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Silent aspiration is associated with pneumonia and mortality, and is poorly identified by traditional clinical swallowing evaluation (CSE). Currently, there is no reliable test for detecting silent aspiration during CSE. There is, however, increasing evidence for the validity of cough reflex testing (CRT) for identifying silent aspiration. This test has the potential to significantly improve clinical assessment of dysphagia. The aim of this research programme was to further investigate the validity, reliability and clinical utility of CRT for identifying patients at risk of silently aspirating. Several aspects of CRT were explored during this research programme. Two correlational studies were conducted to validate CRT for identifying silent aspiration against videofluoroscopic swallowing study (VFSS) and flexible endoscopic evaluation of swallowing (FEES). Cough reflex threshold testing was completed on 181 patients using inhaled, nebulised citric acid. Within one hour, 80 patients underwent VFSS and 101 patients underwent FEES. All tests were recorded and analysed by two researchers blind to the result of the alternate test. Significant associations between CRT result and cough response to aspiration on VFSS (p = .003) and FEES (p < .001) were identified. Sensitivity and specificity were optimised at 0.6mol/L in patients undergoing VFSS (71%, 60% respectively) and at 0.4mol/L in patients undergoing FEES (69%, 71% respectively). A concentration of 0.8mol/L had the highest odds ratio (OR) for detecting silent aspiration (8 based on VFSS, 7 based on FEES). Coughing on lower concentrations of citric acid (0.4mol/L compared with 1.2mol/L) was a better predictive measure of silent aspiration. Diminished cough strength has also been associated with aspiration and increased risk of pneumonia. Reflexive cough is our primary defensive mechanism against aspiration and a measure of reflexive cough strength therefore holds greater relevance than one of voluntary cough strength. Despite common use and clinical applicability, the reliability of subjective cough judgements has received little attention. The inter- and intra-rater reliability of subjective judgements of cough in patients following inhalation of citric acid was assessed. Forty-five speech-language therapists (SLTs) were recruited to the first study. Of these, 11 SLTs were currently using CRT in their clinical practice (experienced raters) and 34 SLTs reported no experience with CRT (inexperienced raters). Participants provided a rating of strong, weak or absent to ten video segments of cough responses elicited by inhalation of nebulised citric acid. The same video segments presented in a different sequence were re- evaluated by the same clinicians following a 15-minute break. Inter-rater reliability for experienced raters was calculated with a Fleiss’ generalised kappa of .49; intra-rater reliability was higher with a kappa of .70. Inexperienced raters showed similar reliability with kappa values for inter-rater and intra-rater reliability of .36 and .62, respectively. SLTs demonstrated only fair to moderate reliability in subjectively judging a patient’s cough response to citric acid. Experience in making cough judgements did not improve reliability significantly. In a second study, specific training in cough physiology and cough judgement was provided to 58 trained SLTs. Inter-rater reliability of subjective judgements of cough in patients following inhalation of citric acid was assessed. Participants provided a rating of present or absent, and if present then a rating of strong or weak, to ten video segments of cough responses. Inter-rater reliability for cough presence was calculated with a Fleiss’ generalised kappa of .71 and cough strength was calculated at .61. Years of clinical experience did not improve inter-rater reliability significantly. Experience in using CRT did improve inter-rater reliability. Further validity and reliability research would be beneficial for guiding clinical guidelines and training programmes. By identifying patients at risk of silent aspiration, more informed management decisions can be made that consequently lead to a reduction in preventable secondary complications such as pneumonia. The clinical utility of CRT for reducing pneumonia in acute stroke patients was assessed through a randomised, controlled trial. Three hundred and eleven patients referred for swallowing evaluation were assigned to either 1) a control group receiving standard evaluation or 2) an experimental group receiving standard evaluation with CRT. Participants in the experimental group were administered nebulised citric acid with test results contributing to clinical decisions. Outcomes for both groups were measured by pneumonia rates at three months post stroke and other clinical indices of swallowing management. Analysis of the data identified no significant differences between groups in pneumonia rate (p = .38) or mortality (p = .15). Results of CRT were shown to influence diet recommendations (p < .0001) and referrals for instrumental assessment (p <.0001). Despite differences in clinical management between groups, the end goal of reducing pneumonia in post stroke dysphagia was not achieved. Through this research, the characteristics and outcomes associated with dysphagia secondary to stroke in New Zealand were identified. Baseline characteristics of 311 patients with dysphagia following acute stroke were collected during their hospital stay and outcomes were measured at three months post stroke. Mortality rates were 16% and pneumonia rates 27%. Mean length of stay was 24 days and only 45% of patients were in their own home at three months post stroke. Pneumonia was significantly associated with mortality and increased length of stay. Only 13% of patients received referral for instrumental assessment of swallowing. These data are discussed in reference to the National Acute Stroke Services Audit 2009 and internationally published data. The outcomes for stroke patients with dysphagia in New Zealand are poor with a high risk of pneumonia and long hospital stays when compared internationally. In summary, this research programme has contributed to our understanding of the use of CRT in patients with dysphagia. The addition of a measure of reflexive cough strength may add to clinical assessment but specific training is required to reach adequate reliability. CRT results are significantly associated with aspiration response on instrumental assessment and lower concentrations of citric acid provide a better predictive measure of silent aspiration. CRT can be standardised and therefore is not as susceptible to interpretative variance that plagues much of CSE. Sensitivity and specificity values using this CRT methodology are adequate for CRT to be incorporated into clinical protocols. Inclusion of CRT alone was not shown to be sufficient to change clinical outcomes however integration of CRT into clinical pathways may prove more successful. Further research evaluating the addition of CRT to a comprehensive CSE would add greatly to the field of dysphagia assessment.

A demência é uma síndrome caracterizada pelo declínio de memória e déficit cognitivo que influenciam no desempenho social do indivíduo. É uma junção de sinais e sintomas que culminam em uma deterioração crônica, e em geral progressiva do funcionamento do intelecto, da personalidade e da comunicação. Entre os principais tipos de demência encontra-se a demência do tipo Alzheimer, a demência vascular, a demência com corpos de Lewy e a demência frontotemporal. Independentemente do tipo de demência, um dos seus primeiros indícios é o comprometimento da memória, maior dificuldade de atenção e concentração, perda de habilidades intelectivas, desorientação espaço-temporal, mudanças no comportamento, no humor e na personalidade. Além destas alterações, conforme a doença evolui, o paciente pode apresentar dificuldades para se alimentar e deglutir, e é função do fonoaudiólogo intervir nos distúrbios de memória, fala e deglutição. O presente trabalho teve por objetivo confeccionar uma cartilha de orientações fonoaudiológicas, relacionadas à linguagem e à deglutição, aos cuidadores e/ou familiares de pacientes com demência. Teve como base as dúvidas mais frequentemente encontradas sobre as manifestações fonoaudiológicas apresentadas no questionário que foi aplicado aos cuidadores e/ou familiares dos pacientes com problemas neurológicos, assim como a contribuição de achados teóricos. / Dementia is a syndrome that is characterized by the decline in memory and cognitive deficits that influence the social performance of an individual. It is a combination of signs and symptoms that culminate in a chronic deterioration, and generally progressive operation of intellect, personality and the communication of an individual. Among the main types of dementia is the dementia of Alzheimer, vascular dementia, dementia with Lewy bodies and frontotemporal dementia. Whatever the type of dementia, the first signs are memory impairment, increased difficulty of attention and concentration, loss of skills intellect, spatial-temporal disorientation, changes in behavior, mood and in personality. In addition to these changes, as the disease progresses, patients may find it difficult to get food and swallow. This is a function of the speech pathologist involved in the disturbances of memory, speech and swallowing. The study aimed was to manufacture a book of guidelines that speech therapists, related to language and swallowing, to caregivers and / or relatives of patients with dementia. It was based on the questions most frequently found on the demonstrations phonoaudiologicals presented in the questionnaire that was applied to caregivers and / or relatives of patients with neurological problems, as well as the contribution of theoretical findings.

A respiração e a deglutição são vitais para o homem. Enquanto a primeira diz respeito a um ato primitivo da vida, a hematose, a segunda trata da manutenção da vida, oferecendo a energia necessária, nutrindo e hidratando, perpassando pelo prazer alimentar, ato tão importante na sociedade contemporânea. A relação funcional entre essas funções ainda não foi totalmente elucidada, porém é crescente o interesse e o número de estudos sobre esta temática. Considerando que a deglutição eficiente tem como pressuposto a capacidade de proteger via aérea inferior, a alteração de deglutição primária ou secundária a um dano pulmonar pode trazer repercussões severas para a integridade do sistema respiratório. O objetivo desse estudo é analisar o processo sinérgico da deglutição em portadores de bronquiectasia, a fim de verificar se há alteração na fisiologia da deglutição e caracterizá-la, assim como, identificar se há correspondência entre alteração da função pulmonar e alteração da deglutição.Para tal foram selecionados randomicamente 30 pacientes na faixa etária de 18 a 65 anos, atendidos no ambulatório de bronquiectasia do HUPE. Destes, 26 indivíduos responderam a um questionário dirigido sobre hábitos alimentares e possíveis dificuldades de alimentação; foram submetidos à avaliação clínica da deglutição; 22 fizeram espirometria no setor de prova de função pulmonar no HUPE e 17 avaliação videofluoroscópica da deglutição. Dos 26 indivíduos estudados 10 eram homens e 16 mulheres, com média de idade de 46,3 anos. Na avaliação clínica da deglutição observaram-se alterações estruturais e funcionais em todos os indivíduos estudados. As principais alterações estruturais detectadas referem-se e a dinâmica laríngea; enquanto na avaliação funcional detectou-se alterações referentes à ejeção oral, dinâmica hiolaríngea, trânsito faríngeo e presença de deglutições múltiplas. Com relação à espirometria 06 indivíduos apresentaram distúrbio obstrutivo leve; 04 distúrbio obstrutivo moderado e 09 distúrbio obstrutivo acentuado. A videofluoroscopia da deglutição corroborou os achados da avaliação clínica da deglutição e evidenciou episódios de penetração e aspiração laríngea Pode-se concluir que: (1) a avaliação clínica da deglutição associada à avaliação videofluoroscópica são métodos eficientes para a análise do processo sinérgico da deglutição; (2) identificou-se alteração do processo sinérgico da deglutição, nos indivíduos avaliados; (3) a ausculta cervical isoladamente, não demonstrou ser um método eficiente para predizer aspiração e/ou penetração laringotraqueal; (4) houve correspondência entre os resultados da avaliação clínica funcional da deglutição e videofluoroscópica, exceto quanto a presença de penetração e/ou aspiração e quanto a capacidade de avaliar a ejeção oral; (5) não foi possível identificar se há correspondência entre alteração da função pulmonar e processo sinérgico da deglutição. / Breathing, as well as swallowing, is vital to men.While the first accounts for a primitive aspect of life, the transference of gases through the blood-air barrier, the second is about the maintenance of life, supplying the necessary energy, nourishing and hydrating the organism and then touching the subject of feeding pleasure, such an important act in contemporary society. The functional relation between these functions has not been completely elucidated; however the interest is increasing and the number of studies about this theme. Considering that the efficient swallowing has the capacity of protecting the low airway as purpose, the alteration of primary or secondary swallowing to a pulmonary damage may bring severe repercussions to the integrity of the respiratory system. The aim of the study is to analyze the swallowing in patients carrying bronchiectasis, in order to verify whether there is an alteration in the swallowing physiology and characterize it, as well as to identify whether there is a correspondence between the alteration of the pulmonary function and swallowing disorders. 30 patients were randomly selected aged between 18 and 62 years old, attended at the bronchiectasis clinic of HUPE. 26 out of those individuals were evaluated. They answered a directed quiz about alimentary habits and possible alimentary difficulties; they were submitted to clinical evaluation of swallowing, 22 were orientated to spirometric evaluation in the sector of pulmonary function test at HUPE and 17 videofluorographic examination of swallowing. From the 26 individuals 10 were male and 16 were female, average age of 26 years old. As for the clinical evaluation of swallowing (structural and functional), all individuals presented some kind of laryngeal alteration in the structural evaluation. In the functional evaluation was noted that the main alterations referred to oral ejection, elevation and anterior movement of the hyoid and larynx, pharyngeal transit and multiple swallowing were also present. In relation to spirometry 06 individuals presented mild obstructive disorder 04 presented moderate obstructive disorders and 09 presented severe obstructive disorders. The videofluorograph examination confirmed the findings of the swallowing clinical evaluation and made clear an episode of larynx penetration of liquids. The present study showed as preliminary results: (1) that the clinical evaluation of swallowing associated with videofluorographic Examination are efficient methods to the analysis of the swallowing process; (2) Alteration in the synergic process of swallowing was identified in the evaluated individuals; (3) Cervical auscutating isolatedly did not prove to be an efficient method to predict larynx-tracheal aspiration and/or penetration; (4) There was a correspondence between the results of clinical evaluation of the swallowing videofluorographic, except for the presence of penetration and/or aspiration and for the capacity of evaluating oral ejection; (5) Was not possible to identify if there is a correlation between alteration of the pulmonary function and swallowing disorders.

Swallowing problems, and the often-associated sequelae including pneumonia, malnutrition, and dehydration are common, potentially life-threatening conditions suffered by many elderly individuals. The combination of cognitive, physical, and sensory impairments commonly seen in individuals with dementia and following stroke often results in eating needs going unmet, leading to increased morbidity and premature mortality. The functional limitations of many of these individuals frequently result in decreased mealtime independence and necessitate extensive or total assistance (i.e., dependence) with consuming food and liquids. Despite the implication of increased safety associated with feeding assistance, the influence and potential risk of absent pre-oral cues are unclear, especially in an already taxed system. This study investigated the cooperative relationships between the sequential sensorimotor acts involved in eating and swallowing, focusing on the anticipatory stage, under various sensory-loss conditions. Kinematic data from the lips, jaw, and hand were obtained from 24 healthy younger adults (ages 18-30) and 24 healthy older adults (ages 70-85) under four different conditions: typical self-feeding, typical assisted feeding (i.e., loss of proprioceptive cues), sensory loss self-feeding (i.e., loss of visual cues and degradation of auditory cues), and sensory loss assisted feeding (i.e., loss/degradation of auditory, proprioceptive, and visual cues). During typical self-feeding, all participants began the mouth opening gesture shortly after the onset of hand movement toward the mouth and prior to the onset of oral sensation. However, differences in the timing of anticipatory onset and offset lip movements were observed between older and younger adults and also on the basis of the presence/absence of feeding dependency and sensory loss. Older adults initiated lowering movement earlier than younger adults given the availability of proprioceptive and/or visual cues. In addition to demonstrating earlier lip lowering, during both self-feeding conditions older adults more consistently attended to the timing between lip lowering onset and hand movement onset as compared to both the younger adults and other relative timing pairs. Given the absence of proprioceptive cues (i.e., during assisted feeding), the onset of anticipatory lip movement was delayed. Sensory loss (i.e., loss of visual cues, reduction in auditory cues) alone did not negatively impact the onset of lip movement for either group as compared to typical self-feeding. Conversely, the presence of sensory loss more negatively impacted the offset of lip movement as compared to the absence of proprioception (e.g., the offset of lip movement was later given only visual/auditory loss as compared to assisted feeding). The presence of both feeding dependence and sensory loss had the greatest negative impact on the timing of both the onset and offset of anticipatory lip movement. These findings suggest that deglutition should be considered as beginning prior to the onset of oral sensation and highlight the necessity of better understanding the role that pre-oral, or anticipatory, sensorimotor information may play in the overall eating and deglutitory process. As older adults consistently demonstrated a "compensatory advantage" via earlier and less variable movement onset given the availability of proprioceptive and/or visual cues, continued investigation into these age-related differences is important. This study provides a first step in clarifying the relationship between these pre-oral cues and anticipatory oral posturing during eating and swallowing, allowing for a better understanding of the potential for increased risk assisted feeding recommendations may elicit. However, the differences observed between older and younger adults, particularly under conditions of sensory loss, may be further exacerbated in a taxed system, potentially increasing risk for various patient populations.

1 Einleitung 2 Überblick über die ungestörte Entwicklung des Essens und Trinkens und deren Einflussfaktoren 3 Diagnostik Kindlicher Dysphagien 4 Überlegungen zum therapeutischen Vorgehen in der ambulanten Praxis 5 Literatur

1. Einleitung 1.1 Schluckstörungen 1.2 Neurophysiologie des Schluckens 2. Diagnostik 2.1 Klinische Schluckuntersuchungen 2.2 Instrumentelle Schluckuntersuchungen 3. Therapie 3.1 Änderung der Nahrungskonsistenz 3.2 Fazilitationstechniken 3.3 Position und Manöver 3.4 Kombinierte Techniken 3.5 Zusammenfassung 4. Ausblick 5 Literatur

1 Einleitung 2 Das Problem der Messbarkeit: Welche Messgrößen kommen in Frage? 3 Wie oft Schlucken ist normal? Schluckfrequenz bei gesunden Erwachsenen 4 Wie viel Schlucken ist normal? Bolusvolumina bei gesunden Erwachsenen 5 Variabilität normaler Funktionen: Mögliche Gründe 6 Fazit 7 Literatur

1 Einleitung und Fragestellung 2 Methode 3 Ergebnis und Diskussion 4 Literatur