SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018 st … · SAC, Edmonton 2018, James L. Coyle,...

SAC, Edmonton 2018, James L. Coyle, Ph.D. 4/1/2018

(c) 2018 James L Coyle except as otherwise attributed 1

Managing Dysphagia in the 21st Century: Keeping Up with the Evidence

James L. Coyle, Ph.D., CCC‐SLP, BCS‐S, F‐ASHA

University of Pittsburgh 1

SAC Conference, Edmonton, May 2018

Disclosure

• University of Pittsburgh (salary)• SAC honorarium

• NIH RO‐1 (25% effort)• NSF career award (PI: E. Sejdic)• No products

2

Evidence Based Practice

Best clinicaljudgment

Best externalevidence

Patient values& expectations

Evidence Based Practice

3



The Medical SLPHalf of day

Recovery

Disability

Rehabilitation

Other half of day

Disease

Survival

Death

Success

Prevention

4

Pneumonia, inadequate nutrition,

dehydration

Dysphagia‐aspiration

Pulmonary disease

Advanced Age & Frailty

Digestive diseases

Iatrogenicdisorders

Neurological diseases

5

The speech mechanism

• Respiration• “[Respiration] requires the movement of air into and out of the lungs during inhalation and exhalation. Air movement through the vocal system during exhalation makes voice production possible. Also important to speech production is the ability to vary both air flow and pressure during exhalation. This chapter will examine the forces that control air flow and pressure.” Dixon & Maue‐Dixon, 1982

Anatomical and Physiological Bases of Speech

6



It’s the aerodigestive tract

7© Feb 26, 2016 OpenStax. Textbook content produced by OpenStax is licensed under a Creative Commons Attribution License 4.0 license

Our clinical domains

• Swallowing• The process of directing solids and liquids• To the digestive system• Bypassing the respiratory system

• Speech• Manipulation of exhaled respiratory gas

• By parts of the digestive + respiratory systems

8

So… we’ll start with…

• Lungs• And work our way down

9



10

trachea

carina

hilum

RUL, RML, RLL, LLLOVERLAP RUL+RLLOVERLAP RML+RLL

Posterior AnteriorRight Left

Right lung

3

11

Anterior PosteriorRight Left

LUL, LLLOVERLAP LUL + LLL

Left lung

12



Breathing: two components

• Ventilation• Moving air in and out of the lungs

• Respiration• Exchanging gases between

• Atmosphere and BLOOD

• BLOOD and working organs

13

Ventilation

• Pumping mechanism…

• Connected to muscles on one end…

• And to the lungs on the other end…

• Lungs and chest wall need to be:• Compliant

14

PhrenicNerve

activates diaphragm

Diaphragm contracts,

pulling on lung and pushing on

viscera

Alveolar inertia

overcome, lung volume increases

Atmospheric air fills

pressure void in lungs

Phrenic nerve impulses cease,

diaphragm relaxesElasticity of

viscera, alveoli are now

unopposed

Compressed viscera, stretched

alveoli, recoil

Alveolar volume

decreases, pressure increases

Intra‐alveolar pressure decreases

(Boyle’s Law)

Alveolar air is “pushed” out

to atmosphere

Ventilation

15



16© Conexions

Boyle’s Law

17

How do we do that?

18Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/ under Creative Commons 3.0 unported license



19© Conexions

• Regulation of respiration• Peripheral, central chemoreceptors

Photo: John A Beal, PhDDep't. of Cellular Biology & Anatomy, Louisiana State University Health Sciences Center Shreveport. Creative Common s license

20

Coordination of Breathing & Swallowing

21



Breathing and Swallowing

volume

pressurepA

+

_

Duration of one swallow(apnea)

22

Breathing and swallowing

•Abnormalities• Stroke: volumes, duration, airflow direction

• Shorter cycle duration at rest*• Direction of airflow after swallow**

• Normals: 96% expiration after swallow

• Stroke: 60% expiration after swallow (p<.01)

• Laryngectomy ***• Evidence of maintained pattern in laryngectomy

*,**Leslie et al., 2002 a,b***Charbonneau et al., 2005

23

inspiration

expiration

Swallow apnea1.5 – 2.5 seconds

Seconds

Abnormal Breathe‐Swallow Phase

24



inspiration

expiration

Swallow apnea1.5 – 2.5 seconds

Seconds

Respiratory Rate = 36/min

Breathing and swallowingAbnormalities: Tachypnea

Abnormalities

25

Aspiration, pneumonia, aspiration pneumonia, other pneumonias

26

What are pneumonitis and pneumonia?

27



Pneumonitis: lung inflammation

Inflammation

ChemicalMedications

Irritanttraumatizes lung

Irritants (e.g. pathogens),Allergens

RadiationTherapy

Inhaled or aspirated sources

28

Pneumonia: lung infection + inflammation

Pneumonia (Infection andPneumonitis)

PathogenColonizes lung

Bacterial

Inhaled or aspirated sources

SystemicSpread

Resolution

Sepsis, Multi‐organ

Failure,Shock

ViralWith or withoutother debris

29

Infection causes inflammation: pneumonia = infection + inflammationPathogens and their waste are irritants

Pneumonia

• Inoculation • Infection

• Proliferation of pathogen• A strong epithelial irritant

• Inflammation• Epithelial trauma, thickening, leakage• Resolution

• Both• Pathogen enters circulatory system sepsis

30



Pneumonitis

Ware & Matthay, 2000

Normal acute resolution

31

Clear alveoli

Thickened epithelium

Infiltrates

32

Pneumonia• Most frequent infectious cause of death*

• 40% higher incidence in elderly **

• #2 nosocomial infection (UTI) in hospitals***

• High case fatality rate• 55% (elderly)• Leading cause of mortality in children under 5****

Marston, et al., 1997*; National Center for Health Statistics, 2003**; ***Niederman, et al., 2002;****Baine et al., 2001; Almirall, et al., 2000 33



What is Pneumonia?

• American Thoracic Society criteria• New and persistent infiltrate on CXR PLUS ONE OF THE FOLLOWING:

• + pleural or blood culture – same organism as lung

• Radiographic evidence of necrosis or cavitation

• Histopathologic evidence of pneumonia

• Two of the following• Core temp > 38.3C

• Leukocytosis (> 10,000)

• Purulent tracheal secretions

34

Classifying pneumonia

• By pathogenic source• Bacterial, viral, fungal, etc.

• By mechanism of inoculation• Aspiration, hematogenous, airborne, etc.

• By inoculation setting• CAP, HAP, HCAP, etc.

35

Classes of pneumonia

• Community acquired pneumonia (CAP)• Inhaled, airborne pathogen• Aspirated pathogen, Bacterial, viral

• 4‐5 million cases per year* **• 600,000 hospitalizations, 45,000 deaths**

• Incidence**• 12 per 1000 persons• 20 per 1000 elderly persons (60% greater)• Some are AP!

• Some are DAP, some are NDAP!

36*Niederman, 2002; **Mandell & Wunderink, 2007



Classes of pneumonia

• Health care associated pneumonia (HCAP)• Ventilator associated pneumonia (VAP)

• Contaminated respiratory circuit/equipment

• Health care worker contamination (VAP, HCAP)

• Aspiration (iatrogenic or missed dysphagia!)

37

Healthcare Associated Pneumonia

CDC MMWR (1997) Vol. 46, RR‐138

Other Types of Pneumonia

• Ventilator Associated Pneumonia• Exposure to mechanical ventilation

• Contaminated respiratory circuits

• Contaminated suction, bronchoscopicequipment

• Aspiration of oral secretions while sedated• Gastroesophageal reflux common in ventilation

39



Other Types of Pneumonia

• Respiratory Syncitial virus (RSV)• Viral, common in children (day care)

• Legionella pneumonia

• Hematogenous pneumonia• Lung infected by bloodborne pathogen• This is sepsis‐related pneumonia

• Pneumonia caused by bloodborne transmission of pathogen from another organ

40

What is aspiration and how do lungs respond to aspiration?

41

Aspiration

• Solid or liquid matter• Not airborne, inhaled pathogen

• Courses by gravity, to its destination• Crosses plane of true vocal folds

42



Aspiration‐destination

• Aspirated material is gravity dependent

Airborne is not

43

R L

RL

Prandial sidelying/supine

AP

Lung response to aspiration: water

Inside alveolus

Plasma containing water inside capillary

RespiratoryMembrane

Water

H2O

H2O

H2O

H2O

RBC’s

WBC’s

Toward (L) heartFrom (R) heart

Capillary membrane

Alveolar membrane

Effros, et al., 2000 44

aquaporins

Inside alveolus

RespiratoryMembrane

Chemical irritant

Lung response to aspiration: pathogens and particulate matter

RBC’s

WBC’s

Plasma containing water inside capillary

Toward (L) heartFrom (R) heart

H2O H2O plasma H2O

Capillary membrane

Alveolar membrane

infiltrate

Chemical pneumonitis 45



What is aspiration pneumonia?

46

Aspiration Pneumonia 15.5%

>Oropharyngeal>Gastric

DAPNon‐DAP

Typical

Pneumonia100%

Hospital Acquired

Pneumonia

VAPAtypical

Inhaled Pathogen

AspiratedPathogen

Non‐VAP

Aspiration pneumonias

Inhaled Pathogen

47PEOPLE CAN ASPIRATE ANYWHERE: AP IS NOT SETTING SPECIFIC!

Pneumonia100%

CAP

Aspiration Pneumonias

• 1. DAP (Dysphagia‐related AP)• Pathogen in solid or liquid matter• Courses by gravity, to its destination• Not airborne, inhaled pathogen• CAN OCCUR ANYWHERE!

• 2. NDAP (Non‐dysphagia related AP)• Colonized emesis

• gastroesophageal esophagopharyngeal reflux

48



Aspiration Pneumonitis(chemical pneumonitis)

• Non‐Infectious‐chemical trauma• Acute Lung Injury: caustic or particulate aspiration

• Inflammation of alveoli by effects of irritants• No primary infection

• Inflammatory edema reduces surface area

• Gastric contents• Sterile, acidic, caustic• Damage to airways, alveoli

49

Differential Diagnosis – pneumonia, pneumonitis

• Aspiration pneumonia• Inflammation

• Cough – productive

• Bronchospasm

• Dyspnea

• Hypoxemia

• Purulent sputum

• Tachypnea

• Malaise

• Aspiration pneumonitis• Inflammation

• Cough ‐ not productive

• Bronchospasm

• Dyspnea

• Hypoxemia

• Frothy or bloody sputum

• Tachypnea

• Respiratory distressminutes to hours after aspiration; may persist

50

Distinguishing AP, Aspiration Pneumonitis, Other Pneumonias

51



Differential Diagnosis: DAP vs. NDAP

• Dysphagia‐related Aspiration Pneumonia (DAP)• Pt. has pneumonia• Infiltrates are in gravity dependent segments

• Patient has DYSPHAGIA!

• Non‐dysphagia related aspiration pneumonia (NDAP)

• Pt. has pneumonia

• Pt. does not have oropharyngeal dysphagia• Aspiration is conceivable due to GE reflux, emesis…

52

• Location of chest infiltrates• Signs and symptoms

• Bacteriology/hematology

• History• Clinical observations

53

Location of chest infiltrates

• NDAP• more diffuse, multifocal

• VAP: often well distributed

54Differential Diagnosis



Location of chest infiltrates – Aspiration

Basilar infiltratesLarge volume or larger

volume chronic aspiration

(R) Upper lobe infiltrates

55

Hilar infiltratesSmaller volume aspiration

• DAP, CAP, Nosocomial Pneumonia: similar.• Dyspnea• Hypoxemia

• Malaise

• Fever• Productive cough• Purulent sputum• Leukocytosis

Signs and Symptoms


• DAP: oral pathogens/oral flora

• CAP: Strep. pneumoniae, Klebsciellapneumoniae, H. influenzae, RSV, Legionella, E. coli, Staph. aureus

• VAP: pseudomonas, proteus species, Staph. Aureus

• Typically multiple organisms

• Nosocomial pneumonia: pseudomonas, proteusspecies, Staph. aureus

• Leukocytosis (elevated WBC)

• Normal: 4.5 – 10.5 k cells/microliter

Bacteriology/Immunology

57

Note: e. coli, staph., pseudomonas, proteus can colonize mouth, nose!

Differential Diagnosis



• DAP: Dysphagia! • Dysphagia‐producing disease, symptom onset following oral intake; position during oral intake; esophageal dysmotility

• Dependent for feeding/oral care, oral biofilm

History


Clinical observations:What does patient with pneumonia look like?

• What we see on assessment is not baseline• Elevated respiratory rate • Mental status

• Cough is present in background• Count coughing before, during, and after oral trials

• Patient may appear acutely dysphagicbecause he is very sick

• Though he may not have “dysphagia”

59

Clinical observations

Sign Interview Oral Facial Exam

Swallow Trials A Swallow Trials B Post‐swallow trials

Cough

Throat clear

Vocal quality

other

TimeTime Time TimeTime Time

duration duration duration duration duration

5 min 5 min 5 min 5 min 5 min

2

112

0.4 sx/min all phases

1

1

1

11

1 1

1 3

3

32

1

0.4 before oral trials, 1.1 during oral trials, 0.2 after oral trials

60



Summary‐pneumonia• Knowledge of normal and abnormal function is essential

• Not just swallowing function…

• Elderly possess many risk factors for pneumonia that are unique to the elderly

• There are many clues pointing to, or away from, a diagnosis of DAP

• This is important background knowledge for the SLP

61

• Things to remember• Aspiration can occur without dysphagia

• Aspiration is one potential source of pneumonia pathogens

• All respiratory illnesses are NOT dysphagia related

• ALL PNEUMONIAS ARE NOT ASPIRATION RELATED

• Patient appearance with pneumonia is NOT baseline

• History, course, physical signs are data for the SLP/clinician

Summary‐pneumonia

62

When patient has other respiratory diseases

• Types/categories• The respiratory conditions seen in the elderly

• Are they suspicious for a dysphagia etiology?

• Chest imaging – what does it mean?

63



ACUTE OBSTRUCTIVE PATHOLOGICAL

CHRONIC RESTRICTIVE IATROGENIC

64

Duration of condition, Recurrence

Mechanism of pulmonary effects

1. Acute: rapid onset2. Chronic: longstanding, recurrent , progressive

1. Obstructive: blocks gas flow to respiratory membrane2. Restrictive: restricts gas volume that can be inhaled

Source of condition

1. Pathological: caused by disease2. Iatrogenic: caused by treatment of another disease

Pulmonary diseases

• Obstructive Diseases• Inspired air is obstructed from the respiratory membrane

• Obstructed gas exchange• Respiratory pump works

• Restrictive Diseases• Airflow or volume is mechanically restricted

• Gas exchange is intact• Patient cannot inhale sufficient volume

65

Pulmonary diseases

• Chronic respiratory conditions• COPD (obstructive)• Congestive Heart Failure (obstructive and restrictive)

• Pulmonary Fibrosis (restrictive)

• Asthma (obstructive and restrictive)

66



Pulmonary diseases

• Acute respiratory conditions• Pneumonia (obstructive and restrictive)• Pneumothorax (restrictive)

• Atelectasis (restrictive)

• ARDS (obstructive and restrictive)• Other acute pneumonitis (usually both)

67

Chest x‐ray reports

• Terms• Pulmonary vascular congestion

• NOT airway congestion

• Blood back‐up in pulmonary vessels

• Alveolar infiltrates are inside alveoli!• The rest of these are NOT alveolar infiltrates.

68

Pulmonary vascular congestion

• Incoming arterial flow obstructed

• Blood “backs up” – casts shadow on image

Pulmonary hypertension69

Pulm. artery Pulm. vein

Obstructed flow



Pulmonary edema

• Leakage of circulatory fluid into alveoli• Most common cause = congestive heart failure• Pulmonary hypertension “pushes” fluid out of capillaries

70

Pulmonary edema

Pulmonary hypertension71

CHF and Pulmonary Edema

72



Pleural effusions

• Fluid filling parts of pleural cavity• Preventing lung expansion during inspiration

• Gravity dependent “bag of water”

73

Pleural effusion

Pleural cavity

74

CHF (transudative), Inflammatory (exudative)

Restrictive Pulmonary Disease

Pleural Effusion

75



76

Pleural Effusions (L>R)

Pneumothorax

• Perforation of pleural membrane• Destroys intrapleural vacuum that holds lung open

Subatmospheric pressure

Pleural cavity

Atmospheric pressure77

Mechanically Restrictive

Pneumothorax Perforation caused by empyema/

abscess Chronic aspiration

78



Atelectasis Areas of collapsed alveoli

Restrictive Pulmonary Disease

79

Iatrogenic causes of respiratory conditions

• Iatrogenic condition: a disease cause by treatment of another disease

• Sedation (restrictive)• CNS depression

• Disruption of pleural linkage (restrictive)• Cardiothoracic surgery

• Transplantation, lobectomy, any thoracotomy

• PICC (subclavian) line accidents, thoracentesis

• Phrenic nerve injury (restrictive)• Cardiothoracic surgery

• Vagal injury (obstructive: vocal fold paralysis)

80

Clinical observations

• Minute volume = tidal volume x resp. rate• Constant for a given activity

• Obstructive/restrictive diseases• Less gas to alveoli • Minute volume must be maintained

• Lower TV per breath more breaths/minute

• Dyscoordination of breathing/swallowing

81



A word on the effects of aging and disease

82

• Maintenance of a constant, stable condition• Organ systems maintain homeostatic equity

• Baseline• Few resources used to maintain homeostasis

• Examples• Digestion, fluid/electrolyte balance [hydration]• Temperature regulation, cardiovascular functions

83

Homeostasis

• The characteristic, progressive constriction of homeostatic reserve that occurs with aging in every organ system.

• With aging, physiologic reserves are increasingly used to maintain homeostasis

• Declining reserves left for meeting new challenges

84

Homeostenosis



Homeostenosis

Available reserve for WHEN WE NEED IT

Amount of reserve used to maintain homeostasis

85

Young Old

Homeostenosis

Age

Available reserve for WHEN WE NEED IT

Amount of reserve used to maintain homeostasis

86

Young Old

Disease

More reserve for emergency Less reserve for emergency

RESERVE DEPLETED

Decompensation & aging

• Chest wall, musculature

• Declining number of alveoli

• Gas diffusion capacity diminishes

• Reduced central ventilatory drive

• Diminished esophageal motility

• Immune system degradation

• Decreased tidal volume increased rate

• Breathlessness: detecting changes in respiration

87



Lung function

• Impaired lung function may cognitive decline

•Diminished expiratory air flow• Impaired cough airway protection

88

Summary

• Disease, Ageing, and DISEASE+AGEING add unique risks to all systems

89

Respiratory problems affect swallowing, what is to be done about them?

• Reversal of swallow‐breathing discoordination

• Consider added fatigue of “eating and drinking”

• Increase respiratory rate even more?

• Mitigating rate increases with supplemental O2• …because we can’t pull off more CO2.

90



Summary

• Ventilation and pulmonary physiology are essential knowledge for the SLP

• Pulmonary disease affects swallow/breathing coordination

• Pulmonary disease can cause, or be caused by, dysphagia

• Mainly characterized by disruption of swallow‐respiratory coordination

91

Questions?

• Glossary • Questions about pulmonary/respiratory terms?

92

The Digestive System

• General digestive anatomy & physiology

• Esophageal anatomy & physiology

• Assessment of esophageal structure, function

• Common esophageal pathology• Anatomic

• Physiologic

93



Digestive System

94

• Ingested food is always “outside” of the body’s tissues

• Digestion breaks down food to liberate absorbable materials

• Nutrients are absorbed into the body’s tissues

• Waste passes on by.

Inside the body, cells, absorbed nutrients

waste

FOOD

Digestive System

95© Conexions

96



The esophagus

97

Anatomy of the gastroesophageal junction

98

Esophagus

99© Conexions

(Vagus)



Esophagus

100

• Muscular Tube‐no skeletal framework• proximal 1/3 skeletal muscle• middle 1/3 transition• distal 1/3 smooth muscle• very delicate mucosal lined• longitudinal bundles on exterior‐shortening/squeeze• circular layer interior‐compression/squeeze

• Enters abdomen through hiatus• hole in diaphragm

• crural diaphragmatic fibers

• lower esophageal sphincter

Esophagus

• Upper 1/3 striated muscle• Muscle diseases affect function

• Myositis, myasthenia gravis

• Lower 2/3 progressive smooth muscle• Other disease mechanisms affect function

• Scleroderma

• Achalasia

101

Esophageal Muscular Layers

102

Longitudinal

Circular



Esophageal Muscular Layers

103

Esophageal “peristalsis”

104Creative Commons 3.0, Gnu public

Esophageal Function

105

• Innervation• Motor:

• Extrinsic – CN X, Autonomic

• Intrinsic – Myenteric Plexus

• Sensory: Somatic thoracic segmental

• referred symptoms to neck, chest

• Peristalsis• superior to inferior wave‐like contractions• squeeze bolus top to bottom



106

107Creative Commons 3.0

Esophageal Physiology

108

• Lower Esophageal Sphincter• resting pressure about 1/3 of UES resting pressure

• prevents gastric contents from re‐entering esophagus

• circular muscle layer, diaphragm (crura)

• intrabolus pressure increases proximal to LES

• LES releases resting posture, bolus enters stomach

• subatmospheric pressure at bolus arrival

• closure‐brief supra‐resting level of contraction



Assessment of esophagus

• Structure ‐ Imaging• Barium swallow• Endoscopy

• Function• Motility – manometry

• High resolution manometry

• GE reflux – pH‐metry

109

Barium swallow (esophagogram)

110

Structure Motility

Sphincter functionReflux

Esophagogram

111



Findings• Dysmotility

• Top‐to‐bottom contraction disrupted• Bolus separation; stasis; retrograde flow (to/fro)

• Gastroesophageal reflux• Gastric contents re‐enter esophagus

• Structural findings• Web, stricture, Schatzki ring; Zenker diverticulum

• Typically affect solid bolus transit

• Both: achalasia

112

Disorders of Esophageal Motility

113

• Gastroesophageal Reflux• LES permits gastric contents to re‐enter esophagus

• food is normally reduced by acid, pepsin, bile

• all strong mucosal irritants

• mucosal injury, inflammation, re‐epithelialization, scarring

• Esophago‐laryngeal reflex (Shaker et al., 1992)

GE Reflux challenge

114



Disorders Related to GER

115

• Esophagitis• Subglottic Stenosis

• Chronic laryngitis, hoarseness, cough• Aspiration Pneumonitis

• Chronic bronchitis, tracheobronchitis

• Globus‐relieved by swallowing• ? increased UES pressure in response to GER

Achalasia

116

Achalasia

117



Schatzki`s ring

118©Copyright Science Press Internet Services

on barium esophagogram

on endoscopy

119

Schatzki ring Esophageal webs

Normal

120Creative Commons 3.0



121© Nevit Dilmen Creative Commons 3.0

Hiatus hernia (but first – review)

122© Connexions via Creative Commons Attribution 3.0 license

122

Hiatus Hernia

• A. Normal anatomy

• B. Flattened flexure

• C. Sliding hernia

• D. Irreducible hernia

123



Paraesophageal hernia

124©Copyright Science Press Internet Services

Hiatus hernia

Hiatus hernia

125

Paraesophageal HH (from below)

Endoscope in LESFundus herniated

HH from above. Note diaphragmclosure and gastric folds.

Normal

Zenker Diverticulum

• Bulge in inferior constrictor

• Pulsion diverticulum

• Outpouching of mucosal envelope

• Superior to cricopharyngeal bar

• High pressure zone

126



Zenker diverticulum

127

Large Zenker diverticulum

128

129



Progression of symptoms• Resistance multiple swallows regurgitation anorexia recurrent unexplained LRTI

• Telltale observations (VF)• Unexplained pyriform sinus residue

• Barium filled defect rises into field

• Air‐fluid level

130

Esophagitis

• Inflammation of esophageal mucosa

• Extrinsic• Irritants mucosal inflammation

• Intrinsic• Eosinophilic esophagitis

• Eosinophils infiltrate esophageal mucosa

• Stricture, impactions, dysmotility

• “Trachealization” of mucosa

131

Esophagitis

132Creative commons 3.0

Candida esophagitis (candidiasis)Herpetic esophagitis



Barrett’s esophagus

133

Normal GE junction

Barrett’s adenocarcinoma

134GIMOBarrett's esophagus; Barrett's adenocarcinoma video

Esophageal Motility Disorders

135

• Esophageal motility disorders Terms: • Dysmotility: disruption of the primary peristaltic wave in 40% or more swallows

• Proximal escape: portion of bolus remains in proximal esophagus, or contrast courses retrograde (rostrally)

• Tertiary contractions: nonpropulsivecontractions, often multiple and simlutaneous, causing focal and simultaneous narrowings of esophageal lumen




136

• Disordered peristalsis• disorganized esophageal clearance with residuals

• Reduced or absent peristalsis• stasis in esophagus

• increased esophagopharyngeal reflux risk• AKA extraesophageal reflux

• AKA L.P.R.

• Achalasia • absent peristalsis with absent LES opening


137

• Diffuse Esophageal Spasm• Nonspecific esophageal motility disorder

• 25‐50% of abnormal motility study results performed for chest pain and dysphagia

• Presbyesophagus• diminished peristalsis

• distal findings more prevalent

• impaired LES distension with proximal dilatation

138

Tertiary contractions Diffuse esophageal spasm



Other esophageal tests

139

Esophageal Manometry

• Esophageal catheter with pressure sensors• Perfused catheter – water inside catheter

• Fluid dynamics produce pressure signals• Compression of water‐filled catheter activate sensors

• Ideal for pharyngoesophageal manometry• Sphincters

• Direct intraluminal transducers• Electronic pressure sensors

• Directly activated by pressure

• Ideal for esophageal manometry

140

GI Motility online (May 2006) | doi:10.1038/gimo13

Figure 1 Primary peristalsis as recorded by an intraluminal manometry catheter.

Manometry

141



142Creative commons 3.0; GNU public

High resolution Manometry

Endoscopy

143

pH‐metry/Impedance monitoring

• Detection of retrograde flow to esophagus• Acidified (pH‐metry), non‐acidic (impedance)

• Catheter with pH sensitive electronic sensors

144



Signs, symptoms: chickens or eggs?

• Esophageal motility disorder

• Achalasia

• Stricture/web• Hiatus hernia• Zenker diverticulum

145

Signs and symptoms

• Myenteric plexus – esophagus has a “brain”• Sensorimotor circuits are diffuse

• Different from somatic sensorimotor circuits

• Vagus• Events causing OPD can cause esophageal disorders

• Esophageal sx. often referred to pharynx• Even many distal diagnoses refer to pharynx

146

Signs and symptoms

• Pharyngeal globus sensation• Stricture (web, ring)• CP bar• Diverticulum• Achalasia• Esophagitis• Hiatus hernia• Esophageal varices

147



Signs and symptoms

• Early satiety• Achalasia• Stricture• Gastroparesis• Hiatus hernia

148

Signs and symptoms

• Cough• Esophagitis (esophagolaryngeal reflex)• Achalasia

• Filling of esophagus aspiration

• Zenker diverticulum• Regurgitation from pouch pharynx aspiration

149

Signs and symptoms

• “a funny squirting sound in my throat…”• Zenker diverticulum

• Need to swallow several times…• Zenker diverticulum• Esophageal motility disorder

• Cricopharyngeal bar• Esophageal varices• Of course, oropharyngeal dysphagia

150



Signs and symptoms

• Postprandial burning• Gastroesophageal reflux

• Nocturnal awakening with cough• Gastroesophageal reflux• Zenker diverticulum

151

Assessment and Treatment

152

• Motility, gastroesophageal reflux assessment• Manometry• dynamic radiography

• 24 hour pH monitoring

• Treatment• medication, posture/gravity enhancement

• surgery

Assessment and Treatment

153

• Structural disorders• stricture: dilatation, surgery• carcinoma: extent of disease, esophagectomy, radiation therapy, palliation



Treatment of esophageal disorders

• Conservative anti‐reflux measures• NPO 2‐3 hours before HS• Exploitation of gravity

• Elevation of head of bed 10‐15cm

• Avoidance of foods that …• Loosen LES closure

• Increase gastric “juice” production

154

Treatment of esophageal disorders• Medications: motility disorders

• Increase motility (prokinetics)• Relax skeletal muscle

• Botulinum toxin, others

• Relax smooth muscle• Loosen lower esophageal sphincter• Esophageal spasm

• Increase speed of gastric emptying

• Medications: gastroesophageal reflux• Acid suppression

• Reduce erosive potential

155


• Endoscopic intervention• Dilatation

• Stricture

• Stent • Intractable stricture, untreatable carcinoma

• Endoscopic Ligation • Esophageal varices

156

GNU free




• Surgery• Laser

• Stricture

• High frequency radio wave ablation• Barrett’s esophagus

• Myotomy• Cricopharyngeal bar• Achalasia

• (PS: CP bar = CP achalasia)

• Esophagectomy• Esophageal cancer• Barrett’s esophagus

157

• Esophagectomy

158

159

http://MIER web page

• “Pneumonia is a major complication ”• 2/3 post‐ER deaths attributed to

respiratory complications

Atkins, Fortes, & Watkins, 2007.



Questions?

• Glossary • Questions about digestive system terms?

160

Dysphagia Treatment: What are We Doing, and Why?

161

Goals

• Least restrictive diet without aspiration?• Adherence to exercise protocol?

• Perform maneuvers independently?

• Or…..

162



Goals

• Fewer hospitalizations for dysphagia‐related disease?

• Lower early mortality due to dysphagia‐related illness?

• Lower pneumonia risk?

• Improved nutritional status?

163

Treatment components

• Structural/tissue properties• Treatment increases “health” of tissue/organ

• Organ function• Treatment results in improved organ function

• Skilled performance• Treatment leads to improved patient organ use

• Cognitive/affective representations• Treatment instills motivation toward participation; importance of problem/treatment

164

Some Common Interventions…

• They are designed for this…• Intended consequences

• But they also do this…• Unintended consequences

• Sometimes good…

• Sometimes not so good…

165



Some Common Interventions… compensate…

1. Head rotation posture* ‐ divert bolus Directs bolus to opposite side of pharynx Compensate for unilateral noncompliance

BUT IT ALSO: Increases UESO diameter (rotation to either side in normals)

Reduces UES pressure (either side, normals)

Increased intrabolus pressure Reduces contralateral pyriform sinus pressure**

166*Logemann et al (1989); **Takasaki et al., 2012

167


• 2. Chin‐down posture*‐ reduce aspiration• Patients with aspiration due to “pharyngeal delay”

• 50% did not aspirate with CDP (OR = 0.5)• Continued aspirators: pyriform sinus residue aspirated• Valleculae widened

• Anterior bolus position (phar. delay, oral containment)

• BUT IT ALSO:• Reduces intrabolus hypopharyngeal pressure**

• Contraindicated in patient with weak constrictors

168*Shanahan et al. (1993); **Bulow et al (2002)




• 3. Increase duration of UES opening*• Mendelsohn Maneuver

• maintains prolonged HLE

• BUT IT ALSO:• Is difficult to teach, difficult to perform

• SEMG biofeedback training improves treatment effect* **

169*Kahrilas et al (1991); ** Coyle (2008)

170


• 4. Self‐protection of airway• Supraglottic swallow (SGS)

• Closes airway before swallow• “super SGS”

• “effortful” vocal fold closure +Tilts arytenoids

• Earlier/longer UES relaxation and HLE* **

171*Bulow et al (2002); **Ohmae et al., 1996;




• Does the work of 3 other interventions• Increased intrabolus pressure*• Increase UES Opening and laryngeal closure*• Reduced oral residue*

• And can be Dangerous!!!• Produces arrhythmia in certain patients**

172*Bulow et al (2002); **Chaudhuri et al. (2001)

BUT IT ALSO:

Swallow respiratory coordination

• Healthy swallows followed by exhalation• Disordered swallows followed by inhalation

• Training patients to coordinate breathing and swallowing?

173Gross et al, 2009; Leslie et al, 2002a,b; Leslie et al, 2005


• 5. Tongue holding/tether• Bulge in PPW during swallow

• Inhibits tongue motion

• Increases oral residue in normals

• BUT IT ALSO:

• Is not intended for use by patients when swallowing!

174

Fujiu & Logemann (1996)




• 6. Bolus modification• Larger bolus

• Earlier HLE, tongue movement, UES opening*

• Taste, temperature, consistency• Earlier activation in some patients**

• Will patient eat/drink it???

175*Cook et al., 1989; **Dantas et al., 1990; Ding et al., 2003

What about texture modification and Water?

176

Diet modification

• Should be the last compensatory method evaluated in testing

• Logemann, 1993

• Issues:• What does texture modification do for patient?

• Is patient amenable to modification?

• Will patient eat the prescribed diet • Malnutrition, dehydration

177



Thickened liquids

• Reduces aspiration of thin liquids• Kuhlemeier et al., 2001; Logemann et al., 2008

• Swallow apnea later/longer with thick liquids• Hiss et al., 2004; Butler et al., 2004

• More effort needed to clear thick• Nicosia et al., 2001

• More residue with thick

178

Thickened liquids

• Do thickened liquids cause dehydration?• Do thick liquids reduce liquid aspiration?

• Do thick liquids lower pneumonia rates in liquid aspirators?

179

Thickened liquids

• Hydration and thick liquids• Sharpe et al., 2007

• >95% water absorbed from thick mixtures

• No difference between water, thick water

• Hydration and thick liquids• Reduced fluid intake when thick prescribed

• Whelan, 2001: 24 stroke patients

• Mean fluid intake = 455 mL/day

180

Whelan, 2001, Finestone et al, 2001



Thickened liquids

• Patients do not like thick liquids• Garcia, 2005: prepackaged vs. mixed

• Prepackaged better : Whelan, 2001

• No, they do not cause dehydration• Dehydration results from lower fluid intake

181

182

PART 1:Do thick liquidsor chin‐down

posture preventaspiration?

Aspirate thin liquids on VFS

(711)

VFS: 1. Thin/chin 2. Nectar 3.

Honey

Aspirate thin liquids on VFS

(711)

VFS: 1. Thin/chin 2. Nectar 3.

Honey

Eligible, consent: VFS

Thin liquid Thin liquid‐chin‐down

Nectar Honey

Aspiration 100% 68% 63% 53%

Preference 1st 2nd 3rd last

Part 1 Results

Aspirated on one or two interventions

Aspirated on NONE OF THE interventions

N=177

Aspirated on ALL OF THE interventions

N=346

Enter Part 2

Do not enter part 2

Logemann et al., 2007

183

PART 2 Design:In liquid aspirators, which has lowest

pneumonia incidence:Thin/CDP?Nectar?Honey?

3 month randomized study

Aspirated on NONE OF THE interventions

N=177


N=346

Thin/Chin259

Nectar133

Honey123

Pneumonia

Death

Secondary Outcomes

3 months

Robbins et al., 2008



184

PART 2 Results:Aspirated on NONE OF THE interventions

N=177


N=348

Thin/Chin259

Nectar133

Honey123

52Pneumonia

(11%)

0 Death

Secondary Outcomes

N=515

Pneumonia

Chin‐thin All thick liquid Nectar Honey

Aspirated none in Part 1 (10) 6 (7%) 4 (5%) 0 (0%) 4 (10%)

Aspirated all 3 in Part 1 (42) 18 (9.8%) 24 (14%) 10 (11.5%) 14 (19%)

185

Thick liquids

• Other results• Dehydration: Thin: 2%, Thick: 6%

• UTI: Thin: 3%, Thick: 6%

• Median hospital stay with pneumonia

• Honey (18 d.), nectar (4 d.), CDP (6 d.)

186



Thick liquids

• Do thick liquids reduce aspiration?• Yes

• Do thick liquids reduce pneumonia risk?• No

• Are aspirators more likely to get pneumonia?• Yes

• Do patients like thick liquids?• No

• Will they drink it if they don’t like it?• Probably not

187

“Free Water Protocol” Principles

• Rationale of protocol per developers:• 1. Safety of water aspiration

• 2. Poor adherence with thick liquids

• 3. Need for hydration – self evident

188

Evidence: one study before 2008

• Garon et al., 1997• 20 aspiration‐documented CVA patients

• Aspirated liquid only on VFSS

• Randomized to free water or no free water

• Duration: treatment + 30 day follow up

• Small and underpowered study• Yet the main evidence for protocol

189



• Results• No patient in either group developed pneumonia

• No dehydration, complications

• Intake of fluids comparable between groups

• 1210 mL (C) ‐ all thick• 1318 mL (E): 855mL thick, 463mL thin

• “Much less water than expected” by investigators (“we were surprised…”)

190

Half of daily needs

Water Protocol Evidence

• Randomization to water protocol or prescribed dietary fluid (26 patients)

• 17 patients requiring feeding assistance• 8 assigned to control, 9 to treatment

• 9 independent feeding patients• 3 assigned to control, 6 to treatment

• All received oral care four times per day

• Outcomes: pneumonia, death, UTI, FIM, LOS, intake

191

Becker, et al., 2008

Water Protocol Evidence• Results

• Pneumonia: 1 patient in each group

• UTI: 2 patients in each group

• FIM: no significant difference

• FCM: no significant difference

• Length of stay: 29.1 days (control) vs. 15.8 (tx)

192Becker, et al., 2008



Water Protocol Evidence

• Death: 2 treatment deaths, no control deaths

• Both patients that died had chronic pulmonary conditions

• Other findings:• Independent patients consumed significantly less fluid than dependent patients (p<.01), regardless of group

193

Recent Evidence

• Karagiannis et al. (2011)• Significant increase in lung complications (6/42) vs. controls (0/34)

• Carlaw et al. (2011)• No complications in either group

• More fluid intake in “protocol” patients

• Conclusion: nothing is FREE.

194

Using the /k/ phoneme

195

Perlman et al, 1989

Modified Valsalva:“make a /k/ as hardas you can and holdit for as long as you can, don’t let anyair escape.”

Hawk:“say the word ‘hawk’,make the /k/ as hardas you can.”



196

“Hawk”, modified valsalva produced ~20% of muscle activity seen during swallow

Carbonated thin liquid

• Order effects**?• Command swallow effects***?

• Cued swallows significantly shorter duration

• No effect on any swallow parameters****

197*Bulow et al., 2003; ** Robbins et al, 1999; *** Daniels et al., 2007; Krival 2007****

*

NMES

• Most studies contain flaws• Most frequent

• No control for recovery• Lack of blinded judges• Subjective criteria for “success”

• Recent work with transoral NMES to pharynx• Interesting, need more data

• Patient selection? What are we treating?

198



Restorative methods

• Emerging efficacy in the literature

• Exercise‐Preventive, Restorative, beyond?• physiologic logic, predicted baseline, target

• muscle strengthening requires repetition to modify contractile properties (hundreds, thousands…)

• Do range of motion exercises do anything?

199

Exercise

200

Testing/measurement Exercise protocol

Tongue Press exercise

Tongue Press exercise

• Reduced oropharyngeal residue• Pharyngeal (p = .03), overall (p = .01 ‐ .02)

• Improved PA scores (3mL, 10mL liquid)• 4 weeks: p = .02; 8 weeks: p = .005

• Increased isometric pressure• Anterior 4‐8 wk:(p = .001); posterior (p = .01, .001)

• Increased swallowing pressure• All consistencies/volumes at 4, 8 weeks.

201

Lingual Strengthening Exercise

Robbins et al., 2007; Rogus‐Pulia et al, 2016



Restorative Methods

• Exercise• Resistive expiratory exercise

• Increase force of expiratory effort

202

Sapienza et al.

By me. Ernstl ‐ Self‐photographed, CC BY‐SA 2.5, https://commons.wikimedia.org/w/index.php?curid=765667

Restorative methods

• “Shaker” exercise*• Head‐Neck flexion while supine

• Increase AP dimension of UES during swallow

• “Eliminated tube feeding in stroke patients”**

203

*Shaker et al (1997), **Shaker et al (2002);

• Sham (7) vs Real (11)• No significant difference in any biomechanical measures

• 11 real exercise pts. Pre‐ Post Real Exercise• AP UESO, anterior laryngeal excursion (ALE), all significantly increased from own baseline

204



Jaw Opening Exercise

205

Fig 1 10 seconds, 5 repetitions with a 10‐second rest period between each, 2 sets daily.

Wada, S., Tohara, H., Iida, T., Inoue, M., Sato, M., & Ueda, K. (2012). Jaw‐Opening exercise for insufficient opening of upper esophageal sphincter. Archives of Physical Medicine and Rehabilitation, 93(11), 1995‐1999.

http://dx.doi.org/10.1016/j.apmr.2012.04.025

Jaw Opening Exercise

Significant increases (p<.05): ‐Vertical hyoid motion‐UES opening diameter, ‐Pharyngeal transit duration

Near significant (p=.05)‐anterior hyoid motion

206

McNeill program

• “Exercise based intervention specific to swallow activity”

• Swallow hard in a single swallow

• Systematic increase bolus volume, consistency as eating rate increased

• Homework (eating what was used in treatment)

• Record keeping at home

• FOIS, MASA, patient self‐rating

• Kinematic analysis

207*Crary et al., 2012 (above); Carnaby‐Mann et al., 2010 (N=8); Lan et al. (2012) N=8



Measure Baseline Post‐treatment

Post tx 3 months

Significance measure

g P g P

MASA 0.94 <0.02 0.13 0.67

FOIS 1.42 0.01 0.74 0.17

VFS 0.18 0.37

VAS 1.26 <0.01 ‐0.21 0.38

LP pressure 0.05 NS208

Facilitative Methods• Interest in manipulating other sensory modalities

• Taste, vibratory sense, electrical stimulation (?)

• Can the brain be rewired in adults?• Emerging evidence that “something” is happening upstream

• MEG, EEG (record the effects), MRI

• TCMS (stimulate motor effects)

• Direct current stimulation

• Exercise

• Implantable intramuscular ES

209Jayasekeran et al., 2010, 2011; Pelletier & Lawless, 2003; Malandraki et al., 2011

Newer methods in need of data

• Manipulation of subcutaneous tissue• Tissue mobilization

• Popular term = “myofascial release”

• Has been practiced for generations in other diseases in limbs, axial soft tissue

210



Stimulation of the brain?!?!?!

• Transcranial stimulation• Magnetic fields• Direct current

• Peripheral (pharyngeal)

211

Mass practice and plasticity

• What is plasticity?• Alteration in the outcome

• Motor learning theory?• Mass practice

• Dosage, intensity, progressive resistance + (other increments)

• Task specificity

• Neural adaptation

212

Treatment

• Questions?

213



Is our profession under siege?

214

Who should manage dysphagia?

• “All you do is change diets. We can change diets too.”

215

Top of license practice

• How does aging affect swallowing?• How do the lungs work (not for speech!)?

• What digestive symptoms mimic dysphagia?

• What medications can cause dysphagia?

• What is a pleural effusion and how does it affect speech and swallowing?

• What treatment does this patient need?• Based on disease and its natural history

216



Responding to these questions as primary care providers for dysphagia?

217http://www.weirdfacts.com/animal‐facts/3217‐armadillo‐facts

Practice at the top of your license!

• Medical SLP’s – be a consultant to physicians

• They seek your advice• And are not prescribing

• Be highly competent!218

SLP is uniquely qualified• The SLP’s training is the right combination

• Aerodigestive anatomy, physiology, kinematics• Human communication (treatment involves learning!)

• Analysis of speech provides intuition regarding dysphagia

• Let’s institutionalize the “pre‐med” preparation (ASHA/SAC – we’re talking to you!)

219



• Thank you!

220

[email protected]

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