Dysphagia

https://doi.org/10.1007/s00455-018-9894-7 (0123456789().,-volV)(0123456789().,-volV)

ORIGINAL ARTICLE

Effect of Nasogastric Tube on Aspiration Risk: Results from 147

Patients with Dysphagia and Literature Review
Gowun Kim1 • Sora Baek1 • Hee-won Park1,2 • Eun Kyoung Kang1 • Gyuhyun Lee1

Received: 16 January 2017 / Accepted: 29 March 2018

 Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Nasogastric tube (NGT) is a common feeding strategy for patients at risk of endotracheal aspiration with an oral diet. With
NGT feeding, however, swallowing of small amounts saliva cannot be avoided. We investigated whether the aspiration rate
when swallowing 1 mL of fluid increased in patients using an NGT in different dysphagia severities. One hundred forty-
seven patients who had been receiving NGT feeding underwent a videofluoroscopic swallowing study (VFSS). During
VFSS, subjects were offered 1 mL of fluid twice: initially, with the tube inserted (NGT-in) and, subsequently, with the tube
removed (NGT-out). Aspiration depth was determined using the 8-point Penetration–Aspiration Scale (PAS) (0 points, no
aspiration/penetration; 8 points, aspiration passing the vocal cords with no ejection efforts). PAS-diff was computed
(PASNGT-in - PASNGT-out), and a positive PAS-diff (PAS-diff [ 0) meant increased aspiration depth in the presence of
NGT. After VFSS, diet recommendations were made according to dysphagia severity assessment: non-oral feeding
(n = 59), diet modification (n = 74), and diet as tolerated (n = 13). Cognitive level (mini-mental state examination,
MMSE) and general functional level (Modified Barthel Index, MBI) were compared between the PAS-diff [ 0 and PAS-
diff B 0 groups. Aspiration severity did not significantly change after NGT removal (PASNGT-in, 2.45 ± 2.40; PASNGT-out,
2.57 ± 2.58; P = .50). Regardless of recommended diet, PAS-diff values were not significantly different (P = .49). MMSE
and MBI were not significantly different (P = .23 and .94) between subjects with PAS-diff [ 0 (n = 25) and PAS-diff B 0
(n = 121). In conclusion, the risk of aspirating a small amount of fluid was not significantly different before and after NGT
removal, regardless of swallowing function, cognitive level, or general functional level.

Keywords Deglutition
Deglutition disorder
Nasogastric tube
Aspiration
Rehabilitation

Introduction feeding purposes [3]. NGT is frequently used to improve

Nasogastric tube (NGT) is widely used for enteral feeding
access because it is simple and inexpensive [1]. An esti-
mated 271,000 NGTs were used annually in the United
Kingdom alone [2]. NGTs vary in bore size, from small
bore (8-12Fr) to large bore (C 14Fr) [1], and large bore
NGTs can be used more often than small bore NGTs for
& Sora Baek
sora.baek@kangwon.ac.kr
1
Department of Rehabilitation Medicine, Kangwon National
University Hospital, Kangwon National University School of
Medicine, Baengnyeong-ro 156, Chuncheon,
Gangwon 24289, South Korea
2
Gangwon-do Rehabilitation Hospital, Chuncheon, South
Korea
nutritional intake for patients with impaired mental status
or patients with inadequate oral intake [1, 3]. It is also used
for patients with dysphagia for oropharyngeal bypass
feeding to avoid endotracheal aspiration during oral feed-
ing and secondary pulmonary complications such as aspi-
ration pneumonia in patients [3].
Pneumonia is related to prolonged hospital stay and
increased mortality. According to mortality reports in the
United States, pneumonitis due to aspirated solids and
liquids is one of the leading causes of death [4]. For
patients with dysphagia, prevention of aspiration pneu-
monia is one of the therapeutic goals, and NGTs are often
placed to prevent aspiration pneumonia [3]. The role of
NGT, however, seems to be limited in its protective effects
against aspiration pneumonia. The incidence of aspiration
pneumonia is still high in patients fed by NGT [5]. In 100

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 Effect of Nasogastric Tube on Aspiration Risk: Results from 147 Patients with Dysphagia and…

patients with stroke, 40% of patients fed by NGT devel-

oped aspiration pneumonia [6].
Several mechanisms have been suggested for the rela-
tively high pneumonia incidence in patients with NGT
feeding. NGT occupies some space in the nasopharynx,
oropharynx, and hypopharynx and may interfere with
pharyngeal swallowing in both healthy individuals and
those with dysphagia. In normal subjects, the presence of
NGT is associated with temporal slowing, delayed initia-
tion of maximal hyolaryngeal excursion, or a longer
duration of upper esophageal sphincter opening and total
swallowing [7, 8].
In previous studies of subjects with impaired swallow-
ing function, the presence of NGT in the pharynx did not
result in changes in aspiration rate. However, the severity
of impaired swallowing function was not considered in the
analysis of the effect of NGT. Severe dysphagia could
compromise the swallowing to a greater degree than less
severe.
We aimed to investigate whether the aspiration risk
would increase with an NGT inserted compared to
removed when swallowing a small amount of fluid, and to Fig. 1 Inclusion flow diagram
determine the effect of NGT on swallowing function in
patients with different severities of dysphagia.

Materials and Methods

Subjects

We retrospectively reviewed the medical records of 591

patients who presented to the Department of Rehabilitation
Medicine at Kangwon National University Hospital for
videofluoroscopic swallowing study (VFSS) for suspected
swallowing difficulties from January 2014 to June 2015.
Among the 591 patients, 221 patients were receiving NGT
feeding. Sixty-five patients were excluded because NGT
had been removed at the ward just before VFSS. Nine
Fig. 2 Nasogastric tube inserted state
patients failed to complete the study after tube removal.
Finally, 147 patients were included in the final analysis,
permits assessment of the potential benefits of compen-
and their medical records were retrospectively reviewed
satory and treatment strategies [9]. The VFSS was per-
(Fig. 1). We did not insert an NGT for the purpose of the
formed to patients in their upright sitting posture by a
study. Only subjects with an NGT inserted before the study
doctor in a fluoroscopy room. Patients arrived at the fluo-
were tested. This study protocol was approved by our
roscopy room with an NGT inserted. The NGT was a 16-Fr
institutional review board. Age, sex, and underlying dis-
all-silicone tube (Levin tube, Sewoon Medical Co., Ltd.,
ease were reviewed.
Cheonan, Korea) in 116 subjects who had the NGT inserted
in our hospital. The size of the NGT was not recorded in 31
Evaluation of Severity of Dysphagia
patients that had their NGTs inserted in other hospitals, but
most NGTs were inserted for the purpose of feeding, and
VFSS was used to assess swallowing function. It permits
thus the size would be 16-Fr in most cases.
collection of detailed information regarding the structure
Swallowing of 1 mL thin fluid was evaluated as a part of
and function of the oropharynx, pharynx, and larynx as
the standard clinical evaluation of VFSS at our hospital. To
well as the upper esophageal swallowing complex. It also

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Effect of Nasogastric Tube on Aspiration Risk: Results from 147 Patients with Dysphagia and…

evaluate the effect of NGT on swallowing function,
patients were evaluated while swallowing 1 mL of thin
fluid with the NGT in place (NGT-in) (Fig. 2). Then the
NGT was removed, and the swallowing of 1 mL of fluid
was re-evaluated (NGT-out). The thin fluid was offered to
the subjects in a spoon.
After completion of the 1 mL fluid tests, patients sub-
sequently attempted to swallow barium-impregnated
boluses of different volumes and consistencies with the
NGT removed: 2 mL thin fluid, 5 mL thin fluid, yogurt,
pudding, solids, and thick liquid. The fluoroscopic images
of the studies were recorded as a video file. For the thin
fluid test, diluted barium fluid was prepared as 43% weight/
volume barium sulfate (Solotop sol 130, Tae Joon Phar-
maceutical, Seoul, Korea). Chest radiographs were taken
after the study and reviewed to look for aspiration.
After VFSS, the dysphagia severity was assessed, and a
decision about the proper diet for each patient was made
based on it: tube feeding, diet modification, or diet as
tolerated. Tube feeding was recommended for patients
with severe dysphagia. Diet modification using viscosity
change was recommended in patients with moderate dys-
phagia. Diet as tolerated was recommended in patients
without evidence of aspiration or penetration during VFSS.
Cognitive Function and General Function
To assess the patients’ cognitive function, the Korean
version of the Mini-Mental State Examination (MMSE-K)
was used [11]. The Korean version of the Modified Barthel
Index (K-MBI) was reviewed to assess the patients’ general
function and ability to perform activities of daily living
[12]. Among the 147 patients, MMSE-K and K-MBI were
investigated in 135 and 125 subjects, respectively.
Statistics
SPSS for Windows, version 21.0 (IBM Corp., Armonk,
NY) was used for statistical analysis. Wilcoxon signed rank
test and Friedman test analyses were used to compare PAS
between the NGT-in and NGT-out states. PAS-diff was
calculated from the difference of PAS in NGT-in and
NGT-out. The PAS-diff value was analyzed according to
the types of recommended diet after VFSS using analysis
of variance. Chi square and t test were used to compare the
baseline characteristics, MMSE-K, and K-MBI between
the PAS-diff [ 0 and PAS-diff B 0 groups.

Penetration–Aspiration Scale in 1 mL Tests

The aspiration/penetration status on the video clip was

reviewed by 2 medical doctors who are experienced in
VFSS. The aspiration severity in both NGT-in and NGT-
out patients was assessed using the 8-point penetration– Table 1 Basic characteristics of subjects (N = 147)
aspiration scale (PAS). PAS was determined by the depth Variable
of material invasion to the airway and by whether or not
material entering the airway was expelled. A higher value Sex, N (%)
indicates more severe aspiration: 0 points, no aspiration/ Men 90 (61.2)
penetration; 8 points, aspiration passing the vocal cords Women 57 (38.8)
with no ejection efforts [10]. Aspiration depths in the 1 mL Age, mean (SD), years 74.2 (9.2)
fluid tests for both NGT-in and NGT-out were compared Cause of dysphagia, N (%)
between subjects with the 3 different recommended diets. Stroke 96 (65.3)
The difference in PAS between the NGT-in and NGT- Hemorrhage 35 (36.4)
out state (PAS-diff = PASNGT-in - PASNGT-out) was cal- Infarction 61 (63.5)
culated. Positive PAS-diff (PAS-diff [ 0) represents the Traumatic brain injury 13 (8.8)
increase in aspiration depth in the presence of NGT. PAS- Parkinson disease 15 (10.2)
diff was compared between subjects with 3 different rec- Dementia 8 (5.4)
ommended diets to determine the effect of NGT on swal- Cervical spine operation 4 (2.7)
lowing function in patients with different severities of Myopathy 1 (0.7)
dysphagia. Then, patients were divided into two groups, Hypoglycemic encephalopathy 1 (0.7)
PAS-diff [ 0 and PAS-diff B 0, to evaluate any differ- Uremic encephalopathy 1 (0.7)
ences in demographic characteristics, severity of dyspha- Viral encephalitis 1 (0.7)
gia, cognitive level, and general functional level between Recurrent laryngeal nerve injury 1 (0.7)
groups. Patients with PAS-diff [ 0 were considered to Unknown 6 (4.1)
have compromised swallowing function in the presence of
SD standard deviation
NGT.

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 Effect of Nasogastric Tube on Aspiration Risk: Results from 147 Patients with Dysphagia and…

Results Discussion

The demographic characteristics and causes of dysphagia
of the 147 patients are summarized in Table 1. The mean
(standard deviation, SD) age was 74.2 (9.2) years, 90
patients were men, and 57 patients were women. The most
common causes of dysphagia were stroke (n = 96, 65.8%),
Parkinson disease (n = 15, 10.2%), and traumatic brain
injury (n = 13, 8.8%). Diet recommendations were deter-
mined based on dysphagia severity as assessed by VFSS:
tube feeding for 59 patients, diet modification for 75
patients, and diet as tolerated for 13 patients.
Mean (SD) PAS values in the NGT-in and NGT-out
states were 2.5 (2.40) and 2.6 (2.58) and were not statis-
tically different (P = .50) (Table 2). The mean (SD) value
of PAS-diff was - 0.1 (2.53). PAS values between rec-
ommended diet groups were significantly different in NGT-
in (P \ .01) and NGT-out (P \ .01) states and were
highest in patients who were recommended to continue
non-oral feeding (Table 3). Mean (SD) values of PAS-diff
were - 0.4 (2.79), 0.0 (2.47), and 0.3 (1.11) in patients
recommended to have tube feeding, diet modification, and
diet as tolerated, respectively, and were not statistically
different between the 3 recommended diet groups
(P = .49).
The basic characteristics of the PAS-diff [ 0) and PAS-
diff B 0 groups are summarized in Table 4. There was no
difference in sex, age, or recommended diet between the
two groups (P = .45). MMSE-K and K-MBI were not
significantly different between the 2 groups (P = .23 and
.94, respectively) (Table 5).
We attempted to investigate whether the presence of NGT
would increase the aspiration risk when swallowing a small
volume, mimicking normal saliva swallowing. In this
study, the risk of aspirating a small amount of fluid was not
significantly different before and after NGT removal,
regardless of swallowing function, cognitive level, or
general functional level.
In many cases, NGT is used for nutrition and prevention
of pneumonia in patients with dysphagia. However, NGT
feeding has not been shown to reduce the risk of aspiration
or pneumonia in many studies [5, 13]. Some researchers
suspect that the oropharyngeal swallowing mechanism
would be disturbed by the NGT in the pharynx and has
been suggested that NGTs are related to gastrointestinal
complications and local irritation [14]. There are normally
produced secretions in the oropharyngeal space [15].
Swallowing of saliva and/or regurgitated gastric contents
occurs continuously during NGT feeding, which could be
related with aspiration pneumonia with NGT-fed patients.
The volume of daily secretions in the subglottic space
was 10–15 mL in patients receiving mechanical ventilation
[16]. The major source of subglottic secretions is saliva.
The amount of saliva in the oral space is about 1 mL, and
the volume of a single swallow is about 0.3 mL [17]. For
patients with stroke, the saliva flow rate (0.09 ± 0.05 mL/
min) was less than in the normal group (0.73 ± 0.37 mL/
min) [18]. Besides salivary secretions, gastric contents are
another source of aspiration. In patients with NGT, the
chance of gastroesophageal reflux of the gastric contents
could be increased compared to that in patients without
NGT [19, 20]. On a pepsin immunoassay analysis, at least
one tracheal secretion was pepsin positive in 88.9%
(n = 320) of the subjects who were tube-fed and mechan-
ically ventilated [21].

Table 2 The 8-grade penetration–aspiration scale before and after nasogastric tube removal (NGT-in and NGT-out) (N = 147)
NGT-in NGT-out P

PAS, mean (SD) 2.5 (2.40) 2.6 (2.58) .50

PAS scale, N (%)
1 Material does not enter the airway 95 (64.6) 96 (65.3) .50
2 Material enters the airway, remains above the vocal folds, and is ejected from the airway 9 (6.1) 7 (4.8)
3 Material enters the airway, remains above the vocal folds, and is not ejected from the airway 10 (6.8) 8 (5.4)
4 Material enters the airway, contacts the vocal folds, and is ejected from the airway 4 (2.7) 4 (2.7)
5 Material enters the airway, contacts the vocal folds, and is not ejected from the airway 10 (6.8) 9 (6.1)
6 Material enters the airway, passes below the vocal folds, and is ejected into the larynx or out of the airway 0 (0.0) 0 (0.0)
7 Material enters the airway, passes below the vocal folds, and is not ejected from the trachea despite effort 3 (2.0) 1 (0.7)
8 Material enters the airway, passes below the vocal folds, and no effort is made to eject 16 (10.9) 22 (15.0)
NGT Nasogastric tube, PAS penetration–aspiration scale, SD standard deviation

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Effect of Nasogastric Tube on Aspiration Risk: Results from 147 Patients with Dysphagia and…

Table 3 PAS-diff according to type of diet recommendation after videofluoroscopic swallowing study
Recommended Subjects, N (%) PASNGT-in, mean P PASNGT-out, mean P PAS-diff, mean F P
diet (SD) (SD) (SD)

Non-oral feeding 59 (40.1) 3.4 (2.74) \ .001 3.8 (2.95) \ .001 -0.4 (2.79) 0.715 .491
Diet modification 77 (52.4) 1.9 (1.98) 1.9 (2.03) 0.0 (2.47)
Diet as tolerated 11 (7.5) 1.3 (1.11) 1.0 (0.00) 0.3 (1.11)
PAS Penetration–aspiration scale, SD standard deviation

Table 4 Baseline characteristics

PAS-diff [ 0 group PAS-diff B 0 group P
of subjects in the PAS-diff [ 0
group (N = 25) and the PAS- Sex, N (%)
diff B 0 group (N = 122)
Men 14 (56.0) 76 (62.3) .705
Women 11 (44.0) 46 (37.7)
Age, [mean (SD), years] 73.6 (7.40) 74.4 (9.54) .559
Recommended diet, N (%)
Non-oral feeding 11 (44.0) 48 (39.3) .449
Diet modification 13 (52.0) 62 (50.8)
Diet as tolerated 1 (4.0) 12 (9.8)
PAS Penetration–aspiration scale, SD standard deviation

Table 5 MMSE-K and K-MBI

PAS-diff [ 0 PAS-diff B 0 t P
in patients in the PAS-diff [ 0
group (N = 25) and PAS- MMSE-K, mean (SD) 16.7 (8.71) 14.4 (8.57) -1.200 .232
diff B 0 group (N = 122)
K-MBI, mean (SD) 23.0 (17.41) 22.6 (22.48) -0.077 .939
MMSE-K Korean version of mini-mental state examination, K-MBI Korean Version of Modified Barthel
Index, PAS penetration–aspiration scale, SD standard deviation

Some of the temporal components of swallowing were
changed in the presence of NGT. Robbins et al. reported
the effect using a manometry tube in swallowing 2 mL of
liquid barium and 2 cm3 of semi-solid barium in normal
subjects [7]. In the manometry tube-in condition, the velar
duration was shorter, and durations of hyoid maximum
elevation, hyoid maximum anterior excursion, and upper
esophageal sphincter opening were longer than the tube out
state. However, there was no aspiration in any subjects. A
similar trend was seen in studies using NGT. The report by
Huggins et al. revealed that pharyngeal transit time was
prolonged with NGT in normal subjects, but there was no
aspiration [8]. There was also prolonged transit time during
NGT-in for patients with stroke, but the difference was not
statistically significant [22]. However, there were no
obvious changes in pharyngeal clearance or airway pro-
tection in normal subjects [8].
Several previous studies have investigated the effect of
NGT on the swallowing mechanism and aspiration
(Table 6) [7, 8, 22–24]. Four of five papers we reviewed
used NGT, and one study used manometry. A manometry
catheter was guided through the patient’s nose into the
esophagus and positioned in a similar location to the NGT.
The size of the tube, the amount of food studied, and the
subjects varied. In the 4 previous studies using NGTs, 16 Fr
tubes were used in one study, and the other 3 studies used 2
tubes with different bore sizes. Most studies evaluated the
effects of diet with a volume of 5 mL, and only one study
tested a 2 mL volume. In 22 stroke patients with minor or
no aspiration, NGT placement did not affect temporal and
non-temporal components of 5 mL fluid swallowing [22].
There were similar trends in 2 other studies on subjects
who were referred for dysphagia evaluation. In both stud-
ies, NGTs did not affect the aspiration status of 5 mL of
fluid or purees [23, 24]. Like previous studies, our results
demonstrated that the aspiration risk for 1 mL of fluid was
not significantly different with or without NGT. We used
PAS to grade the depth of aspiration. There was no sta-
tistical difference in PAS values when swallowing 1 mL of
fluid when comparing NGT-in and NGT-out states and
reaffirmed the previous results that there is no significant
impact of NGT on aspiration risk [22–24].

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 Effect of Nasogastric Tube on Aspiration Risk: Results from 147 Patients with Dysphagia and…

Table 6 Review of literature

Type of Size of Subjects No. of Design Swallowing Studied diets Main changes in Reference
tube tubes subjects (sequence of function of presence of NG tube
tube in and subjects
out)

Manometry NR Normal 80 In/out Normal 2 mL liquid Slowed swallowing Robbins

barium and [7]
2 cm3 semi-
solid barium
NGT 8 Fr and Normal 10 In (8 Fr)/in Normal 5 mL of 96% (w/ Slowed swallowing Huggins
16 Fr (16 Fr)/out v) barium [8]
sulfate
NGT 16 Fr Stroke patients 22 In/out Minor or no 5 mL of thin and No significant changes Wang
aspiration of thick barium in temporal and non- [22]
barium on temporal
VFSS measurements
NGT Group Patients 630 Group 1: in NR 5 mL of thin No change in aspiration Leder
1: 8 Fr referred for (Group Group 2: out liquid and status [24]
or 18 dysphagia 1: pureed food
Fr evaluation 630,
Group Group
2: no 2:
tube 630)
NGT Group Patients 62 Group 1: NR 5 mL of thin No change in aspiration Fattal
1: 8 Fr referred for (Group in ? out liquid and status [23]
or 18 dysphagia 1: 21 Group 2: pureed food
Fr evaluation out ? in
Group
Group 2: 41)
2: 8 Fr
NR not recorded, VFSS videofluoroscopic swallowing study, NGT nasogastric tube

In this study, we also aimed to determine the effect of
NGT on swallowing function in patients with different
severities of dysphagia. Diet recommendations were
determined based on the dysphagia severity assessed by
VFSS: tube feeding for 59 patients, diet modification for 75
patients, and diet as tolerated for 13 patients. We found
that PAS-diff values were not statistically different
between the 3 diet recommendation groups, which showed
that the effect of NGT on swallowing function was also
equally negligible among different severities of dysphagia.
Patients with NGT feeding tend to be more cognitively
and functionally impaired [13]. Previous studies demon-
strated that poor functional status and cognitive function
were associated with poorer swallowing outcomes [25, 26].
These previous researches imply that functional status and
cognitive function are strongly associated with swallowing
function. Among the 147 patients in this study, 25 patients
had a PAS-diff [ 0 and 122 patients had a PAS-diff B 0.
When comparing these groups, MMSE-K and K-MBI were
not significantly different, demonstrating that the risk of
aspiration of a small amount of fluid was not significantly
different before and after removal of NGT regardless of
swallowing function, cognitive level, or general functional
level.
Strengths of our study include the relatively large
number of subjects evaluated. Most studies’ sample size
was 10–80 subjects. There was one study with a larger
sample size than this study, but the design was 630 patients
with NGT matched with controls without NGT [24]. We
evaluated the same subjects with and without NGT. There
were limitations to our study. The order of the various
swallowing tests was not randomized. Our subjects were
already solely tube-fed, and we did not insert NGT for the
purpose of the study. We did not evaluate any hindering
effects of NGT from a kinematic aspect. Even though rate
of aspiration was not increased, temporal change of swal-
lowing was observed in the presence of NGT in previous
studies [7, 8], and kinematic analysis of hyoid bone or
epiglottis movement could have identified the reason of
those temporal changes. Prospective development of
pneumonia after VFSS was not reviewed in this study. In
the future, the effect of NGT on the long-term development
of pneumonia between subjects with similar swallowing
difficulty could be needed. Finally, we did not include

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Effect of Nasogastric Tube on Aspiration Risk: Results from 147 Patients with Dysphagia and…
semi-solid or solid foods to evaluate the effect of NGT. In
most patients, oral diets are provided in semi-solid or solid
form. NGT has been suspected to disrupt normal swal-
lowing and NGT is commonly removed before starting oral
diets in patients that are NGT-fed. Oral diet studies
involving semi-solid diets for patients with in situ NGT
should be considered to provide the basis to allow addi-
tional oral feeding in patients with NGT.
Conclusion
NGT is a widely used tool to administer nutrition, but there
are misunderstandings about the role of NGT. NGT is
believed by many to reduce aspiration events and pul-
monary complications. On the other hand, NGT is con-
sidered to be a risk factor for pneumonia in population
studies and NGT has been suspected to disrupt normal
swallowing. This study showed that the aspiration risk of
swallowing a small amount of fluid was not significantly
different before and after removal of NGT, regardless of
swallowing function, cognitive level, and general func-
tional level. We hope that these results will be valuable for
diet prescription and dysphagia management in patients
that are NGT-fed.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical Approval None of the authors has any proprietary interests in
the materials described in this article. This study protocol was
approved by our institutional review board.
Informed Consent We retrospectively reviewed the medical records,
and informed consent was waived.
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 Effect of Nasogastric Tube on Aspiration Risk: Results from 147 Patients with Dysphagia and…

Eun Kyoung Kang MD, PhD

Gowun Kim MD
Gyuhyun Lee MD
Sora Baek MD, PhD

Hee-won Park MD, MA

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