Best Practices for Patient Airway Protection “Transforming Healthcare: Best Practices” Christine Sapienza, PhD, CCC-SLP csapien@ju.edu College of Health Sciences Jacksonville University Lahaina, Maui, Hawaii, 2015

Airway Rehabilitation Goals of Airway Rehabilitation: Safety Quality of Life Define the “D’s”, Rehabilitate Leder et al., “We are underestimating aspiration risk in patients who aspirated and overestimate aspiration risk in patients who did not aspirate”.

The Common “Dys” Dysphonia Dysphagia Dystussia * Dyspnea ***

Factors Age Disease Oral Hygiene Medications Silent versus audible Trach vs non Trach

Patient Care, Signs and Symptoms Aspiration Cough Choking Pneumonia What are the patient’s ability to swallow? What are the patient’s ability to clear?

Differential Diagnosis Valve: Laryngeal exam Pump: F/V Loops Patient Perception QOL Find the trigger! *

Swallow function Dysphagia (swallowing dysfunction) can occur from early on in a disease process (Ebihara, et. al, 2003). Most patients are “silent” aspirators with little or no cough response (dystussia). 1997).

Assessment of Dysphagia & Dystussia Dysphagia well-recognized sequelae Oral Pharyngeal Esophageal Cough?

Penetration/Aspiration Scale Score Depth to which material passes in the airway and by whether or not material entering the airway is expelled”. Determining at-risk patients. (Rosenbek, et. al, 1996)

Measures of Swallow Safety 1 Contrast does not enter the airway 2 Contrast enters the airway, remains above the vocal folds 3 Contrast remains above the vocal folds with visible residue 4 Contrast contacts vocal folds, no residue 5 Contrast contacts vocal folds, visible residue 6 Contrast passes glottis, no sub-glottic residue 7 Contrast passes glottis, visible sub-glottic residue despite patient response 8 Contrast passes glottis, visible sub-glottic residue, absent of patient response (Penetration-Aspiration Scale; Rosenbek et al., 1996)

Bedside Swallow Exams Nurse versus SLP Testing process Predictability Feeding Choices

Comparing accuracy of the Yale swallow protocol when administered by registered nurses and speech-language pathologists. Warner HL1, Suiter DM, Nystrom KV, Poskus K, Leder SB.

Leder et al., 2013 Participants with incomplete facial symmetry had an odds of aspiration that was 0.76 times the odds of aspiration of those with complete facial symmetry (95% CI = 0.61-0.95, p = 0.017). Isolated incomplete labial closure did not affect the odds of aspiration (p > 0.05).

COUGH

Cough is a mechanism that protects the pulmonary system by generating expiratory airflows that create a “scrubbing” action removing material from the airway. (Leith, Butler, Sneddon & Brian,1990; Smith Hammond, et al, 2001; Pitts et al., 2009). to generate high linear airflow velocities during cough three things must occur: inspiration, vocal fold closure, & forced expiration.

Smith-Hammond Studies Smith Hammond, 2001; Smith Hammond, 2009

Leicester Cough Questionnaire  

Reduced expiratory peak flows during voluntary cough are considered indicative of risk for respiratory complications. This may also be indicative of the mechanics of the pulmonary system (i.e. restrictive lung disease). There is a general “slowing down” of the cough related events. This slowing down decreases the ballistic action of the cough and potentially decreases its effectiveness.

Treatment Options How: Increase load compensation capacity Change peripheral responses, train patient to clear Muscle Force Function Coordination

Intervention Well published, peer reviewed, books, presentations Science Clinical Knowledge Evaluation and Planning Proof of Concept Safety Effectiveness Future Trials

What is RMST? Expiratory pressure threshold training: 4 week program 5 days per week 25 breaths per day Load set at 75% of MEP Describe the program Calibrated deivce consisting of a mouthpiece with a one-way spring-loaded valve against adjustable spring. As long as the threshold pressure is maintained, as air flows through the device. Does not allow for modification of flow rate. Although it primary targ et of this exercise is the expiratory muscles – other biomechanical events spedific to swallow have been observed. Expiratory pressure threshold training: Pressure‑threshold device Spring-loaded valve Not resistance training (physiological load calibrated and imposed) Target muscles: expiratory

General Principles (IMST/EMST) Valve closure via adjustable spring Expiratory or inspiratory force must exceed the pressure valve spring strength for the valve to open As you breathe in/out, the muscle shortens and more muscle activity is needed to keep the valve open There is always a minimum amount of force (equal to the spring strength) required by the muscle during the whole breath Strength training occurs with high intensity exercises for a short time Patient will be asked to breathe in/out, less than 30 times with high loads to the muscles being trained

To Assess Change in Strength Pressure Gauge / Manometer Measures any type of pressure

This is not Incentive Spirometry

RMST Setting (cmH20)

Cough Airflow

Measurement of Cough at Bedside

Contact Information Christine Sapienza, PhD csapien&@ju.edu 904-256-7626