Post-extubation Dysphagia: Does Timing of Evaluation Matter?

Temporal recovery and prognostic factors for dysphagia following cardiovascular surgery: Retrospective analysis and development of predictive score

OBJECTIVE

Dysphagia is a common complication associated with cardiovascular surgery (CVS). This study sought to better understand recovery timelines, identify risk factors, and create a prognostic model for oral intake restoration.

METHODS

This retrospective study included 134 patients who had CVS between April 2022 and March 2024. We assessed swallowing ability through fiberoptic endoscopic evaluation of swallowing (FEES). We randomly divided the patients' data into a training dataset and a test dataset in a ratio of 70/30 and Kaplan-Meier analyses and Cox regression were used to assess predictors of total oral intake. We also created a scoring system using the estimated regression coefficients.

RESULTS

Most patients with CVS achieved total oral intake in 7-11 days after extubation. Over 168 h of intubation, the presence of penetration or aspiration, a poor FEES score (score > 6), and perioperative complications were significant risk factors for delayed total oral intake. The predicting score was calculated by adding the scores for each individual factor, including FEES score, penetration/aspiration, and preoperative complications. Scores ranged 0-8, categorizing patients into 0-2, 3-5, and 6-8 groups, clearly demonstrating that the higher the predicting score, the longer the time to total oral intake in both the training and the test dataset.

CONCLUSIONS

All risk factors for unsuccessful or delayed total oral intake were intubation for more than a week, poor swallowing ability, and the presence of perioperative complications. The scoring system accurately predicts the restoration of oral intake following CVS.

Predictors for postoperative dysphagia in liver transplant recipients

Introduction

Liver transplant recipients are at a heightened risk for oropharyngeal dysphagia; identification of those who are at high risk for postoperative dysphagia could reduce hospital costs and length of stay. We sought to identify predictors of dysphagia, in a large cohort of patients who underwent liver transplantation.

Methods

Electronic medical records were queried for patients undergoing liver transplantation, who underwent instrumental swallowing evaluations. Demographics, functional outcomes, and interventions were collected. Logistic regression analyses were performed to identify predictors of dysphagia.

Results

Seven hundred and ninety-five patients met inclusionary criteria. Multivariate analyses found ethnic group (p = .0191), MELD Score (p < 0001), cold ischemia time (p = .0123), and length of intubation (p < .0001) to be predictors of post-operative development of dysphagia. Pre-transplant dialysis (p < .0001), dysphagia related to end stage liver disease (p < .0001), Karnofsky Performance Status Scale (p < .0001), wait time to transplant (p = 0.0173), surgery time (p = 0.0095), tracheostomy (p < 0.0001), and transfusion of intraoperative RBC (p < .0001), intraoperative platelets (p = 0.0018), intraoperative FFP (p = 0.0495), perioperative FFP (p = 0.0002), perioperative platelets (p = 0.0151) and perioperative RBC (p = 0.0002) were variables of significance associated with the development of postoperative dysphagia from univariate analysis.

Conclusions

Our results propose a set of predictors that should be considered when identifying post-operative critically ill patients at risk for dysphagia.

Postorotracheal intubation dysphagia in patients with COVID-19: A retrospective study

BACKGROUND

The cause of oropharyngeal dysphagia in patients with coronavirus disease (COVID-19) can be multifactorial and may underly limitations in swallowing rehabilitation.

OBJECTIVE

Analyze the factors related to dysphagia in patients with COVID-19 immediately after orotracheal extubation and the factors that influence swallowing rehabilitation.

DESIGN AND SETTING

A retrospective study.

METHODS

The presence of dysphagia was evaluated using the American Speech-Language Hearing Association National Outcome Measurement System (ASHA NOMS) scale and variables that influenced swallowing rehabilitation in 140 adult patients who required invasive mechanical ventilation for >48 h.

RESULTS

In total, 46.43% of the patients scored 1 or 2 on the ASHA NOMS (severe dysphagia) and 39.29% scored 4 (single consistency delivered orally) or 5 (exclusive oral diet with adaptations). Both the length of mechanical ventilation and the presence of neurological disorders were associated with lower ASHA NOMS scores (odds ratio [OR]: 0.80, 95% confidence interval [CI]: 0.74-0.87 P < 0.05; and OR: 0.13, 95% CI: 0.61-0.29; P < 0.05, respectively). Age and the presence of tracheostomy were negatively associated with speech rehabilitation (OR: 0.92; 95% CI: 0.87--0.96; OR: 0.24; 95% CI: 0.80--0.75), and acute post-COVID-19 kidney injury requiring dialysis and lower scores on the ASHA NOMS were associated with longer time for speech therapy outcomes (β: 1.62, 95% CI, 0.70-3.17, P < 0.001; β: -1.24, 95% CI: -1.55--0.92; P < 0.001).

CONCLUSION

Prolonged orotracheal intubation and post-COVID-19 neurological alterations increase the probability of dysphagia immediately after extubation. Increased age and tracheostomy limited rehabilitation.

Improvement in swallowing safety after injection laryngoplasty in patients with unilateral vocal paralysis complicated with aspiration

BACKGROUND

The benefit of injection laryngoplasty (IL) on voice for unilateral vocal fold paralysis (UVFP) is supported increasingly in literatures, yet less is known for swallowing. Also, prevalence of patient-reported dysphagia is substantially higher than instrumental studies. This prospective study focused on swallowing outcomes, with predetermined flexible endoscopic evaluation of swallowing (FEES) protocol that simulates daily life situation.

METHODS

Adult patients with UVFP and aspiration receiving IL were recruited. Voice outcome measurements, as well as swallowing outcomes including Eating Assessment Tool (EAT-10) and FEES, which challenged patients with different fluid volumes: 10 mL, 20 mL, and 90 mL cup sipping were evaluated.

RESULTS

Significant improvements were demonstrated in all voice outcomes. Significant changes were also presented inEAT-10 (P < 0.01). Pre-operatively, penetration-aspiration scale (PAS) was 1.5 ± 1.3, 1.9 ± 1.7 and 2.3 ± 1.8 for 10 mL, 20 mL and 90 mL serial sipping, and improved to 1.1 ± 0.3, 1.1 ± 0.4 and 1.4 ± 0.7 post-operatively (P < 0.01). Safe swallowing (PAS ≤ 2) was achieved in all, except for one patient, who presented with a post-injection PAS of 4 (material enters the airway, contacts the vocal folds, and is ejected from the airway) on 90 mL cup sipping, whose pre-injection PAS was 7 (residue in trachea).

CONCLUSION

Maintaining swallowing function suitable for social environment is important. Our results demonstrated the feasibility of the predetermined FEES protocol, and positive effects of IL on both voice and swallowing outcomes.

Feasibility of Spectral Analysis as a Tool in Nursing Research to Quantify Patterns of Respiration in Premature Infants

Background

Respiratory difficulties are a common concern in preterm infants, and they can lead to long-term health problems. Few studies have investigated the use of spectral analysis as a biomarker to quantify respiration patterns in preterm infants.

Objective

To evaluate the feasibility of using spectral analysis of heart rate variability as a biomarker for the quantification of respiratory patterns in very-low-birth-weight preterm infants compared to direct observation.

Methods

In a comparative, small-scale feasibility study, 18 preterm infants born during their 27th to 28th gestational week (weighing <1500 grams) participated by convenience. Respiratory patterns (regular or irregular; shallow or deep) were directly observed on the 28th week during playback of speech recording. Heart rate variability was simultaneously measured using spectral analysis of heart periods, from which the mean values influenced by respiratory sinus arrhythmia (frequencies of 0.30-1.0 Hz) were compared to each observed respiratory pattern. The magnitudes of respiratory sinus arrhythmia and the area under the curve were determined.

Results

The magnitude of respiratory sinus arrhythmia (frequencies of 0.30-1.0 Hz) in infants observed to be displaying irregular shallow respiration was greater than that in infants with regular deep respiration. Further, there was a shift from lower frequencies (frequency peak = 0.30 Hz) to higher frequencies (peak = 0.70 Hz).

Conclusion

In contrast with direct observation, spectral analysis allowed for the quantification of respiratory patterns in a vulnerable population of preterm infants of interest to the nursing scientific and practice community. Future directions include applying this biomarker to evaluate both developmental and pathological trends in the respiratory patterns of preterm infants.

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

BACKGROUND

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

OBJECTIVES

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

RESULTS

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

CONCLUSION

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

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

AIMS

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

METHODS AND RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Perspectives on speech and language pathology practices and service provision in adult critical care settings in Ireland and international settings: A cross-sectional survey

PURPOSE

Patients admitted to critical care (CC) are at risk of impaired swallowing and communication function. Speech-language pathologists (SLPs) play an important role in this context. In Ireland and internationally speech-language pathology CC guidelines are lacking, with possible variations in practice. To compare clinical practices in dysphagia, communication and tracheostomy management among SLPs working in adult CC units in Ireland and internationally, and explore their perspectives on training, skills and resources.

METHOD

Participants were SLPs working in CC. An international online survey sought information on (i) SLP workforce demographics and staffing levels, (ii) current dysphagia and communication assessment and management practices, (iii) practices and perspectives on training, skills and resources.

RESULT

366 responses were received across 29 countries. 18.03% (66/366) of these respondents worked in Ireland. Findings showed similarities and differences in practices. Total CC SLP whole-time equivalent (WTE) at each staff grade was lower (mean difference: -0.21 to -0.65 WTE p <.001) than desired for optimal service delivery. Negative effects of under-staffing were reported. Recommendations that all tracheostomised patients receive SLP input was unmet in 66% (220/334) of services.

CONCLUSION

SLP input in CC is limited in terms of dedicated posts, multidisciplinary team (MDT) involvement, consistent management approaches and training opportunities internationally. Implications of findings are discussed.

Is Postextubation Dysphagia Underestimated in the Era of COVID-19? A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate the incidence rate of postextubation dysphagia (PED) in patients with COVID-19, as well as relative factors potentially influencing the clinical course of dysphagia.

DATA SOURCES

Six databases including PubMed, MEDLINE, Embase, ScienceDirect, the Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science were searched with no restriction on the language.

REVIEW METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Data were extracted and cross-examined among 3 of the authors. The random-effects model was adopted for the statistical synthesis. The percentage and 95% confidence interval (CI) were adopted as the effect measurements of the PED incidence rate. Subgroup analyses, sensitivity analyses, and metaregression were also performed to identify the heterogeneity among the studies.

RESULTS

A total of 594 patients were enrolled and analyzed from the 10 eligible studies. The weighted incidence of PED in patients with COVID-19 was 66.5% (95% CI: 49.7%-79.9%). Age was the potential factor influencing the incidence rate after heterogeneity was adjusted by the metaregression analysis.

CONCLUSION

Compared to the current evidence reporting only 41% of the non-COVID patients experienced PED, our study further disclosed that a higher 66.5% of COVID-19 patients suffered from PED, which deserves global physicians' attention. With the association between COVID-19 and dysphagia having been more clearly understood, future clinicians are suggested to identify intubated patients' risk factors earlier to strengthen PED care programs in the era of COVID-19.

The Characteristics and Predicators of Post-extubation Dysphagia in ICU Patients with Endotracheal Intubation

The current status and characteristics of post-extubation dysphagia in intensive care unit (ICU) patients with endotracheal intubation remain unclear, we aimed to evaluate the characteristics and identify the predicators for post-extubation dysphagia, to provide reliable reference to the clinical management and nursing care of dysphagia. Patients who underwent tracheal intubation for mechanical ventilation in the ICU of our hospital from January 1, 2020-May 31, 2021 were selected. The characteristics of patients with and without post-extubation dysphagia were analyzed. Univarinate and binary logistic regression analysis were used to screen the risk factors of dysphagia after extubation, and we established the risk prediction model according to the regression coefficients of each risk factor. 316 ICU patients with endotracheal intubation were included, the incidence of post-extubation dysphagia was 27.85%. Logistic regression analysis showed that age ≥ 65 years (OR 2.368, 95%CI 1.633 ~ 3.946), APACHE II score ≥ 15 (OR 3.727, 95%CI 3.312 ~ 4.202), length of tracheal intubation indwelling ≥ 72 h (OR 2.495, 95%CI 1.824 ~ 3.715), length of gastric tube stay ≥ 72 h (OR 1.923, 95%CI 1.452 ~ 2.882) were the risk factors of post-extubation dysphagia in ICU patients with endotracheal intubation(all p < 0.05). Six score was used as the cuff value of the model with good sensitivity and specificity. The area under the ROC curve and 95% confidence interval was 0.822 (0.746, 0.872). There are many risks of post-extubation dysphagia in ICU patients with endotracheal intubation. For high-risk patients with a score ≥ 6, early nursing care and interventions should be given as soon as possible to reduce the post-extubation dysphagia.

A Decision Guide for Assessing the Recently Extubated Patient's Readiness for Safe Oral Intake

BACKGROUND

Postextubation dysphagia is a known consequence of endotracheal intubation. Several risk factors for postextubation dysphagia have been identified that could be used to help determine which patients should undergo swallowing assessment by an appropriate professional.

LOCAL PROBLEM

At the authors' institution, critical care nurses, health care providers, and speech-language pathology professionals lacked a clear process for referring patients for swallowing assessment after extubation, resulting in inefficiency and confusion. Information to guide their decision-making in this area was needed. To address this need, a multidisciplinary group convened and developed a guide with specific indicators.

METHODS

A review of the literature on postextubation dysphagia was conducted to determine the most appropriate indicators for the guide, which was piloted in the medical intensive care unit. The utilization rate was calculated. Referrals to speech-language pathology professionals were tabulated before and after the project.

RESULTS

During the 11 months before implementation of the project, there were 994 speech-language pathology consultations for postextubation evaluation of swallowing. During the 11 months after implementation, there were 831 consultations, representing a 16.4% reduction. The decline in consultations resulted in cost savings in addition to preventing unnecessary testing before patients' resumption of oral intake. The utilization rate for the guide during the project was 58%.

CONCLUSION

The decision guide was an effective tool to help nurses and health care providers determine which patients should be referred to speech-language pathology professionals for swallowing assessment after extubation, facilitating the appropriate use of limited health care resources.

Postextubation dysphagia in critically ill children: A prospective cohort study

INTRODUCTION

Postextubation dysphagia (PED) is reported mainly in adults and is associated with poor outcomes. However, data on pediatric intensive care unit (PICU) patients are scarce. We aimed to assess the incidence, risk factors, and outcomes associated with PED in a PICU population.

METHODS

Between 2019 and 2021, we conducted a prospective, observational cohort study of patients aged 1 month to 15 years. Within 24 h after extubation, a speech-language pathologist routinely screened all consecutive patients receiving mechanical ventilation (>24 h) for dysphagia. A Functional Oral Intake Scale (FOIS) score of less than 6 indicated dysphagia.

RESULTS

A total of 161 patients were included, with a PED incidence of 69%. After adjusting for confounding variables, five variables were significantly associated with PED (odds ratio; 95% confidence interval): age <24 months (4.84; 1.5-15.60), neurological comorbidities (7.47; 1.36-40.96), iatrogenic withdrawal syndrome (5.52; 1.31-23.14), use of neuromuscular blocking agents (4.19; 1.18-14.82), and duration of intubation >72 h (3.22; 1.08-9.64). Dysphagia was significantly associated with longer PICU and hospital stays and a longer delay to oral feeding than patients without PED, 14 versus 7.5 days, 21 versus 15 days, and 6 versus 1 day, respectively. Ten participants (9%) failed to resume total oral intake at hospital discharge.

CONCLUSIONS

These findings indicate that PED is highly prevalent in children and associated with adverse patient outcomes. Identifying a core of risk factors might improve prompt recognition of patients at risk for PED and implement preventive approaches and early interventions.

Dysphagia assessment in ischemic stroke after mechanical thrombectomy: When and how?

Background

Dysphagia is a frequent symptom in acute ischemic stroke (AIS). Endovascular treatment (EVT) has become the standard of care for acute stroke secondary to large vessel occlusion. Although standardized guidelines for poststroke dysphagia (PSD) management exist, they do not account for this setting in which patients receive EVT under general anesthesia. Therefore, the aim of this study was to evaluate PSD prevalence and severity, as well as an appropriate time point for the PSD evaluation, in patients undergoing EVT under general anesthesia (GA).

Methods

We prospectively included 54 AIS patients undergoing EVT under GA. Fiberoptic Endoscopic Evaluation of Swallowing (FEES) was performed within 24 h post-extubation in all patients. Patients presenting significant PSD received a second FEES-assessment to determine the course of dysphagia deficits over time. Dysphagia severity was rated according the Fiberoptic Dysphagia Severity Scale (FEDSS).

Results

At first FEES (FEES 1) assessment, performed in the median 13 h (IQR 5-17) post-extubation, 49/54 patients (90.7%) with dysphagia were observed with a median FEDSS of 4 (IQR 3-6). Severe dysphagia requiring tube feeding was identified in 28/54 (51.9%) subjects, whereas in 21 (38.9%) patients early oral diet with certain food restrictions could be initiated. In the follow up FEES examination conducted in the median 72 h (IQR 70-97 h) after initial FEES 34/49 (69.4%) patients still presented PSD. Age (p = 0.030) and ventilation time (p = 0.035) were significantly associated with the presence of PSD at the second FEES evaluation. Significant improvement of dysphagia frequency (p = 0.006) and dysphagia severity (p = 0.001) could be detected between the first and second dysphagia assessment.

Conclusions

PSD is a frequent finding both immediately within 24 h after extubation, as well as in the short-term course. In contrast to common clinical practice, to delay evaluation of swallowing for at least 24 h post-extubation, we recommend a timely assessment of swallowing function after extubation, as 50% of patients were safe to begin oral intake. Given the high amount of severe dysphagic symptoms, we strongly recommend application of instrumental swallowing diagnostics due to its higher sensitivity, when compared to clinical swallowing examination. Furthermore, advanced age, as well as prolonged intubation, were identified as significant predictors for delayed recovery of swallowing function.

Risk Factors for Dysphagia in Patients Hospitalized with COVID-19

Patients hospitalized with COVID-19 may be at risk for dysphagia and vulnerable to associated consequences. We investigated predictors for dysphagia and its severity in a cohort of patients hospitalized with COVID-19 at a single hospital center. A large level I trauma center database was queried for all patients hospitalized with COVID-19. Demographics, medical information associated with COVID-19, specific to dysphagia, and interventions were collected. 947 patients with confirmed COVID-19 met the criteria. 118 (12%) were seen for a swallow evaluation. Individuals referred for evaluation were significantly older, had a lower BMI, more severe COVID-19, and higher rates of intubation, pneumonia, mechanical ventilation, tracheostomy placements, prone positioning, and ARDS. Pneumonia (OR 3.57, p = 0.004), ARDS (OR 3.57, p = 0.029), prone positioning (OR 3.99, p = 0.036), ventilation (OR 4.01, p = 0.006), and intubation (OR 4.75, p = 0.007) were significant risk factors for dysphagia. Older patients were more likely to have more severe dysphagia such that for every 1-year increase in age, the odds of severe dysphagia were 1.04 times greater (OR 1.04, p = 0.028). Patients hospitalized with COVID-19 are at risk for dysphagia. We show predictive variables that should be considered when referring COVID-19 patients for dysphagia services to reduce time to intervention/evaluation.

Prevalence and evaluation of oropharyngeal dysphagia in patients with severe acute respiratory syndrome coronavirus 2 infection in the intensive care unit

Objective

The main objective was to assess the prevalence of dysphagia in the intensive care unit in patients with coronavirus disease 2019.

Methods. A cohort, observational, retrospective study was conducted of patients admitted to the intensive care unit for severe acute respiratory syndrome coronavirus 2 pneumonia at the University Hospital of Rouen in France.

Results

Over 4 months, 58 patients were intubated and ventilated, 43 of whom were evaluated. Screening revealed post-extubation dysphagia in 62.7 per cent of patients. In univariate analysis, a significant association was found between the presence of dysphagia and: the severity of the initial pathology, the duration of intubation, the duration of curare use, the degree of muscle weakness and the severity indicated on the initial scan. At the end of intensive care unit treatment, 22 per cent of the dysphagic patients had a normal diet, 56 per cent had an adapted diet and 22 per cent still received exclusive tube feeding.

Conclusion

Post-extubation dysphagia is frequent and needs to be investigated.

Characteristics of postintubation dysphagia in ICU patients in the context of the COVID-19 outbreak: A report of 920 cases from a Brazilian reference center

The purpose of this research was to identify risk factors that were independently related to the maintenance of a swallowing dysfunction in patients affected by critical COVID-19. We conducted a prospective observational cohort study of critical patients with COVID-19, who were admitted to a COVID-19 dedicated intensive care unit (ICU) and required prolonged orotracheal intubation (≥48 hours). Demographic and clinical data were collected at ICU admission and/or at hospital discharge or in-hospital death. Swallowing data was based on The Functional Oral Intake Scale (FOIS) and was collected at two distinct moments: initial swallowing assessment and at patient outcome. Patients were divided into two groups according to their FOIS level assigned on the last swallowing assessment: in-hospital resolved dysphagia–patients with FOIS levels 6 and 7; non-resolved dysphagia at hospital outcome–patients with FOIS levels 1 to 5. Nine hundred and twenty patients were included in our study. Results of the multivariate logistic regression model for the prediction of non-resolved dysphagia at hospital outcome in critical COVID-19 patients. indicated that increasing age (p = 0.002), severity at admission (p = 0.015), body mass index (p = 0.008), use of neuromuscular blockers (p = 0.028), presence of neurologic diseases (p = 0.038), presence of Diabetes Mellitus (p = 0.043) and lower FOIS levels on the initial swallowing assessment (p<0.001) were associated with higher chances of presenting dysphagia at hospital outcome. Critical patients with COVID-19 may experience post-acute COVID-19 dysphagia, indicating the need to prepare for the care/rehabilitation of these patients.

Nutritional support protocol for patients with COVID-19

BACKGROUND & AIMS

COVID-19 is a hypercatabolic disease with possible pulmonary and gastrointestinal symptoms, and consequent deterioration of the nutritional status and the worst clinical prognosis. This study presents a protocol to guide the nutritional care of adult and elderly people non-critically and critically ill with COVID-19.

METHODS

A critical review of the literature was carried out in the databases PubMed, Scielo, Bireme, and Science Direct, in search of articles and guidelines that presented assessment criteria and nutritional conduct for COVID-19 and Severe Acute Respiratory Syndrome (SARS), as well as guidelines for managing the symptoms presented by patients.

RESULTS

The results are recommendations based on the literature and the professional experience of nutritionists who provide nutritional assistance to individuals hospitalized with COVID-19 since the beginning of the pandemic in Brazil. We present tools and suggestions for assessing the nutritional status, calculating nutritional needs, initiating nutritional therapy and monitoring tolerance to it, nutritional monitoring during hospitalization, and guidelines for hospital discharge.

CONCLUSION

Patients with COVID-19 are at nutritional risk. A complete nutritional assessment (anthropometric, dietary, and laboratory assessment) enables the establishment of an individualized nutritional approach in order to contribute to better clinical and nutritional prognoses.

Association between timing of speech and language therapy initiation and outcomes among post-extubation dysphagia patients: a multicenter retrospective cohort study

Background

Post-extubation dysphagia (PED) is recognized as a common complication in the intensive care unit (ICU). Speech and language therapy (SLT) can potentially help improve PED; however, the impact of the timing of SLT initiation on persistent PED has not been well investigated. This study aimed to examine the timing of SLT initiation and its effect on patient outcomes after extubation in the ICU.

Methods

We conducted this multicenter, retrospective, cohort study, collecting data from eight ICUs in Japan. Patients aged ≥ 20 years with orotracheal intubation and mechanical ventilation for longer than 48 h, and those who received SLT due to PED, defined as patients with modified water swallowing test scores of 3 or lower, were included. The primary outcome was dysphagia at hospital discharge, defined as functional oral intake scale score < 5 or death after extubation. Secondary outcomes included dysphagia or death at the seventh, 14th, or 28th day after extubation, aspiration pneumonia, and in-hospital mortality. Associations between the timing of SLT initiation and outcomes were determined using multivariable logistic regression.

Results

A total of 272 patients were included. Of them, 82 (30.1%) patients exhibited dysphagia or death at hospital discharge, and their time spans from extubation to SLT initiation were 1.0 days. The primary outcome revealed that every day of delay in SLT initiation post-extubation was associated with dysphagia or death at hospital discharge (adjusted odds ratio (AOR), 1.09; 95% CI, 1.02–1.18). Similarly, secondary outcomes showed associations between this per day delay in SLT initiation and dysphagia or death at the seventh day (AOR, 1.28; 95% CI, 1.05–1.55), 14th day (AOR, 1.34; 95% CI, 1.13–1.58), or 28th day (AOR, 1.21; 95% CI, 1.07–1.36) after extubation and occurrence of aspiration pneumonia (AOR, 1.09; 95% CI, 1.02–1.17), while per day delay in post-extubation SLT initiation did not affect in-hospital mortality (AOR, 1.04; 95% CI, 0.97–1.12).

Conclusions

Delayed initiation of SLT in PED patients was associated with persistent dysphagia or death. Early initiation of SLT may prevent this complication post-extubation. A randomized controlled study is needed to validate these results.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03974-6.

[Postextubation dysphagia in intensive care patients : Current findings and clinical recommendations]

BACKGROUND

A considerable number of critically ill and mechanically ventilated intensive care patients show pronounced dysphagia after extubation. Many studies have shown that postextubation dysphagia (PED) leads to a significant decline of outcome. The awareness, timely diagnostic procedures and integration of suitable treatment methods in intensive care units are therefore of great importance.

OBJECTIVE

Current basic findings on PED, diagnostic possibilities, therapeutic methods as well as the development of concrete recommendations for clinical practice.

METHODS

A selective literature search was performed in PubMed, Medline and Cochrane using keywords.

RESULTS

In the literature the incidence PED is reported very heterogeneous but is probably at least 10% in intensive care patients after mechanical ventilation. The duration of intubation plays a critical role here. A multifactorial interaction of several factors is assumed to be the cause, whereby the impairment of laryngeal structures is of particular relevance. A PED leads to longer hospital stays, higher mortality, more reintubation and a higher number of patients with tube feeding. With respect to diagnostics, screening by trained nurses, clinical swallowing examinations and, in particular, the use of instrumental examinations by flexible endoscopic evaluation of swallowing (FEES) are recommended. The treatment should include adaptive measures in the sense of an adapted diet but also functional exercises. Innovative approaches, such as electrical stimulation are also conceivable. The aim is primarily to avoid penetration and aspiration in order to counteract respiratory complications.

CONCLUSION

In many intensive care units the clinical picture of PED is still neglected despite clear evidence. A simple algorithm in the treatment of intensive care patients can contribute to early detection and initiation of further steps. These should be integrated into clinical treatment standards.

Dysphagia Severity and Management in Patients with COVID-19

COVID-19 has resulted in unprecedented numbers of patients treated at intensive care units (ICUs). Dysphagia is a key concern in critical illness survivors. We investigated the severity of dysphagia in COVID-19 and the need to adapt practices to provide efficient care. We reviewed the literature on COVID-19, post-critical-illness dysphagia, and dysphagia and tracheostomy guidelines during the pandemic. Critically ill COVID-19 patients present a high incidence of dysphagia, aggravated by respiratory distress, deconditioning, and neurological complications. Mechanical ventilation (MV), delirium, sedation and weakness are worse in COVID-19 than in other etiologies of critical care. In awake patients, respiratory compromise impairs breathing-swallowing-coughing coordination. Tracheostomy reduces laryngopharyngeal trauma, sedation, delirium, ICU stay and improves swallowing rehabilitation. Tracheostomy weaning and swallowing evaluation is complex in COVID-19 due to respiratory instability and a team discussion will guide adaptations. Patients assessed in the ICU were 67% recommended to be nil by mouth (were aspirating). Two months following hospital discharge, 83% of those who had undergone tracheostomy were managing a normal diet. Severely ill COVID-19 patients are expected to regain swallow function. Dysphagia care is based on adaptation of practices to the patients' multiple impairments.

Predictors of Aspiration and Silent Aspiration in Patients With New Tracheostomy

Purpose Hospitalized, medically complex patients with new tracheostomy are at risk for aspiration. This study reports incidence of aspiration in these patients with new tracheostomy and investigates possible risk factors for aspiration and silent aspiration in this patient population. Method Retrospective review of instrumental swallowing evaluations from hospitalized inpatients with new tracheostomy tubes to determine frequency of aspiration and silent aspiration and patient factors associated with aspiration. Patient variables including sex, age, reason for hospital admission, reason for tracheostomy, duration of intubation, time since tracheostomy placement, and tracheostomy cuff and cap status were examined as possible risk factors for aspiration and silent aspiration. Results Of the 272 patients with new tracheostomies who underwent instrumental swallowing evaluation, 59% aspirated on at least one consistency. Odds of aspiration were twice as high in patients with uncapped tracheostomy compared to closed (i.e., cap or speaking valve in place). Odds of aspiration were 3.4 times greater with patients who underwent tracheostomy for an oropharyngeal etiology (oropharyngeal or laryngeal tumor, surgery, or infection). Of the patients who aspirated, 81% aspirated silently on at least one consistency. Odds of silent aspiration was 4.5 greater with an uncapped tracheostomy. Conclusions Medically complex patients with new tracheostomy are at risk for aspiration and benefit from instrumental swallowing evaluations. Future prospective research is warranted to determine contributing factors responsible for this risk. Lastly, speech pathologists play an important role in the patient's recovery.

Rehabilitation of intubated COVID-19 patients in a Singapore regional hospital with early intensive care unit and sustained post-intensive care unit rehabilitation

Background

A proportion of patients with COVID-19 become critically ill, but few studies describe the functional outcomes and rehabilitation process of these patients.

Objective

To describe the complications encountered and functional outcomes of critically ill COVID-19 patients requiring intubation and subsequent intensive care unit (ICU) management and rehabilitation.

Methods

Retrospective case note review was conducted on all patients requiring intubation and ICU admission and subsequently discharged from our hospital from February 15, 2020 to May 1, 2020. Demographics, preexisting medical conditions, complications encountered in ICU, ICU and General Ward Length of Stay, number of therapy sessions delivered, nutritional data, and functional outcomes on discharge were collected from electronic medical records and entered in a deidentified database.

Results

Most patients developed significant breathlessness affecting post-ICU rehabilitation, a few patients developed ICU associated delirium while no patient developed ICU-associated weakness. All patients survived and could walk 20 m within 12 days post-extubation.

Conclusion

Early ICU and sustained post-ICU rehabilitation of critically ill, intubated COVID-19 patients is feasible. Further studies could look into the outcomes of this group of patients, in particular the effect of nutrition and pulmonary training on functional outcomes. We strongly recommend an interdisciplinary rehabilitation team approach in managing critically ill COVID-19 patients.

The Association Between Endotracheal Tube Size and Aspiration (During Flexible Endoscopic Evaluation of Swallowing) in Acute Respiratory Failure Survivors

OBJECTIVES

To determine whether a modifiable risk factor, endotracheal tube size, is associated with the diagnosis of postextubation aspiration in survivors of acute respiratory failure.

DESIGN

Prospective cohort study.

SETTING

ICUs at four academic tertiary care medical centers.

PATIENTS

Two hundred ten patients who were at least 18 years old, admitted to an ICU, and mechanically ventilated with an endotracheal tube for longer than 48 hours were enrolled.

INTERVENTIONS

Within 72 hours of extubation, all patients received a flexible endoscopic evaluation of swallowing examination that entailed administration of ice, thin liquid, thick liquid, puree, and cracker boluses. Patient demographics, treatment variables, and hospital outcomes were abstracted from the patient's medical records. Endotracheal tube size was independently selected by the patient's treating physicians.

MEASUREMENTS AND MAIN RESULTS

For each flexible endoscopic evaluation of swallowing examination, laryngeal pathology was evaluated, and for each bolus, a Penetration Aspiration Scale score was assigned. Aspiration (Penetration Aspiration Scale score ≥ 6) was further categorized into nonsilent aspiration (Penetration Aspiration Scale score = 6 or 7) and silent aspiration (Penetration Aspiration Scale score = 8). One third of patients (n = 68) aspirated (Penetration Aspiration Scale score ≥ 6) on at least one bolus, 13.6% (n = 29) exhibited silent aspiration, and 23.8% (n = 50) exhibited nonsilent aspiration. In a multivariable analysis, endotracheal tube size (≤ 7.5 vs ≥ 8.0) was significantly associated with patients exhibiting any aspiration (Penetration Aspiration Scale score ≥ 6) (p = 0.016; odds ratio = 2.17; 95% CI 1.14-4.13) and with risk of developing laryngeal granulation tissue (p = 0.02).

CONCLUSIONS

Larger endotracheal tube size was associated with increased risk of aspiration and laryngeal granulation tissue. Using smaller endotracheal tubes may reduce the risk of postextubation aspiration.

Rehabilitation in Pediatric Heart Failure and Heart Transplant

Survival of pediatric patients with heart failure has improved due to medical and surgical advances over the past decades. The complexity of pediatric heart transplant patients has increased as medical and surgical management for patients with congenital heart disease continues to improve. Quality of life in patients with heart failure and transplant might be affected by the impact on functional status that heart failure, heart failure complications or treatment might have. Functional areas affected might be motor, exercise capacity, feeding, speech and/or cognition. The goal of rehabilitation is to enhance and restore functional ability and quality of life to those with physical impairments or disabilities. Some of these rehabilitation interventions such as exercise training have been extensively evaluated in adults with heart failure. Literature in the pediatric population is limited yet promising. The use of additional rehabilitation interventions geared toward specific complications experienced by patients with heart failure or heart transplant are potentially helpful. The use of individualized multidisciplinary rehabilitation program that includes medical management, rehabilitation equipment and the use of physical, occupational, speech and feeding therapies can help improve the quality of life of patients with heart failure and transplant.

Dysphagia in cervical spinal cord injury: How international literature trends can guide South African practice patterns - A scoping review

Background

The limited data regarding dysphagia in high-level spinal cord injuries (SCIs) stem from economically developed countries. Dysphagia is prevalent in patients with cervical SCI; however, in a South African context, speech-language pathologists (SLPs) are not seen as key when managing this population. This may result in patients not being screened or identified early, leading to possible complications. The literature could provide useful insight on how best to address this clinical gap.

Objectives

The aim of my study was to conduct a scoping review on the description of dysphagia, the risk factors for developing dysphagia post-SCI and the practice patterns of team members working with dysphagia in cervical SCIs.

Methods

A five-step scoping review was undertaken. Data were analysed by using descriptive statistics as well as a thematic analysis by using a top-down approach.

Results

Through the process of screening according to the inclusion and exclusion criteria, 25 articles were included. Primarily, the pharyngeal phase was affected, which can lead to an aspiration pneumonia. The key risk factors were the presence of a tracheostomy tube, the use of ventilation and anterior spinal cord surgery. There was little mention regarding specific practice patterns, but an interdisciplinary approach was suggested as the most efficient model.

Conclusions

Specific guidelines and management options need to be considered for a South African context, given the high incidence of trauma-related injuries. There needs to be locally produced research, providing suggestions on how different team members can screen and identify dysphagia within this population. Solutions need to be unique, and contextually responsive and appropriate.

Clinical implications

The team members and the roles of these different team members need to be re-examined in order to ensure the early identification and management of cervical SCI patients who are at risk of developing a dysphagia.

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

Postextubation dysphagia may impose a substantial burden on intensive care unit patients and healthcare systems. Approximately 517,000 patients survive mechanical ventilation during critical care annually. Reports of postextubation dysphagia prevalence are highly variable ranging between 3% and 93%. Of great concern is aspiration leading to the development of aspiration pneumonia when patients resume oral feeding. Screening for aspiration with a water swallow test has been reported to be positive for 12% of patients in the intensive care unit after extubation. This review aims to increase awareness of postextubation dysphagia and provide an updated overview of the current knowledge regarding prevalence, pathophysiology, diagnostic modalities, and treatment options.

Risk Factors for Postextubation Dysphagia: A Systematic Review and Meta-analysis

OBJECTIVES/HYPOTHESIS

To identify, describe, and where possible meaningfully synthesize the reported risk factors for postextubation dysphagia (PED) in critically ill patients.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic search of peer-reviewed and grey literature was conducted in common scientific databases to identify previously evaluated risk factors of PED. Data extraction and risk of bias assessment used a double-blind approach. Random effects models were used for the meta-analyses. Meta-analyses were conducted where sufficient study numbers allowed after accounting for statistical and clinical heterogeneity.

RESULTS

Twenty-five studies were included, which investigated a total of 150 potential risk factors. Of these, 63 risk factors were previously identified by at least one study each as significantly increasing the risk of PED. After accounting for clinical and statistical heterogeneity, only two risk factors were suitable for meta-analysis, gender, and duration of intubation. In separate meta-analyses, neither gender (RR 1.00 [0.71, 1.43], I² = 0%) nor duration of intubation (RR 1.54 [-0.40, 3.49], I² = 0%) were significant predictors of PED.

CONCLUSIONS

A large number of risk factors for PED have been reported in the literature. However, significant variability in swallowing assessment methods, patient populations, timing of assessment, and duration of intubation prevented meaningful meta-analyses for the majority of these risk factors. Where meta-analysis was possible, gender and duration of intubation were not identified as risk factors for PED. We discuss future directions in clinical and research contexts. Laryngoscope, 2020.

Speech-Language Pathology Management for Adults With COVID-19 in the Acute Hospital Setting: Initial Recommendations to Guide Clinical Practice

Purpose This document outlines initial recommendations for speech-language pathology management of adult patients with COVID-19 in the acute hospital setting. Method The authors initially developed these recommendations by adapting those developed for physical therapists working with patients with COVID-19 by Thomas et al. (2020). The recommendations then underwent review by 14 speech-language pathologists and rehabilitation-focused academics representing seven countries (Belgium, Brazil, Canada, Ireland, Japan, New Zealand, the United States). The authors consolidated and reviewed the feedback in order to decide what should be included or modified. Applicability to a global audience was intended throughout the document. Results The authors had 100% agreement on the elements of the recommendations that needed to be changed/modified or added. The final document includes recommendations for speech-language pathology workforce planning and preparation, caseload management, service delivery and documentation, as well as recommendations for the selection of appropriate personal protective equipment and augmentative and alternative communication equipment in the acute care hospital setting. Conclusions Speech-language pathologists play a critical role in the assessment, management, and treatment of patients with COVID-19. Several important considerations need to be made in order to meet the needs of this unique patient population. As more is learned about the impact of the virus on swallowing and communication, the role of the speech-language pathologist on interdisciplinary care teams will remain paramount.

Swallowing screening practice patterns for nurses in the cardiac surgery intensive care unit

AIMS AND OBJECTIVES

The current study surveyed nurse practice patterns for performing swallowing screens in an academic cardiac intensive care unit (ICU). It aimed to index: training and levels of confidence in conducting dysphagia screens; screening methods employed; timing and frequency of implement; and subsequent plan of care in identified high-risk patients.

BACKGROUND

Swallowing impairment (dysphagia) is common following cardiac surgery and associated with significant morbidity and mortality. Early and accurate detection of dysphagia is therefore critical to afford implementation of interventions to optimise patient care. Currently, no validated instruments or guidelines exist for nursing screening of dysphagia in this setting.

METHODS

An anonymous and voluntary 10-item mixed-methods online survey was conducted using Qualtrics software. Nonprobability purposive sampling was utilised to recruit nurses working in an academic 24-bed cardiac ICU. Thematic analysis using operationally defined coding, SRQR checklist and descriptive statistics were employed.

RESULTS

Sixty-nine nurses completed the survey during a 1-month period, representing an 84% response rate. Formal training in performing swallowing screens was reported in 18.6% of nurses. In rank order, reported level of confidence was the following: "moderately" (49%); "somewhat" (35%); "not" (13%); and "very" (3%). The majority of nurses performed screens within 1 hr (40.6%) or between 1-4 hr (43.8%) of extubation. Fifteen different methods were utilised to screen swallowing function by nurses who reported a total of 31 different clinical signs indicative of dysphagia.

CONCLUSIONS

Survey data of practicing nurses in an academic cardiac ICU revealed limited formal training in swallowing screening methodology, a high degree of variability in screening methods employed and low levels of agreement for dysphagia signs.

RELEVANCE TO CLINICAL PRACTICE

Data highlight a knowledge gap and need for the development of formal education and validated rapid nursing dysphagia screening tools for standardised implementation in the cardiac surgery ICU setting.

Postintubation Dysphagia During COVID-19 Outbreak-Contemporary Review

The COVID-19 is a global pandemic. Its rapid dissemination and serious course require a novel approach to healthcare practices. Severe disease progression is often associated with the development of the Acute Respiratory Distress Syndrome and may require some form of respiratory support, including endotracheal intubation, mechanical ventilation, and enteral nutrition through a nasogastric tube. These conditions increase the risk of dysphagia, aspiration, and aspiration pneumonia. The data on the incidence and risks of dysphagia associated with COVID-19 are not yet available. However, it is assumed that these patients are at high risk, because of respiratory symptoms and reduced lung function. These findings may exacerbate swallowing deficits. The aim of this review is to summarize available information on possible mechanisms of postintubation dysphagia in COVID-19 patients. Recommendations regarding the diagnosis and management of postintubation dysphagia in COVID-19 patients are described in this contemporary review.

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.

Moving Forward with Dysphagia Care: Implementing Strategies during the COVID-19 Pandemic and Beyond

Growing numbers of SARS-CoV-2 cases coupled with limited understanding of transmissibility and virulence, have challenged the current workflow and clinical care pathways for the dysphagia provider. At the same time, the need for non-COVID-19-related dysphagia care persists. Increased awareness of asymptomatic virus carriers and variable expression of the disease have also focused attention to appropriate patient care in the context of protection for the healthcare workforce. The objective of this review was to create a clinical algorithm and reference for dysphagia clinicians across clinical settings to minimize spread of COVID-19 cases while providing optimal care to patients suffering from swallowing disorders. Every practitioner and healthcare system will likely have different constraints or preferences leading to the utilization of one technique over another. Knowledge about this pandemic increases every day, but the algorithms provided here will help in considering the best options for proceeding with safe and effective dysphagia care in this new era.

Dysphagia in the intensive care unit: epidemiology, mechanisms, and clinical management

Dysphagia may present in all critically ill patients and large-scale clinical data show that e.g. post-extubation dysphagia (PED) is commonly observed in intensive care unit (ICU) patients. Recent data demonstrate that dysphagia is mostly persisting and that its presence is independently associated with adverse patient-centered clinical outcomes. Although several risk factors possibly contributing to dysphagia development were proposed, the underlying exact mechanisms in ICU patients remain incompletely understood and no current consensus exists on how to best approach ICU patients at risk.From a clinical perspective, dysphagia is well-known to be associated with an increased risk of aspiration and aspiration-induced pneumonia, delayed resumption of oral intake/malnutrition, decreased quality of life, prolonged ICU and hospital length of stay, and increased morbidity and mortality. Moreover, the economic burden on public health care systems is high.In light of high mortality rates associated with the presence of dysphagia and the observation that dysphagia is not systematically screened for on most ICUs, this review describes epidemiology, terminology, and potential mechanisms of dysphagia on the ICU. Furthermore, the impact of dysphagia on affected individuals, health care systems, and society is discussed in addition to current and future potential therapeutic approaches.

Relationship Between Laryngeal Sensation, Length of Intubation, and Aspiration in Patients with Acute Respiratory Failure

Dysphagia is common in hospitalized patients post-extubation and associated with poor outcomes. Laryngeal sensation is critical for airway protection and safe swallowing. However, current understanding of the relationship between laryngeal sensation and aspiration in post-extubation populations is limited. Acute respiratory failure patients requiring intensive care unit admission and mechanical ventilation received a Flexible Endoscopic Evaluation of Swallowing (FEES) within 72 h of extubation. Univariate and multivariable analyses were performed to examine the relationship between laryngeal sensation, length of intubation, and aspiration. Secondary outcomes included pharyngolaryngeal secretions, pneumonia, and diet recommendations. One-hundred and three patients met inclusion criteria. Fifty-one patients demonstrated an absent laryngeal adductor reflex (LAR). Altered laryngeal sensation correlated with the presence of secretions (p = 0.004). There was a significant interaction between the LAR, aspiration, and duration of mechanical ventilation. Altered laryngeal sensation was significantly associated with aspiration on FEES only in patients with a shorter length of intubation (p = 0.008). Patients with altered laryngeal sensation were prescribed significantly more restricted liquid (p = 0.03) and solid (p = 0.001) diets. No relationship was found between laryngeal sensation and pneumonia. There is a high prevalence of laryngeal sensory deficits in mechanically ventilated patients post-extubation. Altered laryngeal sensation was associated with secretions, aspiration, and modified diet recommendations especially in those patients with a shorter length of mechanical ventilation. These results demonstrate that laryngeal sensory abnormalities impact the development of post-extubation dysphagia.