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Saconato M, Maselli-Schoueri JH, Malaque CMS, Marcusso RM, de Oliveira ACP, Batista LAN, Ultramari G, Lindoso JAL, Gonçalves MIR, Sztajnbok J. Postorotracheal intubation dysphagia in patients with COVID-19: A retrospective study. SAO PAULO MED J 2024; 142:e2022608. [PMID: 38808794 PMCID: PMC11126317 DOI: 10.1590/1516-3180.2022.0608.r3.14032024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 12/09/2023] [Accepted: 03/14/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND The cause of oropharyngeal dysphagia in patients with coronavirus disease (COVID-19) can be multifactorial and may underly limitations in swallowing rehabilitation. OBJECTIVE Analyze the factors related to dysphagia in patients with COVID-19 immediately after orotracheal extubation and the factors that influence swallowing rehabilitation. DESIGN AND SETTING A retrospective study. METHODS The presence of dysphagia was evaluated using the American Speech-Language Hearing Association National Outcome Measurement System (ASHA NOMS) scale and variables that influenced swallowing rehabilitation in 140 adult patients who required invasive mechanical ventilation for >48 h. RESULTS In total, 46.43% of the patients scored 1 or 2 on the ASHA NOMS (severe dysphagia) and 39.29% scored 4 (single consistency delivered orally) or 5 (exclusive oral diet with adaptations). Both the length of mechanical ventilation and the presence of neurological disorders were associated with lower ASHA NOMS scores (odds ratio [OR]: 0.80, 95% confidence interval [CI]: 0.74-0.87 P < 0.05; and OR: 0.13, 95% CI: 0.61-0.29; P < 0.05, respectively). Age and the presence of tracheostomy were negatively associated with speech rehabilitation (OR: 0.92; 95% CI: 0.87--0.96; OR: 0.24; 95% CI: 0.80--0.75), and acute post-COVID-19 kidney injury requiring dialysis and lower scores on the ASHA NOMS were associated with longer time for speech therapy outcomes (β: 1.62, 95% CI, 0.70-3.17, P < 0.001; β: -1.24, 95% CI: -1.55--0.92; P < 0.001). CONCLUSION Prolonged orotracheal intubation and post-COVID-19 neurological alterations increase the probability of dysphagia immediately after extubation. Increased age and tracheostomy limited rehabilitation.
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Affiliation(s)
- Mariana Saconato
- PhD. Speech therapist, Technical manager of the Speech Therapy team, Instituto de Infectologia Emílio Ribas (IIER), São Paulo (SP), Brazil
| | | | - Ceila Maria Sant’Ana Malaque
- PhD. Physician, Intensive Care Unit Physician, Instituto de Infectologia Emílio Ribas (IIER), São Paulo (SP), Brazil
| | - Rosa Maria Marcusso
- MSc. Statistician, Instituto de Infectologia Emílio Ribas (IIER), São Paulo (SP), Brazil
| | | | | | - Graziela Ultramari
- MSc. Physiotherapist, Head of the Diagnostic and Therapeutic Support Department, Instituto de Infectologia Emílio Ribas (IIER), São Paulo (SP), Brazil
| | - José Angelo Lauletta Lindoso
- PhD. Physician, Director of the Diagnostic and Therapeutic Support Department, Instituto de Infectologia Emílio Ribas (IIER), São Paulo (SP), Brazil
| | - Maria Inês Rebelo Gonçalves
- PhD. Speech therapist and Professor, Department of Speech Therapy, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil
| | - Jaques Sztajnbok
- MD. Physician, Head of the Intensive Care Unit, Instituto de Infectologia Emílio Ribas (IIER), São Paulo (SP), Brazil
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Luo X, Lin Y, Mo H, Zhang L. Incidence and factors associated with dysphagia in intensive care unit patients 24 h after extubation. Nurs Crit Care 2024. [PMID: 38429877 DOI: 10.1111/nicc.13026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 03/03/2024]
Abstract
BACKGROUND Post-extubation dysphagia deserves attention because it places patients at risk following extubation, especially critically ill patients in intensive care unit. However, there are limited studies of post-extubation dysphagia in the early stages after extubation. AIMS To investigate the incidence and factors associated with post-extubation dysphagia among patients in intensive care unit within 24 h of extubation. STUDY DESIGN A prospective descriptive study was carried out with 173 adult patients in intensive care unit with tracheal extubation at a tertiary hospital in Guangzhou, China. The Gugging Swallowing Screen was used to evaluate the swallowing function of patients 1, 4 and 24 h after extubation. Demographic and clinical data were retrieved from medical records. RESULTS The incidence of post-extubation dysphagia in patients within 1, 4 and 24 h after extubation was 86.71% (n = 150), 63.01% (n = 109) and 43.35% (n = 75), respectively. The risk factors included older age (OR = 1.057, 95%CI [1.039, 1.072], p < .001), cardiovascular disease (OR = 0.098, 95%CI [0.082, 0.127], p = .012), thyroid dysfunction (OR = 5.042, 95%CI [1.527, 13.684], p < .001), non-post-operative admission (OR = 3.186, 95%CI [1.142, 14.422], p = .036), mechanical ventilation duration >48 h (OR = 3.558, 95%CI [1.217, 10.385], p = .020), intubation duration >24 h (OR = 0.533, 95%CI [0.278, 0.898], p = .048) and intubation model size ≤7 (OR = 0.327, 95%CI [0.158, 0.788], p < .01). CONCLUSIONS This study revealed a high incidence of post-extubation dysphagia in critical patients in the 24 h after extubation, with the incidence decreasing over time. Screening of early post-extubation dysphagia after extubation is needed, but the specific evaluation time point requires further investigation. Patients with older age, cerebrovascular disease, thyroid dysfunction, post-operative admission, longer mechanical ventilation time, thicker intubation models and longer intubation time have a higher risk of the occurrence of post-extubation dysphagia. RELEVANCE TO CLINICAL PRACTICE The incidence of post-extubation dysphagia is very high in the early stage. Within 24 h after extubation, the patient's swallowing function should be actively evaluated, and the occurrence of aspiration should be vigilant. Patients with older age, cerebrovascular disease, thyroid dysfunction, post-operative admission, longer mechanical ventilation time, thicker intubation models and longer intubation time should receive more attention.
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Affiliation(s)
- Xuantian Luo
- School of Nursing, Sun Yat-sen University, Guangzhou, China
| | - Yeqing Lin
- Party Committee Organization Department, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hongping Mo
- Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lifeng Zhang
- School of Nursing, Sun Yat-sen University, Guangzhou, 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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Wang Y, Zhu K, Wang N, Chen X, Cai C, Zhu Y, Shi C. Development and Validation of a Risk Prediction Model to Predict Postextubation Dysphagia in Elderly Patients After Endotracheal Intubation Under General Anesthesia: A Single-Center Cross-Sectional Study. Dysphagia 2024; 39:63-76. [PMID: 37272948 DOI: 10.1007/s00455-023-10594-x] [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: 11/27/2022] [Accepted: 05/17/2023] [Indexed: 06/06/2023]
Abstract
At present, the incidence and risk factors for dysphagia after extubation in elderly inpatients are still unclear, and we aimed to develop and validate a risk prediction model that prospectively identifies high-risk patients to reduce the occurrence rate of dysphagia. The 469 patients recruited were randomly divided into modeling and validation groups in a 7:3 ratio. In the modeling group, the postextubation dysphagia (PED) risk factors were analyzed, and a risk prediction model was established. In the validation group, the model was validated and evaluated. The model was constructed based on the risk factors determined by a binary logistic regression analysis. The discrimination ability of the model was evaluated by the receiver operating characteristic (ROC) curve. The calibration curve and Hosmer‒Lemeshow test were performed to evaluate the model's calibration ability. The clinical utility of the risk prediction model was analyzed by decision curve analysis (DCA). The results showed that the incidence of PED was 15.99%, and age, duration of indwelling gastric tube, difficult endotracheal intubation, atomization after extubation, anesthesia risk level and frailty assessment were identified as important risk factors. The model was validated to have favorable discrimination, calibration ability and clinical utility. It has a certain extension value and clinical applicability, providing a feasible reference for preventing the occurrence of PED.
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Affiliation(s)
- Yixin Wang
- Institute of Nursing Research, Hubei Province Key Laboratory of Occupational Hazard Identification and Control, School of Medicine, Wuhan University of Science and Technology, Wuhan, Hubei, 430065, China
| | - Kaimei Zhu
- Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Nan Wang
- Institute of Nursing Research, Hubei Province Key Laboratory of Occupational Hazard Identification and Control, School of Medicine, Wuhan University of Science and Technology, Wuhan, Hubei, 430065, China
| | - Xiangrong Chen
- General Hospital of PLA Central Theater Command, Wuhan, Hubei, China
| | - Chan Cai
- Institute of Nursing Research, Hubei Province Key Laboratory of Occupational Hazard Identification and Control, School of Medicine, Wuhan University of Science and Technology, Wuhan, Hubei, 430065, China
| | - Yuxin Zhu
- Institute of Nursing Research, Hubei Province Key Laboratory of Occupational Hazard Identification and Control, School of Medicine, Wuhan University of Science and Technology, Wuhan, Hubei, 430065, China
| | - Chongqing Shi
- Institute of Nursing Research, Hubei Province Key Laboratory of Occupational Hazard Identification and Control, School of Medicine, Wuhan University of Science and Technology, Wuhan, Hubei, 430065, China.
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Clayton NA, Ward EC, Norman E, Ryan H, Kol MR. Speech pathology assessment of dysphagia post endotracheal extubation: A service-model evaluation. Aust Crit Care 2024; 37:144-150. [PMID: 37709658 DOI: 10.1016/j.aucc.2023.07.041] [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: 08/22/2022] [Revised: 06/02/2023] [Accepted: 07/25/2023] [Indexed: 09/16/2023] Open
Abstract
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.
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Affiliation(s)
- Nicola A Clayton
- Speech Pathology Department, Concord Repatriation General Hospital, NSW Australia; Intensive Care Unit, Concord Repatriation General Hospital, NSW Australia; School of Health and Rehabilitation Sciences, University of Queensland, QLD Australia; Faculty of Medical and Health Sciences, University of Sydney, NSW Australia.
| | - Elizabeth C Ward
- School of Health and Rehabilitation Sciences, University of Queensland, QLD Australia; Centre for Functioning and Health Research, Metro South Health, Queensland Health, QLD Australia
| | - Eva Norman
- Speech Pathology Department, Concord Repatriation General Hospital, NSW Australia; Intensive Care Unit, Concord Repatriation General Hospital, NSW Australia
| | - Helen Ryan
- Speech Pathology Department, Concord Repatriation General Hospital, NSW Australia
| | - Mark R Kol
- Intensive Care Unit, Concord Repatriation General Hospital, NSW Australia
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Lin CW, Chiang TY, Chen WC, Chiu LW, Su YC, Lin HC, Chang CT. Is Postextubation Dysphagia Underestimated in the Era of COVID-19? A Systematic Review and Meta-Analysis. Otolaryngol Head Neck Surg 2023; 168:935-943. [PMID: 36842159 DOI: 10.1002/ohn.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/01/2022] [Accepted: 09/04/2022] [Indexed: 02/27/2023]
Abstract
OBJECTIVE To investigate the incidence rate of postextubation dysphagia (PED) in patients with COVID-19, as well as relative factors potentially influencing the clinical course of dysphagia. DATA SOURCES Six databases including PubMed, MEDLINE, Embase, ScienceDirect, the Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science were searched with no restriction on the language. REVIEW METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Data were extracted and cross-examined among 3 of the authors. The random-effects model was adopted for the statistical synthesis. The percentage and 95% confidence interval (CI) were adopted as the effect measurements of the PED incidence rate. Subgroup analyses, sensitivity analyses, and metaregression were also performed to identify the heterogeneity among the studies. RESULTS A total of 594 patients were enrolled and analyzed from the 10 eligible studies. The weighted incidence of PED in patients with COVID-19 was 66.5% (95% CI: 49.7%-79.9%). Age was the potential factor influencing the incidence rate after heterogeneity was adjusted by the metaregression analysis. CONCLUSION Compared to the current evidence reporting only 41% of the non-COVID patients experienced PED, our study further disclosed that a higher 66.5% of COVID-19 patients suffered from PED, which deserves global physicians' attention. With the association between COVID-19 and dysphagia having been more clearly understood, future clinicians are suggested to identify intubated patients' risk factors earlier to strengthen PED care programs in the era of COVID-19.
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Affiliation(s)
- Chung-Wei Lin
- Department of Education, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Ting-Yi Chiang
- Department of Education, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Wen-Ching Chen
- Department of General Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Li-Wen Chiu
- Department of Education, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yung-Chung Su
- Department of General Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsin-Ching Lin
- Department of Otolaryngology, Division of Laryngology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Business Management and Institute of Biomedical Science, Institute of Healthcare Management, National Sun Yat-sen University, Kaohsiung, Taiwan.,Sleep Center, Robotic Surgery Center and Center for Quality Management, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chun-Tuan Chang
- Department of Business Management and Institute of Biomedical Science, Institute of Healthcare Management, National Sun Yat-sen University, Kaohsiung, Taiwan
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Royals WJ, Gillis RJ, Campbell JL. A Decision Guide for Assessing the Recently Extubated Patient's Readiness for Safe Oral Intake. Crit Care Nurse 2023; 43:42-51. [PMID: 36720280 DOI: 10.4037/ccn2023722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Postextubation dysphagia is a known consequence of endotracheal intubation. Several risk factors for postextubation dysphagia have been identified that could be used to help determine which patients should undergo swallowing assessment by an appropriate professional. LOCAL PROBLEM At the authors' institution, critical care nurses, health care providers, and speech-language pathology professionals lacked a clear process for referring patients for swallowing assessment after extubation, resulting in inefficiency and confusion. Information to guide their decision-making in this area was needed. To address this need, a multidisciplinary group convened and developed a guide with specific indicators. METHODS A review of the literature on postextubation dysphagia was conducted to determine the most appropriate indicators for the guide, which was piloted in the medical intensive care unit. The utilization rate was calculated. Referrals to speech-language pathology professionals were tabulated before and after the project. RESULTS During the 11 months before implementation of the project, there were 994 speech-language pathology consultations for postextubation evaluation of swallowing. During the 11 months after implementation, there were 831 consultations, representing a 16.4% reduction. The decline in consultations resulted in cost savings in addition to preventing unnecessary testing before patients' resumption of oral intake. The utilization rate for the guide during the project was 58%. CONCLUSION The decision guide was an effective tool to help nurses and health care providers determine which patients should be referred to speech-language pathology professionals for swallowing assessment after extubation, facilitating the appropriate use of limited health care resources.
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Affiliation(s)
- Waverlyn J Royals
- Waverlyn J. Royals is a speech-language pathology clinical specialist and student education coordinator for Rehabilitation Services, ECU Health Medical Center, Greenville, North Carolina
| | - Rita J Gillis
- Rita J. Gillis is a retired speech-language pathologist. At the time this project was initiated, she was Director of Performance Improvement and Professional Practice for Rehabilitation Services, ECU Health Medical Center
| | - Jarvis L Campbell
- Jarvis L. Campbell is an assistant nurse manager for the medical intensive care unit and the Continuous Renal Replacement Therapy program, ECU Health Medical Center
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Dysphagia in Intensive Care Evaluation (DICE): An International Cross-Sectional Survey. Dysphagia 2022; 37:1451-1460. [PMID: 35092486 DOI: 10.1007/s00455-021-10389-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 10/31/2021] [Indexed: 12/16/2022]
Abstract
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.
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Catlow R, Cheeseman C, Newman H. COVID-19: Nutrition and functional outcomes for critical care survivors in a 400- bedded district general hospital in North London. J Intensive Care Soc 2022; 23:510-512. [PMID: 36751351 PMCID: PMC9679901 DOI: 10.1177/17511437211025420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Novel coronavirus disease (COVID-19) has resulted in huge numbers of critically ill patients. This study describes the inpatient recovery and rehabilitation needs of patients admitted with COVID-19 to the critical care unit of a 400 bedded general hospital in London, United Kingdom. The rehabilitation needs of our sample were considerable. It is recommended that the increase demand on allied health professionals capacity demonstrated is considered in future COVID-19-related workforce-planning.
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Affiliation(s)
- Rachel Catlow
- Rachel Catlow, Therapy Department, Barnet
Hospital, London NW3 2 QG, UK.
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Liang T, Li SL, Peng YC, Chen Q, Chen LW, Lin YJ. Efficacy and Safety of Oral Hydration 1 Hour After Extubation of Patients Undergoing Cardiac Surgery: A Randomized Controlled Trial. J Cardiovasc Nurs 2022; Publish Ahead of Print:00005082-990000000-00044. [PMID: 36730988 DOI: 10.1097/jcn.0000000000000953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Thirst is one of the most common and uncomfortable symptoms in patients after cardiac surgery. The postextubation time for early oral hydration (EOH) remains unclear, and there is a lack of studies on its safety and effectiveness. OBJECTIVE The aim of this study was to investigate the effects of oral hydration 1 hour after extubation on thirst, salivary pH, salivary flow, oral mucosa, halitosis, gastrointestinal adverse reactions, aspiration pneumonia, and satisfaction in patients undergoing cardiac surgery. METHODS Eighty-four patients who underwent cardiac surgery were randomly assigned into 2 groups, for either conventional oral hydration (COH) or EOH. The EOH group drank 30 mL of warm water 1 hour post extubation and thereafter 50 mL hourly for 4 hours. The COH group had nil per os for 4 hours after extubation. If no dysphagia was evident after 4 hours, the patients were instructed to slowly drink water. Thirst intensity was evaluated every hour before the intervention. Nausea and vomiting were recorded after drinking water. The salivary pH, unstimulated salivary flow rate, oral odor, and oral mucosal moisture were evaluated at 1 hour post extubation, immediately before the intervention, and at 4 hour post intervention. Aspiration pneumonia data were collected within 72 hours post intervention. Satisfaction was assessed before leaving the intensive care unit. RESULTS The scores for thirst (3.38 ± 1.04; F = 306.21, P < .001), oral mucosa (2.03 ± 0.74; P < .001), and halitosis (2.77 ± 0.63; P < .001) in the EOH group were significantly lower than those in the COH group. The EOH group had significantly higher salivary pH (6.44 ± 1.06; P < .001), unstimulated salivary flow rates (0.18 ± 0.08; P < .001), and patient satisfaction (4.28 ± 0.45; P < .001) than the COH group. Nausea and vomiting did not differ significantly between groups (P = .60). Aspiration pneumonia was not observed in either group. CONCLUSIONS Oral hydration 1 hour after extubation significantly alleviated thirst and stabilized the oral environment without gastrointestinal adverse reactions or aspiration pneumonia, and with increased patient satisfaction.
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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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12
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Silva RDD, Santos RS, Taveira KVM, Guariza Filho O, Basso IB, Ravazzi GMNC, Zeigelboim BS, Stechman-Neto J, Araujo CMD. Deglutition assessment instruments used in critical patients submitted to orotracheal extubation: a scoping review. REVISTA CEFAC 2022. [DOI: 10.1590/1982-0216/20222457222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Rayane Délcia da Silva
- Núcleo de Estudos Avançados em Revisão Sistemática e Meta-Análise, Brasil; Universidade Tuiuti do Paraná, Brazil
| | - Rosane Sampaio Santos
- Núcleo de Estudos Avançados em Revisão Sistemática e Meta-Análise, Brasil; Universidade Tuiuti do Paraná, Brazil
| | - Karinna Verissimo Meira Taveira
- Núcleo de Estudos Avançados em Revisão Sistemática e Meta-Análise, Brasil; Universidade Federal do Rio Grande do Norte, Brazil
| | - Odilon Guariza Filho
- Núcleo de Estudos Avançados em Revisão Sistemática e Meta-Análise, Brasil; Pontifícia Universidade Católica do Paraná, Brazil
| | | | | | - Bianca Simone Zeigelboim
- Núcleo de Estudos Avançados em Revisão Sistemática e Meta-Análise, Brasil; Universidade Tuiuti do Paraná, Brazil
| | - José Stechman-Neto
- Núcleo de Estudos Avançados em Revisão Sistemática e Meta-Análise, Brasil; Universidade Tuiuti do Paraná, Brazil
| | - Cristiano Miranda de Araujo
- Núcleo de Estudos Avançados em Revisão Sistemática e Meta-Análise, Brasil; Universidade Tuiuti do Paraná, Brazil
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13
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Siao SF, Tseng WH, Wang TG, Wei YC, Hsiao TY, Ku SC, Chen CCH. Predicting feeding-tube dependence in patients following endotracheal extubation: a two-item swallowing screen. BMC Pulm Med 2021; 21:403. [PMID: 34872549 PMCID: PMC8647059 DOI: 10.1186/s12890-021-01771-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 11/30/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Shu-Fen Siao
- Department of Nursing, National Taiwan University College of Medicine, Taipei, Taiwan R.O.C
| | - Wen-Hsuan Tseng
- Department of Otolaryngology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan R.O.C
| | - Tyng-Guey Wang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan R.O.C
| | - Yu-Chung Wei
- Graduate Institute of Statistics and Information Science, National Changhua University of Education, Changhua, Taiwan R.O.C
| | - Tzu-Yu Hsiao
- Department of Otolaryngology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan R.O.C
| | - Shih-Chi Ku
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, 7, Chung Shan S. Rd., Zhongzheng Dist., Taipei, 100, Taiwan R.O.C..
| | - Cheryl Chia-Hui Chen
- Department of Nursing, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan R.O.C
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14
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Dysphagia Severity and Management in Patients with COVID-19. CURRENT HEALTH SCIENCES JOURNAL 2021; 47:147-156. [PMID: 34765231 PMCID: PMC8551886 DOI: 10.12865/chsj.47.02.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/07/2021] [Indexed: 11/18/2022]
Abstract
COVID-19 has resulted in unprecedented numbers of patients treated at intensive care units (ICUs). Dysphagia is a key concern in critical illness survivors. We investigated the severity of dysphagia in COVID-19 and the need to adapt practices to provide efficient care. We reviewed the literature on COVID-19, post-critical-illness dysphagia, and dysphagia and tracheostomy guidelines during the pandemic. Critically ill COVID-19 patients present a high incidence of dysphagia, aggravated by respiratory distress, deconditioning, and neurological complications. Mechanical ventilation (MV), delirium, sedation and weakness are worse in COVID-19 than in other etiologies of critical care. In awake patients, respiratory compromise impairs breathing-swallowing-coughing coordination. Tracheostomy reduces laryngopharyngeal trauma, sedation, delirium, ICU stay and improves swallowing rehabilitation. Tracheostomy weaning and swallowing evaluation is complex in COVID-19 due to respiratory instability and a team discussion will guide adaptations. Patients assessed in the ICU were 67% recommended to be nil by mouth (were aspirating). Two months following hospital discharge, 83% of those who had undergone tracheostomy were managing a normal diet. Severely ill COVID-19 patients are expected to regain swallow function. Dysphagia care is based on adaptation of practices to the patients' multiple impairments.
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15
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Dallal York J, Leonard K, Anderson A, DiBiase L, Jeng EI, Plowman EK. Discriminant Ability of the 3-Ounce Water Swallow Test to Detect Aspiration in Acute Postoperative Cardiac Surgical Patients. Dysphagia 2021; 37:831-838. [PMID: 34268585 DOI: 10.1007/s00455-021-10333-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 06/22/2021] [Indexed: 01/22/2023]
Abstract
Dysphagia is a common complication of cardiac surgery (CS) contributing to morbidity and mortality. Although early dysphagia detection is important, no current screening guidelines or validated tools exist in the cardiac intensive care setting. We therefore aimed to examine the discriminant ability of the 3-ounce water swallow test (3 oz. WST) to detect aspiration in acute postoperative CS patients. 196 postoperative CS patients were enrolled in this prospective single-center study. Participants completed the 3 oz. WST and a standardized Flexible Endoscopic Evaluation of Swallowing. Independent duplicate ratings of the penetration aspiration scale (PAS) were performed in a blinded fashion (100% agreement criteria). Receiver operating characteristic curve and area under the curve (AUC) analyses were performed with sensitivity, specificity, positive, and negative predictive values (PPV, NPV) derived. Fifty-four CS patients (28%) were confirmed aspirators (PAS ≥ 6), of whom 48% (n = 26) were silent aspirators (PAS = 8). Both the sensitivity and specificity of the 3 oz. WST to identify instrumentally confirmed aspiration was 63% (AUC: 0.63, 95% CI: 0.54, 0.72), and PPV was 39% and NPV 82%. The 3 oz. WST demonstrated fair discriminant ability to detect aspiration in acute postoperative CS patients. The high rate of silent aspiration may explain, in part, these findings given that the screening fail criteria include an overt cough response. In isolation, the 3 oz. WST does not represent a sensitive screen of aspiration in postoperative CS patients with a need to identify alternative screening tools for this setting.
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Affiliation(s)
- Justine Dallal York
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA.,Department of Speech, Language & Hearing Science, College of Public Health, Health Professions, University of Florida, 1225 Center Drive, PO Box 100174, Gainesville, FL, USA
| | - Kelly Leonard
- Department of Speech, Language & Hearing Science, College of Public Health, Health Professions, University of Florida, 1225 Center Drive, PO Box 100174, Gainesville, FL, USA
| | - Amber Anderson
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA
| | - Lauren DiBiase
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA
| | - Eric I Jeng
- Department of Surgery, Division of Cardiothoracic Surgery, University of Florida, Gainesville, FL, USA
| | - Emily K Plowman
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA. .,Department of Speech, Language & Hearing Science, College of Public Health, Health Professions, University of Florida, 1225 Center Drive, PO Box 100174, Gainesville, FL, USA. .,Department of Surgery, Division of Cardiothoracic Surgery, University of Florida, Gainesville, FL, USA. .,Department of Neurology, University of Florida, Gainesville, FL, USA.
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16
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Predictors of swallowing outcomes in patients with combat-injury related dysphagia. J Trauma Acute Care Surg 2021; 89:S192-S199. [PMID: 32068719 DOI: 10.1097/ta.0000000000002623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Traumatic injuries, such as those from combat-related activities, can lead to complicated clinical presentations that may include dysphagia. METHODS This retrospective observational database study captured dysphagia-related information for 215 US military service members admitted to the first stateside military treatment facility after sustaining combat-related or combat-like traumatic injuries. A multidimensional relational database was developed to document the nature, course, and management for dysphagia in this unique population and to explore variables predictive of swallowing recovery using Bayesian statistical modeling and inferential statistical methods. RESULTS Bayesian statistical modeling revealed the importance of maxillofacial fractures and soft tissue loss as primary predictors of poor swallowing outcomes. The presence of traumatic brain injury (TBI), though common, did not further complicate dysphagia outcomes. A more detailed examination and rating of videofluoroscopic swallow studies from a subset of 161 participants supported greater impairment for participants with maxillofacial trauma and no apparent relationship between having sustained a TBI and swallow functioning. CONCLUSION These analyses revealed that maxillofacial trauma is a stronger indicator than TBI of dysphagia severity and slower or incomplete recovery following combat-related injuries. LEVEL OF EVIDENCE Therapeutic/Care Management study, level IV.
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McIntyre M, Chimunda T, Koppa M, Dalton N, Reinders H, Doeltgen S. Risk Factors for Postextubation Dysphagia: A Systematic Review and Meta-analysis. Laryngoscope 2020; 132:364-374. [PMID: 33320371 DOI: 10.1002/lary.29311] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES/HYPOTHESIS To identify, describe, and where possible meaningfully synthesize the reported risk factors for postextubation dysphagia (PED) in critically ill patients. STUDY DESIGN Systematic review and meta-analysis. METHODS A systematic search of peer-reviewed and grey literature was conducted in common scientific databases to identify previously evaluated risk factors of PED. Data extraction and risk of bias assessment used a double-blind approach. Random effects models were used for the meta-analyses. Meta-analyses were conducted where sufficient study numbers allowed after accounting for statistical and clinical heterogeneity. RESULTS Twenty-five studies were included, which investigated a total of 150 potential risk factors. Of these, 63 risk factors were previously identified by at least one study each as significantly increasing the risk of PED. After accounting for clinical and statistical heterogeneity, only two risk factors were suitable for meta-analysis, gender, and duration of intubation. In separate meta-analyses, neither gender (RR 1.00 [0.71, 1.43], I2 = 0%) nor duration of intubation (RR 1.54 [-0.40, 3.49], I2 = 0%) were significant predictors of PED. CONCLUSIONS A large number of risk factors for PED have been reported in the literature. However, significant variability in swallowing assessment methods, patient populations, timing of assessment, and duration of intubation prevented meaningful meta-analyses for the majority of these risk factors. Where meta-analysis was possible, gender and duration of intubation were not identified as risk factors for PED. We discuss future directions in clinical and research contexts. Laryngoscope, 2020.
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Affiliation(s)
- Melanie McIntyre
- Swallowing Neurorehabilitation Research Lab, Speech Pathology, Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Bedford Park, South Australia, Australia.,Department of Speech Pathology, Bendigo Health, Bendigo, Victoria, Australia
| | - Timothy Chimunda
- Division of Critical Care, Bendigo Health, Bendigo, Victoria, Australia.,Department of Intensive Care Medicine, Goulburn Valley Health, Shepparton, Victoria, Australia.,Department of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Mayank Koppa
- School of Rural Health, Monash University, Melbourne, Victoria, Australia
| | - Nathan Dalton
- School of Rural Health, Monash University, Melbourne, Victoria, Australia
| | - Hannah Reinders
- Department of Speech Pathology, Bendigo Health, Bendigo, Victoria, Australia
| | - Sebastian Doeltgen
- Swallowing Neurorehabilitation Research Lab, Speech Pathology, Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Bedford Park, South Australia, Australia
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18
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Dobak S, Kelly D. Tough Pill to Swallow: Postextubation Dysphagia and Nutrition Impact in the Intensive Care Unit. Nutr Clin Pract 2020; 36:80-87. [PMID: 33242222 DOI: 10.1002/ncp.10602] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/16/2020] [Indexed: 12/31/2022] Open
Abstract
More than 5 million patients are admitted to US intensive care units (ICUs) each year. Many of these patients have risk factors for dysphagia. Dysphagia must be promptly addressed and appropriately treated to avoid the deleterious impacts of aspiration and malnutrition. Therefore, clinicians must be aware of ways to identify and treat dysphagia. This review will highlight the risk factors, mechanisms, and impact of dysphagia in the ICU as well as provide screening, diagnostic, and management options.
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Affiliation(s)
- Stephanie Dobak
- Department of Neurology, Jefferson Weinberg ALS Center, Philadelphia, Pennsylvania, USA
| | - Daniel Kelly
- Department of Rehabilitation, Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
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19
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Dallal York J, Miller S, Chapin J, Gore S, Jeng EI, Plowman EK. Swallowing screening practice patterns for nurses in the cardiac surgery intensive care unit. J Clin Nurs 2020; 29:4573-4582. [PMID: 32920944 DOI: 10.1111/jocn.15490] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/23/2020] [Accepted: 08/24/2020] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES The current study surveyed nurse practice patterns for performing swallowing screens in an academic cardiac intensive care unit (ICU). It aimed to index: training and levels of confidence in conducting dysphagia screens; screening methods employed; timing and frequency of implement; and subsequent plan of care in identified high-risk patients. BACKGROUND Swallowing impairment (dysphagia) is common following cardiac surgery and associated with significant morbidity and mortality. Early and accurate detection of dysphagia is therefore critical to afford implementation of interventions to optimise patient care. Currently, no validated instruments or guidelines exist for nursing screening of dysphagia in this setting. METHODS An anonymous and voluntary 10-item mixed-methods online survey was conducted using Qualtrics software. Nonprobability purposive sampling was utilised to recruit nurses working in an academic 24-bed cardiac ICU. Thematic analysis using operationally defined coding, SRQR checklist and descriptive statistics were employed. RESULTS Sixty-nine nurses completed the survey during a 1-month period, representing an 84% response rate. Formal training in performing swallowing screens was reported in 18.6% of nurses. In rank order, reported level of confidence was the following: "moderately" (49%); "somewhat" (35%); "not" (13%); and "very" (3%). The majority of nurses performed screens within 1 hr (40.6%) or between 1-4 hr (43.8%) of extubation. Fifteen different methods were utilised to screen swallowing function by nurses who reported a total of 31 different clinical signs indicative of dysphagia. CONCLUSIONS Survey data of practicing nurses in an academic cardiac ICU revealed limited formal training in swallowing screening methodology, a high degree of variability in screening methods employed and low levels of agreement for dysphagia signs. RELEVANCE TO CLINICAL PRACTICE Data highlight a knowledge gap and need for the development of formal education and validated rapid nursing dysphagia screening tools for standardised implementation in the cardiac surgery ICU setting.
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Affiliation(s)
- Justine Dallal York
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA.,Department of Speech, College of Public Health, Health Professions, University of Florida, Gainesville, FL, USA
| | - Sarah Miller
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Jennifer Chapin
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA
| | - Stephanie Gore
- Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Eric I Jeng
- Division of Cardiothoracic Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Emily K Plowman
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA.,Department of Speech, College of Public Health, Health Professions, University of Florida, Gainesville, FL, USA.,Division of Cardiothoracic Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA.,Department of Neurology, University of Florida, Gainesville, FL, USA
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20
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McIntyre M, Doeltgen S, Dalton N, Koppa M, Chimunda T. Post-extubation dysphagia incidence in critically ill patients: A systematic review and meta-analysis. Aust Crit Care 2020; 34:67-75. [PMID: 32739246 DOI: 10.1016/j.aucc.2020.05.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 05/10/2020] [Accepted: 05/19/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Post-extubation dysphagia has been associated with adverse health outcomes. To assist service planning and process development for early identification, an understanding of the number of patients affected is required. However, significant variation exists in the reported incidence which ranges from 3% to 62%. OBJECTIVES The objective of this study was to (i) conduct a meta-analysis on the incidence of dysphagia after endotracheal intubation in adult critically ill patients and (ii) describe the extent of heterogeneity within peer-reviewed articles and grey literature on the incidence of dysphagia after endotracheal intubation. DATA SOURCES Databases CINAHL, Cochrane Library, Embase, MEDLINE, PubMed, SpeechBITE, and Google Scholar were systematically searched for studies published before October 2019. REVIEW METHODS Data extraction occurred in a double-blind manner for studies meeting the inclusion criteria. Risk of bias was determined using critical appraisal tools relevant to the individual study design. The overall quality of the synthesised results was described using the Grading of Recommendations Assessment, Development and Evaluation methodology. Raw data were transformed using Freeman-Tukey arcsine square root methodology. A random-effects model was utilised owing to heterogeneity between studies. RESULTS Of 3564 identified studies, 38 met the criteria for inclusion in the final review. A total of 5798 patient events were analysed, with 1957 dysphagic episodes identified. The combined weighted incidence of post-extubation dysphagia was 41% (95% confidence interval, 0.33-0.50). Of the patients with dysphagia, 36% aspirated silently (n = 155, 95% confidence interval, 0.22-0.50). Subgroup meta-regression analysis was unable to explain the heterogeneity across studies when accounting for the method of participant recruitment, method of dysphagia assessment, median duration of intubation, timing of dysphagia assessment, or patient population. CONCLUSION Dysphagia after endotracheal intubation is common and occurs in 41% of critically ill adults. Given the prevalence of dysphagia and high rates of silent aspiration in this population, further prospective research should focus on systematic and sensitive early identification methods.
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Affiliation(s)
- Melanie McIntyre
- Swallowing Neurorehabilitation Research Lab, Speech Pathology, Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, 5001, Australia; Bendigo Health, Department of Speech Pathology, GPO Box 126, Bendigo, Victoria, 3552, Australia.
| | - Sebastian Doeltgen
- Swallowing Neurorehabilitation Research Lab, Speech Pathology, Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, 5001, Australia
| | - Nathan Dalton
- Monash University School of Rural Health, PO Box 666, Bendigo, Victoria, 3552, Australia
| | - Mayank Koppa
- Monash University School of Rural Health, PO Box 666, Bendigo, Victoria, 3552, Australia
| | - Timothy Chimunda
- Bendigo Health, Department of Intensive Care Medicine, GPO Box 126, Bendigo, Victoria, 3552, Australia; University of Queensland, St Lucia, Queensland, 4072, Australia; University of Melbourne, Grattan Street, Parkville, Victoria, 3010, Australia
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21
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Moss M, White SD, Warner H, Dvorkin D, Fink D, Gomez-Taborda S, Higgins C, Krisciunas GP, Levitt JE, McKeehan J, McNally E, Rubio A, Scheel R, Siner JM, Vojnik R, Langmore SE. Development of an Accurate Bedside Swallowing Evaluation Decision Tree Algorithm for Detecting Aspiration in Acute Respiratory Failure Survivors. Chest 2020; 158:1923-1933. [PMID: 32721404 DOI: 10.1016/j.chest.2020.07.051] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 07/06/2020] [Accepted: 07/12/2020] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, Aurora, CO.
| | - S David White
- University of Colorado Denver Rehabilitation Therapy Services, University of Colorado Hospital, Aurora, CO
| | - Heather Warner
- Section of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, CT; Department of Communication Disorders, Southern Connecticut State University, New Haven, CT
| | - Daniel Dvorkin
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, Aurora, CO; The Bioinformatics CRO, Inc, Niceville, FL
| | - Daniel Fink
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, CO
| | | | - Carrie Higgins
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, Aurora, CO
| | - Gintas P Krisciunas
- Department of Otolaryngology, Boston Medical Center, Boston, MA; Department of Otolaryngology, Boston University School of Medicine, Boston, MA
| | - Joseph E Levitt
- Division of Pulmonary and Critical Care, Stanford University, Stanford, CA
| | - Jeffrey McKeehan
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, Aurora, CO
| | - Edel McNally
- Department of Otolaryngology, Boston Medical Center, Boston, MA; Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, MA
| | - Alix Rubio
- Department of Otolaryngology, Boston Medical Center, Boston, MA
| | - Rebecca Scheel
- Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, MA; Division of Speech Language Pathology, Massachusetts General Hospital, Boston, MA
| | - Jonathan M Siner
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT
| | - Rosemary Vojnik
- Division of Pulmonary and Critical Care, Stanford University, Stanford, CA
| | - Susan E Langmore
- Department of Otolaryngology, Boston Medical Center, Boston, MA; Department of Otolaryngology, Boston University School of Medicine, Boston, MA; Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, MA
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22
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Fritz MA, Howell RJ, Brodsky MB, Suiter DM, Dhar SI, Rameau A, Richard T, Skelley M, Ashford JR, O'Rourke AK, Kuhn MA. Moving Forward with Dysphagia Care: Implementing Strategies during the COVID-19 Pandemic and Beyond. Dysphagia 2020; 36:161-169. [PMID: 32519150 PMCID: PMC7282541 DOI: 10.1007/s00455-020-10144-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/04/2020] [Indexed: 01/25/2023]
Abstract
Growing numbers of SARS-CoV-2 cases coupled with limited understanding of transmissibility and virulence, have challenged the current workflow and clinical care pathways for the dysphagia provider. At the same time, the need for non-COVID-19-related dysphagia care persists. Increased awareness of asymptomatic virus carriers and variable expression of the disease have also focused attention to appropriate patient care in the context of protection for the healthcare workforce. The objective of this review was to create a clinical algorithm and reference for dysphagia clinicians across clinical settings to minimize spread of COVID-19 cases while providing optimal care to patients suffering from swallowing disorders. Every practitioner and healthcare system will likely have different constraints or preferences leading to the utilization of one technique over another. Knowledge about this pandemic increases every day, but the algorithms provided here will help in considering the best options for proceeding with safe and effective dysphagia care in this new era.
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Affiliation(s)
- Mark A Fritz
- Department of Otolaryngology, Head and Neck Surgery, University of Kentucky, 740 S Limestone, E300E, Lexington, KY, 40536, USA.
| | - Rebecca J Howell
- Department of Otolaryngology, Head and Neck Surgery, University of Cincinnati, Cincinnati, USA
| | - Martin B Brodsky
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, USA
- Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, USA
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Debra M Suiter
- Department of Communication Sciences and Disorders, University of Kentucky, Lexington, USA
| | - Shumon I Dhar
- Department of Otolaryngology, Head and Neck Surgery, Johns Hopkins University, Baltimore, USA
| | - Anais Rameau
- Department of Otolaryngology, Head and Neck Surgery, Weill Cornell Medical College, New York, NY, USA
| | | | | | | | - Ashli K O'Rourke
- Department of Otolaryngology, Head and Neck Surgery, Medical University of South Carolina, Charleston, USA
| | - Maggie A Kuhn
- Department of Otolaryngology, Head and Neck Surgery, University of California-Davis Medical Center, Sacramento, USA
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23
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Postintubation Dysphagia During COVID-19 Outbreak-Contemporary Review. Dysphagia 2020; 35:549-557. [PMID: 32468193 PMCID: PMC7255443 DOI: 10.1007/s00455-020-10139-6] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/20/2020] [Indexed: 01/08/2023]
Abstract
The COVID-19 is a global pandemic. Its rapid dissemination and serious course require a novel approach to healthcare practices. Severe disease progression is often associated with the development of the Acute Respiratory Distress Syndrome and may require some form of respiratory support, including endotracheal intubation, mechanical ventilation, and enteral nutrition through a nasogastric tube. These conditions increase the risk of dysphagia, aspiration, and aspiration pneumonia. The data on the incidence and risks of dysphagia associated with COVID-19 are not yet available. However, it is assumed that these patients are at high risk, because of respiratory symptoms and reduced lung function. These findings may exacerbate swallowing deficits. The aim of this review is to summarize available information on possible mechanisms of postintubation dysphagia in COVID-19 patients. Recommendations regarding the diagnosis and management of postintubation dysphagia in COVID-19 patients are described in this contemporary review.
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24
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Brodsky MB, Pandian V, Needham DM. Post-extubation dysphagia: a problem needing multidisciplinary efforts. Intensive Care Med 2019; 46:93-96. [PMID: 31768568 DOI: 10.1007/s00134-019-05865-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 11/12/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Martin B Brodsky
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Phipps 181, Baltimore, MD, 21287, USA. .,Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD, USA.
| | - Vinciya Pandian
- Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD, USA.,Department of Nursing Faculty, Johns Hopkins School of Nursing, Baltimore, MD, USA
| | - Dale M Needham
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Phipps 181, Baltimore, MD, 21287, USA.,Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD, USA.,Department of Nursing Faculty, Johns Hopkins School of Nursing, Baltimore, MD, USA.,Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
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