Diagnosis and treatment of post-extubation dysphagia: results from a national survey

Navigating Nutrition Complexity in Critical Care: A Focus on Swallowing Function and Rehabilitation

During the past decade, there has been an increased research focus on the prevalence, nature, and impact of newly acquired critical illness dysphagia. Disordered function can impact the safety and efficiency across all stages of the swallow mechanism, with detrimental impacts on patients' body systems, function, and participation. Accurate assessment of swallow function is key to informed diagnosis and enhances intervention planning. We discuss the current evidence base around dysphagia pathophysiology with a detailed discussion considering the modes of ventilation commonly received in intensive care units. Assessment and management across critical illness are evaluated and future research efforts are presented.

Feasibility of Endoscopic Evaluations of Laryngeal Function After Extubation for Research in Critically Ill Adults

PURPOSE

Flexible nasal laryngoscopy (FNL) is commonly used in intensive care units (ICUs) to assess laryngeal anatomy and function after endotracheal intubation. The use of FNL in research may differ from clinical practice due to requirements of research protocols and related data collection and documentation. This study evaluates the feasibility of performing FNL post-extubation in critically ill adults within the context of a research protocol. Understanding the feasibility of this reference standard assessment is important for supporting future studies and improving patient care.

METHOD

This prospective study, conducted in six ICUs within a single academic medical center, consecutively enrolled adult patients who required mechanical ventilation for at least 8 hr. The primary feasibility outcome was the successful completion of FNL within 72 hr of extubation. Secondary outcomes included completion of the 3-oz water swallow test (Yale Swallow Protocol) during the FNL, patient enrollment/exclusion/withdrawal rates, time from extubation to FNL, procedure duration, and patient-reported pain (using the Wong-Baker FACES Pain Rating Scale).

RESULTS

A total of 80 patients (75%) of 107 eligible patients fully completed FNL. Among the 24 patients who did not receive FNL, eight died, seven were medically inappropriate, and seven declined FNL. The median time from extubation to FNL was 10 hr (IQR [interquartile range]: 8-12 hr), and the median FNL procedure duration was 8.5 min (IQR: 5.8-12.9 min). The median (IQR) pain score was 2 (0, 4) of 10, reflecting only mild discomfort.

CONCLUSION

Post-extubation FNL is feasible within the context of a research protocol and well tolerated by critically ill adults.

Effects of Expiratory Muscle Strength Training on Swallowing in Survivors of Critical Illness: A Protocol for a Systematic Review and Meta-Analysis

Background and Aims

Post Extubation Dysphagia (PED) is a common consequence of mechanical ventilation. Muscular weakness and atrophy are potential causes. Expiratory Muscle Strength Training (EMST) is a technique whereby a subject exhales against a resistance, strengthening the muscles of expiration. There is evidence that EMST causes activation and hypertrophy of the muscles of swallowing, with clinical evidence that it improves swallowing in certain populations. The aim of this systematic review is to collate the existing literature concerning evaluation of swallowing after extubation, and whether EMST positively affects these measures.

Methods

We will perform a systematic review of the literature by searching electronic databases (Pubmed, Medline, EMBASE, and the Cochrane Library), for articles where EMST has been performed (alone or in conjunction with inspiratory muscle training), in patients who have been liberated from a period of mechanical ventilation. We will identify studies that evaluate swallowing after extubation, listing the methods used to evaluate swallowing and data will be extracted from studies evaluating the impact EMST has on these measures.

Results

We will undertake meta-analysis if data permits. Risk of bias will be assessed using the Risk of Bias 2 tool or the Newcastle Ottawa Score for randomized and non-randomized trials. We will use The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the quality of evidence.

Conclusion

The results of this systematic review will enable us to assess the current literature on the use of EMST in critical care, and whether the intervention improves swallowing and respiratory outcomes. Trial Registration: PROSPERO registration: 42023444479.

Independent Risk Factors for Prolonged Tube Feeding After Endotracheal Intubation and Ventilation

PURPOSE

Postextubation dysphagia (PED) can lead to prolonged tube feeding, but risk factors associated with prolonged tube feeding in this population are largely unknown. The purpose of this study was to identify factors independently associated with prolonged tube feeding in adult inpatients who required intubation and mechanical ventilation.

MATERIALS AND METHODS

Retrospective observational cohort study in a dataset of 1.3 million inpatients. Extubated adults without preventilation dysphagia or tube feeding who underwent instrumental swallowing assessment were included. To characterize factors independently associated with prolonged tube feeding, we compiled a set of potential factors, completed factor selection using a random forest algorithm, and performed logistic regression.

RESULTS

In total, 206 of 987 (20.9%) patients had prolonged tube feeding. The regression model produced an area under the curve of 0.79. Factors with the greatest influence on prolonged tube feeding included dysphagia with thickened liquids, dysphagia with soft/solid foods, preadmission weight loss, number of intubations, admission for neurologic disorder, and hospital of admission.

CONCLUSIONS

Several factors predicted prolonged tube feeding after extubation. The strongest were some, but not all, aspects of swallowing function and clinical practice pattern variability. Clinical decision-making should consider bolus-specific data from instrumental swallowing evaluation rather than binary presence or absence of dysphagia.

Interventions for Postextubation Dysphagia in Critically Ill Patients: A Systematic Review and Meta-analysis

OBJECTIVE

This review evaluates the efficacy and safety of dysphagia interventions for patients with prolonged endotracheal intubation (⩾48 h) in critical care units.

DATA SOURCES

We systematically searched PubMed, Cochrane Library, Medline, Embase, OVID, CINAHL, Wanfang (China), CNKI (China), and ProQuest Dissertations for studies published up to December 31, 2023.

STUDY SELECTION

Inclusion criteria encompassed randomized controlled trials (RCTs), quasi-randomized trials, and cohort studies comparing dysphagia rehabilitation - such as swallowing stimulation, swallowing and respiratory muscle exercise, and neuromuscular electrical stimulation - with standard care or no treatment. The primary outcomes assessed were dysphagia severity, time to resume oral intake, and incidence of aspiration and aspiration pneumonia.

DATA EXTRACTION

Detailed information on study design, setting, participant demographics, interventions, and outcomes was systematically extracted.

DATA SYNTHESIS

Our analysis included ten studies with a total of 1031 participants. The findings demonstrate a significant reduction in dysphagia severity, time to oral intake and the risk of aspiration pneumonia, and an improvement in quality of life among patients receiving swallowing therapy. However, no substantial difference was found in nutritional status. Limited data availability necessitated a descriptive presentation of outcomes like the risk of aspiration, ICU/hospital stay duration, pharyngeal/oral residue severity, and intervention-related adverse events.

CONCLUSION

The current evidence for the effectiveness of dysphagia interventions in critically ill patients with prolonged endotracheal intubation is limited. There is a pressing need for future research, particularly high-quality RCTs employing standardized outcome measures, to substantiate these findings.

Incidence and factors associated with dysphagia in intensive care unit patients 24 h after extubation

BACKGROUND

Post-extubation dysphagia deserves attention because it places patients at risk following extubation, especially critically ill patients in intensive care unit. However, there are limited studies of post-extubation dysphagia in the early stages after extubation.

AIM

To investigate the incidence and factors associated with post-extubation dysphagia among patients in intensive care unit within 24 h of extubation.

STUDY DESIGN

A prospective descriptive study was carried out with 173 adult patients in intensive care unit with tracheal extubation at a tertiary hospital in Guangzhou, China. The Gugging Swallowing Screen was used to evaluate the swallowing function of patients 1, 4 and 24 h after extubation. Demographic and clinical data were retrieved from medical records.

RESULTS

The incidence of post-extubation dysphagia in patients within 1, 4 and 24 h after extubation was 86.71% (n = 150), 63.01% (n = 109) and 43.35% (n = 75), respectively. The risk factors included older age (OR = 1.057, 95%CI [1.039, 1.072], p < .001), cardiovascular disease (OR = 0.098, 95%CI [0.082, 0.127], p = .012), thyroid dysfunction (OR = 5.042, 95%CI [1.527, 13.684], p < .001), non-post-operative admission (OR = 3.186, 95%CI [1.142, 14.422], p = .036), mechanical ventilation duration >48 h (OR = 3.558, 95%CI [1.217, 10.385], p = .020), intubation duration >24 h (OR = 0.533, 95%CI [0.278, 0.898], p = .048) and intubation model size ≤7 (OR = 0.327, 95%CI [0.158, 0.788], p < .01).

CONCLUSIONS

This study revealed a high incidence of post-extubation dysphagia in critical patients in the 24 h after extubation, with the incidence decreasing over time. Screening of early post-extubation dysphagia after extubation is needed, but the specific evaluation time point requires further investigation. Patients with older age, cerebrovascular disease, thyroid dysfunction, post-operative admission, longer mechanical ventilation time, thicker intubation models and longer intubation time have a higher risk of the occurrence of post-extubation dysphagia.

RELEVANCE TO CLINICAL PRACTICE

The incidence of post-extubation dysphagia is very high in the early stage. Within 24 h after extubation, the patient's swallowing function should be actively evaluated, and the occurrence of aspiration should be vigilant. Patients with older age, cerebrovascular disease, thyroid dysfunction, post-operative admission, longer mechanical ventilation time, thicker intubation models and longer intubation time should receive more attention.

Identifying High-Quality Non-Instrumental Dysphagia Screening Tools for Detection of Adult Dysphagia Case in Acute-Care Settings: A Systematic Review

INTRODUCTION

As patients nowadays tend to have multiple diseases and complex medical histories, our aim was to identify high-quality, non-instrumental dysphagia screening tools used for the detection of adult dysphagia cases in all disease categories in acute-care settings.

METHOD

A literature search was conducted in five databases from each database's earliest inception to 31 July 2021 and guided by five keywords: 'dysphagia', 'deglutition', 'screening', 'test' and 'measure'. Without limiting the search in any specific disease category, reviewers assessed original studies and identified tools if they had been validated against instrumental evaluations and if they had been designed as a pass-fail procedure to screen whether dysphagia is absent or present. We further excluded any tool if it was (1) for pediatric focus, or (2) a patient self-report questionnaire. All final tool candidates underwent a methodological quality appraisal using the Revised Tool for the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2).

RESULT

Out of 195 studies with 165 tools identified, 20 tool candidates underwent QUADAS-2 review. We found six high-quality, non-instrumental screening tools for detecting adult dysphagia cases in acute-care settings, including the Yale Swallow Protocol, Gugging Swallowing Screen, Toronto Bedside Swallowing Screening Test (both English and Portuguese versions), Sapienza Global Bedside Evaluation of Swallowing and Two-Step Thickened Water Test. These high-quality tools were developed primarily for patients with stroke. Only Yale Swallow Protocol was originally tested for heterogeneous populations with stroke, multiple sclerosis, traumatic brain injury, oesophageal surgery, neurosurgery and head-and-neck cancer.

CONCLUSIONS

The results highlight the gap in the unavailability of high-quality dysphagia screening tool in several emerged high-risk populations including elderly inpatients, or patients following endotracheal extubation. Further research is needed to determine whether these six tools can be effectively applied across different high-risk populations in acute-care settings to screen for cases finding.

Prevalence and Management of Oral Intake Restrictions in Critically Ill Patients: Insights from a Multicenter Point Prevalence Study

Oral intake restrictions due to dysphagia in the intensive care unit (ICU) can increase morbidity, mortality, and negatively impact quality of life. The current oral intake practice and clinical management strategies for addressing dysphagia in the ICU are not well-defined. This study aimed to elucidate the clinical practices surrounding oral intake restrictions due to dysphagia and its management strategies in the ICU. A multicenter, prospective, cross-sectional, 2-day point prevalence study was conducted in Japan. Relevant data on the clinical circumstances surrounding oral intake practice and the implementation of strategies to prevent dysphagia for patients admitted to the ICU on November 1, 2023, and December 1, 2023, were collected. The primary outcome was the prevalence of oral intake restrictions in patients, defined by a Functional Oral Intake Scale score of less than 7 among eligible patients for oral intake. Out of 326 participants, 187 were eligible for the final analysis after excluding 139 patients who were not eligible for oral intake, primarily due to tracheal intubation. Among those eligible, 69.0% (129/187) encountered oral intake restrictions. About 52.4% (98/187) of patients underwent swallowing screenings; 36.7% (36/98) of these were suspected of having dysphagia. Compensatory and behavioral swallowing rehabilitation were provided to 21.9% (41/187) and 10.6% (20/187) of patients, respectively, from ICU admission to the survey date. Only 27.4% (14/51) of post-extubation and 9.3% (3/32) of post-stroke patients received swallowing rehabilitation. Notably, no ICUs had dedicated speech and language therapists, and most (85.7%, 18/21) lacked established swallowing rehabilitation protocols. This 2-point prevalence survey study revealed that oral intake restrictions due to dysphagia are common in ICUs, but few patients are screened for swallowing issues or receive rehabilitation. More clinical studies are needed to develop effective protocols for identifying and managing dysphagia, including screenings and rehabilitation in the ICU.

Association of early oral intake after extubation and independent activities of daily living at discharge among intensive care unit patients: A single centre retrospective cohort study

PURPOSE

We investigated the association between the time to first post-extubation oral intake, barriers to oral intake, and the rate of activities of daily living (ADL) independence at discharge (Barthel Index score <70).

METHOD

Consecutive patients admitted to the intensive care unit, aged ≥18 years, and mechanically ventilated for ≥48 hr were retrospectively enrolled. The time to first oral intake, barriers to oral intake, daily changes, and clinical outcomes were assessed. Multiple logistic regression analysis adjusted for baseline characteristics was used to determine the association between time to first post-extubation oral intake and ADL independence.

RESULT

Among the 136 patients, 74 were assigned to the ADL independence group and 62 to the dependence group. The time to first post-extubation oral intake was significantly associated with ADL independence (adjusted p = < 0.001) and was a predictor of ADL independence at discharge. Respiratory and dysphagia-related factors (odds ratio [OR] 0.35; 95% confidence interval [CI] 0.15-0.82, p = 0.015 and OR 0.07; CI 0.01-0.68, p = 0.021, respectively) were significantly associated with the ADL independence at discharge.

CONCLUSION

Respiratory and dysphagia-related factors, as barriers to the initiation of oral intake after extubation, were significantly associated with ADL independence at discharge.

Screening and early detection of post-extubation oropharyngeal dysphagia: a best practice implementation project

INTRODUCTION

Patients undergoing intubation and mechanical ventilation in an intensive care unit risk developing post-extubation oropharyngeal dysphagia (PED). PED can lead to aspiration complications, aspiration pneumonia, and prolonged hospitalization, as well as increased repeat intubation and in-hospital morbidity and mortality.

OBJECTIVE

This evidence implementation project aimed to promote evidence-based screening and early detection of PED in an adult intensive care unit in a secondary public hospital in Brazil.

METHOD

The project followed the seven-phase JBI Evidence Implementation Framework to promote changes at the study site. The JBI Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRiP) approach were also used. The project was developed considering the main barriers to best practices, which were identified through a baseline audit. An educational program was designed to address the identified barriers. Two follow-up audits were then conducted to assess the changes in compliance with the evidence-based practices.

RESULTS

The baseline audit showed deficits in current practices. The first follow-up audit indicated improved compliance with best practices, with five of the seven audit criteria showing 100% compliance. The second follow-up audit indicated that compliance remained at 100% for those five criteria and increased for the other two after an additional intervention to address poor results in nursing care documentation.

CONCLUSION

The first follow-up audit showed good adherence to the educational program for the screening and detection of PED by nurses. The second follow-up audit, in line with the new strategies, showed improvement in nursing documentation.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A241.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN AND SETTING

A retrospective study.

METHODS

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

RESULTS

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

CONCLUSION

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

Management of swallowing disorders in ICU patients - A multinational expert opinion

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.

Prediction Models for Dysphagia in Intensive Care Unit after Mechanical Ventilation: A Systematic Review and Meta-analysis

OBJECTIVE

Dysphagia is a common condition that can independently lead to death in patients in the intensive care unit (ICU), particularly those who require mechanical ventilation. Despite extensive research on the predictors of dysphagia development, consistency across these studies is lacking. Therefore, this study aimed to identify predictors and summarize existing prediction models for dysphagia in ICU patients undergoing invasive mechanical ventilation.

METHODS

We searched five databases: PubMed, EMBASE, Web of Science, Cochrane Library, and the China National Knowledge Infrastructure. Studies that developed a post-extubation dysphagia risk prediction model in ICU were included. A meta-analysis of individual predictor variables was performed with mixed-effects models. The risk of bias was assessed using the prediction model risk of bias assessment tool (PROBAST).

RESULTS

After screening 1,923 references, we ultimately included nine studies in our analysis. The most commonly identified risk predictors included in the final risk prediction model were the length of indwelling endotracheal tube ≥72 h, Acute Physiology and Chronic Health Evaluation (APACHE) II score ≥15, age ≥65 years, and duration of gastric tube ≥72 h. However, PROBAST analysis revealed a high risk of bias in the performance of these prediction models, mainly because of the lack of external validation, inadequate pre-screening of variables, and improper treatment of continuous and categorical predictors.

CONCLUSIONS

These models are particularly susceptible to bias because of numerous limitations in their development and inadequate external validation. Future research should focus on externally validating the existing model in ICU patients with varying characteristics. Moreover, assessing the acceptance and effectiveness of the model in clinical practice is needed.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:517-525, 2024.

Evaluation and Treatment of Dysphagia in Public and Private Intensive Care Units (ICUs) in Greece

Introduction  Dysphagia is a significant but underrecognized clinical issue in the intensive care unit (ICU), and it is associated with various complications. Despite its clinical importance, there is limited research and no Greek ICU-specific guidelines for managing dysphagic patients. Additionally, only a few ICUs in Greece have dysphagia specialists, specifically speech-language pathologists (SLPs) providing their expertise. Objective  Τo identify the current practices for dysphagia management (screening, assessment, treatment) and gain insight into ICU directors' awareness/perceptions of the prevalence, complications, and risk of dysphagia. Materials and Methods  We identified 138 Greek ICUs. Data were collected from ICU (including pediatric and neonatal) directors, working in public and private hospitals, via a 24-item, anonymous online questionnaire, within a 4-month period. Results  Our survey was completed by 45 ICU directors. Most participants (84.4%) reported that dysphagia is a relevant clinical problem in their ICU, and 51.1% estimated a frequency rate < 20%. Non-instrumental approaches are mainly utilized to screen and diagnose dysphagia, whereas enteral nutrition and diet modifications are used to manage dysphagia. Additionally, 64.4% of ICU directors agreed that SLPs are essential for the management of dysphagic patients, and 66.7%, that awareness of dysphagia in their ICU could be increased. Conclusion  The current study documented the methods and approaches used to manage dysphagic patients in Greek ICUs. The ICU directors seem to recognize the clinical significance of dysphagia and its complications. According to our findings, the employment of SLPs could result in a more comprehensive and intensive approach and improve the quality of care for these patients.

Dysphagia in adult intensive care patients: Results of a prospective, multicentre binational point prevalence study

BACKGROUND

Dysphagia occurs in intensive care unit (ICU) patients. However, there is a lack of epidemiological data on the prevalence of dysphagia in adult ICU patients.

OBJECTIVES

The objective of this study was to describe the prevalence of dysphagia in nonintubated adult patients in the ICU.

METHODS

A prospective, multicentre, binational, cross-sectional point prevalence study was conducted in 44 adult ICUs in Australia and New Zealand. Data were collected in June 2019 on documentation of dysphagia, oral intake, and ICU guidelines and training. Descriptive statistics were used to report demographic, admission, and swallowing data. Continuous variables are reported as means and standard deviations (SDs). Precisions of estimates were reported as 95% confidence intervals (CIs).

RESULTS

Of the 451 eligible participants, 36 (7.9%) were documented as having dysphagia on the study day. In the dysphagia cohort, the mean age was 60.3 years (SD: 16.37) vs 59.6 years (SD: 17.1) and almost two-thirds were female (61.1% vs 40.1%). The most common admission source for those patients with dysphagia were from the emergency department (14/36, 38.9%), and seven of 36 (19.4%) had a primary diagnosis of trauma (odds ratio: 3.10, 95% CI 1.25 - 7.66). There were no statistical differences in Acute Physiology and Chronic Health Evaluation (APACHE II) scores between those with and without a dysphagia diagnosis. Patients with dysphagia were more likely to have a lower mean body weight of 73.3 kg vs 82.1 kg than patients not documented as having dysphagia (95% CI of mean difference: 0.43 to 17.07) and require respiratory support (odds ratio: 2.12, 95% 1.06 to 4.25). The majority of patients with dysphagia were prescribed modified food and fluids in the ICU. Less than half of ICUs surveyed reported unit-level guidelines, resources, or training for management of dysphagia.

CONCLUSIONS

The prevalence of documented dysphagia in adult ICU nonintubated patients was 7.9%. There were a higher proportion of females with dysphagia than previously reported. Approximately two-thirds of patients with dysphagia were prescribed oral intake, and the majority were receiving texture-modified food and fluids. Dysphagia management protocols, resources, and training are lacking across Australian and New Zealand ICUs.

Acute Antipsychotic Use and Presence of Dysphagia Among Older Veterans with Heart Failure

OBJECTIVE

Examine whether new antipsychotic (AP) exposure is associated with dysphagia in hospitalized patients with heart failure (HF).

DESIGN

Retrospective cohort.

SETTINGS AND PARTICIPANTS

AP-naïve Veterans hospitalized with HF and subsequently discharged to a skilled nursing facility (SNF) between October 1, 2010, and November 30, 2019.

METHODS

We linked Veterans Health Administration (VHA) electronic medical records with Centers for Medicare & Medicaid (CMS) Minimum Data Set (MDS) version 3.0 assessments and CMS claims. The exposure variable was administration of ≥1 dose of a typical or atypical AP during hospitalization. Our main outcome measure was dysphagia presence defined by (1) inpatient dysphagia diagnosis codes and (2) the SNF admission MDS 3.0 swallowing-related items to examine post-acute care dysphagia status. Inverse probability of treatment weighting was used for risk adjustment.

RESULTS

The analytic cohort consisted of 29,591 Veterans (mean age 78.5 ± 10.0 years; female 2.9%; n = 865). Acute APs were administered to 9.9% (n = 2941). Those receiving APs had differences in prior dementia [37.1%, n = 1091, vs 22.3%, n = 5942; standardized mean difference (SMD) = 0.33] and hospital delirium diagnoses (7.7%, n = 227 vs 2.8%, n = 754; SMD = 0.22). Acute AP exposure was associated with nearly double the risk for hospital dysphagia diagnosis codes [adjusted (adj.) relative risk (RR) 1.9, 95% CI 1.8, 2.1]. At the SNF admission MDS assessment, acute AP administration during hospitalization was associated with an increased dysphagia risk (adj. RR 1.2, 95% CI 1.0, 1.5) both in the oral (adj. RR 1.7, 95% CI 1.2, 2.0) and pharyngeal phases (adj. RR 1.3, 95% CI 1.0, 1.7).

CONCLUSIONS AND IMPLICATIONS

In this retrospective study, AP medication exposure was associated with increased dysphagia coding and MDS assessment. Considering other adverse effects, acute AP should be cautiously administered during hospitalization, particularly in those with dementia. Swallowing function is critical to hydration, nutrition, and medical management of HF; therefore, when acute APs are initiated, a swallow evaluation should be considered.

Strategies of Screening and Treating Post-Extubation Dysphagia: An Overview of the Situation in Greek-Cypriot ICUs

Post-extubation dysphagia (PED) can lead to serious health problems in critically ill patients. Contrasting its high incidence rate of 12.4% reported in a recent observational study, many ICUs lack routine bedside screening, likely due to limited awareness. This study aimed to establish baseline data on the current approaches and the status of perceived best practices in PED screening and treatment, as well as to assess awareness of PED. A nationwide cross-sectional, online survey was conducted in all fourteen adult ICUs in the Republic of Cyprus in June 2018, with a 100% response rate. Over 85% of ICUs lacked a standard screening protocol for PED. The most commonly reported assessment methods were cough reflex testing and the water swallow test. Treatment approaches included muscle strengthening exercises without swallowing and swallowing exercises. Only 28.6% of ICUs acknowledged PED as a common issue. The study identified significant gaps in awareness and knowledge regarding PED screening and treatment in Greek-Cypriot ICUs. Urgent implementation of comprehensive dysphagia education programs within the units is necessary, and interdisciplinary collaboration among nurses, intensivists, and speech and language therapists is crucial to improve the quality of care provided.

Severe Community-Acquired Pneumonia Caused by Methicillin-Sensitive Staphylococcus aureus: Successfully Treated with Contezolid - A Case Report and Literature Review

Background

Staphylococcus aureus has been well recognized as an important cause of community-acquired pneumonia (CAP), with non-specific characteristics and poor prognosis. In severe CAP (SCAP) guidelines, β-lactam combined with macrolides or fluoroquinolones therapy was recommended, but the efficacy is not satisfactory due to the continued spread of antimicrobial resistance. Contezolid is a new representative of oxazolidinones in clinical development, but no relevant reports have been reported for the treatment of SCAP. This was the first report of a patient with Staphylococcus aureus SCAP who was successfully treated with contezolid combined with other antibiotics and rehabilitation exercise.

Case Presentation

A 44-year-old woman with high blood pressure and diabetes was admitted to our hospital owing to cough, sputum, wheezing for 2 weeks, and aggravation for 2 days. The bronchoscopic alveolar lavage and microorganism-Rapid On Site Evaluation (BAL-mROSE) was used to get pathological data, which were positive for Staphylococcus aureus, in line with blood cultures. During hospitalization, the patient received endotracheal intubation for assisted breathing and anti-infective therapy, including meropenem, linezolid, teicoplanin and tazocin successively. Finally, contezolid obtained excellent result, with platelet recovery to normal levels and significant improvement in pulmonary imaging. Meanwhile, the patient's swallowing disorder improved after continuous rehabilitation exercise. After discharge, she received contezolid consolidation therapy for 1 week and was free of complaints during the 30-day follow-up without any special treatment for SCAP.

Discussion

Treatment with contezolid combined with other antibiotics and rehabilitation exercise for SCAP has shown remarkable efficacy and good safety; hence, this regimen is a promising treatment strategy for this fatal disease.

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

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

COVID-19 and Dysphagia in Children: A Review

Coronavirus (COVID-19) infection usually causes mild symptoms in children. However, serious complications may occur as a result of both acute infection or in association with the multisystem inflammatory syndrome (MIS-C). Dysphagia may develop as a sequela of COVID-19. We review the limited data on dysphagia associated with COVID-19 infection in children. Children can develop acute respiratory distress syndrome (ARDS) due to severe COVID-19 infection leading to endotracheal intubation and mechanical ventilation. These children can possibly develop post-intubation dysphagia. Screening for the presence of dysphagia, in an effort to minimize aspiration, in children with active COVID-19 infection must be done carefully to reduce the risk of transmission of the virus. Those children diagnosed with persistent dysphagia after COVID-19 infection has resolved will need further evaluation and management by pediatric subspecialists experienced in treating children with this condition. We recommend, this evaluation and treatment be done by a pediatric aerodigestive team.

Sepsis, critical illness, communication, swallowing and Sustainable Development Goals 3, 4, 10

PURPOSE

Sepsis is a major global health problem with an estimated 49 million cases globally each year causing as many as 11 million deaths. The primary objective of this commentary is to describe the impacts of sepsis and critical illness on communication and swallowing function, and to discuss management strategies considering the Sustainable Development Goals (SDGs).

RESULT

Communication and swallowing disabilities can occur with sepsis and critical illness. A holistic framework to optimise function, recovery, and future research priorities across the lifespan can be developed through the SDGs.

CONCLUSION

Communication and swallowing disabilities following critical illness associated with sepsis have global impacts. Early multidisciplinary engagement is key to optimising individuals' function. Collaborative research, education, and public awareness is urgently needed to increase equity in health outcomes across populations. This commentary paper supports progress towards good health and well-being (SDG 3), quality education (SDG 4) and reduced inequalities (SDG 10).

Fiberoptic endoscopic validation of a clinical screening test of swallowing function in critically ill patients performed within 24 h after extubation

BACKGROUND

A bedside screening tool of swallowing dysfunction (SD) (BSSD) after extubation would be useful to identify patients who are at risk of SD. We aimed to evaluate the accuracy of our BSSD in comparison with fiberoptic endoscopic evaluation of swallowing (FEES) in critically ill patients after extubation.

METHODS

We conducted a 1-year prospective monocentric study to evaluate the accuracy of our BSSD to diagnose SD following endotracheal intubation in comparison with FEES (gold standard). Patients intubated for longer than 48 h were included. Both tests were assessed within 24 h after extubation. Primary endpoint was the accuracy of the BSSD. Secondary endpoint was to assess risk factors of SD.

RESULTS

Seventy-nine patients were included in the study. Thirty-three patients (42%) presented with a SD. The BSSD showed a sensitivity of 88% (95% CI 0.72-0.97) and a specificity of 91% (95% CI 0.79-0.98), a positive predictive value of 88% (95% CI 0.72-0.97) and a negative predictive value of 91% (95% CI 0.79-0.97). The AUC reached 0.83 (95% CI 0.74-0.92).

CONCLUSION

Our study describes an accurate clinical screening tool to detect SD after extubation in critically ill patients. Screening-positive cases should be confirmed by instrumental tests, ideally using FEES.

Dysphagia in Intensive Care Evaluation (DICE): An International Cross-Sectional Survey

Dysphagia occurs commonly in the intensive care unit (ICU). Despite the clinical relevance, there is little worldwide research on prevention, assessment, evaluation, and/or treatment of dysphagia for ICU patients. We aimed to gain insight into this international knowledge gap. We conducted a multi-center, international online cross-sectional survey of adult ICUs. Local survey distribution champions were recruited through professional and personal networks. The survey was administered from November 2017 to June 2019 with three emails and a final telephone reminder. Responses were received from 746 ICUs (26 countries). In patients intubated > 48 h, 17% expected a > 50% chance that dysphagia would develop. This proportion increased to 43% in patients intubated > 7 days, and to 52% in tracheotomized patients. Speech-language pathologist (SLP) consultation was available in 66% of ICUs, only 4% reported a dedicated SLP. Although 66% considered a routine post-extubation dysphagia protocol important, most (67%) did not have a protocol. Few ICUs routinely assessed for dysphagia after 48 h of intubation (30%) or tracheostomy (41%). A large proportion (46%) used water swallow screening tests to determine aspiration, few (8%) used instrumental assessments (i.e., flexible endoscopic evaluation of swallowing). Swallowing exercises were used for dysphagia management by 30% of ICUs. There seems to be limited awareness among ICU practitioners that patients are at risk of dysphagia, particularly as ventilation persists, protocols, routine assessment, and instrumental assessments are generally not used. We recommend the development of a research agenda to increase the quality of evidence and ameliorate the implementation of evidence-based dysphagia protocols by dedicated SLPs.

The role of nutrition rehabilitation in the recovery of survivors of critical illness: underrecognized and underappreciated

Many survivors of critical illness face significant physical and psychological disability following discharge from the intensive care unit (ICU). They are often malnourished, a condition associated with poor outcomes, and nutrition remains problematic particularly in the early phases of ICU recovery. Yet nutrition rehabilitation, the process of restoring or optimizing nutritional status following illness, is seldom prioritized, possibly because it is an underrecognized and underappreciated area in critical care rehabilitation and research. To date, 16 original studies have been published where one of the objectives includes measurement of indices relating to nutritional status (e.g., nutrition intake or factors impacting nutrition intake) in ICU survivors. The primary aim of this narrative review is to provide a comprehensive summary of key themes arising from these studies which form the basis of our current understanding of nutritional recovery and rehabilitation in ICU survivors. ICU survivors face a multitude of barriers in achieving optimal nutrition that are of physiological (e.g., poor appetite and early satiety), functional (e.g., dysphagia, reduced ability to feed independently), and psychological (e.g., low mood, body dysmorphia) origins. Organizational-related barriers such as inappropriate feeding times and meal interruptions frequently impact an ICU survivor’s ability to eat. Healthcare providers working on wards frequently lack knowledge of the specific needs of recovering critically ill patients which can negatively impact post-ICU nutrition care. Unsurprisingly, nutrition intake is largely inadequate following ICU discharge, with the largest deficits occurring in those who have had enteral nutrition prematurely discontinued and rely on an oral diet as their only source of nutrition. With consideration to themes arising from this review, pragmatic strategies to improve nutrition rehabilitation are explored and directions for future research in the field of post-ICU nutrition recovery and rehabilitation are discussed. Given the interplay between nutrition and physical and psychological health, it is imperative that enhancing the nutritional status of an ICU survivor is considered when developing multidisciplinary rehabilitation strategies. It must also be recognized that dietitians are experts in the field of nutrition and should be included in stakeholder meetings that aim to enhance ICU rehabilitation strategies and improve outcomes for survivors of critical illness.

DYSPHAGIA OCCURRENCE IN COVID-19-POSITIVE PATIENTS IN TWO HOSPITALS IN BRAZIL

BACKGROUND

COVID-19 comprises a respiratory infection resulting from contamination by SARS-CoV-2, with acute respiratory failure being one of its main characteristics, leading to a high frequency of orotracheal intubation (OTI), which in turn increases the risk for dysphagia. Since this can lead to pulmonary impairment, knowing the real occurrence of dysphagia in part of the Brazilian population and its associations allows early and effective clinical management of the multidisciplinary team in relation to patients.

OBJECTIVE

To verify the occurrence of dysphagia in COVID-19-positive adult patients in two Brazilian reference hospitals in the care of the pandemic.

METHODS

This was a prospective, longitudinal observational study carried out in two private hospitals in Brazil, both references in the care of patients with coronavirus isolation. Data were initially collected by consulting the medical records of each patient. Information was collected regarding sex, age, previous diseases, COVID-19 testing, and the OTI period. After data collection, the clinical speech-language assessment of swallowing for each patient was carried out using the adapted Gugging Swallowing Screen (GUSS), the ASHA NOMS and the Functional Oral Intake Scale (FOIS).

RESULTS

A total of 129 participants were evaluated, with a mean age of 72 years. According to the GUSS scale, 9.3% of the patients presented normal/functional swallowing, while 90.7% presented dysphagia, with mild dysphagia in 17.05%, moderate dysphagia in 33.33%, and severe dysphagia in 37.98%. As for the results of the ASHA NOMS, the majority (36.5%) of the patients were at level 1, which represents the patient who is not able to receive his or her food supply orally, having the need to use tube feedings. This is in line with the results observed with the FOIS scale, whereby most patients (42.1%) were classified as Level I, when food intake occurs exclusively through feeding tubes, with no oral supply. Of the 129 participants, 59% of them required OTI. When comparing the time of OTI and the severity of dysphagia, there was a statistically significant difference, with more severe dysphagia, the longer the patient remained intubated.

CONCLUSION

There is a high incidence of oropharyngeal dysphagia in patients with COVID-19, with increased severity during longer periods of OTI.

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

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Addressing the post-acute sequelae of SARS-CoV-2 infection: a multidisciplinary model of care

As of July 31, 2021, SARS-CoV-2 had infected almost 200 million people worldwide. The growing burden of survivorship is substantial in terms of the complexity of long-term health effects and the number of people affected. Persistent symptoms have been reported in patients with both mild and severe acute COVID-19, including those admitted to the intensive care unit (ICU). Early reports on the post-acute sequelae of SARS-CoV-2 infection (PASC) indicate that fatigue, dyspnoea, cough, headache, loss of taste or smell, and cognitive or mental health impairments are among the most common symptoms. These complex, multifactorial impairments across the domains of physical, cognitive, and mental health require a coordinated, multidisciplinary approach to management. Decades of research on the multifaceted needs of and models of care for patients with post-intensive care syndrome provide a framework for the development of PASC clinics to address the immediate needs of both hospitalised and non-hospitalised survivors of COVID-19. Such clinics could also provide a platform for rigorous research into the natural history of PASC and the potential benefits of therapeutic interventions.

Infections in the older population: what do we know?

The incidence of infections increases with age and results in a higher risk of morbidity and mortality. This rise is not mainly related to chronological age per se but has been linked mostly to individual factors such as immunosenescence; the presence of comorbidities; the occurrence of geriatric syndromes such as poor nutrition, polypharmacy, and cognitive disorders; and the presence of functional impairment concomitant with environmental, healthcare-related and microbiological factors such as the increasing risk of multidrug-resistant microorganisms. The geriatric concept of frailty introduces a new approach for considering the risk of infection; this concept highlights the importance of functional status and is a more comprehensive and multicomponent approach that may help to reverse the vulnerability to stress. The aim of this article is to provide some typical hallmarks of infections among older adults in comparison to younger individuals. The main differences among the older population that are presented are an increased prevalence of infections and potential risk factors, a higher risk of carrying multidrug-resistant microorganisms, an increase in barriers to a prompt diagnosis related to atypical presentations and challenges with diagnostic tools, a higher risk of under- and over-diagnosis, a worse prognosis with a higher risk of acute and chronic complications and a particular need for better communication among all healthcare sectors as they are closely linked together.

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

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

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

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

Tough Pill to Swallow: Postextubation Dysphagia and Nutrition Impact in the Intensive Care Unit

More than 5 million patients are admitted to US intensive care units (ICUs) each year. Many of these patients have risk factors for dysphagia. Dysphagia must be promptly addressed and appropriately treated to avoid the deleterious impacts of aspiration and malnutrition. Therefore, clinicians must be aware of ways to identify and treat dysphagia. This review will highlight the risk factors, mechanisms, and impact of dysphagia in the ICU as well as provide screening, diagnostic, and management options.

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.

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

AIMS AND OBJECTIVES

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

Postintubation Dysphagia During COVID-19 Outbreak-Contemporary Review

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

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

BACKGROUND

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

OBJECTIVES

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

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

Development of an Accurate Bedside Swallowing Evaluation Decision Tree Algorithm for Detecting Aspiration in Acute Respiratory Failure Survivors

BACKGROUND

The bedside swallowing evaluation (BSE) is an assessment of swallowing function and airway safety during swallowing. After extubation, the BSE often is used to identify the risk of aspiration in acute respiratory failure (ARF) survivors.

RESEARCH QUESTION

We conducted a multicenter prospective study of ARF survivors to determine the accuracy of the BSE and to develop a decision tree algorithm to identify aspiration risk.

STUDY DESIGN AND METHODS

Patients extubated after ≥ 48 hours of mechanical ventilation were eligible. Study procedures included the BSE followed by a gold standard evaluation, the flexible endoscopic evaluation of swallowing (FEES).

RESULTS

Overall, 213 patients were included in the final analysis. Median time from extubation to BSE was 25 hours (interquartile range, 21-45 hours). The FEES was completed 1 hour after the BSE (interquartile range, 0.5-2 hours). A total of 33% (70/213; 95% CI, 26.6%-39.2%) of patients aspirated on at least one FEES bolus consistency test. Thin liquids were the most commonly aspirated consistency: 27% (54/197; 95% CI, 21%-34%). The BSE detected any aspiration with an accuracy of 52% (95% CI, 45%-58%), a sensitivity of 83% (95% CI, 74%-92%), and negative predictive value (NPV) of 81% (95% CI, 72%-91%). Using recursive partitioning analyses, a five-variable BSE-based decision tree algorithm was developed that improved the detection of aspiration with an accuracy of 81% (95% CI, 75%-87%), sensitivity of 95% (95% CI, 90%-98%), and NPV of 97% (95% CI, 95%-99%).

INTERPRETATION

The BSE demonstrates variable accuracy to identify patients at high risk for aspiration. Our decision tree algorithm may enhance the BSE and may be used to identify patients at high risk for aspiration, yet requires further validation.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT02363686; URL: www.clinicaltrials.gov.

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

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

COVID-19 pandemic. What should Physical and Rehabilitation Medicine specialists do? A clinician's perspective

COVID-19 pandemic is rapidly spreading all over the world, creating the risk for a healthcare collapse. While acute care and intensive care units are the main pillars of the early response to the disease, rehabilitative medicine should play an important part in allowing COVID-19 survivors to reduce disability and optimize the function of acute hospital setting. The aim of this study was to share the experience and the international perspective of different rehabilitation centers, treating COVID-19 survivors. A group of Physical Medicine and Rehabilitation specialists from eleven different countries in Europe and North America have shared their clinical experience in dealing with COVID-19 survivors and how they have managed the re-organization of rehabilitation services. In our experience the most important sequelae of severe and critical forms of COVID-19 are: 1) respiratory; 2) cognitive, central and peripheral nervous system; 3) deconditioning; 4) critical illness related myopathy and neuropathy; 5) dysphagia; 6) joint stiffness and pain; 7) psychiatric. We analyze all these consequences and propose some practical treatment options, based on current evidence and clinical experience, as well as several suggestions for management of rehabilitation services and patients with suspected or confirmed infection by SARS-CoV-2. COVID-19 survivors have some specific rehabilitation needs. Experience from other centers may help colleagues in organizing their services and providing better care to their patients.

The speech pathology workforce in intensive care units: Results from a national survey

BACKGROUND

Admission to the intensive care unit (ICU) with mechanical ventilation can lead to patients experiencing impaired swallowing and communication function. This can negatively affect patient experiences and outcomes. There is increasing research supporting early intervention for swallowing and communication; however, there are no published ICU workforce data to determine patient access.

PURPOSE

The purpose of this study was to describe national ICU access to speech pathology (SP) services and to describe the nature of this workforce.

METHODS

Prospective audit of Australian ICUs with a focussed workforce survey of SP service including workforce demographics, clinical practices, team environments, and training was conducted. Data are described as percentage (%, n) and as median (interquartile range). Qualitative data were analysed using thematic frameworks.

RESULTS

SP services were available at 99% (n = 165) of the sites; 62 sites provided workforce data (45% response rate). Seventy-one percent of respondents serviced the ICU ≤10 h per week, with 23% reporting dedicated funding. Almost a third (32%) reported not participating in ICU team activities, and more than half of the sites (56%) did not provide ICU-specific training with resulting varied clinical confidence ratings. Facilitator and barriers both highlighted team working relationships. Facilitator themes were building working relationships, understanding the SP role in the multidisciplinary team, physical presence in the unit, and access to resources. Barrier themes were the multidisciplinary team's understanding of SP roles and lack of presence of SP services in the ICU.

CONCLUSIONS

SP services are not standard across Australian ICUs, with variations in confidence, funding, training, and team environments. Further research into the impact of these variations on patient outcomes is needed.

The PhINEST study - Pharyngeal ICU Novel Electrical Stimulation Therapy: Study protocol of a prospective, multi-site, randomized, sham-controlled, single-blind (outcome assessor-blinded) study

INTRODUCTION

Post-extubation dysphagia is commonly observed in ICU patients and associated with increased aspiration rates, delayed resumption of oral intake/ malnutrition, prolonged ICU and hospital length of stay, decreased quality of life, and increased mortality. Conventional therapeutic approaches are limited. Pharyngeal electrical stimulation (PES) was previously shown to improve swallowing function and airway safety in severely dysphagic tracheostomised stroke patients.

METHODS

In a multi-center, single-blind, 1:1 randomized controlled study, up to 400 (360 evaluable) mixed emergency adult ICU patients with recent extubation following mechanical ventilation and confirmed oropharyngeal dysphagia will be enrolled at investigational academic ICUs. Primary objective is to evaluate the effectiveness of PES in reducing the severity of unsafe swallows. Patients will be randomized to receive PES (or sham) treatment on 3 consecutive days in addition to best supportive care. Primary endpoint is a composite of 2 endpoints with hierarchy based on clinical priorities: DISCUSSION:: This study will evaluate the effects of PES on swallowing safety in critically ill ICU patients post mechanical ventilation with oropharyngeal dysphagia.

Exploring Consistency and Variation in Fibreoptic Endoscopic Evaluation of Swallowing Practice in Australia

BACKGROUND

Fibreoptic endoscopic evaluation of swallowing (FEES) is an imaging technique used by speech-language pathologists (SLPs) and some other health professionals to assess swallowing.

OBJECTIVES

The primary aim was to gain an insight into FEES practices in Australia by characterising SLPs who use FEES and identifying areas of consistency and variation in practice. The secondary aim was to explore factors associated with variation in practice.

METHOD

Cross-sectional survey methodology was used. The link to a web-based survey was e-mailed to 351 SLPs who practised in adult dysphagia.

RESULTS

The participation rate for the study was 18.8% (n = 66). Twenty-two SLPs (38.6%) used FEES. These SLPs represented a cross-section of workplace settings, caseloads, clinical and training experiences. Consistency and variation in FEES procedural and assessment practices were identified. Some procedural aspects of FEES varied according to whether a medical practitioner was present, type of FEES training, and number of FEES conducted per month.

CONCLUSION

This research represents a benchmark in the knowledge of how FEES is used in Australia. Despite the small number of participants, the findings provide a foundation from which future research questions can be generated. More extensive examination of the use of FEES by SLPs is warranted. Further research is also required to establish methods for attaining and maintaining competency and to achieve consensus on which aspects of swallowing are assessed when using FEES and how the examination should be conducted.

Postextubation Dysphagia in Pediatric Populations: Incidence, Risk Factors, and Outcomes

OBJECTIVE

To assess incidence, risk factors for, and impact on outcomes of postextubation dysphagia. We hypothesized that the incidence of postextubation dysphagia in pediatric patients would approximate or exceed that in adults, that age and duration of intubation would increase odds for postextubation dysphagia, and that the presence of postextubation dysphagia would negatively impact patient outcomes.

STUDY DESIGN

We performed a retrospective, observational cohort study of patients aged 0-16 years admitted between 2011 and 2017. Patients were included if they were extubated in the intensive care unit and fed orally within 72 hours. Records were reviewed to determine dysphagia status and assess the impact of patient factors on odds of postextubation dysphagia. The impact of postextubation dysphagia on patient outcomes was then assessed.

RESULTS

Following application of inclusion and exclusion criteria, the sample size was 372 patients. Postextubation dysphagia was observed in 29% of patients. For every hour of intubation, odds of postextubation dysphagia increased by 1.7% (P < .0001). Age of <25 months increased odds of postextubation dysphagia more than 2-fold (P < .05). When we controlled for age, diagnosis, number of complex chronic conditions, and dysphagia status, patients with dysphagia had an increase in total length of stay of 10.95 days (P < .0001). Postextubation dysphagia increased odds of gastrostomy or nasogastric tube at time of discharge (aOR 22.22, P < .0001).

CONCLUSIONS

This study found that postextubation dysphagia is associated with increased time between extubation and discharge and with odds of gastrostomy or nasogastric tube at time of discharge.

Evaluation of Swallow Function Post-Extubation: Is It Necessary to Wait 24 Hours?

BACKGROUND

Post-extubation dysphagia is associated with an increased incidence of nosocomial pneumonias, longer hospitalizations, and higher re-intubation rates. The purpose of this study was to determine if it is necessary to delay swallow evaluation for 24 hours post-extubation.

METHODS

A prospective investigation of swallowing was conducted at 1, 4, and 24 hours post-extubation to determine if it is necessary to delay swallow evaluation following intubation. Participants were 202 adults from 5 different intensive care units (ICU).

RESULTS

A total of 166 of 202 (82.2%) passed the Yale Swallow Protocol at 1 hour post-extubation, with an additional 11 (177/202; 87.6%) at 4 hours, and 8 more (185/202; 91.6%) at 24 hours. Only intubation duration ≥4 days was significantly associated with nonfunctional swallowing.

CONCLUSIONS

We found it is not necessary to delay assessment of swallowing in individuals who are post-extubation. Specifically, the majority of patients in our study (82.2%) passed a swallow screening at 1 hour post-extubation.