airway protection: clinical management of dysphagia and ... · dysarthria and a moderate...

AirwayProtection:ClinicalManagementofDysphagiaandDystussiainNeurodegenerativedisease

AlexandraE.Brandimore,Ph.D.CCC/SLPMESPAConference

April13,2019

Noconflictsofinterestordisclosuretoreport

•  Protectionofthelowerairwaysinvolvesacontinuumofbehaviors

Background:AirwayProtection

AFrameworktoUnderstandAirwayProtection

FirstcameEccles2009ThenmodifiedbyHeglandetal.,2012

ThenrefinedagainbyTrocheetal.,2014

CerebralcortexConsciouscontrolUrgetoact Voluntarycontrol

Sensationofstimulus

Spinalcord

Respiratorymuscles

Peripheralstimulus

VagusNerve(FacialNerve)

(GlossopharyngealNerve)

Brainstemcontrolcenters

DynamicSensorimotor

pathway

Oropharyngeal/Laryngealmuscles

Background:Cough

(SmithHammondetal.,2001;2009;Pittsetal.,2008;Trocheetal.,2014;Heglandetal.,2014;Milleretal.,1996)

Cough

ReflexVoluntary

tocomputer

Facemaskin-linewithapneumotachograph

Digitized(PowerLab)andrecorded(Chart7,ADInstruments)Irritant

deliveryport Ai

rflow(L/s)

-202468

1:17 1:18.5 1:19 1:19.5

Cr1

(b)

Time,seconds

CEV

IV

CPD

PEFR

•  ResearchershavefoundthatreflexandvoluntarycoughdysfunctionispredictiveofswallowingfunctioninPDandstroke(Pittsetal.,2008;2010;Trocheetal.,2016;SmithHammondetal.,2001;2009)

Background:AirwayProtection

Time(s) Time(s)

PEFR

NonPen/Aspirators Pen/Aspirators

Airflow(L/s)

0

4

8

-4

-8

4

8

-4

-8

0

PEFR

CPD CPD

Background:ReflexCough

•  Reflexcoughisparticularlyimportantforairwayprotectionasitdetectssensorystimuliintheairwayandthenforcefullyejectsthematerial

•  Theexistingresearchhasidentifiedacognitivemotivationalcomponenttoreflexcoughwherebyindividualscanvolitionallymodulatethereflexivebehavior

Background:ModulationofReflexCough•  Anecdotally,modulationofreflexcoughisexperiencedwhenindividualssuppress,ormodifyreflexcoughoutputbasedoninternalandexternalfactors(i.e.environment,verbalcueing,etc.)–  Hutchingsetal.,1993–  Leowetal.,2012

•  Heglandandcolleagues(2012)evaluatedtheabilityofhealthyyoungadultstomodulatereflexcoughairflowbasedonverbalcues–  Participantsvolitionallyup-regulatedreflexcoughairflowwithverbalcuesto“coughlong”,“coughshort”,or“coughnormally”

Background:ModulationofReflexCough

Participants CoughAirflowMeasures

NaturalCough Coughwithcueing

Healthyyoung CPD .42seconds .57secondsadults(n=20) PEFR 4.63L/s 5.63L/s

CVA(PEFR/PEFRT) 85.59L/s/s 109.51L/s/s

•  Theabilitytobehaviorallymodulatereflexcoughairflowisimportantbecausepopulationswithneurodegenerativediseases,suchasParkinson’sdisease(PD)frequentlydevelopdystussia•  Heglandetal.,2014•  Trocheetal.,2014

•  Brandimoreetal.,(2017)identifiedthatHOAsandpeoplewithPDcanimprovereflexcoughairflowwithcueing

Background:Aroleforcoughrehabilitation?

•  Evaluatedtheimpactofsimultaneousvisualandverbalcueingfortheimmediateup-regulationofreflexandvoluntarycougheffectiveness

CoughRehabilitationBrandimoreetal.,2017

(b)

Time,seconds

CEV

IV

CPD

PEFR

Methods:ParticipantDemographics

LVICr1

HOAs PDParticipants n=28 n=16

Sex M=14;F=14 M=9;F=7

Age(years) M=69.63(8.3);F=71.33(5.6)

M=74.22(7.1);F=72.14(4.2)

Height(inches) M=69.56(2.8);F=65.56(2.6)

M=68.17(2.3);F=62.79(2.2)

Weight(pounds) M=201.06(40.6);F=145.67(31.6)

M=182.0(26.8);F=137.29(22.0)

BMI M=27.68(4.3);F=25.69(5.8)

M=27.48(3.2);F=24.21(4.1)

Methods:BaselineCoughTesting•  VoluntarySequentialCoughTesting

-  Instructedto:“Coughlikesomethingwentdownthewrongpipe”(3x)

•  ReflexCoughTesting-  Obtainedbaselinereflexcoughairflowat200µMcapsaicin(3x)-  Instructedto:“Coughifyouneedto”

tocomputer

Facemaskin-linewithapneumotachograph

Digitized(PowerLab)andrecorded(Chart7,ADInstruments)Irritant

deliveryport;

200µMcapsaicin

Airflow(L/s)

-202468

1:17 1:18.5 1:19 1:19.5

Cr1

(b)

Time,seconds

CEV

IV

CPD

PEFR

•  CoughModulationTesting–  Randomizedpresentationsof0and200µMcapsaicin

Methods:ModulatedReflexandVoluntaryCoughTesting

•  WeidentifiedthatHOAsandpeoplewithPDcanimprovebothreflexandvoluntarycougheffectiveness–  Visualandauditorycueingto‘coughhard’effectivelyincreasedPEFRandCEVforbothcoughtypes

– Modulatedcoughs>Baselinecoughs•  PEFR:Increasedupto50%•  CEV:Increasedupto100%

SummaryofFindings

•  TherewereclearlydifferentmechanismsbywhichHOAsandpeoplewithPDmodulatedreflexandvoluntarycough–  WhereasHOAsincreaseIVanddecreaseCPD;therewerenosignificantdifferencesinIVandCPDforpeoplewithPD

SummaryofFindings

Baseline Modulation

HOAs

PD

•  Duringmodulation,voluntarycough=reflexcoughforPEFRandCEV-  Mayhighlightdifferencesintaskexecution

-  Effort-  Stereotypicresponse

Discussion:Reflexvs.VoluntaryCough

*

*

•  TheresultsofthisresearchsuggestthatpeoplewithPD(andlikelyothers)areamenabletoup-regulationofreflexandvoluntarycoughfunctionviacueingstrategies

•  Certainlygivesusonemoretreatmenttargetfordystussia

•  Maycontributetoimprovedairwayprotectiveoutcomes

Discussion:Conclusions

•  Incentivespirometry•  Expandspulmonarytissuesandmay

promoteamoreevenbacterialkillduringrecovery

•  Forpatientswhocannottoleratemildexercise

•  Noresistance•  Peakexpiratoryairflowmeters

•  Inexpensive•  Proxyforcougheffectiveness•  Voluntaryonly

ClinicalImplicationsAcuteCare

•  Perceptualmeasures– Laciugaetal.,2015– UTC

•  CoughScreening– Heglandetal.,2016– ActiveNIHresearchinvestigatingtheutilityofFOGandcapsaicinfortheidentificationofdysphagiainneurodegenerativediseases

Research Opportunities for Cough Screening and Rehabilitation in PD• R21 Cough screening using FOG and capsaicin (Hegland et al., 2015)

– Currently have an R21 evaluating this in over 150 participants with PD – Provides free evaluation of swallowing function to participants

• Cough modulation with biofeedback (Brandimore et al., 2016 in review) – Improved PEFR and CEV in PD and HOA controls

• MJFox Novel Management of Airway Protection Disorders – Just received an MJFox grant to compare EMST and SMTAP in PD

ClinicalImplicationsAcuteCare

•  EMST–  PD–  Stroke– MS–  COPD

Treatment for Dysphagia/Dystussia in Stroke

• Results: – Increased maximum expiratory pressure – Increased cough airflow and effectiveness – Increased perceived magnitude of the UTC – Improved swallowing function

ClinicalImplicationsOutpatient

Treatment for Dysphagia/Dystussia in Stroke

• Results: – Increased maximum expiratory pressure – Increased cough airflow and effectiveness – Increased perceived magnitude of the UTC – Improved swallowing function

•  IMST– Rehabilitationprogramaimedtostrengthinspiratorymusclesanddecreaseworktobreathe

– Populations:asthma,emphysema,restrictivepulmonarydisorders,ventilatordependent

•  CoughBiofeedback– Verbal– Visual– Education– Frequency

ClinicalImplicationsOutpatient

ClinicalImplications:Procedures

•  Coughevaluation•  Voluntarysingleandsequentialcough

production•  ReflexcoughwithFOGorCapsaicin

•  AssessUTC•  Researchonly

•  VideofluoroscopicRehabBariumSwallowingevaluation•  Presentationsofbarium:thin,nectar,

pudding,andpill•  AssessmentofUTC

Evaluation

No Treatment Treatment

Compensatory

Swallow: Postural changes, diet modifications, PEG

Speech: Voice amp, prosthetics, environmental modifications (caregiver training), AAC (low and high)

Combined rehabilitation

and compensation

Rehabilitation

Cough: Preventative cough or throat clear during meals

Speech: LSVT, MPT, rate control therapy, IMST, ARCS, Lips, VNeST

Swallow: Masako, effortful swallow, Mendelsohn, Super-supraglottic, Shaker, EMST

Cough: UTC awareness training, cough modeling, biofeedback

Patient and caregiver counseling and education

Case 1: Corticobasal Syndrome History:June2018•  69year-oldfemalepresentstoyourclinicwithadiagnosisofCBSwith

symptomonsetinSpring2014(rightarmtremor).

•  Thepatientservesasprimaryhistorianandiswell-knowntotheclinic.

•  PMH=August2017:Ourevaluationsrevealedamoderatehypokineticdysarthriaandamoderateoropharyngealdysphagiacharacterizedbyconsistentpenetrationtothelevelofthevocalfoldswiththinliquids(PA=5),moderateresiduethroughoutmechanism,tonguepumping,andpre-swallowspillofallconsistenciestothepyriformsinuses.•  Atthattime,thechintuckwasunsuccessfulatimprovingairway

protection:severaleffortfulswallowswererequired.•  Thepatientbegantherapyatyourclinic:maximumperformance(i.e.

LSVT),traditionalswallowingexercises,andEMST.

Case 1: Corticobasal Syndrome

•  Todaythepatientreportsnochangesinsymptomstatus.•  Shehasnohistoryofpneumonia,dietmodifications,orweightloss.

•  However,sheisreportingcoughingwiththinliquids.

•  Sheisambulatory;howevernotesincreasedfallsresultinginabrokenleftelbow.

•  Thepatientbelievesthattherapywashelpful,buthaslostherEMSTdeviceandisnolongerperformingexercises.

Case 1: Parkinson’s disease Let’swatch…

Case 1: Swallowing Evaluation Pleaserateyoururge-to-cough

0 Noneatall1 Veryslight2 Slight3 Moderate4 Somewhatsevere5 Severe(heavy)67 Very,verysevere8910 Very,very,verysevere(almostmaximal)

UniversityofFloridaLaboratoryforthestudyofUpperAirwayDysfunction

CoughAssessment


Case1Results:Cough

420-2

AirflowL/S

0 0.5 1.0 1.5 2.0 2.5 3.0 3.5

Voluntarysequentialcough

PEFR=1.9L/secCPD=0

PulmonaryFunction: ExpectedPerformance Patient'sPerformance(45%) FVC 3.34 1.53 PEF 6.28 3.49 FEVI 2.57 1.33

Case 1: Results Results:Speechevaluation–Moderate-severehypokineticdysarthria(previouslymoderate)Swallowingevaluation–Advancedtomoderate-severeoropharyngealdysphagia.Characterizedbyintermittentsilentaspirationwiththinliquids(PA=8),andconsistentpenetrationtothevocalfolds.Thepatientwascuedtocough;however,coughwasineffectivetoclearmaterialfromairway.UTC=0.Coughevaluation–Ineffectivevoluntarycoughproduction.PEFR=1.9L/secofpredicted5L/sec

Case 1: Treatment Plan Treatmentplan:Speech:MPTandratecontroltherapy

Swallowing:EMST,andswallowingexercisesMasako,effortfulswallow,Mendelsohn,super-supraglottic,etc.

Cough:Coughmodeling/biofeedback

Compensations:1.)Temporarilydown-gradetonectar-thickenedliquids2.)Smallbites/sipsofsolids/liquids3.)Chewfoodthoroughly4.)Maintaingoodoralhygiene5.)Produceapreventativecoughfollowedbyaneffortfulswallowwhenmaterialissensedneartheairway.

Case 1: Progress •  Thepatientre-initiatedtherapyatourclinic

andhasreceived5sessions(~once/2weeks).Sheremainsmotivated.

•  Additionally,sheparticipatesinPTanda

danceclassofferedonThursdaynights.

•  ImprovedcoordinationandefficiencywithEMSTandswallowingexercises

•  Coughremainsineffective,butimproved

abilitytoproducevoluntarycoughoncommand

Case 2: Parkinsonism History:May2018•  70year-oldmalepresentstoyourclinicwithadiagnosisofPDwith

symptomonsetin2008.

•  Thepatientandhiswifeprovidehistory.

•  PMH=July2017:Ourevaluationsrevealedamoderatehypokineticdysarthriaandamoderateoropharyngealdysphagiacharacterizedbyintermittentpenetrationtothelevelofthevocalfoldswiththinliquids(PA=5),andintermittentsilentaspiration(PA=8)withmoderate-severeresidueinthevalleculaeandmoderateresidueinthepyrifromsinuses,tonguepumping,andpre-swallowspillofallconsistenciestothepyriformsinuses.•  Chintuck,effortfulswallowanddryswallowweresomewhat

successfultoatimprovingairwayprotection•  Thepatientbegantherapyatyourclinic:Traditionalswallowing

exercises,andEMST.


Case2:History•  Todaythepatientreportsmaintenanceofswallowingfunction.

•  However,heacknowledgesrandomcoughingandchokingduringmealswithfatigue,hasmodifieddiettoincludesofterfoods,andcomplainsofawetvocalquality.

•  Hehasnohistoryofpneumoniabutnotesa23poundweightlossoverthelastyear.

•  Thepatientbelievesthattherapywashelpful,buthaslosthisEMSTdeviceandisnolongerperformingexercises.


Case2:SwallowingQOLEAT-10SurveyEAT-10Score:21/401.Myswallowingproblemhascausedmetoloseweight:22.Myswallowingprobleminterfereswithmyabilitytogooutformeals:33.Swallowingliquidtakesextraeffort:24.Swallowingsolidstakesextraeffort:25.Swallowingpillstakesextraeffort:36.Swallowingispainful:27.Thepleasureofeatingisaffectedbymyswallowing:38.WhenIswallow,foodsticksinmythroat:19.IcoughwhenIeat:010.Swallowingisstressful:3

Case 2: Cough Results

6420-2

AirflowL/S

0 0.5 1.0 1.5 2.0

Voluntarysequentialcough

Voluntarycoughevaluation:PEF=2L/secWhatcanwesayabouttheoverallorganizationofcough?


Case2Results:Swallowing


Case2:ResultsResults:Swallowingevaluation:Moderate-severesensorimotororopharyngealdysphagiaconsistentpenetrationandsilentaspirationtothelevelofthevocalfoldswiththinliquids(PA=8),reducedaspirationwithnectar-thickenedliquids,moderate-severevallecularresidueandmoderatepyrifromsinusresidue.Urgetocoughassociatedwithswallowing(UTC=2).Coughevaluation:Extremelyineffectivevoluntarycough=1.9L/secofexpected.


Case2:TreatmentTreatmentPlan:ClosertohomeAssessreflexcoughonre-evaluationRec:Softsolidsdietwithnectar-thickenedliquids,smallbitesandsipsRe-initiatebehavioralexercisestoinclude:effortfulswallowandMasakoandEMSTCoughmodelingandbiofeedbackCounselregardingUTCandthenecessityofproducingacoughContactthetreatingclinician

airway protection: clinical management of dysphagia and ... · dysarthria and a moderate...

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