Chronic Obstructive Pulmonary Disease

And Its Affect On

Deglutition

Kimberly King, B.A.

Candidate for Masters of Arts
Speech Language Pathology
Wayne State University
 Chronic Obstructive Pulmonary
Disease, One of the Most Common
Diseases to Affect the Lungs
Global
Initiative for Chronic Obstructive Lung Disease
(GOLD) definition:
◦ common, preventable, & treatable
◦ usually progressive & associated with persistent airflow
limitation
◦ chronic inflammatory response in the airway & lungs to
noxious particles or gasses
Chronic Obstructive Pulmonary Disease (COPD) is
typically expressed in 2 ways:
◦ Emphysema
◦ Chronic Bronchitis
 Chronic Obstructive Pulmonary
Disease Etiology

Smoking is the number one cause

Other causes include secondhand smoke

certain gases or fumes, pollutants, and
physical structural defects that affect
pulmonary function.
 Chronic Obstructive Pulmonary
Disease and the Numbers

8 million physician office visits (in 2000)

1.5 million ER visits (in 2000)
726,000 hospitalizations (in 2000)
Affects 14 million people in the US (in 2002)
Leading cause of morbidity and mortality
worldwide, resulting in substantial and
increasing economic and social burden
(GOLD, 2011)
 Understanding COPD’s Affect On
Deglutition

Complications:
◦ discoordination of the oral and pharyngeal
swallowing stage
◦ impaired coordination of respiration and
deglutition could contribute to increased
exacerbations and aspiration
◦ Trademark symptom: dyspnea
 COPD’s Affect on Respiration and
Deglutition

Exhale-swallow-exhale preferred by
normal adults
Altered swallow in COPD in which the
inhalation occurs after the swallow could
be dangerous
Studies found that participant risk for
aspiration was greater due to the negative
pressure of inhalation
 Susceptibility To Aspiration

COPD participants swallowed food during

inhalation more and inhaled more quickly after
swallowing semi-solid material than control
group
In another study, COPD participants had
higher resting respiratory rates during 5mm
swallows in upright and supine positions
They found increase resp. rate = increase
number of swallows
 Reported COPD Associated Risks
Affecting Swallowing
 Increasedmastication,
increased resp. rate and
rhythm during chewing
 Delayedpharyngeal response,
decreased tongue retraction,
reduced laryngeal elevation
 Increasedfatigue,
incoordination, weakness of
upper aerodigestive tract
musculature, & sensory
impairment
 Increased
inspiration after
liquid swallow and increased
apneic pause duration
 Could cause air hunger and
likelihood of inhalation
during swallow
 Residue in the
oral/pharyngeal cavity
could lead to aspiration
 Increase the risk of
aspirating on inhalation
 The increased risk from air
hunger during prolonged
chewing times + common co-
occuring oropharyngeal
dysphagia in COPD = higher
risk of aspiration
 Pathophysiology of the Swallowing
Mechanism in COPD Patients

Suggested functional abnormalities predisposing

patients to penetration/aspiration (Cvejic, et al.)
◦ Reduced laryngeal elevation with delayed laryngeal
closure
◦ Reduced hyoid elevation, post swallow penetration, and
oxygen desaturation
◦ Reduced laryngo-pharyngeal sensation
◦ Impaired pharyngeal clearance
◦ Cricopharyngeal dysfunction
◦ GERD
◦ Tachypnoea
 How COPD Exacerbations Affect
Swallowing

Exacerbations typically include an increase in:

◦ dyspnea, sputum, purulence
◦ negative effects on respiration and
swallowing
• Cyclical affect; inflammation – increased
dyspnea – aspiration – pneumonia – COPD
exacerbation
 Severity of Aspiration for COPD
Patients

◦ Patients with dysphagia have greater than 7-times

chance of acquiring aspiration pneumonia (if found to
aspirate during an MBSS) ( Martin-Harris et al., 2012)

◦ Patients who aspirate thickened liquids or semisolids,

the likelihood that they will perish increased by
greater than 9 times

◦ The most significant risk factor for aspiration

pneumonia in nursing home patients was determined
to be COPD (Gross et al., 2009)
Management of COPD and Swallowing
Dysfunction

◦ Top 3 Expectations from Patients

1. breathe
2. walk (including up stairs)
3. manage shortness of breath
 Medical Interventions

Pharmacologic Nonpharmacologic

 Inhaled corticosteroids  Home oxygen

 Long-acting bronchodilators
and Theophyllines (relaxes
& opens restricted bronchi)
 Phosphodiesterase
inhibitors (relaxes blood
vessels)
 Mucolytics (dissolves
mucous)
 Current vaccinations
(Mackay & Hurst, 2012)
 Ventilator support
 Pulmonary
rehabilitation
(American Thoracic Society-European
Respiratory Society, Casaburi &
Wallack, 2009)
 Surgical Interventions

◦ Lung volume reduction surgery

 Been shown to increase exercise
endurance (Fishman, et al., Mackay & Hurst, 2012)
◦ Cricopharyngeal myotomy
 Trials have improved swallowing &
complete or semi-reprieve from
respiratory exacerbations (Stein et al., 1990)
 Behavioral Interventions
• Smaller, more frequent
meals at least fatigued
time of day
• Nutritional and convenient
snacks
• Increasing calories of meals
• Caution with medication
that cause nausea
• Recommend continued use
of oxygen and monitoring
oxygen saturation during
meals for those on long
term oxygen
(Martin-Harris, 2000, p. 315)
 Smoking cessation
 Sleep study to evaluate
appropriateness of CPAP
machine
 Caution against risky
environments that may be
detrimental to health
 Pulmonary rehabilitation
and education
 Encourage early recognition
and self management
 Exercise programs
(McKinstry, Tranter & Sweeney, 2010)
 Swallowing Strategies

◦ Protect airway using chin tuck

◦ Increase oral transit with 60 degree recline posture
(take precautions that increased apnea does not result
from these techniques) (Martin-Harris, 2008)
◦ Manage xerostomia by alternating sips and bites to
clear residue and/or recommending medication to
replace saliva (Martin-Harris, 2000)
◦ Swallowing twice to decrease the amount of residue
◦ Patients with laryngeal penetration during sequential
swallows decrease liquid bolus size to 10 ml and
discontinue sequential swallowing. (Martin-Harris, 2000).
◦ Remain upright after eating and elevating the head of
the bed to reduce GERD
 Conclusion

◦ Small amount of literature available definitively

proving the risk of aspiration associated with
discoordinated breathing and swallowing

◦ There is sufficient evidence that COPD patients

are inclined to swallowing disorders and
predisposed to aspirate

◦ 400,000 deaths per year in developed countries

warrant more development into this area of
dysphagia research
 References
Casaburi R., ZuWallack R. (2009).Pulmonary rehabilitation for management of chronic
obstructive pulmonary disease. N Engl J Med 360. (13), 1329-1335.
Cvejic, L., Harding, R., Churchward, T., Turton, A., Finlay, P., Massey, D., & ... Guy, P. (2011).
Laryngeal penetration and aspiration in individuals with stable COPD. Respirology (Carlton,
Vic.), 16(2), 269-275.
Fishman, A., Martinez, F., Naunheim, K., Piantadosi, S., Wise, R., Ries, A., & ... Wood, D.
(2003). A randomized trial comparing lung-volume-reduction surgery with medical therapy for
severe emphysema. The New England Journal Of Medicine, 348(21), 2059-2073.
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for
Chronic Obstructive Lung Disease (GOLD) (2011). Retrieved from: http://www.goldcopd.org/.
Gross, R., Atwood, C., Ross, S., Olszewski, J., & Eichhorn, K. (2009). The coordination of
breathing and swallowing in chronic obstructive pulmonary disease. American Journal Of
Respiratory And Critical Care Medicine, 179(7), 559-565.
Klahn, M.S., Perlman, A.L. (1999). Temporal and durational patterns associating respiration and
swallowing. Dysphagia, 14: 131-8.
Lopez, A., Shibuya, K., Rao, C., Mathers, C., Hansell, A., Held, L., & Buist, S. (2006). Chronic
obstructive pulmonary disease: current burden and future projections. The European
Respiratory Journal: Official Journal Of The European Society For Clinical Respiratory
Physiology, 27(2), 397-412.
Mannino DM, Homa DM, Akinbami LJ, Ford ES, Redd SC. Chronic obstructive pulmonary disease
surveillance -- United States, 1971-2000. MMWR Surveill Summ 2002;51(SS-6):1-16.
Mackay, A., & Hurst, J. (2012). COPD Exacerbations: Causes, Prevention, and Treatment. The
Medical Clinics Of North America, 96(4), 789-809.
 References
Martin-Harris, B. (2000). Optimal patterns of care in patients with chronic obstructive pulmonary
disease. Seminars In Speech And Language, 21(4), 311-321.
Martin-Harris, B. (2008). Clinical implications of respiratory-swallowing interactions. Current
Opinion In Otolaryngology & Head And Neck Surgery, 16(3), 194-199.
Martin-Harris, B., Brodsky, M., Michel, Y., Ford, C., Walters, B., & Heffner, J. (2005). Breathing
and swallowing dynamics across the adult lifespan. Archives Of Otolaryngology--Head & Neck
Surgery, 131(9), 762-770.
McFarland, D., & Lund, J. (1995). Modification of mastication and respiration during swallowing in
the adult human. Journal Of Neurophysiology, 74(4), 1509-1517.
McKinstry, A., Tranter, M., & Sweeney, J. (2010). Outcomes of dysphagia intervention in a
pulmonary rehabilitation program. Dysphagia, 25(2), 104-111.
Mokhlesi, B., Logemann, J., Rademaker, A., Stangl, C., & Corbridge, T. (2002). Oropharyngeal
deglutition in stable COPD. Chest, 121(2), 361-369.
Pauwels, R., Buist, A., Calverley, P., Jenkins, C., & Hurd, S. (2001). Global strategy for the
diagnosis, management, and prevention of chronic obstructive pulmonary disease.
NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop
summary. American Journal Of Respiratory And Critical Care Medicine, 163(5), 1256-1276.
Polatlı, M., Bilgin, C., Şaylan, B., Başlılar, Ş., Toprak, E., Ergen, H., & ... Yılmaz, M. (2012). A
cross sectional observational study on the influence of chronic obstructive pulmonary disease
on activities of daily living: the COPD-Life study. Tüberküloz Ve Toraks, 60(1),1-12.
Shaker, R., Li, Q., Ren, J., Townsend, W., Dodds, W., Martin, B., & ... Rynders, A. (1992).
Coordination of deglutition and phases of respiration: effect of aging, tachypnea, bolus
volume, and chronic obstructive pulmonary disease. The American Journal Of Physiology,
263(5 Pt 1), G750-G755.
Stein, M., Williams, A., Grossman, F., Weinberg, A., & Zuckerbraun, L. (1990). Cricopharyngeal
dysfunction in chronic obstructive pulmonary disease. Chest, 97(2), 347-352