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ORIGINAL ARTICLE
Outcomes of Dysphagia Intervention in a Pulmonary
Rehabilitation Program
Anita McKinstry
Æ
Maria Tranter
Æ
Joanne Sweeney
Published online: 18 July 2009
ÓSpringer Science+Business Media, LLC 2009
Abstract People with chronic obstructive pulmonary
disease (COPD) or chronic respiratory disease demonstrate
an increased prevalence of oropharyngeal dysphagia as a
consequence of impaired coordination between respiration
and swallowing function. To date, the effect of patient
education and intervention on the management of oropha-
ryngeal dysphagia within pulmonary rehabilitation pro-
grams has not been reported or evaluated. Data were
collected on participants who were enrolled in the Outpa-
tient Pulmonary Rehabilitation Program and who received
dysphagia intervention. Intervention consisted of some or all
of the following: (1) a 1-hour dysphagia education program,
(2) screening for oropharyngeal dysphagia, and (3) indi-
vidual comprehensive oropharyngeal dysphagia assessment
and management if a screening assessment was failed. A
statistically significant improvement was found in partici-
pants’ knowledge of dysphagia and COPD (P\0.001).
Participants’ retention of this knowledge 4 days post edu-
cation remained statistically significant (P\0.001).
Twenty-seven percent of participants who were screened
had symptoms of oropharyngeal dysphagia. Fifty-five (53%)
participants receiving further individual dysphagia assess-
ment/management correctly completed pre/post swallow-
ing-related quality-of-life surveys (SWAL-QOL).
Statistically significant improvement was found in the fol-
lowing subscales: Burden of Dysphagia (P\0.009),
Physical Problems of Dysphagia (P\0.012) and Managing
Diet Options/Food Selection (P\0.016). Dysphagia edu-
cation, screening, and management in a pulmonary
rehabilitation program improved participants’ swallowing-
related quality of life and overall self-management of
chronic respiratory disease and dysphagia.
Keywords Speech pathology Dysphagia Pulmonary
rehabilitation Chronic obstructive pulmonary
disease (COPD) Outcomes Swallowing Deglutition
Deglutition disorders
Chronic obstructive pulmonary disease (COPD) is an
irreversible lung disease characterised by chronic obstruc-
tion of lung airflow that interferes with normal breathing
[1]. COPD is a major cause of disability and economic cost
to the community and has been estimated to become the
fifth leading cause of disability in the world by 2020 [2].
Pulmonary rehabilitation has been recognised as one of
the most effective interventions for patients with COPD
[3]. Recent researchers have demonstrated that pulmonary
rehabilitation relieves dyspnoea and fatigue, improves
emotional function, and enhances patients’ sense of control
over their condition [4]. A comprehensive pulmonary
rehabilitation program consists of both exercise training
and education components [5].
Exercise training is considered a mandatory component to
pulmonary rehabilitation, and the benefits have been well
documented [3]. Education in pulmonary rehabilitation
assists patients to become more active participants in their
health care by improving understanding of changes that
occur with chronic illness and by teaching coping strategies
to deal with changes, thereby enhancing quality of life [6].
Education programs typically involve a range of multidis-
ciplinary team members teaching a patient about COPD,
prevention and treatment of exacerbations, and strategies to
better self-manage their disease [7]. The beneficial effect of
A. McKinstry (&)M. Tranter J. Sweeney
Department of Speech Pathology, Austin Hospital, Level 3,
Lance Townsend Building, 145 Studley Road, P.O. Box 5555,
Heidelberg, VIC 3084, Australia
e-mail: anita.mckinstry@austin.org.au
123
Dysphagia (2010) 25:104–111
DOI 10.1007/s00455-009-9230-3
specific education topics on patient health outcomes, how-
ever, requires further investigation. While recent research
supports the implementation of health education programs in
the continuum of care for patients with COPD [7–10], the
effect of education on self-management and behaviour
modification in COPD remains inconclusive [11].
Aspiration of food and liquid is a recognised risk for
patients with COPD and can contribute to the cause of
recurrent exacerbations and complications such as pneu-
monia and pulmonary fibrosis [3]. People with COPD have
impaired coordination between respiration and swallowing
and are more likely to commence swallowing and resume
respiration in the inspiratory phase, both in the chronic state
as well as during exacerbations of the disease [12].
Reported characteristics of dysphagia in people with COPD
include oral and pharyngeal stasis [13,14], delayed swallow
reflex [14], reduced laryngeal elevation during swallowing
[13], cricopharyngeal dysfunction [16], increased frequency
of compensatory protective swallow manoeuvres [14], lar-
yngeal penetration [13,15] and aspiration [13,14,17].
Figures of prevalence of dysphagia in patients with
COPD vary widely, ranging between 20 and 92% of patients
who self-report swallowing abnormalities [13,14]. Some
researchers, however, indicate that 100% of patients with
COPD display abnormalities in swallowing on videofluo-
roscopic assessment, during both the acute and stable phases
of illness [13]. The true prevalence of dysphagia in patients
with COPD, either during acute exacerbations or during the
stable phase, is unknown, as all studies we examined were
flawed by methodologic limitations, including small sample
size and skewed participant selection.
The potential role of dysphagia education, screening, and
management within pulmonary rehabilitation programs has
not been widely researched. No outcomes have been pub-
lished about whether intervention may improve patients’
quality of life with regard to dysphagia management. In this
article we offer a preliminary evaluation of different com-
ponents of dysphagia education, screening, and manage-
ment within a pulmonary rehabilitation program.
Method
Participants
Participants enrolled in the Pulmonary Rehabilitation Pro-
gram at Austin Health from November 2002 to April 2007
were eligible for inclusion in the study.
Data Collection and Intervention
Demographic data of age at first appointment, gender, FEV
1
,
height, weight, body mass index (BMI) (all measured closest
to initial appointment), and diagnostic category as assigned
by the referring doctor were collected on all participants
enrolled in the Pulmonary Rehabilitation Program. This
information was obtained via the physiotherapy database for
patients on the program and/or medical history audit.
The Pulmonary Rehabilitation Program was an 8-week,
twice weekly multidisciplinary program. In each session,
participants attended a 1-hour exercise session with phys-
iotherapy and a 1-hour education session provided by each
member of the multidisciplinary team (physiotherapist,
speech pathologist, dietitian, nurse, social worker, occu-
pational therapist, respiratory physician).
As part of the education sessions, participants attended a
1-hour education session on identification and management
of dysphagia provided by a speech pathologist. Topics
discussed included normal swallowing/breathing, symp-
toms of dysphagia, consequences of aspiration, and strat-
egies to improve swallowing. An education booklet about
dysphagia in COPD was provided to all participants.
Participants’ knowledge of respiration and dysphagia
was examined by completing an 11-item questionnaire
before and after the education session (Appendix). Scoring
was determined by total number of correct answers.
Readability of the questionnaire was between fifth- and
sixth-grade levels (Flesch-Kincaid educational levels of 5.1
and 5.4, respectively). The questions were derived directly
from the content of the education session. Where possible,
participants who attended both education and subsequent
screening sessions between February 2005 and March 2007
completed the same questionnaire approximately 4 days
post education. This was to assess longer-term retention of
knowledge.
During the 8-week program, participants were screened
to identify symptoms of dysphagia. At the start of this
study, the researchers could not identify an existing vali-
dated instrument to screen for dysphagia in patients with
COPD. Therefore, using evidence from the literature [12–
17] and consensus opinion from speech pathologists
experienced in COPD management, a questionnaire and
screening protocol were developed for use in this study.
The screen consisted of a self-report questionnaire
regarding symptoms of dysphagia and a clinical assessment
of swallowing ability via observations of participant’s
drinking water and eating a dry biscuit, observing for any
overt symptoms of dysphagia.
Participants identified with symptoms of dysphagia were
offered further individual assessment and management of
swallow function provided by a dietitian and speech
pathologist. These patients received a detailed clinical
assessment with or without an instrumental assessment of
their swallowing via either a videofluoroscopy swallowing
study (VFSS) or fibreoptic endoscopic evaluation of
swallowing (FEES) study. Recommendations for
A. McKinstry et al.: Speech Pathology in Pulmonary Rehabilitation 105
123
management of dysphagia were provided on an individual
basis, including texture modification of food/fluids, pos-
tural strategies, and therapeutic exercises. Participants were
also asked to complete a 44-item (9 domain) standardised
dysphagia-specific quality-of-life questionnaire, the
SWAL-QOL survey [18], at initial attendance and
approximately 3 months after initiation of treatment.
Statistical Analysis
All analyses were undertaken using Intercooled Stata 8.2
for Windows (StataCorp, College Station, TX). Statistical
significance was set at P\0.05 for all analyses. Demo-
graphic data are reported as medians (with interquartile
ranges denoted in brackets) or percentages as appropriate.
Differences in medians between those participants enrolled
in the Pulmonary Rehabilitation Program who were either
seen or not seen for dysphagia education or screening with
regard to age at first appointment, FEV
1
, height, weight,
and BMI were assessed via Wilcoxon rank-sum test. The
differences between these same groups with regard to the
variables of gender and diagnostic category were assessed
using the v
2
test. Differences between pre and post edu-
cation survey scores were assessed using the Wilcoxon
signed-ranks test for paired data. Initial and post inter-
vention scores on the SWAL-QOL survey were also
examined using the Wilcoxon signed-ranks test for paired
data.
Results
Six hundred and thirty-two participants were enrolled in
the Pulmonary Rehabilitation Program at Austin Health
over the 4.5-year period. Of those participants, 298 atten-
ded the 1-hour education session on identification and
management of dysphagia and COPD. Forty-seven partic-
ipants did not answer one or more of the questions on the
education survey so they were excluded from final analysis,
leaving 253 participants with completed pre and post
education questionnaires (study group 1). Of the 632 par-
ticipants, 383 underwent basic dysphagia screening (study
group 2). Of these 383 participants, 104 were referred from
screening for individual assessment and management of
dysphagia. Fifty-five of those 104 participants (53%) cor-
rectly completed both initial and repeat SWAL-QOL sur-
veys (study group 3) (Fig. 1). Not all participants enrolled
in the Pulmonary Rehabilitation Program received dys-
phagia education or screening due to a range of factors,
including other research trials and patient unplanned
absences or withdrawal from the program.
Participant demographics for each group are outlined in
Tables 1and 2. There was no statistically significant
difference between participants enrolled in the Pulmonary
Rehabilitation Program that either did or did not attend
either education or screening sessions regarding dysphagia
in relation to median age, FEV
1
, height, weight, or BMI.
Comparing those participants who received dysphagia
education/screening with those who did not, there was a
higher proportion of males in the group screened for dys-
phagia, but no difference for those educated. There was a
higher proportion of patients with a diagnosis of COPD
seen for either dysphagia education or screening compared
with those not seen (P=0.025 for education and
P=0.039 for screening).
Education Results (Study Group 1)
Statistically significant improvement was found in partici-
pant’s pre and post questionnaire results on knowledge of
dysphagia and COPD, with the median score increasing
from 5/11 (IQR 3,6) pre education to 8/11 (IQR 7,9) post
education (P\0.001) (Fig. 2). This positive result
remained in the subgroup of those who completed the
survey 4 days post intervention (P\0.001) (Fig. 3).
Screening Results (Study Group 2)
Twenty-seven percent (104/383) of participants screened
either exhibited or reported symptoms of dysphagia. These
participants were subsequently offered a referral for further
individual dysphagia and nutritional assessment and
management.
Quality-of-Life Results Pre and Post Individual
Dysphagia Management (Study Group 3)
The repeat SWAL-QOL survey was completed a median of
99.5 days (IQR 91-126) after the initial session. Repeat
dates were not recorded for 9/55 participants so they were
excluded from this calculation.
Statistically significant improvement was found in the
subscales Burden of Dysphagia (P\0.009), Physical
Problems of Dysphagia (P\0.012) and Managing Diet
Options/Food Selection (P\0.016) (Table 3). Improve-
ments in the subscale of Managing Stress were approaching
significance (P\0.058). No statistically significant
improvement was seen in the other six subscales.
Discussion
This study found that a participant’s knowledge of COPD
and dysphagia improved significantly after a 1-hour edu-
cation session. This outcome supports existing evidence
that self-management programs increase the patient/carer
106 A. McKinstry et al.: Speech Pathology in Pulmonary Rehabilitation
123
knowledge base [3,9]. Increased knowledge of COPD and
of how to better recognise symptoms may positively affect
patients’ health-seeking behaviour [19] and hence reduce
the risk of exacerbations related to dysphagia. Increasing
knowledge alone, however, is not sufficient to bring about
change in behaviour and improved health outcomes [9,10,
19]. A limitation of this study is that measures were ini-
tially developed to solely evaluate a patient’s improved
knowledge related to dysphagia in COPD and not a
patient’s ability to apply this knowledge for self-
management.
Improved knowledge was partially retained 4 days later.
Long-term retention of knowledge post education, how-
ever, requires further investigation because there is a large
body of research reporting neuropsychological impairment
in patients with COPD [20–36]. In particular, deficits have
been reported in the areas of attention [22,28,31], memory
[20,21,29,31,32,37], and abstract thought processing
[31]. Age-related decline across a variety of cognitive
domains, in those older than 60 years of age, is also
reported in the literature [20,38]. The average age of
participants attending the education session was 74.9 years.
Participants enrolled in Pulmonary Rehabilitation Program (PRP)
n = 632
Total No. of participants who
attended a dysphagia education
session
n = 298
(47% of total PRP group)
Participants who only
attended dysphagia
screening session
n = 107
Participants referred for individual
dysphagia
assessment/management
n = 104
(27% screened group)
STUDY GROUP 3
Participants with completed initial
and 3 month post SWAL QOL
surveys
n = 55
(53 % of participants ref erred for
individual management)
STUDY GROUP 1
Participants with completed pre-
post education questionnaires
n = 253
(84% of dysphagia education group)
Participants who only
attended dysphagia
education session
n = 22
Participants who
attended both
dysphagia education
and dysphagia
screening sessions
n = 276
STUDY GROUP 2
Total No. of participants who
attended a dysphagia screening
session
n = 383
(60% of total PRP group)
Participants not
educated or screened
for dysphagia by
Speech Pathologist
n = 227
Fig. 1 Participants included in
study (November 2002–April
2007)
Table 1 Demographic data of patients enrolled in the Pulmonary Rehabilitation Program comparing those seen with those not seen for
dysphagia education
Attended education session Did not attend education session Pvalue
N298 334 N/A
Age
a
74.9 (67.0, 79.5) 73.8 (66.4, 78.8) 0.193
Males (%) 56.7 52.1 0.245
b
FEV
1
a
1.17 (0.81, 1.64) 1.24 (0.86, 1.66) 0.465
Height (m)
a
1.65 (1.58, 1.72) 1.64 (1.58, 1.71) 0.716
Weight (kg)
a
70 (61, 84) 74 (63, 89) 0.073
BMI
a
26.1 (22.9, 30.8) 27.5 (23.1, 31.8) 0.080
Diagnosis of COPD (%) 79.8 72.2 0.025
b
a
All data for these variables reported as median and interquartile range (IQR)
b
Relates to v
2
test for difference between the two groups; all other pvalues relate to Wilcoxon rank-sum test for difference in medians of the
two groups
A. McKinstry et al.: Speech Pathology in Pulmonary Rehabilitation 107
123
Our finding that 27% of pulmonary rehabilitation par-
ticipants who were screened for dysphagia reported or
exhibited symptoms of dysphagia is similar to the findings
of Mokhlesi et al. [14]. Previous researchers have suggested
that only 4-5% of patients with COPD are referred for
swallow assessment [15,17]. This is a cause for concern
because it highlights the likely underdiagnosis and man-
agement of dysphagia in the COPD population. While there
has been some research into the prevalence of dysphagia in
the stable and acute phases of COPD [13–17], further
research is required to establish a strong evidence base for
dysphagia education and management in this population.
Furthermore, this study did not evaluate the severity of
dysphagia symptoms that patients reported or exhibited.
Further investigation into the severity of patients’ dyspha-
gia symptoms during both the chronic and acute phases of
the disease and whether the severity of COPD correlates
with the severity of dysphagia would provide further evi-
dence to identify individuals at higher risk of aspiration.
Consideration should also be given to identifying the
optimal method of dysphagia screening in this population
to identify patients requiring further management. No
validated tool for dysphagia screening of people with
COPD currently exists.
In the context of the chronic and progressive nature of
COPD, improvement in quality of life should be viewed as a
clinically significant result for this population. The finding
that individual dysphagia assessment and management had a
positive effect on some, but not all, areas of a participant’s
quality of life (as rated by the SWAL-QOL) is not unex-
pected. Given that intervention focused on self-management
skills of the nine subscales in the SWAL-QOL, Burden of
Dysphagia and Managing Diet Options/Food Selection are
the scales in which improvement was most anticipated.
The significant improvement in the subscale of Physical
Problems of Dysphagia was not anticipated given the
chronic and progressive nature of the disease. It is possible
that the dysphagia management plans reduced the partici-
pants’ perception of the severity of the physical problems
Table 2 Demographic data of patients enrolled in the Pulmonary Rehabilitation Program comparing those seen with those not seen for
dysphagia screening
Attended screening session Did not attend screening session Pvalue
N383 249 N/A
Age
a
73.9 (67.0, 79.1) 74.1 (65.7, 79.2) 0.668
Males (%) 58.0 48.6 0.021
b
FEV
1
a
1.18 (0.80, 1.66) 1.24 (0.91, 1.61) 0.808
Height (m)
a
1.65 (1.58, 1.72) 1.64 (1.57, 1.71) 0.234
Weight (kg)
a
71 (61, 86) 74 (64, 88) 0.119
BMI
a
26.1 (22.9, 31.1) 28 (23.3, 32.1) 0.055
Diagnosis of COPD (%) 78.6 71.4 0.039
b
a
All data for these variables reported as median and interquartile range (IQR)
b
Relates to v
2
test for difference between the two groups; all other Pvalues relate to Wilcoxon rank-sum test for difference in medians of the
two groups
0 5 10
Score (max=11)
Pre Post
p<.001
Fig. 2 Education questionnaire results: before education and imme-
diately after education (n=253)
0 5 10
Score (max=11)
Pre Post 4 days post
p<.001
Fig. 3 Education questionnaire results: before education, immedi-
ately after, and 4 days after education (n=78)
108 A. McKinstry et al.: Speech Pathology in Pulmonary Rehabilitation
123
being experienced, in spite of the chronic nature of the
problem. These results support the implementation of
active individual management of dysphagia in this popu-
lation to improve the patient’s quality of life, regardless of
the progressive nature of the disease.
Of interest, the Managing Stress subscale approached
statistically significant improvement. The introduction of
self-management plans for dysphagia may have empow-
ered patients to recognise symptoms and implement strat-
egies, thus reducing their anxiety. Further research,
however, is required in this area to confirm these
impressions.
The lack of significant improvement in the other sub-
scales of the SWAL-QOL was not surprising. These
include the subscales of Desire to Eat, Communication,
Fear of Choking, Social Functioning, and Fatigue.
The desire to eat is multifactorial and management of a
swallowing problem in isolation may not be sufficient to
improve this domain. Indeed, management of dysphagia
may involve texture modification of food and fluids, which
can potentially reduce the desirability of oral intake. This is
a somewhat unfortunate but unavoidable side effect of
avoiding aspiration pneumonia for some people with
COPD.
Participants’ fear of choking did not change after
dysphagia management. As a direct result of intervention,
participants would likely have an increased awareness of
their dysphagia and the potential serious consequences
(i.e., choking and/or aspiration pneumonia). This
increased awareness of the risk and consequences of their
problem possibly meant their level of fear remained
unchanged.
While not significant, the trend toward improvement in
social functioning was encouraging. Modifications to diet
and the introduction of swallowing strategies recom-
mended in the management of dysphagia may negatively
impact on a person’s willingness to eat out socially. Before
intervention, participants reported that they no longer dined
out socially because they found the episodes of coughing or
choking during meals or the increased time required for
meals socially embarrassing.
Conclusion
In this article we document the benefit of dysphagia edu-
cation, screening, and intervention in pulmonary rehabili-
tation programs for patients with COPD. Dysphagia
management and education of patients in pulmonary
rehabilitation programs may contribute toward early iden-
tification and self-management of dysphagia and may
enhance swallowing-related quality of life.
Acknowledgments The authors gratefully acknowledge Dr. Cath-
erine Hill, Tanis Cameron, and Professor Alison Perry for their
contributions to this article, and Sophie Rogers for her statistical
analysis of the data. This study was approved by the Human Research
Ethics Committee, Austin Hospital, Melbourne, Australia.
Appendix Education Session Questionnaire
Name (Please print): ___________________________
DOB: ______________
Yes No Unsure
1. Are people with breathing difficulties more
likely to be at risk of swallowing problems?
hhh
2. Can swallowing problems cause pneumonia? hhh
3. The term ‘‘aspiration’’ means food or drink
going into the lungs?
hhh
4. Can we breath in and out as we swallow? hhh
5. If you cough during a meal, is that a possible
sign of swallowing problems?
hhh
6. Is a cough always triggered when food/drink
goes down the wrong way?
hhh
Table 3 Summary of pre- and post-SWAL-QOL survey results (n=55)
Domain Initial median score (IQR) Post median score (IQR) Pvalue
Burden of Dysphagia (max score: 10) 7 (6, 9) 8 (7, 10) 0.009*
Desire to Eat (max score: 25) 18 (13, 23) 19 (15, 23) 0.137
Physical Problems of Dysphagia (max score: 70) 49 (40, 56) 52 (42, 62) 0.012*
Managing Diet Options, Food Selection (max score: 10) 8 (4, 9) 8 (6, 10) 0.016*
Communication (max score: 10) 10 (6, 10) 10 (8, 10) 0.476
Fear of Choking (max score: 20) 16 (11, 18) 16 (13, 18) 0.109
Mental State, Stress (max score: 25) 18 (12, 23) 20 (15, 25) 0.058
Social Management of Dysphagia (max score: 25) 20 (15, 25) 23 (14, 25) 0.063
Fatigue (max score: 25) 15 (10, 17) 13 (10, 17) 0.381
*Statistically significant
A. McKinstry et al.: Speech Pathology in Pulmonary Rehabilitation 109
123
Appendix continued
Yes No Unsure
7. Can chest infections cause swallowing
problems?
hhh
8. Can an X-ray determine the safety of your
swallow function?
hhh
9. If you need oxygen to help your breathing,
should you take it off when eating and
drinking?
hhh
10. Do we hold our breath for about 5 seconds
when we swallow?
hhh
11. Are liquids always safer to swallow than
solids?
hhh
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A. McKinstry BSpPath (Hons)
M. Tranter BSpPath, GrDipl Bus Manag
J. Sweeney BAppSc (SpPath), MAppLing
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