COPD and Throat Burn Reflux: A Hot Topic
While working in my LTACH in Miami Florida and my two ENT offices in Florida, I started to notice a clinical trend. My FEES referrals were beginning to show increased an increased frequency of LPRD correlating with COPD. Laryngopharyngeal Reflux Disease (LPRD) is something that I have personally. In my humble opinion, it is something that often goes under diagnosed in the Chronic Obstructive Pulmonary Disease patient population. According to Dr Jamie Koufman, a leading researcher in LPRD, this takes places when gastric contents enter the pharynx and larynx. COPD is a progressive lung disease.
Fast forward one year and now I am in Ohio, working in Cincinnati and asked to join a COPD task force. I guess sometimes, the more things change, the more they stay the same. New location, same deficits are being seen. COPD with LPRD is rampant, everywhere I turn. So I began to ask myself, what exactly are we seeing on FEES with these patients. I also began to ponder what the researchers say about the incidence of LPRD in COPD. The question posed to me by a Pulmonolgist recently: Is there a role for the SLP in the management of LPRD in the COPD patient? I joined the committee and said: "Yes sir, there is".
My CE company conducted a live 6 hour reflux course last year with Dr Jonathan Aviv, an internationally known ENT. In reference to LPRD he stated while speaking to a group of speech language pathologists: "We have thousands of patients out there who have symptoms who are never being diagnostically assessed. I think that's the problem and again, this is where you come in, I think Eric Blicker was right that there is a need for this type of course because we are seeing these patients, yet we're not realizing what we have in front of us".
In my humble opinion, we are the primary profession conducting an upper airway endoscopic exams while feeding patients. We are having these COPD patients come in with arytenoid edema and posterior commissure hypertrophy on FEES who are chronically throat clearing with hoarseness. Why do these patients get sent to see a speech language pathologist? The main complaint I get: "I told my doctor I was having trouble swallowing". For those performing FEES, we are often on the front lines as the first discipline to scope a patient. The ability to be aware of these links between LPRD and COPD is critical to make proper referrals for medical reflux management, generally done by either Otolaryngology or Gastroenterology. As speech language pathologists we have a unique opportunity to apply the Reflux Finding Scale (RFS) and the Reflux Symptom Index (RSI) to try and help these COPD patients with LPRD get properly diagnosed and treated. We can take lessons from the work of my mentor, Dr Jonathan Aviv, and teach these patients about using food as medicine. This and other lifestyle changes for the patient are important aspects of reflux management. You are what you eat, essentially.
The research is impressive: Jung et al (2015) found that RSI and RFS were significantly higher in COPD patients vs healthy subjects. They went on to indicate that these scores were significant predictors for COPD exacerbation. They mention a significant increase in diffuse laryngeal edema and erythema in COPD patients with LPRD. Hamdan et al (2016) described some clinical behaviors seen among COPD patients who have LPRD including: hoarseness, throat clearing, excessive mucus, and cough. Eryuksel et al (2009) noted in their research a high frequency of LPRD in COPD patients. They found that once the LPRD was treated, there were improvements in the COPD symptoms. Julia Sanchez Perez at University Hospital Basel in Switzerland has reported that LPRD "may result in the aspiration of gastric acids into the lungs which may exacerbate COPD". It is important to remember that a physician is required to render the LPRD diagnosis. The SLP is able to document and report the symptoms of LPRD to the physician so accurate medical work-up can take place.
When conducting a clinical bedside swallow evaluation with a patient who has COPD, the speech language pathologist might hear coughing, throat clearing, hoarseness. These are some of the same behaviors audible when patients have pharyngeal dysphagia. This is the challenge point for the speech language pathologist. Some of these patients might have dietary consistency modification based on these symptoms without objective testing, which is needed to truly determine what is actually happening. If a COPD patient is having these symptoms, I have learned that a cough is not always from what is going down, but might be from what is coming up. We know that the clinical exam has limitations, including false positives and false negatives. When looking at the big picture, we should recommend FEES for these patients when possible, not to assess for aspiration, but to assess swallow function. Then, when the reflux becomes visible at the UES and enters the trachea, we can provide precise information to the physician, explaining what's up, in this case, the reflux. Feel the burn, advocate for FEES for cases where throat burn reflux is suspected in the COPD population. Present the facts to the physicians to assist in the management of this special population.
Dr. Eric Blicker, M.A. CCC-SLP.D; BRS-S
Dr. Eric Blicker, M.A. CCC-SLP.D; BRS-S (Board Recognized Specialist - Swallowing) is an American Speech-Language-Hearing Association (ASHA) Board Recognized Specialist in Swallowing Disorders since 2008. He received his doctoral degree from Nova Southeastern University, trained in Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) by Dr. Jonathan Aviv, the otolaryngologist who developed FEESST in 200-2001. He started multiple Flexible Endoscopic Evaluation of Swallowing (FEES) programs in the south Florida area. He is currently the President of Community Care Partners Inc and ceualliedhealth.com. If you have questions related to this article or would like to request additional information about CEUs related to COPD and LPRD, please send an e-mail to Dr. Blicker at: firstname.lastname@example.org.
1. Incidence and treatment results of laryngopharyngeal reflux in chronic obstructive pulmonary disease.
Eryuksel E, et al Eur Arch Otorhinolaryngol. 2009 Aug;266(8):1267-71. doi: 10.1007/s00405-009-0922-y. Epub 2009 Feb 17.
4. 2017 International Congress of the European Respiratory Society: Julia Sanchez Perez