Interpreting Pulmonary Long-term acute care (LTACH) me facility - - PowerPoint PPT Presentation

5/6/20 1

Interpreting Pulmonary Findings in Relation to Dysphagia

Sydney Parriott Schumacher, MA, CCC-SLP University of Kansas Health System

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Little about me…

• BA at the University of Missouri
• MA at the University of Kansas
• Experience:
• Long-term acute care (LTACH)

facility

• Focus on ventilators/tracheostomies
• Inpatient rehabilitation
• Acute care/Hospital

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Pro Tip

• I will highlight key

terms/concepts that are most applicable to your future clinical practice in BLUE.

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Objectives

• Identify common assessment techniques

used by physicians to evaluate lung function

• Familiarize terms utilized to describe

radiographic findings and pulmonary function

• Discern information that is pertinent to

possible aspiration based on pulmonary assessment results

• Learn at least two differences between

aspiration pneumonia versus pneumonitis

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Why do SLPs care about chest imaging?

Our goal is to prevent aspiration pneumonia…but how do we know for sure?

• Example Report 1:
• Moderate to severe left lower lobe atelectasis and mild

dependent right lower lobe atelectasis with trace pleural

• effusions. No pneumothorax.
• Example Report 2:
• Low lung volume with similar bibasilar opacities probably
• atelectasis. Right lower lobe infiltrates present. Small left pleural

effusion persists.

• How can we make sense of the radiologist’s findings to apply

to our practice?

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When do SLPs care about chest imaging?

Examples:

• A patient comes in with known history of dysphagia and team would

like you to re-assess. Do you change their diet?

• Assessing chest imaging would tell you if their current diet in the known setting
• f dysphagia is causing medical complications
• A nurse reports to you that a patient is consistently coughing with

their drinks during meal times. Why might that be?

• A review of the patient’s chest imaging tells you they have severe COPD or

emphysema which may be contributing to their dysphagia.

• You upgrade a patient from NPO to a mechanical soft solid, thin liquid
• diet. How do you know if they’re tolerating it versus aspirating?
• Pulmonary findings would tell you if food/drink is collecting in the lungs over a

period of days.

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Lung Sounds

• Auscultation - using a stethoscope to listen to the

lobes of the lungs during respiration

• Who?
• Physician, nursing, respiratory therapy
• Where?

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Lung Sounds Continued

What are they listening for?

• Lung sound subtypes:
• “Clear to auscultation bilaterally”
• Indication of normal lung function
• Evidence that a patient is tolerating their diet without collection of

fluid/aspirated material in lungs

• “Crackles” or “Rales”
• Coarse or fine
• Pneumonia, fibrosis, heart failure
• “Wheezes”
• Asthma, COPD, other airway obstruction
• “Rhonchi”
• Suggests secretions or aspirated material in large airways

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Clinical Application of Lung Sounds

• If changes noted following intake, the

SLP can re-assess for acute changes or if further assessment (e.g., videoswallow) is needed.

Request lung auscultation by nursing before and after meals

• “Clear to auscultation?”
• No fever?
• Stable white blood cell count?
• No increased oxygen needs?

Assess for diet tolerance as part of clinical picture 9

Chest X- Ray (CXR)

• Abnormalities present as areas of

either increased or decreased density from surrounding tissue

• Increased density or opacities are

most common

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Computed Topography (CT – Chest)

• 3-D model to help show size,

shape, and position of the lungs and surrounding structures

• More detailed than CXR
• Often done as a follow-up when

something else is found on an CXR

• Completed in axial, sagittal,

and/or coronal views

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Radiographic Observations

• 4 pattern approach:
• Consolidation
• Interstitial lung disease
• Nodules/masses
• Atelectasis

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Consolidation

• Lung tissue becomes more dense

due to disease replacing alveolar air

• Local vs diffuse
• Acute vs chronic
• Pneumonia most common cause of

consolidation

• Aspiration most likely in gravity

dependent areas (lower lobes)

• Right lower lung lobe is more

likely than the left

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Atelectasis

• Collapse of lung tissue due to air

(pneumothorax), fluid (hydrothorax), or tumor

• Categorized as:
• Collapse (due to air)
• Compression (due to fluid)
• Obstruction (due to tumor)
• Most common finding on x-ray
• Can’t confirm if pneumonia from

x-ray but also cannot be ruled

• ut
• Impact on swallow
• Increased respiratory rate = more

difficulty coordinating breathing and swallowing

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Additional pertinent findings…

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Infiltrates

• Any substance that has entered

the lungs, alveolar space, or tissue space around cells (interstitial compartment)

• Can indicate presence of

pneumonia

• More likely due to aspiration if

infiltrates are present in gravity dependent areas (lower lobes)

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Pleural Effusion

• Fluid build-up
• 2 types:
• Transudative = clear
• Exudative = filled with

proteins

• Type most likely to be

associated with aspiration and pneumonia

• Usually caused by congestive

heart failure

• Possible to be caused by

aspiration, however unlikely

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Opacities

• Tree-in-bud
• Small, clustered, nodular
• Mucous impaction with inflammation
• Miller & Panosian (2013)
• Aspiration cause in 25% of cases
• Ground-glass
• “Haziness”
• Wide variety of causes, one of which is

aspiration

• Need to consider at overall clinical

picture

• Can often be seen together
• May indicate aspiration if in lower

lobes

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Empyema

• Collection of pus between the lung

and surrounding pleural space

• Caused by infection
• Puts pressure on the lungs, causing

shortness of breath

• Physicians will place chest tube to

drain

• Impact on swallow
• Shortness of breath = more difficulty

coordinating breathing and swallowing

• Consider being more conservative with

dysphagia recommendations for these patients

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Lung Disease and Aspiration

• Due to either:
• CNS depression
• Inadequate lung expansion
• Results in increased respiratory rate à

impaired swallow/breath coordination Restrictive lung disease

• Difficulty exhaling due to reduction of

airflow

• Respiratory membrane surface destroyed
• Due to:
• COPD, asthma, emphysema,

bronchiectasis

• Results in increased respiratory rate à

impaired swallow/breath coordination Obstructive lung disease

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5/6/20 6 Pneumonia vs. Pneumonitis: Same or Different?

Aspiration Pneumonia Chemical Pneumonitis

Colonized oropharyngeal material Sterile gastric contents Acute inflammation Acute injury Tachypnea (rapid, shallow breathing), cough Asymptomatic, dyspnea (labored breathing), hypoxia, cough, low-grade fever Can progress quickly, gradually, or over weeks Progresses within 1-2 hours

May need to use your detective skills during your chart review! Did the patient have a recent emesis (vomiting) episode?

Pneumonia Pneumonitis

“Anaerobic pneumonitis” - ASPIRATION “Chemical pneumonitis” – EMESIS or VOMIT Colonized oropharyngeal material; bacterial Gastric contents, sterile due to low pH Acute inflammation Inflammatory injury Tachypnea (rapid, shallow breathing), cough Asymptomatic, dyspnea (labored breathing), hypoxia, cough, low-grade fever Can progress quickly, gradually,

• r over weeks

Progresses within 1-2 hours, will clear after 24-36 hours

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• PLUG FOR ORAL

CARES

• Thorough and FREQUENT!
• At LEAST 3 times per day (after

meals)

• Education patient, family, staff!
• Will reduce the ability for oral

bacteria to colonize, thus reduce the risk of aspiration pneumonia

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Clinical Application of CXR, CT-Chest

• Was your patient tolerating the diet they were on

at home vs since admission to the hospital?

• How compromised is their lung function prior to

completing your bedside assessment?

Current Level of Function

• Pulmonary status helps clinicians predict how well

a patient may tolerate aspiration

• Difference between being more liberal vs more

conservative with your recommendations

Assess for diet tolerance as part of clinical picture

• Does the person already have a pneumonia?
• Consider impact of conditions such as COPD,

emphysema, lung cancer, etc.

Determine pertinent pulmonary diagnoses

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Case Study:

• 78-year old female
• Prior Medical History (PMH):
• Right hemisphere stroke (CVA)
• Gastroesophageal reflux disease (GERD)
• Pneumonia
• History of dysphagia from CVA
• On regular solid/thin liquid diet at home as recommended from

videoswallow completed ~3 months prior

• Small bites/sips, slow rate
• Daughter reports patient is very impulsive since the stroke and often doesn’t

follow swallow guidelines despite lots of encouragement

• Admitted to hospital for respiratory failure requiring intubation for 3

days

• Extubated and put on 3 liters of oxygen for bedside swallow

evaluation

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Case Study:

• Lung auscultation at bedside by physician
• Bilateral coarse rales
• Chest X-ray with 2 views
• Impression: Left lung base consolidation most consistent with pneumonia or

aspiration.

• Other than “aspiration,” what stands out to you?
• CT Chest
• Impression:
• Tree-in-bud opacities within the right upper lobe most consistent with

pneumonia, possibly infectious or from aspiration given some material located centrally and in the right lower lobe.

• Additional mild ground-glass opacities in the right lower lobe which may be

related atelectasis or pneumonia.

• Additional mild bilateral lower lobe atelectasis.
• Mild ground-glass opacities near the lung base, nonspecific though

likely related to atelectasis or pneumonitis.

• What stands out to you?

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Case Study:

• What is going on here?
• What do you expect to see at the bedside?
• What, other than her chest imaging, will you take into consideration?
• Do you suspect this patient is at her baseline?
• If so, what will you do about it?

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Case Study:

• Chart review
• Bedside swallow evaluation
• Patient NPO at time of visit
• No signs/symptoms of aspiration except with liquids by straw
• Decision made to pursue instrumental swallow evaluation
• Why? Why not just start her on a diet?
• FEES completed
• Results:
• Consistent deep penetration with x1 episode of aspiration noted with thin liquids

suspected during and observed after the swallow.

• Penetration also noted with nectars which did not eject from the laryngeal vestibule.

Moderate residue across solid textures.

• Use of swallow strategies effective only to reduce (not resolve) pharyngeal residue;

ineffective to eliminate aspiration/penetration events.

• Why is her swallow worse than her videoswallow ~3 months earlier?
• What is your plan?

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Case Study:

• Plan
• NPO, physicians placed NG tube
• Initiate ice chip protocol to promote pharyngeal muscle use
• Initiate pharyngeal strengthening exercises
• I personally focused on exercises that can be implemented with PO boluses; this was much

easier for her due to her cognition.

• Effortful swallow
• Chin tuck against resistance
• Attempted to implement Masako, Mendelsohn, and also EMST however difficult carry-over

given mentation

• Complete PO trials at the bedside
• Focused on teaspoons of nectar and puree independently and with exercises!
• Give patient’s body time to recuperate from intubation
• Educate patient, family, staff regarding importance of swallow strategies
• Implement environmental aids to improve swallow strategy carryover
• Repeat instrumental assessment when demonstrating improvement at the

bedside

• With repeat evaluation, what is your plan if you see improvement? If it’s the same? If it’s

worse?

• Do we need to recommend a long-term source of nutrition?

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Case Study:

• After 8 days, repeat instrumental completed (modified barium

swallow)

• Results:
• Patient with decreased incidence of penetration with nectars and improved clearance of

pharyngeal residue.

• Consistent penetration of variable depth observed with thin liquids which did not eject

from the laryngeal vestibule

• Flash penetration noted with small sips of nectars; penetration increased in

severity/depth with straw and larger drinks.

• Moderate pharyngeal residue with solids. Multiple swallows and taking a drink after were
• nly effective up to mechanical soft solids.
• Do you start a diet? If so, what consistencies?
• I started her on mechanical soft/nectar thick liquids with additional ice chips

PRN.

• What strategies do you recommend?
• Multiple swallows, alternate bites/sips, small bites/sips, no straws!

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Sources:

• Pleural confusion: Understanding Lung Function in the Assessment

and Management of Dysphagia

• Towino Paramby, CScD, CCC-SLP, BCS-S; Lisa Evangelista, CScD, CCC-SLP, BCS-S
• Jurado, R. & Franco-Paredes, C. (2001). Aspiration pneumonia: a
• misnomer. Clinical Infectious Diseases, 33(9): 1612-1613.
• Miller, W.T. & Panosian, J.S. (2013). Causes and imaging patterns of

tree-in-bud opacities. Chest 144(6): 1883-1892.

• Empyema. (Date Unknown – John Hopkins Medicine). Retrieved from

https://www.hopkinsmedicine.org/health/conditions-and- diseases/empyema

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