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Chen L, Liu C, Yuan M, Yin X, Niu S, Tang J, Chen H, Xiong B, Feng X. Interventions for Postextubation Dysphagia in Critically Ill Patients: A Systematic Review and Meta-analysis. Dysphagia 2024:10.1007/s00455-024-10695-1. [PMID: 38558176 DOI: 10.1007/s00455-024-10695-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 03/06/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE This review evaluates the efficacy and safety of dysphagia interventions for patients with prolonged endotracheal intubation (⩾48 h) in critical care units. DATA SOURCES We systematically searched PubMed, Cochrane Library, Medline, Embase, OVID, CINAHL, Wanfang (China), CNKI (China), and ProQuest Dissertations for studies published up to December 31, 2023. STUDY SELECTION Inclusion criteria encompassed randomized controlled trials (RCTs), quasi-randomized trials, and cohort studies comparing dysphagia rehabilitation - such as swallowing stimulation, swallowing and respiratory muscle exercise, and neuromuscular electrical stimulation - with standard care or no treatment. The primary outcomes assessed were dysphagia severity, time to resume oral intake, and incidence of aspiration and aspiration pneumonia. DATA EXTRACTION Detailed information on study design, setting, participant demographics, interventions, and outcomes was systematically extracted. DATA SYNTHESIS Our analysis included ten studies with a total of 1031 participants. The findings demonstrate a significant reduction in dysphagia severity, time to oral intake and the risk of aspiration pneumonia, and an improvement in quality of life among patients receiving swallowing therapy. However, no substantial difference was found in nutritional status. Limited data availability necessitated a descriptive presentation of outcomes like the risk of aspiration, ICU/hospital stay duration, pharyngeal/oral residue severity, and intervention-related adverse events. CONCLUSION The current evidence for the effectiveness of dysphagia interventions in critically ill patients with prolonged endotracheal intubation is limited. There is a pressing need for future research, particularly high-quality RCTs employing standardized outcome measures, to substantiate these findings.
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Affiliation(s)
- Lan Chen
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Shangcheng District, Hangzhou, Zhejiang Province, 310009, China
| | - Chang Liu
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Shangcheng District, Hangzhou, Zhejiang Province, 310009, China
| | - Mengmei Yuan
- Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, Jinhua, Zhejiang Province, China
| | - Xiaoxiao Yin
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Shangcheng District, Hangzhou, Zhejiang Province, 310009, China
| | - Shan Niu
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Shangcheng District, Hangzhou, Zhejiang Province, 310009, China
| | - Jiaying Tang
- Emergency ICU, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Shangcheng District, Hangzhou, Zhejiang Province, 310009, China
| | - Haotian Chen
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Shangcheng District, Hangzhou, Zhejiang Province, 310009, China
| | - Bing Xiong
- Rehabilitation Department, The Second Affiliated Hospital of Zhejiang, University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Xiuqin Feng
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Shangcheng District, Hangzhou, Zhejiang Province, 310009, China.
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Likar R, Aroyo I, Bangert K, Degen B, Dziewas R, Galvan O, Grundschober MT, Köstenberger M, Muhle P, Schefold JC, Zuercher P. Management of swallowing disorders in ICU patients - A multinational expert opinion. J Crit Care 2024; 79:154447. [PMID: 37924574 DOI: 10.1016/j.jcrc.2023.154447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 09/19/2023] [Accepted: 10/10/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Dysphagia is common in intensive care unit (ICU) patients, yet it remains underrecognized and often unmanaged despite being associated with life-threatening complications, prolonged ICU stays and hospitalization. PURPOSE To propose an expert opinion for the diagnosis and management of dysphagia developed from evidence-based clinical recommendations and practitioner insights. METHODS A multinational group of dysphagia and critical care experts conducted a literature review using a modified ACCORD methodology. Based on a fusion of the available evidence and the panel's clinical experience, an expert opinion on best practice management was developed. RESULTS The panel recommends adopting clinical algorithms intended to promote standardized, high-quality care that triggers timely systematic dysphagia screening, assessment, and treatment of extubated and tracheostomized patients in the ICU. CONCLUSIONS Given the lack of robust scientific evidence, two clinical management algorithms are proposed for use by multidisciplinary teams to improve early systematic detection and effective management of dysphagia in ICU patients. Additionally, emerging therapeutic options such as neurostimulation have the potential to improve the quality of ICU dysphagia care.
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Affiliation(s)
- Rudolf Likar
- Department for Anaesthesiology and Intensive Medicine, Klinikum Klagenfurt am Wörthersee, Austria
| | - Ilia Aroyo
- Department of Neurology and Neurointensive Care Medicine, Klinikum Darmstadt, Germany
| | - Katrin Bangert
- Clinic for Intensive Care Medicine, University Hospital Hamburg, Germany
| | - Björn Degen
- Clinic for Intensive Medicine, Dysphagia Centre, Vienna, Austria
| | - Rainer Dziewas
- Department of Neurology and Neurological Rehabilitation, Klinikum Osnabrück, Osnabrück, Germany
| | - Oliver Galvan
- Department for Hearing, Speech and Voice Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Markus Köstenberger
- Department for Anaesthesiology and Intensive Medicine, Klinikum Klagenfurt am Wörthersee, Austria; Department for Anaesthesiology and Intensive Care Medicine, Medical University Graz, Graz, Austria.
| | - Paul Muhle
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Germany
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Patrick Zuercher
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
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Rheinwald M, Azad SC, Zoller M, Lorenz A, Kraft E. [Postextubation dysphagia in intensive care patients : Current findings and clinical recommendations]. Anaesthesist 2022; 71:546-555. [PMID: 35166868 DOI: 10.1007/s00101-022-01092-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND A considerable number of critically ill and mechanically ventilated intensive care patients show pronounced dysphagia after extubation. Many studies have shown that postextubation dysphagia (PED) leads to a significant decline of outcome. The awareness, timely diagnostic procedures and integration of suitable treatment methods in intensive care units are therefore of great importance. OBJECTIVE Current basic findings on PED, diagnostic possibilities, therapeutic methods as well as the development of concrete recommendations for clinical practice. METHODS A selective literature search was performed in PubMed, Medline and Cochrane using keywords. RESULTS In the literature the incidence PED is reported very heterogeneous but is probably at least 10% in intensive care patients after mechanical ventilation. The duration of intubation plays a critical role here. A multifactorial interaction of several factors is assumed to be the cause, whereby the impairment of laryngeal structures is of particular relevance. A PED leads to longer hospital stays, higher mortality, more reintubation and a higher number of patients with tube feeding. With respect to diagnostics, screening by trained nurses, clinical swallowing examinations and, in particular, the use of instrumental examinations by flexible endoscopic evaluation of swallowing (FEES) are recommended. The treatment should include adaptive measures in the sense of an adapted diet but also functional exercises. Innovative approaches, such as electrical stimulation are also conceivable. The aim is primarily to avoid penetration and aspiration in order to counteract respiratory complications. CONCLUSION In many intensive care units the clinical picture of PED is still neglected despite clear evidence. A simple algorithm in the treatment of intensive care patients can contribute to early detection and initiation of further steps. These should be integrated into clinical treatment standards.
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Affiliation(s)
- Marika Rheinwald
- Physikalische und Rehabilitative Medizin, Muskuloskelettales Universitätszentrum München, LMU Klinikum München, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland.
| | - Shanaz-Christina Azad
- Klinik für Anästhesiologie, Klinikum der Universität München, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Michael Zoller
- Klinik für Anästhesiologie, Klinikum der Universität München, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Andreas Lorenz
- Physikalische und Rehabilitative Medizin, Muskuloskelettales Universitätszentrum München, LMU Klinikum München, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland
| | - Eduard Kraft
- Physikalische und Rehabilitative Medizin, Muskuloskelettales Universitätszentrum München, LMU Klinikum München, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland
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Zuercher P, Dziewas R, Schefold JC. Dysphagia in critical care: focus on therapeutical interventions. Intensive Care Med 2020; 46:1972-1973. [PMID: 32696191 DOI: 10.1007/s00134-020-06189-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Patrick Zuercher
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
| | - Rainer Dziewas
- Department of Neurology, University Hospital Münster, Münster, Germany
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
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Duncan S, McAuley DF, Walshe M, McGaughey J, Anand R, Fallis R, Blackwood B. Interventions for oropharyngeal dysphagia in acute and critical care: a systematic review and meta-analysis. Intensive Care Med 2020; 46:1326-1338. [PMID: 32514597 PMCID: PMC7334257 DOI: 10.1007/s00134-020-06126-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/19/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE To determine the effectiveness of dysphagia interventions compared to standard care in improving oral intake and reducing aspiration for adults in acute and critical care. METHODS We searched electronic literature for randomised and quasi-randomised trials and bibliography lists of included studies to March 2020. Study screening, data extraction, risk of bias and quality assessments were conducted independently by two reviewers. Meta-analysis used fixed effects modelling. The systematic review protocol is registered and published. RESULTS We identified 22 studies (19 stroke, 2 intensive care stroke and 1 general intensive care) testing 9 interventions and representing 1700 patients. Swallowing treatment showed no evidence of a difference in the time to return to oral intake (n = 33, MD (days) - 4.5, 95% CI - 10.6 to 1.6, 1 study, P = 0.15) (very low certainty) or in aspiration following treatment (n = 113, RR 0.79, 95% CI 0.44 to 1.45, 4 studies, I2 = 0%, P = 0.45) (low certainty). Swallowing treatment showed evidence of a reduced risk of pneumonia (n = 719, RR 0.71, 95% CI 0.56 to 0.89, 8 studies, I2 = 15%, P = 0.004) (low certainty) but no evidence of a difference in swallowing quality of life scores (n = 239, MD - 11.38, 95% CI - 23.83 to 1.08, I 2 = 78%, P = 0.07) (very low certainty). CONCLUSION There is limited evidence for the effectiveness of swallowing treatments in the acute and critical care setting. Clinical trials consistently measuring patient-centred outcomes are needed.
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Affiliation(s)
- Sallyanne Duncan
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK.
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - Margaret Walshe
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Leinster St. South, Dublin 2, D02 KF66, Ireland
| | - Jennifer McGaughey
- School of Nursing and Midwifery, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - Rohan Anand
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - Richard Fallis
- Queen's University Belfast Medical Library, Mullhouse Building, Mullhouse Road, Belfast, BT12 6DP, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK
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