DYSPHAGIA  REVIEW

Deanna  Britton,  PhD,  CCC-­‐SLP  Department  of  Rehabilitation  Medicine  University  of  Washington,  Seattle,  WA

Objectives

• Why is it important to assess and manage dysphagia?

• Anatomy & physiology review • MD Role: When to refer for swallowing

assessment & treatment • SP Evaluation of Swallowing

THE  Ability  to  EAT/swallow  is  a  “biopsychosocial,  sensorimotor  activity  that  is  a  key  element  of  healthy  life”    (JoAnne  Robbins)

“Dysphagia”

• Medical  term  referring  to  swallowing  difficulty  

• Includes  difficulty  in  any  of  the  three  phases  of  swallowing:    Oral,  pharyngeal  &/or  esophageal  

The  problem  of  dysphagia

Why  is  assessment  &  management  of  dysphagia  important??

The  problem  of  dysphagia

• High  prevalence  in  rehabilitation  populations,  e.g.,  individuals  with  neurological  impairments

• Leads  to  substantially  longer  hospital  length  of  stay    (Altman  et  al.,  2010)

• In  rehabilitation  patients,  the  presence  of  dysphagia  is  associated  with  a  13-­‐fold  increased  in  risk  for  mortality  (Altman  et  al.,  2010).

Prevalence    of  dysphagia:    EXAMPLES• Neurological  impairments  

• Stroke:    >50%  prevalence  (Mann  et  al  2000)  • Cervical  spinal  cord  injury:  increased  frequency  of  dysphagia  associated  

with  tracheostomy  and  increased  age  (Shin  et  al  2011)  • Developmental  disorders,  e.g.,  Cerebral  Palsy:  90%;  aspiration  in  40%  

(Rogers  et  al,  1994)  • Degenerative  diseases:    e.g.,  PD  as  high  as  80%  (Kalf  2011);  ALS  >95%  

• Head  &  Neck  Cancer    • Other  types  of  cancer:    common  (Raber-­‐Durlacher  et  al  2011)  –  can  be  affected  

by  medications,  chemo,    &  radiation  side  effects,  e.g.,  xerostomia,  mucositis,  fibrosis,  graft  v  host  disease  (e.g.,  following  stem  cell  transplant),  etc.  

• Tracheostomy  /  Ventilator  Dependence  without  neurological  impairments:    Gross  et  al  2003;  Ding  &  Logemann  2005.  

• Following  endotracheal  intubation:    ranges  from  3-­‐62%;  higher  (>50%)  with  prolonged  intubation  (Skoretz  et  al  2010)  

• Mental  Illness:    frequencies  range  from  9  to  42%  (Aldridge  &  Taylor,  2011)

Secondary  complications  of  dysphagia

• Aspiration  pneumonia  • Inadequate  or  mal-­‐nutrition  

• Dehydration  • Weight  loss  • Death

Early  identification  and  management  can  minimize  and/or  prevent  these  complications

Cost:    Dysphagia  untreated  =  expensive!!

The  cost  of  assessing  and  treating  dysphagia  is  well  below  the  cost  for  treating  aspiration  pneumonia.  

EXAMPLE:    Dysphagia  post  stroke  (Katzan  et  al  2007)  • Avg  cost  of  hospitalization  for  

pneumonia  post-­‐stroke  =  $21,043  • Avg  cost  of  hospitalization  for  stroke  

without  pneumonia  =  $6,206

Swallowing  anatomy  &  physiology

A  Basic  Review

upper  airway  -­‐-­‐  multi-­‐functional  purposes

• Breathing  • Speaking  /  singing    • Swallowing  /  Eating

http://sandykalik.com/2012/04/08/a-breathing-meditation-script/ http://lipmag.com/?attachment_id=22601

Swallowing  physiology

• Involves  coordination  of  over  25  pairs  of  small  muscles  &  multiple  cranial  nerves  

• Involves  a  combination  of  voluntary  and  reflexive  behaviors  

• Involves  coordination  of  many  systems:    mouth,  pharynx,  esophagus,  respiratory  system  

• Involves  sensory  and  motor  systems  • Coordinated  by  a  central  pattern  generator  in  the  brainstem

An impairment at any of these levels

could result in a neuromuscular impairment to swallowing.

Swallowing  CPG

Composed of 2 major nuclei (bilateral):

• Nucleus solitarius (dorsal): sensory – activated by CNs &/or supramedullary impulses

• Nucleus ambiguus (ventral): motor impulses carried out via CNs (V, VII, IX, X & XII) and cervical spinal nerves 1-3.

Supramedullary areas include: • Bilateral frontal motor & premotor

cortex • Insula • Anterior cingulate gyrus • Parietal cortex (anterolateral &

posterior) • Superiomedial temporal cortex

A= afferent impulses B= CPG C= cortical impulses D= efferent/motor impulses

Normal Swallow

Smith Hammond, 2008

Valves  of  the  upper  aerodigestive  tract

Conditions  for  optimal  swallowingOral  &  early  pharyngeal  phases

• Lips are sealed & tongue tip elevated to prevent anterior leakage. • Nasal passages are open • Oral mucosa is moistened with saliva. • Bolus is compressed between the tongue, hard palate & soft palate • Forceful retraction of the tongue pushes the bolus into the pharyngeal

cavity

http://www.radiologyassistant.nl/en/440bca82f1b77

Bolus  split  at  Valleculae

http://www.bidmc.org/CentersandDepartments/Departments/RehabilitationServices/OutpatientRehabilitationServices/VoiceSpeechandSwallowing/SwallowingDisorders/FiberopticEndoscopicEvaluationofSwallowingFEES.aspx

ORAL  Phase  problems    -­‐-­‐  examples

• Weakness  of  the  lips,  tongue  or  cheeks  due  to  stroke  or  other  neurological  conditions  

• Xerostomia  • Surgical  resection  of  oral  

structures  • Weakness  of  the  soft  palate

http://www.hopkins-gi.org/GDL_Disease.aspx?CurrentUDV=31&GDL_Disease_ID=0E11DE8C-7FB7-47AE-BC76-766AC830F7BA&GDL_DC_ID=E25BDF77-223D-4B6F-9700-5BE41DBDE28B

HYOLARYNGEAL  SUSPENSION  &  its  relation  to  opening  of  the  UES

Pharyngeal  phase  -­‐-­‐  reflexive• Initiated as bolus passes anterior faucial arch and reaches the pharynx. • Soft palate elevation prevents bolus from entering the nasal cavity. • Pharyngeal contractions begin stripping the bolus toward the esophagus • Muscles attached to the hyoid contract to move larynx anterior-superior • Epiglottis flips over the airway entrance • UES relaxes and is mechanically pulled open • After bolus passes, UES muscles contract and esophageal peristalsis takes

over

http://www.radiologyassistant.nl/en/440bca82f1b77

Pharyngeal  phase  problems  -­‐  examples

• Delayed  timing  of  swallow  reflex  • Penetration  or  aspiration  (may  

be  silent)  • Weakness,  e.g.,  laryngeal  

elevation,  pharyngeal  constrictors  

• UES  dysfunction

http://www.hopkins-gi.org/GDL_Disease.aspx?CurrentUDV=31&GDL_Disease_ID=0E11DE8C-7FB7-47AE-BC76-766AC830F7BA&GDL_DC_ID=E25BDF77-223D-4B6F-9700-5BE41DBDE28B

Esophageal  PHASE:      Peristalsis

PHARYNGEAL  ESOPHAGEAL  SEGMENT  PROBLEM

Esophageal   Achalasia   ESOPHAGEAL  

SPASM  

Coordination  of  Breathing  &  Swallowing

PATHOPHYSIOLOGY  • Increased  post  swallow  inspiration  in  individuals  with  neurodegenerative  disease  

– Motor  Neuron  Disease:  Hadjikoutis  et  al.,  2000  – Parkinson’s  Disease:  Gross  et  al.,  2008,  Troche  et  al.,  2011  

• Increased  post  swallow  inspiration  associated  with  advanced  age  (Martin-­‐Harris  et  al.,  2005)  

• Shorter  SAD  associated  with  hypercapnia  (Boden  et  al.,  2009)

Swallow  apnea  duration  (SAD)   Respiratory-­‐phase  patterns                                 Subglottic  Pressure  Support  for  Swallowing

• Facilitates  healthy  swallowing  – May  aid  expiratory  airflow  following  swallow  apnea  (Lang  et  al.  2002;  

Nishino  &  Honda,  1986)  – May  stimulate  mechanoreceptors  to  aid  laryngeal  adduction  (Shin  

et  al.,  1988)  

– Swallowing  timing  and  efficiency  is  aided  by  higher  lung  volume  (Gross,  2009)  

• PATHOPHYSIOLOGY    – Prolonged  swallowing  associated  with  lower  lung  volume  (Gross,  

2009;  Gross  et  al.,  2003)  

– Improved  swallowing  efficiency  and  timing  when  trached  patients  were  on  (vs.  off)  mechanical  ventilation,  and  associated  with  higher  MIP  (Terzi  et  al.,  2007)

Role  of  the  MD

When  to  refer  for  swallowing  assessment  and  treatment

Warning  signs• Impaired  consciousness  • Cognitive  impairments  • Dependence  for  feeding  • Oral  hygiene  problems  • Aspiration  history  • COPD  or  other  pulmonary  

concerns  • GI  disease  or  reflux  • Weight  loss  • Dehydration  • C/O  pain  or  obstruction

• Feeding  tube  • Trach  tube  • Pocketing  food    • Dysarthric  speech  • Wet  voice  • Hoarse,  breathy  voice  • Coughing  or  choking  • Upper  airway  congestion  • Drooling  • Suction  for  secretions

Possible  Symptoms  of  Dysphagia• Coughing  or  choking  associated  

with  eating/drinking  • Difficulty  coughing  when  

needed  • Difficulty  initiating  a  swallow  • Difficulty  with  managing  saliva,  

e.g.,  coughing,  drooling,  wet  sounding  voice  

• Wet  voice  quality  • Sensation  of  food  “stuck”

• Difficulty  chewing  • Reduced  oral  control  of  

food  • Difficulty  clearing  food  

from  the  mouth  • Needing  more  time  to  

finish  a  meal  • Leakage  of  food  or  liquid  

through  the  nose  • Weight    loss

Treating or managing contributing factors may result in improvements

with swallowing

Possible  Contributing  FactorsEXAMPLES:    • Acid  Reflux  • Poor  oral  care  • Dental  caries  &/or  gingivitis  • Excess  oral  dryness  • Fatigue  • Reduced  level  of  alertness  • Medication  side  effects  • Weak  or  absent  cough  • Tracheostomy  • Cervical  orthotics  • Concomitant  injuries  or  

diagnoses  that  might  affect  swallowing  

• Cognitive  impairments

These  factors  can  exacerbate  dysphagia  symptoms

EVALUATION  OF  SWALLOWING

Evaluation  of  SWALLOWING  –  Most  common  

• Clinical  “Bedside”  Swallow  Evaluation  (BSSE)  • Videoflurorscopic  Swallowing  Study  (VFSS)  • Fiberoptic  Endoscopic  Evaluation  of  Swallowing  (FEES)

EVALUATION  OF  SWALLOWING  –  RESEARCH

• Ultrasound  • Manometry  • Scintigraphy  • EMG  or  SEMG

Clinical  swallowing  examination  

Typically includes 3 components • History

– Medical records review  – Interview: e.g., current symptoms, history,

management and patient expectations

• Physical exam of the structure and physiologic function of muscles for swallowing

• Clinical swallow examination (aka, “bedside swallow examination (BSSE)”)

EAT-­‐10  -­‐-­‐  Belafsky  et  al.,  2008

To  what  extent  do  you  experience  the  following  problems?

1) My  swallowing  problem  has  caused  me  to  lose  weight.  2) My  swallowing  problem  interferes  with  my  ability  to  go  out  

for  meals.  3) Swallowing  liquids  takes  extra  effort.  4) Swallowing  solids  takes  extra  effort.  5) Swallowing  pills  takes  extra  effort.  6) Swallowing  is  painful.  7) The  pleasure  of  eating  is  affected  by  my  swallowing.  8) When  I  swallow  food  sticks  in  my  throat.  9) I  cough  when  I  eat.  10) Swallowing  is  stressful.

Functional  Oral  Intake  Scale  (FOIS)Crary  et  al.,  2005

Tube  dependent  1) Nothing  by  mouth  (NPO)  2) Tube  dependent  with  

minimal  attempts  at  food  or  liquid  

3) Dependent  with  consistent  intake  of  liquid  or  food

Total  oral  4) Total  oral  diet  of  a  single  

consistency  5) Total  oral  diet  with  multiple  

consistencies  but  requiring  special  preparation  or  compensations  

6) Total  oral  diet  with  multiple  consistencies  without  special  preparation  but  with  specific  food  limitations  

7) Total  oral  diet  with  no  restrictions

OROMOTOR  mechanism  ExamINCLUDES: • Integrity of Cranial Nerves that

affect swallowing, e.g., V, VII, IX, X, XII

• Muscles of mastication

• Facial symmetry, strength & function

• Intra-oral exam

• Tissues

• Palatal function, sensation and symmetry

• Lingual function, force, speed, ROM and coordination

• Laryngeal function/voice quality

Measurement  of  Cough  Subjective  Judgment  or  Peak  Cough  Flow

• Peak  cough  flow  (PCEF)  =  maximal  expiratory  flow  rate  during  a  cough  maneuver.

PCF  Level   Clinical  significanceGreater  than  500  L/min

Typical  threshold  for  healthy  adults;  minimal  risk  of  airway  encumbrance

Less  than  270  L/min Increased  risk  for  airway  encumbrance  

160  L/min Minimum  threshold  to  move  mucous  from  lungs  into  the  upper  airway

References:  Bach  &  Saporito,  1996;  Boitano,  2006;  Toussaint  et  al.,  2009;  Table  from:  Britton,  Cleary  and  Miller,  2013

Clinical  swallow  exam

INCLUDES: • Palpation of larynx during

swallow – volitional/dry swallow, and trial with food/liquid (if appropriate)

• Direct observation of oral phase

• Indirect observation for signs of aspiration with pharyngeal phase

Tracheostomy  /  Vent:    Brief  Review

• Trach  is  located  below  vocal  folds

• Inflated  trach  cuff  results  in  aphonia

• Trach/mechanical  ventilation  may  impact  swallow  biomechanics

• Ventilator  settings  affect  subglottic  pressure  for  speech  &  swallowing

Passy  Muir,  Inc

Modified  Evans  Blue  Dye  Test

http://www.phageinblue.com/

0Blue  dye  test  0A  small  amount  of  blue  food  coloring  is  placed  on  the  tongue  

0 Patient  is  suctioned  immediately  

0 Patient  is  suctioned  later  (to  check  for  delayed  aspiration)  

0 Positive  test:  Presence  of  blue  dye  observed  at  the  trach  site  &/or  upon  tracheal  suctioning.  

0Negative  test:    Absence  of  blue  dye  at  the  trach  site  and  upon  tracheal  suctioning.  

0Can  be  mixed  with  ice  chips,  water  &/or  other  food  consistencies  as  well.

A  few  controversies  regarding  blue  dye  swallow  studies

• How  is  the  blue  dye  administered?    Is  it  free  of  contamination?  

• Is  blue  dye  safe?  • How  sensitive  or  specific  are  blue  dye  swallow  studies?

Blue  dye:    ?adverse  effects?Risk  with  use  of  blue  dye  for  those  with  increased  gastrointestinal  permeability  includes  the  following  diagnoses:  • Sepsis  (75%  of  adverse  event  cases  included  septicemia  as  a  diagnosis):    Suggest  avoid  blue  dye  use  in  patients  currently  diagnosed  with  sepsis.  

• According  to  the  FDA,  other  diagnoses  that  may  increase  risk  for  gastrointestinal  permeability  include:    – Burns  – Shock  – Multiple  trauma  (acute)  – Renal  failure  – Inflammatory  Bowel  Disease  – Surgical  Intervention  – Bowel  disease    /    Celiac  Sprue  Disease

Czop  &  Herr,  2002

How  sensitive  /specific  are  blue  dye  studies?

Studies Sensitivity Specificity

Brady  et  al.,  1999 50% Not  reported

Donzelli  et  al.,  2001 50% Not  reported

Peruzzi  et  al.,  2001 45% 100%

Belafsky  et  al.,  2003 82% 38%

O’Neil-­‐Pirozzi  et  al.,  2003 80% 62%

Winklmaier  et  al.,  2007 92% 100%

Blue  dye:    sensitivity• Blue  dye  may  not  adequately  detect  trace  –  min  aspiration.    It  may  detect  larger  amounts  of  aspiration  only  

• For  some  patients,  use  of  blue  dye  may  help  determine  appropriate  timing  for  further  instrumental  exam,  therefore  minimizing  exposure  to  radiation  and  reducing  costs.

VIDEOFLUOROSCOPIC  SWALLOW  STUDY  (VFSS) aka,  modified  barium  swallow  study  (MBSS)

VFSS  -­‐-­‐  Basic  questions  to  ask• Penetration  or  aspiration?  • Residue?  

• Then  determine  – Where?  – When?  – Why?  – Patient  spontaneous  response?  – Interpretation,  in  light  of  the  patient’s  age  and  medical  diagnosis  

– What  can  be  done?

Patient  Position

Make  note  of……  • Position  during  exam,  e.g.,  seated,  standing  

• Positional  restrictions  or  abnormalities  

• Positional  supports

Biomechanics

• Examples  – Closure  of  valves  – Pharyngeal  constriction  – Hyolaryngeal  Elevation  – Laryngeal  valve  closure  – UES  opening

Timing  /  coordination

• Timing  of  aspiration  –  before,  during  or  after  the  swallow  

• Premature  spillage  •  Laryngeal  valve  closure  in  relation  to  bolus  head  

• Adequacy  &  timing  of  PES  opening

Aspiration  /  Penetration

• Observed:    yes  or  no  • Amount    • Estimated  %  of  total  bolus  aspirated  • How  far  into  the  airway  • Patient  response  (e.g.,  expulsion/clearance)  • Timing:    before,  during  or  after  the  swallow

PENETRATION-­‐ASPIRATION  SCALE  Rosenbek,  Robbins  et  al.  Dysphagia.  11,  93-­‐98,  1996 PA  Scale

BENEFITs  • Reliable  method  to  document  

depth  &  response  to  penetration/aspiration  

• Good  outcome  tool–  can  demonstrate  functional  change  

• Can  determine  abnormality.  • Can  characterize  certain  

populations  (see  next  examples).

CAVEATs• Does  not  quantify  all  swallow  

events!  • Does  not  indicate  swallow  

physiology  or  degree  of  dysfunction  

• Not  truly  ordinal  • Not  a  dysphagia  severity  scale.  • Does  not  indicate  timing  of  

aspiration  or  penetration  (i.e.,  before,  during  or  after)

VFSS  –  GOLD  STANDARD

CONS  • Expensive  • Time-­‐consuming  • Unavailable  at  some  

locations  • Radiation  exposure  • May  not  replicate  a  

patient’s  natural  setting  • Variable  procedures  across  

facilities

PROS  • Can  view  features  not  

observable  in  the  clinical  exam  

• Pharyngeal  &  esophageal  stages  

• Silent  aspiration  • Assessment  can  be  subjective  

and/or  objective  

Fiberoptic  endoscopic  evaluation  of  swallowing  (FEES)

• Allows  direct  observation  of  airway  protection  and  pharyngeal  phase  structures  

• Food/liquids  usually  mixed  with  food  coloring    

• Involves  a  scope  with  a  camera  inserted  through  the  nose  

• Accuracy  for  aspiration  is  comparable  with  VFSS

Intrinsic  larynx

ee

Vallecula

False vocal fold

Arytenoid cartilage

Pyriform sinus

True vocal fold

Pyriform

sinus

ValleculaEpiglottis

FEES

Benefits  of  FEES

• Evaluation  of  hypopharynx  and  laryngeal  anatomy  • Visualization  of  pooled  secretions  • Easily  portable  system  • No  adverse  complications  with  repeated  or  longer  exams  

• Direct  examination  of  laryngeal  sensation  • Can  observe  frequency  of  spontaneous  swallows

Limits  of  FEES

• Oral  cavity  and  tongue  are  not  visualized  – Can  visualize  base  of  tongue  – Can  visualize  movement  of  bolus  to  hypopharynx  – Can  visualize  premature  spillage  of  bolus  

• White  out  –  visualization  is  blocked  at  the  height  of  the  swallow  

• Limited  visualization  of  the  UES  opening  • Assessment  or  screening  of  esophageal  phase  is  not  possible

VFSS  vs.  FEES  –Langmore  (2006)

Only  VFSS  • Bolus  during  height  of  

swallow  • Oral  and  esophageal  phases  • Tongue  retraction  • UES  opening  • Laryngeal  elevation  • Extent  of  aspiration  • Submucosal  changes,  e.g,  

osteophytes

Only  FEES• Secretions  • Sensation  (direct  assessment)  • Surface  anatomy  • Mucosal  abnormalities  • Glottic  closure  • Path  of  bolus  (direct)  • Location  of  bolus  in  hypopharynx  • Effect  of  altered  anatomy  on  bolus  

flow  and  airway  protection.

Management  of  Oropharyngeal  Dysphagia

• Diet  • Posture  • Environment    • Maneuvers    • Therapeutic  exercises

Why  consider  pulmonary  function  and  defenses?

An  important  objective  in  assessment  of  swallowing    is  to  estimate  the  individuals'  risk  for  developing  

aspiration  pneumoniaBreathing  is  integral  to  &  tightly  coordinated  with  swallowing.  

– Breathing  swallowing  coordination  – Subglottic  pressure  support  for  swallowing  – Changes  in  swallowing  can  impact  breathing  &  vice  versa

Why  consider  pulmonary  function  and  defenses?

Pulmonary  defensesPulmonary  defenses  guard  the  lungs  from  infections.    Pulmonary  defenses  include  protective…..  • Anatomic  features  • Mucocilary  clearance  • Reflexes,  including  cough  • Volitional  cough  • Cellular  defenses  Certain  conditions  and  interventions  can  impair  pulmonary  defenses

▪ Loss  of  anatomical  defenses

▪ Blunted  protective  reflexes  

▪ Poor  cough

▪ Impaired  mucociliary  clearance

▪ Weakened  immunologic  defenses

Summary:     Host  Defense  Risk  factors  for  pneumonia

Thank  you!  THAT’s  ALL  FOR  NOW!

• Questions???