Dysphagia and mechanical ventilation in SARS-COV-2 pneumonia: It's real

Postextubation Dysphagia Among Patients With COVID-19: Results of Instrumental Swallow Studies and Clinical Swallow Evaluations

PURPOSE

Research has shown that prolonged endotracheal intubation can increase risk of aspiration following extubation. This study examined the relationship between swallowing and intubation among patients with COVID-19. We investigated the association between the duration of intubation and time until an oral diet was safely initiated and the correlation between the length of intubation and reduced sensation with aspiration as seen on flexible endoscopic evaluation of swallowing (FEES)/videofluoroscopic swallowing study (VFSS).

METHOD

This study is a retrospective analysis of all intubated patients admitted with the primary diagnosis of COVID-19 between April 2020 and March 2021 who received an inpatient speech-language pathology consultation. We utilized univariate linear regressions to investigate the dose-response relationship between duration of intubation and time until cleared for oral diet post-extubation. Dysphagia outcomes were analyzed, including results from 39 instrumental evaluations (VFSS and FEES).

RESULTS

During this 1-year period, 94 extubated patients were examined by a speech-language pathologist (SLP). We observed a near-exponential increase in the days until cleared for oral diet from 3% versus 69% when intubated for 10-16 days versus 17-34 days, respectively. Second, 39 patients received a VFSS/FEES evaluation. Of those who aspirated on an instrumental swallow study, there was a 78% rate of silent aspiration.

CONCLUSIONS

Prolonged intubation has a near exponential dose-response on the time until a patient becomes cleared for an oral diet after extubation. Prolonged intubation also increases the rate of aspiration observed on VFSS/FEES evaluations. Thus, SLP evaluation of oropharyngeal swallow physiology is important to minimize complications and improve patient outcomes.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.28165631.

The post ICU trajectory: Post acute and post ICU nutritional care

ICU survivors are growing but a persistent physical and mental disability may occur. The patients discharged from ICU are frequently malnourished and their medical nutritional support is impaired by oral intake limitation due to respiratory support such as non invasive ventilation or high flow nasal cannula oxygen therapy, dysphagia and difficulties to determine energy and protein targets. ICU acquired weakness must be recognized and could be minimized by better energy intake determined by indirect calorimetry, optimal protein intake and physical activity. Early physical activity has become a pivotal element of the improvement of the physical and cognitive condition in the post ICU.

Dysphagia management by nurses in Spanish intensive care units

INTRODUCTION/PURPOSE

Dysphagia is a disorder that presents with specific signs and symptoms in critically ill patients. Intensive care unit (ICU) nurses are responsible for monitoring and detecting abnormalities in critically ill patients, so they must be trained to assess swallowing and the complications that may arise. The aim of this research is to analyse the dynamics of the detection and assessment of dysphagia by ICU nurses.

METHOD

Cross-sectional descriptive study using an electronic questionnaire to nurses from different Spanish ICUs. The survey was adapted from previous research and consisted of 6 sections with 30 items of qualitative questions. The collection period was between December 2022 and March 2023. Statistical analysis was performed using frequencies and percentages, and the Chi-Square test was used for bivariate analysis.

OUTCOMES

43 nurses were recruited. Dysphagia is considered an important problem (90,7%) but in 50,3% of the units there is no standard or care protocol for this disorder. The most common technique is the swallowing test (32,6%). There is a consensus in our sample that aspiration pneumonia is the main problem; however, nurses in the busiest care units consider sepsis to be a frequent complication (p = ,029). The most common treatment is modification of food consistency (86,0%).

CONCLUSION

The findings of this research show a low systematisation of dysphagia screening in the units included. There is a need for greater implementation of interventions and clinical protocols for monitoring complications as well as for compensatory and rehabilitative management.

Nutrition during noninvasive respiratory support

PURPOSE OF REVIEW

The use of noninvasive techniques [noninvasive ventilation (NIV) or high flow nasal cannula (HFNC) oxygen therapy] to support oxygenation and/or ventilation in patients with respiratory failure has become widespread, even more so since the coronavirus disease 2019 pandemic. The use of these modalities may impair the patient's ability to eat. "To breath or to eat" may become a dilemma. In this review, we identify the patients at risk of malnutrition that require medical nutritional therapy and understand the mechanisms of function of the devices to better give adapted nutritional indications for noninvasive ventilation or high flow nasal cannula.

RECENT FINDINGS

The Global Leadership Initiative for Malnutrition has been validated in the Intensive Care setting and can be used in patients requiring NIV. Many patients are underfed when receiving noninvasive ventilation therapies. HFNC may impair the swallowing ability and increase dysphagia while NIV may improve the swallowing reflexes. New technology preventing reflux and ensuring enteral feeding efficacy may increase the medical nutrition therapy safety and provide near-target energy and protein provision.

SUMMARY

The patient requiring noninvasive ventilation presents one of the most challenging nutritional challenges. The main steps to improve nutrition administration are to assess nutritional status, evaluate the presence of dysphagia, choose the most adequate tool of respiratory support, and adapt nutritional therapy (oral, enteral, or parenteral) accordingly.

Therapeutic approach to dysphagia in post-COVID patients in a rehabilitation unit: a descriptive longitudinal study

BACKGROUND

A high rate of hospitalized patients for COVID-19 had dysphagia, frequently underdiagnosed, and not treated, inducing a prolonged dysphagia with protracted recovery. Specific treatments and protocols have not been well described yet.

AIM

Given the potential benefits of respiratory muscle training (IEMT) and neuromuscular stimulation (NMES) in dysphagia treatment, this study aimed to assess the feasibility of the protocol used for treating dysphagia in patients who experienced prolonged hospitalization for COVID-19.

DESIGN

Observational, descriptive, prospective study.

SETTING

Department of Physical Medicine and Rehabilitation of a tertiary University hospital.

POPULATION

Fifty-eight COVID-19 patients were admitted for intensive rehabilitation (March 2020 to October 2021) were prospectively studied.

METHODS

Dysphagia was diagnosed using videofluoroscopy and treated with a 3-week protocol adapted from neuromuscular stimulation (NMES) in a motor threshold and inspiratory/expiratory muscle strength training (IEMST), five sets of five repetitions three times daily for 3 weeks. Feasibility was assessed with adherence, outcomes achieved, and occurrence of adverse/unexpected events. Respiratory function (peak cough flow, maximal inspiratory/expiratory pressures) and swallow function (Penetration-Aspiration Scale and Bolus Residue Scale measured by videofluoroscopy) were recorded descriptive statistics, Student's t test for numerical data, and Wilcoxon Test for ordinal variables were applied. SPPSS vs28 and STATA version 15.1 (StataCorp, College Station, TX, USA) were used for statistical analysis. P values 0.05 were considered significant.

RESULTS

Dysphagia was highly prevalent in severe COVID-19 patients (86.6%); all respiratory and swallow parameters improved after a 3-week intervention and 12 of 18 patients dependent on tube feeding resumed a normal diet (66.7%; McNemar P=0.03), and 84.09% attended a no restriction diet at discharge. Adherence to treatment was 85%. No significant adverse events were detected.

CONCLUSIONS

We conclude that a structured swallowing-exercise training intervention based on IEMT and NMES is feasible and safe in prolonged hospitalization post-COVID patients.

CLINICAL REHABILITATION IMPACT

To describe rehabilitation protocols used to treat dysphagia in post-COVID patients will help us to optimize the available techniques in each center and to induce a faster recovery avoiding potential complications.

The Impact of Frailty, Oropharyngeal Dysphagia and Malnutrition on Mortality in Older Patients Hospitalized for Covid-19

COVID-19 hospital mortality is higher among older patients through as yet little-known factors. We aimed to assess the effect of frailty (FR), oropharyngeal dysphagia (OD) and malnutrition (MN) on mortality in hospitalized COVID-19 older patients. Prospective cohort study of older patients (>70 years) with COVID-19 admitted to a general hospital from April 2020 to January 2021. Patients were evaluated on admission, discharge and at 1- and 3-months follow up. FR was assessed with FRAIL-VIG, OD with Volume-Viscosity Swallowing Test and MN with GLIM criteria. Clinical characteristics and outcomes, including intra-hospital, 1- and 3-month mortality, were analyzed. 258 patients were included (82.5±7.6 years; 58.9% women); 66.7% had FR (mild 28.7%, moderate 27.1% and severe 10.9%); 65.4%, OD and 50.6%, MN. OD prevalence increased from non-FR patients through the severity levels of FR: mild, moderate and severe (29.8%, 71.6%, 90.0%, 96.2%; p<0.0001, respectively), but not that of MN (50.6%, 47.1%, 52.5%, 56.0%). Mortality over the whole study significantly increased across FR categories (9.3% non-FR; 23.0% mild; 35.7% moderate; 75.0% severe; p<.001). Functionality (Barthel pre-admission, HR=0.983, CI-95%:0.973-0.993; p=0.001), OD (HR=2.953, CI-95%:0.970-8.989; p=0.057) and MN (HR=4.279, CI-95%:1.658-11.049; p=0.003) were independent risk factors for intra-hospital mortality. FR, OD and MN are highly prevalent conditions in older patients hospitalized with COVID-19. Functionality, OD and MN were independent risk factors for intra-hospital mortality.

Prediction Models for Dysphagia in Intensive Care Unit after Mechanical Ventilation: A Systematic Review and Meta-analysis

OBJECTIVE

Dysphagia is a common condition that can independently lead to death in patients in the intensive care unit (ICU), particularly those who require mechanical ventilation. Despite extensive research on the predictors of dysphagia development, consistency across these studies is lacking. Therefore, this study aimed to identify predictors and summarize existing prediction models for dysphagia in ICU patients undergoing invasive mechanical ventilation.

METHODS

We searched five databases: PubMed, EMBASE, Web of Science, Cochrane Library, and the China National Knowledge Infrastructure. Studies that developed a post-extubation dysphagia risk prediction model in ICU were included. A meta-analysis of individual predictor variables was performed with mixed-effects models. The risk of bias was assessed using the prediction model risk of bias assessment tool (PROBAST).

RESULTS

After screening 1,923 references, we ultimately included nine studies in our analysis. The most commonly identified risk predictors included in the final risk prediction model were the length of indwelling endotracheal tube ≥72 h, Acute Physiology and Chronic Health Evaluation (APACHE) II score ≥15, age ≥65 years, and duration of gastric tube ≥72 h. However, PROBAST analysis revealed a high risk of bias in the performance of these prediction models, mainly because of the lack of external validation, inadequate pre-screening of variables, and improper treatment of continuous and categorical predictors.

CONCLUSIONS

These models are particularly susceptible to bias because of numerous limitations in their development and inadequate external validation. Future research should focus on externally validating the existing model in ICU patients with varying characteristics. Moreover, assessing the acceptance and effectiveness of the model in clinical practice is needed.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:517-525, 2024.

Is Postextubation Dysphagia Underestimated in the Era of COVID-19? A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate the incidence rate of postextubation dysphagia (PED) in patients with COVID-19, as well as relative factors potentially influencing the clinical course of dysphagia.

DATA SOURCES

Six databases including PubMed, MEDLINE, Embase, ScienceDirect, the Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science were searched with no restriction on the language.

REVIEW METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Data were extracted and cross-examined among 3 of the authors. The random-effects model was adopted for the statistical synthesis. The percentage and 95% confidence interval (CI) were adopted as the effect measurements of the PED incidence rate. Subgroup analyses, sensitivity analyses, and metaregression were also performed to identify the heterogeneity among the studies.

RESULTS

A total of 594 patients were enrolled and analyzed from the 10 eligible studies. The weighted incidence of PED in patients with COVID-19 was 66.5% (95% CI: 49.7%-79.9%). Age was the potential factor influencing the incidence rate after heterogeneity was adjusted by the metaregression analysis.

CONCLUSION

Compared to the current evidence reporting only 41% of the non-COVID patients experienced PED, our study further disclosed that a higher 66.5% of COVID-19 patients suffered from PED, which deserves global physicians' attention. With the association between COVID-19 and dysphagia having been more clearly understood, future clinicians are suggested to identify intubated patients' risk factors earlier to strengthen PED care programs in the era of COVID-19.

Accuracy of Modified Blue-Dye Testing in Predicting Dysphagia in Tracheotomized Critically Ill Patients

(1) Background: Diagnosis of dysphagia in critically ill patients with a tracheostomy is important to avoid aspiration pneumonia. The objective of this study was to analyze the validity of the modified blue-dye test (MBDT) on the diagnosis of dysphagia in these patients; (2) Methods: Comparative diagnostic test accuracy study. Tracheostomized patients admitted to the Intensive Care Unit (ICU) were studied with two tests for dysphagia diagnosis: MBDT and fiberoptic endoscopic evaluation of swallowing (FEES) as the reference standard. Comparing the results of both methods, all diagnostic measures were calculated, including the area under the receiver-operating-characteristic curve (AUC); (3) Results: 41 patients, 30 males and 11 females, mean age 61 ± 13.9 years. The prevalence of dysphagia was 70.7% (29 patients) using FEES as the reference test. Using MBDT, 24 patients were diagnosed with dysphagia (80.7%). The sensitivity and specificity of the MBDT were 0.79 (CI95%: 0.60-0.92) and 0.91 (CI95%: 0.61-0.99), respectively. Positive and negative predictive values were 0.95 (CI95%: 0.77-0.99) and 0.64 (CI95%: 0.46-0.79). AUC was 0.85 (CI95%: 0.72-0.98); (4) Conclusions: MBDT should be considered for the diagnosis of dysphagia in critically ill tracheostomized patients. Caution should be taken when using it as a screening test, but its use could avoid the need for an invasive procedure.

A Comparative Study between the Three Waves of the Pandemic on the Prevalence of Oropharyngeal Dysphagia and Malnutrition among Hospitalized Patients with COVID-19

BACKGROUND

The phenotype of patients affected by COVID-19 disease changed between the waves of the pandemic. We assessed the prevalence of oropharyngeal dysphagia (OD), malnutrition (MN), and mortality between the first three waves of COVID-19 patients in a general hospital.

METHODS

a prospective observational study between April 2020-May 2021. Clinical assessment for OD was made with the volume-viscosity swallowing test; nutritional assessment was performed consistent with GLIM criteria. A multimodal intervention was implemented in the second and third wave, including (a) texturized diets-fork mashable (1900 kcal + 90 g protein) or pureed (1700 kcal + 75 g protein), (b) oral nutritional supplements (500-600 kcal + 25-30 g protein), and (c) fluid thickening (250 mPa·s or 800 mPa·s).

RESULTS

We included 205 patients (69.3 ± 17.6 years) in the 1st, 200 (66.4 ± 17.5 years) in the 2nd, and 200 (72.0 ± 16.3 years;) in the 3rd wave (p = 0.004). On admission, prevalence of OD was 51.7%, 31.3% and 35.1%, and MN, 45.9%, 36.8% and 34.7%, respectively; mortality was 10.7%, 13.6% and 19.1%. OD was independently associated with age, delirium, and MN; MN, with age, OD, diarrhea and ICU admission; mortality, with age, OD and MN. (4) Conclusions: Prevalence of OD, MN and mortality was very high among COVID-19 patients. OD was independently associated with MN and mortality. An early and proactive multimodal nutritional intervention improved patients' nutritional status.

Características de los pacientes con alteraciones de la deglución hospitalizados en UPC con diagnóstico de SARS-CoV-2: una revisión sistemática

Se trata de determinar las características de los pacientes con alteraciones de la deglución hospitalizados en Unidades de Paciente Crítico con diagnóstico de SARS-CoV-2 durante el periodo 2020-2021. Para este objetivo se realiza una revisión sistemática con enfoque cualitativo exploratorio. Se aplicaron estrategias de búsqueda en bases de datos PubMed, ScienceDirect, Web Of Science y Scielo. Se seleccionaron estudios en inglés, español y portugués desde el año 2020, con sujetos mayores de 18 años, hospitalizados en Unidades de Paciente Crítico con COVID-19 y disfagia. Los resultados muestran que el tiempo promedio de hospitalización de pacientes con diagnóstico SARS-CoV-2 en Unidades de Cuidado Intensivo varía entre 15 y 34 días. Respecto a las características de la vía aérea artificial, las más frecuentes son la intubación orotraqueal y la traqueostomía, donde el promedio de uso mínimo es de 10 días y el máximo de 17 días en el caso de la intubación, mientras que para la traqueostomía el mínimo y máximo es de 19 y 30 días respectivamente. La disfagia orofaríngea es frecuente en los sujetos. En los pacientes con COVID-19 y disfagia, el promedio de días de hospitalización y el promedio de uso de vía aérea artificial es mayor a lo reportado en la literatura en épocas sin pandemia. A mayor tiempo de uso de vía aérea artificial, mayor es el riesgo de adquirir una alteración de la deglución y prolongar la estadía de una Unidad de Paciente Crítico. La disfagia orofaríngea es frecuente en pacientes con SARS-CoV-2. Se recomienda continuar con investigaciones observacionales y experimentales en el área.