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Pulmonary 101 Respiratory Diagnosis and Dysphagia Part 1


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Title: Pulmonary 101 Respiratory Diagnosis and Dysphagia Part 1

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

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
    bodys 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

Upper Respiratory Tract
Lower Respiratory Tract
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 lifegiving 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
  • To eliminate carbon dioxide from the body when a
    person exhales
  • To help maintain body fluids at a stable
    acidbase balance.

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.

How Do We breathe?
  • Air enters through the nose
  • nasal hairs remove large particles from inspired
  • 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
  • Gas Exchange occurs through the alveoli.

The Role of the Diaphragm
  • The diaphragm is the primary muscle of
  • 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.

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.

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.

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
  • 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.

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
  • Problems with the normal gas exchange and blood
    flow in the lungs.
  • Respiratory failure, pulmonary edema, pulmonary
    embolism, and pulmonary hypertension (high blood
  • Bacteria or viruses can cause these diseases that
    affect the membrane (or pleura) that surrounds
    the lungs
  • Pneumonia and tuberculosis (TB).

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
  • Caused by drugs, poisons, infections, or
  • 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.

The Research Supports Looking More Closely..
  • Normal laryngeal valving patterns during three
    breath-hold maneuvers a pilot investigation.Mar
    tin 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

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
    (16) 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.

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
  • People who work in mines may be exposed to radon,
    and in some parts of the U.S., radon is found in

What Causes Lung Disease?
  • Asbestos.
  • Asbestos is natural fiber that comes from
  • The fibers tend to break apart easily, into small
    particles that can float in the air and stick to
  • 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.

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
  • 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

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

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

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

Descending into the pharynx
Vallecular Space
Base of Tongue
Viewing the laryngeal vestibule
Vocal Folds
Spillage of milk to vallecular space
Ary-Epiglottic Fold
Vocal Cords
Laryngeal Vestibule
Vallecular Space
Vallecular Space
Spillage of milk to pyriforms
Pyriform Space
Pyriform Space
Borders of Laryngeal Vestibule
Milk builds up in the pyriforms
Aspiration occurs as milk spills into the
laryngeal vestibule and airway
Milk spills over ary-epiglottic folds and
arytenoids into glottis
Anatomical Review of the Swallow
  • View is endoscopic
  • Liquid dyed green for easier viewing
  • Airway compromise results in aspiration

Dysphagia Definition
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?

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?

Therapeutic Considerations
  • Neurological Function Impaired
  • Have you considered the risks of reduced
    sensation in the mouth, pharynx, or esophagus on
  • 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?

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
  • What effect does medication have on cognitive

Therapeutic Considerations
  • Gastrointestinal Function Impairment
  • Does the patient suffer from an unreported GI
  • Are your techniques worsening the effects of the
    GI complication?
  • Is a combination of cognitive, neurological and
    GI impairments resulting in a silent aspiration?

MBS and Endoscopy Views
  • Evaluation of Pharyngeal Stage Dysphagia

Aspiration Via Endoscopy
Aspiration Via MBS
MBS and Endoscopy Views
  • Discrimination of the relationship between
    structure, function, and consistency

Residue and Penetration via Endoscopy
Residue and Penetration via MBS
MBS and Endoscopy Views
  • Visualization of non-barium coated considerations

Copious Secretions in Pharynx
Secretions invisible on MBS
MBS and Endoscopy Views
  • Discrimination of Residue in Pharynx

Residue is Mix of Oral feed and G-Tube Reflux
Residue as seen via MBS
Chronic Obstructive Pulmonary Disease ( COPD)
  • A term used to describe two closely related lung
  • emphysema
  • chronic bronchitis.
  • Often, people have these diseases together
  • 4th Leading cause of death in the US and the
  • ( Natl. Heart, Lung and Blood Institute, 2005)

Tests for COPD
  • Family and personal history
  • Physical exam.
  • Pulmonary function tests
  • the amount of air in the lung (called lung
  • the rate of oxygen and carbon dioxide exchange
  • the amount of oxygen and carbon dioxide in your
  • 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.

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

  • 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.

  • Some of the air sacs deep in your lungs have been
  • 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

  • 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
  • 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.

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

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
  • Instead of helping to clean the lungs, it causes
    obstruction in the airways.
  • The mucus is thicker and more difficult to cough
  • This provides a means for bacteria to settle in
    the lower airways and increases the risk of

Chronic Bronchitis
  • Chronic bronchitis is caused mainly by cigarette
  • 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.

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
  • 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.

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

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

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
  • 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.

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.

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
  • More than 30 conditions can cause ARDS,
  • severe injuries (trauma),
  • systemic infection (sepsis),
  • pneumonia or shock.
  • ARDS sometimes also develops after extensive
  • Symptoms usually appear within 24 to 72 hours
    after the original illness or trauma.

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

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
  • infection of the heart valves and/or heart muscle
    itself  endocarditis and/or myocarditis.

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.

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
  • 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.

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
    Statesmostly older adultsalready 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.

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
  • 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.

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.

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

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
  • itching
  • eczema
  • hives
  • dark circles under and around the eyes
  • recurring headache
  • shortness of breath
  • wheeze
  • cough
  • diarrhea
  • stomach cramps

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

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
  • Most common chronic respiratory disease of
    children--accounts for 1/4 of school absenteeism.
  • It affects twice as many boys as girls in
  • More girls than boys develop asthma as teenagers
  • In adulthood, the ratio becomes 11 males to

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
  • indirect costs, such as lost work days, of 4.6

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.

Respiratory MRSA
  • The incidence of MRSA has increased in health
    care facilities in the United States since the
  • 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.

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

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
  • other signs of inflammation (warmth, redness,
  • Infection is confirmed by positive cultures from
    sites such as blood, urine, sputum, or wound.

Respiratory MRSA
  • Colonized and infected residents serve as the
    major reservoir of MRSA in long term care
  • 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.

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

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

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

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.

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

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
  • Pleuritic chest pain suggests either pulmonary
    embolism or an inflammatory pleural process.
  • Systemic toxicity evidenced by fever, weight
    loss, and inanition suggests empyema.

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
  • Dispels some myths about protection from
    aspiration with feeding tube placement

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 Rippes
    intensive care medicine. 4th ed. Vol1)
  • (Cassiere HA, Niederman MS. Aspiration
    pneumonia, lipoid pneumonia, and lung abscess.
    Texbook of pulmonary diseases, 6th ed. Vol1.)

Aspiration Pneumonitis
  • Aspiration pneumonitis (Mendelsons syndrome) is
    a chemical injury caused by the inhalation of
    sterile gastric contents

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

Aspiration Pneumonia
  • Pneumonia is an inflammation or infection of the
  • 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.

  • Pulmonary aspiration is an important cause of
    serious illness and death among residents of
    nursing homes as well as hospitalized patients.
  • (Irwin and Rippes Intensive Care medicine, 4th
    edition. Vol1)
  • (Texbook of pulmonary Diseases, 6th edition,
  • (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)

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

Pneumonia Risk following Aspiration of Gastric
  • 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.

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

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
  • Patients who aspirate in upright or
    semi-recumbent position involvement in basal
    segments of the lower lobes

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

Diagnostic Risks
  • Elderly persons
  • Increased incidence of dysphagia
  • Increased gastroesophageal reflux
  • Poorer oral care

Diagnostic Risks
  • Stroke
  • Prevalence of swallowing dysfunction ranges from
  • 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.

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)

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)

Assessing the Risk Clinically
  • Behavior Modification
  • Dietary Risk
  • Medical Management

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

G-Tube / NG-Tube Comparison
  • G-tube more effective in delivering prescribed
  • 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

N-G Tube complications
  • Discomfort
  • Excessive gagging
  • Esophagitis
  • Misplacement
  • Displacement
  • Clogging
  • More appropriate for few weeks placement

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

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

Bacteriology --Community Acquired Aspiration
  • 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

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

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

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

One Patient4 SNF Admissions No
Instrumentation for DysphagiaRespiratory

Select Itemized Cost Assumptions
  • Antibiotic treatment 168.00 for a 14 course of
  • 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
  • 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.

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.

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

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.

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 _at_ 3L 2100.00
  • G-Tube Pump 266.64
  • Wound Care 15,400.00
  • Specialty Beds 1125.00
  • Total Repeat Pneumonia Costs 25,200.04

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.

Costs associated with Stay 3
  • Itemized Costs Associated with Stay 3
  • DX of Fx Hip
  • Liquid thickener per month0. ( 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

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

Costs associated with Stay 4
  • Itemized Costs Associated with Stay 4
  • Dx of Bronchitis
  • Liquid thickener per month120
  • 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

(No Transcript)
(No Transcript)
  • 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.

Reference Websites
  • http//www.lung.ca/copd/anatomy/emphysema.html
  • http//www.e-breathing.com/ Altruis Biomedical
  • http//www.sk.lung.ca/content.cfm?edit_realwordxt
    ra0218 The Lung Association
  • http//www.nlm.nih.gov/medlineplus/ency/article/00
  • http//www.annals.org/cgi/content/full/134/6/487
    Annals of Internal Medicine
  • http//www.emedicine.com/emerg/topic108.htm

Reference Websites
  • http//www.mayoclinic.com/invoke.cfm?idDS00412
  • 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/
  • http//www.respiratoryreviews.com/novdec99/rr_novd
  • http//www.emedicine.com/emerg/topic108.htm
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