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• Placing nasogastric tubes in stroke patients with dysphagia
  Shinji Teramoto
  Published on: 13 April 2016
• Impaired swallowing reflex in dysphagic stroke patients - a reply to Teramoto et al.
  Rainer Dziewas
  Published on: 13 April 2016

• Published on: 13 April 2016

  Placing nasogastric tubes in stroke patients with dysphagia

  • Shinji Teramoto, MD, Lecturer
  • Other Contributors:
    • Hiroshi Yamamoto*, MD, Yasuhiro Yamaguchi,* MD, and Yasuyoshi Ouchi*, MD

  Dear Editor

  Because patients who have had an acute stroke often have dysphagia and tube feeding becomes necessary, the simple and comfort method for placing nasogastric tubes by inducing the swallowing reflex is identical.[1,2]

  The "reflex placement" method is originally based on our study. Our reflex method, i.e. simple swallowing provocation test (SPT) is easy, safe, and is independent of the patient's a...

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  Dear Editor

  Because patients who have had an acute stroke often have dysphagia and tube feeding becomes necessary, the simple and comfort method for placing nasogastric tubes by inducing the swallowing reflex is identical.[1,2]

  The "reflex placement" method is originally based on our study. Our reflex method, i.e. simple swallowing provocation test (SPT) is easy, safe, and is independent of the patient's ability to co-operate.[3,4] The simple SPT by using swallowing reflex induced by a bolus injection of 0.4-2.0 ml distilled water through a small nasal catheter is very useful to differentiate the patients predisposed to aspiration in subjects with or without stroke.[3,4] Although the swallowing reflex was always induced by the small amount of water injection in healthy young and elderly subjects, the reflex was not always induced by the small water injection in patients with acute and chronic stroke.[5-7] These patients with diminished swallowing reflex were highly susceptible to suffer from aspiration pneumonia. Thus the substantial question is remained in the present study. Because the clinically detectable aspiration is often found in patients with stroke, the swallowing reflex is not easily induced in such patients who necessitate tube feeding.[5-7] We very agree with the authors that the "reflex placement" method is successful and is much less distressing for some patients with dysphagia than conventional methods for placing nasogastric tubes. This method is not always perfect for all the stroke patients. The severe stroke patients with dysphagia may not be a good candidate for applying the "reflex placement" method.

  References

  1) Dziewas R, Schilling M, Konrad C, Stogbauer F, Ludemann P. Placing nasogastric tubes in stroke patients with dysphagia: efficiency and tolerability of the reflex placement. J Neurol Neurosurg Psychiatry. 2003;74:1429-1431

  2)Dziewas R, L¨¹demann P, Konrad C, et al. Simple method for placing nasogastric tubes in patients with dysphagia. Lancet 2001;358:725,C6

  3) Teramoto, S, Matsuse, T, Fukuchi, Y, et al. Simple two-step swallowing provocation test for elderly patients with aspiration pneumonia [Research letter]. Lancet 1999;353,1243

  4) Teramoto, S, Fukuchi, Y Detection of aspiration and swallowing disorder in older stroke patients: simple swallowing provocation test versus water swallowing test. Arch Phys Med Rehabil 2000;81,1517-1519

  5) Teramoto, S, Matsuse, T, Fukuchi, Y Decision-making for safe feeding after stroke [letter]. Lancet 2000;356,1352

  6) Teramoto, S, Ishii, T, Matsuse, T, et al. Use of a new tool and detection of aspiration in decision-making for safe feeding after stroke. Age Ageing 2001;30,527-528

  7) Teramoto, S, Yamamoto H, Yamaguchi Y, Matsuse, T A novel diagnostic test for the risk of aspiration pneumonia in the elderly. Chest. 2004 ;125(2):801-2.

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  Conflict of Interest:
  None declared.

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• Published on: 13 April 2016

  Impaired swallowing reflex in dysphagic stroke patients - a reply to Teramoto et al.

  • Rainer Dziewas
  • Other Contributors:
    • Matthias Schilling, and Carsten Konrad

  Dear Editor

  We appreciate the interesting comment on our paper [1] and the important clinical observations by Teramoto et al.

  In their recent studies the authors have shown that the simple swallowing provocation test (SPT) is able to identify patients being predisposed to aspiration pneumonia.[2,3] Based on their experience, featuring a failure of the SPT in 18 of 26 patients (70%), the authors are rig...

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  Dear Editor

  We appreciate the interesting comment on our paper [1] and the important clinical observations by Teramoto et al.

  In their recent studies the authors have shown that the simple swallowing provocation test (SPT) is able to identify patients being predisposed to aspiration pneumonia.[2,3] Based on their experience, featuring a failure of the SPT in 18 of 26 patients (70%), the authors are right in mentioning that the swallowing reflex is not always easily provoked in patients having suffered a severe stroke. Our own data are in apparent conflict with their findings, since we observed a failure of the reflex placement of nasogastric tubes in only 2 of 16 patients (12.5%). There are, however, some differences between the studies in question that may easily account for this discrepancy. First, the patient collective studied by Teramoto et al. was older than ours (72.4 ± 4.1 years versus 67.9 ± 14.4 years). This may be of importance as several studies have shown an age-dependent increase in the delay of pharyngeal swallow.[4,5]

  Second, Teramoto et al. studied patients who had acquired aspiration pneumonia at that time already. These patients are prone to suffer from pharyngeal pooling of mobilised bronchial secretions, which they are unable to disgorge or to swallow. As has been shown by Langmore et al., the presence of pharyngeal secretion impedes the assessment of the swallowing reflex and may lead to false negative findings.[6] Therefore the study of Teramoto et al. may indeed overrate the incidence of a disturbed swallowing reflex in their patient collective. To avoid such problems we recommend to apply gentle suctioning of the pharyngeal space prior to testing the swallowing reflex and also prior to using the "reflex placement" method of nasogastric tubes.

  References

  1. Dziewas R, Schilling M, Konrad C, Stögbauer F, Lüdemann P (2003) Placing nasogastric tubes in stroke patients with dysphagia: efficiency and tolerability of the reflex-placement. J Neurol Neurosurg Psychiatry 74:1429-1431.

  2. Teramoto S, Fukuchi Y (2000) Detection of aspiration and swallowing disorder in older stroke patiens: simple swallowing provovation test versus water swallowing test. Arch Phys Med Rehabil 81:1517-1519.

  3. Teramoto S, Matsuse T, Fukuchi Y (1999) Simple two-step swallowing provocation test for elderly patients with aspiration pneumonia. Lancet 353:1243.

  4. Tracy JF, Logemann JA, Kahrilas PJ, Jacob P, Kobara M, Krugler C (1989) Preliminary observations on the effects of age on oropharyngeal deglutition. Dysphagia 4:90-94.

  5. Logemann JA, Pauloski BR, Rademaker AW, Colangelo LA, Kahrilas PJ, Smith CH (2000) Temporal and biomechanical characteristics of oropharyngeal swallow in younger and older men. J Speech Lang Hear Res 43:1264-1274.

  6. Langmore SE, Aviv JE, Endoscopic procedures to evaluate oropharyngeal swallowing, in Endoscopic evaluation and treatment of swallowing disorders, Langmore SE, Editor. 2001, Thieme: New York, Stuttgart. p. 73- 100.

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  Conflict of Interest:
  None declared.

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