Assessing laryngeal reflexes and the risk of developing pneumonia after a stroke
Inthospital comparison.
Dynamic
Foundation and Purpose-We tried to assess the viability of testing the laryngeal hack reflex in recognizing pneumonia hazard in intense stroke patients.
Techniques We played out an imminent investigation of 400 continuous intense stroke patients analyzed utilizing the reflex hack test (RCT) contrasted and 204 sequential intense stroke patients from a sister office inspected without utilizing the RCT. The parallel endpoint for the review result was the improvement of pneumonia.
Consequences Of the 400 patients analyzed with the RCT, 5 created pneumonia. Of the 204 patients analyzed without the RCT, 27 created pneumonia (P<0.001). Three of the 27 patients kicked the bucket in the recovery medical clinic of respiratory disappointment auxiliary to pneumonia. Seven others were moved to the crisis office with intense respiratory pain. Power investigation for this correlation was 0.99. There could have been no other critical contrasts between the 2 gatherings.
Decisions An ordinary RCT after an intense stroke demonstrates a neurologically flawless laryngeal hack reflex, a safeguarded aviation route, and an okay for creating desire pneumonia with oral taking care of. A strange RCT shows the hazard of an unprotected aviation route and an expanded frequency of goal pneumonia. Substitute taking care of procedures and preventive measures are vital with an unusual RCT. Clinical treatment calculation and remedy of food, liquids, and drugs are talked about based on RCT results.
After a stroke, one of the most challenging decisions faced by a doctor is to institutionalize fluid recipes, food, and oral medicines safely. The question is safe to feed patients mostly guessed and for the try-and-error approach. The doctor has historically delayed this dilemma for pathological speeches or other personnel. It is estimated that up to 38% of stroke victims died in the first month after the onset of stroke.12 Pneumonia contributed up to 34% of all stroke deaths and represented the third-highest cause of death in the first month after the stroke. Pneumonia has been expected to occur in one-third of all stroke victims and is the most common respiratory complication.
The Florida Hospital Association reported total costs for dysphagia and food pneumonitis/vomiting to $ 1.2 billion in 1997 for the State of Florida, increased from $ 1.1 billion in 1996. In 1996, Florida was ranked 15th The next national on the charges for the international classification along with the disease, the ninth revision code: 787.2 (Dysphagia) and 507.0 (food pneumonitis/vomiting).45 The effect of the development of pneumonia has been described in terms of individual care costs. The development of pneumonia after stroke produces an additional financial burden of around $ 10,000 per event and the length of the hospital extended an average of 7 days.6 Given the incidence of strokes, the prevalence of aspiration, the risk of aspiration, and the effect of pneumonia in terms of morbidity, mortality, and maintenance costs, patient identification which is at risk for the development of clinically and financially pneumonia.
Cough laryngeal reflex testing (LCR) and prevention of secondary pneumonia for aspiration after stroke is the main focus of our research. We use Kemoirritant stimulation with tartaric acid to study LCR. Kemoirritant receptors in the aditus larynx, when stimulated, induces unwatery reflex cough.789 Cough reflexes are very important for the protection of the airway and prevention of aspiration pneumonia. After strokes or other neurological events, LCR may weaken or does not exist. This increases the risk of aspirations for food, liquids, drugs, or secretions through the actual vocal cords and can cause the development of pneumonia. The only way to test the status of the airway protection mechanism is to stimulate reflexes.
The internal branch of the superior laryngeal nerve, especially the middle Ramus, conveyed afferent information from LCR to the brain stem.1112 receptor in the aditus larynx emerging polymodal. , medium, and inferior flax. Ramus Branches Superior distributes to mucosa recess piriform. Ramus Middle Stay Mucosa from Vestibule or Supraglottic Region of Laryngs.11
LCR is a mechanism for the survival of the primal brain stem. If LCR does not recover quickly after neurological events, morbidity and mortality increase. Like other accidental neurological processes, such as respiratory encouragement, this tends to recover quickly or bad results occur. After a stroke, LCR can experience a disturbance for up to a month or more, and in some cases, it can remain disturbed indefinitely.21 The purpose of this study is to compare the results of patients with the use of RCT and clinical treatment algorithms, as shown in this number, with results Patients with the use of standard assessment and treatment approaches for binary endpoints from pneumonia development.
Subject and method
The reflex cough test (RCT) stimulates cough receptors in the front room of the larynx and initiates the LCR.92232425 test which is used as a 20% solution of the L-tartaric acid level recipe dissolved in 2 ml of normal saline. Solution.
Placed in Nebulizer Bennett Twin and inhaled as a microerosol a. During Inhalation, the subject's nose was tightened closed. The Nebulizer output is 0.2 ml / min.7910222325 test given by one of the speech pathologists or respiratory therapists besides the bed and needed ≈10 minutes to complete.
Subjects are tested for a maximum of 3 effective withdrawals. The subject was asked to exhale and then put the funnel and take a sharp, deep inhalation. The leak around the funnel and "sucking" nebulizer was not considered an effective withdrawal. The test ends when a cough response is wrong or the subject fails to respond after 3 inhalations. The LCR response is considered normal or abnormal (weak or not). If the subject's response is not present, a higher concentration of tartar acid is not used. The RCT algorithm is followed by further treatment strategies such as a limited diet, not by mouth, or nutritional support by means of the percutaneous gastrostomy (PEG) (PEG). The treatment strategy is recorded for all subjects.
After testing cough reflexes, speech pathologists conduct swallow bedside evaluations and test for cognition, swallows and post swallow sound quality, and cranial nerve function. In this study, bedside swallowing evaluations consist of 3-section screens including voluntary cough evaluations, 2-section water tests, progressive food experiments, and liquid consistency. Water tests are considered the ability of the subject to hold 15 ml of water in his mouth for 10 seconds. The test is repeated with 30 ml of water. The volume of water returned to the container was recorded. The food used in this evaluation includes porridge, chopped, and cohesive bolus food. Thin and thick liquid ranges from water to thick spoon fluids. Swallow standard bedside evaluation was carried out in the hospital sister by a speech pathologist, and videofluoroscopic examination was carried out when it was clinically believed to be shown by their staff.
This is a prospective study in which 400 consecutive acute stroke patients were tested by RCT in an acute rehabilitation hospital. The patients were later treated clinically based on normal, weak test results, or no LCR. A clinical algorithm treatment plan was followed (Figure). A similar group of 204 consecutive acute stroke patients from the nearby hospital rehabilitation sister was used to compare the incidence of pneumonia between groups. The chart review of 204 patients in a row acute stroke (<30 days after onset) was carried out using standard criteria for the development of pneumonia. Pneumonia is diagnosed if the patient has good respiratory symptoms of temperature> 101 ° F, leukocytosis, or both. Infiltration is needed to have an X-ray chest confirmation.
T-test compares 2 groups for age and time from stroke onset until it goes into acute rehabilitation. The χ2 test is done for sex and as a predictor for the development of pneumonia. Logistic regression is considered long to live in acute rehabilitation for 2 facilities.
The binary main endpoint for this research is the development of pneumonia. Using the Odds ratio test, we compare opportunities in support of not developing pneumonia among patients given RCT with opportunities in support of not developing pneumonia among patients who are not given the RCT.
In unparalleled studies, there is a standard formula to determine the sample size for comparison of proportions. Level of significance, test strength, and proportion evaluated.
RESULTS
Of the 400 subjects in this study, 40 (10%) had a weak LCR or not when tested with RCT. When asked to produce voluntary cough, 81 of 400 subjects (20.3%) have abnormal voluntary coughs (weak or non-existence) (Table 1). The main end of the binary endpoint for this study is the development of pneumonia (Table 2). The exact test of the significance for this situation is the χ2 test, with a zero hypothesis that there is no difference between the patient given RCT and patients who are not given RCT. Significant differences were found There are no side effects or detrimental complications of the RCT administration.
Five of the 400 patients given RCT developed pneumonia. They are treated with oral antibiotics and recover. None of the 5 transfers are needed from rehabilitation facilities. Of the 400 patients who received RCT, 20 accepted the placement of percutaneous endoscopic gastrostomy. Of this amount, 7 were removed before exiting. 204 Patients at your facility did not receive RCT, and 27 of these patients developed pneumonia. Three of the 27 patients died of pneumonia at hospital rehabilitation, and 7 were transferred to the emergency department and intensive care settings.
In addition to the significance test, interest in determining CI 95% for P1-P2, where P1 is the proportion of patients who develop pneumonia after RCT is given and P2 is the proportion of patients who develop pneumonia without giving RCT. The suitable CI is CI for independent samples. 95% CI for P1-P2 is -0.167 to -0.072, with a 95% confidence level.
Supporting opportunities do not develop pneumonia among patients given by RCT compared to supporting opportunities not to develop pneumonia among patients who are not given RCT. The ODDS ratio test shows that supporting opportunities do not develop pneumonia for patients who do not receive RCTs significantly smaller than supporting opportunities not developing pneumonia for patients who receive RCT. In fact, the ratio of the opportunity was 0.08, which was significantly <1, and a 95% CI for the Odds ratio was 0.031 to 0.219 (Table 3).
In unparalleled studies, there is a standard formula to determine the sample size for the comparison of 2 proportions. Sample size options depend on the level of significance, test strength, and proportions. The sample size for this study was set at N1 = 400 (patients who received RCT) and N2 = 204 (patients who did not receive RCT). Power analysis is very important to determine the right sample size. When the significance level was set at 0.05, the test strength was 0.99. Thus, there is a 99% possibility to find a significant difference with the use of sample size (N1 = 400, N2 = 204). There is no significant difference between the 2 groups for age (Table 4), the length of life in the arrangement of acute care (Table 5), and sex (Table 6).
Discussion
Assessing LCR neurological integrity after neurological events is very important to determine the appropriate clinical care plan for food, liquid, and medicine recipes. RCT helps increase the risk of pneumonia and improve results through a decrease in morbidity, mortality, and costs.
The LCR function may or may not reflect the degree of dysphagia in a stroke patient. The term aspiration is silent, as interpreted clinically, can be used as a negative description of the normal physiological process. Every person aspiration of his own secretions to a certain extent, which requires the need for throat clearing, cough voluntary clearing, and lung ciliary cleaning system. LCR is intact unconsciously cleanse food bolus, liquid, secretion, or medicines that enter the airway. What recognizes this receptor as usual or abnormal is not entirely clear, and there is a probability
Different degrees of reflex response depend on stimulants.
A chemoirritant such as stimulating tartar at acid A LCR suddenly, strong, and unconscious in normal patients without impairment.22252627 The same neurological response is seen in all ordinary RCT patients regardless of hemiparesis, dysphagia, dysarthria, or cognitive deficits. Many normal LCR patients have heavy wet or dysphagia quality but are fed on the basis of the experienced bedside evaluation of pathologists, using the RCT response as an important factor that shows the protection of the airway. Many begin diets are modified or placed in supervised dining arrangements, with a progress diet based on clinical examination and repairs. A videoFluoroscopic examination is only used to evaluate structural problems such as fistulas, tracheostomy, or tumors and only if the patient has a normal LCR.
If a neurological breath protection mechanism, namely, LCR, normal function, then the patient can be fed on the basics of the beds of physiological findings and diets may advance on the basis of improvement with therapeutical swift exercise treatment. An abnormal LCR (weak or not) must be seen as a warning signal. Patients with Normal LCR require attention and planning to prevent aspiration pneumonia. In patients with poor intake of calories, lethargy, or significant aphasia, PEG can be justified. This will allow no food, liquid, or mouth. In the case of non-protected neurological airways, this will help reduce the production of oral secretions that can be sucked in volumes that can cause pneumonia. Nasogastric tubes are avoided because of the development of improving the secretion and decrease in pharyngeal proprioception caused by long-term use.
Patients with abnormal LCR are observed to clean their throats less often and not as easily as starting voluntary clearing cough as people with normal LCR. Strangely, many patients with severely disarrayed, dysphagia, and solid hemiparesis have normal cough reflexes and can take calories and adequate drugs verbally, solely on the basis of bedside checks. Conversely, other stroke patients, which will historically be classified as low risk (due to some physical deficits), have no response to the chemoirritant. This is often a person with a stroke location of the brain stem. These patients were not fed through their original mouths and accepted Peg's placement. While in rehabilitation, these patients have recovered their LCR as determined by RCT, and they are then fed by mouth. Peg was then safely removed no earlier than 4 weeks after insertion. It is very possible that patients in this category were previously developed "silent aspiration pneumonia" even at a high functional level. Twenty-five patients with abnormal RCT did not accept Pegs and were finally retested as usual on the RCT and verbally eating. Six Peg was included before entering the rehabilitation settings. During rehabilitation, 20 pegs were included; 7 These patients have normal RCTs, and 13 have abnormal RCTs. Seven of 20 pegs were removed before the patient was sent back from rehabilitation arrangements, and 13 were still in place 3 months after the onset of the stroke.
Neurology protection of airway and physiology swallowing is a separate process. Neurological examination of LCR and breathing protection is more important in terms of the risk of pneumonia from dysphagia physiological examinations. If the neurological protection of the breath is intact, the physiological deficit swallows may be more aggressively treated, and the diet can be easier to advance with a reduced risk of the development of pneumonia. A normal LCR raises further discussions and modifying treatment plans.
Regularly, the family is included in the decision-making
The process of whether the patient must have PEG or must be fed orally, although there is a risk of development of pneumonia, based on the will of life or a healthy substitute. Many of these patients receive pegs to bulk calorie intake and their medicine and then feed the safest consistency verbally for the quality of life and pleasure. After getting information about the risk of harming helping families and patients to make difficult decisions about feeding, which affects the quality of life.
RCT is a safe, reliable, and cost-effective procedure to test LCR. In addition, other medical conditions may require the need to assess reflex cough. This procedure is currently being reviewed for approval by the food and drug administration.
Commercial parties with direct financial interests in reflex cough tests can provide financial benefits to one or more writers. Cough reflex test (Pneumovax) of patented cough laryngeal reflexes and trademarks by Dysphagia Systems, Inc., Melbourne, FLA. Pneumoflex has not been used commercially in the past or now. Dysphagia Systems, Inc., is pursuing applications and administrative approval drugs. The use of this technique in a health care system requires the approval of food and drug.
