(Chest. 1999;116:1251-1256.)
© 1999
American College of Chest Physicians
Satisfaction of Patients Treated Surgically for Intractable Aspiration*
Yoshihisa Takano, MD;
Moritaka Suga, MD, PhD;
Osamu Sakamoto, MD, PhD;
Keizo Sato, MD, PhD;
Yasuhiro Samejima, MD, PhD and
Masayuki Ando, MD, PhD, FCCP
*
From the First Department of Internal Medicine (Drs. Takano, Suga, Sakamoto, Sato, and Ando) and Department of Otorhinolaryngology (Dr. Samejima), Kumamoto University School of Medicine, Kumamoto, Japan.
Correspondence to: Moritaka Suga, MD, First Department of Internal Medicine, Kumamoto University School of Medicine, 1–1-1 Honjo, Kumamoto 860-0811, Japan; e-mail: suga{at}gpo.kumamoto-u.ac.jp
 |
Abstract
|
|---|
Study objective: Impaired laryngeal protective function
can result in intractable aspiration requiring surgical treatment.
There are, however, few reports evaluating the satisfaction of patients
and the efficacy of surgical therapy. The purpose of this study is to
determine whether surgery for intractable aspiration is beneficial for
alleviating depression and improving the mood of patients who have
undergone surgical treatment and whether patients and their families
are satisfied with the therapy.
Patients and study
design: Seven patients with recurrent aspiration pneumonia that
could not be controlled by appropriate medical therapies participated
in the study. These patients had no hope of recovering laryngeal
function. Six underwent laryngectomy and one underwent laryngotracheal
separation. After surgery, we evaluated the efficacy of the therapy and
the patients’ satisfaction with the therapy.
Methods:
The following clinical variables concerning surgical procedure were
examined: operation time, time until oral intake, videofluorographic
study, and surgical complications. The treatment methods including
feeding status were also examined before and after surgery. In
addition, the following markers were examined to evaluate the efficacy
of the surgery: score of aspiration pneumonia, body mass index, total
protein, albumin, hematocrit, WBC count, C-reactive protein,
erythrocyte sedimentation rate, and the Barthel Index, an indicator of
daily activity. Furthermore, the grade of depression and mood, and
satisfaction of patients and their caretakers among family members were
scored by the Zung self-rating depression scale, a 20-picture face
scale, and the visual analog scale.
Results: After
surgical therapy, we confirmed by videofluorography that aspiration was
completely prevented. No surgical complications occurred. By 18 ± 6
days, all seven patients were able to ingest a meal orally. The need
for extensive medical care and repeated hospitalizations became
unnecessary after surgery. The control of pneumonia and albumin
improved significantly. The grade of depression and mood of patients
and their families also improved significantly. Satisfaction scores of
patients receiving therapy were very high.
Conclusions: Our study shows that surgical therapy to
prevent aspiration improves the depression and mood of patients and
their families as well as feeding status and clinical outlook. Surgical
therapy for patients with intractable aspiration is effective and
beneficial.
Key Words: feeding status • intractable aspiration • patient’s satisfaction • surgical therapy
|
Introduction
|
|---|
Aspiration
is a major cause of pulmonary infections,1
2
and recurrent
aspiration can cause life-threatening pulmonary
diseases.3
4
Swallowing difficulties resulting in
aspiration occur in a variety of swallowing and laryngeal dysfunctions
associated with neuromuscular, esophageal, and laryngeal
disorders.5
6
Management of patients with aspiration
initially requires discontinuation of oral intake.5
In
some instances, pulmonary lavage may be indicated. Next, alimentary
routes are changed to enteral routes requiring nasogastric tube feeding
(NTF) and gastrostomy, or IV hyperalimentation (IVH).5
7
In addition, antimicrobial therapy may be necessary to counteract
bacterial infections.3
These medical managements are
ordinarily effective; however, in some patients, intractable
aspiration and aspiration pneumonia necessitate surgical
procedures,5
8
9
mainly laryngectomy or laryngotracheal
separation. Although these procedures separate the airway and digestive
systems and can effectively eliminate intractable aspiration, patients
who undergo these therapies lose the ability to speak after
surgery.8
9
To determine the efficacy of surgical therapy, we examined changes in
medical management, including feeding conditions, and clinical data of
patients who underwent surgery. Moreover, because it is unclear whether
such patients and their families are truly satisfied with surgical
therapy, we also investigated whether depression levels and mood of
patients and families changed after surgery. In this article, we show
that the surgical therapy for intractable aspiration improves at least
some variables of quality of life including feeding conditions and
clinical data. In addition, we show that this therapy also improves the
depression and mood of both patients and families.
|
Materials and Methods
|
|---|
Subjects
Seven patients with intractable aspiration and recurrent
aspiration pneumonia participated in this study. We confirmed the
aspirations by videofluorography and clinical evaluation in all
patients. The indications for surgical therapy for intractable
aspiration are as follows: (1) aspiration cannot be controlled by
medical treatments; (2) there is an irreversible laryngeal dysfunction;
(3) phonation disturbance is aphonia or unintelligible speech; (4)
there are no other diseases with a poor prognosis, such as end-stage
malignancies; (5) prognosis would improve if aspiration was completely
prevented; (6) informed consent is provided agreeing to loss of speech;
(7) there is a desire to be able to eat orally and taste food; and (8)
there is no contraindication for general anesthesia. All of our
patients fulfilled these criteria. These studies were approved by the
Institutional Review Board of Kumamoto University. Each subject was
informed of the purpose of the study and gave written consent. As
surgical therapy, six patients underwent laryngectomy and one underwent
laryngotracheal separation. The laryngotracheal separation procedure
was performed by dividing the trachea horizontally at the level of the
tracheostomy. Then proximal end-to-side tracheoesophageal anastomosis
and distal tracheostomy were performed.10
Clinical Data
Scores of aspiration pneumonia reflect the frequency of
occurrence and are defined as follows: 0, no occurrence; 1, one or two
times per year; 2, three to five times per year; 3, every month or two.
Conditions of phonation were defined as follows: 0, fully understood by
others; 1, mostly understood by others; 2, slightly understood by
others; 3, not understood by others. Body mass index (BMI) was measured
as a marker of nutritional state. Among laboratory data, total protein,
albumin, and hematocrit were measured as nutritional markers. In
addition, WBC count, C-reactive protein (CRP), and erythrocyte
sedimentation rate (ESR) were measured as inflammatory markers. Daily
activity was evaluated by the Barthel Index. (0 to 100).11
Mental status was evaluated by the following tests: depression was
scored by the Zung self-rating depression scale (SDS) (20 to
80),12
nonverbal mood was scored by the face scale (1 to
20),13
and satisfaction was scored by the visual analog
scale (VAS). In the SDS, patients were asked to rate each of 20 items
as to how it applied to them at the time of testing in terms of four
quantitative levels: a little of the time, some of the time, a good
part of the time, or most of the time. The SDS is constructed so that a
less-depressed patient will have a low score on the scale and a
more-depressed patient will have a high score. The face scale contains
20 drawings of a single face, arranged in serial order by rows with
each face depicting a slightly different mood state. They are arranged
in decreasing order of mood and numbered from 1 to 20, with 1
representing the most-positive mood and 20 representing the
most-negative mood. The VAS is a 20-cm horizontal line with opposite
descriptions such as "not satisfied with surgical therapy at all"
(lower end 0%) and "extremely satisfied" (upper end 100%). The
validity and reliability of these scales have been confirmed by
previous reports.13
14
15
Data Collection
The following clinical data concerning the surgical procedure
were examined: operation time, time until oral intake,
videofluorographic study, and surgical complications. The medical
management for aspiration including feeding condition was also examined
before and after surgery. Scores of aspiration pneumonia, BMI,
laboratory data, the Barthel Index, the SDS, the face scale, and the
VAS were determined 1 month before surgery and again 14.5 ± 6.7
months (range, 8 to 25 months) after surgery. All patients were
clinically stable 1 month before surgery and did not suffer from
respiratory failure caused by pneumonia. In addition, the SDS, the face
scale, and the VAS of families were evaluated before and after surgery.
Statistical Analysis
Data are shown as means ± SD. The differences before and after
surgical therapy were compared using the Wilcoxon signed-rank test. A
value of p < 0.05 was considered significant. Further multiple tests
of clinical data were determined using Bonferroni/Dunn test.
|
Results
|
|---|
Table 1
summarizes the characteristics before surgical therapy of patients
participating in this study. The BMI of all patients was very low
(16.9 ± 3.5 kg/m2), and control of aspiration
pneumonia was also very poor. All patients had intractable aspiration
and suffered from recurrent aspiration pneumonia. Phonation was poor in
all patients; therefore, they could not communicate well with others by
speech. Preoperative feeding conditions of patients were as follows:
NTF in five, IVH in four, and percutaneous endoscopic gastrostomy (PEG)
in three. We discontinued PEG before surgery in all three because of
aspiration and peristomal wound infection.
Clinical data of surgical procedures are shown in Table 2
. Mean operation time was 201 ± 47 min. The time until oral intake
was 18 ± 6 days. Videofluorography revealed that no patient suffered
from aspiration after surgery. There were no surgical complications in
any patient.
Table 3
shows the types and rates of medical procedures required before and
after surgery. Medical care such as the elimination of thin liquids,
education about optimal feeding techniques, and repeated
hospitalization became unnecessary after surgery. The number of
patients who needed frequent suctioning of oral secretions, and general
rehabilitation was reduced after surgery, and six of the seven patients
were able to satisfy their nutritional needs solely by oral intake. One
patient required a supplemental tube feeding because he could not chew
well.
Clinical data before and after surgical therapy are given in Table 4
. After surgery, the scores of aspiration pneumonia, BMI, total protein,
albumin, hematocrit, CRP, and ESR were significantly better than the
scores before surgery (p < 0.05). Postsurgery satisfaction scores,
as determined by the VAS, were very high in both patients
(95.4 ± 6.7 points) and families (96.7 ± 5.2 points).
As shown in Figure 1
, significant improvements in depression were observed in the patients
(p < 0.05) and their families (p < 0.05) after surgery. Before
surgery, six of seven patients and three of the families were depressed
according to their scores on the SDS, which defines depression as a
score of > 40 points. After surgery, six of seven patients and all
families showed a decrease in depression score. Furthermore, as shown
in Figure 2
, significant improvements in the face scale were also observed in both
patients (p < 0.05) and families (p < 0.05).
View larger version (17K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1. Depression scale of patients (left,
A) and their families (right,
B) before and after the surgical therapy. The grade of
depression significantly improved in both patients and their families
after the surgical therapy (p < 0.05). In the SDS, a depressive
state is defined by a score > 40 points (a broken line).
|
|
View larger version (16K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2. The face scale of patients (left,
A) and their families (right,
B) before and after the surgical therapy. The nonverbal
mood improved significantly in both patients and their families after
the surgical therapy (p < 0.05).
|
|
Moreover, these clinical data were evaluated by multiple tests. After
surgery, scores of aspiration pneumonia (p < 0.0001), albumin
(p = 0.002), the SDS of patients (p = 0.0006) and their families
(p = 0.04), and the face scale of patients (p < 0.0001) and their
families (p < 0.0001) were significantly better than scores before
surgery.
|
Discussion
|
|---|
Laryngectomy and laryngotracheal separation are therapies used to
treat intractable aspiration.5
8
9
These procedures
separate the airway and digestive systems and can eliminate aspiration
completely. However, such procedures have both advantages and
disadvantages: for example, patients recover the ability to eat, which
is a significant sensual pleasure, but they lose the ability to speak.
The latter condition can make it difficult to assess patients’
satisfaction with such treatment. As far as we could determine, no
study has evaluated the satisfaction of patients with such therapy.
Here, we have attempted to evaluate the benefits of surgical
intervention for both patients and their families.
Patients who continue to have aspiration and pneumonia despite
appropriate medical therapies and skilled nursing care exhibit
malnutrition and cachexia because of recurrent pneumonia and parenteral
feeding.8
When aspiration is completely eliminated after
surgery and aspiration pneumonia is controlled, patients can eat
orally, which results in a gradual improvement in their nutritional
status.5
8
9
In our patients, aspiration was completely
eliminated after surgical therapy and the change of feeding conditions
to oral intake from NTF, IVH, or PEG. In addition, a number of medical
treatments including repeated hospitalization became unnecessary after
surgery. Furthermore, the score for aspiration pneumonia and albumin
significantly improved after surgery. These results indicate that
surgery prevented recurrent aspiration pneumonia in our patients and
that change to enteral feeding from parenteral feeding improved their
nutritional status. Eibling et al16
reviewed 34 patients
who underwent laryngotracheal separation for intractable aspiration. In
their series, 14 patients were able to resume a regular or liquid diet
and sustain their weight without supplemental feedings postoperatively.
Although more than half of their patients required permanent
nasogastric or gastrostomy tube feedings because of neurologic
impairment, their results also show that surgical treatment for
intractable aspiration enables patients to resume an oral diet.
Compared with parenteral nutrition, enteral nutrition is superior in
respect to host immune responses or host defense
systems.17
18
The gut mucosa is an important barrier to
microbial translocation from the gut to the mesenteric lymph nodes, the
spleen, and the liver. Therefore, intestinal atrophy associated with
parenteral nutrition leads to increasing passage of bacteria and other
toxins from the gut. Translocation of these products has been
implicated as a cause of infection and organ failure. Thus, the option
of enteral rather than parenteral feeding after surgery is very
important not only for nutrition but also for host defense mechanisms.
PEG and NTF are useful and effective methods using the enteral route
for intractable aspiration. However, a number of complications of PEG
and NTF have also become apparent.19
20
The most
significant complication in both is aspiration and the resultant
aspiration pneumonia. In our study, although PEG was applied to three
of seven patients before surgery, it was stopped because of aspiration
and peristomal wound infection. In general, patients cannot resume an
oral diet or taste food during artificial enteral feeding. Therefore,
we consider that laryngectomy and laryngotracheal separation are
superior to artificial enteral feeding for patients who continue to
have intractable aspiration and who wish to resume oral intake and to
be able to taste their food.
Inasmuch as both feeding and overall well-being improved after surgery,
our patients were satisfied with the therapy. Mental status as
evaluated by the SDS and the face scale significantly improved in
parallel with improvements in the patients’ health. The mental status
of patients’ family members also significantly improved, demonstrating
that surgical intervention benefits not only those suffering from
intractable aspiration but their caregivers as well. Moreover,
satisfaction scores, as determined by the VAS, were very high in both
patients and families. These results suggest that patients who undergo
surgical therapy are satisfied with the therapy in spite of their loss
of speech.
We consider the indications for surgical therapy for intractable
aspiration to be as follows: aspiration that cannot be controlled by
medical treatments; irreversible laryngeal dysfunction; phonation
impairment manifesting as aphonia or unintelligible speech; improvement
in prognosis if aspiration is completely prevented; willingness to
completely give up being able to speak; and the desire for oral intake
and tasting of food. Among these criteria, we think that the patient’s
desire for oral intake and the ability to taste food is the most
important factor. In one of our seven patients, we could not sustain
the patient’s weight without supplemental feedings because the patient
could not chew well. We consider a surgical procedure to be suitable
for patients who retain the ability to chew and have a sense of taste.
Because laryngotracheal separation is a procedure that can recover
phonation, it is suitable for patients who want to retain the
possibility of phonation.
In summary, the results from our indexes evaluating patient
satisfaction, mental health, nutritional state, overall health, and
patients’ family outlook argue in favor of surgical intervention to
treat intractable aspiration. However, because our evaluation is based
on data gathered from a small group of patients, larger studies are
required to confirm the efficacy of such therapy.
|
Footnotes
|
|---|
Abbreviations: BMI = body mass index;
CRP = C-reactive protein; ESR = erythrocyte sedimentation rate;
IVH = IV hyperalimentation; NTF = nasogastric tube feeding;
PEG = percutaneous endoscopic gastrostomy; SDS = Zung self-rating
depression scale; VAS = visual analog scale
Received for publication October 6, 1998.
Accepted for publication June 15, 1999.
|
References
|
|---|
-
Kikuchi, R, Watabe, N, Konno, T, et al (1994) High incidence of silent aspiration in elderly patients with community-acquired pneumonia. Am J Respir Crit Care Med 150,251-253[Abstract]
-
Nakagawa, T, Sekizawa, K, Arai, H, et al (1997) High incidence of pneumonia in elderly patients with basal ganglia infarction. Arch Intern Med 157,321-324[Abstract]
-
Bartlett, JG (1998) Aspiration disease and anaerobic infection. Fishman, AP eds. Pulmonary diseases and disorders 3rd ed. ,2011-2019 McGraw-Hill New York, NY.
-
Ribaudo, CA, Grace, WJ (1971) Pulmonary aspiration. Am J Med 50,510-520[CrossRef][Medline]
-
Eisele, DW (1991) Surgical approaches to aspiration. Dysphagia 6,71-78[Medline]
-
Chan, ED, Welsh, CH (1998) Geriatric respiratory medicine. Chest 114,1704-1733[Free Full Text]
-
Finucane, TE, Bynum, JP (1996) Use of tube feeding to prevent aspiration pneumonia. Lancet 348,1421-1424[CrossRef][ISI][Medline]
-
Blitzer, A (1990) Approaches to the patient with aspiration and swallowing disabilities. Dysphagia 5,129-137[CrossRef][Medline]
-
Cannon, CR, McLean, WC (1982) Laryngectomy for chronic aspiration. Am J Otolaryngol 3,145-149[Medline]
-
Lindeman, RC (1975) Diverting the paralyzed larynx: a reversible procedure for intractable aspiration. Laryngoscope 85,157-180[Medline]
-
Mahoney, FT, Barthel, DW (1965) Functional evaluation: Barthel index. MD State Med J 14,61-65[Medline]
-
Zung, WWK (1965) A self-rating depression scale. Arch Gen Psychiatry 12,63-70
-
Lorish, CD, Maisiak, R (1986) The face scale: a brief, nonverbal method for assessing patient mood. Arthritis Rheum 29,906-909[ISI][Medline]
-
Naughton, MJ, Shumaker, SA, Anderson, RT, et al (1996) Psychological aspects of health-related quality of life measurement: test and scales. Spilker, B eds. Quality of life and pharmacoeconomics in clinical trials 2nd ed. ,117-131 Lippincott-Raven Philadelphia, PA.
-
Miller, MD, Ferris, DG (1993) Measurement of subjective phenomena in primary care research: the visual analogue scale. Fam Pract Res J 13,15-24[Medline]
-
Eibling, DE, Snyderman, CH, Eibling, C (1995) Laryngotracheal separation for intractable aspiration: a retrospective review of 34 patients. Laryngoscope 105,83-85[ISI][Medline]
-
Alverdy, J, Chi, HS, Sheldon, GF (1985) The effect of parenteral nutrition on gastrointestinal immunity: the importance of enteral stimulation. Ann Surg 202,681-684[ISI][Medline]
-
Lo, CW, Walker, WA (1989) Changes in the gastrointestinal tract during enteral or parenteral feeding. Nutr Rev 47,193-198[ISI][Medline]
-
Schapiro, GD, Edmundowicz, SA (1996) Complications of percutaneous endoscopic gastrostomy. Gastrointest Endosc Clin N Am 6,409-422[Medline]
-
Eisenberg, P (1991) Pulmonary complications from enteral nutrition. Crit Care Nurs Clin North Am 3,641-649[Medline]
This article has been cited by other articles:
|
|
|
|
 
S. Teramoto, K. Kon, Y. Iwasaki, Y. Takano, O. Sakamoto, M. Suga, and M. Ando
Morale and Depression in Patients Treated Surgically for Intractable Aspiration
Chest,
August 1, 2000;
118(2):
564 - 565.
[Full Text]
[PDF]
|
|
|
TOP
Abstract
Introduction
