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7/25/2016

DysphagiaandRespiratory
Disorders

Dr.DavidT.Hutchings,CCCSLP.D.
VicePresidentofTherapyServices
Amedisys,Inc

DiagnosesandSymptoms
Requiresincreasedassistanceduringmeals
Stroke
Dementias Coughingorchokingwhileeatingordrinking.runny
nose
CervicalNeckInjuriesorSurgeries
HeadandNeckCancers TemperatureSpikes Recurrenttemperaturespikes
Laryngectomy Frequentthroatclearingduringmeals
RenalInsufficiency Refusingtoeat,lackofIntake
IntracranialHemorrhage
DecreasedFluidintake
ProgressiveNeurologicalDiseases
TraumaticBrainInjury Unexplainedweightloss/significantweightloss
Diabetes Wetorgurglyvoicequality/sound
PEGTube Foodfallingoutofmouth
AnyRespiratoryDiagnosis(i.e.,COPD)
FrequentHiccupsduringoraftermeal
CHF
MuscleWeakness Difficultychewing
Dehydration/Malnutrition Complainingofpainwhenswallowing
Wounds Decreasedlipclosure
Afteroralproceduralcodes
Respiratoryproblems
GIConditions
Malnutrition/dehydration
Historyofpneumonia,recurrentpneumonia
Vomiting/regurgitationduringoraftermeals

ThinkBeyondAspiration
Only69%ofaspirationoccursduringtheswallow
60%ofaspirationissilentorasymptomatic
Aspiration respiratorydistress,pneumonia,death
Choking airwaycompromise
Malnutrition/dehydration
Weightloss
Wound/pressureulcer
Chronicrespiratoryillness(COPD,HF)
PEGorJTubePlacement
Death
Dysphagiamayresultinpneumonia,whichisthefifthleadingcauseof
deathamongindividualsover65yearsofageandincreasingtothethird
leadingcauseofdeathinindividualsover80yearsofage(Robbins,1999).

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PrevalenceandStatistics
Approximately64%ofCOPDdischargesare65year
andolder
1.5millionERvisits
726,000hospitalizations
Affects14millionpeopleintheUS
Leadingcauseofmorbidityandmortalityworldwide,
resultinginsubstantialandincreasingeconomicand
socialburden
Smokingtendstobeprimarycause

PrevalenceandStatistics
AstheprevalenceofCOPDcontinuestoincreaseoneofthemostdifficult
challengesthehealthcareindustrycontinuestofaceisAcuteRehospitalizations
(ACH).
Anestimated15millionhaveCOPD.PrevalenceofCOPDincreased,from3.2%
amongthoseaged1844yearstogreaterthan11.6%amongthoseaged65years
andolder.
COPD,wasthethirdleadingcauseofdeathintheUnitedStatesin2011.
(CDC.gov)
FifteenmillionAmericansreportthattheyhavebeendiagnosedwithCOPD
(CDC.gov).

PrevalenceandStatistics
ThedirecteconomiccostattributabletoCOPDandasthmain2008hasbeen
estimatedat
$53.7billionintheUS.Thesecostsincludethosefor
prescriptionmedicines($20.4billion)
outpatientorofficebasedproviders($13.2billion)
hospitalinpatientstays($13.1billion)
homehealthcare($4.0billion)
emergencyroomvisits($3.1billion)

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Logemann,JohnHopkinsStudy
Theabilitytoputintheappropriateclinicalservicespriortodeveloping
pneumoniaorrespiratoryinfectionsduetodysphagiaiscriticaltokeeping
patientsfrombeingrehospitialized.
COPDisnotedtobeacommonreasonpatientsarerehospitialized.
Rehospitalizationratescontinuetobeamajorconcernforhealthcareprofessions.
Todate,theinfluenceofthedisciplineofSpeechLanguagePathologyon
rehospitalizationshasnotbeendetermined.

Logemann,JohnHopkinsStudy
Inthisretrospectivestudypatientswillbeselectedbasedonhavinghe
respiratorydiagnosesandscoringaShortnessofBreathwithEatingandTalking
andShortnessofBreathatRestontheStartofCareOASIS.
ThehypothesisofthisinvestigationisthatpatientswhoreceivedSpeech
PathologyServicesoftwoormorevisitswilldemonstrateadecreasedpercentage
ofrehospitalizationscomparedtothosewhodidnotreceiveSpeechPathology
servicesaccountingforotherindividuals.

(M1400)Whenisthepatientdyspneic
ornoticeablyShortofBreath?
0 Patientisnotshortofbreath
1 Whenwalkingmorethan20feet,climbingstairs
2 Withmoderateexertion(e.g.,whiledressing,usingcommodeor
bedpan,walkingdistanceslessthan20feet)
3 Withminimalexertion(e.g.,whileeating,talking,orperforming
otherADLs)orwithagitation
4 Atrest(duringdayornight)

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Logemann,JohnHopkinsStudy
ResearchQuestions:
DopatientswithCOPDthatscoreM1400#3orM1400#4ontheOASISwho
receiveSpeechPathologyservicesoftwoormorevisitsdemonstratealower
rehospitalizationpercentage?
DopatientswithCOPDthatscoreM1400#3orM1400#4ontheOASISwho
donotreceiveSpeechPathologyservicesoftwoormorevisitsdemonstratea
higherrehospitalizationpercentage?

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Logemann,JohnHopkinsStudy
300,065Patientsidentified
OneofthelargestDysphagiaStudiesconducted
SpeechPathologyandACH
PlacingSpeechPathologyontheforefrontofhealthcareissues
Clinically
Financially

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10PrinciplesofNeuralPlasticity
UseitorLoseit
UseitandImproveit
PlasticityisExperienceSpecific
RepetitionMatters
IntensityMatters
TimeMatters
SalienceMatters
AgeMatters
Transference
Interference

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COPDandDysphagia
UpperRespiratoryTract
NasalCavity
OralCavity
Pharynx
Larynx

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COPDandDysphagia
OralCavity
Primaryroleisrespiration,
butisalsousedforswallow,digestionandspeech
Lips sealoralcavityforswallow,articulation
Tongue oralprep,oraltransit(baseoftongueisthe
primarymuscleusedtopropelfood itrestsonhyoid
bone)
SalivaryGlands secrete

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COPDandDysphagia
Pharynx
Musculartubethatis
duelpassagewayfor
respirationandswallow
The3segmentsare:
Nasopharynx
Oropharynx
Gagreflex13%nogag notpredictorofdysphagia
LaryngopharynxSeparatesdigestiveandrespiratorytracts

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COPDandDysphagia
Pharynx
Vallecula
Recessbetweenbaseoftongueandepiglottis
Commonlandmarkduringintubation
PharyngealMuscles
Suspendedfromhyoidboneforlaryngealelevationandanteriormotion
Epiglottis
Separatestherespiratoryanddigestivesystemforairwayprotection
Actslikearuddertodeflectfoodlaterallyawayfromtheairway

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COPDandDysphagia

Larynx
Larynxisthegatekeeper
topreventaspirationat
multiplelevels
PharyngealMuscles musclesattachedtohyoidelevate
larynxupandpullitforward
LaryngealMuscles closelarynxatvocalfoldlevelto
createasealthatseparatesairwayfromdigestivetract

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SharedResponsibility

Thesemanypressurechangeswithinthe
aerodigestive tract(sharedpassagewayfor
respirationandswallow)protecttheairway,&
speedthefoodbolus.Literaturesupportsthe
importanceofcoordinatingbreathingand
swallowing.(Dikeman,Kazandjian 2ndEdition)

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AssessmentofSwallowApneaand
RespiratoryFunctioning
Objectives:Examinedeglutitioninstablepts withCOPDandlunghyperinflation.
Subjects:20eligibleCOPDpts
Intervention:PatientsreceivedVFSSandcomparedto20controlledpts.
Controlledforageandsexwascontrolledfor.
Measurements:Meantotallungcapacity,functionalresidualcapacity,and
residualvolume.
Conclusions:Researchesconcludedthathyperinflated patientswithCOPDhave
alteredswallowingphysiology.
Orophayrngeal DeglutitioninStableCOPD.Mokhlesi,Logemann,
Rademaker,Stangl,&Corbridge.(2002).Chest.2,361.

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LungVolumeDuringSwallowing:Single
BolusSwallowsinHealthyYoungAdults
Purpose:Examinedtherelationshipbetweenswallowingandlungvolumeinitiationinhealthy
adultsduringsingleswallowsofbolusesdifferinginvolumeandconsistency.Differencesinlung
volumeaccordingtorespiratoryphasesurroundingtheswallowwerealsoexamined.
Method:9menand11womenbetween19and28y/o.
Results:Significantdifferencesinlungvolumeatswallowinitiationwerefoundbasedonbolus
consistencybutnotonbolusvolume.Nodifferenceswerefoundforlungvolumeinitiationbased
ontherespiratoryphasesurroundingtheswalloworfortherespiratorypatternbasedonbolus
volume
Conclusions:Findingsofthestudyextendtheexistingknowledgebaseregardingtheinteraction
ofswallowingandrespiratorysystems.

Hegland etal.(2009).JournalofSpeech,Languageand
HearingResearch.52,17887.

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AssessmentofSwallowApneaand
RespiratoryFunctioning
AnyRespiratoryCondition
COPD
ChronicBronchitis
Pneumonia
Emphysema
CHF
COPDpts willfrequentlyinhalepost
swallow.Normalswallowingis
characterizedbyexhalationpostswallow.
OASIS:SOBwithEatingandTalking
orAtRest

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GlobalInitiativeforChronicObstructiveLung
Disease
GlobalInitiativeforChronicObstructiveLungDisease(GOLD)
definition:
Common,preventable,&treatable
Usuallyprogressive&associatedwithpersistentairflow
limitation
Chronicinflammatoryresponseintheairway&lungsto
noxiousparticlesorgasses
ChronicObstructivePulmonaryDisease(COPD)istypically
expressedin2ways:
Emphysema
ChronicBronchitis

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COPDandDysphagia
COPDpatienthavebeennotedtohavealteredswallowingphysiology
anddeficitstotheswallowincludingreducedtonguecontrol,vertical
movement,anteriorposteriormovement,stabilization,lateralization
andstrength
Reducedlaryngealelevationwithdelayedlaryngealclosure
Reducedhyoidelevation,postswallowpenetration,andoxygen
desaturation
Reducedlaryngopharyngealsensation
Impairedpharyngealclearance
Cricopharyngealdysfunction
GERD
Tachypnoea/Tachynea

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COPDandDysphagia(King,MichiganSLP.org)
Increasedmastication,increasedresp.rateand Couldcauseairhungerandlikelihoodof
rhythmduringchewing inhalationduringswallow

Delayedpharyngealresponse,decreasedtongue Residueintheoral/pharyngealcavitycould
retraction,reducedlaryngealelevation
leadtoaspiration

Increasedfatigue,incoordination,weaknessof
upperaerodigestive tractmusculature,&sensory Increasetheriskofaspiratingoninhalation
impairment

Theincreasedriskfromairhungerduring
Increasedinspirationafterliquidswallowand prolongedchewingtimes+commonco
increasedapneicpauseduration occuring oropharyngealdysphagiainCOPD=
higherriskofaspiration

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COPDandDysphagia(King,MichiganSLP.org)
Patientswithdysphagiahavegreaterthan7timeschance
ofacquiringaspirationpneumonia(iffoundtoaspirate
duringanMBSS)(MartinHarrisetal.,2012)

Patientswhoaspiratethickenedliquidsorsemisolids,the
likelihoodthattheywillperishincreasedbygreaterthan9
times

Themostsignificantriskfactorforaspirationpneumoniain
nursinghomepatientswasdeterminedtobeCOPD(Grosset
al.,2009)

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COPDandDysphagia(King,MichiganSLP.org)
Exacerbationstypicallyincludeanincreasein:
Dyspnea,sputum,purulence
Negativeeffectsonrespirationandswallowing
Cyclicalaffect;inflammation increaseddyspnea aspiration
pneumonia COPDexacerbation

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AssessmentofSwallowApneaand
RespiratoryFunctioning
Aerophagia Aswallowingincoordinationcausingpatienttoswallow
airresultinginpain,frequentbelchingandbloating.
Commonlyseeninpatientswhohaveloosedentures,excessivesmokingand
carbonateddrinks.
Occursinabout9%ofCognitivelyimpairedpatients

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AssessmentofSwallowApneaand
RespiratoryFunctioning
Inabilitytoclearallfoodfrommouthandthroat
Swallowingfrequentlyinterruptedbysuddeninspiration
Inhalationpostswallowiscommon
LaryngealElevationissues
Decreasedmobilityoffoodandliquids
Nonproductivecoughreflex
Airwayexposure
Increasingaspiration
Increasingairwayobstructionandchoking.

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COPDandDysphagiaTreatmentApproach
OralhygieneissuesarealsocommonamongpatientswithCOPD.
WhatcausesCOPDpatientstohaveoralhygieneproblemscanlikely
beattributedtopersistentmouthbreathingandtheuseofinhaled
bronchodilatorsandcorticosteroids.

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10PrinciplesofNeuralPlasticity
UseitorLoseit
UseitandImproveit
PlasticityisExperienceSpecific
RepetitionMatters
IntensityMatters
TimeMatters
SalienceMatters
AgeMatters
Transference
Interference

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TreatmentofSwallowApneaand
RespiratoryFunctioning
Firstobjectiveistoeliminatetheaspirationriskorriskofairwayobstruction

Food
ModifyDiet TimetoSOB Position
Presentation

Swallow
Exercises OralCare MPT
Maneuvers

Swallow
Breather
Exhale

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COPDandDysphagiaTreatmentApproach
Modificationofthedieteliminateanddietthatcanbeaspiratedeasyinoral
stageorpostswallow(drycrumblyfoods)
Shortenlengthofthemealtoensurepatientdoesnotbecomefatiguedduring
intake
Positioning
Pharyngealandrespiratoryrelatedexercisetoincreaseswallowandrespiratory
strengthandcoordinationOralexercises,andswallowmaneuversthatdonot
requirethept toholdthebreath(hardswallow)

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COPDandDysphagiaTreatmentApproach
Increasingairwayclosure
Oralcare
UseofResistiveBreathertoincreaseendurance,strengthandairwayclosure
Trainthept toswallowthenexhale. TypicallyCOPDpts dotheopposite.
UseMaximumPhonationTime(MPT).Seebelowfornormativedata. Itypicallywillhavethept dohata
highpitch,lowpitch,loudandsoftintensity.
Maximumphonationtimeinseconds*
o Youngmales28.5
o Youngfemales22.7
o Elderlymales13.8
o Elderlyfemales14.4
Duffy,J.(1995).MotorSpeechDisorders.St.Louis;MO.MosbyPublishing

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TheResistiveBreather

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TheResistiveBreather
Purpose
Strengthenandtoneinspiratorymuscles.(i.e.,diaphragm,externalintercostals,
accessorymusclesoftheneck,pharyngeal,andlaryngealmuscles)
Strengthenandtoneexpiratorymuscles.(i.e.internalintercostals,abdominals)
Generateimprovedairflowthroughthevocalfolds.
Improveswallowing.
Improveprotectivecoughandassistairwayclearance.
Assistteachingdiaphragmaticbreathing/deeperbreathing(incentivespirometry).
Indications
Dysarthria
DysphoniaorAphonia
PharyngealDysphagia
ShortnessofBreath(i.e.,chronicobstructivelungdisease;asthma,CHF,stress)

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BehavioralTreatments
Smaller,morefrequentmealsatleast Smokingcessation
fatiguedtimeofday Sleepstudytoevaluateappropriatenessof
Nutritionalandconvenientsnacks CPAPmachine
Increasingcaloriesofmeals
Cautionagainstriskyenvironmentsthatmay
Cautionwithmedicationthatcause bedetrimentaltohealth
nausea
Pulmonaryrehabilitationandeducation
Recommendcontinueduseofoxygen
andmonitoringoxygensaturationduring Encourageearlyrecognitionandself
mealsforthoseonlongtermoxygen management
Exerciseprograms
(McKinstry,Tranter&Sweeney,2010)

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LeeSilvermanVoiceTreatment
VoiceDisorders:Impairmentsofthevocalfoldsinthethroatthat
compromisevoicingandcommunication
VoiceProblemsare:
Weakvoice
Lowvolume 89%ofindividuals
SoftVoice whohaveParkinsons Only34%seekand
Monotone Diseasehavevoice receivetreatment
SwallowingProblems andspeechdisorders..
Aspiration
Pneumonia
Weightloss

LeeSilvermanVoiceTreatment(LSVT)
Evidencebasedtreatmenttoimpact:

Improve
Voice
abilityto Swallowing
intensity/ Swallowing
comm. andsafe
Vocal Dysphagia
wantsand intake
Loudness
needs

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LeeSilvermanVoiceTreatment
Dailytasks
Firsthalfoftreatmentsession
RescaleamplitudeofmotoroutputthroughCORELoud
Sustainedah(minimum15reps)
High/Lowah(minimum15reps)
Functionalphrases(minimum50reps)

Hierarchicalspeechtasks
Secondhalfofsession
TrainamplitudefromCOREexercisesintoincontextspecificandvariablespeakingactivities
Week1 words,phrases
Week2 sentences
Week3 reading
Week4 conversation

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LeeSilvermanVoiceTreatment
LSVTLOUDcanbedoneinpatientswithCOPD. Afew
considerations:
Consultwithphysicianand/orrespiratorytherapists
Mayneedlongerrestperiods
Useyourclinicaljudgement
Ptswillhaveshorterdurationmaxsustainedphonation,and
thuswillneedtodomorereps.
Considerhavingthemwearapulseoximeterifyouare
concernedaboutsaturations,andthatrespiratorylaryngeal
coordinationandincreasedbreathsupport

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SubmandibularPlacementVFSS

Polansky,R.2009

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NeuromuscularElectricalStimulation:
Hutchings&Barnes,2009
1.DoesNMESincreasethetimingofthepharyngealswallow?
2.DoesNMESincreasemusclestrengthinmusclesresponsibleforthepharyngealstageofdeglutition?

Thepresentinvestigationfollowedarepeatedmeasuresresearchdesign.Theexperimentalgroupconsistedof20subjects
meetingcriteriadesignedtoeliminatevariablestoimpedethestudysaccuracy.TheEMPI300wasusedtodeliver
electricalstimulationtothesubmental region.Procedureandelectrodeplacementfollowedasubmental placementof
electrodes.Surfaceelectromyographywasutilizedtomeasurethelevelofpharyngealbaselinemuscleactivitypre and
postNMEStreatments.
Atotalof18participantsdemonstratedanincreaseinsEMG readingsafter8NMEStreatments.Oftheparticipantswho
demonstratedanincreaseinsEMG readings,only2demonstratedadecreaseinsEMG readingafter8NMEStreatment
sessions.TheseresultsindicatedthatNMESincreasedthetimingofthepharyngealswallowandanincreaseinmuscle
strengthresponsibleforthepharyngealswallow.

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Conclusion
HowYouBreatheMatters
Thereislikelyaninteractivecooperation
betweenswallowingandrespiration.(Gross2009)
WehavearesponsibilityasHealthCare
Practitionerstocooperateandtakeateam
approachintheassessmentandtreatmentof
tracheostomized andmechanicallyventilated
patients.

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QUESTIONS

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