Evaluation and Management of Dysphagia a Team Approach Rebecca L. Gould, MSC, CCC-SLP...
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Evaluation and Management of Dysphagia a Team
ApproachRebecca L. Gould, MSC, CCC-SLP
[email protected](561) 833-2090
www.med-speech.com
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“More than 15 million Americans have some degree of dysphagia, and with regular treatment 83% recover or significantly improve”.
Bello, J. (1994) compiled by Communication Facts.
ASHA Research Division
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Pneumonia occurs in 38% of all stroke victims and is the most common respiratory complication. Pneumonia contributes to about 34% of all stroke deaths and represents the third cause of mortality in the first month following stroke.Stepphens & Addington, 1999
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EVALUATION
Clinical “bedside” swallow evaluation.Videofluoroscopic Swallowing Study
(VFSS) Fiberoptic Endoscopic Evaluation of
Swallowing (FEES)(Reflexive cough test)
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Two Goals of Swallowing Evaluation:
1. Determine the Safest and Least Restrictive Level of P.O.
2. Determine the physiologic breakdown of the swallow so it can be rehabilitated in treatment.
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Leder, Sasaki, Burrell (1998)
FEES/Fluoro Comparison, n = 56
96% Agreement:1 silently aspirated during MBS but
coughed during FEES1 did not aspirate during MBSS but did
during FEES
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Will Test ALL Types of Food/Liquid
Thin liquidThick liquid (Nectar)PureeSolid Mixed ConsistencyPillsChallenging food (i.e. nuts, peanuts, etc.)
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Will give MULTIPLE trials of each consistency
CPG can break downLarge bolus sizeConsistencyFatigueLack of coordination (COPD)
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ProtocolSaliva – Secretion ratingAnatomy screenLaryngeal physiology assessmentSwallowing physiology assessment
Functional – Patient self-administer bolus
Diet recommendationsRecommendations for swallowing
therapy/follow-up
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Swallow Initiation
Bolus spills to valleculae or pyriform sinuses for greater than one second before the swallow (white-out).
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Issues With ResidueResidue in Vallecula?
Residue in Pyriform Sinuses?
Diffuse Pharyngeal Residue?
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In GeneralFEES = better detector of role of
anatomy on swallowing physiology, aspiration, and appropriate diet
ModBASW = better detector of role of UES and esophagus on pharyngeal function
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Incidence and patient characteristics associated with silent aspiration in the
acute care setting1001 patients underwent videoflurographic evaluation of their swallowing during a 2-year period:469 aspirated 276 were silent aspirating
Coughing is a physiologic response to aspiration in normal healthy individuals. No cough in response to aspiration silent aspiration
Smith, C.H. et al (1999)
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Aspiration risk after acute stroke: Comparison of clinical examination and
Fiberoptic Evaluation of Swallowing
Conclude: Clinical exam underestimated aspiration risk. FEES accurately assessed.
19 correct identification of aspiration risk3 incorrect identification of aspiration risk 19 incorrect identification of aspiration risk 8 correct identification of no aspiration risk
Leder, S.B. et al (2002)
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14% false negative rate – most important20% false negative rate for VFSS0% false negative rate for endoscopy
“Fallacy to rely on bedside evaluation when instrumentation is possible”
Aviv, J.E. (1997)
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Oropharyngeal secretions and swallowing frequency in predicting aspiration
Presence rated with endoscopic view.Scale 0, 1, 2, 3,Strong association between the presence of
oropharyngeal secretions in the laryngeal vestibule and the likelihood of aspiration of food or liquid.
Patients who demonstrate trouble in clearing oropharyngeal secretions for whatever reason will also demonstrate the same trouble with food or liquid while swallowing.
J. Murray et al. (1996)
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Oropharyngeal secretions and swallowing
frequency in predicting aspiration (cont’d) Significant decrease in the frequency of
swallowing in the aspirating hospitalized patients.The frequency of spontaneous swallows can be
easily sampled at bedside with simple instrumentation or palpation of the larynx to monitor elevation associated with the pharyngeal stage of the swallow.
J. Murray et al. (1996)
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A randomized control study to determine the effects of unlimited oral intake of water
in patients with identified aspiration
Small number: 20 patients with aspiration pneumonia.
10 with thick water 10 with “free water”
Results: “No patient in either group developed pneumonia”
Garon, B. et al. (1997)
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Thick, “crusted” mucous throughout hypopharynx.
Mucous appears moist and dispersed following hydration. (tsp. of water).
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Predictors of Dysphagia
Measured radiographically >70 years male gender disabling stroke (Barthel score <60) palatal weakness or assymetry incomplete oral clearance impaired pharyngeal response (cough/gurgle)
Mann, G. & Hankey, G.J.(2001)
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Clinical predictors of aspiration
Measured radiographicallydelayed oral transitincomplete oral clearance
Mann, G. & Hankey, G.J.(2001)
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Tube feeding is associated with a higher rate of pneumonia than with patients who are eating.
M.J. Feinberg, MD (1990)
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Look to correlate frequency of pneumonia with prandial aspiration. Found there is not a simple relation between liquid aspiration and pneumonia.
M.J. Feinberg, MD (1996)
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Begin of study50 non aspirators51 minor aspirators51 major aspirators
Studied 152 SNF residents - average age of 86. Followed for 3 years.
End of study37384730 artificial feeding
expired
M.J. Feinberg, MD (1996)
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SNF PATIENT (very elderly and/or frail) - RISK FACTORS
Delayed recognition of pneumonia as signs and symptoms are subtle and different from younger individuals.
Advanced ageDifficult antibiotic treatment:
difficult to identify pathogenaltered drug metabolismmedication side effects M.J. Feinberg, MD (1996)
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SNF PATIENT - RISK FACTORS(cont’d)
Dependency for feeding.Depressed and/or fluctuating levels of consciousness
(medication and/or neurological disease).Microaspiration of oropharyngeal secretions that had
been pathologically colonizedovergrowth gram negative enteric rods associated with
functional declineAnaerobic bacteria overgrowth secondary to gum disease or
dentures M.J. Feinberg, MD (1996)
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Pneumonia frequency was higher in months of artificial feeding.
Patients with artificial feeding are at risk for aspiration of refluxed material.
PEG’s/JEG’s do not help to protect those who are known to aspirate.
M.J. Feinberg, MD (1996)
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“Artificial feeding does not seem to be a satisfactory solution for preventing pneumonia in elderly prandial aspirators”.
M.J. Feinberg, MD
(1996)
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Colonization (Altered Oropharyngeal Flora)
Dependent for oral careNumber of decayed teethNumber of medications
Tube feeding
Aspiration into lungs
Large volume aspiration (liquid, food, GER, saliva) Microaspiration (saliva, plaque, GER)
Dependent for feeding
Host resistancePulmonary clearance
Now smokingSystemic Immunologic response
Multiple Medical Diagnoses
PNEUMONIA
Langmore, S. (1997)
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Pneumonia in acute stroke patients fed by nasogastric tube
100 consecutive patients with acute CVA (outcome was assessed at three months)
Determine risk given the frequency of pneumonia in acute stroke patients fed by nasogastric tube.
Identify variables significantly associated with the ocurrence of pneumonia and those related to a poor outcome.
Dziewas R. et al, Jun 2004
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Pneumonia in acute stroke patients fed by nasogastric tube
(cont’d)Results:Pneumonia was diagnosed in 44% of the tube fed
patients. Most patients acquired pneumonia on the second
or third day after stroke onset. Patients with pneumonia more often required
endotracheal intubation and mechanical ventilation.
Dziewas R. et al, Jun 2004
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Pneumonia in acute stroke patients fed by nasogastric tube
(cont’d)Independent predictors Decreased level of consciousness Severe facial palsy.
Conclusion Nasogastric tubes offer only limited protection against aspiration pneumonia in patients with dysphagia from acute stroke.
Dziewas R. et al, Jun 2004
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189 male veterans (55 outpatients), 41 or 21.7% developed pneumonia. (Bivariate analysis to determine predictive risk factors).
Langmore, et al (1998)
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“Dysphagia and aspiration are necessary but not sufficient conditions to predict development of aspiration pneumonia… a multifactorial phenomenon”.
Langmore,S. (1998)
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Focus on context of risk factors in given setting.
Assess strengths/weaknesses.
Langmore,S. et al(2000)
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Predictors of aspiration pneumonia in nursing homes patients
102,842 patient suctioning useCOPDCHFpresence of feeding tubebedfast
3,118 pneumonia = 3%deliriumweight lossswallowing problemsUTI’smechanically altered
diet Langmore, S. et al. (2002)
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Predictors of aspiration pneumonia in nursing homes patients (cont’d)
dependence for feedingbed mobilitylocomotionnumber of medicationsage CVAtracheotomy care
1998 Predictorsdependence for oral caresmokingmultiple medical
diagnosisnumerous decayed teeth
Langmore, S. et al. (2002)
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Impaired cough reflex in patients with recurrent pneumonia
7 Patients with recurrent pneumonia Capsaicin cough sensitivy 2-6 episodes of pneumoniaCough threshold was significantly higher in
patients than in controls
Conclusion: Impaired cough reflex may be involved in the pathogenesis of recurrent pneumonia.
Niimi A., et al (2003)
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What is a safe amount of aspiration?What is the long term consequence of
chronic aspiration?What factors predict who will get
pneumonia?
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SCALE PREDICTIVENESS OF PNEUMONIA RISK IF FED
FACTORSMultiple or progressive disease/one diagnosisMultiple medications (>5)/ <5 medicationsNPO (PEG)/ oralOral hygiene fair – poor/ good – excellentSmoker / non-smoker
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SCALE PREDICTIVENESS OF
PNEUMONIA RISK IF FED (cont’d)
FACTORSInpatient / outpatientPhysical ability (mobile)/ sedentaryReflexive cough (present) / absent – delayedCognitive status (fair-poor)/ good – excellentSecretion Pooling (minimal) / copious
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SCALE PREDICTIVENESS OF
PNEUMONIA RISK IF FED (cont’d)
Score
< 7 = Use extreme caution5–6 = fair – good <3 = good – excellent
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Inpatient“sick” (acute/ exacerbation of chronic condition)+ sedentary “bed rest/ bathroom privileges”number of medicationsmultiple medical diagnosis.tube feedingdependent for oral care/ hygiene statusdependent for feedingsmoking
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Outpatient
may have multiple diagnosis; however, “stable”
+ mobilitynumber of medications if tube feeding, bolus fedtypically are not dependent for feeding smoking
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Consensus
VFSS and FEES/FEEST are good for identifying aspiration.
However, identifying aspiration is not sufficient for predicting who will and who won’t develop pneumonia.
Some chronic aspirators appear to fair quite well i.e. head and neck CA, hemilaryngectomees, supraglottic laryngectomees.
Status of reflexive cough appears important.
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TECHNIQUES OF DYSPHAGIA THERAPY
- M E N D E L S O H N M A N E U V E R- S U P R A G L O T T IC S W A L L O W
- M O D IFIE D V A L S A L V AE X P E C T O R A T IO N M A N E U V E R
P O S T U R E S &P O S IT IO N ING
- E -S T IM- E M G
- O R A L M O T O R E X E R C IS E S- B O L U S W E IG HT
S T R E N G T H E N IN G
- T H IC K- T H IC K E R
- T H IC K E S T
M A N IP U L A T IO N O FC O N S IS T E N C Y
- R E S P IR A T O R Y C O N T R O L- W H E N T O S W A L L O W
- H O W M A N Y S W A L L O W S- S E Q U E N C E
T IM IN G
- C O G N IT IO N- G E N E R A L H X .
- C O P D- A C T IV ITY L E V E L
P A T IE N TN U A N C E S
A U N IQ U EP A T IE N T
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Electrode Placement
Genioglossus (GG)Superior pharyngeal constrictor (SPC)
- Posterior pharyngeal wall below level of the soft palate, lateral to the midline
Longitudinal muscles of the pharynx (LP)- Transorally in the midportion of the posterior tonsillar pillar
McCulloch, T. (Voice, Swallow & Airway 2005)
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Electrode Placement (cont’d)
Thyroarytenoid (TA)- Local, transcutaneously, subjects phonated, at level to the cricothyroid membrane angle 30 degrees superior and 30 degrees medial to normal plane, verification maneuvers
Cricopharyngeus (CP)- Local, transcutaneously at level of the cricothyroid membrane, needle advanced in a posterior and inferior direction, verification maneuvers
McCulloch, T. (Voice, Swallow & Airway 2005)
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Methods
Five normal subjects (4 male, 1 female)Human subject approvalSimultaneous endoscopy (fiberoptic endoscope,
camera and video recorder) multichannel electromyography (hook wire electrodes, amplification, filtration, and on line monitoring) during swallow
Time code generator (time lock endoscopic and electromyographic events)
McCulloch, T. (Voice, Swallow & Airway 2005)
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Instructions The supraglottic swallow
- “Inhale and hold your breath- Swallow while holding your breath- Cough immediately after your swallow without breathing in”
The Mendelsohn Maneuver
- “Swallow your saliva several times and pay attention to your neck as you swallow
- Now, when you swallow feel your Adam’s apple/voice box lift and lower
- Swallow don’t let your Adam’s apple drop
- Hold it up with your muscles for several seconds”
McCulloch, T. (Voice, Swallow & Airway 2005)
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Emphasis
EMG of the cricopharyngeus (CP) during the Mendelsohn maneuver
EMG of the thyroarytenoid (TA) and CP during the supraglottic swallow
McCulloch, T. (Voice, Swallow & Airway 2005)
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Muscle examined
Superior pharyngeal constrictor (SPC)Tongue base (GG)Cricopharyngeus (CP)Thyroarytenoid (TA)
McCulloch, T. (Voice, Swallow & Airway 2005)
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DiscussionA number of studies have concluded the
Mendelsohn maneuver prolonges UES opening, these employed manometric recordings and videofluorgraphic evaluation. None have employed the use of simultaneous
Studies have demonstrated that the UES diameter may increase with the use of swallowing maneuvers without increasing the duration of UES opening
McCulloch, T. (Voice, Swallow & Airway 2005)
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Discussion Traction of the anterior wall of the UES during the
Mendelsohn may lead to a prolongation of opening of the UES, despite the resumption of tone in the Cricopharyngeus (CP)
The study presented was that of normal volunteers, with normal swallowing function. We cannot predict the efficacy of these maneuvers on the head and neck patient who is status post anatomic and physiologic changes from neurologic/ surgical insults. In such patients these maneuvers may improve coordination of swallowing.
McCulloch, T. (Voice, Swallow & Airway 2005)
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Conclusions
Swallowing is the result of a series of coordinated neuromuscular events.
Certain aspects of swallowing may be superceded by volitional control.
The thyroarytenoid (TA) activity in the supraglottic swallow and the Mendelsohn it is prolonged along the “tail” end of the swallow.
McCulloch, T. (Voice, Swallow & Airway 2005)
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Conclusions
Cricopharyngeal quiescence is not prolonged by changes in swallowing maneuvers.
The basic order of events swallowing is predetermined.
The physical ends results may be modified by extraneous biomechanical forces.
McCulloch, T. (Voice, Swallow & Airway 2005)
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Conclusions
We are able to eat, talk, breath and swallow like a great orchestra.
Timing is everything. There is a delicate balance. The “escalation” neuromuscular
patterns add to the efficiently of the system.
It is no wander that patients with nearly any head or neck problem are at risk for dysphagia.
McCulloch, T. (Voice, Swallow & Airway 2005)
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IDEALInstrumental exam for
each patient.Coordinated team.Plenty of time.Medical experts
making decisions.Salient/clear data
presented.
REALITYTreatment without
exam.Piece meal.Little time.3rd party payer
control.Lengthy reports.
Check lists-important information lost “in the trees”.
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SOLUTIONSAssess your environment.Establish “partnership”/collaborative working
relationships with instrumental source. “Trust and understand results”.
Streamline reports. Highlight pertinent information.Foster open communication among practitioners.Focus on what you can do. “Prioritize”. Be resourceful.