Evaluation and Management of Dysphagia a Team Approach Rebecca L. Gould, MSC, CCC-SLP [email protected] (561) 833-2090

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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“IS IT SAFE TO FEED

THIS PATIENT?”

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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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MBSS? or FEES?

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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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FEES (Fiberoptic Endoscopic Evaluation of

Swallowing)

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RESIDUAL

Leftover material in the oral pharynx after swallow has occurred.

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PENETRATION

Entry of material into the laryngeal vestibule to the level of the vocal folds.

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ASPIRATION

Entry of material below the level of true vocal folds.

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Assess secretions

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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

Typically use green food coloring

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FEES Interpretation

4 Main Parameters:Delay in Swallow InitiationPenetrationAspirationResidue

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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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Penetration/Aspiration

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Timing of Penetration/Aspiration

Before the SwallowDuring the SwallowAfter the Swallow

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Issues With ResidueResidue in Vallecula?

Residue in Pyriform Sinuses?

Diffuse Pharyngeal Residue?

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Zenker’s Diverticulum

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Cervical Osteophytes

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Cervical Osteophytes

Globus

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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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Gurgly vocal quality predictive of who will

aspirate on VFSS

Linden (1993)

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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.


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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


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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.


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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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(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.


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(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.


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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.

SWALLOWING TREATMENT

“The human body is one of the greatest compensatory mechanisms.”

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GOAL: TARGET MOST CRITICAL RISK FACTORS.

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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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Timing of laryngopharyngeal events during swallow:

an EMG perspective

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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


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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)


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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”


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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


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Muscle examined

Superior pharyngeal constrictor (SPC)Tongue base (GG)Cricopharyngeus (CP)Thyroarytenoid (TA)


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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


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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.


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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.


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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.


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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.


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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.

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Documents

Evaluation and Management of Dysphagia a Team Approach Rebecca L. Gould, MSC, CCC-SLP [email protected] (561) 833-2090