Dysphagia: Clinical Management in Adults and Children, 2e

386 Pages·2016·34.04 MB·English

by  Michael E. Groher PhD

DYSPHAGIA
Clinical Management
in Adults and Children
Michael E. Groher, PHD, FASHA
Professor
Truesdail Center for Communicative Disorders
University of Redlands
Redlands, California
Michael A. Crary, PHD, FASHA
Professor, Speech-Language Pathology
Director, Swallowing Research Laboratory
Department of Communication Sciences and Disorders
University of Central Florida
Orlando, Florida
3251 Riverport Lane
St. Louis, Missouri 63043
DYSPHAGIA: CLINICAL MANAGEMENT IN ADULTS ISBN: 978-0-323-18701-5
AND CHILDREN, SECOND EDITION
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Notices
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Library of Congress Cataloging-in-Publication Data
Groher, Michael E., author.
Dysphagia : clinical management in adults and children / Michael E. Groher, Michael A. Crary.—Second
edition.
p. ; cm.
ISBN 978-0-323-18701-5
I. Crary, Michael A., 1952- , author. II. Title.
[DNLM: 1. Deglutition Disorders. WI 250]
RC815.2
616.3′23—dc23
2015009495
Content Strategy Director: Penny Rudolph
Content Development Manager: Jolynn Gower
Senior Content Development Specialist: Brian Loehr
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Printed in United States of America
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Contributors
Second Edition First Edition
PAMELA DODRILL, PHD, CCC-SLP JO PUNTIL-SHELTMAN, BCS-S
Feeding & Swallowing Team Board Certified Specialist in Swallowing and Swallowing
Department of Otolaryngology & Communication Disorders
Enhancement Speech-Language Pathologist
Boston Children’s Hospital Dixie Regional Medical Center
Boston, Massachusetts St. George, Utah
Developmental Therapy Team
HELENE M. TAYLOR, MA, CCC-SLP, CLE
Department of Pediatric Newborn Medicine
Speech-Language Pathologist
Brigham & Women’s Hospital
Dysphagia and Craniofacial Clinic Team Member
Boston, Massachusetts
Primary Children’s Medical Center
Salt Lake City, Utah
v
This book is dedicated to the individuals who have influenced our own work, many of
whom were pioneers in the development and support of the multidisciplinary concept
of dysphagia management. The clinical and translational research that each has pro-
vided has built the foundation for a subspecialty that undoubtedly will continue to grow
and benefit the patients we treat:
Joan Arvedson, Ian Cook, Nick Diamant, Olle Ekberg, Michael Feinberg, Susan Lang-
more, George Larsen, Maureen Lefton-Greif, Jeri Logemann, Arthur Miller, Robert
Miller, JoAnn Robbins, Reza Shaker
And to the members of the first multidisciplinary dysphagia team at a major teaching
hospital, Johns Hopkins:
Jim Bosma, David Bucholtz, Martin Donner, Bronwyn Jones, Haskins Kashima, Patti
Linden, Bill Ravich
And finally, to those who represent a new generation of clinical scientists, many of
whom have influenced our efforts and others with whom we have worked directly.
These individuals and many others whose work we have read and respect will continue
to provide us with important insights:
Margareta Bülow, Susan Butler, Giselle Carnaby, Julie Cichero, Ichiro Fujishima,
Maggie Lee Huckabee, Paula Leslie, Rosemary Martino, Gary McCulloch, Bonnie
Martin-Harris, Cathy Pelletier, David Smithard, Catriona Steele, Koji Takahashi,
and more.
Clinical science can be a slow science. It requires not only dedication to time and
effort, but true commitment to the patients who will eventually benefit from these
efforts. Clinical science is not without setbacks, pitfalls, and flaws. So to those who
engage in clinical science in the name of helping others, we attempt to remember the
words of two prominent world citizens, and we apologize if we convey their words
incorrectly:
First they ignore you,
then they laugh at you, then they argue with you, then you win.
Mahatma Gandhi
It is common sense to take a method and try it.
If it fails, admit it frankly and try another.
But above all, try something.
Franklin D. Roosevelt
With best wishes to all,
M. G. & M. C.
Preface
Welcome to the second edition of Dysphagia: Clinical own biases and insights with anecdotal stories (Practice
Management in Adults and Children! As in any new field Notes in the chapters) given to us by the hundreds of
of endeavor, information accumulates rapidly and subse- patients we have treated.
quently changes our perspectives. This is a good thing in The Table of Contents has been revised based on feed-
the clinical sciences; we continue to add to our understand- back from practicing clinicians and professors involved in
ing of a problem, in this case, swallowing disorders in the care of infants and children. In the prior edition material
children and adults. First and foremost we have updated relevant to infants and children was embedded in chapters
each chapter to reflect new understandings. Access to that also addressed adults. In this edition, infants and chil-
imaging materials and critical thinking cases on Evolve has dren have been assigned a separate section (Part III, chap-
improved. Critical thinking cases that have proven so valu- ters 12-15). We hope that this reorganization might facilitate
able in classroom discussions remain, and new ones to teaching and the comprehension of concepts related to this
highlight different aspects of patient management have specific patient group.
been added. We are pleased to welcome Pamela Dodrill, It is our opinion that dysphagia management is best
PhD, to the list of contributing authors. Pamela has recently taught by illustrating approaches to problem solving. To
moved to Boston Children’s Hospital from the Royal Chil- this end we have tried to avoid being prescriptive in favor
dren’s Hospital in Brisbane, Australia, where she spent 12 of an emphasis on discovering available options for care
years as the senior speech-language pathologist on the dys- and in weighing the risks and benefits of those options. Too
phagia team. She has published numerous papers on pedi- often prescriptive approaches in clinical care take away
atric swallowing issues and is a frequent presenter on this one’s options to solve patient care problems.
topic at international meetings. The successful management of persons with dysphagia
Our focus continues to be for the clinician who wants is accomplished only through the cooperation of numerous
to establish a basic and comprehensive foundation in specialists (see Chapter 1). Although it is well known that
managing infants, children, and adults with swallowing a multidisciplinary approach with these patients is best, this
disorders. The emphasis is on the processes of providing approach also may suffer from failure to coordinate care.
diagnostic and treatment services for persons with dys- Often, the coordination of that care is accomplished by the
phagia, and on the research that supports those services. speech-language pathologist. In this text we have empha-
Because of the comprehensive approach, some details of sized the role of the speech-language pathologist. The roles
diagnosis and treatment will not be fully appreciated after of other disciplines are explained largely in the clinical case
the first reading by novice clinicians, but will be useful presentations within each chapter.
for journeyman clinicians. It is our opinion that the Ultimately, this is a text that highlights the problems of
organization of this text will be an aid to the professor persons with dysphagia and how professionals might
who is providing instruction in dysphagia management at ameliorate their swallowing difficulties. It will become
a basic and advanced level. Aids in teaching include apparent that swallowing difficulty may be secondary to a
access to an extensive library of swallowing examinations large number of medical and sometimes nonmedical (psy-
(on the companion Evolve website); a liberal use of short, chogenic) disorders, and that swallowing problems are
clinically based examples of a myriad of problems associ- more than a physiologic change in the swallowing mecha-
ated with dysphagia; critical thinking case examples nism. The text takes the perspective that being unable to
(Clinical Corner boxes in the chapters); and cases that swallow normally might result in major consequences to
require students to analyze their own decision-making one’s medical and psychological health. Secondary
skills as they integrate historical, clinical, and imaging medical problems such as aspiration pneumonia, undernu-
results using a series of prompts that probe their problem- trition, and dehydration may predispose the patient to
solving skills (on the Evolve website). Unfamiliar terms other complications such as immunocompromise, mental
have been highlighted in bold and defined in an accompa- confusion, or death. Because of this, dysphagia specialists
nying glossary. In addition, we have tried to infuse our must develop a strong background of general medical
vii
viii  Preface
knowledge. The reader should be able to understand or be Managing persons with dysphagia has become a subspe-
alerted to key medical concepts relating to the dysphagic cialty for many health care professionals. For the speech-
circumstance within each chapter, but may have to go language pathologist it is a specialty that has emerged only
beyond this text for more detailed explanations of some within the last 30 years. As clinicians have become more
concepts. familiar with the issues involved in the care of dysphagic
Being unable to ingest one’s favorite foods safely, or persons, clinical and basic science investigators have helped
being unable to eat normally in public, understandably will answer and ask questions that have helped improve the
affect one’s quality of life with the potential for secondary quality of that care. Many of these efforts have come
episodes of depression, anxiety, and social withdrawal. together in a journal (Dysphagia) devoted exclusively
Preparation of special diets is time consuming and in some to dysphagia; a research society that meets annually
cases economically challenging. In short, our lifestyles fre- (the Dysphagia Research Society); and the largest special
quently revolve around mealtimes. Interruptions to these interest division, number 13 (Dysphagia), within the
normal routines are potentially devastating. Therefore treat- American Speech-Language-Hearing Association. There
ments are geared not only to the restoration of physiologic also has been a steady increase of texts with contributions
function, but ultimately to a state of psychosocial normalcy from many disciplines aimed at the pathologic condition,
that was disturbed as a result of a failure to swallow nor- diagnosis, and treatment of persons with swallowing disor-
mally. Care of persons with dysphagia should be viewed as ders. It is our hope that this text will not only add to that
an attempt to rehabilitate lost function as well as prevent number, but also inspire those researchers and clinicians
future medical complications by retaining learned rehabili- interested in dysphagia to continue the quest to improve the
tative strategies. lives of persons with swallowing disorders.
Part I
Foundations
CHAPTER 1
Dysphagia Unplugged
Michael E. Groher and Jo Puntil-Sheltman
To view additional case videos and content, please visit the website.
CHAPTER OUTLINE
What Is Dysphagia? 1 Neurologist 12
Incidence and Prevalence 3 Dentist 12
Prevalence by setting 3 Nurse 12
Consequences of Dysphagia 8 Dietitian 12
Medical consequences 8 Occupational therapist 12
Psychosocial consequences 8 Neurodevelopmental specialist 12
Clinical management 9 Pulmonologist and respiratory therapist 12
Clinical examination 9 Levels of Care 13
Imaging examination 9 Acute care setting 13
Treatment options 9 Neonatal intensive care unit 13
Who Manages Dysphagia? 10 Subacute care setting 14
Speech-language pathologist 10 Rehabilitation setting 14
Otolaryngologist 11 Skilled nursing facility 14
Gastroenterologist 11 Home health 15
Radiologist 11 Take Home Notes 15
it connotes a disorder of or difficulty with swallowing. It is
OBJECTIVES
correctly pronounced with a long or short a. The final syl-
1. Define dysphagia and its ramifications.
lable, “ja,” requires a hard pronunciation rather than the soft
2. Discuss the epidemiology of dysphagia.
“dja” to avoid confusion with the communicative language
3. Discuss the medical and social consequences of dysphagia.
disorder, dysphasia (see Practice Note 1-1).
4. Provide an overview of the clinical management of
Taber’s Cyclopedic Medical Dictionary1 defines five
dysphagia.
subcategories of dysphagia:
5. Discuss the role of persons who manage dysphagia.
6. Discuss the types of settings in which dysphagic patients 1. Constricta: narrowing of the pharynx or esophagus
might be seen and how this might affect their management. 2. Lusoria: esophageal compression by the right subclavian
artery
3. Oropharyngeal: difficulty with propulsion from the
WHAT IS DYSPHAGIA?
mouth to the esophagus
Dysphagia takes its name from the Greek root phagein, 4. Paralytica: Paralysis of muscles of mouth, pharynx, or
meaning to ingest or engulf. Combined with the prefix dys-, esophagus
1
2 PART | I Foundations
PRACTICE NOTE 1-1 BOX 1-1  SUMMARY OF CONDITIONS THAT MAY 
CONTRIBUTE TO DYSPHAGIA
While acting as a consultant to a food production
company, I asked them what they thought the extent of Neurologic Diagnoses
their market would be, indicating that to my knowledge Stroke
we only had gross estimates of how many persons with Traumatic brain injury
dysphagia would benefit from specialized foods. They Dementia
told me that they had been working with a firm that did Motor neuron disease
an extensive analysis on this topic and had prepared a Myasthenia gravis
detailed report on the potential market. I asked them to Cerebral palsy
send me a copy because I was interested in data that Guillain-Barré syndrome
documented the incidence of dysphagia in the United Poliomyelitis
States. Two weeks later I received a package with a copy Infectious disorders
of the data. To my surprise, there were at least 15 pages Myopathy
of references. On closer inspection of the first page, I
Progressive Disease
noticed that the firm they had hired had used the key
Parkinsonism
word dysphasia, not dysphagia. I broke the news to them
Huntington’s disease
that what they had paid for was an extensive review of
Progressive supranuclear palsy
the literature on language disorders after neurologic
Wilson’s disease
injury, not swallowing disorders. What a difference a
Age-related changes
single letter can make!
Connective Tissue/Rheumatoid Disorders
Poly- and dermatomyositis
Progressive systemic sclerosis
5. Spastica: Dysphagia from spasm of the pharynx or
Sjögren’s disease
esophagus Scleroderma
In clinical practice, only oropharyngeal dysphagia from Overlap syndromes
this list is used with any frequency.
Structural Diagnoses
Interestingly, medical students learn that dysphagia is a
Any tumor involving the alimentary tract
swallowing problem primarily associated with disease of
the esophagus. However, when used properly the term Iatrogenic Diagnoses
should refer to a swallowing disorder that involves any one Radiation therapy
Chemotherapy
of the three stages of swallowing: oral, pharyngeal, or
Intubation or tracheostomy
esophageal. Some might extend the term to the stomach or
Postsurgical cervical spine fusion
lower gastrointestinal tract as primary disorders in these
Postsurgical coronary artery bypass grafting
structures such as the stomach may secondarily affect other
Medication-related
parts of the gastrointestinal tract such as the esophagus. It
is not a primary medical diagnosis but rather a symptom Other or Related Diagnoses
of underlying disease and therefore is described most often Severe respiratory compromise
Psychogenic condition(s)
by its clinical characteristics (signs). Complaints such as
coughing and choking during or after a meal, food sticking,
regurgitation, odynophagia, drooling, unexplained weight
loss, and nutritional deficiencies all may be associated with
dysphagia. Because dysphagia is a symptom of underlying the upper airway or lungs, or material that enters the mouth,
disease that is not necessarily specific to the swallowing pharynx, or esophagus during swallowing attempts but fails
tract, it can be associated with varied diagnoses. These to reach the stomach. In these circumstances, classification
diagnoses are summarized in Box 1-1. Throughout this text, of dysphagia by either clinical or imaging examination seems
most of these diagnoses will receive individualized atten- warranted and straightforward.
tion. See Chapter 7 for a full discussion of symptoms and However, not all patients with physiologic abnormalities
signs associated with dysphagia. of the swallowing mechanism show obvious delay in bolus
Dictionary-based definitions of dysphagia imply that it is flow or misdirection of bolus flow. The question that may
the result of a physiologic change in the muscles needed for arise for the clinician (and often for the researcher who
swallowing. Physiologic change often leads to the two hall- has selected a cohort of patients with dysphagia) is
marks of dysphagia: delay in the propulsion of a bolus as it the degree of severity of physiologic changes in the swal-
transits from the mouth to the stomach or misdirection of a lowing musculature needed before a patient is classified as
bolus. Misdirection can be defined as bolus material entering having dysphagia. For instance, physiologic changes in the
Dysphagia Unplugged  CHAPTER | 1 3
swallowing musculature have been described in older
INCIDENCE AND PREVALENCE
persons2—such as reduction in tongue strength or esopha-
geal motility—both of which may delay the delivery of food The incidence of a disorder is the reported frequency of
or liquid to the stomach. However, only when such changes new occurrences of that disorder over a long time (usually
result in perceptible changes in eating habits or associated at least 1 year) in relation to the population in which it
medical complications such as undernutrition or aspira- occurs. The prevalence of a disorder is the number of cases
tion pneumonia is a person classified as truly having dys- in a population during a shorter, prescribed period, usually
phagia. Because swallowing is a dynamic process, persons in a specific setting. Exact measures of the incidence and
may not exhibit signs and symptoms of dysphagia with every prevalence of swallowing disorders in large and various
swallow and every bolus type. In these cases, they may be populations are impossible because of differences in
considered to be at risk for dysphagia or, alternatively, opera- accepted definitions of dysphagia, the setting in which it is
tionally defined as dysphagic. It is also possible that the measured (acute, rehabilitation, chronic), and differences
swallowing musculature is normal but the patient is not alert in the measurement tools across studies to detect it.5 For
enough to use that musculature because of his or her decom- instance, asking a patient if she or he has a swallowing
pensated medical condition. In such cases it is assumed that disorder to determine the prevalence is a very different
attempts to swallow would result in dysphagic complica- method of detection compared with the use of an imaging
tions. In these cases, the patient may be classified as at risk examination such as videofluoroscopy. Most demographic
for dysphagia. Patients may demonstrate abnormalities of data that are reported relating to swallowing disorders are
behavior that interfere with the normal swallowing process; prevalence data. The importance of knowing the prevalence
these may cause dysphagic signs and symptoms or put the of a disorder can help guide clinicians in the detection of
patient at risk for dysphagia. Therefore dysphagia is defined that disorder and therefore helps plan how resources might
not only by abnormalities of the mechanics of the swallow- be devoted to that disorder. For instance, if an examiner
ing musculature, but also by the consequences of failure, or knew that a certain abnormality was found in less than 1%
potential failure, of that musculature owing to factors not of that population, the examiner may not spend time looking
always specifically related to swallow mechanics. For this for that abnormality because its expected frequency of
reason the authors prefer the definition of dysphagia offered occurrence would be low. If, however, a particular abnor-
by Tanner3: “Dysphagia: [an] impairment of emotional, cog- mality was found in more than 50% of the persons with a
nitive, sensory, and/or motor acts involved with transferring particular disorder, the examiner would be alerted to expect
a substance from the mouth to stomach, resulting in failure the occurrence of deficits associated with that disorder.
to maintain hydration and nutrition, and posing a risk of Therefore if the data suggested that 50% of patients who
choking and aspiration” (p. 16). have had an acute stroke could have dysphagia, and that
A swallowing disorder should be distinguished from a 20% of that group might have silent aspiration, an exam-
feeding disorder. A feeding disorder is impairment in the iner would expect that half of the patients with acute stroke
process of food transport outside the alimentary system. A would have swallowing impairment and about half of those
feeding disorder usually is the result of weakness or inco- are at high risk for silent aspiration. Furthermore, pneumo-
ordination in the hand or arm used to move the food from nia develops in 37% of acute stroke patients with aspira-
the plate to the mouth. In the United Kingdom and the tion.6 Knowledge of these prevalence data provides valuable
United States a feeding disorder, particularly in the context assistance to medical personnel who initially screen for and
of infants and children, may be the same as a swallowing manage the medical complications after acute stroke (see
disorder. Persons with feeding disorders (motor transfer Chapters 3 and 7).
problems) also may be dysphagic, such as those with cer- The American Speech-Language-Hearing Association
ebral palsy whose neurologic disability affects both feeding (ASHA) estimates that 6 to 10 million Americans show
(motoric transfer) and swallowing. It is not known whether some degree of dysphagia, although it is not known how
a feeding disorder that might require assistance with food these estimates were made.7 Kuhlemeier8 reported that the
transport also affects the subsequent act of swallowing, incidence of reported dysphagia in the state of Maryland
perhaps by interfering with timing of swallowing events. rose from 3 in 1000 in 1979 to 10 in 1000, probably as a
A swallowing disorder also is to be distinguished from result of better reporting methods. Using these estimates,
an eating disorder such as anorexia or bulimia nervosa. approximately 25,000 persons in Maryland in 1989 had
Whereas patients with dysphagia, bulimia, and anorexia dysphagia as either a primary or secondary diagnosis.
may have difficulty with poor appetite, changes in dietary
selections, and problems with the oral preparation of the
Prevalence by Setting
bolus, patients with bulimia and anorexia rarely have
demonstrable changes in or complaints of swallowing Estimates of prevalence of dysphagia vary by setting
difficulty.4 because certain age groups (older adults and premature
4 PART | I Foundations
two urban nursing homes in South Korea, and in eight
nursing homes in Portugal.14-16 One study found that when
CLINICAL CASE EXAMPLE 1-1
feeding and swallowing difficulty were combined, as many
The hospital’s chief of staff was reviewing a request from
as 87% of the residents in a home for the aged were at risk
the dysphagia team to hire an additional speech patholo-
for inadequate oral intake.17 Follow-up data of nursing
gist and dietitian to screen and treat patients on the
hospital’s new stroke and acute geriatric units. Part of home residents with oropharyngeal dysphagia indicate a
the rationale for the request was based on recent pub- mortality rate of 45% at 1 year.18
lished guidelines from the Centers for Medicare & Med-
icaid Services that screening for dysphagia on a stroke Acute General Hospitals
unit was prudent because of evidence that early detec- Using the Fleming Index of Dysphagia, a tool to identify
tion may prevent associated morbidity and mortality, dysphagia, Layne et al.19 found that nearly one third of their
both of which would increase costs for the health care
patients had a diagnosis consistent with dysphagia. These
system and, by implication, the hospital. Furthermore,
findings were nearly 18% higher than those provided by
prevalence data from five studies were submitted indi-
Groher and Bukatman,20 who reported a 13% prevalence
cating that at least half of the patients on the stroke unit
rate in similar settings. The discrepancy in prevalence was
and a similar number on the acute geriatric unit may
explained by the fact that patients who were dehydrated in
have dysphagia. The financial officer estimated that early
detection and treatment of dysphagia would result in a the study by Layne et al. were classified as dysphagic,
cost savings that far exceeded the cost of the two new whereas this was not a marker for dysphagia used in the
employees who would be assigned to those units. After collection of the Groher and Bukatman data.
integrating the request from the dysphagia team, the
evidence from the literature on prevalence, and the Acute Rehabilitation Unit
potential cost savings to the medical center, the chief of Of 307 consecutive admissions to an acute rehabilitation
staff approved the request. facility, one third of patients were dysphagic.21 Of this
group, half had dysphagia as a result of a stroke, followed
by traumatic brain injury (20%), spinal cord injury and
brain tumor (7%), and progressive neurologic disease (5%).
newborns) and diagnoses (neurogenic) are more likely to On admission, the patients with the most severe dysphagia
demonstrate dysphagia. For instance, patients entering a were those with traumatic brain injury, followed by stroke.
rehabilitation setting may not have as many accompany- The least severe dysphagia occurred in those with brain
ing medical problems and dysphagia as those entering a tumors.
nursing home. Conversely, infants born prematurely may
Special Populations
have many medical problems that may secondarily result
in dysphagia. In a survey of the entire population of an Some primary medical diagnoses are more likely to precipi-
acute general hospital, fewer patients with dysphagia would tate dysphagic symptomatology, such as diseases that affect
be found in the general population compared with a survey the central and peripheral nervous system and disorders
of a special section of that hospital, such as the stroke unit. affecting the structures of the alimentary tract, such as
cancer. An estimated 300,000 to 600,000 persons in the
Community
United States each year are affected by dysphagia from
Estimates of the prevalence of dysphagia among older neurologic disorders alone; most cases occur after a stroke.5
persons living in the community range from 16% to If these data are reliable, dysphagia is a common symptom
22%.9,10 One study reported on the prevalence of after a stroke.
dysphagia in a younger cohort (14- to 30-year-olds)
living in the community who had been referred for com- Stroke
plaints of dysphagia.11 In this selected group, 70% had Prevalence reports of dysphagia after stroke depend on
demonstrable pathologic conditions that accompanied when in the course of recovery the detection of a swal-
their symptoms. lowing impairment was made. For instance, in acute
stroke (less than 5 days after onset) the prevalence of
Acute and Chronic Geriatric Care
dysphagia may be as high as 50%, whereas 2 weeks after
Of the 211 patients admitted to an acute geriatric unit in stroke only 10% to 28% of patients may be dysphagic.
Singapore, the prevalence of dysphagia was 29% on admis- Recognizing these discrepancies, Smithard et al.22 pro-
sion and 28% at discharge.12 In a nursing home in Maryland vided follow-up of 121 (untreated) acute stroke patients
(chronic care), as many as 60% of residents had a combina- for 6 months using a clinical dysphagia examination and
tion of swallowing and feeding difficulty.13 A similar videofluoroscopy to detect swallowing deficits. Immedi-
number (53%) was found in a chronic care facility in Spain, ately after stroke, 51% were believed to be at risk for