Pulmonary 101 Respiratory Diagnosis and Dysphagia Part 1

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Pulmonary 101Respiratory Diagnosis and
DysphagiaPart 1

• Carol G. Winchester
• BEST Dysphagia Management Services, Inc.
• 888-592-BEST

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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
  lungs.

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

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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.

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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.

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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.

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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.

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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.

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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.

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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).

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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.

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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

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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.
  

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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.

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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.

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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.

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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.

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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.

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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

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Descending into the pharynx
Epiglottis
Vallecular Space
Base of Tongue
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Viewing the laryngeal vestibule
Arytenoid
Arytenoid
Vocal Folds
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Spillage of milk to vallecular space
Ary-Epiglottic Fold
Vocal Cords
Laryngeal Vestibule
Vallecular Space
Vallecular Space
Epiglottis
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Spillage of milk to pyriforms
Pyriform Space
Pyriform Space
Borders of Laryngeal Vestibule
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Milk builds up in the pyriforms
Pyriforms
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Aspiration occurs as milk spills into the
laryngeal vestibule and airway
Milk spills over ary-epiglottic folds and
arytenoids into glottis
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Anatomical Review of the Swallow

• View is endoscopic
• Liquid dyed green for easier viewing
• Airway compromise results in aspiration

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Dysphagia Definition
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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?

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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?

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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?

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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?

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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?

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MBS and Endoscopy Views

• Evaluation of Pharyngeal Stage Dysphagia

Aspiration Via Endoscopy
Aspiration Via MBS
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MBS and Endoscopy Views

• Discrimination of the relationship between
  structure, function, and consistency

Residue and Penetration via Endoscopy
Residue and Penetration via MBS
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MBS and Endoscopy Views

• Visualization of non-barium coated considerations

Copious Secretions in Pharynx
Secretions invisible on MBS
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MBS and Endoscopy Views

• Discrimination of Residue in Pharynx

Residue is Mix of Oral feed and G-Tube Reflux
Residue as seen via MBS
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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)

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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.

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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

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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.

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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

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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.

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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

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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.

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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.

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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.

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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

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Pulmonary Edema

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

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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.

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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.

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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.

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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

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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.

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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.

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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.

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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.

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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.

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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 11 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 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.)

80
Aspiration Pneumonitis

• Aspiration pneumonitis (Mendelsons 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 Rippes 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 _at_ 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 _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

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 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

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 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

113
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114
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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_realwordxt
  ra0218 The Lung Association
• http//www.nlm.nih.gov/medlineplus/ency/article/00
  0140.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?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/
  665
• http//www.respiratoryreviews.com/novdec99/rr_novd
  ec99_asppneu.html
• http//www.emedicine.com/emerg/topic108.htm