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Relationship of pharyngeal transition time and presence of residue with dyspnea and lung function in chronic obstructive pulmonary disease

ABSTRACT

Purpose

To relate pharyngeal transit time and the presence of residues with dyspnea and lung function in individuals with Chronic Obstructive Pulmonary Disease COPD.

Methods

Study conducted with 19 adults (11 men, 8 women) with a clinical and spirometric diagnosis of COPD and a mean age of 63.8 years (SD = 9.3). Data collection was performed using the COPD Assessment Test (CAT) questionnaire, the modified Medical Research Council scale (mMRC) and a digital manovacuometer, to characterize the impact of the disease on the individual, dyspnea and lung function. The data related to pharyngeal transit time and pharyngeal residue were collected through the analysis of videofluoroscopic images performed by three blinded judges.

Results

No significant relationship was found between pharyngeal transit time (PTT) with lung function (r = -0.71), pharyngeal residue and dyspnea (r = -0.06). PTT, when compared to normality, was increased.

Conclusion

Individuals with COPD, regardless of the severity of the disease, showed no association between PTT and pharyngeal residue and dyspnea and lung function.

Keywords
Pulmonary Disease; Chronic Obstructive; Deglutition; Deglutition Disorders; Dyspnea; Lung Diseases

RESUMO

Objetivo

Relacionar o tempo de trânsito faríngeo e a presença de resíduos com a dispneia e a função pulmonar em indivíduos com Doença Pulmonar Obstrutiva Crônica DPOC.

Método

Estudo realizado com 19 adultos (11 homens e 8 mulheres) com diagnóstico clínico e espirométrico de DPOC e idade média de 63,8 (±9,3) anos. A coleta de dados foi realizada utilizando o questionário COPD Assessment Test (CAT, Teste de Avaliação da DPOC) a escala de dispneia do Medical Research Council modificada (mMRC) e um manovacuômetro digital, para caracterizar o impacto da doença no indivíduo, a dispneia e a função pulmonar. Os dados referentes ao tempo de trânsito faríngeo e resíduo faríngeo foram coletados por meio de análise das imagens videofluoroscópicas realizada por três juízes cegados.

Resultados

Não foram encontradas relações significativas entre tempo de trânsito faríngeo (TTF) com função pulmonar (r = -0,71), e entre presença de resíduo faríngeo com a dispneia (r= -0,06). O TTF, quando comparado com a normalidade, apresentou-se aumentado.

Conclusão

Os indivíduos com DPOC, independente da gravidade da doença, não manifestaram associação entre alterações no TTF e resíduo faríngeo e dispneia e função pulmonar.

Descritores
Doença Pulmonar; Obstrutiva Crônica; Deglutição; Transtornos de Deglutição; Dispneia; Pneumopatias

INTRODUCTION

Swallowing is a complex neuromotor process and concise coordination of phases that are essential for the transit of the bolus from the mouth to the stomach, starting with the preparatory and oral phases (voluntary) and, afterwards, culminating in the pharyngeal and esophageal phases (involuntary)(11 Lynch CS. Análise da fisiologia da deglutição por meio da ultra-sonografia. Radiol Bras. 2008;41(6):390. http://dx.doi.org/10.1590/S0100-39842008000600016.
http://dx.doi.org/10.1590/S0100-39842008...
). In this sense, failure in any of these phases is classified as dysphagia, which can result in food aspiration in the airways, causing damage to the patient, such as malnutrition, dehydration, pulmonary complications, aspiration pneumonia, and can even lead to death(11 Lynch CS. Análise da fisiologia da deglutição por meio da ultra-sonografia. Radiol Bras. 2008;41(6):390. http://dx.doi.org/10.1590/S0100-39842008000600016.
http://dx.doi.org/10.1590/S0100-39842008...

2 Bassi D, Furkim AM, Silva CA, Coelho MS, Rolim MR, Alencar ML, et al. Identification of risk groups for oropharyngeal dysphagia in hospitalized patients in a university hospital. CoDAS. 2014;26(1):17-27. http://dx.doi.org/10.1590/s2317-17822014000100004. PMid:24714855.
http://dx.doi.org/10.1590/s2317-17822014...
-33 Machado JRS, Steidl EMS, Bilheri DFD, Trindade M, Weis GL, Jesus PRO, et al. Efeitos do exercício muscular respiratório na biomecânica da deglutição de indivíduos normais. Rev CEFAC. 2015;17(6):1909-15. http://dx.doi.org/10.1590/1982-0216201517621514.
http://dx.doi.org/10.1590/1982-021620151...
).

Thus, in the pharyngeal phase of swallowing, as an essential defense process to protect the airways(44 Terada K, Muro S, Ohara T, Kudo M, Ogawa E, Hoshino Y, et al. Abnormal Swallowing Reflex and COPD Exacerbations. Chest. 2010;137(2):326-32. http://dx.doi.org/10.1378/chest.09-0482. PMid:19783670.
http://dx.doi.org/10.1378/chest.09-0482...
), the inversion of the epiglottis occurs over the entrance of the larynx, upper anterior displacement of the hyolaryngeal complex, closing of the vocal folds and opening of the upper esophageal sphincter. These are involuntary events that aim to protect the respiratory tract. Then, the esophageal phase is reached, in which the bolus is transported to the stomach(55 Steidl EMS, Gonçalves BFT, Bilheri D, Brancher EC, Pasqualoto AS, Mancopes R. Aplicação do método ultrassonográfico na avaliação da biomecânica da deglutição – revisão de literatura. Distúrb Comun. 2016;28(2):219-28.).

Thus, the measurement of these swallowing events is considered a predictor for changes in swallowing(66 Santos RRD, Cola PC, Jorge AG, Peres FM, Lauris JRP, Silva RG. Correlação entre tempo de trânsito oral e faríngeo no acidente vascular cerebral. Audiol Commun Res. 2015;20(3):198-202. http://dx.doi.org/10.1590/S2317-64312015000300001567.
http://dx.doi.org/10.1590/S2317-64312015...
). Among the quantitative measures of the pharyngeal phase of swallowing, the pharyngeal transit time (duration of the movement of the bolus through the pharynx) is considered one of these main measures(77 Vale-Prodomo LP. Caracterização videofluoroscópica da fase faríngea da deglutição [Internet]. [tese]. São Paulo (SP): Fundação Antonio Prudente; 2010 [citado em 2019 Abr 25]. Disponível em: https://accamargo.phlnet.com.br/Doutorado/2010/LProdomo/LProdomo.pdf
https://accamargo.phlnet.com.br/Doutorad...
). Previous studies that evaluated the pharyngeal phase of swallowing in individuals with chronic obstructive pulmonary disease (COPD) demonstrated increased pharyngeal transit times in this population when compared to healthy subjects(88 Cassiani RA, Santos CM, Baddini-Martinez J, Dantas RO. Oral and pharyngeal bolus transit in patients with chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2015;10:489-96. http://dx.doi.org/10.2147/COPD.S74945. PMid:25784795.
http://dx.doi.org/10.2147/COPD.S74945...
,99 de Deus Chaves R, Chiarion Sassi F, Davison Mangilli L, Jayanthi SK, Cukier A, Zilberstein B, et al. Swallowing transit times and valleculae residue in stable chronic obstructive pulmonary disease. BMC Pulm Med. 2014;14(1):62. http://dx.doi.org/10.1186/1471-2466-14-62. PMid:24739506.
http://dx.doi.org/10.1186/1471-2466-14-6...
).

Another quantitative measure for swallowing is the presence of pharyngeal residues after swallowing, which may occur in several structures and cavities, being the main ones the residues in vallecula and the residues in pyriform sinuses. Since this factor is reported as one of the main changes that lead to the occurrence of laryngeal penetration and tracheal aspiration(77 Vale-Prodomo LP. Caracterização videofluoroscópica da fase faríngea da deglutição [Internet]. [tese]. São Paulo (SP): Fundação Antonio Prudente; 2010 [citado em 2019 Abr 25]. Disponível em: https://accamargo.phlnet.com.br/Doutorado/2010/LProdomo/LProdomo.pdf
https://accamargo.phlnet.com.br/Doutorad...
).

To measure these measures, it is necessary to carry out an instrumental swallowing assessment. Videofluoroscopy of Swallowing (VFS) is considered a gold standard for instrumental evaluation, as it allows the extraction of temporal and visuospatial measurements for further analysis(1010 Baijens LWJ, Speyer R, Passos VL, Pilz W, Roodenburg N, Clave P. Swallowing in Parkinson Patients versus Healthy Controls: reliability of measurements in videofluoroscopy. Gastroenterol Res Pract. 2011;2011:380682. http://dx.doi.org/10.1155/2011/380682.
http://dx.doi.org/10.1155/2011/380682...
). However, in addition to VFS, it is essential to use image analysis software in order to obtain reliable quantitative measurements.

Another mechanism of great importance for the safety of swallowing is the adequate coordination between swallowing and breathing. Healthy individuals, involuntarily, do a respiratory apnea, swallow and, later, return to breathing with an expiratory phase(33 Machado JRS, Steidl EMS, Bilheri DFD, Trindade M, Weis GL, Jesus PRO, et al. Efeitos do exercício muscular respiratório na biomecânica da deglutição de indivíduos normais. Rev CEFAC. 2015;17(6):1909-15. http://dx.doi.org/10.1590/1982-0216201517621514.
http://dx.doi.org/10.1590/1982-021620151...
). However, in individuals who have impaired lung function, as in COPD, the reciprocity between swallowing and breathing is compromised(1111 Coelho CA. Preliminary findings on the nature of dysphagia in patients with chronic obstructive pulmonary disease. Dysphagia. 1987;2(1):28-31. http://dx.doi.org/10.1007/BF02406975. PMid:3507288.
http://dx.doi.org/10.1007/BF02406975...
,1212 Kobayashi S, Kubo H, Yanai M. Impairment of the swallowing reflex in exacerbations of COPD. Thorax. 2007;62(11):1017. http://dx.doi.org/10.1136/thx.2007.084715. PMid:17965087.
http://dx.doi.org/10.1136/thx.2007.08471...
).

Some studies have shown that the failure of this protective mechanism may occur more in individuals with COPD than in healthy individuals, as well as it has been associated with episodes of exacerbations of the disease(1212 Kobayashi S, Kubo H, Yanai M. Impairment of the swallowing reflex in exacerbations of COPD. Thorax. 2007;62(11):1017. http://dx.doi.org/10.1136/thx.2007.084715. PMid:17965087.
http://dx.doi.org/10.1136/thx.2007.08471...
,1313 Teramoto S, Kume H, Ouchi Y. Altered swallowing physiology and aspiration in COPD. Chest. 2002;122(3):1104-5, author reply 1105. http://dx.doi.org/10.1378/chest.122.3.1104. PMid:12226067.
http://dx.doi.org/10.1378/chest.122.3.11...
). However, the etiology and characterization of dysphagia in COPD is still not clear. Thus, the aim of the present study was to relate the time of pharyngeal transit and the presence of residues with dyspnea and lung function in individuals with COPD.

METHOD

This is a cross-sectional observational study, approved by the Research Ethics Committee (REC) of the institution under registration number 1.967.549, and in accordance with the guidelines of the Conselho Nacional de Saúde in Resolution 466/2012, with the signing of the Informed Consent Form (ICF) of all participants.

The present sample consisted of 19 adult individuals, 11 (57.9%) were male and eight (42.1%) were female, aged between 39 and 74 years (mean age of 63.8 (± 9.3) years), with clinical and spirometric diagnosis of COPD, according to the criteria of the Global Initiative for Chronic Obstructive Lung Disease (GOLD)(1414 GOLD: Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease [Internet]. 2006 [citado em 2019 Ago 11]. Disponível em: http://www.who.int/respiratory/copd/GOLD_WR_06.pdf
http://www.who.int/respiratory/copd/GOLD...
). The individuals were referred to the Pulmonary Rehabilitation Program (PRP) by the Pulmonology Service of the Hospital Universitário de Santa Maria (HUSM) during the period of August 2017 and October 2018. The characterization of the sample according to anthropometric variables, the impact of the disease, dyspnea and lung function, can be observed in Table 1. It was divided, according to the severity of the disease, into two groups: mild and moderate COPD (n = 6) and severe and very severe COPD (n = 13).

Table 1
Characterization regarding anthropometric variables, impact of the disease, dyspnea and pulmonary function

Inclusion criteria were: spirometric diagnosis of COPD, with GOLD criteria(1414 GOLD: Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease [Internet]. 2006 [citado em 2019 Ago 11]. Disponível em: http://www.who.int/respiratory/copd/GOLD_WR_06.pdf
http://www.who.int/respiratory/copd/GOLD...
) for FEV1/FVC <70 (Forced Expiratory Volume in the first second/Forced Vital Capacity); respiratory failure of moderate to severe degree (FEV1 <80% of predicted); ability of performing activities of daily living without the help of a caregiver and ability to communicate and cooperate.

On the other hand, the exclusion criteria were: having participated in respiratory physiotherapeutic intervention or speech therapy intervention in the last 6 months; medical diagnosis of coexistence of neurological condition; acute exacerbation that required hospitalization or use of systemic corticosteroids preceding 4 weeks; severe orofacial pain, including trigeminal neuropathy and uncontrolled systemic arterial hypertension.

ASSESSMENTS

Sociodemographic data (date of birth, age, etc.) and clinical data (last hospital stay, number of exacerbations in the last year, spirometry - collected from the medical record) were collected in addition to the anthropometric assessment to calculate BMI (Body Mass Index). The reference values used to classify the BMI were: BMI < kg/m2 - malnutrition; BMI between 22 and 27 kg/m2 - normal weight; and BMI> 27 kg/m2 for obesity(1515 Nutrition Screening Initiative. American Academy of Family Physicians. American Dietetic Association. A physician’s guide to nutrition in chronic disease management for older adults. Washington (DC): Nutrition Screening Initiative; 2002.). Physiotherapeutic and speech assessments took place on different days, within a week.

Physiotherapeutic clinical assessment

The physiotherapeutic assessment was performed by a physiotherapist blinded to the research aims, on the impact of COPD on the individual, degree of self-reported dyspnea and respiratory muscle strength, performed in sequence in the same session.

The impact of the disease was assessed using the COPD (Chronic Obstructive Pulmonary Disease) Assessment Test (CAT), a questionnaire of easy application and completed by the patient, composed of eight questions related to COPD symptoms that most bother the patient. The score ranges from 0 to 5 points on each item, reaching a total of 40 points, with lower scores corresponding to a low impact of the disease on health status. The impact classification is given according to the scores obtained: mild - 6 to 10 points; moderate - 11 to 20 points; severe - 21 to 30 points; and very serious - 31 to 40 points. The test questions are objective and the applicator does not influence the answers(1616 Silva GP, Morano MT, Viana CM, Magalhães CB, Pereira ED. Portuguese-language version of the COPD Assessment Test: validation for use in Brazil. J Bras Pneumol. 2013;39(4):402-8. http://dx.doi.org/10.1590/S1806-37132013000400002. PMid:24068260.
http://dx.doi.org/10.1590/S1806-37132013...
,1717 Jones PW, Harding G, Berry P, Wiklund I, Chen WH, Kline Leidy N. Development and first validation of the COPD Assessment Test. Eur Respir J. 2009;34(3):648-54. http://dx.doi.org/10.1183/09031936.00102509. PMid:19720809.
http://dx.doi.org/10.1183/09031936.00102...
).

For the degree of dyspnea, the modified Medical Research Council scale (MRCm) was used. In this method, the patient self reports the degree of dyspnea subjectively, in a rating from 0 to 4, with 0 representing shortness of breath at maximum efforts and 4 at minimum efforts(1818 Ferrer M, Alonso J, Morera J, Marrades RM, Khalaf A, Aguar MC, et al. Chronic obstructive pulmonary disease stage and health-related quality of life. The Quality of Life of Chronic Obstructive Pulmonary Disease Study Group. Ann Intern Med. 1997;127(12):1072-9. http://dx.doi.org/10.7326/0003-4819-127-12-199712150-00003. PMid:9412309.
http://dx.doi.org/10.7326/0003-4819-127-...
).

Respiratory muscle strength was assessed by maximum inspiratory pressure (MIP) and maximum expiratory pressure (MPE), using a digital manovacuometer (MDI®, MVD 300, GlobalMed, Porto Alegre, Brazil). The interpretation of the results followed the reference values of normality proposed by Pessoa et al.(1919 Pessoa IMBS, Houri Neto M, Montemezzo D, Silva LA, Andrade AD, Parreira VF. Predictive equations for respiratory muscle strength according to international and Brazilian guidelines. Braz J Phys Ther. 2014;18(5):410-8. http://dx.doi.org/10.1590/bjpt-rbf.2014.0044. PMid:25372003.
http://dx.doi.org/10.1590/bjpt-rbf.2014....
) for the Brazilian population.

Speech assessment

The speech assessment was carried out by means of videofluoroscopy of swallowing (VDS), performed at the Radiology Department of HUSM, performed by a technician or radiologist and accompanied by a speech therapist with experience in the area. The videofluoroscopy images were obtained using the Siemens equipment, model Axiom Iconos R200, being captured and recorded using the software ZScan6 Gastro - Version: 6.1.2.11, installed on Itautec Infoway computer, Windows 7, Intel Pentium P6200 processor, with the image being recorded at 36 frames/second and with ideal quality for the study of the visualized regions(2020 Peladeau-Pigeon M, Steele C. Understanding image resolution and quality in videofluoroscopy. Perspect Swallowing Swallowing Disord. 2015;24(3):115-24. http://dx.doi.org/10.1044/sasd24.3.115.
http://dx.doi.org/10.1044/sasd24.3.115...
). The subjects were assessed in the sitting position, with lateral projection. The videofluoroscopic image field included the lips, oral cavity, cervical spine and proximal cervical esophagus(2121 Cook IJ, Dodds WJ, Dantas RO, Kern MK, Massey BT, Shaker R, et al. Timing of videofluoroscopic, manometric events, and bolus transit during the oral and pharyngeal phases of swallowing. Dysphagia. 1989;4(1):8-15. http://dx.doi.org/10.1007/BF02407397. PMid:2640180.
http://dx.doi.org/10.1007/BF02407397...
).

The consistencies used in the exam, according to the IDDSI Framework(2222 Cichero JAY, Lam P, Steele CM, Hanson B, Chen J, Dantas RO, et al. Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: the IDDSI Framework. Dysphagia. 2017;32(2):293-314. http://dx.doi.org/10.1007/s00455-016-9758-y. PMid:27913916.
http://dx.doi.org/10.1007/s00455-016-975...
), state: Thin: 25ml liquid + 25ml barium and Extremely Thick (25ml liquid + 25ml barium + 1 spoon and a half of 1.2g of RESOURCE® ThickenUp Clear from Nestlé).

The volumes used during the swallowing assessment were 10 ml offered with a spoon and free sips, with three repetitions of each consistency being observed and, subsequently, the best image for analysis was selected. Food was previously prepared by the examiner just before the exam.

The equipment used for the procedure was an Iconos R200 model (Siemens Medical Systems, Forcheim, Germany), coupled to a computerized image recording system, in fluoroscopy mode, with 36 frames per second; the videos were recorded in the capture software Zscan6. This software has as main technical characteristics: image with matrix until 720x576; 32-bit image resolution; JPEG image format with 1440 dpi; video system NTSC, PAL, SECAM (all standard); video up to 720x576 with images in real time (36 frames per second (frames/s) AVI format and divX compressor can be recorded on DVD and CD. The average dose value generated in this procedure is 0.14 mR/frame (2.1 mR/s), these dose measurements were performed under conditions that reproduce the technique and the positioning of the patient, using a 4 cm aluminum simulator and a Radcal electrometer, model 9010 with specific ionization chamber for procedures in fluoroscopy of 60 cm3.

Subsequently, the analyzes of the VFS images were made, and three speech therapists, trained and experienced in the area of videofluoroscopy for at least five years, performed the analysis of the biomechanics of swallowing using the Kinovea® software (version 8.20, 2012)(2323 Bilheri DFD. Medidas de excursão laríngea pré e pós exercícios respiratórios em sujeitos normais [Internet] [dissertação]. Santa Maria (RS): Universidade Federal de Santa Maria; 2016 [citado em 2020 Ago 11]. Disponível em: http://repositorio.ufsm.br/handle/1/13650
http://repositorio.ufsm.br/handle/1/1365...
), blindly for research purposes, the identification of the subjects and the evaluation of the other judges.

The judges were instructed to carry out the swallowing analysis, contemplating visual-perceptual parameters (residue in vallecula and residue in pyriform recesses) and temporal parameter (pharyngeal transit time) as proposed by Baijens et al.(1010 Baijens LWJ, Speyer R, Passos VL, Pilz W, Roodenburg N, Clave P. Swallowing in Parkinson Patients versus Healthy Controls: reliability of measurements in videofluoroscopy. Gastroenterol Res Pract. 2011;2011:380682. http://dx.doi.org/10.1155/2011/380682.
http://dx.doi.org/10.1155/2011/380682...
). The analyzed parameters were defined and measured as follows: Stale in vallecula: stasis of the bolus in vallecula after complete swallowing, being considered: 0 - absence of stasis; 1 - residue filled up to 50% of the vallecula; 2 - residue filled more than 50% of the vallecula. Stasis in pyriform recesses: stasis of the bolus in pyriform recesses after complete swallowing, being considered: 0 - absence of stasis; 1 - mild to moderate stasis; 2 - severe stasis, filling the piriform recesses. Pharyngeal transit time: defined as the time interval in seconds between the opening of the glossopalatal junction and the closure of the upper esophageal sphincter.

Additionally, the classification of swallowing was analyzed by the Dysphagia severity scale (O'neil et al., 1999)(2424 O’Neil KH, Purdy M, Falk J, Gallo L. The Dysphagia Outcome and Severity Scale. Dysphagia. 1999; 14(3):139–145.) and organized, according to the sample, into dysphagia (including levels 4 and 5), and 2 without dysphagia (including levels 6 and 7).

Statistical analysis

Descriptive analysis of the variables was performed with calculations of mean, standard deviation or median and interquartile range. For the comparison between numerical variables with normal distribution, the independent Student t test was used and, for the ones with non-normal distribution, the Mann-Whitney U test; for qualitative variables, the Chi-square test was used. For associations between numerical variables, the Pearson's correlation test was used. Statistical analysis was performed using the Statistical Package for the Social Sciences software, version 21.0 (SPSS Inc. Chicago, IL, USA).

The linear regression model was used to verify which clinical variables were independently associated with PTT.

To verify the agreement between the three judges, the Wilcoxon test was applied for the temporal variable and Kappa for the visual-perceptual variables, the classification proposed by Landis and Koch(2525 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159-74. http://dx.doi.org/10.2307/2529310. PMid:843571.
http://dx.doi.org/10.2307/2529310...
): <0.00 poor agreement; 0.00 - 0.9 poor agreement; 0.20 – 0.39 weak agreement; 0.40 – 0.59 moderate agreement; 0.60 – 0.79 substantial agreement; 0.80 – 1.00 almost perfect agreement. For the variables of residue in vallecula and residue in pyriform sinuses, the agreement was 1.00 and for pharyngeal transit time it was 0.51.

The sample calculation was performed with the use of the OpenEpi program (Version 3), considering the number of patients seen in the second semester of 2017 at the PRP (n = 21). With a confidence level of 80% and a margin of error of 5%, 19 individuals were estimated.

RESULTS

19 individuals were stratified from the sample according to the severity of the disease, six with mild to moderate degree of the disease and 13 were classified between severe to very severe. Dysphagia, assessed by VFS, was found in 23.1% of the subjects with the most severe stage of COPD. The swallowing variables are presented according to the COPD severity classification (Table 2).

Table 2
Characterization of the sample for swallowing variables

No association between PTT in liquid and pasty consistencies with anthropometric and disease severity variables (FEV1) and respiratory muscle strength was found (Table 3).

Table 3
Relationship of Pharyngeal Transit Time in liquid and pasty consistencies with anthropometric and pulmonary function variables

In Tables 4 and 5, residue in vallecula in liquid and pasty consistencies, and residue in pyriform sinuses in pasty consistency, with the severity of COPD, impact of COPD and dyspnea were respectively related. A moderate association was verified between the very serious classification of the impact of the disease with residue in the vallecula, both in liquid consistency (r = 0.687, p = 0.001) and in pasty consistency (r = 0.687, p = 0.001). However, when analyzing the association between the ratio of Residues in Pyriform Sinuses with the degree of the disease, with the impact of the disease and with the sensation of dyspnea, no association was noticed between the variables analyzed.

Table 4
Relationship between residue in vallecula in liquid and pasty consistencies with variables of severity and impact of the disease and dyspnea
Table 5
Relationship between Residues in Pyriform Sinuses in pasty consistency with severity and impact of the disease and dyspnea

DISCUSSION

The results of the present study showed no relationship between PTT, in both consistencies, with dyspnea and pulmonary function, in COPD individuals. Likewise, no relationship was found between the presence of residues in vallecula and pyriform sinuses, in liquid and pasty consistency, with dyspnea and lung function. However, there was a significant association between the presence of residue in the vallecula, in both consistencies, and CAT, which assesses the impact of the disease on the subject.

In the present sample, four individuals presented residues in one of the consistencies in vallecula or pyriform sinuses. The presence of pharyngeal residue demonstrates impaired swallowing efficiency(2626 Logemann JA. Dysphagia: evaluation and treatment. Folia Phoniatr Logop. 1995;47(3):140-64. http://dx.doi.org/10.1159/000266348. PMid:7640720.
http://dx.doi.org/10.1159/000266348...
) and it increases the risk of bronchoaspiration(2727 Murray J, Langmore SE, Ginsberg S, Dostie A. The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia. 1996;11(2):99-103. http://dx.doi.org/10.1007/BF00417898. PMid:8721067.
http://dx.doi.org/10.1007/BF00417898...
), which can worsen the respiratory condition of patients with COPD. However, in a study aimed at exploring the relationship between pharyngeal residues with penetration/aspiration episodes, there was no relationship of residue in pyriform sinuses with the safety of swallowing, raising the hypothesis that the use of multiple swallows may be a functional strategy to reduce the quantity of residue and, as a consequence, the risk of aspiration(2828 Molfenter SM, Steele CM. The relationship between residue and aspiration on the subsequent swallow: an application of the normalized residue ratio scale. Dysphagia. 2013;28(4):494-500. http://dx.doi.org/10.1007/s00455-013-9459-8. PMid:23460344.
http://dx.doi.org/10.1007/s00455-013-945...
). In the present study, we did not evaluate the presence of multiple swallows. However, we observed that there was no significant residue in pyriform sinuses, as well as no association with the severity of the disease, dyspnea or even some impact of the disease on the subject.

It should also be noted that most of the patients who presented pharyngeal residue were classified as grade 3 in terms of COPD severity, CAT from moderate to very severe and dyspnea degree equal to or greater than 2. Patients with these clinical features are eligible for pharmacological treatment in groups B or D according to the ABCD scheme proposed in GOLD(1414 GOLD: Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease [Internet]. 2006 [citado em 2019 Ago 11]. Disponível em: http://www.who.int/respiratory/copd/GOLD_WR_06.pdf
http://www.who.int/respiratory/copd/GOLD...
). Although the relationship is not clear, studies have pointed to the inhaled medication used in the treatment of COPD as a possible cause of sensory changes detected in the oral and laryngopharyngeal cavities of individuals with COPD(2929 de Deus Chaves R, Chiarion Sassi F, Davison Mangilli L, Jayanthi SK, Cukier A, Zilberstein B, et al. Swallowing transit times and valleculae residue in stable chronic obstructive pulmonary disease. BMC Pulm Med. 2014;14(1):62. http://dx.doi.org/10.1186/1471-2466-14-62. PMid:24739506.
http://dx.doi.org/10.1186/1471-2466-14-6...
-3030 da Rosa FB, Pasqualoto AS, Steele CM, Mancopes R. Oral and oropharyngeal sensory function in adults with chronic obstructive pulmonary disease. Am J Speech Lang Pathol. 2020;29(2):864-72. http://dx.doi.org/10.1044/2019_AJSLP-19-00095. PMid:32202915.
http://dx.doi.org/10.1044/2019_AJSLP-19-...
). The sensory impairment in the laryngopharynx may justify the presence of pharyngeal residue in these individuals.

In a study carried out by Vale-Prodomo(77 Vale-Prodomo LP. Caracterização videofluoroscópica da fase faríngea da deglutição [Internet]. [tese]. São Paulo (SP): Fundação Antonio Prudente; 2010 [citado em 2019 Abr 25]. Disponível em: https://accamargo.phlnet.com.br/Doutorado/2010/LProdomo/LProdomo.pdf
https://accamargo.phlnet.com.br/Doutorad...
), the pharyngeal phase of swallowing was assessed in 58 healthy individuals and there was an average time of duration of the pharyngeal phase of 0.71 seconds in liquid consistency. The PTT of the individuals evaluated in our research, in the liquid consistency, was 0.86 seconds, that is, considered high, when compared to normality. Similarly, de Deus Chaves et al.(2929 de Deus Chaves R, Chiarion Sassi F, Davison Mangilli L, Jayanthi SK, Cukier A, Zilberstein B, et al. Swallowing transit times and valleculae residue in stable chronic obstructive pulmonary disease. BMC Pulm Med. 2014;14(1):62. http://dx.doi.org/10.1186/1471-2466-14-62. PMid:24739506.
http://dx.doi.org/10.1186/1471-2466-14-6...
) carried out a study to evaluate the pharyngeal transit time of swallowing and the characteristics of residue in the vallecula of 20 individuals with stable COPD and without complaints of swallowing and compared it with 20 healthy individuals. COPD subjects presented a PTT higher than the ones from the control group. The authors infer that this increase in time is a protective physiological maneuver, so that breathing and swallowing events have more time to coordinate, even before the swallowing reflex starts. This hypothesis corroborates the findings of our research, since these adaptive events contribute to safer swallowing. In the present study, it was also observed that there was no significant relationship between PTT and BMI or lung function.

When it comes to the fact that no association was verified between PTT with dyspnea and pulmonary function variables, it is possible to infer the possibility that the condition of respiratory muscle strength may have contributed, since patients may be using the diaphragmatic muscles more effectively and, as a consequence, the accessory muscles and coordination swallowing breathing is better preserved.

However, the lack of a control group can be considered as a limiting factor of the study. Future research should consider analyzing patients with stable COPD and in an episode of exacerbation, in order to better understand the impacts of the severity of the disease on the dynamics of swallowing.

CONCLUSION

We concluded that subjects with COPD, regardless of the severity of the disease, showed no association between PTT, presence of pharyngeal residue and dyspnea and lung function.

  • Study conducted at Universidade Federal de Santa Maria – UFSM, Santa Maria (RS), Brasil.
  • Financial support: CAPES - Código de Financiamento 001.

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Publication Dates

  • Publication in this collection
    13 Sept 2021
  • Date of issue
    2021

History

  • Received
    24 Mar 2020
  • Accepted
    09 Dec 2020
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