Abstract
The purpose of this study was to describe the swallowing characteristics of elderly patients requiring mechanical ventilation with tracheostomy admitted to a long-term, acute-care hospital. The study was conducted through retrospective record review of patients on mechanical ventilation who had received a Modified Barium Swallow Study (MBSS) during their hospitalization. In a period from 1994 to 2002, 58 patients met the inclusion criteria. The study examined the results of both the clinical and the MBSS evaluations and compared the results and recommendations of the two examinations. Data were obtained from the MBSS records to describe the group in terms of dysphagia symptoms, frequency and occurrence of aspiration, respiratory status, and demographic variables. Parametric and nonparametric statistics were used to determine differences between the evaluations and any significant associations between aspiration and demographic variables, pharyngeal symptoms, and cognitive deficits. Significant differences were found between diet recommendations before and after the MBSS, and significant associations were found between aspiration and three pharyngeal symptoms. Although aspiration and especially silent aspiration occurred frequently in this group, most individuals were able to begin some level of oral intake after the MBSS evaluation. Due to the lack of reliable clinical evaluation measures, the MBSS is necessary for differential diagnosis of dysphagia and dietary recommendations for these individuals.
Similar content being viewed by others
Patients who require long-term mechanical ventilation with tracheostomy are at risk for swallowing disorders for various reasons. Individuals on mechanical ventilation frequently exhibit difficulty coordinating breathing and swallowing, decreased laryngeal elevation, decreased pharyngeal and laryngeal sensation, and decreased subglottal pressure [1,2,3,4,5,6,7,8]. Additionally, individuals who are dependent upon a ventilator are likely to aspirate [2,4,5,9,10,11,12,13], and the aspiration is usually silent [14]. Both oral and pharyngeal stage swallowing abnormalities have been documented in this group, including oral transit and bolus formation deficits, delayed swallow initiation, residue throughout the pharynx and pyriform sinuses [4,10,13], and decreased duration of vocal fold closure during swallowing [8]. Swallowing disorders create serious health risks and can complicate respiratory disease and nutritional status.
Speech–language pathologists (SLPs) use a combination of evaluation techniques to determine the presence and characteristics of dysphagia. The clinical or bedside swallowing evaluation (CBSE) provides important information about oral motor abilities and cognitive skills and also allows the SLP to observe visible and audible signs of aspiration [15,16]. However, the clinical evaluation without the support of an instrumental measure like a Modified Barium Swallow Study (MBSS) will not provide an accurate assessment of pharyngeal skills and may underestimate the severity of dysphagia and aspiration which is often asymptomatic [13,14,16,17,18,19,20,21]. The CBSE is especially unreliable for identifying aspiration in patients requiring mechanical ventilation or tracheostomy [7,21].
Instrumentation like the MBSS is also necessary to objectively determine strategies or maneuvers to increase swallowing safety and efficiency and to make dietary recommendations [4,10,20,22,23,24]. Dietary recommendations based on only a clinical evaluation often differ from recommendations after a MBSS and may either be overly restrictive or place the individual at risk for aspiration and choking [21,23,24]. Definitive diagnosis and appropriate swallowing guidelines are especially critical for patients with compromised respiratory status since they are more likely to have complications if they aspirate [5,14].
Although researchers are attempting to create more accurate and reliable clinical evaluations for dysphagia assessment, existing measures serve only as a screening to determine those patients who require instrumental assessment. Several studies have identified clinical indicators of dysphagia, and these in combination have been used to indicate a need for further diagnostic testing [17,22,25]. The use of multiple clinical features can better identify individuals who need further instrumental study, but this practice is not reliable enough since underestimating dysphagia can have serious consequences for the medical status of the patient. Specifically, patients with ventilator dependency who are being considered to begin oral feeding should routinely be referred for the MBSS because of the frequent occurrence of silent aspiration in this group.
The use of mechanical ventilation in elderly patients is increasing [26,27], and age may play a factor in mortality and morbidity for those with respiratory conditions that require mechanical ventilation [26,28,29,30,31,32,33]. Mortality rates after respiratory failure are higher with increasing age although other factors such as premorbid health status also impact prognosis. Aging creates physiologic changes in pulmonary function such as gas exchange and elastic recoil, respiratory muscle strength, and the functional reserve of the other systems that support respiration and swallowing [34,35,36,37].
The purpose of this study was to determine the swallowing characteristics and incidence of dysphagia in elderly patients on mechanical ventilation admitted to a long-term, acute-care hospital. The co-occurrence of aspiration with swallowing disorders has been documented in patients with respiratory complications, but specific characteristics of different patient groups have not been explored extensively. Most of the patients in this study used a Passy–Muir speaking valve (PMV) as part of respiratory and swallowing rehabilitation, and although evidence is conflicting, studies have indicated that the PMV improves swallowing function and decreases aspiration [3,12,38,39]. However, since this was a retrospective chart review, it was not possible to determine the direct impact of the PMV with this group because of the nature in which the original dysphagia evaluations were conducted. Specific areas of interest in the study included any differences in recommendations from the clinical swallowing evaluation versus the MBSS, characteristics and incidence of dysphagia, and the effect of demographic variables.
Methods
Sample
Individuals in the study were adults admitted to this violates confidentiality, a 60-bed, long-term, acute-care hospital with an intensive care unit in a midwestern US city. The population of this hospital was predominantly elderly and medically complex individuals with multiple diagnoses, and many required long-term ventilator support. A major focus of the hospital was ventilator weaning and physical rehabilitation in patients transferred from area hospitals.
Procedure
Data were obtained from a retrospective review of patient medical records from 1994 when the hospital opened until April 2002. Each medical chart in the facility was reviewed by the researchers. All patients on mechanical ventilation with tracheostomy who were being considered as candidates to begin oral feeding and had undergone a MBSS were included in the study. Patients who were orally intubated, who had only a tracheostomy without mechanical ventilation, or who were comatose were excluded. The average length of stay in the facility across diagnoses was 28 days. The underlying causes for the respiratory conditions varied, and the respiratory diagnoses of the subjects included respiratory failure, ventilator dependency, and airway obstruction. A protocol was designed and used by the researchers to assure that uniform information was obtained (see Appendix). Information collected from each medical record included ventilator status, dysphagia symptoms from both the CBSE and the MBSS, recommendations from the CBSE and the MBSS, demographics, and method of nutritional intake.
Protocol for the Clinical Bedside Swallowing Evaluation
Individuals were administered two presentations of 1/2 teaspoon of thin liquids, puree, and soft solid food consistencies (i.e., graham cracker) in that order unless the prior consistency had resulted in obvious signs of aspiration or choking. Patients who wore a PMV (91.4%) had the valve on and the cuff deflated for trial swallows. Patients who could not tolerate cuff deflation or the PMV received trial swallows with the cuff inflated. The use of food coloring or suctioning after swallows was not routinely utilized since this was regarded only as a gross screening measure for aspiration. The average length of time between the CBSE and MBSS was 9.9 days. Any delay in the MBSS after the CBSE was due to individuals being inappropriate candidates for the MBSS at the time of the CBSE because of a low level of consciousness, poor response to the trial swallows, or a medical complication prior to the study being conducted.
Definition of Terms
Aspiration was defined as material passing below the level of the true vocal folds. Silent aspiration was defined as aspiration that occurred without an audible reaction or cough from the individual. Penetration was defined as the presence of material in the laryngeal vestibule or airway entrance that may or may not have been cleared but that did not pass below the level of the true vocal folds during the observed period. A uniform CBSE protocol and MBSS protocol was utilized by the SLPs who performed the original assessments. The policy for SLPs in this facility was to recommend the MBSS for ventilator-dependent patients as soon as individuals could tolerate the procedure if there was any suspected pharyngeal component from the clinical examination. Therefore, the majority of patients on mechanical ventilation underwent a MBSS before beginning oral intake.
Results
Data Analysis
Statistical comparisons were made with the measures of chi squared, t-test, and one-way ANOVA using SPSS version 11.0 statistical software (SPSS Inc., Chicago, IL). Descriptive statistics were also calculated for means and frequency counts.
Demographics
There were 58 patients who met the requirements for inclusion in the study over the specified time period. A description of each subject and diet recommendations are provided in Table 1. Summary information about age, gender, PMV use, and NPO status is listed in Table 2. The primary respiratory condition which created the need for mechanical ventilation was respiratory failure for 86% of subjects (50/58) and ventilator dependence for 14% (8/58). History information about the underlying disease creating the respiratory condition was not available. Individuals who had been previously prescribed a PMV by their physicians used the valve during the dysphagia evaluations. Gender distribution was roughly commensurate at 58.6% female and 41.4% male. The mean age of the group was 69.7 years of age with a range of 36–86 years. Discharge dispositions at the end of the hospital stays were home (19%), expired (36.2%), nursing home (37.9%), and hospital transfer (6.9%). This information gives an indication of the severity of illness in these individuals.
CBSE and MBSS Results
Prior to the MBSS, 84.5% of the participants were NPO or prohibited from any oral intake. A paired-samples t-test revealed that the differences between diet recommendations from the CBSE and the MBSS were statistically significant for both food (t = −7.021, df = 57, p = 0.001) and liquid (t = −7.592, df = 57, p = 0.001). After the MBSS, only 24.1% of individuals remained NPO, and 69.6% were allowed thin or nectar-consistency liquids indicating that the results of the MBSS allowed for a less restrictive diet than was recommended from the CBSE (see Table 2). However, this result may have been impacted by the fact that the SLPs at this facility regularly used MBSS with patients on mechanical ventilation prior to beginning an oral diet due to the high incidence of clinically undetected pharyngeal dysfunction. SLPs in other hospitals may be more likely to recommend an oral diet from only the CBSE without instrumental assessment. The most common dietary consistency initiated after the MBSS was puree (34.5%) followed closely by mechanical soft (32.8%). The most common liquid recommendations for patients after the MBSS were thin (44.6%), nectar (25%), honey (7.1%), and no liquids (23.3%). Compensatory strategies that alleviated aspiration were identified on the MBSS for 63.8% of patients.
Dysphagia Symptoms
Patients exhibited multiple symptoms of both oral and pharyngeal stage dysphagia during the MBSS, including impaired anterior–posterior bolus transport, delayed swallow, laryngeal penetration, and vallecular and pyriform sinus residue (see Table 3). Aspiration was present in 41.4% of patients and occurred with equal frequency before and during the swallow (12.1%) and at times during both the oral and pharyngeal stages of the swallow (10.3%). Aspiration was silent 83.3% of the time when it occurred.
Chi-squared analysis was used to determine associations between the presence of aspiration and gender, laryngeal penetration, cognitive deficits, vallecular residue, pyriform residue, delayed pharyngeal swallow, and decreased anterior–posterior bolus transport. The presence of residual material in the pyriform sinuses (p = 0.039), laryngeal penetration (p = 0.001), and decreased anterior–posterior bolus transport (p = 0.027) were significantly associated with aspiration. A one-way ANOVA demonstrated no significant association between age and aspiration although it was expected that aspiration would be associated with increasing age.
Discussion
Many patients who are ventilator-dependent are elderly and have swallowing disorders that result in aspiration. In this study, as in other studies, patients on mechanical ventilation aspirated frequently. With mechanical ventilation and tracheostomy, adverse changes in the swallowing mechanism occur as a result of disuse muscle atrophy, desensitization, and chronic laryngeal damage, and these affects accumulate over time. Reinstituting oral intake as soon as it is safe may prevent further loss of feeding and swallowing skills. Since aspiration in patients with ventilator dependence is typically silent, the MBSS is necessary when these individuals are being considered as candidates to begin oral feeding.
Diet recommendations made from the CBSE in this study were significantly different from those made after the MBSS was conducted and, almost always, the individual was allowed to begin oral intake or upgrade the diet. These data demonstrate that although elderly patients on mechanical ventilation are at high risk for dysphagia, they can often safely have some oral intake and should not be assumed to be profound aspirators because of their respiratory status. It is important to provide oral intake as soon as patient safety is ascertained with the MBSS in order to avoid the negative affects of being NPO, including discomfort, muscle atrophy, sensory deprivation, tube feeding risks, and nutritional deficiencies. A return to oral intake is associated with increased quality of life, social interaction, independence, and as an important step toward recovery [40,41,42,43,44,45,46,47].
It should be noted that 91.4% of individuals utilized the PMV while eating and swallowing, although it was not possible to determine its impact on swallowing. It is interesting that the individuals in this study on mechanical ventilation aspirated with equal frequency before and during the swallow and also tended to aspirate during the oral and pharyngeal stages of the swallow. Oral stage dysfunction may occur from a combination of factors including generalized weakness and frailty, dry mouth from the ventilator from being NPO, decreased oral motor skills from disuse, and oral motor deficits from underlying neurological conditions. The multiple instances of aspiration that occurred may have been due to difficulty coordinating swallowing with the cycling of the ventilator.
Additionally, patients on mechanical ventilation frequently require anti-anxiety medications and these may cause sedation and decrease cognitive awareness needed for safe swallowing. Laryngeal penetration and pyriform sinus residue may occur from reduced sensitivity to material in the pharynx, poor laryngeal elevation from the tracheostomy tube tethering, and a weak swallow from decreased subglottal pressure. Once food or liquid reached the level of the airway entrance, these patients were unable to clear the material.
Conclusion
This research provides information about the characteristics and prevalence of dysphagia in elderly patients on mechanical ventilation and, as with other patient groups, demonstrates the importance of the MBSS. These results provide additional justification for the routine use of the MBSS to improve patient safety and to facilitate a timely return to oral feeding. The clinical examination is valuable but is not sufficient for determining the safety of oral feeding or appropriate dietary recommendations. Elderly adults with ventilator dependence vary in their strengths and weaknesses, and many can tolerate some level and amount of oral intake. These individuals may have multiple symptoms of dysphagia that are not visible or audible, and SLPs and medical personnel should not make assumptions about the swallowing status of individuals who are ventilator-dependent.
Instrumental assessment like the MBSS is critical for making any type of dietary recommendation and to assure an adequate diagnosis of oropharyngeal and laryngeal function. The MBSS can be performed with patients on mechanical ventilation using a portable ventilator in the radiology suite or a portable fluoroscopy unit at the bedside. An individual’s quality of life may be greatly improved by determining if there are any consistencies that can be eaten safely as opposed to unnecessarily restricting oral intake.
Eating is a positive functional outcome of dysphagia intervention, may prevent further loss of skills and muscle atrophy, and is less expensive than tube feeding. As technology extends lifespan, the number of patients with ventilator dependence will increase. SLPs will be frequently required to evaluate and make recommendations regarding swallowing safety for these patients and must be aware of the complicated issues involved. Long-term acute care with mechanical ventilation and nonoral feeding is very costly with uncertain outcomes and no reliable method of prediction for mortality rates and quality of life. Healthcare providers are seeking the tools to best assess and intervene with these chronically ill patients to balance safety, quality of life, and costs of care. The ability to swallow safely is a very important part of overall health and well-being, and appropriate dysphagia intervention can increase both psychosocial and physical outcomes.
References
PC Bonanno (1971) ArticleTitleSwallowing dysfunction after tracheotomy. Ann Surg 174 29–33 Occurrence Handle5092509
JA Buckwalter CT Sasaki (1984) ArticleTitleEffect of tracheotomy on laryngeal function. Otolaryngol Clin North Am 17 41–48
MA Dettelbach RD Gross J Mahlmann DE Eibling (1995) ArticleTitleEffect of the Passy–Muir valve on aspiration in patients with tracheostomy. Head Neck 17 297–302 Occurrence Handle1:STN:280:ByqH3czhtl0%3D Occurrence Handle7672970
MA DeVita L Spierer–Rundback (1990) ArticleTitleSwallowing disorders in patients with prolonged orotracheal intubation or tracheostomy tubes. Crit Care Med 18 1328–1330 Occurrence Handle1:STN:280:By6D2MbmtFY%3D Occurrence Handle2245604
EH Elpern ER Jacobs RC Bone (1987) ArticleTitleIncidence of aspiration in tracheally intubated adults. Heart Lung 16 527–531 Occurrence Handle1:STN:280:BieD3cnosVI%3D Occurrence Handle3115917
L Fornataro–Clerici T Roop (1997) Clinical management of adults requiring tracheostomy tubes and ventilators. Northern Speech Services Gaylord, MI
SB Leder (1999) ArticleTitleEffect of a one-way tracheostomy speaking valve on the incidence of aspiration in previously aspirating patients with tracheotomy. Dysphagia 14 73–77 Occurrence Handle1:STN:280:DyaK1M7ltl2hsQ%3D%3D Occurrence Handle10028036
R Shaker M Milbrath J Ren B Campbell R Toohill W Hogan (1995) ArticleTitleDeglutitive aspiration in patients with tracheostomy: Effect of tracheostomy on the duration of vocal fold closure. Gastroenterology 108 1357–1360 Occurrence Handle1:STN:280:ByqB2cnps1M%3D Occurrence Handle7729626
JL Cameron J Reynolds GD Zuidema (1973) ArticleTitleAspiration in patients with tracheostomies. Surg Gynecol Obstet 136 68–70
EH Elpern MG Scott L Petro MH Ries (1994) ArticleTitlePulmonary aspiration in mechanically ventilated patients with tracheostomies. Chest 105 563–566 Occurrence Handle1:STN:280:ByuC3sbkt1Y%3D Occurrence Handle8306764
M Nash (1988) ArticleTitleSwallowing problems in the tracheotomized patient. Otolaryngol Clin North Am 21 701–709
J Muz RH Mathog R Nelson LA Jones (1989) ArticleTitleAspiration in patients with head and neck cancer and tracheostomy. Am J Otolaryngol 10 282–286
K Tolep CL Getch GJ Criner (1996) ArticleTitleSwallowing dysfunction in patients receiving prolonged mechanical ventilation. Chest 109 167–172 Occurrence Handle1:STN:280:BymC3s3islI%3D Occurrence Handle8549181
TG Pannunzio (1996) ArticleTitleAspiration of oral feedings in patients with tracheostomies. AACN Clin Issues 7 560–569 Occurrence Handle1:STN:280:ByiC38rhslw%3D Occurrence Handle8970257
SE Langmore JA Logemann (1991) ArticleTitleAfter the clinical bedside swallowing examination: What next? Am J Speech Lang Pathol 1 13–20
J Logemann (1998) Evaluation and treatment of swallowing disorders, 2nd ed. Pro-Ed Austin, Tx
P Linden KV Kuhlemeier C Patterson (1993) ArticleTitleThe probability of correctly predicting subglottic penetration from clinical observations. Dysphagia 8 170–179 Occurrence Handle1:STN:280:ByyA28rivFw%3D Occurrence Handle8359036
J Logemann (1997) ArticleTitleRole of the modified barium swallow in management of patients with dysphagia. Otolaryngol Head Neck Surg 116 335–338 Occurrence Handle1:STN:280:ByiB2cvks1w%3D Occurrence Handle9121786
G Mann GJ Hankey D Cameron (1999) ArticleTitleSwallowing disorders following acute stroke: Prevalence and diagnostic accuracy. Cerebrovasc 10 380–386 Occurrence Handle10.1159/000016094
R Sorin S Somers W Austin S Bester (1988) ArticleTitleThe influence of videofluoroscopy on the management of the dysphagic patient. Dysphagia 2 127–135 Occurrence Handle1:STN:280:BiaB1cbhtlY%3D Occurrence Handle3251686
ML Splaingard BS Hutchins LD Sulton G Chaudhuri (1988) ArticleTitleAspiration in rehabilitation patients: Videofluoroscopy vs bedside clinical assessment. Arch Phys Med Rehabil 69 637–640 Occurrence Handle1:STN:280:BieA3cfmvFQ%3D Occurrence Handle3408337
SK Daniels CP McAdam K Brailey AL Foundas (1997) ArticleTitleClinical assessment of swallowing and prediction of dysphagia severity. Am J Speech Lang Pathol 6 17–24
B Martin–Harris JA Logemann S McMahon M Schleicher J Sandidge (2000) ArticleTitleClinical utility of the modified barium swallow. Dysphagia 15 136–141 Occurrence Handle1:STN:280:DC%2BD3czpsVKmsQ%3D%3D Occurrence Handle10839826
DJ Ott RG Hodge A Pikna MY Chen DW Gelfand (1996) ArticleTitleModified barium swallow: Clinical and radiographic correlation and relation to feeding recommendations. Dysphagia 11 187–190 Occurrence Handle1:STN:280:BymA2cbmtlQ%3D Occurrence Handle8755463
SK Daniels LA Ballo M Mahoney AL Foundas (2000) ArticleTitleClinical predictors of dysphagia and aspiration risk: Outcome measures in acute stroke patients. Arch Phys Med Rehabil 81 1030–1033 Occurrence Handle10.1053/apmr.2000.6301 Occurrence Handle1:STN:280:DC%2BD3cvgvVKksg%3D%3D Occurrence Handle10943750
BP Krieger (1994) ArticleTitleRespiratory failure in the elderly. Clin Geriatr Med 10 103–119 Occurrence Handle1:STN:280:ByuB387ltVE%3D Occurrence Handle8168018
BA Phelan DA Cooper P Sangkachand (2002) ArticleTitleProlonged mechanical ventilation and tracheostomy in the elderly. AACN Clin Issues 13 84–93 Occurrence Handle11852726
G Albaugh B Dann MM Puc P Vemulapalli S Marra S Ross (2000) ArticleTitleAge-adjusted outcomes in traumatic flail chest injuries in the elderly. Am Surg 66 978–992 Occurrence Handle1:STN:280:DC%2BD3M7mtFWqsA%3D%3D Occurrence Handle11261629
IL Cohen J Lambrinos (1995) ArticleTitleInvestigating the impact of age on outcome of mechanical ventilation using a population of 41,848 patients from a statewide database. Chest 107 1673–1680 Occurrence Handle1:STN:280:ByqA3c%2Flt1w%3D Occurrence Handle7781366
EW Ely GW Evans EF Haponik (1999) ArticleTitleMechanical ventilation in a cohort of elderly patients admitted to an intensive care unit. Ann Intern Med 131 96–104 Occurrence Handle1:STN:280:DyaK1MzjtlSntA%3D%3D Occurrence Handle10419447
CJ Kurek IL Cohen J Lambrinos FV Booth DF Chalfin (1997) ArticleTitleClinical and economic outcome of patients undergoing tracheostomy for prolonged mechanical ventilation in New York state during 1993: Analysis of 6,353 cases under diagnosis-related group 483. Crit Care Med 25 983–988 Occurrence Handle10.1097/00003246-199706000-00015 Occurrence Handle1:STN:280:ByiA2cvms10%3D Occurrence Handle9201051
JE Spicher DP White (1987) ArticleTitleOutcome and function following prolonged mechanical ventilation. Arch intern Med 147 421–425 Occurrence Handle1:STN:280:BiiC2MrmtlA%3D Occurrence Handle3827415
AJ Swinburne AJ Fedullo K Bixby DK Lee GW Wahl (1993) ArticleTitleRespiratory failure in the elderly: Analysis of outcome after treatment with mechanical ventilation. Arch Intern Med 153 1657–1662 Occurrence Handle1:STN:280:ByyA38ngs1E%3D Occurrence Handle8333803
J Robbins (1996) ArticleTitleNormal swallowing and aging. Semin Neurol 16 309–317 Occurrence Handle1:STN:280:ByiB28nlsFw%3D Occurrence Handle9112310
J Robbins (1999) ArticleTitleOld swallowing and dysphagia: Thoughts on intervention and prevention. Nutr Clin Pract 14 S21–S26
JA Robbins RL Levine J Wood (1995) ArticleTitleAge effects on lingual pressure generation as a risk factor for dysphagia. J Gerontol Med Sci 50A M257–262
J Robbins JW Hamilton GL Lof GB Kempster (1992) ArticleTitleOropharyngeal swallowing in normal adults of different ages. Gastroenterology 103 823–829 Occurrence Handle1:STN:280:By2A28zhsFM%3D Occurrence Handle1499933
SW Lichtman IL Birnbaum MR Sanfilippo JT Pellicone WJ Damon ML King (1995) ArticleTitleEffect of a tracheostomy speaking valve on secretions, arterial oxygenation, and olfaction: A quantitative evaluation. J Speech Hear Res 38 549–555 Occurrence Handle1:STN:280:ByqH3cvps1w%3D Occurrence Handle7674646
RJ Stachler SL Hamlet J Choi S Fleming (1996) ArticleTitleScintigraphic quantification of aspiration reduction with the Passy–Muir value. Laryngoscope 106 231–234
N Buchholz (1997) Neurologic disorders of Swallowing. M Groher (Eds) Dysphagia: Diagnosis and Management, 3rd ed. Butterworth-Heinemann Newton, MA 37–72
T Finucane C Christmas K Travis (1999) ArticleTitleTube feeding in patients with advanced dementia: A review of the evidence. JAMA 282 1365–1370 Occurrence Handle10.1001/jama.282.14.1365 Occurrence Handle1:STN:280:DyaK1MvlsVejug%3D%3D Occurrence Handle10527184
B Klor F Milianti (1999) ArticleTitleRehabilitation of neurogenic dysphagia with percutaneous endoscopic gastrostomy. Dysphagia 14 162–164 Occurrence Handle1:STN:280:DyaK1M3oslOltA%3D%3D Occurrence Handle10341114
SE Langmore (1999) ArticleTitleIssues in the management of dysphagia. Folia Phoniatr Logop 51 220–230 Occurrence Handle10.1159/000021499 Occurrence Handle1:STN:280:DyaK1MzotVShtw%3D%3D Occurrence Handle10450028
J Robbins B Priefer G Gunter–Hunt M Johnson C Singaram M Schilling D Watts (1997) . B Sonies (Eds) Dysphagia: A Continuum of Care. Aspen Gaithesburg, MD 41–54
G Scofield (1991) ArticleTitleArtificial feeding: The least restrictive environment? J Am Geriatr Soc 39 1217–1220 Occurrence Handle1:STN:280:By2D2s7lt1w%3D Occurrence Handle1960366
H Segel M Smith (1995) ArticleTitleTo feed or not to feed. Am J Speech Lang Pathol 4 11–14
FJ Shih SH Chu PJ Yu WY Hu GS Huang (1997) ArticleTitleTurning points in recovery from cardiac surgery during the intensive care transition. Heart Lung 26 99–108 Occurrence Handle1:STN:280:ByiB2croslA%3D Occurrence Handle9090514
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Davis, L.A., Thompson Stanton, S. Characteristics of Dysphagia in Elderly Patients Requiring Mechanical Ventilation . Dysphagia 19, 7–14 (2004). https://doi.org/10.1007/s00455-003-0017-7
Issue Date:
DOI: https://doi.org/10.1007/s00455-003-0017-7