Managing the Patient with Dysphagia Patricia K. Lerner, MA, CCC, ASHA Fellow Board Certified Specialist in Swallowing & Swallowing Disorders Clinical Assistant Professor New York University School of Medicine March 2015
Incidence Approximately 10 million Americans are evaluated each year with swallowing difficulties (Domench & Kelly, 1999) With stroke patients over 50% initially show swallow dysfunction (Gonzalez-Fernandez) Dysphagia is most pronounced during the first 72 hours (Martino,R, 2005) In Multiple Sclerosis, over 30% of patients experience swallowing problems (Prosiegel, M, 2004) With Parkinson s disease dysphagia is reported in 20 40% of patients (Volunte et al, 2002) ALS Dysphagia is highly prevalent in individuals with ALS, (Kidney, et al, 2004)
Incidence A review of 270 trauma patients using a clinical swallow evaluation within 24 hours of extubation, showed 42% had oropharyngeal dysphagia. Risks increased as length of intubation increased. Kwok et al Bordon et al, 2011, documented that 41% of post-extubation trauma patients showed swallow dysfunction with the risk increasing by 14% for every day the patient required intubation Up to 50% of dementia patients exhibit dysphagia, Alagiakrishnan et al, 2013 Swallowing difficulties were also present in13 38% of elderly persons living independently (Kawashima et al, 2004; Serra-Prat et al, 2011) Patricia K, Lerner, M.A., CCC, BCS-S, ASHA Fellow
Hospitalized Patients Falsetti et al (2009) found that dysphagia is seen in over 1/3 rd of patients in Rehabilitation units. Altman & Schaefer (2010) in a review of hospital admissions concluded that dysphagia had a significant impact on hospital LOS. They stated that early recognition of dysphagia and early intervention in the hospitalized patient is advised to reduce morbidity and LOS. Up to 68% of residents in long term care settings are diagnosed with dysphagia (NIH study,1997)
Possible Outcomes of Dysphagia Increased medical and systemic complications Malnutrition and dehydration Increased disability Aspiration pneumonia Increased length of hospital stay Reduced quality of life
Penetration & Aspiration Penetration of material into the laryngeal airway entrance (laryngeal vestibule) from the oropharynx. Material enters to a level on/or above the true vocal cords Aspiration is passage of material into the airway (trachea) below the level of the true vocal cords Penetration &/or aspiration can occur before, during and/or after swallowing Patricia K. Lerner, M.A., CCC, BCS-S, ASHA Fellow
Aspiration In stroke, incidence of aspiration within the first 5 days post stroke ranges from 19.5-42% 68% who aspirate do so silently (Daniels, 1997) Co-occurring with aspiration is a high incidence of pneumonia With nearly 50% of those who initially aspirate, swallow difficulties may resolve within the week Over half of the remaining 50% will experience lasting deficits
SILENT ASPIRATION Smith, Logemann et al (1999) investigated the incidence of silent aspiration in an acute hospital & rehab population by analyzing all videofluoroscopic swallow studies performed over a 2-year period 2200 studies were reviewed representing Ss ages 3 98 with a variety of medical diagnoses 1101 studies showed dysphagia Of that group 467 patients aspirated 276 (59%) of that group silently aspirated Patricia Lerner, M.A., CCC/SLP, BRSS, ASHA Fellow 7
Clinical/Bedside Screening Identifies signs and symptoms of dysphagia Can grossly assess oral anatomy May provide you with some indirect evidence of a swallowing impairment Does not define anatomy or physiology of the oropharynx or pharynx nor resulting swallow impairments Patricia Lerner, M.A., CCC/SLP, BCSS, ASHA Fellow 8
Clinical Screenings 3-oz water test, Leder & Suiter, 2010 Pulse Oximetry Detect changes in O2 saturation levels during swallowing of liquids/foodstuffs Food testing patient given tastes of a variety of foodstuffs of different consistencies Cervical Auscultation assess airway sound changes produced when swallowing Questionnaire (MASA) Gag testing Patricia Lerner, M.A., CCC/SLP, BCSS, ASHA Fellow
NYULMC Dysphagia Screening Step 1: Initial Assessment/Inclusion Criteria Significant lethargy/difficult to arouse Copious secretions/drooling/ frequent Prolonged intubation (> 48 hours) Wet/gurgly vocal quality/wet breathing at baseline Respiratory instability, distress or Tracheostomy **If any screening questions from Step 1 are answered yes, DO NOT proceed to Step 2.
NYULMC Dysphagia Screening Step 2: Pre-Swallow Checklist Produces a strong cough on command Produces a loud ahh sound Moves tongue in all directions If there is a no to any question, a swallow consult is automatically generated
NYULMC Dysphagia Screening Step 3: Swallow Trials Provide oral care with antibacterial material Give sips of water from cup (maximum 60ml) Is there coughing, choking, wet/gurgly voice? **If there is a yes to the question, a swallow consult will be generated automatically
Suggested In-Patient Evaluation Process Obtain a dysphagia nursing screen within hours after patient admission If risks noted, obtain clinical assessment by swallowing specialist ASAP within 24 hours As needed, obtain instrumental assessment by swallow specialist &/or medical practitioner.
Modified Barium Swallow (Videofluoroscopic Swallow Study) Examines swallow physiology & identifies abnormalities Examines all stages of the swallow Identifies presence/absence of penetration & aspiration Defines etiology of aspiration and other deficits Devises appropriate swallow treatment plan Examines effect of specific treatment procedures Identifies best method of nutritional intake, e.g. oral, nonoral or combination of the two (Martin-Harris et al, 2008)
Fiberoptic Endoscopic Evaluation of Swallowing (FEES) (Aviv, Kaplan et al, 2000) FEES - the passage of a fiberoptic laryngoscope through the nasal passageway, over the velum and into the nasopharynx above the epiglottis to view the pharyngeal swallow Foodstuffs mixed with food coloring are viewed as they pass the pharynx and larynx Pharyngeal and laryngeal functions can be viewed
Fiberoptic Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) Uses standard endoscopic assessment with the added feature of sensory testing of the supraglottic mucosa Assesses sensation in the larynx by attempting to elicit an airway protective reflex An air pulse sensory stimulator sends a pulse of air through a port in the flexible endoscope If positive there would be an awareness of material in the oropharynx and therefore an ability to protect the airway from aspiration
VFSS FEES Non-Invasive Invasive Views all stages of swallowing: oral, pharyngeal & cervical esophageal Excellent view of the swallow physiology Can view aspiration when it is occurring Can determine causation of aspiration Can determine effective techniques & compensatory strategies Can observe UES/cervical esophageal function Radiation exposure Can assess impact of osteophytes, diverticulum, cervical spinal fusion etc Views primarily the pharyngeal stage of swallowing Excellent view of the swallow anatomy Often cannot view aspiration when it occurs Often cannot determine causation of aspiration Limited viewing & assessment of techniques and strategies Cannot fully observe UES/cervical function No radiation exposure Can assess impact of laryngeal & pharyngeal lesions
Possible Outcomes of Dysphagia Malnutrition and dehydration Increased Length of Stay Aspiration pneumonia Dysphagia is predictor of being less likely to be discharged home In one study, 46% of acute stroke patients who had dysphagia were discharged to nursing homes (Odderson, 1995)
Costs of Dysphagia and PNA A study in the Journal of Neurology, 2007, p1938-1943 comparing the cost of treating a patient with & without aspiration PNA showed the following: Nationally the mean cost post CVA pt with PNA was $21,043 The mean cost post CVA pt without PNA, $6,206 Extrapolated to >500,000 patients hospitalized each year for stroke in the US, the annual cost of PNA as a complication after acute stroke is approx. $459 million
Swallow Treatment Compensatory Interventions designed to reduce, avoid or bypass the effects of impaired structures and physiology and redirect the biomechanics of bolus flow. Rehabilitative - interventions include exercise programs that aim at improving the neuromuscular anatomy, physiology, or the neural circuitry, thus providing a direct influence on the biological underpinnings of swallowing. (Malandraki, Johnson & Robbins, 2011)
Interventions designed to reduce, avoid or bypass the effects of impaired structures and physiology and redirect the biomechanics of bolus flow Control the flow of food and reduce/eliminate symptoms, e.g. aspiration, but do not change the physiology Compensatory strategies Generally can be used with patients at varying cognitive levels and ages Require less muscle work and therefore less patient fatigue For example, elimination of certain food consistencies or taking small sips/bites can improve swallow safety
Compensatory Strategies Postural changes can facilitate the best swallow for the anatomical or physiological deficits identified during the evaluation Chin down Chin up Head rotation Head tilt Back lying Side lying
Sensory Techniques Techniques to improve oral sensory awareness include: Increased pressure on tongue Presentation of a cold/sour/spicy/flavored bolus Presentation of a larger volume bolus Increasing sensory input by self feeding, etc
Swallow Treatment Direct swallow treatment is designed to change the swallow physiology Improve range of motion or strength of structure Take voluntary control over timing and coordination of specific swallow movements Enhance the strength, speed, timing and coordination of the swallow musculature
Specific Treatment Modalities Oral motor exercises Specific oral tongue strengthening regimes Pharyngeal & laryngeal exercises Thermal Tactile Sensory Stimulation Oral resistance protocols Surface EMG with Biofeedback Neuromuscular electrical stimulation
Neuromuscular Electrical Stimulation Electrical Stimulation activates muscles through stimulation of the intact peripheral nerves Premise: By increasing electrical current higher amplitude E-Stim stimulates nerve endings in muscles beneath the skin and possibly stimulates deep muscles, pharyngeal & laryngeal, used to swallow (Ludlow et al,2007) Major treatment goals: Strengthen weak muscles Help in the recovery of motor control Increase pharyngeal contraction & speed
Neuromuscular Electrical Stimulation Cont. Electrical stimulation may assist swallowing either by - augmenting hyolaryngeal elevation or increasing sensory input to the CNS to enhance elicitation of swallowing Patricia K. Lerner, M.A., C CC, BCS-S, ASHA Fellow
Neuromuscular Electrical Stimulation A recent investigation presented at the Dysphagia Research Society by Carnaby, Crary et al (3/12) used randomly assigned post-stroke patient groups and presented 3 methods of treatment, 1 hour daily for 3 weeks Findings showed that intense swallow exercises resulted in superior functional outcomes including reduction in swallow impairment, improved oral intake and maintenance of function when compared to the NMES or other Usual Care approaches.
Neuromuscular Electrical Stimulation Ludlow s 2010 article in Dysphagia reviewing all the efficacy literature stated: Two recent controlled studies comparing traditional therapy to NMES. Findings: No benefit with NMES over traditional therapy in post-stroke patients and very limited improvement in only 1 of 4 outcome measures in head & neck cancer patients with dysphagia
Surface EMG Biofeedback Translates muscle movements during swallowing into real time visual and audio signals Increases patient awareness of muscle movements during swallowing The patient attempts to match a target performance The device tracts the patient s progress and provides visual and audio feedback based on successful performance
Frazier Free Water Protocol A clinical protocol for allowing patients who are NPO or on a restricted diet to have thin water by mouth throughout the day Patients receive aggressive oral care prior to any drinking of water Based on certain premises: Aspiration of different materials may not be of equal risk for development of aspiration pneumonia Water is relatively benign when or if absorbed in small amounts by the lungs Problem: Risk of bacteria in mouth, (Carlaw et al, 2012)
Surgical and Medical Options 1. Cricopharyngeal Myotomy A surgical incision into & through the cricopharyngeal muscle, slitting the fibers of the muscle from top to bottom to permanently open the sphincter. The myotomy diminishes the obstruction induced by a noncompliant cricopharyngus muscle. The patient must be able to propel material through the oral and phyaryngeal stages into the UES region 2. Dilitation Stretching of the UES to create a wider lumen May be only temporary and need to be repeated periodically
Surgical and Medical Options 3. Vocal Fold Augmentation: Adds bulk to one cord usually the weak cord - to improve closure of the cords & thus airway protection Considered when dysphagia is due to reduced vocal fold adduction, vocal fold paralysis, vocal fold atrophy or scaring of the folds. 4. Laryngoplasty: Vocal fold medialization to decrease the space between the 2 cords 5. Botox: Injection of Botox into the cricopharyngeous muscle. Only temporary may last 4-6 months and have to be repeated
Non-Oral feeding Criteria for Non-Oral Feeding - May Consider: A patient who is aspirating significantly more than 10% of all food consistencies (Logemann,1998) When more than 10 seconds is needed to swallow a single bolus during all types of food intake When the patient is malnourished and dehydrated 2 0 to a swallowing disorder A patient with a severe structurally impaired oropharynx and/or esophagus
Mitigating Circumstances History of frequent aspiration PNAs, bronchitis etc Fragile, non-mobile patient vs. younger physically healthy person Compromised respiratory system or severely impaired immune system Patient with severe dementia/alzheimer s disease Conscious quality of life decision Terminally ill patient, etc
NON-ORAL FEEDINGS FOR END OF LIFE PATIENTS Use of artificial nutrition & hydration in the severely demented, end of life, or palliative care patient is controversial & emotional Professionals often rely on feeding tubes for needed nutrition However there are questions about the efficacy of a feeding tube for this population Recent studies have shown a feeding tube does not Prevent occurrence or improve the healing of pressure sores Prevent malnutrition Prevent pneumonia Prevent end of life
NON-ORAL FEEDING - CONT Golan et al (2007), study surveyed 106 MDs and 126 family members of demented patients referred for PEG placement Results showed 50% of families were dissatisfied with the decision-making process Physicians often rely on feeding tubes to supply needed nutrition, improve quality of life & increase longevity MDs sometimes felt pressured to place a PEG by the need to transfer patients to a nursing home Recent studies are showing that a feeding tube does not prolong life or enhance quality of life
Take Away Message Screen patients oropharngeal swallow early upon admission If further testing is indicated perform instrumental evaluation Treatment goal: Improve the strength, range, coordination and timing of the oropharyngeal swallow mechanism Intensity of treatment matters Conservative approach to oral feeding of patients who aspirate 3 oz water test as a swallow evaluation does not hold water