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Respiration
Physiologic requirements
Eliminate accumulated waste
Acquire nutrients
Oxygen and Carbon Dioxide concentrations Oxygen and Carbon Dioxide concentrations are balanced by the respiratory system
31
Medullary, peripheral centers sensitive to pH changes
Rate, depth of ventilation quickly altered by response to pH
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Photo: John A Beal, PhDDep't. of Cellular Biology & Anatomy, Louisiana State University Health Sciences Center Shreveport
Lungs
Circulation&
Respiration
ExternalRespiration
(Blood Atmosphere)
capillaries
Right Heart Left
Heart
33
Give Off CO2Pick Up O2
InternalRespiration
Blood Organs
Working Tissues & Organs
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External External RespirationRespiration
Alveoli exchangewith blood
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with blood
Breathing and Swallowing
35
Respiration and Deglutition
Upper aerodigestive tract is shared
Ventilation stops Ventilation stops with swallowing (apnea)
Larynx closes “bottom to top”
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Charbonneau et al., 2005; Hiss et al., Charbonneau et al., 2005; Hiss et al., 2003; 2003; Perlman et al., 2005 Perlman et al., 2005
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Normal Spirometry
IRVInspiration (expansion)
Max. lung volume
37
TV
ERV
REL
RV
Expiration (“collapse”)
Seconds>. . . . . .
20 s.
RR=20
breaths
Respiration and Deglutition
In Normals...
Exhale Swallow Exhale; Young and Old1
Respiratory rate (young) is about 16/min.2
“ “ (elderly) “ “ 20/min.y
Total Swallow Duration, Swallow Apnea Duration3
Increase with age
Decrease with lower lung volumes
38
1.1. Perlman et al., 2005; Hiss et al., 2002; Leslie et al., 2002; Perlman et al., 2005; Hiss et al., 2002; Leslie et al., 2002; 2.2. Leslie et al., 2002;Leslie et al., 2002;3.3. Gross et al., 2003; Hiss et al., Gross et al., 2003; Hiss et al., 2003; 2003; Leslie et al., 2005.Leslie et al., 2005.
inspiration Swallow apnea1.5 – 2.5 seconds
Total Swallow Duration=1.5 – 2.5 seconds
Normal Respiratory Rate‐swallow on expiration
expiration
Seconds
Respiratory Rate = 16/min
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Aspiration Pneumonia and the SLP James L. Coyle, Ph.D., CCC-SLP, BRS-S
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Types of Pneumonia
Ventilator Associated Pneumonia
Exposure to mechanical ventilation
Contaminated respiratory circuits
Contaminated suction, bronchoscopic equipment
Gastroesophageal reflux common in Ventilation
Early, late onset
Early: typically CAP pathogens
Late: MRSA, other drug‐resistant pathogens
64
Aspiration Pneumonia (AP)
Aspiration
Foreign matter enters the respiratory system
Pneumonia
Infectious acute inflammation
Reaction to pathogen
Aspiration Pneumonia
Pulmonary infectioncaused by aspiration of colonizedmatter
65
Aspiration pneumonia
CAP
Nosocomial
Aspiration Pneumonia
AP can originate in the community or in a hospital/HCF
Has reached epidemic proportions in the US*
66*Baine, Yu, & Summe, 2001
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Aspiration Pneumonia
Human Costs of Aspiration Pneumonia
AP admissions highest case‐fatality rate
23.1% during hospitalization*
Is fatal in 20%‐50% of confirmed cases Is fatal in 20%‐50% of confirmed cases
Annual mortality (1998 numbers) >25,000 annual deaths due to AP
Economic Costs of Aspiration Pneumonia
$1.5 billion
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*Baine et al, 2001;
Importance:
If we reduce the incidence of AP by a modest 20%
5,000 saved lives each year
If we reduce the admissions or length of stay for AP by a modest 20%
$300 million saved
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Data extrapolated from Mandell & Wunderink, 2007; Baine et al, 2001
Patient with dysphagia
…and other risk factors favoring pneumonia
aspirates colonized oral secretions
What is Dysphagia‐Related Aspiration Pneumonia (DAP)?
…aspirates colonized oral secretions
…causing infection of airways and/or alveoli
Where do these pathogens come from?
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Oral biofilm development
70http://bioinfo.bact.wisc.edu/themicrobialworld/streptococci_biofilm.jpg; Public health image library #3074, Centers for Disease Control
Oral biofilm
Variety of microorganisms in dental plaqueOral anaerobes
How Does DAP Develop?
Host Risk Factors
Mental status, immunological health, oral condition, upper GI obstruction, etc.
What was aspirated?
And what is its pathogen load?
Iatrogenic Risk Factors (institutionalized)
Feeding tube, postoperative impairments, medications, etc.
71* CDC/MMWR 46, RR‐1, (1997); **Langmore et al, (1998)
Where Does DAP Develop?
Site of occurrence:
Can occur in a health care facility (HCF)
Nosocomial Aspiration Pneumonia
Can occur outside of the HCF
Community Acquired Aspiration Pneumonia
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Aspiration Pneumonitis
Non‐Infectious
Acute Lung Injury caused by aspiration of caustic or particulate matter
Inflammation of alveoli by effects of irritants
No infection (sterile/non‐pathogenic material)
Inflammatory edema reduces surface area
Gastric contents
Sterile, acidic, caustic
Damage to airways, alveoli
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O2O
O2
CO2
74capillary
2O2
O2
O2
O2O2
CO2CO2
CO2
O2
O2O2
O2
O2
O2
O2O2
CO2
CO2
CO2
CO2
CO2 CO2
A new source of AP?
Gastric contents are normally sterile
pH : 2‐3* (nothing can survive)
However….
When stomach is de‐acidified and patient When stomach is de acidified, and patient exhibits GE reflux or emesis, , aspirated, colonized gastric contents can produce pneumonia
Increased use of acid suppressing drugs**
Raise gastric pH to 4.0 to 6.0*
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*Feldman & Barnett, 1991; **Laheij, et al., 2004.
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A new source of AP?
Laheij et al., 2004*
365,000 patients
Users and non‐users of acid suppression drugs
Some were prior usersp
5,551 patients developed pneumonia
PPI users were twice as likely to develop pneumonia
OR = 1.94‐2.28
H2 receptor agonist users
OR = 1.36‐1.64
AND…Eurich, et al., 2010; Herzig, et al., 2009
76*Marik, 2001; Marik and Zaloga, 2002; Laheij, et al., 2004;
Distinguishing AP, Aspiration Pneumonitis, Other Pneumonias
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The Medical Record contains important clues
HISTORY OF ONSET
The course and progression of the disease
Presence/absence of underlying source/cause of Presence/absence of underlying source/cause of aspiration
Results of lab, radiographic tests
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Aspiration Pneumonia and the SLP James L. Coyle, Ph.D., CCC-SLP, BRS-S
Non‐dysphagia related AspirationPneumoniaPneumonia
Aspiration does not occur because of dysphagia
Safely swallowed material
Gastroesophageal reflux or emesis (colonized)
Deacidified gastric contents
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DAP vs. other Pneumonias
1. Location of chest infiltrates
DAP: typically gravity dependent segments
Lower lobes an segments
DAP
segments
Position while aspirating
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NDAP
Giorgio Conrad (P.D.)
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Radiographic evidence
Infiltrates
Chest x‐ray shows “shadows” at sites of infection‐ induced inflammation
Advanced pneumonia may involve entire lobes Advanced pneumonia may involve entire lobes
Infection can spread
Aspiration Pneumonitis ‐Does not spread…
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Aspiration Related Infiltrates
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Aspiration produces pneumonitis or pneumonia in gravity dependentgravity dependent portions of lung(s).“Dependence” depends on posture when aspiration occurs“Dependence” depends on posture when aspiration occurs, density & volume aspirated.
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Thickened liquids
Median hospital LOS with pneumonia
Honey (18 d.), nectar (4 d.), CDP (6 d.)
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Thickened liquids
Summary on thickened liquids
Reduces aspiration but is not preferred
Thick liquids do not dehydrate
Reduced intake of fluidsReduced intake of fluids
Probable source of dehydration
Test results do not match diet thickness
Anticipated results cannot be expected
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Thickened liquids
Summary on thickened liquids
Compliance
Patient preferences
Patient satisfaction
Aspiration of thick liquids may produce a worse pulmonary consequences than thin liquids
If treatment plan will not be implemented…
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Evidence Summary for using Free Water Protocols
“Free Water” Protocols
2291625‐1700
Frazier Rehab Institute Water Protocol Kathy Panther, M.S., CCC, Louisville, Kentucky
“... Concern over patient and family non‐compliance with thin liquid restrictions compliance with thin liquid restrictions both within the facility and after discharge led us to alter our protocol in 1984. …oral intake of water became a major feature in both treatment and day to day hydration. Features of Frazier’s program …”
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Free Water Protocols
Literature search
1. “Free Water”, + Deglutition Disorders
2. Panther, K.
One citation on semantic relations in JSHD 1983
Perspectives article in 03/05 describing protocolPerspectives article in 03/05 describing protocol
“Currently there is no published evidence that will give dysphagia clinicians a definitive scientific basis for the safe delivery of water to patients with dysphagia”
ASHA journal (pre “Leader”) piece in 1998
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Leonard, L. B., Steckol, K. F., & Panther, K. M. (1983). Returning meaning to semantic relations: some clinical applications. Journal of Speech and Hearing Disorders, 48, 25‐36.
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Developers discuss
Safety of Water
Hydration
Compliance
“Free Water” Protocol Principles
p
232
1. “Safety of Water”
“Small amounts of water … are quickly absorbedinto the body pool.”
“Free Water” Protocol Principles
Large amounts are not.
“Water has a neutral pH…is free of bacteria…”
“Aspiration of other liquids can lead to respiratory infections and pneumonia.”
Cited evidence: animal studies, drowning case studies
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Pneumonia and aspiration
Drowning
Water fills air spaces
Plasma is hypertonic
Meaning: it contains lower concentration of water
At membrane, water flows into capillary
234capillary
Na+Na+ Na+
Na+
water
Effros, et al., 2000
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Pneumonia and aspiration
Example: seawater contains
High NaCL concentration
Is hypertonic Is hypertonic
Compared to plasma
Seawater drowning
Plasma enters lung
Similar with aspiration of any hypertonic solution
235capillary
Na+Na+ Na+
Sea waterNa+
Na+Na+
Na+
Na+
Na+
Na+
Na+
Na+
1. “Safety of Water”
“Water provides a safe means of assessing patients”
Opinion
“Free Water” Protocol Principles
Opinion
“All patients (of any diagnosis) referred to Speech Pathology are screened for dysphagia with water.
OK
“Water is safely utilized in daily treatment
“Swallow compensations can be practiced with thin liquid.
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2. “Hydration”
“Free water consumption is encouraged for all patients and makes a significant contribution in hydration for many.”
“Free Water” Protocol Principles
hydration for many.
Evidence?
“The risk and cost of IV fluids should be decreased.
“Post‐discharge surveys… indicate water often is the primary means of hydration.”
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3. “Compliance”
“Patients reported thickened liquids did not quench thirst.
“ ti t l i t h l ”
“Free Water” Protocol Principles
“…patient complaints are now much less”
“…patients object to thickened liquids.
“…patients appear more likely to comply with the thin liquids restriction.”
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“Free Water” Protocol Principles
3. “Compliance”
“…preparation of thickened liquids (is) burdensome.
“family may tire of patient complaints and abandon thi k d li idthickened liquids.
“Availability and cost of thickening may preclude compliance.
“Thick liquid preparation, … can overwhelm many families.”
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Free Water Protocols Evidence
Bronchoalveolar lavage
Whelan et al. (2001) reduced fluid intake in patients prescribed thick liquids
Numerous citations on dehydration in Numerous citations on dehydration in dysphagia
Animal studies of water aspiration
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Free Water Protocols Evidence
Garon et al., 1997
20 aspiration‐documented CVA patients
Aspirated liquid only on VFSS
Randomized to
(C): Thick liquids only at all times (10)
(E): All liquids thickened, AND free water (10)
Duration: treatment + 30 day follow up
Small and underpowered study
Yet the main evidence for protocol
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Garon et al., 1997
Exclusion
“Severe cough” when aspirating
Cannot rinse and expectorate
Cannot self‐feed
Pre‐existing hydration concern
148 patients screened: 13% enrolled
34 patients declined participation
94 patients ineligible
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Garon et al., 1997
Water placed out of reach
No water with meal or within 1hour
No compensatory swallow therapyp y py
Outcome variables
Pneumonia, hydration, time to no aspiration
Fluid intake
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Garon et al., 1997
Results
No patient in either group developed pneumonia, dehydration, complications
Intake of fluids comparable between groups
1210 mL (C) ‐ all thick
1318 mL (E): 855mL thick, 463mL thin
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Free Water Protocols Evidence
Garon et al., 1997
Time to recovery of aspiration
Experimental: 19.1 days (range 7‐35 days)
Control: 27.2 days (range: 8‐64 days)
Control: 42% longer to recover
More severe aspirators in control so OK
Small sample
Time to pneumonia outcome: adequate?
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Free Water Protocols Evidence
Garon et al., 1997
“Much less water than expected” by investigators (“we were surprised…”)
Satisfaction: only one control patient was satisfiedwith thick liquid
“all study patients satisfied with water”
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Free Water Protocols Evidence
Robbins et al. 2008. Protocol 201
Pneumonia‐no difference
Thin liquids/chin‐down posture: 10%
Thick liquids: 11%
Nectar: 8%, Honey: 15%
Dehydration: Thin: 2%, Thick: 6%
UTI: Thin: 3%, Thick: 6%
3 times longer hospital stay in honey‐thick who developed pneumonia
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Two recent studies
Two presented at ASHA 2008
Bronson‐Lowe, et al., 2008. Effects of a free water protocol for patients with dysphagia.
Free Water Protocols
Becker et al., 2008. An oral water protocol in rehabilitation patients with dysphagia for liquids.
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Bronson‐Lowe, et al., 2008
1. Retrospective study comparing patients with historical controls (via chart review)
Pneumonia, dehydration: no difference
Free Water Protocols (#1)
Fluid intake greater in treatment group (p=.03)
2. Sample of convenience concurrent comparison
Fewer pneumonia and more fluid intake
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Authors’ discussion
Authors could not determine whether results were influenced by
Increased oral hygiene in the treatment group
Increased oral hydration in the treatment group
More compliance with aspiration precautions in treated More compliance with aspiration precautions in treated patients
Hydration not affected by treatment/control assignment
This needs to be replicated prospectively
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Bronson‐Lowe, et al., 2008
Free Water Protocols (#2)
Randomization to water protocol or prescribed dietary fluid (26 patients)
17 patients requiring feeding assistance
8 assigned to control 9 to treatment8 assigned to control, 9 to treatment
9 independent feeding patients
3 assigned to control, 6 to treatment
All received oral care four times per day
Becker, et al., 2008
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Dependent Variables
Adverse events (pneumonia, UTI, death)
Objective measures not assigned by clinician/judges
FIM, FCM scores
Free Water Protocols (#2)
,
not blinded, assigned by treating clinician/judges
Length of stay
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Becker, et al., 2008
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Results
Pneumonia: 1 patient in each group
UTI: 2 patients in each group
Death: 2 treatment deaths, no control deaths
Free Water Protocols (#2)
,
FIM: no significant difference
FCM: no significant difference
Length of stay: 29.1 days (control) vs. 15.8 (tx)
Diet influence length of stay?
253
Becker, et al., 2008
Other findings:
Independent patients consumed significantly lessfluid than dependent patients (p<.01), regardless of group
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Free Water Protocols (#2)
255Becker, et al., 2008
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Discussion
The presence of two deaths in the treatment group cannot be ignored
…and may underscore the importance of clinical
Free Water Protocols (#2)
judgment in applying this and other treatments
Both patients that died had chronic pulmonary conditions
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Becker, et al., 2008
Other issue – implied endorsement
257
“Free water protocols”
Summary
25 years experience by developers
No published, peer reviewed data
anecdote only
Minimal objective evidence
No pneumonia difference
Other differences seem to exist
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“Free water protocols”
Summary
Physiologic justification exists
But not for all patients
Severe pulmonary disease
One size does not fit all
Developers obligation to publish data
Opinion here: there is no one protocol that is appropriate for every patient
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Feeding tubes
260
Feeding tubes
Indications
Artificial nutrition
Gastric decompression
Digestive system incompetenceg y p
Paralysis, obstruction, absorption disease
“Transfer dysphagia”
Oropharyngeal transfer disorder
Delivery:
Directly to gut blood (enteral)
Directly to blood (parenteral)
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Non‐Oral Nutrition Enteral nutrition Delivered to the gut
Utilizes digestive system
Tube name entry, deliverydelivery Naso‐gastric (NG); gasatrojejunostomy (GJ)
Depth: sphincters, absorption
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Non‐Oral Nutrition
Parenteral nutrition Bypasses the digestive system‐intravenous
Central, peripheral Percutaneous Intravenous Central Catheter
i f b h d proteins, fats, carbohydrates, etc.
Peripheral vein – few nutrients can be delivered
TPN, PPN
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Non‐Oral Nutrition
Nasopharyngeal entry
Fluoroscopic
Blind
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Non‐Oral Nutrition
Surgical entry
Fluoroscopically guided
Endoscopically guided
PEG
Open surgical
All involve opening abdominal wall so all are surgical
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Non‐Oral Nutrition
PEG
266
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Enteral Tube Indications
Intractable aspiration
Failed interventions
Recurrent illness attributed to prandialaspirationp
Permanenttemporary
Replacement/substitute for oral intake
Supplement to oral intake
Replacement for types of materials aspirated
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Contraindications
Ileus/Gastroparesis, SBO
Paralysis, obstruction
Absorption Deficits
Default to parenteral nutrition Default to parenteral nutrition
Prior abdominal resections/anatomy diff.
Surgically inserted abdominal enteral tubes
GER, severe.
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Feeding Tubes
Aspiration
Is not mitigated (25‐40% in PEG)
Saliva production
may increase – new site (Metheny et al., 2006)y ( y , )
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Complications
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Feeding Tubes Evidence
272
Enteral Tube Feeding
N= 70 tube fed patients, age 65‐95, over 11 mo. Indications refusal to swallow 50%
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Coyle, Pneumonia Seminar References
Acheson, D. E. (2003). FDA Public Health Advisory: Reports of blue discoloration and death in patients receving enteral feedings tinted with the dye, FD&C blue No. 1. http://www.cfsan.fda.gov/~dms/col-ltr2.html.
Ajemian, M. S., Nirmul, G. B., Anderson, M. T., Zirlen, D. M., & Kwasnik, E. M. (2001). Routine fiberoptic endoscopic evaluation of swallowing following prolonged intubation: implications for management. Archives of Surgery., 136(4), 434-437.
Alia, I., & Esteban, A. (1999). Protocol-guided weaning: a key issue in reducing the duration of mechanical ventilation. Intensivmed, 36(5), 429-435.
Alkhuja, S. (1998). Dysphagia in the patient with a tracheostomy: six cases of inappropriate cuff deflation or removal. Heart & Lung: Journal of Acute & Critical Care., 27(1), 74.
Almirall, J., Bolibar, I., Vidal, J., Sauca, G., Coll, P., Niklasson, B. et al. (2000). Epidemiology of community-acquired pneumonia in adults: a population-based study. European Respiratory Journal, 15, 757-763.
Apfelbaum, R. I., Kriskovich, M. D., & Haller, J. R. (2000). On the incidence, cause, and prevention of recurrent laryngeal nerve palsies during anterior cervical spine surgery. Spine, 25(22), 2906-2912.
Atkins, B. Z., Fortes, D. L., & Watkins, K. T. (2007). Analysis of respiratory complications after minimally invasive esophagectomy: preliminary observation of persistent aspiration risk. Dysphagia, 22(1), 49-54.
Azarpazhooh, A., & Leake, J. L. (2006). Systematic review of the association between respiratory diseases and oral health. Journal of Periodontology, 77(9), 1465-1482.
Baine, W. B., Yu, W. M., & Summe, J. P. (2001). Epidemiologic trends in the hospitalization of elderly medicare patients for pneumonia, 1991-1998. American Journal of Public Health, 91, 1121-1123.
Barquist, E., Brown, M., Cohn, S., Lundy, D., & Jackowski, J. (2001). Postextubation fiberoptic endoscopic evaluation of swallowing after prolonged endotracheal intubation: A randomized, prospective trial. Critical Care Medicine, 29(9), 1710-1713.
Becker, D. L., Tews, L. K., & Lemke, J. H. (2008). An oral water protocol in rehabilitation patients with dysphagia for liquids. 2008 ASHA convention technical session.
Belafsky, P. C., Blumenfeld, L., LePage, A., & Nahrstedt, K. (2003). The accuracy of the modified Evan's blue dye test in predicting aspiration. Laryngoscope., 113(11), 1969-1972.
Blunt, M. C. (2008). Gel lubrication of the tracheal tube cuff reduces pulmonary aspiration. Anesthesiology, 95(2), 377-381.
Brady, S. L., Hildner, C. D., & Hutchins, B. F. (1999). Simultaneous videofluoroscopic swallow study and modified Evans blue dye procedure: An evaluation of blue dye visualization in cases of known aspiration. Dysphagia., 14(3), 146-149.
Bronson-Lowe, C. R., Leisling, K., Bronson-Lowe, D., Lanham, S., Hayes, S. M., Ronquillo, A. M., et al. (2008). Effects of a free water protocol for patients with dysphagia. 2008 ASHA convention technical session.
Butler, R., Keenan, S. P. M., Inman, K. J. M., Sibbald, W. J. M., & Block, G. (1999). Is there a preferred technique for weaning the difficult-to-wean patient? A systematic review of the literature. Critical Care Medicine, 27(11), 2331-2336.
Cameron, J. L., Reynolds, J., & Zuidema, G. D. (1973). Aspiration in patients with tracheotomies. Surgical Gynecology and Obstetrics, 136, 68-70.
Centers for Disease, C., & Prevention (2003). Guidelines for preventing health-care associated pneumonia, 2003 (No. MMWR, 53 (RR-3)).
Charbonneau, I., Lund, J. P., & McFarland, D. H. (2005). Persistence of respiratory-swallowing coordination after laryngectomy. Journal of Speech Language & Hearing Research, 48(1), 34-44.
Ciocon, J. O., Silverstone, F. A., Graver, L. M., & Foley, C. J. (1988). Tube feedings in elderly patients: indications, benefits, and complications. Archives of Internal Medicine, 148(2), 429-433.
Coyle, J. L., Davis, L. A., Easterling, C., Graner, D. E., Langmore, S., Leder, S. B., et al. (2009). Oropharyngeal dysphagia assessment and treatment efficacy: setting the record straight (response to Campbell-Taylor). Journal of the American Medical Directors Association, 10(1), 62-66.
Coyle, J. L., & Robbins, J.A. (1997). Assessment and behavioral management of oropharyngeal dysphagia. Current Opinion in Otolaryngology & Head & Neck Surgery, 5(3), 147-152.
Czop, M., & Herr, D. L. M. (2002). Green skin discoloration associated with multiple organ failure. Critical Care Medicine, 30(3), 598-601.
Davis, L. A., & Thompson, S. S. (2004). Characteristics of dysphagia in elderly patients requiring mechanical ventilation. Dysphagia, 19(1), 7-14.
deLarminat, V., Montravers, P., Dureuil, B., & Desmonts, J. M. (1995). Alteration in swallowing reflex after extubation in intensive care unit patients. Critical Care Medicine, 23(3), 486-490.
Dettelbach, M. A., Gross, R. D., Mahlmann, J., & Eibling, D. E. (1995). Effect of the Passy-Muir Valve on aspiration in patients with tracheostomy. Head & Neck, 17(4), 297-302.
Dikeman, K., & Kasandjian, M. (2003). Communication and swallowing management of tracheostomized and ventilator-dependent adults. Clifton Park, N.J.: Thomson Delmar Learning.
Doggett, D. L., Tappe, K. A., Mitchell, M. D., Chapell, R., Coates, V., & Turkelson, C. M. (2001). Prevention of pneumonia in elderly stroke patients by systematic diagnosis and treatment of dysphagia: an evidence-based comprehensive analysis of the literature. Dysphagia, 16(4), 279-295.
Doggett, D. L., Turkelson, C. M., & Coates, V. (2002). Recent developments in diagnosis and intervention for aspiration and dysphagia in stroke and other neuromuscular disorders. Current Atherosclerosis Reports.4(4):311-8.
Donzelli, J., Brady, S., Wesling, M., & Craney, M. (2001). Simultaneous modified Evans blue dye procedure and video nasal endoscopic evaluation of the swallow. Laryngoscope., 111(10), 1746-1750.
Dua, K., Bardan, E., Ren, J., Sui, Z., & Shaker, R. (2002). Effect of chronic and acute cigarette smoking on the pharyngoglottal closure reflex. Gut, 51(6), 771-775.
Duchin, S., & van Houte, J. (1978). Colonization of teeth in humans by Streptococcus mutans as related to its concentration in saliva and host age. Infection & Immunity, 20(1), 120-125.
Dziewas, R., Ritter, M., Schilling, M., Konrad, C., Oelenberg, S., Nabavi, D. G., et al. (2004). Pneumonia in acute stroke patients fed by nasogastric tube. Journal of Neurology, Neurosurgery & Psychiatry, 75(6), 852-856.
Dziewas, R., Warnecke, T., Hamacher, C., Oelenberg, S., Teismann, I., Kraemer, C., et al. (2008). Do nasogastric tubes worsen dysphagia in patients with acute stroke? BMC Neurology, 8, 28.
Effros, R. M., Jacobs, E. R., Schapira, R. M., & Biller, J. (2000). Response of the lungs to aspiration. The American Journal Of Medicine, 108(4, Supplement 1), 15-19.
Eibling, D. E. & Gross, R. D. (1996). Subglottic air pressure: a key component of swallowing efficiency. Annals of Otology, Rhinology & Laryngology, 105, 253-258.
El Solh, A., Okada, M., Bhat, A., & Pietrantoni, C. (2003). Swallowing disorders post orotracheal intubation in the elderly. Intensive Care Medicine, 29(9), 1451-1455.
El Solh, A. A., Sikka, P., Ramadan, F., & Davies, J. (2001). Etiology of severe pneumonia in the very elderly. American Journal of Respiratory & Critical Care Medicine., 163(3 Pt 1), 645-651.
Engoren, M., Arslanian-Engoren, C., & Fenn-Buderer, N. (2004). Hospital and long-term outcome after tracheostomy for respiratory failure. Chest, 125(1), 220-227.
Coyle, Pneumonia Seminar References
Eurich, D. T., Sadowski, C. A., Simpson, S. H., Marrie, T. J., & Majumdar, S. R. (2010). Recurrent community-acquired pneumonia in patients starting acid-suppressing drugs. The American Journal of Medicine, 123(1), 47-53.
Feldman, M. & Barnett, C. (1991). Fasting gastric pH and its relationship to true hypochlorhydria in humans. Digestive Diseases and Sciences, 36, 866-869.
Feinberg, M. J., Knebl, J., & Tully, J. (1996). Prandial aspiration and pneumonia in an elderly population followed over 3 years. Dysphagia, 11, 104-109.
File, T. M., Tan, J. S., Thomson, R. B., Stephens, C., & Thompson, P. (1995). An outbreak of Pseudomonas aeruginosa ventilator-associated respiratory infections due to contaminated food coloring dye--further evidence of the significance of gastric colonization preceding nosocomial pneumonia. Infection Control & Hospital Epidemiology, 16(7), 417-418.
Finucane, T. E., & Bynum, J. P. (1996). Use of tube feeding to prevent aspiration pneumonia. Lancet, 348(9039), 1421-1424.
Garren, K. C., & Meyers, A. D. (1999). The use of simultaneous videofluoroscopic swallow study and modified Evans blue dye procedure: An evaluation of blue dye visualization in cases of known aspiration. Dysphagia., 14(3), 150-151.
Girard, T. D., & Ely, E. W. (2008). Protocol-drived ventilator weaning: reviewing the evidence. Clinics in Chest Medicine, 29(241), 252.
Gleeson, K., Eggli, D. F., & Maxwell, S. L. (1997). Quantitative aspiration during sleep in normal subjects. Chest, 111(5), 1266-1272.
Gomes, G. F., Pisani, J. C., Macedo, E. D., & Campos, A. C. (2003). The nasogastric feeding tube as a risk factor for aspiration and aspiration pneumonia. Current Opinion in Clinical Nutrition and Metabolic Care, 6(3), 327-333.
Good-Fratturelli, M. D., Curlee, R. F., & Holle, J. L. (2000). Prevalence and nature of dysphagia in VA patients with COPD referred for videofluoroscopic swallow examination. Journal of Communication Disorders, 33(2), 93-110.
Gosney, M., Martin, M. V., & Wright, A. E. (2006). The role of selective decontamination of the digestive tract in acute stroke. Age & Ageing, 35 (1), 42-47.
Gotfried, M. H. (2001). Epidemiology of clinically diagnosed community-acquired pneumonia in the primary care setting: results from the 1999-2000 respiratory surveillance program. American Journal of Medicine., 111(Suppl 9A), 25S-29S.
Griffiths, J., Barber, V. S., Morgan, L., & Young, J. D. (2005). Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation, from http://www.bmj.com/cgi/content/abstract/bmj.38467.485671.E0v1 doi:10.1136/bmj.38467.485671.E0 (published 18 May 2005)
Gross, R. D., Atwood, C. W., Jr., Ross, S. B., Olszewski, J. W., & Eichhorn, K. A. (2009). The coordination of breathing and swallowing in chronic obstructive pulmonary disease. American Journal of Respiratory & Critical Care Medicine, 179(7), 559-565.
Gross, R. D., Mahlmann, J., & Grayhack, J. P. (2003). Physiologic effects of open and closed tracheostomy tubes on the pharyngeal swallow. Annals of Otology, Rhinology & Laryngology., 112(2), 143-152.
Gross, R. D., Atwood, C. W., Jr., Grayhack, J. P., & Shaiman, S. (2003). Lung volume effects on pharyngeal swallowing physiology. Journal of Applied Physiology, 95, 2211-2217.
Hale, K. J., American Academy of Pediatrics Section on Pediatric, D., & Hale, K. J. (2003). Oral health risk assessment timing and establishment of the dental home. Pediatrics, 111(5 Pt 1), 1113-1116.
Hall, J. B., Schmidt, G. A., & Wood, L. D. H. (2003). Principles of Critical Care Medicine (3rd ed.): McGraw Hill.
Hassett, J. M., Sunby, C., & Flint, L. M. (1988). No elimination of aspiration pneumonia in neurologically disabled patients with feeding gastrostomy. Surgery, Gynecology & Obstetrics, 167(5), 383-388.
Heffner, J. E., & Zamora, C. A. (1990). Clinical predictors of prolonged translaryngeal intubation in patients with the adult respiratory distress syndrome. Chest, 97(2), 447-452.
Herzig, S. J., Howell, M. D., Ngo, L. H., & Marcantonio, E. R. (2009). Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA, 301(20), 2120-2128.
Hiiemae, K. M., & Palmer, J. B. (1999). Food transport and bolus formation during complete feeding sequences on foods of different initial consistency. Dysphagia, 14(1), 31-42.
Hiss, S. G., Strauss, M., Treole, K., Stuart, A., & Boutilier, S. (2003). Swallowing apnea as a function of airway closure. Dysphagia, 18(4), 293-300.
Hiss, S. G., Treole, K., & Stuart, A. (2001). Effects of age, gender, bolus volume, and trial on swallowing apnea duration and swallow/respiratory phase relationships of normal adults. Dysphagia, 16(2), 128-135.
Huxley, E. J., Viroslav, J., Gray, W. R., & Pierce, A. K. (1978). Pharyngeal aspiration in normal adults and patients with depressed consciousness. American Journal of Medicine, 64(4), 564-568
Katzan, I. L., Cebul, R. D., Husak, S. H., Dawson, N. V., & Baker, D. W. (2003). The effect of pneumonia on mortality among patients hospitalized for acute stroke. Neurology, 60, 620-625.
Knol, W., van Marum, R. J., Jansen, P. A., Souverein, P. C., Schobben, A. F., & Egberts, A. C. (2008). Antipsychotic drug use and risk of pneumonia in elderly people. Journal of the American Geriatrics Society, 56(4), 661-666.
Kononen, E., Asikainen, S., Saarela, M., Karjalainen, J., & Jousimies-Somer, H. (1994). The oral gram-negative anaerobic microflora in young children: longitudinal changes from edentulous to dentate mouth. Oral Microbiology & Immunology, 9(3), 136-141.
Kriskovich, M. D., Apfelbaum, R. I., & Haller, J. R. (2000). Vocal fold paralysis after anterior cervical spine surgery: incidence, mechanism, and prevention of injury. Laryngoscope, 110(9), 1467-1473.
LaCroix, A. Z., Lipson, S., Miles, T. P., & White, L. (1989). Prospective study of pneumonia hospitalizations and mortality of U.S. older people: the role of chronic conditions, health behaviors, and nutritional status. Public Health Reports, 104(4), 350-360.
Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia, 17, 298-307.
Laheij, R. J., Sturkenboom, M. C., Hassing, R. J., Dieleman, J., Stricker, B. H., & Jansen, J. B. (2004). Risk of community-acquired pneumonia and use of gastric acid-suppressive drugs. JAMA: The Journal of the American Medical Association, 292, 1955-1960.
Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D. et al. (1998). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia, 13, 69-81.
Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia, 17(4), 298-307.
Leder, S. B. (1999). Effect of a one-way tracheotomy speaking valve on the incidence of aspiration in previously aspirating patients with tracheotomy. Dysphagia., 14(2), 73-77.
Leder, S. B., & Ross, D. A. (2000). Investigation of the causal relationship between tracheotomy and aspiration in the acute care setting. Laryngoscope., 110(4), 641-644.
Lederman, D. S., Klein, E. F., Drury, W. D., Donnelly, W. H., Applefeld, J. J., Chapman, R. L., et al. (1974). A Comparison of Foam and Air-Filled Endotracheal-Tube Cuffs. Anesth Analg, 53(4), 521-526.
Leonard, L. B., Steckol, K. F., & Panther, K. M. (1983). Returning meaning to semantic relations: some clinical applications. Journal of Speech and Hearing Disorders, 48(1), 25-36.
Coyle, Pneumonia Seminar References
Leslie, P., Drinnan, M. J., Ford, G. A., & Wilson, J. A. (2002). Resting respiration in dysphagic patients following acute stroke. Dysphagia, 17(3), 208-213.
Leslie, P., Drinnan, M. J., Ford, G. A., & Wilson, J. A. (2002b). Swallow respiration patterns in dysphagic patients following acute stroke. Dysphagia., 17(3), 202-207.
Leslie, P., Drinnan, M. J., Ford, G. A., & Wilson, J. A. (2005). Swallow respiratory patterns and aging: presbyphagia or dysphagia? Journals of Gerontology Series A-Biological Sciences & Medical Sciences, 60(3), 391-395.
Lindeboom, R. (2005). Timing and route of enteral tube feeding did not affect death or combined death or poor outcome in stroke and dysphagia. Evidence-Based Nursing, 8(4), 117.
Logemann, J. A., Gensler, G., Robbins, J., Lindblad, A. S., Brandt, D., Hind, J. A., et al. (2008). A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson's disease. Journal of Speech Language & Hearing Research, 51(1), 173-183.
Lucarelli, M. R., Shirk, M. B., Julian, M. W., & Crouser, E. D. (2004). Toxicity of food drug and cosmetic blue no. 1 dye in critically ill patients. Chest, 125(2), 793-795.
Maloney, J. P., Halbower, A. C., Fouty, B. F., Fagan, K. A., Balasubramaniam, V., Pike, A. W., et al. (2000). Systemic absorption of food dye in patients with sepsis. New England Journal of Medicine, 343(14), 1047-1048.
Mandell, L. A., Wunderink, R. G., Anzueto, A., Bartlett, J. G., Campbell, G. D., Dean, N. C., et al. (2007). Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clinical Infectious Diseases, 44(Suppl 2), S27-72.
Marik, P. E. (2001). Aspiration pneumonitis and aspiration pneumonia. New England Journal of Medicine, 344, 665-671.
Marik, P. E. & Kaplan, D. (2003). Aspiration pneumonia and dysphagia in the elderly. Chest, 124, 328-336.
Marik, P. E. & Zaloga, G. P. (2003). Gastric versus post-pyloric feeding: a systematic review. Critical Care (London), 7, R46-R51.
Marston, B. J., Plouffe, J. F., File, T. M., Jr., Hackman, B. A., Salstrom, S. J., Lipman, H. B. et al. (1997). Incidence of community-acquired pneumonia requiring hospitalization. Results of a population-based active surveillance Study in Ohio. The Community-Based Pneumonia Incidence Study Group. Archives of Internal Medicine, 157, 1709-1718.
Martin-Harris, B. (2000). Optimal patterns of care in patients with chronic obstructive pulmonary disease. Seminars in Speech & Language, 21(4), 311-321.
McClave, S. A., & Chang, W. K. (2003). Complications of enteral access. Gastrointestinal Endoscopy, 58(5), 739-751.
Meert, K. L., & Metheny, N. A. (2004). Incidence and risk factors for oropharyngeal aspiration in mechanically ventilated infants and children. Pediatric Critical Care Medicine, 5(2), 194-196.
Metheny, N. A., Clouse, R. E., Chang, Y.-H., Stewart, B. J., Oliver, D. A., & Kollef, M. H. (2006). Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients: Frequency, outcomes, and risk factors. Critical Care Medicine, 34(4), 1007-1015.
Millns, B., Gosney, M., Jack, C. I., Martin, M. V., & Wright, A. E. (2003). Acute stroke predisposes to oral gram-negative bacilli -- a cause of aspiration pneumonia? Gerontology, 49(3), 173-176.
Mokhlesi, B., Logemann, J. A., Rademaker, A. W., Stangl, C. A., & Corbridge, T. C. (2002). Oropharyngeal deglutition in stable COPD. Chest., 121(2), 361-369.
National Center for Health Statistics (2003). National vital statistics report. Deaths: Leading causes for mortality in 2003. Preliminary data for 2003.
Niederman, M. & Fein, A. (1991). Community-acquired pneumonia in the elderly. In M.Niederman (Ed.), Respiratory Infections in the Elderly (pp. 45-62). New York: Raven Press.
Coyle, Pneumonia Seminar References
Niederman, M. S. (2002). Community-acquired pneumonia: management controversies, part 1; practical recommendation from the current guidelines. Journal of Respiratory Diseases, 23, 10-17.
Niederman, M. S., McCombs, J. S., Unger, A. N., Kumar, A., & Popovian, R. (1998). The cost of treating community-acquired pneumonia. Clinical Therapeutics, 20, 820-837.
Nseir, S., Di Pompeo, C., Jozefowicz, E., Cavestri, B., Brisson, H., Nyunga, M., et al. (2007). Relationship between tracheotomy and ventilator-associated pneumonia: a case control study. European Respiratory Journal, 30(2), 314-320.
O'Neil-Pirozzi, T. M., Lisiecki, D. J., Jack, M. K., Connors, J. J., & Milliner, M. P. (2003). Simultaneous modified barium swallow and blue dye tests: a determination of the accuracy of blue dye test aspiration findings. Dysphagia., 18(1), 32-38.
Owayed, A. F., Campbell, D. M., & Wang, E. E. L. (2000). Underlying causes of recurrent pneumonia in children. Arch Pediatr Adolesc Med, 154(2), 190-194.
Perlman, A. L., He, X., Barkmeier, J., & Van Leer, E. (2005). Bolus location associated with videofluoroscopic and respirodeglutometric events. Journal of Speech Language & Hearing Research, 48(1), 21-33.
Peruzzi, W. T., Logemann, J. A., Currie, D., & Moen, S. G. (2001). Assessment of aspiration in patients with tracheostomies: comparison of the bedside colored dye assessment with videofluoroscopic examination. Respiratory Care, 46(3), 243-247.
Power, K. J. (1990). Foam cuffed tracheal tubes: Clinical and laboratory assessment. Br. J. Anaesth., 65(3), 433-437.
Raghu, G. (2003). The role of gastroesophageal reflux in idiopathic pulmonary fibrosis. American Journal of Medicine,115 Suppl 3A:60S-64S.
Ravelli, A. M., Panarotto, M. B., Verdoni, L., Consolati, V., & Bolognini, S. (2006). Pulmonary aspiration shown by scintigraphy in gastroesophageal reflux-related respiratory disease. Chest, 130(5), 1520-1526.
Saitoh, E., Shibata, S., Matsuo, K., Baba, M., Fujii, W., & Palmer, J. B. (2007). Chewing and food consistency: effects on bolus transport and swallow initiation. Dysphagia, 22(2), 100-107.
Sandhu, R. S., Pasquale, M. D., Miller, K., & Wasser, T. E. (2000). Measurement of endotracheal tube cuff leak to predict postextubation stridor and need for reintubation. Journal of the American College of Surgeons., 190(6), 682-687.
Santos, P. M., Afrassiabi, A., & Weymuller, E. A., Jr. (1994). Risk factors associated with prolonged intubation and laryngeal injury. Otolaryngology - Head & Neck Surgery, 111(4), 453-459.
Sarkar, M. M. D., Hennessy, S. P. P., & Yang, Y.-X. M. D. M. (2008). Proton-pump inhibitor use and the risk for community-acquired pneumonia. Annals of Internal Medicine, 149(6), 391-398.
Schreiner, A. (1983). Anaerobic pulmonary infections. Scandinavian Journal of Gastroenterology, 85S, 55-59.
Segal, R., Dan, M., Pogoreliuk, I., & Leibovitz, A. (2006). Pathogenic colonization of the stomach in enterally fed elderly patients: Comparing percutaneous endoscopic gastrostomy with nasogastric tube. Journal of the American Geriatrics Society, 54(12), 1905-1908.
Sheikh, S., Allen, E., Shell, R., Hruschak, J., Iram, D., Castile, R., et al. (2001). Chronic aspiration without gastroesophageal reflux as a cause of chronic respiratory symptoms in neurologically normal infants. Chest, 120(4), 1190-1195.
Stein, M., Williams, A. J., Grossman, F., Weinberg, A. S., & Zuckerbraun, L. (1990). Cricopharyngeal dysfunction in chronic obstructive pulmonary disease. Chest.97(2):347-52.
Suiter, D. M., McCullough, G. H., & Powell, P. W. (2003). Effects of cuff deflation and one-way tracheostomy speaking valve placement on swallow physiology. Dysphagia., 18(4), 284-292.
Coyle, Pneumonia Seminar References
Theodoropoulos, D. S., Pecoraro, D. L., & Efstratiadis, S. E. (2002). The association of gastroesophageal reflux disease with asthma and chronic cough in the adult. American Journal of Respiratory Medicine., 1(2), 133-146.
Thompson-Henry, S., & Braddock, B. (1995). The modified Evan's blue dye procedure fails to detect aspiration in the tracheostomized patient: five case reports. Dysphagia.10(3):172-4.
Tobin, R. W., Pope, C. E., Pellegrini, C. A., Emond, M. J., Sillery, J., & Raghu, G. (1998). Increased prevalence of gastroesophageal reflux in patients with idiopathic pulmonary fibrosis. American Journal of Respiratory & Critical Care Medicine, 158, 1804-1808.
Vestbo, J., Anderson, W., Coxson, H. O., Crim, C., Dawber, F., Edwards, L., et al. (2008). Evaluation of COPD longitudinally to identify predictive surrogate end-points (ECLIPSE). European Respiratory Journal, 31(4), 869-873.
Wagner, D. R., Elmore, M. F., & Knoll, D. M. (1994). Bacterial contamination of enteral feeding reservoirs. Journal of Parenteral & Enteral Nutrition, 18(6), 562-Dec.
Wan, A. K., Seow, W. K., Purdie, D. M., Bird, P. S., Walsh, L. J., Tudehope, D. I., et al. (2003). A longitudinal study of Streptococcus mutans colonization in infants after tooth eruption. Journal of Dental Research, 82(7), 504-508.
Ware, L. B. & Matthay, M. A. (2000). The acute respiratory distress syndrome. The New England Journal of Medicine, 342, 1334-1349.
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