Pulmonary 101 Respiratory Diagnosis and Dysphagia Part 1

1. Pulmonary 101Respiratory Diagnosis and DysphagiaPart 1 Carol G. Winchester BEST Dysphagia Management Services, Inc. 888-592-BEST

2. Respiratory System The respiratory system is the body system responsible for breathing. lungs and a series of tubes and passageways ­that allow air into and out of the body. The respiratory system helps sustain life by bringing oxygen, essential for life, to the body’s cells, while at the same time getting rid of carbon dioxide, a waste product. The respiratory system is divided into two parts: Upper respiratory tract. This includes the nose and throat (pharynx) Lower respiratory tract. This includes voice box (larynx) and the windpipe (trachea) bronchi and lungs.

3. Lungs

4. Upper Respiratory Tract

5. Lower Respiratory Tract

6. Gas Exchange During respiration, three gases are exchanged between the atmosphere and the body: oxygen, carbon dioxide nitrogen. The respiratory system combines with the circulatory system (the heart and blood vessels) to help deliver life–giving oxygen to the cells of the body. There are three primary functions of the respiratory system: To bring oxygen into the body when a person inhales To eliminate carbon dioxide from the body when a person exhales To help maintain body fluids at a stable acid–base balance.

7. Respiratory System The respiratory system is uniquely designed to extract oxygen from ambient air and remove waste gases from the body. The exchange surface must efficiently: Exchange gasses Defend against environmental assaults such as irritants, and infection. Gases have to be exchanged between air and an aqueous environment. Respiration occurs automatically but can be voluntarily controlled.

8. How Do We breathe? Air enters through the nose nasal hairs remove large particles from inspired air. Swell body on the nasal fossae swells and decreases the flow of air on that side. Happens every 20-30 minutes on one side or the other thus allowing the respiratory epithelium to recover from desiccation. Allergic reactions and infections can cause abnormal enlargement obstructing airflow The structures of the nose, mouth and pharynx act to warm and moisten the air From the larynx, air is conducted through the trachea, bronchi, and bronchioles Air finally reaches the thin membranes of the alveoli Gas Exchange occurs through the alveoli.

9. The Role of the Diaphragm The diaphragm is the primary muscle of inspiration. Thin, dome-shaped sheet of muscle that inserts into the lower ribs. When it contracts, it pushes downward and spreads out, increasing the vertical dimension of the chest cavity- driving up abdominal pressure. Increase in pressure drives the abdominal contents down and out, increasing the transverse size of the chest cavity.

10. How the Diaphragm Works Because the diaphragm is covered by the inferior surface of the parietal pleura, when it contracts it pulls the pleura with it. This lowers the pleural pressure, which causes the alveolar pressure to drop, which, in turn, causes air to flow into the lungs. During quiet expiration, the diaphragm passively relaxes and returns to its equilibrium position. During exercise, expiration becomes an active process-- the abdominal muscles contract to raise abdominal pressure, which pushes the diaphragm upward and forces air out of the lungs. During quiet breathing, the diaphragm moves a centimeter or two up and down, but during exercise, it can move more than 10 cm. The diaphragm is supplied by the phrenic nerve from cervical segments 3,4, and 5.

11. Respiration Rate At rest a person breathes 12-15 times per minute, 500 ml per breath and therefore 6--8 L/min is inspired and expired. Each minute, 250 ml of oxygen enters the body and 200 ml of CO2 is excreted. Some 250 different volatile substances have been found in human breath.

12. Our Lungs Our lungs allow us to breath and get oxygen into the bloodstream and the cells of our bodies. During a normal day, we breathe nearly 25,000 times, and take in (or inhale) large amounts of air. The air we take in is mostly oxygen and nitrogen. Air also has things in it that can hurt our lungs - bacteria, viruses, tobacco smoke, car exhaust, and other air pollutants.

13. Diseases of the Lungs Grouped according to how they affect the lungs. Limit or block flow of air in or out of the lung Asthma, chronic bronchitis, emphysema, and cystic fibrosis. Problems with the normal gas exchange and blood flow in the lungs. Respiratory failure, pulmonary edema, pulmonary embolism, and pulmonary hypertension (high blood pressure). Bacteria or viruses can cause these diseases that affect the membrane (or pleura) that surrounds the lungs Pneumonia and tuberculosis (TB).

14. Lung Diseases, cont. Lung cancer. The number one cause of lung cancer is smoking. Stiffening and scarring of lungs. The spaces between the tissues of the lungs (called the interstitium) can become stiff and scarred. Caused by drugs, poisons, infections, or radiation. Lung disorders from unusual atmospheric pressure. Atmospheric pressures that are not typical can cause lung disorders, or lung problems. This includes high altitudes (like in the mountains) where the air has less oxygen, or deep water where there is more atmospheric pressure and higher nitrogen levels in the blood.

15. The Research Supports Looking More Closely….. Normal laryngeal valving patterns during three breath-hold maneuvers: a pilot investigation.Martin BJ, Logemann JA, Shaker R, Dodds WJ.Department of Communication and Swallowing Disorders, Saint Joseph's Hospital, Atlanta, Georgia 30342-1701.Synchronized videonasendoscopy and respiratory recordings were conducted in six healthy male subjects to evaluate activity of the arytenoid cartilages, true vocal folds, false vocal folds, and epiglottis during repeated trials of three breath-hold maneuvers: EASY hold, INHALE HARD hold, and INHALE/EXHALE HARD hold. Five of the six subjects demonstrated maximal laryngeal valving on the HARD breath-hold conditions. One subject showed maximal laryngeal valving on the EASY hold condition, and rarely demonstrated any medial displacement or contact of the laryngeal valves on either effortful breath-hold maneuver. Arytenoid approximation and true vocal fold closure were produced consistently by the majority of subjects on all breath-hold maneuvers, but false vocal fold approximation and anterior arytenoid tilting were accomplished by the majority of subjects only during the effortful breath-hold conditions. Intratrial and intersubject variation indicated that presence or degree of laryngeal valving cannot be assumed during a breath-hold maneuver. We conclude that videonasendoscopy has merit in assessing a patient's laryngeal valving ability and progress in effectively using a breath-hold maneuver for safe swallowing function.PMID: 8436017 [PubMed - indexed for MEDLINE]

16. The Research Supports Looking More Closely…… Phasic Vagal Influence on the Rate and Timing of Reflex Swallowing” Fumiko Yamamoto and Takashi Nishino Department of Anesthesiology, Graduate School of Medicine, Chiba University, Chiba, Japan “The swallowing reflex is probably the most complex "all or none" reflex that involves the coordinated contraction of several muscles in the mouth, upper airway, and esophagus. Respiration and swallowing cannot coexist because both behaviors use a common passageway, and therefore, the two activities must be coordinated so that mutual compromise does not occur. A high degree of coordination between respiration and swallowing is essential for the maintenance of adequate ventilation without causing pulmonary aspiration, particularly during repeated swallows. Although changes in swallowing pattern may change respiratory patterns and vice versa, much attention has been paid to the effects of swallowing on respiration in previous studies (1–6) and less information is available as to the effects of respiration on swallowing. “ “In a previous study (7) we showed that lung inflation has an inhibitory influence on the swallowing reflex and modulates the timing of swallowing. Assuming that lung inflation stimulates vagal receptors in the airways, it is possible that vagally mediated reflexes play an important role in the control of reflex swallowing. If these reflexes are operative in normal physiologic situations, a sudden change in ventilation would promptly alter the frequency and timing of reflex swallowing. “ “In the present study, we examined the effect of sudden changes in ventilation induced by voluntary hyperpnea and breath-holding on repetitive reflex swallowing elicited by continuous infusion of distilled water into the pharynx. In these experimental settings, we reasoned that voluntary hyperpnea would augment the effect of vagally mediated reflexes, whereas breath-holding would attenuate the reflex effect. “

17. What Causes Lung Disease? Smoking. Being around second-hand smoke also increases your chances of getting lung disease. Bear in mind that smoking includes not just cigarettes, but cigars and pipes as well. Exposure to radon gas. Radon, a gas that occurs in the soil and rocks, can damage the lungs, which may lead to lung cancer. People who work in mines may be exposed to radon, and in some parts of the U.S., radon is found in houses.

18. What Causes Lung Disease? Asbestos. Asbestos is natural fiber that comes from minerals. The fibers tend to break apart easily, into small particles that can float in the air and stick to clothes. When a person inhales these particles, they can stick in the lungs, damage cells, and lead to lung cancer. Pollution. Research shows a link between lung cancer and certain air pollutants, such as car exhaust. More studies are needed to find out if pollution causes lung cancer. Some lung diseases, such as tuberculosis (TB), put a person more at risk for lung cancer. Lung cancer tends to develop in the areas of the lung that are scarred from TB.

19. How do we swallow? Oral Preparatory PhaseTake the food or liquid into your mouth and prepare to swallow it. Chew the food and mix the food with saliva until it is a safe consistency to swallow. Teeth are used to chew and grind food to a soft consistency. Lips seal closed to keep the food in your mouth. Cheeks can tighten up if needed to help keep the food on the teeth for chewing. Tongue is extremely important to move the food around your mouth to keep it on the teeth for chewing and to mix it with saliva for swallowing. Oral preparatory phase of the swallow is under your purposeful control for the most part. Lasts varying lengths of time, depending on how much chewing you need to prepare the food to swallow.

20. Oral Phase of the Swallow Once the food is adequately chewed, mixed with saliva, and of the right consistency, the preparatory phase ends and the actual oral swallow begins. Tongue collects all the food from around your mouth, forms it into a little ball, or bolus on the top of your tongue, and pushes it to the back of your mouth. Once the bolus reaches the back of the mouth, the tongue gives it a final push into the throat. Hard and soft palates in your mouth provide resistance for the tongue to push against as it works the bolus to the back of the mouth. The soft palate also lifts up and closes off the nasal passage temporarily to prevent food and liquid from going up into your nose. The oral phase of the swallow lasts only about one second. It is a patterned motor program, but is something that you can purposefully control to a large degree.

21. Pharyngeal Phase Bolus moves from the mouth, down the throat, and enters the esophagus. The most important part of this phase of the swallow is that the airway is momentarily closed off to prevent the bolus from entering the trachea and causing you to choke. Airway protection is accomplished by the larynx lifting up in the throat, the vocal cords closing like a trap door, and the epiglottis flipping down over the airway like a lid. The base of the tongue, the walls of the pharynx, and the muscles of the larynx are all very important to move food through the throat and to protect the airway. The pharyngeal phase is very rapid and lasts only a second. It is a patterned response; some even call it a reflex although you can at times exert some degree of influence over the swallow at this point.

22. Esophageal Phase The esophageal phase of the swallow starts when the bolus enters through the upper esophageal sphincter and lasts until the bolus has traveled all the way down the esophagus into the stomach. This take a relatively long time for solid foods, several seconds at least. The muscles of the esophagus contract in a distinct pattern to propel the food from the top to the bottom of the esophagus. You have very little control over this phase

23. Descending into the pharynx Explain the anatomy on these slides and how the scope goes in through the nose, and then aims down into the pharynx, like opening up the lions mouth and sticking your head in and looking down.Explain the anatomy on these slides and how the scope goes in through the nose, and then aims down into the pharynx, like opening up the lions mouth and sticking your head in and looking down.

24. Viewing the laryngeal vestibule Identify the anatomy..and explain how when you swallow, you hold your breath..the cords come together, the false cords come together, and the epiglottis retroverts to close over the airway….ie identifying the three levels of protection against food and liquid going into the airway. Identify the anatomy..and explain how when you swallow, you hold your breath..the cords come together, the false cords come together, and the epiglottis retroverts to close over the airway….ie identifying the three levels of protection against food and liquid going into the airway.

25. Spillage of milk to vallecular space Transit into the pharynx is vital to identifying the potential risk factors associated with swallowing. Here you can see the milk, dyed green,falling down from the mouth into the vallecular space. The function of the epiglottis is to keep that milk out of the airway as it transits to the left or to the right to fall down into the pyriforms.Transit into the pharynx is vital to identifying the potential risk factors associated with swallowing. Here you can see the milk, dyed green,falling down from the mouth into the vallecular space. The function of the epiglottis is to keep that milk out of the airway as it transits to the left or to the right to fall down into the pyriforms.

26. Spillage of milk to pyriforms The pyriforms are like two bucket like pockets on either side of the laryngeal vestibule that hold the food or liquid until the swallow is initiated. The aryepiglottic folds act like dams to keep it out of the airway. Here you can see the borders of the laryngeal vestibule ( name the structures for ID again)The pyriforms are like two bucket like pockets on either side of the laryngeal vestibule that hold the food or liquid until the swallow is initiated. The aryepiglottic folds act like dams to keep it out of the airway. Here you can see the borders of the laryngeal vestibule ( name the structures for ID again)

27. Milk builds up in the pyriforms Food or liquid that sits in the pyriform spaces for more than a few seconds increases the risk that it will become a problem. You can see how as the milk continues to fall, it builds up. Depending on how big, or deep a patient’s pyriform space is, they may or may not be able to handle it. Anatomy is so different on everyone . Endoscopy allows you to add that information to your risk prediction and better identify consistencies and techniques. Food or liquid that sits in the pyriform spaces for more than a few seconds increases the risk that it will become a problem. You can see how as the milk continues to fall, it builds up. Depending on how big, or deep a patient’s pyriform space is, they may or may not be able to handle it. Anatomy is so different on everyone . Endoscopy allows you to add that information to your risk prediction and better identify consistencies and techniques.

28. Aspiration occurs as milk spills into the laryngeal vestibule and airway When the amount of liquid exceeds the storage capacity pre-swallow, it falls over the aryepiglottic folds and into the glottis. Note the bubbling at the glottis as air escapes and it is aspirated. Most aspiration happens before or after the swallow, as the breakdown in timing and coordination occurs.When the amount of liquid exceeds the storage capacity pre-swallow, it falls over the aryepiglottic folds and into the glottis. Note the bubbling at the glottis as air escapes and it is aspirated. Most aspiration happens before or after the swallow, as the breakdown in timing and coordination occurs.

29. Anatomical Review of the Swallow View is endoscopic Liquid dyed green for easier viewing Airway compromise results in aspiration

30. Dysphagia Definition

31. Therapeutic Considerations Respiratory Function Impaired Will the therapeutic techniques be a strain to an already compromised respiratory system? Will the Patient be able to tolerate repetitive motions or movements without fatigue? Is the respiratory treatment contradictory to your dysphagia recommendations? Lets now look at what questions we need to ask ourselves when we identify a system that is contributing to the dysphagia. Ask whether the therapeutic technique will fatigue the patient. Remember that it takes holding your breath 1-2 seconds in order to swallow. Try to swallow your saliva , and note how long you hold your breath to transit it through your pharynx. Will your techniques cause them to just get tired, increasing the risk for complications? Do you need to think about your techniques and recommendations in the evening versus first thing in the morning? Respiratory treatments: Think about what they are intended to do. They are intended to think out secretions so that they can be expelled from the lungs. In order to expel them, they come up from the lungs, into the pharynx, and must be either swallowed or spit out. The residue in the pharynx then can mix with a thickened liquid and thin it out. In addition, the bubbling, or frothy foam of the secretions very often fills up the pharynx, making swallowing the food and liquid from a meal difficult. Discuss the timing of the treatments with nursing.Lets now look at what questions we need to ask ourselves when we identify a system that is contributing to the dysphagia. Ask whether the therapeutic technique will fatigue the patient. Remember that it takes holding your breath 1-2 seconds in order to swallow. Try to swallow your saliva , and note how long you hold your breath to transit it through your pharynx. Will your techniques cause them to just get tired, increasing the risk for complications? Do you need to think about your techniques and recommendations in the evening versus first thing in the morning? Respiratory treatments: Think about what they are intended to do. They are intended to think out secretions so that they can be expelled from the lungs. In order to expel them, they come up from the lungs, into the pharynx, and must be either swallowed or spit out. The residue in the pharynx then can mix with a thickened liquid and thin it out. In addition, the bubbling, or frothy foam of the secretions very often fills up the pharynx, making swallowing the food and liquid from a meal difficult. Discuss the timing of the treatments with nursing.

32. Therapeutic Considerations Muscular Function Impaired Will the patient be able to perform the compensatory techniques repeatedly? Will fatigue increase the risk? Will the patient suffer from muscle aches and pains as a result of the exercises or techniques? Will medications increase dis-coordination or fatigue of the muscles? A good rule of thumb here is to try your compensatory techniques yourself. If you cannot tolerate the repetitive exercises, IE if they make you tired or sore, then think about how your patient feels. Do some research. Find out about massage, brushing, icing, thermal stim, and exercise combined to make good use of the time you have to work on increasing muscle function. Ask about meds for Parkinson’s, MS, etc, and find out if it is increasing or decreasing the muscle’s ability to coordinate movements. Are they contradictory to your exercise program? Ask those questions .A good rule of thumb here is to try your compensatory techniques yourself. If you cannot tolerate the repetitive exercises, IE if they make you tired or sore, then think about how your patient feels. Do some research. Find out about massage, brushing, icing, thermal stim, and exercise combined to make good use of the time you have to work on increasing muscle function. Ask about meds for Parkinson’s, MS, etc, and find out if it is increasing or decreasing the muscle’s ability to coordinate movements. Are they contradictory to your exercise program? Ask those questions .

33. Therapeutic Considerations Neurological Function Impaired Have you considered the risks of reduced sensation in the mouth, pharynx, or esophagus on safety? Does thermal or tactile stimulation increase patient awareness and safety? Does fatigue affect the effects of thermal or tactile stimulation? How does medication affect the neurological function of the swallow? You are going to want to be asking the same kinds of questions about loss of feeling or sensation in the mouth or pharynx. Look into the diagnosis that might signify loss of sensation. Try some thermal or tactile stimulation techniques and see if they help to stimulate awareness. Watch for fatigue, as as the patient tires, their ability to identify sensation may decrease. Watch too for medications, as the effects of medications can mimic loss of sensation.You are going to want to be asking the same kinds of questions about loss of feeling or sensation in the mouth or pharynx. Look into the diagnosis that might signify loss of sensation. Try some thermal or tactile stimulation techniques and see if they help to stimulate awareness. Watch for fatigue, as as the patient tires, their ability to identify sensation may decrease. Watch too for medications, as the effects of medications can mimic loss of sensation.

34. Therapeutic Considerations Cognitive Function Impairment Does the patient realize what the risks of dysphagia mean to him/her? Have you included, in your therapy plan, the cognitive ability to understand the risks, relearn safety techniques, and make good judgments? What effect does medication have on cognitive ability? Cognition is vital to the success of dysphagia treatment. Having at least one cognitive goal for your dysphagia is important when the patient has the ability to improve understanding of the following: Review above Remember: those medication sheets are so important in understanding the abilities and potentials that your patient has. Ask the questions when you aren’t sure what a med is for. The medications change so often, generic names replace brand names, and if we don’t ask what something is for and what the potential reactions are, we cannot effectively plan our treatments.Cognition is vital to the success of dysphagia treatment. Having at least one cognitive goal for your dysphagia is important when the patient has the ability to improve understanding of the following: Review above Remember: those medication sheets are so important in understanding the abilities and potentials that your patient has. Ask the questions when you aren’t sure what a med is for. The medications change so often, generic names replace brand names, and if we don’t ask what something is for and what the potential reactions are, we cannot effectively plan our treatments.

35. Therapeutic Considerations Gastrointestinal Function Impairment Does the patient suffer from an unreported GI complication? Are your techniques worsening the effects of the GI complication? Is a combination of cognitive, neurological and GI impairments resulting in a silent aspiration? Before we used to include this function into our realm of thinking, we, as SLP’s, worked diligently on getting our patients to swallow effectively. Trouble was, if the food or liquid wasn’t staying down, the patient was at even more risk as the food and liquid was now laced with stomach acid. Acid is very caustic to the lungs and causes trauma to the lining. We need to be looking at the GI function in order to assess the techniques that we recommend. Does the patient suffer from unreported GI Complications? Watch how you ask the questions. If you ask, DO you have reflux…they may say no, but if you point to the G-tube feeding and ask what it tastes like, more times than not they will say it’s cold and chalky tasting if they are refluxing it up into the pharynx. Watch, then, for the techniques you are going to incorporate into your therapy plan. For example, do you want to do anything that requires pushing or an effortful swallow if in fact the patient is refluxing? Put two and two together in order to assess whether a combination of cognitive, neurological and GI impairments might be resulting in silent aspiration. They may not be feeling it, have reflux and don’t understand that what is happening to them, or what they are ingesting may be contributing to the problem. Be a detective and try to put the pieces together. Before we used to include this function into our realm of thinking, we, as SLP’s, worked diligently on getting our patients to swallow effectively. Trouble was, if the food or liquid wasn’t staying down, the patient was at even more risk as the food and liquid was now laced with stomach acid. Acid is very caustic to the lungs and causes trauma to the lining. We need to be looking at the GI function in order to assess the techniques that we recommend. Does the patient suffer from unreported GI Complications? Watch how you ask the questions. If you ask, DO you have reflux…they may say no, but if you point to the G-tube feeding and ask what it tastes like, more times than not they will say it’s cold and chalky tasting if they are refluxing it up into the pharynx. Watch, then, for the techniques you are going to incorporate into your therapy plan. For example, do you want to do anything that requires pushing or an effortful swallow if in fact the patient is refluxing? Put two and two together in order to assess whether a combination of cognitive, neurological and GI impairments might be resulting in silent aspiration. They may not be feeling it, have reflux and don’t understand that what is happening to them, or what they are ingesting may be contributing to the problem. Be a detective and try to put the pieces together.

36. MBS and Endoscopy Views Evaluation of Pharyngeal Stage Dysphagia It is important to understand the value of both MBS and endoscopy in identifying issues related to dysphagia. This is a view of the MBS and aspiration. Note the passage of the barium coated material into the trachea as the rest of the bolus passes into the esophagus ( point out) Here is the endoscopic view. Note that as the milk is aspirated through the glottis that it forms bubbles as the air escapes through the vocal folds and the milk falls into the glottis.It is important to understand the value of both MBS and endoscopy in identifying issues related to dysphagia. This is a view of the MBS and aspiration. Note the passage of the barium coated material into the trachea as the rest of the bolus passes into the esophagus ( point out) Here is the endoscopic view. Note that as the milk is aspirated through the glottis that it forms bubbles as the air escapes through the vocal folds and the milk falls into the glottis.

37. MBS and Endoscopy Views Discrimination of the relationship between structure, function, and consistency The speech pathologist’s role in instrumentation via endoscopy is to identify the relationship between the structure as presented, the function of those structures in the swallowing process, and how the consistency of food and liquid that is being presented is handled during the oral and pharyngeal stage. It is NOT the responsibility of the SLP, nor is it in our scope of practice to diagnose or judge the integrity of the structures as presented. Only physician’s can do that. Note here that with residue on the MBS you can identify that it is there. With endoscopy you can see the relationship of the residue ( green) to the function of the aryepiglottic fold, for example, in keeping, or not keeping it out of the laryngeal vestibule.The speech pathologist’s role in instrumentation via endoscopy is to identify the relationship between the structure as presented, the function of those structures in the swallowing process, and how the consistency of food and liquid that is being presented is handled during the oral and pharyngeal stage. It is NOT the responsibility of the SLP, nor is it in our scope of practice to diagnose or judge the integrity of the structures as presented. Only physician’s can do that. Note here that with residue on the MBS you can identify that it is there. With endoscopy you can see the relationship of the residue ( green) to the function of the aryepiglottic fold, for example, in keeping, or not keeping it out of the laryngeal vestibule.

38. MBS and Endoscopy Views Visualization of non-barium coated considerations The MBS is a wonderful tool in judging the overall passage of food and liquid from the oral through to the esophageal stage of the swallow. All endoscopists have performed MBS studies and are competent at the procedure. In the nursing home we have found, however, that the three biggest predictors of risk include reflux, secretions and residue identification. In the MBS, only those substances that are coated with barium show up on the X-ray. In this picture the secretions are invisible. Note in the picture on the right how the secretions fill up the pharynx. If the vallecula and pyriforms are full of secretions, where is the food and liquid going to transit? This piece of the puzzle helps us to examine secretion management via medication, thermal stim, multiple swallows etc. in order to keep the pharynx clean for safe transit of the food and liquid.The MBS is a wonderful tool in judging the overall passage of food and liquid from the oral through to the esophageal stage of the swallow. All endoscopists have performed MBS studies and are competent at the procedure. In the nursing home we have found, however, that the three biggest predictors of risk include reflux, secretions and residue identification. In the MBS, only those substances that are coated with barium show up on the X-ray. In this picture the secretions are invisible. Note in the picture on the right how the secretions fill up the pharynx. If the vallecula and pyriforms are full of secretions, where is the food and liquid going to transit? This piece of the puzzle helps us to examine secretion management via medication, thermal stim, multiple swallows etc. in order to keep the pharynx clean for safe transit of the food and liquid.

39. MBS and Endoscopy Views Discrimination of Residue in Pharynx Identification of reside is important in predicting the risk of dysphagia complications. On the MBS, however, residue is seen as a coating on the pharynx. On the endoscopy one can see that the residue is a mix of the oral feeding ( yellow in the pyriform) and the residue of g-tube feeding that is seeping up through the esophageal inlet ( point to that). It is important to note that because you can then work on reflux precautions and management techniques, working together with the physician and nursing, prior to attempting to introduce more food and liquid consistencies into the mix. SHOW NORMAL ANATOMY CLIP VIA ENDOSCOPY (4 min) Identification of reside is important in predicting the risk of dysphagia complications. On the MBS, however, residue is seen as a coating on the pharynx. On the endoscopy one can see that the residue is a mix of the oral feeding ( yellow in the pyriform) and the residue of g-tube feeding that is seeping up through the esophageal inlet ( point to that). It is important to note that because you can then work on reflux precautions and management techniques, working together with the physician and nursing, prior to attempting to introduce more food and liquid consistencies into the mix. SHOW NORMAL ANATOMY CLIP VIA ENDOSCOPY (4 min)

40. Chronic Obstructive Pulmonary Disease ( COPD) A term used to describe two closely related lung diseases emphysema chronic bronchitis. Often, people have these diseases together 4th Leading cause of death in the US and the World ( Natl. Heart, Lung and Blood Institute, 2005)

41. Tests for COPD Family and personal history Physical exam. Pulmonary function tests the amount of air in the lung (called lung volume); the rate of oxygen and carbon dioxide exchange; the amount of oxygen and carbon dioxide in your blood. Lung volumes are measured by breathing into and out of a device called a spirometer. Researchers are still looking for a way to figure out a person's chances of developing COPD, because none of the current tests find the disease before lung damage that cannot be repaired occurs.

42. Treatment for COPD Causes shortness of breath that can make you need oxygen. Treatments can include: bronchodilators antibiotics exercise to strengthen muscles. pulmonary rehabilitation lung transplants Lung volume reduction surgery

43. Emphysema Emphysema causes the walls between the air sacs within the lungs to become weak and break, making it hard for you to feel like you get enough air. While more men suffer from emphysema than women, it is increasing in women. Symptoms can include: a cough that never seems to go away or that gets worse over time, increased mucus, a frequent need to clear your throat, shortness of breath, or trouble exercising.

44. Emphysema Some of the air sacs deep in your lungs have been damaged. When the bronchi become irritated, the normal elasticity of the air sacs and the walls of the airways are destroyed. People with emphysema need to forcefully blow the air out in order to empty the lungs. Forcing the air out in this way puts pressure on the airways from the outside, compresses them and causes them to collapse. The walls of the tiny air sacs may even tear. Excessive coughing may cause the airways to collapse as well

45. Emphysema As the stretching and tearing of the walls of the air sacs continues, the lungs may become enlarged and less efficient at moving air into the lungs and contaminants out of the lungs. Because the walls of the air sacs are destroyed, there is less surface area available for gas exchange. Damage to the air sacs in the lungs not only results in difficulty breathing, but the heart also has to work harder to circulate blood through the lungs. All these changes make less oxygen available to the body. Emphysema is characterized by a large barrel-shaped chest, a poor air pumping system, and shortness of breath (SOB). In advanced stages, every breath is difficult. A cough may or may not be present with emphysema.

46. Chronic Bronchitis Chronic bronchitis is an inflammation that ends up scarring the lining of the bronchial tubes Women have higher rates of chronic bronchitis than men…. the cells lining the inside of the bronchi are continuously inflamed Airways in your lungs have become narrow and partly clogged with mucus

47. Chronic Bronchitis The bronchi are air passages connecting the trachea with the alveoli, where oxygen is taken up by the blood. Bronchitis is an inflammation of the bronchi. This inflammation causes excessive production of mucus and swelling of the bronchial walls. Airflow into and out of the lungs is obstructed. With chronic bronchitis, the mucus cannot be cleared. Instead of helping to clean the lungs, it causes obstruction in the airways. The mucus is thicker and more difficult to cough up. This provides a means for bacteria to settle in the lower airways and increases the risk of infection.

48. Chronic Bronchitis Chronic bronchitis is caused mainly by cigarette smoke. It is characterized by: persistent cough production of mucus The degree of breathlessness experienced depends on the degree of congestion of the airways and inflammation of the bronchial mucus membranes.

49. Pulmonary Edema Your lungs contain millions of small, elastic air sacs called alveoli. With each breath, these air sacs take in oxygen and release carbon dioxide, a waste product of metabolism. Normally, the exchange of oxygen and carbon dioxide takes place without problems. Increased pressure in the blood vessels in your lungs forces fluid into the air sacs, filling your lungs with fluid and preventing them from absorbing oxygen — a condition called pulmonary edema.

50. Pulmonary Edema In most cases, heart problems are the cause of pulmonary edema. Fluid can accumulate in your lungs for other reasons, including lung problems such as : Pneumonia exposure to certain toxins and medications climbing or living at high altitudes. Pulmonary edema is a medical emergency and requires immediate care. Although it can sometimes prove fatal, the outlook is often good when you receive prompt treatment along with therapy for the underlying problem

51. Pulmonary Edema Additional symptoms: Nasal flaring Coughing up blood Inability to speak from air hunger Decreased level of awareness

52. Pulmonary Edema Non-cardiac pulmonary edema Fluid may also leak from the capillaries in your lungs' air sacs because the capillaries themselves become more permeable or leaky, even without the buildup of back pressure from your heart. Your heart isn't the cause of the problem. Some factors that can cause increased capillary permeability leading to non-cardiac pulmonary edema are: Lung infections. When pulmonary edema results from lung infections, such as pneumonia, the edema occurs only in the part of your lung that's inflamed. Exposure to certain toxins. These include toxins you inhale — such as chlorine, ammonia or nitrogen dioxide — as well as those that may circulate within your body. For example, women giving birth may develop pulmonary edema when amniotic fluid reaches the lungs through the veins of the uterus (amniotic fluid embolism). Severe allergic reactions (anaphylaxis). You can have serious allergic reactions to some medications as well as to certain foods and insect venom.

53. Pulmonary Edema Smoke inhalation. The smoke from these fires often contains chemicals that irritate the lining of the lungs, causing the tiny blood vessels to leak. Near-drowning and drowning. Drug overdose. Drugs ranging from narcotics, such as heroin, to aspirin can cause non-cardiac pulmonary edema. Aspirin-induced pulmonary edema can occur in people who take increasingly large doses of aspirin to relieve pain or other symptoms. For reasons that aren't clear, smokers who use aspirin are at greater risk.

54. Pulmonary Edema Acute respiratory distress syndrome (ARDS). This serious disorder, which affects hundreds of thousands of people every year, occurs when your lungs suddenly become unable to take in enough oxygen. More than 30 conditions can cause ARDS, including: severe injuries (trauma), systemic infection (sepsis), pneumonia or shock. ARDS sometimes also develops after extensive surgery. Symptoms usually appear within 24 to 72 hours after the original illness or trauma.

55. Pulmonary Edema High altitudes. Mountain climbers and people who live in or travel to high-altitude locations run the risk of developing high-altitude pulmonary edema (HAPE). This condition — which typically occurs at elevations above 8,000 feet — can also affect skiers who start exercising at higher altitudes without first becoming acclimated. But even people who have hiked or skied at high altitudes in the past aren't immune. Symptoms include: headaches insomnia fluid retention cough and shortness of breath. without appropriate care, HAPE can be fatal

56. Congestive Heart Failure (CHF) Congestive heart failure (CHF), or heart failure, is a condition in which the heart can't pump enough blood to the body's other organs. narrowed arteries that supply blood to the heart muscle — coronary artery disease. past heart attack, or myocardial infarction, with scar tissue that interferes with the heart muscle's normal work. high blood pressure. heart valve disease due to past rheumatic fever or other causes. primary disease of the heart muscle itself, called cardiomyopathy. heart defects present at birth — congenital heart defects. infection of the heart valves and/or heart muscle itself — endocarditis and/or myocarditis.

57. Complications of CHF The "failing" heart keeps working but not as efficiently as it should. As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing congestion in the tissues. Often swelling (edema) results. Most often there's swelling in the legs and ankles, but it can happen in other parts of the body, too. Sometimes fluid collects in the lungs and interferes with breathing, causing shortness of breath, especially when a person is lying down. Heart failure also affects the kidneys' ability to dispose of sodium and water. The retained water increases the edema.

58. CHF Effects If the left side of your heart is not working properly (left-sided heart failure): blood and fluid back up into your lungs you will feel short of breath be very tired have a cough (especially at night). If the right side of your heart is not working properly (right-sided heart failure): the slowed blood flow causes a buildup of fluid in your veins your feet, legs, and ankles will begin to swell. This swelling is called edema. sometimes edema spreads to the lungs, liver, and stomach. because of the fluid buildup, you may need to go to the bathroom more often, especially at night. Fluid buildup is also hard on your kidneys. As heart failure progresses: You have trouble breathing or lying flat because you feel short of breath. You feel tired, weak, and are unable to exercise or perform physical activities. You have weight gain from excess fluid. You feel chest pain. You do not feel like eating, or you feel like you have indigestion. Your neck veins are swollen. Your skin is cold and sweaty. Your pulse is fast or irregular. You feel restless, confused, and find that your attention span and memory are not as good as they were.

59. CHF Statistics According to the American Heart Association, people 40 and older have a 1 in 5 chance of developing CHF in their lifetime. Nearly 5 million people in the United States—mostly older adults—already have CHF, and the number of people with CHF keeps rising. About 550,000 people develop CHF each year. This is because people are living longer and surviving heart attacks and other medical conditions that put them at risk for CHF. People who have other types of heart and vessel disease are also at risk for CHF.

60. CHF Statistics Approximately 30-40% of patients with CHF are hospitalized every year. CHF is the leading diagnosis-related group (DRG) among hospitalized patients older than 65 years. The 5-year mortality rate after diagnosis was reported in 1971 as 60% in men and 45% in women. In 1991, data from the Framingham heart study showed the 5-year mortality rate for CHF essentially remaining unchanged, with a median survival of 3.2 years for males and 5.4 years for females. The most common cause of death is progressive heart failure, but sudden death may account for up to 45% of all deaths. Patients with coexisting insulin-dependent diabetes mellitus have a significantly increased mortality rate. Race: African Americans are 1.5 times more likely to die of CHF than whites are. Sex: Prevalence is greater in males than in females for patients aged 40-75 years. No sex predilection exists for patients older than 75 years. Age: Prevalence of CHF increases with increasing age and affects about 10% of the population older than 75 years.

61. Asthma / Allergies What Is An Allergy? an abnormal reaction by your body to substances which you are sensitized to these substances are called allergens an allergic person produces antibodies against these allergens Each time the allergic person comes in contact with an allergen after that first contact, certain cells in the body release chemical substances called mediators. Mediators, like histamine and leukotrienes, can cause one or more of the following symptoms: redness Swelling itching increased mucous production. The body's response to the allergen results in individual signs and symptoms - not necessarily the same result in all people. The tendency to be allergic is inherited; the actual allergy is not inherited.

62. Asthma / Allergies Important Asthma Triggers: Environmental Tobacco Smoke, Also Known As Secondhand Smoke Dust Mites Outdoor Air Pollution Cockroach Allergen Pets Mold Other Triggers: strenuous physical exercise adverse weather conditions like freezing temperatures, high humidity, and thunderstorms foods and food additives and drugs can trigger asthma episodes strong emotional states also can lead to hyperventilation and an asthma episode

63. Asthma / Allergies Signs and Symptoms of Allergies asthma itchy, watery eyes itchy, runny nose allergic salute - pushing up on the nose, causing a white crease to appear across the bridge of the nose itching eczema hives dark circles under and around the eyes recurring headache shortness of breath wheeze cough diarrhea stomach cramps

64. Asthma / Allergies What Is Asthma? Asthma is a chronic lung condition. It is characterized by difficulty in breathing. People with asthma have extra sensitive or hyper-responsive airways. The airways react by narrowing or obstructing when they become irritated. This makes it difficult for the air to move in and out. This narrowing or obstruction can cause one or a combination of the following symptoms: wheezing coughing shortness of breath chest tightness This narrowing or obstruction is caused by: Airway inflammation Broncho-constriction

65. Asthma / Allergies Asthma Facts and Statistics Asthma is a chronic lung condition that can develop at any age. Most common in childhood --7-10% of the pediatric population. Most common chronic respiratory disease of children--accounts for 1/4 of school absenteeism. It affects twice as many boys as girls in childhood More girls than boys develop asthma as teenagers In adulthood, the ratio becomes 1:1 males to females.

66. Asthma / Allergies Asthma Statistics , continued In 1998, an estimated 17 million Americans, or 6.4 percent of the population, had asthma. Asthma affects slightly more African Americans (5.8 percent) than whites (5.1 percent). In 1993 however, African Americans were 3 to 4 times more likely than whites to be hospitalized for asthma. In 1996, African Americans were 4 to 6 times more likely than whites to die from asthma. More than 5,000 people die from asthma each year in the United States. In 1994, asthma caused 451,000 hospitalizations. Children under 15 accounted for 169,000 of these. In 1995, asthma caused more than 1.8 million emergency room visits. Asthma cost the U.S. economy an estimated $10.7 billion in 1994 including a direct health care cost of $6.1 billion indirect costs, such as lost work days, of $4.6 billion

67. Respiratory MRSA The term “methicillin-resistant Staphylococcus aureus” (MRSA) refers to those strains of Staphylococcus aureus bacteria that have acquired resistance to the antibiotics: methicillin Oxacillin Nafcillin cephalosporins Imipenem and/or other beta-lactam antibiotics.

68. Respiratory MRSA The incidence of MRSA has increased in health care facilities in the United States since the mid-1970s. Guidelines recommend the most widely used approaches to the control of MRSA include Recognition of infected or colonized residents; Appropriate infection control measures; Communications between acute care and long term care facilities; and Personnel policies related to MRSA.

69. Respiratory MRSA Once MRSA has become firmly established in a facility, it is rarely eliminated. MRSA is not a “super bug.” MRSA is of special concern because it is often multi-drug resistant, thus limiting treatment options.

70. Respiratory MRSA MRSA infection is a condition whereby: the bacteria has invaded a body site is multiplying in tissue is causing clinical manifestations of disease Fever suppurative wound pneumonia or other respiratory illness or symptoms other signs of inflammation (warmth, redness, swelling) Infection is confirmed by positive cultures from sites such as blood, urine, sputum, or wound.

71. Respiratory MRSA Colonized and infected residents serve as the major reservoir of MRSA in long term care facilities. Point prevalence studies have found that 23% - 35% of residents in Veterans’ Affairs affiliated units may become colonized over a period of one to two years. In the few prevalence surveys performed in freestanding long term care facilities located in areas where MRSA is common, 9% - 12% of residents were colonized. MRSA colonization may disappear with treatment and reappear weeks or months later.

72. Pleural Effusion Approximately 1 million pleural effusions are diagnosed in the United States each year. The clinical importance of pleural effusions ranges from incidental manifestations of cardiopulmonary diseases to symptomatic inflammatory or malignant diseases requiring urgent evaluation and treatment. The normal pleural space contains approximately 1 mL of fluid In the US: The estimated incidence is 1 million cases per year with most effusions caused by: congestive heart failure malignancy infections pulmonary emboli Internationally: The estimated prevalence is 320 cases per 100,000 people in industrialized countries

73. Pleural Effusion Causes: Transudates are ultrafiltrates of plasma in the pleura caused by a small, defined group of etiologies. The following cause transudates: Congestive heart failure Cirrhosis (hepatic hydrothorax) Atelectasis (which may be due to malignancy or pulmonary embolism) Hypoalbuminemia Nephrotic syndrome Peritoneal dialysis Myxedema Constrictive pericarditis

74. Pleural Effusion In contrast, exudates are produced by a variety of inflammatory conditions and often require more extensive evaluation and treatment. The more common causes of exudates include the following: Parapneumonic Malignancy (carcinoma, lymphoma, mesothelioma) Pulmonary embolism Collagen-vascular (rheumatoid arthritis, lupus) Tuberculous Asbestos-related Pancreatitis Trauma Postcardiac injury syndrome Esophageal perforation Radiation pleuritis Drug-induced Chylothorax Meigs syndrome Sarcoidosis Yellow nail syndrome

75. Pleural Effusion Dyspnea (abnormal or uncomfortable breathing) is the most common symptom associated with pleural effusion and is related more to distortion of the diaphragm and chest wall during respiration than to hypoxemia.

76. Pleural Effusion In many patients, drainage of pleural fluid alleviates symptoms despite limited improvement in gas exchange. Underlying intrinsic lung or heart disease, obstructing endobronchial lesions, or diaphragmatic paralysis can also cause dyspnea, especially after coronary artery bypass surgery. Drainage of pleural fluid may partially relieve symptoms but also may allow the underlying disease to be recognized on repeat chest radiographs.

77. Pleural Effusion Other symptoms may suggest the etiology of the pleural effusion. More severe cough or production of purulent or bloody sputum suggests an underlying pneumonia or endobronchial lesion. Constant chest wall pain may reflect chest wall invasion by bronchogenic carcinoma or malignant mesothelioma. Pleuritic chest pain suggests either pulmonary embolism or an inflammatory pleural process. Systemic toxicity evidenced by fever, weight loss, and inanition suggests empyema.

78. Aspiration Pneumonitis and Aspiration Pneumonia Article in the New England Journal of Medicine, Volume 344, No. 9, 3-1-2001 Compares the epidemiology of Aspiration Pneumonitis versus Aspiration Pneumonia Discusses assessing the risk of oropharyngeal aspiration Dispels some myths about protection from aspiration with feeding tube placement

79. Definition of Aspiration Aspiration is defined as the inhalation of oropharyngeal or gastric contents into the larynx and lower respiratory tract. (Irsin RS. Aspiration, Irwin and Rippe’s intensive care medicine. 4th ed. Vol1) (Cassiere HA, Niederman MS. Aspiration pneumonia, lipoid pneumonia, and lung abscess. Texbook of pulmonary diseases, 6th ed. Vol1.)

80. Aspiration Pneumonitis Aspiration pneumonitis (Mendelson’s syndrome) is a chemical injury caused by the inhalation of sterile gastric contents

81. Aspiration Pneumonia Aspiration pneumonia is an infectious process caused by the inhalation of oropharyngeal secretions that are colonized by pathogenic bacteria.

82. Aspiration Pneumonia Pneumonia is an inflammation or infection of the lungs. The lungs' air sacs fill with pus, mucus, and other liquid and can not function properly. Oxygen can not reach the blood. If there is insufficient oxygen in the blood, body cells can not function properly and may die. Lobar pneumonia affects a section lobe of a lung. Bronchial pneumonia affects patches throughout both lungs.

83. Consequences Pulmonary aspiration is an important cause of serious illness and death among residents of nursing homes as well as hospitalized patients. (Irwin and Rippe’s Intensive Care medicine, 4th edition. Vol1) (Texbook of pulmonary Diseases, 6th edition, Vol1) (Infectious diseases and death among nursing home residents: results of surveillance in 13 nursing homes. Infection Control Hospital Epidemiology, 1994) (Nursing home-acquired pneumonia, a case control sgudy, J Am Geriatr Soc 1986)

84. Consequences of Aspiration of Gastric Contents Chemical burn of the tracheobronchial tree Chemical burn of the pulmonary parenchyma Causes an intense parenchymal inflammatory reaction First phase peaks one to two hours after aspiration Second phase, four to six hours

85. Pneumonia Risk following Aspiration of Gastric Contents Depends on effectiveness of cellular mechanisms in clearing infectious material Impaired defense mechanisms + bacterial burden of oropharyngeal secretions increases risk Risk of aspiration pneumonia less in patients without teeth and those with aggressive oral hygienic care.

86. Infiltrate Evidence In Aspiration Pneumonia---episode of aspiration usually not witnessed In Aspiration Pneumonitis-- episode of aspiration usually witnessed.

87. Radiographic Evidence Inferred diagnosis = Patients who aspirate while in a recumbent position = involvement in posterior segments of the upper lobes and apical segments of the lower lobes Patients who aspirate in upright or semi-recumbent position = involvement in basal segments of the lower lobes

88. Diagnostic Risks Patients with : Neurologic dysphagia Disruption of the gastro-esophageal junction Anatomical abnormalities of the upper aero-digestive tracts = increased risk for oro-pharyangeal aspiration

89. Diagnostic Risks Elderly persons: Increased incidence of dysphagia Increased gastroesophageal reflux Poorer oral care

90. Diagnostic Risks Stroke Prevalence of swallowing dysfunction ranges from 40-70% High incidence of silent aspiration Among stroke patients, pneumonia is seven times as likely to develop in those with confirmed aspiration than in those who do not aspirate.

91. Assessing the Risk Clinically Assessment of the cough and gag reflexes is an unreliable means of identifying patients at risk for aspiration. (Langmore, Schatz, Olson) Endoscopic and videofluoroscopic evaluations of swawllowing and aspriation. Ann Otol Rhinol Laryngol 1991) (Fiberoptic Endoscopic Examination of Swallowing Safety; A new procedure. Dyspahgia 1988) (Splaingard, Hutchins, Sulton, Chaudhuri. Aspiration in rehabilitation patients: videofluoroscopy vs bedside lcinical assessment. Arch Phys Med Rehabil 1988)

92. Assessing the Risk Clinically A comprehensive swallowing evaluation, supplemented by either a videofluoroscopic swallowing study or a fiberoptic endoscopic evaluation, is required. ( same references as previous slide)

93. Assessing the Risk Clinically Behavior Modification Dietary Risk Medical Management

94. Tube Feeding Risk and Aspiration Pneumonia 1995: >121,000 percutaneous endoscopic gastrostomy tubes were placed in Medicare Recipients in the US Most common reason = Dysphagia after stroke. Data does not support superiority of G-tube over NG-Tube in preventing aspiration in these patients.

95. G-Tube / NG-Tube Comparison G-tube more effective in delivering prescribed nutrition No protection from colonized oral secretions with either tube type Similar Aspiration Pneumonia incidence Evidence of aspiration of gastric contents in G-tube patients Aspiration Pneumonia most common cause of death long term in G-tube patient

96. N-G Tube complications Discomfort Excessive gagging Esophagitis Misplacement Displacement Clogging More appropriate for ‘few weeks’ placement

97. Critically Ill Patients Higher incidence of aspiration and aspiration pneumonia Supine position Gastroesophageal reflux up to 30% of those in supine position Gastroparesis Gastrointestinal dysmotility Nasogastric intubation

98. Post Endotracheal Intubation Risks in Critically Ill Patients Increases risk of aspiration which may / may not resolve in 48 hours residual effects of sedative drugs presence of a nasogastric tube Alterations in upper-airway sensitivity glottic injury laryngeal muscular dysfunction

99. Bacteriology --“Community Acquired Aspiration Pneumonia” Anaerobic organisms - predominant pathogens Antibiotics to fight these organisms became standard of care for all patients with aspiration pneumonia or aspiration pneumonitis Many of customers had chronic alcoholism

100. Management of Aspiration Pnuemonitis Suction upper airway following witness of aspiration of gastric contents Endotracheal intubation considered for those unable to protect their airway Not recommended for prophylactic use of antibiotics unless indicated by diagnosis Antibiotics if no resolution within 48 hours or those

101. Aspiration Pneumonia Antibiotic therapy unequivocally indicated Choice of antibiotic depends on the setting in which the aspiration occurs and well as patients general health Penicillin and clindamycin, standards for aspiration pneumonia re often inadequate for most patients

102. Pneumonia / Pneumonitis Vitally important to distinguish aspiration pneumonitis from aspiration pneumonia Some overlap exists--but they are distinct clinical syndromes

103. One Patient4 SNF Admissions No Instrumentation for DysphagiaRespiratory Complications

104. Select Itemized Cost Assumptions Antibiotic treatment = $168.00 for a 14 course of treatment Wound Care = rate of $175.00 per day including supplies and debridement. Liquid Thickeners per month = daily cost of $1.00/nectar, $2.00/Honey, $3.00/Pudding thick consistency modifications. G-tube pump cost = a cost of $2.96 per day Cost of the Jevity or Glucerna was NOT figured into these estimates as they represent dietary costs. Oxygen use = cost of the oxygen and the tank at $35.00 per day. Specialty beds = lowest estimated cost of $25.00 per day. Respiratory Care = cost for Albuterol at $2.04 per day. Therapy Costs are represented by a daily RUG rate of $90/Ultra High, $70/Very High, $55/High, $36/Medium, $18/Low.

105. Stay # 1 Patient admitted to the Nursing home with a diagnosis of pneumonia. Patient was on O2 at 3L. Patient stayed = 36 days Patient returned to the hospital with pneumonia . Patient was on a honey thick liquid consistency during stay number one.

106. Costs associated with Stay #1 Itemized Costs Associated with Stay #1: DX of Pneumonia Liquid thickener per month : $60.00 Therapy Costs at Ultra High RUG: $3240.00 Antibiotic Treatment: $336 Respiratory Drugs: $73.44 Oxygen @ 3L: $1260 Total Pneumonia Costs: $4969.44

107. Stay #2 The patient returned to the facility for 88 days G-tube placed for nutrition and hydration Placed in a specialty bed for decubitus. On a thickened liquid of a pudding thick Patient fell and fractured a hip Returned to the hospital for repair.

108. Costs associated with Stay #2 Itemized Costs Associated with Stay # 2 DX : Repeat Pneumonia Liquid thickener per month: $90.00 Therapy Costs at Ultra High RUG: $5760.00 Antibiotic Treatment: $336 Respiratory Drugs: $122.40 Oxygen @ 3L: $2100.00 G-Tube Pump: $266.64 Wound Care: $15,400.00 Specialty Beds $1125.00 Total Repeat Pneumonia Costs: $25,200.04

109. Stay #3 FX Hip repaired at the hospital Patient returned to the facility with a diet order including thin liquids. Patient stay = 13 days Returned to the hospital with DX of increasing congestion and dehydration.

110. Costs associated with Stay #3 Itemized Costs Associated with Stay #3 DX of Fx Hip Liquid thickener per month:$0. ( p on thin liquids again) Therapy Costs $0 Antibiotic Treatment $168.00 Respiratory Drugs $26.52 Oxygen at 3L $455.00 G-tube $0 Wound Care $2275.00 Specialty Bed $0 Total Additional Costs $2924.52

111. Stay #4 Diagnosis upon return to the facility was Bronchitis. Patient was placed on a pudding thick liquid for the course of this stay. Pt Died on day 61 of Stay #4

112. Costs associated with Stay #4 Itemized Costs Associated with Stay #4: Dx of Bronchitis Liquid thickener per month$120 Therapy Costs $4270 Antibiotic Treatment $168.00 Respiratory Drugs $61.12 Oxygen at 3L $1050.00 G-Tube $0 Wound Care $10,675.00 Specialty Bed $1525 Total Additional Costs $33,094.00

115. Conclusion Accurate diagnosis of pharyngeal stage dysphagia is vital. Risk of silent aspiration, reflux, fatigue, and nutritional compromise MUST be addressed in the Care Planning Proactive Treatment of Dysphagia , rather than Reactive Treatment of Dysphagia may not only improve patient outcome, but improve the cost effectiveness of their care. It is extremely difficult to ‘best guess’ a diagnosis and subsequent treatment options, without instrumentation, when the risk factors are present. Quality of care and cost effectiveness can coincide for more positive patient outcomes.

116. Reference Websites http://www.lung.ca/copd/anatomy/emphysema.html http://www.e-breathing.com/ Altruis Biomedical Network http://www.sk.lung.ca/content.cfm?edit_realword=xtra0218 The Lung Association http://www.nlm.nih.gov/medlineplus/ency/article/000140.htm http://www.annals.org/cgi/content/full/134/6/487 Annals of Internal Medicine http://www.emedicine.com/emerg/topic108.htm

117. Reference Websites http://www.mayoclinic.com/invoke.cfm?id=DS00412 http://www.lung.ca/asthma/allergies/ http://www.cdc.gov/asthma/faqs.htm http://www.nlm.nih.gov/medlineplus/asthma.html http://content.nejm.org/cgi/content/extract/344/9/665 http://www.respiratoryreviews.com/novdec99/rr_novdec99_asppneu.html http://www.emedicine.com/emerg/topic108.htm