电视荧光放射录相术对脑卒中后吞咽障碍患者的评估价值

背景：电视荧光放射录相术(video flurography，VFG)可以了解吞咽过程中不同时相的通过时间，有无钡剂残留和误吸，从而了解吞咽障碍的特点，对临床制定治疗计划有一定的参考价值，在国外早已普遍应用。目的：探讨VFG对脑卒中后吞咽障碍患者的评估的价值。设计：非随机、标准对照、开放实验，前瞻性研究。地点和对象：在中国中医研究院广安门医院神经内科病房选择脑卒中后吞咽障碍患者60例。同时向社会招募健康中老年人20例。干预：以上两组由中国中医研究院广安门医院放射科王德文医师行VFG检查。主要观察指标：分别记录两组受试者吞咽稀钡及半胶钡(含钡面糊)过程中的口通过时间和咽通过时间，并评价口、咽功能，记录有无舌肌运动减弱，钡剂残留梨状隐窝、会厌骼，是否误吸人气管。结果：①吞咽障碍组各吞咽时间相通过时间均较健康中老年组延长。②会厌羚钡剂残留在患者中发生率最高，梨状隐窝钡剂残留发生率较高。③脑干病变组各病理征象发生率均高于大脑半球病变组。经统计学处理，脑干病变组与大脑半球病变组误吸发生率差异有显著性意义(P&;lt;0．05)。结论：VFG可以对吞咽全过程特别咽时相的病理征象进行更详细的观察，是脑卒中后吞咽障碍检查的有效方法。     

缺血性脑卒中患者吞咽障碍与病变部位的关系

目的 探讨缺血性脑卒中患者吞咽障碍与病变部位的关系。 方法 选取2015年1月至2022年3月在徐州市中心医院住院治疗的脑梗死患者178例，依据脑梗死的部位，将其分为幕上脑梗死组（幕上组）111例，和幕下脑梗死组（幕下组）67例，幕上组再根据其脑梗死的侧别，分为左侧大脑半球梗死组59例，右侧大脑半球梗死组34例，双侧大脑半球梗死组18例，共3个亚组。对所有入选患者的吞咽造影录像资料进行回顾性分析。所有患者均接受吞咽造影录像检查，对其唇闭合、食团成形、吞咽失用、舌与硬腭接触、食团后漏、口腔运送时间、咽期吞咽启动、会厌谿残留、喉上抬、梨状隐窝滞留、咽后壁残留、咽期通过时间、误吸、渗漏等14项指标进行分析和比较。 结果 幕上组与幕下组患者在食团成型（χ2=5.116，P=0.024）、吞咽失用（χ2=7.928，P=0.005）、口腔运送时间（χ2=14.152，P<0.01）、咽期吞咽启动（χ2=5.558，P=0.018）、喉上抬（χ2=19.424，P<0.01）、误吸（χ2=4.212，P=0.040）等方面，组间差异均有统计学意义（P＜0.05）。左侧大脑半球梗死患者、右侧大脑半球梗死患者和双侧大脑半球梗死患者的误吸发生率（χ2=10.277，P=0.006），组间差异有统计学意义（P＜0.05）；两两比较，双侧大脑半球梗死患者与左侧大脑半球梗死患者在误吸方面，组间差异有统计学意义（P＜0.017）。 结论 幕上脑梗死患者较幕下脑梗死患者更易发生口期吞咽障碍，包括食团成型障碍、吞咽失用及口腔运送时间延长；幕下脑梗死患者较幕上脑梗死患者更易发生咽期吞咽障碍，包括咽期吞咽启动延迟、喉上抬障碍及误吸。双侧大脑半球梗死患者较左侧大脑半球梗死患者更易发生误吸。     

脑卒中急性期吞咽障碍的临床影像评价

目的:探讨脑卒中急性期吞咽障碍的临床及影像学检查的表现,分析脑卒中部位与吞咽障碍发生类型的关系。方法:首次发病的急性脑卒中患者62例,根据不同病变部位分为单侧大脑半球组、双侧大脑半球组、脑干与小脑组及多发性卒中组。入院后3d内完成临床吞咽功能评估;入院7d进行吞咽X线荧光透视检查(VFSS);记录分析吞咽障碍的类型和脑卒中的病变部位。结果:入院3d内临床吞咽评定4组患者中有29例(46.8%)存在吞咽困难,其中脑干及小脑组发生吞咽困难的百分率明显高于其他组(P0.05);于7d时VFSS检测11例能完成,其中单侧大脑半球组3例、双侧大脑半球组2例,多出现口腔期困难;脑干及小脑组2例,多出现咽期困难;多发卒中组4例,口腔期和咽期均受影响。吞咽异常表现类型为唇闭合无力、舌运动减弱、误吸及环咽肌功能不全、吞咽反射延迟、喉上抬差、会厌谷和/或梨状窝滞留、喉渗透等。结论:脑卒中后吞咽障碍的临床评定可明确吞咽口阶段的生理状态,VFSS可明确咽阶段及有无误吸。为避免吞咽困难所致的并发症及预防或治疗吞咽困难,需尽早完成吞咽评定,且可以节省患者总体费用及加快改善预后。     

不同病灶部位脑卒中患者吞咽障碍特点分析

目的 探讨不同病灶部位脑卒中患者吞咽障碍特点。 方法 纳入2015年1月至2016年8月期间在我院治疗且病变局限于单侧大脑或脑干的92例脑卒中患者作为研究对象。根据病变部位分为3组,其中单侧脑干病变29例（纳入单侧脑干组）,左侧半球（皮质+白质）病变37例（纳入左侧半球组）,右侧半球（皮质+白质）病变26例（纳入右侧半球组）。入院后所有患者进行吞咽造影检查,记录并对比各组患者口腔运送、吞咽启动、残留、渗漏、误吸、咳嗽反射及环咽肌开放等指标结果。 结果 3组患者在口腔运送（χ2=0.712,P=0.918）、吞咽启动（χ2=1.564,P=0.458）、渗漏（χ2=5.615,P=0.060）、咳嗽反射（χ2=5.882,P=0.053）方面组间差异均无统计学意义,单侧脑干组在会厌谷、梨状窦残留（χ2=6.508,P=0.011）和误吸（χ2=7.803,P=0.005）方面与左侧半球组间差异具有统计学意义,单侧脑干组在环咽肌开放方面与左侧半球组及右侧半球组间差异均具有统计学意义（χ2分别为29.555和24.630,均P<0.05）。 结论 单侧脑干较单侧大脑半球卒中更容易发生咽期吞咽障碍,主要表现为残留、误吸及环咽肌开放异常等方面,两侧大脑半球卒中后吞咽障碍特点无明显差异。     

吞钡造影在神经源性吞咽障碍评估中的应用

目的:探讨吞钡造影在神经源性吞咽障碍评估中的价值。方法:30例患者分别于康复治疗前和康复治疗后行吞钡造影,观察吞咽的动态过程及其障碍发生的不同时相。结果:吞咽障碍可出现口腔内食物异常滞留、鼻腔逆流、误咽、梨状隐窝食物残留等情况,吞咽康复训练1个月前后比较,上述症状明显改善(P<0.01)。结论:吞钡造影评估神经源性吞咽障碍客观、简便、有效。     

电视透视下吞咽能力检查在口咽期吞咽障碍中的应用

目的 分析吞咽障碍患者电视透视下吞咽能力检查(VFSS)结果.方法 16例知情同意吞咽障碍患者接受VFSS检查.分别采用稀钡餐(50％ w/v)、稠钡餐(270％ w/v)、饼干沾稠钡餐进行咀嚼测试.一口量为10 ml.采用正位、侧位动态造影测试,依次观察双侧梨状窝对称情况、口期时长、咽期起始时间、咽期时长、滞留、误吸及其时间、剂量等.结果5例为口期吞咽障碍;3例为咽期吞咽障碍,显示存在咽期起始迟缓,并且有1例表现为吞咽后误吸;8例为口咽期吞咽障碍,其中5例不伴误吸,3例伴有误吸,其中2例为安静误吸,1例表现为吞咽前误吸,1例表现为吞咽后误吸(梨状窝滞留引起),1例无法判断误吸时间.4例误吸患者中,3例存在钡剂25％以上的重度误吸,1例存在5％的轻度误吸,同时配合吞咽康复治疗.结论VFSS检测可为制订吞咽障碍的康复方案提供参考.     

脑卒中急性期吞咽障碍环咽肌功能的临床及影像学评定

目的：探讨脑卒中急性期吞咽障碍患者环咽肌功能障碍（CPD）的临床及影像学评定,旨在找到有效治疗CPD的依据和方法。方法：首次发病的急性脑卒中患者100例,均在入院24h进行临床吞咽功能评定,入院7d内完成吞咽造影录像检查（VFSS）,以确定患者的吞咽异常模式及客观判断环咽肌功能。结果：100例患者中存在吞咽障碍40例,能完成VFSS 30例,其中环咽肌功能正常24例;存在CPD 6例,其病变部位在脑干及小脑,临床上表现为中重度吞咽障碍,其中口咽期均受损2例,咽期障碍4例。6例中环咽肌打开不能1例,打开不全5例,同一患者可以存在多种吞咽异常模式,包括喉上抬不足、梨状窝较多钡剂残留、喉渗透及误吸。结论：脑卒中后CPD主要发生在脑干的损伤部位,表现为环咽肌打开困难,其发生的机制可能为环咽肌的皮质延髓通道发生退行性变,使之呈现去抑制的后果。CPD对患者生活影响很大,应及时给予相应的康复干预。     

五禽戏—猿提改良动作在咽期吞咽障碍康复中的应用研究

目的:验证猿提动作对于脑卒中和脑外伤后咽期吞咽障碍的治疗效果。方法:将符合纳入标准的38名咽期吞咽障碍患者随机分入研究组和对照组,每组19人,2组均接受常规训练,研究组另外接受猿提改良动作训练,对照组另外采用Shaker训练法、门德尔松手法并结合低头转头法,每周5次,共治疗20次。2组患者治疗前后均分别采用功能性经口摄食量表(FOIS)评级和电视荧光吞咽造影检查(VFSS)进行吞咽功能评定。结果:治疗后,2组的FOIS均明显上升(均P<0.05),2组治疗前后稀钡及稠钡的会厌谷及梨状窝滞留、渗透量、喉上抬、喉前移的距离差异均有统计学意义(均P<0.05),治疗后2组FOIS及VFSS参数比较差异均无统计学意义。结论:五禽戏——猿提改良动作能改善脑卒中和脑外伤后咽期吞咽障碍患者的吞咽功能,且能增加吞咽时喉上抬及喉前移的距离,减少渗透与误吸,并能减少梨状窝滞留。     

脑卒中后吞咽障碍的康复进展

脑卒中后吞咽障碍（ dysphagia oftcr stroke, DAS）是临床常见症状,据统计约37％-74％的急性脑卒中患者存在吞咽功能障碍,其中伴有吞咽障碍的患者吸人性肺炎发生率可增加3倍,而误吸的发生率则可增加到11倍[1]。有国外学者统计,左、右侧大脑半球病变者出现误吸几率分别为12．1％和9．9％,双侧大脑半球病变者出现误吸几率则为39．5％[2]。     

吞钡造影评估30例脑卒中吞咽障碍患者吞咽各期的功能状态

目的观察吞钡造影对脑卒中吞咽障碍患者吞咽各期的功能状态的评估效果。方法选择邢台市第三医院2000-01/2005-02收治的吞咽障碍患者30例,其中,延髓麻痹9例,假性延髓麻痹21例。在胃肠造影机下,按半流食-软食-流食顺序令其吞咽,评估吞钡各期吞咽障碍发生情况。结果30例患者全部完成测试进入结果分析。延髓麻痹吞咽障碍主要在咽喉期,占82%,其中梨状隐窝滞留发生率为100%,误咽发生率为89%;假性延髓麻痹以口腔吞咽障碍为主占77%,其中口唇闭合差占90%,舌运动差占95%,两种麻痹食道期功能障碍均较轻。吞咽食物浓度从易到难依次为:半流食-软食-流食-水。结论吞钡造影可以了解吞咽各期的功能状态,了解吞咽障碍的部位、程度、进食时体位和食物浓度的关系。     

The effect of nasogastric tubes on swallowing function in persons with dysphagia following stroke

OBJECTIVE: To determine whether the use of a nasogastric tube influences swallowing function in stroke patients with dysphagia. DESIGN: Before-after trial. SETTING: Primary care center. PARTICIPANTS: A total of 22 patients with stroke (12 men, 10 women; mean age, 69.7 y; range, 19-85 y) participated in the study. Time from onset of stroke to time of assessment averaged 20.3 days (range, 14-38 d). All participants continued to use a nasogastric tube for nutrition supply and had either minor or no aspiration of barium on videofluoroscopic examination of swallowing (VFES). INTERVENTION: The swallowing function was evaluated by VFES with thin and thick bariums (5 mL each) as a contrast medium. MAIN OUTCOME MEASURES: The oral transit, swallowing trigger, and pharyngeal transit times were measured and compared before and after the removal of the nasogastric tube. The patients were also observed for changes in velopharyngeal closure, pharyngeal contraction, epiglottic tilt, valleculae stasis, pyriform sinus stasis, penetration, and aspiration. RESULTS: Transit times were reduced by 0.2 to 0.6 seconds after removal of the nasogastric tube, but the reduction was not statistically significant. These transit times were slightly longer with thick barium than with thin barium, but were without statistical significance. Similarly, most of the patients had no change in nontemporal assessment of swallowing function after the tube was removed. CONCLUSIONS: The placement of a nasogastric tube did not affect temporal and nontemporal measurement of swallowing in stroke patients with dysphagia with or without minor aspiration.     

Effects of neck exercises on swallowing function of patients with stroke

[Purpose] This study examined the effects of neck exercises using PNF on the swallowing function of stroke patients with dysphasia. [Subjects and Methods] A total of 26 study subjects were selected and randomly divided into an experimental group of 13 subjects, who received the PNF-based short neck flexion exercises, and a control group of 13 subjects, who received the Shaker exercise. [Results] The experimental group showed statistically significant improvements in premature bolus loss, residue in the valleculae, laryngeal elevation, epiglottic closure, residue in the pyriform sinuses, and coating of the pharyngeal wall after swallowing, and improvements in pharyngeal transit time, and aspiration on both the new VFSS scale and the ASHA NOMS scale. [Conclusion] PNF-based short neck flexion exercises appear to be effective at improving swallowing function of stroke patients with dysphagia.Key words: Proprioceptive neuromuscular facilitation, Dysphagia, Stroke     

Dysphagia in patients with brainstem stroke: incidence and outcome

OBJECTIVE: This study was conducted to delineate the incidence and outcome of dysphagia among hospitalized patients who were referred for rehabilitation because of brainstem stroke. DESIGN: We retrospectively reviewed the medical records of 36 patients who were admitted because of brainstem stroke. Information on the patients' clinical features, feeding status, and the results of clinical and videofluoroscopic swallowing examinations were obtained through chart review. Follow-up interviews were conducted via telephone to learn the general medical condition and feeding status of the patients 7-43 mo after hospital discharge. RESULTS: A total of 81% of the patients had dysphagia at the time of initial clinical swallowing evaluation, which was performed 10-75 days after the onset of stroke. A total of 79% of the dysphagic individuals depended on tube feeding at the initial evaluation; 22% of all individuals could not resume oral intake at discharge. Statistical analyses revealed a significant association between poor outcome and disease involving the medulla, the presence of a wet voice during the initial swallowing test, and a delay or absence of the swallowing reflex. The incidence of aspiration pneumonia was 11%. There was a correlation between the detection of aspiration by modified barium meal videofluoroscopy and the development of aspiration pneumonia. Follow-up interviews showed that 88% of the 27 patients who were contacted had resumed full oral intake 4 mo after the onset of stroke. CONCLUSIONS: The incidence of dysphagia was relatively high in our study population. The long-term outcome was favorable.     

Quantifying swallowing function after stroke: A functional dysphagia scale based on videofluoroscopic studies

OBJECTIVE: To develop a sensitive, specific scale for quantifying functional dysphagia in stroke patients, using results obtained from videofluoroscopic swallowing studies. DESIGN: Data collected from a serial oral and pharyngeal videofluoroscopic swallowing study. SETTING: A dysphagia clinic in a department of rehabilitation medicine at a tertiary care university hospital. PARTICIPANTS: One hundred three consecutively admitted stroke patients. INTERVENTIONS: Videoflurorscopy to measure a scale of 11 variables: lip closure score, bolus formation, residue in oral cavity, oral transit time, triggering of pharyngeal swallow, laryngeal elevation and epiglottic closure, nasal penetration, residue in valleculae, coating of pharyngeal wall after swallow, and pharyngeal transit time. MAIN OUTCOME MEASURES: Polychotomous linear logistic regression analysis of videofluoroscopic and aspiration results. Scale sensitivity and specificity, and the correlation between the total score of the scale and aspiration grade were analyzed. RESULTS: The scale's sensitivity and specificity for detecting supraglottic penetration and subglottic aspiration were 81%, 70.7%, and 78.1%, 77.9%, respectively. A significant positive correlation was found between the scale's total score and the severity of aspiration (Spearman's r =.58943, p =.00001). CONCLUSION: This functional dysphagia scale, which was based on a videofluoroscopic swallowing study in stroke patients, is a sensitive and specific method for quantifying the severity of dysphagia.     

不同稠度和容积吞咽任务对卒中后吞咽障碍患者吞咽生理成分表现及渗漏误吸的影响

目的 探讨不同稠度和容积吞咽任务对卒中后吞咽障碍患者吞咽生理成分表现及渗漏误吸的影响。 方法 选取在我院康复科治疗的59例脑卒中后吞咽障碍患者作为研究对象,参照中国改良容积粘度测试程序,按2、1、0、3号（分别对应中稠度、低稠度、硫酸钦原液及高稠度）顺序分别对每种稠度食物进行3、5、10 ml的吞咽造影检查。使用标准化吞钡造影功能障碍评价量表（MBSImP）和Rosenbek渗漏/误吸量表进行量化分析。记录患者在执行不同稠度及容积吞咽任务时其各个吞咽生理成分评分和渗漏误吸分级。 结果 入选患者舌控制、咽期吞咽启动及喉关闭均在吞咽0号食物时表现较差,口腔残留在执行大容积吞咽任务时表现较差,咽蠕动在执行较小容积吞咽任务时表现较差。入选患者在执行低稠度、大容积吞咽任务时发生渗漏误吸的风险较高;其渗漏误吸分级与咽期总分间具有明显正相关性（r=0.365,P<0.01）,并以喉关闭与渗漏误吸分级间的相关性尤为显著（r=0.772,P<0.01）。 结论 脑卒中吞咽障碍患者口咽期各吞咽生理成分的表现与进食食物稠度及容积密切相关,患者在执行较低稠度、较大容积吞咽任务时发生渗漏误吸的风险较高。     

高龄脑卒中吞咽障碍患者误吸的影响因素分析

目的分析高龄脑卒中吞咽障碍患者误吸的影响因素,为制定防护策略,降低该类患者误吸提供依据。方法选取医院2019年4月—2020年4月住院的高龄脑卒中吞咽障碍患者111例,对患者的性别、年龄、既往病史、鼻胃管进食、口腔运送时间、镇静药物或抗精神病药物、神志、是否合并多种高龄慢性疾病、进食卧位、是否有人工气道等数据进行统计学分析,筛选高龄脑卒中吞咽障碍患者误吸的影响因素。结果单因素分析显示,年龄≥75岁、气管切开与机械通气、仰卧位、进食过快、口腔运送时间大于1.5 s、咽启动延迟、会厌谷残留是影响高龄脑卒中吞咽障碍患者误吸的影响因素(P<0.05)。多因素Logistic回归分析显示,年龄≥75岁、气管切开与机械通气、仰卧位、口腔运送时间大于1.5 s是高龄脑卒中吞咽障碍患者的影响因素(P<0.05)。结论高龄吞咽障碍的误吸发生率较高,护理人员需加强对上述高危因素的识别与防护,及时消除高危因素,降低误吸发生风险。     

Dysphagia in stroke: Development of a standard method to examine swallowing recovery

This study began development of a standard method that uses the videofluoroscopic swallow study for evaluation of swallowing recovery after stroke based on a definition of dysphagia derived from three domains: bolus timing, bolus direction, and bolus clearance. Two experiments were conducted: one that defined normal versus disordered swallowing based on the range of scores in a sample of healthy adults (n = 13), and one that applied these thresholds to nine stroke patients to identify the presence of dysphagia. Results indicate that acute and protracted dysphagia may be more accurately detected by identifying abnormalities on multiple objective measures of swallowing rather than on laryngeal penetration or aspiration alone. Results indicate that our selected measures and use of healthy control subjects to establish normal thresholds may eventually contribute to the definition and differentiation of dysphagic and nondysphagic patients. Further research with a broader sample of healthy controls and stroke patients is mandatory.     

脑梗死后认知-情感、感觉缺损对吞咽功能恢复的影响

目的：探讨认知功能缺损、感觉障碍对脑梗死伴吞咽功能障碍并进行吞咽功能训练的患者吞咽功能恢复的影响.方法：34例脑梗死并发摄食-吞咽功能障碍患者,根据MMSE认知功能评定将患者分为吞咽功能障碍合并认知功能缺损组16例（A组）,单纯吞咽功能障碍组18（B组）.B组患者给予吞咽功能训练并行针灸治疗,A组在B组治疗方法的基础上进行认知功能的评定、训练和心理疏导.结果：治疗前洼田氏评分A组与B组比较差异有显著性意义（P＜0.05）,1个月后两组吞咽评定与自身治疗前相比差异有显著性意义（P＜0.05）,但两组间洼田氏评分比较差异无显著性意义（P＞0.05）.治疗前A组的颜面失用/流涎、失语、口腔感觉程度与B组相比差异有显著性意义（P＜0.05）;A组在认知功能训练后MMSE评定与自身治疗前相比有明显提高（P＜0.05）,治疗前后认知功能评分与吞咽障碍等级均呈负相关（相关系数分别为：-0.650和-0.51）.结论：脑梗死后认知功能缺损的存在可加重吞咽功能障碍的程度,认知功能的改善可促进吞咽功能的恢复.     

Training in swallowing prevents aspiration pneumonia in stroke patients with dysphagia

This study investigated the frequency of aspiration pneumonia in conscious stroke patients fed by a family member and examined the effect of introducing training in swallowing techniques by nurses. A total of 96 consecutive patients presenting with dysphagia due to acute stroke were included in the study. Patients presenting between January 2000 and July 2003 (n = 48) were fed orally by a family member given general nursing information (group A), whereas those presenting between August 2003 and March 2005 (n = 48) were fed orally by an experienced nurse trained in specific swallowing techniques (group B). All patients were examined daily for the presence of aspiration pneumonia. The incidence of aspiration pneumonia was 33.3% in group A and 6.3% in group B (P < 0.05). The incidence of aspiration pneumonia in dysphagic stroke patients who are orally fed is still high. Training in swallowing during oral feeding offers clear protection against pneumonia in conscious stroke patients.