alexa Differences of Aspiration between Liquid and Solid Foods in Video Fluoroscopic Swallowing Study: A Review of Literature

ISSN: 2329-9096

International Journal of Physical Medicine & Rehabilitation

Differences of Aspiration between Liquid and Solid Foods in Video Fluoroscopic Swallowing Study: A Review of Literature

Masaru Konishi1*, Yukimi Yasuhara1, Toshikazu Nagasaki1, Atia Hossain2, Keiji Tanimoto1 and Madeleine Rohlin3
1Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
2Department of Surgical and Diagnostic Sciences, College of Dentistry, Dar Al Uloom University, Riyadh, Kingdom of Saudi Arabia
3Department of Oral and Maxillofacial Radiology, Faculty of Odontology, Malmö University, Malm?, Sweden
*Corresponding Author: Masaru Konishi, Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan, Tel: 81822575691, Email: [email protected]

Received Date: Jan 05, 2018 / Accepted Date: Jan 17, 2018 / Published Date: Jan 18, 2018

Abstract

The videofluoroscopic swallowing study (VFSS) is commonly considered the gold standard for assessing a patient’s swallowing ability. Most dysphagic patients arrange food to make it thicker or softer and thus easier and safer to swallow. A popular point of discussion, even argument, about VFSS among clinicians is whether to use barium sulfate in isolation or in combination with real food. No firm answer has emerged from these discussions, and proponents of both perspectives have seemingly valid points. The aim of the present study was to review whether there were differences between the results using liquid or solid foods in VFSS. We performed a literature search and interpreted the data acquired according to a systematic method. After data extraction and interpretation, we were left with 14 publications that were considered relevant. Most of the research showed that the rate of aspiration was higher with liquids than with solid foods. According to the results of VFSS by using the various textured-foods, the aspiration risk was highest with two-phase food diet such as the mixtures of liquid and solid foods. However, descriptions of their results were often inadequate although many test foods were used for the VFSS. There were a few publications containing the detailed information of the food textures.

As the VFSS images provide valuable data, the methods and the results should be described in as much detail as possible to help readers of the articles. Most patients make allowances for the differences in thin liquids, thick liquids, and solid foods. Hence, writing the details of test food textures would lead to improve the quality of the VFSS in the future.

Keywords: Fluoroscopy; Deglutition; Deglutition disorder; Aspiration; Contrast medium

Introduction

Swallowing problems are common in hospitalized patients, particularly in otorhinolaryngology and dentistry departments. Swallowing disorders often manifest as laryngeal penetration and aspiration. Swallowing difficulty is related to several diseases, including stroke, neurologic diseases, and oral cancer. It is often difficult to evaluate the accurate swallowing functions of the patient due to the causes of many diseases. Groher et al. reported that 91% of the residents in nursing facilities were at dietary levels below that which they could tolerate safely [1]. Various methods are used to examine the ability to swallow. One is videofluoroscopic swallowing study (VFSS) using radiography and contrast medium like barium sulfate, which is commonly considered to be the reference standard for assessing patients’ swallowing ability. VFSS also plays a key role in determining an appropriate dietary level. As the dietary level with the dysphagic patient varies, it is impossible to examine the safety of all the foods that the patient will be provided in terms of increasing the radiation exposure. For this reason, in many cases, some kinds of dietary meals such as liquids, puddings, and cookies are conducted [2]. The appropriate choices of these dietary meals are frequently discussed among clinicians. Groher et al. raised the question whether to use barium sulfate in isolation or in combination with real food items. No firm answer has emerged from these discussions and proponents of both perspectives have seemingly valid points [3]. That being so, it is important to grasp the current situations of the contrast media and foods used for VFSS. The aim of the present study is to review whether there are differences between the results using liquid or solid foods in VFSS by using the systematic literature search.

Materials and Methods

To achieve a systematic approach, we conducted the literature review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement [4] and the Centre for Reviews and Dissemination (CRD) guidelines for undertaking reviews in health care [5]. The following steps were defined: 1. problem specification; 2. formulation of a plan for the literature search; 3. literature search and publication retrieval; 4. data extraction, interpretation of data from the literature.

Problem specification

The problem addressed during VFSS was, “Were results about the aspiration different using liquid food or solid food?” Prior to the literature search, we defined the following terms via the Medical Subject Headings (MeSH).

• Deglutition disorder was defined as difficulty SWALLOWING, which may result from a neuromuscular disorder or mechanical obstruction.

Dysphagia was classified into two distinct types: (a) oropharyngeal dysphagia due to malfunction of the PHARYNX and UPPER ESOPHAGEAL SPHINCTER; (b) esophageal dysphagia due to malfunction of the ESOPHAGUS.

Plan for the literature search

The first step in the literature approach was to search the electronic databases: MEDLINE using PubMed as the search engine and the Japan Medical Abstracts Society (JMAS) database. The PubMed search, presented in Table 1, was based on MeSH terms and free-text terms. The search of the JMAS database is shown in Table 2.

Indexing terms Publications (n)
#1 Videofluoroscopy OR Videofluoroscopic 1602
#2 Videofluorography OR Videofluorographic 7919
#3 #1 and #2 131
#4 Dysphagia [MeSH] OR Deglutition Disorders [MeSH]) OR Swallowing Disorders [MeSH] 41567
#5 #3 AND #4 931
#6 Filters: Entrez date 1 January 1995 to 31 December 2014, abstract, human, English, Japanese 729
1. Database search date: 15 January 2015; 2. Entrez date: 1 January 1995 to 31 December 2014; 3. Filters: (1) abstract, (2) human, (3) English, Japanese.

Table 1: Search strategies and number of publications retrieved from search in PubMed.

Indexing terms Publications (n)
#1 Enge-zouei (Japanese, means videofluoroscopic swallow study) 374
1. Publication data: free; 2. Database search date: 24 January 2015; 3. Limits: human, abstract, except for case report, presentation paper at conference

Table 2: Search strategies and number of publications retrieved from a search of the Japan Medical Abstracts Society database.

The search was limited to publications with an abstract and with an entry date during the period from January 1, 1995 to January 26, 2014. The sond step was to examine the reference lists of the selected publications and systematic reviews.

Literature search and retrieval of publications

The literature searches are summarized in Tables 1 and 2. Two of the authors independently read the retrieved titles and abstracts. When at least one considered that a publication matched the problem specification, the publication was ordered, and the full text was read. Then, the two authors independently reviewed all complete texts and included/excluded them using a piloted protocol (Appendix). The inclusion criteria were formulated in accordance with the 2009 CRD guidelines for undertaking reviews in health care [5].

Population: humans with swallowing disorders

Study design: primary study

Methods/criteria: solid food (foods difficult to swallow without mastication). Index test: VFSS with liquid or solid foods

Reference standard (control methods): liquid swallow assessed by VFSS

Outcome: data on materials (contrast medium, food) used for VFSS of patients with swallowing disorders

• Aspiration

Outcome measures: differences between solid food and liquid food

Language: English or Japanese with an abstract in English

Data extraction and interpretation of data

When at least one of the authors identified a full-text publication to meet the criteria, two authors independently extracted and tabulated the study characteristics and results of each study. Any disagreement was resolved by consensus.

Results

Literature identification

Figure 1 presents the process for the literature search and retrieval. The electronic searches yielded 1103 titles and abstracts. Among them, 892 publications were discarded after reviewing the abstracts. The full texts of the remaining 181 citations were examined, and 151 of the studies did not meet the criteria. Of the 14 accepted publications, 11 came from MEDLINE and 3 from JMAS. As presented in Figure 1, most of the publications were excluded on grounds of the lack of a description of aspiration when using solid foods assessed by VFSS. Meta-analysis was not possible given the heterogeneity of the types of studies identified and the nature of the data gleaned from the literature search. Therefore, the outcome of the literature review is presented in a narrative format.

physical-medicine-rehabilitation-Flowchart-selection

Figure 1: Flowchart of the selection strategy used for the systematic review and publications remaining at each stage. 1. All abstracts were read by two authors. Publications were selected according to the inclusion criterion of the patients using solid foods as a test material. 2. All abstracts were read by two authors. Publications were selected according to inclusion and exclusion criteria as follows. Inclusion: patients using solid foods as test materials. Exclusion: commentative papers. 3. Patients were selected based on aspiration detected by VFSS, and papers that described the VFSS results of the solid foods in detail, especially the comparison of liquid and solid foods.

Were Results About Aspiration Different Using Liquid Food or Solid Food?

For a comparison of liquid and solid foods in regard to aspiration as an outcome (Table 3), 14 studies met the inclusion criteria.

First author (Reference) Total subjects (n) Sample characteristics
Number of subjects (n)
Test material
-Contrast media
-Food
Texture measurement of test materials Endpoint Results
Osawa [6] 155 Cerebral stroke (n=155) -Barium sulfate
-Jelly
-Rice gruel
-Liquid
×  Aspiration
Penetration
Pharyngeal residue
Laryngeal reflex
Jelly: Aspiration (6.5%), Pharyngeal residue (49.7%),
Late laryngeal reflex (24.5%), Penetration (16.1%),
Rice gruel: Aspiration (11.6%), Pharyngeal residue (50.3%),
Late laryngeal reflex (18.1%), Penetration (25.8%)
Liquid: Aspiration (32.3%), Pharyngeal residue (25.8%),
Late laryngeal reflex (4.5%), Penetration (23.9%)
Lee [7] 29 Ischemia (n=15), Hemorrhage (n=10),
Hypoxic brain damage (n=2),
Guillain-Barre syndrome (n=1),
Brain tumor (n=1)
-Barium sulfate
-Cooked rice (12 g RICE)
-Thin liquid (5 ml LIQUID)
-Mixed consistency  of rice and liquid(MIX) 
× Aspiration
Penetration Residue
RICE: aspiration (3.4%), penetration (6.9%),
LIQUID: aspiration (48.3%), penetration (10.3%)
MIX: aspiration (48.3%), penetration (0%)
Hirai [8] 105 Cerebral infarction (n=34), cerebral hemorrhage (n=18), degenerative disorder(n=12),
208others (n=41)
-Iopamidol
-Water with 33% Iopamidol
-Jelly
-Yogurt
-Soft diet using freeze infusion (carrot)
Aspiration, Penetration,
Residue
33 % Iopamidol: aspiration (n=20), penetration (n=19),
Carrot: aspiration (n=0), penetration (n=3)
Jerry/yoghurt: residue (n=37),
Carrot: residue (n=40)
Ozaki [9] 229 Stroke (n=100),
Neuromuscular disease (n=27), respiratory disease (n=17), cardiovascular disease (n=14), head and neck cancer(n=12), others (n=59)
-Barium sulfate
-4 ml pudding-thick barium (PD), -4 ml,10 ml thin liquid barium (LQ4, LQ10), -a cup of thin liquid barium (CUP), - 8 g corned beef hash with barium (CB), - 4 g corned beef hash with barium
- 5 ml thin liquid barium (MX)  
× Aspiration(A), Penetration(P)
of particular consistencies
PD (n=205): A (0 %), P (6.3 %),
LQ4 (n=214): A (13.6 %), P (36.4 %),
LQ10 (n=157): A (10.8 %), P (36.3 %),
CUP (n=168): A (18.5 %), P (48.2 %),
CB (n=179): A (3.9%), P (14.0 %),
MX (n=180): A (22.2%), P(38.3%)
Baylow [10] 15 Acute stroke(n=15) -Barium sulfate
-1 ml thin liquid barium,
-1 ml barium pudding,
-1/4 piece of biscuit with barium paste
× Sensitivity(SENS), specificity(SPEC), positive predictive value(PPV), negative predictive value(NPV), positive likelihood ratio(+LR), negative likelihood ratio(-LR) for detecting aspiration, no posture and posture (SENS%)-(SPEC%)-(PPV%)-(NPV%)-(+LR)-(-LR),
1ml thin liquid (no posture): (40)-(80)-(29)-(87)-(2)-(0.8)
1ml thin liquid (posture): (50)-(82)-(17)-(96)-(2.8)-(0.6)
1ml pudding (no posture): (0)-(93)-(0)-(93)-(0)-(1.1)
1ml pudding (posture): (0)-(90)-(0)-(100)-(0)-(1.1)
1/4 biscuit (no posture): (67)-(92)-(50)-(96)-(8.4)-(0.4)
1/4 biscuit (posture): (0)-(88)-(0)-(100)-(0)-(1.1)
Lefton-Greif [11] 19 Children with unexplained respiratory problems dysphagic concerns (n=19) -Barium sulfate
-Thin liquid (TL),
-very thin liquid (very TL),
-thick liquid,
-puree consistency, -solid foods(graham cracker or favourite soft cookie)
TL:19, TL+thick liquid:13, TL+thick liquid + very TL: 5, TL+thick liquid + very TL+ solid foods: 5
× Aspiration and penetration, 
Inefficient anterior or posterior bolus containment,
Alterations in bolus formation or transfer,
Delayed pharyngeal swallow onset,
Aspiration or penetration (n, %)
Very TL: n=4 (80.0 %), TL: n=16 (84.2 %), thick liquids: n=10 (76.9 %),
purees: n=2 (15.4 %), solid foods: n=0(0%)
Inefficient bolus containment (n)
TL: n= 3, thick liquids: n= 1, puree: n= 1 
Alterations in bolus formation (n)
TL: n= 2, purees: n= 4
Delayed swallow onset (%)
Very TL: 100 %, TL: 94.7 %, thick liquids: 100 %, purees:61.5 %
Saito [12 36 Cerebral infarction(n=17 ),
cerebral hemorrhage(n=9 ),
disuse atrophy after pneumonia(n=6 ),
others(n=4 )
-Iopamidol
-4 types of cooked rice(normal rice,
soft rice, rice gruel, paste rice),
agar dissolved in water(control)
Aspiration, Penetration Aspiration: Agar(n=7), 4 types of cooked rice (n=0)
Penetration: Agar (n=6), paste rice (n=2), 3types of rice (n=0)
Seki  [13] 32 Stroke(n=32) -Barium sulfate
-5 ml water
-5 ml fluid food (liquefied food)
One piece of solid food (approximately 5ml of a cookie)
× Aspiration
Pharyngeal retention
(after acupuncture)
Before and after Intervention (acupuncture)
Aspiration:
water; 40% (before)→0% (after)
fluid food; 8% (before)→0% (after)
solid food; 25% (before)→0% (after)
Pharyngeal retention: significant decreases
DeMatteo [14] 75 Children with Cerebral palsy, prematurity, Pierre Robin sequence, hypoxic-ischemic encephalopathy, Vacterl syndrome, Angelman syndrome, infantile spasms, cardiac condition, Down syndrome, developmental delay, seizure disorder, failure to thrive, acquired brain injury, brain tumor (n=75) -Barium sulfate
-Fluids :100, 250, 800, 2000 cps barium liquid
-Solid: child’s own foods with pre-mixed liquid barium and/or powdered barium
Sensitivity, specificity, positive and negative predictive values of  aspiration,
penetration between clinical assessment and VFSS
Aspiration:
Fluids;  sensitivity 92%, specificity 46%
(P=0.002)  positive predictive value 54%
negative predictive value 89%
Solids;    sensitivity 33%, specificity 65%
(P=0.67)   positive predictive value 18%
negative predictive value 81%
Penetration:
Fluids;    sensitivity 80%, specificity 42%
(P=0.05)   positive predictive value 65%
negative predictive value 60%
Solids;    sensitivity 70%, specificity 55%
(P=0.15)    positive predictive value 41%
negative predictive value 80%
Lewin [15] 26 After esophagectomy
Adenocarcinoma (n=19), squamous cell carcinoma (n=5), Barrett’s esophagus (n=2)
-Barium sulfate
-5 ml thin liquid barium,
-5 ml thick liquid barium
-5 ml applesauce mixed with barium,
-One-fourth of a cracker coated with barium
× Aspiration
before and after chin tuck maneuver
Aspiration:
Liquid: n=21/26(81%)
Thin and thick liquid: n=8/21 (38 %)
Thin and thick liquid and pureed: n=3/21(14 %)  
Solid: n=0(0%)
Hughes [16] 50 Nasopharyngeal carcinoma, after radiotherapy treatment(n=50) -Barium sulfate
-5 ml liquid
-5 ml paste
-Biscuit
-15 ml liquid
× Aspiration
Laryngeal penetration, poor bolus formation, prolonged oral transit, poor velopharyngeal closure, delayed onset of swallow reflex, disordered pharyngeal contraction, decreased laryngeal elevation
Pharyngeal transit time (PTT)
Aspiration:
Liquid: n=11, Paste: n=1, Biscuit: n= 0
Laryngeal penetration:
Liquid: n=34, Paste: n=0, Biscuit: n=0
Poor bolus formation:
Liquid: n=23, Paste: n=27, Biscuit: n=27
Prolonged oral transit:
Liquid: n=38, Paste: n=44, Biscuit: n= 48
Poor velopharyngeal closure:
Liquid: n=5, Paste: n=5, Biscuit: n=5
Delayed onset of swallow reflex:
Liquid: n=31, Paste: n=18, Biscuit: n=18
Disordered pharyngeal contraction:
Liquid: n=39, Paste: n=46, Biscuit: n=46
Decreased laryngeal elevation:
Liquid: n=47, Paste: n=47, Biscuit: n=47
Pharyngeal transit time (PTT):
Liquid:1.3 (s), Semi solid/paste: 1.7(s), Solid:1.9 (s)
Morton1999
[17
34 Children with Spastic quadriplegia (n=26), learning disabilities (n=6), Rett syndrome (n=2) -Solid, -liquid × Aspiration Aspiration ; solid; n= 12/34 , liquid; n= 19/34
Mathisen
[18]
20 Gastro-oesophageal reflux disease (GORD) (n=20) -Puree, -lumpy,
-mashed,-liquid
× Aspiration, Aspiration: Puree; n=0, lumpy; n=1 mashed; n=1 liquid; n=2
Wright [19 16 Severe cerebral palsy(n=16) -Liquid, -paste, -puree, -biscuit,- jelly,-mince × Aspiration Aspiration:
Liquid; n=2, liquid and puree; n=1, puree; n=1, shortbread; n=1
Osawa [6] 155 Cerebral stroke (n=155) -Barium sulfate
-Jelly
-Rice gruel
-Liquid
×  Aspiration
Penetration
Pharyngeal residue
Laryngeal reflex
Jelly: Aspiration (6.5%), Pharyngeal residue (49.7%),
Late laryngeal reflex (24.5%), Penetration (16.1%),
Rice gruel: Aspiration (11.6%), Pharyngeal residue (50.3%),
Late laryngeal reflex (18.1%), Penetration (25.8%)
Liquid: Aspiration (32.3%), Pharyngeal residue (25.8%),
Late laryngeal reflex (4.5%), Penetration (23.9%)
Lee  [7] 29 Ischemia (n=15), Hemorrhage (n=10),
Hypoxic brain damage (n=2),
Guillain-Barre syndrome (n= 1),
Brain tumor (n=1)
-Barium sulfate
-Cooked rice (12 g RICE)
-Thin liquid (5 ml LIQUID)
-Mixed consistency  of rice and liquid(MIX) 
× Aspiration
Penetration Residue
RICE: aspiration (3.4%), penetration (6.9%),
LIQUID: aspiration (48.3%), penetration (10.3%)
MIX: aspiration (48.3%), penetration (0%)
Hirai [8] 105 Cerebral infarction (n=34), cerebral hemorrhage (n=18), degenerative disorder(n=12),
208others (n=41)
-Iopamidol
-Water with 33% Iopamidol
-Jelly
-Yogurt
-Soft diet using freeze infusion (carrot)
Aspiration, Penetration,
Residue
33% Iopamidol: aspiration (n=20), penetration (n=19),
Carrot: aspiration (n=0), penetration (n=3)
Jerry/yoghurt: residue (n=37),
Carrot: residue (n=40)
Ozaki 2010
[9]
229 Stroke (n=100),
Neuromuscular disease (n=27), respiratory disease (n=17), cardiovascular disease (n=14), head and neck cancer(n=12), others (n=59)
-Barium sulfate
-4 ml pudding-thick barium (PD), -4 ml,10 ml thin liquid barium (LQ4, LQ10), -a cup of thin liquid barium (CUP), -8 g corned beef hash with barium (CB), - 4 g corned beef hash with barium
-5 ml thin liquid barium (MX)  
× Aspiration (A), Penetration (P)
of particular consistencies
PD (n=205): A (0%), P (6.3%),
LQ4 (n=214): A (13.6%), P (36.4%),
LQ10 (n=157): A (10.8%), P (36.3%),
CUP (n=168): A (18.5%), P (48.2%),
CB (n=179): A (3.9%), P (14.0%),
MX (n=180): A (22.2%), P (38.3%)
Baylow 2009 [10] 15 Acute stroke(n=15) -Barium sulfate
-1 ml thin liquid barium,
-1 ml barium pudding,
-1/4 piece of biscuit with barium paste
× Sensitivity(SENS), specificity(SPEC), positive predictive value(PPV), negative predictive value(NPV), positive likelihood ratio(+LR), negative likelihood ratio(-LR) for detecting aspiration, no posture and posture (SENS%)-(SPEC%)-(PPV%)-(NPV%)-(+LR)-(-LR),
1ml thin liquid (no posture): (40)-(80)-(29)-(87)-(2)-(0.8)
1ml thin liquid (posture): (50)-(82)-(17)-(96)-(2.8)-(0.6)
1ml pudding (no posture): (0)-(93)-(0)-(93)-(0)-(1.1)
1ml pudding (posture): (0)-(90)-(0)-(100)-(0)-(1.1)
1/4 biscuit (no posture): (67)-(92)-(50)-(96)-(8.4)-(0.4)
1/4 biscuit (posture): (0)-(88)-(0)-(100)-(0)-(1.1)
Lefton-Greif [11] 19 Children with unexplained respiratory problems dysphagic concerns (n=19) -Barium sulfate
-Thin liquid (TL), -very thin liquid (very TL), -thick liquid, -puree consistency, -solid foods(graham cracker or favorite soft cookie)
TL:19, TL+thick liquid:13, TL+thick liquid + very TL: 5, TL+thick liquid + very TL+ solid foods: 5
× Aspiration and penetration, 
Inefficient anterior or posterior bolus containment,
Alterations in bolus formation or transfer,
Delayed pharyngeal swallow onset,
Aspiration or penetration (n,%)
Very TLs: n=4 (80.0 %), TLs: n=16 (84.2%), thick liquids: n=10 (76.9 %),
Purees: n=2 (15.4 %), solid foods: n=0(0%)
Inefficient bolus containment (n)
TLs: n=3, thick liquids: n=1, puree: n=1 
Alterations in bolus formation (n)
TLs: n=2, purees: n=4
Delayed swallow onset (%)
Very TLs: 100%, TLs: 94.7%, thick liquids: 100%, purees:61.5%
Saito [12]   36 Cerebral infarction(n=17 ,
cerebral hemorrhage(n=9 ,
disuse atrophy after pneumonia(n=6 ,
others(n=4 )
-Iopamidol
-4 types of cooked rice(normal rice,
soft rice, rice gruel, paste rice),
agar dissolved in water (control)
Aspiration, Penetration Aspiration: Agar (n=7), 4 types of cooked rice (n=0)
Penetration: Agar (n=6), paste rice (n=2), 3 types of rice (n=0)
Seki [13] 32 Stroke(n=32) -Barium sulfate
-5 ml water
-5 ml fluid food (liquefied food)
One piece of solid food (approximately 5ml of a cookie)
× Aspiration
Pharyngeal retention
(after acupuncture)
Before and after Intervention (acupuncture)
Aspiration:
water; 40%(before)→0%(after)
fluid food; 8% before)→0%(after)
solid food; 25%(before)→0%(after)
Pharyngeal retention: significant decreases
DeMatteo [14] 75 Children with Cerebral palsy, prematurity, Pierre Robin sequence, hypoxic-ischemic encephalopathy, Vacterl syndrome, Angelman syndrome, infantile spasms, cardiac condition, Down syndrome, developmental delay, seizure disorder, failure to thrive, acquired brain injury, brain tumor (n=75) -Barium sulfate
-Fluids :100, 250, 800, 2000 cps barium liquid
-Solid: child’s own foods with pre-mixed liquid barium and/or powdered barium
Sensitivity, specificity, positive and negative predictive values of  aspiration,
penetration between clinical assessment and VFSS
Aspiration:
Fluids;  sensitivity 92%, specificity 46%
(P=0.002)  positive predictive value 54%
negative predictive value 89%
Solids;    sensitivity 33%, specificity 65%
(P=0.67)   positive predictive value 18%
negative predictive value 81%
Penetration:
Fluids;    sensitivity 80%, specificity 42%
(P=0.05)   positive predictive value 65%
negative predictive value 60%
Solids;    sensitivity 70%, specificity 55%
(P=0.15)    positive predictive value 41%
negative predictive value 80%
Lewin [15] 26 After esophagectomy
Adenocarcinoma (n=19), squamous cell carcinoma (n=5), Barrett’s esophagus (n=2)
-Barium sulfate
-5 ml thin liquid barium,
-5 ml thick liquid barium
-5 ml applesauce mixed with barium,
-One-fourth of a cracker coated with barium
× Aspiration
before and after chin tuck maneuver
Aspiration:
Liquid: n=21/26(81%)
Thin and thick liquid: n=8/21 (38%)
Thin and thick liquid and pureed: n=3/21(14 %)  
Solid: n=0(0%)
Hughes [16] 50 Nasopharyngeal carcinoma, after radiotherapy treatment(n=50) -Barium sulfate
-5 ml liquid
-5 ml paste
-Biscuit
-15 ml liquid
× Aspiration
Laryngeal penetration, poor bolus formation, prolonged oral transit, poor velopharyngeal closure, delayed onset of swallow reflex, disordered pharyngeal contraction, decreased laryngeal elevation
Pharyngeal transit time (PTT)
Aspiration:
Liquid: n=11, Paste: n=1, Biscuit: n= 0
Laryngeal penetration:
Liquid: n=34, Paste: n=0, Biscuit: n=0
Poor bolus formation:
Liquid: n=23, Paste: n=27, Biscuit: n=27
Prolonged oral transit:
Liquid: n=38, Paste: n=44, Biscuit: n= 48
Poor velopharyngeal closure:
Liquid: n=5, Paste: n=5, Biscuit: n=5
Delayed onset of swallow reflex:
Liquid: n=31, Paste: n=18, Biscuit: n=18
Disordered pharyngeal contraction:
Liquid: n=39, Paste: n=46, Biscuit: n=46
Decreased laryngeal elevation:
Liquid: n=47, Paste: n=47, Biscuit: n=47
Pharyngeal transit time (PTT):
Liquid:1.3 (s), Semi solid/paste: 1.7 (s), Solid:1.9 (s)
Morton [17 34 Children with Spastic quadriplegia (n=26), learning disabilities (n=6), Rett syndrome (n=2) -Solid, -liquid × Aspiration Aspiration ; solid; n=12/34 , liquid; n=19/34
Mathisen [18] 20 Gastro-oesophageal reflux disease (GORD) (n=20) - Puree, - lumpy,
- mashed,- liquid
× Aspiration, Aspiration: Puree; n=0, lumpy; n=1 mashed; n=1 liquid; n=2
Wright [19] 16 Severe cerebral palsy(n=16) -Liquid, -paste, -puree, -biscuit,- jelly,-mince × Aspiration Aspiration:
Liquid; n=2, liquid and puree; n=1, puree; n=1, shortbread; n=1

Table 3: Characteristics of the articles with sufficient methodologic quality (n=14).

Most publications reported that the rate of aspiration was higher with liquids than with solid foods. In some studies, there was no aspiration of solid foods, although many patients aspirated the liquids [8,13,15,16] or agar [12]. Lefton-Greif et al. [11] reported that the aspiration rate for thin or thick liquids was 57.9%, whereas that of solid foods was 0%. Saito et al. [12] reported that seven patients aspirated agar, whereas none aspirated cooked rice. Hirai et al. [8] reported that 20 of 107 patients aspirated diluted iopamidol (33%) with water, but no patients aspirated softened carrots.

Lee at al. [7] reported that swallowing mixed consistencies was not dangerous, and it was safer in regard to penetration-aspiration than swallowing a liquid. The possible implication is that a diet of mixed constituencies is more simulative than a liquid diet. Swallowing of all mixed consistencies is thus not dangerous in regard to penetration-aspiration. The risk of penetration-aspiration may depend not only on the consistency but also on various factors that affect protection of the airway, including the texture of foods.

Ozaki et al. [9] examined 524 patients with various test foods: 4 ml and 10 ml of liquids (LQ4, LQ10), pudding (PD), corned beef hash alone (CB), a two-phase mixture of CB and liquid containing barium sulfate (MX), and one swallow from a cup of thin liquid barium (CUP). Aspiration risk increased in the following order: PD, CB, LQ4, LQ10, CUP, and MX. They concluded that aspiration risk was highest with the two-phase food diet.

The sensitivity, specificity, positive predictive values, and negative predictive values for detecting aspiration were reported to be higher for solid food than for liquids [10]. In contrast, DeMatteo et al. [14] reported that the sensitivity of liquid aspiration was higher than that of solid food.

Discussion

Methodological considerations

To ensure the retrieval of many publications, the search strategies comprised two databases: PubMed and JMAS. The search of at least two electronic sources was regarded as improving the methodologic quality of a systematic review [20]. There was no search for evidence to underpin the recommendations because we considered it impossible to formulate a search with MeSH terms to find evidence on the importance of testing solid foods using VFSS.

The main purpose of this review was to investigate differences in the results depending on the type of food, especially liquid and solid foods. Although there are many publications on VFSS, there were few that compared the results of using liquid and solid foods. It was difficult to search and select the publications because terms that were relevant to VFSS were not yet included on the MeSH list. It was also difficult to determine the search terms. Hence, videofluoroscopy and videofluoroscopic were adopted for the study. We propose the following definition of VFSS as a MeSH term: “A fluoroscopic examination of dysphagic patients using a contrast medium and various types of food.”

Differences in VFSS results between liquids and solid food

Detection of aspiration: DeMatteo et al. [14] reported that experienced therapists were able to detect exactly the presence or absence of penetration or aspiration of liquids by the clinical assessment. In contrast, however, detection of the penetration or aspiration of solid foods was less accurate. Further diagnostic tests, such as VFSS, would be required to evaluate swallowing of solid foods. Some patients aspirate liquids but not solid foods. In some publications, as a matter of policy, a thin or thick liquid was initially tested. If the patient aspirated one or both of these liquids, VFSS was suspended at that point and the solid foods were not tried. The swallowing abilities of the patient would not be accurately evaluated in this way. It is necessary to test the real daily foods in order to serve the foods appropriate to the exact abilities of swallowing.

Other VFSS evaluations of swallowing liquid and solid foods

Compared with using contrast medium and foods for VFSS, results for individual test foods have been documented but with fewer details, which means that they are insufficiently described in most publications. One explanation might be that some authors were not aware of the importance of the effects of the nature of the material examined. There were some publications, however, that described in detail the texture or consistency of the test materials. As the regulation of food texture depends on the individual’s sensory preferences, the detailed description of the textures would be helpful for assessing the VFSS results.

As VFSS is a comparatively new instrumental examination derived from the oesophageal, clinicians may not have been familiar with the technical parameters involved that influence swallowing and are assessed by VFSS. A team approach is required for treating dysphagic patients. Thus, a variety of personnel speech pathologists, doctors, dentists, nurses, physical therapists, occupational therapists, nutritionists are needed to address dysphagia. With more studies and results, publications will report more parameters that are necessary for assessing the swallowing function and ultimately for suggesting appropriate meals for these patients. We believe that more texture parameters should be documented in dysphagic patients. Expertise in the food texture fields is needed not only to design studies but to interpret the results of the VFSS studies. Moreover, VFSS will be applied to an increasing extent in studies on outcomes of the various treatment methods. For studies that evaluate dysphagic patients, the texture parameters and their influence on the study results must be highlighted and described by those experts in the field of food texture.

Conclusion

Many test food types were used in the VFSS studies in the literature, but the descriptions of the results were often inadequate. Because the VFSS images provide valuable data, the methods and results of these studies should be described in as much detail as possible. Most patients react differently to thin liquids, thick liquids, and solid foods. To improve the quality of VFSS results, we should tailor (customize, individualize) the test material of the examination to fit the individual being tested.

References

Citation: Konishi M, Yasuhara Y, Nagasaki T, Hossain A, Tanimoto K, et al. (2018) Differences of Aspiration between Liquid and Solid Foods in Videofluoroscopic Swallowing Study: A Review of Literature. Int J Phys Med Rehabil 6: 446. DOI: 10.4172/2329-9096.1000446

Copyright: ©2018 Konishi M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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