Dysphagia Aspiration and Feeding Tubes

Dysphagia, Aspiration and Feeding Tubes Susan Ledbetter, D.O. Assistant Professor NSU-COM Department of Geriatrics Objectives  Understand the mechanics of normal swallowing    Know the work-up of dysphagia Describe the various causes of dysphagia Understand the medical and social impact of aspiration Describe the interventions for dysphagia and aspiration   Understand the complications of artificial nutrition Epidemiology  Estimates that 20% of community dwelling adults over age 50 have some difficulty with swallowing at least once a week Study of two large, teaching hospitals showed almost 1/3 of patients had difficulty with swallowing Estimates that 30-50% of those with history of CVA, Parkinson’s or other neurologic injury have difficulty with swallowing Approximately 60% of those in a long-term care setting have difficulty with swallowing  45% mortality rate at 12months for those with dysphagia and aspiration    Normal Swallowing   Complex mechanism, centered in the medulla Voluntary and involuntary muscles involved  Pharyngeal contraction transfers the bolus through the upper sphincter into the esophagus  Peristalsis carries the bolus to the lower sphincter and into the stokmach Cranial nerves involved in both afferent input & efferent activity  Trigeminal (CN5)  Facial (CN7)  Glossopharyngeal (CN9)  Vagus (CN10)  Hypoglossal (CN12)  Phases of Swallowing  Oral Phase: preparatory phase and propulsive phase  Food bolus is formed by mastication and lubrication  Soft palate lifts, closing off the nasopharynx  Tongue propels bolus into the pharynx Pharyngeal Phase  Voluntary contraction of muscles elevates soft palate, sealing nasopharynx  Tongue lifts against hard palate, sealing oropharynx  Larynx and hyoid elevate, sealing off respiratory passage  Cricopharyngeus muscle (upper sphincter) relaxes and bolus progresses into the esophagus Esophageal Phase  Peristalsis propels bolus to stomach • Peristalsis can be triggered by swallowing itself or by distension of stomach or other factors   Phases of Swallowing Schematic of anatomic structures and physiologic function of the normal swallow Hammond, CA and LB Goldstein. Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines. Chest January 2006; 129 (1). Swallowing Dysfunction  Dysphagia  Greek derivation • Dys = difficulty • Phagia = to eat  Abnormal transfer of food from the mouth to the stomach • Oropharyngeal: dysfunction of bolus passage into esophagus • Esophageal dysphagia: dysfunction of bolus transfer into stomach  Often confused with   Odynophagia: painful swallowing Globus sensation: non-painful lump in the throat Who needs a swallowing evaluation?    Reflexive cough during or after feeding Weak voluntary cough Recurrent lower lobe pneumonia or abnormal chest radiography Presence of high-risk conditions  Cerebrovascular disease with residual speech dysfunction  Neurodegenerative diseases: progressive multiple sclerosis, Alzheimer’s disease, ALS  Alterations or reduced level of consciousness • Remember dysfunction may improve as level of consciousness improves   Malnutrition or unintentional weight loss Evaluation Methods  History and examination   Quality and localization can determine between oropahryngeal dysphagia and esophageal dysphagia Assessment of voluntary cough is less useful that a thorough medical history Speech-language pathologist or therapist Direct observation of patient response to various liquids and solids • Also may include utilization of behavioral or compensatory mechanisms in subjective assessment  Speech and swallowing evaluation   Evaluation Methods  Video swallowing evaluation   “Modified Barium Swallow” Fluoroscopic examination utilizing varying volumes and consistencies of barium • Imaging obtained from a lateral view, recorded on videotape • Permits slow-motion play back and visualization of the first 2 phases of swallowing • Recording also allows for review of objective success of dietary interventions and compensatory mechanisms   Best method for visualization of oropharyngeal lesions and structural lesions Good for those with silent aspiration MASS ACHALASIA Barium Swallow Hyperlink http://video.google.com/videop lay?docid=43755308056024 16900&q=Barium+Swallow& hl=en Evaluation Methods  Endoscopic evaluation  Testing of choice for suspected dysphagia of specific esophageal origin • Also useful when no source of oropharyngeal dysphagia is identified on barium studies  Advantages include direct visualization of mucosal lesions, tissue biopsy/cytology Gold standard for esophageal motor disorders Utilized after barium studies and endoscopic evaluation  Manometry   Mechanical versus Motor disorders History Onset Progression Type of Bolus problem Mechanical Disorder Gradual or sudden Often Solid (until very late stage) Motor Disorder Gradual Rarely Solid and/or liquids Response to bolus Typically must be regurgitated No Passes with repeated attempts or drinking liquids Worse with cold liquids, can improve with warm liquids Temperature dependent B A S I C D Y S P H A G I A O R O P H A R Y N G E A L D Y S P H A G I A Causes of Dysphagia  Neurologic Impairment        Cerebrovascular accidents Brainstem tumors Head trauma/brain injury Encephalopathy Parkinson’s Disease Dementia • Alzheimers, fronto-temporal dementia Neuro-degenerative diseases • Huntington’s, multiple sclerosis, amyotrophic lateral sclerosis, Guillain-Barre syndrome Causes of Dysphagia  Infectious   Botulism, lyme disease, syphilis Mucositis • Candida, herpes  Structural   Tumors: gastrointestinal or mediastinal Strictures, esophageal web/rings Medication induced • Sedating medications, neuroleptics  Iatrogenic    Post-surgical: neurologic or anatomic Radiation induced Causes of Dysphagia  Metabolic    Amyloidosis Cushings Thyrotoxicosis Achalasia Connective tissue disorders • Scleroderma, rheumatoid arthritis  Myopathic      Myasthenia gravis Polymyositis Sarcoidosis Medical Complications of Dysphagia   Dehydration and malnutrition Aspiration pneumonia  Mortality rate between 20 and 60%  Pneumonia vs. pneumonitis    Often used interchangeably Pneumonia: results from aspiration of bacteria from the mouth, from poor dentition or wounds Pneumonitis: results from airway inflammation and irritation due to aspiration of acidic contents, seen in adenturic patients. • Increases likelihood of bacterial pneumonia PNEUMONIA PNEUMONITIS Penetration vs. Aspiration  Penetration: food enters into the laryngeal area but not past the vocal cords into the trachea  Aspiration: food into the laryngeal area, then past the true vocal cords into the trachea  Silent aspiration occurs when the dysfunction does not produce cough Social Implications of Dysphagia  Social Isolation  Embarrassment over coughing, dietary restrictions • Pureed foods often equated with baby food  Eating is social activity • People eat more when in a group  Depression  Eating is enjoyable and its loss can be devastating  Family or caregiver guilt  Providing nutrition for your family is seen as a duty and as a sign of love Management Individualized approach  Multi-disciplinary approach recommended   Physician, nurse, pharmacist, speech therapist, occupational and physical therapists, dietician and social services • Studies show decreased aspiration pneumonia, reduction of mortality and reduction of costs with multi-disciplinary approach Goals of Management  Reduction in aspiration Improved swallowing ability   Optimized nutritional status Optimized quality of life  Interventions  Behavioral/dietary modifications  Determination of optimal diet • Thin liquids vs thickened liquids • Improved bolus formation and decreased aspiration  Compensatory maneuvers  Dependent on ability to follow instruction • Chin-down with forceful swallow; chin-up, head-rotated, head-tilted • Dementia DOES NOT preclude use of maneuvers • Supervised eating and prompting can be successful The Evidence?  Studies are not conclusive on the significance of aggressive post-stroke therapy programs  Outcomes favor decreased institutionalization, decreased aspiration and aspiration pneumonia, improved swallowing function and/or recovery of swallowing function  Results mostly do not reach statistical significance BUT  Therapies ARE recommended, evidence is low, but potential benefit is high, with little to no risk to patients (grade level “B”) Interventions  Swallowing exercises  Early stages of investigation • Muscle strengthening exercises: head lifts and swallowing • Biofeedback and electro-stimulation  NOT recommended at this time, evidence is low and benefit is conflicting (grade level “I”) • Electrical stimulation is showing promise but studies have not been completed yet as to benefit vs. risk over current therapy Interventions  Pharmacologic  NO recommendations at this time, further study needed before recommendations are made • Research shows some decrease in aspiration & pneumonia using ACE-inhibitors • Pathway considered is reduction of substance P which may have a role in cough and swallowing sensation • Studies do not control for outside factors • But studies did show a significant difference when compared to calcium channel blockers Interventions  Surgical: aspiration prevention  Measures are radical and in early stages • Laryngectomy with stoma creation • Eliminates pathway of aspiration • Implantable electrode to stimulate swallowing • Triggered by patient when swallowing • Benefit is with liquids over pureed consistencies  Therapies ARE recommended for intractable aspiration only, evidence is low, but potential benefit is high (grade level “B”) ARTIFICIAL NUTRITION  Potentially indicated in high risk patients  Factors: nutritional requirements, patient survival probability, quality of life Short term • Hyperalimentation • Parenteral • Partial parenteral nutrition (PPN): peripheral access • Total parenteral nutrition (TPN): central access required  Short-term vs Long-term  • Enteral • Naso-gastric feeding tubes, Dobhoff tubes  Long term • Percutaneous endoscopic gastromy tubes and jejunostomy tubes (PEG tubes, J-tubes respectively) Factors in choosing artificial nutrition  Caloric requirements generally decrease with age  Lower activity level, decreased lean muscle mass Stress states increase requirements 1.2 – 2 times over basal metabolic requirements • Sepsis: 1.3 times over basic requirement • Post-surgery with cardiopulmonary disease: 1.3 – 1.5 times over basic requirements • Burns: 1.3 – 1.8 times over basic requirements  Stress factors increase nutritional needs  Factors in choosing artificial nutrition  Nutritional needs: calculations  Harris-Benedict Equation • Around since 1919 • Some say it overestimates caloric requirements by 150% • Men: 66 + (13.7 x kg weight) + (5x cm height) – (6.8 x age in years) • Women: 655 + (9.6 x kg weight) + (1.7 x cm height) – (4.7 x age in yrs)  World Health Organization: quick calculaiton • Men: (13.5 x kg weight) + 487 • Women: (10.5 x kg weight) + 596 Factors in choosing artificial nutrition  Nutritional needs: quick reference in hospital Non-stress state: 26-28 kcal per kilogram per day  Stress state: 30 kcal per kilogram per day Daily fluid requirements      Approximately 70% of tube feeding volume is fluid and counts to fulfilling daily requirements Quick estimate: 30cc per kilogram per day Calculation: (100cc x first 10 kilograms) + (50cc x next 10 kilograms) + (20cc x each additional kilogram) Limitations and Complications of Artificial Nutrition  Parenteral  Partial parenteral nutrition • 7 – 10 days only based on osmolality limitations • Major complication is phlebitis/thrombophlebitis  Total parenteral nutrition • Requires daily labs, micro-management of electrolytes/nutrients • Daily lipid, protein requirements can be complex • Major complications include electrolyte imbalances, hyperglycemia, liver function abnormalities, catheter sepsis Limitations and Complications of Artificial Nutrition  Enteral   Data on benefits divided Cancer patients • Some studies show improved weights but no overall improved survival at 4yrs post placement; some show improved mortality at 1yr  Dementia/neurodegenerative patients • No studies show statistically significance benefit in maintaining skin integrity, decreasing aspiration, improving functional status or prolonging of life • Minimal benefits were offset by impact on quality of life • Increased need for restraints, increased agitation • J-tubes may ultimately provide statistically significant decrease in aspiration, improved quality of life Limitations and Complications of Artificial Nutrition  Enteral  Cultural considerations • Differences exist in populations who get feeding tubes • Most likely patient: younger, non-caucasian, male, recent decline in status  Palliative care considerations • Those more likely to have feeding tube placement • Those without advanced directives • Those with intact mental status after stroke • PEG tubes preferable to NG tubes due direct impact on swallowing recovery, social considerations THE ETHICAL DEBATE  Are people dying because they are not eating or are the not eating because they are dying?  Studies suggest over 60% terminally ill patients did not experience hunger or thirst  Are patients deprived of social interaction and the pleasure of eating?  Studies suggest that quality of life and happiness improve for the family and caregivers more so than the patients THE ETHICAL DEBATE  Are patients more likely to suffer with or without feeding tube placement?  20-40% of patients with feeding tubes still aspirate • Progression to pneumonia and respiratory distress unknown and dependent on multiple factors like patient oral health  Average time from feeding tube placement to development of complication was 7 – 8months THE ETHICAL DEBATE  Is the benefit to risk ratio worth the placement of feeding tube?  Studies are indeterminate and timing appears crucial • ALS patients with placement once vital capacity drops below 40% have a 10% increase in 30 day mortality over those without placement. Those with placement with a vital capacity greater than 50% had a 0% increase mortality • Review of hospitalized patients 65yr and older showed 20-25% mortality rate at 30 days after placement, 60% at one year, 75% at 3-5 years Main Consideration in Artificial Nutrition  PATIENT WISHES what the patient wants the patient gets  Patients who are competent have the right to selfdetermination no matter the opinions of others • Family or physicians  If a patient cannot peak for him or herself, ideally his or her wishes still guide care • Advance directives, conversations with family friends about wishes (substituted judgment)  Fortunately or unfortunately, feeding and hydration are very personal issues and the factors in consideration may not always be objective • “Denying” a loved on nutrition and water may seem unbearable to families References       Carnaby, G; GJ Hankey and J Pizzi. Behavioural Intervention for Dysphagia in Acute Stroke: a Randomised Controlled Trial. The Lancet Neurology, January 2006; 5 (1). Current Diagnosis and treatments in Gastroenterology, 2nd edition (2003). McGraw-Hill, Co., New York, NY. Current Geriatric Diagnosis and Treatment, 1st edition (2004). McGraw-Hill, Co., New York, NY. Current Surgical Diagnosis and Treatment, 12th Edition (2006). McGraw-Hill, Co., New York, NY. Hammond, CA and LB Goldstein. Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines. Chest, January 2006; 129 (1). Lind, CD. Dysphagia: Evaluation and Treatment. Gastroenterology Clinics of North America, 2003; 32: 553-575. References      McClave, SA and CS Ritchie. The Role of Endoscopically Placed Feeding or Decompression Tubes. Gastroenterology Clinics of North America, 2006; 35: 83-100. McMahon, MM, et al. Medical and Ethical Aspects of LongTerm Enteral Feeding. Mayo Clinic Proceedings, 2005; 80: 1461-1476. Miller, SJ. Parenteral Nutrition. Us Pharmacist website: www.uspharmacist.com. Odnall, N. IMAGEBASE. Radiology website: www.eradiography.net. Saud, BM and RD Szyjkowski. A Diagnostic Approach to Dysphagia. Clinics in Family Practice, September 2004; 6 (3).