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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
(c) 2018 James L Coyle except as otherwise attributed 1
Managing Dysphagia in the 21st Century: Keeping Up with the Evidence
James L. Coyle, Ph.D., CCC‐SLP, BCS‐S, F‐ASHA
University of Pittsburgh 1
SAC Conference, Edmonton, May 2018
Disclosure
• University of Pittsburgh (salary)• SAC honorarium
• NIH RO‐1 (25% effort)• NSF career award (PI: E. Sejdic)• No products
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Evidence Based Practice
Best clinicaljudgment
Best externalevidence
Patient values& expectations
Evidence Based Practice
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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
(c) 2018 James L Coyle except as otherwise attributed 2
The Medical SLPHalf of day
Recovery
Disability
Rehabilitation
Other half of day
Disease
Survival
Death
Success
Prevention
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Pneumonia, inadequate nutrition,
dehydration
Dysphagia‐aspiration
Pulmonary disease
Advanced Age & Frailty
Digestive diseases
Iatrogenicdisorders
Neurological diseases
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The speech mechanism
• Respiration• “[Respiration] requires the movement of air into and out of the lungs during inhalation and exhalation. Air movement through the vocal system during exhalation makes voice production possible. Also important to speech production is the ability to vary both air flow and pressure during exhalation. This chapter will examine the forces that control air flow and pressure.” Dixon & Maue‐Dixon, 1982
Anatomical and Physiological Bases of Speech
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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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It’s the aerodigestive tract
7© Feb 26, 2016 OpenStax. Textbook content produced by OpenStax is licensed under a Creative Commons Attribution License 4.0 license
Our clinical domains
• Swallowing• The process of directing solids and liquids• To the digestive system• Bypassing the respiratory system
• Speech• Manipulation of exhaled respiratory gas
• By parts of the digestive + respiratory systems
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So… we’ll start with…
• Lungs• And work our way down
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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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10
trachea
carina
hilum
RUL, RML, RLL, LLLOVERLAP RUL+RLLOVERLAP RML+RLL
Posterior AnteriorRight Left
Right lung
3
11
Anterior PosteriorRight Left
LUL, LLLOVERLAP LUL + LLL
Left lung
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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
(c) 2018 James L Coyle except as otherwise attributed 5
Breathing: two components
• Ventilation• Moving air in and out of the lungs
• Respiration• Exchanging gases between
• Atmosphere and BLOOD
• BLOOD and working organs
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Ventilation
• Pumping mechanism…
• Connected to muscles on one end…
• And to the lungs on the other end…
• Lungs and chest wall need to be:• Compliant
14
PhrenicNerve
activates diaphragm
Diaphragm contracts,
pulling on lung and pushing on
viscera
Alveolar inertia
overcome, lung volume increases
Atmospheric air fills
pressure void in lungs
Phrenic nerve impulses cease,
diaphragm relaxesElasticity of
viscera, alveoli are now
unopposed
Compressed viscera, stretched
alveoli, recoil
Alveolar volume
decreases, pressure increases
Intra‐alveolar pressure decreases
(Boyle’s Law)
Alveolar air is “pushed” out
to atmosphere
Ventilation
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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
(c) 2018 James L Coyle except as otherwise attributed 6
16© Conexions
Boyle’s Law
17
How do we do that?
18Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/ under Creative Commons 3.0 unported license
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19© Conexions
• Regulation of respiration• Peripheral, central chemoreceptors
Photo: John A Beal, PhDDep't. of Cellular Biology & Anatomy, Louisiana State University Health Sciences Center Shreveport. Creative Common s license
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Coordination of Breathing & Swallowing
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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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Breathing and Swallowing
volume
pressurepA
+
_
Duration of one swallow(apnea)
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Breathing and swallowing
•Abnormalities• Stroke: volumes, duration, airflow direction
• Shorter cycle duration at rest*• Direction of airflow after swallow**
• Normals: 96% expiration after swallow
• Stroke: 60% expiration after swallow (p<.01)
• Laryngectomy ***• Evidence of maintained pattern in laryngectomy
*,**Leslie et al., 2002 a,b***Charbonneau et al., 2005
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inspiration
expiration
Swallow apnea1.5 – 2.5 seconds
Seconds
Abnormal Breathe‐Swallow Phase
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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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inspiration
expiration
Swallow apnea1.5 – 2.5 seconds
Seconds
Respiratory Rate = 36/min
Breathing and swallowingAbnormalities: Tachypnea
Abnormalities
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Aspiration, pneumonia, aspiration pneumonia, other pneumonias
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What are pneumonitis and pneumonia?
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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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Pneumonitis: lung inflammation
Inflammation
ChemicalMedications
Irritanttraumatizes lung
Irritants (e.g. pathogens),Allergens
RadiationTherapy
Inhaled or aspirated sources
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Pneumonia: lung infection + inflammation
Pneumonia (Infection andPneumonitis)
PathogenColonizes lung
Bacterial
Inhaled or aspirated sources
SystemicSpread
Resolution
Sepsis, Multi‐organ
Failure,Shock
ViralWith or withoutother debris
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Infection causes inflammation: pneumonia = infection + inflammationPathogens and their waste are irritants
Pneumonia
• Inoculation • Infection
• Proliferation of pathogen• A strong epithelial irritant
• Inflammation• Epithelial trauma, thickening, leakage• Resolution
• Both• Pathogen enters circulatory system sepsis
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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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Pneumonitis
Ware & Matthay, 2000
Normal acute resolution
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Clear alveoli
Thickened epithelium
Infiltrates
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Pneumonia• Most frequent infectious cause of death*
• 40% higher incidence in elderly **
• #2 nosocomial infection (UTI) in hospitals***
• High case fatality rate• 55% (elderly)• Leading cause of mortality in children under 5****
Marston, et al., 1997*; National Center for Health Statistics, 2003**; ***Niederman, et al., 2002;****Baine et al., 2001; Almirall, et al., 2000 33
SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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What is Pneumonia?
• American Thoracic Society criteria• New and persistent infiltrate on CXR PLUS ONE OF THE FOLLOWING:
• + pleural or blood culture – same organism as lung
• Radiographic evidence of necrosis or cavitation
• Histopathologic evidence of pneumonia
• Two of the following• Core temp > 38.3C
• Leukocytosis (> 10,000)
• Purulent tracheal secretions
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Classifying pneumonia
• By pathogenic source• Bacterial, viral, fungal, etc.
• By mechanism of inoculation• Aspiration, hematogenous, airborne, etc.
• By inoculation setting• CAP, HAP, HCAP, etc.
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Classes of pneumonia
• Community acquired pneumonia (CAP)• Inhaled, airborne pathogen• Aspirated pathogen, Bacterial, viral
• 4‐5 million cases per year* **• 600,000 hospitalizations, 45,000 deaths**
• Incidence**• 12 per 1000 persons• 20 per 1000 elderly persons (60% greater)• Some are AP!
• Some are DAP, some are NDAP!
36*Niederman, 2002; **Mandell & Wunderink, 2007
SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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Classes of pneumonia
• Health care associated pneumonia (HCAP)• Ventilator associated pneumonia (VAP)
• Contaminated respiratory circuit/equipment
• Health care worker contamination (VAP, HCAP)
• Aspiration (iatrogenic or missed dysphagia!)
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Healthcare Associated Pneumonia
CDC MMWR (1997) Vol. 46, RR‐138
Other Types of Pneumonia
• Ventilator Associated Pneumonia• Exposure to mechanical ventilation
• Contaminated respiratory circuits
• Contaminated suction, bronchoscopicequipment
• Aspiration of oral secretions while sedated• Gastroesophageal reflux common in ventilation
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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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Other Types of Pneumonia
• Respiratory Syncitial virus (RSV)• Viral, common in children (day care)
• Legionella pneumonia
• Hematogenous pneumonia• Lung infected by bloodborne pathogen• This is sepsis‐related pneumonia
• Pneumonia caused by bloodborne transmission of pathogen from another organ
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What is aspiration and how do lungs respond to aspiration?
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Aspiration
• Solid or liquid matter• Not airborne, inhaled pathogen
• Courses by gravity, to its destination• Crosses plane of true vocal folds
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Aspiration‐destination
• Aspirated material is gravity dependent
Airborne is not
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R L
RL
Prandial sidelying/supine
AP
Lung response to aspiration: water
Inside alveolus
Plasma containing water inside capillary
RespiratoryMembrane
Water
H2O
H2O
H2O
H2O
RBC’s
WBC’s
Toward (L) heartFrom (R) heart
Capillary membrane
Alveolar membrane
Effros, et al., 2000 44
aquaporins
Inside alveolus
RespiratoryMembrane
Chemical irritant
Lung response to aspiration: pathogens and particulate matter
RBC’s
WBC’s
Plasma containing water inside capillary
Toward (L) heartFrom (R) heart
H2O H2O plasma H2O
Capillary membrane
Alveolar membrane
infiltrate
Chemical pneumonitis 45
SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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What is aspiration pneumonia?
46
Aspiration Pneumonia 15.5%
>Oropharyngeal>Gastric
DAPNon‐DAP
Typical
Pneumonia100%
Hospital Acquired
Pneumonia
VAPAtypical
Inhaled Pathogen
AspiratedPathogen
Non‐VAP
Aspiration pneumonias
Inhaled Pathogen
47PEOPLE CAN ASPIRATE ANYWHERE: AP IS NOT SETTING SPECIFIC!
Pneumonia100%
CAP
Aspiration Pneumonias
• 1. DAP (Dysphagia‐related AP)• Pathogen in solid or liquid matter• Courses by gravity, to its destination• Not airborne, inhaled pathogen• CAN OCCUR ANYWHERE!
• 2. NDAP (Non‐dysphagia related AP)• Colonized emesis
• gastroesophageal esophagopharyngeal reflux
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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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Aspiration Pneumonitis(chemical pneumonitis)
• Non‐Infectious‐chemical trauma• Acute Lung Injury: caustic or particulate aspiration
• Inflammation of alveoli by effects of irritants• No primary infection
• Inflammatory edema reduces surface area
• Gastric contents• Sterile, acidic, caustic• Damage to airways, alveoli
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Differential Diagnosis – pneumonia, pneumonitis
• Aspiration pneumonia• Inflammation
• Cough – productive
• Bronchospasm
• Dyspnea
• Hypoxemia
• Purulent sputum
• Tachypnea
• Malaise
• Aspiration pneumonitis• Inflammation
• Cough ‐ not productive
• Bronchospasm
• Dyspnea
• Hypoxemia
• Frothy or bloody sputum
• Tachypnea
• Respiratory distressminutes to hours after aspiration; may persist
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Distinguishing AP, Aspiration Pneumonitis, Other Pneumonias
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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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Differential Diagnosis: DAP vs. NDAP
• Dysphagia‐related Aspiration Pneumonia (DAP)• Pt. has pneumonia• Infiltrates are in gravity dependent segments
• Patient has DYSPHAGIA!
• Non‐dysphagia related aspiration pneumonia (NDAP)
• Pt. has pneumonia
• Pt. does not have oropharyngeal dysphagia• Aspiration is conceivable due to GE reflux, emesis…
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• Location of chest infiltrates• Signs and symptoms
• Bacteriology/hematology
• History• Clinical observations
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Location of chest infiltrates
• NDAP• more diffuse, multifocal
• VAP: often well distributed
54Differential Diagnosis
SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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Location of chest infiltrates – Aspiration
Basilar infiltratesLarge volume or larger
volume chronic aspiration
(R) Upper lobe infiltrates
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Hilar infiltratesSmaller volume aspiration
• DAP, CAP, Nosocomial Pneumonia: similar.• Dyspnea• Hypoxemia
• Malaise
• Fever• Productive cough• Purulent sputum• Leukocytosis
Signs and Symptoms
56Differential Diagnosis
• DAP: oral pathogens/oral flora
• CAP: Strep. pneumoniae, Klebsciellapneumoniae, H. influenzae, RSV, Legionella, E. coli, Staph. aureus
• VAP: pseudomonas, proteus species, Staph. Aureus
• Typically multiple organisms
• Nosocomial pneumonia: pseudomonas, proteusspecies, Staph. aureus
• Leukocytosis (elevated WBC)
• Normal: 4.5 – 10.5 k cells/microliter
Bacteriology/Immunology
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Note: e. coli, staph., pseudomonas, proteus can colonize mouth, nose!
Differential Diagnosis
SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
(c) 2018 James L Coyle except as otherwise attributed 20
• DAP: Dysphagia! • Dysphagia‐producing disease, symptom onset following oral intake; position during oral intake; esophageal dysmotility
• Dependent for feeding/oral care, oral biofilm
History
58Differential Diagnosis
Clinical observations:What does patient with pneumonia look like?
• What we see on assessment is not baseline• Elevated respiratory rate • Mental status
• Cough is present in background• Count coughing before, during, and after oral trials
• Patient may appear acutely dysphagicbecause he is very sick
• Though he may not have “dysphagia”
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Clinical observations
Sign Interview Oral Facial Exam
Swallow Trials A Swallow Trials B Post‐swallow trials
Cough
Throat clear
Vocal quality
other
TimeTime Time TimeTime Time
duration duration duration duration duration
5 min 5 min 5 min 5 min 5 min
2
112
0.4 sx/min all phases
1
1
1
11
1 1
1 3
3
32
1
0.4 before oral trials, 1.1 during oral trials, 0.2 after oral trials
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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
(c) 2018 James L Coyle except as otherwise attributed 21
Summary‐pneumonia• Knowledge of normal and abnormal function is essential
• Not just swallowing function…
• Elderly possess many risk factors for pneumonia that are unique to the elderly
• There are many clues pointing to, or away from, a diagnosis of DAP
• This is important background knowledge for the SLP
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• Things to remember• Aspiration can occur without dysphagia
• Aspiration is one potential source of pneumonia pathogens
• All respiratory illnesses are NOT dysphagia related
• ALL PNEUMONIAS ARE NOT ASPIRATION RELATED
• Patient appearance with pneumonia is NOT baseline
• History, course, physical signs are data for the SLP/clinician
Summary‐pneumonia
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When patient has other respiratory diseases
• Types/categories• The respiratory conditions seen in the elderly
• Are they suspicious for a dysphagia etiology?
• Chest imaging – what does it mean?
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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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ACUTE OBSTRUCTIVE PATHOLOGICAL
CHRONIC RESTRICTIVE IATROGENIC
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Duration of condition, Recurrence
Mechanism of pulmonary effects
1. Acute: rapid onset2. Chronic: longstanding, recurrent , progressive
1. Obstructive: blocks gas flow to respiratory membrane2. Restrictive: restricts gas volume that can be inhaled
Source of condition
1. Pathological: caused by disease2. Iatrogenic: caused by treatment of another disease
Pulmonary diseases
• Obstructive Diseases• Inspired air is obstructed from the respiratory membrane
• Obstructed gas exchange• Respiratory pump works
• Restrictive Diseases• Airflow or volume is mechanically restricted
• Gas exchange is intact• Patient cannot inhale sufficient volume
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Pulmonary diseases
• Chronic respiratory conditions• COPD (obstructive)• Congestive Heart Failure (obstructive and restrictive)
• Pulmonary Fibrosis (restrictive)
• Asthma (obstructive and restrictive)
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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
(c) 2018 James L Coyle except as otherwise attributed 23
Pulmonary diseases
• Acute respiratory conditions• Pneumonia (obstructive and restrictive)• Pneumothorax (restrictive)
• Atelectasis (restrictive)
• ARDS (obstructive and restrictive)• Other acute pneumonitis (usually both)
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Chest x‐ray reports
• Terms• Pulmonary vascular congestion
• NOT airway congestion
• Blood back‐up in pulmonary vessels
• Alveolar infiltrates are inside alveoli!• The rest of these are NOT alveolar infiltrates.
68
Pulmonary vascular congestion
• Incoming arterial flow obstructed
• Blood “backs up” – casts shadow on image
Pulmonary hypertension69
Pulm. artery Pulm. vein
Obstructed flow
SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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Pulmonary edema
• Leakage of circulatory fluid into alveoli• Most common cause = congestive heart failure• Pulmonary hypertension “pushes” fluid out of capillaries
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Pulmonary edema
Pulmonary hypertension71
CHF and Pulmonary Edema
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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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Pleural effusions
• Fluid filling parts of pleural cavity• Preventing lung expansion during inspiration
• Gravity dependent “bag of water”
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Pleural effusion
Pleural cavity
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CHF (transudative), Inflammatory (exudative)
Restrictive Pulmonary Disease
Pleural Effusion
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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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Pleural Effusions (L>R)
Pneumothorax
• Perforation of pleural membrane• Destroys intrapleural vacuum that holds lung open
Subatmospheric pressure
Pleural cavity
Atmospheric pressure77
Mechanically Restrictive
Pneumothorax Perforation caused by empyema/
abscess Chronic aspiration
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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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Atelectasis Areas of collapsed alveoli
Restrictive Pulmonary Disease
79
Iatrogenic causes of respiratory conditions
• Iatrogenic condition: a disease cause by treatment of another disease
• Sedation (restrictive)• CNS depression
• Disruption of pleural linkage (restrictive)• Cardiothoracic surgery
• Transplantation, lobectomy, any thoracotomy
• PICC (subclavian) line accidents, thoracentesis
• Phrenic nerve injury (restrictive)• Cardiothoracic surgery
• Vagal injury (obstructive: vocal fold paralysis)
80
Clinical observations
• Minute volume = tidal volume x resp. rate• Constant for a given activity
• Obstructive/restrictive diseases• Less gas to alveoli • Minute volume must be maintained
• Lower TV per breath more breaths/minute
• Dyscoordination of breathing/swallowing
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SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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A word on the effects of aging and disease
82
• Maintenance of a constant, stable condition• Organ systems maintain homeostatic equity
• Baseline• Few resources used to maintain homeostasis
• Examples• Digestion, fluid/electrolyte balance [hydration]• Temperature regulation, cardiovascular functions
83
Homeostasis
• The characteristic, progressive constriction of homeostatic reserve that occurs with aging in every organ system.
• With aging, physiologic reserves are increasingly used to maintain homeostasis
• Declining reserves left for meeting new challenges
84
Homeostenosis
SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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Homeostenosis
Available reserve for WHEN WE NEED IT
Amount of reserve used to maintain homeostasis
85
Young Old
Homeostenosis
Age
Available reserve for WHEN WE NEED IT
Amount of reserve used to maintain homeostasis
86
Young Old
Disease
More reserve for emergency Less reserve for emergency
RESERVE DEPLETED
Decompensation & aging
• Chest wall, musculature
• Declining number of alveoli
• Gas diffusion capacity diminishes
• Reduced central ventilatory drive
• Diminished esophageal motility
• Immune system degradation
• Decreased tidal volume increased rate
• Breathlessness: detecting changes in respiration
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Lung function
• Impaired lung function may cognitive decline
•Diminished expiratory air flow• Impaired cough airway protection
88
Summary
• Disease, Ageing, and DISEASE+AGEING add unique risks to all systems
89
Respiratory problems affect swallowing, what is to be done about them?
• Reversal of swallow‐breathing discoordination
• Consider added fatigue of “eating and drinking”
• Increase respiratory rate even more?
• Mitigating rate increases with supplemental O2• …because we can’t pull off more CO2.
90
SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
(c) 2018 James L Coyle except as otherwise attributed 31
Summary
• Ventilation and pulmonary physiology are essential knowledge for the SLP
• Pulmonary disease affects swallow/breathing coordination
• Pulmonary disease can cause, or be caused by, dysphagia
• Mainly characterized by disruption of swallow‐respiratory coordination
91
Questions?
• Glossary • Questions about pulmonary/respiratory terms?
92
The Digestive System
• General digestive anatomy & physiology
• Esophageal anatomy & physiology
• Assessment of esophageal structure, function
• Common esophageal pathology• Anatomic
• Physiologic
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Digestive System
94
• Ingested food is always “outside” of the body’s tissues
• Digestion breaks down food to liberate absorbable materials
• Nutrients are absorbed into the body’s tissues
• Waste passes on by.
Inside the body, cells, absorbed nutrients
waste
FOOD
Digestive System
95© Conexions
96
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The esophagus
97
Anatomy of the gastroesophageal junction
98
Esophagus
99© Conexions
(Vagus)
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Esophagus
100
• Muscular Tube‐no skeletal framework• proximal 1/3 skeletal muscle• middle 1/3 transition• distal 1/3 smooth muscle• very delicate mucosal lined• longitudinal bundles on exterior‐shortening/squeeze• circular layer interior‐compression/squeeze
• Enters abdomen through hiatus• hole in diaphragm
• crural diaphragmatic fibers
• lower esophageal sphincter
Esophagus
• Upper 1/3 striated muscle• Muscle diseases affect function
• Myositis, myasthenia gravis
• Lower 2/3 progressive smooth muscle• Other disease mechanisms affect function
• Scleroderma
• Achalasia
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Esophageal Muscular Layers
102
Longitudinal
Circular
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Esophageal Muscular Layers
103
Esophageal “peristalsis”
104Creative Commons 3.0, Gnu public
Esophageal Function
105
• Innervation• Motor:
• Extrinsic – CN X, Autonomic
• Intrinsic – Myenteric Plexus
• Sensory: Somatic thoracic segmental
• referred symptoms to neck, chest
• Peristalsis• superior to inferior wave‐like contractions• squeeze bolus top to bottom
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106
107Creative Commons 3.0
Esophageal Physiology
108
• Lower Esophageal Sphincter• resting pressure about 1/3 of UES resting pressure
• prevents gastric contents from re‐entering esophagus
• circular muscle layer, diaphragm (crura)
• intrabolus pressure increases proximal to LES
• LES releases resting posture, bolus enters stomach
• subatmospheric pressure at bolus arrival
• closure‐brief supra‐resting level of contraction
SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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Assessment of esophagus
• Structure ‐ Imaging• Barium swallow• Endoscopy
• Function• Motility – manometry
• High resolution manometry
• GE reflux – pH‐metry
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Barium swallow (esophagogram)
110
Structure Motility
Sphincter functionReflux
Esophagogram
111
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Findings• Dysmotility
• Top‐to‐bottom contraction disrupted• Bolus separation; stasis; retrograde flow (to/fro)
• Gastroesophageal reflux• Gastric contents re‐enter esophagus
• Structural findings• Web, stricture, Schatzki ring; Zenker diverticulum
• Typically affect solid bolus transit
• Both: achalasia
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Disorders of Esophageal Motility
113
• Gastroesophageal Reflux• LES permits gastric contents to re‐enter esophagus
• food is normally reduced by acid, pepsin, bile
• all strong mucosal irritants
• mucosal injury, inflammation, re‐epithelialization, scarring
• Esophago‐laryngeal reflex (Shaker et al., 1992)
GE Reflux challenge
114
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Disorders Related to GER
115
• Esophagitis• Subglottic Stenosis
• Chronic laryngitis, hoarseness, cough• Aspiration Pneumonitis
• Chronic bronchitis, tracheobronchitis
• Globus‐relieved by swallowing• ? increased UES pressure in response to GER
Achalasia
116
Achalasia
117
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Schatzki`s ring
118©Copyright Science Press Internet Services
on barium esophagogram
on endoscopy
119
Schatzki ring Esophageal webs
Normal
120Creative Commons 3.0
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121© Nevit Dilmen Creative Commons 3.0
Hiatus hernia (but first – review)
122© Connexions via Creative Commons Attribution 3.0 license
122
Hiatus Hernia
• A. Normal anatomy
• B. Flattened flexure
• C. Sliding hernia
• D. Irreducible hernia
123
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Paraesophageal hernia
124©Copyright Science Press Internet Services
Hiatus hernia
Hiatus hernia
125
Paraesophageal HH (from below)
Endoscope in LESFundus herniated
HH from above. Note diaphragmclosure and gastric folds.
Normal
Zenker Diverticulum
• Bulge in inferior constrictor
• Pulsion diverticulum
• Outpouching of mucosal envelope
• Superior to cricopharyngeal bar
• High pressure zone
126
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Zenker diverticulum
127
Large Zenker diverticulum
128
129
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Progression of symptoms• Resistance multiple swallows regurgitation anorexia recurrent unexplained LRTI
• Telltale observations (VF)• Unexplained pyriform sinus residue
• Barium filled defect rises into field
• Air‐fluid level
130
Esophagitis
• Inflammation of esophageal mucosa
• Extrinsic• Irritants mucosal inflammation
• Intrinsic• Eosinophilic esophagitis
• Eosinophils infiltrate esophageal mucosa
• Stricture, impactions, dysmotility
• “Trachealization” of mucosa
131
Esophagitis
132Creative commons 3.0
Candida esophagitis (candidiasis)Herpetic esophagitis
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Barrett’s esophagus
133
Normal GE junction
Barrett’s adenocarcinoma
134GIMOBarrett's esophagus; Barrett's adenocarcinoma video
Esophageal Motility Disorders
135
• Esophageal motility disorders Terms: • Dysmotility: disruption of the primary peristaltic wave in 40% or more swallows
• Proximal escape: portion of bolus remains in proximal esophagus, or contrast courses retrograde (rostrally)
• Tertiary contractions: nonpropulsivecontractions, often multiple and simlutaneous, causing focal and simultaneous narrowings of esophageal lumen
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Esophageal Motility Disorders
136
• Disordered peristalsis• disorganized esophageal clearance with residuals
• Reduced or absent peristalsis• stasis in esophagus
• increased esophagopharyngeal reflux risk• AKA extraesophageal reflux
• AKA L.P.R.
• Achalasia • absent peristalsis with absent LES opening
Esophageal Motility Disorders
137
• Diffuse Esophageal Spasm• Nonspecific esophageal motility disorder
• 25‐50% of abnormal motility study results performed for chest pain and dysphagia
• Presbyesophagus• diminished peristalsis
• distal findings more prevalent
• impaired LES distension with proximal dilatation
138
Tertiary contractions Diffuse esophageal spasm
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Other esophageal tests
139
Esophageal Manometry
• Esophageal catheter with pressure sensors• Perfused catheter – water inside catheter
• Fluid dynamics produce pressure signals• Compression of water‐filled catheter activate sensors
• Ideal for pharyngoesophageal manometry• Sphincters
• Direct intraluminal transducers• Electronic pressure sensors
• Directly activated by pressure
• Ideal for esophageal manometry
140
GI Motility online (May 2006) | doi:10.1038/gimo13
Figure 1 Primary peristalsis as recorded by an intraluminal manometry catheter.
Manometry
141
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142Creative commons 3.0; GNU public
High resolution Manometry
Endoscopy
143
pH‐metry/Impedance monitoring
• Detection of retrograde flow to esophagus• Acidified (pH‐metry), non‐acidic (impedance)
• Catheter with pH sensitive electronic sensors
144
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Signs, symptoms: chickens or eggs?
• Esophageal motility disorder
• Achalasia
• Stricture/web• Hiatus hernia• Zenker diverticulum
145
Signs and symptoms
• Myenteric plexus – esophagus has a “brain”• Sensorimotor circuits are diffuse
• Different from somatic sensorimotor circuits
• Vagus• Events causing OPD can cause esophageal disorders
• Esophageal sx. often referred to pharynx• Even many distal diagnoses refer to pharynx
146
Signs and symptoms
• Pharyngeal globus sensation• Stricture (web, ring)• CP bar• Diverticulum• Achalasia• Esophagitis• Hiatus hernia• Esophageal varices
147
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Signs and symptoms
• Early satiety• Achalasia• Stricture• Gastroparesis• Hiatus hernia
148
Signs and symptoms
• Cough• Esophagitis (esophagolaryngeal reflex)• Achalasia
• Filling of esophagus aspiration
• Zenker diverticulum• Regurgitation from pouch pharynx aspiration
149
Signs and symptoms
• “a funny squirting sound in my throat…”• Zenker diverticulum
• Need to swallow several times…• Zenker diverticulum• Esophageal motility disorder
• Cricopharyngeal bar• Esophageal varices• Of course, oropharyngeal dysphagia
150
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Signs and symptoms
• Postprandial burning• Gastroesophageal reflux
• Nocturnal awakening with cough• Gastroesophageal reflux• Zenker diverticulum
151
Assessment and Treatment
152
• Motility, gastroesophageal reflux assessment• Manometry• dynamic radiography
• 24 hour pH monitoring
• Treatment• medication, posture/gravity enhancement
• surgery
Assessment and Treatment
153
• Structural disorders• stricture: dilatation, surgery• carcinoma: extent of disease, esophagectomy, radiation therapy, palliation
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Treatment of esophageal disorders
• Conservative anti‐reflux measures• NPO 2‐3 hours before HS• Exploitation of gravity
• Elevation of head of bed 10‐15cm
• Avoidance of foods that …• Loosen LES closure
• Increase gastric “juice” production
154
Treatment of esophageal disorders• Medications: motility disorders
• Increase motility (prokinetics)• Relax skeletal muscle
• Botulinum toxin, others
• Relax smooth muscle• Loosen lower esophageal sphincter• Esophageal spasm
• Increase speed of gastric emptying
• Medications: gastroesophageal reflux• Acid suppression
• Reduce erosive potential
155
Treatment of esophageal disorders
• Endoscopic intervention• Dilatation
• Stricture
• Stent • Intractable stricture, untreatable carcinoma
• Endoscopic Ligation • Esophageal varices
156
GNU free
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Treatment of esophageal disorders
• Surgery• Laser
• Stricture
• High frequency radio wave ablation• Barrett’s esophagus
• Myotomy• Cricopharyngeal bar• Achalasia
• (PS: CP bar = CP achalasia)
• Esophagectomy• Esophageal cancer• Barrett’s esophagus
157
• Esophagectomy
158
159
http://MIER web page
• “Pneumonia is a major complication ”• 2/3 post‐ER deaths attributed to
respiratory complications
Atkins, Fortes, & Watkins, 2007.
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Questions?
• Glossary • Questions about digestive system terms?
160
Dysphagia Treatment: What are We Doing, and Why?
161
Goals
• Least restrictive diet without aspiration?• Adherence to exercise protocol?
• Perform maneuvers independently?
• Or…..
162
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Goals
• Fewer hospitalizations for dysphagia‐related disease?
• Lower early mortality due to dysphagia‐related illness?
• Lower pneumonia risk?
• Improved nutritional status?
163
Treatment components
• Structural/tissue properties• Treatment increases “health” of tissue/organ
• Organ function• Treatment results in improved organ function
• Skilled performance• Treatment leads to improved patient organ use
• Cognitive/affective representations• Treatment instills motivation toward participation; importance of problem/treatment
164
Some Common Interventions…
• They are designed for this…• Intended consequences
• But they also do this…• Unintended consequences
• Sometimes good…
• Sometimes not so good…
165
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Some Common Interventions… compensate…
1. Head rotation posture* ‐ divert bolus Directs bolus to opposite side of pharynx Compensate for unilateral noncompliance
BUT IT ALSO: Increases UESO diameter (rotation to either side in normals)
Reduces UES pressure (either side, normals)
Increased intrabolus pressure Reduces contralateral pyriform sinus pressure**
166*Logemann et al (1989); **Takasaki et al., 2012
167
Some Common Interventions… compensate…
• 2. Chin‐down posture*‐ reduce aspiration• Patients with aspiration due to “pharyngeal delay”
• 50% did not aspirate with CDP (OR = 0.5)• Continued aspirators: pyriform sinus residue aspirated• Valleculae widened
• Anterior bolus position (phar. delay, oral containment)
• BUT IT ALSO:• Reduces intrabolus hypopharyngeal pressure**
• Contraindicated in patient with weak constrictors
168*Shanahan et al. (1993); **Bulow et al (2002)
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Some Common Interventions… compensate…
• 3. Increase duration of UES opening*• Mendelsohn Maneuver
• maintains prolonged HLE
• BUT IT ALSO:• Is difficult to teach, difficult to perform
• SEMG biofeedback training improves treatment effect* **
169*Kahrilas et al (1991); ** Coyle (2008)
170
Some Common Interventions… compensate…
• 4. Self‐protection of airway• Supraglottic swallow (SGS)
• Closes airway before swallow• “super SGS”
• “effortful” vocal fold closure +Tilts arytenoids
• Earlier/longer UES relaxation and HLE* **
171*Bulow et al (2002); **Ohmae et al., 1996;
SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018
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Some Common Interventions… compensate…
• Does the work of 3 other interventions• Increased intrabolus pressure*• Increase UES Opening and laryngeal closure*• Reduced oral residue*
• And can be Dangerous!!!• Produces arrhythmia in certain patients**
172*Bulow et al (2002); **Chaudhuri et al. (2001)
BUT IT ALSO:
Swallow respiratory coordination
• Healthy swallows followed by exhalation• Disordered swallows followed by inhalation
• Training patients to coordinate breathing and swallowing?
173Gross et al, 2009; Leslie et al, 2002a,b; Leslie et al, 2005
Some Common Interventions… compensate…
• 5. Tongue holding/tether• Bulge in PPW during swallow
• Inhibits tongue motion
• Increases oral residue in normals
• BUT IT ALSO:
• Is not intended for use by patients when swallowing!
174
Fujiu & Logemann (1996)
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Some Common Interventions… compensate…
• 6. Bolus modification• Larger bolus
• Earlier HLE, tongue movement, UES opening*
• Taste, temperature, consistency• Earlier activation in some patients**
• Will patient eat/drink it???
175*Cook et al., 1989; **Dantas et al., 1990; Ding et al., 2003
What about texture modification and Water?
176
Diet modification
• Should be the last compensatory method evaluated in testing
• Logemann, 1993
• Issues:• What does texture modification do for patient?
• Is patient amenable to modification?
• Will patient eat the prescribed diet • Malnutrition, dehydration
177
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Thickened liquids
• Reduces aspiration of thin liquids• Kuhlemeier et al., 2001; Logemann et al., 2008
• Swallow apnea later/longer with thick liquids• Hiss et al., 2004; Butler et al., 2004
• More effort needed to clear thick• Nicosia et al., 2001
• More residue with thick
178
Thickened liquids
• Do thickened liquids cause dehydration?• Do thick liquids reduce liquid aspiration?
• Do thick liquids lower pneumonia rates in liquid aspirators?
179
Thickened liquids
• Hydration and thick liquids• Sharpe et al., 2007
• >95% water absorbed from thick mixtures
• No difference between water, thick water
• Hydration and thick liquids• Reduced fluid intake when thick prescribed
• Whelan, 2001: 24 stroke patients
• Mean fluid intake = 455 mL/day
180
Whelan, 2001, Finestone et al, 2001
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Thickened liquids
• Patients do not like thick liquids• Garcia, 2005: prepackaged vs. mixed
• Prepackaged better : Whelan, 2001
• No, they do not cause dehydration• Dehydration results from lower fluid intake
181
182
PART 1:Do thick liquidsor chin‐down
posture preventaspiration?
Aspirate thin liquids on VFS
(711)
VFS: 1. Thin/chin 2. Nectar 3.
Honey
Aspirate thin liquids on VFS
(711)
VFS: 1. Thin/chin 2. Nectar 3.
Honey
Eligible, consent: VFS
Thin liquid Thin liquid‐chin‐down
Nectar Honey
Aspiration 100% 68% 63% 53%
Preference 1st 2nd 3rd last
Part 1 Results
Aspirated on one or two interventions
Aspirated on NONE OF THE interventions
N=177
Aspirated on ALL OF THE interventions
N=346
Enter Part 2
Do not enter part 2
Logemann et al., 2007
183
PART 2 Design:In liquid aspirators, which has lowest
pneumonia incidence:Thin/CDP?Nectar?Honey?
3 month randomized study
Aspirated on NONE OF THE interventions
N=177
Aspirated on ALL OF THE interventions
N=346
Thin/Chin259
Nectar133
Honey123
Pneumonia
Death
Secondary Outcomes
3 months
Robbins et al., 2008
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184
PART 2 Results:Aspirated on NONE OF THE interventions
N=177
Aspirated on ALL OF THE interventions
N=348
Thin/Chin259
Nectar133
Honey123
52Pneumonia
(11%)
0 Death
Secondary Outcomes
N=515
Pneumonia
Chin‐thin All thick liquid Nectar Honey
Aspirated none in Part 1 (10) 6 (7%) 4 (5%) 0 (0%) 4 (10%)
Aspirated all 3 in Part 1 (42) 18 (9.8%) 24 (14%) 10 (11.5%) 14 (19%)
185
Thick liquids
• Other results• Dehydration: Thin: 2%, Thick: 6%
• UTI: Thin: 3%, Thick: 6%
• Median hospital stay with pneumonia
• Honey (18 d.), nectar (4 d.), CDP (6 d.)
186
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Thick liquids
• Do thick liquids reduce aspiration?• Yes
• Do thick liquids reduce pneumonia risk?• No
• Are aspirators more likely to get pneumonia?• Yes
• Do patients like thick liquids?• No
• Will they drink it if they don’t like it?• Probably not
187
“Free Water Protocol” Principles
• Rationale of protocol per developers:• 1. Safety of water aspiration
• 2. Poor adherence with thick liquids
• 3. Need for hydration – self evident
188
Evidence: one study before 2008
• Garon et al., 1997• 20 aspiration‐documented CVA patients
• Aspirated liquid only on VFSS
• Randomized to free water or no free water
• Duration: treatment + 30 day follow up
• Small and underpowered study• Yet the main evidence for protocol
189
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• Results• No patient in either group developed pneumonia
• No dehydration, complications
• Intake of fluids comparable between groups
• 1210 mL (C) ‐ all thick• 1318 mL (E): 855mL thick, 463mL thin
• “Much less water than expected” by investigators (“we were surprised…”)
190
Half of daily needs
Water Protocol Evidence
• Randomization to water protocol or prescribed dietary fluid (26 patients)
• 17 patients requiring feeding assistance• 8 assigned to control, 9 to treatment
• 9 independent feeding patients• 3 assigned to control, 6 to treatment
• All received oral care four times per day
• Outcomes: pneumonia, death, UTI, FIM, LOS, intake
191
Becker, et al., 2008
Water Protocol Evidence• Results
• Pneumonia: 1 patient in each group
• UTI: 2 patients in each group
• FIM: no significant difference
• FCM: no significant difference
• Length of stay: 29.1 days (control) vs. 15.8 (tx)
192Becker, et al., 2008
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Water Protocol Evidence
• Death: 2 treatment deaths, no control deaths
• Both patients that died had chronic pulmonary conditions
• Other findings:• Independent patients consumed significantly less fluid than dependent patients (p<.01), regardless of group
193
Recent Evidence
• Karagiannis et al. (2011)• Significant increase in lung complications (6/42) vs. controls (0/34)
• Carlaw et al. (2011)• No complications in either group
• More fluid intake in “protocol” patients
• Conclusion: nothing is FREE.
194
Using the /k/ phoneme
195
Perlman et al, 1989
Modified Valsalva:“make a /k/ as hardas you can and holdit for as long as you can, don’t let anyair escape.”
Hawk:“say the word ‘hawk’,make the /k/ as hardas you can.”
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196
“Hawk”, modified valsalva produced ~20% of muscle activity seen during swallow
Carbonated thin liquid
• Order effects**?• Command swallow effects***?
• Cued swallows significantly shorter duration
• No effect on any swallow parameters****
197*Bulow et al., 2003; ** Robbins et al, 1999; *** Daniels et al., 2007; Krival 2007****
*
NMES
• Most studies contain flaws• Most frequent
• No control for recovery• Lack of blinded judges• Subjective criteria for “success”
• Recent work with transoral NMES to pharynx• Interesting, need more data
• Patient selection? What are we treating?
198
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Restorative methods
• Emerging efficacy in the literature
• Exercise‐Preventive, Restorative, beyond?• physiologic logic, predicted baseline, target
• muscle strengthening requires repetition to modify contractile properties (hundreds, thousands…)
• Do range of motion exercises do anything?
199
Exercise
200
Testing/measurement Exercise protocol
Tongue Press exercise
Tongue Press exercise
• Reduced oropharyngeal residue• Pharyngeal (p = .03), overall (p = .01 ‐ .02)
• Improved PA scores (3mL, 10mL liquid)• 4 weeks: p = .02; 8 weeks: p = .005
• Increased isometric pressure• Anterior 4‐8 wk:(p = .001); posterior (p = .01, .001)
• Increased swallowing pressure• All consistencies/volumes at 4, 8 weeks.
201
Lingual Strengthening Exercise
Robbins et al., 2007; Rogus‐Pulia et al, 2016
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Restorative Methods
• Exercise• Resistive expiratory exercise
• Increase force of expiratory effort
202
Sapienza et al.
By me. Ernstl ‐ Self‐photographed, CC BY‐SA 2.5, https://commons.wikimedia.org/w/index.php?curid=765667
Restorative methods
• “Shaker” exercise*• Head‐Neck flexion while supine
• Increase AP dimension of UES during swallow
• “Eliminated tube feeding in stroke patients”**
203
*Shaker et al (1997), **Shaker et al (2002);
• Sham (7) vs Real (11)• No significant difference in any biomechanical measures
• 11 real exercise pts. Pre‐ Post Real Exercise• AP UESO, anterior laryngeal excursion (ALE), all significantly increased from own baseline
204
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Jaw Opening Exercise
205
Fig 1 10 seconds, 5 repetitions with a 10‐second rest period between each, 2 sets daily.
Wada, S., Tohara, H., Iida, T., Inoue, M., Sato, M., & Ueda, K. (2012). Jaw‐Opening exercise for insufficient opening of upper esophageal sphincter. Archives of Physical Medicine and Rehabilitation, 93(11), 1995‐1999.
http://dx.doi.org/10.1016/j.apmr.2012.04.025
Jaw Opening Exercise
Significant increases (p<.05): ‐Vertical hyoid motion‐UES opening diameter, ‐Pharyngeal transit duration
Near significant (p=.05)‐anterior hyoid motion
206
McNeill program
• “Exercise based intervention specific to swallow activity”
• Swallow hard in a single swallow
• Systematic increase bolus volume, consistency as eating rate increased
• Homework (eating what was used in treatment)
• Record keeping at home
• FOIS, MASA, patient self‐rating
• Kinematic analysis
207*Crary et al., 2012 (above); Carnaby‐Mann et al., 2010 (N=8); Lan et al. (2012) N=8
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Measure Baseline Post‐treatment
Post tx 3 months
Significance measure
g P g P
MASA 0.94 <0.02 0.13 0.67
FOIS 1.42 0.01 0.74 0.17
VFS 0.18 0.37
VAS 1.26 <0.01 ‐0.21 0.38
LP pressure 0.05 NS208
Facilitative Methods• Interest in manipulating other sensory modalities
• Taste, vibratory sense, electrical stimulation (?)
• Can the brain be rewired in adults?• Emerging evidence that “something” is happening upstream
• MEG, EEG (record the effects), MRI
• TCMS (stimulate motor effects)
• Direct current stimulation
• Exercise
• Implantable intramuscular ES
209Jayasekeran et al., 2010, 2011; Pelletier & Lawless, 2003; Malandraki et al., 2011
Newer methods in need of data
• Manipulation of subcutaneous tissue• Tissue mobilization
• Popular term = “myofascial release”
• Has been practiced for generations in other diseases in limbs, axial soft tissue
210
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Stimulation of the brain?!?!?!
• Transcranial stimulation• Magnetic fields• Direct current
• Peripheral (pharyngeal)
211
Mass practice and plasticity
• What is plasticity?• Alteration in the outcome
• Motor learning theory?• Mass practice
• Dosage, intensity, progressive resistance + (other increments)
• Task specificity
• Neural adaptation
212
Treatment
• Questions?
213
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Is our profession under siege?
214
Who should manage dysphagia?
• “All you do is change diets. We can change diets too.”
215
Top of license practice
• How does aging affect swallowing?• How do the lungs work (not for speech!)?
• What digestive symptoms mimic dysphagia?
• What medications can cause dysphagia?
• What is a pleural effusion and how does it affect speech and swallowing?
• What treatment does this patient need?• Based on disease and its natural history
216
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Responding to these questions as primary care providers for dysphagia?
217http://www.weirdfacts.com/animal‐facts/3217‐armadillo‐facts
Practice at the top of your license!
• Medical SLP’s – be a consultant to physicians
• They seek your advice• And are not prescribing
• Be highly competent!218
SLP is uniquely qualified• The SLP’s training is the right combination
• Aerodigestive anatomy, physiology, kinematics• Human communication (treatment involves learning!)
• Analysis of speech provides intuition regarding dysphagia
• Let’s institutionalize the “pre‐med” preparation (ASHA/SAC – we’re talking to you!)
219
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• Thank you!
220
References - Adult
Ajemian, M. S., Nirmul, G. B., Anderson, M. T., Zirlen, D. M., & Kwasnik, E. M. (2001). Routine fiberoptic endoscopic evaluation of swallowing following prolonged intubation: implications for management. Archives of Surgery., 136(4), 434-437.
Anderson, J. A., Pathak, S., Rosenbek, J. C., Morgan, R. O., & Daniels, S. K. (2016). Rapid aspiration screening for suspected stroke: Part 2: Initial and sustained nurse accuracy and reliability. Archives of Physical Medicine and Rehabilitation, 97(9), 1449-1455. doi:http://dx.doi.org/10.1016/j.apmr.2016.03.024
Barker, J., Martino, R., Reichardt, B., Hickey, E. J., & Ralph-Edwards, A. (2009). Incidence and impact of dysphagia in patients receiving prolonged endotracheal intubation after cardiac surgery. Canadian Journal of Surgery, 52(2), 119-124.
Barquist, E., Brown, M., Cohn, S., Lundy, D., & Jackowski, J. (2001). Postextubation fiberoptic endoscopic evaluation of swallowing after prolonged endotracheal intubation: a randomized, prospective trial. Critical Care Medicine, 29(9), 1710-1713.
Boden, K., Cedborg, A. I., Eriksson, L. I., Hedstrom, H. W., Kuylenstierna, R., Sundman, E., & Ekberg, O. (2009). Swallowing and respiratory pattern in young healthy individuals recorded with high temporal resolution. Neurogastroenterol Motil, 21(11), 1163-e1101. doi:10.1111/j.1365-2982.2009.01352.x
Bolser, D. C., Gestreau, C., Morris, K. F., Davenport, P. W., & Pitts, T. E. (2013). Central neural circuits for coordination of swallowing, breathing, and coughing: predictions from computational modeling and simulation. Otolaryngologic Clinics of North America, 46(6), 957-964. doi:http://dx.doi.org/10.1016/j.otc.2013.09.013
Bordon, A., Bokhari, R., Sperry, J., Testa, D. t., Feinstein, A., & Ghaemmaghami, V. (2011). Swallowing dysfunction after prolonged intubation: analysis of risk factors in trauma patients. American Journal of Surgery, 202(6), 679-682. doi:http://dx.doi.org/10.1016/j.amjsurg.2011.06.030
Brodsky, M. B., Gellar, J. E., Dinglas, V. D., Colantuoni, E., Mendez-Tellez, P. A., Shanholtz, C., . . . Needham, D. M. (2014). Duration of oral endotracheal intubation is associated with dysphagia symptoms in acute lung injury patients. J Crit Care, 29(4), 574-579.
Bulow, M., Olsson, R., & Ekberg, O. (2002). Supraglottic swallow, effortful swallow, and chin tuck did not alter hypopharyngeal intrabolus pressure in patients with pharyngeal dysfunction. Dysphagia, 17(3), 197-201.
Burns, H. P., Dayal, V. S., Scott, A., van Nostrand, A. W., & Bryce, D. P. (1979). Laryngotracheal trauma: observations on its pathogenesis and its prevention following prolonged orotracheal intubation in the adult. Laryngoscope, 89(8), 1316-1325.
Carnaby-Mann, G. D., & Crary, M. A. (2010). McNeill dysphagia therapy program: a case-control study. Archives of Physical Medicine & Rehabilitation, 91(5), 743-749.
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