•why is it important to assess and manage dysphagia ...an impairment at any of these levels could...
TRANSCRIPT
DYSPHAGIA REVIEW
Deanna Britton, PhD, CCC-‐SLP Department of Rehabilitation Medicine University of Washington, Seattle, WA
Objectives
• Why is it important to assess and manage dysphagia?
• Anatomy & physiology review • MD Role: When to refer for swallowing
assessment & treatment • SP Evaluation of Swallowing
THE Ability to EAT/swallow is a “biopsychosocial, sensorimotor activity that is a key element of healthy life” (JoAnne Robbins)
“Dysphagia”
• Medical term referring to swallowing difficulty
• Includes difficulty in any of the three phases of swallowing: Oral, pharyngeal &/or esophageal
The problem of dysphagia
Why is assessment & management of dysphagia important??
The problem of dysphagia
• High prevalence in rehabilitation populations, e.g., individuals with neurological impairments
• Leads to substantially longer hospital length of stay (Altman et al., 2010)
• In rehabilitation patients, the presence of dysphagia is associated with a 13-‐fold increased in risk for mortality (Altman et al., 2010).
Prevalence of dysphagia: EXAMPLES• Neurological impairments
• Stroke: >50% prevalence (Mann et al 2000) • Cervical spinal cord injury: increased frequency of dysphagia associated
with tracheostomy and increased age (Shin et al 2011) • Developmental disorders, e.g., Cerebral Palsy: 90%; aspiration in 40%
(Rogers et al, 1994) • Degenerative diseases: e.g., PD as high as 80% (Kalf 2011); ALS >95%
• Head & Neck Cancer • Other types of cancer: common (Raber-‐Durlacher et al 2011) – can be affected
by medications, chemo, & radiation side effects, e.g., xerostomia, mucositis, fibrosis, graft v host disease (e.g., following stem cell transplant), etc.
• Tracheostomy / Ventilator Dependence without neurological impairments: Gross et al 2003; Ding & Logemann 2005.
• Following endotracheal intubation: ranges from 3-‐62%; higher (>50%) with prolonged intubation (Skoretz et al 2010)
• Mental Illness: frequencies range from 9 to 42% (Aldridge & Taylor, 2011)
Secondary complications of dysphagia
• Aspiration pneumonia • Inadequate or mal-‐nutrition
• Dehydration • Weight loss • Death
Early identification and management can minimize and/or prevent these complications
Cost: Dysphagia untreated = expensive!!
The cost of assessing and treating dysphagia is well below the cost for treating aspiration pneumonia.
EXAMPLE: Dysphagia post stroke (Katzan et al 2007) • Avg cost of hospitalization for
pneumonia post-‐stroke = $21,043 • Avg cost of hospitalization for stroke
without pneumonia = $6,206
Swallowing anatomy & physiology
A Basic Review
upper airway -‐-‐ multi-‐functional purposes
• Breathing • Speaking / singing • Swallowing / Eating
http://sandykalik.com/2012/04/08/a-breathing-meditation-script/ http://lipmag.com/?attachment_id=22601
Swallowing physiology
• Involves coordination of over 25 pairs of small muscles & multiple cranial nerves
• Involves a combination of voluntary and reflexive behaviors
• Involves coordination of many systems: mouth, pharynx, esophagus, respiratory system
• Involves sensory and motor systems • Coordinated by a central pattern generator in the brainstem
An impairment at any of these levels
could result in a neuromuscular impairment to swallowing.
Swallowing CPG
Composed of 2 major nuclei (bilateral):
• Nucleus solitarius (dorsal): sensory – activated by CNs &/or supramedullary impulses
• Nucleus ambiguus (ventral): motor impulses carried out via CNs (V, VII, IX, X & XII) and cervical spinal nerves 1-3.
Supramedullary areas include: • Bilateral frontal motor & premotor
cortex • Insula • Anterior cingulate gyrus • Parietal cortex (anterolateral &
posterior) • Superiomedial temporal cortex
A= afferent impulses B= CPG C= cortical impulses D= efferent/motor impulses
Normal Swallow
Smith Hammond, 2008
Valves of the upper aerodigestive tract
Conditions for optimal swallowingOral & early pharyngeal phases
• Lips are sealed & tongue tip elevated to prevent anterior leakage. • Nasal passages are open • Oral mucosa is moistened with saliva. • Bolus is compressed between the tongue, hard palate & soft palate • Forceful retraction of the tongue pushes the bolus into the pharyngeal
cavity
http://www.radiologyassistant.nl/en/440bca82f1b77
Bolus split at Valleculae
http://www.bidmc.org/CentersandDepartments/Departments/RehabilitationServices/OutpatientRehabilitationServices/VoiceSpeechandSwallowing/SwallowingDisorders/FiberopticEndoscopicEvaluationofSwallowingFEES.aspx
ORAL Phase problems -‐-‐ examples
• Weakness of the lips, tongue or cheeks due to stroke or other neurological conditions
• Xerostomia • Surgical resection of oral
structures • Weakness of the soft palate
http://www.hopkins-gi.org/GDL_Disease.aspx?CurrentUDV=31&GDL_Disease_ID=0E11DE8C-7FB7-47AE-BC76-766AC830F7BA&GDL_DC_ID=E25BDF77-223D-4B6F-9700-5BE41DBDE28B
HYOLARYNGEAL SUSPENSION & its relation to opening of the UES
Pharyngeal phase -‐-‐ reflexive• Initiated as bolus passes anterior faucial arch and reaches the pharynx. • Soft palate elevation prevents bolus from entering the nasal cavity. • Pharyngeal contractions begin stripping the bolus toward the esophagus • Muscles attached to the hyoid contract to move larynx anterior-superior • Epiglottis flips over the airway entrance • UES relaxes and is mechanically pulled open • After bolus passes, UES muscles contract and esophageal peristalsis takes
over
http://www.radiologyassistant.nl/en/440bca82f1b77
Pharyngeal phase problems -‐ examples
• Delayed timing of swallow reflex • Penetration or aspiration (may
be silent) • Weakness, e.g., laryngeal
elevation, pharyngeal constrictors
• UES dysfunction
http://www.hopkins-gi.org/GDL_Disease.aspx?CurrentUDV=31&GDL_Disease_ID=0E11DE8C-7FB7-47AE-BC76-766AC830F7BA&GDL_DC_ID=E25BDF77-223D-4B6F-9700-5BE41DBDE28B
Esophageal PHASE: Peristalsis
PHARYNGEAL ESOPHAGEAL SEGMENT PROBLEM
Esophageal Achalasia ESOPHAGEAL
SPASM
Coordination of Breathing & Swallowing
PATHOPHYSIOLOGY • Increased post swallow inspiration in individuals with neurodegenerative disease
– Motor Neuron Disease: Hadjikoutis et al., 2000 – Parkinson’s Disease: Gross et al., 2008, Troche et al., 2011
• Increased post swallow inspiration associated with advanced age (Martin-‐Harris et al., 2005)
• Shorter SAD associated with hypercapnia (Boden et al., 2009)
Swallow apnea duration (SAD) Respiratory-‐phase patterns Subglottic Pressure Support for Swallowing
• Facilitates healthy swallowing – May aid expiratory airflow following swallow apnea (Lang et al. 2002;
Nishino & Honda, 1986) – May stimulate mechanoreceptors to aid laryngeal adduction (Shin
et al., 1988)
– Swallowing timing and efficiency is aided by higher lung volume (Gross, 2009)
• PATHOPHYSIOLOGY – Prolonged swallowing associated with lower lung volume (Gross,
2009; Gross et al., 2003)
– Improved swallowing efficiency and timing when trached patients were on (vs. off) mechanical ventilation, and associated with higher MIP (Terzi et al., 2007)
Role of the MD
When to refer for swallowing assessment and treatment
Warning signs• Impaired consciousness • Cognitive impairments • Dependence for feeding • Oral hygiene problems • Aspiration history • COPD or other pulmonary
concerns • GI disease or reflux • Weight loss • Dehydration • C/O pain or obstruction
• Feeding tube • Trach tube • Pocketing food • Dysarthric speech • Wet voice • Hoarse, breathy voice • Coughing or choking • Upper airway congestion • Drooling • Suction for secretions
Possible Symptoms of Dysphagia• Coughing or choking associated
with eating/drinking • Difficulty coughing when
needed • Difficulty initiating a swallow • Difficulty with managing saliva,
e.g., coughing, drooling, wet sounding voice
• Wet voice quality • Sensation of food “stuck”
• Difficulty chewing • Reduced oral control of
food • Difficulty clearing food
from the mouth • Needing more time to
finish a meal • Leakage of food or liquid
through the nose • Weight loss
Treating or managing contributing factors may result in improvements
with swallowing
Possible Contributing FactorsEXAMPLES: • Acid Reflux • Poor oral care • Dental caries &/or gingivitis • Excess oral dryness • Fatigue • Reduced level of alertness • Medication side effects • Weak or absent cough • Tracheostomy • Cervical orthotics • Concomitant injuries or
diagnoses that might affect swallowing
• Cognitive impairments
These factors can exacerbate dysphagia symptoms
EVALUATION OF SWALLOWING
Evaluation of SWALLOWING – Most common
• Clinical “Bedside” Swallow Evaluation (BSSE) • Videoflurorscopic Swallowing Study (VFSS) • Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
EVALUATION OF SWALLOWING – RESEARCH
• Ultrasound • Manometry • Scintigraphy • EMG or SEMG
Clinical swallowing examination
Typically includes 3 components • History
– Medical records review – Interview: e.g., current symptoms, history,
management and patient expectations
• Physical exam of the structure and physiologic function of muscles for swallowing
• Clinical swallow examination (aka, “bedside swallow examination (BSSE)”)
EAT-‐10 -‐-‐ Belafsky et al., 2008
To what extent do you experience the following problems?
1) My swallowing problem has caused me to lose weight. 2) My swallowing problem interferes with my ability to go out
for meals. 3) Swallowing liquids takes extra effort. 4) Swallowing solids takes extra effort. 5) Swallowing pills takes extra effort. 6) Swallowing is painful. 7) The pleasure of eating is affected by my swallowing. 8) When I swallow food sticks in my throat. 9) I cough when I eat. 10) Swallowing is stressful.
Functional Oral Intake Scale (FOIS)Crary et al., 2005
Tube dependent 1) Nothing by mouth (NPO) 2) Tube dependent with
minimal attempts at food or liquid
3) Dependent with consistent intake of liquid or food
Total oral 4) Total oral diet of a single
consistency 5) Total oral diet with multiple
consistencies but requiring special preparation or compensations
6) Total oral diet with multiple consistencies without special preparation but with specific food limitations
7) Total oral diet with no restrictions
OROMOTOR mechanism ExamINCLUDES: • Integrity of Cranial Nerves that
affect swallowing, e.g., V, VII, IX, X, XII
• Muscles of mastication
• Facial symmetry, strength & function
• Intra-oral exam
• Tissues
• Palatal function, sensation and symmetry
• Lingual function, force, speed, ROM and coordination
• Laryngeal function/voice quality
Measurement of Cough Subjective Judgment or Peak Cough Flow
• Peak cough flow (PCEF) = maximal expiratory flow rate during a cough maneuver.
PCF Level Clinical significanceGreater than 500 L/min
Typical threshold for healthy adults; minimal risk of airway encumbrance
Less than 270 L/min Increased risk for airway encumbrance
160 L/min Minimum threshold to move mucous from lungs into the upper airway
References: Bach & Saporito, 1996; Boitano, 2006; Toussaint et al., 2009; Table from: Britton, Cleary and Miller, 2013
Clinical swallow exam
INCLUDES: • Palpation of larynx during
swallow – volitional/dry swallow, and trial with food/liquid (if appropriate)
• Direct observation of oral phase
• Indirect observation for signs of aspiration with pharyngeal phase
Tracheostomy / Vent: Brief Review
• Trach is located below vocal folds
• Inflated trach cuff results in aphonia
• Trach/mechanical ventilation may impact swallow biomechanics
• Ventilator settings affect subglottic pressure for speech & swallowing
Passy Muir, Inc
Modified Evans Blue Dye Test
http://www.phageinblue.com/
0Blue dye test 0A small amount of blue food coloring is placed on the tongue
0 Patient is suctioned immediately
0 Patient is suctioned later (to check for delayed aspiration)
0 Positive test: Presence of blue dye observed at the trach site &/or upon tracheal suctioning.
0Negative test: Absence of blue dye at the trach site and upon tracheal suctioning.
0Can be mixed with ice chips, water &/or other food consistencies as well.
A few controversies regarding blue dye swallow studies
• How is the blue dye administered? Is it free of contamination?
• Is blue dye safe? • How sensitive or specific are blue dye swallow studies?
Blue dye: ?adverse effects?Risk with use of blue dye for those with increased gastrointestinal permeability includes the following diagnoses: • Sepsis (75% of adverse event cases included septicemia as a diagnosis): Suggest avoid blue dye use in patients currently diagnosed with sepsis.
• According to the FDA, other diagnoses that may increase risk for gastrointestinal permeability include: – Burns – Shock – Multiple trauma (acute) – Renal failure – Inflammatory Bowel Disease – Surgical Intervention – Bowel disease / Celiac Sprue Disease
Czop & Herr, 2002
How sensitive /specific are blue dye studies?
Studies Sensitivity Specificity
Brady et al., 1999 50% Not reported
Donzelli et al., 2001 50% Not reported
Peruzzi et al., 2001 45% 100%
Belafsky et al., 2003 82% 38%
O’Neil-‐Pirozzi et al., 2003 80% 62%
Winklmaier et al., 2007 92% 100%
Blue dye: sensitivity• Blue dye may not adequately detect trace – min aspiration. It may detect larger amounts of aspiration only
• For some patients, use of blue dye may help determine appropriate timing for further instrumental exam, therefore minimizing exposure to radiation and reducing costs.
VIDEOFLUOROSCOPIC SWALLOW STUDY (VFSS) aka, modified barium swallow study (MBSS)
VFSS -‐-‐ Basic questions to ask• Penetration or aspiration? • Residue?
• Then determine – Where? – When? – Why? – Patient spontaneous response? – Interpretation, in light of the patient’s age and medical diagnosis
– What can be done?
Patient Position
Make note of…… • Position during exam, e.g., seated, standing
• Positional restrictions or abnormalities
• Positional supports
Biomechanics
• Examples – Closure of valves – Pharyngeal constriction – Hyolaryngeal Elevation – Laryngeal valve closure – UES opening
Timing / coordination
• Timing of aspiration – before, during or after the swallow
• Premature spillage • Laryngeal valve closure in relation to bolus head
• Adequacy & timing of PES opening
Aspiration / Penetration
• Observed: yes or no • Amount • Estimated % of total bolus aspirated • How far into the airway • Patient response (e.g., expulsion/clearance) • Timing: before, during or after the swallow
PENETRATION-‐ASPIRATION SCALE Rosenbek, Robbins et al. Dysphagia. 11, 93-‐98, 1996 PA Scale
BENEFITs • Reliable method to document
depth & response to penetration/aspiration
• Good outcome tool– can demonstrate functional change
• Can determine abnormality. • Can characterize certain
populations (see next examples).
CAVEATs• Does not quantify all swallow
events! • Does not indicate swallow
physiology or degree of dysfunction
• Not truly ordinal • Not a dysphagia severity scale. • Does not indicate timing of
aspiration or penetration (i.e., before, during or after)
VFSS – GOLD STANDARD
CONS • Expensive • Time-‐consuming • Unavailable at some
locations • Radiation exposure • May not replicate a
patient’s natural setting • Variable procedures across
facilities
PROS • Can view features not
observable in the clinical exam
• Pharyngeal & esophageal stages
• Silent aspiration • Assessment can be subjective
and/or objective
Fiberoptic endoscopic evaluation of swallowing (FEES)
• Allows direct observation of airway protection and pharyngeal phase structures
• Food/liquids usually mixed with food coloring
• Involves a scope with a camera inserted through the nose
• Accuracy for aspiration is comparable with VFSS
Intrinsic larynx
ee
Vallecula
False vocal fold
Arytenoid cartilage
Pyriform sinus
True vocal fold
Pyriform
sinus
ValleculaEpiglottis
FEES
Benefits of FEES
• Evaluation of hypopharynx and laryngeal anatomy • Visualization of pooled secretions • Easily portable system • No adverse complications with repeated or longer exams
• Direct examination of laryngeal sensation • Can observe frequency of spontaneous swallows
Limits of FEES
• Oral cavity and tongue are not visualized – Can visualize base of tongue – Can visualize movement of bolus to hypopharynx – Can visualize premature spillage of bolus
• White out – visualization is blocked at the height of the swallow
• Limited visualization of the UES opening • Assessment or screening of esophageal phase is not possible
VFSS vs. FEES –Langmore (2006)
Only VFSS • Bolus during height of
swallow • Oral and esophageal phases • Tongue retraction • UES opening • Laryngeal elevation • Extent of aspiration • Submucosal changes, e.g,
osteophytes
Only FEES• Secretions • Sensation (direct assessment) • Surface anatomy • Mucosal abnormalities • Glottic closure • Path of bolus (direct) • Location of bolus in hypopharynx • Effect of altered anatomy on bolus
flow and airway protection.
Management of Oropharyngeal Dysphagia
• Diet • Posture • Environment • Maneuvers • Therapeutic exercises
Why consider pulmonary function and defenses?
An important objective in assessment of swallowing is to estimate the individuals' risk for developing
aspiration pneumoniaBreathing is integral to & tightly coordinated with swallowing.
– Breathing swallowing coordination – Subglottic pressure support for swallowing – Changes in swallowing can impact breathing & vice versa
Why consider pulmonary function and defenses?
Pulmonary defensesPulmonary defenses guard the lungs from infections. Pulmonary defenses include protective….. • Anatomic features • Mucocilary clearance • Reflexes, including cough • Volitional cough • Cellular defenses Certain conditions and interventions can impair pulmonary defenses
▪ Loss of anatomical defenses
▪ Blunted protective reflexes
▪ Poor cough
▪ Impaired mucociliary clearance
▪ Weakened immunologic defenses
Summary: Host Defense Risk factors for pneumonia
Thank you! THAT’s ALL FOR NOW!
• Questions???