MBSImP. Case example 3/6/2018. Esophageal Dysphagia and the role of the SLP Management of Lung Transplant Patients

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1 Esophageal Dysphagia and the role of the SLP Management of Lung Transplant Patients March 10, 2018 Regina Carr MS CCC-SLP Why address the esophagus? ASHA: A basic understanding of oropharyngeal and esophageal swallowing relationships will allow the clinician to provide optimal services, reducing the risk that underlying causes of a patient s dysphagia will go undetected responsibility of physicians to evaluate and diagnose In not addressing all components of swallowing we risk poor decision making or misdiagnosis may employ bogus treatment American Speech-Language Hearing Association Knowledge Guidelines required: for Speech language pathologists The interrelationships performing of the VFSS oral, pharyngeal, and esophageal phases of swallowing. The range of symptoms that may be reported by individuals, caretakers, or parents that reflect possible oral, pharyngeal, and/or esophageal dysphagia. Skills required: Identify and document the anatomic and physiologic swallow disorder(s) of the oral preparatory, oral, and pharyngeal phases. If esophageal screening is completed, describe any suspected anatomic and/or physiologic abnormalities of the esophagus which might impact the pharyngeal swallow, deferring to radiology for diagnostic statements. MBSImP Esophageal Impairment Esophageal Clearance Upright Position 0= complete clearance; esophageal coating 1= esophageal retention (mid to distal) 2= esophageal retention with retrograde flow below PES 3= esophageal retention with retrograde flow through PES (ie Zenker s diverticulum) 4= minimal to no esophageal clearance (ie LES achalasia) Optimally scored in AP view The goal is to observe esophageal clearance in the position in which the patient eats/drinks (ie bolus flow assisted by gravity) Case example 62 year old M with centrilobular empysema referred for barium swallow study as part of lung transplant workup Known hx of reflux, on omeprazole 20mg 9/19/17 Oral Stage: Adequate bolus containment with prompt and complete bolus transfer. Adequate tongue tip elevation and soft palate elevation. Pharyngeal Stage: Timely and adequate hyoid movement. Slightly delayed closure of laryngeal vestibule and delayed and slightly diminished epiglottic inversion. Laryngeal penetration and subsequent mild aspiration (silent) with high density and thin barium. There was no aspiration/penetration seen with nectar thick or pudding barium. Adequate pharyngeal contraction without significant barium retention aside from coating of high density barium (subsequently cleared with water). As d/w radiologist, high volume/high level spontaneous reflux in prone position and c/f candida esophagitis Outpt SLP f/u x1 to educate on NTL; pt self upgraded to thin liquids Initiated fluconazole and increased omeprazole to 40mg Repeat MBS 2/9/18 Oral Stage: Adequate bolus containment with prompt and complete bolus transfer. Adequate and timely tongue tip elevation and soft palate elevation. Pharyngeal Stage: There was timely and adequate hyoid movement. There was slightly delayed closure of laryngeal vestibule as well as delayed and?slightly diminished epiglottic inversion. This results in trace, largely transient laryngeal penetration with thin barium. There was no aspiration/penetration seen throughout the study. There was adequate pharyngeal contraction without significant barium 1

2 Causes of Esophageal Dysphagia Structural Abnormalities Chief complaint: solid food dysphagia Strictures Peptic stricture/reflux Radiation induced Pill induced vs caustic injury induced Malignancy Rings and Webs Peptic rings Shatski s ring Plummer-Vinson syndrome Esophageal Carcinoma Esophageal Compression Motor Abnormalitiesevaluated while prone Solid food and liquid dysphagia Achalasia DES Reflux related dysmotility Radiation induced dysmotility Scleroderma involving the Esophagitis Infectious (candida, herpes simplex) Chemical induced Radiation induced Immune mediated disease Basic physiology of the esophageal Primary Peristalsisphase Induced by swallowing Contractile waves of circular muscles of esophageal body Relaxation of UES and LES Secondary Peristalsis Occurs as a result of distention of the esophagus Associated with LES relaxation only- not related to swallowing Tertiary Contractions Non-propulsive Can cause choking sensation Advanced Lung Disease Population GER and altered motility are common among patients with lung disease and post lung transplant population Highest risk of significant aspiration leading to acute rejection may be early after transplant While acute cellular rejection is well defined histologically, no reproducible specific features of AMR are currently identified Combination of clinical features, serology, histopathology, and immunologic findings is suggested for the diagnosis of AMR SLP POC with lung transplant patients Pre-op barium swallow study- evaluate oropharyngeal and esophageal stages SLP presents findings and concerns at weekly transplant listing meeting GI/GI Rads not present Post op: limited clinical evaluation to determine if the pt is ready for objective evaluation- FEES vs barium swallow study input from MD desire to again look at esophageal functioning Per ALD MD, pts with scleroderma/dysmotility are told at time of listing that they will be NPO with G/J tube for 3-6 months Working with SLP to fine tune post op POC 2

3 Scleroderma Identify disease subtype, stage, and involved organs Current therapies use medications that focus on the four main features of the disease: Inflammation (NSAIDs or corticosteroids) Autoimmunity (methotrexate, cyclosporine, antithymocyte globulin, mycophenolate mofetil and cyclophosphamide) Vascular disease Tissue fibrosis (research focusing on new drugs to alter fibrotic reaction) Scleroderma Frequent esophageal involvement (75-80%) Atrophy of the esophageal smooth muscle occurs, impeding peristalsis and impacting LES tone Free reflux may occur Fibrosis and stricture development Also may have delayed gastric emptying if stomach is involved Difference between Scleroderma and Achalasia is that with scleroderma, barium will empty to gravity in a more timely Treatment Aggressive reflux management Antacids Histamine H2- receptor agonists (H2 blockers) PPI Baclofen? Anti reflux surgery not an option 2/2 poor peristaltic function CASE STUDIES 37 year old M with hx of scleroderma, ILD, esophageal dysmotility, phtn, transferred from OSH in NY to HUP for lung transplant eval Significant decline in functional capacity x8 months including progressive SOB, worsening GERD, 10lb weight loss Pre-op barium swallow study Normal oral motility Slightly diminished epiglottic inversion Trace subepiglottic penetration intermittently Moderate GER Moderately to markedly and diffusely dilated esophagus and aperistalsis c/w scleroderma SLP: Esophageal clearance in upright position=esophageal retention (mid to distal)= 1 s/p B/L Lung txp 9/27; VDRF 9/17-10/4; G/J tube 10/1 No SLP involvement; NPO Readmitted 11/13 with recent development of increased fullness/bloating with TEN via J, G to vent Imaging revealing G tube within transverse colon Plan to allow G tube EC fistula tract to heal; monitor for signs of intra-abdominal leak vs development of high output ECF MBS 3

4 Post op MBS 11/13 Normal oral/pharyngeal phases Esophageal clearance: standing barium in distal esophagus is cleared when pt is positioned fully upright Initiated on regular diet/thin liquids (<2mo post op) with reflux precautions 52 y.o. F with hx of MCTD, fibrotic lung dz, PAH Pre op study Normal oropharyngeal motility Small hiatal hernia, small-volume GER Considerable weakening and intermittent absence of primary peristalsis in thoracic esophagus = Moderate esophageal dysmotility, likely 2/2 underlying reflux SLP: esophageal clearance= complete clearance; esophageal coating= 0 s/p B/L lung txp 11/17/17 Extubated 11/19 Reintubated 11/21 with increased RLL consolidation, likely atelectasis/mucous plug Reintubated again 11/27 in s/o air embolization pulling central line Extubated successfully 11/29 to HFNC 12/13 G/J placed 12/15/17: Attending wishes to advance pt to sips of liquids for comfort Requests MBS with thin barium only to r/o pharyngeal aspiration Intermittent trace subepiglottic penetration Cleared for sips of thin liquids 12/17 Pt with tachycardia to 140s, labored respirations, increasing nausea, some vomiting, TEN held. Gastric tube to suction, no drainage CT abdomen with pneumatosis and portal venous gas Possible loop of volvulized bowel New lactic acidosis concerning for bowel ischemia To OR emergently for ex lap Pneumatosis intestinalis, SBO TEN restarted 1/5/18 Initiated on full nectar thick liquid following FEES 1/8; defer solid food per ALD To rehab 1/11 Advanced to ground diet, thin liquids by 1/25 and regular diet, thin liquids by 1/30 4

5 69 year old M with COPD, alpha 1 antitrypsin deficiency, phtn 8/2/17 pre op study Oropharyngeal motility WNL without penetration or aspiration Normal esophageal motility No observed reflux?mild reflux esophagitis No stricture seen s/p B/L lung txp on 8/19/17, extubated 8/20 FEES 8/22: pharyngeal swallow WFL SLP recs: clear vs full liquids in s/o concern for gastric bubble, advance to regular diet as able 8/23 NGT to suction 8/25 ileus resolved 8/27 advanced to regular diet/ thin liquids 8/28: N/V after breakfast, food feeling stuck in esophagus per pt report 8/29 Esophagram: SLP: esophageal clearance= 4 Esophageal dysfunction of uncertain etiology per Radiologist Vigorous form of achalasia or DES with associated LES dysfunction- REC esophageal manometry c/f LES dysfunction and gastroparesis NPO, plan for G/J placement 8/30 EGD was unremarkable 9/5 repeat esophagram without improvement 9/7 G/J, TEN for 3-6 months Copious diarrhea 2/2 TEN Not improved with change in formula Not improved with stopping MMF/starting azathioprine TPN started via PICC 9/11 SLP reconsulted to initiate PO Full liquids OOB to chair, upright 1-2 hours; G tube clamped during this time 9/18 c/o fullness +diarrhea Advanced to regular diet, thin liquids; TEN stopped Final Thoughts Difficulty with providing the pt with clear expectations vs managing as a case by case basis Pts verbalize agreement pre op but post op reality is harder to grasp/tolerate Highlight need for SLP to be proactive in collaboration with MD/RD References Almeida MSTM (2012) Scleroderma Lung Disease Other Lung Complications in Systemic Sclerosis. Rheumatology S1:009. doi: / s1-009 Eur Respir J 2008; 31: DOI: / Castor JM, Wood RK, Muir AJ, Palmer SM, Shimpi RA. Gastroesophageal reflux and altered motility in lung transplant rejection. Neurogastroenterol Motil (2010) 22,