nsha 15 treatment -...

NSHA 2015 Convention, J. Coyle, PhD, Treatment

03/20/2015

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Dysphagia Treatment: What are We Doing, and Why?

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James L. Coyle, Ph.D., CCC‐SLP, BCS‐SUniversity of Pittsburgh

[email protected]

NSHA Convention, 2015; Las Vegas, NV

Disclosures

• University of Pittsburgh (salary)

• NSHA honorarium

• Continuing education

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3

speaking Pittsburghese


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What is treatment?

• Are we treating the bolus, the patient, or something else?

• Agenda:• Common interventions and their effects

• Thick liquids and Water protocols

• Managing the aftermath of mechanical ventilation

• How to decide?

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TreatmentAttributes of Groupings

Structural Tissue

Properties

Organ function

Skilled performance

Cognitive/ affective

representations

Targets Size, shape, flexibility

Output, efficiency, etc.

Speed, efficiency Knowledge, change attitude

Mechanism of action

Remodeling of tissue

Habituation, substitution

Learning Affective processing

Essential ingredient

Apply energy to tissues

Change in output

Facilitation of performance

Facilitate acquisition

Active ingredients

Types of energy applied

Patient effort, motivation

Instructions, guidance, feedback

How knowledge is organized, learned

by patient

Dosing parameters

Amount, intensity,

progression

Methods to enhance effort, motivation

Progression, schedule (intensity, dosage)

Amount of information/time, repetition, rehearsal

Examples Muscle enlargement

Strengthening, plasticity

Swallowing training, control

Pt education, counseling, referrals

Hart et al., 20145

Goals and objectives

• Goals: the end point we seek to attain in treatment

• What is our Goal?• Eliminate aspiration?

• Cause patient to swallow “better”?

• Least restrictive diet without aspiration?

• Improve biomechanics?

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Consequences of Dysphagia

• Aspiration

• Bolus mismanagement

• Pneumonia

• Malnutrition

• Premature mortality

Objectives

Goals

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Selecting goals/objectives

• Treatment decisions require accurate diagnosis• The observation always has a cause

• …and if we miss it, we treat a symptom and not its cause

• Pneumonia is multifactorial

• Aspiration pneumonia incidence is relatively low!

• Perfect swallowing is often not feasible

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Justifying Treatment

• Is there a reason to believe that:• Dysphagia will cause/has caused health problems?

• Current function is worse than prior function?

• Selected intervention will likely improve health/function?

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• Objective measure of change(+ or ‐) ?• Incremental reassessment

• Data collection – are we doing it?

• Termination criteria?

• Would I (we) pay for this out of pocket?

• Is patient a good candidate for selected behavioral interventions?

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Justifying Treatment

Strategies & Tactics

• 1. Eliminate aspiration

• 2. Train airway protection

• 3. Increase compliance

• 4. Speed recovery

• 5. Retest, modify independence

• 6. Etc.

Tactics short‐term goals




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Strategy LONG‐TERM GOALHEALTHIER PATIENT


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Some Common Interventions…

• They are designed for this…• Intended consequences

• But they also do this…• Unintended consequences

• Sometimes good…

• Sometimes not so good…

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Some Common Interventions… compensate…

1. Head rotation posture* ‐ divert bolus Directs bolus to opposite side of pharynx Compensate for unilateral noncompliance

BUT IT ALSO: Increases UESO diameter (rotation to either side in normals)

Reduces UES pressure (either side, normals)

Increased intrabolus pressure Reduces contralateral pyriform sinus pressure**

14*Logemann et al (1989); **Takasaki et al., 2012


• 2. Chin‐down posture*‐ reduce aspiration• Patients with aspiration due to “pharyngeal delay”

• 50% did not aspirate with CDP (OR = 0.5)• Continued aspirators: pyriform sinus residue aspirated• Valleculae widened

• Anterior bolus position (phar. delay, oral containment)

• BUT IT ALSO:• Reduces intrabolus hypopharyngeal pressure**

• Contraindicated in patient with weak constrictors

15*Shanahan et al. (1993); **Bulow et al (2002)


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Oral containment vs. delay?

• Pharyngeal delay• Abnormally long pause between volitional oral transit of an organized bolus and onset of hyolaryngeal excursion

• Oral containment impairment• Loss of posterior bolus containment (tongue & soft palate); unorganized material enters pharynx before hyolaryngeal excursion

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Pharyngeal Delay

Impaired oral containment

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•3. Head/neck lateral flexion posture

• oral flow diversion toward side of flexion

• unilateral lingual, oral/facial motor, sensory deficits

• It does not affect pharyngeal physiology

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• 4. Increase duration of UES opening*• Mendelsohn Maneuver

• maintains prolonged HLE

• BUT IT ALSO:• Is difficult to teach, difficult to perform

• SEMG biofeedback training improves treatment effect* **

19*Logemann et al (1990); ** Coyle (2008)

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First VisitBaseline (A-1)

Second VisitPost-Treatment (B-2)

2‐Standard Deviation Band Sample Graphic

2 SD Band Test: p<0.05;C Statistic: p=0.00001.

p<0.05

UES OpeningDuration

seconds


• 5. Self‐protection of airway• Supraglottic swallow (SGS)

• Closes airway before swallow• “super SGS”

• “effortful” vocal fold closure +Tilts arytenoids

• Earlier/longer UES relaxation and HLE* **

21*Bulow et al (2002); **Ohmae et al., 1996;


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• Does the work of 3 other interventions• Increased intrabolus pressure*• Increase UES Opening and laryngeal closure*• Reduced oral residue*

• And can be Dangerous!!!• Produces arrhythmia in certain patients**

22*Bulow et al (2002); **Chaudhuri et al. (2001)

BUT IT ALSO:


Swallow respiratory coordination

• Healthy swallows followed by exhalation• Disordered swallows followed by inhalation

• Training patients to coordinate breathing and swallowing?

23Gross et al, 2009; Leslie et al, 2002a,b; Leslie et al, 2005

• 6. Tongue holding/tether• Bulge in PPW during swallow

• Inhibits tongue motion

• Increases oral residue in normals

• BUT IT ALSO:

• Is not intended for use by patients when swallowing!

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Fujiu & Logemann (1996)



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• 7. Bolus modification• Larger bolus

• Earlier HLE, tongue movement, UES opening*

• Taste, temperature, consistency• Earlier activation in some patients**

• Will patient eat/drink it???

25*Cook et al., 1989; Dantas et al., 1990; **Ding et al., 2003


• And when we combine maneuvers we treat multiple problems

• …but we need evidence that each is appropriate for the impairment

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What about texture modification and Water?

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Diet modification

• Should be the last compensatory method evaluated in testing

• Logemann, 1993

• Issues:• What does texture modification do for patient?

• Is patient amenable to modification?

• Will patient eat the prescribed diet • Malnutrition, dehydration

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Diet modification

• Assuming that behavioral/compensation fails

• Increasing friction and reducing flow rate (thick)• When pharyngeal stage is delayed and dangerous

• Oral containment cannot be otherwise managed

• Some times when laryngeal closure is incomplete

• Decreasing friction and increasing flow rate (thin)

• Inability to propel bolus• UES does not distend adequately• Need good airway protection

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Thickened liquids

• Reduces aspiration of thin liquids• Kuhlemeier et al., 2001; Logemann et al., 2008

• Swallow apnea later/longer with thick liquids• Hiss et al., 2004; Butler et al., 2004

• More effort needed to clear thick• Nicosia et al., 2001

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Thick liquids

• Thin liquids aspirated most frequently• Compared to other viscosities

• Spawned experimentation with thick liquids

• Theory for dysphagia use:• Slowing the flow

• Compensates for mistimed airway closure

• What do we know about them?

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Water

• Intake of water: ~2300 mL per day• 2100mL through intake• 200 mL synthesized by body (CHO metabolism)

• Variations in water intake• Climate, habits, physical activity

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Thickened liquids

• Patients do not like thick liquids• Garcia, 2005: prepackaged vs. mixed

• Prepackaged better : Whelan, 2001

• Great variability in thick liquids• Prepackaged & mixed: UW/VA Swallowing Research Lab, 1999

• Prepackaged: Garcia, et al., 2005; Steele, 2005

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Do thickened liquids cause dehydration?

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Thickened liquids

• Hydration and thick liquids• Sharpe et al., 2007

• >95% water absorbed from thick mixtures

• No difference between water, thick water

• Hydration and thick liquids• Reduced fluid intake when thick prescribed

• Whelan, 2001: 24 stroke patients

• Mean fluid intake = 455 mL/day

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Whelan, 2001,Finestone et al, 2001

Thick liquids

• Protocol 201 (Logemann et al., 2007; Robbins et al., 2008)

• Problem: Thin liquid aspiration

• Chin Down Posture vs. Thick liquids• Nectar, honey

• Parkinson’s disease, dementia, both

• Part 1: liquid aspiration prevention

• Part 2: pneumonia incidenc

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Aspirate thin liquids on VFS (711)

VFS: 1. Thin/chin 2. Nectar

3. Honey

Aspirate thin liquids on VFS (711)

VFS: 1. Thin/chin 2. Nectar

3. Honey

Eligible, consent: VFS

PART 1:Do thick liquidsor chin‐down

posture preventaspiration?

Thin liquid Thin liquid‐chin‐down

Nectar Honey

Aspiration 100% 68% 63% 53%

Preference 1st 2nd 3rd last

Part 1 Results

Aspirated on one or two interventions

Aspirated on NONE OF THE interventions

N=177

Aspirated on ALL OF THE interventions

N=346

Enter Part 2

Do not enter part 2

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N=177


N=346

PART 2:In liquid aspirators, which has lowest

pneumonia incidence:Thin/CDP?Nectar?Honey?

3 month randomized study

Thin/Chin259

Nectar133

Honey123

Pneumonia

Death

Secondary Outcomes

3 months

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N=177


N=346

Results of Part 2

Thin/Chin259

Nectar133

Honey123

52Pneumonia

(11%)

Death

Secondary Outcomes


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Pneumonia

Chin‐thin All thick liquid

Nectar Honey

Aspirated none in

Part 1 (10)6 (7%) 4 (5%) 0 (0%) 4 (10%)

Aspirated all 3 in

Part 1 (42)18 (9.8%) 24 (14%) 10 (11.5%) 14 (19%)

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Thick liquids

• Other results• Dehydration: Thin: 2%, Thick: 6%

• UTI: Thin: 3%, Thick: 6%

• Median hospital stay with pneumonia

• Honey (18 d.), nectar (4 d.), CDP (6 d.)

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Thick liquids

• Do thick liquids reduce aspiration?• Yes

• Do thick liquids reduce pneumonia risk?• No

• Are aspirators more likely to get pneumonia?• Yes

• Do patients like thick liquids?• No

• Will they drink it if they don’t like it?• Probably not

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Thick liquids

• So, what are we doing when we prescribe thick liquids???

• We think we are reducing risk…

• Are we just shifting risk to a different place?• Hydration kidneys? QOL?

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Evidence Summary for using Free Water Protocols

“Free Water” Protocols

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• Rationale of protocol per developers:• 1. Need for hydration – self evident

• 2. Poor compliance with thick liquids

• We have reviewed that data

• 3. Safety of water aspiration

• One study published before 2008!!!

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“Free Water Protocol” Principles


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Safety of water aspiration

• Bronchoalveolar lavage

• Whelan et al. (2001) reduced fluid intake in patients prescribed thick liquids

• Numerous citations on dehydration in dysphagia

• Animal studies of water aspiration

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Evidence: one study before 2008

• Garon et al., 1997• 20 aspiration‐documented CVA patients

• Aspirated liquid only on VFSS

• Randomized to free water or no free water

• Duration: treatment + 30 day follow up

• Small and underpowered study• Yet the main evidence for protocol

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• Results• No patient in either group developed pneumonia

• No dehydration, complications

• Intake of fluids comparable between groups

• 1210 mL (C) ‐ all thick• 1318 mL (E): 855mL thick, 463mL thin

• “Much less water than expected” by investigators (“we were surprised…”)

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Half of daily needs


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Water Protocol Evidence

• Randomization to water protocol or prescribed dietary fluid (26 patients)

• 17 patients requiring feeding assistance• 8 assigned to control, 9 to treatment

• 9 independent feeding patients• 3 assigned to control, 6 to treatment

• All received oral care four times per day

• Outcomes: pneumonia, death, UTI, FIM, LOS, intake

Becker, et al., 2008

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• Results• Pneumonia: 1 patient in each group

• UTI: 2 patients in each group

• FIM: no significant difference

• FCM: no significant difference

• Length of stay: 29.1 days (control) vs. 15.8 (tx)


50Becker, et al., 2008


• Death: 2 treatment deaths, no control deaths

• Both patients that died had chronic pulmonary conditions

• Other findings:

• Independent patients consumed significantly less fluid than dependent patients (p<.01), regardless of group

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Recent Evidence

• Karagiannis et al. (2011)

• Significant increase in lung complications (6/42) vs. controls (0/34)

• Carlaw et al. (2011)

• No complications in either group

• More fluid intake in “protocol” patients

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Using the /k/ phoneme

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Perlman et al, 1989

Modified Valsalva:“make a /k/ as hardas you can and holdit for as long as you can, don’t let anyair escape.”

Hawk:“say the word ‘hawk’,make the /k/ as hardas you can.”

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“Hawk”, modified valsalva produced ~20% of muscle activity seen during swallow


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Carbonated thin liquid

• Order effects**?

• Command swallow effects***?• Cued swallows significantly shorter duration

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*Bulow et al., 2003; ** Robbins et al, 1999; *** Daniels et al., 2007

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NMES

• Most studies contain flaws• Most frequent

• No control for recovery• Lack of blinded judges• Subjective criteria for “success”

• Recent work with transoral NMES to pharynx• Interesting, need more data

• Patient selection? What are we treating?

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• “This preliminary meta‐analysis revealed a smallbut significant summary effect size for transcutaneous NMES for swallowing. Because of the small number of studies and low methodological grading for these studies, caution should be taken in interpreting this finding. These results support the need for more rigorous research in this area.”

• Small = clinically insignificant

• Low grading = invalid results

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Carnaby‐Mann & Crary, 2007


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End of life intervention

• What is the goal?

• Medicine tries to achieve the best balance of risks and benefits to achieve the goal

• Patient comfort vs. adverse outcomes?

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Feeding tubes?

• Unequivocal lack of benefit • At end of life

• In advanced dementia

• Imposes additional (and unintended) risks

• Increased aspiration risk from stomach

• Does not mitigate oral aspiration

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What’s going on in the research?

• Exercise• Plasticity

• Diagnostic methods to assist with treatment

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Restorative methods

• Emerging efficacy in the literature

• Exercise‐Preventive, Restorative, beyond?• physiologic logic, predicted baseline, target

• muscle strengthening requires repetition to modify contractile properties (hundreds, thousands…)

• Do range of motion exercises do anything?

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Exercise

Tongue Press exercise

• AKA tongue press exercise• Device assisted with biofeedback

Lingual Strengthening Exercise

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Testing/measurement Exercise protocol

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Significant Differences

• Reduced oropharyngeal residue• Pharyngeal (p = .03), overall (p = .01 ‐ .02)

• Improved PA scores (3mL, 10mL liquid)• 4 weeks: p = .02; 8 weeks: p = .005

• Increased isometric pressure• Anterior 4‐8 wk:(p = .001); posterior (p = .01, .001)

• Increased swallowing pressure• All consistencies/volumes at 4, 8 weeks.

Lingual Strengthening Exercise

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Restorative Methods

• Exercise• Resistive expiratory exercise

• Increase force of expiratory effort

Sapienza et al.

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• “Shaker” exercise*• Head‐Neck flexion while supine

• Increase AP dimension of UES during swallow

• “Eliminated tube feeding in stroke patients”**

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*Shaker et al (1997), **Shaker et al (2002);

Restorative methods


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• Sham (7) vs Real (11)• No significant difference in any biomechanical measures

• 11 real exercise pts. Pre‐ Post Real Exercise• AP UESO, anterior laryngeal excursion (ALE), all significantly increased from own baseline

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Jaw Opening Exercise

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Fig 1 10 seconds, 5 repetitions with a 10‐second rest period between each, 2 sets daily.

Wada, S., Tohara, H., Iida, T., Inoue, M., Sato, M., & Ueda, K. (2012). Jaw‐Opening exercise for insufficient opening of upper esophageal sphincter. Archives of Physical Medicine and Rehabilitation, 93(11), 1995‐1999.

http://dx.doi.org/10.1016/j.apmr.2012.04.025

Jaw Opening Exercise

Significant increases (p<.05): ‐Vertical hyoid motion‐UES opening diameter, ‐Pharyngeal transit duration

Near significant (p=.05)‐anterior hyoid motion

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• “Exercise based intervention specific to swallow activity”

• Swallow hard in a single swallow

• Systematic increase bolus volume, consistency as eating rate increased

• Homework (eating what was used in treatment)

• Record keeping at home

• FOIS, MASA, patient self‐rating

• Kinematic analysis

70*Crary et al., 2012 (above); Carnaby‐Mann et al., 2010 (N=8); Lan et al. (2012) N=8

McNeill program

• Statistically significant increases in all measures after treatment

• Marginal maintenance at 3 months in physiologic measures

• Clinical significance (Effect sizes ‐ Hedge’s g)• MASA 0.94

• FOIS 1.42• VFS 0.18• VAS 1.26

• N=9

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Measure Baseline Post‐treatment

Post tx 3 months

Significance measure

g P g P

MASA 0.94 <0.02 0.13 0.67

FOIS 1.42 0.01 0.74 0.17

VFS 0.18 0.37

VAS 1.26 <0.01 ‐0.21 0.38

LP pressure 0.05 NS72


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• Thermal Tactile Stimulation

• Thought to stimulate afferent pathways *

• No evidence supports sustained effects• High dosage over long term produced momentarily quicker onset of HLE (reduced DST)**

• Taste‐sour bolus (50% lemon juice/barium)

• Reduced aspiration in neuro patients***

• Reduced DST in stroke patients***

73*Fujiu et al. (1994); **Rosenbek et al (1991, 1996, 1998); ***Logemann et al (1994)

Facilitative Methods

Facilitative Methods• Interest in manipulating other sensory modalities

• Taste, vibratory sense, electrical stimulation (?)

• Can the brain be rewired in adults?• Emerging evidence that “something” is happening upstream

• MEG, EEG (record the effects), MRI

• TCMS (stimulate motor effects)

• Direct current stimulation

• Exercise

• Implantable intramuscular ES

Jayasekeran et al., 2010, 2011; Pelletier & Lawless, 2003; Malandraki et al., 2011 74

• What is plasticity?• Alteration in the outcome

• Motor learning theory?• Mass practice

• Dosage, intensity, progressive resistance + (other increments)

• Task specificity• Neural adaptation

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Stimulation of the brain?!?!?!

• Transcranial stimulation• Magnetic fields

• Direct current

• Peripheral (pharyngeal)

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Managing the Aftermath of Prolonged Mechanical

Ventilation

Mechanical Ventilation

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Central drive

Peripheral neuromuscularintegrity

Muscular integrity

Obstruction/ Compliance

“Cage” Restriction

Ability to move air

neuromuscular junction

Mechanical Ventilators

• Two primary functions

• Replace the work of pumping air into the lungs• Workload exceeds patient’s capacity

• Ventilatory support increases respiratory surface area

• Increase oxygenation• Room air FiO2 insufficient to oxygenate

• Respiratory support

• Increased ventilation should increase oxygenation and decrease CO2 retention

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• Nature of respiratory failure• Impaired surface area?

• Patient may have insufficient diffusion capacity

• Impaired workload capacity?• Patient cannot perform the work of breathing

• Combined?

• Weaning involves restoring workload of breathing to patient, while diffusion capacity improves

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Mechanical Ventilation• Initial treatment for respiratory failure

• Increase FiO2

• Beyond 100%, mechanical support required• Endotracheal tube or tracheostomy with cuff is required to prevent leakage

• Noninvasive mask methods increasingly popular

• Excess secretions, chest/facial trauma, altered MS, unable to participate with less invasive ventilation (CPAP via nasal, oral mask), hemodynamically unstable

82*pressure support

Mechanical Ventilation Methods

• 1. Positive pressure ventilation (PPV)• “Inflate lungs from inside (blow them open)”

• Volume cycled: preset volume, pressures may vary

• Pressure cycled*: preset pressure, volume may vary

• Time cycled: preset inspiratory, expiratory phase dur.

• 2. High Frequency Ventilation• Small tidal volume per cycle

• Lungs too noncompliant – high pressure risks barotrauma

• 3. Negative pressure ventilation• iron lung, rocking bed, etc.

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84Downloaded from: StudentConsult (on 6 July 2006 12:08 PM)

© 2005 Elsevier


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• Complications of PPV• Barotrauma (alveolar damage, excessive pressure)

• Atelectasis (alveolar collapse, insufficient P a)

• Infection

• ETT, tracheostomy: direct inoculation route for nosocomial pathogens

• Respiratory disuse (deconditioning)

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Ventilator Variables(parameters)

• Minute ventilation (Rate x TV)• Determines CO2 elimination

• Inspiratory duration: alveolar recruitment

• FiO2: % oxygen in inspired air

• PEEP: keeps alveoli “open” longer’• A lower FiO2 can be maintained

• Chronic hypercapnia: Hypoxemia becomes primary respiratory drive

• Excess FiO2 can eliminate respiratory drive

• IPAP, EPAP

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• Modes

• Volume dependent modes• Specific volume is delivered over a set duration

• Necessary pressure depends on system compliance

• Pressure dependent modes• Specific pressure is applied over a set duration

• Necessary volume depends on system compliance

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• Volume Modes‐ simpler modes• Preset tidal volume delivered

• Machine (control) or patient (assist) triggered• Pressure or flow

• Backup rate is preset in event pt. does not breathe

• Parameters (5)• Ventilation parameters: Backup rate, TV

• Oxygenation parameters: cycle duration, FiO2, PEEP

• Patient does little work

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• Pressure Modes‐more complex• Constant inspiratory pressure is preset

• Can be machine (control) or patient (assist) triggered

• Parameters:

• Parameters (5)• Ventilation parameters: Backup rate, Insp. Pressure level

• Oxygenation parameters: I/E ratio, FiO2, PEEP

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• Hybrid modes

• IMV (intermittent mandatory volume)• Machine adds control breaths between patient breaths, regardless of patient spontaneous rate

• SIMV – machine breaths synchronized with patient’s

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• More modes• Who/what initiates each breath?

• Control mode ventilation (CMV)• Ventilator does everything

• Patient is sedated to avoid injury due to resistance

• Assist/control modes• Control ‐ vent. cycles on if patient does not breathe

• Assist – vent. cycles on when patient initiates a breath

• Small breathing workload but can hyperventilate

• Usually set below patient’s RR

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• Specific Common Ventilator Modes• 1. Assist‐Control mode

• User sets TV, FiO2, PEEP, I/E ratio, pressure limit

• Patient or timer triggered (timer backup)

• Vent assists patient

• Not synchronized with patient effort

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Pt. triggered Timer triggered

Volume limiter

• 2. Synchronized Intermittent Mandatory Ventilation• Same user parameters as ACMV

• Patient breathes between vent assisted or controlled breaths (synchronized with patient effort)

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Vent triggered (no pt. effort)

Vent assistPatient triggeredbreath


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• 3. CPAP‐ continuous positive airway pressure

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Pt. triggered

Restingexpiratorylevel)

• 4. Pressure Control Ventilation (PCV)• Preset rate, pressure is limiter

95

• 5. Pressure Support (Assist) Mode

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High End Life Support

• ECMO• Extracorporeal membrane oxygenation

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After Mechanical Ventilation

• Weaning

• Prolonged endotracheal intubation

• Ventilator associated pneumonia

• Clinical evaluation of tracheostomy patients

• Instrumental Testing

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• Ventilator Weaning

• Upper airway function must be intact• Often the question we are asked to answer

• When patient can:• Maintain SaO2 >90%, and

• Maintain pH 7.35‐7.40, and

• Weaning index <105• Resp. rate (BPM) /TV (L)

• E.g. RR=30, TV=0.5L; 30/0.5 = 60

• At FiO2 of <50% and PEEP < 5 cmH2O

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• Spontaneous breathing trial (SBT)• Either T‐piece or CPAP mode, 5 min/hour, increase by 5 minute increments

• One hour rest between trials

• Independent for several hours…

• Ready to extubate

• Or…Wean off SIMV by reducing mandatory backup breaths

• Or…wean off PSV by reducing PS level

101

Weaning Protocols

102Hall, Schmidt, & Wood, 2004 (Ch. 44)


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Weaning

103Alia & Esteban (1999)

Complications

• ETT‐related • malfunction, mucus plug, leak, position

• Self extubation

• Mucosal necrosis

• Pneumonia

• Laryngeal edema

• Tracheal erosion

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Complications

• Ventilator‐related• Alveolar hypo‐ hyperventilation

• Hypotension

• Barotrauma• Pneumothorax

• Diffuse alveolar damage

105


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After Mechanical Ventilation

• Weaning

• Prolonged endotracheal intubation

• Ventilator associated pneumonia

• Clinical evaluation of tracheostomy patients

• Instrumental Testing

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Prolonged Intubation

• Definition• Generally, >24‐48 hours

• Dependent on other host risk factors• Age, method of intubation, underlying disease

• >24 hours (frail elderly)

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Prolonged Intubation

• Evidence• Ajemian et al., 2001

• 48 patients > 48 hours intubation, < 48 hours extubated

• 27/48 (56%) aspirated, 12/27 (44%) silent aspiration

• 19/27 thin liquid aspirators, 9/27 puree

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• El Solh et al., 2003• 42 elderly, 42 nonelderly; all > 48 hours intubation

• FEES at 2 days post‐extubation, and 5,9,14 days (aspirators)

• 22/42 elderly, 15/42 non‐elderly, aspiration

• 13% elderly persistent dysphagia after 2 weeks• 0% non‐elderly)

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Examination considerations

• Medication timing and the evaluation• Assess patient functions r/t recent medications

• Bronchodilators, sedating medications, anxiolytics

• Timing of “breathing treatments”

• Duration of endurance• Can influence meal duration/frequency

• Patient who is “safe” for short periods

• Mix and match• The above parameters can be flexibly manipulated

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Other adaptations

• Observe all important vital signs• Respiratory rate in context of…

• Oxygen saturation• Pulse oximetry does not help with dysphagia assessment; identifies hypoxemia over longer periods

• Endurance/fatigue• Speaking, feeding, etc.

• Overall mental status

• Can the rate be brought down, temporarily?• i.e. the duration of a “meal”

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Recent developments

• Mobilization during intubation

• Noninvasive Mechanical Ventilation

• BiPAP/CPAP and feeding controversy

112

Summary of Proposed Effects That Determine Therapeutic Effects of High-Flow Nasal Cannula.

Ward, J. J. Respir Care 2013;58:98-122

(c) 2012 by Daedalus Enterprises, Inc.

Upper airway pressure versus time scalar of a subject using a high-flow nasal cannula.




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115

Kelley's Textbook of Internal Medicine Table of Contents > PART 8 ‐ PULMONARY AND CRITICAL CARE MEDICINE > SECTION III ‐ DIAGNOSTIC AND THERAPEUTIC MODALITIES > Chapter 390 ‐ RESPIRATORY THERAPY TECHNIQUES

Bench evaluation comparing FIO2 delivered by high-flow nasal cannula (HFNC) versus reservoir mask.



Should this patient be eating?

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Tips for Using Your CPAP/BIPAPA few helpful tips for using your CPAP/BIPAP machine safely and comfortably.Related: How CPAP Units WorkAvoiding 10 Common CPAP ProblemsWhen should I use my CPAP/BIPAP?Wear your CPAP/BIPAP whenever you sleep, including naps. You have sleep apnea whether it is day or night. Also this will help you get used to the cpap/bipap.CPAP/BIPAP must be worn every night to be effective. Symptoms may return if any nights are missed.Take your CPAP/BIPAP with you when you travel, or are admitted to the hospital.CPAP/BIPAP Safety

Do not eat or drink while using your CPAP/BIPAP. You are likleyto inhale the food or drink into your lungs.Avoid eating large meals one to two hours prior to using your CPAP/BIPAP.Using a humidifier

Using a CPAP/BIPAP humidifier may help improve some nasal symptoms by providing warmth and moisture to the air.Only use distilled water.Humidifier units should be placed below your head to avoid condensation into your mask and tubing while you sleep.Empty your humidifier chamber before moving your unit to ensure the water does not enter your motor.©2014 Respicair PC, all rights reserved.

766 Main Street, Niagara Falls, NY 14301. (716) 278-0204

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Pt education handout

• USE OF CPAP OR BIPAP

• The respiratory therapist or technician will help you get used to wearing the mask. Some people feel claustrophobic(a trapped or closed in feeling) at first, because the mask needs to be fairly snug on your face.

• It may help you to get used to the mask gradually, by first holding the mask loosely over your nose or mouth using a low pressure setting on the machine. Gradually the mask can be applied more snugly with increased pressure. You can also gradually increase the amount of time the mask is used.

• People with sleep apnea will use the mask and machine at night when they are sleeping. Others, like those with ALS or other breathing difficulties, may need the CPAP or BIPAP all the time.

• If the first mask you try does not fit well, or is uncomfortable, there are other types and sizes that can be tried.

• If you tend to breathe through your mouth, a chin strap may be applied to help keep your mouth closed (if you are using a nasal mask).

• The CPAP and BIPAP machines have alarms that may sound if the mask comes off or develops a leak.

• You should not eat or drink while the CPAP or BIPAP is on. Food or fluids could get pushed into your lungs by the pressure of the CPAP or BIPAP.

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• Questions?

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Hype & enthusiasm

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Evidence. What is Evidence?

Smith et al., 2003123There is no evidence that parachutes prevent injury or death


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“… significant inverse relationship between pirates and global temperature.”

p<0.05!!!

A Little Data Can Be a Dangerous Thing…

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Tactic 1 Tactic 2 Tactic 3

Strategies

STG

Improved Health, Reduced RiskLong‐termGoals

NewEvidence!

PriorEvidence!

How to decide?

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Evaluating the evidence

• PEDro

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Summary

• Treatment is guided by accurate diagnosis

• Strategies are guided by many factors

• Tactics are scaffolded to make a strategy

• Evidence is essential• Generate your own evidence!

• Evidence consumers are the customers!

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Thank you

[email protected]

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Questions?

nsha 15 treatment -...

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