2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

O. Ortega et al.

Neurogastroenterology and Motility

potential respiratory pathogens and gram-negative bacteria. 43 In this study, we also confirmed that OD-APN patients had severely impaired swallow and airway protection mechanisms. We observed VFS signs of impaired safety in 46.7% (OD-PNP), 33.3% (OD) and 61.5% (OD-APN) of our patients, showing that aspira- tion is a common finding in older patients with pneumonia. 6,7 We previously found that prevalence of OD in patients with CAP was 91.7% and delayed LVC was the main mechanism of impaired airway protec- tion as we have found in our study. 6 Laryngeal vestibule closure was seriously delayed in all OD groups in our study, especially OD-APN, increasing risk of aspirations. In addition, all the aspirations presented by OD-APN were silent (15.4%), indicating probable impaired cough reflex. A recent study on older patients with CAP showed similar results with a prevalence of silent aspirations of 16.7%. 6 The high prevalence of OD and risk factors among older patients in this study suggests that a high percentage of CAPs in older persons are caused by oropharyngeal aspirations. In addition, 4/7 pathogens that were found to be the etiological cause of pneumonia in 7/17 patients from group OD-APN on admission, were then found in oral samples of the qPCR analysis. We thus propose that the main etiological mechanism that leads to pneu- monia in FOP is aspiration rather than inhalation. If true, prevention and treatment of pneumonia in FOP need revising. Finally, our VFS studies show that increasing bolus viscosity can avoid aspirations; up to 100% of all groups with OD presented safe swallow when using spoon-thick viscosity. Thus, OD in these patients with pneumonia can be diagnosed by clinical methods and/or complementary explorations, and aspirations effectively avoided by using thickeners at an appropriate level of viscosity. Many studies have reported that the presence of caries, periodontal disease, and dental plaque are associated with the appearance, severity, and mortality of AP in older patients and a relationship has been established between oral colonization and respiratory pathogens. 2,16,18,38,44 – 47 Periodontal pathogens may facilitate the colonization of the oral cavity by pneu- monia pathogens. 47 Periodontal disease and poor oral hygiene result in a higher concentration of gram- negative and anaerobic oral pathogens in saliva. 48 Oral biofilm acts as a reservoir for respiratory pathogens, which appear in the oral cavity before colonizing the lungs in patients with AP. 18,49 We previously found a high prevalence of periodontal diseases (93%) and caries (53%) and high accumulation of dental plaque and calculus measured with the OHI-S in older

Table 3 Proportion of patients colonized by respiratory pathogens at tested locations

Location

Group

Proportion

p -value

Nasal cavity

OD-PNP

0.60 0.53

0.23 0.36 0.36 0.50 0.10 0.05 0.09 0.15 0.02 0.23 0.03 0.19 0.23 0.04 0.18 0.22 0.06 0.50 0.45 0.67 0.20 0.50 0.35 0.22 0.04 0.04 0.07

OD

OD-APN 0.53

H

0.47 0.13 0.33 0.13 0.27 0.20 0.07 0.60 0.80 0.47 0.53 0.73 0.40 0.73 0.87 0.60 0.29 0.20 0.27 0.33 0.40 0.33 0.93 0.93

Nasopharynx

OD-PNP

OD

OD-APN 0.41

H

Oropharynx

OD-PNP

OD

OD-APN 0.41

H

Oral rinse

OD-PNP

OD

OD-APN 0.62

H

Saliva

OD-PNP

OD

OD-APN 0.56

H

Sputum

OD-PNP

OD

OD-APN 0.60

H

Teeth (dental plaque)

OD-PNP

OD

OD-APN 0.41

H

Tongue

OD-PNP

OD

OD-APN 0.47

H

Any location

OD-PNP

OD

OD-APN 0.88

H

0.67

OD-PNP, patients with OD and prior pneumonia; OD, patients with oropharyngeal dysphagia; OD-APN, patients with OD and acute pneumonia; H, healthy older persons. p -values are for comparisons of a given group with healthy older persons. Significant values are shown in bold and values just short of significance are underlined.

Despite the high diagnostic sensitivity and specificity of the V-VST for clinical signs of impaired safety of swallow, 28 we confirmed our clinical findings with VFS. We found prevalent VFS signs of impaired efficacy (mainly residue) and safety of swallow in the OD groups, particularly OD-APN. Oropharyngeal residue caused by weak tongue propulsion 29 was found in 60% (G1 and G2) and 61.5% (G3) of OD patients, causing deficient oropharyngeal clearance, which can be aggra- vated by reduced salivation (associated with aging, medication, and dehydration). 18 Effective salivary flow and swallowing are needed to clear gram-negative bacteria from the oral and pharyngeal cavities. 42 Reduction in mechanical clearance, together with poor oral hygiene and impaired immunity, could contribute to oral and pharyngeal colonization by opportunistic or

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