Oropharyngeal dysphagia: analyses of Brazilians and Americans protocols of fluoroscopy

Patrícia Dorotéia de Resende Juliane Borges Dobelin Iara Bittante de Oliveira Karen Fontes Luchesi About the authors

Resumo:

Este artigo tem por objetivo analisar e comparar o uso de protocolos brasileiros e norte-americanos para videofluoroscopia da deglutição em pacientes com histórico de acidente vascular encefálico. Trata-se de uma revisão bibliográfica de artigos brasileiros e norte-americanos. Foram selecionados artigos com descrição de procedimentos para videofluoroscopia da deglutição em sujeitos que sofreram acidente vascular encefálico, publicados entre 2003 e 2013. Os procedimentos descritos para realização de videofluoroscopias foram analisados de forma quantitativa e qualitativa. Consideraram-se as variáveis: posicionamento para o exame, consistências e quantidades de oferta de bolo, tipos de utensílios e utilização de protocolos Foram encontrados 16 artigos que atenderam aos critérios supracitados, sendo nove (56,25%) norte-americanos e sete (43,75%) brasileiros. Observou-se que quatro dos estudos nacionais (57,14%) não relatam as quantidades oferecidas, enquanto todos os artigos norte-americanos detalharam as quantidades, que variaram entre 2 e 15 mL; os tipos de alimento e suas consistências foram detalhadas em todos os estudos nacionais e norte-americanos, porém os nacionais o fizeram de forma genérica, sem identificação dos alimentos. Quanto à posição do paciente durante o exame, 57,14% dos artigos nacionais não relataram e todos os artigos norte-americanos o fizeram. Os utensílios para oferta do bolo são citados em 55,55% dos artigos norte-americanos e em apenas 14,28 % dos nacionais. Quanto à utilização de protocolos para avaliação 33% dos estudos norte-americanos não os citam, comparados aos 71,42% dos nacionais. Observou-se a necessidade de padronização dos procedimentos e terminologias utilizadas na videofluoroscopia da deglutição, de modo a facilitar a intercompreensão e reprodutibilidade dos estudos.

Descritores:
Deglutição; Fluoroscopia; Transtornos da Deglutição; Acidente Vascular Cerebral

Abstract:

The aim of this study is to analyze and compare the use of Brazilian and North American protocols for videofluoroscopy in patients with stroke. A literature review of Brazilian and North American articles was conducted. Articles containing the description of procedures for videofluoroscopy of swallowing in subjects who had stroke published between 2003 and 2013 were selected. Qualitative and quantitative analysis of the procedures for videofluoroscopy was performed. The following variables were considered: positioning for the exam, consistency and quantity of the bolus, types of tools and use of protocols. Sixteen studies were included, nine (56.25%) North American and 7 (43.75%) Brazilian. It was observed that four of the national studies (57.14%) did not report the quantity offered, while all American ones detailed it between 2 and 15 mL; the types of food and their consistencies were detailed in all national and North American studies, but national studies did it generically, without identification of foods. Regarding the position of the patient during the examination, 57.14% of the national articles did not report it, while all American articles did. Equipment used to offer the bolus are mentioned in 55.55% of Americans articles and in just 14.28% of the national ones. As for the use of protocols, only 33% of American articles did not mention it, while 71.42% of national articles failed to mention it. There is a need to standardization of procedures and terminologies in videofluoroscopy, both in Brazilian as North American publications.

Keywords:
Deglutition; Fluoroscopy; Deglutition Disorders; Stroke

Introduction

Swallowing is frequently seen as a simple act, once it is often involuntary and quotidian. Nevertheless, it is a complex process involving several structures that are correlated and connected to a neuronal mechanism. It uses a common space with breathing and aims at transporting material from the oral cavity to the stomach, without penetration in the airways, including several structures of mouth, pharynx, larynx and esophagus.

Any disorder interrupting the process of a safe and efficient swallowing is classified as dysphagia, and it may be of mechanic, neurogenic, senile or psychogenic origin11 Prodomo LPV, Angelis EC, Barros ANP. Avaliação clínica fonoaudiológica das disfagias. In: Jotz GP, Angelis EC, Barros APB. Tratado da deglutição e disfagia: no adulto e na criança. Rio de Janeiro: Revinter; 2010. p.61-7..

There is a significant number of dysphagia in patients with a clinical history of stroke22 Mann G, Graeme J, Hankey GJ. Initial clinical and demographic predictors of swallowing impairment following acute stroke. Dysphagia. 2001;16:208-15..

Dysphagia is considered one of the main risk factor for aspiration pneumonia, the most common complication in strokes, configuring the main cause of deaths in Brazil33 Lessa I. Epidemiologia das doenças cerebrovasculares no Brasil. Rev Soc Cardiol. 1999;9(4):509-18..

The assessment of swallowing is important in order to understand the way the food is being transported from the mouth until the stomach, and also to support the clinical and therapeutic planning. Such assessment may be divided in two stages: clinical and instrumental. The clinical assessment comprises the anamnesis, structural and functional evaluation of speech and swallowing structures, and the observation of clinical signs during feeding44 León AR, Clavé P. Videofluoroscopia y disfagia neurogénica. Rev Esp Enf Dig. 2007;99(1):3-6..

The videofluoroscopy is the instrument that allows the assessment of all phases of swallowing. It may be characterized by the recording, in magnetic media, of biological and dynamic events generated by the exposure to X radiation. The recording is performed in real time (30 square per minute) and with an adequate quality for the morphofunctional study of the exposed region. One of the advantages of the exam is the possibility to register data and allow revisions without needing a new image capture and exposure to radiations55 Costa MM. Videofluoroscopia: método radiológico indispensável para a prática médica. Radiol Bras. 2010;43(2):7-8.. It has as its main purpose to analyze whether the patient may have a safe and efficient oral feeding66 Kim Y, Mccullough GH, Asp CW. Temporal measurements of pharyngeal swallowing in normal populations. Dysphagia. 2005;20:290-6..

All the swallowing process, since the capture, preparation of the bolus and ejection, may by analyzed during the exam. The oral transit, the palatal competence, the protection of airways, and the competence of esophageal sphincter may be seen and re-seen55 Costa MM. Videofluoroscopia: método radiológico indispensável para a prática médica. Radiol Bras. 2010;43(2):7-8.. Nowadays, the videofluoroscopy is considered the best instrumental exam to assess dysphagia55 Costa MM. Videofluoroscopia: método radiológico indispensável para a prática médica. Radiol Bras. 2010;43(2):7-8. 77 Marques CH, André C, Rosso ALZ. Disfagia no AVE agudo: revisão sistemática sobre métodos de avaliação. Acta Fisiatr. 2008;15(2):106-10..

This study aims to analyze and compare national and north-American researches using protocols for videofluoroscopic swallowing study, emphasizing the knowledge of procedures and specifications in the assessment of dysphagia after a cerebrovascular accident.

Methods

A systematic review of national and international literature was performed. During the first semester of 2013, articles published in indexed journals were selected from the following database: Medical Literature Analysis and Retrieval System (MEDLINE), Scientific Electronic Library Online (SciELO) and Caribbean and Latin-American Literature in Health Sciences (LILACS), once these database include most of national and international journals in health sciences.

The Health Sciences Descriptors was consulted in order to research the scientific articles. The following descriptors were selected in Portuguese and in English: deglutition disorders, radiography, physiopathology, rehabilitation, diagnosis, fluoroscopy, methods, standards, instrumentation, deglutition, physiology, barium, cerebrovascular accident. The terms "human" and "adults" were limiter.

The descriptors were used isolated and combined aiming at obtaining the greatest number of possible associations.

Selection Criteria

The articles selection obeyed the following inclusion criteria: national and north-American articles; articles published between 2003 and 2013, including a review that revealed the actual state of scientific production on videofluoroscopy in patients with stroke; articles describing the application of videofluoroscopic exams in patients after a cerebrovascular accident, and recommending procedures for the conduction of such exams, with analysis of the advantages.

The inclusion of north-American articles was determined in order to establish a comparative analysis with the Brazilian production.

Articles involving other diseases; articles that did not match the period chosen for the research or that did not present the stages of videofluoroscopy detailed in the study were excluded.

Data Analysis

The procedures used for the videofluoroscopy were analyzed qualitative and quantitatively.

The qualitative analysis was based in Bardin88 Bardin L. Análise de conteúdo. 3ª. Edição. Tradução de Luís Antero Reto e Augusto Pinheiro. São Paulo: Edições 70; 2011. and aimed to describe objectively and systematically the existing content of the researched articles. At first, it was an exploratory analysis from an approximation with the main theme and the search of familiarity with the raised facts. Afterwards, the characteristics of facts and phenomena were described. Finally, the determinant factors for the occurrence of facts/phenomena were raised; this was characterized as the explicative phase of the research99 Silva EL, Menezes EM. Metodologia da pesquisa e elaboração de dissertação. 4ª.edição. Florianópolis: Laboratório de Ensino a Distância da UFSC, 2005..

Results were distributed in the following analysis categories: Brazilian article, north-American article, position criteria for the exam, consistency used, amount offered in milliliters (mL), equipment used for offering the bolus, and use of protocols for the procedures and/or results analysis.

The quantitative analysis was based on the obtaining of the absolute and relative frequencies (percentage) of the results classified in the above categories.

Literature Review

Of the 36 articles analyzed, 16 were pertinent to the theme, fulfilling all the inclusion criteria. Nine articles (56,25%) were north-American and seven (43,75%) were national (Figures 1 and 2).

Figure 1:
Brazilian articles published between 2003 and 2013 related to videofluoroscopic assessment of swallowing in oropharyngeal dysphagia in adults after a cerebrovascular accident.

Figure 2:
North-American articles published between 2003 and 2013 related to videofluoroscopic assessment of swallowing in oropharyngeal dysphagia in adults after a cerebrovascular accident.

Of the national articles, four (57,14%) did not report the amount in milliliters of the food offered during the exam, while all north-American articles detailed the milliliters used, which varied from 2 to 15mL (Figure 3).

Figure 3:
Quantity (in mL) of food offered for the videofluoroscopy of patients after stroke, according to national/Brazilian articles (N=8) and north-American articles (N=9), published between 2003 and 2013.

Silva1010 Silva RG. Disfagia orofaríngea pós-acidente vascular encefálico. In: Ferreira LP, Befi-Lopes DM, Limongi SCO (orgs). Tratado de fonoaudiologia. São Paulo: Roca; 2004. p.354-69. describes the volumes of 5 to 10mL, thick consistency as ideal for the identification of suggestive signals of penetration and aspiration, as well as to facilitate the interpretation and definition of conducts for patients after a cerebrovascular accident.

Regarding the type of consistency, all north-American articles brought detailed information about the consistency and the type of food offered. The national articles also mentioned the consistency used, although, generically without the identification of the food offered (Figure 4).

Figure 4:
Consistencies offered during the videofluoroscopic exam in patients after stroke, according to national/Brazilian articles (N=8) and north-American articles (N=9), published between 2003 and 2013.

Liquid and thick consistencies are processed and swallowed differently1111 Furkim AM, Manrique D, Martinez SO. Protocolo de avaliação funcional da deglutição em crianças: fonoaudiológica e nasofibrolaringoscópica. In: Macedo Filho E, Pisani JC, Carneiro J, Gomes G. Disfagia: Abordagem Multidisciplinar. 2ª edição. São Paulo: Frôntis; 1999. p.119-34.. The propulsion of the bolus and its conduction vary according to the amount, the density and the viscosity of the material to be swallowed. The bolus characteristics determine the pressure to be generated in this cavity during the ejection, influencing the pharyngeal phase1212 Carrara-De Angelis E, Brandão AP, Martins NM, Fúria CLB. Rumos atuais da Fonoaudiologia em Oncologia. Fon Brasil. 1998;3:115-20.. Most of the researches1313 Schelp AO, Cola PC, Gatto AR, Silva RG, Carvalho LR. Incidência de disfagia orofaríngea após acidente vascular encefálicoem hospital público de referência. Arq Neuropsiquiatr. 2004;62:503-6. 2424 Michou E, Mistry S, Jefferson S, Singh S, Rothwell J, Hamdy S. Targeting unlesioned pharyngeal motor cortex improves swallowing in healthy individuals and after dysphagic stroke. Gastroenterology. 2012;142(1):29-38.described the consistencies and the amounts tested. Some studies2525 Bassi AE, Mitre EI, Silva MAOM, Arroyo MAS, Pereira MC. Associação entre disfagia e o topodiagnóstico da lesão encefálica pós-acidente vascular encefálico. Rev CEFAC. 2004;6(2):135-42. 2828 Doria S, Abreu MAB, Busch R, Assumpção R, Nico MAC, Ekcley CA et al. Estudo comparativo da deglutição com nasofibrolaringoscopia e videodeglutograma em pacientes com acidente vascular cerebral. Rev Bras Otorrinolaringol. 2003;69:636-42.reported the consistency tested, however did not bring information regarding the amount offered.

It is generally considered important that the assessment includes more than one consistency2929 Logemann JA. Manual for the videofluorographic study of swallowing. 2ª. edição. Austin: ProEd; 1993.. It can be observed in Figure 2 that the studies expressively differ regarding the consistency used during the exam. However, the great majority offered two or more consistencies.

Despite the variation, north-American studies usually bring the liquid as the main tested consistency; among the national studies, five of the nine analyzed ones, tested three consistencies.

Concerning the patient's position during the exam, four (57,14%) of the national articles did not report the patient's position. All north-American articles detailed the subject's position (Figure 5).

Figure 5:
Subjects' position for the performance of the videofluoroscopic exam in patients after stroke, according to national/Brazilian articles (N=8) and north-American articles (N=9), published between 2003 and 2013.

Subjects' position during the exam is proposed by Logemann2929 Logemann JA. Manual for the videofluorographic study of swallowing. 2ª. edição. Austin: ProEd; 1993.in the lateral and anteroposterior view. It is preconized that the position should be as close as possible to the natural positioning of the individual11 Prodomo LPV, Angelis EC, Barros ANP. Avaliação clínica fonoaudiológica das disfagias. In: Jotz GP, Angelis EC, Barros APB. Tratado da deglutição e disfagia: no adulto e na criança. Rio de Janeiro: Revinter; 2010. p.61-7.. Both, the national and the north-American studies revealed gaps by not informing the view of the exam. Most of national studies do not bring any information regarding the subjects' position. Some north-American studies bring information only regarding the body position, but not regarding the cervical view.

The equipment used for the offering of the bolus is quoted by five (55,55%) north-American articles and only by one (14,28%) national article (Figure 6).

Figure 6:
Specifications regarding the equipment for offering the bolus during the videofluoroscopic exam in patients after stroke, according to national/Brazilian articles (N=8) and north-American articles (N=9), published between 2003 and 2013.

The instruments used for offering the bolus is another important aspect of methodology, once tools may change the dynamics of capture of the bolus. The syringe, despite uncommon for feeding, becomes interesting for standardization and for greater control over the bolus offered1414 Spadotto AA, Gatto AR, Cola PC, Montagnoli NA, Schelp AO, Silva RG et al. Software para análise quantitativa da deglutição. Radiol Bras. 2008;41:25-8. 1616 Kim Y, McCullough GH. Stage transition duration in patients post stroke. Dysphagia. 2007;22(4):299-305. 2020 Smith Hammond CA, Goldstein LB, Horner RD, Ying J, Gray L, Rothi LG et al. Predicting aspiration in patients with ischemic stroke: comparison of clinical signs and aerodynamic measures of voluntary cough. Chest. 2009;135:769-77. 2121 Gallas S, Marie JP, Leroi AM, Verin E. Sensory transcutaneous electrical stimulation improves post-stroke dysphagic patients. Dysphagia. 2009;25(4):291-7. 2626 Xerez DR, Carvalho YSV, Costa MMB. Estudo clínico e videofluoroscópico da disfagia na fase subaguda do acidente vascular encefálico. Radiol Bras. 2004;37(1):9-14. 3030 Tohara H, Saitoh E, Mays KA, Kuhlemeier K, Palmer JB. Three tests for predicting aspiration without videofluorography. Dysphagia. 2003;18(2):126-34..

Concerning the use of standardized procedures for the performance of the exam and analysis of results, six north-American articles (66,66%) and five (71,42%) national ones did not mention the use of an scale for laryngotracheal penetration and aspiration. Three (42,85%) national articles and five (55,55%) north-American ones reported models of protocols (Figure 7). The videofluoroscopic exam, as originally described by Logemann2929 Logemann JA. Manual for the videofluorographic study of swallowing. 2ª. edição. Austin: ProEd; 1993., is still being followed by most of clinical practices. However, there is not a protocol or standard procedure1010 Silva RG. Disfagia orofaríngea pós-acidente vascular encefálico. In: Ferreira LP, Befi-Lopes DM, Limongi SCO (orgs). Tratado de fonoaudiologia. São Paulo: Roca; 2004. p.354-69. 2929 Logemann JA. Manual for the videofluorographic study of swallowing. 2ª. edição. Austin: ProEd; 1993. 3030 Tohara H, Saitoh E, Mays KA, Kuhlemeier K, Palmer JB. Three tests for predicting aspiration without videofluorography. Dysphagia. 2003;18(2):126-34..

Figure 7:
Use of protocols for the analysis of the videofluoroscopy results in patients after stroke, according to national/Brazilian articles (N=8) and north-American articles (N=9), published between 2003 and 2013.

Conclusion

Most of the national articles do not describe methodology. This was not observed in the north-American articles. However, it is observed that there is not a standardization for procedures in videofluoroscopic assessment.

The terminologies used, mainly regarding the consistency and the dosage in milliliters are distinct. Studies that detailed the recipe and the type of food offered diverge regarding the classification of food consistency. The dosage in milliliters varies expressively in most of the analyzed studies.

Therefore, there is a need for standardization of procedures and terminologies used in videofluoroscopic swallowing study, in order to facilitate the inter-comprehension and reproducibility of studies.

References

  • 1
    Prodomo LPV, Angelis EC, Barros ANP. Avaliação clínica fonoaudiológica das disfagias. In: Jotz GP, Angelis EC, Barros APB. Tratado da deglutição e disfagia: no adulto e na criança. Rio de Janeiro: Revinter; 2010. p.61-7.
  • 2
    Mann G, Graeme J, Hankey GJ. Initial clinical and demographic predictors of swallowing impairment following acute stroke. Dysphagia. 2001;16:208-15.
  • 3
    Lessa I. Epidemiologia das doenças cerebrovasculares no Brasil. Rev Soc Cardiol. 1999;9(4):509-18.
  • 4
    León AR, Clavé P. Videofluoroscopia y disfagia neurogénica. Rev Esp Enf Dig. 2007;99(1):3-6.
  • 5
    Costa MM. Videofluoroscopia: método radiológico indispensável para a prática médica. Radiol Bras. 2010;43(2):7-8.
  • 6
    Kim Y, Mccullough GH, Asp CW. Temporal measurements of pharyngeal swallowing in normal populations. Dysphagia. 2005;20:290-6.
  • 7
    Marques CH, André C, Rosso ALZ. Disfagia no AVE agudo: revisão sistemática sobre métodos de avaliação. Acta Fisiatr. 2008;15(2):106-10.
  • 8
    Bardin L. Análise de conteúdo. 3ª. Edição. Tradução de Luís Antero Reto e Augusto Pinheiro. São Paulo: Edições 70; 2011.
  • 9
    Silva EL, Menezes EM. Metodologia da pesquisa e elaboração de dissertação. 4ª.edição. Florianópolis: Laboratório de Ensino a Distância da UFSC, 2005.
  • 10
    Silva RG. Disfagia orofaríngea pós-acidente vascular encefálico. In: Ferreira LP, Befi-Lopes DM, Limongi SCO (orgs). Tratado de fonoaudiologia. São Paulo: Roca; 2004. p.354-69.
  • 11
    Furkim AM, Manrique D, Martinez SO. Protocolo de avaliação funcional da deglutição em crianças: fonoaudiológica e nasofibrolaringoscópica. In: Macedo Filho E, Pisani JC, Carneiro J, Gomes G. Disfagia: Abordagem Multidisciplinar. 2ª edição. São Paulo: Frôntis; 1999. p.119-34.
  • 12
    Carrara-De Angelis E, Brandão AP, Martins NM, Fúria CLB. Rumos atuais da Fonoaudiologia em Oncologia. Fon Brasil. 1998;3:115-20.
  • 13
    Schelp AO, Cola PC, Gatto AR, Silva RG, Carvalho LR. Incidência de disfagia orofaríngea após acidente vascular encefálicoem hospital público de referência. Arq Neuropsiquiatr. 2004;62:503-6.
  • 14
    Spadotto AA, Gatto AR, Cola PC, Montagnoli NA, Schelp AO, Silva RG et al. Software para análise quantitativa da deglutição. Radiol Bras. 2008;41:25-8.
  • 15
    Abdulmassih EMS, Macedo Filho ED, Santos RS, Jurkiewicz AL. Evolução de pacientes com disfagia orofaríngea em ambiente hospitalar. Int Arch Otorhinolaryngol. 2009;13(1):55-62.
  • 16
    Kim Y, McCullough GH. Stage transition duration in patients post stroke. Dysphagia. 2007;22(4):299-305.
  • 17
    Bulow M, Speyer S, Baijens L, Woisard V, Ekberg O. Neuromuscular electrical stimulation (NMES) in stroke patients with oral and pharyngeal dysfunction. Dysphagia. 2008;23:202-9.
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    Han TR, Paik NJ, Park JW, Kwon BS. The prediction of persistent dysphagia beyond six months after stroke. Dysphagia. 2008;23(1):29-64.
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    Falsetti P, Acciai C, Palilla R, Bosi M, Carpinteri F, Zingarelli A et al. Oropharyngeal dysphagia after stroke: incidence, diagnosis, and clinical predictors in patients admitted to a neurorehabilitation unit. J Stroke Cerebrovasc Dis. 2009;18(5):329:35.
  • 20
    Smith Hammond CA, Goldstein LB, Horner RD, Ying J, Gray L, Rothi LG et al. Predicting aspiration in patients with ischemic stroke: comparison of clinical signs and aerodynamic measures of voluntary cough. Chest. 2009;135:769-77.
  • 21
    Gallas S, Marie JP, Leroi AM, Verin E. Sensory transcutaneous electrical stimulation improves post-stroke dysphagic patients. Dysphagia. 2009;25(4):291-7.
  • 22
    Cola PC, Gatto AR, Silva RG, Spadotto AA, Schelp AO, Henry ACA. The influence of sour taste and cold temperature in pharyngeal transit duration in patients with stroke. Arq Gastroenterol. 2010;47(1):18-21.
  • 23
    Seo HG, Oh BM, Han TR. Longitudinal changes of the swallowing process in subacute stroke patients with aspiration. Dysphagia. 2011;26(1):41-8.
  • 24
    Michou E, Mistry S, Jefferson S, Singh S, Rothwell J, Hamdy S. Targeting unlesioned pharyngeal motor cortex improves swallowing in healthy individuals and after dysphagic stroke. Gastroenterology. 2012;142(1):29-38.
  • 25
    Bassi AE, Mitre EI, Silva MAOM, Arroyo MAS, Pereira MC. Associação entre disfagia e o topodiagnóstico da lesão encefálica pós-acidente vascular encefálico. Rev CEFAC. 2004;6(2):135-42.
  • 26
    Xerez DR, Carvalho YSV, Costa MMB. Estudo clínico e videofluoroscópico da disfagia na fase subaguda do acidente vascular encefálico. Radiol Bras. 2004;37(1):9-14.
  • 27
    Silva RG, Jorge AG, Peres FM, Cola PC, Gatto AR, Spadotto AA. Protocolo para controle de eficácia terapêutica em disfagia orofaríngea neurogênica (Procedon). Rev CEFAC. 2010;12(1):75-81.
  • 28
    Doria S, Abreu MAB, Busch R, Assumpção R, Nico MAC, Ekcley CA et al. Estudo comparativo da deglutição com nasofibrolaringoscopia e videodeglutograma em pacientes com acidente vascular cerebral. Rev Bras Otorrinolaringol. 2003;69:636-42.
  • 29
    Logemann JA. Manual for the videofluorographic study of swallowing. 2ª. edição. Austin: ProEd; 1993.
  • 30
    Tohara H, Saitoh E, Mays KA, Kuhlemeier K, Palmer JB. Three tests for predicting aspiration without videofluorography. Dysphagia. 2003;18(2):126-34.

Publication Dates

  • Publication in this collection
    Oct 2015

History

  • Received
    09 Apr 2015
  • Accepted
    12 June 2015
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