Dysphagia and Self Feeding in Acute Tetraplegia

Transcription

1 Dysphagia and Self Feeding in Acute Tetraplegia Danielle R. Karhut, OTR/L Robert Masterson, MS, CCC-SLP Spinal Cord Rehabilitation Unit UPMC Mercy Hospital/Centers for Rehab Services Pittsburgh, PA

2 Tetraplegia (Quadriplegia) CERVICAL INJURY UE & LE affected Sensory and/or motor impairment Impairment varies with complete vs. incomplete injury C4: Diaphragm, trapezius: Respiration C5: Biceps: Elbow Flexion C6: Radial wrist extensors: Wrist Extension C7:Triceps: Elbow Extension C8: Flexor digitorum: Finger Flexion

3 Incidence/Prevalence of OP dysphagia & SF deficits in Tetraplegia? SCI/Tetraplagia*: SCI Incidence estimated 54 cases per million, approx. 17,000 new cases a year SCI Prevalence approx. 282,000 in the US 13.3% Complete Tetraplegia, 45% Incomplete Tetraplegia Common Cause of Death in SCI Septicemia and Pna Presence of Self Feeding Problems and OP dysphagia in SCI? Unknown but likely HIGH in patients with Tetraplegia *=National SCI Statistical Center 2016

4 Risk Factors for OP dysphagia following SCI Iruthayarajah et al, Spinal Cord (2018) Significant Factor Include: Level of Injury Severity of Injury Need for Bronchosopies Tracheostomy (ORR=3.67) Presence of NG tube C-Spine surgery (ORR=1.3) Poor Cough, Poor breath support Age

5 Swallowing 101: How does it work? Sensory input and feedback Coordinated neurophysiologic events Voluntary control CPG Involuntary control (Esophageal) Biomechanics, Fluid dynamics & pressure-driven events Labial seal VP seal Laryngeal valving UES LES Respiratory control Flow, volume and pressure

6 Phases of Swallowing (Simultaneous Activity) 1. Oral Preparatory Phase 2. Oral Transit Phase Stage Transition: Onset of the Pharyngeal stage 3. Pharyngeal Phase 4. Esophageal Phase

7 What is Dysphagia? Difficulty with eating which may include one or more of the following: Chewing food Swallowing solids and/or liquids Coughing or choking when eating Food sticking in the throat or chest *It is estimated that more than 15 million people in the United States have Dysphagia

8 Dysphagia is not a Disease! (Coyle, 2011) Disease, Condition: Neurologic, Traumatic, Neoplastic, Structural, Iatrogenic, deconditioning, Pulmonary, etc. Dysphagia Disease, Condition: Pulmonary, Nutritional, Community-acquired, Social, Psychological, etc. 8

9 Dysphagia Management Behavioral Tx: Compensatory Strategies Facilitation: Strengthening ex Diet texture/viscosity modification NMES (VitalStim), Sensory Stimulation Neurodevelopment Approach (NDT) Biofeedback Medical/Surgical Interventions Pharmacological interventions 9

10 Effective Dysphagia Management Requires a Multidisciplinary Approach Critical Care Medicine Pulmonary Medicine Infectious Disease Otolaryngology Gastroenterology Radiology Neurology, Neurosurgery & Neurovascular Medicine Psychiatry Physical Medicine and Rehabilitation Dietitian, Pharmacy Nursing Physician Assistants Respiratory therapy Speech Language Pathology (Speech Therapy) Physical Therapy Occupational Therapy Case Management/Social worker Psychologist, Neuropsychologist

11 Self Feeding Important goal for patients with high-level injury Consider aspiration precautions Options for adaptive equipment Muscle groups C5: Biceps: Elbow Flexion C6: Radial wrist extensors: Wrist Extension C7:Triceps: Elbow Extension C8: Flexor digitorum: Finger Flexion

12 Splints & Braces Dorsal wrist splint Positioning (wrist drop) Universal cuff Different types

13 Assistive devices Built up utensils - Different foams - Premade Scoop dishes/ bowls Cups/ mugs

14 Mobile arm support/ sabeo Mas Assistive devices

15 Proper set up Positioning Body (trunk, Upper extremities) Table height * support Upper extremities, difficult seeing (braces), comorbities (shoulders)

16 What does the Research show? Perceived quality of life has negative effect on secondary conditions (Hammell, 2010) Independent verses assisted feeding has significant impact on quality of life and self esteem (Martinsen, 2008)

17 Let s talk about some Cases

18 Case Presentation #1: ACDF with post op Edema 84 YOM admitted to UPMC Mercy on 11/2/17 after falling Right frontal SAH/IVH and C5-6 disc burst s/p C4-6 ACDF and Corpectomy on 11/3/17 Post operatively had posterior pharyngeal wall edema and dysphagia MBS completed on 11/7: NPO, severe edema NPO with DHT (feeding tube) Short course of Decadron (steroid medication)

19 Anterior Cervical Diskectomy and Fusion (ACDF) and Post Op Dysphagia Acute post op changes Prevertebral edema posterior pharyngeal wall Risk for RLN injury TVF injury, dysphonia Impaired superior HLE, epiglottic inversion Post swallow residue Penetration, aspiration AFTER the swallow

20 MBS Video #1 on 11/7/17: ACDF and Post Op Edema: POD#4

21 MBS Video #2 on 11/15/17: ACDF and Post Op Edema After Decadron

22 Case Presentation #2: SCI, ACDF and Esophageal Fistula 28 YOM w/pmh of anxiety, migraine headaches, pancreatitis admitted to 7/23/17 after ATV (all terrain vehicle) accident Surgery: s/p C3-C6 ACDF on 7/23/17 Post op Right TVF paralysis and dysphagia Prevertebral edema, needed steroids x2 days Regular diet w/nectar thick liquids Transferred to UPMC Mercy Spinal Cord Rehab Unit on 8/2/17 ASIA-C on admission (spinal cord assessment rating)

23 UPMC Mercy Spinal Cord Rehab Dysphagia Evaluations Clinical Beside Swallow Evaluation on 8/2/17: Overt s/s of aspiration on admission, not tolerating diet Repeat MBS, additional tx pending results MBS 8/3/17: Aspiration during the swallow due to incomplete TVF closure Severe residue with pudding Diet rx: Full liquid diet with Nectar thick liquids Tx: Effortful swallow and throat clear after swallow MBS 8/10/17: Essentially unchanged from 8/3/17, Rx: Mechanical soft foods and nectar thick liquids

24 UPMC Mercy Spinal Cord Rehab Dysphagia Evaluations (continued) MBS 10/4/17: Post repair from esophageal fistula (cleared by ENT/surgery) SEVERE PPW edema, scar tissue Aspiration DURING/AFTER the swallow due to reduced pharyngeal clearance, impaired HLE Diet Rx: NPO with swallowing ex, compensatory swallow strategies (effortful swallow) MBS 10/16/17: IMPROVEMENT from 10/4/17, severe residue with thicker viscosities (nectar, honey), penetration/aspiration after the swallow Rx: FULL liquid diet w/effortful swallow, throat clear

25 Neurosurgical, Cardiothoracic and Radiological Evaluations Otolaryngology Evaluation on 8/10 via flexible laryngoscopy: Rx: TVF gelfoam injection, Gastroview esophogram swallow to r/o leak Neurosurgery noted air/gas on repeat neck CT on 8/12/17 Ordered Gastroview/Esophogram and consult to surgery Radiology completed Gastroview/Esophogram 8/24/2017 1cm posterior wall of the cervical esophagus

26 Gastroview Swallow (Barium Esophogram) 8/24/17 Suspected leak based on repeat Neck CT imaging (gas/air pocket?) Pt c/o odynophagia, increased secretions Only tolerating nectar thick liquids in small volumes.. SLP thickened gastroview contrast to reduce aspiration risk Gastroview aspiration is DANGEROUS!!!! Found 1cm fistula in PW of cervical esophagus

27 MBS #1 on 8/3/17: SCI/ACDF/Esophageal tear

28 MBS #2 on 8/10/17: SCI/ACDF/Esophageal tear

29 Gastroview/Esophogram #1 on 8/24/17: SCI/ACDF/Esophageal tear

30 Gastroview/Esophogram #2 on 10/3/17: SCI/ACDF/Esophageal tear

31 MBS #3 on 10/4/17: SCI/PCDF/Esophageal fistula repair

32 MBS #4 on 10/16/17: SCI/PCDF/Esophageal fistula repair

33 Questions