Prevalence, Pathophysiology, Diagnostic Modalities, and Treatment Options for Dysphagia in Critically Ill Patients

Management of adults with a tracheostomy: An international survey of speech-language pathologists' practice

PURPOSE

Speech-language pathologists are specialists in communication, swallowing, and weaning as core members of the multidisciplinary tracheostomy team. Inconsistent tracheostomy care is known to result in staff and patient frustration, delayed intervention, and patient harm. Little is known about international speech-language pathology tracheostomy practices.

METHOD

This global survey explored training, clinical practices, perceived knowledge, skills and roles, as well as barriers to change and successes. Questions consisted of likert scale and open-ended questions. 1 458 Speech-language pathologists completed the survey representing six continents and 52 countries.

RESULT

Overall, speech-language pathologists were confident in their knowledge and skills. Tracheostomy teams were viewed as a key facilitator of best care. Access to Flexible Endoscopic Evaluation of Swallowing was variable and considered valuable by all. Four key themes emerged: Knowledge and skills, roles and multidisciplinary tracheostomy team relationships, written documentation and protocols, and access to resources. Multidisciplinary tracheostomy team relationships and being valued as a professional were the most common concerns. Speech-language pathologists had a plethora of successes to share that had changed their workplace.

CONCLUSION

This survey shows speech-language pathologists are aligned internationally with common purpose and values. Speech-language pathologists voiced challenges in multidisciplinary tracheostomy team relationships, standardising practice, and resourcing. Benchmarking is the first step to targeted change and we hope this will support and empowerclinicians to continue to innovate tracheostomy practice.

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.

Analysis of Patients' Dietary Status/Restrictions Following Instrumental Swallow Evaluations in Skilled Nursing Facilities

Many residents in Skilled Nursing Facilities (SNFs) present with dysphagia and receive altered diets or liquids to minimize the risk of complications. Limited access to timely instrumental evaluations of swallow may impede the best management of these dysphagic residents. De-identified FEES reports completed by a mobile FEES company during a single month, January 2019, were reviewed. Descriptive statistics were used to summarize the pre-study diet/liquid levels and the post-study diet/liquid recommendations. FEES reports (n = 952) were reviewed. Before the FEES evaluation, 209 residents were receiving only non-oral nutrition. After the FEES evaluation, 76% of these residents were recommended to receive oral nutrition. Before the FEES evaluation, 442 (46%) residents were receiving thickened liquids, after the FEES evaluation, 244 (26%) were recommended to have a less restrictive liquid level. Before the FEES evaluation, 576 (60%) residents were receiving altered food texture, after the FEES evaluation, 413 (43%) were recommended to have a less restrictive food texture. The percentage of residents recommended to receive thin liquids increased from 32 to 68% and those recommended to receive a regular diet increased from 18 to 34%. These data indicate that access to instrumental swallow evaluations in the SNF setting generally resulted in lifting liquid and diet restrictions for many residents in the cohort reviewed and potentially improved their quality of life.

Kangaroo Stimulation Game in Tracheostomized Intensive Care-Related Dysphagia: Interventional Feasibility Study

Background

Dysphagia is common in intensive care unit (ICU) patients. Using surface electromyography (sEMG) signals as biofeedback training exercises might offer a promising path to improving swallowing function. The Rephagia biofeedback system uses sEMG to assess muscle strength, stamina, and timing of the swallowing action.

objectives

The aim of this study was to evaluate the feasibility of the Rephagia system in ICU patients with dysphagia.

Methods

This feasibility study included patients admitted to a 14-bed mixed medical-surgical ICU. All patients underwent a new tracheostomy placement during ICU stay due to persistent aspiration and ICU-acquired weakness, accompanied by verified dysphagia. Following Rephagia training, patients completed a questionnaire assessing comprehension, satisfaction, and motivation. Swallowing characteristics were assessed via mean sEMG peak values during exercise.

Results

Twenty patients with a mean age of 69.4 (SD 8.2) years were included. The means of sEMG values at the beginning of a measurement were not significantly different at baseline versus everyone's last measurement (52 µV [23 µV] vs 57 µV [22 µV]; P=.50). The means of sEMG values obtained at the end of a measurement were not significantly different at baseline versus everyone's last measurement (56 µV [18 µV] vs 59 µV [23 µV]; P=.62). However, dysphagia improved in all patients. Patients understood the importance of the game in relation to their swallowing problems (16/80, 89%), which kept them motivated to participate in the training sessions (9/18, 50%).

Conclusions

The Rephagia biofeedback system for stimulating swallowing actions in tracheotomized ICU patients with dysphagia is feasible. No relation was found between clinical improvement in swallowing function and sEMG signals.

Safety-related outcomes for patients with a tracheostomy and the use of flexible endoscopic evaluation of swallowing (FEES) for assessment and management of swallowing: A systematic review

PURPOSE

The purpose of this systematic review was to examine safety-related outcomes for patients with tracheostomy after flexible endoscopic evaluation of swallowing (FEES) to assess and manage their swallow, when compared to other non-instrumental swallow assessments such as clinical swallowing examination (CSE) and/or a modified Evans blue dye test (MEBDT).

METHOD

Three databases were searched for articles referring to safety-related outcome data for adults with a tracheostomy, who underwent FEES and CSE and/or MEBDT. Articles were screened using predefined inclusion/exclusion criteria.

RESULT

The search strategy identified 2097 articles; following abstract and full-text screening, seven were included for review. The summary of evidence found low to very low certainty that FEES was associated with improved outcomes across swallow safety, physiological outcomes, tracheostomy cannulation duration, functional outcomes, and detection of upper airway pathologies.

CONCLUSION

This systematic review demonstrated low to very low certainty evidence from seven heterogeneous studies with low sample sizes that incorporating FEES may be associated with improved safety-related outcomes. There is less evidence supporting the accuracy of other swallow assessments conducted at the point of care (i.e. CSE and MEBDT). Future research requires studies with larger sample sizes and routine reporting of safety-related outcomes with use of FEES.

Intensive care unit-acquired dysphagia - change in feeding route after a standardized dysphagia assessment in neurocritical care patients

BACKGROUND

Dysphagia is a frequent finding on intensive care units (ICUs) and is associated with increased reintubation rates, pneumonia, and prolonged ICU-stay. Only a limited numbers of ICUs have access to a Speech and Language Pathologist (SLP). Hence, it falls upon the critical care team to estimate dysphagia risk and define the safest feeding route. Therefore, the aim of this study was to evaluate if the feeding route established by the ICU-team is changed after a standardized dysphagia assessment (DA) by an SLP. Furthermore, we tried to identify predictors for the need of a SLP assessment looking at the change in feeding route (CIFR) after DA.

METHODS

We performed a retrospective analysis of patients consecutively admitted for at least 48 h in 2018, to the ICU of the Department of Neurology and Neurosurgery. Following variables were assessed: Referral to an SLP, feeding route before and after DA by an SLP, main diagnosis, and ventilation parameters.

RESULTS

From 497 included patients (65 years, IQR 51-77), 148 received a DA, confirming dysphagia in 125 subjects. DA by the SLP resulted in a significant CIFR, with 32 (21.6%) subjects receiving stricter diets, and in 29 (19.6%) cases a reduction of dietary recommendations. 50 patients lacked readiness for oral intake due to severely affected oral phase or reduced consciousness.

CONCLUSION

Dysphagia is a frequent finding in the Neuro-ICU. Assessment of dysphagia-risk and safest feeding route differ significantly between the SLP and the critical care team. Besides implementation of standardized operating procedures for DA, the presence of ICU-specific trained SLP should be mandatory.

A Pilot Study of a Modified Swallowing Screening Tool for Critically Ill Patients in the Intensive Care Unit

The lack of early assessment tools for swallowing function in patients in the intensive care unit (ICU) may lead to delays in oral intake. This study assessed the effectiveness of a new bedside swallowing screening tool in detecting dysphagia in patients in the ICU or isolation settings, where isolation settings refer to conditions such as COVID-19, where patient mobility is limited. We assessed swallowing function in 13 patients with severe acute respiratory distress syndrome. To ensure patient safety, a bedside preliminary investigation was performed to assess the patient's alertness level, and ultrasound findings of the vocal cords were obtained. Patients were nasogastric(NG) tube feeding or fasted if they did not meet a certain readiness level. Additionally, patients who passed the preliminary investigation underwent methylene blue dye or citric acid swallowing tests if they had or had not undergone tracheostomy, respectively. The Gugging Swallowing Screen (GUSS) test was used to determine whether an oral diet was appropriate. Of the 13 patients, 1 failed to meet the criteria during the preliminary examination, and 12 underwent the examination and initiated oral intake. Significant differences were found in the GUSS scores between the tracheostomy and non-tracheostomy groups but not in the examination validity. NG tube was implemented if the examination criteria were not met at each stage. Patients who passed the newly developed dysphagia screening tool exhibited no aspiration symptoms post-oral feeding initiation, enabling their discharge. In conclusion, the proposed screening test can be performed safely and easily, allowing for early dysphagia detection, reduced aspiration risk, and safe oral feeding in patients in the ICU or isolation settings.

Prevalence and Management of Oral Intake Restrictions in Critically Ill Patients: Insights from a Multicenter Point Prevalence Study

Oral intake restrictions due to dysphagia in the intensive care unit (ICU) can increase morbidity, mortality, and negatively impact quality of life. The current oral intake practice and clinical management strategies for addressing dysphagia in the ICU are not well-defined. This study aimed to elucidate the clinical practices surrounding oral intake restrictions due to dysphagia and its management strategies in the ICU. A multicenter, prospective, cross-sectional, 2-day point prevalence study was conducted in Japan. Relevant data on the clinical circumstances surrounding oral intake practice and the implementation of strategies to prevent dysphagia for patients admitted to the ICU on November 1, 2023, and December 1, 2023, were collected. The primary outcome was the prevalence of oral intake restrictions in patients, defined by a Functional Oral Intake Scale score of less than 7 among eligible patients for oral intake. Out of 326 participants, 187 were eligible for the final analysis after excluding 139 patients who were not eligible for oral intake, primarily due to tracheal intubation. Among those eligible, 69.0% (129/187) encountered oral intake restrictions. About 52.4% (98/187) of patients underwent swallowing screenings; 36.7% (36/98) of these were suspected of having dysphagia. Compensatory and behavioral swallowing rehabilitation were provided to 21.9% (41/187) and 10.6% (20/187) of patients, respectively, from ICU admission to the survey date. Only 27.4% (14/51) of post-extubation and 9.3% (3/32) of post-stroke patients received swallowing rehabilitation. Notably, no ICUs had dedicated speech and language therapists, and most (85.7%, 18/21) lacked established swallowing rehabilitation protocols. This 2-point prevalence survey study revealed that oral intake restrictions due to dysphagia are common in ICUs, but few patients are screened for swallowing issues or receive rehabilitation. More clinical studies are needed to develop effective protocols for identifying and managing dysphagia, including screenings and rehabilitation in the 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.

Swallowing during provision of helmet ventilation: Review and provisional multidisciplinary guidance

Use of noninvasive ventilation provided by a helmet increased globally during and after the COVID-19 pandemic. This approach may reduce need for intubation and its associated clinical complications in critically ill patients. Use of helmet interface minimizes virus aerosolization while enabling verbal communication, oral feeding and coughing/expectoration of secretions during its administration. Although improved oral hydration is a recognized benefit of helmet NIV, relatively little is known about the safety and efficiency of swallowing during helmet NIV. Risk of aspiration is a key consideration given the fragile pulmonary status of critically ill patients requiring respiratory support, and therefore the decision to initiate oral intake is best made based on multidisciplinary input. We reviewed the current published evidence on NIV and its effects on upper airway physiology and swallowing function. We then presented a case example demonstrating preservation of swallowing performance with helmet NIV. Last, we offer provisional multidisciplinary guidance for clinical practice, and provide directions for future research.

Best Practice Recommendations for Dysphagia Management in Intensive Care Unit (ICU): A Delphi Study from Multidisciplinary Experts in Turkey

There is no study about all aspects of oropharyngoesophageal (OPE) dysphagia from diagnosis to follow-up in a multidisciplinary manner in the world. In order to close this gap, we aimed to create a recommendation study that can be used in clinical practice, addressing all aspects of dysphagia in the ICU in detail with the opinion of experienced multidisciplinary experts. This recommendation paper was generated by a multidisciplinary team, using the seven-step process and a three-modified Delphi round via e-mail. Firstly, 15 open-ended questions were created, and then detailed recommendations including general principles, management, diagnosis, rehabilitation, and follow-up were created with the answers from these questions, Each recommendation item was voted on by the experts as overall consensus (strong recommendation), approaching consensus (weak recommendation), and divergent consensus (not recommended).In the first Delphi round, a questionnaire consisting of 413 items evaluated with a scale of 0-10 was prepared from the opinions and suggestions given to 15 open-ended questions. In the second Delphi round, 55.4% were accepted and revised suggestions were created. At the end of the third Delphi round, the revised suggestion form was approved again and the final proposals containing 133 items were created. This study includes comprehensive and detailed recommendations, including a broad perspective from diagnosis to treatment and follow-up, as detailed as possible, for management of dysphagia in patients with both oropharyngeal- and esophageal-dysphagia in ICU.

Management of swallowing disorders in ICU patients - A multinational expert opinion

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.

Speech pathology assessment of dysphagia post endotracheal extubation: A service-model evaluation

BACKGROUND

As postextubation dysphagia (PED) is correlated with pneumonia, feeding-tube placement, and in-hospital mortality, early identification is paramount. Endotracheal intubation duration of ≥48 h is independently predictive for PED. Therefore, a blanket intensive care unit (ICU) referral protocol was implemented to conduct PED assessment of patients intubated for ≥48 h.

OBJECTIVES

The objective of this study was to review outcomes of an established blanket referral model for PED assessment in patients intubated for ≥48 h. Outcomes of the model were examined over a 2-year period (June 2015-June 2017) for (i) numbers and clinical characteristics of patients meeting criteria and referred for speech pathology (SP) assessment; (ii) frequency identified with PED on clinical swallow examination; (iii) severity and duration of PED; and (iv) SP management within the ICU.

RESULTS

There was 96% adherence to the pathway with 108 participants (68% male) assessed. Median intubation duration was 142 h (mode = 61; interquartile range [IQR] = 131.75), and median ICU admission was 9 days (mode = 8; IQR = 6.75). SP referral occurred at a median of 19.5 h (mode = 4; IQR = 18.75) after extubation. Dysphagia assessment occurred at a median of 22 h (mode = 4; IQR = 19), with 34% assessed on the same day and 77% within 24 h of extubation. PED was observed in 89%, with 26% exhibiting profound PED. Dysphagia recovery occurred at a median of 7 days (mode = 2; IQR = 11). Dysphagia severity was associated with duration to swallow recovery (p = 0.001). A median of two occasions of service and 90 min clinical time was spent by the speech pathologist in the ICU.

CONCLUSION

The blanket referral model enabled timely triage and assessment of dysphagia in a patient cohort at high risk of PED in our facility.

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.

Postoperative dysphagia as a predictor of functional decline and prognosis after undergoing cardiovascular surgery

AIMS

Post-extubation dysphagia (PED), an often overlooked problem, is a common and serious complication associated with mortality and major morbidity after cardiovascular surgery. Dysphagia is considered an age-related disease, and evaluating its long-term effects is a pressing issue with rapidly progressing ageing worldwide. Therefore, we examined the effect of PED on functional status and long-term cardiovascular events in patients undergoing cardiovascular surgery.

METHODS AND RESULTS

This single-centre, retrospective cohort study included 712 patients who underwent elective cardiovascular surgery and met the inclusion criteria. Patients were divided into PED and non-PED groups based on their post-operative swallowing status. The swallowing status was assessed using the Food Intake Level Scale. Functional status was evaluated as hospital-associated disability (HAD), defined as a decrease in activities of daily living after hospital discharge compared with preoperative values. The patients were subsequently followed up to detect major adverse cardiac and cerebrovascular events (MACCEs). Post-extubation dysphagia was present in 23% of the 712 patients and was independently associated with HAD (adjusted odds ratio, 2.70). Over a 3.5-year median follow-up period, MACCE occurred in 14.1% of patients. Multivariate Cox proportional hazard analysis revealed HAD to be independently associated with an increased risk of MACCE (adjusted hazard ratio, 1.85), although PED was not significantly associated with MACCE.

CONCLUSION

Post-extubation dysphagia was an independent HAD predictor, with the odds of HAD occurrence being increased by 2.7-fold due to PED. Hospital-associated disability accompanied by PED is a powerful predictor of poor prognosis. Perioperative evaluation and management of the swallowing status, and appropriate therapeutic interventions, are warranted.

Dysphagia outcomes in COVID-19 patients: experiences in long-term acute care hospital (LTACH)

PURPOSE

Long term acute care hospitals (LTACHs) saw a significant increase in COVID-19 patients with prolonged acute illness recovery. Speech language pathologists (SLP) in LTACHs were integral in assessing swallowing and providing rehabilitation for dysphagia, however, there is limited research on LTACHs and dysphagia. Our aim was to describe this unique dysphagia management experience to improve future patient care.

METHODS

Retrospective chart reviews were conducted for patients admitted to RML Specialty Hospital for respiratory failure secondary to COVID-19 from April 1, 2020 to October 31, 2021. Demographic information, videofluoroscopic swallow study (VFSS) reports with Penetration and Aspiration Scale (PAS) scores and SLP notes were reviewed. Descriptive statistics and chi-square analysis were performed.

RESULTS

A total of 213 patients met inclusion criteria. Most patients presented with tracheostomy (93.9%) and were NPO (92.5%) on admission. A strong correlation (p = 0.029) was noted between dependence on mechanical ventilation and significant airway invasion, as indicated by PAS score of 7 or 8 on VFSS. There was a strong association (p = 0.001) between patients who had tracheostomy placed within 33 days of VFSS and recommendation for thin liquids. Upon discharge, the majority of patients (83.57%) transitioned successfully to oral diets, however, a strong association (p = 0.009) between higher age (≥ 62) and NPO at discharge was demonstrated.

CONCLUSION

Patients admitted post COVID-19 to LTACH, especially those requiring tracheostomy, demonstrated various degrees of dysphagia and benefited from SLP intervention and instrumental swallow assessments. Most patients admitted to LTACH for COVID-19 were successfully rehabilitated for dysphagia.

Strategies of Screening and Treating Post-Extubation Dysphagia: An Overview of the Situation in Greek-Cypriot ICUs

Post-extubation dysphagia (PED) can lead to serious health problems in critically ill patients. Contrasting its high incidence rate of 12.4% reported in a recent observational study, many ICUs lack routine bedside screening, likely due to limited awareness. This study aimed to establish baseline data on the current approaches and the status of perceived best practices in PED screening and treatment, as well as to assess awareness of PED. A nationwide cross-sectional, online survey was conducted in all fourteen adult ICUs in the Republic of Cyprus in June 2018, with a 100% response rate. Over 85% of ICUs lacked a standard screening protocol for PED. The most commonly reported assessment methods were cough reflex testing and the water swallow test. Treatment approaches included muscle strengthening exercises without swallowing and swallowing exercises. Only 28.6% of ICUs acknowledged PED as a common issue. The study identified significant gaps in awareness and knowledge regarding PED screening and treatment in Greek-Cypriot ICUs. Urgent implementation of comprehensive dysphagia education programs within the units is necessary, and interdisciplinary collaboration among nurses, intensivists, and speech and language therapists is crucial to improve the quality of care provided.

Effects of a swallowing and oral-care program on resuming oral feeding and reducing pneumonia in patients following endotracheal extubation: a randomized, open-label, controlled trial

BACKGROUND

The resumption of oral feeding and free from pneumonia are important therapeutic goals for critically ill patients who have been successfully extubated after prolonged (≥ 48 h) endotracheal intubation. We aimed to examine whether a swallowing and oral-care (SOC) program provided to critically ill patients extubated from prolonged mechanical ventilation improves their oral-feeding resumption and reduces 30-day pneumonia incidence.

METHODS

In this randomized, open-label, controlled trial, participants were consecutively enrolled and randomized to receive the SOC program or usual care. The interventions comprised three protocols: oral-motor exercise, sensory stimulation and lubrication, and safe-swallowing education. Beginning on the day following patient extubation, an SOC nurse provided the three-protocol care for seven consecutive days or until death or hospital discharge. With independent outcome assessors, oral-feeding resumption (yes, no) corresponded to level 6 or level 7 on the Functional Oral Intake Scale (censored seven days postextubation) along with radiographically documented pneumonia (yes, no; censored 30 days postextubation), abstracted from participants' electronic medical records were coded.

RESULTS

We analyzed 145 randomized participants (SOC group = 72, control group = 73). The SOC group received, on average, 6.2 days of intervention (14.8 min daily) with no reported adverse events. By day 7, 37/72 (51.4%) of the SOC participants had resumed oral feeding vs. 24/73 (32.9%) of the control participants. Pneumonia occurred in 11/72 (15.3%) of the SOC participants and in 26/73 (35.6%) of the control participants. Independent of age and intubation longer than 6 days, SOC participants were likelier than their control counterparts to resume oral feeding (adjusted hazard ratio, 2.35; 95% CI 1.38-4.01) and had lower odds of developing pneumonia (adjusted odds ratio, 0.28; 95% CI 0.12-0.65).

CONCLUSIONS

The SOC program effectively improved patients' odds that oral feeding would resume and the 30-day pneumonia incidence would decline. The program might advance dysphagia care provided to critically ill patients extubated from prolonged mechanical ventilation.

TRIAL REGISTRATION

NCT03284892, registered on September 15, 2017.

Dysphagia in intensive care, a real problem: analysis of risk factors

AIMS

To identify risk factors present in patients with dysphagia in a population of critically ill patients.

METHODS

Case series of a cohort of patients recruited in the intensive care unit (ICU) until hospital discharge. Patients who gave consent and met the inclusion criteria were recruited. The Volume-Viscosity clinical examination method was used for the screening of dysphagia. An uni- and bivariate statistical analysis was performed using odds ratio (OR) to detect risk factors for dysphagia.

OUTCOMES

103 patients were recruited from 401 possible. The mean age was 59,33 ± 13,23, men represented 76,7%. The severity of the sample was: APACHE II (12,74 ± 6,17) and Charlson (2,98 ± 3,31). 45,6% of patients showed dysphagia, obtaining significant OR values (p < 0,050) for the development of dysphagia: older age, neurological antecedents, COVID19, long stay in ICU and hospitalization, and the presence of tracheotomy. COVID19 patients represented 46,6% of the sample, so an analysis of this subgroup was performed, showing similar results, with a Charlson risk (OR:4,65; 95% CI:1,31-16,47; p = 0,014) and a hospital stay (OR: 8,50; 95%CI: 2,20-32,83; p < 0,001) On discharge from the ICU, 37,9% of the population still had dysphagia; 12,6% maintained this problem at hospital discharge.

CONCLUSIONS

Almost half of our patients developed dysphagia. Clinical severity and the presence of tracheotomy were risk factors. We observed in patients with dysphagia a longer stay in both ICU and hospitalization.

Evaluation of Esophageal Dysphagia in Elderly Patients

PURPOSE OF REVIEW

While guidelines exist for the evaluation and management of esophageal dysphagia in the general population, dysphagia disproportionately affects the elderly. In this article, we reviewed the literature on evaluating esophageal dysphagia in elderly patients and proposed a diagnostic algorithm based on this evidence.

RECENT FINDINGS

In older patients, dysphagia is often well compensated for by altered eating habits and physiologic changes, underreported by patients, and missed by healthcare providers. Once identified, dysphagia should be differentiated into oropharyngeal and esophageal dysphagia to guide diagnostic workup. For esophageal dysphagia, this review proposes starting with endoscopy with biopsies, given its relative safety even in older patients and potential for interventional therapy. If endoscopy shows a structural or mechanical cause, then further cross-sectional imaging should be considered to assess for extrinsic compression, and same session endoscopic dilation should be considered for strictures. If biopsies and endoscopy are normal, then esophageal dysmotility is more likely, and high-resolution manometry and additional workup should be performed following the updated Chicago Classification. Even after diagnosis of the root cause, complications including malnutrition and aspiration pneumonia should also be assessed and monitored, as they both result from and can further contribute to dysphagia. The successful evaluation of esophageal dysphagia in elderly patients requires a thorough, standardized approach to collecting a history, selection of appropriate diagnostic workup, and assessment of risk of potential complications, including malnutrition and aspiration.

Does Dysphagia Predict Inpatient Morbidity and Mortality in Geriatric Patients Admitted for Aspiration Pneumonia?

Background Aspiration pneumonia is common in older adults admitted for community-acquired pneumonia and is associated with significant morbidity and mortality. Factors that put this population at higher risk of aspiration include cognitive impairment, neuromuscular dysfunction, and dysphagia. This study aimed to determine whether a concurrent diagnosis of dysphagia conferred a higher risk of complications in the elderly admitted for aspiration pneumonia. Methods The National Inpatient Sample 2001-2013 database was queried for patients, aged 65 or older, with a diagnosis of aspiration pneumonia using International Classification of Diseases, Ninth Revision (ICD-9) codes. Sepsis, respiratory failure, and intubation were identified with their respective ICD-9 codes. A chi-square test and binary logistic regression analysis were used to examine socio-demographic and complication variables, with a significance level of α <0.001. Results A total of 1,097,325 patients were admitted for aspiration pneumonia, of which 349,861 (24.2%) had dysphagia. After incorporating socio-demographic variables, the dysphagia group had a significantly lower likelihood of having sepsis (OR=0.72), respiratory failure (OR=0.92), intubation (OR=0.52), and inpatient mortality (OR = 0.59). Patients with dysphagia had a significantly higher likelihood of increased length of stay (OR=1.24). Conclusions Elderly patients admitted with aspiration pneumonia with a co-diagnosis of dysphagia were less likely to have inpatient morbidity and mortality compared to their counterparts. This may be due to improved speech evaluation and treatment in patients with dysphagia allowing for better control of macro and micro aspiration. Future research is needed to examine if universal speech therapy can reduce hospitalization and long-term mortality for such patients.

Screening for oropharyngeal dysphagia in hospitalized COVID-19 patients: a prospective study

PURPOSE

To screen for oropharyngeal dysphagia (OD) in hospitalized COVID-19 patients.

METHODS

A descriptive longitudinal study was conducted on 500 adult patients with confirmed COVID-19 in the age range of 19-65 years who were admitted to the main university isolation hospital (whether admitted in the ward or the intensive care unit). Screening for OD was done using the Arabic version of the Eating Assessment Tool (EAT-10) and the Yale swallow protocol.

RESULTS

45.4% of the admitted and 40.97% of the discharged COVID-19 patients had a positive screen for OD. Several risk factors for OD could be detected. These include older age, longer duration of presenting symptoms of COVID-19, presence of ageusia and anosmia, presence of dysphonia, ICU admission, lower oxygen saturation, higher respiratory rate, presence of OD at admission, longer duration of hospital stay, and use of noninvasive ventilation (NIV) and/or invasive mechanical ventilation (IMV).

CONCLUSIONS

Screening for OD in hospitalized COVID-19 patients is a mandatory procedure, whether for admitted or discharged patients.

The prevalence of post-extubation dysphagia in critically ill adults: an Australian data linkage study

Objective: To define the prevalence of dysphagia after endotracheal intubation in critically ill adult patients. Design: A retrospective observational data linkage cohort study using the Australian and New Zealand Intensive Care Society Adult Patient Database and a mandatory government statewide health care administration database. Setting: Private and public intensive care units (ICUs) within Victoria, Australia. Participants: Adult patients who required endotracheal intubation for the purpose of mechanical ventilation within a Victorian ICU between July 2013 and June 2018. Main outcome measures: Presence of dysphagia, aspiration pneumonia, ICU length of stay, hospital length of stay, and cost per episode of care. Results: Endotracheal intubation in the ICU was required for 71 124 patient episodes across the study period. Dysphagia was coded in 7.3% (n = 5203) of those episodes. Patients with dysphagia required longer ICU (median, 154 [interquartile range (IQR), 78-259] v 53 [IQR, 27-107] hours; P < 0.001) and hospital admissions (median, 20 [IQR, 13-30] v 8 [IQR, 5-15] days; P < 0.001), were more likely to develop aspiration pneumonia (17.2% v 5.6%; odds ratio, 3.0; 95% CI, 2.8-3.2; P < 0.001), and the median health care expenditure increased by 93% per episode of care ($73 586 v $38 108; P < 0.001) compared with patients without dysphagia. Conclusions: Post-extubation dysphagia is associated with adverse patient and health care outcomes. Consideration should be given to strategies that support early identification of patients with dysphagia in the ICU to determine if these adverse outcomes can be reduced.

Exploring the Influence of Dysphagia and Tracheostomy on Pneumonia in Patients with Stroke: A Retrospective Cohort Study

Background: Pneumonia is common in patients with tracheostomy and dysphagia. However, the influence of dysphagia and tracheostomy on pneumonia in patients with stroke remains unclear. The aim of this study was to explore the risk factors related to pneumonia, and the association between dysphagia, tracheostomy and pneumonia in patients with stroke was investigated. Methods: Patients with stroke who experienced tracheostomy and dysphagia were included and divided into two groups based on record of pneumonia at discharge. Clinical manifestations and physical examination were used to diagnose pneumonia, whereas clinical swallowing examination, and videofluoroscopy swallowing studies (VFSS) were used to evaluate swallowing function. Results: There were significant differences between the pneumonia group and the no pneumonia group in total tracheostomy time (6.3 ± 5.9 vs. 4.3 ± 1.7 months, p = 0.003), number of instances of ventilator support (0.41 ± 0.49 vs. 0.18 ± 0.38, p = 0.007), PAS score (5.2 ± 1.92 vs. 4.3 ± 1.79, p = 0.039), impaired or absent cough reflex (76.4 vs. 55.6%, p = 0.035), oropharyngeal phase dysfunction (60.6 vs. 40.8%, p = 0.047), length of hospital stay (36.0 ± 7.2 vs. 30.5 ± 11.7 days, p = 0.025) and direct medical costs (15,702.21 ± 14,244.61 vs. 10,923.99 ± 7250.14 United States dollar [USD], p = 0.042). Multivariate logistic regression showed that the total tracheostomy time (95% confidence interval [CI], 1.966−12.922, p = 0.001), impaired or absent cough reflex (95% CI, 0.084−0.695, p = 0.008), and oropharyngeal phase dysfunction (95% CI, 1.087−8.148, p = 0.034) were risk factors for pneumonia. Spearman’s correlation analysis demonstrated that PAS scores were significantly correlated with cough reflex dysfunction (r = 0.277, p = 0.03), oropharyngeal phase dysfunction (r = 0.318, p < 0.01) and total tracheostomy time (r = 0.178, p = 0.045). The oropharyngeal phase dysfunction was significantly correlated with cough reflex (r = 0.549, p < 0.001) and UES opening (r = 0.643, p < 0.01). Conclusions: Tracheostomy and dysphagia increased the risk of pneumonia in patients with stroke. Total tracheostomy time, duration of ventilator support, degree of penetration and aspiration, and oropharyngeal phase dysfunction are risk factors. Given this, we also found that there may be a correlation between tracheostomy and dysphagia.

Post-extubation Dysphagia-Early Detection by Serial Tongue Pressure Measurements: Is it Practical?

How to cite this article: Paul S, Pande RK. Post-extubation Dysphagia-Early Detection by Serial Tongue Pressure Measurements: Is it Practical? Indian J Crit Care Med 2022;26(12):1233-1234.

Dysphagia in Intensive Care Evaluation (DICE): An International Cross-Sectional Survey

Dysphagia occurs commonly in the intensive care unit (ICU). Despite the clinical relevance, there is little worldwide research on prevention, assessment, evaluation, and/or treatment of dysphagia for ICU patients. We aimed to gain insight into this international knowledge gap. We conducted a multi-center, international online cross-sectional survey of adult ICUs. Local survey distribution champions were recruited through professional and personal networks. The survey was administered from November 2017 to June 2019 with three emails and a final telephone reminder. Responses were received from 746 ICUs (26 countries). In patients intubated > 48 h, 17% expected a > 50% chance that dysphagia would develop. This proportion increased to 43% in patients intubated > 7 days, and to 52% in tracheotomized patients. Speech-language pathologist (SLP) consultation was available in 66% of ICUs, only 4% reported a dedicated SLP. Although 66% considered a routine post-extubation dysphagia protocol important, most (67%) did not have a protocol. Few ICUs routinely assessed for dysphagia after 48 h of intubation (30%) or tracheostomy (41%). A large proportion (46%) used water swallow screening tests to determine aspiration, few (8%) used instrumental assessments (i.e., flexible endoscopic evaluation of swallowing). Swallowing exercises were used for dysphagia management by 30% of ICUs. There seems to be limited awareness among ICU practitioners that patients are at risk of dysphagia, particularly as ventilation persists, protocols, routine assessment, and instrumental assessments are generally not used. We recommend the development of a research agenda to increase the quality of evidence and ameliorate the implementation of evidence-based dysphagia protocols by dedicated SLPs.

Frequency, associated factors, and associated outcomes of dysphagia following sepsis

BACKGROUND

Identifying dysphagia as a potential complication of sepsis may improve swallowing function and survival while decreasing hospital length of stay.

OBJECTIVES

Our goal was to determine the frequency of dysphagia in sepsis survivors on the 7th day after admission, as well as their associated factors and outcomes.

METHODS

This single-centre, retrospective, observational study analysed data from sepsis survivors admitted to Okayama Saiseikai General Hospital from 2018 to 2019. Participants with sepsis were assigned to one of two study groups based on the presence or absence of dysphagia using the criterion of Functional Oral Intake Scale score <5 on the 7th day after admission. We used multivariate logistic regression to determine factors independently associated with dysphagia on the 7th day after admission. Multivariate logistic regression was also used to determine associations between groups and outcomes, including dysphagia on hospital discharge, direct discharge home (discharge of patients directly to their home), and total dependency (Barthel Index score ≤20) on hospital discharge.

RESULTS

One hundred one patients met the study inclusion criteria, 55 with dysphagia and 46 without dysphagia. Fasting period (adjusted odds ratio [AOR]: 1.31, 95% confidence interval [CI]: 1.07-1.59) and enteral tube feeding (AOR: 8.56, 95% CI: 1.95-37.5) were independently associated with the presence of dysphagia on the 7th day after admission. Dysphagia on the 7th day after admission was associated with dysphagia on hospital discharge (AOR: 46.0, 95%, CI: 7.90-268.3), a lower chance of direct discharge home (AOR: 0.03, 95% CI: 0.01-0.15), and a higher incidence of total dependency (AOR: 9.30, 95% CI: 2.68-32.2).

CONCLUSIONS

We found that dysphagia was commonly encountered post sepsis. Fasting period and enteral tube feeding were independently associated with dysphagia on the 7th day after admission. Dysphagia on the 7th day after admission was also associated with dysphagia on hospital discharge, nondirect discharge home, and dependency in activities of daily living at the time of hospital discharge.

[COVID-19-New challenges in dysphagia and respiratory therapy]

Coronavirus disease 2019 (COVID-19) can lead to severe disease courses with multiple organ involvement, respiratory and neurological functional impairments. Swallowing disorders (dysphagia) in this patient group can result from primary damage to the central and peripheral neuronal swallowing network but also from the frequently prolonged intensive care treatment and mechanical ventilation. Clinical observations indicate persistence of dysphagia in post-acute COVID-19 syndrome (long COVID), so that these patients probably also need long-term interventions for rehabilitation of safe and sufficient oral feeding. Therefore, structured disease-specific monitoring of dysphagia symptoms should be integrated into the treatment of COVID-19 patients and respiratory therapy should be an essential part of dysphagia management to re-establish cough effectiveness and breathing-swallowing coordination. Challenges arise from necessary adjustments to established treatment standards to prevent infections. Furthermore, the selection and intensity of therapeutic measures have to be adapted to the capacities and the specific pathophysiology of COVID-19 and long COVID patients to prevent further functional deterioration.

Impact of Frailty on Postoperative Dysphagia in Patients Undergoing Elective Cardiovascular Surgery

Background

Postextubation dysphagia (PED) is a serious postoperative complication following cardiovascular surgery that can lead to a worse prognosis. On the other hand, frailty is a prognostic factor in patients who undergo cardiac surgery.

Objectives

This study investigated the effect of frailty status on PED and impact of PED on postoperative complications.

Methods

This single-center retrospective cohort study included 644 consecutive patients who underwent elective cardiovascular surgery between May 1, 2014, and December 31, 2020; they were assigned to the PED or non-PED group based on postoperative swallowing status, and postoperative complications were investigated. Frailty status and physical functions, including walking speed, grip strength, Short Physical Performance Battery, and 6-minute walking distance, were preoperatively assessed; the frailty-status cutoff for predicting PED was determined from the receiver-operating characteristic curve.

Results

In this study cohort (mean age 67.7 years), the overall PED prevalence was 14.8%; preoperative frailty had a significantly higher prevalence in the PED group (50.0%) than in the non-PED group (20.3%; P < 0.001). PED correlated with a higher incidence of postoperative pneumonia and prolonged intensive care unit or hospital stay (P < 0.05 for all). After adjustment for confounders, multiple regression analysis revealed that preoperative frailty was independently associated with PED (P < 0.001).

Conclusions

PED occurred commonly after cardiovascular surgery and increased the risk of postoperative complications. Preoperative frailty was independently associated with PED. The 6-minute walking distance was the most powerful predictor of PED. Evaluation of preoperative frailty status is important for risk stratification and prevention of postoperative morbidity in patients undergoing surgery.

Swallowing function in COVID-19 patients after invasive mechanical ventilation

Objective

To explore swallowing function and risk factors associated with delayed recovery of swallowing in COVID-19 patients post invasive mechanical ventilation using the Functional Oral Intake Scale (FOIS).

Design

Longitudinal cohort study.

Setting

3 secondary-level hospitals.

Participants

Invasively ventilated patients (n=28), hospitalized with severe COVID-19 who were referred to the Speech and Language Pathology (SLP) departments post mechanical ventilation between March 5 and July 5 2020 for an evaluation of swallowing function before commencing oral diet.

Interventions

SLP assessment, advice and therapy for dysphagia.

Main outcome measures

Oral intake levels at baseline and hospital discharge according to the Functional Oral Intake Scale (FOIS). Patients were stratified according to FOIS (1-5=dysphagia, 6-7= functional oral intake). Data regarding comorbidities, frailty, intubation and tracheostomy, proning and SLP evaluation were collected.

Results

Dysphagia was found in 71% of the patients at baseline (in total 79% male, age 61 ±12 years, BMI 30 ±8 kg/m²). Median FOIS score at baseline was 2 (IQR 1) vs 5 (IQR 2.5) at hospital discharge. Patients with dysphagia were older (64 ±8.5 vs 53 ±16 years; p= 0.019), had a higher incidence of hypertension (70% vs 12%; p=0.006) were ventilated invasively longer (16 ±7 vs 10 ±2 days; p=0.017) or with tracheostomy (9 ±9 vs 1 ±2 days; p=0.03) longer. A negative association was found between swallowing dysfunction at bedside and days hospitalized (r=-0.471, p=0.01), and number of days at the Intensive Care Unit (ICU) (r=-0.48, p=0.01).

Conclusion

Dysphagia is prevalent in COVID-19 patients post invasive mechanical ventilation and is associated with number of days in hospital and number of days in the ICU. Swallowing function and tolerance of oral diet improved at discharge (p<0.001).

Aspiration syndromes and associated lung injury: incidence, pathophysiology and management

Aspiration is a common condition affecting healthy or sick patients which could create an acute or chronic inflammatory reaction in the lungs. Aspiration syndromes could be categorized according to a content entering the respiratory system into bacterial aspiration pneumonia with the gastric or oropharyngeal bacteria entering, aspiration chemical pneumonitis with bacteria-freegastric acid aspiration, or aspiration of a foreign body which causes an acute pulmonary emergency. There are differences in the clinical presentation of volume-dependent aspirations (microaspiration and macroaspiration): the higher is the volume of aspiration, the greater is the injury to the patient and more serious are the health consequences (with 70 % mortality rate for hospitalized patients). Aspiration syndromes can affect both the airways and pulmonary parenchyma, leading to acute lung injury, increased hospitalization rate and worse outcomes in critically ill patients. Impaired alveolar-capillary permeability, oedema formation, neutrophilic inflammatory response and pulmonary surfactant inactivation lead to reduced lung compliance and loss of aerated lung tissue and give rise to hypoxemia and respiratory failure. This review discusses the effect of aspiration events on the pulmonary tissue. The main focus is to distinguish the differences between bacterial and chemical pneumonia, their clinical presentation and symptoms, risk factors of developing the changes, possibilities of diagnostics and management as well as prevention of aspirations. Because of a risk of serious lung damage after the aspiration, pathophysiology and processes leading to lung tissue injury are discussed in detail. Data sources represent a systematic literature search using relevant medical subject headings.

Predicting feeding-tube dependence in patients following endotracheal extubation: a two-item swallowing screen

BACKGROUND

To meet the surging demands for intubation and invasive ventilation as more COVID-19 patients begin their recovery, clinicians are challenged to find an ultra-brief and minimally invasive screen for postextubation dysphagia predicting feeding-tube dependence persisting for 72 h after extubation.

METHODS

This study examined the predictive validity of a two-item swallowing screen on feeding-tube dependence over 72 h in patients following endotracheal extubation. Intensive-care-unit (ICU) patients (≥ 20 years) successfully extubated after ≥ 48 h endotracheal intubation were screened by trained nurses using the swallowing screen (comprising oral stereognosis and cough-reflex tests) 24 h postextubation. Feeding-tube dependence persisting for 72 h postextubation was abstracted from the medical record by an independent rater. To verify the results and cross-check whether the screen predicted penetration and/or aspiration during fiberoptic endoscopic evaluation of swallowing (FEES), participants agreeing to receive FEES were analyzed within 30 min of screening.

RESULTS

The results showed that 95/123 participants (77.2%) failed the screen, which predicted ICU patients' prolonged (> 72 h) feeding-tube dependence, yielding sensitivity of 0.83, specificity of 0.35, and accuracy of 0.68. Failed-screen participants had 2.96-fold higher odds of feeding-tube dependence (95% CI, 1.13-7.76). For the 38 participants receiving FEES, the swallowing screen had 0.89 sensitivity to detect feeding-tube dependence and 0.86 sensitivity to predict penetration/aspiration, although specificity had room for improvement (0.36 and 0.21, respectively).

CONCLUSION

This ultra-brief swallowing screen is sufficiently sensitive to identify high-risk patients for feeding-tube dependence persisting over 72 h after extubation. Once identified, a further assessment and care are indicated to ensure the prompt return of patients' oral feeding.

TRIAL REGISTRATION

NCT03284892, registered on September 15, 2017.

Management of COVID-19 ICU-survivors in primary care: - a narrative review

Many survivors of critical illness suffer from long-lasting physical, cognitive, and mental health sequelae. The number of affected patients is expected to markedly increase due to the COVID-19 pandemic. Many ICU survivors receive long-term care from a primary care physician. Hence, awareness and appropriate management of these sequelae is crucial. An interdisciplinary authorship team participated in a narrative literature review to identify key issues in managing COVID-19 ICU-survivors in primary care. The aim of this perspective paper is to synthesize important literature to understand and manage sequelae of critical illness due to COVID-19 in the primary care setting.

Post-extubation dysphagia and dysphonia amongst adults with COVID-19 in the Republic of Ireland: A prospective multi-site observational cohort study

Objectives

This study aims to (i) investigate post‐extubation dysphagia and dysphonia amongst adults intubated with SARS‐COV‐2 (COVID‐19) and referred to speech and language therapy (SLT) in acute hospitals across the Republic of Ireland (ROI) between March and June 2020; (ii) identify variables predictive of post‐extubation oral intake status and dysphonia and (iii) establish SLT rehabilitation needs and services provided to this cohort.

Design

A multi‐site prospective observational cohort study.

Participants

One hundred adults with confirmed COVID‐19 who were intubated across eleven acute hospital sites in ROI and who were referred to SLT services between March and June 2020 inclusive.

Main Outcome Measures

Oral intake status, level of diet modification and perceptual voice quality.

Results

Based on initial SLT assessment, 90% required altered oral intake and 59% required tube feeding with 36% not allowed oral intake. Age (OR 1.064; 95% CI 1.018–1.112), proning (OR 3.671; 95% CI 1.128–11.943) and pre‐existing respiratory disease (OR 5.863; 95% CI 1.521–11.599) were predictors of oral intake status post‐extubation. Two‐thirds (66%) presented with dysphonia post‐extubation. Intubation injury (OR 10.471; 95% CI 1.060–103.466) and pre‐existing respiratory disease (OR 24.196; 95% CI 1.609–363.78) were predictors of post‐extubation voice quality. Thirty‐seven per cent required dysphagia intervention post‐extubation, whereas 20% needed intervention for voice. Dysphagia and dysphonia persisted in 27% and 37% cases, respectively, at hospital discharge.

Discussion

Post‐extubation dysphagia and dysphonia were prevalent amongst adults with COVID‐19 across the ROI. Predictors included iatrogenic factors and underlying respiratory disease. Prompt evaluation and intervention is needed to minimise complications and inform rehabilitation planning.

Characterization of dysphagia and laryngeal findings in COVID-19 patients treated in the ICU-An observational clinical study

Background

Dysphagia appears to be common in patients with severe COVID-19. Information about the characteristics of dysphagia and laryngeal findings in COVID-19 patients treated in the intensive care unit (ICU) is still limited.

Objectives

The aim of this study was to evaluate oropharyngeal swallowing function and laryngeal appearance and function in patients with severe COVID-19.

Method

A series of 25 ICU patients with COVID-19 and signs of dysphagia were examined with fiberendoscopic evaluation of swallowing (FEES) during the latter stage of ICU care or after discharge from the ICU. Swallowing function and laryngeal findings were assessed with standard rating scales from video recordings.

Results

Pooling of secretions was found in 92% of patients. Eleven patients (44%) showed signs of silent aspiration to the trachea on at least one occasion. All patients showed residue after swallowing to some degree both in the vallecula and hypopharynx. Seventy-six percent of patients had impaired vocal cord movement. Erythema of the vocal folds was found in 60% of patients and edema in the arytenoid region in 60%.

Conclusion

Impairment of oropharyngeal swallowing function and abnormal laryngeal findings were common in this series of patients with severe COVID-19 treated in the ICU. To avoid complications related to dysphagia in this patient group, it seems to be of great importance to evaluate the swallowing function as a standard procedure, preferably at an early stage, before initiation of oral intake. Fiberendoscopic evaluation of swallowing is preferred due to the high incidence of pooling of secretion in the hypopharynx, silent aspiration, and residuals. Further studies of the impact on swallowing function in short- and long-term in patients with COVID-19 are warranted.

The incidence and clinical outcomes of postextubation dysphagia in a regional critical care setting

BACKGROUND

Postextubation dysphagia (PED) has been shown to occur in 41% of critically ill patients requiring endotracheal intubation. With one-third of patients with PED experiencing silent aspiration, it is reasonable to anticipate negative health outcomes are likely, although this has not yet been systematically explored in an Australian context.

OBJECTIVES

The aim of the study was to determine the impact of PED, in a regional Australian intensive care unit (ICU), on rates of pneumonia, the length of stay in the ICU and hospital, and healthcare expenditure.

METHODS

This study was conducted as a retrospective cohort analysis, which used administrative healthcare data of patients who received endotracheal intubation for invasive mechanical ventilation. Patients with a tracheostomy or known pre-existing dysphagia were excluded.

RESULTS

A total of 822 patient episodes were identified, of which 7% (n = 58) presented with PED. Half of all patients within the PED cohort (53%) were intubated for fewer than 48 h. Patients with PED had a longer median length of stay in the ICU (5 days versus 3 days, p < 0.001) and were more likely to develop pneumonia (odds ratio = 2.51, 95% confidence interval = 1.28, 4.95) than extubated patients without dysphagia. Median cost per hospital admission for patients with PED was double that for extubated patients without dysphagia (AUD $42,685 versus AUD $20,840, p < 0.001).

CONCLUSIONS

This study highlights that even a short duration of intubation may carry a risk of PED. The presence of PED, regardless of duration of intubation, increased the rates of pneumonia, length of stay in the ICU and hospital, and healthcare expenditure.

Clinical Manifestation, Evaluation, and Rehabilitative Strategy of Dysphagia Associated With COVID-19

ABSTRACT

Dysphagia is the difficulty in swallowing because of the presence of certain diseases; it particularly compromises the oral and/or pharyngeal stages. In severe acute respiratory syndrome coronavirus 2 infection, neuromuscular complications, prolonged bed rest, and endotracheal intubation target different levels of the swallowing network. Thus, critically ill patients are prone to dysphagia and aspiration pneumonia. In this review, we first discuss the possible cause and pathophysiology underlying dysphagia associated with coronavirus disease 2019, including cerebrovascular events, such as stroke, encephalomyelitis, encephalopathy, peripheral neuropathy, and myositis, that may lead to the dysphagia reported as a complication associated with the coronavirus disease 2019. Next, we present some recommendations for dysphagia evaluation with modifications that would allow a safe and comprehensive assessment based on available evidence to date, including critical considerations of the appropriate use of personal protective equipment and optimization individual's noninstrumental swallowing tasks evaluation, while preserving instrumental assessments for urgent cases only. Finally, we discuss a practical managing strategy for dysphagia rehabilitation to ensure safe and efficient practice in the risks of severe acute respiratory syndrome coronavirus 2 exposure, in which swallowing therapy using newer technology, such as telerehabilitation system or wearable device, would be considered as a useful option.

The addition of respiratory muscle strength training to facilitate swallow and pulmonary rehabilitation following massive tissue loss and severe deconditioning: A case series

INTRODUCTION

Impaired respiratory and swallow function in patients with intensive care unit-acquired deconditioning, such as associated with massive tissue loss, is not uncommon and can require prolonged rehabilitation.

AIM

The aim of the study was to examine the effect of combined inspiratory and expiratory respiratory muscle strength training (RMST) on respiratory and swallow function in two critical care patients with marked deconditioning after massive tissue loss.

METHODS

Case 1 was a 19-year-old male patient with 80% body surface area burns; case 2 was a 45-year-old man with group A streptococcus myositis necessitating quadruple amputation. Both required prolonged intensive care and mechanical ventilation. Both received routine intensive pulmonary and swallow rehabilitation before the trial; however, chronic aspiration and poor secretion clearance remained. At 25 and 26 weeks after initial injury, RMST was performed using EMST150 (expiratory) and Threshold IMT (inspiratory) devices, respectively. At baseline and throughout treatment, data collected included peak expiratory flow (PEF), anthropometry measures, aspiration risk (Penetration-Aspiration Scale [PAS]), pharyngeal clearance (Yale Pharyngeal Residue Scale), secretions (New Zealand Secretion Scale [NZSS]), and functional diet (Functional Oral Intake Scale [FOIS]) via endoscopy.

RESULTS/DISCUSSION

At baseline, the PEF score of case 1 was 41% (predicted age-height norm) and the PEF score of case 2 was 14%, indicating severe expiratory compromise. Both had extreme energy requirements (3300 kcal/day; 3500 kcal/day). The baseline swallowing scores of case 1 and 2 were as follows: PAS, 8 and 8; Yale, 9 and 10; NZSS, 4 and 7; and FOIS, 1 and 1, respectively, indicating profound dysphagia. At week 3 of 7 of RMST, swallow function improved to allow both to commence oral intake, followed by tracheostomy decannulation. At weeks 10 and 11, full dysphagia resolution was achieved (FOIS = 7; PAS = 1, Yale = 2, NZSS = 0), with PEF at 70% and 48% predicted respectively. Both patients continued RMST, and at discharge from the acute facility, PEF was 84% and 80% predicted respectively.

CONCLUSION

The addition of RMST assisted swallow and pulmonary rehabilitation in both cases and was clinically viable to deliver. Controlled validation trials are now required.

Detecting Oropharyngeal and Esophageal Emptying by Submental Ultrasonography and High-Resolution Impedance Manometry: Intubated vs. Non-Intubated Video-Assisted Thoracoscopic Surgery

Postoperative swallowing, affected by general anesthesia and intubation, plays an important part in airway and oral intake safety regarding effective oropharyngeal and esophageal emptying. However, objective evidence is limited. This study aimed to determine the time required from emergence to effective oropharyngeal and esophageal emptying in patients undergoing non-intubated (N) or tracheal-intubated (I) video-assisted thoracoscopic surgery (VATS). Hyoid bone displacement (HBD) by submental ultrasonography and high-resolution impedance manometry (HRIM) measurements were used to assess oropharyngeal and esophageal emptying. HRIM was performed every 10 min after emergence, up to 10 times. The primary outcome was to determine whether intubation affects the time required from effective oropharyngeal to esophageal emptying. The secondary outcome was to verify if HBD is comparable to preoperative data indicating effective oropharyngeal emptying. Thirty-two patients suitable for non-intubated VATS were recruited. Our results showed that comparable HBDs were achieved in all patients after emergence. Effective esophageal emptying was achieved at the first HRIM measurement in 11 N group patients and 2 I group patients (p = 0.002) and was achieved in all N (100%) and 13 I group patients (81%) within 100 min (p = 0.23). HBD and HRIM are warranted for detecting postoperative oropharyngeal and esophageal emptying.

Potential for Cognitive Communication Impairment in COVID-19 Survivors: A Call to Action for Speech-Language Pathologists

Purpose Severe acute respiratory syndrome coronavirus 2 is the virus resulting in COVID-19 infections in nearly 4.3 million Americans with COVID-19 in the United States as of July 29, 2020, with nearly 150,000 deaths and hundreds of thousands of survivors (https://www.coronavirus.jhu.edu/map.html). This tutorial reviews (a) what has been reported about neurological insults in cases of COVID-19 infection, (b) what is known from similar conditions in other disorders, and (c) how that combined information can inform clinical decision making. Method PubMed and the Cochrane Central Register of Controlled Trials were searched for COVID-19 or other coronavirus infections, cognitive impairment observed following critical care, and disorders for which intermittent or chronic hypoxia is characteristic. These were combined with searches relating to cognition, brain, and communication. All searches were conducted between April 8 and May 23, 2020. Meta-analyses and randomized clinical trials addressing other critical illnesses were also included to extend findings to potential cognitive communication outcomes following COVID-19. Results COVID-19 infection results in a combination of (a) respiratory infection with mechanical ventilation secondary to inadequate oxygenation, (b) inflammatory system reactivity, and (c) increased blood clotting factors. These affect central nervous system function incurring long-term cognitive communication impairment in a proportion of survivors. Diagnostic and intervention approaches for such impairments are discussed. Conclusions The existing literature on cognitive sequela of COVID-19 infection is small to date, but much can be learned from similar viral infections and disorders. Although COVID-19 is novel, the speech-language pathology approaches to evaluation and intervention of other populations of critical care patients are applicable. However, speech-language pathologists have not routinely been involved in these patients' acute care. As such, this is a call to action to speech-language pathologists to address the unprecedented numbers of patients who will need their services early in the disease process and throughout recovery.

A Consensus Statement for the Management and Rehabilitation of Communication and Swallowing Function in the ICU: A Global Response to COVID-19

Objective

To identify core practices for workforce management of communication and swallowing functions in coronavirus disease 2019 (COVID-19) positive patients within the intensive care unit (ICU).

Design

A modified Delphi methodology was used, with 3 electronic voting rounds. AGREE II and an adapted COVID-19 survey framework from physiotherapy were used to develop survey statements. Sixty-six statements pertaining to workforce planning and management of communication and swallowing function in the ICU were included.

Setting

Electronic modified Delphi process.

Participants

Speech-language pathologists (SLPs) (N=35) from 6 continents representing 12 countries.

Interventions

Not applicable.

Main Outcome Measures

The main outcome was consensus agreement, defined a priori as ≥70% of participants with a mean Likert score ≥7.0 (11-point scale: 0=strongly disagree, 10=strongly agree). Prioritization rank order of statements in a fourth round was also conducted.

Results

SLPs with a median of 15 years of ICU experience, working primarily in clinical (54%), academic (29%), or managerial positions (17%), completed all voting rounds. After the third round, 64 statements (97%) met criteria. Rank ordering identified issues of high importance.

Conclusions

A set of global consensus statements to facilitate planning and delivery of rehabilitative care for patients admitted to the ICU during the COVID-19 pandemic were agreed by an international expert SLP group. Statements focused on considerations for workforce preparation, resourcing and training, and the management of communication and swallowing functions. These statements support and provide direction for all members of the rehabilitation team to use for patients admitted to the ICU during a global pandemic.

Development of an Accurate Bedside Swallowing Evaluation Decision Tree Algorithm for Detecting Aspiration in Acute Respiratory Failure Survivors

BACKGROUND

The bedside swallowing evaluation (BSE) is an assessment of swallowing function and airway safety during swallowing. After extubation, the BSE often is used to identify the risk of aspiration in acute respiratory failure (ARF) survivors.

RESEARCH QUESTION

We conducted a multicenter prospective study of ARF survivors to determine the accuracy of the BSE and to develop a decision tree algorithm to identify aspiration risk.

STUDY DESIGN AND METHODS

Patients extubated after ≥ 48 hours of mechanical ventilation were eligible. Study procedures included the BSE followed by a gold standard evaluation, the flexible endoscopic evaluation of swallowing (FEES).

RESULTS

Overall, 213 patients were included in the final analysis. Median time from extubation to BSE was 25 hours (interquartile range, 21-45 hours). The FEES was completed 1 hour after the BSE (interquartile range, 0.5-2 hours). A total of 33% (70/213; 95% CI, 26.6%-39.2%) of patients aspirated on at least one FEES bolus consistency test. Thin liquids were the most commonly aspirated consistency: 27% (54/197; 95% CI, 21%-34%). The BSE detected any aspiration with an accuracy of 52% (95% CI, 45%-58%), a sensitivity of 83% (95% CI, 74%-92%), and negative predictive value (NPV) of 81% (95% CI, 72%-91%). Using recursive partitioning analyses, a five-variable BSE-based decision tree algorithm was developed that improved the detection of aspiration with an accuracy of 81% (95% CI, 75%-87%), sensitivity of 95% (95% CI, 90%-98%), and NPV of 97% (95% CI, 95%-99%).

INTERPRETATION

The BSE demonstrates variable accuracy to identify patients at high risk for aspiration. Our decision tree algorithm may enhance the BSE and may be used to identify patients at high risk for aspiration, yet requires further validation.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT02363686; URL: www.clinicaltrials.gov.