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Christine Sapienza, PhD, CCC-SLP csapien@ju.edu College of Health Sciences Jacksonville University Best Practices for Patient Airway Protection Transforming Healthcare: Best Practices Lahaina, Maui, Hawaii, 2015

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Airway Rehabilitation Goals of Airway Rehabilitation: Safety Quality of Life Define the Ds, Rehabilitate Leder et al., We are underestimating aspiration risk in patients who aspirated and overestimate aspiration risk in patients who did not aspirate.

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The Common Dys Dysphonia Dysphagia Dystussia * Dyspnea ***

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Factors Age Disease Oral Hygiene Medications Silent versus audible Trach vs non Trach

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Patient Care, Signs and Symptoms Aspiration Cough Choking Pneumonia What are the patients ability to swallow? What are the patients ability to clear?

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QOL Differential Diagnosis Valve: Laryngeal exam Pump: F/V LoopsPatient Perception Find the trigger!

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Swallow function Dysphagia (swallowing dysfunction) can occur from early on in a disease process (Ebihara, et. al, 2003). Most patients are silent aspirators with little or no cough response (dystussia). 1997).

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Assessment of Dysphagia & Dystussia Dysphagia well-recognized sequelae Oral Pharyngeal Esophageal Cough?

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Penetration/Aspiration Scale Score Depth to which material passes in the airway and by whether or not material entering the airway is expelled. Determining at-risk patients. ( Rosenbek, et. al, 1996)

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Measures of Swallow Safety 1Contrast does not enter the airway 2Contrast enters the airway, remains above the vocal folds 3Contrast remains above the vocal folds with visible residue 4Contrast contacts vocal folds, no residue 5Contrast contacts vocal folds, visible residue 6Contrast passes glottis, no sub-glottic residue 7Contrast passes glottis, visible sub-glottic residue despite patient response 8Contrast passes glottis, visible sub-glottic residue, absent of patient response (Penetration-Aspiration Scale; Rosenbek et al., 1996)

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Bedside Swallow Exams Nurse versus SLP Testing process Predictability Feeding Choices

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Comparing accuracy of the Yale swallow protocol when administered by registered nurses and speech-language pathologists. Warner HL Warner HL 1, Suiter DM, Nystrom KV, Poskus K, Leder SB.Suiter DMNystrom KVPoskus K Leder SB

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Leder et al., 2013 Participants with incomplete facial symmetry had an odds of aspiration that was 0.76 times the odds of aspiration of those with complete facial symmetry (95% CI = 0.61-0.95, p = 0.017). Isolated incomplete labial closure did not affect the odds of aspiration (p > 0.05).

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COUGH

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Cough is a mechanism that protects the pulmonary system by generating expiratory airflows that create a scrubbing action removing material from the airway. (Leith, Butler, Sneddon & Brian,1990; Smith Hammond, et al, 2001; Pitts et al., 2009). to generate high linear airflow velocities during cough three things must occur: inspiration, vocal fold closure, & forced expiration.

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Smith-Hammond Studies Smith Hammond, 2001; Smith Hammond, 2009

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Leicester Cough Questionnaire

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Reduced expiratory peak flows during voluntary cough are considered indicative of risk for respiratory complications. This may also be indicative of the mechanics of the pulmonary system (i.e. restrictive lung disease). There is a general slowing down of the cough related events. This slowing down decreases the ballistic action of the cough and potentially decreases its effectiveness.

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Treatment Options How: Increase load compensation capacity Change peripheral responses, train patient to clear Muscle Force Function Coordination

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Intervention Well published, peer reviewed, books, presentations Science Clinical Knowledge Evaluation and Planning Proof of Concept Safety Effectiveness Future Trials

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What is RMST? Expiratory pressure threshold training: Pressure threshold device Spring-loaded valve Not resistance training (physiological load calibrated and imposed) Target muscles: expiratory 4 week program 5 days per week 25 breaths per day Load set at 75% of MEP

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Valve closure via adjustable spring Expiratory or inspiratory force must exceed the pressure valve spring strength for the valve to open As you breathe in/out, the muscle shortens and more muscle activity is needed to keep the valve open There is always a minimum amount of force (equal to the spring strength) required by the muscle during the whole breath Strength training occurs with high intensity exercises for a short time Patient will be asked to breathe in/out, less than 30 times with high loads to the muscles being trained General Principles (IMST/EMST)

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To Assess Change in Strength Pressure Gauge / Manometer Measures any type of pressure

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This is not Incentive Spirometry

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RMST Setting (cmH 2 0)

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Cough Airflow

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Measurement of Cough at Bedside

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Contact Information Christine Sapienza, PhD csapien&@ju.edu 904-256-7626