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Interpreting Pulmonary Findings in Relation to Dysphagia

Sydney Parriott Schumacher, MA, CCC-SLP University of Kansas Health System

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Little about me…

• BA at the University of Missouri•MA at the University of Kansas• Experience:• Long-term acute care (LTACH)

facility• Focus on ventilators/tracheostomies

• Inpatient rehabilitation • Acute care/Hospital

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Pro Tip

• I will highlight key terms/concepts that are most applicable to your future clinical practice in BLUE.

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Objectives

• Identify common assessment techniques used by physicians to evaluate lung function

• Familiarize terms utilized to describe radiographic findings and pulmonary function

• Discern information that is pertinent to possible aspiration based on pulmonary assessment results

• Learn at least two differences between aspiration pneumonia versus pneumonitis

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Why do SLPs care about chest imaging?

Our goal is to prevent aspiration pneumonia…but how do we know for sure?• Example Report 1: •Moderate to severe left lower lobe atelectasis and mild

dependent right lower lobe atelectasis with trace pleural effusions. No pneumothorax.

• Example Report 2: • Low lung volume with similar bibasilar opacities probably

atelectasis. Right lower lobe infiltrates present. Small left pleural effusion persists.

• How can we make sense of the radiologist’s findings to apply to our practice?

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When do SLPs care about chest imaging?

Examples:• A patient comes in with known history of dysphagia and team would

like you to re-assess. Do you change their diet?• Assessing chest imaging would tell you if their current diet in the known setting

of dysphagia is causing medical complications

• A nurse reports to you that a patient is consistently coughing with their drinks during meal times. Why might that be?• A review of the patient’s chest imaging tells you they have severe COPD or

emphysema which may be contributing to their dysphagia. • You upgrade a patient from NPO to a mechanical soft solid, thin liquid

diet. How do you know if they’re tolerating it versus aspirating?• Pulmonary findings would tell you if food/drink is collecting in the lungs over a

period of days.

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Lung Sounds

• Auscultation - using a stethoscope to listen to the lobes of the lungs during respiration• Who?

• Physician, nursing, respiratory therapy• Where?

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Lung Sounds Continued What are they listening for?• Lung sound subtypes:

• “Clear to auscultation bilaterally” • Indication of normal lung function• Evidence that a patient is tolerating their diet without collection of

fluid/aspirated material in lungs• “Crackles” or “Rales”

• Coarse or fine• Pneumonia, fibrosis, heart failure

• “Wheezes”• Asthma, COPD, other airway obstruction

• “Rhonchi”• Suggests secretions or aspirated material in large airways

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Clinical Application of Lung Sounds

• If changes noted following intake, the SLP can re-assess for acute changes or if further assessment (e.g., videoswallow) is needed.

Request lung auscultation by nursing before and after meals

• “Clear to auscultation?”• No fever?• Stable white blood cell count?• No increased oxygen needs?

Assess for diet tolerance as

part of clinical picture

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Chest X-Ray (CXR)

• Abnormalities present as areas of either increased or decreaseddensity from surrounding tissue• Increased density or opacities are

most common

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Computed Topography (CT – Chest)

• 3-D model to help show size, shape, and position of the lungs and surrounding structures• More detailed than CXR• Often done as a follow-up when

something else is found on an CXR• Completed in axial, sagittal,

and/or coronal views

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Radiographic Observations

•4 pattern approach:• Consolidation• Interstitial lung disease• Nodules/masses• Atelectasis

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Consolidation• Lung tissue becomes more dense

due to disease replacing alveolar air• Local vs diffuse• Acute vs chronic

• Pneumonia most common cause of consolidation• Aspiration most likely in gravity

dependent areas (lower lobes) • Right lower lung lobe is more

likely than the left

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Atelectasis • Collapse of lung tissue due to air (pneumothorax), fluid (hydrothorax), or tumor• Categorized as:• Collapse (due to air)• Compression (due to fluid) • Obstruction (due to tumor)

• Most common finding on x-ray• Can’t confirm if pneumonia from

x-ray but also cannot be ruled out• Impact on swallow

• Increased respiratory rate = more difficulty coordinating breathing and swallowing

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Additional pertinent findings…

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Infiltrates• Any substance that has entered

the lungs, alveolar space, or tissue space around cells (interstitial compartment)• Can indicate presence of

pneumonia• More likely due to aspiration if

infiltrates are present in gravity dependent areas (lower lobes)

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Pleural Effusion• Fluid build-up• 2 types:• Transudative = clear• Exudative = filled with

proteins • Type most likely to be

associated with aspiration and pneumonia

• Usually caused by congestive heart failure• Possible to be caused by

aspiration, however unlikely

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Opacities • Tree-in-bud

• Small, clustered, nodular• Mucous impaction with inflammation• Miller & Panosian (2013)

• Aspiration cause in 25% of cases

• Ground-glass • “Haziness” • Wide variety of causes, one of which is

aspiration• Need to consider at overall clinical

picture• Can often be seen together• May indicate aspiration if in lower

lobes

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Empyema• Collection of pus between the lung

and surrounding pleural space• Caused by infection• Puts pressure on the lungs, causing

shortness of breath• Physicians will place chest tube to

drain• Impact on swallow

• Shortness of breath = more difficulty coordinating breathing and swallowing

• Consider being more conservative with dysphagia recommendations for these patients

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Lung Disease and Aspiration

• Due to either:• CNS depression • Inadequate lung expansion

• Results in increased respiratory rate àimpaired swallow/breath coordination

Restrictive lung disease

• Difficulty exhaling due to reduction of airflow

• Respiratory membrane surface destroyed• Due to:

• COPD, asthma, emphysema, bronchiectasis

• Results in increased respiratory rate àimpaired swallow/breath coordination

Obstructive lung disease

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Pneumonia vs. Pneumonitis: Same or Different?

Aspiration Pneumonia Chemical PneumonitisColonized oropharyngealmaterial

Sterile gastric contents

Acute inflammation Acute injury

Tachypnea (rapid, shallow breathing), cough

Asymptomatic, dyspnea (labored breathing), hypoxia, cough, low-grade fever

Can progress quickly, gradually, or over weeks

Progresses within 1-2 hours

May need to use your detective skills during your chart review! Did the patient have a recent emesis (vomiting) episode?

Pneumonia Pneumonitis“Anaerobic pneumonitis” -ASPIRATION

“Chemical pneumonitis” –EMESIS or VOMIT

Colonized oropharyngeal material; bacterial

Gastric contents, sterile due to low pH

Acute inflammation Inflammatory injuryTachypnea (rapid, shallow breathing), cough

Asymptomatic, dyspnea (labored breathing), hypoxia, cough, low-grade fever

Can progress quickly, gradually,or over weeks

Progresses within 1-2 hours, will clear after 24-36 hours

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•PLUG FOR ORAL CARES• Thorough and FREQUENT!• At LEAST 3 times per day (after

meals)• Education patient, family, staff!

•Will reduce the ability for oral bacteria to colonize, thus reduce the risk of aspiration pneumonia

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Clinical Application of CXR, CT-Chest

• Was your patient tolerating the diet they were on at home vs since admission to the hospital?

• How compromised is their lung function prior to completing your bedside assessment?

Current Level of Function

• Pulmonary status helps clinicians predict how well a patient may tolerate aspiration

• Difference between being more liberal vs more conservative with your recommendations

Assess for diet tolerance as part of

clinical picture

• Does the person already have a pneumonia?• Consider impact of conditions such as COPD,

emphysema, lung cancer, etc.

Determine pertinent pulmonary diagnoses

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Case Study:

• 78-year old female• Prior Medical History (PMH):

• Right hemisphere stroke (CVA)• Gastroesophageal reflux disease (GERD) • Pneumonia

• History of dysphagia from CVA• On regular solid/thin liquid diet at home as recommended from

videoswallow completed ~3 months prior• Small bites/sips, slow rate• Daughter reports patient is very impulsive since the stroke and often doesn’t

follow swallow guidelines despite lots of encouragement

• Admitted to hospital for respiratory failure requiring intubation for 3 days• Extubated and put on 3 liters of oxygen for bedside swallow

evaluation

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Case Study: • Lung auscultation at bedside by physician

• Bilateral coarse rales• Chest X-ray with 2 views

• Impression: Left lung base consolidation most consistent with pneumonia or aspiration.

• Other than “aspiration,” what stands out to you? • CT Chest

• Impression: • Tree-in-bud opacities within the right upper lobe most consistent with

pneumonia, possibly infectious or from aspiration given somematerial located centrally and in the right lower lobe.

• Additional mild ground-glass opacities in the right lower lobe which may be related atelectasis or pneumonia.

• Additional mild bilateral lower lobe atelectasis.• Mild ground-glass opacities near the lung base, nonspecific though

likely related to atelectasis or pneumonitis. • What stands out to you?

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Case Study:• What is going on here?• What do you expect to see at the bedside?• What, other than her chest imaging, will you take into consideration?• Do you suspect this patient is at her baseline?

• If so, what will you do about it?

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Case Study:• Chart review• Bedside swallow evaluation

• Patient NPO at time of visit• No signs/symptoms of aspiration except with liquids by straw• Decision made to pursue instrumental swallow evaluation

• Why? Why not just start her on a diet?

• FEES completed• Results:

• Consistent deep penetration with x1 episode of aspiration noted with thin liquids suspected during and observed after the swallow.

• Penetration also noted with nectars which did not eject from the laryngeal vestibule. Moderate residue across solid textures.

• Use of swallow strategies effective only to reduce (not resolve) pharyngeal residue; ineffective to eliminate aspiration/penetration events.

• Why is her swallow worse than her videoswallow ~3 months earlier?• What is your plan?

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Case Study:• Plan

• NPO, physicians placed NG tube• Initiate ice chip protocol to promote pharyngeal muscle use• Initiate pharyngeal strengthening exercises

• I personally focused on exercises that can be implemented with PO boluses; this was much easier for her due to her cognition. • Effortful swallow• Chin tuck against resistance

• Attempted to implement Masako, Mendelsohn, and also EMST however difficult carry-over given mentation

• Complete PO trials at the bedside• Focused on teaspoons of nectar and puree independently and with exercises!

• Give patient’s body time to recuperate from intubation • Educate patient, family, staff regarding importance of swallow strategies• Implement environmental aids to improve swallow strategy carryover• Repeat instrumental assessment when demonstrating improvement at the

bedside • With repeat evaluation, what is your plan if you see improvement? If it’s the same? If it’s

worse?• Do we need to recommend a long-term source of nutrition?

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Case Study:• After 8 days, repeat instrumental completed (modified barium

swallow)• Results:

• Patient with decreased incidence of penetration with nectars and improved clearance of pharyngeal residue.

• Consistent penetration of variable depth observed with thin liquids which did not eject from the laryngeal vestibule

• Flash penetration noted with small sips of nectars; penetration increased in severity/depth with straw and larger drinks.

• Moderate pharyngeal residue with solids. Multiple swallows and taking a drink after were only effective up to mechanical soft solids.

• Do you start a diet? If so, what consistencies?• I started her on mechanical soft/nectar thick liquids with additional ice chips

PRN.

• What strategies do you recommend?• Multiple swallows, alternate bites/sips, small bites/sips, no straws!

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Sources: • Pleural confusion: Understanding Lung Function in the Assessment

and Management of Dysphagia• Towino Paramby, CScD, CCC-SLP, BCS-S; Lisa Evangelista, CScD, CCC-SLP, BCS-S

• Jurado, R. & Franco-Paredes, C. (2001). Aspiration pneumonia: a misnomer. Clinical Infectious Diseases, 33(9): 1612-1613. • Miller, W.T. & Panosian, J.S. (2013). Causes and imaging patterns of

tree-in-bud opacities. Chest 144(6): 1883-1892. • Empyema. (Date Unknown – John Hopkins Medicine). Retrieved from

https://www.hopkinsmedicine.org/health/conditions-and-diseases/empyema

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