Approximately 40% of quadriplegics admitted to acute rehabilitation hospitals have impairments in swallowing referred to as dysphagia. Dysphagia places them at risk of developing aspiration pneumonia, which is a dangerous pneumonia caused by bacteria in the mouth that pass into the lungs with aspirated saliva, liquids, or solid food particles. Aspiration refers to passage of saliva, liquids, or food particles below the level of the vocal cords into the respiratory tract. In normal people, reflex coughing will protect the airways in the case of aspiration.
In quadriplegics, dysphagia is particularly significant since there is an increased risk related to pneumonia because of the underlying paralysis caused by the spinal cord injury. The weakness in the muscles of respiration decreases the functional lung volumes by nearly seventy-five percent. A seemingly small pneumonia can consequently lead to decreased oxygenation, need for mechanical ventilation, hinder rehabilitation efforts, and lead to prolonged hospitalization.
Every acutely injured quadriplegic patient should undergo evaluation by a speech pathologist with a bedside swallow evaluation (BSE). In cases where the patient requires a ventilator a respiratory therapist should also be involved. Dysphagia will be diagnosed by the BSE if there are signs of aspiration which may include coughing, choking, suctioning of food, wet sounding voice, watery eyes, and watery nose. The BSE will identify most patients with dysphagia. Patients who pass the BSE are generally placed on a regular diet unless there is a recent history of aspiration pneumonia.
Patients who fail a BSE should be referred for a videofluoroscopic swallow study (VSS). This test is generally performed by a speech therapist along with a radiologist. It allows for the direct visualization of the anatomical structures involved in swallowing and allows for imaging the patient as they chew and swallow radiopaque food substances and liquids. This test will allow for the diagnosis of dysphagia and provide information regarding the patient’s ability to swallow various textures of food and liquids without aspirating. In addition, if aspiration does occur the study will indicate if the patient is able to reflexively cough and clear out the aspirated material from the respiratory tract or if there is silent aspiration where liquids and food material are aspirated without a reflex cough.
Unfortunately quadriplegics who have passed a BSE and a VSS may still develop aspiration pneumonia. Understanding the severe risk of aspiration pneumonia in the quadriplegic population because of their underlying decreased pulmonary reserve, all quadriplegics who develop an aspiration pneumonia should receive a VSS to identify the textures of food and liquids that the patient can tolerate without aspiration as well as a fiberoptic evaluation by an otolaryngologist.
The fiberoptic evaluation provides information that the BSE and the VSS do not. It allows for the direct testing of sensation below the level of the vocal cords to determine if there are any sensory deficits that prevent the reflex cough necessary to protect the airway. In the quadriplegic patient with a history of aspiration pneumonia and a VSS without evidence of silent aspiration, these patients require a fiberoptic exam to properly assess sensation below the vocal cords.
The otolaryngologist in a patient with a history of aspiration pneumonia will directly test sensation by directly stimulating below the vocal cords with the fiberscope. If stimulation does not trigger a reflex cough they remain at risk for aspiration pneumonia despite the normal VSS. These patients will need to be counseled on the risk versus benefits of oral nutrition versus alternative nutritional options.
Case managers working with Academic Physician Life Care Planners must understand that quadriplegics must be referred to acute rehabilitation hospitals with the scope of services that include VSS and otolaryngologist consultation to properly evaluate those at risk for aspiration pneumonia. In addition, daily physician evaluations are necessary to monitor and timely intervene for symptoms and signs of aspiration pneumonia in the quadriplegic population. In addition, patients who continue to require a tracheostomy remain at risk for aspiration pneumonia, and this risk will need to be accounted for in the Academic Physician Life Care Plan.
Dr. Greg Vigna, MD, JD Academic Physician Life Care Planner
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