Swallow-respiratory coordination. Liza Bergström, Leg. logoped.

Transcription

1 Swallow-respiratory coordination Liza Bergström, Leg. logoped.

2 Biological timeshare When we breathe, we don t swallow When we swallow, we don t breathe Body will always choose to breathe over anything else (including swallowing)

3 Normal swallow-respiratory coordination Apnea Inhalation Swallow Exhalation OR Inhalation Exhalation Swallow Apnea Exhalation

4 Biomechanics Inhalation diaphragm lowered Connection diaphragmoesophagus-pharynx Lengthening and resistance against pharynx Exhalation = better for pharyngeal shortening Strap muscles are best placed to assist hyolaryngeal excursion during exhalation During inhalation the larynx is lowering

5 Swallow-respiratory cycle specifics SPOON Inhalation at spoon contact Small exhalation Apnoea during swallow Exhalation after the swallow CUP Inhalation prior to lip-cup contact Period of apnoea - liquid transferred to oral cavity Pre-swallow expiration Apnoea during swallow Exhalation after the swallow

6 Liza Bergström, Leg. logoped. Swallow respiratory cycle Selley, 1990; Selley, 1994; Pinnington, 2006

7 Exhalation after the swallow - healthy individuals Selley et al.(1989a) 95% Hiss et al. (2001) 86% Hiss et al. (2002) 91% Butler et al. (2007) 83% Dozier et al. (2006a) 79%, n= 70 50ml ingestion cycles (period of sustained apnoea including one or more swallows) 50ml 4.3 swallows (mean); 3.2 ingestion cycles

8 Dozier et al. 2006a contd. Vestibular opening following swallows Always open 67% Mixed (open and closed) 31% Always closed 1.4% Methodological variability Single vs. sequential swallows Task complexity? at greater risk with sequential swallows or no? (skipping rhythm) Evaluation to include BOTH: single and sequential swallows

9 Eating and breathing (solid food) Palmer & Hiiemae(2003) Caveat (small n; n=5) 8g banana; 8g brittle cookie Perturbations of nasal air pressure correlated with masseter activity Produced by motions of jaw Oro-nasal airflow occurs during chewing Facilitates olfaction, taste and flavour perception

10 Air movement at bare minimum during time bolus accumulates towards valleculae Final stages of bolus preparation occurred during plateau in nasal air pressure Variable cycles depending on what is being consumed Extend from 3 sec pre-feeding cycle to up to 15 s feeding cycle (average 6s cookie; 8 sec banana more swallows for banana)

11 Swallow-respiratory patterns Exhalation swallow- exhalation (EE) Inhalation swallow exhalation (IE) more common Exhalation swallow inhalation (EI) Inhalation swallow inhalation (II) less common Look for patterns Same pattern Irregular pattern red flag?

12 Apnoea what we know Apnoea duration increases with age Age (gets longer as we age) Gender (longer in females than males) Volume (see above) Apnoea starts before vocal fold closure and is independent of vocal fold closure Active engagement of diaphragm during apnoea Routinely fixation of abdomen and rib cage during exhalation = active breath holding

13 Drinking and breathing Healthy individuals Deglutition apnoea 1.09 s For all of 3ml, 10ml, 20ml boluses For 100ml continuous drinking 7.7 sec deglutition apnoea Inspiratory post swallow breath

14 Swallow respiratory cycle specifics (Selley et al.) Stroke Variable respiration at spoon contact Variable respiration post swallow (43% Inhalation) Multiple Sclerosis Variable respiration prior to swallow Longer to initiate swallow Apnoea begins earlier and is prolonged

15 Swallow respiratory cycle specifics Motor Neurone Disease As per normal except rapid and multiple swallows per teaspoon of fluid (5ml)

16 Swallow-respiratory patterns Leslie et al. (2002) Stroke Some no difference to healthy pattern Others apnoea of sec followed by 8-12 breaths 25% had Abnormal swallow-respiratory patterns Faster respiratory rates than controls during resting respiration Laryngectomy Triple the period of deglutition apnoea compared with healthy individuals

17 Swallow-respiratory patterns Chronic Obstructive Pulmonary Disease (COPD) (Shaker et al., 1992) Interrupt the inspiratory phase to swallow and recommence in the inspiratory phase Different swallow-respiratory patterns in basal state compared with acute exacerbation

18 Swallow-respiratory patterns Adults = 79% - 96% exhale post swallow Babies = 83% exhale post swallow Stroke = 43% exhale post swallow COPD = depending on the severity, some studies suggest 20 40% exhale.

19 Swallow-respiratory cycle contd Have to go further than the swallow. Swallowing + respiration are intimately linked! Listen for: tidal breathing cessation of breathing-> swallow sounds unvalving of laryngeal system tidal breathing Any deviation from this should be treated as suspect

20 Swallow-respiratory cycle Pre-swallow sounds Swallow sounds Post swallow sounds Glottal release Tidal breathing Practise

21 Healthy pre-swallow sounds Perceptual Breathing, bolus preparation Acoustics Intensity 25 db, frequency 447 Hz Oropharyngeal transit (OPT) time 1.6 sec Viscosity and volume Longer OPT with larger bolus Longer OPT for viscous bolus (thin 1.62, thick 1.92 sec)

22 Swallow sounds Discussed in detail Workbook 2

23 Healthy post swallow sounds: Glottal release sound Perceptually Distinct release of valved air 0.2 secs, 38dB, 1015 Hz Physiological evidence Perlman et al. (2000) Provides similar info to deglutition apnoea Longer period of glottic closure with advancing age and larger bolus volume

24 Liza Bergström, Leg. logoped. Differentiating Features -normal versus abnormal 1. Duration Longer swallow sounds Cichero, 2003 Length of deglutition apnoea Borr, 2007 Glottal release further away Cichero, Number of swallows Borr, 2007; Santamato, Extraneous / abnormal swallow sounds Listen for quality of sounds; intensity of sounds and added sounds Talley & O Connor, Change in post swallow respiration

25 Liza Bergström Normal versus abnormal Why? Describe..

26 Liza Bergström, Leg. logoped. Normal v abnormal swallow-respiration Research There ARE differences between dysphagic vs non-dysphagic swallows Clinically Youmans, 2010; Moriniere, 2008,; Borr 2007 Paediatrics - Almeida, 2008; Lee, 2006 Normal vs abnormal swallow sounds Tune your ear Respiration : normal / changed? Apnoeic period : long? Quick / distinct swallow sounds yes or no? Glottal release? Extraneous sounds (? audible pooling, gurgle, bubbles, crackles, high pitched squeaks)

27 Questions?