DYSPHAGIA IN MEDICALLY FRAGILE ADULTS

Transcription

1 DYSPHAGIA IN MEDICALLY FRAGILE ADULTS Lisa Rosencrantz, M.S. CCC-SLP October 10, 2017 Morris County Speech and Hearing Association Disclosures I have a full time job I am receiving an honorarium for this lecture I am not a partner or owner in any products that I discuss No conflicts of interest Objectives Medically Fragile Define Medically Fragile Identify the SLP s role in the management of care Identify and discuss severe illness and its effects on other systems Participants will demonstrate knowledge and skills needed to implement evidence based practice strategies for assessment and treatment of swallowing No clear definition Any problem that interferes with the airway, breathing, and or circulatory system. Jo Puntil-Sheltman

2 Medical SLP s role Respiratory System Consistently assess patient s swallow ability Extensive bedside evaluation of swallow Determine appropriate diet Can the patient maintain adequate nutrition PO Fragile patients can change from day to day Ventilation and Respiration Acute vs Chronic Disease Obstructive Disease vs Restrictive Disease

3 Modes of Ventilation Chronic Diseases COPD CHF Pulmonary Fibrosis Asthma Chronic Obstructive Pulmonary Disease (COPD) Normal lungs vs Lugs with COPD Google Images Anatomical-- Progressive destruction of the alveoli and capilaries (e.g. Emphysema) Clinical-- Chronic Bronchitis Physiological Airflow obstruction

4 COPD and Dysphagia Congestive Heart Failure Increased RR Weak cough reduced clearance of mucus Congestive heart failure, Heart failure resulting in the accumulation of fluid in the lungs and other body tissues. It is related mainly to salt and water retention in the tissues rather than directly to reduced blood flow. Blood pools in the veins (vascular congestion) because the heart does not pump efficiently enough to allow it to return. It may vary from the most minimal symptoms to sudden pulmonary edema or a rapidly lethal shocklike state. Symptoms tend to worsen as the body s attempts to compemsate for the condition create a vicious circle. The patient has trouble breathing at first during exertion and later even at rest. Treatment is directed toward increasing the stength of the heart muscle contraction, reduction of fluid accumulation, and elimination of underlying cause of the failure. Britanica Academia Congestive Heart Failure (CHF) Pleural Effusion, Google Images Coughing Edema in legs and abdomen Pleural Effusions Pulmonary Edema

5 Pulmonary Edema, Google Images CHF and Dysphagia Tidal volume is reduced Respiratory rate increased RR higher than 30 leads to incoordination of respiration and swallow In normal swallows- exhale apnea swallow exhale (Perlman et al 2005) CHF and dysphagia Fatigue Common among patients with compromised pulmonary system Breathing is primary Higher incidence of laryngeal penetration and eventual inconsistent aspiration when fatigued (Puntil-sheltman, 2002) Sepsis Systemic infection Symptoms: Body temperature above 101 F (38.3 C) or below 96.8 F (36 C) Heart rate higher than 90 beats a minute Respiratory rate higher than 20 breaths a minute Severe sepsis Diagnosis will be upgraded to severe sepsis if at least one of the following signs and symptoms are present, which indicate an organ may be failing: Significantly decreased urine output Abrupt change in mental status Decrease in platelet count Difficulty breathing Abnormal heart pumping function Abdominal pain

6 Sepsis Sepsis and Dysphagia Damage to vascular structures and organs Effects of sepsis depend on which organs are effected Change mental status Lethargy Muscle weakness High respiratory rate Prolonged intubation/ trach possible Tracheostomy and Dysphagia Boyle s Law Airway clearance Obstruction Immobilization Airway pressure changes- Boyle s Law If a gas is kept at a constant temperature, pressure and volume are inversely proportional and have a constant product

7 Tracheostomy and Dysphagia Coordination of respiration Sensory loss in upper airway Assessment of Swallow for Patients with Tracheostomy Deflation of the cuff Trial phonation with manual occlusion Speaking valve candidacy Check voice quality, pitch, intensity Monitor vital signs (HR, RR, BP) Monitor labs (Albumin, WBC, Hgb) Benefits of Passy Muir Speaking Valve passymuir.com Restores positive airway pressure Improves swallow and may reduce aspiration Restores communication Facilitates secretion management Improves oxygenation Expedites ventilator weaning and decannulation Improves smell, taste, and sensation Miami J Collar Cervical neck brace Keeps neck and spine straight Approximately 66% of patients who wear a cervical neck brace have problems swallowing

8 Assessment Post Extubation Leder et al., 2016 How and when? No evidence based practice guidelines exist to screen for aspiraiton risk n=105, 61M 18-81years; 45F years Intubation mean 3.6 days Yale Swallow Protocol After 1 hour extubation 75% of patients passed and were placed on PO diets Three Ounce Water Test Labs Screening tool to identify patients at risk of aspiration Wu et al choking during the 100ml Water Swallow Test may be a potential specific indicator for aspiration Leder et al % of patients who passed the three ounce water test did not aspirate on FEES; 70% of those that failed were able to be on a po diet Albumin- a protein made in the liver. Its main function is to regulate the colloidal osmotic pressure of blood. It aids in tissue growth and healing. Low albumin level- may be caused by liver disease, burns, malabsorption, malnutrition. High albumin- almost always due to dehydration. Could also be high protein diet. WBC, Hgb

9 Changes in Normal Swallow with Age Logemann et al., year old Timing of swallow Safety and efficacy of swallow Changes in Normal Swallow with Age Logemann et al, 2002 Hyoid and laryngeal maximum vertical movement is significantly reduced in 80+ Reduced flexibility- decreased cricopharyngeal opening duration and diameter reduced Range of motion exercises may improve reserve and flexibility in otherwise normal. Healthy adults CONCLUSION- Healthy older adults exhibit highly safe and efficient swallows despite the differences Illness causing extreme weakness may cause dysphagia in otherwise normal 80+ year olds Swallow in the Normal Healthy Elderly Dysphagia and the Elderly Exhibit intermittent laryngeal penetration while swallowing (Robbins et al 1999; Daggett et al 2006) Greater frequency of laryngeal penetration with patients with COPD (Good-Fratturelli et al 2000) Postparandial retention greater than 50% of the height of the pyriform sinuses is predictive of postprandial aspiration (Eisenhuber et al., 2002) Pooling of the valleculae for several seconds during mastication of solids (Hiemes &Palmer, 1999) Prolonged endotracheal intubation can produce reversible, temporary dysphagia (El Solh et al., 2003; delarminant et al., 1995) Polypharmacy Cognition Medical Status Hydration Status Mobility Oral health status Self feeding abilities Presence or absence of symptoms on the clinical bedside evaluation and/or instrumental assessment

10 Dementia and Dysphagia Loss of appetite Loss of understanding how to eat Inability to recognize food Indifferent to food Easily distracted Clinical Swallow Evaluation- What can you observe? Orientation to bolus Oral initiation of swallow Laryngeal elevation Symptoms of aspiration Spontaneous dry swallow/ throat clear in response to residue Oral tongue function (residue and location) Factors associated with aspiration after swallow Coughing Abnormal gag Dysarthria Dysphonia Cough after trial swallows Voice change after trial swallows Daniels et al 1998 Penetration Aspiration Scale 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 airway despite effort. 8. Material enters the airway, passes below the vocal folds and no effort is made to eject. Rosenbeck, JC, Robbins, J, Roecker EV, Coyle, JL, & Woods, JL. A Penetration Aspiration Scale. Dysphagia 11:93-98, 1996

11 What is our goal for this patient? James Coyle, 2015 Intervention of swallowing disorders Eliminate aspiration? Help patient to swallow better? Least restrictive diet without aspiration? Improve biomechanics of swallow? Postural modifications Swallow techniques Exercises Diet modifications Postural Modifications Postural Modifications Sitting posture 90 degree hip flexion Lateral trunk supports Tray or table to lean on Chin tuck Head turn Head tilt

12 Swallow Techniques Bonnie Martin-Harris, 2008 Dry swallow Effortful swallow (i.e. Hard Swallow) Supraglottic swallow maneuver Super Supraglottic swallow Maneuver Mendelsohm Maneuver Post swallow throat clear Exercises to rehabilitate dysphagia Langmore & Pisegna (2015) Shaker Masako IOPI protocol Expiratory Muscle Strength Training Shaker Exercise Shaker and Antonik, 1997 Isometric and isokinetic neck exercise aimed at strengthening the suprahyoid muscles including the geniohyoid, thryohyoid, and digastric muscles. 3 consecutive head lifts for 60 seconds each with 60 second rest between 30 consecutive head lifts without holding Three times a day for six weeks Masako Exercise Byeon, 2016 Oropharyngeal exercise rehabilitation technique to enhance function of the constrictor pharyngeus superior Designed to push food bolus from oral cavity to pharynx

13 IOPI Protocol Clark et al., 2009 IOPI Make swallow stronger Push against bulb with tongue tip as hard as you can Expiratory Muscle Strength Training Troche, et al 2010 Sapienza, et al 2011 EMST Strengthen expiratory and sub-mental muscles by increasing the physiologic load Inhale, then quickly and forcefully exhale into a mouthpiece with a one way valve that blocks expiration until sufficient pressure is produced

14 Diet Modifications Logemann, Should be the last compensatory method evaluated in testing Adjust consistency of foods for consumption Dysphagia Management for Patients with Cancer Nausea Loss of Appetite Food Aversions Dry Mouth Sore Mouth and Throat Diarrhea and Cramping Nutrition Dysphagia Management for patients with Dementia What if our patient doesn t take our advice? Environment Background/foreground Utensils

15 Predictors of Aspiration Pneumonia Langmore, 1998 Oral hygiene Dependent for feeding Dependent for oral care Number of decayed teeth Tube feeding More than one medical diagnosis Number of medications Smoking Frazier Free Water Protocol Panther, 2005 Waivers and consents

16 Thank you!! Byeon H. (2016) Effect of the Masako maneuver and neuromuscular electrical stimulation on the improvement of swallowing function in patients with dysphagia caused by stroke. Journal of Physical Therapy Science 28(7), Coyle, J (2016, November). : What s Wrong with My Patient? Seminar presented at the annual convention of the American Speech-Language-Hearing Association, Philadelphia, PA Coyle, J (2015) What s wrong with my patient? Sepsis, Congestive heart failure, esophageal function and disorders. Georgia Speech-Hearing Association. Athens,GA Coyle JL, Easterling, C, Lefton-Greif M, Mackay L; (2007). Evidence-based to reality-based dysphagia practice. ASHA Leader, 12(14), 10-13, 32. Freeman, B. D., & Morris, P. E. (2012). Tracheostomy practice in adults with acute respiratory failure. Critical Care Medicine, 40(10), Hewitt, A., Hind, J. A., Kays, S. A., Nicosia, M. A., Doyle, J., Tompkins, W.,... Robbins, J. A. (2008). Standardized instrument for lingual pressure measurement. Dysphagia, 23(1), Higgins, D. M. (1997). Dysphagia in the patient with tracheostomy: Six cases of inappropriate cuff deflation or removal. Heart & Lung: Journal of Acute & Critical Care, 26(3), Lisa.Rosencrantz@rwjbh.org Kays, S., & Robbins, J. (2006). Effects of sensorimotor exercise on swallowing outcomes relative to age and age-related disease. Seminars in Speech & Language, 27(4), Langmore S, Terpenning M, hcork, Achen Y, Murray J et al (1998) Predicrtors of Aspiration Pneumonia: How important is dysphagia? Dysphagia, NY; 13.2, Leder SB, Espinosa JF. Aspiration risk after acute stroke: Comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia. 2002;17(3): Leder SB, Suiter DM, Green BG. Silent aspiration risk is volume-dependent. Dysphagia. 2011;26(3): doi: /s Leder, S, Warner, H, Suiter, D, Bhattacharya, B, Rosenbaum, S, Schuster, K (2016 November) A Protocol to determine when to Begin Safe Oral Alimentation in Post Extubation Surgical Patients, Philadelphia, PA Leslie, P., Drinnan, M. J., Ford, G. A., & Wilson, J. A. (2005). Swallow respiratory patterns and aging: presbyphagia or dysphagia? Journals of Gerontology Series A- Biological Sciences & Medical Sciences, 60(3), LoCicero, J. (1984). Logemann, J (1998) Evaluation and Treatment of Swallowing Disorders. San Diego, CA College Hill Press Logemann, J. A., Pauloski, B. R., & Colangelo, L. (1998). Light digital occlusion of the tracheostomy tube: a pilot study of effects on aspiration and biomechanics of the swallow. Head & Neck., 20(1), Martin-Harris, B (2008) Treatment of Dysphagia in Adults:Methods and Effects ASHA Self Study Robbins, J., Gangnon, R. E., Theis, S. M., Kays, S. A., Hewitt, A. L., & Hind, J. A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatrics Society, 53(9), Panther, K (2005) The Frazier Free Water Protocol. Swallowing and Swallowing Disorders Puntil-Sheltman, J (2002). Medically Fragile Patients: Fitting Dysphagia Into the Bigger Clinical Picture, The ASHA Leader, Vol. 7, Daggett, A., Logemann, J., Rademaker, A., & Pauloski, B. (2006). Laryngeal penetration during deglutition in normal subjects of various ages. Dysphagia, 21(4), doi: Good-Furtelli, MD, Curlee RF, Holle, J (2000) Prevalence and nature of dysphagia in va patients with copd referred for videofluoroscopic swallow examination. Journal of Communoication Disorders. 33 (2) Eisenhuber E, Schima W, Schober E, Pokieser P, Stadler A, Scharitzer M, Oschatz E. Videofluoroscopic assessment of patients with dysphagia: Pharyngeal retention is a predictive factor for aspiration. AJR Am J Roentgenol. 2002;178:393 8 El Solh A, Okada M, Bhat A, Pietrantoni C. Swallowing disorders post orotracheal intubation in the elderly. Intensive Care Med. 2003;29(9): doi: /s de Larminat V, Montravers P, Dureuil B, et al. Alteration in swallowing reflex after extubation in intensive care unit patients. Crit Care Med 1995;23: Hiiemae, K. M., & Palmer, J. B. (1999). Food transport and bolus formation during complete feeding sequences on foods of different initial consistency. Dysphagia, 14(1), Daniels, S.K., Brailey, K., Priestly, D.H., Herrington, L.R., Weisberg, L.A., Foundas, A.L.; (1998) Aspiration in patients with acute stroke. Archives of Physical Medicine and Rehabilitation, 79 (1), pp Gaieski, D. F., & Goyal, M. (2013). What is sepsis? what is severe sepsis? what is septic shock? searching for objective definitions among the winds of doctrines and wild theories. Expert Review of Anti-Infective Therapy, 11(9), Logemann, J.A., Pauloski, B.R., Rademaker, A. W., Kahrilas, P.J. (2002). Oropharyngeal swallow in younger and older women: Videofloroscopic analysis. Journal of Speech, Language, and Hearing Reasearch, 45, Langmore, S. E., & Pisegna, J. M. (2015). Efficacy of exercises to rehabilitate dysphagia: A critique of the literature. International Journal Of Speech-Language Pathology, 17(3), doi: / Robbins, J., Coyle, J. L., Rosenbek, J. C., Roecker, E. B., & Wood, J. L. (1999). Differentiation of normal and abnormal airway protection during swallowing using the penetration-aspiration scale. Dysphagia, 14(4), Rosenbeck, JC, Robbins, J, Roecker EV, Coyle, JL, & Woods, JL. A Penetration Aspiration Scale. Dysphagia 11:93-98, 1996 Sapienza, C. M., Troche, M., Pitts, T., & Davenport, P. W. (2011). Respiratory strength training: concept and intervention outcomes. Seminars in Speech & Language, 32(1), Shaker, R, Antonik, S, (2006) The Shaker Exercise; US Gastroenterology Review, Shaker R, Kern, M, Bardan, E, et al.; (1997)Augmentation of deglutitive upper esophageal sphincter opening in the elderly by exercise. Am J Physiol ; pp G Sharp, H; (2005) When Patients refuse recommendations for Dysphagia Treatment; Perspectives on Swallowing and Swallowing Disorders, Vol. 14, No. 3, pp. 3-7 Stambolis, V., Brady, S., & Klos, D. (2003) The Effects of Cervical Bracing Upon Swallowing in Young, Normal, Healthy Volunteers. Dysphagia, 18, Stierwalt, J (2011) Managing Swallowing and Communication Function in Trach/Vent Dependent Patients, Valhalla, NY Suiter, D.M., & Leder, S.B. (2008).Clinical utility of the 3-ounce water swallow test. Dysphagia, 23, Suiter, D.M., Sloggy, Leder, S (2014) Validation of the Yale Swallow Protocol: A prospective double blinded videofluoroscopy study. 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17 Teramoto S. A possible pathological link among swallowing dysfunction, gastroesophageal reflex, and sleep apnea in acute exacerbation in COPD patients. International Journal of Chronic Obstructive Pulmonary Disease. 2016;11: doi: /copd.s99663.