Respiratory Disorders Lecture Slides PDF

Respiratory Disorders (Ferrand, Speech Science: an Integrated Approach (4th ed) Chapter 3) Glen Nowell, MSc., SLP-Reg, S-LP(C) Speech-Language Pathologist Today we will cover +Assessment of respiratory variables +Classifications of breathing disorders and their sy...

Respiratory Disorders (Ferrand, Speech Science: an Integrated Approach (4th ed) Chapter 3) Glen Nowell, MSc., SLP-Reg, S-LP(C) Speech-Language Pathologist Today we will cover +Assessment of respiratory variables +Classifications of breathing disorders and their symptoms +Impact of different types of issues that can affect respiratory function (neurological disorders, asthma, stuttering, dysphonia, mechanical ventilation) and their impact on speech dysphonia: problems with voice Residual Volume Measurement of trumpet’s residual volume using 10-ton Buffalo Springfield Steam Roller. Due to challenge sterilizing steam rollers, not available for use in clinical settings. Measurement of Respiratory variables +Lung volumes, air pressures, air flows, chest wall positioning and movement +Interaction of variables means measurement of one facet can infer information about another facet. +Spirometry directly measures lung volume and flows +"Pulmonary Function Testing" Pulmonary Function Testing +What can clients inhale, exhale, how efficiently. +Norms based on age, gender, body height and size, race. +Common measures: + Forced vital capacity (FVC) + Forced expiratory volume in 1 second (FEV1) + Forced Expiratory Flow (FEF) + Peak Expiratory Flow Rate (PEFR) + MVV (max voluntary ventilation) essentially hyperventilation + FEF50/FIF50 + Ferrand p. 89 for full chart and definitions) Flow Volume Loops +Graph that shows velocity of airflow on Y-axis and air volume on X axis FLOW VOLUME LOOP Respiratory Kinematic Analysis +Allow assessment of respiration during SPEECH! +Plethysmography +Linearized Magnetometer Plethysmograph +Synopsis: Pant into a mouthpiece while sealed in an aquarium. +Air pressure and volume in the aquarium (and against mouthpiece) change due to movement of chest wall. Calculates lung volume accurately. +Paraphrased from Ferrand, p, 92-93. Respiratory Inductance Plethysmography +Synopsis: wear 2 elastic straps containing coiled wire (chest and epigastrium). Breathing movements stretch coils in straps apart, changing electromagnetic field. +Calculating movement of ribs and abdomen: inference of lung volume. Linearized magnetometer +Synopsis: 2 pucks with coils of wire inside. One stuck on back and one stuck on front. One sends signal, other reads signal. + Fluctuating strength of signal infers thoracic or abdominal expansion, gives data about lung volume.  Air pressures for speech +Palv (in lungs) +Psub (below vocal folds) +Ptrach (in trachea) +Poral (intra-oral) Palv & Ptrach should be the same Poral is not necessarily the same Manometer (do doo do do do) +Measure static pressure (e.g., max inspiratory and expiratory pressure) +Can use it to train (maintain target pressure for exercise) +5 cm H20 for 5 seconds, for example +Limitations: not permanent record, not good at measuring constantly fluctuating pressures of speech breathing. Need a transducer and computer to gather complex fluctuations for speech. Under pressure… +Most conversation Ptrach is 5 cm to 10 cm H20 pressure. +Duration and fluctuations are dynamic. +To increase speech dB by 8 or 9 dB, double Ptrach +Use oral pressure transducer to infer Ptrach during voiceless stop (/p/). Poral=Ptrach=Palv at that moment. lips sealed voiceless**  Airflow (volume velocity) +ml/sec, l/min, ml/syll +Pneumotachometer (mouthpiece with mesh screen) +Pressure against screen over time calculates airflow rate +Can measure both oral and nasal airflow +Laryngeal configuration influences airflow during speech task (breathy/pressed) breathy: higher; pressed: higher +Soft palate weakness captured with nasal emission weak soft palate: may sound more nasaly due to not being able to form a strong seal Average flow rates for /a/ (ml/sec) +cis boys age 7: 95.9 ml/sec +cis girls age 7: 71.6 ml/sec +cis men: 112.4 ml/sec +cis women: 93.7 ml/sec +Can also capture peak flow rates for fricatives, stop release bursts, etc. Respiratory Disorders +Any issue that impedes air movement and oxygen exchange +Dyspnea (feeling of discomfort in breathing in or out)– SOB, chest tightness, effort, SOBOE +Triggers: interaction between sensory receptors in respiratory system (lungs, airways, thorax), blood vessels, areas of the brain, physical (BMI, conditioning, spinal cord injury) and psychological characteristics of the person. +Causes of dyspnea: obstructive, restrictive or central issues, fatigue or exercise, stress or emotion Stridor +Alternate name for Aragorn +Audible sound during inspiration and/or expiration. +Inspiratory stridor, expiratory stridor or biphasic stridor. +May be high or low pitch turbulent noise from narrow/obstructed segment of airway +Note on laryngomalacia: collapsing hyperflexible laryngeal tissue typically causes INSPIRATORY stridor as it collapses inward. Classifications of Respiratory Disorders 01 02 03 OBSTRUCTIVE RESTRICTIVE CENTRAL Obstructive Respiratory Disorders +Narrowing or blockage of the airways +Foreign body +Inflammation +Spasms of the smooth airway muscle +Other obstructions Obstructive Respiratory Disorders +Commonly affects Exhalation +Asthma +Bronchitis +Emphysema +COPD (chronic obstructive pulmonary disease) Restrictive Lung Diseases affects EXPANSION +Often impede lung expansion and reduce lung volume. Affects Inspiration. +Fibrosis +Connective Tissue Diseases +Neuromuscular Diseases +Diseases of the Pleura Central Respiratory Disorders BRAIN’S INITIATION OF RESPIRATION +Caused by neurological dysfunction in respiratory brain centers in the brain stem +CVA STROKE +Medications that depress nervous system function +ALS +Brain tumour +Muscular Dystrophy +Symptom: Hypoventilation (inadequate ventilation) Principles of Clin Mgt of Resp Disorders +1. Measure respiratory function (speech and non-speech tasks) +2. Tailor Tx to specific respiratory difficulty. +3. Sequence clinical activities in order of: pressure variables, volume variables and chest-wall shape variables +4. Practice respiratory exercises in speech contexts Neurological Disorders +May have issues with respiratory muscles or the nervous system communication with those muscles. +Spasticity or flaccidity or generalized weakness. +Posture may be affected. +E.g., Parkinson’s, ALS, MD, spinal cord injury, CP Parkinson’s +SLP has lots of different ways to help these clients! +For this class: weakness, low dB may be partly from reduced respiratory support (muscular rigidity—restrictive resp prob). +Reduced rib expansion, more abdominal expansion noted. +Dyspnea worsens with exertion and over course of disease. +Start phrase at lower lung volume +Go further below REL at end of phrase +Used more vital capacity per syllable (poor laryngeal control of flow) + May be related to difficulty controlling flow of air through larynx Parkinson’s +Can develop adequate Ptrach +Reduced Poral: loss of pressure through lips or velopharynx +Reduces intelligibility (reduced pressure for stops and fricatives) Clinical Mgt of Parkinson’s +Cue short phrases (don’t fight rigid chest walls) +Increase Psub to improve intensity (stronger glottic closure) +Lee Silverman Voice Treatment (long, loud, increase force, deep breath, Expiratory Muscle Strength training) +Rationale: increase Palv –longer utterances, increased dB, better VQ  Cerebellar Disease + Cerebellum’s job: smooth coordination of voluntary movement + Speed, direction, force and amplitude of movement + Damage to cerebellum: jerky, uncoordinated, like intoxicated. + Difficulty with subtle Fo, dB and stress adjustments: slurred, slow, excess and equal stress. + Sudden jerky movements of diaphragm or ribcage: inhalation mid-sentence (inspiratory gasps), sudden changes in dB. + Many begin utterance at or below REL. + Challenging to treat! Cue deeper breath before speaking. Cervical Spinal Cord Injury Cervical Spinal Cord Injury +May have weakness or paralysis of respiratory muscles +May be ventilator dependent (unable to breathe independently) +May have some diaphragm function but not able to generate adequate flow and pressure +Reduced Poral, short breath groups, slow inspiration CSCI +Dyspnea (breathing problems) during speech +Reduced VC, TLC, FRC, ERV, reduced inspiratory and expiratory muscle strength +Pts with Quadriplegia may recruit ACCESSORY muscles …SCM, trapezius to boost dB. May also increase abdominal volume. +Fewer syllables per breath CSCI +Some may inhale more air (increase elastic recoil). Increases dB, but may shorten utterance length. +Useful to teach clients.  Cerebral Palsy Spastic CP: too much tone, but also weakness Athetoid CP: involuntary movements; uncontrolled, irregular movements (bursts of in/exhalation) Ataxic CP: incoordination; irregular rate, rhythm and depth of tidal breathing Cerebral Palsy +All parameters of respiratory function may be affected (lower pressure, volume, flow, atypical chest wall shape). +Difficulty accessing IRV and/or ERV. +May need to use more of their VC +Poor valving (Velopharynx, larynx, articulators) wastes air +Chest wall shape altered by: posture, muscle tone/weakness +Posture may improve with Ataxic CP. +Spastic CP: flexed position, worsens breathing over time Intervention for CP +Strengthen respiratory muscles +Muscle conditioning protocol (mask that resisted expiratory breath stream for 15 minutes daily, 5 days per week, 6 weeks. Improved Ptrach, dB. +Deep and quick inhalation exercises, with checking practice +Postural support (seating changes, abdominal trussing) Mechanical Ventilation Mechanical Ventilation +Cannula (tube) in stoma (hole in neck to trachea) +Pumps air into resp system (inspiratory phase) +May allow recoil for expiratory phase) +May be sealed system (no air passes VF) +May allow leak past VF to allow speech during INSPIRATORY phase Mechanical ventilation issues +Speaker cannot control timing +Ptrach are high (up to 26 cmH20), change rapidly +Have to balance speech with resp needs +Tidal volumes may be WAY higher for vented patients (3x) +Shorter than normal syllables per breath (stop sooner than needed) Mechanical Ventilation Intervention +Talk to the very end of recoil +Consider speaking valve (Passy-Muir or similar) +One-way valve over trach Voice Disorders +Clients with VF nodules: larger lung volume excursion (more in, more out). Glottic leak due to nodules may be cause. (Sapienza and Stathopoulos (1994) +Nodules: shouted starting at lower lung volume, used more air, breathed more often but to lower amount (Iwarsson and Sundberg (1999) +Higher than normal Ptrach +Lesions: went below REL, but some even STARTED below REL +Led to muscle strain and inefficiency Voice Disorders +Hyperfunctional voice disorders: shallow resp, poor coordination of expiration and phonation, clavicular breathing +Air hunger complaints, respiratory fatigue Stuttering +Disorder characterized by disfluencies. +Blocking, prolongation, part or whole word repetition, fillers, sometimes secondary behaviours +Difficulty coordinating respiration with production of sound during fluent AND stuttered speech +May be lack of coordination between speech subsystems (resp, phon, artic) and possibly within them +Atypical resp control during inspiration Stuttering respiratory behaviours +Incoordination between abdominal and thoracic resp +Irregular resp cycles +Prolonged expirations/inspirations +Interruption of expiration by inspiration +Cessation of breathing +Lower lung volumes +Expiration going below REL +Lung volumes during speech in low portion of VC +Abnormal Psub (low, high, fluctuates) Stuttering interventions +Focus on regulating speech breathing patterns (costo- diaphragmatic, rather than clavicular/high thoracic) +Regulated breathing: when stuttering, relax, focus on breath, exhale before starting again +CAFET (Computer Assisted Fluency Enhancement Training (respiratory inductance plethysmography) Asthma +Chronic disorder with acute flare-ups (Attacks) +narrowing of large and small airways. +Bronchial narrowing: inflammation of mucosal lining, and bronchial smooth muscle contracture Chronic Asthma +Nocturnal cough +SOBOE +Throat clearing, chronic cough +Chest tightness +Reduced O2 sats Acute Asthma attack +SOB +Laboured breathing +Expiratory wheeze +Chest tightness +May require hospitalization +Reduced O2 sats (worse) Asthma triggers +Pet dander +Dust, mold, pollen +Allergies +Viral infection +Exercise +Smoke or chemicals +GERD +stress Resp findings for Asthma +Flattened expiratory limb of flow volume loop +Reduced FEV1 +Reduced FEV1/FVC ratio +Measure VC, TLC, RV, PEF (peak expiratory flow rates) +PEF: max airflow rate during exhalation. Measures rate of flow from large airways (Bronchi, trachea) +FEV1 (measures large and medium airways) +FEF25-75% (measures smaller airways) +The more severe the asthma, the worse the expiratory measures Asthma management +ICS (inhaled corticosteroids)—reduces inflammation and mucus +May combine ICS with a bronchodilator (relaxes smooth muscle constriction of the airways) +Improves FEF25-75% and FEV1 Asthma and speech/voice +Oral breathers, dry air increases PTP +ICS can cause hoarseness and thrush +Can cause clavicular/thoracic respiration +Poor breath support can lead to reduced intensity and hoarseness Inducible Laryngeal Obstruction +AKA Vocal Fold Dysfunction, sometimes called Laryngospasm +Historically called Paradoxical Vocal Fold Motion, even called Munchausen’s Stridor, Hysterical dyspnea! +Vocal folds partly adduct during inspiration—leads to stridor, anxiety, dyspnea +When asymptomatic, respiratory function is normal +O2 sats DO NOT DROP ILO +Flattened inspiratory limb of Flow Volume Loop. +If expiratory phase is also involved (or concomitant Asthma), may flatten expiratory limb too (but less likely). +Treatment: Voice therapy! + Thorough case history to determine triggers + Improve breathing technique + Reduce tension + Use specific techniques to recover from ILO + Double sniff /s/, pursed lips breathing, slow abdominal breathing, fist breathing + Extinguish reaction to triggers EILO +Exercise-induced laryngeal obstruction +Difficult to tell apart from exercise-induced asthma +New Treatment recently developed (EILOBI) +In new hospital, I HOPE to get set up to treat EILOBI Voice disorder intervention +Start phonation at higher lung volumes. +Stop phonating before they get too empty. Residual Volume Review References +https://www.mayoclinic.org/ +Speech Science: an Integrated Approach to Theory and Clinical Practice (4th ed.) Ferrand (2018).