Confirmation of No Causal Relationship Between Tracheotomy and Aspiration Status: A Direct Replication Study

Dysphagia therapy in adults with a tracheostomy: A scoping review protocol

BACKGROUND

Swallowing impairment (dysphagia) and tracheostomy coexist. Research in this area has often provided an overview of dysphagia management as a whole, but there is limited information pertaining to specific dysphagia therapy in the tracheostomy population. The aim of this scoping review is to provide a detailed exploration of the literature with regard to dysphagia therapeutic interventions in adults with a tracheostomy. The scoping review will describe current evidence and thus facilitate future discussions to guide clinical practice.

METHODS

A scoping review using the Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews guideline will be used. Ten electronic databases from inception to December 2023 and grey literature will be searched. From identified texts forward and backward citation chasing will be completed. Data extraction will compose of population demographics, aetiology and dysphagia therapy (type, design, dose and intensity). A number of citations and papers included in the scoping review will be presented visually.

DISCUSSION

The scoping review aims to expand upon the existing literature in this field. A detailed description of the evidence is required to facilitate clinical discussions and develop therapeutic protocols in a tracheostomised population. The results of this scoping review will support future research in dysphagia therapy and provide the basis for the development of best practice guidelines.

WHAT THIS PAPER ADDS

What is already known on this subject There is an abundance of evidence available regarding dysphagia therapy targeting impairments of the swallowing sequence in a variety of populations including stroke, head and neck cancer, progressive neurological conditions and critical illness. However, there is a paucity in the literature with regard to identifying dysphagia therapy for adults with a tracheostomy. What this study adds The study protocol aims to describe the methodological features that need to be extracted from existing studies to outline dysphagia therapy for adults with a tracheostomy. To the researchers' knowledge, this is the first study protocol to describe the methodological features of dysphagia therapy for people with a tracheostomy from the literature using a standardised approach (Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA] guideline). This will ensure that the protocol is replicable for other researchers to use and demonstrates transparency in research methods. What are the clinical implications of this work? The development of a robust protocol is necessary in order to facilitate the scoping review to describe the current evidence and thus facilitate future discussions to guide clinical practice for speech and language therapists working with adults who have a tracheostomy and dysphagia. The publication of the scoping review protocol allows future clinical researchers in the area of tracheostomy and dysphagia management a blueprint with which to narrow their own research questions and it also enables replicability as the principles of good research practice dictate.

Diagnostic Accuracy of the Yale Swallow Protocol in Moderate-to-Severe Traumatic Brain Injury: A Prospective Blinded Videofluoroscopic Investigation

OBJECTIVE

The study aimed to assess the accuracy of the Yale Swallow Protocol (YSP) in screening aspiration in adults with acute moderate-to-severe traumatic brain injury (TBI) by comparing the YSP with a videofluoroscopic swallow study (VFSS).

SETTING

Level 1 academic trauma center.

PARTICIPANTS

The study involved a cohort of 50 consecutive adults with a history of acute moderate-to-severe TBI.

DESIGN

The prospective cohort study was conducted between July 2020 and June 2021. Participants underwent the YSP to assess aspiration risk, followed by a VFSS within 5 to 10 minutes after the YSP, to assess the accuracy of the YSP compared with the VFSS.

MAIN MEASURE

The accuracy of the YSP in identifying aspiration in adults with acute moderate-to-severe TBI.

RESULTS

The interrater agreement for identifying aspiration on the VFSS and the YSP was excellent, as well as 100% agreement between the speech-language pathologists and the radiologist and between the 2 speech-language pathologists, respectively. Of the 50 participants, 16 passed the YSP, while 34 failed. Among those who failed, 30 were confirmed to have aspirated on the VFSS (true-positives) and 4 did not show aspiration on the VFSS (false-positives). The YSP demonstrated a high sensitivity of 96.8%, a specificity of 78.9%, a positive predictive value of 88.2%, and a negative predictive value of 93.8% in identification of aspiration in this cohort.

CONCLUSIONS

To date, no dedicated prospective studies have been conducted to assess the utility of the YSP as a screening tool for identifying aspiration risk in persons with moderate-to-severe TBI. The results of this study conclude that the YSP is an effective screening tool for prediction of aspiration in acute care patients with moderate-to-severe TBI due to its high sensitivity and negative predictive value. These factors aid in identification of individuals at risk for aspiration and facilitate timely interventions to prevent complications.

Swallowing biomechanics in tracheostomised critically ill patients compared to age- and gender-matched healthy controls

Objective

The mechanistic effects of a tracheostomy on swallowing are unclear. Pharyngeal high-resolution manometry with impedance (P-HRM-I) is a novel swallow assessment tool providing quantifiable metrics. This study aimed to characterise swallowing biomechanics in tracheostomised critically ill (non-neurological) patients.

Design

Cohort study.

Setting

Australian tertiary hospital intensive care unit.

Participants

Tracheostomised adults, planned for decannulation.

Main outcome measures

Swallowing assessment using P-HRM-I, compared to healthy age- and gender-matched controls.

Results

In this tracheostomised cohort (n = 10), the Swallow Risk Index, a global measure of swallow function, was significantly elevated (p < 0.001). At the upper oesophageal sphincter (UOS), hypopharyngeal intrabolus pressure and UOS integrated relaxation pressure were significantly elevated (control 0.65 mmHg [-1.02, 2.33] v tracheostomy 13.7 mmHg [10.4, 16.9], P < 0.001; control -4.28 mmHg [-5.87, 2.69] v tracheostomy 12.2 mmHg [8.83, 15.6], P < 0.001, respectively). Furthermore, UOS opening extent and relaxation time were reduced (control 4.83 mS [4.60, 5.07] v tracheostomy 4.33 mS [3.97, 4.69], P = 0.002; control 0.52 s [0.49, 0.55] v tracheostomy 0.41 s [0.37, 0.45], P < 0.001, respectively). Total pharyngeal contractility (PhCI) measuring pharyngeal pressure generation was significantly elevated (control 199.5 mmHg cm.s [177.4, 221.6] v tracheostomy 326.5 mmHg cm.s [253.3, 399.7]; P = 0.001).

Conclusion

In a critically ill tracheostomised cohort, UOS dysfunction was the prevalent biomechanical feature, with elevated pharyngeal pressures. Pharyngeal weakness is not contributing to dysphagia in this cohort. Instead, elevated pharyngeal pressures may represent a compensatory mechanism to overcome the UOS dysfunction. Further studies to extend these findings may inform the development of timely and targeted rehabilitation.

Utility of the modified Volume-Viscosity Swallow Test for bedside screening of dysphagia in critically ill patients

BACKGROUND AND AIM

Aspiration and dysphagia are frequent in critically ill patients, and evidence of the validity of bedside screening tests is lacking. This study evaluated the modified Volume-Viscosity Swallow Test (mV-VST) as a screening tool for aspiration and dysphagia in intensive care unit patients.

METHODS

An observational, prospective longitudinal cohort single-center study included patients older than 18 years old, on mechanical ventilation for at least 48 h, conscious and cooperative. Patients had been admitted in intensive care between March 2016 and August 2019 at a university hospital in Spain. Data from the mV-VST and the flexible endoscopic evaluation of swallowing (FEES) test in extubated and tracheostomized patients were collected; the ROC curve was obtained for each group, and the sensitivity (Se), specificity (Sp), positive (pPV) and negative (nPV) predictive values of mV-VST were calculated and compared with the FEES results. We calculated percentages and 95% confidence intervals (CI) for qualitative variables and means or medians for quantitative variables according to the Shapiro-Wilk test. A univariate analysis identified dysphagia risk factors in each group.

RESULTS

The study included 87 patients: 44 extubated and 43 tracheostomized with similar age, body mass index, Sequential Organ Failure Assessment, Charlson comorbidity index, type and reason for admission. Aspiration with FEES was significantly higher in extubated patients than in tracheostomized patients, 43.2% vs. 23.2%, respectively, p = 0.04. With the mV-VST, aspiration was detected in 54.5% of extubated patients and in 39.5% of tracheostomized patients. In the extubated group, the Se of mV-VST to detect aspiration was 89.5%, Sp was 72%, and nPV was 90%. In the tracheostomized group, Se was 100%, Sp was 78.8%, and nPV was 100%. The ROC curve showed that mV-VST similarly identifies aspiration in extubated and tracheostomized patients.

CONCLUSIONS

Dysphagia and aspiration are frequent amongst patients in intensive care after mechanical ventilation. The mV-VST is a valid screening tool to detect aspiration and dysphagia in extubated and tracheostomized patients.

Resuming Swallowing and Oral Feeding in Tracheostomized COVID-19 Patients: Experience of a Swiss COVID-Center and Narrative Literature Review

During the COVID-19 pandemic, percutaneous tracheostomy proved to be an effective option in the management of patients with prolonged periods of intubation. In fact, among other things, it allowed early discharge from ICUs and contributed to reducing overcrowding in intensive care settings, a central and critical point in the COVID pandemic. As a direct consequence, the management and the weaning of frail, tracheostomized and ventilated patients was diverted to sub-intensive or normal hospitalization wards. One central challenge in this setting is the resumption of swallowing and oral feeding, which require interdisciplinary management involving a phoniatrician, ENT, pneumologist, and speech therapist. With this article, we aim to share the experience of a Swiss COVID-19 Center and to draw up a narrative review on the issues concerning the management of the tracheostomy cannula during swallowing resumption, integrating the most recent evidence from the literature with the clinical experiences of the professionals directly involved in the management of tracheostomized COVID-19 patients. In view of the heterogeneity of COVID-19 patients, we believe that the procedures described in the article are applicable to a larger population of patients undergoing tracheostomy weaning.

Protocols and assessment procedures in fiberoptic endoscopic evaluation of swallowing: an updated systematic review

INTRODUCTION

Neurological alterations can generate swallowing disorders and fiberoptic endoscopic evaluation of swallowing is one of the tests performed for its diagnosis, as well as assistance in dysphagia management.

OBJECTIVE

To identify and describe a fiberoptic endoscopic evaluation of swallowing standardized protocol for the neurological adult population and its stages.

METHODS

Systematic review registered on the PROSPERO platform (CRD42018069428), carried out on the websites: MEDLINE, Cochrane Library and Scielo; published between 2009 and 2020. Randomized clinical trials, cross-sectional, and longitudinal studies were included. Two independent judges evaluated the study design and extracted the data from the selected studies. Doubts regarding inclusion or not of the studies were evaluated by a third judge. Scientific articles included were those with adult neurological remained patients with outcomes: (1) diagnosis of swallowing disorder (2) change in sensitivity in laryngeal region (3) penetration of food offered (4) aspiration of food offered.

RESULTS

3724 articles were initially selected, after personalized search for patients with neurological alterations 101 studies remained. In the end, 21 qualitative studies from 2009 to 2020 remained in the systematic review and they were described in detail and compared. Seven articles used protocols of the institutions in which the research took place and four mentioned using the same protocol. The reliable reproducibility of the protocols is feasible only in three of the articles, even presenting different protocols.

CONCLUSION

There is no standard or validated protocol to assess the swallowing function of adults with neurological diseases.

The Sheba Medical Center Protocol for Bedside Evaluation of Swallowing Disorders Among Tracheotomized Patients

The Sheba Blue Dye Test Protocol (SBDTP) is a swallowing bedside evaluation for tracheotomized patients (TP). It is based on the Modified Evans' Blue Dye Test (MEBDT), but includes several modifications that aim to overcome previously described caveats of the traditional MEBDT. These modifications include evaluating the patient three times, with increasing quantities of bolus. The purpose of this study was to examine the rates of positive and negative results of TP undergoing the SBDTP, in comparison to the MEBDT, which, generally, consists of a single evaluation. The study included a cohort of 39 TP admitted to the Sheba general hospital with various background diseases. Findings indicated that the percentage of positive results increased significantly from the first (18%) to the last stage (46.2%) of the SBDTP. This result demonstrated the advantage of the SBDTP as a more reliable evaluation for tracing aspiration among TP, especially in cases where access to instrumental examination is limited.

Characterizing dysphagia after spinal surgery

Context/Objective: Dysphagia after spinal surgery is well recognised. Characteristics of post-operative dysphagia are not well defined. This study explored severity, longevity, and physiological characteristics of dysphagia.Design: Prospective, observational study.Setting: Tertiary urban hospital.Participants: Two-hundred fifty patients consecutively receiving spinal surgery.Interventions: Demographic and clinical information were collected. Flexible endoscopic evaluation of swallowing (FEES) and videofluoroscopic study of swallowing (VFSS) recordings were analyzed.Outcomes Measures: FEES recordings were analyzed using three validated symptom scales. VFSS recordings were analyzed using 10 objective digital measures of timing, displacement and symptoms.Results: Of 250 patients, 75 were referred for swallowing assessment. Sixty-two received FEES and 11 VFSS. Patients with anterior approach surgery for cervical level injuries represented 85% of referrals (n = 64). Secretion accumulation, aspiration and residue scores decreased significantly within 2 months for most patients. For those with persisting dysphagia, objective VFSS measures demonstrated significant impairments in pharyngeal constriction, hyoid displacement and pharyngoesophageal segment opening with corresponding residue and aspiration scores. By 6 months, all patients had returned to a regular diet except three patients following anterior cervical discectomy and fusion (ACDF) who remained nil by mouth with severe physiological impairments.Conclusions: A quarter of patients following spinal surgery present with dysphagia. For most, symptoms decrease significantly by 2 months and patients return to normal diets. Early screening of dysphagia is critical to avoid secondary complications and prolonged hospitalizations. For some, significant pharyngeal impairments persist and high-quality case series exploring efficacy of rehabilitation programmes are needed.

Speech and language therapists' management of ventilated patients and patients with tracheostomy in Israel

BACKGROUND

There is increased involvement of speech and language therapists (SLTs) in critical care and long-term units supporting patients with ventilatory needs and complex dysphagia. SLTs have a range of specialist knowledge in the function of the pharynx and larynx to enable them to support therapeutic interventions and contribute to the management of those patients. In Israel, there are currently no designated courses or training programmes for SLTs to establish advanced clinical skills in tracheostomy and ventilator management. There are currently standards of care for SLT working in designated wards for ventilated patients, however not in acute wards, critical care, and internal medicine wards where ventilated patients can be hospitalized.

AIMS

To identify the skills and expertise of the Israeli SLT workforce working with tracheostomy patients. Specifically, to identify their level of training, access to training, client population, work settings, and level of work confidence.

METHODS

The study involved electronic distribution of a 55-item online survey to SLTs in Israel. The questions included demographic information, training, confidence, and clinical support.

RESULTS

Responses were received from 47 SLTs. The majority (40.4%) spent between 1% and 9% of their clinical time with ventilated patients. Almost 80% work with seniors (≥65 years) and almost 70% work with adults (18-65 years) half the time or more. In inpatient rehabilitation, 46.8% reported that they manage patients with tracheostomy half the time or more. In outpatient rehabilitation settings, 21.3% reported that they manage patients with tracheostomy half the time or more. Prior to managing complex airway patients independently, 55.3% received less than 5 h formal tracheostomy training whilst 68.1% received less than 5 h training on ventilated patients. Multidisciplinary teams (MDTs) existed for tracheostomy patients (85.1%) and ventilated patients (70.2%) and high levels of confidence were reported for managing patients with tracheostomies (mode of 4 in a scale of 0-5, where 5 means fully confident) and ventilated patients (mode of 3 in a scale of 0-5). A significant relationship was found between level of confidence and presence of an MDT.

CONCLUSIONS

Limited training access was found for SLTs working with this complex population. A competency framework needs to be established with access to training and supervision. MDT existence contributes to confidence. Most respondents worked in rehabilitation settings, and very few worked in acute care, critical care, and internal medicine wards. It seems reasonable that in order to change this, minimal standards of care should be established on these wards.

WHAT THIS PAPER ADDS

What is already known on the subject Speech and language therapists (SLTs) have an important role in critical care and long-term units supporting patients with complex dysphagia and undergo formal training and supervision in UK and Australia. What this paper adds to existing knowledge In Israel, most SLTs work with tracheostomy and ventilated adult patients in rehabilitation settings, whilst few work in acute, critical care, and internal medicine wards. There are limited opportunities for formal training and supervision, although MDT support enhances clinical confidence. What are the potential or actual clinical implications of this work? SLTs in Israel would benefit from establishing a competency framework for tracheostomy and ventilator patient management to support training, standards of care, and increase clinical involvement in acute settings. This will enhance clinical outcomes for their large population of complex airway patients.

European white paper: oropharyngeal dysphagia in head and neck cancer

PURPOSE

To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe.

METHODS

Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion.

RESULTS

Twenty-four sections on HNC-specific OD topics.

CONCLUSION

This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.

Predictors of swallowing outcomes in patients with combat-injury related dysphagia

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.

Impact of Tracheal Tube on Swallowing in Post-Operative Head and Neck Cancer Patients: Scintigraphic Analysis

Dysphagia is common in tracheostomized patients who underwent head and neck surgery for cancer treatment. The objective of this study was to evaluate, by means of oropharyngoesophageal scintigraphy (OPES), the impact of an occluded tracheal tube (TT) on swallowing in patients treated for head and neck cancer before hospital discharge, to provide further information to the benefit of out-patient care management. From October 2018 to November 2019, we enrolled 19 tracheostomized patients (6 females and 13 males; mean age 61 years) who underwent primary surgical resection of head and neck tumor and swallowing rehabilitation during hospitalization. All subjects underwent a double-standard OPES, one with occluded tracheal tube and the other without TT, with their tracheal stoma being closed directly by a plaster. For each study, we assessed and compared the following quantitative parameters: oral transit time (OTTsec), pharyngeal transit time (PTTsec), esophageal transit time (ETTsec), oral retention index (ORI%), pharyngeal retention index (PRI%), esophageal retention index (ERI%), and aspiration percentage (AP%). The mean values of OTT, PTT, ORI%, PRI%, and ERI% were abnormal during OPES both with TT and without TT and did not statistically differ between the two tests (p > 0.05). Aspiration was detected in 4 cases out of 19 (21.05%) cases during OPES with TT and in 4/19 (21.05%) cases without TT who showed a mean AP% of 11.4% and 11.5% respectively (p > 0.05). Patients with abnormal AP% (> 0%) during OPES with TT showed aspiration signs without TT. Our study showed that the mere presence of a closed tracheal tube does not impact significantly the oropharyngeal transit of bolus during swallowing. This result suggests the possibility to maintain a small-diameter occluded tracheal tube in place for the postsurgical management of head and neck cancer patients.

Association between Prevertebral Soft Tissue Thickening and Dysphagia in Cases of Traumatic Cervical Spinal Cord Injury

Objective

The objectives of this study were to clarify whether prevertebral soft tissue (PVST) thickening increases the risk of dysphagia, to identify at which vertebral level determining PVST thickness is useful, and to determine cutoff values.

Methods

A total of 80 patients with traumatic cervical spinal cord injury (TCSCI) treated over a 43-month period at a single regional institution specializing in cervical spinal cord injuries participated in the study. The exclusion criteria were having undergone anterior cervical spine surgery; a history of complicated traumatic brain injury, complicated vertebral artery injury, or brain injury; endotracheal intubation at day 30 after onset; the disappearance of neurological symptoms within 24 hours after onset; and the use of a halo vest. The associations between PVST thicknesses at C1, C2, C3, C6, and C7 measured by CT on the day of onset and the presence of dysphagia (Food Intake LEVEL Scale score <8) at 30 and 60 days after onset of TCSCI were analyzed using ROC curves to calculate the maximum area under the curve and the PVST cutoff values for these vertebrae. Associations between various risk factors, including PVST thickness, and dysphagia at days 30 and 60 after onset were examined using univariate and multivariate analyses.

Results

Independent associations with dysphagia were found with the C3 PVST thickness (day 30: ≥8.3 mm, day 60: ≥9.4 mm) and tracheostomy.

Conclusion

PVST thickness or injury seems to be an independent risk factor for dysphagia. By measuring PVST, it is possible to estimate the severity of dysphagia even in acute conditions.

Translating Dysphagia Evidence into Practice While Avoiding Pitfalls: Assessing Bias Risk in Tracheostomy Literature

Critically ill patients who require a tracheostomy often have dysphagia. Widespread practice guidelines have yet to be developed regarding the acute assessment and management of dysphagia in patients with tracheostomy. In order for clinicians to base their practice on the best available evidence, they must first assess the applicable literature and determine its quality. To inform guideline development, our objective was to assess literature quality concerning swallowing following tracheostomy in acute stages of critical illness in adults. Our systematic literature search (published previously) included eight databases, nine gray literature repositories and citation chasing. Using inclusion criteria determined a priori, two reviewers, blinded to each other, conducted an eligibility review of identified citations. Patients with chronic tracheostomy and etiologies including head and/or neck cancer diagnoses were excluded. Four teams of two reviewers each, blinded to each other, assessed quality of included studies using a modified Cochrane Risk of Bias tool (RoB). Disagreements were resolved by consensus. Data were summarized descriptively according to study design and RoB domain. Of 6,396 identified citations, 74 studies met our inclusion criteria. Of those, 71 were observational and three were randomized controlled trials. Across all studies, the majority (> 75%) had low bias risk with: participant blinding, outcome reporting, and operationally defined outcomes. Areas requiring improvement included assessor and study personnel blinding. Prior to translating the literature into practice guidelines, we recommend attention to study quality limitations and its potential impact on study outcomes. For future work, we suggest an iterative approach to knowledge translation.

Investigating Swallowing and Tracheostomy Following Critical Illness: A Scoping Review

OBJECTIVES

Tracheostomy and dysphagia often coexist during critical illness; however, given the patient's medical complexity, understanding the evidence to optimize swallowing assessment and intervention is challenging. The objective of this scoping review is to describe and explore the literature surrounding swallowing and tracheostomy in the acute care setting.

DATA SOURCES

Eight electronic databases were searched from inception to May 2017 inclusive, using a search strategy designed by an information scientist. We conducted manual searching of 10 journals, nine gray literature repositories, and forward and backward citation chasing.

STUDY SELECTION

Two blinded reviewers determined eligibility according to inclusion criteria: English-language studies reporting on swallowing or dysphagia in adults (≥ 17 yr old) who had undergone tracheostomy placement while in acute care. Patients with head and/or neck cancer diagnoses were excluded.

DATA EXTRACTION

We extracted data using a form designed a priori and conducted descriptive analyses.

DATA SYNTHESIS

We identified 6,396 citations, of which 725 articles were reviewed and 85 (N) met inclusion criteria. We stratified studies according to content domains with some featuring in multiple categories: dysphagia frequency (n = 38), swallowing physiology (n = 27), risk factors (n = 31), interventions (n = 21), and assessment comparisons (n = 12) and by patient etiology. Sample sizes (with tracheostomy) ranged from 10 to 3,320, and dysphagia frequency ranged from 11% to 93% in studies with consecutive sampling. Study design, sampling method, assessment methods, and interpretation approach varied significantly across studies.

CONCLUSIONS

The evidence base surrounding this subject is diverse, complicated by heterogeneous patient selection methods, design, and reporting. We suggest ways the evidence base may be developed.

Clinical predictors for oropharyngeal dysphagia and laryngeal dysfunction after lung and heart transplantation

BACKGROUND

Oropharyngeal dysphagia and laryngeal dysfunction are two lesser known complications after lung and heart transplantation. The presence of these features places this immunocompromised population at high risk of pulmonary complications and subsequent medical deterioration. Early identification of swallowing and voice dysfunction would be beneficial to optimize management.

AIMS

To examine the association between patient risk factors and postoperative outcomes with referral to speech pathology (SP) following signs of swallowing and voice dysfunction.

METHODS & PROCEDURES

A retrospective review was conducted on demographic data, patient risk factors and postoperative course in 284 patients following lung and/or heart transplantation between 2010 and 2013. Variables were analysed for any association between pre- and postoperative factors and SP referral.

OUTCOMES & RESULTS

A total of 24% were referred to SP with a mean age of 47 years. Binary logistic regression identified a statistically significant association between the number of intubations (odds ratio (OR) = 2.066, p = 0.028), intubation duration (OR = 1.004, p < 0.01), length of stay in the intensive care unit (ICU) (OR = 1.068, p < 0.01), and number of ICU admissions (OR = 1.384, p = 0.046) and SP referral. Intubation time and the total days in ICU were greater for patients referred to SP. Mortality also increased for these variables and for the numbers of reintubations and readmissions. Analysis of pre-operative risk factors revealed cerebrovascular disease to be a significant predictor of SP referral (OR = 6.747, p = 0.032).

CONCLUSIONS & IMPLICATIONS

This study demonstrates significant clinical indicators for referral to SP for the management of oropharyngeal dysphagia and laryngeal dysfunction in patients after lung or heart transplantation. Further studies are needed to investigate the most efficacious intervention approaches to manage swallowing and voice dysfunction in these patients.

Awareness and Management of Dysphagia in Dutch Intensive Care Units: A Nationwide Survey

Dysphagia is a common problem in the intensive care unit (ICU), yet no national guidelines on dysphagia prevention, screening, and management exist. We performed a survey to learn which strategies are commonly being used in Dutch ICUs. A survey was developed based on current literature and experts' opinions. It comprised questions regarding hospital and ICU characteristics, perceived prevalence and importance of dysphagia, screening strategies, modalities used to prevent aspiration, and interventions used to improve swallowing function. It was sent to all 90 non-pediatric ICUs in The Netherlands. 67 of 90 addressed ICUs (74%) replied to our survey. A median relevance score of 4 (IQR 4-5) out of 5 was given to the topic of dysphagia. In 22% and 45% of ICUs, patients were always screened for dysphagia after extubation or tracheotomy, respectively. The water swallow test was always part of the work-up in 88% of ICUs. Fiberoptic endoscopic evaluation of swallowing was used occasionally in 60% of ICUs, versus videofluoroscopic swallowing study in 25%. In 49% of ICUs, no standardized active rehabilitation protocol for dysphagia existed. In the remaining 51%, swallowing exercises were always part of standard rehabilitation, occasionally supplemented by electrical stimulation or surface-EMG biofeedback training in 6 and 10%, respectively. Most Dutch ICUs do not regularly screen for dysphagia and almost half do not seem to have a diagnostic, treatment, or rehabilitation protocol, despite recognizing it as a significant and relatively frequent problem in the ICU with potentially serious patient consequences.

Predictors of dysphagia in critically injured patients with neck trauma

PURPOSE

Trauma patients admitted to the intensive care unit (ICU) are at heightened risk for oropharyngeal dysphagia and pulmonary aspiration. Timely and appropriate referrals for dysphagia may reduce mortality rates and hospital readmissions. This study sought to identify predictors of dysphagia in a large cohort of patients with multiple traumatic injuries.

METHODS

The Trauma Registry Database was queried for admissions at a level 1 trauma center from 2012 to 2016 who underwent instrumental swallowing evaluations. Relevant demographics, injuries, and interventions known to be associated with dysphagia were collected. The Dysphagia Outcome and Severity Scale (DOSS) was utilized to define severity of dysphagia. Regression analyses were performed to identify predictors of dysphagia.

RESULTS

Two hundred and sixty two patients met criteria. Multivariate analyses found injury severity (p<0.01), tracheostomy (p<0.05), TBI (p<0.05), and cervical spinal bracing (p<0.001) to be predictors of dysphagia development. Furthermore, length of ICU stay (p<0.01) and cervical spinal bracing (p<0.01) were associated with a greater severity of dysphagia.

CONCLUSIONS

Oropharyngeal dysphagia is a common complication in trauma patients. Our results propose a set of predictors that should be considered when identifying critically injured patients at risk for dysphagia.

Swallowing Mechanics Associated With Artificial Airways, Bolus Properties, and Penetration-Aspiration Status in Trauma Patients

PURPOSE

Artificial airway procedures such as intubation and tracheotomy are common in the treatment of traumatic injuries, and bolus modifications may be implemented to help manage swallowing disorders. This study assessed artificial airway status, bolus properties (volume and viscosity), and the occurrence of laryngeal penetration and/or aspiration in relation to mechanical features of swallowing.

METHOD

Coordinates of anatomical landmarks were extracted at minimum and maximum hyolaryngeal excursion from 228 videofluoroscopic swallowing studies representing 69 traumatically injured U.S. military service members with dysphagia. Morphometric canonical variate and regression analyses examined associations between swallowing mechanics and bolus properties based on artificial airway and penetration-aspiration status.

RESULTS

Significant differences in swallowing mechanics were detected between extubated versus tracheotomized (D = 1.32, p < .0001), extubated versus decannulated (D = 1.74, p < .0001), and decannulated versus tracheotomized (D = 1.24, p < .0001) groups per post hoc discriminant function analysis. Tracheotomy-in-situ and decannulated subgroups exhibited increased head/neck extension and posterior relocation of the larynx. Swallowing mechanics associated with (a) penetration-aspiration status and (b) bolus properties were moderately related for extubated and decannulated subgroups, but not the tracheotomized subgroup, per morphometric regression analysis.

CONCLUSION

Specific differences in swallowing mechanics associated with artificial airway status and certain bolus properties may guide therapeutic intervention in trauma-based dysphagia.

Swallowing Function and Kinematics in Stroke Patients with Tracheostomies

The purpose of this study was to compare the swallowing function and kinematics in stroke patients with and without tracheostomies. In this retrospective matched case-control study, we compared stroke patients with (TRACH group, n = 24) and without (NO-TRACH group, n = 24) tracheostomies. Patients were matched for age, sex, and stroke-type. Swallowing function was evaluated using the videofluoroscopic dysphagia scale (VDS) and functional oral intake scale (FOIS) obtained from videofluoroscopic swallow study (VFSS) images. Swallowing kinematics were evaluated using a two-dimensional kinematic analysis of the VFSS images. Mean duration of tracheostomy was 132.38 ± 150.46 days in the TRACH group. There was no significant difference in the total VDS score between the TRACH (35.17 ± 15.30) and NO-TRACH groups (29.25 ± 16.66, p = 0.247). FOIS was significantly lower in the TRACH group (2.33 ± 1.40) than in the NO-TRACH group (4.33 ± 1.79, p = 0.001). The TRACH group had a significantly lower maximum vertical displacement (15.23 ± 7.39 mm, p = 0.011) and velocity (54.99 ± 29.59 mm/s, p = 0.011), and two-dimensional velocity (61.07 ± 24.89 mm/s, p = 0.013) of the larynx than the NO-TRACH group (20.18 ± 5.70 mm, 82.23 ± 37.30 mm/s, and 84.40 ± 36.05 mm/s, respectively). Maximum horizontal velocity of the hyoid bone in the TRACH group (36.77 ± 16.97 mm/s) was also significantly lower than that in the NO-TRACH group (47.49 ± 15.73 mm/s, p = 0.032). This study demonstrated that stroke patients with tracheostomies had inferior swallowing function and kinematics than those without tracheostomies. A prospective longitudinal study is needed to elucidate the effect of a tracheostomy on swallowing recovery in stroke patients.

Screening adult patients with a tracheostomy tube for dysphagia: a mixed-methods study of practice in the UK

BACKGROUND

Patients with tracheostomy tubes are at risk of aspiration and swallowing problems (dysphagia), and because of their medical acuity, complications in this patient population can be severe. It is well recognized that swallow screening in stroke significantly reduces potential complications by allowing early identification and appropriate management of patients at risk (by health professionals), thereby reducing delays in commencing oral intake and preventing unnecessary, costly interventions by speech and language therapists (SLTs). However, there is no standardized swallow screen for the tracheostomised population and there is a paucity of literature regarding either current or best practice in this area.

AIMS

To investigate current UK practice for dysphagia screening in adult patients with tracheostomy tubes and to explore and describe health professionals' perceptions of their current practice or current systems used.

METHODS & PROCEDURES

A mixed-methods approach was adopted comprising a semi-structured online questionnaire and recorded follow-up telephone interviews. Participants were SLTs, nurses and physiotherapists working with patients with tracheostomies. Responses were analysed to determine current practice with regard to swallow screening. Thematic analysis of interviews allowed further exploration and clarification of the questionnaire findings.

OUTCOMES & RESULTS

A total of 221 questionnaires were completed. Approximately half (45%) the participants worked in trusts with formal swallow screens, whilst the remainder used a variety of other approaches to identify patients at risk, often relying on informal links with multidisciplinary teams (MDT). In line with current evidence, patients with neurological diagnoses and a tracheostomy were consistently referred directly to speech and language therapy (SLT). Only one-quarter of questionnaire participants thought their current system was effective at identifying patients at risk of swallowing problems. Eleven questionnaire participants were interviewed. They highlighted the important role of MDT team working here, emphasizing both its strengths and weaknesses when working with these patients.

CONCLUSIONS & IMPLICATIONS

Current practice in the UK for screening patients with a tracheostomy for swallow problems is varied and often suboptimal. Despite the evidence for enhancing outcomes, MDT working is still perceived as problematic. A swallow screening tool for use with this population, to enhance MDT working whilst also ensuring that practice fits in line with current evidence, may improve patient safety and care.

Improved Dysphagia After Decannulation of Tracheostomy in Patients With Brain Injuries

Objective

To investigate improved dysphagia after the decannulation of a tracheostomy in patients with brain injuries.

Methods

The subjects of this study are patients with brain injuries who were admitted to the Department of Rehabilitation Medicine in Myongji Hospital and who underwent a decannulation between 2012 and 2014. A video fluoroscopic swallowing study (VFSS) was performed in order to investigate whether the patients' dysphagia had improved. We measured the following 5 parameters: laryngeal elevation, pharyngeal transit time, post-swallow pharyngeal remnant, upper esophageal width, and semisolid aspiration. We analyzed the patients' results from VFSS performed one month before and one month after decannulation. All VFSS images were recorded using a camcorder running at 30 frames per second. An AutoCAD 2D screen was used to measure laryngeal elevation, post-swallow pharyngeal remnant, and upper esophageal width.

Results

In this study, a number of dysphagia symptoms improved after decannulation. Laryngeal elevation, pharyngeal transit time, and semisolid aspiration showed no statistically significant differences (p>0.05), however after decannulation, the post-swallow pharyngeal remnant (pre 37.41%±24.80%, post 21.02%±11.75%; p<0.001) and upper esophageal width (pre 3.57±1.93 mm, post 4.53±2.05 mm; p<0.001) showed statistically significant differences.

Conclusion

When decannulation is performed on patients with brain injuries who do not require a ventilator and who are able to independently excrete sputum, improved esophageal dysphagia can be expected.

The use of tracheostomy speaking valves in mechanically ventilated patients results in improved communication and does not prolong ventilation time in cardiothoracic intensive care unit patients

PURPOSE

The aim of this study was to assess the effect of the introduction of in-line tracheostomy speaking valves (SVs) on duration of mechanical ventilation and time to verbal communication in patients requiring tracheostomy for prolonged mechanical ventilation in a predominantly cardiothoracic intensive care unit (ICU).

MATERIALS AND METHODS

We performed a retrospective preobservational-postobservational study using data from the ICU clinical information system and medical record. Extracted data included demographics, diagnoses and disease severity, mechanical ventilation requirements, and details on verbal communication and oral intake.

RESULTS

Data were collected on 129 patients. Mean age was 59 ± 16 years, with 75% male. Demographics, case mix, and median time from intubation to tracheostomy (6 days preimplementation-postimplementation) were unchanged between timepoints. A significant decrease in time from tracheostomy to establishing verbal communication was observed (18 days preimplementation and 9 days postimplementation, P <.05). There was no difference in length of mechanical ventilation (20 days preimplementation-post) or time to decannulation (14 days preimplementation-postimplementation). No adverse events were documented in relation to the introduction of in-line SVs.

CONCLUSIONS

In-line SVs were successfully implemented in mechanically ventilated tracheostomized patient population. This resulted in earlier verbal communication, no detrimental effect on ventilator weaning times, and no change in decannulation times.

PURPOSE

The purpose of the study was to compare tracheostomy outcomes in mechanically ventilated patients in a cardiothoracic ICU preintroduction and postintroduction of in-line SVs. It was hypothesized that in-line SVs would improve communication and swallowing specific outcomes with no increase in average time to decannulation or the number of adverse events.

Selective rehabilitative approach to neurological dysfunctions of the oro-pharyngo-laryngeal trivium

CONCLUSION

A dedicated team proved to provide the optimal approach for the rehabilitation of patients with neurological oro-pharyngo-laryngeal dysfunctions.

OBJECTIVES

To assess the effectiveness of a dedicated and specialist team (otolaryngologist, phoniatrician, speech therapist) in the management of patients with severe neurological impairments of the upper airways and digestive routes.

METHODS

Fifty-one subjects with neurological impairment of the upper airways and digestive tract due to either central or peripheral causes, who underwent tracheotomy if needed, were recruited at a tertiary university hospital. Two different rehabilitative approaches were used: the classic approach (CA), where a specialist ENT consultation was requested by the professionals if needed; and a selective approach (SA) where a specialist team directly followed and monitored the different phases of management and rehabilitation. Different temporal parameters, in relation to tracheotomy, fenestration of the tracheal tube, and decannulation time, were taken into account and compared between these two approaches.

RESULTS

The decannulation time, management of the tracheal tube, and recovery of swallowing function were significantly shorter in patients who were treated according to the SA (p < 0.05). The presence of the tracheal tube and the site of the damage did not affect the outcome in the different study groups (p > 0.05).

Oral Feed for Patients with a Tracheostomy: Balancing Risks and Benefits

Many patients on the intensive care unit have tracheostomies sited, following which some clinicians advocate that they should be fed via a nasogastric tube, as taking food orally might present a risk of aspiration. However, nasogastric (NG) tubes also have associated risks, harms and costs. The Royal Bolton Hospital is a district general hospital in the UK with an 8-bedded, mixed medical/surgical intensive care unit admitting around 430 level 3 patients per year. We describe our clinical practice in terms of a liberal attitude to offering oral feed to a selected group of patients with tracheostomies in situ. We postulate that this approach has several advantages and that the balance between risk and benefit must be assessed in each individual case. Expert assessment by Speech and Language therapists can help these judgements. Some beliefs regarding aspiration risk in patients with tracheostomies lack supporting evidence.

Swallowing disorders in tracheostomised patients: a multidisciplinary/multiprofessional approach in decannulation protocols

Safe removal of tracheal cannula is a major goal in the rehabilitation of tracheostomised patients to achieve progressive independence from mechanical support and reduce the risk of respiratory complications. A tracheal cannula may also cause significant discomfort to the patient, making verbal communication difficult. Particularly when cuffed, tracheal cannula reduces the normal movement of the larynx which can further compromise the basic swallowing defect. A close connection between respiratory, phonating, swallowing and feeding abilities to be recovered, implies a strict integration among different professionals of the rehabilitation team. An appropriate management of tracheostomy cannula is closely connected with assessment and treatment of swallowing disorders in order to limit the development of severe pulmonary and nutritional complications, but at present there are no uniform protocols in the scientific literature. Furthermore, several studies report as an essential criterion for decannulation the presence of good patient consciousness, which is often altered in patients with tracheostomy, but a general agreement is lacking.

ICU-acquired swallowing disorders

OBJECTIVES

Patients hospitalized in the ICU can frequently develop swallowing disorders, resulting in an inability to effectively transfer food, liquids, and pills from their mouth to stomach. The complications of these disorders can be devastating, including aspiration, reintubation, pneumonia, and a prolonged hospital length of stay. As a result, critical care practitioners should understand the optimal diagnostic strategies, proposed mechanisms, and downstream complications of these ICU-acquired swallowing disorders.

DATA SOURCES

Database searches and a review of the relevant medical literature.

DATA SYNTHESIS

A significant portion of the estimated 400,000 patients who annually develop acute respiratory failure, require endotracheal intubation, and survive to be extubated are determined to have dysfunctional swallowing. This group of swallowing disorders has multiple etiologies, including local effects of endotracheal tubes, neuromuscular weakness, and an altered sensorium. The diagnosis of dysfunctional swallowing is usually made by a speech-language pathologist using a bedside swallowing evaluation. Major complications of swallowing disorders in hospitalized patients include aspiration, reintubation, pneumonia, and increased hospitalization. The national yearly cost of swallowing disorders in hospitalized patients is estimated to be over $500 million. Treatment modalities focus on changing the consistency of food, changing mealtime position, and/or placing feeding tubes to prevent aspiration.

CONCLUSIONS

Swallowing disorders are costly and clinically important in a large population of ICU patients. The development of effective screening strategies and national diagnostic standards will enable further studies aimed at understanding the precise mechanisms for these disorders. Further research should also concentrate on identifying modifiable risk factors and developing novel treatments aimed at reducing the significant burden of swallowing dysfunction in critical illness survivors.

Validation of the Yale Swallow Protocol: a prospective double-blinded videofluoroscopic study

The purpose of this prospective, double-blinded, multirater, systematic replication study was to investigate agreement for aspiration risk, in the same individual, between videofluoroscopic swallow studies (VFSS) and the Yale Swallow Protocol. Participants were 25 consecutive adults referred for dysphagia testing who met the inclusion criteria of completion of a brief cognitive assessment, oral mechanism examination, and no tracheotomy tube. First, all participants were administered the Yale Swallow Protocol by two experienced speech-language pathologists trained in protocol administration. Failure criteria were inability to drink the entire amount, interrupted drinking, or coughing during or immediately after drinking. Second, all participants completed a VFSS within 5-10 min of protocol administration. A speech-language pathologist, blinded to protocol results, reviewed the VFSS to determine aspiration status in a binary (yes/no) manner. Inter-rater agreement between two speech-language pathologists was 100 % for identification of aspiration risk with the Yale Swallow Protocol. Inter-rater agreement between the speech-language pathologist and the radiologist for identification of aspiration status with VFSS was 100 %. Twenty percent of VFSS recordings were viewed again 3-6 months after initial data collection, and intrarater agreement for identification of thin liquid aspiration was 100 %. Sensitivity for the Yale Swallow Protocol = 100 %, specificity = 64 %, positive predictive value = 78 %, and negative predictive value = 100 %. Importantly, all participants who passed the protocol did not aspirate during VFSS. Multiple, double-blinded raters and VFSS as the reference standard agreed with previous research with a single, nonblinded rater and FEES as the reference standard for identification of aspiration risk. The clinical usefulness and validity of the Yale Swallow Protocol for determining aspiration risk in a small sample size of male participants has been confirmed. Future research is needed with a larger and more heterogeneous population sample.

Decannulation and assessment of deglutition in the tracheostomized patient in non-neurocritical intensive care

With intensive care patients, decannulation and deglutition disorders are frequent reasons for otorhinolaryngological assessment. The objective of a tracheostomy is to maintain a patent airway. It does not necessarily prevent episodes of aspiration and may even favour them. When the cause that led to the tracheostomy resolves, a decannulation may be proposed. Deglutition is a complex act involving the coordinated interaction of several structures of the aerodigestive tract. Fibre-optic endoscopy and videofluoroscopy are 2 useful, complementary tools for the evaluation of patients with swallowing disorders. In managing these patients, a thorough knowledge of laryngeal and swallowing physiology, as well as of the different therapeutic alternatives, is required. Although it is not uncommon for swallowing disorders to coexist in tracheostomy patients, decannulation evaluation is not synonymous with deglutition assessment. A patient could be a candidate for decannulation and have a swallowing disorder, or a tracheostomy patient could swallow adequately. Knowing and understanding these concepts will lead to more efficient management and help to clarify communication between the intensive care physician and the otorhinolaryngologist. Ideally, a multidisciplinary team should be formed to evaluate and manage these patients.

Swallowing dysfunction in head and neck cancer patients treated by radiotherapy: review and recommendations of the supportive task group of the Italian Association of Radiation Oncology

PURPOSE

Dysphagia is a debilitating complication in head and neck cancer patients (HNCPs) that may cause a high mortality rate for aspiration pneumonia. The aims of this paper were to summarize the normal swallowing mechanism focusing on its anatomo-physiology, to review the relevant literature in order to identify the main causes of dysphagia in HNCPs and to develop recommendations to be adopted for radiation oncology patients. The chemotherapy and surgery considerations on this topic were reported in recommendations only when they were supposed to increase the adverse effects of radiotherapy on dysphagia.

MATERIALS AND METHODS

The review of literature was focused on studies reporting dysphagia as a pre-treatment evaluation and as cancer and cancer therapy related side-effects, respectively. Relevant literature through the primary literature search and by articles identified in references was considered. The members of the group discussed the results and elaborated recommendations according to the Oxford CRBM levels of evidence and recommendations. The recommendations were revised by external Radiation Oncology, Ear Nose and Throat (ENT), Medical Oncology and Speech Language Pathology (SLP) experts.

RESULTS

Recommendations on pre-treatment assessment and on patients submitted to radiotherapy were given. The effects of concurrent therapies (i.e. surgery or chemotherapy) were taken into account.

CONCLUSIONS

In HNCPs treatment, disease control has to be considered in tandem with functional impact on swallowing function. SLPs should be included in a multidisciplinary approach to head and neck cancer.

Does removal of tracheostomy affect dysphagia? A kinematic analysis

Tracheostomy tubes are thought to increase the incidence of aspiration and several mechanisms that might cause this have been suggested. Some studies reported alterations in laryngeal elevation during swallowing, which they attributed to an anchoring effect of the tracheostomy tube resulting in dysphagia. The purpose of the present study was to kinematically investigate the effect of tracheostomy on the swallowing process in dysphagic patients. Thirteen patients (7 males, 6 females; mean age = 61.4 years) were prospectively enrolled between August 2008 and December 2009. The inclusion criteria for a patient who had undergone tracheostomy were an ability to tolerate tube plugging for 48 h and the capacity to expectorate without assistance. All patients underwent two videofluoroscopic swallow studies (VFSS), before and after decannulation. We measured 21 time interval variables during swallowing in the pharyngeal phase and the extent of laryngeal elevation. No patient exhibited any change in swallowing function status [Penetration - Aspiration Scale (PAS) (median value = 1)] in the interval between the two VFSS tests. Upon kinematic analysis, no significant difference in any variable pertaining to laryngeal elevation or pharyngeal constriction was found when pre- and post-decannulation VFSS test data were compared (p > 0.05). The present study thus showed that removal of a tracheostomy tube does not affect the kinematics of swallowing. Our results support previous findings that indicated no relationship between tracheostomy tube placement and dysphagia.

A clinical audit of the management of patients with a tracheostomy in an Australian tertiary hospital intensive care unit: Focus on speech-language pathology

Speech-language pathologists manage communication and swallowing disorders, both of which can occur in patients after tracheostomy insertion. An audit on the incidence and timing of speech-language pathology intervention for adults with tracheostomies has not previously been published. Data were retrospectively extracted from the medical records of all patients who were tracheostomized at Royal Prince Alfred Hospital, NSW, Australia, from October 2007 for 1 year. Extracted data included diagnosis, date and type of tracheostomy, time to speech-language pathologist involvement, time to phonation, and time to oral intake. Among the 140 patients (mean age 58 years, range 16-85), diagnoses were neurological (32%), head and neck (25%), cardiothoracic (24%), respiratory (6%), and other (13%). Speech-language pathology was involved with 78% of patients, with initial assessment on average 14 days after tracheostomy insertion (14 days to 166 days). Median time from tracheostomy insertion to phonation was 12 days (range 1-103). Median time from tracheostomy insertion to oral intake was 15 days (range 1-142). Only 20% of patients returned to verbal communication within 1 week after tracheostomy insertion. Further research into access to and timing of speech-language pathology intervention in the critical care setting is warranted.

Nutrition management for the patient requiring prolonged mechanical ventilation

Patients requiring prolonged mechanical ventilation are often medically complex and present with a wide range of pulmonary conditions, including neuromuscular diseases, chronic pulmonary diseases, and chronic critical illness. These patients present the nutrition support professional with many challenges. However, accurate nutrition assessment, timely and effective nutrition interventions, and careful monitoring will help patients meet their medical and nutrition goals.

Initiating safe oral feeding in critically ill intensive care and step-down unit patients based on passing a 3-ounce (90 milliliters) water swallow challenge

BACKGROUND

Pulmonary aspiration is a leading cause of nosocomial infection in the intensive care unit (ICU) and step-down unit (SDU). A key goal is to identify patients who exhibit increased aspiration risk before beginning oral alimentation. This study investigated the success of recommending specific oral diets to ICU and SDU patients based on passing a 3-oz water swallow challenge.

METHODS

A referral-based sample of 401 ICU and 92 SDU patients were prospectively analyzed. Amount of liquid and food ingested at the next day's meal 12 hours to 24 hours after passing a 3-oz challenge and specific diet recommendations were accessed electronically from oral intake information entered on each participant's daily care sheets. Drinking and eating success, clinically evident aspiration events, and accuracy of diet order recommendations were recorded. Care providers were blinded to the purpose of the study.

RESULTS

All 401 ICU and 92 SDU patients were successfully drinking thin liquids and eating 12 hours to 24 hours after passing a 3-oz challenge. Mean volume of liquid ingested at the next day's meal was 360 mL±181.2 mL for ICU and 356.4 mL±173.5 mL for SDU patients. Percent of meal eaten ranged from 10% to 100%. Patient care sheets indicated specific diet recommendations were followed with 100% accuracy.

CONCLUSIONS

Successfully recommending specific oral diets for ICU and SDU patients based on passing a 3-oz water swallow challenge was supported. Importantly, when a simple bedside 3-oz challenge administered by a trained provider is passed, specific diet recommendations can be made safely and confidently without the need for further objective dysphagia testing.

Silent aspiration risk is volume-dependent

Clinical swallow protocols cannot detect silent aspiration due to absence of overt behavioral signs, but screening with a much larger bolus volume, i.e., 90 cc vs. 1-10 cc, may elicit a reflexive cough in individuals who might otherwise exhibit silent aspiration. A swallow screen that maintains high sensitivity to identify aspiration risk while simultaneously reducing the false-negative rate for silent aspiration would be beneficial. The purpose of this study was to investigate whether silent aspiration risk was volume-dependent by using a 3-oz. (90-cc) water swallow challenge to elicit a reflexive cough when silent aspiration occurred on smaller bolus volumes. A prospective, consecutive, referral-based sample of 4102 inpatients from the acute-care setting of a large urban tertiary-care teaching hospital participated. Silent aspiration was determined first by fiberoptic endoscopy and then each participant was instructed to drink 3 oz. of water completely and without interruption. Criteria for challenge failure were inability to drink the entire amount, stopping and starting, or coughing and choking during or immediately after completion. Improved identification of aspiration risk status occurred for 58% of participants who exhibited silent aspiration on smaller volumes, i.e., an additional 48% of liquid silent aspirators and 65.6% of puree silent aspirators coughed when attempting the 3-oz. water swallow challenge. A low false-negative rate was observed for the entire population sample, i.e., ≤2.0%. A combined false-negative rate for participants who silently aspirated was 6.9%, i.e., 7.8% if silently aspirated liquid and 6.1% if silently aspirated puree consistency. Determination of silent aspiration risk was shown to be volume-dependent, with a larger volume eliciting a reflexive cough in individuals who previously silently aspirated on smaller volumes. A 3-oz. water swallow challenge's previously reported high sensitivity for identification of aspiration risk combined with the newly reported low false-negative rate mitigates the issue of silent aspiration risk during clinical swallow screening.

Swallowing dysfunction in nonneurologic critically ill patients who require percutaneous dilatational tracheostomy

BACKGROUND

The aim of this study was to determine the incidence of swallowing dysfunction in nonneurologic critically ill patients who require percutaneous dilatational tracheostomy (PDT) for prolonged mechanical ventilation (MV) and to compare the duration of the cannulation period and length of stay in the critical care unit (CCU) in patients with and without swallowing dysfunction.

METHODS

A total of 40 consecutive patients without neurologic disorders who require PDT for prolonged MV were included. Previous to the tracheostomy decannulation process, an otolaryngologist performed a fiberoptic endoscopic evaluation of swallowing (FEES). We used analysis of variance for the analysis; the results are presented as mean values +/- SD.

RESULTS

Mean age was 62 +/- 15 years. Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores were 21 +/- 2 and 9 +/- 1, respectively. Time of MV previous to PDT was 20 +/- 11 days, total MV duration was 38 +/- 16 days, and CCU stay was 63 +/- 27 days. The incidence of swallowing dysfunction in this group of patients was 38% (15/40). No difference was found in the age or time period of MV previous to PDT between groups. The time period between FEES to tracheostomy decannulation process was 19 +/- 11 days in patients with swallowing dysfunction vs 2 +/- 4 days in those patients without dysfunction (P < .001). Patients who developed swallowing dysfunction stayed longer in the CCU (69 +/- 23 vs 47 +/- 19 days, P < .01).

CONCLUSIONS

Nearly 40% of nonneurologic critically ill patients requiring PDT for prolonged MV presented swallowing dysfunction and experienced a significant delay in their tracheostomy decannulation process.

Pilot date on swallow function in nondysphagic patients requiring a tracheotomy tube

Objective. To evaluate the effects of occlusion status (i.e., open, finger, capped) of the tracheotomy tube and removal of the tracheotomy tube that may have upon bolus flow and durational measurements in nondysphagic persons requiring a tracheotomy tube. Study Design. Prospective, single subject, repeated measure design. Methods. Participants had their swallow evaluated with 5 mL pureed boluses using nasal endoscopy with the tracheotomy tube in place, removed, and under the following occlusion conditions: open, finger, and capped. The order of occlusion condition was randomized. Results. Aspiration was never observed but laryngeal penetration was a common finding. Durational measurements for swallow initiation and duration of white out were not significantly different by occlusion status or after removal of the tracheotomy tube. Conclusion. This study provides corroborating evidence demonstrating the lack of a relationship between a tracheotomy tube and swallowing dysfunction.