Dysphagia Diagnostic Procedures

Transcription

1 The Role of Lingual Pressures In Dysphagia Screening Andrew Kaufman, BS Jackie Hind, MS Georgia Malandraki, PhD JoAnne Robbins, PhD American Speech Language Hearing Association Annual Meeting New Orleans, LA November 19, 2009 Disclosures Wisconsin Alumni Research Foundation The key to treatment is identification of the etiology for the dysphagia/ (not just) aspiration; that is, the underlying physiology or anatomical reasons. Dysphagia Diagnostic Procedures Videofluoroscopy Fiberoptic endoscopy (Logemann, 1983) Videofluoroscopy: Diagnostic/Treatment Package visualize interelationships between head and neck structures/dynamics and bolus flow Bolus flow Direction (pen/asp) Duration (timing) Clearance (residue) Oropharyngeal kinematics ROM Coordination STRENGTH NO!! (Pressure)/Weakness Residue in the oropharynx after the swallow is a sign of dysphagia and can put patients at risk for aspiration 1

2 Videofluoroscopy and FEES Time consuming Expensive $ Travel Comfort No strength measurement Clinical Bedside Exam Conflicting Reports of Effectiveness Only 42% of patients who aspirated on fluoroscopy were correctly identified by clinical assessment (Splaingard, 1988) Up to 90% of patients who were observed to aspirate on fluoroscopy were correctly identified by clinicians (Daniels, 1998) Bedside not absolute, but careful assessment (may) reveal (some) patients at elevated risk for airway penetration (Linden and Siebens, 1983) No objective strength information so target tx goals remain unclear The key to treatment is identification of the etiology for the dysphagia (not just) aspiration; that is, the underlying physiology or anatomical reasons. (Logemann, 1983) The tongue and its many attachments generate pressures to propel the bolus safely through the oropharynx Oral residue, which is a bolus flow parameter associated with dysphagia, increases in healthy and stroke patients when maximum isometric tongue strength is low (Ono et al, 2007; Hind et al, 2001; Nicosia et al 2000) 2

3 As isometric lingual pressure improved with an 8 week exercise regimen, stroke patients exhibited reduced residue and lower penetration aspiration scale scores (Rosenbek et al, Dysphagia, 1996; Robbins et al, Dysphagia, 1999) Weak Image Conversely, patients with lower pressures had increased oropharyngeal residue and were more likely to aspirate Robbins et al, 2007) Strong Movie With the existing knowledge re: benefits of higher isometric lingual strength and simple methods to quantify it Lingual pressure measurement may be useful to screen for dysphagia Screening for Dysphagia Challenging and controversial topic/endeavor Screening* Screening for presence of Dysphagia Risk Factors by means of: Self report Clinical history Clinical observation *No gold standard screening tool exists (DePippo et al; Lindon et al) 3

4 Who? What? 3 oz H 2 O Swallowing Test Observe patient Swallow saliva? Drink? Eat? Identified 80% (16/20) patients aspirating during subsequent VFSS (Sensitivity 76%, Specificity 59%) (DePippo et al, 1992) Current Dysphagia Screenings: Inherently non-specific Result in high false negatives or false positive rates Do not provide evidence-based target goals for treatment planning No single approach to screening has both good sensitivity and specificity in identifying the likelihood of dysphagia, or more specifically, the etiology for treatment of the dysphagia (Suiter and Leder, Dysphagia 2008) (Martino et al, 2000; Perry and Love, 2001) TOR-BSST Developed by Dr. Rosemary Martino Screening tool for other staff to use Trained by SLP who complete a 4-hour workshop on how to train Several hours to train staff Video examples For purchase General Consensus: Swallowing Screening Procedures have broad construct validity That is, they measure the presence of clinical signs and symptoms that are considered relevant as indicators of the presence or absence of dysphagia SLPs train the screeners 4

5 VA Rapid Response Grant Beverly Priefer, RN, PhD (PI) Advisory group of 6 RNs and 3SLPs Literature review by SLP/RN dyad Prevalence of dysphagia by diagnosis Most common signs of dysphagia Current screening tools Re-convened and drafted 6-item evidence-based screening tool for use by nursing VA Rapid Response Grant Not sufficient evidence to support RNs performing water swallows Currently piloting screening tool at Madison VA Dysphagia Risk Assessment Place check in box for any yes answer Diagnosis of new stroke, head and neck cancer, or traumatic brain injury Modified texture Diet/Eating maneuvers (e.g. chin tuck; head turn) Unable to follow commands Wet/gurgly voice Drooling while awake Tongue deviation from midline Screening Tool Inclusive of professionals (nurses, SLPs ) Provide information relevant to treatment plan If any of above boxes are checked, notify provider, and request Speech Pathology consult. Lingual pressure diminishes in Healthy old adults (Robbins et al, 2005) Stroke patients (Robbins et al, 2007) Treated head and neck cancer patients (Lazarus et al, 2007) Oral residue, which can lead to aspiration after the swallow, has been shown to increase in the presence of low maximum isometric lingual strength (stroke and H & N ca patients) (Ono et al, 2007; Hind et al, 2001; Robbins et al 2007) 5

6 Tools/Instrumentation Used Strain-gauge manometric probes (Dantes et al, 1990) Iowa Oral Performance Instrument (Robbins et al, 2007, Nicosia et al, 2000) Palatal Plate (Hori et al, 2006) Madison Oral Strengthening Therapeutic (MOST) Device (Robbins) Kay/Pentax Swallow Workstation (Robbins et al, 2007; Steele et al., 2009) We report a potential screening method that: Identifies the risk - likely presence of dysphagia and Provides important pressure (strength) information for inclusion in development of treatment plans Can be performed by a variety of professionals Hypotheses tested In a general clinical population: Lingual strength is a useful indicator of the presence of dysphagia as demonstrated by follow up diagnostic validation (videofluroscopy) Diminished strength associated with increased residue is a characteristic of dysphagia that may put individuals at risk for aspiration and/or malnutrition Isometric Lingual Resistance Press tongue to roof of mouth (isometric) Air-filled bulb Anterior & posterior tongue Maximum pressure (3x) (IOPI, 1992) Bolus Flow - Residue Videofluoroscopy Bolus conditions (Varibar ) thin liquid nectar liquid thin honey honey semi-solid Subjects n = 36 patients in UW or VA Swallowing Clinic Sex = 13f, 23m Age = mean of 67 years < 70 n = 16 (mean of 53 years) > 70 n = 20 (mean of 79 years) Diagnoses = Neuro (e.g., muscle, trauma, stroke) Head & Neck Cancer Medical (e.g., frail, pneumonia) 6

7 Swallows Multidimensional depth of airway invasion and residue, single-digit scoring system for the Penetration-Aspiration Scale. (Rosenbek et al, Dysphagia, 1996; Robbins et al, Dysphagia, 1999) Category Score Description N = 315 Thin liquid Nectar Thin honey Thick honey Semisolid Total Number of Swallows Number of Subjects No Penetration or aspiration P E N E T R A T I O N A S P I R A T I O N Contrast does not enter the airway Contrast enters the airway, remains above vocals, no residue Contrast remains above vocal folds, visible residue remains Contrast contacts vocal folds, no residue Contrast contacts vocal folds, visible residue remains Contrast passes glottis, no sub-glottic residue visible Contrast passes glottis, visible sub-glottic residue despite patient s response Contrast passes glottis, visible sub-glottifc residue, absent patient response Residue Scale 0 none 1 coating 2 pooling Statistical Analysis Mixed effects linear regression model adjusted for Sex Fixed effects Age Diagnosis Bolus Type Random effect Subject (Hind et al, 2001) Results Lingual pressures Aspiration/Penetration (NS) Lingual pressures Residue (S) (p<.05) Residue by Bolus Type and Tongue Location Thin (4cps) Nectar (300cps) Thin Honey (1500cps) Thick Honey (3000cps) Semisolid (5,000cps) Oral Cavity Valleculae Post Pharyngeal Wall + + Pyriform Sinus UES + Anterior Tongue Posterior Tongue *p<0.05 +p<0.07 All Locations 7

8 Residue by Bolus Type and Tongue Location Thin (4cps) Nectar (300cps) Thin Honey (1500cps) Thick Honey (3000cps) Semisolid (5,000cps) Oral Cavity Valleculae Oral (Pulsive) Post Pharyngeal Wall + + Pyriform Sinus UES + MOST VISCOUS Anterior Tongue Posterior Tongue *p<0.05 +p<0.07 All Locations Esophageal (Clearing) (Pouderoux & Kahrilas, 1995) Tongue Pressure Applies Pulsive Force to the Bolus Motive force (Pouderoux & Kahrilas, 1995) Drag force Is greater with less viscous boli Is greater with more viscous boli Oral Residue (all bolus types) and Anterior Pressure with Age Oral Residue (all bolus types) and Posterior Pressure with Age pressure (kpa) young old <70 >70 Linear (<70) Linear (>70) pressure (kpa) young old <70 >70 Linear (<70) Linear (>70) p < Residue Scale p < Residue Scale Oral Residue and Anterior Pressure with Thin Liquid By Age Oral Residue and Anterior Pressure with Nectar By Age young Pressure (kpa) young old < 70 >70 Linear (< 70) Linear (>70) Pressure (kpa) old Max Ant <70 >70 Linear (Max Ant <70) Linear (>70) Residue Scale Residue Scale 8

9 Summary of Findings (p<0.05) Higher/stronger lingual pressures oral and vallecular reduced/less residue Lower/weaker lingual pressures increased/more oral and vallecular residue Young and Old dysphagic patients who are weaker demonstrate increased residue Clinical Application Increased residue in the oropharynx may put the weaker patients at risk for aspiration, particularly after the swallow or malnutrition (fatigue, endurance) leading to change in health status Limitations Subjects larger subject group Standardize protocol Bolus increase number of nectar and honey relative to thin and semisold Device Device Limitations High cost No exact location in mouth Sensor only at single site Air-filled bulbs leak Madison Oral Strengthening Therapeutic (MOST) Device Conclusion Tongue pressure/strength measurement is a promising addition Simple method all professionals with minimal training Screen or bedside Element of treatment plan U.S. patent # FDA Registered 9

10 Acknowledgements Jackie Hind, MS, CCC-SLP, BRS-S Georgia Malandraki, PhD Scott Reeder, MD, PhD Richard Hartel, PhD Sterling Johnson, PhD Josh Medow, MD Jill Zielinski Betsy Divyak Andy Waclawik, MD Justin Sattin, MD Steven Barczi, MD Laura Isaacson, MS, RD Shirley McCallum, MS, RD Abby Duane, BS Amanda Joyce, BS John Doyle, DDS It is to be emphasized that predicting aspiration is but one purpose of the Clinical/Bedside Evaluation VA NIH USDA UW (McCullough et al, 2001) One Swallow Does Not A Meal Make Effects of Meal Consumption on Tongue Endurance Purpose: to determine if age-related differences in tongue endurance and associated fatigue markers are evidenced during dining Eating is an ENDURANCE activity Swallow again and again and again Specific fatigue indicators examined were: the duration required to consume a meal perceptions of effort during dining signs and symptoms of swallowing difficulty (e.g., wet voice, cough or throat clear) (Kays and Robbins, JSLHR, in press, 2009) Pressure Measures Subjects (healthy) compressed an airfilled bulb between the tongue and hard palate at 2 tongue locations to determine: Maximum Pressure: Highest pressures (kpa) generated when asked to press as hard as possible (2 sets of 3 trials) Tongue Endurance: Time(s) for which 50% of the maximum pressure can be sustained (1 trial) Change Post-Meal: Tongue Strength and Tongue Endurance All subjects demonstrated reduced tongue strength and endurance post-meal

11 Post-Meal Tongue Endurance Significant decline across all subjects (age and gender) in anterior and posterior tongue endurance post-meal compared with pre-meal Anterior (p=0.01); Posterior (p=0.03) Meal durations were longer in older adults compared to younger (p=0.07) The 3 oldest subjects (ages 78-82) demonstrated significant swallowing difficulty during the second half of the meal including wet voice, cough and/or throat clear) The oldest woman (79 years old) requested to skip the second portion of the meal Screening for Dysphagia and Determining Treatment: Observe older patients during mealtime Is 3oz water test a sensitive screening tool for identifying patients at risk for clinically significant aspiration who need referral for more definitive swallowing evaluation Obtain lingual pressures pre and post meal (DePippo et al, 1992) Toronto Bedside Swallowing Screen Test (TOR-BSST) Alertness Participation in test Oral motor function Presence of cough coughing during and for up to one minute after and a wet or hoarse voice suggest abnormal swallow 11

12 SELECTED REFERENCES Daniels SK, Brailey K, Priestly DH, et al. (1998) Aspiration in patients with acute stroke. Arch Phys Med Rehabil 79: DePippo KL, Holas MA, Reding MJ. (1992) Validation of the 3-oz water swallow test for aspiration following stroke. Arch Neurol 49: Hind J, Nicosia M, Carnes M, Roecker E, Robbins J. (2001) Comparison of effortful and non-effortful swallowing in healthy middle aged and older adults. Arch Phys Med Rehabil, 82; Hori K, Ono T, Iwata H, Nokubi T, Kumakura I. (2005) Tongue pressure against hard palate during swallowing in post-stroke patients. Gerodontology Dec;22(4): Linden P, Siebens AA. (1983) Dysphagia: predicting laryngeal penetration. Arch Phys Med Rehabil. 64(6): Linden P, Kuhlemeier KV, & Patterson C. (1993). The probability of correctly predicting subglottic penetration from clinical observations. Dysphagia 8: Logemann J. (1983). Evaluation and Treatment of Swallowing Disorders. College-Hill Press, Inc. San Diego, CA, Martino R, Pron G, Diamant N. (2000) Screening for oropharyngeal dysphagia in stroke: Insufficient evidence for guidelines. Dysphagia 15: Nicosia MA, Hind JA, Roecker EB, et al. (2000) Age effects on temporal evolution of isometric and swallowing pressure. Journal of Gerontology, Medical Sciences, 55A:M634-M640. Ono T, Kumakura I, Arimoto M, Hori K, Dong J, Iwata H, Nokubi T, Tsuga K, Akagawa Y. (2007) Influence of bite force and tongue pressure on oropharyngeal residue in the elderly. Gerodontology 24(3): Perry L & Love CP. (2001) Screening for dysphagia and aspiration in acute stroke: a systematic review. Dysphagia 16(1): Pouderoux P and Kahrilas PJ. (1995) Deglutitive tongue force modulation by volition, volume and viscosity in humans. Gastroenterology 8(5): Robbins JA, Coyle J, Rosenbek J, et al. (1999) Differentiation of normal and abnormal airway protection during swallowing using Penetration Aspiration scale. Dysphagia 14: Robbins J, Gangnon R, Theis S, et al. (2005) The Effects of Lingual Exercise on Swallowing in Older Adults. Journal of the American Geriatric Society 53(9): Robbins J, Kays S, Gangnon R, et al. (2007) The Effects of Lingual Exercise in Stroke Patients with Dysphagia. Archives of Physical Medicine and Rehabilitation 88: Rosenbek JC, Robbins JA, Roecker EB, et al. (1996) A Penetration-Aspiration Scale. Dysphagia 11: Splaingard ML, Hutchins B, Sulton LD, Chaudhuri G. (1988) Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment. Arch Phys Med Rehabil. 69(8): Suiter DM, Leder SB. (2008) Clinical Utility of the 3-oz water swallow test. Dysphagia 23: