中風病人之吞嚥障礙 台東馬偕神經內科 洪國華醫師

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1 中風病人之吞嚥障礙 台東馬偕神經內科 洪國華醫師

2 大綱 1. 中風病人與吞嚥障礙之相關性 2. 吞嚥之解剖生理學 3. 吞嚥困難之分類 4. 如何偵測吞嚥困難? 5. 我們能做什麼?

3 1. 中風病人與吞嚥障礙之相關性 中風後 27-50% dysphagia 43-54% aspiration 37% pneumonia

4 Dysphagia Greek dys (difficulty, disordered) and phagia (to eat) Sensation that food is hindered in its passage from the mouth to the stomach Most patients complain that food sticks, hangs up, stops, just won't go down right

5 吞嚥困難很常見 13~15% 急性病房病人有吞嚥困難 40~50% 安養機構病人有吞嚥困難

6 吞嚥困難可造成 Dehydration Weight loss Poor nutrition Pneumonia Chronic lung disease

7 證據顯示 有計畫的篩檢 診治中風病人之吞嚥困難, 可減少 肺炎發生率 長期使用胃管之機率 住院日

8 2. 吞嚥之解剖生理學 Swallowing Anatomy

9 Physiology of the Normal Swallow 4 Stages 1. Oral preparatory phase 2. Oral-propulsive phase 3. Pharyngeal phase 4. Esophageal phase

10 Physiology of Swallowing: Oral Phase Pharyngeal Phase

11 Physiology of Swallowing Pharyngeal and Esophageal Phase:

12 Normal swallowing of a liquid bolus based on a videofluorographic recording

13 Esophageal Anatomy Muscular tube connecting the pharynx to the stomach Esophagus begins where the inferior pharyngeal constrictor merges with the cricopharyngeus Upper esophageal sphincter (UES) 18 to 26 cm in length Lower esophageal sphincter (LES) Thickened circular smooth muscle 40cm from incisors

14 Esophageal Peristalsis At rest UES & LES tonically contracted Immediately after a swallow UES pressure falls transiently Shortly thereafter LES pressure falls and remains low until the peristaltic contraction closes the LES 問 : 倒立時可吞嚥嗎?

15 要怎麼吃才 不會胖?

16 Diseases and disorders causing dysphagia Neurologic disorders and stroke Cerebral infarction Brain-stem infarction Intracranial hemorrhage Parkinson s disease Multiple sclerosis Motor neuron disease Poliomyelitis Myasthenia gravis Dementias Connective tissue diseases Polymyositis Muscular dystrophy Structural lesions Thyromegaly Cervical hypertosis Congenital web Zenker s diverticulum Ingestion of caustic material Neoplasm Iatrogenic causes Surgical resection Radiation fibrosis Medications Psychiatric disorders Psychogenic dysphagia

17 3. 吞嚥困難之分類 吞嚥困難分兩大類 Oropharyngeal dysphagia Difficult initiating swallows Esophageal dysphagia Food sticks after swallow

18 Oropharyngeal Dysphagia

19 Oral Dysphagia Oral Preparatory deficits: - difficulties manipulating food and forming a bolus Oral Propulsive deficits: - > 2 seconds transferring bolus from oral cavity to pharynx

20 Oral dysphagia following stroke Lip weakness: Anterior loss of bolus. Loss of food. Difficulty in holding the bolus in mouth. Tongue weakness: Difficulty with process of mastication and bolus transit. Residue may remain in oral cavity. Pre mature spill over may occur too. Cheeks weakness: Difficulty with retaining food in the mouth. May result in pocketing of food on the weak side. Reduced Oral Sensitivity: Food is not felt in the mouth and may be lost earlier in the oral cavity and aspirated before swallow. Jaw weakness: May affect the adult rotary chewing pattern.

21 Symptoms of Oral Dysphagia Drooling Oral spillage Residuals in lateral sulci Scattered lingual residuals Nasal regurgitation Increased oral prep and oral transit Decreased or absent gag reflex Mashing chewing pattern

22 Pharyngeal Dysphagia More difficult to detect because structures and processes are not easily seen. Difficulty moving food/liquids into the esophagus. - penetration(a)/aspiration (B) - pharyngeal residue

23 Pharyngeal dysphagia following stroke Weakness of throat: Laryngeal muscles not strong enough to move up and down Epiglottis does not completely fall down Disorders that may affect pharyngeal stage are: Delayed or absent swallow reflex Inadequate velum closure resulting in nasal regurgitation One sided weakness of pharynx Reduced peristalsis Reduced laryngeal elevation and closure Cricopharyngeal dysfunction

24 Symptoms of Pharyngeal Phase Delayed initiation of the swallow Wet voice Cough before, during or after the swallow Absent swallow reflex Reduced laryngeal elevation

25 Dysphagia in different strokes

26 檢查口咽性吞嚥困難兩大利器 VFSS 和 FEES Concurrent Videofluoroscopic Swallow Study (top panel) & Fiberoptic Endoscopic Evaluation of Swallowing(bottom panel)

27 Videofluoroscopic Swallow Study (VFSS) Vs Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

28 Fiberoptic Endoscopic Evaluation of Swallowing (FEES) Epiglottis Vallecular Space Base of Tongue

29 Viewing the laryngeal vestibule Arytenoid Arytenoid Vocal Folds

30 Spillage of milk to vallecular space Vocal Cords Ary-Epiglottic Fold Laryngeal Vestibule Vallecular Space Vallecular Space Epiglottis

31 Spillage of milk to pyriforms Pyriform Space Pyriform Space Borders of Laryngeal Vestibule

32 Milk builds up in the pyriforms Pyriforms

33 Aspiration occurs as milk spills into the laryngeal vestibule and airway Milk spills over ary-epiglottic folds and 33 arytenoids into glottis

34 Esophageal Dysphagia Bolus takes longer than normal to travel to the stomach Retention of food in the esophagus caused by mechanical obstruction, motility disorder or impaired LES function.

35 Symptoms of Esophageal Dysphagia Regurgitation Patient complains of food sticking high in throat Pain in the chest when they swallow (odynophagia)

36 Esophageal Dysphagia

37

38 Diagnosis Esophagogram Delineate the stricture Distal stricture Caustic ingestion Endoscopy Evaluate the mucosa normal mucosa Barrett's metaplasia

39 Barium Esophagram

40 Management of Esophageal Dysphagia

41 Gastroesophageal Reflux Disease GERD is recognized in about 10-15% of the population Reflux esophagitis Changes in the esophageal mucosa Present in 30% to 40% Barrett's esophagus 10% to 20% Defects in the esophagogastric barrier such as LES incompetence Transient relaxation of LES Hiatal hernia

42 Gastroesophageal Reflux Disease

43 GERD Diagnosis Classic symptom is heartburn Retrosternal burning discomfort and acid regurgitation Other symptoms are dysphagia, odynophagia, and belching

44 GERD Vs Silent Reflux

45 Swallowing Problems

46 Drugs that cause dysphagia (1) Xerostomia Anticholinergics Antihypertensives Cardiovascular agents Diuretics Opiates Antipsychotics Antiemetics Antidepressents Muscle relaxants Antihistamines

47 Drugs that cause dysphagia (2) Reduced lower esophageal sphincter pressure (increased reflux risk) Theophylline Nitrates Calcium antagonists Anticholinergics Diazepam Morphine

48 Drugs that cause dysphagia (3) Esophageal injury Alendronate and biphosphonates Tetracycline and derivatives Ascorbic acid NSAIDs and aspirin Ferrous sulfate Prednisone Potassium chloride Quinidine

49 Drugs that cause dysphagia (4) Extrapyramidal effects Antipsychotics Metoclopramide Prochlorperazine (Risperidone)

50 Tracheostomy & Laryngotracheal Separation

51 4. 如何偵測吞嚥困難? 嚴重中風 意識不清 / 癱瘓 / 失語 / 半側忽略 / 視野缺損 高齡 嚴重失智 顏面神經麻痺 無力咳嗽 說話時發出呼嚕音 肺炎 潛在吞嚥困難者

52 Sword-swallowing cowboy busts record

53 A man needed surgery after accidentally swallowing scissors while laughing

54 馬偕紀念醫院台東分院腦中風病房 測試步驟 吞嚥功能檢測法 1. 讓病人坐著接受檢測 2. 倒 30ml 白開水於小藥杯中, 再讓病人服用 3. 觀察以下項目並記錄之 觀察項目 1. 吞嚥之口咽期 2. 流口水 3. 喝水時或飲用後一分鐘之內咳嗽 4. 發聲困難

55 馬偕紀念醫院台東分院腦中風病房 吞嚥功能檢測法觀察項目 吞嚥之口咽期 : <2 秒 ( 正常 ) 2~3 秒 ( 輕度吞嚥遲滯 ) >3 秒 ( 顯著吞嚥遲滯 ) 流口水 ( 無法控制飲用之水, 以致其從嘴角溢出, 且口中含著過多的水 ) 喝水時或飲用後一分鐘之內咳嗽 發聲困難 ( 喝水後說話有濕囉音或聲音沙啞 )

56 吞嚥之口咽期 ( 從水進入口腔至舌骨開始升起之時 ) 可用手指觸摸並感知之

57 馬偕紀念醫院台東分院腦中風病房 吞嚥功能檢測法評估及處置 吞嚥功能正常 ( 無異常項目 ) 可選擇一般飲食 輕度吞嚥功能障礙 ( 病患僅有輕度吞嚥遲滯或其他一項異常項目 ) 給予半流質飲食並使用輕鬆吞 顯著吞嚥功能障礙 ( 病患有顯著吞嚥遲滯或至少兩項之異常項目 ) 給予管灌餵食

58 5. 我們能做什麼? Stroke survivors NPO Swallowing team screening for dysphagia NEGATIVE POSITIVE Eat or be fed normally SLP assessment of swallow RD assessment of nutrition Low risk High Risk Monitoring by any dysphagia team member Monitoring by SLP

59 Dysphagia Team Golden Ticket Certified Nursing Assistants Nurse Doctor Dietitian Physical Therapy Occupational Therapy Speech Therapist Family Patient

60 中風後吞嚥困難病人 宜用學習杯嗎?

61 中風後吞嚥困難病人 可以使用吸管喝水嗎?

62 Oral hygiene and dysphagia The two modifiable risk factors that could prevent development of nursing home acquired pneumonia Patients do not need these risk factors to occur simultaneously for pneumonia to develop Management of oral hygiene and swallowing difficulties may reduce the risk of pneumonia Quagliarello, V., Ginter, S., Han, L., Van Ness, P., Allore. H., & Tinetti, M. (2005). Modifiable risk factors for nursing home-acquired pneumonia. Clinical Infectious Diseases, 40, 1-6

63 Flow chart of pneumonia development Dysphagia & pneumonia: a complex relationship (Langmore 1998) Colonisation (altered oropharyngeal flora): Aspiration into lungs Host resistance Pneumonia

64 Signs of poor oral hygiene Plaque and debris Development of infections in the mouth such as mouth ulcers Dental caries Loss of teeth Pain and discomfort in the mouth Altered taste

65 Signs of poor oral hygiene Dry mouth Fissures of the tongue Inability to wear dentures Periodontal disease Halitosis (Rieger et al 2005; Roberts 2000)

66 Oral Hygiene For patients who cannot tolerate managing secretions/expectorating, there are suction toothbrushes available (or brush and suction with Yankauer simultaneously)

67 Aspiration Occurs when food or liquid (including saliva) enter the trachea Silent aspiration occurs in individuals with reduced laryngeal sensation (no coughing, throat clearing or changes in vocal quality) Not everyone who aspirates develops aspiration pneumonia (AP)

68 Factors of Aspiration Pneumonia Oral hygiene Dependency on others for oral care/feeding Dental caries Tube feeding Medical conditions (COPD, cancer, malnutrition, cardiac disease, DM, multiple strokes)

69 Clinical assessment of swallowing and prediction of dysphagia severity Six clinical features were associated with risk of aspiration Dysphonia Dysarthria Abnormal volitional cough Abnormal gag reflex Cough on trial swallow Voice change on trial swallow The presence of any 2 of these 6 clinical features correctly identified risk of aspiration with 92% accuracy Am J Speech Lang Pathol 1997;6:17 24

70 Timing of Aspiration Episode

71 There are several options for treating dysphagia Compensatory Techniques - Help to decrease symptoms of dysphagia without changing the actual process of swallowing Direct Treatment - Involves active exercises that can alter muscle function and the actual process of swallowing (Bloom & Ferrand, 1997). (Bloom & Ferrand, 1997).

72 Compensatory Techniques Include Changing the head or body posture, such as tilting the chin down to help narrow the airway. Increasing sensory input, such as food with a sour taste or pushing the spoon down on the tongue when food is given (Bloom & Ferrand, 1997). Changing food or liquid thickness. Changes in liquid thickness are most often considered when there is a risk for aspiration, decreased control over the mouth or tongue, or there is a reduced sensory awareness (Chambers, Garcia, & Molander, 2005). Modifying feeding techniques by allowing extra time between swallows or placing food in a sensitive area of the mouth (Bloom & Ferrand, 1997).

73 Direct Treatment Techniques Include Range-of-motion exercises for the tongue, jaw, lips, and vocal folds, which require moving the structure as much as you can in a certain direction and then holding it in that position for one second and then relaxing. Swallowing maneuvers that help to control specific areas of swallowing. One example of a maneuver is the supraglottic swallow, which involves holding your breath before and during swallowing. This particular maneuver helps protect the airway before you swallow and also while you are swallowing (Bloom & Ferrand, 1997).

74 FEES image of head turn to left compensatory maneuver to close off the left pyriform sinus and lateral pharyngeal area to aid in pharyngeal clearing and promote safe swallowing

75 Electrical Stimulation for Treatment of Patients with Dysphagia Delivers a small electrical current to the muscles in the throat that are part of the swallowing system The current passes through electrodes placed on the neck in order to re-educate the muscles around the throat to help restore swallowing function

76 Contraindication of Electrical Stimulation Carotid sensitivity Evidence of heart block Patients using pacemakers Patients who are pregnant Those with hypersensitive skin Those recovering from surgery at or very close to the site of intended electrode placement (Huckabee and Pelletier, 1999; Leelamanit et al., 2002)

77 NG vs. PEG Feeding NG tube PEG (Percutaneous endoscopic gastrostomy) Advantages Widely available Cheap Rarely displaced Cosmetically acceptable Long-term use practical Disadvantages Often pulled out Unsightly Uncomfortable May lead to aspiration Nasal ulcer Interference with swallow Limited availability Expensive Aspiration when sedated Wound infections Bleeding Peritonitis

78 經皮內視鏡 胃造廔術 經皮內視鏡 空腸造廔術

79 Questions?

80 Thank you!