Risk scores for predicting dysphagia in critically ill patients after cardiac surgery

Utility of Fiberoptic Endoscopic Evaluation of Swallowing After Left Ventricular Assist Device Implantation

Objective Dysphagia following cardiac surgery is common and associated with adverse outcomes. Among patients receiving left ventricular assist devices (LVAD), we evaluated the impact of fiberoptic endoscopic evaluation of swallowing (FEES) on outcomes. Methods A single-center pilot study was conducted in adults (≥18 years of age) undergoing durable LVAD (February 2019 - January 2020). Six patients were prospectively enrolled, evaluated, and underwent FEES within 72 hours of extubation-they were compared to 12 control patients. Demographic, surgical, and postoperative outcomes were collected. Unpaired two-sided t-tests and Fisher's exact tests were performed. Results Baseline characteristics were similar between groups. Intraoperative criteria including duration of transesophageal echo (314 ± 86 min) and surgery (301 ± 74 min) did not differ. The mean time of intubation was comparable (57.3 vs. 68.7 hours, p=0.77). In the entire cohort, 30-day, one-year, two-year, and three-year mortality were 0%, 5.6%, 5.6%, and 16.7%, respectively. Sixty-seven percent of the patients that underwent FEES had inefficient swallowing function. The FEES group trended to a shorter hospital length of stay (LOS) (29.1 vs. 46.6 days, p=0.098), post-implantation LOS (25.3 vs 30.7 days, p=0.46), and lower incidence of postoperative pneumonia (16.7% vs. 50%, p=0.32) and sepsis (0% vs. 33.3%, p=0.25). Conclusion FEES did not impact 30-day, one-year, two-year, or three-year mortality. Though not statistically significant, patients who underwent FEES trended toward shorter LOS and lower postoperative pneumonia and sepsis rates. Additionally, we report a higher incidence of dysphagia among patients undergoing FEES despite comparable baseline risk factors with controls.

Evaluation of a Machine Learning-Based Dysphagia Prediction Tool in Clinical Routine: A Prospective Observational Cohort Study

Based on a large number of pre-existing documented electronic health records (EHR), we developed a machine learning (ML) algorithm for detection of dysphagia and aspiration pneumonia. The aim of our study was to prospectively apply this algorithm in two large patient cohorts. The tool was integrated in the hospital information system of a secondary care hospital in Austria. Based on existing data such as diagnoses, laboratory, and medication, dysphagia risk was predicted automatically, and patients were stratified into three risk groups. Patients' risk groups and risk factors were visualized in a web application. Prospective predictions of 1270 admissions to geriatric or internal medicine departments were compared with the occurrence of dysphagia or aspiration pneumonia of routinely documented events. The discriminative performance for internal medicine patients (n = 885) was excellent with an AUROC of 0.841, a sensitivity of 74.2%, and a specificity of 84.1%. For the smaller geriatric cohort (n = 221), the AUROC was 0.758, sensitivity 44.4%, and specificity 93.0%. For both cohorts, calibration plots showed a slight overestimation of the risk. This is the first study to evaluate the performance of a ML-based prediction tool for dysphagia in a prospective clinical setting. Future studies should validate the predictions on data of systematic dysphagia screening by specialists and evaluate user satisfaction and acceptance. The ML-based dysphagia prediction tool achieved an excellent performance in the internal medicine cohort. More data are needed to determine the performance in geriatric patients.

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.

Changes in Maximum Tongue Pressure and Postoperative Dysphagia in Mechanically Ventilated Patients after Cardiovascular Surgery

Background

There is no objective quantitative parameter for dysphagia, and the relationship between changes in maximum tongue pressure values and dysphagia is unknown. This study aimed to determine whether there is a difference in the change in maximal tongue pressure after extubating patients who were ventilated after cardiovascular surgery, with or without dysphagia.

Materials and methods

Adult patients who underwent mechanical ventilation via endotracheal intubation following cardiovascular surgery were included. Tongue pressure was measured before cardiovascular surgery and at 6 hours; 3 and 7 days after extubation. Dysphagia was confirmed by the functional oral intake scale (FOIS) on day 7 after extubation; an FOIS level above or equal to 6 was considered "dysphagia-negative."

Results

Of 68 patients, 15 (22.1%) were in the dysphagia-positive group, which significantly showed a history of diabetes mellitus, prolonged mechanical ventilation, and postextubation hospitalization. Additionally, the postoperative C-reactive protein level was significantly higher in the dysphagia-positive group than in the dysphagia-negative group. Maximum tongue pressure was significantly lower in the dysphagia-positive group at 3 and 7 days postextubation. Using a cutoff value of 27.6 kPa in a receiver operating characteristic (ROC) curve for maximum tongue pressure at 3 days after extubation, the area under the curve (AUC) was 0.82, sensitivity was 84.9%, and specificity was 84.2%.

Conclusion

Tongue pressure at 3 days after extubation is significantly lower in patients with dysphagia after cardiovascular surgery than in patients without dysphagia. If the maximum tongue pressure value is below 27.6 kPa on the third day following extubation, oral intake should be performed with caution.

How to cite this article

Yamada T, Ochiai R, Kotake Y. Changes in Maximum Tongue Pressure and Postoperative Dysphagia in Mechanically Ventilated Patients after Cardiovascular Surgery. Indian J Crit Care Med 2022;26(12):1253-1258.

Acupuncture Reduces the Risk of Dysphagia in Stroke Patients: A Propensity Score-Matched Cohort Study

Background: Post-stroke dysphagia (PSD) affects the quality of life in stroke patients, impairs their rehabilitation ability, and causes other complications following stroke. Currently, there is currently some understanding of PSD risk factors, but its protective factors remain largely unknown. Objective: To analyze the effects of acupuncture (AP) on dysphagia in stroke patients and explore its potential as a preventive therapy. Methods: Patients with a diagnosis of stroke from 2010 to 2019 were selected and followed until 2020, utilizing factors such as age, gender, stroke location, stroke type, and baseline comorbidity. To compare the incidence of dysphagia, equal numbers of stroke patients treated with and without AP (n = 1,809) were matched by 1:1 propensity scoring. The Cox proportional hazards model and Kaplan-Meier method were used to assess the risk of dysphagia as an outcome measure. Results: The stroke patients treated with AP had a lower risk of dysphagia after adjusting for age, gender, stroke location, stroke type, and baseline comorbidity [adjusted hazard ratio (AHR) = 0.43, 95% confidence interval = 0.37-0.49] compared with those in the non-AP cohort. AP also decreased the risk of PSD among different gender groups. The risk ratios were AHR = 0.45 and AHR = 0.33 for males and females, respectively. AP also reduced the risk for PSD among different age groups. The risk ratios were AHR = 0.20, AHR = 0.37, AHR = 0.41, and AHR = 0.45 for the 18-39, 40-59, 60-79, and >80 years-old groups. Regarding stroke types (ischemic, hemorrhagic, and mixed type), patients treated with AP had a lower risk (AHR = 0.47, 0.28 and 0.17, respectively). With respect to stroke location, the risk of PSD in AP-treated patients was decreased regardless of location: brain stem (AHR = 0.41), diencephalon (AHR = 0.13), or multiple lesions (AHR = 0.40), the risk of PSD in AP-treated patients was decreased. For all baseline comorbidities, AP attenuated the risk of dysphagia. The cumulative incidence of dysphagia was remarkably lower in the AP group than in the non-AP group (log-rank test, P = 0.000). Limitations: First, this was a single-center clinical retrospective study. Second, we did not classify the severity of stroke and dysphagia. Third, all data were extracted manually. Lastly, the sample size was relatively small. Thus, future studies with larger sample sizes are warranted to verify our findings. Conclusion: Acupuncture treatment attenuates the risk of dysphagia in stroke patients. Future research should increase the sample size and elaborate further on the details of the AP protocol.

Development and validation of a nomogram to predict postoperative pulmonary complications following thoracoscopic surgery

Background

Postoperative pulmonary complications (PPCs) after thoracoscopic surgery are common. This retrospective study aimed to develop a nomogram to predict PPCs in thoracoscopic surgery.

Methods

A total of 905 patients who underwent thoracoscopy were randomly enrolled and divided into a training cohort and a validation cohort at 80%:20%. The training cohort was used to develop a nomogram model, and the validation cohort was used to validate the model. Univariate and multivariable logistic regression were applied to screen risk factors for PPCs, and the nomogram was incorporated in the training cohort. The discriminative ability and calibration of the nomogram for predicting PPCs were assessed using C-indices and calibration plots.

Results

Among the patients, 207 (22.87%) presented PPCs, including 166 cases in the training cohort and 41 cases in the validation cohort. Using backward stepwise selection of clinically important variables with the Akaike information criterion (AIC) in the training cohort, the following seven variables were incorporated for predicting PPCs: American Society of Anesthesiologists (ASA) grade III/IV, operation time longer than 180 min, one-lung ventilation time longer than 60 min, and history of stroke, heart disease, chronic obstructive pulmonary disease (COPD) and smoking. With incorporation of these factors, the nomogram achieved good C-indices of 0.894 (95% confidence interval (CI) [0.866–0.921]) and 0.868 (95% CI [0.811–0.925]) in the training and validation cohorts, respectively, with well-fitted calibration curves.

Conclusion

The nomogram offers good predictive performance for PPCs after thoracoscopic surgery. This model may help distinguish the risk of PPCs and make reasonable treatment choices.

Risk Score for Predicting Dysphagia in Patients After Neurosurgery: A Prospective Observational Trial

Background: Acquired dysphagia is common in patients with tracheal intubation and neurological disease, leading to increased mortality. This study aimed to ascertain the risk factors and develop a prediction model for acquired dysphagia in patients after neurosurgery.

Methods: A multicenter prospective observational study was performed on 293 patients who underwent neurosurgery. A standardized swallowing assessment was performed bedside within 24 h of extubation, and logistic regression analysis with a best subset selection strategy was performed to select predictors. A nomogram model was then established and verified.

Results: The incidence of acquired dysphagia in our study was 23.2% (68/293). Among the variables, days of neurointensive care unit (NICU) stay [odds ratio (OR), 1.433; 95% confidence interval (CI), 1.141–1.882; P = 0.005], tracheal intubation duration (OR, 1.021; CI, 1.001–1.062; P = 0.175), use of a nasogastric feeding tube (OR, 9.131; CI, 1.364–62.289; P = 0.021), and Acute Physiology and Chronic Health Evaluation (APACHE)-II C score (OR, 1.709; CI, 1.421–2.148; P < 0.001) were selected as risk predictors for dysphagia and included in the nomogram model. The area under the receiver operating characteristic curve was 0.980 (CI, 0.965–0.996) in the training set and 0.971 (0.937–1) in the validation set, with Brier scores of 0.045 and 0.056, respectively.

Conclusion: Patients who stay longer in the NICU, have a longer duration of tracheal intubation, require a nasogastric feeding tube, and have higher APACHE-II C scores after neurosurgery are likely to develop dysphagia. This developed model is a convenient and efficient tool for predicting the development of dysphagia.

Post-extubation dysphagia incidence in critically ill patients: A systematic review and meta-analysis

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.

Medical Nutrition Therapy in Critically Ill Patients Treated on Intensive and Intermediate Care Units: A Literature Review

Medical nutrition therapy in critically ill patients remains challenging, not only because of the pronounced stress response with a higher risk for complications, but also due to their heterogeneity evolving from different phases of illness. The present review aims to address current knowledge and guidelines in order to summarize how they can be best implemented into daily clinical practice. Further studies are urgently needed to answer such important questions as best timing, route, dose, and composition of medical nutrition therapy for critically ill patients and to determine how to assess and to adapt to patients’ individual needs.