Swallowing rehabilitation of dysphagic tracheostomized patients under mechanical ventilation in intensive care units: a feasibility study

Efficacy of speech therapy in post-intubation patients with oropharyngeal dysphagia: a randomized controlled trial

PURPOSE

to verify the efficacy of speech therapy in the early return of oral intake in patients with post-orotracheal intubation dysphagia.

METHODS

It was a double-blinded randomized controlled trial for two years with patients of intensive care units of a hospital. Study inclusion criteria were orotracheal intubation>48hours, age≥18 years old, clinical stability, and dysphagia. Exclusion criteria were tracheotomy, score 4 to 7 in the Functional Oral Intake Scale (FOIS), neurological disorders. Patients were randomized into speech treatment or control group (ten days of follow-up). The treated group (TG) received guidance, therapeutic techniques, airway protection and maneuvers, orofacial myofunctional and vocal exercises, diet introduction; the control group (CG) received SHAM treatment. Primary outcomes were oral intake progression, dysphagia severity, and tube feeding permanence.

RESULTS

In the initial period of study, 240 patients were assessed and 40 (16.6%) had dysphagia. Of this, 32 patients met the inclusion criteria, and 17 (53%) received speech therapy. Tube feeding permanence was shorter in TG (median of 3 days) compared to CG (median of 10 days) (p=0.004). The size effect of the intervention on tube feeding permanence was statistically significant between groups (Cohen's d=1.21). TG showed progress on FOIS scores compared to CG (p=0.005). TG also had a progression in severity levels of Dysphagia protocol (from moderate to mild dysphagia) (p<0.001).

CONCLUSION

Speech therapy favors an early progression of oral intake in post-intubation patients with dysphagia. Clinical Trial Registration: RBR-9829jk.

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

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

Management of tracheostomies in the intensive care unit: a scoping review

OBJECTIVES

While there is an extensive body of literature surrounding the decision to insert, and methods for inserting, a tracheostomy, the optimal management of tracheostomies within the intensive care unit (ICU) from after insertion until ICU discharge is not well understood. The objective was to identify and map the key concepts relating to, and identify research priorities for, postinsertion management of adult patients with tracheostomies in the ICU.

DESIGN

Scoping review of the literature.

DATA SOURCES

PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature were searched from inception to 3 October 2019. Additional sources were searched for published and unpublished literature.

ELIGIBILITY CRITERIA

We included studies of any methodology that addressed the a priori key questions relating to tracheostomy management in the ICU. No restrictions were placed on language or year of publication.

DATA EXTRACTION AND SYNTHESIS

Titles and abstracts were screened by two reviewers. Studies that met inclusion criteria were reviewed in full by two reviewers, with discrepancies resolved by a third. Data were extracted for included studies, and results mapped along the prespecified research questions.

RESULTS

6132 articles were screened, and 102 articles were included for detailed analysis. Protocolised weaning was found to be successful in liberating patients from the ventilator in several cohort studies. Observational studies showed that strategies that use T-pieces and high-flow oxygen delivery improve weaning success. Several lines of evidence, including one clinical trial, support early cuff deflation as a safe and effective strategy as it results in a reduced time to wean, shorter ICU stays and fewer complications. Early tracheostomy downsizing and/or switching to cuffless tubes was found to be of benefit in one study. A substantial body of evidence supports the use of speaking valves to facilitate communication. While this does not influence time to wean or incidence of complications, it is associated with a major benefit in patient satisfaction and experience. Use of care bundles and multidisciplinary team approaches have been associated with reduced complications and improved outcomes in several observational studies.

CONCLUSIONS

The limited body of evidence supports use of weaning protocols, early cuff deflation, use of speaking valves and multidisciplinary approaches. Clinical trials examining post-tracheostomy management strategies in ICUs are a priority.

Medical criteria to indicate and remove alternative feeding routes in hospitalized older adults

ABSTRACT Purpose: to describe the medical criteria and the role of the speech therapist’s procedure in indicating and removing alternative feeding routes in older adults. Methods: a cross-sectional study conducted with the medical team of a public hospital. A questionnaire was administered with items on the medical criteria to indicate and remove alternative feeding routes and on the speech therapist’s work. Descriptive statistics were used for categorical variables in relative and absolute frequencies. Results: the data obtained from the participation of the 59 physicians enabled the main criteria for the indication of an alternative feeding route to be defined as follows: consciousness level, clinical condition, nutritional status, respiratory condition, and dysphagia assessment by a speech therapist. The main criteria for the removal of the alternative feeding route were the stable clinical and respiratory conditions, adequate nutritional support, and recommendation by a speech therapist. Conclusion: the clinical and respiratory conditions, nutritional status, and the speech therapist’s procedure were the main criteria considered by the medical team in the decisions to indicate and remove the alternative feeding route. The work of the speech therapist was relevant in both medical decisions, regarding the alternative feeding route in older patients.

Effectiveness of Therapy on Post-Extubation Dysphagia: Clinical and Electromyographic Findings

Introduction:

Patients who require prolonged endotracheal intubation (>48 hours) are at risk of dysphagia. Speech-language pathologists should perform swallowing exercises after extubation due to the high probability of developing aspiration pneumonia. There are no studies describing the use of swallowing techniques employed in post-extubation therapy aided by surface electromyography.

Objectives:

To evaluate the effects of swallowing function therapy in extubated patients after prolonged orotracheal intubation by means of clinical and electromyographic evaluation.

Methods:

A total of 15 patients were enrolled in this study (average age 48.6 ± 16.5 years). The study was carried out in three phases: (1) Clinical and electromyographic evaluation using the Dysphagia Risk Assessment Protocol following dysphagia scores criteria, and the measurement of the suprahyoid muscles amplitude (μV) expressed by root mean square (RMS), respectively; (2) swallowing rehabilitation program; and (3) reevaluation of patients after therapy. The Wilcoxon paired test assuming a significance level of 5% was used for statistical analysis.

Results:

By means of the swallowing scale, it was verified that patients suffered from severe oropharyngeal dysphagia at the first evaluation (80%), but the rehabilitation therapy reduced clinical signs, persistent only in one patient (6.7%) post-therapy, thus, improving swallowing. Significant differences, pre- and post-therapy, for suprahyoid muscles during maximal voluntary isometric contractions of right (P = .0067) and left (P = .0215), saliva swallowing by right (P = .0413) and left (P = .0151), and liquid swallowing by right (P = .0479) and left (P = .0215) sides, were found, as shown by electromyography.

Conclusions:

Swallowing exercises carried out by extubated patients after prolonged orotracheal intubation increased neuromuscular recruitment of suprahyoid muscles involved with swallowing and reduced dysphagia levels.

Ethical and legal issues of tracheostomy ventilation in patients with amyotrophic lateral sclerosis

Doctors owe a legal duty of care to patients, of which legal standard of care, especially on advice, evolves over time. With the modified Montgomery test, informed consent involves a process of best interests decision-making accompanied by disclosure of relevant information in a comprehensible fashion, to the patient. Ethical issues confronting treatment decision and advice are also manifold and have to be confronted. For example, in amyotrophic lateral sclerosis (ALS), an incurable disease, death is usually due to respiratory failure. Tracheostomy ventilation (TV) may be the only alternative to death, yet patients on TV may be subject to the relentless progression of ALS resulting in a locked-in state. Through a case vignette of invasive ventilation for ALS, we examine the ethical and legal issues regarding choice of assisted ventilation in these patients, especially for TV, to ensure reasoned and defensible methodology in patient care. We also include a tracheostomy counselling info kit applicable for use prior to tracheostomy insertion.