PS#2: Consideration of GERD When Diagnosing and Treating Oropharyngeal Dysphagia

Position Statement: 

Gastro-esophageal reflux disorder (GERD) is a common condition—impacting up to 40% of adults (Bajwa et al. 2011).  While the diagnosis and treatment of GERD falls outside the standard scope of practice for speech-language pathologists (SLPs), reflux can cause significant respiratory complications and may confound the diagnosis of dysphagia at bedside.  Treatment of dysphagia by altering diet texture or liquid viscosity can significantly reduce quality of life and may exacerbate reflux.  Hence, screening for dysphagia should include a through history that includes common symptoms of reflux, and treatment for dysphagia should not begin prior to completing an instrumental (VFSS or FEES) assessment of swallowing.  Signs concerning for undiagnosed or poorly controlled reflux warrant an immediate physician consult. 

 Position Evidence and Support:

Laryngotracheal aspiration may result in respiratory complications, including pneumonia, which can increase morbidity and mortality.  Thus, screening for aspiration risk is critical for intervening prior to developing respiratory complications.  Still, many patients already diagnosed with, or suspected to have, pneumonia and other respiratory issues are routinely referred for swallow evaluations to determine if dysphagia could be the cause of their respiratory complications. 

At bedside dysphagia screenings—whether completed by speech-language pathologists or other medical professionals—rely heavily on cough during oral intake as an indicator of possible laryngeal penetration or aspiration.  However, only 29% of SLPs report using a statistically valid tool to evaluate dysphagia (Carnaby & Harenberg 2013).  Therefore, any medical condition that can cause coughing is likely to confound bedside evaluations.

Roughly, 40% of adults in the United States report weekly GERD symptoms and 10% experience GERD weekly or daily (Bajwa et al., 2011).  GERD can cause coughing during or after meals, and it is a common cause of chronic cough.  In fact, GERD may present only with a cough—and no other GI symptoms—in up to 75% of cases (Irwin, 2006).  Even further complicating the clinical picture for clinicians seeking to diagnose dysphagia at bedside, there is a correlation between reflux and many chronic or recurrent respiratory conditions: pneumonia, bronchitis, COPD, asthma, and pulmonary fibrosis (Bajwa et al., 2011).

In medical settings, there is often a systemic urge to treat a cough—as the hallmark of aspiration—at bedside without imaging.  In short, SLPs are often tasked with eliminating or reducing frequent coughing with meals, when drinking, or when taking medications.  However, attempting to ameliorate a symptom, without knowing its cause, is problematic at best.  Moreover, when SLPs are consulted, a common intervention is diet texture modification or liquid viscosity alteration.  Indeed, up to 30% of long-term care residents receive thickened liquids and mechanically altered diet textures (Castellanos et al., 2004).  Thickened liquids are known to slow digestion (Cichero, 2013) which may exacerbate reflux.  Thus, treating a cough of unknown origin with traditional swallowing therapy may prove futile and could ultimately cause harm.

The rate of pneumonia from prandial aspiration remains relatively low—as evidenced by multiple methodologically sound studies—and continuing to eat and drink orally, even when significant laryngotracheal aspiration is observed via FEES or VFSS, is poorly correlated with the development of pneumonia (Andersen et al., 2013; Beck et al., 2017; Brogan et al., 2014; Feinberg et al., 1996; Hanson et al., 2011; Hibberd et al., 2013; Hines et al., 2010; Langdon et al., 2008; Langmore et al., 2002; Loeb et al., 2003; Speyer et al., 2010; Topol 2011).  Actually, individuals who aspirate—followed for three years in a skilled nursing facility—who continued to eat and drink by mouth had rates of pneumonia similar to those who do not aspirate at all (Feinberg et al., 1996).  While trace aspiration of food and liquid may cause pneumonia or other complications, morbidity and mortality for gastric aspiration (due to reflux or emesis) is high—accounting for 30-40% of all acute respiratory distress-related mortality (Acosta-Herrera, et al., 2014; Davidson, 2010; Franquet et al., 2000).  

GERD Considerations after FEES:

If evidence of unknown or poorly controlled reflux is observed during FEES, a physician consult is warranted.  Further, if aspiration of esophageal or gastric contents is witnessed during FEES, medical staff should be informed immediately. 

When making recommendations based on the results of FEES, clinicians should weigh the risks of any recommendation that could exacerbate GERD.  Uncontrolled reflux can cause significant medical complications, and there is a poor correlation between prandial aspiration and pneumonia.  Thus, the reduction or elimination of aspiration alone is not the singular focus of recommendations based on FEES results.  Hence, diet texture modifications and liquid viscosity alterations will be made with regard to their impact on quality of life, nutrition, hydration, and the possibility to exacerbate underlying conditions such as GERD.

References:

Acosta-Herrera, M., Pino-Yanes, M., Perez-Mendez, L., Villar, J., & Flores, C. (2014). Assessing the quality of studies supporting genetic susceptibility and outcomes of ARDS. Frontiers in genetics, 5, 20.

Andersen et al., 2013 -

Bajwa, A. A., Usman, F., Samuel, V., Cury, J. D., & Shujaat, A. (2011). Impact of GERD on common pulmonary diseases. Northeast Florida Medicine, 62(1), 31-34.

Beck, A. F., Florin, T. A., Campanella, S., & Shah, S. S. (2015). Geographic variation in hospitalization for lower respiratory tract infections across one county. JAMA pediatrics, 169(9), 846-854.

Brogan, E., Langdon, C., Brookes, K., Budgeon, C., & Blacker, D. (2014). Dysphagia and factors associated with respiratory infections in the first week post stroke. Neuroepidemiology, 43(2), 140-144.

Carnaby, G. D., & Harenberg, L. (2013). What is “usual care” in dysphagia rehabilitation: a survey of USA dysphagia practice patterns. Dysphagia, 28, 567-574. 

Castellanos, V. H., Butler, E., Gluch, L., & Burke, B. (2004). Use of thickened liquids in skilled nursing facilities. Journal of the American Dietetic Association, 104(8), 1222-1226.

Cichero, J. A., Steele, C., Duivestein, J., Clavé, P., Chen, J., Kayashita, J., ... & Murray, J. (2013). The need for international terminology and definitions for texture-modified foods and thickened liquids used in dysphagia management: foundations of a global initiative. Current physical medicine and rehabilitation reports, 1, 280-291.

Davidson, B. A. (2010). The synergistic interaction of gastric acid and food material in the pathogenesis of aspiration pneumonitis. State University of New York at Buffalo.

Feinberg, M. J., Knebl, J., & Tully, J. (1996). Prandial aspiration and pneumonia in an elderly population followed over 3 years. Dysphagia, 11(2), 104-109.

Franquet, T., Giménez, A., Rosón, N., Torrubia, S., Sabaté, J. M., & Pérez, C. (2000). Aspiration diseases: findings, pitfalls, and differential diagnosis. Radiographics, 20(3), 673-685.

Hanson, L. C., Carey, T. S., Caprio, A. J., Lee, T. J., Ersek, M., Garrett, J., ... & Mitchell, S. L. (2011). Improving decision‐making for feeding options in advanced dementia: a randomized, controlled trial. Journal of the American Geriatrics Society, 59(11), 2009-2016.

Hibberd, J., Fraser, J., Chapman, C., McQueen, H., & Wilson, A. (2013). Can we use influencing factors to predict aspiration pneumonia in the United Kingdom?. Multidisciplinary respiratory medicine, 8, 1-7.

Hines, S., McCrow, J., Abbey, J., & Gledhill, S. (2010). Thickened fluids for people with dementia in residential aged care facilities. International Journal of Evidence‐Based Healthcare, 8(4), 252-255.

Irwin, R. S. (2006). Chronic cough due to gastroesophageal reflux disease: ACCP evidence-based clinical practice guidelines. Chest, 129(1), 80S-94S.

Langdon, P. C., Lee, A. H., & Binns, C. W. (2009). High incidence of respiratory infections in ‘nil by mouth’tube-fed acute ischemic stroke patients. Neuroepidemiology, 32(2), 107-113.

Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia, 17, 298-307.

Loeb, M. B., Becker, M., Eady, A., & Walker‐Dilks, C. (2003). Interventions to prevent aspiration pneumonia in older adults: a systematic review. Journal of the American Geriatrics Society, 51(7), 1018-1022.

Speyer, R., Baijens, L., Heijnen, M., & Zwijnenberg, I. (2010). Effects of therapy in oropharyngeal dysphagia by speech and language therapists: a systematic review. Dysphagia, 25, 40-65.

Topol, E. J., & Yadav, J. S. (2000). Recognition of the importance of embolization in atherosclerotic vascular disease. Circulation, 101(5), 570-580.

04/19/2020

Developed by:

Matthew Ward

Jessica Scott

Holly Blankenship

Travis Camp