Transcript Predicting Pneumonia risk in patients with dysphagia

Evaluation and Management
of Dysphagia a Team
Approach
Rebecca L. Gould, MSC, CCC-SLP
[email protected]
(561) 833-2090
www.med-speech.com
“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 FEES
1 did not aspirate during MBSS but did
during FEES
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Will Test ALL Types of
Food/Liquid
Thin liquid
Thick liquid (Nectar)
Puree
Solid
Mixed Consistency
Pills
Challenging food (i.e. nuts, peanuts, etc.)
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Will give MULTIPLE trials of
each consistency
CPG can break down
Large bolus size
Consistency
Fatigue
Lack of coordination (COPD)
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Protocol
Saliva – Secretion rating
Anatomy screen
Laryngeal physiology assessment
Swallowing physiology assessment
Functional – Patient self-administer
bolus
Diet recommendations
Recommendations for swallowing
therapy/follow-up
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Typically use green
food coloring
FEES Interpretation
4 Main Parameters:
Delay in Swallow Initiation
Penetration
Aspiration
Residue
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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 Swallow
During the Swallow
After the Swallow
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Issues With Residue
Residue in Vallecula?
Residue in Pyriform Sinuses?
Diffuse Pharyngeal Residue?
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Zenker’s Diverticulum
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Cervical Osteophytes
Cervical
Osteophytes
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Globus
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In General
FEES = 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 setting
1001 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 risk
3 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
important
20% false negative rate for VFSS
0% 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 radiographically
delayed oral transit
incomplete 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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Studied 152 SNF residents - average
age of 86. Followed for 3 years.
Begin of study
50 non aspirators
51 minor aspirators
51 major aspirators
End of study
37
38
47
30 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 age
Difficult antibiotic treatment:
difficult to identify pathogen
altered drug metabolism
medication 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 colonized
overgrowth gram negative enteric rods associated with
functional decline
Anaerobic 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 care
Number of decayed teeth
Number of medications
Tube feeding
Aspiration into lungs
Large volume aspiration
Microaspiration
(liquid, food, GER, saliva)
(saliva, plaque, GER)
Dependent for feeding
Host resistance
Pulmonary clearance
Now smoking
Systemic Immunologic response
Multiple Medical Diagnoses
Langmore, S. (1997)
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PNEUMONIA
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
3,118 pneumonia = 3%
suctioning use
COPD
CHF
presence of feeding
tube
bedfast
delirium
weight loss
swallowing problems
UTI’s
mechanically altered
diet
Langmore, S. et al. (2002)
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Predictors of aspiration pneumonia in
nursing homes patients (cont’d)
dependence for
feeding
bed mobility
locomotion
number of medications
age
CVA
tracheotomy care
1998 Predictors
dependence for oral
care
smoking
multiple medical
diagnosis
numerous 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 pneumonia
Cough 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
FACTORS
Multiple or progressive disease/one diagnosis
Multiple medications (>5)/ <5 medications
NPO (PEG)/ oral
Oral hygiene fair – poor/ good – excellent
Smoker / non-smoker
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SCALE PREDICTIVENESS OF
PNEUMONIA RISK IF FED (cont’d)
FACTORS
Inpatient / outpatient
Physical ability (mobile)/ sedentary
Reflexive cough (present) / absent – delayed
Cognitive status (fair-poor)/ good – excellent
Secretion Pooling (minimal) / copious
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SCALE PREDICTIVENESS OF
PNEUMONIA RISK IF FED (cont’d)
Score
< 7=
5–6=
<3 =
Use extreme caution
fair – good
good – excellent
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Inpatient
“sick” (acute/ exacerbation of chronic condition)
+ sedentary “bed rest/ bathroom privileges”
number of medications
multiple medical diagnosis.
tube feeding
dependent for oral care/ hygiene status
dependent for feeding
smoking
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Outpatient
may have multiple diagnosis; however,
“stable”
+ mobility
number of medications
if tube feeding, bolus fed
typically 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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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
A UNIQUE
PATIENT
POSTURES &
POSITIONING
STRENGTHENING
- MENDELSOHN MANEUVER
- E-STIM
- SUPRAGLOTTIC SWALLOW
- EMG
- MODIFIED VALSALVA
- ORAL MOTOR EXERCISES
EXPECTORATION MANEUVER
- BOLUS WEIGHT
MANIPULATION OF
CONSISTENCY
TIMING
PATIENT
NUANCES
- THICK
- THICKER
- THICKEST
- RESPIRATORY CONTROL
- WHEN TO SWALLOW
- HOW MANY SWALLOWS
- SEQUENCE
- COGNITION
- GENERAL HX.
- COPD
- ACTIVITY LEVEL
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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
McCulloch, T. (Voice, Swallow & Airway 2005)
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Methods
Five normal subjects (4 male, 1 female)
Human subject approval
Simultaneous 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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Discussion
A 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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IDEAL
REALITY
Instrumental exam for
each patient.
Coordinated team.
Plenty of time.
Medical experts
making decisions.
Salient/clear data
presented.
Treatment without
exam.
Piece meal.
Little time.
3rd party payer
control.
Lengthy reports.
Check lists-important
information lost “in
the trees”.
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SOLUTIONS
Assess 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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