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Chinta S, Haleem A, Sibala DR, Kumar KD, Pendyala N, Aftab OM, Choudhry HS, Hegazin M, Eloy JA. Association Between Modified Frailty Index and Postoperative Outcomes of Tracheostomies. Otolaryngol Head Neck Surg 2024; 170:1307-1313. [PMID: 38329229 DOI: 10.1002/ohn.667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/11/2023] [Accepted: 12/17/2023] [Indexed: 02/09/2024]
Abstract
OBJECTIVE The 5-item modified frailty index (mFI-5) has been used to stratify patients based on the risk of postoperative complications in several surgical procedures but has not yet been done in tracheostomies. This study investigates the association between the mFI-5 score and tracheostomy complications. STUDY DESIGN Retrospective database review. SETTING United States hospitals. METHODS The National Surgical Quality Improvement Program database was queried for tracheostomy patients between 2005 and 2018. The mFI-5 was calculated for each patient by assigning 1 point for each of the following comorbidities: diabetes mellitus, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functionally dependent health status. Univariate and multivariable analyses were conducted to determine associations between the mFI-5 score and postoperative complications. RESULTS A total of 4438 patients undergoing tracheostomies were queried and stratified into the following groups: mFI = 0 (N = 1741 [39.2%], mFI = 1 (N = 1720 [38.8%]), mFI = 2 (N = 726 [16.4%]), and mFI of 3 or higher (N = 251 [5.7%]). Univariate analysis showed that patients with higher mFI-5 scores had a greater proportion of smoking, dyspnea, obesity, steroid use, emergency cases, complications, reoperations, and mortality (P < .001). Multivariable analyses found associations between mFI-5 score and any complication (odds ratio [OR]: 1.49, 95% confidence interval [CI]: 1.03-2.16, P = .035), mortality (OR: 2.32, 95% CI: 1.15-4.68, P = .019), and any medical complication (OR: 2.75, 95% CI: 1.88-4.02, P < .001). CONCLUSION This study suggests an association between the mFI-5 score and postoperative complications in tracheostomies. mFI-5 score can be used to stratify tracheostomy patients by operative risk.
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Affiliation(s)
- Sree Chinta
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Afash Haleem
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Dhiraj R Sibala
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Keshav D Kumar
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Navya Pendyala
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Owais M Aftab
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Hannaan S Choudhry
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Michael Hegazin
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Otolaryngology and Facial Plastic, Surgery, Saint Barnabas Medical Center-RWJBarnabas Health, Livingston, New Jersey, USA
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Eskildsen SJ, Hansen CA, Kallemose T, Curtis DJ, Wessel I, Poulsen I. Factors Associated With Time to Decannulation in Patients With Tracheostomy Following Severe Traumatic Brain Injury. Respir Care 2024; 69:566-574. [PMID: 38649274 PMCID: PMC11147609 DOI: 10.4187/respcare.11376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
BACKGROUND Prolonged tracheal tube placement following severe traumatic brain injury (TBI) can cause serious complications. Safe removal requires sufficient ability for independent breathing and airway protection. Thus, identifying important factors for time to removal of the tracheal tube (decannulation) is essential for safe and efficient weaning. This study aimed to identify significant factors for time to decannulation in a Danish population of subjects with tracheostomy after TBI. METHODS This was a retrospective register-based cohort study. Subjects with moderate and severe TBI and a tracheal tube were selected from the Danish Head Trauma Database between 2011-2021. Time to decannulation was calculated as time from injury to decannulation. Associations between selected explanatory variables representing demographic and clinical characteristics and time to decannulation were analyzed using linear regression models. RESULTS A total 324 subjects were included with a median of 44 d to decannulation. Primary analysis found that an improvement in swallowing ability during the initial 4 weeks of rehabilitation was associated with an 8.2 d reduction in time to decannulation (95% CI -12.3 to -4.2, P < .001). Change in overall sensorimotor ability reduced time to decannulation by 0.94 (95% CI -0.78 to -0.10, P = .03) d. Change in cognitive abilities from rehab admission to 4-week follow-up did not significantly affect the number of days to decannulation (P = .66). Secondary analysis showed pneumonia was associated with the largest estimated increase of 24.4 (95% CI 15.9-32.9, P < .001) d and that increased cognitive functioning at rehabilitation admission was associated with a significant reduction in time to decannulation. CONCLUSIONS This study found that a change in swallowing ability is a potentially significant factor for reducing time to decannulation. Identifying factors that could explain differences in time to decannulation is essential for patient outcomes, especially if these factors are modifiable and could be targeted in rehabilitation and treatment.
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Affiliation(s)
- Signe J Eskildsen
- Department of Occupational Therapy and Physiotherapy, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; and Aarhus University, Health, Department of Public Health, Aarhus, Denmark.
| | - Carrinna A Hansen
- Department of Orthopaedic Surgery, Zealand University Hospital, University of Copenhagen, Koege, Denmark; and University of Southern Denmark, the Faculty of Health Sciences, Department of Regional Health Research, Odense, Denmark
| | - Thomas Kallemose
- Department of Clinical Research, Copenhagen University Hospital, Amager and Hvidovre Hospital, Hvidovre, Denmark
| | - Derek J Curtis
- Department of Pediatric Rehabilitation, Children's Therapy Center, The Child and Youth Administration, Copenhagen, Denmark
| | - Irene Wessel
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; and Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Ingrid Poulsen
- Department of Clinical Research, Copenhagen University Hospital, Amager and Hvidovre Hospital, Denmark; and Aarhus University, Health, Department of Public Health, Aarhus, Denmark
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Frazure M, Greene CL, Iceman KE, Howland DR, Pitts T. Dysphagia as a Missing Link Between Post-surgical- and Opioid-Related Pneumonia. Lung 2024; 202:179-187. [PMID: 38538927 PMCID: PMC11135177 DOI: 10.1007/s00408-024-00672-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/21/2024] [Indexed: 04/07/2024]
Abstract
PURPOSE Postoperative pneumonia remains a common complication of surgery, despite increased attention. The purpose of our study was to determine the effects of routine surgery and post-surgical opioid administration on airway protection risk. METHODS Eight healthy adult cats were evaluated to determine changes in airway protection status and for evidence of dysphagia in two experiments. (1) In four female cats, airway protection status was tracked following routine abdominal surgery (spay surgery) plus low-dose opioid administration (buprenorphine 0.015 mg/kg, IM, q8-12 h; n = 5). (2) Using a cross-over design, four naive cats (2 male, 2 female) were treated with moderate-dose (0.02 mg/kg) or high-dose (0.04 mg/kg) buprenorphine (IM, q8-12 h; n = 5). RESULTS Airway protection was significantly affected in both experiments, but the most severe deficits occurred post-surgically as 75% of the animals exhibited silent aspiration. CONCLUSION Oropharyngeal swallow is impaired by the partial mu-opioid receptor agonist buprenorphine, most remarkably in the postoperative setting. These findings have implications for the prevention and management of aspiration pneumonia in vulnerable populations.
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Affiliation(s)
- Michael Frazure
- Department of Physiology, School of Medicine, University of Louisville, Louisville, KY, USA
- Department of Neurological Surgery and Kentucky Spinal Cord Injury Research Center, College of Medicine, University of Louisville, Louisville, KY, USA
| | - Clinton L Greene
- Department of Speech Language and Hearing Sciences and Dalton Cardiovascular Center, University of Missouri, 701 S Fifth St, Columbia, MO, 65203, USA
| | - Kimberly E Iceman
- Department of Speech Language and Hearing Sciences and Dalton Cardiovascular Center, University of Missouri, 701 S Fifth St, Columbia, MO, 65203, USA
| | - Dena R Howland
- Department of Neurological Surgery and Kentucky Spinal Cord Injury Research Center, College of Medicine, University of Louisville, Louisville, KY, USA
| | - Teresa Pitts
- Department of Speech Language and Hearing Sciences and Dalton Cardiovascular Center, University of Missouri, 701 S Fifth St, Columbia, MO, 65203, USA.
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Rose L, Messer B. Prolonged Mechanical Ventilation, Weaning, and the Role of Tracheostomy. Crit Care Clin 2024; 40:409-427. [PMID: 38432703 DOI: 10.1016/j.ccc.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Depending on the definitional criteria used, approximately 5% to 10% of critical adults will require prolonged mechanical ventilation with longer-term outcomes that are worse than those ventilated for a shorter duration. Outcomes are affected by patient characteristics before critical illness and its severity but also by organizational characteristics and care models. Definitive trials of interventions to inform care activities, such as ventilator weaning, upper airway management, rehabilitation, and nutrition specific to the prolonged mechanical ventilation patient population, are lacking. A structured and individualized approach developed by the multiprofessional team in discussion with the patient and their family is warranted.
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Affiliation(s)
- Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, 57 Waterloo Road, London SE1 8WA, UK; Department of Critical Care and Lane Fox Unit, Guy's & St Thomas' NHS Foundation Trust, King's College London, 57 Waterloo Road, London SE1 8WA, UK.
| | - Ben Messer
- Royal Victoria Infirmary, Newcastle-Upon-Tyne NHS Hospitals NHS Foundation Trust, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK
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Kadri W, Halfpenny R, Whiten B, Mulkerrin S, Smith C. Dysphagia therapy in adults with a tracheostomy: A scoping review protocol. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2024. [PMID: 38533839 DOI: 10.1111/1460-6984.13029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 03/09/2024] [Indexed: 03/28/2024]
Abstract
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.
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Affiliation(s)
- Waiza Kadri
- Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, England
- University College London (UCL), Division of Psychology and Language Sciences, London, England
| | - Rhiannon Halfpenny
- University College London (UCL), Division of Psychology and Language Sciences, London, England
- Great Ormond Street Hospital, London, England
| | - Breege Whiten
- University College London (UCL), Division of Psychology and Language Sciences, London, England
| | - Siofra Mulkerrin
- Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England
| | - Christina Smith
- University College London (UCL), Division of Psychology and Language Sciences, London, England
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Asayama R, Tanaka-Nishikubo K, Okada M, Mukai N, Annen S, Matsumoto H, Takeba J, Sato N, Hato N. Dysphagia in patients with severe COVID-19: a retrospective study. Sci Rep 2024; 14:6829. [PMID: 38514734 PMCID: PMC10957916 DOI: 10.1038/s41598-024-57508-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/19/2024] [Indexed: 03/23/2024] Open
Abstract
To investigate dysphagia after extubation in patients with severe coronavirus disease 2019 (COVID-19). We retrospectively examined patients with severe COVID-19 treated in our hospital between August 2021 and March 2022. Feeding outcomes were categorized into two groups-(1) total oral intake, and (2) difficulty in oral intake. To assess the feeding outcome, we used modified water-swallowing test (MWST) for all patients. However, in cases where aspiration or recurrent laryngeal nerve palsy was suspected, we conducted the fiberoptic endoscopic evaluation of swallowing after MWST. Patient data were collected from medical records. Forty-six patients with severe COVID-19 were included. Among the 46 patients, 14 (30.4%) experienced difficulties with oral intake. Older age, longer length of hospitalization, duration of mechanical ventilation, tracheostomy, diabetes, and higher serum levels of C-reactive protein (CRP) and procalcitonin (PCT) at the time of intubation were associated with difficulty in oral intake. The rate of difficulty with oral intake in patients with severe COVID-19 was 30.4%, which is not as high as reported in previous studies. Older age, longer duration of mechanical ventilation, tracheostomy, diabetes, and higher levels of CRP and PCT were associated with the prevalence of oral intake difficulty, suggesting that early attention should be paid to high-risk patients who have preexisting deterioration of swallowing function due to aging and comorbidities, or who have prolonged intubation or tracheostomy to prevent aspiration pneumonia.
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Affiliation(s)
- Rie Asayama
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan.
| | - Kaori Tanaka-Nishikubo
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Masahiro Okada
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Naoki Mukai
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Suguru Annen
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Hironori Matsumoto
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Jun Takeba
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Norio Sato
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Naohito Hato
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
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7
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Raynor EM, Wohl D. Tracheostomy-Related Swallowing Issues in Children. Otolaryngol Clin North Am 2024:S0030-6665(24)00030-6. [PMID: 38508881 DOI: 10.1016/j.otc.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
Children with tracheostomies have multiple challenges with respect to achieving normal deglutition. These children may have underlying neurologic or genetic conditions that can predispose to dysphagia, but even in children without underlying comorbidities, the presence of a tracheostomy tube impacts the mechanics of swallowing, leading to difficulty with different consistencies as well as management of normal oral secretions. Intubation prior to tracheostomy also impacts sensation in the upper aerodigestive tract increasing the risk of aspiration. Occlusion of the tracheostomy with a speaking valve or cap improves outcomes in swallow and prognosis for oral feeding.
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Affiliation(s)
- Eileen M Raynor
- Department of Head and Neck Surgery & Communication Sciences, Duke Health System, DUMC Box 3805, Durham, NC 27710, USA.
| | - Daniel Wohl
- Pediatric Otolaryngology Associates, 4114 Sunbeam Road, Jacksonville, FL 32257, USA
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Morris K, Taylor NF, Freeman-Sanderson A. Safety-related outcomes for patients with a tracheostomy and the use of flexible endoscopic evaluation of swallowing (FEES) for assessment and management of swallowing: A systematic review. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024:1-11. [PMID: 38462820 DOI: 10.1080/17549507.2023.2293633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE The purpose of this systematic review was to examine safety-related outcomes for patients with tracheostomy after flexible endoscopic evaluation of swallowing (FEES) to assess and manage their swallow, when compared to other non-instrumental swallow assessments such as clinical swallowing examination (CSE) and/or a modified Evans blue dye test (MEBDT). METHOD Three databases were searched for articles referring to safety-related outcome data for adults with a tracheostomy, who underwent FEES and CSE and/or MEBDT. Articles were screened using predefined inclusion/exclusion criteria. RESULT The search strategy identified 2097 articles; following abstract and full-text screening, seven were included for review. The summary of evidence found low to very low certainty that FEES was associated with improved outcomes across swallow safety, physiological outcomes, tracheostomy cannulation duration, functional outcomes, and detection of upper airway pathologies. CONCLUSION This systematic review demonstrated low to very low certainty evidence from seven heterogeneous studies with low sample sizes that incorporating FEES may be associated with improved safety-related outcomes. There is less evidence supporting the accuracy of other swallow assessments conducted at the point of care (i.e. CSE and MEBDT). Future research requires studies with larger sample sizes and routine reporting of safety-related outcomes with use of FEES.
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Affiliation(s)
- Katherine Morris
- Speech Pathology Department, Eastern Health, Melbourne, Australia
- School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia
| | - Nicholas F Taylor
- School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia
- Allied Health Clinical Research Office, Eastern Health, Box Hill, Australia
| | - Amy Freeman-Sanderson
- Graduate School of Health, University of Technology Sydney, Sydney, Australia
- Speech Pathology Department, Royal Prince Alfred Hospital, Sydney, Australia
- Critical Care Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Weppner J, Senol S, Larick R, Jackson S. Diagnostic Accuracy of the Yale Swallow Protocol in Moderate-to-Severe Traumatic Brain Injury: A Prospective Blinded Videofluoroscopic Investigation. J Head Trauma Rehabil 2024:00001199-990000000-00130. [PMID: 38453631 DOI: 10.1097/htr.0000000000000929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
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.
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Affiliation(s)
- Justin Weppner
- Author Affiliations: Department of Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke (Dr Weppner); Department of Internal Medicine, Edward Via College of Osteopathic Medicine, Blacksburg, Virginia (Dr Weppner); Department of Internal Medicine, Carilion Clinic, Roanoke, Virginia (Dr Weppner and Ms Jackson); and Department of Physical Medicine and Rehabilitation (Dr Senol), Eastern Virginia Medical School (Mr Larick), Norfolk, Virginia
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10
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Likar R, Aroyo I, Bangert K, Degen B, Dziewas R, Galvan O, Grundschober MT, Köstenberger M, Muhle P, Schefold JC, Zuercher P. Management of swallowing disorders in ICU patients - A multinational expert opinion. J Crit Care 2024; 79:154447. [PMID: 37924574 DOI: 10.1016/j.jcrc.2023.154447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 09/19/2023] [Accepted: 10/10/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Dysphagia is common in intensive care unit (ICU) patients, yet it remains underrecognized and often unmanaged despite being associated with life-threatening complications, prolonged ICU stays and hospitalization. PURPOSE To propose an expert opinion for the diagnosis and management of dysphagia developed from evidence-based clinical recommendations and practitioner insights. METHODS A multinational group of dysphagia and critical care experts conducted a literature review using a modified ACCORD methodology. Based on a fusion of the available evidence and the panel's clinical experience, an expert opinion on best practice management was developed. RESULTS The panel recommends adopting clinical algorithms intended to promote standardized, high-quality care that triggers timely systematic dysphagia screening, assessment, and treatment of extubated and tracheostomized patients in the ICU. CONCLUSIONS Given the lack of robust scientific evidence, two clinical management algorithms are proposed for use by multidisciplinary teams to improve early systematic detection and effective management of dysphagia in ICU patients. Additionally, emerging therapeutic options such as neurostimulation have the potential to improve the quality of ICU dysphagia care.
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Affiliation(s)
- Rudolf Likar
- Department for Anaesthesiology and Intensive Medicine, Klinikum Klagenfurt am Wörthersee, Austria
| | - Ilia Aroyo
- Department of Neurology and Neurointensive Care Medicine, Klinikum Darmstadt, Germany
| | - Katrin Bangert
- Clinic for Intensive Care Medicine, University Hospital Hamburg, Germany
| | - Björn Degen
- Clinic for Intensive Medicine, Dysphagia Centre, Vienna, Austria
| | - Rainer Dziewas
- Department of Neurology and Neurological Rehabilitation, Klinikum Osnabrück, Osnabrück, Germany
| | - Oliver Galvan
- Department for Hearing, Speech and Voice Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Markus Köstenberger
- Department for Anaesthesiology and Intensive Medicine, Klinikum Klagenfurt am Wörthersee, Austria; Department for Anaesthesiology and Intensive Care Medicine, Medical University Graz, Graz, Austria.
| | - Paul Muhle
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Germany
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Patrick Zuercher
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
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11
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Rajski B, Furey V, Nguyen A, Duffner LA, Young B, Husain IA. Dysphagia outcomes in COVID-19 patients: experiences in long-term acute care hospital (LTACH). Eur Arch Otorhinolaryngol 2023; 280:4255-4260. [PMID: 37222822 PMCID: PMC10206353 DOI: 10.1007/s00405-023-08032-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/17/2023] [Indexed: 05/25/2023]
Abstract
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.
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Affiliation(s)
- Barbara Rajski
- RML Specialty Hospital-Department of Rehabilitation, Hinsdale, IL, USA.
| | - Vicki Furey
- RML Specialty Hospital-Department of Rehabilitation, Hinsdale, IL, USA
| | - Alvin Nguyen
- University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - Lisa A Duffner
- RML Specialty Hospital-Office of Clinical Research, Hinsdale, IL, USA
| | - Bryce Young
- Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, IL, USA
| | - Inna A Husain
- Department of Otolaryngology, Community Hospital, Munster, IN, USA
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Ye DH, Hong G, Kang CJ, Kim JJ, Choi KH. Prevalence and clinical predictors of dysphagia after heart transplantation. Clin Transplant 2023; 37:e15037. [PMID: 37229575 DOI: 10.1111/ctr.15037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/09/2023] [Accepted: 05/15/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Dysphagia is a common complication after heart transplantation (HTPL), but few studies exist on dysphagia after HTPL, and the prevalence is unknown. The objective of our current study was to establish the prevalence and risk factors for dysphagia after HTPL and to classify its characteristics through Videofluoroscopic Swallowing Studies (VFSS). METHODS The recipients of HTPL carried out at a single center from January 2011 to November 2019 were assessed retrospectively. Dysphagia was evaluated by a bedside swallowing exam and VFSS to evaluate for evidence of aspiration. The duration of ventilator and preoperative extracorporeal membrane oxygenation (ECMO) support, intensive care unit, hospital stay, the progress of oral feeding after surgery, the presence of a tracheostomy, and vocal cord palsy were analyzed. On the third and seventh days following surgery, we looked at the relationship between risk factors and oral feeding progress, respectively. Additionally, we contrasted these risk variables with the no penetration/aspiration (PA) group and the PA group on VFSS. RESULTS Among the study cohort of 421 patients, 222 (52.7%) patients had access to oral feeding on the third day of surgery. The number of patients who underwent VFSS due to clinically suspected dysphagia was 96 (22.8%). Of these, 54 (56.2%) had aspiration or penetration (PA group), while 42 (43.8%) had no abnormal findings (No-PA group). In the multivariable regression model, preoperative ECMO support, vocal cord abnormalities, tracheostomy, and emergent need for HTPL were identified as independent risk variables for oral feeding progress on postoperative days (PODs) 3 and 7. Among these factors, preoperative ECMO support had the highest odds ratio (OR) at PODs 3 (OR: 4.73, CI: 1.997, 11.203, p < .001) and 7 (OR: 5.143, CI: 2.294, 11.53, p < .001). CONCLUSION We identified the prevalence and potential risk factors for postoperative dysphagia in this retrospective analysis of 421 heart transplant recipients. The pathophysiology of postoperative dysphagia was multifactorial, and it was more common than the incidence after general cardiothoracic surgery.
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Affiliation(s)
- Dong Hyun Ye
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Republic of Korea
| | - Garam Hong
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Republic of Korea
| | - Cheon Ji Kang
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Republic of Korea
| | - Jae Joong Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Republic of Korea
| | - Kyoung Hyo Choi
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Republic of Korea
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Armas-Navarro LP, Santana-Padilla YG, Mendoza-Segura L, Ramos-Díaz M, Santana-López BN, Alcaraz-Jiménez JA, Rico-Rodríguez J, Santana-Cabrera L. Dysphagia in intensive care, a real problem: analysis of risk factors. ENFERMERIA INTENSIVA 2023; 34:115-125. [PMID: 36935305 DOI: 10.1016/j.enfie.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 08/08/2022] [Indexed: 03/19/2023]
Abstract
AIMS To identify risk factors present in patients with dysphagia in a population of critically ill patients. METHODS Case series of a cohort of patients recruited in the intensive care unit (ICU) until hospital discharge. Patients who gave consent and met the inclusion criteria were recruited. The Volume-Viscosity clinical examination method was used for the screening of dysphagia. An uni- and bivariate statistical analysis was performed using odds ratio (OR) to detect risk factors for dysphagia. OUTCOMES 103 patients were recruited from 401 possible. The mean age was 59,33 ± 13,23, men represented 76,7%. The severity of the sample was: APACHE II (12,74 ± 6,17) and Charlson (2,98 ± 3,31). 45,6% of patients showed dysphagia, obtaining significant OR values (p < 0,050) for the development of dysphagia: older age, neurological antecedents, COVID19, long stay in ICU and hospitalization, and the presence of tracheotomy. COVID19 patients represented 46,6% of the sample, so an analysis of this subgroup was performed, showing similar results, with a Charlson risk (OR:4,65; 95% CI:1,31-16,47; p = 0,014) and a hospital stay (OR: 8,50; 95%CI: 2,20-32,83; p < 0,001) On discharge from the ICU, 37,9% of the population still had dysphagia; 12,6% maintained this problem at hospital discharge. CONCLUSIONS Almost half of our patients developed dysphagia. Clinical severity and the presence of tracheotomy were risk factors. We observed in patients with dysphagia a longer stay in both ICU and hospitalization.
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Affiliation(s)
- L P Armas-Navarro
- Unidad de Medicina Intensiva de adultos del Complejo Hospitalario Universitario Insular Materno Infantil de Gran Canaria, Canary Islands, Spain
| | - Y G Santana-Padilla
- Area Quirúrgica del Complejo Hospitalario Universitario Insular Materno Infantil de Gran Canaria, Canary Islands, Spain
| | - L Mendoza-Segura
- Unidad de Medicina Intensiva de adultos del Complejo Hospitalario Universitario Insular Materno Infantil de Gran Canaria, Canary Islands, Spain
| | - M Ramos-Díaz
- Unidad de Medicina Intensiva de adultos del Complejo Hospitalario Universitario Insular Materno Infantil de Gran Canaria, Canary Islands, Spain
| | - B N Santana-López
- Unidad de Medicina Intensiva del Hospital Universitario de Gran Canaria Dr. Negrín, Canary Islands, Spain
| | - J A Alcaraz-Jiménez
- Unidad de Medicina Intensiva de adultos del Complejo Hospitalario Universitario Insular Materno Infantil de Gran Canaria, Canary Islands, Spain
| | - J Rico-Rodríguez
- Unidad de Medicina Intensiva de adultos del Complejo Hospitalario Universitario Insular Materno Infantil de Gran Canaria, Canary Islands, Spain
| | - L Santana-Cabrera
- Unidad de Medicina Intensiva de adultos del Complejo Hospitalario Universitario Insular Materno Infantil de Gran Canaria, Canary Islands, Spain.
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Cheriyan SS, Schar MS, Woods CM, Bihari S, Cock C, Athanasiadis T, Omari TI, Ooi EH. Swallowing biomechanics in tracheostomised critically ill patients compared to age- and gender-matched healthy controls. CRIT CARE RESUSC 2023; 25:97-105. [PMID: 37876599 PMCID: PMC10581277 DOI: 10.1016/j.ccrj.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
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.
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Affiliation(s)
- Sanith S. Cheriyan
- Department of Otolaryngology, Head and Neck Surgery, Flinders Medical Centre, Bedford Park, SA, Australia
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Mistyka S. Schar
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
- Department of Speech Pathology and Audiology, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Charmaine M. Woods
- Department of Otolaryngology, Head and Neck Surgery, Flinders Medical Centre, Bedford Park, SA, Australia
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Shailesh Bihari
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
- Department of Intensive & Critical Care, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Charles Cock
- Department of Gastroenterology & Hepatology, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Theodore Athanasiadis
- Department of Otolaryngology, Head and Neck Surgery, Flinders Medical Centre, Bedford Park, SA, Australia
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Taher I. Omari
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Eng H. Ooi
- Department of Otolaryngology, Head and Neck Surgery, Flinders Medical Centre, Bedford Park, SA, Australia
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
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Cavalli E, Belfiori G, Molinari G, Peghetti A, Zanoni A, Chinelli E. Does a decannulation protocol exist in COVID-19 patients? The importance of working in a multiprofessional team. DISCOVER HEALTH SYSTEMS 2023; 2:14. [PMID: 37520514 PMCID: PMC10099004 DOI: 10.1007/s44250-023-00031-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/27/2023] [Indexed: 08/01/2023]
Abstract
As a Covid Hub in Emilia Romagna, we have experienced an increasing number of tracheostomized patients, prompting us to develop a standardized decannulation protocol for COVID-19 ARDS patients. Currently, there are no guidelines or protocols for decannulation in this population, and few studies have investigated the early outcomes of tracheostomy in COVID-19 patients, with no detailed analysis of the decannulation process. We recognized the importance of mutual reliance among our team members and the significant achievements we made compared to previous decannulation methods. Through the optimization of the decannulation process, we identified a clear, safe, and repeatable method based on clinical best practice and literature evidence. We decided to implement an existing standardized decannulation protocol, which was originally designed for severe brain-damaged patients, due to the growing number of COVID-19 patients with tracheostomy. This protocol was designed for daily practice and aimed to provide a uniform approach to using devices like fenestrated cannulas, speaking valves, and capping. The results of our implementation include:expanding the applicability of the protocol beyond severe brain-damaged patients to different populations and settings (in this case, patients subjected to a long period of sedation and invasive ventilation)early activation of speech therapy to facilitate weaning from the cannula and recovery of physiological swallowing and phonationearly activation of otolaryngologist evaluation to identify organic problems related to prolonged intubation, tracheostomy, and ventilation and address proper speech therapy treatmentactivation of more fluid and effective management paths for decannulation with a multiprofessional team.
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Affiliation(s)
- E. Cavalli
- Physical Medicine and Rehabilitation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni N°15, 40138 Bologna, Italy
| | - G. Belfiori
- Physical Medicine and Rehabilitation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni N°15, 40138 Bologna, Italy
| | - G. Molinari
- Otolaryngology and Audiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni N°15, 40138 Bologna, Italy
| | - A. Peghetti
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni N°15, 40138 Bologna, Italy
| | - A. Zanoni
- Anesthesia and Intensive Care in Local, Regional and National Emergencies and in Major Abdominal Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni N°15, 40138 Bologna, Italy
| | - E. Chinelli
- Anesthesia and Intensive Care in Local, Regional and National Emergencies and in Major Abdominal Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni N°15, 40138 Bologna, Italy
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Copeland-Halperin LR, Divakar P, Stewart T, Demsas F, Levy JJ, Nigriny JF, Paydarfar JA. Predictors of Gastrostomy Tube Placement in Head and Neck Cancer Patients at a Rural Tertiary Care Hospital. JOURNAL OF RECONSTRUCTIVE MICROSURGERY OPEN 2023. [DOI: 10.1055/s-0043-1760757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
Abstract
Background Head and neck cancer is a leading cause of cancer. Treatment often requires surgical resection, free-flap reconstruction, radiation, and/or chemotherapy. Tumor burden and pain may limit swallowing and impair nutrition, increasing complications and mortality. Patients commonly require gastrostomy tubes (G-tube), but predicting which patients are in need remains elusive. This study identifies predictors of G-tube among head and neck cancer patients undergoing immediate free-flap reconstruction.
Methods Institutional Review Board approval was obtained. Retrospective database review was performed of patients at 18 years of age or older with head and neck cancer who underwent resection with immediate free-flap reconstruction from 2011 to 2019. Patients who underwent nonfree-flap or delayed reconstruction or with mortality within 7 days postoperatively were excluded. Patient demographics and comorbidities, tumor/treatment characteristics, and need for G-tube were analyzed to identify univariate and multivariate predictors.
Results In total, 107 patients were included and 72 required G-tube placement. On multivariate analysis, tracheostomy (odds ratio [OR]: 81.78; confidence interval [CI]: 7.43–1,399.92; p < 0.01), anterolateral thigh flap reconstruction (OR: 16.18; CI: 1.14–429.66; p = 0.04), and age 65 years or younger (OR: 9.35; CI: 1.47–89.11; p = 0.02) were predictors of G-tube placement.
Conclusion Head and neck cancer treatment commonly involves extensive resection, reconstruction, and/or chemoradiation. These patients are at high risk for malnutrition and need G-tube. Determining who requires a pre- or postoperative G-tube remains a challenge. In this study, the need for tracheostomy or ALT flap reconstruction and age 65 years or younger were predictive of postoperative G-tube placement. Future research will guide a multidisciplinary perioperative pathway to facilitate the optimization of nutrition management.
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Affiliation(s)
| | - Prashanthi Divakar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Talia Stewart
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Falen Demsas
- Department of Surgery, The Massachusetts General Hospital, Boston, Massachusetts
| | - Joshua J. Levy
- Department of Biomedical Sciences, Geisel School of Medicine, Hanover, New Hampshire
| | - John F. Nigriny
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Joseph A. Paydarfar
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Lee CL, Huang G, Banda KJ, Chu YH, Jen HJ, Chu H, Liu D, Pien LC, Chen R, Chou KR. Prevalence of oropharyngeal dysphagia and risk of mortality among hospitalized COVID-19 patients: A meta-analysis. J Glob Health 2022; 12:05058. [PMID: 36579715 PMCID: PMC9798345 DOI: 10.7189/jogh.12.05058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background Post-extubation and neurologic complications in COVID-19 patients have been shown to cause oropharyngeal dysphagia (OD). We performed the first meta-analysis to explore and estimate the pooled prevalence of OD, risk of mortality, and associated factors among hospitalized COVID-19 patients. Methods We searched Scopus, PubMed, Embase, CINAHL, WHO COVID-19 database, and Web of Science for literature on dysphagia in COVID-19 patients. We used the generalized linear mixed model (GLMM) to determine the prevalence estimates of OD in the R software and the DerSimonian-Lard random-effects model in the Comprehensive Meta-Analysis software to explore the risk of mortality and associated factors of OD, presented as odds ratios (ORs) and corresponding 95% confidence intervals (CIs). We used Cochran's Q, τ2, and the I2 statistic to assess heterogeneity and conducted a moderator analysis to identify moderator variables. Results We included eighteen studies with a total of 2055 participants from the 910 studies retrieved from electronic databases. The prevalence of OD among hospitalized COVID-19 patients was estimated at 35% (95% CI = 21-52; low certainty of evidence) associated with a high risk of mortality (OR = 6.41; 95% CI = 1.48-27.7; moderate certainty of evidence). Intubation (OR = 16.3; 95% CI = 7.10-37.3; high certainty of evidence), use of tracheostomies (OR = 8.09; 95% CI = 3.05-21.5; high certainty of evidence), and proning (OR = 4.97; 95% CI = 1.34-18.5; high certainty of evidence) among hospitalized COVID-19 patients were highly associated with developing OD. The prevalence of OD was higher among hospitalized COVID-19 patients who were admitted in intensive care units (ICU), intubated, and mechanically ventilated. Conclusions The prevalence of OD among hospitalized COVID-19 patients is estimated at 35% associated with a high risk of mortality. OD assessment among hospitalized COVID-19 patients who are managed in an ICU, prone position, intubated, and mechanical ventilated deserves more attention. Registration PROSPERO CRD42022337597.
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Affiliation(s)
- Chi-Li Lee
- Division of Intensive Care Medicine, Department of Internal Medicine, Yuan's General Hospital, Kaohsiung, Taiwan
| | - Garry Huang
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan,Australasian College of Paramedicine, Australia,Australian Institute of Project Management, Australia
| | - Kondwani Joseph Banda
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan,Endoscopy Unit, Surgery Department, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Yu-Hao Chu
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University
| | - Hsiu-Ju Jen
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan,Department of Nursing, Taipei Medical University-Shuang Ho Hospital, New Taipei, Taiwan
| | - Hsin Chu
- Institute of Aerospace and Undersea Medicine, School of Medicine, National Defense Medical Center, Taipei, Taiwan,Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Doresses Liu
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan,Department of Nursing, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan,Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Li-Chung Pien
- Post-Baccalaureate Program in Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan,Psychiatric Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ruey Chen
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan,Department of Nursing, Taipei Medical University-Shuang Ho Hospital, New Taipei, Taiwan,Post-Baccalaureate Program in Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Kuei-Ru Chou
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan,Department of Nursing, Taipei Medical University-Shuang Ho Hospital, New Taipei, Taiwan,Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan,Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan,Neuroscience Research Center, Taipei Medical University, Taipei, Taiwan
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Exploring the Influence of Dysphagia and Tracheostomy on Pneumonia in Patients with Stroke: A Retrospective Cohort Study. Brain Sci 2022; 12:brainsci12121664. [PMID: 36552123 PMCID: PMC9775301 DOI: 10.3390/brainsci12121664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/26/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
Background: Pneumonia is common in patients with tracheostomy and dysphagia. However, the influence of dysphagia and tracheostomy on pneumonia in patients with stroke remains unclear. The aim of this study was to explore the risk factors related to pneumonia, and the association between dysphagia, tracheostomy and pneumonia in patients with stroke was investigated. Methods: Patients with stroke who experienced tracheostomy and dysphagia were included and divided into two groups based on record of pneumonia at discharge. Clinical manifestations and physical examination were used to diagnose pneumonia, whereas clinical swallowing examination, and videofluoroscopy swallowing studies (VFSS) were used to evaluate swallowing function. Results: There were significant differences between the pneumonia group and the no pneumonia group in total tracheostomy time (6.3 ± 5.9 vs. 4.3 ± 1.7 months, p = 0.003), number of instances of ventilator support (0.41 ± 0.49 vs. 0.18 ± 0.38, p = 0.007), PAS score (5.2 ± 1.92 vs. 4.3 ± 1.79, p = 0.039), impaired or absent cough reflex (76.4 vs. 55.6%, p = 0.035), oropharyngeal phase dysfunction (60.6 vs. 40.8%, p = 0.047), length of hospital stay (36.0 ± 7.2 vs. 30.5 ± 11.7 days, p = 0.025) and direct medical costs (15,702.21 ± 14,244.61 vs. 10,923.99 ± 7250.14 United States dollar [USD], p = 0.042). Multivariate logistic regression showed that the total tracheostomy time (95% confidence interval [CI], 1.966−12.922, p = 0.001), impaired or absent cough reflex (95% CI, 0.084−0.695, p = 0.008), and oropharyngeal phase dysfunction (95% CI, 1.087−8.148, p = 0.034) were risk factors for pneumonia. Spearman’s correlation analysis demonstrated that PAS scores were significantly correlated with cough reflex dysfunction (r = 0.277, p = 0.03), oropharyngeal phase dysfunction (r = 0.318, p < 0.01) and total tracheostomy time (r = 0.178, p = 0.045). The oropharyngeal phase dysfunction was significantly correlated with cough reflex (r = 0.549, p < 0.001) and UES opening (r = 0.643, p < 0.01). Conclusions: Tracheostomy and dysphagia increased the risk of pneumonia in patients with stroke. Total tracheostomy time, duration of ventilator support, degree of penetration and aspiration, and oropharyngeal phase dysfunction are risk factors. Given this, we also found that there may be a correlation between tracheostomy and dysphagia.
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Armas-Navarro L, Santana-Padilla Y, Mendoza-Segura L, Ramos-Díaz M, Santana-López B, Alcaraz-Jiménez J, Rico-Rodríguez J, Santana-Cabrera L. La disfagia en cuidados intensivos, un problema real: análisis de factores de riesgo. ENFERMERIA INTENSIVA 2022. [DOI: 10.1016/j.enfi.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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McRae J, Morgan S, Wallace E, Miles A. Oropharyngeal Dysphagia in Acute Cervical Spinal Cord Injury: A Literature Review. Dysphagia 2022:10.1007/s00455-022-10535-0. [DOI: 10.1007/s00455-022-10535-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 10/26/2022] [Indexed: 11/16/2022]
Abstract
AbstractDysphagia (swallowing impairment) is a frequent complication of cervical spinal cord injury (cSCI). Recently published national guidance in the UK on rehabilitation after traumatic injury confirmed that people with cSCI are at risk for dysphagia and require early evaluation while remaining nil by mouth [National Institute for Health and Care Excellence. Rehabilitation after traumatic injury (NG211), 2022, https://www.nice.org.uk/guidance/ng21]. While the pathogenesis and pathophysiology of dysphagia in cSCI remains unclear, numerous risk factors have been identified in the literature. This review aims to summarize the literature on the risk factors, presentation, assessment, and management of dysphagia in patients with cSCI. A bespoke approach to dysphagia management, that accounts for the multiple system impairment in cSCI, is presented; the overarching aim of which is to support effective management of dysphagia in patients with cSCI to prevent adverse clinical consequences.
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Resuming Swallowing and Oral Feeding in Tracheostomized COVID-19 Patients: Experience of a Swiss COVID-Center and Narrative Literature Review. Med Sci (Basel) 2022; 10:medsci10040057. [DOI: 10.3390/medsci10040057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/05/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
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.
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Holdiman A, Rogus-Pulia N, Pulia MS, Stalter L, Thibeault SL. Risk Factors for Dysphagia in Patients Hospitalized with COVID-19. Dysphagia 2022; 38:933-942. [PMID: 36109398 PMCID: PMC9483550 DOI: 10.1007/s00455-022-10518-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/26/2022] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Anna Holdiman
- Division of Otolaryngology, Department of Surgery, UW-Madison, 5103 WIMR, 1111 Highland Ave., Madison, WI, 53705, USA
| | - Nicole Rogus-Pulia
- Division of Geriatrics and Gerontology, Department of Medicine, UW-Madison, Madison, WI, USA
| | - Michael S Pulia
- Department of Emergency Medicine, UW-Madison, Madison, WI, USA
| | - Lily Stalter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, UW-Madison, Madison, WI, USA
| | - Susan L Thibeault
- Division of Otolaryngology, Department of Surgery, UW-Madison, 5103 WIMR, 1111 Highland Ave., Madison, WI, 53705, USA.
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Lee T, Tan QL, Sinuff T, Kiss A, Mehta S. Outcomes of prolonged mechanical ventilation and tracheostomy in critically ill elderly patients: a historical cohort study. Can J Anaesth 2022; 69:1107-1116. [PMID: 35478085 DOI: 10.1007/s12630-022-02263-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/07/2022] [Accepted: 02/04/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE With an aging global population, the increased proportion of elderly patients in the intensive care unit (ICU) raises important questions regarding optimal management. Currently, data on tracheostomy and its outcomes in the elderly are limited. We aimed to determine the in-hospital survival of elderly ICU patients following tracheostomy, and describe impacts on discharge disposition and functional outcomes. METHODS We conducted a historical cohort study at two academic hospitals in Toronto. All patients aged ≥ 70 yr who received a tracheostomy during their ICU stay between January 2010 and June 2016 were included in a retrospective chart review. Data on patient demographics, frailty, tracheostomy indication, and outcomes were collected. RESULTS The study included 270 patients with a mean (standard deviation) age of 81 (6) yr. The majority were admitted to ICU for respiratory failure (147/270, 54%) and received a tracheostomy for prolonged mechanical ventilation (202/270, 75%). Intensive care unit and hospital mortality were 26% (68/270) and 46% (125/270), respectively. Twenty-five percent (67/270) of patients were decannulated during hospital admission, a median [interquartile range (IQR)] of 41 [25-68] days after tracheostomy. Intensive care unit and hospital length of stay were 31 [17-53] and 81 [46-121] days, respectively. At hospital discharge, 6% (17/270) of patients were discharged home, all were frail (median Clinical Frailty Score of 7) and most were tube-fed (101/270, 70%), unable to speak (81/270, 56%), and nonambulatory (98/270, 68%). CONCLUSIONS In patients aged ≥ 70 yr, tracheostomy during ICU stay marked a transition toward prolonged chronic critical illness. Nearly half of the patients died during the admission, and although a quarter were successfully decannulated, the majority of survivors were left with severe frailty and functional impairment.
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Affiliation(s)
- Tiffany Lee
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Qiao Li Tan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Tasnim Sinuff
- Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | - Alex Kiss
- Department of Research Design and Biostatistics, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, 600 University Ave, Suite 18-216, Toronto, ON, M5G 1X5, Canada.
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Murray M, Shen C, Massey B, Stadler M, Zenga J. Retrospective analysis of post-tracheostomy complications. Am J Otolaryngol 2022; 43:103350. [PMID: 34974381 DOI: 10.1016/j.amjoto.2021.103350] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/13/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To elucidate patient, disease, and surgical factors that are significantly associated with 90-day tracheostomy complications, readmissions, and mortality. STUDY DESIGN Retrospective case series with chart review. SETTING A single academic tertiary care center between 2011 and 2018. METHODS Patients who underwent tracheostomy by any technique for any indication were included. Demographic, disease, and operative details were examined. Multivariable analysis was performed to determine factors associated with 90-day complications, 90-day readmissions, and overall mortality. RESULTS 697 patients were included. 75% of patients had severe comorbidity (ACE-27 score of 3).1 Patients were intubated for 12 days prior to tracheostomy placement on average. The primary indication was ventilator dependence due to critical illness (85%). 74% were performed open and 26% percutaneous. 10% of patients had a tracheostomy-related complication within 90 days. Complications occurred at a median of post-operative day 11, and hemorrhage was most common (n = 35). 14 patients required immediate return to the operating room, and 3 patients died of their complication, all within 3 days of tracheostomy placement. 40% of patients undergoing tracheostomy died within 30 days. In multivariable analysis, only a documented difficult tracheostomy placement was significantly associated with a 90-day complication. CONCLUSIONS While complications after tracheostomy are infrequent, they are often severe. A heightened level of preparedness to immediately manage accidental tracheostomy decannulation or hemorrhage is required for patients with a difficult tracheostomy placement. 30-day mortality is high, which reinforces the need for multi-disciplinary evaluation, including palliative care, to determine appropriate candidacy for tracheostomy.
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Affiliation(s)
- Molly Murray
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Wauwatosa, WI 53226, United States of America.
| | - Christine Shen
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Wauwatosa, WI 53226, United States of America
| | - Becky Massey
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Wauwatosa, WI 53226, United States of America
| | - Michael Stadler
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Wauwatosa, WI 53226, United States of America
| | - Joseph Zenga
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Wauwatosa, WI 53226, United States of America
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Update on Tracheostomy and Upper Airway Considerations in the Head and Neck Cancer Patient. Surg Clin North Am 2022; 102:267-283. [DOI: 10.1016/j.suc.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Clunie GM, Bolton L, Lovell L, Bradley E, Bond C, Bennington S, Roe J. Considerations for speech and language therapy management of dysphagia in patients who are critically ill with COVID-19: a single centre case series. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2022. [DOI: 10.12968/ijtr.2021.0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background/Aims Patients treated with intubation and tracheostomy for COVID-19 infection are at risk of increased incidence of laryngeal injury, dysphagia and dysphonia. Because of the novelty of the SARS-CoV-2 virus, little is known about the type of dysphagia patients experience as a result of infection and critical illness. The aim of this case series report was to progress understanding of COVID-19 and dysphagia following admission to an intensive care unit and to guide speech and language therapy clinical practice in the ongoing pandemic. Methods A retrospective case review was conducted of all patients at Imperial College Healthcare NHS Trust, London who underwent a tracheostomy because of COVID-19 and received an instrumental assessment of swallowing in the early stages of the pandemic. Results A total of 11 patients were identified, and descriptive statistics were used to present demographic data, with a narrative account of their dysphagia profile used to describe presentation. Causes and presentation of dysphagia were heterogenous, with each patient requiring individualised clinical management to maximise outcome. A positive trend was seen in terms of recovery trajectory and progressing to oral intake. Conclusions This study reports on early experience of the presentation of dysphagia in patients with COVID-19 and demonstrates the value of instrumental assessment. It indicates the need for further research to consolidate knowledge and guide clinical practice.
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Affiliation(s)
- Gemma M Clunie
- Speech and Language Therapy Department, Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Lee Bolton
- Speech and Language Therapy Department, Imperial College Healthcare NHS Trust, London, UK
| | - Lindsay Lovell
- Speech and Language Therapy Department, Imperial College Healthcare NHS Trust, London, UK
| | - Elizabeth Bradley
- Speech and Language Therapy Department, Imperial College Healthcare NHS Trust, London, UK
| | - Cara Bond
- Speech and Language Therapy Department, Imperial College Healthcare NHS Trust, London, UK
| | - Sarah Bennington
- Speech and Language Therapy Department, Imperial College Healthcare NHS Trust, London, UK
| | - Justin Roe
- Speech and Language Therapy Department, Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
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Escudero C, Sassi FC, de Medeiros GC, de Lima MS, Cardoso PFG, de Andrade CRF. Decannulation: a retrospective cohort study of clinical and swallowing indicators of success. Clinics (Sao Paulo) 2022; 77:100071. [PMID: 35759922 PMCID: PMC9240975 DOI: 10.1016/j.clinsp.2022.100071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 05/04/2022] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To investigate the clinical and swallowing indicators related to a successful decannulation process during the hospital stay. METHODS A retrospective cohort clinical study. The study sample comprised a heterogeneous patient population who had submitted to a tracheostomy procedure in a tertiary hospital. Patients were divided into two groups (decannulated vs. non-decannulated) and compared not only in terms of demographic and clinical data but also the results of a swallowing assessment and intervention outcome. RESULTS Sixty-four patients were included in the present study: 25 (39%) who had been successfully decannulated, and 39 (61%) who could not be decannulated. Between-group comparisons indicated that both groups presented similar clinical and demographic characteristics. The groups also presented similar swallowing assessment results prior to intervention. However, significant differences were observed regarding the time to begin swallowing rehabilitation. The decannulated group was assessed nine days earlier than the non-decannulated group. Other significant differences included the removal of the alternate feeding method (72.0% of decannulated patients vs. 5.1% of non-decannulated patients) and the reintroduction of oral feeding (96.0% of decannulated patients vs. 41.0% of non-decannulated patients) and functional swallowing level at patient disclosure. The non-decannulated patient group presented higher death rates at disclosure. CONCLUSION The results of the present study indicated that the following parameters were associated with a successful decannulation process: early swallowing assessment, swallowing rehabilitation, and improvement in the swallowing functional level during the hospital stay. The maintenance of low swallowing functional levels was found to be negatively associated with successful decannulation.
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Affiliation(s)
- Carina Escudero
- Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Fernanda Chiarion Sassi
- Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Gisele Chagas de Medeiros
- Divisão de Fonoaudiologia do Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Maíra Santilli de Lima
- Divisão de Fonoaudiologia do Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Paulo Francisco Guerreiro Cardoso
- Departamento Cardiopneumologia, Disciplina de Cirurgia Torácica da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Claudia Regina Furquim de Andrade
- Divisão de Fonoaudiologia do Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.
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Dysphagia Severity and Management in Patients with COVID-19. CURRENT HEALTH SCIENCES JOURNAL 2021; 47:147-156. [PMID: 34765231 PMCID: PMC8551886 DOI: 10.12865/chsj.47.02.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/07/2021] [Indexed: 11/18/2022]
Abstract
COVID-19 has resulted in unprecedented numbers of patients treated at intensive care units (ICUs). Dysphagia is a key concern in critical illness survivors. We investigated the severity of dysphagia in COVID-19 and the need to adapt practices to provide efficient care. We reviewed the literature on COVID-19, post-critical-illness dysphagia, and dysphagia and tracheostomy guidelines during the pandemic. Critically ill COVID-19 patients present a high incidence of dysphagia, aggravated by respiratory distress, deconditioning, and neurological complications. Mechanical ventilation (MV), delirium, sedation and weakness are worse in COVID-19 than in other etiologies of critical care. In awake patients, respiratory compromise impairs breathing-swallowing-coughing coordination. Tracheostomy reduces laryngopharyngeal trauma, sedation, delirium, ICU stay and improves swallowing rehabilitation. Tracheostomy weaning and swallowing evaluation is complex in COVID-19 due to respiratory instability and a team discussion will guide adaptations. Patients assessed in the ICU were 67% recommended to be nil by mouth (were aspirating). Two months following hospital discharge, 83% of those who had undergone tracheostomy were managing a normal diet. Severely ill COVID-19 patients are expected to regain swallow function. Dysphagia care is based on adaptation of practices to the patients' multiple impairments.
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29
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Marvin S, Thibeault SL. Predictors of Aspiration and Silent Aspiration in Patients With New Tracheostomy. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2021; 30:2554-2560. [PMID: 34618595 DOI: 10.1044/2021_ajslp-20-00377] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Stevie Marvin
- Voice and Swallow Clinic, University of Wisconsin Hospitals and Clinics, Madison
| | - Susan L Thibeault
- Division of Otolaryngology-Head and Neck Surgery, School of Medicine and Public Health, University of Wisconsin-Madison
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Masuda H, Ueha R, Sato T, Goto T, Koyama M, Yamauchi A, Kaneoka A, Suzuki S, Yamasoba T. Risk Factors for Aspiration Pneumonia After Receiving Liquid-Thickening Recommendations. Otolaryngol Head Neck Surg 2021; 167:125-132. [PMID: 34582292 PMCID: PMC9251747 DOI: 10.1177/01945998211049114] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objective We examined the influence of liquid thickness levels on the frequency of
liquid penetration-aspiration in patients with dysphagia and evaluated the
clinical risk factors for penetration-aspiration and aspiration pneumonia
development. Study Design A case series. Setting Single-institution academic center. Methods We reviewed medical charts from 2018 to 2019. First, we evaluated whether
liquid thickness levels influence the frequency of liquid
penetration-aspiration in patients with dysphagia. Penetration-aspiration
occurrence in a videofluoroscopic swallowing study was defined as
Penetration-Aspiration Scale (PAS) scores ≥3. Second, the association
between liquid thickness level and penetration-aspiration was analyzed, and
clinical risk factors were identified. Moreover, clinical risk factors for
aspiration pneumonia development within 6 months were investigated. Results Of 483 patients, 159 showed penetration-aspiration. The thickening of liquids
significantly decreased the incidence of penetration-aspiration
(P < .001). Clinical risk factors for
penetration-aspiration were vocal fold paralysis (odds ratio [OR], 1.99),
impaired laryngeal sensation (OR, 5.01), and a history of pneumonia (OR,
2.90). Twenty-three patients developed aspiration pneumonia while
undertaking advised dietary changes, including liquid thickening.
Significant risk factors for aspiration pneumonia development were poor
performance status (OR, 1.85), PAS score ≥3 (OR, 4.03), and a history of
aspiration pneumonia (OR, 7.00). Conclusion Thickening of liquids can reduce the incidence of penetration-aspiration.
Vocal fold paralysis, impaired laryngeal sensation, and history of
aspiration pneumonia are significant risk factors of penetration-aspiration.
Poor performance status, PAS score ≥3, and history of aspiration pneumonia
are significantly associated with aspiration pneumonia development following
recommendations on thickening liquids. Level of Evidence 3.
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Affiliation(s)
- Hiroaki Masuda
- Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Rumi Ueha
- Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.,Swallowing Center, The University of Tokyo, Tokyo, Japan
| | - Taku Sato
- Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takao Goto
- Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Misaki Koyama
- Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akihito Yamauchi
- Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Asako Kaneoka
- The University of Tokyo Hospital, Rehabilitation Center, Tokyo, Japan
| | - Sayaka Suzuki
- Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Yamasoba
- Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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Dysphagic disorder in a cohort of COVID-19 patients: Evaluation and evolution. Ann Med Surg (Lond) 2021; 69:102837. [PMID: 34512968 PMCID: PMC8423675 DOI: 10.1016/j.amsu.2021.102837] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/06/2021] [Accepted: 09/06/2021] [Indexed: 01/08/2023] Open
Abstract
Background COVID-19 is a multisystem disease complicated by respiratory failure requiring sustanined mechanical ventilation (MV). Prolongued oro-tracheal intubation is associated to an increased risk of dysphagia and bronchial aspiration. Purpose of this study was to investigate swallowing disorders in critically ill COVID-19 patients. Material and methods This was a retrospective study analysing a consecutive cohort of COVID-19 patients admitted to the Intensive Care Unit (ICU) of our hospital. Data concerning dysphagia were collected according to the Gugging Swallowing Screen (GUSS) and related to demographic characteristics, clinical data, ICU Length-Of-Stay (LOS) and MV parameters. Results From March 2 to April 30, 2020, 31 consecutive critically ill COVID-19 patients admitted to ICU were evaluated by speech and language therapists (SLT). Twenty-five of them were on MV (61% through endotracheal tube and 19% through tracheostomy); median MV length was 11 days. Seventeen (54.8%) patients presented dysphagia; a correlation was found between first GUSS severity stratification and MV days (p < 0.001), ICU LOS (p < 0.001), age (p = 0.03) and tracheostomy (p = 0.042). No other correlations were found. At 16 days, 90% of patients had fully recovered; a significant improvement was registered especially during the first week (p < 0.001). Conclusion Compared to non-COVID-19 patiens, a higher rate of dysphagia was reported in COVID-19 patients, with a more rapid and complete recovery. A systematic early SLT evaluation of COVID-19 patients on MV may thus be useful to prevent dysphagia-related complications.
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Sella Weiss O, Gvion A, Mcrae J. Speech and language therapists' management of ventilated patients and patients with tracheostomy in Israel. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2021; 56:1053-1063. [PMID: 34357667 DOI: 10.1111/1460-6984.12655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 06/06/2021] [Accepted: 06/15/2021] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Oshrat Sella Weiss
- Department of Communication Sciences and Disorders, University of Haifa, Haifa, Israel
- Speech and Language Department, Reuth Rehabilitation Hospital, Tel Aviv, Israel
| | - Aviah Gvion
- Speech and Language Department, Reuth Rehabilitation Hospital, Tel Aviv, Israel
- Department of Communication Sciences and Disorders, Ono Academic College, Kiryat Ono, Israel
| | - Jackie Mcrae
- Center for Allied Health, St George's University of London, United Kingdom of Great Britain and Northern Ireland, London, UK
- Speech and Language Therapy Department, University College London Hospitals, NHS Foundation Trust
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Ma DJ, Van Abel KM. Treatment De-intensification for HPV-associated Oropharyngeal Cancer: A Definitive Surgery Paradigm. Semin Radiat Oncol 2021; 31:332-338. [PMID: 34455988 DOI: 10.1016/j.semradonc.2021.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV+OPSCC) constitutes the majority of head and neck diagnoses within the United States. Patients with HPV+OPSCC have biologically and demographically distinct disease, leading to high cure rates after standard treatments. This long survivorship period coupled with the toxicity of standard treatments makes de-intensification strategies an urgent research question. Surgery has generally been avoided for HPV+OPSCC as historical surgical techniques were invasive and morbid. With the advent of minimally invasive transoral techniques, definitive surgical options are becoming more popular. Minimally invasive surgery offers unique opportunities in a de-intensification paradigm, including more detailed patient selection, radiation volume reduction, and radiation dose de-intensification. Nevertheless, careful patient selection must be exercised as surgical defects may lead to quality of life decrements beyond what is gained through de-intensification. Ongoing phase III efforts will help clarify the patient cohorts best suited for surgically oriented de-intensification.
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Affiliation(s)
- Daniel J Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN.
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Formisano E, Di Maio P, Ivaldi C, Sferrazzo E, Arieta L, Bongiovanni S, Panizzi L, Valentino E, Pasta A, Giudice M, Demontis S. Nutritional therapy for patients with coronavirus disease 2019 (COVID-19): Practical protocol from a single center highly affected by an outbreak of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Nutrition 2021; 82:111048. [PMID: 33277149 PMCID: PMC7645291 DOI: 10.1016/j.nut.2020.111048] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/26/2020] [Accepted: 11/02/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Coronavirus disease 2019 (COVID-19) carries a high risk for malnutrition owing to the state of debilitation that results from acute respiratory failure symptoms. The aim of this study was to provide an approach to reduce the risk for malnutrition and improve patients' clinical outcomes. METHODS Short age-adjusted Nutritional Risk Screening was performed with 94 non-intensive care unit (ICU) patients admitted to the Giovanni Borea Civil Hospital in Sanremo. Forty-nine patients in the ICU were considered at risk for malnutrition without screening and were fed with enteral nutrition plus supplemental parenteral nutrition. In the non-ICU setting, patients underwent a personalized nutritional protocol, considering their conditions, which consisted of a high-protein and high-calorie pureed diet, oral nutritional supplements, and/or artificial nutrition or other personalized nutritional path. RESULTS The nutritional treatment was well tolerated by the patients. Of the non-ICU patients, 19.1% died. They were mainly women, with higher body mass indices and older in age. Of the patients in the ICU, 53.1% died. Of the 94 non-ICU patients, 72 scored positive on at least one nutritional risk screening item (excluding age). Of the 94 non-ICU patients, 68 were >70 y of age. Non-ICU patients whose energy and protein needs were not met were older (P = 0.01) and had a higher death rate than patients whose needs were met (P < 0.001). CONCLUSIONS This protocol should not be considered as a guideline; rather, it is intended to report the clinical experience of a nutrition team in an Italian reference center for the treatment of patients with COVID-19. Nutritional strategies should be implemented to prevent worsening of clinical outcomes.
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Affiliation(s)
- Elena Formisano
- Nutritional Unit, Giovanni Borea Civil Hospital, Sanremo, Italy
| | - Pasquale Di Maio
- Department of Otolaryngology-Head and Neck Surgery, Giovanni Borea Civil Hospital, Sanremo, Italy
| | - Cecilia Ivaldi
- Nutritional Unit, Giovanni Borea Civil Hospital, Sanremo, Italy
| | - Elsa Sferrazzo
- Nutritional Unit, Giovanni Borea Civil Hospital, Sanremo, Italy
| | | | | | | | - Elena Valentino
- Nutritional Unit, Giovanni Borea Civil Hospital, Sanremo, Italy
| | - Andrea Pasta
- Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Marco Giudice
- Department of Otolaryngology-Head and Neck Surgery, Giovanni Borea Civil Hospital, Sanremo, Italy
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