ESPEN Congress Madrid 2018

Transcription

1 ESPEN Congress Madrid 2018 Dysphagia In Hospital Setting Diagnosis And Management Of Oropharyngeal And Oesophageal Dysphagia N. Rommel (BE)

2 ESPEN Symposium : Dysphagia in the hospital setting 1 st September 2018, Madrid, Spain Diagnosis and management of oropharyngeal and oesophageal dysphagiao Prof Dr Nathalie Rommel University of Leuven, Neurosciences, Exp ORL, Deglutology TARGID University Hospitals Leuven, Neurogastroenterology & Motility Belgium

3 FNM disclosures Patent holder on AIM technology with T Omari No financial or commercial disclosures

4 Dysphagia Abnormality in the sensorimotor function of mouth, pharynx and oesophagus o o o structural integrity peristaltic function transit of swallow or refluxed food

5 Not OR but AND Oropharyngeal mouth - pharynx upper esophageal sphincter UES Oesophageal esophageal body esophagogastric junction (EGJ)

6 Aims of swallow assessment Identify patients at risk for dysphagia Lessen the impact of dysphagia Provide adequate nutrition

7 Oro - Pharyngeal Dysphagia OPD

8 Fundamental questions in suspected OP dysphagia 1. Is the swallow normal or abnormal? 2. Is aspiration present? 3. Can an anatomical abnormality be identified that might be amenable to surgical or endoscopic intervention (eg, stricture, pouch, cancer)? 4. Can specific motor patterns be identified that assist in dictating swallow therapy

9 Diagnostic options for oropharyngeal dysphagia Rommel & Hamdy, Nature Reviews Gastroenterology Hepatology, 2015

10 Diagnostic options for oropharyngeal dysphagia Rommel & Hamdy, Nature Reviews Gastroenterology Hepatology, 2015

11 Clinical Bedside Dysphagia Examination: aims review of medical/clinical record observation signs and symptoms structural and functional assessment muscles and structures actual swallowing function airway protection and coordination of respiration and swallowing assessment of the effect of bolus modification therapeutic postures or swallow maneuvers tools to detect clinical dysphagia signs eg cervical auscultation and pulse oximetry Rommel N & Hamdy S, Nature Reviews Gastroenterol Hepato 2015 Dysphagia: manifestations and diagnosis Source: ASHA Guidelines Clinical Indicators for Instrumental Assessment of Dysphagia :

12 Signs and symptoms of oropharyngeal dysphagia Symptoms : patient reported Indirect symptoms Signs : observable evidence of dysphagia Rommel & Hamdy, Nature Reviews Gastroenterology Hepatology, 2015

13 Which dysphagia evaluation is indicated? Clinical Assessment Video fluoroscopy FEES Objective? N N N Expertise dependent? Y Y Y Swallowing function evaluation Inter-Rater Reliability Fair-Moderate )Moderate remains to Moderate to (Experts) (poor) Substantial subjective Substantial At the bedside? Y Nin clinical practice Y Readily repeatable? Y N Y Radiation? N Y N Anatomy Partially Y Y Motor function oral Y N Sensory function oral N Y Entire swallow N Y N Aspiration/residue N Y Y

14 Diagnostic options for oropharyngeal dysphagia Rommel & Hamdy, Nature Reviews Gastroenterology Hepatology, 2015

15 Instrumental examination is indicated 1. Patient's signs and symptoms : inconsistent with findings on clinical examination 2. Need to confirm a suspected medical diagnosis and/or assist in the determination of a differential medical diagnosis eg Zenker diverticulum 3. Need to confirm and/or differential diagnosis of dysphagia 4. Presence of nutritional or pulmonary compromise and rule out if oropharyngeal dysphagia is contributing to these conditions 5. Safety and efficiency of the swallow remains a concern 6. Patient is swallow rehabilitation candidate and specific information is needed to guide management and treatment Adapted from Source: ASHA Guidelines Clinical Indicators for Instrumental Assessment of Dysphagia :

16 Which instrumental evaluation is indicated? ESSD Certification courses: Flexible endoscopic Evaluation of Swallowing (FEES) Videofluoroscopic Swallow Evaluation (VFSS) High Resolution Manometry Impedance (HRMI) Master in KU Leuven: Reality : choice also determined by available expertise, equipment and resources Rommel & Hamdy, Nature Reviews Gastroenterology Hepatology, 2015

17 Which dysphagia evaluation is indicated? Clinical Assessment Video fluoroscopy FEES Objective? N N N Expertise dependent? Y Y Y Inter-Rater Reliability (Experts) Fair-Moderate Moderate to Substantial Moderate to Substantial At the bedside? Y N Y Readily repeatable? Y N Y Radiation? N Y N Anatomy Partially Y Y Motor function oral Y N Sensory function oral N Y Entire swallow N Y N Aspiration/residue N Y Y Swallowing function is subjectively in clinical practice

18 Why are diagnostics so difficult? One swallow : a complex series of timed actions 1. laryngeal elevation : upwards movement or proximal excursion UES 2. pharyngeal stripping wave : a peristaltic sequence of pressure increase over time along the entire pharynx 3. UES relaxation : pressure drop over time at the UES 4. reconstitution of the UES resting pressure initiating proximal esophageal contraction

19 Deglutition and its disorders Normal swallow 1. Safe : airway closure 2. Efficient : effective mechanisms of 1. bolus propulsion (oral) 2. bolus clearance (pharynx / UES) Dysphagia = abnormal swallow 1. Not safe (aspiration/penetration) 2. No efficient clearing (residue)

20 Causes of pharyngeal dysphagia Airway closure (laryngeal inlet) Anterior tonguebase movement Posterior pharyngeal wall hypocontractility paralysis UES dysfunction Incomplete relaxation Incomplete opening Motor function or Sensory function

21 Aspiration/ penetration on videofluoroscopy Penetration Aspiration Score PAS scores (Rosenbek) Score Description of Events 1. Material does not enter airway 2. Material enters the airway, remains above the vocal folds, and is ejected from the airway. 3. Material enters the airway, remains above the vocal folds, and is not ejected from the airway. 4 Material enters the airway, contacts the vocal folds, and is ejected from the airway. 5. Material enters the airway, contacts the vocal folds, and is not ejected from the airway. 6. Material enters the airway, passes below the vocal folds, and is ejected into the larynx or out of the airway. 7. Material enters the airway, passes below the vocal folds, and is not ejected from the trachea despite effort. 8. Material enters the airway, passes below the vocal folds, and no effort is made to eject. Rosenbek J, 1996, Dysphagia

22 Aspiration penetration : timing Source : radiologyassistant.nl

23 Zenker Diverticulum abnormal anatomical structure in the pharynx : herniation posteriorly just proximal to the cricopharyngeal muscle (Zenker, 1878). secondary to normally relaxing UES unable to fully distend during UES opening (Cook IJ 2013). restricted UES opening results of muscle fiber degeneration fibro-adipose tissue replacement

24 Web a thin, membranous tissue covered with squamous epithelium often located anteriorly in the post-cricoid region dysphagia non obstructive (liquids) Lateral

25 Osteophyt Lateral a fibrocartilage-capped bony outgrowth of cervical vertebrae common feature of osteoarthritis compress pharyngo-esophageal and laryngo-tracheal segments Identification of Phenotypic Patterns of Dysphagia Garand & Martin-Harris et al, Am J Speech Lang Pathol.2018, Aug 6;27(3):

26 Incoordination of PE segment cricopharyngeal bar (indentation < 3 cm) posterior indentation of pharyngeal lumen between cervical vertebrae 3 and 6 (C3-C6) causing a reduction in UES diameter (Leonard et al, 2004) caused by reduced compliance by CP fibrosis (Dantas R et al, 1990). In most patients does not cause symptoms unless the CP bar is prominent enough to narrow the UES diameter Lateral Distance 2 cm Indentation < 3 cm

27 Videofluoroscopy - Manometry Impedance Videofluoroscopy BOLUS FLOW Manometry MOTILITY Impedance BOLUS FLOW UES Catheter : solid state (OD 3.2mm) : 36 1cm-spaced pressure sensors 16 impedance segments (2 cm)

28 Swallow UES UES Pharyngeal luminal closure UES opening Pharyngeal contractility : force generation UES relaxation Nativ-Zeltzer et al 2016 Dysphagia, Omari et al, Gastroenterol 2012

29 Pressure Flow Analysis (PFA) Impedance Pressure

30 Gastroenterology 2011, Am J Phys 2011, 2012, Am J Gastro 2011, Clin Gastro Hep 2013, UEGJ 2015 Neurogastr Mot , JPGN 2013,; Int J ORL 2015, Frontiers in Neuroscience 2015

31 Sensor Number Measuring swallow function: PFA (pressure flow analysis) Impedance -1 = admittance Impedance Nadir impedance: maximal bolusflow Peak admittance: maximal bolusflow Omari T et al. Gastroenterology 2011, Am J Phys 2011, 2012, Am J Gastroenterol 2011 Rommel et al, Neurogastro Mot 2012, JPGN 2013 Neurogastro Mot 2014 Ferris L, et al Int J ORL 2015, J Peds 2016

32 Sensor Number Pressure Flow Analysis (PFA) PP PNI TNIPP Flow Interval UES NI and admittance Contractile Vigour Bolus Pressurisation Bolus Propulsion Bolus Flow UES Opening Swallow Risk Index (SRI) (Global Swallow Dysfunction) SRI correlates with aspiration on RX = Non-radiological marker for swallow dysfunction Sensitivity = 0.95 Specificity = 1.0 Kappa = Flow Interval*PNI PP*(TNIPP +1) *100 (Gastroenterology, 2011)

33 Diagnosis based on Pressure-Flow Analysis Abnormal Swallow Risk Index (Swallow dysfunction) PP PNI TNIPP Flow Interval UES NI Contractile Force Intrabolus pressure Bolus Propulsion Bolus Flow UES Opening Gastroenterology, 2011

34 Presbyphagia : increased swallow risk in healthy aging Functional Reserve Marker for swallow dysfunction leading to aspiration risk Swallow risk index Significant age effect per volume ANOVA p<0.05 Data : 68 Asymptomatic controls yrs (Omari et al., NMO 2013)

35 PFA in patients with Motor Neuron Disease (MND) Swallow risk index < 15 predictive for PEG free survival in patients with motor neuron disease PEG free survival PEG free survival SRI < 15 SRI => Days elapsed N = 18 Early data P > 0.05 Cock et al. In review

36 Clinical scenarios of inadequate UES opening 1. Normal UES relaxation and pharyngeal hypocontractility 2. Abnormal UES relaxation and normal pharyngeal contractility 3. Abnormal UES relaxation and pharyngeal hypocontractility 4. Normal UES relaxation and normal pharyngeal contractility and abnormal sensitivity/poor oral control

37 Inadequate UES opening UES relaxation : normal Pharynx : hypocontractility Female pt, 63 yrs, oropharyngeal tumor, currently chemotherapy Clinical complaint : coughing during liquids?: oral feeding? swallow safety?

38 Inadequate UES opening UES relaxation : incomplete Pharynx : normal contractility Female pt, 66 yrs, dyshagia for solids Clinical complaint : effort to swallow, difficult oral intake solids?: UES dysfunction? Aspiration?

39 Inadequate UES opening UES relaxation : incomplete Pharynx : abnormal contractility Male pt, 59 yrs, progressive dyshagia for liquids and solids Clinical complaint : choking difficult oral intake?: UES dysfunction? Aspiration?

40 Inadequate UES opening UES relaxation : complete Pharynx : normal contractility abnormal sensitivity/poor oral control Female pt, 54 yrs, progressive supranuclear paresis (PSP) Clinical complaint : dyshagia on liquids?: UES dysfunction? Aspiration?

41 Management oropharyngeal dysphagia PO, NPO, partial NPO Focus on dysfunction o Central o Neuroplasticity, reorganisation: transcranial / pharyngeal electrical stimulation Periferal Rehabilition : maneuvers, exercises : strength versus skill Endoscopic interventions : dilation, botox Chirurgical intervention : myotomy, vocal fold medialisation, laryngectomy o Both Focus on recovery of function, despite permanent dysfunction : compensation Positioning bolus modification (European Classification EC label viscosity IDDSI)

42 Normal swallow LIQUID SEMISOLID SOLID

43 BOLUS VELOCITY PHARYNGEAL SHEAR RATE B BOLUS VELOCITY (cm/s) HEALTHY V. SHEAR RATE S -1 Oral phase 50 GPJ s Mesoparynx 120 Time (ms) t UES Lingual Pressure Bolus Velocity Pharyngeal Shear Rate Hypopharynx Bolus head (35 cms/s) Bolus tail (10 cm/s) Esophagus (3 cm/s DYSPHAGIA Hypopharynx 10 cm/s (Elderly OD)

44 VISCOSITY DURING SWALLOWING Apparent viscosity of thickened fluids is strongly affected by dose of thickener (amount in g) by shear-thinning behavior effect of salivary amylase Apparent viscosity of the liquid depends on shear rate decreases as the shear rate (and bolus velocity) increases There is a characteristic shear rate that dominates oral (50 s -1 ) pharyngeal ( s -1 ) bolus flow mesopharynx ( s -1 ) The viscosity at the mesopharynx (laryngeal vestibule) strongly affects safety of swallow Gallegos C, et al Adv Food Nutr Res Zhu JF, et al J Text Stu

45 TERMINOLOGY. LEVELS OF VISCOSITY Terminology of each level of viscosity and labelling EC 250 EC= ESSD Classification/ Terminology of viscosity levels for fluid thickening in OD The number indicates the apparent viscosity (mpa.s) at 50s -1 and 25ºC EC 250 EC 500 EC 1000

46 EXAMPLE OF LABELLING PRE-THICKENED FLUIDS EC 1500 Composition: 40% Xanthan Gum / 60% Maltodextrin Dose = 12 g / 100 ml Viscosity at 300s -1 = 400 mpa.s Viscosity by Amylase = 1300 mpa.s Indication to Use and Instructions in the leaflet. Viscosity at 50s - 1 Compositio n Dose Shear Thinning Amylase Resistance Instructions for Patients

47 Oesophageal Dysphagia

48 Clinical diagnostic algorithm dysphagia aerophagia belching rumination Post fundoplication Bariatric surgery Nature Reviews Gastroenterology Hepatology, Zerbib & Omari, 2015

49 High Resolution Manometry (HRM) HRM : test of choice for oesophageal function testing Goal: measure o o contractile events relaxation in its sphincters UES Proximal (striated) o o timing amplitude Distal (smooth) Distal (smooth) LES / EGJ

50 High resolution manometry (HRM) Low resolution Line plot HRM line plot HRM Pressure iso-contour plot Clouse plot mmhg

51 High resolution Manometry (HRM) High resolution manometry: technical (r)evolution Low to high resolution Perfused to solid state Clinical applicability Reliability of equipment catheter diameter Gyawali et al. Neurogastroenterology Motility 2013

52 HRM catheter Solid state HRM catheter Water perfused HRM catheter Silicon catheter, mm OD Transnasal placement with topical anesthesia Sensors straddle UES, esophageal body, LES

53 High resolution manometry Length along the 15 esophagus (cm) 20 Onset of swallow M UES mmhg s EGJ 0

54 High Resolution Manometry

55 Normal Minor disorders of peristalsis Major disorders of peristalsis EGJ disorders IRP normal 100% failed peristalsis or spasm Achalasia Type I: no contractility Type II: 20% panesophageal pressurization Type III: 20% spasm (DL <4.5s) IRP normal not Type I-III achalasia EGJ outflow obstruction Incompletely expressed achalasia Mechanical obstruction IRP normal short DL or high DCI or 100% failed peristalsis Distal esophageal spasm (DES) 20% premature (DL<4.5) Jackhammer esophagus 20% DCI >8000 mmhg.cm.s Absent contractility No scorable contraction (DCI <100 mmhg.cm.s), consider achalasia IRP normal 50% ineffective swallows Ineffective motility (IEM) 50% ineffective swallows (DCI <450 mmhg.cm.s) Fragmented peristalsis 50% fragmented swallows (breaks >5 cm) and not ineffective (DCI >450 mmhg.cm.s) IRP normal >50% effective swallows Normal esophageal motility

56 Normal Minor disorders of peristalsis Major disorders of peristalsis EGJ disorders IRP normal 100% failed peristalsis or spasm Achalasia Type I: no contractility Type II: 20% panesophageal pressurization Type III: 20% spasm (DL <4.5s) IRP normal not Type I-III achalasia EGJ outflow obstruction Incompletely expressed achalasia Mechanical obstruction IRP normal short DL or high DCI or 100% failed peristalsis Distal esophageal spasm (DES) 20% premature (DL<4.5) Jackhammer esophagus 20% DCI >8000 mmhg.cm.s Absent contractility No scorable contraction (DCI <100 mmhg.cm.s), consider achalasia IRP normal 50% ineffective swallows Ineffective motility (IEM) 50% ineffective swallows (DCI <450 mmhg.cm.s) Fragmented peristalsis 50% fragmented swallows (breaks >5 cm) and not ineffective (DCI >450 mmhg.cm.s) IRP normal >50% effective swallows Normal esophageal motility

57 EGJ disorders: Achalasia Three types achalasia Type 1 Type 2 Type 3

58 EGJ Disorders EGJ Outflow Obstruction (EGJOO)

59 Normal Minor disorders of peristalsis Major disorders of peristalsis EGJ disorders IRP normal 100% failed peristalsis or spasm Achalasia Type I: no contractility Type II: 20% panesophageal pressurization Type III: 20% spasm (DL <4.5s) IRP normal not Type I-III achalasia EGJ outflow obstruction Incompletely expressed achalasia Mechanical obstruction IRP normal short DL or high DCI or 100% failed peristalsis Distal esophageal spasm (DES) 20% premature (DL<4.5) Jackhammer esophagus 20% DCI >8000 mmhg.cm.s Absent contractility No scorable contraction (DCI <100 mmhg.cm.s), consider achalasia IRP normal 50% ineffective swallows Ineffective motility (IEM) 50% ineffective swallows (DCI <450 mmhg.cm.s) Fragmented peristalsis 50% fragmented swallows (breaks >5 cm) and not ineffective (DCI >450 mmhg.cm.s) IRP normal >50% effective swallows Normal esophageal motility

60 Major disorders of peristalsis Spasmes Jackhammer Aperistalsis

61 Normal Minor disorders of peristalsis Major disorders of peristalsis EGJ disorders IRP normal 100% failed peristalsis or spasm Achalasia Type I: no contractility Type II: 20% panesophageal pressurization Type III: 20% spasm (DL <4.5s) IRP normal not Type I-III achalasia EGJ outflow obstruction Incompletely expressed achalasia Mechanical obstruction IRP normal short DL or high DCI or 100% failed peristalsis Distal esophageal spasm (DES) 20% premature (DL<4.5) Jackhammer esophagus 20% DCI >8000 mmhg.cm.s Absent contractility No scorable contraction (DCI <100 mmhg.cm.s), consider achalasia IRP normal 50% ineffective swallows Ineffective motility (IEM) 50% ineffective swallows (DCI <450 mmhg.cm.s) Fragmented peristalsis 50% fragmented swallows (breaks >5 cm) and not ineffective (DCI >450 mmhg.cm.s) IRP normal >50% effective swallows Normal esophageal motility

62 Minor Disorders of Peristalsis IEM Fragmented Peristalsis Ineffective Esophageal Motility (IEM) Normal EGJ relaxation 50% ineffective swallows DCI 18 mmhg.s.cm DCI 187 mmhg.s.cm Failed, but less than 100 % Weak

63 Normal Minor disorders of peristalsis Major disorders of peristalsis EGJ disorders IRP normal 100% failed peristalsis or spasm Achalasia Type I: no contractility Type II: 20% panesophageal pressurization Type III: 20% spasm (DL <4.5s) IRP normal not Type I-III achalasia EGJ outflow obstruction Incompletely expressed achalasia Mechanical obstruction IRP normal short DL or high DCI or 100% failed peristalsis Distal esophageal spasm (DES) 20% premature (DL<4.5) Jackhammer esophagus 20% DCI >8000 mmhg.cm.s Absent contractility No scorable contraction (DCI <100 mmhg.cm.s), consider achalasia IRP normal 50% ineffective swallows Ineffective motility (IEM) 50% ineffective swallows (DCI <450 mmhg.cm.s) Fragmented peristalsis 50% fragmented swallows (breaks >5 cm) and not ineffective (DCI >450 mmhg.cm.s) IRP normal >50% effective swallows Normal esophageal motility

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65 Management oesophageal dysphagia o o o o Revalidation Positioning: alterations Maneuvers: effortful swallowing Endoscopic interventions Dilatation Botox injection Per Oral Endoscopic Myotomy (POEM) Chirurgical intervention myotomy Pharmacological treatment e.g. Buspirone: serotonin receptor agonist (5-HT1A) anxiolytic drug, oral increases esophageal contractily Scheerens C et al UEG Journal 2016

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69 Take home messages Dysphagia : oropharyngeal AND esophageal o o biomechanics remain specific per patient biomechanics are not always similar in subgroups of pathology fe MS, Parkinson Assessment If RX pathologic : 1. different physiological processes can drive RX pathology 2. important for management to define these processes Combined HRM with video or impedance, are implemented into clinical care Novel assessment e-platforms available and clinically implemented Management o o Novel therapies? Some experimental : e.g. pharyngeal electrical stimulation Improved management in OPD? Yes e.g. pharmacological agents Reason = improved understanding of pathophysiology : improved patient care: KEY meassage : target the failed biomechanics

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