Faculty Bibliography

INTRODUCTION: Bronchiectasis is a common chronic pulmonary condition characterized by inflammation and recurrent infections. There is evidence that gastroesophageal reflux disease (GERD) is associated with bronchiectasis and can increase the severity of pulmonary disease. Data regarding esophageal function in this population is sparse. We aimed to assess whether patients with bronchiectasis have an increased prevalence of esophageal motility disturbances and GERD.
METHOD(S): We conducted a single-center matched cohort study of all adult patients with confirmed bronchiectasis who underwent esophageal high-resolution manometry (HRM) between 11/ 2014-3/2018. All cases were randomly matched with a control by age (65 years) and sex. Chicago Classification 3.0 was used to characterize HRM findings. Combined multichannel intraluminal impedance-pH (pH-MII) was utilized to assess reflux burden. Statistical relationships between proportions were evaluated by Chi-square or Fisher's exact test and continuous variables were compared using t-test or rank sum test.
RESULT(S): 63 bronchiectasis patients underwent HRM, of which 54 underwent pH-MII. Of the controls, 63 underwent HRM, of which 39 underwent pH-MII. Baseline characteristics between cases and controls were similar. Mean age of bronchiectasis patients was 65 (SD 12.73), mean body mass index was 25.51 (SD 8.50), 70% were female, and 48% had a smoking history (Table). HRM did not demonstrate any significant differences between cases and controls. pH-MII trended towards a greater reflux burden among controls. However, nearly half of cases had conclusive evidence of pathologic reflux by esophageal acid exposure on pH-MII. On endoscopy, no significant differences were noted.
CONCLUSION(S): Esophageal motility and acid exposure did not significantly differ among patients with bronchiectasis and controls, which may indicate that esophageal physiology in bronchiectasis is not unique. Nevertheless, more than half of the bronchiectasis group had evidence of abnormal esophageal motility and almost half of patients had conclusive evidence of pathologic reflux. Small differences are likely due to the high prevalence of GERD and associated motility disorders in the control group. Larger studies are warranted to further characterize esophageal physiology in these patients and the potential impact on pulmonary pathology. (Table Presented)

Introduction: Non-tuberculous mycobacteria (NTM) is an intracellular microorganism that causes cavitary disease and nodular bronchiectatic disease of the lung. Patients with NTM appear to have impaired swallow function as represented by impaired airway protection and pharyngeal bolus clearance. It is unknown whether impaired swallowing contributes to the pathophysiology of NTM. Our aim is to determine swallow physiology in patients with bronchiectasis and NTM compared with a control group.
Method(s): Video fluoroscopy (VF) was prospectively collected from 195 patients: 132 patients with NTM (90 females; ages 30-90) and 63 agematched and sex-matched controlswith noNTM(39 females; ages 27-92). Two boluses of 3, 5, 10ml thin liquid, two 5ml puree Varibar, and cracker were analyzed per subject (N = 1755 swallows). Outcome measures included ordinal ratings of residue in the valleculae and pyriform sinuses.
Result(s): Inter-and intra-rater reliability of the ordinal ratings were assessed using one-way mixed intraclass correlation coefficients (ICC) (ICC(2,1)) on 20% of the data with good results (intra-rater: ICC = 0.92, 95% range CI 0.70-0.97 and inter-rater: ICC = 0.92, 95% range CI 0.81-0.97). The ratings of residue in the valleculae were significantly higher (worse) in the NTM group compared to the control group for one of the 3mL bolus (p = 0.008), for both 5 mL boluses (p = 0.009 and p = 0.004), both 10mL boluses (p = 0.0005 and p = 0.0006), puree (p = 0.006), cracker (p = 0.005). The ratings of residue in the pyriform sinuses were also significantly higher in the NTM group for 3 mL boluses (p = 0.0002 and p = 0.01), both 5 mL boluses (p = 0.0003 and p = 0.002), both 10mL boluses (p = 0.001 and p = 0.001), both puree trials (p<0.0001 and p<0.0001).
Conclusion(s): Future work is needed to elucidate responsiveness to swallowing treatment for patients with NTM

Purpose: Non-tuberculous mycobacteria (NTM) can cause clinically significant lung disease and frequent pneumonias. It is unknown whether impaired swallowing contributes to the pathophysiology of NTM. Patients with NTM may exhibit decreased airway protection. Our aim is to determine airway protection and bolus clearance in patients with NTM. Method(s): Videofluoroscopy (VF) was prospectively collected from 98 patients with NTM (67 female; ages 33-88). Two boluses of 3,5,10 ml thin liquid, two 5 cc puree Varibar, cracker were analyzed per subject (N = 980 swallows).Outcome measures included Penetration/Aspiration Scale (PAS) and ordinal ratings of residue in the valleculae and pyriform sinuses. Worst PAS scores categorized subject as unsafe (C 3) or safe (B 2). The correlation between clinical information and the present of penetration/aspiration and pharyngeal residue structures was analyzed. Result(s): Inter-and intra-rater reliability of PAS ratings were assessed using two-way mixed intraclass correlation coefficients (ICC) on 20% of the data with excellent results (intra-rater: ICC 0.98, 95% CI 0.95-0.98 and inter-rater: ICC 0.85, 95% CI 0.69-0.92). The proportion of impaired swallows in the whole dataset was 12.9% (127/980 swallows with PAS scores C 3). There was no correlation between presence of penetration/aspiration and pharyngeal residue with productive cough, pneumonia, smoking history and presence of acid reflux. Conclusions (Including Clinical Relevance): Patients with NTM appear to have impaired swallow function as represented by impaired airway protection. Future work should explore swallowing physiology compared to a control group

Purpose/UNASSIGNED:The aim of this study was to investigate improvements in swallowing function and physiology in a series of healthy older adults with radiographically confirmed dysphagia, following completion of an exercise-based swallowing intervention. Patients and methods/UNASSIGNED:Nine otherwise healthy older adults (six females, mean age =75.3, SD =5.3) had confirmed impairments in swallowing safety and/or efficiency on a modified barium swallow study. Each participant completed an 8-week swallowing treatment protocol including effortful swallows, Mendelsohn maneuvers, tongue-hold swallows, supraglottic swallows, Shaker exercises and effortful pitch glides. Treatment sessions were conducted once per week with additional daily home practice. Penetration-Aspiration Scale and the Modified Barium Swallowing Impairment Profile (MBSImP) were scored in a blind and randomized fashion to examine changes to swallowing function and physiology from baseline to post-treatment. Results/UNASSIGNED:There were significant improvements in swallowing physiology as represented by improved oral and pharyngeal composite scores of the MBSImP. Specific components to demonstrate statistical improvement included initiation of the pharyngeal swallow, laryngeal elevation and pharyngeal residue. There was a nonsignificant reduction in median PAS scores. Conclusion/UNASSIGNED:Swallowing physiology can be improved using this standardized high-intensity exercise protocol in healthy adults with evidence of dysphagia. Future research is needed to examine the individual potential of each exercise in isolation and to determine ideal dose and frequency. Studies on various etiological groups are warranted.

Purpose: Despite being widely adopted in clinical practice, the rehabilitative potential of swallowing exercises is not well documented (Langmore & Pisegna, 2015). While collecting a sample of 98 videofluoroscopies (VF) from healthy individuals to serve as a control group for an unrelated study, we discovered 13 subjects with incidental findings of impaired swallowing (safety and/or efficiency deficits). Our purpose was to explore the impact of a standardized 'one-size-fits-all' treatment (tx) protocol on impaired swallowing function in this cohort of otherwise healthy individuals. Method(s): 13 healthy individuals (9 F, mean age = 71.5, SD = 11.9) completed 8 weeks of swallowing exercises. Treatment sessions (once per week) consisted of 20 repetitions of each of the following exercises: effortful swallows, tongue hold swallows, supraglottic swallows, Shaker exercises and Mendelsohn maneuvers, as well as 10 repetitions of effortful pitch glides. Subjects were also asked to complete daily homework consisting of 3 additional treatment sets per day. VF was collected pre-and post-tx with a standardized protocol and scored using the MBSimPTM method. Scores for components 1-5 and 6-16 were combined for an oral total (OT) and pharyngeal total (PT) respectively. Wilcoxon rank sum tests compared OT and PT scores from pre-to post-tx. Result(s): The pre-tx and post-tx OT median scores remained unchanged (4). The median PT score was 10 pre-tx (range 2-14) and reduced to 7 post-tx (range 3-11), though this change narrowly missed statistical significance (Z =-1.99; p = .058). Post-hoc evaluations revealed that 8 subjects demonstrated improved PT scores, 2 worsened, 3 were unchanged and that the greatest changes came from components 6 (initiation of the pharyngeal swallow), 8 (laryngeal elevation), 15 (tongue base retraction) and 16 (pharyngeal residue). Conclusions (Including Clinical Relevance): Our sample of otherwise healthy individuals with VF evidence of impaired swallowing completed a standardized 'one-size-fits-all' approach to dysphagia rehabilitation that is common place in clinical practice. The approach appeared to rehabilitate aspects of swallowing function-especially in the pharyngeal phase-for the majority of subjects. Future research should compare physiologically-targeted exercises with one-size-fits all approaches. Further investigations into dose, frequency and maintenance of exercise interventions will be vital contributions

Purpose: Non-tuberculous mycobacteria (NTM) is an intracellular microorganism that causes cavitary disease and nodular bronchiectatic disease of the lung. Common symptoms include chronic cough, sputum production and frequent pneumonias. Patients with NTM appear to have impaired swallow function as represented by impaired airway protection. Our aim is to determine bolus clearance in patients with NTM compared with a control. Method(s): Videofluoroscopy (VF) was prospectively collected from 195 patients:132 patients with NTM (90 females; ages 30-90) and 63 age-and sex-matched normal controls with normal pulmonary function tests and no pulmonary disease (39 females; ages 27-92).Two boluses of 3, 5, 10 mL thin liquid, two 5 mL puree Varibar, and cracker were analyzed per subject (N = 1,755 swallows).Outcome measures included ordinal ratings of residue in the valleculae and pyriform sinuses. The correlation between clinical information and the present of pharyngeal residue structures was analyzed by Fisher's exact test for categorical variables and Wilcoxon's rank sum test for comparisons of continuous variables between groups. Result(s): Inter-and intra-rater reliability of the ordinal ratings were assessed using two-way random intraclass correlation coefficients (ICC(2,1)) on 20% of the data with good results (intra-rater: ICC = 0.92, 95% CI 0.70-0.97 and inter-rater: ICC = 0.92, 95% CI 0.81-0.97).The ratings of residue in the valleculae were significantly higher in the NTM group compared to the control group for one of the 3 mL bolus (p = 0.008), for 5 mL boluses (p = 0.009 and p = 0.004), 10 mL boluses (p = 0.0005 and p = 0.0006), puree (p = 0.006), cracker (p = 0.005).The ratings of residue in the pyriform sinuses were also significantly higher in the NTM group for 3 mL boluses (p = 0.0002 and p = 0.01), 5 mL boluses (p = 0.0003 and p = 0.002), 10 mL boluses (p = 0.001 and p = 0.001), puree trials (p<0.0001 and p<0.0001).Wilcoxon's rank sum test determined no age difference and Fisher's exact test determined no gender difference between the NTM and control groups. Conclusions (Including Clinical Relevance): Patients with NTM appear to have reduced bolus clearance than healthy individuals with no pulmonary disease, as represented by ratings of residue in the valleculae and pyriform sinuses.Future work is needed to elucidate the interaction between the respiratory-swallowing systems and airway protection and responsiveness to swallowing treatment for patients with NTM

Background: Aspiration is associated with non-tuberculous mycobacterial (NTM) pulmonary disease and airway dysbiosis is associated with increased inflammation. We examined whether NTM disease was associated with a distinct airway microbiota and immune profile.Methods: 297 oral wash and induced sputum samples were collected from 106 participants with respiratory symptoms and imaging abnormalities compatible with NTM. Lower airway samples were obtained in 20 participants undergoing bronchoscopy. 16S rRNA gene and a nested mycobacteriome sequencing approaches characterised microbiota composition. Inflammatory profiles of lower airway samples were also examined.Results: The prevalence of NTM+ cultures was 58%. Few changes were noted in microbiota characteristic or composition in oral wash and sputum samples among groups. Among NTM+ samples, 27% of the lower airway samples were enriched with Mycobacterium A mycobacteriome approach identified Mycobacterium in a greater percentage of samples, including some non-pathogenic strains. In NTM+ lower airway samples, taxa identified as oral commensals were associated with increased inflammatory biomarkers.Conclusions: The 16S rRNA gene sequencing approach is not sensitive in identifying NTM among airway samples which are culture positive. However, associations between lower airway inflammation and microbiota signatures suggest a potential role for these microbes in the inflammatory process in NTM disease.