1. Dysphagia and Speech in Acute Care Setting July 5, 2016 Valerie Weber M.S., CCC-SLP, BCS-S Board Certified Specialist in Swallowing and Swallowing Disorders Lead Speech-Language Pathologist Speech Department x 5262

2. Dysphagia Definition: A disruption in the swallowing process resulting in difficulty eating. (Paik, 2008) Deficits can occur in any of the three phases: oral, pharyngeal, and esophageal. (Paik, 2008) Over 50 muscles and 6 CN involved in swallowing

3. What Is Dysphagia? Dysphagia is the medical term for difficulty swallowing. A person with dysphagia may exhibit difficulty in the oral, pharyngeal or esophageal stage of swallow  Difficulty chewing food  Difficulty swallowing solids, liquids or pills  Coughing or choking while eating/drinking  Sensation of food sticking in the throat  Difficulty managing own secretions  Dysphagia affects as many as 15 million Americans and approximately one million new cases are diagnosed each year (Vital Stimulation Therapy, Chattanooga Group, 2008)  43 - 54% of stroke patients with dysphagia will experience aspiration  Of those patients, 37% will develop pneumonia  If dysphagia is not identified and treated properly, 3.8% with pneumonia will die (60,000) (Jacho, 2008)  40 - 60% of stroke patients are silent aspirators ( no cough response)

4.  Stroke  Acquired Brain Injury  Degenerative Disease (i.e. Parkinson’s, MS, Huntington’s)  Brain Tumors  Muscular and Nerve Disorders (i.e., Motor Neuron Disease, ALS, Myasthenia Gravis)  Alzheimer’s Diseases and other dementias  Head and Neck Cancer  Structural Lesions  Motility Disorders (i.e. Scleroderma, Myositis, Achalasia)  Psychiatric (Dementia, Alzheimer's, depression)  Medications  Iatrogenic (medication induced, post operative radiation therapy or chemo TX  Prolonged intubation, COPD, tracheostomy 4 Diseases Associated with Dysphagia

5. Incidence and Prevalence of Dysphagia  8.1-80 % of stroke patients develop dysphagia  30 % of acute care patients  43 - 54% of stroke patients with dysphagia will experience aspiration  Of those patients, 37% will develop pneumonia  If dysphagia is not identified and treated properly, 3.8% with pneumonia will die (60,000) (Jacho, 2008)  40 - 60% of stroke patients are silent aspirators ( no cough response)  50 % nursing home population  47% of frail elderly in hospitalized for an acute illness

6. Complications of Dysphagia  Aspiration  Malnutrition  Dehydration  Asphyxia or Choking  Death  Poor Quality of Life  Fear of eating  Social Isolation  Depression  Poor wound healing

8.  Difficulty manipulating food or liquids in the mouth  Inability to chew or propel food  Pocketing of food on one side of the oral cavity  Holding of the food in the oral cavity (pocketing)  Drooling or loss of food/liquid from the mouth  Food remaining in the mouth after a meal SIGNS AND SYMPTOMS OF ORAL PHASE DYSPHAGIA

9. SIGNS AND SYMPTOMS OF PHARYNGEAL DYSPHAGIA  Coughing, choking during or immediately after eating/drinking  Wet or gurgly vocal quality and/or breath sounds after eating or drinking  Sensation of food sticking in the throat  Respiratory changes while eating or drinking (i.e., drop in O2 Sats, wheezing or shortness of breath)  Delayed swallow, painful swallow, audible swallow, multiple swallows

10. Signs and Symptoms of Esophageal Dysphagia  Frequent episodes of regurgitation, reflux (heartburn) or spitting up after a meal, burping  Difficulty managing solid foods (may be due to stenosis/ Zenker’s diverticulum, motility problem)  Sensation of food sticking in the throat or chest area (“globus”)  “ It won’t go down”  Pain on swallowing (odynophagia)

11. Aspiration Definition: Passage of food or liquid below the level of the true vocal cords. (Paik, 2008) Aspiration can lead to diffuse lung injury. (i.e. Pneumonia) (Zaloga, 2002) Silent Aspiration: No cough or outward signs of swallowing difficulty in response to aspiration

12. How is Dysphagia Evaluated?  Clinical Bedside Evaluation  Assess cranial nerves VII, Xl, X, Xll  Oral motor structures, range of motion, strength and coordination, Cough reflex (ability to protect airway),  Vocal quality, (dysphonia/aphonia)  Cognitive awareness, can they maintain alertness long enough to ingest a meal  Secretion management  Dental status/Oral hygiene  If appropriate, will introduce trials of food and or liquids  Observe oral manipulation, chewing, timeliness of the swallow (delayed/weak or absent). Palpate the pharynx to feel for laryngeal elevation and efficiency of swallow.  Observe overt signs/symptoms of aspiration- cough/throat clear, wet vocal quality, dysphonia/aphonia, respiratory changes  Determine need for objective swallow test- Diet recommendations as appropriate

13. Modified Barium Swallow Study  Modified Barium Swallow / Videofluoroscopic Swallow (MBS/VSS) Evaluation is an x-ray procedure that assesses the function of the mouth, throat and upper esophagus  This test is performed in Radiology with a SLP and radiology technician  A variety of food and liquids in different textures and viscosity are presented to the patient  Determines if patient is aspirating and why

14. VIDEO

17. FEES  Fiberoptic Endoscopic Evaluation of Swallowing (FEES) uses a special camera on a small endoscope to look at the throat while the patient is swallowing  The narrow tube is inserted via one side of the nose and positioned to view the epiglottis, arytenoids, false and true vocal folds, pharyngeal recesses and entry into the airway.  Pictures are taken as the food and liquid is introduced  Provides us with a good look at the vocal folds and their integrity  This test can be performed at the patient’s bedside or in the GI suite  Beneficial for the patient who cannot come down to the fluoroscopy suite

18. VIDEO

19. Treatment Options Depending on the cause of the dysphagia and the patient’s medical and cognitive condition the following may be recommended:  Dysphagia Therapy (strengthening, use of compensatory strategies or postural changes)  Medical Intervention  Surgical Intervention  Dietary Modifications  Alternate Means of Nutrition/Hydration  May be safe to eat but has poor intake- dietary involved calorie count et.

20. Dysphagia Diets  “Mechanically Altered Diet”  Puree - All foods are blended to a smooth consistency and no chewing is required.  Dysphagia ll (Ground) - Soft to chew foods with ground meats and pureed vegetables  Mechanical Soft- Soft to chew foods with chopped meats and vegetables

21. Liquids  Pudding Thick (spoon thick) (not adequate to maintain hydration)  Honey Thick Liquids  Nectar Thick Liquids

22. Other diet recommendation  Soft- This is not mechanically altered but just softer foods which we often will recommend for elderly patient, patient with edentulous status  Regular  Thin/all Liquids  If patient is unable to have liquids from a GI perspective or some other reason and cannot tolerate thin liquids we may recommend a  Full nectar thick liquid  Full honey thick liquid diet  Clear nectar thick liquid diet 22

23. Dysphagia and Tracheostomies Does tracheostomy have an effect on swallowing function? Disordered laryngeal reflexes Desensitization of the oropharynx and larynx as a result of airflow diversion Reduced effectiveness of the cough reflex to clear accumulated supra glottic secretions Reduced subglottic air pressure Diffuse atrophy of the laryngeal muscles Aspiration more likely to occur due to medical/respiratory status versus the actual presence of trach tube (severe pulmonary disease, trauma, prolonged intubation, altered mental status, medications, advanced age, reduced functional reserve due to sarcopenia)

24. Do inflated cuffs prevent Aspiration?  Inflated cuff is to maintain air delivered from the vent to patient’s lung- inflated cuff is a balloon that surrounds the outer cannula of the trach tube, fills the tracheal space around the tube and prevents breath from escaping through the upper airway – prevents leakage if air so there is a closed system. This of course creates inability to phonate.  Cuff provides little protection against penetration or aspiration- aspiration material can leak around the sides of the tube and into the airway and residue that lays on top of the cuff can be aspirated after cuff deflation

25. When are they ready to eat?  Manage secretions?  Tolerate cuff deflation?  Can they phonate when we occlude the trach?  Passy Muir Speaking Valve trials  Improves ability to phonate (one way valve)  Improves swallow by allowing for improved subglottal airway pressure and restores the flow of the upper airway  Improves management of oral secretions  “Blue Dye” testing- used here as a screening tool- 24 hour screening often may see delayed aspiration  Usually determine when can either start PO or an objective swallow study (FEES/MBS) is indicated 25

26. A word about breathing and swallowing….  Study in patient with COPD- pattern of inhalation and exhalation. COPD patients swallowed solid food during inhalation more frequently than normal subjects (P.O. 002) and had a significantly higher rate of inhaling after swallowing semi solid material (P greater 0.001).  Conclusion: Disrupted breathing-swallowing coordination could increase the risk of aspiration in patient’s with advanced COPD and may contribute to exacerbation. (Gross, R.D, et al, The coordination of breathing and swallowing in chronic obstructive pulmonary disease. Am J Respi Crit Care Medicine. 2009, )  Bi-pap- not safe to eat while on Bi-Pap, air is being pushed into the lungs

27. If you can’t breathe, you can’t swallow… N27

28. Aspiration Pneumonia Literature reports there is a strong relationship between oral-pharyngeal dysphagia (OD) and respiratory complications  Two recent studies on elderly patients with community acquired pneumonia (CAP) admitted to a general hospital, the prevalence of OD was 55% (patients over 80 years old or older) and 52.8% (patients 70 years old and older.)  Patients with CAP followed for one year Mortality was higher in patients with OP dysphagia 80 year old population (55.4% vs 26.7%) 70 year old population (40% vs 7%)  Both studies concluded that OD is a highly prevalent clinical finding in elderly patients with CAP and is an indicator of disease severity and poor prognosis  Concluded: Respiratory infections and aspiration pneumonia lead to readmissions and high mortality among patient’s at risk and appropriate management is important to avoid these complications. (Almirall J.,et al, Oropharyngeal dysphagia is a risk factor for community acquired pneumonia in the elderly. Eur Respiratory Journal. 2013;(4) 28

29. Highest Predictors of Aspiration Pneumonia  Dependence for feeding  Dependence for oral care  Number of decayed teeth  Tube feeding  Multiple medical diagnoses  Number of medications prescribed  Smoking ( Susan Langmore et. Al, 1998 )

30. AHS Aspiration Prevention Policy  Reduce risk of aspiration and aspiration pneumonia in high risk patient population groups  Reduce incidence of mortality related to aspiration and aspiration pneumonia  Improve quality of patient care  Reduce length of stay and associated hospital costs following diagnosis of aspiration pneumonia 30 Wrist Band Aspiration Precautions

31. Why Does a Swallow Screen Matter ?  Up to 35% of deaths that occur after stroke are due to pneumonia (Hinchey et al., 2005)  Up to 50% of patients with dysphagia aspirate (Hinchey et al., 2005)  Silent aspiration occurs in 40-67% of patients with dysphagia who aspirate (Daniels et al., 1998:Splaingard, Hutchins, Sulton, & Chaudhuri, 1988)  5-15% of the 4.5 million cases of community-acquired pneumonia (CAP) result from aspiration pneumonia  Nosocomial bacterial pneumonia is the second most likely cause of nosocomial infections, second only to urinary tract infection, and it is the leading cause of death from hospital acquired infections, Medscape, June 27, 2013 Anand Swaminathan, MD, MPH; Chief Editor: Zab Mosenifar, MD)  60,000 Americans die from complications associated with swallow dysfunction, most commonly, aspiration pneumonia (Agency for Health Care Policy)

32.  3 ounces of water goes a long way…. (DePippo, Holas, & Reding, 1995) Screening Item =3 ounce water test

33. RN Swallow Screen vs Clinical Dysphagia Evaluation RN Swallow Screen  Performed by a nurse who has been instructed in nurse swallow screen  No order needed - part of nursing assessment  Provides a quick determination of likelihood of dysphagia  Give patient water only  Determines if it is safe to feed patient orally or give medications  Is a pass/fail screen  Time it takes = 15 seconds  Observes for “overt” signs of aspiration Dysphagia Evaluation  Conducted by a Speech-Language Pathologist  Obtain detailed history  Complete a cranial nerve assessment  Trial various textures of food and liquid  Determine safety of initiating oral diet  Determine need for objective testing (MBS/FEES)  Recommend swallow therapy/strategies  Make referrals to other specialists as indicated (GI/ENT)  Evaluation is not a pass/fail test

34. Case study: 70 year old patient admitted with new onset right facial droop, slurred speech, history of CVA, Parkinson’s Disease, DM. Patient is alert. Had RN swallow screen in ED which demonstrates coughing with thin liquids, wet voice, poor cough reflex. SLP gone for the day. What would you recommend? NPO except meds Clear Liquids Mechanically Altered Puree and thick liquids Regular Other NPO What other consults would you recommend ?

35. Speech/Dysphagia Orders: 2 separate orders Speech Evaluation covers: assessment for aphasia/dysarthria/apraxia/voice/ Cognitive Evaluation covers: assessment for TBI, attention, orientation, memory, functional problem solving, executive function, judgment, money management skills Dysphagia Evaluation covers: assessment of swallow at the bedside Bedside evaluation done prior to ordering an objective study (MBS or FEES) Status Post Intubation- If patient has been intubated for greater than 48 hours, wait 24 hours prior to Dysphagia Eval How/When to Order A Speech/Swallow or Cognitive Evaluation

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