Investigating Swallowing and Tracheostomy Following Critical Illness: A Scoping Review

Feasibility of Endoscopic Evaluations of Laryngeal Function After Extubation for Research in Critically Ill Adults

PURPOSE

Flexible nasal laryngoscopy (FNL) is commonly used in intensive care units (ICUs) to assess laryngeal anatomy and function after endotracheal intubation. The use of FNL in research may differ from clinical practice due to requirements of research protocols and related data collection and documentation. This study evaluates the feasibility of performing FNL post-extubation in critically ill adults within the context of a research protocol. Understanding the feasibility of this reference standard assessment is important for supporting future studies and improving patient care.

METHOD

This prospective study, conducted in six ICUs within a single academic medical center, consecutively enrolled adult patients who required mechanical ventilation for at least 8 hr. The primary feasibility outcome was the successful completion of FNL within 72 hr of extubation. Secondary outcomes included completion of the 3-oz water swallow test (Yale Swallow Protocol) during the FNL, patient enrollment/exclusion/withdrawal rates, time from extubation to FNL, procedure duration, and patient-reported pain (using the Wong-Baker FACES Pain Rating Scale).

RESULTS

A total of 80 patients (75%) of 107 eligible patients fully completed FNL. Among the 24 patients who did not receive FNL, eight died, seven were medically inappropriate, and seven declined FNL. The median time from extubation to FNL was 10 hr (IQR [interquartile range]: 8-12 hr), and the median FNL procedure duration was 8.5 min (IQR: 5.8-12.9 min). The median (IQR) pain score was 2 (0, 4) of 10, reflecting only mild discomfort.

CONCLUSION

Post-extubation FNL is feasible within the context of a research protocol and well tolerated by critically ill adults.

High Flow Nasal Oxygen (HFNO), swallowing and dysphagia in adults: A narrative review with implications for ICU clinical practice and future research

The use of high flow nasal oxygen (HFNO) in clinical practice is increasing with robust evidence of its respiratory benefits. Swallowing is known to be heavily coordinated with breathing, in addition to sharing a physical pathway in the upper airway. Applying HFNO via these spaces may also have an impact on the swallowing process. Yet, there is a lack of literature regarding the effect of HFNO on swallowing and on dysphagia. This narrative review aims to summarise the existing literature, draw conclusions on important clinical questions where possible and set the scene for future research. A database search was conducted on 24/01/2024 across CINAHL, Medline and Embase. Due to paucity of literature, studies with adult participants within and outside of ICU were included, and references cross-checked. Conference abstracts were also included. The search was repeated on 5/6/2024. Twelve articles were included in direct data comparison, in addition to studies examining the biomedical effect of HFNO that is, the impact of HFNO on the physiology of the oropharynx and swallow function. The authors conclude that whilst studies are limited in numbers and some results controversial, indications are that HFNO may demand adaptations to swallowing and some patients may not have this capability to adapt. HFNO should not be a barrier to a swallow assessment, irrespective of flow rate and the decision to assess should be based on overall patient presentation, as with any other population. Instrumental swallowing assessment is recommended to confirm any detrimental or beneficial impact of HFNO on swallow function. Robust research and guidelines are needed.

Navigating Nutrition Complexity in Critical Care: A Focus on Swallowing Function and Rehabilitation

During the past decade, there has been an increased research focus on the prevalence, nature, and impact of newly acquired critical illness dysphagia. Disordered function can impact the safety and efficiency across all stages of the swallow mechanism, with detrimental impacts on patients' body systems, function, and participation. Accurate assessment of swallow function is key to informed diagnosis and enhances intervention planning. We discuss the current evidence base around dysphagia pathophysiology with a detailed discussion considering the modes of ventilation commonly received in intensive care units. Assessment and management across critical illness are evaluated and future research efforts are presented.

Impacts of long-term nasogastric tube feeding and tracheostomy on pharyngeal and laryngeal structure in ABI patients: an FEES study

OBJECTIVES

To investigate the characteristics of pharyngeal and laryngeal structure in patients with acquired brain injury (ABI), who were long time wearing nasogastric tube (NGT) with or without tracheostomy.

METHODS

103 ABI patients with NGT indwelled for more than 1 month were retrospectively studied and divided into two groups by whether or not undergoing tracheostomy. Age, gender, types of brain injury, course of the disease, disorders of consciousness, activities of daily living (ADL) and fiberoptic endoscopic examination of swallowing (FEES) were evaluated. The structure and function of pharyngeal and laryngeal were assessed by FEES, focusing on the morphology of the arytenoid cartilage, epiglottis, vocal folds, tongue base, and pharyngeal cavity.

RESULTS

Prolonged indwelling nasogastric tubes and tracheostomy tubes might lead to abnormal alterations of the structure and function in the arytenoid cartilage, epiglottis, tongue base, and pharyngeal cavity. Epiglottis shape abnormality, glossoptosis and pharyngeal stenosis were present in a larger proportion of the NGT-TRACH (nasogastric tube with tracheostomy) group than the NGT group (p < 0.05).

CONCLUSIONS

This study highlights potential physiological changes associated with prolonged placement of nasogastric tubes and tracheostomy tubes, which could impede the recovery of swallowing function and decannulation. We hope to provide valuable evidence to develop effective management strategies for ABI patients with NGT or tracheostomy.

[Post-Intensive Care Syndrome: functional impairments of critical illness survivors]

With a decrease in mortality of critically ill patients in recent years, intensive care medicine research has shifted its focus on functional impairments of intensive care units (ICU) survivors. ICU survivorship is characterized by long-term impairments of cognition, mental health, and physical health. Since 2012, these impairments have been summarized with the umbrella term Post-Intensive Care Syndrome (PICS). Mental health impairments frequently entail new are aggravated symptoms of depression, anxiety, and posttraumatic stress disorder. Beyond impairments in the three PICS domains, critical illness survivors frequently suffer from chronic pain, dysphagia, and nutritional deficiencies. Furthermore, they have a higher risk for osteoporosis, bone fractures, and diabetes mellitus. Taken together, these sequelae reduce their health-related quality of life. Additionally, ICU survivors are challenged by social problems such as isolation, economic problems such as treatment costs and lost earnings, and return to previous employment. Yet, patients and caregivers have described post-ICU care as inadequate and fragmented. ICU follow-up clinics could improve post-ICU care, but there is insufficient evidence for their effectiveness. Thus far, large high-quality trials with multicomponent and interdisciplinary post-ICU interventions have mostly failed to improve patient outcomes. Hence, preventing PICS and minimizing risk factors by optimizing ICU care is crucial, e.g. by implementing the ABCDE bundle. Future studies need to identify effective components of post-ICU recovery interventions and determine which patient populations may benefit most from ICU recovery services.

Aspiration after Critical Illness: Role of Endotracheal Tube, Tracheostomy, and Swallowing Disorders

Swallowing is a complex process that involves over 50 muscles and nerves and has two critical roles: passing food from the oral cavity through the pharynx and into the esophagus and preventing contents from entering the airway. If a patient's swallowing physiology or airway protective mechanisms are disturbed, the airways and the lungs have innate defense systems to protect against injury and infection. However, critically ill patients are more likely to develop dysphagia, which is an impairment or malfunction in any aspect of the swallowing mechanism, due to the numerous interventions they undergo. When airway reflexes fail, commonly in the presence of dysphagia, aspiration can occur, which is the entry of a fluid or solid below the level of the true vocal cords. If left unmanaged, dysphagia has been associated with aspiration pneumonia, pneumonitis, airway obstruction, delayed enteral nutrition, prolonged length of intensive care unit (ICU) and hospital stay, reduced quality of life, and even death; in some cases, dysphagia is an independent risk factor for mortality. It is important to routinely assess dysphagia in all critically ill patients using a multimodal approach, including systematic assessments, scoring indices, trained specialists, and ICU nurses. Several interventions are crucial for preventing and managing dysphagia and its associated problems. Further research is necessary to help determine the best ways to prevent and manage pulmonary aspiration in critically ill patients. Several interventions are essential in preventing and managing dysphagia and the sequelae of swallowing dysfunction. Further research is needed to help elucidate the best way to avoid and manage pulmonary aspiration in critically ill patients.

Research report: Management of dysphagia using pharyngeal electrical stimulation in the general intensive care population - A service development

Background

Dysphagia places a substantial burden on the critically ill, affecting 12%-84% of this cohort, and is independently associated with worse outcomes. Pharyngeal electrical stimulation (PES-treatment) is a novel dysphagia therapy with an emerging evidence base. This retrospective observational study describes our dysphagia service and reports the use of PES-treatment as a standard of care in recovering critically ill patients at a single-site tertiary UK hospital.

Methods

Patients admitted to Acute or Cardio-Thoracic adult intensive care units between 1st July 2017 and 30th June 2022 were routinely referred to Speech and Language Therapy (SLT) following tracheostomy, or suspected dysphonia/dysphagia. Clinical assessments and direct laryngeal visualisation using Fibreoptic Evaluation of Swallowing (FEES) were performed. Severe dysphagia was defined as Penetration-Aspiration Score of ⩾6 and patients were offered PES-treatment when staffing allowed.

Results

Of 289 patients with severe dysphagia, 19 underwent a course of PES-treatment with the remaining patients receiving standard care. PES-treatment patients were significantly less likely to remain nil-by-mouth (11.1% vs 62.5%, Chi2 p < 0.001) or to have an enteral feeding tube in situ at discharge from critical care (27.8% vs 62.5%, p = 0.006) than those receiving standard dysphagia care. Both groups demonstrated an improvement in Penetration-Aspiration Score at repeat FEES: PES-treatment mean difference -2.0 (p = 0.003); non-PES-treatment -1.68 (p < 0.001); (61% PES-treatment improved vs 40% non-PES-treatment, p = 0.09).

Conclusion

Our observations suggest that PES may be effective in the general critical care population. PES may offer new treatment options for patients and healthcare staff managing severe dysphagia and its significant consequences.

Dysphagia therapy in adults with a tracheostomy: A scoping review protocol

BACKGROUND

Swallowing impairment (dysphagia) and tracheostomy coexist. Research in this area has often provided an overview of dysphagia management as a whole, but there is limited information pertaining to specific dysphagia therapy in the tracheostomy population. The aim of this scoping review is to provide a detailed exploration of the literature with regard to dysphagia therapeutic interventions in adults with a tracheostomy. The scoping review will describe current evidence and thus facilitate future discussions to guide clinical practice.

METHODS

A scoping review using the Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews guideline will be used. Ten electronic databases from inception to December 2023 and grey literature will be searched. From identified texts forward and backward citation chasing will be completed. Data extraction will compose of population demographics, aetiology and dysphagia therapy (type, design, dose and intensity). A number of citations and papers included in the scoping review will be presented visually.

DISCUSSION

The scoping review aims to expand upon the existing literature in this field. A detailed description of the evidence is required to facilitate clinical discussions and develop therapeutic protocols in a tracheostomised population. The results of this scoping review will support future research in dysphagia therapy and provide the basis for the development of best practice guidelines.

WHAT THIS PAPER ADDS

What is already known on this subject There is an abundance of evidence available regarding dysphagia therapy targeting impairments of the swallowing sequence in a variety of populations including stroke, head and neck cancer, progressive neurological conditions and critical illness. However, there is a paucity in the literature with regard to identifying dysphagia therapy for adults with a tracheostomy. What this study adds The study protocol aims to describe the methodological features that need to be extracted from existing studies to outline dysphagia therapy for adults with a tracheostomy. To the researchers' knowledge, this is the first study protocol to describe the methodological features of dysphagia therapy for people with a tracheostomy from the literature using a standardised approach (Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA] guideline). This will ensure that the protocol is replicable for other researchers to use and demonstrates transparency in research methods. What are the clinical implications of this work? The development of a robust protocol is necessary in order to facilitate the scoping review to describe the current evidence and thus facilitate future discussions to guide clinical practice for speech and language therapists working with adults who have a tracheostomy and dysphagia. The publication of the scoping review protocol allows future clinical researchers in the area of tracheostomy and dysphagia management a blueprint with which to narrow their own research questions and it also enables replicability as the principles of good research practice dictate.

Rehabilitative intervention for successful decannulation in adult patients with acquired brain injury and tracheostomy: a systematic review

PURPOSE

Tracheostomy and dysphagia are independently associated with increased complications and poorer functional outcome after acquired brain injury (ABI). The aim of this study was to identify and evaluate rehabilitation to restore functional swallowing ability and respiratory capacity during tracheal tube weaning.

MATERIALS AND METHODS

The review was conducted according to PRISMA guidelines. Any study design with adult patients with ABI and tracheostomy was eligible. The primary outcome was decannulation.

RESULTS

A total of 2647 records were identified and eight papers included. Four studies investigated pharyngeal electrical stimulation (PES), two explored Facial Oral Tract Therapy (F.O.T.T.), one respiratory physiotherapy (RPT), and one study investigated external subglottic air flow (ESAF). Two RCTs found a significant difference between intervention and control on successful decannulation and readiness for decannulation in favour of PES. Time from rehabilitation admission and tracheostomy to decannulation was significantly reduced after implementing an F.O.T.T.-based protocol.

CONCLUSION

Four interventions were identified, PES, F.O.T.T., RPT, and ESAF, all aimed at increasing oropharyngeal sensory input through stimulation. Due to heterogeneity of interventions, designs and outcome measures, effect could not be estimated. This review highlights the limited research on rehabilitative interventions and thus the limited evidence to guide clinical rehabilitation.

Worth a try or a last resort: Healthcare professionals' experiences and opinions of above cuff vocalisation

BACKGROUND

Above cuff vocalisation (ACV) involves the application of an external flow of air via the subglottic port of a tracheostomy. ACV can facilitate vocalisation and may improve swallowing and quality of life for patients with a tracheostomy. A recent systematic review highlighted the limited evidence available for the acceptability, effectiveness, safety or optimal implementation of ACV.

AIMS

To explore the experience of healthcare professionals (HCPs) using ACV and their perceptions of best practice.

METHODS AND PROCEDURES

Semi-structured interviews were conducted with a range of HCPs with experience using ACV. Topics included: experiences with ACV, management of ACV, opinions about ACV, impact of COVID-19, future directions for ACV and impact on length of stay. Interviews were conducted online from December 2020 to March 2022. Data were analysed using reflexive thematic analysis.

OUTCOMES AND RESULTS

Twenty-four HCPs were interviewed from seven countries and five professional groups. Four interconnected themes were developed: (1) moral distress amplifying the need to fix patients; (2) subjectivity and uncertainty leading to variations in practice and purpose; (3) knowledge and experience leading to control and caution; and (4) worth a try or a last resort. Theme four contained three sub-themes: (a) part of the toolbox; (b) useful but limited tool; and (c) following the patient's lead. The moral distress experienced by HCPs and their essential 'need to fix' patients seems to underpin the varied opinions of ACV. These opinions appear to be formed primarily on the basis of experience, because of the underlying subjectivities and uncertainties. As knowledge and experience with ACV increased, and adverse events were experienced, most HCPs became more cautious in their approach to ACV.

CONCLUSIONS AND IMPLICATIONS

More research is needed to reduce the subjectivities and uncertainties surrounding ACV. The implementation of standardised procedures, processes, and competencies may help to reduce the frequency of adverse events and support a more controlled approach. Widening the focus of the purpose of ACV to include swallowing may help to maximise the potential benefits.

WHAT THIS PAPER ADDS

What is already known on the subject There is limited and low-quality evidence for above cuff vocalisation (ACV) and clinical application and practice varies substantially. However, the reasons for this variation in practice and healthcare professionals' (HCPs') opinions of ACV were unclear. What this study adds HCPs' experiences and opinions of ACV vary as a result of the uncertainty and subjectivity surrounding ACV compounded by their personal experiences with it. A need for caution also appears to emerge as HCPs become more familiar and experienced with using ACV. What are the clinical implications of this work? Implementing standardised procedures, safety processes and competencies may help to compensate for the uncertainty and subjectivity surrounding ACV and may reduce the frequency of adverse events. Widening the focus of purpose of ACV, including swallowing in addition to communication, may increase the number of potential candidates and increase the potential benefits of ACV. Using multidisciplinary team (MDT) simulation training for ACV competency development might help to improve MDT working and ACV implementation.

Dysphagia Prevalence and Outcomes Associated with the Evolution of COVID-19 and Its Variants in Critically Ill Patients

Data collected during the 2020-21 COVID-19 alpha wave indicated dysphagia prevalence rates up to 93%. Whilst many patients recovered during hospital admission, some experienced persistent dysphagia with protracted recovery. To explore (1) prevalence, (2) treatment, and (3) recovery patterns and outcomes for swallowing, in the ICU patient with Delta and subsequent variants of COVID-19. Prospective observational study. Patients admitted to 26 Intensive Care Units (ICUs) over 12 months, diagnosed with COVID-19, treated for survival and seen by Speech-Language Pathology (SLP) for clinical swallowing assessment were included. Demographic, medical, SLP treatment, and swallowing outcome data were collected. 235 participants (63% male, median age = 58 years) were recruited. Median mechanical ventilation was 16 days, and ICU and hospital length of stay (LOS) were 20 and 42 days, respectively. ICU-Acquired Weakness (54%) and delirium (49%) were frequently observed. Prevalence of dysphagia was 94% with the majority (45%) exhibiting profound dysphagia (Functional Oral Intake Scale = 1) at initial assessment. Median duration to initiate oral feeding was 19 days (IQR = 11-44 days) from ICU admission, and 24% received dysphagia rehabilitation. Dysphagia recovery by hospital discharge was observed in 71% (median duration = 30 days [IQR = 17-56 days]). Positive linear associations were identified between duration of intubation, mechanical ventilation, hospital and ICU LOS, and duration to SLP assessment (p = 0.000), dysphagia severity (p = 0.000), commencing oral intake (p = 0.000), dysphagia recovery (p < 0.01), and enteral feeding (p = 0.000). Whilst older participants had more severe dysphagia (p = 0.028), younger participants took longer to commence oral feeding (p = 0.047). Dysphagia remains highly prevalent in ICU COVID-19 patients. Whilst invasive ventilation duration is associated with swallowing outcomes, more evidence on dysphagia pathophysiology is required to guide rehabilitation.

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.

Dysphagia in adult intensive care patients: Results of a prospective, multicentre binational point prevalence study

BACKGROUND

Dysphagia occurs in intensive care unit (ICU) patients. However, there is a lack of epidemiological data on the prevalence of dysphagia in adult ICU patients.

OBJECTIVES

The objective of this study was to describe the prevalence of dysphagia in nonintubated adult patients in the ICU.

METHODS

A prospective, multicentre, binational, cross-sectional point prevalence study was conducted in 44 adult ICUs in Australia and New Zealand. Data were collected in June 2019 on documentation of dysphagia, oral intake, and ICU guidelines and training. Descriptive statistics were used to report demographic, admission, and swallowing data. Continuous variables are reported as means and standard deviations (SDs). Precisions of estimates were reported as 95% confidence intervals (CIs).

RESULTS

Of the 451 eligible participants, 36 (7.9%) were documented as having dysphagia on the study day. In the dysphagia cohort, the mean age was 60.3 years (SD: 16.37) vs 59.6 years (SD: 17.1) and almost two-thirds were female (61.1% vs 40.1%). The most common admission source for those patients with dysphagia were from the emergency department (14/36, 38.9%), and seven of 36 (19.4%) had a primary diagnosis of trauma (odds ratio: 3.10, 95% CI 1.25 - 7.66). There were no statistical differences in Acute Physiology and Chronic Health Evaluation (APACHE II) scores between those with and without a dysphagia diagnosis. Patients with dysphagia were more likely to have a lower mean body weight of 73.3 kg vs 82.1 kg than patients not documented as having dysphagia (95% CI of mean difference: 0.43 to 17.07) and require respiratory support (odds ratio: 2.12, 95% 1.06 to 4.25). The majority of patients with dysphagia were prescribed modified food and fluids in the ICU. Less than half of ICUs surveyed reported unit-level guidelines, resources, or training for management of dysphagia.

CONCLUSIONS

The prevalence of documented dysphagia in adult ICU nonintubated patients was 7.9%. There were a higher proportion of females with dysphagia than previously reported. Approximately two-thirds of patients with dysphagia were prescribed oral intake, and the majority were receiving texture-modified food and fluids. Dysphagia management protocols, resources, and training are lacking across Australian and New Zealand ICUs.

Effectiveness of interprofessional tracheostomy teams: A systematic review

AIM(S)

To systematically locate, evaluate and synthesize evidence regarding effectiveness of interprofessional tracheostomy teams in increasing speaking valve use and decreasing time to speech and decannulation, adverse events, lengths of stay (intensive care unit (ICU) and hospital) and mortality. In addition, to evaluate facilitators and barriers to implementing an interprofessional tracheostomy team in hospital settings.

DESIGN

Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Johns Hopkins Nursing Evidence-Based Practice Model's guidance.

METHODS

Our clinical question: Do interprofessional tracheostomy teams increase speaking valve use and decrease time to speech and decannulation, adverse events, lengths of stay and mortality? Primary studies involving adult patients with a tracheostomy were included. Eligible studies were systematically reviewed by two reviewers and verified by another two reviewers.

DATA SOURCES

MEDLINE, CINAHL and EMBASE.

RESULTS

Fourteen studies met eligibility criteria; primarily pre-post intervention cohort studies. Percent increase in speaking valve use ranged 14%-275%; percent reduction in median days to speech ranged 33%-73% and median days to decannulation ranged 26%-32%; percent reduction in rate of adverse events ranged 32%-88%; percent reduction in median hospital length of stay days ranged 18-40 days; no significant change in overall ICU length of stay and mortality rates. Facilitators include team education, coverage, rounds, standardization, communication, lead personnel and automation, patient tracking; barrier is financial.

CONCLUSION

Patients with tracheostomy who received care from a dedicated interprofessional team showed improvements in several clinical outcomes.

IMPLICATIONS FOR PATIENT CARE

Additional high-quality evidence from rigorous, well-controlled and adequately powered studies are necessary, as are implementation strategies to promote broader adoption of interprofessional tracheostomy team strategies. Interprofessional tracheostomy teams are associated with improved safety and quality of care.

IMPACT

Evidence from review provides rationale for broader implementation of interprofessional tracheostomy teams.

REPORTING METHOD

PRISMA and Synthesis Without Meta-analysis (SWiM).

PATIENT/PUBLIC CONTRIBUTION

None.

Guideline on multimodal rehabilitation for patients with post-intensive care syndrome

BACKGROUND

Intensive Care Unit (ICU) survivors often experience several impairments in their physical, cognitive, and psychological health status, which are labeled as post-intensive care syndrome (PICS). The aim of this work is to develop a multidisciplinary and -professional guideline for the rehabilitative therapy of PICS.

METHODS

A multidisciplinary/-professional task force of 15 healthcare professionals applied a structured, evidence-based approach to address 10 scientific questions. For each PICO-question (Population, Intervention, Comparison, and Outcome), best available evidence was identified. Recommendations were rated as "strong recommendation", "recommendation" or "therapy option", based on Grading of Recommendations, Assessment, Development and Evaluation principles. In addition, evidence gaps were identified.

RESULTS

The evidence resulted in 12 recommendations, 4 therapy options, and one statement for the prevention or treatment of PICS.

RECOMMENDATIONS

early mobilization, motor training, and nutrition/dysphagia management should be performed. Delirium prophylaxis focuses on behavioral interventions. ICU diaries can prevent/treat psychological health issues like anxiety and post-traumatic stress disorders. Early rehabilitation approaches as well as long-term access to specialized rehabilitation centers are recommended. Therapy options include additional physical rehabilitation interventions. Statement: A prerequisite for the treatment of PICS are the regular and repeated assessments of the physical, cognitive and psychological health in patients at risk for or having PICS.

CONCLUSIONS

PICS is a variable and complex syndrome that requires an individual multidisciplinary, and multiprofessional approach. Rehabilitation of PICS should include an assessment and therapy of motor-, cognitive-, and psychological health impairments.

Swallowing biomechanics in tracheostomised critically ill patients compared to age- and gender-matched healthy controls

Objective

The mechanistic effects of a tracheostomy on swallowing are unclear. Pharyngeal high-resolution manometry with impedance (P-HRM-I) is a novel swallow assessment tool providing quantifiable metrics. This study aimed to characterise swallowing biomechanics in tracheostomised critically ill (non-neurological) patients.

Design

Cohort study.

Setting

Australian tertiary hospital intensive care unit.

Participants

Tracheostomised adults, planned for decannulation.

Main outcome measures

Swallowing assessment using P-HRM-I, compared to healthy age- and gender-matched controls.

Results

In this tracheostomised cohort (n = 10), the Swallow Risk Index, a global measure of swallow function, was significantly elevated (p < 0.001). At the upper oesophageal sphincter (UOS), hypopharyngeal intrabolus pressure and UOS integrated relaxation pressure were significantly elevated (control 0.65 mmHg [-1.02, 2.33] v tracheostomy 13.7 mmHg [10.4, 16.9], P < 0.001; control -4.28 mmHg [-5.87, 2.69] v tracheostomy 12.2 mmHg [8.83, 15.6], P < 0.001, respectively). Furthermore, UOS opening extent and relaxation time were reduced (control 4.83 mS [4.60, 5.07] v tracheostomy 4.33 mS [3.97, 4.69], P = 0.002; control 0.52 s [0.49, 0.55] v tracheostomy 0.41 s [0.37, 0.45], P < 0.001, respectively). Total pharyngeal contractility (PhCI) measuring pharyngeal pressure generation was significantly elevated (control 199.5 mmHg cm.s [177.4, 221.6] v tracheostomy 326.5 mmHg cm.s [253.3, 399.7]; P = 0.001).

Conclusion

In a critically ill tracheostomised cohort, UOS dysfunction was the prevalent biomechanical feature, with elevated pharyngeal pressures. Pharyngeal weakness is not contributing to dysphagia in this cohort. Instead, elevated pharyngeal pressures may represent a compensatory mechanism to overcome the UOS dysfunction. Further studies to extend these findings may inform the development of timely and targeted rehabilitation.

Functional Laryngeal Assessment in Patients with Tracheostomy Following COVID-19 a Prospective Cohort Study

To explore laryngeal function of tracheostomised patients with COVID-19 in the acute phase, to identify ways teams may facilitate and expedite tracheostomy weaning and rehabilitation of upper airway function. Consecutive tracheostomised patients underwent laryngeal examination during mechanical ventilation weaning. Primary outcomes included prevalence of upper aerodigestive oedema and airway protection during swallow, tracheostomy duration, ICU frailty scores, and oral intake type. Analyses included bivariate associations and exploratory multivariable regressions. 48 consecutive patients who underwent tracheostomy insertion as part of their respiratory wean following invasive ventilation in a single UK tertiary hospital were included. 21 (43.8%) had impaired airway protection on swallow (PAS ≥ 3) with 32 (66.7%) having marked airway oedema in at least one laryngeal area. Impaired airway protection was associated with longer total artificial airway duration (p = 0.008), longer tracheostomy tube duration (p = 0.007), multiple intubations (p = 0.006) and was associated with persistent ICU acquired weakness at ICU discharge (p = 0.03). Impaired airway protection was also an independent predictor for longer tracheostomy tube duration (p = 0.02, Beta 0.38, 95% CI 2.36 to 27.16). The majority of our study patients presented with complex laryngeal findings which were associated with impaired airway protection. We suggest a proactive standardized scoring and review protocol to manage this complex group of patients in order to maximize health outcomes and ICU resources. Early laryngeal assessment may facilitate weaning from invasive mechanical ventilation and liberation from tracheostomy, as well as practical and objective risk stratification for patients regarding decannulation and feeding.

How Valid and Reliable Is the International Dysphagia Diet Standardisation Initiative (IDDSI) When Translated into Another Language?

Swallowing difficulties are estimated to affect 590 million people worldwide and the modification of food and fluids is considered the cornerstone of dysphagia management. Contemporary practice uses the International Dysphagia Diet Standardisation Initiative (IDDSI), however, the validity and reliability of IDDSI when translated into another language has not been investigated. This study describes the translation process and confirms the validity and reliability of IDDSI when translated into another language (Swedish). The translation used a 12-step process based on the World Health Organization recommendations. Validity was tested using Content Validity Index (CVI) based on three ratings by a panel of 10-12 experts (Dietitians and Speech-Language Pathologists [SLPs]). The translation was rated for linguistic correlation as well as understandability and applicability in a Swedish context. Inter-rater reliability was calculated using Intraclass Correlation Coefficient (ICC) from 20 SLP assessments of 10 previously published patient cases. Significant improvement (p < 0.05) of CVI between Expert Panel assessments was shown for linguistic correlation (improvement from 0.74-0.98) and understandability/applicability (improvement from 0.79-0.93 across ratings). Excellent validity (Item-CVI > 0.78 and Scale-CVI/Average > 0.8) and very high inter-rater reliability (ICC > 0.9) were demonstrated. Results show that, when using a multi-step translation process, a translated version of IDDSI (into Swedish) demonstrates high validity and reliability. This further contributes to the evidence for use of IDDSI.

Clinical profile and recovery pattern of dysphagia in the COVID-19 patient: A prospective observational cohort within NSW

BACKGROUND

The impact of COVID-19 on swallowing function is not well understood. Despite low hospital admission rates in Australia, the virus and subsequent treatment affects swallow function in those requiring intensive care unit (ICU) treatment. As such, the current pandemic provides a unique opportunity to describe swallowing function and outline dysphagia characteristics and trajectory of recovery for a series of cases across NSW.

AIM

The aims of this study were to describe (i) physiological characteristics of swallowing dysfunction and (ii) pattern of swallowing recovery and outcomes, in ICU patients with COVID-19.

METHODS

All patients admitted to 17 participating NSW Health ICU sites over a 12-month period (March 2020-March 2021), diagnosed with COVID-19, treated with the aim for survival, and seen by a speech pathologist for clinical swallowing examination during hospital admission were considered for inclusion. Demographic, critical care airway management, speech pathology treatment, and swallowing outcome data were collected.

RESULTS

Twenty-seven patients (22 male; 5 female) with a median age of 65 years (interquartile range [IQR] = 15.5) were recruited. All required mechanical ventilation. Almost 90% of the total cohort had pre-existing comorbidities, with the two most frequently observed being diabetes (63%, 95% confidence interval = 44%-78%) and cardiac disease (59%, 95% confidence interval = 40%-75%) in origin. Prevalence of dysphagia was 93%, with the majority (44%) exhibiting profound dysphagia at the initial assessment. Median duration to initiate oral feeding was 38.5 days (IQR = 31.25) from ICU admission, and 33% received dysphagia rehabilitation. Dysphagia recovery was observed in 81% with a median duration of 44 days (IQR = 29). Positive linear associations were identified between duration of intubation, mechanical ventilation, hospital and ICU length of stay, and the duration to speech pathology assessment (p < 0.005), dysphagia severity (p < 0.002), commencing oral intake (p < 0.02), dysphagia recovery (p < 0.004), and enteral feeding (p < 0.024).

CONCLUSION

COVID-19 considerably impacted swallowing function in the current study. Although many patients recovered within an acceptable timeframe, some experienced persistent severe dysphagia and a protracted recovery with dependence on enteral nutrition.

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 Holistic Approach to Managing Secondary Dysphagia Following Prolonged Intubation and Tracheostomy: A Case Report

The ability to swallow and maintain the airway is a critical rehabilitation milestone for patients with swallowing disorders following prolonged tracheal intubation. Tracheostomy and dysphagia often coexist in critically ill patients and given the medical complexity analyzing the evidence to optimize swallowing assessment and management is challenging. It takes a holistic approach to dealing with issues in a critical care patient as we also need to deal with issues other than medical. We present a case of a 68-year-old gentleman who was admitted to the critical care unit following a double barrel ileostomy and had multiple complications and organ dysfunction requiring prolonged supportive management, tracheostomy, and mechanical ventilation. After recovering from primary illness and complications, he had a swallowing disorder (secondary dysphagia), which was managed successfully over the next month. The case highlights the need for screening, a multidisciplinary team, empathy, and effort as a part of a holistic management approach.

A Predictive Model for Dysphagia after Ventilator Liberation in Severe Pneumonia Patients Receiving Tracheostomy: A Single-Center, Observational Study

The main purpose of this study was to develop a model predictive of dysphagia in hospital survivors with severe pneumonia who underwent tracheostomy during their hospital stay. The present study included 175 patients (72% male; mean age, 71.3 years) over 5 years. None of these patients had a history of deglutition disorder before hospital admission. Binary logistic regression analysis was performed to identify factors predicting dysphagia at hospital discharge. Dysphagia scores were calculated from β-coefficients and by assigning points to variables. Of the enrolled patients, 105 (60%) had dysphagia at hospital discharge. Factors prognostic of dysphagia at hospital discharge included being underweight (body mass index < 18.5 kg/m2), non-participation in a dysphagia therapy program, mechanical ventilation ≥ 15 days, age ≥ 74 years, and chronic neurologic diseases. Underweight and non-participation in a dysphagia therapy program were assigned +2 points and the other factors were assigned +1 point. Dysphagia scores showed acceptable discrimination (area under the receiver operating characteristic curve for dysphagia 0.819, 95% confidence interval: 0.754−0.873, p < 0.001) and calibration (Hosmer−Lemeshow chi-square = 9.585, with df 7 and p = 0.213). The developed dysphagia score was predictive of deglutition disorder at hospital discharge in tracheostomized patients with severe pneumonia.

Development of a swallowing risk screening tool and best practice recommendations for the management of oropharyngeal dysphagia following acute cervical spinal cord injury: an international multi-professional Delphi consensus

PURPOSE

International multi-professional expert consensus was sought to develop best practice recommendations for clinical management of patients following cervical spinal cord injury with oropharyngeal dysphagia and associated complications. Additionally, risk factors for dysphagia were identified to support the development of a screening tool.

MATERIALS AND METHODS

A two-round Delphi study was undertaken with a 27-member panel of expert professionals in cervical spinal cord injury and complex dysphagia. They rated 85 statements across seven topic areas in round one, using a five-point Likert scale with a consensus set at 70%. Statements not achieving consensus were revised for the second round. Comparative group and individual feedback were provided at the end of each round.

RESULTS

Consensus was achieved for 50 (59%) statements in round one and a further 12 (48%) statements in round two. Recommendations for best practice were agreed for management of swallowing, respiratory function, communication, nutrition and oral care. Twelve risk factors for dysphagia were identified for components of a screening tool.

CONCLUSIONS

Best practice recommendations support wider clinical management to prevent complications and direct specialist care. Screening for risk factors allows early dysphagia identification with the potential to improve clinical outcomes. Further evaluation of the impact of these recommendations is needed.Implications for RehabilitationDysphagia is an added complication following cervical spinal cord injury (cSCI) affecting morbidity, mortality and quality of life.Early identification of dysphagia risk allows focused interventions that reduce associated nutritional and respiratory impairments.Best practice recommendations based on expert consensus provide a baseline of appropriate interventions, in the absence of empirical evidence.A multi-professional approach to rehabilitation encourages a consistent and coordinated approach to care across acute and rehabilitation settings.

The role of nutrition rehabilitation in the recovery of survivors of critical illness: underrecognized and underappreciated

Many survivors of critical illness face significant physical and psychological disability following discharge from the intensive care unit (ICU). They are often malnourished, a condition associated with poor outcomes, and nutrition remains problematic particularly in the early phases of ICU recovery. Yet nutrition rehabilitation, the process of restoring or optimizing nutritional status following illness, is seldom prioritized, possibly because it is an underrecognized and underappreciated area in critical care rehabilitation and research. To date, 16 original studies have been published where one of the objectives includes measurement of indices relating to nutritional status (e.g., nutrition intake or factors impacting nutrition intake) in ICU survivors. The primary aim of this narrative review is to provide a comprehensive summary of key themes arising from these studies which form the basis of our current understanding of nutritional recovery and rehabilitation in ICU survivors. ICU survivors face a multitude of barriers in achieving optimal nutrition that are of physiological (e.g., poor appetite and early satiety), functional (e.g., dysphagia, reduced ability to feed independently), and psychological (e.g., low mood, body dysmorphia) origins. Organizational-related barriers such as inappropriate feeding times and meal interruptions frequently impact an ICU survivor’s ability to eat. Healthcare providers working on wards frequently lack knowledge of the specific needs of recovering critically ill patients which can negatively impact post-ICU nutrition care. Unsurprisingly, nutrition intake is largely inadequate following ICU discharge, with the largest deficits occurring in those who have had enteral nutrition prematurely discontinued and rely on an oral diet as their only source of nutrition. With consideration to themes arising from this review, pragmatic strategies to improve nutrition rehabilitation are explored and directions for future research in the field of post-ICU nutrition recovery and rehabilitation are discussed. Given the interplay between nutrition and physical and psychological health, it is imperative that enhancing the nutritional status of an ICU survivor is considered when developing multidisciplinary rehabilitation strategies. It must also be recognized that dietitians are experts in the field of nutrition and should be included in stakeholder meetings that aim to enhance ICU rehabilitation strategies and improve outcomes for survivors of critical illness.

Speech and language therapists' management of ventilated patients and patients with tracheostomy in Israel

BACKGROUND

There is increased involvement of speech and language therapists (SLTs) in critical care and long-term units supporting patients with ventilatory needs and complex dysphagia. SLTs have a range of specialist knowledge in the function of the pharynx and larynx to enable them to support therapeutic interventions and contribute to the management of those patients. In Israel, there are currently no designated courses or training programmes for SLTs to establish advanced clinical skills in tracheostomy and ventilator management. There are currently standards of care for SLT working in designated wards for ventilated patients, however not in acute wards, critical care, and internal medicine wards where ventilated patients can be hospitalized.

AIMS

To identify the skills and expertise of the Israeli SLT workforce working with tracheostomy patients. Specifically, to identify their level of training, access to training, client population, work settings, and level of work confidence.

METHODS

The study involved electronic distribution of a 55-item online survey to SLTs in Israel. The questions included demographic information, training, confidence, and clinical support.

RESULTS

Responses were received from 47 SLTs. The majority (40.4%) spent between 1% and 9% of their clinical time with ventilated patients. Almost 80% work with seniors (≥65 years) and almost 70% work with adults (18-65 years) half the time or more. In inpatient rehabilitation, 46.8% reported that they manage patients with tracheostomy half the time or more. In outpatient rehabilitation settings, 21.3% reported that they manage patients with tracheostomy half the time or more. Prior to managing complex airway patients independently, 55.3% received less than 5 h formal tracheostomy training whilst 68.1% received less than 5 h training on ventilated patients. Multidisciplinary teams (MDTs) existed for tracheostomy patients (85.1%) and ventilated patients (70.2%) and high levels of confidence were reported for managing patients with tracheostomies (mode of 4 in a scale of 0-5, where 5 means fully confident) and ventilated patients (mode of 3 in a scale of 0-5). A significant relationship was found between level of confidence and presence of an MDT.

CONCLUSIONS

Limited training access was found for SLTs working with this complex population. A competency framework needs to be established with access to training and supervision. MDT existence contributes to confidence. Most respondents worked in rehabilitation settings, and very few worked in acute care, critical care, and internal medicine wards. It seems reasonable that in order to change this, minimal standards of care should be established on these wards.

WHAT THIS PAPER ADDS

What is already known on the subject Speech and language therapists (SLTs) have an important role in critical care and long-term units supporting patients with complex dysphagia and undergo formal training and supervision in UK and Australia. What this paper adds to existing knowledge In Israel, most SLTs work with tracheostomy and ventilated adult patients in rehabilitation settings, whilst few work in acute, critical care, and internal medicine wards. There are limited opportunities for formal training and supervision, although MDT support enhances clinical confidence. What are the potential or actual clinical implications of this work? SLTs in Israel would benefit from establishing a competency framework for tracheostomy and ventilator patient management to support training, standards of care, and increase clinical involvement in acute settings. This will enhance clinical outcomes for their large population of complex airway patients.

Profile of users receiving Speech-Language Therapy service at a Critical Patient Unit

ABSTRACT Objective: to describe the profile of patients treated by Speech-Language therapists in a Critical Patient Unit. Methods: an ex post facto, observational and descriptive study was carried out. Monthly statistical data of patients hospitalized in the period January-December 2018 were analyzed, in the Intensive Care Unit at a public hospital. Data were described from the analysis of frequency and measures of central tendency. The distribution of the variables was determined through the skewness-kurtosis test, considering a significance level of p<0.05. Results: 217 individuals got 868 speech-language therapy services. Men (57.26%), older than 65 years old, required a more frequent intervention. The main medical diagnosis of admission to the unit corresponded to non-specific pathologies (57.14%), respiratory disease (15.21%) and cerebrovascular disease (12.79%). The speech-language therapy functions were related to the evaluation of swallowing (54.31%) and voice (32.4%). In relation to the intervention, the treatment of dysphagia (25.82%) and oral motor functions (25.04%) was predominant in the duties. Functions associated with language, speech and cognition were secondary. Conclusion: the profile of the critical patient and the speech-language therapy work in this field represent a first step to characterize the role of the speech-language therapist in Intensive Medicine teams.

Assessment, Diagnosis, and Treatment of Dysphagia in Patients Infected With SARS-CoV-2: A Review of the Literature and International Guidelines

Purpose Speech-language pathologists are playing a crucial role in the assessment and management of patients infected with severe acute respiratory syndrome coronavirus 2. Our goal was to synthesize peer-reviewed literature and association guidelines from around the world regarding dysphagia assessment and management for this specific population. Method A review of publications available in the PubMed database and official guidelines of international groups was performed on May 23, 2020. The information was synthesized and categorized into three content areas for swallowing: clinical evaluation, instrumental assessment, and rehabilitation. Results Five publications were identified in the PubMed database. Following title, abstract, and full-text review, only three publications met inclusion criteria: two reviews and one narrative report. Additionally, 19 international guidelines were reviewed. To assess swallowing, a modified clinical evaluation was recommended and only following a risk assessment. Instrumental assessments were often considered aerosol generating, especially transnasal procedures such as endoscopy and manometry. For this reason, many associations recommended that these examinations be performed only when essential and with appropriate personal protective equipment. Guidelines recommended that intervention should focus on compensatory strategies, including bolus modification, maneuvers/postural changes, and therapeutic exercises that can be conducted with physical distancing. Respiratory training devices were not recommended during rehabilitation. Conclusions International associations have provided extensive guidance regarding the level of risk related to the management of dysphagia in this population. To date, there are no scientific papers offering disease and/or recovery profiling for patients with dysphagia and coronavirus disease 2019. As a result, research in this area is urgently needed.

Swallowing and Communication Management of Tracheostomy and Laryngectomy in the Context of COVID-19: A Review

IMPORTANCE

The care of patients with a surgically modified airway, such as tracheostomy or laryngectomy, represents a challenge for speech-language pathologists (SLPs) in the context of the coronavirus disease 2019 (COVID-19) pandemic. The objective was to review available publications and practice guidelines on management of tracheostomy and laryngectomy in the context of COVID-19. This study performed a review and synthesis of information available in the PubMed database and from national SLP organizations across 6 countries.

OBSERVATIONS

From the search, 22 publications on tracheostomy and 3 referring to laryngectomy were identified. After analysis of titles and abstracts followed by full-text review, 4 publications were identified as presenting guidelines for specific approaches to tracheostomy and were selected; all 3 publications on laryngectomy were selected. The main guidelines on tracheostomy described considerations during management (eg, cuff manipulation, suctioning, valve placement) owing to the increased risk of aerosol generation and transmission during swallowing and communication interventions in this population. Regarding laryngectomy, the guidelines focused on the care and protection of both the professional and the patient, offering recommendations on the management of adverse events and leakage of the tracheoesophageal prosthesis.

CONCLUSIONS AND RELEVANCE

Frequent guideline updates for SLPs are necessary to inform best practice and ensure patient and health care worker protection and safety while providing high-quality care and rehabilitation.

Translating Dysphagia Evidence into Practice While Avoiding Pitfalls: Assessing Bias Risk in Tracheostomy Literature

Critically ill patients who require a tracheostomy often have dysphagia. Widespread practice guidelines have yet to be developed regarding the acute assessment and management of dysphagia in patients with tracheostomy. In order for clinicians to base their practice on the best available evidence, they must first assess the applicable literature and determine its quality. To inform guideline development, our objective was to assess literature quality concerning swallowing following tracheostomy in acute stages of critical illness in adults. Our systematic literature search (published previously) included eight databases, nine gray literature repositories and citation chasing. Using inclusion criteria determined a priori, two reviewers, blinded to each other, conducted an eligibility review of identified citations. Patients with chronic tracheostomy and etiologies including head and/or neck cancer diagnoses were excluded. Four teams of two reviewers each, blinded to each other, assessed quality of included studies using a modified Cochrane Risk of Bias tool (RoB). Disagreements were resolved by consensus. Data were summarized descriptively according to study design and RoB domain. Of 6,396 identified citations, 74 studies met our inclusion criteria. Of those, 71 were observational and three were randomized controlled trials. Across all studies, the majority (> 75%) had low bias risk with: participant blinding, outcome reporting, and operationally defined outcomes. Areas requiring improvement included assessor and study personnel blinding. Prior to translating the literature into practice guidelines, we recommend attention to study quality limitations and its potential impact on study outcomes. For future work, we suggest an iterative approach to knowledge translation.

A Systematic Review of Tracheostomy Modifications and Swallowing in Adults

Dysphagia occurs in 11% to 93% of patients following tracheostomy. Despite its benefits, the tracheostomy often co-exists with dysphagia given its anatomical location, the shared pathway of the respiratory and alimentary systems, and the medical complexities necessitating the need for the artificial airway. When tracheostomy weaning commences, it is often debated whether the methods used facilitate swallowing recovery. We conducted a systematic review to determine whether tracheostomy modifications alter swallowing physiology in adults. We searched eight electronic databases, nine grey literature repositories and conducted handsearching. We included studies that reported on oropharyngeal dysphagia as identified by instrumentation in adults with a tracheostomy. We accepted case series (n > 10), prospective or retrospective observational studies, and randomized control trials. We excluded patients with head and neck cancer and/or neurodegenerative disease. Two independent and blinded reviewers rated abstracts and articles for study inclusion. Data abstraction and risk of bias assessment was conducted on included studies. Discrepancies were resolved by consensus. A total of 7079 citations were identified, of which, 639 articles were reviewed, with ten articles meeting our inclusion criteria. The studies were heterogeneous in study design, patient population, and outcome measures. For these reasons, we presented our findings descriptively. All studies were limited by bias risk. This study highlights the limitations of the evidence and therefore the inability to conclude whether tracheostomy modifications alter swallowing physiology.