Medical University of South Carolina College of Health Professions Communication Sciences and Disorders. Kate Humphries:

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1 Kate Humphries BA, Katherine Viars BS, Laura Draize BS, Amy Hartenburg BS, Kelly MacDonald BA, Shannon Torres BA, Yvonne Michel PhD, Julie Blair MA, Bonnie Martin-Harris PhD Medical University of South Carolina College of Health Professions Communication Sciences and Disorders Kate Humphries:

2 What is COPD? Chronic Obstructive Pulmonary Disease the presence of airflow limitation due to chronic bronchitis or emphysema; the airflow obstruction is generally progressive, may be accompanied by airway hyperreactivity, and may be partially reversible. American Thoracic Society (1995)

3 What is COPD? Chronic bronchitis Emphysema Dyspnea, the hallmark symptom of COPD Muscle disease: Hypoxemia Oral and pharyngeal discoordination Lower laryngeal resting position Martin-Harris (2000), Rabe et al. (2007), Reid (2001)

4 What is COPD? 4th leading cause of chronic morbidity and mortality in the United States. (GOLD 2007) 10 million U.S. adults reported physiciandiagnosed COPD. (NCHS 2002) 24 million U.S. adults have evidence of impaired lung function (NHANES III 1994) COPD is grossly underdiagnosed Morinno et al. 2002

5 Background and Significance Coelho (1987): diminished strength and coordination slower bolus transit times Shaker et al. (1992): swallow significantly more in inspiratory phase and resume with inspiration Good-Fratturelli, Curlee, & Holle (2000): Penetration/Aspiration noted in 70% of subjects on all consistencies

6 Background and Significance Mokhlesi et al. (2002): Lower laryngeal position at rest Reduced tongue control Delayed pharyngeal response Decreased base of tongue retraction Decreased laryngeal elevation. Gross et al. (2009): Inhalation/Exhalation on solid bolus Exhalation/Inhalation on semi-solid bolus Aspiration increased with low tidal volumes at end exhalation

7 Purpose To determine the nature of swallowing impairment in a large group of subjects with COPD. Standardized approach Preliminary to associating respiratory phase pattern with swallowing impairment in future studies

8 Methods

9 Methods Retrospective Standard examination protocol Descriptive/correlational Subanalysis of a larger study on swallowing impairment: Clinical records from 107 subjects with COPD referred for modified barium swallow studies (MBS) at the Medical University of South Carolina Speech-language pathologists trained under the MBS Impairment Profile (MBSImP) (Martin-Harris et al. 2008)

10 Methods Videofluroscopic Examination: Digital Swallowing Workstation, model 7100, Lincoln Park, NJ: KayPENTAX Respiratory Data: Inductotrace Nasal Airflow Tracing

11 Methods MBS Impairment Profile (MBSImP) Valid, reliable, and standardized measurement 17 components of oral, pharyngeal, and esophageal physiology Rank order severity scale Martin-Harris et al. 2008

12 MBSImP MBS Impairment Profile Valid, Reliable, and Standardized Measurement Martin-Harris et al. 2008

13 Methods Component Possible Scores Not Impaired (%) Impaired (%) Most frequently occurring severity ranking > 0 ( if imp. > not imp.) 1 (0 4) (0 3) (0 3) (1) 4 (0 4) (3) 5 (0 4) (1) 6 (0 4) (3) 7 (0 4) (0 4) (1) 9 (0 4) (0 2) (0 2) (1) 12 (0 2) (0 3) (0 3) (1) 15 (0 4) (3) 16 (0 4) (2) 17 (0 3) 60 40

14 Methods Penetration-Aspiration Scale (PAS) 1 = Does not enter airway 2 = Enters airway / above folds / ejected 3 = Enters airway / above folds / not ejected 4 = Enters airway / contacts folds / ejected 5 = Enters airway / contacts folds / not ejected 6 = Enters airway / below folds / ejected 7 = Enters airway / below folds / not ejected despite effort 8 = Enters airway / below folds / no effort Penetration: material that enters the larynx but does not pass below the true vocal folds Aspiration: material that passes below the level of the vocal folds. Rosenbek et al. 1996

15 Methods PAS divided into 3 categories Normal: PAS 1 2 Penetration: PAS 3 5 Aspiration: PAS 6 8 Spearman s Rho Overall PAS, Oral Total, Pharyngeal Total

16 Methods Expiration/Expiration (EE) Expiration/Inspiration (EI) Inspiration/Expiration (IE) Inspiration/Inspiration (II) Martin-Harris et al. (2005)

17 Methods 5 subjects Inductotrace and Nasal Airflow Tracing Respiratory phase pattern 12 different bolus volumes and consistencies Standard MBSImP protocol

18 Methods Dependent Variables: MBSImP Scores Penetration/Aspiration Scale (PAS) Scores Respiratory Phase Patterns

19 Results

20 Results Lingual Motility

21 Results Initiation of the Pharyngeal Swallow

22 Results Anterior Hyoid Excursion

23 Results Laryngeal Elevation

24 Results Laryngeal Vestibular Closure

25 Results Pharyngoesophageal Segment (PES) Opening

26 Results Tongue Base Retraction and Pharyngeal Residue

27 Frequency of Severity Score (%) Results Severity Score (0-4) by Component

28 Results Frequency of Occurrence (%) Normal Penetration Aspiration PAS Categories

29 Mean Oral Total with 5 Components Results Mean Pharyngeal Total with 9 Components Mean Oral Total Mean Pharyngeal Total Normal Penetrated Aspirated 0 Normal Penetrated Aspirated Overall PAS Overall PAS

30 Mean Component Scores Results Mean Oral Components Mean Pharyngeal Components Normal Penetrated Aspirated

31 Results Frequency of Occurrence (%) EE EI IE II Respiratory Phase Pattern

32 Discussion Hyolaryngeal mechanics and laryngeal closure Lingual motility and initiation of the pharyngeal swallow Penetration-Aspiration ratio PAS scores and impaired oral and pharyngeal mechanics Increased trend towards inspiration prior to or following respiratory cessation to accommodate the swallow Expiration/Inspiration and air hunger Coehlo (1987), Good-Fraturelli et al. (2000), Gross et al. 2009), Mokhlesi et al. (2002), Martin-Harris et al. (2005), Pauloski & Logeman (2002), Rabe et al. (2007), Shaker et al. (1992)

33 Clinical Implications Dysphagia profile for the nature of swallowing impairment in patients with COPD: Physiologic components Penetration-Aspiration Respiratory Phase Patterns Facilitates efficient evaluation and treatment of patients with COPD Potential use to profile dysphagia at various stages of the disease and to help quantify impairment during exacerbation of COPD.

34 Prospective Study Respiratory Pattern and Swallowing Impairment in COPD Identify components of functional swallowing impairment and respiratory phase patterns. Relate temporal characteristics of swallowing physiology to airflow and kinematic respiratory data. Clarify the presence and nature of swallowing impairment as related to respiratory-swallow coordination. Current grant: training respiratory phase pattern to improve the swallow.

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