Swallowing is a Sensory – Motor Act · Sensory – Motor Act • Sensory feedback plays an integral role in the infant swallowing mechanism • Allows for : • appropriate positioning

January2020

Copyright:LouisaFerrara,SLP,PC 1

Oral Feedings on Respiratory

Devices: Picking Apart

the Controversy

Louisa Ferrara, PhD, CCC-SLP, BCS-S, CNTBoard Certified Specialist in Pediatric Feeding & Swallowing Disorders.

Certified Neonatal TherapistClinical Researcher : NYU-Winthrop Hospital

Assistant Professor : Molloy College

•  Describe the anatomy and physiology of both the swallowing and breathing mechanisms to gain improved understanding of the precise, interconnection between these two acts.

•  Discuss prevalence of neonatal respiratory disease and types of respiratory devices, and how respiratory illness affects mealtime success.

•  Report on recent research findings related to neonatal swallowing safety while on respiratory devices.

Goals & Objectives:

What is Swallowing?A complex task requiring participation of:• 6 pairs of cranial nerves, • 31 pairs of muscles, •  close regulation and coordination between

aerodigestive reflexes• highly dependent on respiratory status

Swallowing is a Sensory – Motor Act

•  Sensory feedback plays an integral role in the infant swallowing mechanism

•  Allows for :•  appropriate positioning of anatomic

structures,•  Modulation of the strength, velocity, and

timing of muscle contractions during all phases of swallowing.

Afferent Sensory Sequences

•  Chemo Receptors = chemical concentrations•  Mechano Receptors = touch, pressure, stretch

(shape, texture, size of bolus)•  Thermo Receptors = temperature changes•  Nociceptors = Pain

Types of Sensory Receptors

Used for both Swallowing function and Respiratory function

January2020


The American Academy of Pediatrics recommends that preterm infants demonstrate competent oral feeding skills before hospital discharge.

(AAP, 1998)

the attainment:•  of exclusive oral feedings•  coordination of suck, swallow

and breathe

•  The maturation of suck, swallow and breathe coordination reflects a predictable pattern of timed neurodevelopment rather than experiential or learned behavior

(Gewolb, et al., 2001; Miller & Kang, 2007)

•  Fetal development is important to understand as it is a continuum of skills which we observe in preterm infants

Development of Suck-Swallow-Breathe

1st Swallowing

Rhythmical Swallowing

1st Sucking

Rhythmical Sucking

Didactic Sequence ofSuck : Swallow

Development of Suck – Swallow - Breathe

12

13

32

33 34

40

Geddes, Kent, Mitoulas & Hartmann, 2008; Hafstrom & Kjellmer, 2000; Simpson, et al., 2002

Goldfield & Smith, 2011

3 Phases of SwallowingOral PhasePharyngeal PhaseEsophageal Phase

January2020


SWALLOWING BREATHING

•  The frequency of aspiration is often underestimated from clinical evaluations in this population, as most infants aspirate silently without such typical symptoms as coughing or choking.

•  According to Lee et al., 2011, WJP•  Dysphagia•  70% of VLBW infants >35w PMA

•  Aspiration•  60% of preterm infants born <25 w GA •  23% of preterm infants born between 26 to 28w •  0% of preterm infants born >29 w

Dysphagia (Dysfunctional Swallowing)

1.  Anatomic Anomalies•  Clefts, Laryngomalacia, atresia, etc.

2.  Motor Deficits•  Reduced tone & Weak muscular movements

3.  Sensory Deficits•  Poor reception of liquid within pharynx

4.  Coordination Deficits•  Inability to coordinate suck-swallow-breathe

Reasons for Dysphagia

Vallecula

Penetration

Aspiration

Naso Pharyngeal Reflux

1.  Anatomic Anomalies•  Clefts, Laryngomalacia, atresia, etc.

2.  Motor Deficits•  Reduced tone & Weak muscular movements

3.  Sensory Deficits•  Poor reception of liquid within pharynx

4.  Coordination Deficits•  Inability to coordinate suck-swallow-breathe

Reasons for Dysphagia

January2020


Respiratory Disease in the Newborn•  Surfactant Deficiency (HMD,RDS, BPD)•  Meconium Aspiration Syndrome (MAS)•  Pneumonia/ Sepsis•  Pneumothorax or other air leak syndromes•  Congenital Abnormalities of the Lung/Thorax

•  Congenital Heart Disease (CHD)•  Congenital Diaphragmatic Hernia (CDH)•  Congenital Cystic Adenomatiod Malformation (CCAM)•  Tracheal Abnormalities•  Esophageal Atresia•  Pulmonary Hypoplasia

•  Persistent Pulmonary Hypertension of the Newborn (PPHN)

Respiratory Devices•  Primary Goals:

•  Support O2 delivery and CO2 elimination•  Prevent added injury•  Decrease ongoing injury by using:

•  least amount of FiO2 •  least amount of ventilator pressure and tidal

volume •  Enhance normal lung development

Success at these goals depends upon the infant’s disease process

Resp

irat

ory

Dev

ices

Respiratory DevicesTypes of Respiratory Support•  Mechanical Ventilation

•  High-Frequency Ventilator •  Conventional Ventilator•  Non-Invasive Mechanical Ventilation

•  NIPPV, nSIMV, etc.•  CPAP

•  Oxygen Delivery Systems•  High Flow (HFNC)•  Low Flow

Most Support

LeastSupport

NCPAP = nasal continuous positive airway pressure•  Continuous pressure for:

•  Oxygenation = O2 in•  Ventilation = CO2 out•  Airation = keeps alveoli open

= supports EELV (end expiration lung volume)

= maintains adequate FRC which supports release of surfactant

NCPAPDevices:

Neotech Ram Cannula Teleflex Hudson Prong

NCPAP

January2020


Motor Effects of CPAP •  Increases transpulmonary pressure and functional

residual capacity (FRC) •  Improves lung compliance•  Assists in reducing alveolar collapse at end exhalation•  Conserves surfactant•  Stabilizes the chest wall•  Increases airway diameter and stents open the airways•  Inhibits laryngeal closure •  Inhibits the swallowing reflex•  Increases the mean airway pressure

•  Sensory feedback plays an integral role in the infant swallowing mechanism

•  Allows for :•  appropriate positioning of anatomic structures,•  Modulation of the strength, velocity, and timing

of muscle contractions during all phases of swallowing.

Sensory Effects of CPAP

How can these sensory receptors attend to a liquid bolus if they are potentially desensitized by pressurized airflow???

Neural Circuitry

involved in Swallowing

NA

Medulla

Two main groups of interneurons

Dorsal Swallowing

Group (DSG)

Ventral Swallowing Group (VSG)

DSG

VSGNA

Medulla

& Breathing

Four Major Nuclei within Medulla

Dorsal Respiratory

Group (DRG)

Ventral Respiratory Group (VRG)

Pre-Botzinger

complex (pre-BotC)

Botzinger complex (BotC)

DRG

BotCPre-BotC

VRG

Neural Circuitry

involved in Swallowing

Hmmm…Something doesn’t

seem right

Is it safe to feed neonates while on NCPAP?

January2020


•  Dalgleish et al., 2016 •  Tested feeding outcomes (Eating in SINC)

•  Hanin et al 2015 •  Tested time �aero-digestive milestones, resource utilization,

oral feeding milestones and safety metrics•  Glackin et al., 2017

•  Tested oral feeding milestones•  Leder et al., 2015

•  Tested oral feeding milestones•  Shetty et al., 2016

•  Tested oral feeding milestones•  Jadcherla et al., 2016

•  Tested breathing and motility patterns

Literature Review •  Bernier et al., 2012•  Djeddi et al., 2013•  Samson et al., 2017•  Samson et al., 2018

Literature Review

HypothesisWe hypothesize that mechanoreceptors, which perceive sensory input from the liquid bolus, may be altered by the reception of pressurized airflow provided by the NCPAP, hence increase risk of aspiration.

Inclusion/Exclusion criteria•  > 34 weeks

•  On NCPAP (Ram cannula. PEEP of 5)

•  Tolerating at least 50% of their total required intake by mouth from a bottle.

•  Asymptomatic infants. Not reported to have any significant feeding difficulties.

•  Infants with upper airway anomalies, brain injury, neuromuscular disease, and life threatening congenital disease were excluded from study.

Procedure•  Video Fluoroscopic Swallow Studies (VFSS). •  20 Swallows on CPAP•  20 Swallows off CPAP

•  replaced by nasal cannula 1 lit/min to deliver O2•  2-5 minute break to swap out equipment

January2020


Deep Penetration (from 43.7% to 25.3%) Aspiration (from 33.5% to 14.6%)

Our NICU safety committee decided to stop the study citing the documented risk associated with

oral feeding on NCPAP

What we learned??

•  There is a significant risk of tracheal aspiration and laryngeal penetration events while orally feeding neonates on NCPAP.

•  Our findings provided neonatologist with an evidence-based approach to initiate oral feeding for infants who require NCPAP.

Retrospective Outcome Study

July 2015

Babies fed on nCPAP Babies fed off nCPAP

n = 30 n = 30

n = 30 in each group Feeding ON CPAP

Feeding OFF CPAP

Mean GA 27.27 ± 2.1727.56 ± 2.14

Length of Stay – Median 86 80

Days on CPAP after 34 w – Median

22.5 8

Sever BPD % 60 33.33

Home Oxygen % 13.33 3.33

Diuretics at Discharge % 16.67 3.33

Retrospective Outcome Data

January2020


What About HFNC?Advantages when compared to CPAP:•  Reduces nasal trauma •  Increases infant comfort •  Increases Parental Satisfaction •  Nurse Satisfaction •  Reduces risk of CPAP belly syndrome •  Baby can expirate on their own, which promotes

normal lung development•  Reduces risks of pneumothorax

What About HFNC?Disadvantages:•  Pressures generated are unpredictable and unregulated

•  aka Inadvertent CPAP•  Flows of 1-2.5 l/min were found to have similar

distending pressures to CPAP (Sreenan et al., 2001 & Saslow et al 2006)

>1.5 lit/min

<1.5 lit/min

Louisa Ferrara, PhD, CCC-SLP, BCS-S, CNT

[email protected]

Thank you!•  Bernier A, Catelin C, Ahmed MA, Samson N, Bonneau P, Praud JP.

(2012). Effects of nasal continuous positive-airway pressure on nutritive swallowing in lambs. J Appl Physiol; 112(12), 1984–91.

•  Dalgleish, SR., Kostecky, LL., Blachly, N. (2016). Eating in “SINC”: Safe Individualized Nipple-feeding Competence, a quality improvement project to explore infant-driven oral feeding for very premature infants requiring noninvasive respiratory support. Neonatal Network, 35(4), pp. 217-227,

•  Djeddi D, Cantin D, Samson N, Tian H, Praud JP. (2013). Absence of effect of nasal continuous positive-airway pressure on the esophageal phase of nutritive swallowing in newborn lambs. J Pediatr Gastroenterol Nutr; 57:188–191

•  Dodrill P, Gosa M, Thoyre S, Shaker C, Pados B, Park J, et al. (2016). FIRST, DO NO HARM: a response to “oral alimentation in neonatal and adult populations requiring high-flow oxygen via nasal cannula”. Dysphagia; 31(6):781–2.

Bibliography

•  Ferrara L, Bidiwala A, Sher I, et al. (2017). Effect of nasal continuous positive airway pressure on the pharyngeal swallow in neonates. J Perinatol;37:398–403.

•  �Gewolb IH, Vice FL, Schwietzer-Kenney EL, Taciak VL, Bosma JF. (2001). Developmental patterns of rhythmic suck and swallow in preterm infants. Dev Med Child Neurol; 43(1): 22–27.

•  Glackin SJ, O’Sullivan A, George S, Semberova J, Miletin J. (2017). High flow nasal cannula versus NCPAP, duration to full oral feeds in preterm infants: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed; 102(4):F329–32. �

•  Goldfield, E. C., & Goldfield, E. C., & Smith, V. (2010). Preterm infant swallowing and respiration coordination during oral feeding: Relationship to dysphagua and aspiration. Current Pediatric Reviews, 6, 143–150.

Bibliography•  Hanin M, Nuthakki S, Malkar MB, Jadcherla SR. (2015). Safety and efficacy

of oral feeding in infants with BPD on nasal CPAP. Dysphagia;30: 121–7.

•  Jadcherla SR, Hasenstab KA, Sitaram S, Clouse BJ, Slaughter JL, Shaker R. (2016). Effect of nasal noninvasive respiratory support methods on pharyngeal provocation-induced aerodigestive reflexes in infants. Am J Physiol Gastrointest Liver Physioy;310:G1006–14.

•  Jadcherla SR, Hasenstab KA, Shaker R, Castile RG. (2015). Mechanisms of cough provocation and cough resolution in neonates with bronchopulmonary dysplasia. Pediatr Res;78:462–9.

•  Leder SB, Siner JM, Bizzarro MJ, McGinley BM, Lefton-Greif MA (2016). Oral alimentation in neonatal and adult populations requiring high-flow oxygen via nasal cannula. Dysphagia; 31:154–9

Bibliography

January2020


•  Lee, J. H., Chang, Y. S., Yoo, H. S., Ahn, S. Y., Seo, H. J., Choi, S. H., … Park, W. S. (2011). Swallowing dysfunction in very low birth weight infants with oral feeding desaturation. World Journal of Pediatrics  : WJP, 7(4), 337–343.

•  Miller, J. L., & Kang, S. M. (2007). Preliminary ultrasound observation of lingual movement patterns during nutritive versus non-nutritive sucking in a premature infant. Dysphagia, 22(2), 150–160.

•  �Samson, N., Michaud, A., Othman, R., Nadeau, C., Nault, S., Cantin, D., … Praud, J. (2017). Nasal continuous positive airway pressure influences bottle-feeding in preterm lambs. Nature Publishing Group, 82(6), 926–933.

•  Samson, N., Nadeau, C., Vinvent, L., Cantin, D.,. Praud JP., (2018). Effects of nasal continuous positive airway pressure and high-flow nasal cannula on sucking, swallowing, and breathing during bottle-feeding in lambs Front. Pediatr., 5, p. 296

•  Shetty S, Hunt K, Douthwaite A, Athanasiou M, Hickey A, Greenough A. (2016). High-flow nasal cannula oxygen and nasal continuous positive airway pressure and full oral feeding in infants with bronchopulmonary dysplasia. Arch Dis Child Fetal Neonatal Ed, 101(5):F408–11.

Bibliography

Swallowing is a Sensory – Motor Act · Sensory – Motor Act • Sensory feedback plays an integral role in the infant swallowing mechanism • Allows for : • appropriate positioning

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