FOXcast SLP: A Guide To Treating Patients With COPD And Dysphagia

Monitoring vital signs is super important with our people with COPD. Knowing what the norms are for vital signs is also really important.

Welcome to FOXcast SLP. A podcast for clinician’s made by clinician’s. It’s brought to you by FOX rehabilitation. Find out more at foxrehab.org.

Jimmy McKay, PT, DPT: Welcome to FOXcast SLP I’m your host Jimmy McKay. Back on the program yet again one of my colleagues here at FOX rehabilitation Alexis Streetman. Alexis welcome back to the show.

Alexis Streetman, MCD, CCC-SLP: It’s great to be back. Thank you for having me.

Jimmy: Talking about COPD and dysphagia. So what’s the overview of how those two things come together?

Alexis: In order to swallow effectively. You have to deal with to coordinate your breath with the pattern of swallowing. You take a breath, you exhale or hold your breath just a little bit. Swallow whatever is in your mouth and then you exhale again. And a lot of times people with COPD instead of exhaling just that short very brief second of holding their breath. Means that they have to inhale again so that messes up their swallowing pattern a little bit.

Jimmy: So just messing up the coordination really.

Alexis: Yeah.

Jimmy: How do you treat that? Where Do you start?

Alexis: There are a couple of different ways you can treat and work with that. You can work a little bit with respiratory muscle strength training. There are a lot of different products on the market to work with that and there are also some things that we can do a speech pathologist that do not involve devices at all. So part of what you can do is with pursed lip breathing. So basically when you do pursed lips breathing you instruct someone to breathe through their nose for a count probably two just to get a deep breath in through the nose. And then you through pursed lips exhale for a count of three to four. It’s really great if you have somebody who needs a visual for that to work on blowing bubbles with them or to work on blowing cotton balls across the table with their lips pursed. Because that way they are making sure that they’re able to exhale forcefully enough to really be able to work on strengthening those muscles. And just like in physical therapy or occupational therapy you’re working on muscular overload. So you’re really working on strengthening those muscles.

Jimmy: What other insights we know for respiratory coordination with the first step that swallow?

Alexis: If you have someone who is having a hard time with that coordination. One of the problems that they can run into is if they breathe in and they still have food in their airway they can actually end up with food in their lungs. Usually it will go in the right lung, the lower right lobe of the lung. Because that’s the easiest way for food to end up in your lungs. A lot of times we will see people who have aspiration pneumonia and it’s because that aspirate has ended up in their lower right low. So for someone with COPD obviously they’ve got enough lung issues that it as it is you don’t want them ending up with pneumonia on top of the obstructive pulmonary disease that they already have.

Jimmy: So what do you do there?

Alexis: Part of what we can do in terms of keeping aspirates out of the lung. We talked about that coordination of breathing. But if someone does end up breathing in food they need to be able to cough it up. Part of what you can do to work on cough responses is you can work on what’s called a control cough. You are trying to get someone to cough twice on the same breath to basically get them to take a deep breath in. Do a small cough and then do a major cough. So the smaller cough works to get that aspirate or if someone is having trouble managing their own secretions in their own mucus or their own saliva. That helps getting back into the airway and the second cough actually helps you clear out of the airway. It’s like this, you take a deep breath in. <Cough> <Louder Cough>. On the Same breath. So you’re really forcing it out of your airway.

Jimmy: So one in two out. So that cough response and control cough really helping the situation with reduced sensory awareness.

Alexis: So reduced sensory awareness is an interesting part of COPD. And I kind of want to stress the importance when you’re working with dysphagia to make sure that you have all the information that’s available to you. I always when I work with any sort of dysphagia say I really think it’s worth it to make sure that you have an objective swallow study. Either FEES or a modified Barium swallow study. The nice thing about FEES is that you can actually do sensory testing as part of that because the endoscope is flexible. You can try to stimulate the laryngopharynx to see if it causes a response in the person that you’re working with. Definitely something that I tell my patients who have this dysphagia that they really need to get that. I always say you really need an objective study. If they have a diagnosis of dysplasia and they have not gotten an objective study already.

Jimmy: What else is next on your list for working with individuals with COPD?

Alexis: I do want to switch gears a little bit and talk about how people with COPD unfortunately will often end up with mild cognitive impairment. When you have COPD your oxygen saturation levels are lower than they would be normally. And you can end up with anoxia which is basically when you’re just not getting enough oxygen to vital tissues like your brain. So you can end up with mild cognitive impairment associated with COPD. That has a major effect on your quality of life. It affects your ability to control your medications it affects your ability to keep appointments. So it really affects your ability to manage your disease. But it also affects your ability to manage your other personal affairs and your relationships as well. So anyone that you’re working with, with COPD it’s at least worth it to have a conversation with them about cognitive impairment and the potential risk of cognitive impairment associated with disease.

Jimmy: That’s great advice. I like how you put that very very simply laying it out there for individuals with COPD and what that response can do especially over time.

Alexis: Yeah and the other thing is a lot of times with mild cognitive impairment it just seems like forgetfulness. And you know you and I talked a little bit about this before in terms of cognitive impairment it manifests in different ways and different people. So sometimes it’s a matter of just a routine that is maybe a little bit out of whack and you can’t quite figure out why your routine is not working the way it used to. And sometimes that thing. Like I said before about forgetting appointments or not being able to take your medications on time. Right now I’m working with a client who has COPD and actually we’re working on cognitive impairment and we are using an alarm system to make sure that he’s taking his medications when he needs to.

Jimmy: It’s great inside that fact that you’re actually addressing that and making sure that you recognize that that could be one of his reasons. On top of a couple of different other different reasons. Making sure you’re taking a look at that COPD is not just maybe a respiratory issue.

Alexis: I think the other part of this it’s so important is, you know I’m a speech pathologist. It’s really important for me to be able to have conversations obviously with the patient and their caregiver but if the patient is working with a pulmonologist, which if they have COPD they should be. It’s important to be able to have a conversation it’s necessary with a pulmonologist about what’s going on with your patient. Which brings me up to the next thing which is vital signs. Monitoring vital signs is super important with our people with COPD. Knowing what the norms are for vital signs is also really important. The respiratory rate for an adult is 12 to 20 breaths per minute if you’re working with someone with COPD and you’re working on any sort of swallowing maneuvers. You need to be able to identify when that person’s starting to get into trouble because they can end up with a carbon dioxide retention. Because they’re basically trapping air in their lungs, don’t have heavy breathing. They’ll have a hard time exhaling fully and end up trapping carbon dioxide and not getting the oxygen that they need to. So being able to identify respiratory rate and then also keep an eye on what their O2 saturation is. So for most people your oxygen saturation should be above 93 percent. If it drops below that, that’s when you can start to get into trouble. Knowing that is an important part of what we do. You should also be monitoring blood pressure during all this because if you’re working on swallowing maneuvers blood pressure changes can indicate issues as well. And I will say when you were working on dysphagia with people who have COPD you should not be doing any of the valsalva type maneuvers to things like the supraglottic swallow. Where you hold on to the bottom of a chair and really force your valsalva closed. Are not necessarily good for people with COPD.

Jimmy: OK. Important. So those vital signs they are in fact vital. Respiratory rate, blood pressure, O2 saturation just to name a couple. Very important when working with individuals with COPD.

Alexis: Right. And there’s a lot you know I will say and actually I’m going to give a shout out to a couple of places where you can look for information about COPD and ways that they can effectively help your practice as a speech pathologist. Dysphagia Cafe is a phenomenal resource and it’s accessible to clinicians but it’s also a great resource for families as well. And they have an entire section about COPD. Sig 15 from the American Speech Language Hearing Association which is gerentology is wonderful. Sig 13 is wonderful that swallowing. If you have access to it CHEST which is a journal specifically or pulmonologist and respiratory therapist is wonderful may have sections about COPD frequently. And it’s worth it to know that it is there and you can take a look at it and kind of browse it to see what you need to know that may affect your practice. Science direct and pubmed are great resources for finding journal articles for free. And obviously the American Journal of speech language pathology in the American Journal of speech languag and hearing research are also great places to for information.

Jimmy: Love it. Alexis appreciate you having some time for us to give us some insight on treating individuals with COPD.

Alexis: Thank you so much for chatting with me.

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