COPD (chronic obstructive pulmonary disease) is a common lung disease that can severely impact eating and drinking. The SLP can play an important role on the medical team. This topic is complex, and what follows is a general overview.
Free DIRECT download: Swallow tips for COPD (patient handout). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Outline:
- What is COPD?
- How is breathing affected by COPD?
- How does COPD affect swallowing?
- Why should people with COPD be screened for a swallowing problem?
- Swallow assessment in COPD.
- Dysphagia treatment for COPD.
- References.
- Related Eat, Speak, & Think posts.
What is COPD?
COPD, or chronic obstructive pulmonary disease, is a lung disease characterized by restricted airflow on exhalation. It is a common disease, most often affecting adults but may also affect children.
COPD may take the form of conditions such as chronic bronchitis or emphysema. Usually both co-occur. Chronic bronchitis is the inflammation of the bronchial tubes. Emphysema is caused by the destruction of alveoli due to exposure to smoke or other irritants.
COPD can also co-occur with other respiratory conditions, such as asthma. Asthma is another obstructive lung disease.
The severity of COPD symptoms varies. It’s a chronic, progressive disease. It’s treatable, but not curable. People living with COPD generally experience periods of stable symptoms which may be punctuated by exacerbations of their symptoms.
COPD exacerbation may require hospitalization for treatment, frequently for pneumonia. People hospitalized for pneumonia generally require longer hospital stays and have a higher mortality rate. People with COPD have more hospitalizations than people with other chronic health conditions, according to WebMD.
The goals for COPD management are to reduce symptoms, slow the progression of the disease, improve quality of life and life participation, and minimize acute exacerbations.
How is breathing affected by COPD?
For a nice explanation of how COPD affects respiration, check out The Essentials: Dysphagia and COPD* on MedBridge. Here are the main ideas, as I understand them.
People who have COPD have difficulty exhaling all the air out of their lungs. This resistance to airflow leads them to exhale air more slowly than normal, and they have more air left in their lungs at the end of their exhalation. This is called air-trapping.
Air-trapping leads to hyperinflation of the lungs, which pulls the larynx into a lower resting position. This means that the larynx has a longer way to travel to reach the epiglottis during a swallow.
The hyperinflation of the lungs also compresses the esophagus and the stomach, which can cause reflux.
People with COPD also experience an increase in inspiratory flow resistance and diminished elastic recoil.
Because there is decreased surface area for gas exchange, they retain carbon dioxide. This can lead to hypoxia and is “associated with muscle weakness, fatigue, and difficulty in carrying out daily activities… and self-care” (Mancopes et al., 2021, p. 1214).
But the take-away message is that people with COPD “run out of air” for even the most basic daily living tasks such as walking, talking, eating, drinking, or bathing. And as we will see, having COPD raises the risk of dysphagia and the consequences that may come along with it.
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How does COPD affect swallowing?
Renata Mancopes and colleagues provide a number of ways that COPD may affect swallowing ability in their 2021 review article on COPD, including:
- Muscle weakness and fatigue associated with carbon dioxide retention.
- Prolonged oral transit time.
- Respiratory-swallow discoordination.
- Longer pharyngeal transit times.
- Increased time of the laryngeal vestibule closure (LVC).
- Incomplete LVC.
- Delayed LVC.
- Longer duration of hyoid movement.
- Pharyngeal residue.
- Decreased sensation in the oral cavity, pharynx, and larynx.
Mancopes, et al. (2021, pp. 1215-1216) report a recent study that showed short LVC duration with thickened liquids (mildly, moderately, and extremely thick liquids), as well as increased pharyngeal residue. They attribute the pharyngeal residue to reduced pharyngeal constriction and shorter opening of the UES.
They report another 2021 study which found that 20% of 151 adults with stable COPD penetrated or aspirated on larger volumes of thin liquids (100 mL) (p. 1216).
So COPD is associated with slower and less-complete movements of swallow muscles, decreased sensation, and impaired coordination between breathing and swallowing. According to one study, 1 in 5 adults with stable COPD penetrated or aspirated while drinking thin liquids. Aspiration can lead to COPD exacerbation.
Why should people with COPD be screened for dysphagia?
People with COPD who have dysphagia generally fail to recognize that they may have a swallowing impairment, according to Mancopes et al. (2021). Instead, they tend to think that coughing or shortness of breath during oral intake is a symptom of COPD.
And some of them are undoubtedly correct. Mancopes et al. report on one of their studies that looked at the correlation of scores on the EAT-10 and:
“We concluded that because cough is a common symptom in patients with COPD, it should not necessarily be assumed to be associated with dysphagia.”
Mancopes et al., 2021, p. 1213
But research suggests that 20% of people with stable COPD showed penetration-aspiration while drinking 100-mls of thin liquid (reported in Mancopes et al., 2021, p. 1215).
Additionally, older community-dwelling adults tend to dismiss changes in swallowing as a natural consequence of aging and don’t seek treatment (Madhavan et al., 2021).
This suggests that some people with COPD, especially older adults are living with an undiagnosed swallowing impairment. This unnecessarily increases their risk of hospitalization and mortality. Screening may lead to assessment and treatment for these people.
Swallow assessment in COPD
Angela Mansolillo shared excellent information in her MedBridge course The Essentials: Dysphagia and COPD*. Here are some key points.
Chart review and intake interview:
- COPD symptoms?
- Recent exacerbations?
- GERD or LPR?
- Supplementary oxygen?
- Chest X-rays?
Assessment:
- Oxygen saturation at baseline (low is <94%).
- Respiratory rate at baseline (rapid RR is >25 bpm).
- Dyspnea with speech or swallowing.
- Respiratory muscle strength.
As we conduct our clinical swallow evaluations, we can monitor O2 saturation, RR, and dyspnea. We can place our hand on their upper chest to get a sense of the breathing -swallow coordination.
We can see if there is a change in these measures between rest and eating or drinking. We can also see if there is a change across bolus types and sizes. Finally, we can see if there is a change between the start of a meal and the end of a meal.
We should also screen cognition and anxiety level.
Trach and ventilated patients are beyond the scope of this article, but Mansolillo discusses these considerations.
We should consider instrumental assessment for this population.
*This is an affiliate link. At no extra cost to you, you can help keep Eat, Speak, & Think sustainable if you subscribe through this link or use the code EatSpeakThink. Learn more about the discount.
Dysphagia treatment for people with COPD
Mansolillo et al. (2021) offers strategies for people with COPD:
- Sit upright.
- Take breaks to conserve energy.
- Use pursed-lip breathing.
- Take small bites and sips to allow more time for breathing.
- Eat and drink at a slow pace.
- Use an oral hold.
- Avoid breath-holding maneuvers.
She points out that an oral hold taps into voluntary swallow control and increases time for breathing. This may improve breathing and increase post-swallow exhalation.
Expiratory Muscle Strength Training is a treatment option. Research shows that completing EMST leads to higher maximum expiratory pressures and improved respiratory muscle strength.
Diet recommendations:
- Choose high-calorie foods and drinks.
- Consider easy-to-chew foods.
- Eat high protein snacks.
- Limit salt intake.
- Consume fluids at the end of meals to avoid early fullness.
References
- Madhavan, A., Shuman, N., Snyder, C., & Etter, N. (2021). Comparison of Self-Report of Dysphagia Using the Eating Assessment Tool and the Sydney Swallowing Questionnaire in Community Dwelling Older Adults. Perspectives of the ASHA Special Interest Groups, 6, 1198-1204. https://doi.org/10.1044/2021_PERSP-21-00101
- Mancopes, R., Borowsky da Rosa, F., Tomasi, L. L., Pasqualoto, A. S., & Steele, C. M. (2021). Chronic Obstructive Pulmonary Disease & Dysphagia: What Have We Learned So Far and What Do We Still Need to Investigate? Perspectives of the ASHA Special Interest Groups, 6, 112-1221. https://doi.org/10.1044/2021_PERSP-20-00288
- Mansolillo, Angela. The Essentials: Dysphagia and COPD*. MedBridge Education. https://www.medbridgeeducation.com/courses/details/essentials-dysphagia-copd-angela-mansolillo
*This is an affiliate link. At no extra cost to you, you can help keep Eat, Speak, & Think sustainable if you subscribe through this link or use the code EatSpeakThink. Learn more about the discount.
Related Eat, Speak, & Think posts
- 10 factors that increase risk of aspiration pneumonia.
- ALS guide for speech-language pathologists.
- The SLP’s quick guide to Bell’s palsy.
Free DIRECT download: Swallow tips for COPD (patient handout). (Email subscribers get free access to all the resources in the Free Subscription Library.
Featured image by oracast from Pixabay.
Lisa earned her M.A. in Speech-Language Pathology from the University of Maryland, College Park and her M.A. in Linguistics from the University of California, San Diego.
She participated in research studies with the National Institute on Deafness and other Communication Disorders (NIDCD) and the University of Maryland in the areas of aphasia, Parkinson’s Disease, epilepsy, and fluency disorders.
Lisa has been working as a medical speech-language pathologist since 2008. She has a strong passion for evidence-based assessment and therapy, having earned five ASHA Awards for Professional Participation in Continuing Education.
She launched EatSpeakThink.com in June 2018 to help other clinicians be more successful working in home health, as well as to provide strategies and resources to people living with problems eating, speaking, or thinking.
Hello Lisa, I just want to praise you on this excellent website and information you provide. Really well thought through and clearly presented 🙂 Thank you!
I am a fellow SLP in the UK. Best wishes, Sally.
Thanks so much, Sally! I really appreciate the kind feedback.
Best wishes to you as well,
Lisa