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

2. 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”.

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

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

5. 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?

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

7. 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).

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

9. 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)

10. Measures of Swallow Safety1
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)

11. Bedside Swallow Exams Nurse versus SLP Testing process Predictability
Feeding Choices

12. 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.

13. 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 = , p = 0.017). Isolated incomplete labial closure did not affect the odds of aspiration (p > 0.05).

14. COUGH

15. 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.

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

17. Leicester Cough Questionnaire

18. 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.

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

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

21. 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

22. 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

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

24. This is not Incentive Spirometry

25. RMST Setting (cmH20)

26. Cough Airflow

27. Measurement of Cough at Bedside

28. Contact Information
Christine Sapienza, PhD