Keywords
Pulmonary Disease - Chronic Obstructive - Deglutition Disorders - Respiration - Smoking
- Heart Rate - Respiratory Rate
Introduction
Chronic obstructive pulmonary disease (COPD) is characterized by progressive and partially
reversible airway obstruction. This airflow obstruction is associated with an abnormal
inflammatory response of the lungs and occurs between 5% and 15% of the adult population[1]
[2]
[3] and is a leading cause of death worldwide. Smoking is responsible for more than
90% of the cases, with a prevalence of disease found in men[4].
The diagnosis of COPD should be considered in the presence of cough, sputum production,
dyspnea, and a history of exposure to risk factors such as smoking, environmental
pollution, and occupational exposure to toxic gases or particles[1].
Several factors can lead to inadequate food intake in patients with COPD, causing
weight loss, oropharyngeal dysphagia (possibly due to difficulty in chewing), dyspnea,
cough, fatigue, and secretion[5].
Oropharyngeal dysphagia is a swallowing disorder with specific signs and symptoms
that are characterized by alterations at any stage and/or between the steps of the
dynamics of swallowing; this condition may be congenital or acquired[6]
[7]. Stable dysphagic patients with COPD can present important clinical complications
such as malnutrition, pulmonary complications, dehydration, and discomfort when eating[8]
[9].
In patients with oropharyngeal dysphagia, clinical evaluation of swallowing associated
with instrumental evaluation techniques such as nasolaryngofibroscopy (FEES)[10] is required, which assists in the application of therapeutic approaches.
The present study aimed to characterize swallowing in patients with COPD and correlate
the findings of swallowing with the degree of COPD, heart and respiratory rate, oxygen
saturation, and smoking.
Method
A prospective cohort study was performed in 19 patients with confirmed diagnosis of
COPD. Seven patients (40.0%) were female and 12 patients (60.0%) were male. Patient
age ranged between 50 and 85 years, with a mean of 66.7 years. This study was approved
by the research ethics committee of our institution (No. OF. CEP Hospital Angelina
Caron 42/09). Subjects signed a consent form after being informed of the objectives,
procedures, and responsibilities of the study, as well as receiving answers to any
questions regarding the study.
Inclusion criteria included patients of both genders aged over 50 years with a diagnosis
of COPD according to the GOLD scale[11], who had not used inhaled medication up to 4 h before evaluations, and were smokers
and non-smokers. Patients with a lowered level of consciousness and clinically unstable
patients were excluded from the study.
The time for COPD diagnosis was 5.7 years on average, with a minimum of 2 months,
a maximum of 12 years, and a standard deviation of 10.0 years. Of the 19 patients,
14 (75.0%) were smokers with a mean duration of smoking of 41.1 years and a standard
deviation of smoking of 5.0 years. The remaining 5 patients (25.0%) had never smoked.
The study was conducted in 2 stages on the same day. Patients referred to the pulmonology
clinic with a clinical diagnosis of COPD were transferred to the otolaryngology clinic
of the same hospital, where the tests were conducted. The first stage consisted of
clinical evaluation of swallowing and the second stage consisted of functional assessment
of swallowing using FEES[10], with vital signs being checked by the medical team during both assessments.
During the first stage, the protocol data for clinical evaluation of swallowing used
in our hospital were followed. The clinical signs of aspiration (cough, dyspnea, and
“wet” voice) were recorded[12]. The food consistencies used (liquid, nectar, honey, pudding, and solid) followed
the pattern of the American Dietetic Association (ADA)[13]. For this evaluation, patients completed a sequence of 3 swallows (free swallow,
5 mL, and 10 mL) for each food consistency. Swallowing function was evaluated by uptake
of the bolus, closing of the lips, preparation of the bolus, subsequent extraoral
exhaust, waste in the oral cavity, throat clearing, and coughing reflex. After evaluation,
the Functional Oral Intake Scale (FOIS)[14] was applied to assess the level of food intake of each patient.
During the second stage, FEES[10] was performed by otolaryngologists following the protocol data for FEES evaluation
of swallowing used in our hospital. We used the same consistency of foods offered
during the clinical evaluation of swallowing function, plus the inorganic dye aniline
blue to contrast with the pink color of the mucosa. During examination, the presence
of exhausted intraoral posterior pharyngeal residue in the posterior pharyngeal wall,
epiglottic vallecula, and piriform sinus as well as pharyngeal clearance (number of
swallows needed for clearance) and laryngeal penetration or tracheal aspiration (with
or without reflex cough) were observed. The Severity Scale for Dysphagia: Penetration
and Aspiration[15] was applied to the results.
Results
Regarding respiratory impairment, 16 patients (85.0%) were in ambient air and 3 patients
(15.0%) were oxygen dependent, one (5.0%) with 2 liters of oxygen, one (5.0%) with
3 liters of oxygen, and one (5.0%) with 5 liters of oxygen. Regarding breathing pattern,
4 patients (20.0%) had wheezing, 1 (5.0%) showed mouth breathing, 4 (20.0%) were mixed,
1 (5.0%) had tachypnea, and 9 (50.0%) had dyspnea.
Upon clinical evaluation of swallowing, all patients showed clinical signs of cough.
Regarding food intake, all 19 patients (100.0%) were at level 7 (oral full and unrestricted)
of the FOIS. FEES findings indicated that exhausted intraoral posterior residue prevailed
in 5 patients (26.5%) and no patient had tracheal aspiration. Residue in the epiglottic
vallecula occurred in 1 patient (5.0%) with liquid and in 2 patients (10.5%) with
solid food, both with bleaching.
At the significance level of 0.05, there was no significant relationship between subsequent
intraoral escape and the degree of COPD, heart and respiratory rate, oxygen saturation,
or smoking, which can be observed in [Tables 1], [2], [3], [4], and [5], respectively. The Severity Scale for Dysphagia: Penetration and Aspiration score
was 1 (contrast does not enter the airway) in all 19 patients (100.0%).
Table 1.
Relationship between the degree of copd and intraoral escape.
|
COPD GRADE
|
INTRAORAL ESCAPE
|
|
Pudding
|
Liquid
|
Solid
|
|
A
|
P
|
A
|
P
|
A
|
P
|
|
II
|
2 (10.5%)
|
−
|
1 (5.0%)
|
1 (5.0%)
|
2 (10.5%)
|
−
|
|
III
|
8 (42.5%)
|
1 (5.0%)
|
9 (47.5%)
|
−
|
7 (37.0%)
|
2 (10.5%)
|
|
IV
|
7 (37.0%)
|
1 (5.0%)
|
6 (31.5%)
|
2 (10.5%)
|
5 (26.0%)
|
3 (16.0%)
|
|
p
|
0.6784
|
0.3756
|
0.3359
|
COPD = chronic obstructive pulmonary disease, A = absent, P = present.
Fisher's test at a significance level of 0.05.
Table 2.
Relationship between heart rate and intraoral escape.
|
HR (bpm)
|
INTRAORAL ESCAPE
|
|
Pudding
|
Liquid
|
Solid
|
|
A
|
P
|
A
|
P
|
A
|
P
|
|
Less than 80
|
2 (10.5%)
|
1 (5.0%)
|
3 (16.0%)
|
−
|
2 (10.5%)
|
1 (5.0%)
|
|
80–89
|
7 (37.0%)
|
−
|
7 (37.0%)
|
−
|
6 (31.5%)
|
1 (5.0%)
|
|
90–99
|
6 (31.5%)
|
−
|
3 (16.0%)
|
3 (16.0%)
|
5 (26.5%)
|
1 (5.0%)
|
|
100 or more
|
2 (10.5%)
|
1 (5.0%)
|
3 (16.0%)
|
−
|
1 (5.0%)
|
2 (10.5%)
|
|
p
|
0.7368
|
0.0867
|
0.4443
|
HR = heart rate, bpm = beats per minute, A = absent, P = present.
Fisher's test at a significance level of 0.05.
Table 3.
Relationship between respiratory rate and intraoral escape.
|
RR (bpm)
|
INTRAORAL ESCAPE
|
|
Pudding
|
Liquid
|
Solid
|
|
A
|
P
|
A
|
P
|
A
|
P
|
|
Less than 17
|
7 (37.0%)
|
−
|
7 (37.0%)
|
−
|
7 (37.0%)
|
−
|
|
17–18
|
8 (42.5%)
|
1 (5.0%)
|
6 (31.5%)
|
3 (16.0%)
|
6 (31.5%)
|
3 (16.0%)
|
|
19 or more
|
2 (10.5%)
|
1 (5.0%)
|
3 (16.0%)
|
−
|
1 (5.0%)
|
2 (10.5%)
|
|
p
|
0.3860
|
0.2270
|
0.0681
|
RR = respiratory rate, bpm = breaths per minute, A = absent, P = present.
Fisher's test at a significance level of 0.05.
Table 4.
Relationship of oxygen saturation with intraoral escape.
|
O2 SATURATION (mmHg)
|
INTRAORAL ESCAPE
|
|
Pudding
|
Liquid
|
Solid
|
|
A
|
P
|
A
|
P
|
A
|
P
|
|
Less than 80
|
1 (5.0%)
|
1 (5.0%)
|
2 (10.5%)
|
−
|
1 (5.0%)
|
1 (5.0%)
|
|
80–89
|
2 (10.5%)
|
−
|
2 (10.5%)
|
−
|
1 (5.0%)
|
1 (5.0%)
|
|
90 or more
|
14 (73.5%)
|
1 (5.0%)
|
12 (64.0%)
|
3 (16.0%)
|
12 (64.0%)
|
3 (16.0%)
|
|
p
|
0.3860
|
0.4696
|
0.2722
|
O2 = oxygen, A = absent, P = present.
Fisher's test at a significance level of 0.05.
Table 5.
Relationship between smokers and non-smokers and intraoral escape.
|
GROUP
|
INTRAORAL ESCAPE
|
|
Pudding
|
Liquid
|
Solid
|
|
A
|
P
|
A
|
P
|
A
|
P
|
|
TAB
|
12 (63.5%)
|
2 (10.5%)
|
12 (65.0%)
|
2 (10.0%)
|
10 (55.0%)
|
4 (20.0%)
|
|
NTAB
|
5 (26.0%)
|
−
|
4 (20.0%)
|
1 (5.0%)
|
4 (20.0%)
|
1 (5.0%)
|
|
p
|
0.5322
|
0.6244
|
0.6026
|
TAB = smoker, NTAB = non-smoker, A = absent, P = present.
Fisher's test at a significance level of 0.05.
Discussion
Defining the incidence of oropharyngeal dysphagia in patients with COPD, as well as
the identification of possible risk factors, may be useful in the management and prevention
of complications resulting from this disease, assisting in the control of morbidity
and mortality and cost reduction[16].
When the results of a previous study were corrected for smoking, the risk for chronic
bronchitis became equal for men and women[17]. In the current study of 19 patients, 60.0% were male and 73.5% had contact with
smoke or were smokers, which is similar to results found in the literature.
Dyspnea is the most common symptom of COPD, and is a term used to characterize the
subjective experience of respiratory distress. There is a correlation between COPD
and swallowing disorders, which shows that breathing during swallowing is halted and
resumed predominantly in the inspiratory phase, increasing the risk of aspiration[18]. Cough can be considered as a variable parameter in clinical evaluation, since it
can be present in both COPD and dysphagia. The presence of this symptom in patients
with oropharyngeal dysphagia, regardless of form or intensity, is a warning sign of
the presence of potential tracheal aspiration, especially when it is associated with
food. This kind of aspiration increases the risk of aspiration pneumonia, regardless
of the mechanism of action.
In the present study, posterior intraoral escape was the variable most commonly found
in patients during FEES. This finding is related to motor impairment of swallowing,
and the longer the delay in firing the swallowing reflex, the greater the chance of
aspirating part of the bolus, since the airway remains open[19]
[20].
The presence of food residues in the epiglottic vallecula and/or piriform sinus can
occur because of changes in the preparatory phase and/or oral swallowing, inefficiency
of the ejection bolus, delayed triggering of the swallowing reflex, a decrease in
peristalsis, reduced laryngeal elevation, or anterior and/or incoordination of the
cricopharyngeal muscle[21].
Since the presence of the characteristic symptoms of COPD affects the quality of life
of these patients, we chose to correlate symptoms including degree of COPD, heart
and respiratory rate, oxygen saturation, and smoking with intraoral exhaust with a
view to subsequent observation of the impact of swallowing on worsening of pulmonary
symptoms. Patients with COPD have impaired swallowing and a greater risk of aspiration
pneumonia when compared with healthy patients[22].
Patients with COPD have abnormal autonomic control of cardiac function and this study
corroborates the research in question[23].
The lack of coordination between swallowing and breathing increases the risk of aspiration
in tachypneic or dyspneic patients, since they may not be able to tolerate longer
periods or even short periods of apnea during swallowing. The normal respiratory rate
based on a normal adult ranges from 12 to 20 breaths per minute[24].
In the current study, it was observed that for pudding and liquid food consistencies,
10.5% of patients had posterior intraoral escape, but for solid food consistency,
21.0% of patients had subsequent intraoral escape. There have been no previous studies
on this association published in the literature. When cough is a major symptom during
clinical evaluation of patients with COPD, it is evident that instrumental assessment
is important for a more accurate diagnosis. With the evolution of disease, patients
with COPD develop a profile of dysphagia, and the cough reflex should be taken into
consideration by the audiologist as a possible sign of swallowing disorders[12].
The role of the speech therapist in multidisciplinary teams is effective in dysphagic
patient outcomes, and their early intervention allows regress of the increased risk
of dysphagia in patients with COPD. The late identification of swallowing disorders
can lead to severe pulmonary complications associated with aspiration[25].
With health care programs aimed at recognition by professionals involved in the care
of patients with COPD, the signs and symptoms of swallowing disorders can be incorporated
into multidisciplinary care.
Conclusion
In this study, it was concluded that patients with COPD showed no oropharyngeal dysphagia
upon clinical evaluation of swallowing. FEES revealed that there was a prevalence
of oral dysphagia with the finding of subsequent intraoral escape. There was no relationship
between subsequent intraoral escape and the degree of COPD, heart and respiratory
rate, oxygen saturation, or smoking.
