Research Corner: Silent aspiration — Who is at risk?

Velayutham, P., Irace, A. L., Kawai, K., Dodrill, P., Perez, J., Londahl, M., … & Rahbar, R. (2017). Silent aspiration: Who is at risk?. The Laryngoscope.

Among 1,286 patients who underwent MBS, 440 (34%) demonstrated aspiration. Within the aspiration group, 393 (89%) specifically demonstrated silent aspiration. Thin fluids were silently aspirated in 81% of these patients. Of children aged <6 months, 41% were found to aspirate and, of those, 95% silently aspirated. Median age at which patients demonstrated silent aspiration was 1.1 years. Silent aspiration was documented in 41% of patients with laryngeal cleft, 41% of patients with laryngomalacia, and 54% of patients with unilateral vocal fold paralysis. Laryngeal cleft, laryngomalacia, unilateral vocal fold paralysis, developmental delay, epilepsy/seizures, syndrome, and congenital heart disease were all associated with silent aspiration.

Their conclusions: Silent aspiration may be associated with several underlying conditions and is more common than previously described. Caregivers and clinicians should be aware that the absence of cough does not eliminate the possibility of aspiration. Modified barium swallow studies can reveal silent aspiration, which is difficult to detect on clinical feeding evaluation. Modified barium swallow findings can guide feeding therapy and the overall management of aspiration.

Read more…. https://onlinelibrary.wiley.com/doi/abs/10.1002/lary.27070

 

Research Corner: Quality Improvement Initiatives Related to Cue-Based Feeding in Preterm Infants

Fry, T. J., Marfurt, S., & Wengier, S. (2018). Systematic Review of Quality Improvement Initiatives Related to Cue-Based Feeding in Preterm Infants. Nursing for women’s health.

A nursing team at The Children’s Hospital, OU Medicine, in Oklahoma City, OK examined and synthesized the outcomes of quality improvement (QI) initiatives related to cue-based feeding of preterm infants to facilitate implementation of findings to improve nursing practice.

Their review yielded seven studies related to cue-based feeding of preterm infants. Five studies included multidisciplinary stakeholder teams to assess their respective NICU environments and facilitate project completion. In two studies, feeding “champions” were designated as facilitators. In one study, researchers used a Plan–Do–Study–Act approach and emphasized process over outcome. In six studies, researchers measured hospital length of stay, which decreased in five intervention groups. In three studies, researchers measured infant weight gain, which increased in two intervention groups. In two studies, researchers monitored weight gain velocity, and in five studies, researchers reported earlier attainment of full oral feedings.

They concluded: Weight gain, time to full oral feedings, and hospital length of stay may be improved with the use of cue-based feeding. QI initiatives are a practical means to bring best evidence and multidisciplinary collaboration to the NICU.

Read more…..https://www.sciencedirect.com/science/article/pii/S1751485118301727

 

Problem-Solving: Stridor in Newborn Requiring NICU Care

Problem-Solving: Stridor in Newborn Requiring NICU Care

QUESTION:

We have an infant in our NICU who is presenting with stridor during inhalation and congested/loud breathing on what appears to be during exhalation. I have found with some infants demonstrating stridor they won’t have that congested sound to them, but others will. I asked one of our 38-year veteran nurses and she said she has found the same thing; some will have the congested/loud breathing sound and others won’t. We also do not have ENT’s in house so those that we find have stridor are RARELY sent out for it and we never get to see a report if an infant is seen in out-patient what the findings are. I feel my area of expertise is lacking in this area and would love some more guidance and education on the topic. My question is: Is this typical and if it is what is the reason for the different sound?

ANSWER:

Sounds like you are describing inspiratory stridor. Can have varying etiologies, such as EER/LPR, laryngomalacia. Generally reflects a level of obstruction of the upper airway. The worry is that, with dynamic sucking, swallowing and breathing, it is not uncommon for the etiology/alterations related to the stridor to increase risk for airway invasion during PO feeding. With this clinical presentation, many physicians do not consult ENT, unfortunately, and assume its ok to just wait it out without knowing what’s causing the stridor. They perhaps due not understand the possible functional and safety implications.

In my experience, a clinical swallowing evaluation followed by an ENT consult/flexible scope at bedside can guide us to etiology, reinforce the need for a videoswallow study to objectify impact on physiology and likely interventions. The ENT may see reddened larynx or cords, altered airway structures that are known to adversely affect swallowing physiology.

Many infants with stridor mis-direct the bolus from below or above in my experience. The co-occurring congestion suggests either saliva/refluxate in the hypopharynx and/or laryngeal inlet (may be related to EER) and/or saliva (may be also related to EER and or poor swallowing), if congestion heard at rest. If congestion with PO, suggests potentially a mis-directed toward/above/in the airway. May be a combination of both.

Without hearing the infant, I am at a loss but loud breathing on exhalation suggests perhaps prolonged exhalation which may he be using to try to re-open the collapsing airway and/or to open the alveoli and add PEEP if there’s indeed some airway obstruction, or his trying to clear the congested material off the vocal cords or out of the supraglottic space perhaps. Just hypothesizing.

Other co-morbidities if present need to be correlated, though this may be an “isolated” altered airway problem. I use the quotes around “isolated” as it really is never truly isolated since it is part of a dynamic system (the swallow).  Could also be an additional component of lower airway alteration (tracheal/bronchial). ENT sounds essential to elucidate the integrity of the airway to assist you in your differential.

Clinical problem-solving is my passion. That’s why I developed my 2-day Advanced Pediatric Dysphagia seminar which will be offered again in 2019!

New Shaker Publication – “You Got This Mom” – in the American Speech-Language Hearing Association (ASHA) Leader

New Shaker Publication – “You Got This Mom” – in the American Speech-Language Hearing Association (ASHA) Leader

Feeding is Communication. When we help NICU caregivers  interpret what their preemie is telling them during feeding, we support the parent-infant relationship.

Excerpt: ” What builds confidence is shifting the focus to feeding quality and their relationship with their infant. We get there by helping parents conceptualize feeding as a “conversation” with their infant. Our role as feeding specialists in the neonatal intensive care unit (NICU) is to guide parents to develop this “co-regulation” with their infant—this line of communication that drives feeding, and, ultimately, the parent-infant relationship itself. With our ongoing support, parents can begin to see their relationship with their infant as the foundation for feeding. Intake is then viewed as the byproduct of a quality feeding interaction, not the feeding’s only goal. And so, the parent-infant-relationship begins, through infant-guided feeding.”

Read more ………

Follow the link below to the full article on the ASHA Website.

 

https://leader.pubs.asha.org/article.aspx?articleid=2705737#.W7QHfbT5TR4.email