Transcript Chronic Obstructive Pulmonary Disease And Its Affect On Deglutition

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Global Initiative for Chronic Obstructive Lung
Disease (GOLD) definition:
◦ common, preventable, & treatable
◦ usually progressive & associated with persistent
airflow limitation
◦ chronic inflammatory response in the airway &
lungs to noxious particles or gasses
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Chronic Obstructive Pulmonary Disease
(COPD) is typically expressed in 2 ways:
◦ Emphysema
◦ Chronic Bronchitis
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Smoking is the number one cause
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Other causes include secondhand smoke
certain gases or fumes, pollutants, and
physical structural defects that affect
pulmonary function.
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8 million physician office visits (in 2000)
1.5 million ER visits (in 2000)
726,000 hospitalizations (in 2000)
Affects 14 million people in the US (in 2002)
Leading cause of morbidity and mortality
worldwide, resulting in substantial and
increasing economic and social burden
(GOLD, 2011)
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Complications:
◦ discoordination of the oral and pharyngeal
swallowing stage
◦ impaired coordination of respiration and
deglutition could contribute to increased
exacerbations and aspiration
◦ Trademark symptom: dyspnea
Exhale-swallow-exhale preferred by
normal adults
 Altered swallow in COPD in which the
inhalation occurs after the swallow could
be dangerous
 Studies found that participant risk for
aspiration was greater due to the negative
pressure of inhalation
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COPD participants swallowed food during
inhalation more and inhaled more quickly
after swallowing semi-solid material than
control group
In another study, COPD participants had
higher resting respiratory rates during 5mm
swallows in upright and supine positions
They found increase resp. rate = increase
number of swallows
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Increased mastication,
increased resp. rate and
rhythm during chewing
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Could cause air hunger
and likelihood of inhalation
during swallow
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Delayed pharyngeal
response, decreased
tongue retraction, reduced
laryngeal elevation
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Residue in the
oral/pharyngeal cavity
could lead to aspiration
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Increase the risk of
aspirating on inhalation
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The increased risk from air
hunger during prolonged
chewing times + common
co-occuring oropharyngeal
dysphagia in COPD = higher
risk of aspiration
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Increased fatigue,
incoordination, weakness
of upper aerodigestive tract
musculature, & sensory
impairment
Increased inspiration after
liquid swallow and
increased apneic pause
duration
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Suggested functional abnormalities
predisposing patients to penetration/aspiration
(Cvejic, et al.)
◦ Reduced laryngeal elevation with delayed laryngeal
closure
◦ Reduced hyoid elevation, post swallow penetration,
and oxygen desaturation
◦ Reduced laryngo-pharyngeal sensation
◦ Impaired pharyngeal clearance
◦ Cricopharyngeal dysfunction
◦ GERD
◦ Tachypnoea
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Exacerbations typically include an increase in:
◦ dyspnea, sputum, purulence
◦ negative effects on respiration and
swallowing
• Cyclical affect; inflammation – increased
dyspnea – aspiration – pneumonia – COPD
exacerbation
◦ Patients with dysphagia have greater than 7times chance of acquiring aspiration pneumonia
(if found to aspirate during an MBSS) ( MartinHarris et al., 2012)
◦ Patients who aspirate thickened liquids or
semisolids, the likelihood that they will perish
increased by greater than 9 times
◦ The most significant risk factor for aspiration
pneumonia in nursing home patients was
determined to be COPD (Gross et al., 2009)
◦ Top 3 Expectations from Patients
1. breathe
2. walk (including up stairs)
3. manage shortness of breath
Inhaled corticosteroids
Long-acting
bronchodilators and
Theophyllines (relaxes &
opens restricted bronchi)
 Phosphodiesterase
inhibitors (relaxes blood
vessels)
 Mucolytics (dissolves
mucous)
 Current vaccinations
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(Mackay & Hurst, 2012)
Home oxygen
 Ventilator support
 Pulmonary
rehabilitation
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(American Thoracic Society-European
Respiratory Society, Casaburi &
Wallack, 2009)
◦ Lung volume reduction surgery
 Been shown to increase exercise
endurance (Fishman, et al., Mackay & Hurst, 2012)
◦ Cricopharyngeal myotomy
 Trials have improved swallowing &
complete or semi-reprieve from
respiratory exacerbations (Stein et al., 1990)
• Smaller, more frequent
meals at least fatigued
time of day
• Nutritional and
convenient snacks
• Increasing calories of
meals
• Caution with medication
that cause nausea
• Recommend continued
use of oxygen and
monitoring oxygen
saturation during meals
for those on long term
oxygen
(Martin-Harris, 2000, p. 315)
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Smoking cessation
Sleep study to evaluate
appropriateness of CPAP
machine
Caution against risky
environments that may be
detrimental to health
Pulmonary rehabilitation
and education
Encourage early recognition
and self management
Exercise programs
(McKinstry, Tranter & Sweeney, 2010)
◦ Protect airway using chin tuck
◦ Increase oral transit with 60 degree recline posture
(take precautions that increased apnea does not result
from these techniques) (Martin-Harris, 2008)
◦ Manage xerostomia by alternating sips and bites to
clear residue and/or recommending medication to
replace saliva (Martin-Harris, 2000)
◦ Swallowing twice to decrease the amount of residue
◦ Patients with laryngeal penetration during sequential
swallows decrease liquid bolus size to 10 ml and
discontinue sequential swallowing. (Martin-Harris, 2000).
◦ Remain upright after eating and elevating the head of
the bed to reduce GERD
◦ Small amount of literature available definitively
proving the risk of aspiration associated with
discoordinated breathing and swallowing
◦ There is sufficient evidence that COPD patients
are inclined to swallowing disorders and
predisposed to aspirate
◦ 400,000 deaths per year in developed countries
warrant more development into this area of
dysphagia research
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