HOW YOU BREATHE MATTERS: 10/27/2010 SWALLOWING SAFELY

HOW YOU BREATHE MATTERS: SWALLOWING SAFELY

Presenter

Gail M. Sudderth, RRT Clinical Specialist Passy‐Muir, Inc. (800) 634‐5397 (949) 833‐8255

Course Objectives

• Describe normal aerodigestive physiology and common swallowing issues diagnosed in the tracheostomized and ventilator dependent population and recognize clinical symptoms placing patients at risk for swallowing problems, including aspiration.

• Discuss the role of subglottic pressure and the timing of the swallow during the respiratory cycle and how this is affected by the placement of a tracheostomy tube.

• List goals and formulate a treatment plan utilizing the Passy- Muir® Valve and team approach for diagnosis and treatment of common issues facing the tracheostomized ventilator patient.

Passy‐Muir Inc. 1 HOW YOU BREATHE MATTERS: 10/27/2010 SWALLOWING SAFELY

Outline

• What is Normal ? • Respiration & Swallowing: A Shared System • - Aspiration • Interruptions to Normal Breathing Patterns • Complications of a Tracheostomy Tube • The role of the Passy-Muir® Valve in dysphagia treatment • Treatment Plans • Importance of the Team Approach • Q & A

Normal Respiration

• CNS control

– Responds to changes in CO2 – stem, Medulla & , Phrenic & Thoracic nerves • Muscles of respiration – Diaphragm – Intercostal – Abdominal • Pressures and Inspiratory Flow • Compliance, Resistance and Lung Recoil

Normal Respiration

Passy‐Muir Inc. 2 HOW YOU BREATHE MATTERS: 10/27/2010 SWALLOWING SAFELY

Lung Volumes and Capacities

Normal Swallow

• Anatomy • Mechanical • Pressure Driven • Airflow • Phases of swallow • Timing of swallow

ANATOMY OF SWALLOW

• Nasal Cavity Nasal Cavity • Oral Cavity • Oral Cavity • • Pharynx

Larynx

Esophagus

Passy‐Muir Inc. 3 HOW YOU BREATHE MATTERS: 10/27/2010 SWALLOWING SAFELY

MECHANICS OF A SWALLOW

• Phases of swallow – Anticipatory – Oral Preparatory – Oral – Pharyngeal – Esophageal

Subglottic Pressure: Role in Swallow

• Positive Pressure- Subglottic – Lung recoil: pressure increases

• Negative pressure- Esophageal – Opening of UES: pressure decreases

Timing of Swallow

The usual pattern in healthy adults is to time swallows to occur at mid-exhalation. Healthy individuals also nearly exclusively follow each swallow with exhalation. This pattern assures there is sufficient air pressure below the vocal folds during a swallow to inhibit aspiration of food residue after the swallow. Inhale - Exhale – Swallow – Exhale Inhale – Swallow - Exhale

Dr. Roxann Diez Gross 2009

Passy‐Muir Inc. 4 HOW YOU BREATHE MATTERS: 10/27/2010 SWALLOWING SAFELY

Timing of Swallow

In natural tasks such as cup , the onset of breathing cessation seemed to be variable. When instructed to take a cup and bring it to their , many patients discontinue breathing well before it reaches the lips.

Dr. Bonnie Martin-Harris 2007

Timing of Swallow-Lung Volumes

Breathing and Swallowing: A Shared System

• Anatomy • Timing • Pressures • CNS Control

• Dysphagia – difficulty swallowing • Aspiration – any material that penetrates below the level of the vocal folds.

Passy‐Muir Inc. 5 HOW YOU BREATHE MATTERS: 10/27/2010 SWALLOWING SAFELY

Disruption to Normal Breathing Patterns

• Illness – Neuromuscular – COPD – Restrictive disease • Medications • Tracheostomy • Mechanical Ventilation

Dysphagia & Aspiration Risk

• AGE • ILLNESS • ARTIFICIAL AIRWAY – TRACH TUBE • Tube size and type • Cuff • Airflow • Laryngeal tethering • Reduced airway protection • Loss of positive airway pressure • Disuse atrophy • MECHANICAL VENTILATION

Clinical Complications: Inflated Cuff

• Over-inflated cuff • Cuff affect on aspiration

Passy‐Muir Inc. 6 HOW YOU BREATHE MATTERS: 10/27/2010 SWALLOWING SAFELY

Documentation of Aspiration

• Diagnostic tools • Bedside evaluation-Blue Dye (?) • FEES • MBS

• Signs and Symptoms of Aspiration • Wet sounding voice • Drooling • Multiple swallows • Coughing while • Recurrent RLL pneumonia

FEES vs. MBS

Treatment Plan: A Team Approach

Co-treatment Strategies

Passy‐Muir Inc. 7 HOW YOU BREATHE MATTERS: 10/27/2010 SWALLOWING SAFELY

Shared Goals – RCP & SLP

• The Patient Will : – Communicate – Manage secretions – oral and tracheal – Tolerate cuff deflation – Swallow without signs or symptoms of aspiration – Participate in weaning and rehabilitation efforts – Be liberated from continuous mechanical ventilation – Decannulate

Benefits of the Passy-Muir® Valve

• Restores normal physiology-reconnects the upper and lower airway & closed system – Airflow – Positive airway pressure – Laryngeal movement & – Airway closure – Is “physical therapy” for the upper airway (Burkhead 2004)

Compensatory and Treatment Strategies

The Role of the Passy-Muir® Valve

Passy‐Muir Inc. 8 HOW YOU BREATHE MATTERS: 10/27/2010 SWALLOWING SAFELY

Clinical Benefits of Passy-Muir® Valve Use

• Restoration of normal physiology and improved: – Speech and communication – Secretion management – Taste and smell – Oxygenation, reduce atelectasis – Swallow and may reduce aspiration – Participation in rehab (Massery 2010) – Weaning and decannulation time – Infection control – Quality of life

Compensatory & Treatment Strategies

• To improve swallow the SLP might suggest : • Cuff deflation and Passy-Muir® Valve use • Modifications in diet • Textures • Meeodthod of eaeag/dting/drinking • Posture or position during and after eating • Timing of the swallow • Strengthening maneuvers • Mendlesohn, Shaker Head-Lift, • Inspiratory and/or Expiratory muscle training How does this involve the RCP?

Co-treatment: SLP & RCP

• Mechanical ventilation & Passy-Muir® Valve in-line – The RCP can make necessary ventilator modifications to enhance Passy-Muir® Valve tolerance and ability to perform treatment modalities. (I-time, RR, Volume)

– The SLP can cue the patient and perform and or assist with treatment or compensatory strategies during mechanical ventilation. (Swallow, I/E muscle training)

– Co-treatment, collaborative reassessment and care planning as warranted enhances the rehab experience for the patient.

Passy‐Muir Inc. 9 HOW YOU BREATHE MATTERS: 10/27/2010 SWALLOWING SAFELY

Co-treatment

• Swallowing during • EMT during mechanical mechanical ventilation ventilation

Conclusion: How You Breathe Matters

• There is likely an “interactive cooperation” between swallowing and respiration. (Gross 2009)

We have a resppyonsibility as Health Care Practitioners to co-operate and take a team approach in the assessment and treatment of tracheostomized and mechanically ventilated patients.

Questions?

Gail M. Sudderth, RRT Clinical Specialist Passy‐Muir, Inc. (800) 634‐5397 (949) 833‐8255

Passy‐Muir Inc. 10 HOW YOU BREATHE MATTERS: 10/27/2010 SWALLOWING SAFELY

Resources

• Perspectives on Swallowing and Swallowing Disorders (2009) Vol. 18, No. 1, pp 1-41. March 2009 • Wheeler K, Huber J, Sapienza C.(2009) Lung Volumes During Swallowing: Single Bolus Swallows in Healthy Young Adults. Journal of Speech, Language and Hearing Research, Vol. 52; p 178- 187 • Martin-Harris B. (2007) Advance Vol. 17, Issue 34, page 6

Resources

• Gross RD, Atwood CW, Grayhack JP, Shaiman S. (2002) Lung volume effects on pharyngeal swallow physiology. Journal of Applied Physiology, 95: 2211-2217.

• Gross RE, Atwood CW, Ross SB; et al. (2009) The coordination of breathing and swallowing in COPD. American Journal of Respiratory and Critical Care Medicine, 179 (7): 559-565.

Resources

• Burkhead L, Sapienza C, Rosenbek, J. (2007) Strength training exercise in dysphagia rehabilitation: Principals, procedures and direction for future research. Dysphagia, 22, 251-265. • Massery, M. (2010) Breathing and Upright Posture: Simultaneous Needs. 28th International Breathing Symposium. • Hagins M. et al. (2004) The effects of breathing control on intra-thoracic pressure during lifting tasks. Spine; 29(4): 464-469.

Passy‐Muir Inc. 11