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The Tokyo University Hospital, Tokyo, Japan Yokohama City University Medical Center, Yokohama, Japan
Correspondence to: Shinji Teramoto, MD, Department of Geriatric Medicine, The Tokyo University Hospital, Tokyo, 7-3-1 Honho Bunkyo-ku, Tokyo 113-8655, Japan; e-mail: shinjit-tky{at}umin.ac.jp
To the Editor:
Paul E. Marik and Danielle Kaplan (July 2003)1 have comprehensively summarized the cause and treatment of aspiration pneumonia and dysphagia in the elderly. Owing to the increasing number of the aged population, many pulmonologists and geriatricians recognize that silent aspiration might be very important for the pathogenesis of aspiration pneumonia and nosocomial pneumonia in older patients.2 3 Thus, the current review article1 is very important and useful to understand the diagnosis, assessment, and management of aspiration pneumonia in the elderly. Marik and Kaplan1 suggest that elderly patients with clinical signs suggestive of dysphagia and/or who have community-acquired pneumonia should be referred for a swallow evaluation. This is very true for assessment of factors that increase the risk of pneumonia in patients who aspirate. However, the conventional clinical assessment of swallowing function is not efficient to detect the risk of aspiration pneumonia.
Because aspiration is a fairly common event for critically ill patients receiving enteral tube feeding, progression to aspiration pneumonia is difficult to predict due to variation in host factors and characteristics of the aspirate material.4
5
Aspiration of oropharyngeal secretions is of equal if not greater importance than aspiration of gastric contents. Monitors for aspiration such as glucose oxidase, blue food coloring, and gastric residual volumes are insensitive and unreliable. A number of clinical risk factors cannot be fully identified at the bedside. Although the videofluoroscopic swallow assessment (VFSS) is the most commonly utilized instrumental assessment tool in the clinical setting to determine the nature and extent of the swallow disorder, this method may be too sensitive for detection of swallowing disorders in the elderly. Because the age-dependent retraction of the larynx, age-dependent muscle weakness, and decreased volume of salivary secretion with age dependently or independently affect the impaired swallowing function, the perfect swallowing function is rarely found by the VFSS in the old persons aged 
80 years old.
We have reported,6 7 8 9 10 however, clinically applicable methods for the assessment of the risk of aspiration pneumonia in the elderly: the swallowing provocation test (SPT) and the simple SPT (S-SPT). These methods are very useful to differentiate the patients with or without stroke who are predisposed to aspiration. Twenty-six stroke patients with aspiration pneumonia (mean age, 72.1 ± 4.1 years [± SD]) and 26 age-matched stroke patients without aspiration pneumonia (mean age, 69.4 ± 3.9 years) were tested, The normal response to SPT was determined by inducing swallowing reflex within 3 s after 0.4 mL or 2 mL of distilled water injection into the suprapharynx. In the water swallowing test (WST), subjects drank quantities of 10 mL and 30 mL of water from a cup within 10 s. The subject who drank water without interruption—without evidence of aspiration—was determined to be normal. The sensitivity and specificity of first-step SPT using 0.4 mL of water for the detection of aspiration pneumonia were 100% and 83.8%, respectively. Those of the second-step SPT using 2 mL of water were 76.4% and 100%, respectively. The sensitivity and specificity of first-step WST using 10 mL of water for the detection of aspiration pneumonia were 71.4% and 70.8%, respectively. Those of the second-step WST using 30 mL of water were 72% and 70.3%, respectively.8 The S-SPT is more useful than the WST in differentiating patients predisposed to aspiration pneumonia, with high sensitivity and specificity. While the cooperation of the patient is needed for the WST and VFSS, the S-SPT does not necessarily require the patient’s cooperation. Furthermore, the test was reproducible by other investigators.11 12 13
Clinically detectable aspiration is associated with increased morbidity. Since silent aspiration remains a major difficulty, and patients with swallowing disorders are at a risk of aspiration, the SPT and S-SPT are useful and widely applicable methods for the assessment of aspiration pneumonia in the frail elderly.
References
This article has been cited by other articles:
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  S. Teramoto, T. Ishii, H. Yamamoto, Y. Yamaguchi, and Y. Ouchi Nasogastric tube feeding is a cause of aspiration pneumonia in ventilated patients Eur. Respir. J., February 1, 2006; 27(2): 436 - 437. [Full Text] [PDF]
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S. Teramoto, T. Ishii, H. Yamamoto, Y. Yamaguchi, R. Namba, Y. Hanaoka, M. Takizawa, T. Okada, M. Ishii, and Y. Ouchi Significance of chronic cough as a defence mechanism or a symptom in elderly patients with aspiration and aspiration pneumonia Eur. Respir. J., January 1, 2005; 25(1): 210 - 211. [Full Text] [PDF]
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