Chronic Obstructive Pulmonary Disease And Its Affect On Deglutition

1. Chronic Obstructive Pulmonary Disease And Its Affect On Deglutition Kimberly King, B.A. Candidate for Masters of Arts Speech Language Pathology Wayne State University

2. 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 • Chronic Obstructive Pulmonary Disease (COPD) is typically expressed in 2 ways: • Emphysema • Chronic Bronchitis Chronic Obstructive Pulmonary Disease, One of the Most Common Diseases to Affect the Lungs

3. Smoking is the number one cause • Other causes include secondhand smoke certain gases or fumes, pollutants, and physical structural defects that affect pulmonary function. Chronic Obstructive Pulmonary Disease Etiology

4. 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) Chronic Obstructive Pulmonary Disease and the Numbers

5. 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 Understanding COPD’s Affect On Deglutition

6. 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 COPD’s Affect on Respiration and Deglutition

7. 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 Susceptibility To Aspiration

8. Reported COPD Associated Risks Affecting Swallowing • Could cause air hunger and likelihood of inhalation during swallow • Residue in the oral/pharyngeal cavity could lead to aspiration • Increase the risk of aspirating on inhalation • The increased risk from air hunger during prolonged chewing times + common co-occuringoropharyngealdysphagia in COPD = higher risk of aspiration • Increased mastication, increased resp. rate and rhythm during chewing • Delayed pharyngeal response, decreased tongue retraction, reduced laryngeal elevation • Increased fatigue, incoordination, weakness of upper aerodigestive tract musculature, & sensory impairment • Increased inspiration after liquid swallow and increased apneic pause duration

9. 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 Pathophysiology of the Swallowing Mechanism in COPD Patients

10. Exacerbations typically include an increase in: • dyspnea, sputum, purulence • negative effects on respiration and swallowing • Cyclical affect; inflammation – increased dyspnea – aspiration – pneumonia – COPD exacerbation How COPD Exacerbations Affect Swallowing

11. Patients with dysphagia have greater than 7-times chance of acquiring aspiration pneumonia (if found to aspirate during an MBSS) ( Martin-Harris 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) Severity of Aspiration for COPD Patients

12. Top 3 Expectations from Patients • breathe • walk (including up stairs) • manage shortness of breath Management of COPD and Swallowing Dysfunction

13. Pharmacologic Nonpharmacologic • Inhaled corticosteroids • Long-acting bronchodilators and Theophyllines (relaxes & opens restricted bronchi) • Phosphodiesterase inhibitors (relaxes blood vessels) • Mucolytics (dissolves mucous) • Current vaccinations (Mackay & Hurst, 2012) • Home oxygen • Ventilator support • Pulmonary rehabilitation (American Thoracic Society-European Respiratory Society, Casaburi & Wallack, 2009) Medical Interventions

14. Lung volume reduction surgery • Been shown to increase exercise endurance (Fishman, et al., Mackay & Hurst, 2012) • Cricopharyngealmyotomy • Trials have improved swallowing & complete or semi-reprieve from respiratory exacerbations (Stein et al., 1990) Surgical Interventions

15. 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) • 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) Behavioral Interventions

16. 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 Swallowing Strategies

17. 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 Conclusion

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