Abstract In limb muscles, corticospinal excitability is modulated by motor context, with greater facilitation during movement initiation and dynamic contractions than during sustained isometric activation. Whether this applies to the human diaphragm remains uncertain, given the hybrid automatic‐voluntary control and continuous activity of respiratory motoneurones. To determine whether corticospinal excitability of the human diaphragm is influenced by the dynamics of voluntary inspiratory contraction at a given level of inspiratory mouth pressure, nine healthy participants (3 women, 6 men; age 23–39 years) performed inspiratory efforts against an occluded mouthpiece. Diaphragm motor evoked potentials (Di‐MEPs) elicited by transcranial magnetic stimulation were recorded from validated chest surface sites at end‐expiration with the airway occluded, at rest, during sustained static inspiratory efforts at graded fractions of maximal inspiratory mouth pressure (Pi,max), and during dynamic inspiratory efforts matched for pressure (20% Pi,max) but differing in rate of pressure development (slow vs. fast). Static efforts increased Di‐MEP amplitude and shortened latency in a pressure‐dependent manner. Slow dynamic efforts produced similar facilitation to static efforts. Fast dynamic efforts elicited greater facilitation, with increased amplitude and shortened latency. Corticospinal excitability of the diaphragm is modulated by contraction dynamics, with rapid efforts inducing additional facilitation beyond force alone.

Objective To investigate the effects of olfactory stimulation with menthol on exertional dyspnea and physiological data during cycling exercise in patients with chronic obstructive pulmonary disease (COPD). Design Controlled trial. Patients with COPD hospitalized for pulmonary rehabilitation performed endurance exercise training using a cycle ergometer and resistance training with and without menthol to decrease respiratory sensations. Setting Three exercise sessions on a cycle ergometer. Participants Twenty-one adult patients (N=21; women; mean age ± SD, 64±8y; Global Initiative for Chronic Obstructive Lung Disease (GOLD) score IV) referred for pulmonary rehabilitation with functional chronic dyspnea (rated ≥2 on the modified Medical Research Council scale) were included. Interventions Session 1 without menthol, session 2 with menthol, and session 3 without menthol. Main Outcome Measures The primary evaluation criterion was the maximum dyspnea experienced during the sessions on a cycle ergometer. Several parameters were recorded and analyzed, including oxygen saturation, heart rate, muscle fatigue (assessed using the modified Borg scale), and dyspnea, as well as the duration of exercise, power output, and distance covered on the cycle ergometer. After completing the sessions, patients were asked about their preference regarding the use of menthol (with or without). Results Three types of patients were identified based on dyspnea during exercise: responders (n=7; 33%), partial responders (n=7; 33%), and nonresponders (n=7; 33%). The comparison between responders and nonresponders showed a significant difference regarding the oxygen flow rate during effort (2.5 [0.0-3.0] vs 0.0 [0.0-0.8] l/min; P=.04). No significant differences were found in the other parameters, even with the MDP questionnaire. Conclusions Menthol could be an adjuvant to exercise rehabilitation, improving exercise-induced dyspnea in patients with chronic dyspnea, particularly in patients with high oxygen flow during exercise.

Our study aimed to investigate swallowing coordination by analyzing ventilatory patterns during of solids and liquids food intakes. Twenty-one patients with severe to very severe stable COPD (GOLD III and IV) underwent ventilation and swallowing recordings while performing standardized swallowing tasks. The results revealed that the expiratory-expiratory (EE) swallowing pattern was predominant, accounting for 80 % of swallows, with no significant differences between solid and liquid swallows. Non-EE patterns occurred in an average of 20.68 % of swallows per patient. Our results demonstrated an increased inspiratory time (IT) during liquid swallows compared to rest (1.05 ± 0.28 s vs 1.29 ± 0.22 s; p < 0.0125), as well as prolonged expiratory time (ET: 2.09 ± 0.78 s vs 3.42 ± 1.16 s; p < 0.001) and total respiratory cycle time (TT: 3.14 ± 1.03 s vs 4.70 ± 1.21 s; p < 0.01) during both solid and liquid swallows compared to rest. These changes resulted in a decreased IT/TT ratio during swallowing. Our findings confirm that the EE swallowing pattern remains predominant in stable COPD patients, consistent with observations in healthy individuals. Additionally, the study highlights significant alterations in ventilatory patterns during swallowing. These results contribute to a better understanding of the interplay between swallowing and ventilation in COPD and its potential implications for airways protection.

INTRODUCTION:Brain injuries are the leading cause of disorders of consciousness and are often complicated by swallowing disorders. The aim of this study was to determine whether a correlation existed between swallowing and level of consciousness in patients with acquired brain injury. METHODS:This pilot and observational study was conducted in the post intensive care coma arousal rehabilitation on 10 patients with acquired brain injury with disorder of consciousness and swallowing disorder evaluated with the Coma Recovery Scale-Revised (CRS-R) CRS-R evaluation or WHIM scale and a SWallowing Disorders in Disorders of Consciousness (SWADOC) assessment, both conducted in the same timeline frame. Swallowing function was assessed using the SWADOC scale. The level of consciousness was evaluated with the CRS-R and the Wessex Head Injury Matrix (WHIM). A Pearson correlation analysis was performed to examine the potential relationship between swallowing capacity and level of consciousness. RESULTS:A strong correlation was identified between the CRS-R and WHIM scales with the SWADOC evaluation. Indeed, the correlation between SWADOC and CRS-R reached 0.70, while the correlation between SWADOC and WHIM was above 0.60. CONCLUSION:These findings highlight the importance of integrating swallowing evaluation within the multimodal assessment of consciousness recovery.

Introduction: The proportion of eldery patient undergoing surgery increases each year and postoperative pain management is fundamental. Postoperative pain of eldery population is currently underestimated and insufficiently managed. The study was performed to evaluate prescribed analgesics and compare them to recommendations with the aim of improving practices. Patients and methods: A retrospective and descriptive study was performed between January 2017 and April 2022. The main objective was to describe the analgesics prescribed on admission and assess their recommendation’s adequacy. Results: 611 patients aged 65 and over and admitted after knee arthroplasty were included. 90.4% patients were painful, with 9.6% presenting neuropathic pain. 40% of over-medications were found. Among patients with neuropathic pain, 68.4% did not receive the recommended first-line analgesic. Conclusion: Although probably overestimated, the proportion of over-medication underline the importance of the correct prescription, especially in the elderly. Management of neuropathic pain constitutes an area of improvement identified by this study.

Videofluoroscopic swallowing studies (VFSS) remain the gold standard for the instrumental assessment of oropharyngeal swallowing disorders alongside flexible endoscopic evaluation of swallowing (FEES), requiring a high standard of quality and correct implementation. The current best practice position statements aim to guide the clinical practice of VFSS in individuals experiencing swallowing disorders. An international expert consensus panel with expertise in oropharyngeal dysphagia, comprised of radiologists, speech-language therapists, otolaryngologists, and other professionals in the field, convened by the European Society of Swallowing Disorders (ESSD) and the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), developed best practice position statements. They were established using an online Delphi methodology involving an online panel discussion and item preparation and three consecutive rounds. Consensus was reached when ≥ 80

Objective This study aimed to investigate the prevalence of oropharyngeal dysphagia among institutionalised children with multiple disabilities, a topic with limited literature coverage.Methods The study employed a questionnaire, specifically the F-PEDI-EAT-10, to screen for dysphagia in children. Trained nurses administered the questionnaire to the participants.Results The study included 117 children with multiple disabilities (51.3 per cent boys and 48.7 per cent girls) with an average age of 14 +/- 4.7 years. The questionnaire revealed that 53 per cent (n = 62) of the children had a positive score and, surprisingly, 29 per cent of them (n = 18) did not have a confirmed diagnosis of oropharyngeal dysphagia. Notably, children with a positive F-PEDI-EAT-10 score had a significantly higher prevalence of pneumopathy and undernutrition compared with those with a negative score.Conclusion This study underscores the high prevalence of oropharyngeal dysphagia among children with multiple disabilities, a condition that is often underdiagnosed.

Chronic respiratory diseases are known to increase the prevalence of oropharyngeal dysphagia (OD), especially in COPD patients. It could induce severe complications as pulmonary infections or malnutrition, which increase the morbidity and the mortality. Nevertheless, in COPD patients, the mechanism of oropharyngeal dysphagia is unclear, and we aimed to identified if it was due to a default of propulsion of the bolus or to a default of protection of upper airway. We prospectively studied the deglutition of severe COPD patients (gold III or IV) admitted in rehabilitation center after an acute respiratory decompensation. 28 patients (age 69±8 y,12 f) were studied using a clinical screening test of oropharyngeal dysphagia validated in geriatric population with a high sensitivity and a high specificity (V-VST). Our results demonstrated that 11 (39%) patients had an oropharyngeal dysphagia (abnormal V-VST). In those patients, 9 had a default of airway protection and 7 had a lake of bolus propulsion (5 had both). There was no difference between patients with normal deglutition and patients with abnormal deglutition regarding age, gold score, FEV1 or VC. There presented all frequent exacerbations, chronic cough and rest dyspnea. This preliminary study demonstrated that oropharyngeal dysphagia is frequent in severe COPD patients, with a lack of airway protection. This dysphagia is not explained by age or functional respiratory data. Discussion about the mechanisms implicated will be discussed during the presentation.

The aim of this study was to compare feeding modalities and the level of consciousness in patients with a severe brain injury during reeducation and rehabilitation. The clinical data of vegetative state or minimal conscious state due to severe traumatic brain injury hospitalized in a coma arousal unit were collected from 2012 to 2019. Feeding modalities were evaluated clinically and with functional endoscopy evaluation of swallowing or video fluoroscopy and functional oral intake scale. Evolution of consciousness was evaluated using Wessex Head Injury Matrix scale (WHIM). Comparison between WHIM score and feeding modalities were performed at admission and at discharge of the arousal unit. Of the 93 patients considered, 33 were included corresponding to inclusion criteria (traumatic brain injury, disorder of consciousness and age > 18 years). The mean age was 44.8 ± 16.8 years, and there were 6 females for 27 males. At admission, all patients were fed by gastrostomy (n = 25) or by nasogastric tube (n = 8) and 27 had a tracheostomy. At discharge, 10 patients keep an exclusive alimentation by gastrostomy (Group 1, G1) as 23 had exclusive oral feeding (Group 2, G2). The score of the WHIM at admission was identical in both groups (21.7 ± 10.9 (G1) vs. 21.0 ± 15.33 (G2) (ns)). At discharge, WHIM increased to 38.3 ± 15.4 in G1 and to 49.8 ± 9.7 in G2 (P < .05). WHIM score was significantly higher in G2 than in G1 (P < .05). There was a positive correlation between functional oral intake scale and WHIM at discharge. Our results demonstrated that recovery of oral feeding in patients with a severe traumatic brain injury appeared in those who had the better improvement of consciousness level.

To date, no consensus exists on the complex clinical decision-making processes involved in oropharyngeal dysphagia, or swallowing disorders. This study aimed to develop an international consensus on a clinical decision tree for the disease trajectory of oropharyngeal dysphagia in adults, taking into account physiological impairments of swallowing, risk factors for the development of complications from oropharyngeal dysphagia, and prognostic factors for treatment outcomes. Using the Delphi technique, consensus was achieved among dysphagia experts across 31 countries, resulting in a total of 10 physiological impairments, 23 risk factors and 21 prognostic factors identified as relevant factors in the clinical decision-making process. Factors most contributing to the severity of oropharyngeal dysphagia were ‘Aspiration’, ‘Incomplete ejection or failure to eject aspirated materials from the airways’, ‘Weak or absent cough’, ‘Choking’ and ‘Sensory deficits in the oropharynx’. To connect the existing theoretical framework to clinical practice, future research will develop the current findings by corroborating the domains based on relevant factors for clinical decision making and those that contribute to the severity of oropharyngeal dysphagia.

Objective: Swallowing disorders are systematically present in patients with severe brain injury, disorders of consciousness, and subsequently poor quality of life. The study hypothesis was that taste and smell could improve swallowing function and quality of life in such patients, who are fed by gastrostomy tube. Methods: Eight patients with unresponsive wakefulness syndrome were included in this study. All patients had been in a stable state for at least 2 years, and the delay between the neurological event and the study was always more than 2 years. Strong tastes and smells were selected using the Pfister olfactory classification. Taste and smell stimulations were performed every weekday, Monday to Friday, for 1 week (5 sessions) by a speech and language therapist. Evaluation of swallowing was performed before the first session and after the fifth session, and included the number of spontaneous swallows during 10 min, the presence of drooling, and spontaneous tongue and velum mobility. Results: The number of spontaneous swallows at the initial evaluation was 6.8 ± 5.1 n/min. At the final evaluation there was a significant increase in the number of spontaneous swallows (9.1 ± 4.1 n/min, p < 0.01). Conclusion: This clinical observation has shown that taste and smell stimulations are relevant in clinical practice to improve spontaneous swallowing.

Objective The main objective was to assess the prevalence of dysphagia in the intensive care unit in patients with coronavirus disease 2019. Methods. A cohort, observational, retrospective study was conducted of patients admitted to the intensive care unit for severe acute respiratory syndrome coronavirus 2 pneumonia at the University Hospital of Rouen in France. Results Over 4 months, 58 patients were intubated and ventilated, 43 of whom were evaluated. Screening revealed post-extubation dysphagia in 62.7 per cent of patients. In univariate analysis, a significant association was found between the presence of dysphagia and: the severity of the initial pathology, the duration of intubation, the duration of curare use, the degree of muscle weakness and the severity indicated on the initial scan. At the end of intensive care unit treatment, 22 per cent of the dysphagic patients had a normal diet, 56 per cent had an adapted diet and 22 per cent still received exclusive tube feeding. Conclusion Post-extubation dysphagia is frequent and needs to be investigated.

Swallowing is a complex function that relies on both brainstem and cerebral control. Cerebral neurofunctional evaluations are mostly based on functional magnetic resonance imaging (fMRI) and positron emission tomography (PET), performed with the individual laying down; which is a non-ecological/non-natural position for swallowing. According to the PRISMA guidelines, a review of the non-invasive non-radiating neurofunctional tools, other than fMRI and PET, was conducted to explore the cerebral activity in swallowing during natural food intake, in accordance with the PRISMA guidelines. Using Embase and PubMed, we included human studies focusing on neurofunctional imaging during an ecologic swallowing task. From 5948 unique records, we retained 43 original articles, reporting on three different techniques: electroencephalography (EEG), magnetoencephalography (MEG) and functional near infra-red spectroscopy (fNIRS). During swallowing, all three techniques showed activity of the pericentral cortex. Variations were associated with the modality of the swallowing process (volitional or non-volitional) and the substance used (mostly water and saliva). All techniques have been used in both healthy and pathological conditions to explore the precise time course, localization or network structure of the swallowing cerebral activity, sometimes even more precisely than fMRI. EEG and MEG are the most advanced and mastered techniques but fNIRS is the most ready-to-use and the most therapeutically promising. Ongoing development of these techniques will support and improve our future understanding of the cerebral control of swallowing.

Objectives.- This study seeks to better understand caregivers' experience of the support their loved ones, with disorders of consciousness, receive in a dedicated unit. Methods. - The focus here is on the qualitative component of a larger study that also includes a quantitative component. An inductive and iterative approach was prioritized, i.e., one similar to grounded theory; a thematic analysis was used to analyze 20 comprehensive semi-structured interviews. Results. - Three main themes emerged: the discovery of a new worldby a patient's loved ones, i.e., the disorders of consciousness; the psychological and somatic impact on loved ones; and the relationships between family caregivers and professionals of the dedicated unit. Discussion. - The new living situation of people with disorders ofconsciousness requires caregivers to engage in an intense psychological process. First, this process is necessary to their understanding of the situation and its consequences. Second, it allows them to cope with the reorganization of the emotional and relational ties between the patient and the caregiver, and in the entire family dynamic. Lastly, healthcare professionals consider that caregivers are also the witnesses of the patient's earlier life, capable of linking the past and present, and often the interpreters of patients' emotional reactions according to their former personality. Conclusion. - Caregivers are affected by the frailty and somatic dependence of their loved ones; and they also bear the history and psychological continuity of patients. Professionals must take this double burden into account, which helps explain families' psychological exhaustion and their need for help. Understanding these phenomena is crucial for improving patient care in dedicated units. (C) 2020 Elsevier Masson SAS. All rights reserved.

Post-stroke dysphagia (PSD) is present in more than 50% of acute stroke patients, increases the risk of complications, in particular aspiration pneumonia, malnutrition and dehydration, and is linked to poor outcome and mortality. The aim of this guideline is to assist all members of the multidisciplinary team in their management of patients with PSD. These guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. An interdisciplinary working group identified 20 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence and wrote evidence-based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found moderate quality of evidence to recommend dysphagia screening in all stroke patients to prevent post-stroke pneumonia and to early mortality and low quality of evidence to suggest dysphagia assessment in stroke patients having been identified at being at risk of PSD. We found low to moderate quality of evidence for a variety of treatment options to improve swallowing physiology and swallowing safety. These options include dietary interventions, behavioural swallowing treatment including acupuncture, nutritional interventions, oral health care, different pharmacological agents and different types of neurostimulation treatment. Some of the studied interventions also had an impact on other clinical endpoints such as feedings status or pneumonia. Overall, further randomized trials are needed to improve the quality of evidence for the treatment of PSD.

Apraxia occurs frequently in patients with dementia. Buccofacial apraxia (BFA) characteristics have been less investigated than limb or speech apraxia. An association between BFA and oropharyngeal dysphagia (OD) in old patients with dementia has not yet been explored. We aimed to assess the prevalence of BFA in patients with dementia and evaluate the relationship between BFA, OD, and dementia. We have prospectively included 117 outpatients with dementia referred to a geriatric consultation. Oropharyngeal dysphagia was diagnosed using the volume viscosity swallowing test (V-VST). Buccofacial apraxia was evaluated by miming 7 meaningless gestures. A complementary geriatric assessment of 6-domains completed the evaluation. Buccofacial apraxia was present in 54 (48.6%) patients. Proxies reported OD more frequently in the group of patients with BFA compared to the group without ( P = .04). Prevalence of OD assessed with the V-VST was similar between patients with and without apraxia ( P = .9). Patients with BFA had a significant lower Mini-Mental State Examination suggesting a more severe cognitive decline (18.1 ± 4.5 vs 15.8 ± 5, P = .01), a lower activities of daily living relative to disabilities (5 ± 0.8 vs 4.3 ± 1.3, P = .001), and had a lower gait speed that indicated frailty ( P = .03).In conclusion, our results indicate a relationship between BFA and severity of dementia, disability, and frailty with no significant association between BFA and OD.

This White Paper by the European Society for Swallowing Disorders (ESSD) reports on the current state of screening and non-instrumental assessment for dysphagia in adults. An overview is provided on the measures that are available, and how to select screening tools and assessments. Emphasis is placed on different types of screening, patient-reported measures, assessment of anatomy and physiology of the swallowing act, and clinical swallowing evaluation. Many screening and non-instrumental assessments are available for evaluating dysphagia in adults; however, their use may not be warranted due to poor diagnostic performance or lacking robust psychometric properties. This white paper provides recommendations on how to select best evidence-based screening tools and non-instrumental assessments for use in clinical practice targeting different constructs, target populations and respondents, based on criteria for diagnostic performance, psychometric properties (reliability, validity, and responsiveness), and feasibility. In addition, gaps in research that need to be addressed in future studies are discussed. The following recommendations are made: (1) discontinue the use of non-validated dysphagia screening tools and assessments; (2) implement screening using tools that have optimal diagnostic performance in selected populations that are at risk of dysphagia, such as stroke patients, frail older persons, patients with progressive neurological diseases, persons with cerebral palsy, and patients with head and neck cancer; (3) implement measures that demonstrate robust psychometric properties; and (4) provide quality training in dysphagia screening and assessment to all clinicians involved in the care and management of persons with dysphagia.