Beyond the Pharynx: A New Approach to Esophageal Dysphagia
Being a medical speech pathologist is the best job in the world. That's not just hyperbole. I mean it. I know I'm biased but think about it. We have the chance to bring the joy of eating and drinking to patients who didn't have anyone to turn to before SLPs became the go-to experts. Our young field can already do SO much to manage swallowing disorders. I bet you feel similarly. This is a very exciting time to be an SLP, and the excitement is palpable. One of the most exciting parts is that our research is expanding in quantity, quality, and scope each and every day. I remember when I first graduated 12 years ago, we were told not to assess or treat any area below the cricopharyngeal segment (AKA the UES). Don't touch it. Don't even look at it. It's. Not. For. You. As a young, bright-eyed, and bushy-tailed med SLP, I was ready to conquer the world of dysphagia. I was excited to dive into the world of modified barium swallow studies, FEES, and all those fancy compensatory maneuvers. But as soon as I encountered a patient with esophageal dysphagia, the UES was like the Berlin wall.
But things have changed since then. Today, SLPs are not only welcomed into the world of esophageal dysphagia management but we are also encouraged to help patients with nowhere else to turn. We can be their saving grace. To further discuss this area, I'd like to discuss a groundbreaking technique that has revolutionized how SLPs can approach esophageal dysphagia management. It's called the Dysphagia Intervention for the Esophageal Zone (DIEZ) technique.
What is the DIEZ technique? Developed by the brilliant Dr. Roxann Diez Gross PhD, CCC-SLP, ASHA Fellow, the DIEZ technique is a respiratory-based therapy that addresses non-pathologic esophageal stasis and globus.
The DIEZ technique is rooted in the fascinating interplay between our respiratory and digestive systems. Think of it this way: your esophagus is like a waterslide, and the food bolus is a thrill-seeker ready for the plunge. But the water slide is in a pressure chamber. The pressure changes caused by breathing can either propel the bolus down the slide or create an airlock that hinders its smooth journey. It all depends on how much air is in the lungs and, most importantly, how we inhale and exhale while swallowing.
The Esophagus and Respiration: A Dynamic Duo
The DIEZ technique is founded on the close anatomical and physiological relationship between the esophagus and the respiratory system. These two systems are closely intertwined, and changes in respiratory patterns can directly influence esophageal function.
Pressure changes are the "driving force" behind the improved motility. The key is in the pressure gradient created by breathing. When we inhale, the diaphragm contracts, and the lungs expand, creating negative pressure within the thoracic cavity. This negative pressure can impact the esophagus, which sits next to the lungs and diaphragm. But timing is everything here. The DIEZ technique strategically manipulates breathing patterns to optimize esophageal clearance. By taking a deep breath and holding it before swallowing, we increase the pressure within the thoracic cavity. This positive pressure helps to propel the bolus down the esophagus and prevents it from getting stuck. A slow exhalation is the finishing touch. It allows for a gradual decrease in thoracic pressure, ensuring the bolus continues its smooth journey toward the stomach. Gross created a detailed, six-step approach to facilitating the most effective breathing pattern, which can be viewed in her full course (Link below). In essence, the DIEZ technique harnesses the power of coordinated breathing to create a favorable pressure environment for the bolus to move through the esophagus more easily. It's like giving the bolus a gentle push and a smooth ride down the esophageal slide.
Benefits of DIEZ in a Nutshell:
Improved bolus transit
Reduced esophageal stasis
Alleviation of globus sensation
Enhanced esophageal clearance
Does It Work?
In Dr. Gross's clinical experience, the DIEZ technique has proven remarkably effective in resolving symptoms like globus sensation, food sticking, and even regurgitation in patients for whom traditional medical interventions failed. Many patients have felt like they were on a deserted island with esophageal dysphagia. Sending out smoke signals for anyone to answer their call. DIEZ is like the ship on the horizon, heading to them with trays of their favorite food and drink.
Many options to treat esophageal dysphagia can be invasive and life-altering. Medications can have serious side effects that significantly impact quality of life. And at the end of all the testing and interventions, some patients STILL don't have the right answer. DIEZ might be a great option for these reasons because of its non-invasive and low-risk nature.
Research and Limitations: While the DIEZ technique boasts impressive success stories, it's worth noting that research on this technique is limited. Rigorous studies are still needed to solidify its place in the dysphagia management landscape.
Challenges and Success Stories
One of the main challenges of the DIEZ technique is making it habitual. It can take around 40 days of consistent practice for the coordinated breathing-swallowing pattern to become automatic. But the results may be worth the effort. Dr. Gross has shared numerous inspiring success stories of patients who have overcome their esophageal dysphagia with the help of DIEZ.
One of Dr. Gross's patients, a 62-year-old woman, had been experiencing globus sensation for several months. She had undergone various tests, including a barium swallow and FEES, but no structural or functional abnormalities were detected. She had also tried multiple medications, including PPIs, but nothing seemed to alleviate her symptoms.
The patient was then referred to Dr. Gross for a swallowing evaluation. During the review, Dr. Gross observed that the patient had difficulty coordinating her breathing and swallowing, contributing to her globus sensation.
Dr. Gross then introduced the patient to the DIEZ technique and guided her through the steps. The patient practiced the technique regularly and gradually noticed an improvement in her symptoms. After several weeks of consistent practice, her globus sensation had completely resolved.
The patient was thrilled with the outcome and grateful to Dr. Gross for introducing her to the DIEZ technique. She reported that she could finally eat and drink without the constant feeling of a lump in her throat for the first time in months!
When to Proceed with Caution
While DIEZ is generally safe, there are a few contraindications to keep in mind:
Cardiovascular Issues: The DIEZ technique involves holding your breath and then exhaling slowly. This can temporarily affect blood pressure and heart rate. In individuals with cardiovascular problems, these changes might be risky, potentially leading to dizziness or even fainting.
Chronic Obstructive Pulmonary Disease (COPD): People with COPD often have difficulty exhaling fully. The DIEZ technique emphasizes slow exhalation, which could be challenging for someone with COPD. It might cause discomfort or breathing difficulties as air gets trapped in the lungs.
Tracheostomy: A tracheostomy alters the typical airflow in and out of the lungs. The DIEZ technique relies on the coordination of breathing and swallowing with the subglottic pressure that the natural airway allows. With a tracheostomy, an artificial airway disrupts this pressure by bypassing the larynx and the upper airway, making the technique difficult to employ and may be less effective. There have not been any studies to utilize DIEZ with a tracheostomy tube, capped trach, or speaking valve, which may improve subglottic pressure but may introduce other risks not yet accounted for.
Want to Learn More?
If you're intrigued by the DIEZ technique and want to add this powerful tool to your SLP arsenal, I highly recommend checking out Dr. Roxann Diez Gross's course on Northern Speech Services. You can access it here. Please do not attempt to use this technique unless you've taken the full course. This article is not meant to serve as a comprehensive description of the intervention and cannot be used as an alternative to the course or official training. Questions and comments below!
*Note: I am not receiving royalties for this post. I enjoyed this course and want to bring awareness to this technique.
Written by George Barnes MS, CCC-SLP, BCS-S, and reviewed by Dr. Rozann Diez Gross. Created with Northern Speech Service’s permission.
