Fiberoptic Endoscopic Evaluation of Swallow (FEES) in Intensive Care Unit Patients Post Extubation

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

Background

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

Materials and methods

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

Results

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

Conclusion

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

How to cite this article

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Current approaches to reporting pharyngo-laryngeal secretions

PURPOSE OF REVIEW

Accumulated secretions in the pharynx and larynx are associated with dysphagia, aspiration and pneumonia, as well as increased social, health and economic burden. This article reviews developments in the instrumental reporting of pharyngo-laryngeal secretions over the last 2 years.

RECENT FINDINGS

Although the healthy pharynx and larynx is moist, accumulation of secretions is indicative of abnormality. Using standardized secretion scales allows early identification, quantification of risk in patients, and sensitive monitoring of patients over time. Nonstandardized and subjective secretion reporting is common in recently published research despite the validation of a number of publicly available tools. Research characterizing accumulated secretions has contributed to our understanding of pathophysiology associated with poor secretion management and may inform future treatment studies.

SUMMARY

Routine and standardized reporting of secretions is critical for patient assessment and should be reported in the most standardized way possible. Further research investigating the clinical relevance and treatment of accumulated secretions relies on quantitative pharyngolaryngeal secretions reporting.

[Post-intensive care syndrome]

Post-intensive care syndrome is an entity defined in 2010 and covering any sequelae following an extended hospitalization in intensive care unit. It comprises psychological, cognitive and physical disorders (neuromyopathy, respiratory dysfunction, joint stiffness, among others). These sequelae have important consequences on autonomy and quality of life of these patients, as well as on their healthcare consumption and on mortality. Psychological sequelae can also be seen in hospitalized patients' relatives. Screening and management of these disorders is more and more frequent but no method has formally proven effective. The number of patients surviving an intensive care unit hospitalization is increasing, and management of post-intensive care syndrome is a major issue. It seems important that the internist be aware of this syndrome, given his pivotal role in global management of patients and frequent implication into care after the intensive care unit.

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

OBJECTIVES/HYPOTHESIS

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

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Assessment, Diagnosis, and Treatment of Dysphagia in Patients Infected With SARS-CoV-2: A Review of the Literature and International Guidelines

Purpose Speech-language pathologists are playing a crucial role in the assessment and management of patients infected with severe acute respiratory syndrome coronavirus 2. Our goal was to synthesize peer-reviewed literature and association guidelines from around the world regarding dysphagia assessment and management for this specific population. Method A review of publications available in the PubMed database and official guidelines of international groups was performed on May 23, 2020. The information was synthesized and categorized into three content areas for swallowing: clinical evaluation, instrumental assessment, and rehabilitation. Results Five publications were identified in the PubMed database. Following title, abstract, and full-text review, only three publications met inclusion criteria: two reviews and one narrative report. Additionally, 19 international guidelines were reviewed. To assess swallowing, a modified clinical evaluation was recommended and only following a risk assessment. Instrumental assessments were often considered aerosol generating, especially transnasal procedures such as endoscopy and manometry. For this reason, many associations recommended that these examinations be performed only when essential and with appropriate personal protective equipment. Guidelines recommended that intervention should focus on compensatory strategies, including bolus modification, maneuvers/postural changes, and therapeutic exercises that can be conducted with physical distancing. Respiratory training devices were not recommended during rehabilitation. Conclusions International associations have provided extensive guidance regarding the level of risk related to the management of dysphagia in this population. To date, there are no scientific papers offering disease and/or recovery profiling for patients with dysphagia and coronavirus disease 2019. As a result, research in this area is urgently needed.

Abnormalities of Aspiration and Swallowing Function in Survivors of Acute Respiratory Failure

The mechanisms responsible for aspiration are relatively unknown in patients recovering from acute respiratory failure (ARF) who required mechanical ventilation. Though many conditions may contribute to swallowing dysfunction, alterations in laryngeal structure and swallowing function likely play a role in the development of aspiration. At four university-based tertiary medical centers, we conducted a prospective cohort study of ARF patients who required intensive care and mechanical ventilation for at least 48 h. Within 72 h after extubation, a Fiberoptic Flexible Endoscopic Evaluation of Swallowing (FEES) examination was performed. Univariate and multivariable analyses examined the relationship between laryngeal structure and swallowing function abnormalities. Aspiration was the primary outcome, defined as a Penetration- Aspiration Scale (PAS) score of 6 or greater. Two other salient signs of dysphagia-spillage and residue-were secondary outcomes. A total of 213 patients were included in the final analysis. Aspiration was detected in 70 patients (33%) on at least one bolus. The most commonly aspirated consistency was thin liquids (27%). In univariate analyses, several abnormalities in laryngeal anatomy and structural movement were significantly associated with aspiration, spillage, and residue. In a multivariable analysis, the only variables that remained significant with aspiration were pharyngeal weakness (Odds ratio = 2.57, 95%CI = 1.16-5.84, p = 0.019) and upper airway edema (Odds ratio = 3.24, 95%CI = 1.44-7.66, p = 0.004). These results demonstrated that dysphagia in ARF survivors is multifactorial and characterized by both anatomic and physiologic abnormalities. These findings may have important implications for the development of novel interventions to treat dysphagia in ARF survivors.Clinical Trials Registration ClinicalTrials.gov Identifier: NCT02363686, Aspiration in Acute Respiratory Failure Survivors.

Development of an Ultrasonic Doppler Sensor-Based Swallowing Monitoring and Assessment System

Existing swallowing evaluation methods using X-ray or endoscopy are qualitative. The present study develops a swallowing monitoring and assessment system (SMAS) that is nonintrusive and quantitative. The SMAS comprises an ultrasonic Doppler sensor array, a microphone, and an inertial measurement unit to measure ultrasound signals originating only from swallowing activities. Ultrasound measurements were collected for combinations of two viscosity conditions (water and yogurt) and two volume conditions (3 mL and 9 mL) from 24 healthy participants (14 males and 10 females; age = 30.5 ± 7.6 years) with no history of swallowing disorders and were quantified for 1st peak amplitude, 2nd peak amplitude, peak-to-peak (PP) time interval, duration, energy, and proportion of two or more peaks. The peak amplitudes and energy significantly decreased by viscosity and the PP time interval and duration increased by volume. The correlation between the time measures were higher (r = 0.78) than that of the amplitude measures (r = 0.30), and the energy highly correlated with the 1st peak amplitude (r = 0.86). The proportion of two or more peaks varied from 76.8% to 87.9% by viscosity and volume. Further research is needed to examine the concurrent validity and generalizability of the ultrasonic Doppler sensor-based SMAS.

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

BACKGROUND

Post-extubation dysphagia has been associated with adverse health outcomes. To assist service planning and process development for early identification, an understanding of the number of patients affected is required. However, significant variation exists in the reported incidence which ranges from 3% to 62%.

OBJECTIVES

The objective of this study was to (i) conduct a meta-analysis on the incidence of dysphagia after endotracheal intubation in adult critically ill patients and (ii) describe the extent of heterogeneity within peer-reviewed articles and grey literature on the incidence of dysphagia after endotracheal intubation.

DATA SOURCES

Databases CINAHL, Cochrane Library, Embase, MEDLINE, PubMed, SpeechBITE, and Google Scholar were systematically searched for studies published before October 2019.

REVIEW METHODS

Data extraction occurred in a double-blind manner for studies meeting the inclusion criteria. Risk of bias was determined using critical appraisal tools relevant to the individual study design. The overall quality of the synthesised results was described using the Grading of Recommendations Assessment, Development and Evaluation methodology. Raw data were transformed using Freeman-Tukey arcsine square root methodology. A random-effects model was utilised owing to heterogeneity between studies.

RESULTS

Of 3564 identified studies, 38 met the criteria for inclusion in the final review. A total of 5798 patient events were analysed, with 1957 dysphagic episodes identified. The combined weighted incidence of post-extubation dysphagia was 41% (95% confidence interval, 0.33-0.50). Of the patients with dysphagia, 36% aspirated silently (n = 155, 95% confidence interval, 0.22-0.50). Subgroup meta-regression analysis was unable to explain the heterogeneity across studies when accounting for the method of participant recruitment, method of dysphagia assessment, median duration of intubation, timing of dysphagia assessment, or patient population.

CONCLUSION

Dysphagia after endotracheal intubation is common and occurs in 41% of critically ill adults. Given the prevalence of dysphagia and high rates of silent aspiration in this population, further prospective research should focus on systematic and sensitive early identification methods.