Brain & N eurorehabilitation Vol. 2,. 2, September, 29 삼킴곤란평가 동국대학교의과대학재활의학교실박진우 Evaluation of Dysphagia Jin-Woo Park, M.D. Department of Physical Medicine and Rehabilitation, Dongguk University College of Medicine Dysphagia is common, especially in the elderly, and may cause dehydration, weight loss, aspiration pneumonia and airway obstruction. It may occur because of a wide variety of structural or functional conditions, including stroke, cancer, neurologic disease and gastroesophageal reflux disease. A thorough history and a careful physical examination are important in the diagnosis but investigations such as videofluoroscopic swallowing study (VFS), fiberoptic endoscopic examination of swallowing (FEES) and manometry are more useful for confirming diagnosis, identifying the pathophysiology of a swallowing disorder and testing the therapeutic and compensatory techniques. This article reviews various evaluating methods for dysphagia. (Brain & NeuroRehabilitation 29; 2: 13-17) Key Words: deglutition disorders, dysphagia, endoscopy, evaluation, manometry, scale 서론 삼킴곤란은근신경계통의이상이나입에서상부식도에구조적이상으로인해발생하는삼킴의어려움으로이로인해흡인성폐렴이나기도막힘이일어날수있고영양장애나탈수등의증상도일으킬수도있다. 삼킴곤란에접근하기위해서는근본적으로이를일으킨원인질환을아는것이중요하며원인질환이치료가능한경우삼킴곤란도완치가되는경우도종종있다. 하지만대개의경우원인질환치료가어려우며같은원인질환인경우에도다양한형태의삼킴장애를일으켜삼킴장애의패턴을분석하여그자체로치료적접근을하는것 ( 재활의학적접근 ) 이더도움이된다. 따라서삼킴기능의평가에병력이나이학적검사도매우중요한수단이긴하지만이러한삼킴장애패턴을분석하기위해서는검사실검사가훨씬더유용하다. 검사실검사에는비디오투시삼킴검사, 광섬유내시경적삼킴검사, 인두및식도압력검사가있다. 본논문에서는삼킴곤란을평가하는다양한검사들에대한기본적개념, 장단점등에대하여알아보고자한다. 교신저자 : 박진우, 경기도고양시일산동구식사동 1 11-773, 동국대학교일산병원재활의학과 Tel: 31-961-7, Fax: 31-961-7 E-mail: jinwoo_park@duih.org 본론 1) 임상검사 (clinical tests for dysphagia) 침상에서의임상검사가검사실검사에비하면기도흡인을밝혀내는데한계가있는것은사실이지만 1 선별검사로서의충분한의미를줄수있기때문에다양한연구가진행되었다. Kidd 등 2 은감소된인두감각과뇌졸중의중등도가기도흡인과매우밀접한관련이있다고보고하였고, Mari 등 3 은삼킴시사래가든경험과 3온스물마시기검사 (3-oz water test) 의이상소견이기도흡인의예측에좋은결과를보였다고하였다. 3온스물마시기검사는 Depippo가개발한선별검사로높은민감도와특이도를보이기는하였지만 3온스의물은비교적많은양으로삼킴곤란환자가이를쉼없이마시기에는어려운점이많았다. 199년발표된 Burke 삼킴곤란선별검사 (Burke dysphagia screening test) 는 3온스물마시기검사를포함하면서그밖에뇌졸중의병변, 식사의양과시간, 뇌졸중급성기의폐렴등 7가지항목으로구성하여이들중한가지라도이상이있으면불합격으로간주하였고, 불합격인경우합병증발생률이합격인경우에비해 7.6배나높다고보고하였다. Daniels 등 6 도비슷한방법으로삼킴시기침의유무, 음색의변화, 비정상적자발적기침등 6가지항목중 2가지이상에서이상이나타나면중등도이상의삼킴곤란과관련이있다고하였다. 이들두방법은비교 13
Brain& NeuroRehabilitation:29; 2: 13~17 적여러임상소견을포괄적으로다루고는있으나어떤항목이더중요한지에대해서는언급할수없고또한정량적이지못한단점이있었다. 한등 7 은이러한단점을보완하여임상적삼킴기능척도 (Table 1) 를개발하였고 점이상인경우기도흡인에대한민감도를 1% 로보고하였다. 한편최근발표된리뷰 에의하면맥박산소측정법 (pulse oximetry) 을조합한물마시기검사 (water test) 가 Table 1. Clinical Dysphagia Scale (CDS) Location Valuables Coded value Score Tracheostomy tube Aspiration history within 1 month Lip sealing Chewing Tongue protrusion Laryngeal elevation Reflex cough Total n-stem lesion Stem lesion ne ne ne ne 2 1 2 1 3 2 1 1 3 1 73 9% 의민감도를보이며가장우수한선별검사로추천되었다. 2) 비디오투시삼킴검사 (videofluoroscopic swallowing study; VFS) 삼킴이상의진단을위해가장많이사용하는검사법이며, 현재표준검사 (gold standard) 로인정을받고있다. 9,1 Logemann은 19년대초반표준화된방법 (protocol) 을제시하였고이후약간씩의변형은있지만기본틀이되고있다. 11,12 검사를통해삼킴과정과관련된해부학적구조 ( 구강, 인두, 후두, 식도 ) 와그들의움직임, 조화등을관찰할수있으며기도흡인 (aspiration) 의원인을확인하고치료적인접근을동시에할수있는장점이있다. 13 방사선투시판과 x-선튜브사이에환자를앉히고주로옆면 (lateral view) 에서검사식을삼키는과정을투시해보면서과정을녹화한다 (Fig. 1). 검사식은점도를달리한음식에바륨을섞어서준비하며 1 이를통해환자에게안전한점도의식이를결정하는것이매우중요하다. 1-17 또한다양한마뉴버 (maneuver) 나자세의변화를시도해역시치료적효과유무를확인하는과정이필요하다. 1-2 앞면 (anterior-posterior view) 촬영은식도와기도가겹쳐지는이유로기도흡인의확인은어려우나좌우대칭성을보는데유용하다. 삼킴의과정이불과 1초미만이기때문에녹화된비디오를저속으로분석함으로써보다정확한진단을할수있다. 방사선노출의위험이있으나그정도가크지않으며다른방사선검사와비교해서도받아드릴수있는수준이다. 21,22 검사시기도흡인되는바륨도비교적안전한것으 Fig. 1. Videofluoroscopic swallowing study (VFS). (A) Shows the preparation of VFS. (B) Shows VFS image illustrating the anatomy of the oropharynx. 1
박진우 : 삼킴곤란평가 로알려져있다. 23 하지만결과분석및치료방향결정을위해서는일정기간의훈련이필요하며검사자간해석이다른경우가있어단점으로지적된다. 2 3) 광섬유내시경적삼킴검사 (fiberoptic endoscopic evaluation of swallowing; FEES) 19년 Langmore 에의해처음소개되었으며, 2 현재비디오삼킴검사와함께가장많이시행되고있는검사이다. 3 mm 직경의광섬유내시경을코로삽입하여코인두 (nasopharynx), 입인두 (oropharynx) 그리고후두위까지차례로내리면서해부학적이상유무및삼킴생리를관찰한다 (Fig. 2). 삼킴기능이상및기도흡인을관찰하면그원인에따른보상적방법을선택하여치료적접근을할수있다. 26 이동이어렵고자세를취하기어려운환자도가능하며그림자가아닌칼라영상으로직접관찰할수있어도움이된다. 검사에방사선조사의위험이없으며음식물도바륨을섞어변형된음식이아닌일상적인음식으로검사가가능하다는장점이있다. 한편검사를시행하면서감각검사 (fiberoptic endoscopic evaluation of swallowing with sensory test; FEESST) 를동시에실시할수있는데이는모뿔-후두덮개주름 (aryepiglottic fold) 에정량화된공기압력을불어넣어후두내전반사 (laryngeal adduction reflex; LAR) 를유발하는것으로 27 6 mmhg 이상에서도반응이없는경우이상으로보며 2 이런경우기도흡인이나흡인성폐렴과관련이높다. 29 하지만삼킴이일어나는중요한시기에인두수축근이수축하고후두덮개가뒤집히면서렌즈를가리는 white out 현상이일어나, 후두통과나기도흡인여부를직접볼수없으며, 구강기 (oral phase) 와식도기 (esophageal phase) 또한관찰할수없다는단점이지적된다. 그리고검사를하기위해숙련도높은기술이필요하다. 검사로인한부작용으로코피, 구역질, 실신, 후두경련등이있을수있으나그발생은극히드물며매우안전한검사로알려졌다. 3,31 검사의타당도는대부분 VFS와비교한것으로기도흡인의민감도가 FEES가매우높은것으로보고됐다. 32,33 그럼과연 VFS와 FEES 중어느검사가더좋은검사일까? 앞서언급했듯이두검사모두장단점을가지고있고우수성에있어서도비슷하다는평가를받고있다 (Table 2). 따라서어느한검사가더낫다기보다서로보완적인관계를가질수있고검사하는기관의여건에따라혹은환자의상태에따라선택을달리할수있겠다. 3 ) 인두및식도압력검사 (pharyngeal and upper esophageal manometry) 압력검사는직경 3 mm의구부러지는튜부형태의압력센서를코를통해삽입한후압력측정부를인두부및상부식도조임근위치에거치시킴으로써이부위의압력을측정하는것이다. 이는기존의식도운동장애의진단을위해쓰인식도압력검사와차이가있는데이는식도압력검사가 2초정도의진행을측정하는것과달리인두부의경우 1초미만의압력변화를측정해야함으로압력에민감한센서를사용해야한다. 12 모든삼킴곤란환자에실시해야하는것은아니며주로인두수축근의약화가의심되거나상부식도조임근이잘열리지않는경우, 혹은이들간의협동장애가의심되는경우에매우도움이된다. 3 하지만기술적으로정확한데이터를얻기가매우어려운데이는삼킴과정에서움직임이일어나처음센서를둔위치에서벗어나기때문이다. 36 이러한이유로압력검 Table 2. The Comparison Between VFS and FEES Anatomic area/movement VFS FEES Fig. 2. View with fiberoptic endoscopic evaluation of swallowing (FEES). (1) Route to esophagus, (2) trachea, (3) vocal cord, () aryepiglottic folds, () epiglottis, (6) pyriform sinus, (7) fluid with dye in vallecula. Oral cavity/tongue Vocal cord mobility Hyo-laryngeal movement Pharyngeal wall motion UES opening Laryngopharyngeal sensation 1
Brain& NeuroRehabilitation:29; 2: 13~17 Table 3. Penetration-Aspiration Scale 1. Material does not enter the airway 2. Material enters the airway, remains above the vocal folds, and is ejected from the airway 3. Material enters the airway, remains above the vocal folds, and is not ejected from the airway. Material enters the airway, contacts the vocal folds, and is ejected from the airway. Material enters the airway, contacts the vocal folds, and is not ejected from the airway 6. Material enters the airway, passes below the vocal folds and is ejected into the larynx or out of the airway 7. Material enters the airway, passes below the vocal folds, and is not ejected from the trachea despite effort. Material enters the airway, passes below the vocal folds, and no effort is made to eject 사는단독으로시행하기보다 VFS와동시에시행함으로써압력센서의위치에대한확인및식괴의움직임에따른부위별압력에대한보다정확한정보를얻을수가있으며이를 manofluorography 혹은 videomanometry라고한다. 37 ) 종합척도삼킴곤란은삼킴기능에문제를일으키는일종의장애로 FIM (functional independence measure) 나바텔지수 (Barthel index) 와같이포괄적으로그기능을평가할수있는도구들이필요하다. 이를통해환자의상태를전체적으로파악하여치료진간의사소통을원활하게하고시간경과나치료후에기능변화여부를측정할수있다. 미국언어청각협회 (American Speech-Language-Hearing Association; ASHA) 에서는환자에게요구되는지도 (supervision) 의정도와가능한식사수준에따라 1에서 7까지구분하는포괄적도구로서삼킴척도 (National Outcome Measurement System swallowing level scale; NOMS) 를제안하였다. 3 삼킴곤란결과및증증도척도 (The Dysphagia Outcome and Severity Scale; DOSS) 역시 7단계로구성된포괄적척도로서독립의수준, 구강섭취가가능한정도, 그리고식사수준및변형정도에따라나누었으며 9% 이상의검사자내, 검사자간신뢰도를보였다. 39 한편한등 은뇌졸중환자에서 6개월이후에도삼킴곤란이회복되지않는것을예측하고자비디오투시삼킴척도 (Videofluoroscopic Dysphagia Scale; VDS) 를개발하였는데, 이또한비디오투시삼킴검사의소견을종합적으로반영하고 1점만점의점수로표기되어종합척도로사용할수있다고제안하였다. 후두통과- 기도흡인척도 (Penetration- Aspiration Scale; PA scale) (Table 3) 는 Rosenbek 등 1 에의해제안되었고이역시비디오투시삼킴검사소견상후두통과와기도흡인의정도및음식물이노력에의해기도밖으로배출될수있는지여부에따라 단계로나누어져있다. 검사자간그리고검사자내신뢰도가매우높고간단하고쉬워서널리사용되고있다. 결론 이상에서삼킴기능평가에가장널리사용되고있는검사법및기능척도에대하여알아보았다. 이들평가도구들중어느한도구가뛰어나다기보다장단점에따라혹은검사기관의사정에따라적절히선택해사용하는것이중요하며, 평가는평가로끝나는것이아니라반드시치료적인계획과연결되야한다는점을강조하고싶다. 참고문헌 1) Splaingard ML, Hutchins B, Sulton LD, Chandhury G. Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment. Arch Phys Med Rehabil. 19;69: 637-6 2) Kidd D, Nesbitt LR, MacMahon J. Aspiration in acute stroke: a clinical study with videofluoroscopy. QJM. 1993;6:2-29 3) Mari F, Matei M, Ceravolo MG, Pisani A, Montesi A, Provinciali L. Predictive value of clinical indices in detecting aspiration in patients with neurological disorders. J Neurol Neurosurg Psychiatry. 1997;63:6-6 ) Depippo KL, Holas MA, Reding MJ. Validation of the 3-oz water test for aspiration following stroke. Arch Neurol. 1992; 9:129-1261 ) Depippo KL, Holas MA, Reding MJ. The Burke dysphagia screening test: validation of its use in patients with stroke. Arch Phys Med Rehabil. 199;7:12-126 6) Daniels SK, Ballo LA, Nahoney MC, Foundas AL. Clinical predictors of dysphagia and aspiration risk: outcome measures in acute stroke patients. Arch Phys Med Rehabil. 2;1:13-133 7) Han TR, Paik NJ, Park JW. The clincal functional scale for dysphagia in stroke patients. Korean J Stroke. 21;3: 13-17 ) Bours GJ, Speyer R, Lemmens J, Limburg M, de Wit R. Bedside screening tests vs. videofluoroscopy or fibreoptic endoscopic evaluation of swallowing to detect dysphagia in patients with neurological disorders: systematic review. J Adv Nurs. 29;6:77-93 9) Palmer JB, Kuhlemeier KV, Tippett DC, Lynch C. A protocol 16
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