US20010023698A1

US20010023698A1 - Stimulation of nociceptor (irritant) and c-fibre receptors in patient's throat by nebulized application of chemostimulant and contrast material that allows fluoroscopy observation of larynx response for identifying patient's risk to dysphagia

Info

Publication number: US20010023698A1
Application number: US09/797,196
Authority: US
Inventors: W. Addington; Robert Stephens; Stuart Miller
Original assignee: Pneumoflex Systems LLC
Current assignee: Pneumoflex Systems LLC
Priority date: 1995-11-16
Filing date: 2001-03-01
Publication date: 2001-09-27
Anticipated expiration: 2015-11-16
Also published as: US6568397B1

Abstract

The injection of an aerosol containing a chemostimulant into a patient's throat to stimulate nociceptor (irritant) and c-fiber receptors is augmented by the inclusion of a medically safe and accepted contrast substance, such as barium. The addition of a contrast substance to the aerosol allows fluoroscopic observation of the patient's (larynx) response, to facilitate a medical practitioner's identification of whether the patient is at risk to one or more abnormal physiological conditions, such as oral or pharyngeal dysphagia, and pneumonia.

Description

CROSS-REFERENCE TO RELATED APPLICATION

The present application is a continuation-in-part of co-pending U.S. patent application, Ser. No. 09/734,404 (hereinafter referred to as the '404 application), filed Dec. 11, 2000, entitled: “Aspiration Screening Process for Assessing Need for Modified Barium Swallow Study,” by W. Robert Addington et al, which is a continuation of U.S. patent application, Ser. No. 09/224,431, filed Dec. 31, 1998, which is a continuation of U.S. patent application, Ser. No. 08/885,360, filed Jun., 30, 1997, now U.S. Pat. No. 5,904,656, which is a continuation of U.S. patent application, Ser. No. 08/559,562, filed Nov. 16, 1995, now U.S. Pat. No. 5,678,563, the disclosures of which are incorporated herein. [0001]
In addition, the present application claims the benefit of co-pending U.S. Provisional patent application, Ser. No. 60/186,826, filed Mar. 3, 2000, by W. Robert Addington et al, entitled: “Stimulation of Nociceptor (Irritant) and C-Fibre Receptors in Patient's Throat by Nebulized Application of Chemostimulant and Contrast Material That Allows Fluoroscopy Observation of Larynx Response for Identifying Patient's Risk to Dysphagia,” and the disclosure of which is incorporated herein.[0002]

FIELD OF THE INVENTION

The present invention relates in general to the field of speech pathology, and is directed to determining whether a patient is at risk for one or more abnormal physiological conditions, including but not limited to oral or pharyngeal dysphagia, and pneumonia. In particular, the present invention is directed to an enhancement to the invention disclosed in the above-referenced '404 application, that involves the addition of a contrast substance to the aerosol chemostimulant, so as to allow fluoroscopic observation of the patient's (larynx) response, and facilitate a medical practitioner's visual monitoring of the patient's airway during the aerosol application of the chemostimulant.

BACKGROUND OF THE INVENTION

As described in the above-referenced '404 application, the conventional technique employed by speech pathologists for clinically identifying patients at risk for aspiration has involved the evaluation of a patient's swallow. A normal human swallow can be separated into four phases: 1)- oral preparation, 2) the oral phase, 3)- the pharyngeal phase, and 4)- the esophageal phase. Patients who have suffered a stroke, traumatic brain injury or neuromuscular disorder (such as MS or ALS) have an increased risk of aspiration, and may have difficulty with either the oral phase, the pharyngeal phase or both, secondary to neurologic deficits.

Poor tongue movement in chewing or in the swallow can cause food to fall into the pharynx and into the open airway before the completion of the oral phase. A delay in triggering the pharyngeal swallowing reflex can result in food falling into the airway during the delay when the airway is open. Reduced peristalsis in the pharynx, whether unilateral or bilateral, will cause residue in the pharynx after the swallow that can fall or be inhaled into the airway. Laryngeal or cricopharyngeal dysfunction can lead to aspiration because of decreased airway protection during the swallow.

An abnormal human swallow is termed dysphagia. The oropharyngeal physiology involved in a normal swallow is very complicated, and many different neurological disturbances can disrupt normal swallowing and can cause aspiration of food material, liquid or solid, into the lungs, leading to increased morbidity in hospitalized patients and possible pneumonia. See, for example, the article by Jeri Logemann, entitled: “Swallowing Physiology and Pathophysiology,” Otolaryngologic Clinics of North America, Vol. 21, No. 4, Nov. 1988, and the article by L. Kaha et. al., entitled: “Medical Complications During Stroke Rehabilitation, Stroke Vol. 26, No. 6, June 1995.

Speech pathologists have tried many procedures to detect or predict aspiration in patients with neurological deficits. Although the standard bedside swallow exam to screen patients is beneficial for evaluating patients at risk for oral or pharyngeal dysphagia, studies have shown that, when compared to a modified barium swallow (MBS) videofluoroscopic examination, it is neither very specific nor sensitive in detecting aspiration. (The MBS test customarily involves having the patient ingest a volume of barium in a semisolid or liquid form. Through fluoroscopy, the travel path of the swallowed barium may be observed by a medical practitioner to determine whether any quantity has been aspirated—which could lead to acute respiratory syndrome or pneumonia.) See, for example, the article by Mark Splaingard et. al. entitled: “Aspiration in Rehabilitation Patients: ideofluoroscopy vs. Bedside Clinical Assessment; Archives of Physical Medicine and Rehabilitation, Vol. 69, Aug., 1988, and the article by P. Linden, et. al., entitled” “The Probability of Correctly Predicting Subglottic Penetration from Clinical Observations”, Dysphagia, 8: pp 170-179, 1993.

As discussed in the above-referenced Logemann article, and also in an article entitled: “Aspiration of High-Density Barium Contrast Medium Causing Acute Pulmonary Inflammation—Report of Two Fatal Cases in Elderly Women with Disordered Swallowing,” by C, Gray et al, Clinical Radiology, Vol. 40, 397-400, 1989, videofluoroscopic evaluations are more costly than bedside evaluations and videofluoroscopy is not entirely without risk. Because of the poor predictability of bedside exams, the MBS is being used more and more with its increased reliability for diagnosing aspiration. Many studies using videofluoroscopy have tried to pinpoint the exact anatomical or neurological deficit causing the dysphagia, as well as what stage of the swallow is primarily affected in different disorders.

Patients with a head injury, stroke or other neuromuscular disorder can aspirate before, during, or after the swallow, and a high percentage can be silent aspirators. Unfortunately, these patients might not display any indication of aspiration during a clinical exam, but can be detected by the MBS, as discussed in the Logemann article and in an article by C. Lazurus et al, entitled: “Swallowing Disorder in Closed Head Trauma Patients,” Archives of Physical Medicine and Rehabilitation, Vol. 68, Feb., 1987, an article by J. Logemann, entitled: “Effects of Aging on the Swallowing Mechanism,” Otolaryngologic Clinics of North America, Vol. 23, No. 6, Dec. 1990, and an article by M. DeVito et. al., entitled: “Swallowing Disorders in Patients with Prolonged Orotracheal Intubation or Tracheostomy Tubes,” Critical Care Medicine, Vol. 18, No. 12, 1990.

The bedside swallow exam that has been customarily performed by most speech pathologists evaluates history, respiratory status, level of responsiveness and an oral exam. The oral examination includes a detailed evaluation of the muscles of mastication, lips, tongue, palate, position in which the patient is tested, as well as swallowing evaluation. Sensation, various movements and strength are carefully evaluated. In the pharyngeal stage, the patient is tested for a dry swallow, thin liquid, thick liquid, pureed textures and solid textures.

A typical bedside exam looks for nasal regurgitation, discomfort or obstruction in the throat or multiple swallows, as well as any visible signs that may indicate risk for aspiration, gurgling, impaired vocal quality, and coughing. The bedside exam results are then analyzed to determine whether the patient should have an MBS study to evaluate swallowing physiology and to rule out aspiration. Although the bedside exam is very thorough, and can identify patients who are at risk for or have dysphagia, it is not effective in determining which patients will aspirate.

In addition to the foregoing, speech pathologists have historically had difficulty studying the sensory afferents of the larynx involved in airway protection. As described in an article by J. Widdicombe et al, entitled: “Upper Airway Reflex Control,” Annual New York Academy of Science, Vol. 533, 252-261, 1988, the sensory afferents for general coughing travel the internal branch of the superior laryngeal nerve. A patient may have a voluntary cough present with the efferent motor system intact, but not have any sensation on the larynx secondary to the afferents becoming completely or partially affected, which would be indicative of risk for silent aspiration.

Although an MBS test is of value to patients that silently aspirate, it is difficult to decide which patients should have an MBS test. Not all patients with a closed head injury or a stroke will aspirate. Moreover, it is not economically realistic to employ an MBS test to evaluate all patients with neurologic deficits for aspiration.

Fortunately, the chemostimulant-based, cough-invoking screening process described in the '404 application and its parent predecessors, referenced above, successfully overcomes shortcomings of such conventional processes that have attempted to detect aspiration in patients with neurological deficits. Referring to FIG. 1, pursuant to the invention disclosed in these applications, a patient 10 (wearing a nose clip 12) is subjected to an chemostimulant-based, inhalation cough test. In this test, a prescribed quantity of a chemostimulant that stimulates nociceptor (irritant) and C-fibre receptors of the patient's larynx is injected into the patient's mouth.

Injection of the chemostimulant may be readily accomplished by using a

standard nebulizer

14, that has been loaded with an aerosol chemostimulant, such as an atomized solution of tartrate mixed with saline. Not only has this solution has been demonstrated to stimulate a cough 100% of the time in normal individuals, but tartrate is considered safe, does not cause pain or discomfort, and has not been shown to cause bronchoconstriction or complications in asthmatics when inhaled in an aerosol form.

The quantity of chemostimulant is injected into the patient's mouth for a prescribed period of time (e.g., on the order of 15 seconds). The nebulizer output spray rate may be on the order of 0.2 ml/min. as a non-limiting example. The patient may be tested a prescribed number of times (e.g., up to three times) at different stimulant strengths until a cough is elicited. During each successive chemostimulant application, the patient receives progressively increasing concentrations of the aerosol for the prescribed period of time by tidal breathing at one minute intervals using successively increasing percentage concentrations (e.g. 20, 50 and 80 percent).

Once a cough is elicited from the patient as a result of the inhaled aerosol stimulant, the patient's response to the inhalation test is graded. The patient may be graded as being at low risk for pneumonia (where the patient coughs immediately in response to the initial aerosol spray) or at a high risk for pneumonia (where a cough is present but decreased, or the patient does not readily cough in response to the initial concentration spray, but requires a more concentrated aerosol application).

Now although the chemostimulant-based, cough-invoking screening process described in the '404 application is effective to determine whether a patient is at risk for one or more abnormal physiological conditions, including but not limited to oral or pharyngeal dysphagia, and pneumonia, the standard modified barium swallow (MBS) test is still considered by medical practitioners to be a beneficial technique as it allows the practitioner to (fluoroscopically) observe the patient's airway.

SUMMARY OF THE INVENTION

In accordance with the present invention, the use of a chemostimulant to stimulate nociceptor (irritant) and c-fibre receptors in the patient's throat as described in the above-referenced '404 application is augmented by the inclusion of a medically safe and accepted contrast substance, such as barium. The addition of a contrast substance to the aerosol allows fluoroscopic observation of the patient's (larynx) response, to facilitate a medical practitioner's identification of whether the patient is at risk to one or more abnormal physiological conditions, such as oral or pharyngeal dysphagia, and pneumonia.

This improved process of, and the nebulized contrast and chemostimulant combination offers a significant improvement over a standard modified barium swallow (MBS) test. As described above, the standard MBS test customarily involves having the patient ingest a volume of barium in a semi-solid or liquid form. Through fluoroscopy, the travel path of the swallowed barium may be observed by a medical practitioner to determine whether any quantity has been aspirated, which could lead to acute respiratory syndrome or pneumonia.

The spraying of a mixture of contrast material (such as barium) and laryngeal chemostimulant (such as tartrate) in saline to the patient's throat avoids this swallow-based problem, yet still allows fluoroscopic observation of the patient. On the one hand, the chemostimulant serves to stimulate a cough response from nociceptor (irritant) and c-fibre receptors in the patient's throat; secondly, the contrast material enables fluoroscopic observation of that event.

Pursuant to a non-limiting embodiment, the aerosol mixture may comprise an atomized solution of 20% concentration by volume of tartrate mixed with saline. The quantity of barium in the chemostimulant saline solution is established in accordance with the sensitivity characteristics of the fluoroscopic equipment and display/video observation requirements of the practitioner.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 diagrammatically illustrates the use of an aerosol inhaler in the chemostimulant-based, inhalation cough test disclosed in the '404 application; and [0023]
FIG. 2 diagrammatically illustrates the fluoroscopy image contrast material-augmented chemostimulant-based, inhalation cough test according to the invention.[0024]

DETAILED DESCRIPTION

As pointed out above, the present invention provides an enhancement to use of a chemostimulant to stimulate nociceptor (irritant) and c-fibre receptors in the patient's throat as described in the above-referenced '404 application, by adding a prescribed quantity of a medically safe and accepted contrast substance, such as barium, to the inhaled aerosol. The addition of a contrast substance to the aerosol allows fluoroscopy observation of the patient's (larynx) response, and thereby allows a medical practitioner's to visually monitor the patient's airway in the course of determining whether the patient is at risk to one or more abnormal physiological conditions, such as oral or pharyngeal dysphagia, and pneumonia. [0025]
The fluoroscopy image contrast material-augmented process according to the present invention is diagrammatically shown in FIG. 2. Similar to the chemostimulant-based, inhalation cough test of FIG. 1, described above, a prescribed quantity of a throat injected mixture is loaded into an [0026] aerosol delivery system 14, such as a standard nebulizer, for delivery into the mouth of a patient 10, shown as wearing a nose clip 12.
In a non-limiting embodiment, the aerosol inhalant may be delivered by a standard aerosol inhaler, such as a commercially available Bennett Twin nebulizer. Pursuant to the invention, the mixture loaded into the aerosol delivery system includes two components: 1) a chemostimulant that stimulates nociceptor (irritant) and C-fibre receptors of the patient's larynx is injected into the patient's mouth; and 2) a contrast material that allows fluoroscopic viewing of the patient's airway in the course of injection of and patient's response to the aerosol. [0027]
In a non-limiting, but preferred embodiment, the chemostimulant component of the mixture may comprise an atomized solution of 20% concentration by volume of tartrate mixed with saline, as described in the '533 Patent. As pointed out above, this solution has been demonstrated to stimulate a cough 100% of the time in normal individuals; also tartrate is considered safe, does not cause pain or discomfort, and has not been shown to cause bronchoconstriction or complications in asthmatics when inhaled in an aerosol form. [0028]
The contrast substance may comprise a premeasured volumetric quantity of barium, or other like material used in the medical industry for internal fluoroscopic analysis. The quantity of the contrast material component within the chemostimulant saline solution mixture is based upon the sensitivity characteristics of the fluoroscopic equipment and display/video observation requirements of the practitioner. [0029]
In preparation for and in the course of the inhalation/imaging test, the [0030] patient 10 is placed in a prescribed fluoroscopic monitoring proximity of a fluoroscopic sensor 16, that allows the medical practitioner to observe the imaging monitor 18 of an attendant fluoroscopic workstation 20 to which the imaging sensor 16 is coupled. As in the inhalation test performed in accordance with the methodology described in the '533 Patent, using the nebulizer 14, the mixture of chemostimulant and fluoroscopic imaging contrast material is then injected into the patient's mouth for a prescribed period of time (e.g., on the order of 15 seconds).
Again, the nebulizer output spray rate may be on the order of 0.2 ml/min. as a non-limiting example. Also, the patient may be tested a prescribed number of times (e.g., up to three times) at different stimulant strengths until a cough is elicited. The presence of the contrast material in the aerosol spray not only allows the condition of the patient's airway to be continuously monitored during the test, but with continuous digital image capture and storage by the fluoroscopy workstation [0031] 20, the medical practitioner is able to selectively retrieve, observe and evaluate respective images of the condition/response of the nociceptor (irritant) and C-fibre receptors of the patient's larynx to the inhaled chemostimulant, generated during the test.
As in the inhalation testing procedure described in the '533 Patent, during each successive chemostimulant application, the patient may receive progressively increasing concentrations of the chemostimulant within the aerosol mixture for the prescribed period of time by tidal breathing at prescribed (e.g., one minute) intervals, using successively increasing percentage concentrations (e.g. 20, 50 and 80 percent) of chemostimulant. The volumetric quantity of barium, which is used for imaging purposes only, is preferably unchanged for each aerosol injection. Once a cough is elicited from the patient as a result of the inhaled aerosol mixture, the patient's response to the inhalation test may be graded, as in the patient evaluation process detailed in the '533 Patent. [0032]
As will be appreciated from the foregoing description, by adding a contrast substance to the chemostimulant aerosol employed in the inhalation testing methodology detailed in the '533 Patent, the present invention provides for fluoroscopic observation of the patient's (larynx) response, and thereby allows both real time and post image capture fluoroscopic observation of the patient's (larynx) response, thereby facilitating a determination by a medical practitioner's of whether the patient is at risk to one or more abnormal physiological conditions, such as oral or pharyngeal dysphagia, and pneumonia. The use of a mixture of contrast material (e.g., barium) and laryngeal chemostimulant (e.g., tartrate) in saline to the patient's throat avoids the MBS swallow-based problem, yet still allows fluoroscopic observation of the patient. The chemostimulant component serves to stimulate a cough response from nociceptor (irritant) and c-fibre receptors in the patient's throat, while the contrast material enables fluoroscopic observation of the patient's airway and cough response. [0033]
While we have shown and described an embodiment in accordance with the present invention, it is to be understood that the same is not limited thereto but is susceptible to numerous changes and modifications as known to a person skilled in the art. We therefore do not wish to be limited to the details shown and described herein, but intend to cover all such changes and modifications as are obvious to one of ordinary skill in the art. [0034]

Claims

What is claimed:

1. A method of evaluating a patient comprising the steps of:

(a) providing a substance which, when supplied to the throat of the patient, is effective to stimulate a sensory innervation of the larynx of and thereby elicit an involuntary cough from an individual who does not suffer from a prescribed abnormal physiological condition, and which is detectable by an instrument through which the throat of the patient may be externally monitored;

(b) supplying said substance provided in step (a) to the patient's throat; and

(c) externally monitoring the patient's throat using said instrument, in response to the supplying of said substance to the patient's throat in step (b).

2. The method according to

claim 1

, further including the step (d) of evaluating the response of the patient to the substance supplied to the patient's throat in step (b), and determining a prescribed physiological condition of the patient other than the patient's ability to cough.

3. The method according to

claim 1

, wherein said substance includes a first component that stimulates a sensory innervation of the patient's throat and causes the patient to cough involuntarily, and a second component that is detectable by a sensor for an instrument through which the throat of the patient may be externally visually monitored in step (c).

4. The method according to

claim 3

, wherein said first component comprises a chemical that is effective to stimulate nociceptor (irritant) and C-fibre receptors in the patient's throat, and said second component comprises a material that is detectable by a sensor for a fluoroscopic instrument through which the throat of the patient may be externally visually monitored in step (c).

5. The method according to

claim 4

, wherein said first component contains tartrate mixed with saline, and said second component contains barium.

6. The method according to

claim 2

, wherein said prescribed abnormal physiological condition is one of dysphagia, aspiration, and pneumonia.

7. A method of evaluating a patient comprising the steps of:

(a) supplying, to the throat of the patient, a substance that contains progressively different stimulant strengths of a chemostimulant that is effective to stimulate a sensory innervation of the larynx of and thereby elicit an involuntary cough from an individual who does not suffer from a prescribed abnormal physiological condition, and which is detectable by an instrument through which the throat of the patient may be externally monitored; and

(b) externally monitoring a condition of the patient's throat, in response to the supplying of said substance to the patient s throat in step (a), using said instrument.

8. The method according to

claim 7

, further including the step (c) of evaluating the response of the patient to the substance supplied to the patient's throat in step (a), and determining a prescribed physiological condition of the patient other than the patient's ability to cough.

9. The method according to

claim 7

, wherein said substance comprises a chemical that is effective to stimulate nociceptor (irritant) and C-fibre receptors in the patient's throat, and said component comprises a material that is detectable by a sensor for a fluoroscopic instrument through which the throat of the patient may be externally visually monitored in step (b).

10. The method according to

claim 9

11. The method according to

claim 8

, wherein step (c) comprises evaluating an involuntary cough of the patient to determine whether the patient is at risk for pneumonia.

12. The method according to

claim 7

, wherein step (a) comprises supplying to the patient's throat aerosols containing respectively increasing concentrations of said chemostimulant.

13. The method according to

claim 8

, wherein step (c) comprises determining the patient to be at low risk for pneumonia in response to the patient's involuntary cough appearing normal, but determining the patient to be at high risk for pneumonia in response to the patient having a decreased or weak involuntary cough, or requiring a higher strength of said chemostimulant to elicit an involuntary cough.

14. A test arrangement for identifying a risk of a patient to a prescribed abnormal physiological condition comprising:

a predetermined quantity of a medium containing a first component which, upon being supplied to the throat of an individual who does not suffer from said prescribed abnormal physiological condition, is effective to stimulate a sensory innervation of said individual's larynx and elicit an involuntary cough from said individual, and a second component, which is detectable by an instrument through which the throat of the patient may be externally monitored;

a device that is adapted to supply said medium to the throat of the patient so as to be detectable by a sensor of said instrument through which the throat of the patient may be externally monitored; and

a sensor, coupled with said instrument, and adapted to be placed relative to the throat of said patient, and which is operative to detect said second component of said medium as supplied to the throat of said patient by said device, so as to enable visual monitoring of said throat of said patient by said instrument.

15. The test arrangement according to

claim 14

, wherein said device comprises a nebulizer that is adapted to supply to the larynx of said patient a prescribed measure of an aerosol containing a chemostimulant that is effective to stimulate a sensory innervation of the larynx of and elicit an involuntary cough from the throat of an individual who does not suffer from said prescribed abnormal physiological condition, and a material that is detectable by a sensor for a fluoroscopic instrument.

16. The test arrangement according to

claim 14

, wherein said nebulizer is adapted to supply a prescribed measure of an aerosol chemostimulant containing tartrate mixed with saline, that is effective to stimulate nociceptor (irritant) and C-fibre receptors in the patient's throat, and barium.

17. The test arrangement according to

claim 14