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HOW YOU BREATHE MATTERS: SWALLOWING SAFELY
10/27/2010
HOW YOU BREATHE MATTERS:
SWALLOWING SAFELY
Presenter
Gail M. Sudderth, RRT
Clinical Specialist
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 PassyMuir® Valve and team approach for diagnosis and treatment of
common issues facing the tracheostomized ventilator patient.
Passy‐Muir Inc.
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HOW YOU BREATHE MATTERS: SWALLOWING SAFELY
10/27/2010
Outline
What is Normal ?
Respiration & Swallowing: A Shared System
Dysphagia - 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
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Normal Respiration
• CNS control
– Responds to changes in CO2
– Brain stem, Medulla & Pons, Phrenic & Thoracic nerves
• Muscles of respiration
– Diaphragm
– Intercostal
– Abdominal
• Pressures and Inspiratory Flow
• Compliance, Resistance and Lung Recoil
Normal Respiration
Passy‐Muir Inc.
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HOW YOU BREATHE MATTERS: SWALLOWING SAFELY
10/27/2010
Lung Volumes and Capacities
Normal Swallow
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Anatomy
Mechanical
Pressure Driven
Airflow
Phases of swallow
Timing of swallow
ANATOMY OF SWALLOW
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Nasal Cavity
Oral Cavity
Pharynx
Larynx
Esophagus
Nasal Cavity
Oral Cavity
Pharynx
Larynx
Esophagus
Passy‐Muir Inc.
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HOW YOU BREATHE MATTERS: SWALLOWING SAFELY
10/27/2010
MECHANICS OF A SWALLOW
• Phases of swallow
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Anticipatory
Oral Preparatory
Oral
Pharyngeal
Esophageal
Subglottic Pressure: Role in Swallow
• Positive PressureSubglottic
– Lung recoil: pressure
increases
• Negative pressureEsophageal
– 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.
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HOW YOU BREATHE MATTERS: SWALLOWING SAFELY
10/27/2010
Timing of Swallow
In natural tasks such as cup drinking, the onset of
breathing cessation seemed to be variable.
When instructed to take a cup and bring it to their
mouth, 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
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Anatomy
Timing
Pressures
CNS Control
• Dysphagia – difficulty swallowing
• Aspiration – any material that penetrates below
the level of the vocal folds.
Passy‐Muir Inc.
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HOW YOU BREATHE MATTERS: SWALLOWING SAFELY
10/27/2010
Disruption to Normal Breathing Patterns
• Illness
– Neuromuscular
– COPD
– Restrictive disease
• Medications
• Tracheostomy
• Mechanical Ventilation
Dysphagia & Aspiration Risk
• AGE
• ILLNESS
• ARTIFICIAL AIRWAY
– TRACH
C TUBE
U
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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.
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HOW YOU BREATHE MATTERS: SWALLOWING SAFELY
10/27/2010
Documentation of Aspiration
• Diagnostic tools
• Bedside evaluation-Blue Dye (?)
• FEES
• MBS
• Signs and Symptoms of Aspiration
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Wet sounding voice
Drooling
Multiple swallows
Coughing while eating
Recurrent RLL pneumonia
FEES vs. MBS
Treatment Plan: A Team Approach
Co-treatment Strategies
Passy‐Muir Inc.
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HOW YOU BREATHE MATTERS: SWALLOWING SAFELY
10/27/2010
Shared Goals – RCP & SLP
• The Patient Will :
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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
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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.
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HOW YOU BREATHE MATTERS: SWALLOWING SAFELY
10/27/2010
Clinical Benefits of Passy-Muir® Valve Use
• Restoration of normal physiology and improved:
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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
e od of
o eating/drinking
ea g/d
g
• Method
• 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.
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HOW YOU BREATHE MATTERS: SWALLOWING SAFELY
10/27/2010
Co-treatment
• Swallowing during
mechanical ventilation
• EMT during mechanical
ventilation
Conclusion: How You Breathe Matters
• There is likely an “interactive cooperation”
between swallowing and respiration. (Gross 2009)
p
y as Health Care
We have a responsibility
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
Passy‐Muir, Inc.
(800) 634‐5397
(949) 833‐8255
Passy‐Muir Inc.
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HOW YOU BREATHE MATTERS: SWALLOWING SAFELY
10/27/2010
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 178187
• 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.
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