Normal and Abnormal Oral and Pharyngeal Swallow. Complications.
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1 ESPEN Congress Gothenburg 2011 Assessment and treatment of dysphagia What is the evidence? Normal and Abnormal Oral and Pharyngeal Swallow. Complications. Pere Clavé
2 Educational Session. Assessment and treatment of dysphagia What is the evidence? 33nd ESPEN Congress, 6 September 2010 Normal and Abnormal Oral and Pharyngeal Swallow. Complications. Pere Clavé MD, PhD. European Society for Swallowing Disorders. Department of Surgery. Hospital de Mataró, Catalonia, Spain. Fundació de Gastroenterologia Dr. F. Vilardell. Autonomous University of Barcelona, Catalonia, Spain. CIBEREHD. Instituto de Salud Carlos III.
3 ESSD MISSION To promote care, education and research in oropharyngeal dysphagia Cooperation with other societies (ESPEN). To consolidate the society as the society for dysphagia in Europe. European Society for Swallowing Disorders
4 Hospital de Mataró, Catalonia, Spain. Autonomous University of Barcelona.
5 OROPHARYNGEAL DYSPHAGIA: 1. Serious symptom / specific complications. Aspiration pneumonia / malnutrition 2. Can be diagnosed. VFS / Pharyngeal Swallow Response. 3. Can be treated. Therapeutic effect of bolus viscosity. 4. Multidisciplinary approach. - Nutritional domain.
6 OROPHARYNGEAL DYSPHAGIA Difficulty from the mouth to the stomach. Functional Oropharyngeal Dysphagia. Prevalence: >50% Neurological diseases. Neurodegenerative diseases. Older people. >30, EU citizens with dysphagia
7 OROPHARYNGEAL DYSPHAGIA: COMPLICATIONS: Impaired Efficacy of deglutition: Malnutrition. Dehydration. Impaired Safety: Chocking. Aspiration (50% pneumonia). Aspiration Pneumonia (mortality 50%).
8 Healthy volunteer Healthy volunteer. 10 ml nectar. VIDEOFLUOROSCOPY Dynamic exploration of swallowing: X Ray-tube. Lateral plane. Hydro soluble contrast. Viscosity: Liquid-nectar-pudding. Volume: ml
9 VIDEOFLUOROSCOPY Aims: Evaluate safety and efficacy of swallow. Identification of VFS signs. Effect of treatments. Measurements of swallow response.
10 Oral phase. Efficacy. Tongue control (abnormal). Tongue propulsion (abnormal). Oral residue (abnormal) Apraxia. Impaired tongue motion.
11 Oral phase. Safety. Bolus. Soft Palate. Glossopalatal seal. Tongue. Aspiration. Pre-deglutitive Aspiration.
12 Pharyngeal phase. Efficacy. Vallecula. Pyriform Sinus. Unilateral residue in Right Pyriform Sinus. Pharyngeal residue.
13 Pharyngeal phase. Safety. Penetration. EPIGLOTTIS PENETRATION Laryngeal Vestibule. ARYTENOID VOCAL FOLDS >360 ms. >440 ms.
14 Pharyngeal phase. Safety. Aspiration. EPIGLOTTIS Laryngeal Vestibule. ARYTENOID VOCAL FOLDS ASPIRATION.
15 Aspiration after swallow. Aspiration. Postdeglutitive Residue in Pyriform Sinus. Aspiration. VOCAL FOLDS
16 VFS Signs of OD. Disease I. Efficacy I. Safety Aspirations Stroke 39.5% 61.4% 21.9% Neurodegenerative 44.4% 45.7% 16.2% Mixed (H/N) 45% 45.9% 29.4% Frail Elderly 63.3% 57.10% 17.1% CA Pneumonia 40% 43.5% 20% Clavé. APT, Clavé, Clin Nutr, Rofes, NGM, 2010
17 Oropharyngeal Swallow Response. RESPIRATORY DIGESTIVE RESPIRATORY GPJO-VPJ GPJO-LVC GPJO-UESO UESC-GPJC UESC-VPJO UESC-LVO RECONFIGURATION DURATION. CONCLUSION. GPJO-GPJC VPJC-VPJO LVC-LVO UESO-UESC TOTAL DURATION. GPJO-UESC GPJO-LVO
18 OSR in healthy subjects. 5 ml. TOTAL DURATION. INCREASED by VOLUME UNAFFECTED by VISCOSITY 20 ml. RECONFIGURATION. CONSTANT VERY FAST <200 ms (LVC). <250 ms (UESO) cm/s Clavé P. Rofes BOLUS VELOCITY
19 Total Duration of OSR in Dysphagia. TOTAL DURATION (GPJO-UESC) * P<0.05 ms * * * HEALTHY VOLUNTEERS NEUROGENIC DYSPHAGIA ELDERLY Clavé P. Gastroenterology, 2004.
20 Timing of OSR in dysphagia. CNS diseases. Neurodeg. * * RECONFIGURATION (*p<0.01). DURATION (ns). CONCLUSION (ns). Clavé P. APT, 2006.
21 Propulsion Forces. Elderly. P<0.05 P<0.05 B GPJ s UES t Time (ms) Reduced Tongue Propulsion Residue Clavé P. Neurogastroenterology Motility, 2010.
22 PATHOPHYSIOLOGY OF DYSPHAGIA Impaired OSR in patients with O. Dysphagia: Prolonged duration of OSR Delayed LVC and UESO. Weak tongue propulsion. Neural Muscular Silent aspirations: 55% aspirations in stroke. 21% aspirations in neurodegenerative ds. 44% aspirations in frail elderly. Rofes L. Gastroenterology Research Practice, 2010.
23 SWALLOWING THERAPY. EFFICACY + SAFETY + VFS signs - EFFICACY - SAFETY ORAL FEEDING NON ORAL FEEDING 1) FREE 2) VOLUME & CONSISTENCY 3) POSTURE SENSORY INPUT MANEUVERS 4) PEG +/- REHABILITATION FAMILIES / NURSES SWALLOWING THERAPISTS / DIETITIANS DOCTORS
24 The effect of Bolus Viscosity Effect of bolus modification / Level of evidence: All studies in pubmed on treatment up to November 2008 (59) A. High quality randomized controlled trials. B. Well-Designed non randomized controlled trials. C. Consensus or expert opinions. Speyer R. Dysphagia 2010.
25 The effect of Bolus Viscosity on Dysphagia A) Level A. High quality, randomized. Groher ME, Soft diet / Thickened Fluids B) Level B. Well-designed, non-randomized. Bisch EM, 1994 Thickened Fluids Groher and McKaig, 1995 Pureed Diet Bhattachary N, 2003 Thickened Fluids Clavé P, 2006 Thickened Fluids Speyer R. Dysphagia 2010.
26 VISCOSITY RANGES FOR THICKENED LIQUIDS. Bolus Dynamic viscosity. Thin / Liquid mpa.s Nectar mpa.s Honey mpa.s Pudding. >1750 mpa.s American Dietetic Association, 2002.
27 Therapeutic Effect of Viscosity. 5 ml liquid 5 ml nectar Aspiration. No Aspiration.
28 Impaired safety in the frail elderly. Penetration. Aspiration Liquid 55% Nectar 45% # Pudding 20% # 25 Liquid 15% Nectar 10% # # Pudding 5% 0 Liquid Nectar Pudding 0 Liquid Nectar Pudding # Strong Therapeutic effect of bolus viscosity.
29 Nutritional Status in O. Dysphagia. CNS diseases. Neurodegenerative. Elderly. MNA SGA IMC WL>10% SGA IMC WL>10% 0 SGA IMC WL>10% 0 SGA IMC WL>10% 16-24% %. 66%. Malnutrition. Clavé P. Alimentary Pharmacology Therapeutics, Carrion S & Clavé P, ESSD Meeting, 2011.
30 b) OD in hospitalized elderly patients. Geriatric Unit. Hospital de Mataró. Admissions. N = Age = 84 Dysphagia NO Dysph. Prevalence 44% 66% Malnutrition (MNA<17) 33.3%* 16% Grip Strength (Kg) 16.2* 19.9 Stage (days) 12.2* 10 Barthel at discharge 49.5* yr Mortality 40.4%* 30.6% Cabré M, Serra-Prat M, Clavé P
31 d) Aspiration Pneumonia in Older Adults. 139 elderly patients admitted for pneumonia. Prevalence of dysphagia (VVS-T) : 55% 1-YEAR MORTALITY: 55.4% dysphagia 26.7% safe swallow SAFE SWALLOW Cabré M, Serra-Prat M, Clavé P. Age&Aging, 2010.
32 SUMMARY More than 40% patients with stroke, neurodegenerative diseases or frail elderly patients presented alterations on safety of swallowing (liquids) due to slow pharyngeal response, and are at risk of aspiration pneumonia or respiratory complications. Up to 2/3 patients with neurological diseases presented alterations of efficacy of deglutition caused by impaired tongue propulsion and pharyngeal clearance leading to high prevalence of malnutrition.
33 CONCLUSION Neurogenic dysphagia / older people: High prevalence of malnutrition and respiratory complications. Uniting Europe Against O. Dysphagia. Raising awareness, providing education and standardizing measurements and methods on diagnosis and treatment of OD: Clinical Guidelines. Dysphagia Day EU Consensus on Stages and Viscosities
34 Support the European Society for Swallowing Disorders (ESSD). Thank You
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