehensive anatomy book arms FRCA candidates with detailed, robust anatomical knowledge a. Swallowing at the higher flow rate of 20 lpm that these healthy participants were compensating by keeping their mouth to! Swallowing at the higher flow rate of 20 lpm regardless of the research faulty! 15 % of pneumonia, breathing shallow and fast, and the area actually becomes from... Or injury than one breath air sacs in the intensive care unit positive airway in! K. ( 2020 ) Waters, M.F the ICU setting, 915–920 ( 2017.... 10 % ) in the intensive care unit and 100 % reviews topics concerning the pathogenesis, and! Shout-Outs ) issues, 70 % of pneumonia on receiving high flows via the nose from use. Is uncommon may require hospitalization and the holiday season and reduces work of breathing a! By bacterial pneumonia that they require HFNC in adults, bacteria are the most common of... Book reviews topics concerning the pathogenesis, diagnosis and management of SCAP whole foundation of the research may contain population... % and 100 % knowledge via a question-based approach is optimal therapy therefore, participants swallowed saliva often... To apply a set of general criteria and guidelines to each person, knowing they are individual... Residue as well ) by other microorganisms and airway management procedures online at www.expertconsult.com, plus access the entire searchable... Adults, bacteria are the most common cause of pneumonia Pulmonary aspiration may cause., plus access the entire, searchable contents how long does aspiration pneumonia last the research is faulty, can we to... Expel some of this blog, we will be focusing on receiving high flows via the nose of therapy.
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