Impact of Respiratory Compromise on Swallowing

respiratory and swallowing norms

1. respiratory phase pattern

2. apnea duration

3. apnea + swallowing total time

Respiratory phase pattern for swallowing

exhale-swallow-exhale

Apnea Duration

1 sec duration

Apnea + Swallowing Total Time

2 sec total (1 sec apnea + 1 sec swallow)

• Onset is hyoid excursion

• Offset (end) is hyoid return to rest

respiratory rate: when does it rise?

Rises when O2 levels don’t meet body’s needs, or when CO2 levels get too high

respiratory consideration

RR and flow rate (LPM)

Normal inspiratory flow rate:

20-30 LPM (tidal breathing)

Higher flow rates increase _____ airway pressures in the ____, which may impact ability to sustain ______ _______ during the swallow

positive, oropharynx, airway closure

Physiologic Impact of Trach on oral phase

Should be spared

Physiologic Impact of Trach on pharyngeal phase

1. Reduced laryngeal elevation

2. Saliva and secretion management changes

3. Disruption of subglottic airway pressure

4. Reduction of airflow through the glottis

5. Disruption of normal apneic interval with ventilator support

Physiologic Impact of Trach on esophageal phase

• Reduced distention (opening) of the upper esophageal segment

• Impingement in bolus passage from cuff inflation

Using your new knowledge about trachs and what you know up to this point about swallowing, consider:

Is a clinical swallow evaluation a sufficient assessment method for a pt with a trach? (Comment on your ability to assess the following)

1. Presence or absence of aspiration? Why or why not?

2. Laryngeal function? How?

3. Pharyngeal function? How?

1. Not without instrumentation (we can see s/s)

2. No, not definitively

3. No, we should not overstate

dysphagia assessment

1. collect a case history

2. structure and function exam (OME)

3. cuff deflation

4. replace PMV

5. clinical swallow eval

6. instrumental eval

collect a case history

Baseline dysphagia? Mechanism of injury prompting trach? Prior intubation? Respiratory status?

Should be assessing with every pt

structure and function exam (OME)

cuff deflation unless what?

using in-line PMV

Few indications for swallow evaluation without what?

PMV

only rare occasions without one

clinical swallow eval

Trial ice chips, puree, soft and bite sized

Readiness for participation in instrumental?

instrumental eval

FEES or VFSS

Trach patients aspirated on at least one consistency (n=272)

59%

Increase in odds of aspiration in uncapped trach compared to cap or PMV

2x

Increase in odds of aspiration when trach placement is for oropharyngeal etiology

3.4 x

Of those who aspirate, do so silently

81%

Increase in odds of silent aspiration with uncapped trach

4.5x

Benefits of FEES in Trach Patients

Visualization of:

1. Laryngeal structure and function

2. pharyngeal strength (squeeze)

3. retrograde bolus flow through the esophagus

*Trach pts are usually ICU level acuity and FEES is mobile

Benefits of VFSS in Trach Patients

• Visualization of:

  • all three stages of the swallow

• Can clearly assess for aspiration with and without the PMV in place

• Accurately assess esophageal clearance

• May be better tolerated in pts who are agitated

List two advantages to using FEES with trach patients (midterm ?)

1. see laryngeal structures

2. more accessible 

List two advantages to using VFSS with trach patients (midterm ?)

1. aspiration during the swallow

2. see all three stages

dysphagia treatment

• Respiratory re-training

• Oral motor and/or oral phase therapy

• Pharyngeal exercises

• Vocal fold adduction exercises

• Bolus-driven therapy

• Compensatory strategies

• Postures

• Diet modification

respiratory re-training

• Training swallow to occur on the mid-low expiratory phase of swallow (not on inhale)

• Biofeedback with imaging

compensatory strategies

• Breath hold

• Supraglottic

• Repeat swallow

• Liquid flush

• Diet modifications

• Positioning strategies/postures

compensatory strategies for reduced hyolaryngeal elevation

• Breath hold

• Supraglottic

compensatory strategies for  poor pharyngeal clearance

• Repeat swallow

• Liquid flush

Oral Motor/Oral Phase strategies

• Stretching

• Trismus

  • Therabite

• Lingual range of motion

• Lingual strength

  • IOPI

pharyngeal phase strategies

• Effortful swallows

• Mendelsohn

pharyngeal phase strategies that are NOT recommended for trach patients

CTAR (chin tuck against resistance), EMST, Shaker

vocal fold adduction tx

• Voice exercises

  • Sustained /a/

  • Pitch glides

  • Increase MPT

• Push/pull phonation

Bolus Driven Therapy

This focuses on progressive increases in the volume and the viscosity with effortful, quick swallows

Use food as the weight

Despite the known benefits of communication and swallow intervention…

• Only about 30% (n= 255) recieved_______

• Only about half received ______

• Delay in SLP evaluation averaged ~_ days from trach placement

• speaking valves

• swallow study

• 6

Consistent improvement in downsize and decannulation rates when an SLP was involved in care

Why does this disconnect occur?

Who is responsible for advancing the clinical practice?

• they may not realize the need, blanket recommendations with past SLPs, some SLPs don’t know what they are doing

• we are. There is a need for education and advocacy. 

List 2 treatment methods for improving pharyngeal stage dysphagia

1. effortful swallow

2. bolus driven therapy

What are 3 possible compensatory strategies or modifications that may be used for a pt with dysphagia?

1. diet modification

2. posture changes

3. breath hold, supraglottic swallow