Therapeutic Science for Rehabilitation (재활치료과학)

Korean Society of Neurological Occupational Therapy (대한신경계작업치료학회)
권호 표지
DOI QR코드

DOI QR Code

Treatment of Dysphagia in a Cardiac Transplantation Patient: A Case Study

심장 이식 수술 환자의 연하장애 재활치료: 단일 사례 연구

  • Lee, Su-Jung (Former Kangbuk Samsung Hospital) ;
  • Kim, Tu-Kyu (Kangbuk Samsung Hospital) ;
  • Seo, Sang-Min (Dept. of Occupational Therapy, Semyung University)
  • 이수정 (강북삼성병원 작업치료실) ;
  • 김두규 (강북삼성병원 작업치료실) ;
  • 서상민 (세명대학교 보건바이오대학 작업치료학과)
  • Received : 2024.06.21
  • Accepted : 2024.07.18
  • Published : 2024.08.31
Download PDF
⟨ Previous Next ⟩

Abstract

Objective : This case study aimed to explore dysphagia symptoms in post-cardiac transplantation patients and evaluate the effectiveness of dysphagia rehabilitation therapy in an occupational therapy clinic. Methods : A patient with post-cardiac transplant dysphagia underwent videofluoroscopic swallowing studies to assess the Functional Dysphagia Scale (FDS), Penetration-Aspiration Scale (PAS), and Dysphagia Outcome and Severity Scale (DOSS). Assessments were performed three times at two-week intervals. The treatment, administered from July 19 to August 21, 2023, included eight sessions of 30 minutes each. Treatments included corrective techniques (tongue-hold maneuver, chin tuck against resistance, mendelsohn maneuver, effortful swallowing, and respiratory muscle exercise) and compensatory strategies (chin-tuck position, multiple swallowing, modification of volume, and viscosity), alongside caregiver education. Results : The FDS scores decreased from 50 to 30, PAS scores improved from 5 to 3, and DOSS scores improved from Stage 2 to Stage 4. Conclusion : Dysphagia rehabilitation therapy improved swallowing function in a post-cardiac transplantation patient. However, further studies are required to confirm these findings.

목적 : 사례연구를 통해 심장이식 수술 후 연하장애가 발생한 환자의 증상을 알아보고 작업치료실에서 적용한 연하장애 재활치료의 효과에 대해 알아보고자 하였다. 연구방법 : 심장 이식 수술 후 연하장애가 발생한 환자 1명을 대상으로 비디오 투시 연하검사를 통해 기능적 연하장애 척도와 침습-흡인 척도, 삼킴 곤란 결과 및 증증도 척도를 2주 간격으로 총 3회 실시하였다. 치료 기간은 2023년 7월 19일부터 8월 21일까지 회기당 30분씩 총 8회 실시하였다. 후두 상승과 상부식도조임근의 충분한 열림 및 잔여물의 감소를 위한 교정적 치료(혀-유지 기법, 저항성 턱 당기기 운동, 멘델슨 기법, 노력 삼킴, 호흠근육 운동)와 기도보호를 위한 보상적 치료(턱 당기기 자세, 여러 번 삼키기, 음식 양과 점도 변경) 및 보호자 교육을 실시하였다. 결과 : 기능적 연하장애 척도 검사의 점수가 50점에서 30점으로 감소하였으며, 침습-흡인 척도의 단계는 5단계에서 3단계로 향상되었다. 삼킴 곤란 결과 및 중증도 척도에서는 2단계에서 4단계로 향상되었다. 결론 : 심장 이식 수술 후 연하장애를 보이는 경우 연하재활치료가 환자의 삼킴 기능 향상에 도움을 주는 것을 확인하였다. 향후 심장 이식 수술 환자의 연하장애 재활치료의 효과에 대한 보완 연구가 필요할 것이다.

Keywords

Acknowledgement

본 연구는 대한연하재활학회의 지원을 받아 수행되었음.

References

  1. Arnold, R. J., & Bausek, N. (2020). Effect of respiratory muscle training on dysphagia in stroke patients: A retrospective pilot study. Laryngoscope Investigative Otolaryngology, 5(6), 1050-1055. https://doi.org/10.1002/lio2.483
  2. Atkins, B. Z., Trachtenberg, M. S., Prince-Petersen, R., Vess, G., Bush, E. L., Balsara, K. R., Lin S. S., & Davis, R. D., Jr. (2007). Assessing oropharyngeal dysphagia after lung transplantation: Altered swallowing mechanisms and increased morbidity. Journal of Heart and Lung Transplantation, 26(11), 1144-1148. https://doi.org/10.1016/j.healun.2007.07.038
  3. Barker, J., Martino, R., Reichardt, B., Hickey, E. J., & Ralph-Edwards, A. (2009). Incidence and impact of dysphagia in patients receiving prolonged endotracheal intubation after cardiac surgery. Canadian Journal of Surgery, 52(2), 119-124.
  4. Barquist, E., Brown, M., Cohn, S., Lundy, D., & Jackowski, J. (2001). Postextubation fiberoptic endoscopic evaluation of swallowing after prolonged endotracheal intubation: A randomized, prospective trial. Critical Care Medicine, 29(9), 1710-1713. https://doi.org/10.1097/00003246-200109000-00009
  5. Black, R. J., Bogaardt, H., McCabe, P., Glanville, A. R., MacDonald, P., & Madill, C. (2019). Clinical predictors for oropharyngeal dysphagia and laryngeal dysfunction after lung and heart transplantation. International Journal of Language & Communication Disorders, 54(6), 894-901. https://doi.org/10.1111/1460-6984.12492
  6. Black, R. J., Novakovic, D., Plit, M., Miles, A., MacDonald, P., & Madill, C. (2021). Swallowing and laryngeal complications in lung and heart transplantation: Etiologies and diagnosis. Journal of Heart and Lung Transplantation, 40(12), 1483-1494. https://doi.org/10.1016/j.healun.2021.08.006
  7. Brodsky, M. B., Levy, M. J., Jedlanek, E., Pandian, V., Blackford, B., Price, C., Cole, G., Hillel, A., Best, S., & Akst, L. M. (2018). Laryngeal injury and upper airway symptoms after oral endotracheal intubation with mechanical ventilation during critical care: A systematic review. Critical Care Medicine, 46(12), 2010-2017. https://doi.org/10.1097/CCM.0000000000003368
  8. Cumming, T. B., Marshall, R. S., & Lazar, R. M. (2013). Stroke, cognitive deficits, and rehabilitation: Still an incomplete picture. International Journal of Stroke, 8(1), 38-45. https://doi.org/10.1111/j.1747-4949.2012.00972.x
  9. Daly, E., Miles, A., Scott, S., & Gillham, M. (2016). Finding the red flags: Swallowing difficulties after cardiac surgery in patients with prolonged intubation. Journal of Critical Care, 31(1), 119-124. https://doi.org/10.1016/j.jcrc.2015.10.008
  10. de Larminat, V., Montravers, P., Dureuil, B., & Desmonts, J. M. (1995). Alteration in swallowing reflex after extubation in intensive care unit patients. Critical Care Medicine, 23(3), 486-490. https://doi.org/10.1097/00003246-199503000-00012
  11. Deem, S. (2006). Intensive-care-unit-acquired muscle weakness. Respiratory Care, 51(9), 1042-1053. https://doi.org/10.4187/aarc04269
  12. DeVita, M. A., & Spierer-Rundback, L. (1990). Swallowing disorders in patients with prolonged orotracheal intubation or tracheostomy tubes. Critical Care Medicine, 18(12), 1328-1330. https://doi.org/10.1097/00003246-199012000-00004
  13. Finck, C. (2006). Laryngeal dysfunction after thyroid surgery: Diagnosis, evaluation and treatment. Acta Chirurgica Belgica, 106, 378-387. https://doi.org/10.1080/00015458.2006.11679911
  14. Fujiu, M., & Logemann, J. A. (1996). Effect of a tongue-holding maneuver on posterior pharyngeal wall movement during deglutition. American Journal of Speech-Language Pathology, 5(1), 23-30. https://doi.org/10.1044/1058-0360.0501.23
  15. Gamez, J., Salvado, M., Martinez-de La Ossa, A., Deu, M., Romero, L., Roman, A., Sacanell. J., Laborda. C., Rochera. I., Nadal. M., Carmona. F., Santamaria. E., Raguer. N., Canela, M., & Sole, J. (2017). Influence of early neurological complications on clinical outcome following lung transplant. PloS One, 12(3), e0174092. https://doi.org/10.1371/journal.pone.0174092
  16. Goldsmith, T. (2000). Evaluation and treatment of swallowing disorders following endotracheal intubation and tracheostomy. International Anesthesiology Clinics, 38(3), 219-242. https://doi.org/10.1097/00004311-200038030-00015
  17. Grimm, J. C., Magruder, J. T., Ohkuma, R., Dungan, S. P., Hayes, A., Vose, A. K., Orland. M., Sussman. M., Cameron, D. E., & Whitman, G. J. (2015). A novel risk score to predict dysphagia after cardiac surgery procedures. The Annals of Thoracic Surgery, 100(2), 568-574. https://doi.org/10.1016/j.athoracsur.2015.03.077
  18. Groher, M. E., & Crary, M. A. (2015). Dysphagia: Clinical management in adults and children. Elsevier.
  19. Hamdan, A. L., Moukarbel, R. V., Farhat, F., & Obeid, M. (2002). Vocal cord paralysis after open-heart surgery. European Journal of Cardio-thoracic Surgery, 21(4), 671-674. https://doi.org/10.1016/S1010-7940(02)00019-2
  20. Han, T. R., Paik, N. J., & Park, J. W. (1999). The Functional Dysphagia Scale using Videofluoroscopic Swallowing Study in stroke patients. Journal of the Korean Academy of Rehabilitation Medicine, 23(6), 1118-1126.
  21. Hermans, G., De Jonghe, B., Bruyninckx, F., & Berghe, G. V. D. (2008). Clinical review: Critical illness polyneuropathy and myopathy. Critical Care, 12, 1-9. https://doi.org/10.1186/cc7100
  22. Hinchey, J. A., Shephard, T., Furie, K., Smith, D., Wang, D., & Tonn, S. (2005). Formal dysphagia screening protocols prevent pneumonia. Stroke, 36(9), 1972-1976. https://doi.org/10.1161/01.STR.0000177529.86868.8d
  23. Jung, J. S., & Park, J. H. (2015). The treatment of dysphagia in total thyroidectomy patients: A case study. Korean Journal of Occupational Therapy, 23(2), 95-106. https://doi.org/10.14519/jksot.2015.23.2.08
  24. Kim, M. J., Park, Y. H., Park, Y. S., & Song, Y. H. (2015). Associations between prolonged intubation and developing post-extubation dysphagia and aspiration pneumonia in non-neurologic critically ill patients. Annals of Rehabilitation Medicine, 39(5), 763-771. https://doi.org/10.5535/arm.2015.39.5.763
  25. Lacomis, D. (2011). Neuromuscular disorders in critically ill patients: Review and update. Journal of Clinical Neuromuscular Disease, 12(4), 197-218. https://doi.org/10.1097/CND.0b013e3181b5e14d
  26. Lim, J. H. (2009). Conservative treatment of dysphagia. Brain & Neurorehabilitation, 2(2), 108-112. https://doi.org/10.12786/bn.2009.2.2.108
  27. Logemann, J. A. (1998). Evaluation and treatment of swallowing disorder (2nd ed.). PRO-ED Inc. https://doi.org/10.1097/00020840-199812000-00008
  28. Logemann, J. A. (2008). Treatment of oral and pharyngeal dysphagia. Physical Medicine and Rehabilitation Clinics of North America, 19(4), 803-816. https://doi.org/10.1016/j.pmr.2008.06.003
  29. Macht, M., Wimbish, T., Bodine, C., & Moss, M. (2013). ICU-acquired swallowing disorders. Critical Care Medicine, 41(10), 2396-2405. https://doi.org/10.1097/CCM.0b013e31829caf33
  30. Miles, A., Barua, S., McLellan, N., & Brkic, L. (2021). Dysphagia and medicine regimes in patients following lung transplant surgery: A retrospective review. International Journal of Speech-Language Pathology, 23(4), 339-348. https://doi.org/10.1080/17549507.2020.1807051
  31. Mirzakhani, H., Williams, J. N., Mello, J., Joseph, S., Meyer, M. J., Waak, K., Schimidt. U., Kelly. E., & Eikermann, M. (2013). Muscle weakness predicts pharyngeal dysfunction and symptomatic aspiration in long-term ventilated patients. Anesthesiology, 119(2), 389-397. https://doi.org/10.1097/ALN.0b013e31829373fe
  32. Murty, G. E., & Smith, M. C. F. (1989). Recurrent laryngeal nerve palsy following heart-lung transplantation: Three cases of vocal cord augmentation in the acute phase. Journal of Laryngology & Otology, 103(10), 968-969. https://doi.org/10.1017/S0022215100110643
  33. O'Neil, K. H., Purdy, M., Falk, J., & Gallo, L. (1999). The dysphagia outcome and severity scale. Dysphagia, 14, 139-145. https://doi.org/10.1007/PL00009595
  34. Palmer, J. B., Kuhlemeier, K. V., Tippett, D. C., & Lynch, C. (1993). A protocol for the Videofluorographic Swallowing Study. Dysphagia, 8, 209-214. https://doi.org/10.1007/BF01354540
  35. Pereira, J. A., Girvent, M., Sancho, J. J., Parada, C., & Sitges-Serra, A. (2003). Prevalence of long-term upper aerodigestive symptoms after uncomplicated bilateral thyroidectomy. Surgery, 133(3), 318-322. https://doi.org/10.1067/msy.2003.58
  36. Plowman, E. K., Anderson, A., York, J. D., DiBiase, L., Vasilopoulos, T., Arnaoutakis, G., Beavr. T., Martun. R., & Jeng, E. I. (2023). Dysphagia after cardiac surgery: Prevalence, risk factors, and associated outcomes. Journal of Thoracic and Cardiovascular Surgery, 165(2), 737-746. https://doi.org/10.1016/j.jtcvs.2021.02.087
  37. Ponfick, M., Linden, R., & Nowak, D. A. (2015). Dysphagia-a common, transient symptom in critical illness polyneuropathy: A fiberoptic endoscopic evaluation of swallowing study. Critical Care Mdicine, 43(2), 365-372. https//doi.org/10.1097/CCM.0000000000000705
  38. Puthucheary, Z., Montgomery, H., Moxham, J., Harridge, S., & Hart, N. (2010). Structure to function: Muscle failure in critically ill patients. The Journal of Physiology, 588(23), 4641-4648. https://doi.org/10.1113/jphysiol.2010.197632
  39. Raut, M. S., Maheshwari, A., Joshi, R., Joshi, R., Dubey, S., Shivnani, G., & Shad, S. (2016). Vocal cord paralysis after cardiac surgery and interventions: A review of possible etiologies. Journal of Cardiothoracic and Vascular Anesthesia, 30(6), 1661-1667. https://doi.org/10.1053/j.jvca.2016.08.002
  40. Rosenbek, J. C., Robbins, J. A., Roecker, E. B., Coyle, J. L., & Wood, J. L. (1996). A penetration-aspiration scale. Dysphagia, 11, 93-98. https://doi.org/10.1007/BF00417897
  41. Shaker, R., Easterling, C., Kern, M., Nitschke, T., Massey, B., Daniels, S., Grande. B., Kazandjian. M., & Dikeman. K. (2002). Rehabilitation of swallowing by exercise in tubefed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology, 122(5), 1314-1321. https://doi.org/10.1053/gast.2002.32999
  42. Skoretz, S. A., Yau, T. M., Ivanov, J., Granton, J. T., & Martino, R. (2014). Dysphagia and associated risk factors following extubation in cardiovascular surgical patients. Dysphagia, 29, 647-654. https://doi.org/10.1007/s00455-014-9555-4
  43. Song, W. I., & Jung, M. Y. (2018). The treatment of swallowing disorders in stroke patients: A systematic review. Korean Journal of Occupational Therapy, 26(2), 113-128. https://doi.org/10.14519/jksot.2018.26.2.09
  44. Song, Y. J., Park, E. J., Yoon, I. J., & Choi, K. H. (2012). Swallowing therapy and quality of life in head and neck cancer patients. Journal of the Korean Dysphagia Society, 2(2), 53-61. https://doi.org/10.34160/jkds.2012.2.2.004
  45. Sorensen, R. T., Rasmussen, R. S., Overgaard, K., Lerche, A., Johansen, A. M., & Lindhardt, T. (2013). Dysphagia screening and intensified oral hygiene reduce pneumonia after stroke. Journal of Neuroscience Nursing, 45(3), 139-146. https://doi.org/10.1097/JNN.0b013e31828a412c
  46. Thille, A. W., Boissier, F., Muller, M., Levrat, A., Bourdin, G., Rosselli, S., Frat. J. P., Coudroy. R., & Vivier, E. (2020). Role of ICU-acquired weakness on extubation outcome among patients at high risk of reintubation. Critical Care, 24(1), 86. https://doi.org/10.1186/s13054-020-2807-9
  47. Tobin, M. J., Laghi, F., & Jubran, A. (2010). Narrative review: Ventilator-induced respiratory muscle weakness. Annals of Internal Medicine, 153(4), 240-245. https://doi.org/10.7326/0003-4819-153-4-201008170-00006
  48. Woo, J. H., Jeong, W. M., Kim, Y. G., & Koo, J. W. (2009). The relevant factors and effect of swallowing function on oropharyngeal stimulation program in stroke patients with swallowing disorder. Korean Journal of Occupational Therapy, 17(4), 1-12.
  49. Ye, D. H., Hong, G., Kang, C. J., Kim, J. J., & Choi, K. H. (2023). Prevalence and clinical predictors of dysphagia after heart transplantation. Clinical Transplantation, 37(9), e15037. https://doi.org/10.1111/ctr.15037
  50. Yoon, I. J., & Park, M. J. (2010). The treatment of dysphagia in dermatomyositis patients: A case study. Korean Journal of Occupational Therapy, 18(4), 77-92.
  51. Yoon, W. L., Khoo, J. K. P., & Rickard Liow, S. J. (2014). Chin tuck against resistance (CTAR): New method for enhancing suprahyoid muscle activity using a Shaker-type exercise. Dysphagia, 29, 243-248. https://doi.org/10.1007/s00455-013-9502-9
  52. Zuercher, P., Moret, C. S., Dziewas, R., & Schefold, J. C. (2019). Dysphagia in the intensive care unit: Epidemiology, mechanisms, and clinical management. Critical Care, 23, 103. https://doi.org/10.1186/s13054-019-2400-2