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Tu1454 Inter-Rater Agreement for Analysis of Pharyngeal High Resolution Manometry Parameters
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comparison. In addition, the pharyngo-esophageal characteristics induced by the infusions were similar across maturation (Table). Conclusions: Unlike that observed in normal maturation of adaptive pharyngeal reflexes, infants with HIE lack improvement in the neuromotor characteristics of pharyngeal stimulus induced adaptive responses despite advanced maturation. Therefore, these patients may not only require cautious oral feeding approaches at follow-up, but also prolonged aerodigestive therapies after discharge so as to maximize their successful feeding transition. *Supported in part by R01 DK 068158 (Jadcherla). Table 1: Pharyngo- esophageal Responses to Pharyngeal Provocation Across Maturation
AGA Abstracts
Inter-Rater Agreement for Analysis of Pharyngeal High Resolution Manometry Parameters Mark Kern, Gokulakrishnan Balasubramanian, Ling Mei, Rachael Manderle, Arash Babaei, Reza Shaker Introduction: Pharyngeal manometry using high resolution technology is a developing field that is being advocated for evaluation of dysphagic symptoms that are not explained by a conclusive or objective finding on routine evaluation such as radiography. Fundamental to the success of this approach, automated analysis techniques not withstanding, is the reliability and reproducibility of the measurements performed by the clinicians. Our aim was to determine the inter-rater reliability for measurements of deglutitive pharyngeal peristaltic pressure wave characteristics such as peak peristaltic amplitude, pharyngeal contractile integral (PCI), nadir upper esophageal sphincter (UES) deglutitive pressure and intrabolus pressure (IBP). Methods: We studied 11 healthy individuals (age 56±25 years, 6F) by high resolution manometry using a catheter with 36 recording sites spaced at 1 cm intervals that recorded from the entire pharyngeal contractile zone, UES and proximal esophagus. Each volunteer swallowed 0.5 ml of room temperature water 40 times with 20 seconds intervals between swallows. Three raters (one seasoned, two with recent training) each independently analyzed a total of 3080 pressure signatures, 440 pharyngeal contractile integrals and 440 intra-bolus pressures. Measured parameters included peak peristaltic wave pressures at specific manometric locations 2, 3, 4, 5, 6, 7, and 8 cm above the upper margin of the UES high pressure zone, as well as PCI, nadir UES deglutitive pressure and IBP. Inter-rater agreement was evaluated using Bland-Altman intra-class correlation coefficient (ICC) analysis. Results: As seen in the table, agreement among the three raters all for all manometric locations was highly significant (p<0.001) with sites p2 and p3 (2 and 3cm above the upper margin of the UES) having the lowest levels of agreement. Furthermore, metrics with a single value for each swallow like PCI and UES nadir pressure also showed highly significant agreement whereas IBP measurements did not. A graphical depiction of intra-rater agreement is shown in the figure for PCI as a representative parameter. Conclusion: Analysis of pharyngeal pressure parameters by individuals with proper training is reproducible as evidenced by high level of agreement between the results obtained independently by three different raters. Supported in part by EOPH grant and PPG. Supported in part by R01DK025731 and P01DK068051
Data presented as mean ± SEM or as % Tu1456 Effect of Postmenstrual Age (PMA) on Pharyngeal and Respiratory Biorhythms in Orally Fed Nicu Neonates Kathryn Hasenstab, Swetha Sitaram, Sudarshan Jadcherla Background: Premature infants frequently experience feeding difficulties, and adaptation of respiratory and pharyngeal biorhythms are critical to feeding success. The effect of gestational and postnatal maturation on respiratory and pharyngeal adaptation at full term status is not known. Aims: To study varying effects of gestational and postnatal maturation on pharyngeal provocation induced respiratory regulation and pharyngeal rhythms in preterm born infants. Methods: 56 preterm infants (33 male) were evaluated between 36-40 wks PMA, utilizing concurrent pharyngo-esophageal motility and respiratory inductance plethysmography methods to evaluate pharyngeal and respiratory responses to graded pharyngeal water stimuli (0.1, 0.3, and 0.5 ml). We measured: 1) prevalence and duration of deglutition apnea, and 2) pharyngeal recruitment, frequency, variability, and stability of initial and composite responses. Initial response was defined as the first pharyngeal burst and composite response was defined as the presence of pharyngeal activity until the terminal swallow restored respiratory normalcy and esophageal quiescence. Comparisons were made between WHO defined categories of extremely preterm (EPT, <28 wks gestational age (GA)), very preterm (VPT, 28 1/7 - 31 6/7 wks GA), and moderate preterm (MPT, 32 1/7- 37 wks GA) using linear mixed and GEE models. Data stated as mean±SEM or %. Results: Responses to 423 pharyngeal stimuli were analyzed (Tables 1, 2). Pharyngeal reflexive swallow occurrence was 74% for EPT, 67% for VPT, and 68% for MPT (p=0.5). Overall, feeding method at evaluation was 23% gavage, and at discharge 100% full oral. Conclusions: Pharyngealrespiratory biorhythms between 36-40 weeks PMA are similarly developed in prematurely born successful oral feeders at discharge. *Supported in part by R01 DK 068158 (Jadcherla) and PPG-P01 DK 068051 (Jadcherla/Shaker) Table 1. Characteristics of stimulus induced respiratory responses
Tu1455 Pharyngeal Stimulus Induced Reflexes Are Impaired in Infants With Hypoxic Ischemic Encephalopathy (HIE) During Maturation Preceousa S. Jensen, Theresa Shubert, Swetha Sitaram, Ish K. Gulati, Sudarshan Jadcherla Background: Survival with aerodigestive morbidity is increasing among neonates with HIE. About 65% of survivors have dysphagia, and abnormal pharyngo-esophageal motility is a common concern. We have previously shown that development of pharyngo-esophageal motility reflexes matures over a period of 2-4 weeks in healthy pre-term neonates (Ped Res, 2014, PMID: 25279989); changes during maturation in infants with HIE is unclear. Interval changes in this prototype are important to rationalize the development of long-term feeding and airway protection strategies and anticipatory guidance. Therefore, we undertook this study to evaluate pharyngeal provocation induced adaptive reflexes in infants with HIE during maturation. Specifically, we evaluated the frequency recruitment and characteristics of Pharyngeal Reflexive Swallow (PRS) and Pharyngo Upper esophageal sphincter contractile reflex (PUCR) in response to graded stimulus. Methods: Infants with HIE (N=8, 6 males, 38.5 ± 0.4 wks gestation) were evaluated longitudinally at 39.5 ± 0.9 wks post menstrual age (PMA) and at 45 ± 0.7 wks PMA using concurrent pharyngeal provocation and high resolution manometry methods. Pharyngo-esophageal responses to graded pharyngeal stimulus (0.1 mL, 0.3 mL, and 0.5 mL saline) are reported. Primary reflex was considered if a response (PRS or PUCR) occurred within 5 sec of the stimulus. Pharyngeal waveform frequency and duration were also evaluated. Contractile front velocity (CFV), the tangential line from the proximal esophagus to the central deceleration point along the 30 mmHg isobaric contour line, was analyzed. Total response duration was defined as the response duration from the onset of infusion to the end of terminal swallow, when aerodigestive quiescence has been restored. Statistical analysis was performed using linear mixed models; t-tests were used for demographic comparisons. Data are presented as mean ± SEM. Results: Overall, there were 64 and 68 infusions analyzable infusions for Time 1 and Time 2, respectively. Threshold volumes (0.1 ± 0.03 mL vs. 0.2 ± 0.03 mL; P= 0.1) and the proportion of primary reflexive responses (PRS:PUCR:None; P= 0.1) were similar upon longitudinal
AGA Abstracts
Data stated as mean±SEM or %, *P<0.05 vs EPT for pairwise comparison Table 2. Characteristics of stimulus induced pharyngeal rhythms
Initial: first pharyngeal burst response, Composite: total pharyngeal response until aerodigestive normalcy, Data stated as mean±SEM, *P<0.05 vs EPT for pairwise comparison
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comparison. In addition, the pharyngo-esophageal characteristics induced by the infusions were similar across maturation (Table). Conclusions: Unlike that observed in normal maturation of adaptive pharyngeal reflexes, infants with HIE lack improvement in the neuromotor characteristics of pharyngeal stimulus induced adaptive responses despite advanced maturation. Therefore, these patients may not only require cautious oral feeding approaches at follow-up, but also prolonged aerodigestive therapies after discharge so as to maximize their successful feeding transition. *Supported in part by R01 DK 068158 (Jadcherla). Table 1: Pharyngo- esophageal Responses to Pharyngeal Provocation Across Maturation
AGA Abstracts
Inter-Rater Agreement for Analysis of Pharyngeal High Resolution Manometry Parameters Mark Kern, Gokulakrishnan Balasubramanian, Ling Mei, Rachael Manderle, Arash Babaei, Reza Shaker Introduction: Pharyngeal manometry using high resolution technology is a developing field that is being advocated for evaluation of dysphagic symptoms that are not explained by a conclusive or objective finding on routine evaluation such as radiography. Fundamental to the success of this approach, automated analysis techniques not withstanding, is the reliability and reproducibility of the measurements performed by the clinicians. Our aim was to determine the inter-rater reliability for measurements of deglutitive pharyngeal peristaltic pressure wave characteristics such as peak peristaltic amplitude, pharyngeal contractile integral (PCI), nadir upper esophageal sphincter (UES) deglutitive pressure and intrabolus pressure (IBP). Methods: We studied 11 healthy individuals (age 56±25 years, 6F) by high resolution manometry using a catheter with 36 recording sites spaced at 1 cm intervals that recorded from the entire pharyngeal contractile zone, UES and proximal esophagus. Each volunteer swallowed 0.5 ml of room temperature water 40 times with 20 seconds intervals between swallows. Three raters (one seasoned, two with recent training) each independently analyzed a total of 3080 pressure signatures, 440 pharyngeal contractile integrals and 440 intra-bolus pressures. Measured parameters included peak peristaltic wave pressures at specific manometric locations 2, 3, 4, 5, 6, 7, and 8 cm above the upper margin of the UES high pressure zone, as well as PCI, nadir UES deglutitive pressure and IBP. Inter-rater agreement was evaluated using Bland-Altman intra-class correlation coefficient (ICC) analysis. Results: As seen in the table, agreement among the three raters all for all manometric locations was highly significant (p<0.001) with sites p2 and p3 (2 and 3cm above the upper margin of the UES) having the lowest levels of agreement. Furthermore, metrics with a single value for each swallow like PCI and UES nadir pressure also showed highly significant agreement whereas IBP measurements did not. A graphical depiction of intra-rater agreement is shown in the figure for PCI as a representative parameter. Conclusion: Analysis of pharyngeal pressure parameters by individuals with proper training is reproducible as evidenced by high level of agreement between the results obtained independently by three different raters. Supported in part by EOPH grant and PPG. Supported in part by R01DK025731 and P01DK068051
Data presented as mean ± SEM or as % Tu1456 Effect of Postmenstrual Age (PMA) on Pharyngeal and Respiratory Biorhythms in Orally Fed Nicu Neonates Kathryn Hasenstab, Swetha Sitaram, Sudarshan Jadcherla Background: Premature infants frequently experience feeding difficulties, and adaptation of respiratory and pharyngeal biorhythms are critical to feeding success. The effect of gestational and postnatal maturation on respiratory and pharyngeal adaptation at full term status is not known. Aims: To study varying effects of gestational and postnatal maturation on pharyngeal provocation induced respiratory regulation and pharyngeal rhythms in preterm born infants. Methods: 56 preterm infants (33 male) were evaluated between 36-40 wks PMA, utilizing concurrent pharyngo-esophageal motility and respiratory inductance plethysmography methods to evaluate pharyngeal and respiratory responses to graded pharyngeal water stimuli (0.1, 0.3, and 0.5 ml). We measured: 1) prevalence and duration of deglutition apnea, and 2) pharyngeal recruitment, frequency, variability, and stability of initial and composite responses. Initial response was defined as the first pharyngeal burst and composite response was defined as the presence of pharyngeal activity until the terminal swallow restored respiratory normalcy and esophageal quiescence. Comparisons were made between WHO defined categories of extremely preterm (EPT, <28 wks gestational age (GA)), very preterm (VPT, 28 1/7 - 31 6/7 wks GA), and moderate preterm (MPT, 32 1/7- 37 wks GA) using linear mixed and GEE models. Data stated as mean±SEM or %. Results: Responses to 423 pharyngeal stimuli were analyzed (Tables 1, 2). Pharyngeal reflexive swallow occurrence was 74% for EPT, 67% for VPT, and 68% for MPT (p=0.5). Overall, feeding method at evaluation was 23% gavage, and at discharge 100% full oral. Conclusions: Pharyngealrespiratory biorhythms between 36-40 weeks PMA are similarly developed in prematurely born successful oral feeders at discharge. *Supported in part by R01 DK 068158 (Jadcherla) and PPG-P01 DK 068051 (Jadcherla/Shaker) Table 1. Characteristics of stimulus induced respiratory responses
Tu1455 Pharyngeal Stimulus Induced Reflexes Are Impaired in Infants With Hypoxic Ischemic Encephalopathy (HIE) During Maturation Preceousa S. Jensen, Theresa Shubert, Swetha Sitaram, Ish K. Gulati, Sudarshan Jadcherla Background: Survival with aerodigestive morbidity is increasing among neonates with HIE. About 65% of survivors have dysphagia, and abnormal pharyngo-esophageal motility is a common concern. We have previously shown that development of pharyngo-esophageal motility reflexes matures over a period of 2-4 weeks in healthy pre-term neonates (Ped Res, 2014, PMID: 25279989); changes during maturation in infants with HIE is unclear. Interval changes in this prototype are important to rationalize the development of long-term feeding and airway protection strategies and anticipatory guidance. Therefore, we undertook this study to evaluate pharyngeal provocation induced adaptive reflexes in infants with HIE during maturation. Specifically, we evaluated the frequency recruitment and characteristics of Pharyngeal Reflexive Swallow (PRS) and Pharyngo Upper esophageal sphincter contractile reflex (PUCR) in response to graded stimulus. Methods: Infants with HIE (N=8, 6 males, 38.5 ± 0.4 wks gestation) were evaluated longitudinally at 39.5 ± 0.9 wks post menstrual age (PMA) and at 45 ± 0.7 wks PMA using concurrent pharyngeal provocation and high resolution manometry methods. Pharyngo-esophageal responses to graded pharyngeal stimulus (0.1 mL, 0.3 mL, and 0.5 mL saline) are reported. Primary reflex was considered if a response (PRS or PUCR) occurred within 5 sec of the stimulus. Pharyngeal waveform frequency and duration were also evaluated. Contractile front velocity (CFV), the tangential line from the proximal esophagus to the central deceleration point along the 30 mmHg isobaric contour line, was analyzed. Total response duration was defined as the response duration from the onset of infusion to the end of terminal swallow, when aerodigestive quiescence has been restored. Statistical analysis was performed using linear mixed models; t-tests were used for demographic comparisons. Data are presented as mean ± SEM. Results: Overall, there were 64 and 68 infusions analyzable infusions for Time 1 and Time 2, respectively. Threshold volumes (0.1 ± 0.03 mL vs. 0.2 ± 0.03 mL; P= 0.1) and the proportion of primary reflexive responses (PRS:PUCR:None; P= 0.1) were similar upon longitudinal
AGA Abstracts
Data stated as mean±SEM or %, *P<0.05 vs EPT for pairwise comparison Table 2. Characteristics of stimulus induced pharyngeal rhythms
Initial: first pharyngeal burst response, Composite: total pharyngeal response until aerodigestive normalcy, Data stated as mean±SEM, *P<0.05 vs EPT for pairwise comparison
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