Dysphagia Lecture Notes

Dysphagia and Related Disorders

Amyotrophic Lateral Sclerosis (ALS)

• Swallowing deficits in ALS are characterized by:
  • Difficulty with chewing.
  • Anterior spillage (leakage of bolus from the mouth).
  • Reduced tongue mobility and bolus control.
  • Delayed pharyngeal swallow response.
  • Reduced pharyngeal contraction.
  • Reduced laryngeal elevation.
  • Residue in the valleculae and pyriform sinuses.
  • Residue on the pharyngeal walls.
  • Penetration and aspiration (Logemann, 1998).

Myasthenia Gravis

• Chronic autoimmune neuromuscular disease.
• Causes weakness in skeletal muscles affecting:
  • Eye and eyelid movement.
  • Facial expression.
  • Chewing.
  • Talking.
  • Swallowing.
  • Breathing.
  • Limb movements.
• Muscle weakness worsens after periods of activity and improves after periods of rest.

Sjögren’s Syndrome

• An autoimmune disorder.
• Results in severe dryness of mucous membranes in the mouth, eyes, pharynx, larynx, and digestive tract, along with other neurological symptoms.
• Can occur with other autoimmune diseases such as Multiple Sclerosis, Raynaud’s Syndrome, and scleroderma.
• Dysphagia presents as a complicating factor.
• Rosus-Pulia and Logemann (2011) study:
  • Examined the relationship between dysphagia symptoms in patients with Sjogren’s on VFSS (Videofluoroscopic Swallowing Study).
  • Patients perceived their swallowing to be more impaired than the VFSS suggested.

Case Study 1

• A 72-year-old female with a past medical history (PMHX) of hypertension (HTN), hyperlipidemia, and hypothyroidism presented to the ER with right-sided weakness and slurred speech.
• A Stroke Alert was called.
• Chest X-ray (CXR) showed lungs were clear, no active pulmonary disease; CT scan revealed an evolving infarct with no hemorrhage, mass effect, or midline shift.
• Admitted to the Neuro ICU; RN reports patient’s speech is difficult to understand and patient exhibits drooling on the right side.
• The patient is NPO (nothing by mouth) pending results of the clinical swallow evaluation.
• Questions to consider:
  • What is suspected to be happening with this patient?
  • Is she at risk for dysphagia? Why?
  • What problems with eating and drinking do you suspect she might have? Why?
  • Provide 2 additional questions you would ask the nurse to learn more?

Respiratory Disorders

• Overview of the respiratory system and its relation to swallowing.

Respiratory System

• The respiratory system includes three major parts:
  • Airway: Mouth, nose, pharynx, larynx, trachea
  • Lungs
  • Muscles of respiration

Respiration and Swallowing

• Respiration and swallowing are linked by their anatomy (common use of the mouth and pharynx) and their neuro-anatomic controls (brainstem-medulla).
• Respiration is inhibited by swallowing. Breathing stops when the bolus is passing through the pharynx (Swallow apnea).
• Disorders of breathing can be a cause for dysphagia or can exacerbate it.

Ventilation and Respiration

• Ventilation
  • Transfer of air into and out of the lungs.
  • Three requirements for ventilation:
    • Pumping mechanism (muscles, diaphragm-pump).
    • Pump attached to the lungs (pleural membrane keeps lungs attached to ribs and muscles).
    • Easy to inflate lungs (lungs stay partially inflated at all times).
• Respiration
  • Gas movement across membranes.
  • Trading of atmospheric gas with blood gases and blood gases with organ produced gases.

Respiratory Disorders

• Respiratory Failure
  • Respiratory failure occurs when not enough oxygen passes from your lungs into your blood.
  • Respiratory failure can also occur if your lungs can’t move enough carbon dioxide out of your blood.
  • Some patients enter the hospital with primary respiratory tract disease, while others enter the hospital for other medical reasons and have pulmonary complications.
• Respiratory failure can be acute or chronic.
• Caused by:
  • Lung diseases such as COPD & asthma.
  • Pneumonia, pulmonary embolism, cystic fibrosis, infections/sepsis.
  • Conditions that affect the nerves and muscles that control breathing, such as spinal cord injuries, muscular dystrophy, and stroke.
  • Damage to the tissues and ribs around the lungs due to an injury to the chest.
  • Drug or alcohol overdose.
  • Injuries from inhaling smoke or harmful chemicals.

Artificial Airways

• Patients with compromised respiratory status may require special intervention to support basic life functions.
• Intubation (endotracheal)
  • Procedure by which a tube is inserted through the mouth down into the trachea.
  • This is done before surgery or during emergency situations.
  • They are designed to be attached to a ventilator, a machine that mechanically breaths for the patient.
  • An intubated patient cannot talk or swallow.

Post-Extubation

• Structural & Mechanical problems post-extubation
  • Oro-pharyngeal atrophy
  • Reduced laryngeal elevation
  • Alterations of the receptors of the pharyngeal and laryngeal mucosa
  • Epiglottal dysfunction
  • Laryngeal atrophy
  • Reduced VF closure/VF immobility

Tracheostomy

• Patients who have difficulty weaning from endotracheal intubation require the surgical placement of a tracheostomy tube.
• Tracheotomy
  • Surgical procedure which consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea.
  • Advantages include: allowing access to the lungs for suctioning, less trauma to the vocal folds, and the possibility of speaking and swallowing.

Tracheostomy Details

• Stoma – hole made in the neck and trachea.
• Parts of a tracheostomy tube:
  • Outer cannula.
  • Inner cannula.
• Tracheostomy tubes can be cuffed or cuffless.
• Cuff
  • Portion at the end of the tracheostomy tube that can be inflated with air externally using a syringe.
  • When the cuff is inflated it can seal off the entrance to the lungs to reduce food or secretions entering.
  • Ensures that volume of air being delivered via mechanical ventilation is accurate.

Tracheostomy and Swallowing

• Studies have found a higher prevalence of aspiration events in patients with tracheotomy compared with those without (Bonano, 1971; Elpern et al., 1987; Nash, 1988).
• Factors that increase risk for aspiration include:
  • Loss of subglottic air pressure.
  • Poor laryngeal elevation.
  • Loss of upper airway sensitivity.
  • Loss of normal laryngeal closure reflex.
  • Inability to coordinate normal swallow.

Passy-Muir Valve

• One-way valve which redirects air flow through the vocal folds, mouth and nose enabling voice and improved communication.
  • Closes the respiratory system and restores positive airway pressure and subglottic pressure which can help restore a more normal swallow.
  • Directs airflow back over the vocal folds and through the oral cavity for communication.
• Studies of tracheostomized patients showed improvement in swallowing with PMV (Blumenfeld, 2012; Dettlebach et al., 1995; Lian et al., 2022; Manzano et al., 1993; www.passy-muir.com).

Chronic Obstructive Pulmonary Disease (COPD)

• COPD is a progressive disease that makes it hard to breathe.
  • COPD can cause coughing that produces large amounts of mucus, wheezing, shortness of breath, chest tightness, and other symptoms.
  • Cigarette smoking is the leading cause of COPD. Most people who have COPD smoke or used to smoke.
  • Long-term exposure to other lung irritants—such as air pollution, chemical fumes, or dust—also may contribute to COPD.

COPD - Mechanisms

• In COPD, less air flows in and out of the airways because of one or more of the following:
  • The airways and air sacs lose their elastic quality.
  • The walls between many of the air sacs are destroyed.
  • The walls of the airways become thick and inflamed.
  • The airways make more mucus than usual, which can clog them.
• In the U.S., the term COPD usually refers to emphysema or chronic bronchitis.

COPD - Emphysema

• Emphysema
  • The walls between many of the air sacs are damaged.
  • As a result, the air sacs lose their shape and become floppy.
  • This damage also can destroy the walls of the air sacs, leading to fewer and larger air sacs instead of many tiny ones.
  • This leads to a reduction in the amount of gas exchange in the lungs.

COPD - Chronic Bronchitis

• Chronic bronchitis
  • The lining of the airways is constantly irritated and inflamed.
  • This causes the lining to thicken.
  • Lots of thick mucus forms in the airways, making it hard to breathe.
• According to the National Heart, Lung & Blood Institute, most people have both emphysema and chronic bronchitis.
  • COPD is the sixth leading cause of death in the United States (CDC, 2024).

COPD - Treatment

• Medications
  • Bronchodilators (inhalers).
  • Anti-inflammatories (steroids).
  • Antibiotics.
  • Vaccinations.
• Oxygen therapy.
• Pulmonary rehabilitation.
• Life style changes
  • Quit smoking.
  • Avoid exposure to irritants.
• Surgery (transplants, lung reduction).

Pneumonitis

• Pneumonitis
  • Inflammation of the lungs.
  • Caused by infections, chemicals, irritants, allergens, radiation therapy, medications, gastric contents.
  • Trauma to the alveoli and airway cause inflammation and edema.
• Pneumonia is a type of pneumonitis
  • Caused by a pathogen/bacteria/virus/debris
• Pneumonia = infection + inflammation.
• Not all pneumonias are related to dysphagia!

Pneumonia

• Pneumonia is an infection in one or both of the lungs.
  • Bacteria, viruses, and fungi can cause pneumonia.
• The infection inflames your lungs' air sacs, which are called alveoli.
  • The air sacs may fill up with fluid or pus, causing symptoms such as a cough with phlegm, fever, chills, and trouble breathing.
• Pneumonia and its symptoms can vary from mild to severe.

Pneumonia - Severity

• Many factors affect how severity of pneumonia such as the type of germ causing the infection and your age and overall health.
• Pneumonia tends to be more serious for:
  • Infants and young children.
  • Older adults (people 65 years or older).
  • People who have other health problems, such as heart failure, diabetes, or COPD.
  • People who have weak immune systems as a result of diseases or other factors. (HIV, chemotherapy, organ transplant).

Pneumonia - Symptoms & Etiologies

• Symptoms include:
  • Productive cough.
  • Fever.
  • Difficulty breathing.
  • Chest pain.
  • Fatigue.
  • Reduced level of consciousness.
• Etiologies of pneumonia
  • Community acquired.
  • Nosocomial.
  • Aspiration.

COVID-19

• Severe Acute Respiratory Syndrome (SARS-CoV-2).
• Declared global pandemic in March, 2020, now Covid-19 is endemic.
• Infects mucosa of the upper airway.
• Spread through droplets and aerosols.
• Signs and symptoms can be mild, but it can lead to serious illness.

COVID-19 and Swallowing

• Sensory changes – taste and smell.
• Other upper respiratory system effects
  • Sore throat, pharyngeal erythema, voice impairments.
• Stroke
  • Hypercoagulation, release of microparticles, atrial fibrillation, blood vessel injuries/destabilization of plaques.
• Dyspnea
  • Leads to difficulty coordinating breathing and swallowing.
• Pneumonia.
• Respiratory failure – leads to intubation.
• Long-term intubation
  • Typically convert to tracheostomy within 14 days, but with Covid-19, patients were staying orally intubated longer.

Pulmonary Clearance Mechanisms

• Two components
• Upper respiratory clearance mechanism
  • Based on the ciliary activity of the tracheobronchial mucosa
    • Cough
    • Muco-ciliary escalator - the ciliated cells transport the mucus together with any deposited particles proximal direction and eventually the mucus is expectorated or swallowed

Pulmonary Clearance Mechanisms - Alveolar

• Alveolar clearance mechanism
  • Alveolar macrophages (WBC) slowly dispose of particles either by:
    • Transporting them along the alveolar surface to the muco-ciliary escalator
    • Translocation to tracheobronchial lymph
    • Internal enzymatic degradation

Cough

• Reflex that keeps your airway clear
  • Voluntary and involuntary
• Acute and chronic
• Types of cough
  • Wet (produces mucus)
  • Dry
  • Paroxysmal cough (uncontrollable/fits)
  • Croup cough (barking sound)

Penetration & Aspiration in Normal Adults

• As many as half of healthy adults aspirate small amounts of their secretions, usually in our sleep (Gleeson, et al., 1997).
• Laryngeal penetration occurs frequently in normal adults and increases with age (>50 yrs) (Daggett, et al., 2006).

Aspiration Pneumonia

• This type of pneumonia can occur if you inhale food, drink, vomit, or saliva from your mouth into your lungs
  • This may happen if something disturbs your normal swallowing reflex, such as a brain injury, stroke, or excessive use of alcohol or drugs
  • Often polymicrobial
• Patient must have dysphagia for aspiration pneumonia. Dysphagia precedes pneumonia.
• Infiltrates appear on chest x-rays in dependent portion of lung (Lower lobe, posterior).

Why Aspiration Pneumonia?

• What was aspirated?
  • Acidity
  • Fat molecules vs. Water molecules
  • Weight
  • Bacteria
• Thicker fluids & semi-solids are more predictive of aspiration pneumonia if aspirated in CVA patients (Schmidt, et al., 1994, Holas et al., 1994).

Pneumonia Risk Factors

• Predictors of Pneumonia after Stroke
  • Older age
  • Stroke severity
  • COPD
  • Dysphagia
  • CAD
  • Preadmission dependency (Finlayson, et al., 2011)
• Predictors of Pneumonia in Head & Neck Cancer
  • Aspiration on MBS
  • Malnutrition
  • Smoking (Purkey, et al., 2009)

Chest X-Ray

• The chest x-ray is the most commonly performed diagnostic x-ray examination
• A chest x-ray produces images of the heart, lungs, airways, blood vessels and the bones of the spine and chest
• An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat medical conditions
• The chest x-ray is a very useful examination, but it has limitations

Chest X-ray Terminology

• Costophrenic angles
  • Intersection between chest wall and diaphragm
  • Should be sharp and well delineated
  • Blunted costophrenic angles – typically pleural effusion
• Pneumonitis - Inflammation of the lungs
• Pneumonia – Inflammation + infection
• Terms which may be associated with pneumonia
  • Density/Opacity/Consolidation
  • Shadow indicating something denser than air
  • Infiltrates
  • More solid matter has infiltrated an air-filled space

Normal Chest X-Ray

• Normal appearance of a chest x-ray.

Chest X-Ray - Right Lobe Pneumonia

• Appearance of right lobe pneumonia on a chest x-ray.

Aspiration

• Visual representation of aspiration.

Bloodwork Values

• White Blood Cells
  • Normal values 4,500 – 11,000 c/mcl
  • Neutrophils – first line of defense
• Blood Gases
  • Arterial blood gases
  • paCO_2=38-45 mmHg
  • paO_2=85-100 mmHg (different from pulse Ox)
  • pH=7.4 normal (acidosis low pH)
• Oxygen Saturation (Pulse Ox)
  • SaO2=% hemoglobin O2 >90-100%
  • Estimate, not as detailed as blood gas

Treatment of Pneumonia

• Antibiotics
• Oxygen Therapy
• Respiratory therapy treatments
• Other medications
  • Anti-inflammatory meds
  • Bronchodilators
• Fluids
• Rest
• Prevention – oral care, vaccines

Case Study 2

• A 78-year-old patient was admitted to the hospital from his skilled nursing facility due to shortness of breath. You received orders for a swallow evaluation and when reviewing his chart you find that his CXR showed infiltrates in the right lower lobe. His past medical history included osteoarthritis, HTN, & dementia. The patient is NPO pending the results of the clinical swallow evaluation.
• Questions to consider:
  • What do you suspect is happening with this patient?
  • Is he at risk for dysphagia? Why?
  • What problems with eating and drinking do you suspect he might have? Why?
  • Provide 2 additional questions you would ask the nurse to learn more about this patient?