Cynthia D. Hildner, MS, CCC-SLPNorthern Illinois University

Kathryn O’Sullivan, MA, CCC-SLP

Lee M. Akst, MDLoyola University Medical Center, Maywood, Illinois

ASHA 2008 Hildner, O'Sullivan, Akst

After this presentation we hope that you will be able to:

Differentiate the needs of patients requiring ICU admission.What medically defines critical illness?

Indentify and interpret equipment used for pt monitoring in an ICU setting.

Describe abnormal physiologic parameters that may complicate or preclude the BSSE or resumption of oral intake.

ASHA 2008 Hildner, O'Sullivan, Akst

Prevalence of dysphagia in ICU

There is no comprehensive, clear data related to prevalence of dysphagia in ICU

Limited data exist for: Cervical spinal cord injury (Wolf, Meiners 2003)

○ 80% (N = 51) patients had dysphagia Trauma (Leder, Cohn, Moller 1998)

○ Incidence of aspiration 45% following extubation in critically ill trauma patients

44% of these had SILENT aspiration Stroke (Mann & Hankey 2001)

○ 42-60% of stroke patients (median 3 days post stroke)

ICU Landscape

Equipment Monitor Vent-mask Non-Rebreather Mask

(NRB) Bi-PAP, C-PAP Ventilator LVAD/Heartmate Dialysis machine Apheresis machine

Line and tubes PICC Cordis catheter Chest tube Balloon pump Dialysis port/catheter Hickman line Triple lumen Jackson-Pratt drain

ASHA 2008 Hildner, O'Sullivan, Akst

ICU: Acute vs. Chronic

Acute – new condition affecting homeostasisTrauma, recent surgery, acute infection, etc.More often SICU

Chronic – decompensation of existing illness requiring ICU careCOPD exacerbation with intubationCHF with fluid overloadMore often MICUMore often aged, with other comorbidity

Co-morbidities

As difference between acute and chronic reveals, pre-ICU functional status of the patient is critically important

Dysphagia in the ICU involves 2 things:Changes in swallowing created by ICU setting

○ Patient factors – why the patient is in the ICU○ ICU factors – impact of tubes, etc

Ability of the patient to compensate for those changes

Feeding Tubes – The Good ICU patients have high metabolic needs

Require nutrition for proper healing

Can be meet with Enteral or Parenteral nutritionEnteral – via GI tract – PO, NGT, PEGParenteral – via circulation – TPN, PPN

Feeding Tubes – The Bad

“Aspiration is the most feared complication of enteral tube feeds”

Do nasogastric tubes cause aspiration? Do nasogastric tubes cause dysphagia? How

NGT cause aspiration: PEG as alternative to NGT

Feeding Tubes – The Ugly Nasogastric tube syndrome

Post-cricoid tube leads to mechanical irritation of the posterior cricoarytenoid muscles bilateral TVC paralysis

Paralytic dysphoniaInability to close glottis aspirationTreatment is PEG tubeRare but real condition

Tracheal Tubes – The Good Breathing is good

Assisted ventilation for respiratory failure (most common reason, especially in MICU)

Stabilize pulmonary situation if patient might have cardiopulmonary instability (eg, remaining intubated after lengthy surgery)

Bypass upper airway obstructionHyperventilation to diminish cerebral edema

Pulmonary toiletteEasier with tracheotomy than ETT

Tracheal Tubes – The Bad Endotrachal tubes can impair swallowing Aspiration – difficult to estimate incidence Ventilator associated pneumonia Decreased sensation cont. post-extubation Muscle atrophy: larynx, pharynx, tongue, BOT Respiratory fatigue, decreased cough Direct trauma to larynx with decreased closure Disrupts swallowing coordination Role of subglottic pressure

Tracheal Tubes – The Ugly “The Ugly” = permanent damage

Permanent damage from prolonged intubation occurs as a pressure-induced injury

Injuries vary in severity and manifest differently

Changes may be acute or chronic

Special Populations Information regarding other populations will assist in

one’s confidence in varied ICU settings Bone Marrow Transplant/Oncology Burn Lung Transplant Cardiovascular surgery Elderly

Associated conditions PulmonaryImmunosuppression Mucositis

○ Oral care issues Mucosal injury Vocal fold paralysis and aspiration Pneumonia risk factors

ASHA 2008 Hildner, O'Sullivan, Akst

How do we make dysphagia management decisions regarding critically ill patients? Consider

Pt readiness for evaluation○ Know your patient

Evaluation type○ Have a paradigm for work-up

Risk factors Suggestions

Delay oral feeding in pts with prior hx of aspiration Reduce risk of pulmonary complications Consider co-morbidities Implement dysphagia exercises: “strength training”

Teamwork – Multidisciplinary Approach

Cynthia D. Hildner, MS, CCC-SLP childner@niu.edu

Northern Illinois University , DeKalb, Illinois

Kathryn O’Sullivan, MA, CCC-SLP kosullivan@lumc.edu

Loyola University Medical Center, Maywood, Illinois

Lee M. Akst, MD

Director of Laryngology,

Department of Otolaryngology Head and Neck Surgery

Loyola University Medical Center, Maywood, Illinois

ASHA 2008 Hildner, O'Sullivan, Akst

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