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Beth Israel Deaconess Medical Center and Harvard Medical School Boston, MA 02215
Pikus et al. [1] conclude their article by pointing out that "patients with no laryngeal penetration—regardless of whether they have normal or abnormal swallowing—have the lowest risk of developing pneumonia" and "therefore, findings on videofluoroscopic swallowing studies can be used to guide management of patients potentially at risk for pneumonia." I found much of this article to be déjà vu.
A dozen years ago an AJR article by Feinberg and Ekberg [2] reached similar conclusions: "an accurate and valid assessment of oropharyngeal dysfunction in elderly patients with aspiration is possible" and "critical management decisions regarding dietary alterations, degrees of oral intake, and institution of artificial feeding often depend on videofluoroscopic assessment of aspiration."
Equally applicable to the current article by Pikus et al. [1] are my comments about the article by Feinberg and Ekberg [2] in a letter to the editor [3]:
Obviously, in selected patients, videofluoroscopic assessment of swallowing function is useful.... A patient's ability to tolerate different foods, solids vs liquids, or small vs large boluses often can be assessed better by the astute observer who feeds the patient each day than it can be during the short period of observation in the fluoroscopic suite when artificial radiopaque food materials are used.... My own limited experience has been that once such an examination is offered, it is used increasingly in patients whose mental status is severely limited.... The question of efficacy was not addressed in this article and, to my knowledge, it has not been addressed in any previous publication. Certainly, it would be difficult to assess in a controlled fashion.
In a response to my letter, Feinberg and Ekberg [4] acknowledged that
...the efficacy of swallowing studies has not been established. No large, well-controlled clinical trials have been done that indicate a significant reduction in morbidity or mortality for any age group or specific condition. However, the discipline is relatively new and is still in the descriptive phase....
That statement is as true today as it was a dozen years ago. We are still describing the findings on videofluoroscopic studies, but in most instances the value of this examination remains unclear. Our specialty needs more outcomes research.
References
Hospital of the University of Pennsylvania Philadelphia, PA 19104
We thank Dr. Hall for his letter concerning our recent article in AJR on swallowing dysfunction [1]. Hall compared our study with an earlier study by Feinberg and Ekberg [2] in which a retrospective review of videofluoroscopic swallowing studies in 50 elderly patients with aspiration permitted identification of specific patterns of oropharyngeal dysfunction as the cause of their aspiration.
In our study, however, we assessed the relationship between the degree of swallowing dysfunction on barium studies and the risk of developing pneumonia in a series of 381 patients. Those with no laryngeal penetration had the lowest risk of developing pneumonia, whereas those with laryngeal penetration, tracheobronchial aspiration, and silent tracheobronchial aspiration were approximately four times (p = 0.008), 10 times (p < 0.0001), and 13 times (p < 0.0001) more likely to develop pneumonia, respectively, than those with normal findings on swallowing studies. We concluded that the degree of swallowing dysfunction on videofluoroscopic swallowing studies directly correlates with the risk of developing pneumonia.
We recognize that our investigation has the inherent limitations of a retrospective study and that prospective trials are needed to further elucidate the usefulness of videofluoroscopic swallowing studies as a diagnostic test for identifying patients at risk for developing aspiration pneumonia. We therefore agree with Hall about the need for future outcomes research in this area.
References
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