lpsuryh´ - neoncrm · slide 4 1991 - 98, number of patients hospitalized for aspiration pneumonia...

The Use of Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

as a Tool for Clinical Decision Making in the Evaluation and

Management of Dysphagia

Rebecca L. Gould, MSC, CCC-SLP, BRS-SMSHA Convention 2012

March 29, [email protected]

(561) 833-2090www.med-speech.com

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Slide 2

“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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Slide 3 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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1991-98, number of

patients hospitalized for aspiration pneumonia increased by 93.5% making it the second most common reason for hospitalization.

American Journal Public Health 91:1121-1123, 2001

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Slide 5

“IS IT SAFE TO FEED

THIS PATIENT?”

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Slide 6

STATE

OF THE ART

EVALUATION

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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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Slide 8 SWALLOWING

Swallowing involves a highly coordinated series of events with voluntary and involuntary control

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Slide 9

Innervation

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The cranial nerves

I Olfactory

II Optic

III Oculomotor

IV Trochlear

V Trigeminal

VI Abducens

VII Facial

VIII Vestibular

IX Glosso-

pharyngeal

X Vagus

XI Accessory

XII Hypoglossal

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Slide 11

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Type of

nerve

Site of origin Site of

termination

Function

Sensory-afferent Mucus membrane

lining respiratory

& digestive tracts

Pharynx, larynx,

trachea,

esophagus, heart,

abdominal

viscera

Medulla Taste &

sensation from

larynx, neck,

thorax &

abdomen

Motor-efferent Medulla Muscles of

pharynx &

larynx

Parasym fibres

to abdominal &

thoracic viscera

[motor to all

smooth muscle;

almost all

thoracic &

abdominal

organs]

Swallowing,

movement of

pharynx &

larynx

Inhibitory fibres

to heart;

secretion of

gastric glands &

pancreas;

vasodilator

fibres to

abdominal

viscera

[secretory to all

glands]

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Slide 12

The cranial nervesRLG

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Swallowing

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Slide 14 SWALLOWING STAGES BY PHASE

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Oral Phase

The food is collected

Sealed between the roof of the mouth and the tongue

The tongue moves the food back with a stripping wave into the back of the throat (pharynx)

This begins the actual swallow

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Slide 15

Oral peripheral examination should include assessment of dentition

Oral disease factor impacts pneumonia risk

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SWALLOWING STAGES BY PHASE (cont’d)

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Oro-pharyngeal Phase

Soft palate elevates

Preventing food from escaping into the nose

Tongue base moves back to contact pharyngeal

wall

Larynx (voice box) moves up and forward

Epiglottis (top part of larynx) is tilted down and

back to guide the food past the airway

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Slide 17

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Muscles of the pharynx create the

pharyngeal compression

during swallow

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Slide 18 SWALLOWING STAGES BY PHASE (cont’d)

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Esophageal Phase

Breathing momentarily stops

Vocal folds come together to further protect airway

Muscles of the pharynx contract

Move the food towards the esophagus (tube leading to stomach)

Upper esophageal sphincter relaxes

Food passes into the esophagus

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SWALLOWING STAGES

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Slide 20

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Slide 21 PHYSIOLOGY

Swallowing

Muscular act involving muscles and structures in the oral, pharyngeal, laryngeal, and esophageal cavities

Coordinated to allow food to be transported from the oral cavity to the stomach without spillage, residue, or laryngeal penetration

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Comments

Swallowing is everything but a simple system

Swallowing consist in 2 central patterns generators (CPGs)

Supramedullary control

Both excitation and inhibition

Neurons and neuronal pools in swallowing CPG are shared by other neuromuscular systems, for example breathing

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Slide 23

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Clinical decision making flow chart provides framework for “thinking the question”

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Slide 24

Clinical Evaluation

1. Case History

a) Onset (acute vs. chronic)

b) Progression (rocky vs. smooth)

c) Activity level (sedentary vs. mobile)

d) Cognition (treatment to patient or caretaker)

e) Family, caretaker support

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Clinical Evaluation (cont’d)

2. Test Information

a) CXR/PFT results

b) Blood chemistries

c) Neurological system

d) Immune system

e) GI system

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Slide 26 Clinical Evaluation (cont’d)

3. “Bedside” evaluation

Oral peripheral exam (gag, palatal function, state of dentition)

Cranial nerves (V, VII, IX, X, XII)

Motor speech exam

Presentation of food

Auscultation of swallow

Secretions

Tartaric acid test (Reflex cough)

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Slide 27

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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Slide 29 FEES (FiberopticEndoscopic Evaluation of Swallowing)

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Slide 30

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Slide 32

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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Slide 33

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Give MULTIPLE trials of each consistency

CPG can break down

◦Large bolus size

◦Consistency

◦Fatigue

◦Lack of coordination (COPD)

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Slide 35

Typically use green food coloring

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Slide 36

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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Assess secretions

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Slide 38 Swallow Initiation

Bolus spills to valleculae or pyriform sinuses for greater than one second before the swallow (white-out).

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Slide 39

FEES Interpretation

Four Main Parameters:

Delay in Swallow Initiation

Penetration

Aspiration

Residue

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Timing of Penetration/Aspiration

Before the Swallow

During the Swallow

After the Swallow

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Slide 41

PENETRATION

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

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Slide 42

ASPIRATION

Entry of

material

below the

level of true

vocal folds.

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ASPIRATION

FEES VFSS

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Slide 44

ASPIRATIONRLG

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Slide 45 ASPIRATION

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Slide 47

RESIDUAL

Leftover material in the oral pharynx after swallow has occurred.

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Slide 48 Residual

FEESVFSS

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Issues With Residue

Residue in Valleculae?

Residue in Pyriform Sinuses?

Diffuse Pharyngeal Residue?

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Slide 50

RESIDUAL

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Slide 51

Zenker’s DiverticulumRLG

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Esophageal Achalasia

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Slide 53

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Cervical

Osteophytes

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Slide 54

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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Slide 56 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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Slide 57 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

3incorrect identification of aspiration risk

19 incorrect identification of aspiration risk

8correct identification of no aspiration riskLeder, 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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Slide 59

Bastian nicely delineates +/- of VFSS vs. FEES

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Slide 60 Indications for instrumental examinations

Unresolved clinical condition

Oral stage dysphagia (f)

Upper esophageal or esophageal stage dysphagia (f)

Vague complaints (f)

Clinically inexplicable weight loss (f)

Initial exam for longstanding dysphagia (f)

(f) fluoroscopy (e) endoscopy

Bastian, R.W. (1993)

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Indications for instrumental examinations (cont’d)

Unresolved clinical condition Food stuck at thyroid notch or lower (f) Sudden onset of pharyngeal dysphagia

(f) (e) Food “stuck” above thyroid notch (f) (e) Retest, pharyngeal dysphagia (f) (e) Biofeedback, pharyngeal dysphagia (f)

(e)



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Slide 62 Indications for instrumental examinations (cont’d)

Unresolved clinical condition

Aspiration of secretions (e)

Anatomic anomalies (e)

Assess airway protection patterns (e)

Fluoroscopic unavailable (e)



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Slide 63

Fluoroscopic Image

Views will include:pharynx

oral cavity

portions of the striated esophagus

- Opportunity to screen esophageal phase or perform full esophogram

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Laryngoscopic Image

Views will include:nasal cavity

nasopharynx

hypopharynx

endolarynx

anterior wall of trachea

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Slide 65

Studied reliability of the correlation between clinical indicators than events of dysphagia. Found that less than 50% of the measures that clinicians typically employ are rated with sufficient inter-and intrajudge reliability.

Murray, J. (2000)

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Slide 66

Studied six expert judges

Conclusion: Better at reporting normal

findings/absence of abnormal findings Less reliable for making definitive

pathophysiological diagnoses

Murray, J. (2000)

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VFSS appears more useful for determining which foods a subject can swallow without aspiration than it is for making definitive pathophysiologicial diagnoses.

Kuhlemeier, K. et al. (1998)

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Slide 68 The safety of Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST): An analysis of 500 Consecutive Evaluations

498 evaluations were completed 3 instances of epistaxis no cases of airway compromise no significant differences in heart rate

pre and posttest measurements 81% noted mild or not discomfort

FEEST is a safe method of evaluating dysphagia in the tertiary care setting.

Aviv, J.E. et al (2000)

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Slide 69 Role of the Speech-Language Pathologist in the performance and interpretation of Endoscopic Evaluation of Swallowing: Guidelines

ASHA Scope of Practice in Speech Language Pathology (ASHA, 2001) includes conducting instrumental swallowing evaluation, including fiberoptic endoscopic examinations of swallowing (FEES)

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Role of the Speech-Language Pathologist in the performance and interpretation of Endoscopic Evaluation of Swallowing: Guidelines

(cont’d)

ASHA Code of Ethics (ASHA, 2003) states “Individuals shall engage in only those aspects of the profession that are within their competence, considering their level of education, training, and experience”.

ASHA (2004) Role of the Speech-Language Pathologist in the performance

and interpretation of Endoscopic Evaluation of Swallowing: Guidelines

Http//www.asha.org/members/deskref-journals/deskref/default

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Slide 71 Role of the Speech-Language Pathologist in the performance and interpretation of Endoscopic Evaluation

of Swallowing: Guidelines (cont’d)

FEES procedure as a comprehensive functional evaluation of the pharyngeal stage of swallowing, leading to recommendations regarding the adequacy of the swallow, the advisability of oral feeding and the use of appropriate interventions to facilitate safe and efficient swallowing (ASHA, 2004b)



Http//www.asha.org/members/deskref-journals/deskref/default

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Slide 72 Role of the Speech-Language Pathologist in the performance and interpretation of Endoscopic Evaluation

of Swallowing: Guidelines (cont’d)

Purpose allows for: 1. Identification of normal and abnormal

anatomy and physiology of the swallow2. Integrity of airway protection as it relates to

swallowing function3. The effectiveness of postures, maneuvers,

bolus modifications, and sensory enhancements in improving swallowing.

4. Provision of recommendations regarding the optimum delivery and maintenance of nutrition and hydration



Http//www.asha.org/members/deskref-journals/deskref/defaultRLG

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Comments Scanning the esophagus provides complete

study of all 3 dynamic phases of swallow. Failure to follow bolus into the stomach prevents visualization of diverticulums, stricture, achalasia, and LES. May not happen routinely due to: 1) reimbursement/ liability issues. 2) Inadequate communication between speech pathologist and radiologist. 3) Inadequate knowledge on part of SLP.

The MBS is viewed as the gold standard for evaluation of all 3 phases of swallow function. Drawbacks: radiation exposure, scheduling/logistics issues, number of people required to perform exam.

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Slide 74

Comments

FEES: excellent repeat study. Some researchers suggest 90% correlation between these two studies in experienced clinicians. FEES: Advantages: no radiation exposure, less people required to perform test, may be done at bedside, great biofeedback, evaluates handling of secretions, no barium required. Disadvantages: do not see actual moment of swallow; however, may infer when aspiration occurred, not good for evaluation of oral and esophageal phases.

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Slide 75

Competency

Currently, “competency” is granted by your employing institution/“In house,” competency standard is along with state law.

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You can take ten courses; however, no course will certify you as an expert

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Slide 77 Position of state licensing boards

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Some states specifically include endoscopy in the speech-language pathology scope of practice and more recently some provide clear definition in statute.

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Slide 78 Position of state licensing boards

For example Tennessee (2007)"The practice of speech-language pathology shall include the use of rigid and flexible endoscopes to observe the pharyngeal and laryngeal areas of the throat in order to observe, collect data, and measure the parameters of communication and swallowing for the purpose of functional assessment and rehabilitation planning."

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Position of state licensing boards

New York has indicated that endoscopy is within the scope of SLPs' practice if they assume responsibility for its risks and do not administer any anesthesia.

[individual responsibility]

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Slide 80

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What is ASHA's response to the March 2003 position statement of the Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS)

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Slide 81

1999:

"SLPs with specialized training are qualified to use FEES for assessment of swallowing function. Physicians use fiberopticendoscopic examinations to render medical diagnoses."

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2003: "Physicians are the only professionals

qualified and licensed to render medical diagnoses related to the pathology affecting swallowing functions... Consequently; examinations should be viewed and interpreted by an otolaryngologist or other physician with training in this procedure."..."In addition, otolaryngologists or other physicians with training in this procedure should directly supervise non-physician professionals who are performing this procedure."

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Slide 83

In 2005, ASHA issued a revised position statement that supports the SLPs' independent role in performing endoscopic evaluations of swallowing.

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Slide 84 Some local Medical Review Policies (LMRPs) restrict payment to settings where a physician is available in the office suite. Many of these LMRPs also include wording indicating that in a hospital setting, the physician supervision requirement is presumed to be met and need not be documented. "Direct supervision" is used by Medicare to mean that the physician needs to be available in case assistance is needed, but "personal supervision" is not required by Medicare for these procedures.

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Tell physicians the SLP role is to provide a functional diagnosis of swallowing, not a medical diagnosis.

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Slide 86

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Slide 87

ASPIRATION PNEUMONIA

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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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Slide 89 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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Slide 90 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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Slide 92 ClinicalPredictors 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)

delayed oral transit

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Mann, G. & Hankey, G.J.(2001)

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Slide 93

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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Slide 95 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


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Slide 96 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


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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


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Slide 98 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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Slide 99

“Artificial feeding does not

seem to be a satisfactory solution for preventing pneumonia in elderly prandial aspirators”.


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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

RLG

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Slide 101 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.


RLG

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Slide 102 Pneumonia in acute stroke patients fed by nasogastric tube (cont’d)

Independent predictors Decreased level of consciousness Severe facial palsy.

ConclusionNasogastric tubes offer only limited protection against aspiration pneumonia in patients with dysphagia from acute stroke.


RLG

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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)

RLG

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Slide 104

RLG

Colonization (Altered Oropharyngeal Flora)

Dependent for oral care

Number of decayed teeth

Number of medications

Tube feeding

Aspiration into lungsLarge volume aspiration (liquid, food, GER, saliva)

Microaspiration (saliva, plaque, GER)

Dependent for feeding

Host resistance

Pulmonary clearance

Now smoking

Systemic Immunologic response

Multiple Medical Diagnoses

PNEUMONIA

Langmore, S. (1997)

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Slide 105

“Dysphagia and aspiration

are necessary but not sufficient conditions to predict development of aspiration pneumonia… a multifactorial phenomenon”.

Langmore,S. (1998)

RLG

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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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Slide 107 Predictors of aspiration pneumonia in nursing homes patients

102,842 patient suctioning use

COPD

CHF

presence of feeding tube

bedfast

3,118 pneumonia = 3%

delirium

weight loss

swallowing problems

UTI’s

mechanically altered diet

Langmore, S. et al. (2002)

RLG

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Slide 108 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)

RLG

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Assessment of the adult with dysphagia

Conventional wisdom

Aspiration = Pneumonia

Prevention of aspiration = prevention of pneumonia

Tube feeding = safety

Murray, J. (Voice, Swallow & Airway 2002)

RLG

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Slide 110

Constructs for thinking

What makes the elderly different?

The prevalence of swallowing impairment increases with

age

Nilsson, H. et al. (1996)

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Slide 111

25% of the elderly suffer from oral dryness and related complaints

Salivary gland morphology and composition of saliva change with age

Vissink, A., et al. (1996)

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Impact of/on Nutritional status

Poor nutrition is cardinal feature of failure to thrive (FTT)

Associated difficulties:

Difficulty shopping 85%

Difficulty with meal preparation 85%

Poor appetite 55%

Weight loss 45% Chronic

anemia 42% Dehydration 36% Dysphagia 23% Pressure

sores 10% Alcohol abuse 7% Severe

constipation 6%


RLG

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Slide 113

What is a safe amount of aspiration?

What is the long term consequence of chronic aspiration?

What factors predict who will get pneumonia?

How important is age?

RLG

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Slide 114

The Elderly

Lose weight Become apathetic Experience loss of cognitive/intellectual capacity

Experience loss of motor skill Fail to maintain social relatedness skills

Newhern, V. (1992)

RLG

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The Elderly

Loss of taste and smell are common in the elderly and result from normal aging

Schiffman, S. (1997)

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Slide 116

The Elderly

Clinical picture usually so diffuse that it provides few indications of the cause or of possible treatment.

The deterioration is disproportionate to the patient’s physical and physiological condition and beyond the expected age-associated “normal decline.

Newhern, V. (1992)

RLG

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Slide 117 The Elderly

Literature fails to answer these questions:

Risk for poor outcome Ability to maintain nutrition/hydration

via oral feeding Plan for management of safety and

vitality Means for improving physiology Plan manage decline and compensation Means for insuring quality of life


RLG

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Subgroups at risk

85 years of age and older

< age 65 FTT correlated with imminent death female (60%)

25 – 50% of patients were widowed

24 – 45% lived alone prior to admission to an acute care facility


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Slide 119 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-smokerRLG

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Slide 120 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

RLG

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SCALE PREDICTIVENESS OF

PNEUMONIA RISK IF FED (cont’d)

Score

< 7 = Use extreme caution

5–6 = fair – good

<3 = good – excellent

RLG

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Slide 122 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

RLG

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Slide 123 Outpatient

may have multiple diagnosis; however, “stable”

+ mobility number of medications if tube feeding, bolus fed typically are not dependent for feeding

smoking

RLG

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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.

RLG

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Slide 125

•RLG

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Slide 126

TREATMENT

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SWALLOWING TREATMENT

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

RLG

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Slide 128

GOAL: TARGET MOST CRITICAL RISK FACTORS.

RLG

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Slide 129 TECHNIQUES OF DYSPHAGIA THERAPY

- MENDELSOHN MANEUVER

- SUPRAGLOTTIC SWALLOW

- MODIFIED VALSALVA

EXPECTORATION MANEUVER

POSTURES &

POSITIONING

- E-STIM

- EMG

- ORAL MOTOR EXERCISES

- BOLUS WEIGHT

STRENGTHENING

- THICK

- THICKER

- THICKEST

MANIPULATION OF

CONSISTENCY

- RESPIRATORY CONTROL

- WHEN TO SWALLOW

- HOW MANY SWALLOWS

- SEQUENCE

TIMING

- COGNITION

- GENERAL HX.

- COPD

- ACTIVITY LEVEL

PATIENT

NUANCES

A UNIQUE

PATIENT

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Dysphagia therapyAre we doing what we think

we are doing?

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Slide 131

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Slide 132 Types of Treatments MANGEMENT

Indirect therapy

Modifying food and environment

Teach compensatory strategies

Maintain function

Reduce morbidity

Should be short term

REHABILITIATION

Direct/active therapy

Training patient

Strengthens muscles

Improves swallow physiology

More lasting improvement

•Anticipated outcome: increase safe oral intake to advance diet

•Secondary outcomes: improved nutritional status and enhanced long term functioning

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TECHNIQUES OF DYSPHAGIA THERAPY

Postures &

Positioning

•Mendelsohn Maneuver

•Supraglottic Swallow (swallow high &

strong)

•Modified Vasalva

•Expectoration Maneuver

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Slide 134 Strength-Training Exercise in Dysphagia Rehabilitation: Principles, Procedures, and Directions for Future Research

Explored the over-riding principles of neuromuscular plasticity with regard to strength training.

Evaluated how current exercise-training interventions in dysphagia rehabilitation correspond to this principles, and

Postulated directions for future study of normal and disordered swallowing and determine how to incorporate this principles into dysphagia rehabilitation.

Burkhead, L et al. (2007)RLG

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Slide 135

“Chin Tuck”

It is not worth attempting if aspirated material is originating in the pyriform sinuses. Shanahan et al. (1993) had 30 aspirating patients use the chin-down posture. It eliminated aspiration in half (15) of them. However all 15 patients whose aspirated material originated I the pyriform sinuses continued to aspirate. This posture actually directs such residue into the larynx.

RLG

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•Strengthening

•Electrical Stimulation

(E-stim) Excellent for

Head neck CA patients/

couple with myo-facial

release

•EMG•Oral Motor

Exercises•Expectoration

maneuver

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Slide 137 Thermal Stimulation

Thermal stimulation or thermal-tactile application has been investigated quite a bit and has largely been dismissed as it has been shown to produce only momentary and non-durable reductions in stage transition duration (pharyngeal delay time).

Rosenbek et al. (1991, 1996, 1998)

Hamdy et al. (2003)

Miyaoka et al. (2006)

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RLG

•Manipulation of

Consistency

•Thick

•Thicker

•Thickest

•Diet

•Puree•Mechanical soft

“moist cohesive bolus”•Regular

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Dysphagia Diet

PUREED or pudding texture:Hot cereal

Mashed potatoes

Custard-style yogurt

Pudding

“Anything can be pureed.”

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Slide 140

Dysphagia Diet continued…

MECHANICAL SOFT or ground food texture:Macaroni and cheese

Soft, canned vegetables

Cottage cheese

Meat loaf

Diced canned fruit

Canned pasta products

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Slide 141

Diet Modification

-Why do we change a person’s diet?-How do we know when to

upgrade/downgrade?rotary chewing?

cueing still needed?efficient, appropriate swallows?

good clearance? any signs/symptoms of aspiration?endoscopic/fluoroscopic results?

-Goal: gradually maximize safe oral intake to avoid compromising nutritional status

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Dysphagia Diet continued…

ADVANCED or regular texture: EXCEPTIONS:

Dry, tough meats

Dried fruits

Nuts, popcorn, dry cookies

Hard, crunchy, stringy vegetables

Hard, crunchy food items (granola, tortilla chips)

Raw, hard, crunchy fruits (apples, pears, pineapple)

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Slide 143 Liquids for Dysphagia Diets Pudding-like

texture: Very thick milkshakes Any liquid thickened

with a thickening agent

Nectar-thick texture: Syrups, tomato soup,

fruit-nectar, eggnog

Thin liquids:Water, milk, juices,

coffee, tea, carbonated beverages, broth-based soup

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RLG

•Patient Nuances

•Cognition

•General history

•COPD•Activity

Level

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•Timing

•Respiratory

control

•When to

swallow

•How many swallows (double

swallow)•Sequence

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Slide 146

GOAL

Keep the patient swallowing for as long as possible to maintain swallow function,

nutrition and hydration – BUT we want to do it in a way wherein the person is

swallowing safely and efficiently.

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Slide 147 Electrical Stimulation (ES)

“Neuromuscular electrical stimulation (NMES) is a noninvasive modality that directly stimulates the peripheral nervous system to evoke an action potential via surface electrodes “ (Biber et. al)

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E-stim

Current FDA approved uses for NMES include:

muscle reeducation

prevent/retard disuse atrophy

relax muscle spasm

increase local blood circulation

immediate post surgical stimulation of calf muscles to prevent DVT

maintain or increase ROM

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Slide 149 HISTORY

In past years E-stim has been used for:

Tremors in Parkinson’s (deep brain stimulation)

Wound healing

Pain management

Reduction of edema

Muscle enhancement, specifically: (Increasing ROM, Improving strength, Reeducating contraction patterns and timing & Correcting abnormal muscle tone)

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Slide 150

HISTORY

E-Stim for treatment of dysphagia was introduced:

1975- Marcy Freed developed her protocol while at Hillcrest Hospital in Ohio.

1999- Teresa Biber in collaboration with PT and Otolaryngology departments while

at the Cleveland Clinic in Florida.

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WHY E-STIM?

Traditional Treatment: Compensatory vs. Rehabilitative

Compensatory Intervention = “strategies that provide an immediate but typically transient effect on the efficiency or safety of swallowing. As a rule, if the strategy is not consistently executed, swallowing will return to the prior dysfunctional status. Posturing (chin tuck, head turn)

Diet/texture modifications

Tube feeding

Airway protection techniques (supraglottic swallow)

Thermal-tactile stimulation

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Slide 152 WHY E-STIM?

Rehabilitative Intervention = “intervention that, when provided over the course of time, are thought to result in permanent changes in the substrates underlying deglutition: i.e., changing the physiology of the swallowing mechanism.” Oral motor exercises

Shaker Exercise

LSVT

Swallowing Maneuvers in combination with EMG biofeedback

E-Stim ???

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Slide 153 HOW DOES E-STIM WORK?

Electrical impulses transmitted transcutaneously via 2 electrodes places on the submental area, away from carotid arteries and not directly on larynx.

Body tissue (muscle) conduct electricity, causing a depolarization of the nerve fibers, thus creating a muscle contraction by dispersing an action potential across the muscle fibers.

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Normal vs. Stimulated muscle contraction

Normal muscle contraction occurs when action potential is transferred to the muscle by the nerve.

Stimulated muscle contraction occurs as a result of muscle fibers being directly stimulated by the electrical current from the voltage source.

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Slide 155 GOAL/OBJECTIVE

Achieve adequate laryngeal elevation

Pair swallowing with e-stim to reeducate the brain

Change swallow mechanism not just trigger swallow

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Slide 156 TREATMENT USES

Maintain/strengthen muscle mass during inactive periods

Maintain/gain ROM: Facilitates laryngeal elevation by strengthening the extrinsic laryngeal muscles (laryngeal muscles are like other skeletal muscles stimulated by PT or OT). Ultimately, airway protection is achieved.

Facilitate voluntary motor control (swallowing maneuvers)

Increase sensory awareness (laryngeal/pharyngeal)

Muscle reeducation

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Transcutaneous electrical stimulation versus traditional dysphagia therapy: A nonconcurrent cohort study

The results of this nonconcurrent cohort study suggest that dysphagia therapy with transcutaneous electrical stimulation is superior to traditional dysphagia therapy alone in individuals in a long-term acute care facility.

Blumenfeld, L. et al (2006)

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Slide 158 Timing of laryngopharyngealevents during swallow: an EMG perspective

RLG

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Slide 159

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)

RLG

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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


RLG

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Slide 161

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)


RLG

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Slide 162 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”


RLG

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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


RLG

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Slide 164

Muscle examined

Superior pharyngeal constrictor (SPC)

Tongue base (GG)

Cricopharyngeus (CP)

Thyroarytenoid (TA)


RLG

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Slide 165 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


RLG

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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.


RLG

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Slide 167 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.


RLG

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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.


RLG

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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.

RLG


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However, please know help is available via skilled multidisciplinary team with skilled professionals: SLP, ENT, GI, Pulmonologist, Radiation-oncologist, Dietitian.

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Slide 171 IDEAL

Instrumental exam for each patient.

Coordinated team.

Plenty of time.

Medical experts making decisions.

Salient/clear data presented.

REALITY Treatment without

exam.

Piece meal.

Little time.

3rd party payer control.

Lengthy reports. Check lists-important information lost “in the trees”.

RLG

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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.RLG

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Slide 173

•RLG

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Slide 174

CASE STUDIES

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Questions…Please contact me!

Rebecca L. [email protected]

See www.med-speech.com for more information about voice, swallow and airway disorders

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Slide 176

•RLG

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lpsuryh´ - neoncrm · slide 4 1991 - 98, number of patients hospitalized for aspiration pneumonia...

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