Swallowing Dysfunction in COPD: A Comparison Between Stable and Exacerbated Disease States

Abstract: Dysphagia co-occurs in persons living with COPD. Exacerbated state COPD has been posited to negatively impact swallow function when compared to stable state. Penetration-aspiration frequency and swallow timing were examined using videofluoroscopy swallow study analysis. Higher rates of silent aspiration and longer pharyngeal duration were found in exacerbated COPD.

Description: Background
Chronic Obstructive Pulmonary Disease (COPD) is a progressive respiratory disease that impacts one’s quality of life due to airflow limitations resulting in shortness of breath (dyspnea). As COPD progresses, , exacerbations, a sudden decline in respiratory function that increases risk for hospitalizations, pneumonia, and mortality (Cvejic et al., 2011; Terada, 2010), typically increase in frequency.

Mounting evidence demonstrates that dysphagia co-occurs with COPD. Though not fully understood, abnormal respiratory-swallow coordination has been demonstrated to contribute to dysphagia and increase the risk for aspiration (bolus entry into the airway) in this patient group (Cvejic et al., 2011; Nagami et al., 2017). Reduced laryngopharyngeal sensitivity may also contribute to reduced airway protection (Clayton et al., 2014). Abnormal motor movement such as reduced hyolaryngeal elevation (Mokhlesi et al., 2002) risking increased residue in the pharynx and incomplete laryngeal vestibule closure (Mancopes et al., 2020) occurrence in COPD. Longer laryngeal vestibule closure reaction time and shorter laryngeal vestibule closure duration (Mancopes et al., 2020) as well as longer pharyngeal duration (bolus movement through the pharynx) (Drulia et al., 2021) are noted in stable COPD.

Dysphagia is associated with COPD disease exacerbations (Steidl et al., 2015; Yoshimatsu et al., 2020). While swallow function has been limitedly studied in stable and exacerbated state COPD independently, there has been no investigation that compares swallowing function in stable and exacerbated condition of COPD.

The aim of this retrospective study was to compare laryngeal vestibule closure reaction time (LVCRT), laryngeal vestibule closure duration (LVCD), pharyngeal duration and frequency rates of penetration and aspiration, in persons with Chronic Obstructive Pulmonary Disease (COPD) in the exacerbated and stable states.

Procedures/Methods
A database search was conducted of extant clinical videofluoroscopy swallow study recordings (VFSS) completed between August 2020 and August 2021 by a mobile VFSS company using key terms of chronic obstructive pulmonary disease, hypoxia, and respiratory failure. The search yielded 534 patient records which were reviewed using inclusion study parameters. Exacerbated and stable COPD patient records were included if they were diagnosed with COPD and they had no history of neurological disease, neck surgery or dysphagia treatment in previous three months. Exacerbated state COPD records were included if the exacerbation diagnosis was within three weeks of the VFSS completion date. Stable state COPD records were included if there was no history of a COPD exacerbation in last two months. COPD records with incomplete VFSS files, inadequate capture of all requisite structures to enable complete analyses, and excessive motion artifacts during bolus trials were excluded.

Extant VFSS recordings were completed using a modifiable clinical protocol approach related to texture order, number of bolus trials, and inclusion of compensatory or swallow maneuver trials as needed to ensure the patient’s safety. VFSS bolus order began with liquids, typically nectar, and progressed to solid textures such as puree (pudding), semi-solids (diced fruit in syrup) and solids (cracker). A radiographic barium solution (E-Z Paque 96% w/w or 60% w/v) was used for bolus visibility. Liquid boluses were administered by teaspoon (3 ml) or cup sip. Thickened liquids were prepared using SimplyThick Easy Mix to a prescribed nectar or honey thick level per manufacturer instructions. VFSS recordings were captured using a sample rate of 30 frames per second.

Analysis
VFSS video files were imported into FIJI, an enhanced version of Image J, for video analyses. Penetration and aspiration events were assigned a score from 1 to 8 using the Penetration-Aspiration Scale (PAS) (Rosenbeck et al., 1996). The worst score was utilized when multiple trials of a single texture were completed. Numeric PAS scores were converted to a categorical four-level model (A-D) as follows: A = 1,2 and 4 PAS scores; B=3,5 and 6 PAS scores; C=7 PAS score; and D= 8 PAS score (Steele and Grace-Martin, 2017). Frequency and percentage of occurrence of penetration-aspiration for groups were determined for seven bolus types including: thin by teaspoon, thin by cup, nectar by teaspoon, nectar by cup, puree, semi-solid and solid.

Swallow timing measures of laryngeal vestibule closure reaction time, laryngeal vestibule closure duration and pharyngeal duration were measured using frame-by-frame analyses in FIJI. Timing measures were determined using prescribed onset/offset events previously identified in the literature. When multiple trials of a texture were administered, trials were averaged. Statistical analyses for swallow timing measures were completed using IBM SPSS (v.26). Significance was determined based on p<.05.

Results
Extant VFSS recordings from twenty-four exacerbated state COPD patients (M=75 years; 15 male) and twenty-five persons with stable state COPD patients (M=83 years; 9 male) were included in this study. Fifty-eight percent of persons in the exacerbated state of COPD were dependent on oxygen (≥ 2 liters) and 36% of persons in the stable COPD state were oxygen dependent.

The exacerbated COPD group demonstrated eleven B-level scores (8%), no C-level scores (0%) , and four D-level scores (3%) while the majority (124; 89%) of bolus texture trials earned a A-level score. Textures which resulted in aspiration without an attempt to eject (D-level score) were thin liquid by cup (n=2), nectar by cup (n=1) and puree (n=1). Stable COPD group had twenty-one B-level scores (14%), one C-level score (1%), and one D-level score (1%). Similarly, the stable COPD group had 127 A-level scores (84%) indicating no penetration or aspiration. Aspiration without attempts to eject the bolus (D-level score) occurred on puree (n=1) and semi-solid textures (n=1).

A significantly longer pharyngeal duration was found in the exacerbated COPD group (Mdn=1385 ms) than the stable group (Mdn=1038 ms) when conducting a Mann-Whitney U test, U= 12,527, z = -3.08, p=.002. LVDD (p=.12) and LVCRT (p=.08) were not different between the exacerbated and stable COPD groups.

Conclusions
Exacerbated COPD patients had an increased frequency of aspiration with no bolus ejection (silent aspiration) compared to stable COPD. Penetration was frequent in both the exacerbated and stable groups and more often occurred in liquid boluses than in solids. Exacerbated COPD had a longer pharyngeal duration than in stable COPD. However, laryngeal vestibule closure reaction time and duration were not different between groups.

Presentation Format & Methods: Visual Poster
Interactive Dialogue

Supporting Research: Reference 1: 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, 16(2), 269-275.

Supporting Research: Reference 2: Mancopes, R., Peladeau-Pigeon, M., Barrett, E., Guran, A., Smaoui, S., Pasqualoto, A. S., & Steele, C. M. (2020). Quantitative Videofluoroscopic Analysis of Swallowing Physiology and Function in Individuals With Chronic Obstructive Pulmonary Disease. Journal of speech, language, and hearing research: JSLHR, 63(11), 3643–3658. https://doi.org/10.1044/2020_JSLHR-20-00154

Supporting Research: Reference 3: Steele, C. M., & Grace-Martin, K. (2017). Reflections on Clinical and Statistical Use of the Penetration-Aspiration Scale. Dysphagia, 32(5), 601-616. https://doi:10.1007/s00455-017-9809-z

Supporting Research: Reference 4: Drulia, T. C., Kamarunas, E., O'Donoghue, C., & Ludlow, C. L. (2021). An exploration of lung volume effects on swallowing in chronic obstructive pulmonary disease. American Journal of Speech-Language Pathology, 30(5), 2155-2168. https://doi.org/10.1044/2021_AJSLP-20-00389

Supporting Research: Reference 5: Complete Reference List

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, 16(2), 269-275.

Clayton, N. A., Carnaby, G. D., Peters, M. J., & Ing, A. J. (2014). Impaired laryngopharyngeal sensitivity in patients with COPD: the association with swallow function. International journal of speech-language pathology, 16(6), 615–623. https://doi.org/10.3109/17549507.2014.882987

Drulia, T. C., Kamarunas, E., O'Donoghue, C., & Ludlow, C. L. (2021). An exploration of lung volume effects on swallowing in chronic obstructive pulmonary disease. American Journal of Speech-Language Pathology, 30(5), 2155-2168. https://doi.org/10.1044/2021_AJSLP-20-00389

Mancopes, R., Peladeau-Pigeon, M., Barrett, E., Guran, A., Smaoui, S., Pasqualoto, A. S., & Steele, C. M. (2020). Quantitative Videofluoroscopic Analysis of Swallowing Physiology and Function in Individuals With Chronic Obstructive Pulmonary Disease. Journal of speech, language, and hearing research: JSLHR, 63(11), 3643–3658. https://doi.org/10.1044/2020_JSLHR-20-00154

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Steele, C. M., & Grace-Martin, K. (2017). Reflections on Clinical and Statistical Use of the Penetration-Aspiration Scale. Dysphagia, 32(5), 601-616. https://doi:10.1007/s00455-017-9809-z

Steidl, E., Ribeiro, C. S., Gonçalves, B. F., Fernandes, N., Antunes, V., & Mancopes, R. (2015). Relationship between Dysphagia and Exacerbations in Chronic Obstructive Pulmonary Disease: A Literature Review. International archives of otorhinolaryngology, 19(1), 74–79. https://doi.org/10.1055/s-0034-1376430

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