Clinical Decision Making in Dysphagia Management for ...

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.


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


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


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 [email protected]

Northern Illinois University , DeKalb, Illinois

Kathryn O’Sullivan, MA, CCC-SLP [email protected]

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


References Atkins BZ, Trachtenberg MS, Prince-Petersoen R, Vess G, Bush EL,

Balsara KR, Lin SS, Davis RD Jr. (2007) Assessing oropharyngeal dysphagia after lung transplantation: altered swallowing mechanisms and increased morbidity J Heart Lung Transplant; 26(11):1144-8.

Barquist, Erik MD; Brown, Margaret MSN; Cohn, Stephen MD; Lundy, Donna CCC; Jackowski, Julie RN (2001) Postextubation fiberoptic endoscopic evaluation of swallowing after prolonged endotracheal intubation: A randomized, prospective trial. Critical Care Medicine. 29(9):1710-1713.

Burkhead LM, Sapienza CM, Rosenbek JC (2007) Strength-Training Exercise in Dysphagia Rehabilitation: Principles, Procedures, and Directions for Future Research Dysphagia 22:251-265.

Clanton, N, Kennedy, P (2007) Management of Dysphagia in Toxic Epidermal Necrolysis (TEN) and Stevens-Johnson Syndrome (SJS). Dysphagia. 22(3): 187-92

deLarminat V, Montravers P, Dureuil B, Desmonts J-M (1995). Alteration in swallowing reflex after extubation in intensive care patients. Crit Care Med 23:486-490.


Ding, R & Logemann J. (2000) “Pneumonia in stroke patients: a retrospective review.” Dysphagia 15:51-57.

Easterling CS, Bousamra M, Lang IM, Kern MK, Nitschke T, Bardan E, Shaker R. (2000) Pharyngeal Dysphagia in Postesophagectomy Patients: Correlation With Deglutitive Biomechanics. Annals of Thoracic Surgery. 69:989-92

Elpern EH. Nutr Clin Pract 1997; 12:5-13 El Solh A. Okada M. Bhat A. Pietrantoni C. (2003) Swallowing disorders post

orotracheal intubation in the elderly. Intensive Care Medicine. 29(9):1451-5. Epstein J. Mucositis in the Cancer Patient and Immunosuppressed Host.

Infectious Disease Clinics of North America Ferraris VA, Ferraris SP, Moritz DM, Welch S. (2001) Oropharyngeal

Dysphagia After Cardiac Operations. Annals of Thoracic Surgery. 71: 1792-6.

Gross RD et al. Ann Otol Rhinol Laryngol 2003; 112:143-152


Hafner G, Neuhuber A, Hirtenfelder S, Schmedler B & Eckel HE (2008) Fiberoptic endoscopic evaluation of swallowing in intensive care unit patients. Eur Arch Otorhinolaryngol (2008) 265:441-446

Harrington OB, Duckworth JK, Starnes CL, White P, Fleming L, Kritchevsky SB, Pickering R. (1998). Silent Aspiration After Coronary Artery Bypass Grafting. 65:1599-603

Hogue CW, Lappas GD, Creswell LL, Ferguson TB, Sample M, Pugh D, Balfe D, Cox JL, Lappas DG (1995) Swallowing Dysfunction After Cardiac Operations. Journal of Thoracic Cardiovascular Surgery. 110:517-22.

Huggins PS, Tuomi SK, Young C (1999) Effects of nasogastric tubes on the young, normal swallowing mechanism Dysphagia. 14:157-161

Keefe DM, Schubert MM, Elting LS, Sonis ST, Epstein JB, Raber-Durlacher JE, Migliorati, CA, McGuire DB, Hutchins RD, Peterson DE. (2007) Updated Clinical Practice Guidelines for the Prevention and Treatment of Mucositis. Cancer 109(5): 820-831.

Langmore S, Terpenning M, Schork A, Chen Y, Murray J, Lopatin D, Loesche W(1998) Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia, 13: 69-81


Langmore S, Skarupski KA, Park PS, Ries BE. (2002) Predictors of aspiration pneumonia in nursing home residents. Dysphagia, 17: 298-307

Leder SB, Cohn SM, Moller BA. (1998) Fiberoptic endoscopic documentation of the high incidence of aspiration following extubation in critically ill trauma patients. Dysphagia 13:208-212.

Leder SB, Ross DA. (2005) Incidence of Vocal Fold Immobility in Patients with Dysphagia. Dysphagia 20:63-67.

Leder SB. (1999) Fiberoptic Endoscopic Evaluation of Swallowing in Patients with Acute Traumatic Brain Injury. Journal of Head Trauma Rehabilitation. 14(5):448-453.

McClave S, Dryden G. (2003) Semin GI Dis. 14:2-10 Mann G & Hankey GJ (2001) Initial clinical and demographic predictors of

swallowing impairment following acute stroke. Dysphagia 16(3): 2008-15. Marik, P, Kaplan, D, (2003) Aspiration Pneumonia and Dysphagia in the

Elderly. Chest. 124:328-336.


McCullough GH. (2006) Zen and the art of swallowing maintenance: best evidence, best practice. ASHA Special Interest Division 13 National Newsletter

Murray J. (2008) Frailty, functional reserve, and sarcopenia in the geriatric dysphagic patient. Perspectives on Swallowing and Swallowing Disorders (Dysphagia) 17 3-11.

Muz J, Hamlet, R Mathog, R Farris (1994) Scintiigraphic assessment of aspiration in head and neck cancer patient with tracheostomy. Head Neck 16:17-20

Padovani AR, Furquim de Andrade CR. (2007) Einstein 5(4): 358-362 (online article)

Partik B, Pokieser P, Schima W, Schober E, Stadler A, Eisenhuber E, Denk D and Lechner G (2000) Videofluoroscopy of swallowing in symptomatic patients who have undergone long-term intubation. Am J Roent; 174:1409-1412

Ramsey D, Smithard D, Kalra Lalit (2005) Silent aspiration, what do we know. Dysphagia 20:218–225


Robbins, J, Gangnon RE, Theis SM, Kays SA, Hewitt AL, Hind JA (2005) The Effects of Lingual Exercise on Swallowing in Older Adults JAm Ger Soc: 53 (9): 1483-1489

Rousou, JA, Tighe DA, Garb JL, Krasner H, Engelman RM, Flack JE, Deaton DW. (2000) Risk of Dysphagia After Transesophageal Echocardiography During Cardiac Operations. Annals of Thoracic Surgery. 69:486-90

Schindler A, Vincon E, Grosso E, Mietto AM, DiRosa R Schindler O. (2008) 23: 230-236 Rehabilitative management of oropharyngeal dysphagia in acute care settings: data from a large Italian teaching hospital. Dysphagia 23:230-236.

Sasaki C et al. Trans Am Acad Opthal Otol 1973; 77:403-10 Sellars C, Dunnet C, Carter R. (1998) A preliminary comparison of

videofluoroscopy of swallow and pulse oximetry in the identification of aspiration in dysphagia patients. Dysphagia. 12:82-86


Setzen M. (2003) The association between laryngopharyngeal sensory deficits, pharyngeal motor function, and the prevalence of aspiration with thin liquids. Otolaryngology - Head and Neck Surgery , Volume 128 , Issue 1 , Pages 99 - 102.

Shaker , R, Milbrath M, Ren J, Campbell B, Toohill R. Hogan W. (1995) Deglutitive aspiration in patients with tracheostomy: Effect of tracheostomy on the duration of vocal cord closure. Gastroenterology , Volume 108 , Issue 5 , Pages 1357 – 1360

Spielberger R, Stiff P, Bensinger W, Gentile T, Weisdorf D, Kewalramani T, Shea T, Yanovich S, Hansen K, Noga S, McCarty J, LeMaistre, Sung EC, Blazar BR, Elhardt D, Chen M, Emmanouilides C (2004) Palifermin for Oral Mucositis after Intensive Therapy for Hematologic Cancers. New England Journal of Medicine. 351:2590-8.

Stiff, P. (2001) Mucositis associated with stem cell transplantation: current status and innovative approaches to management. Bone Marrow Transplantation. 27, Supp, S3-S11

Wang TG et al. Arch Phy Med Rehab 2006; 87:1270-1273 Wolf C, Meiners TH (2003) Dysphagia in patients with acute cervical spinal cord

injury. Spinal Cord. 41, 347-353.


Clinical Decision Making in Dysphagia Management for ...

Documents

Transcript of Clinical Decision Making in Dysphagia Management for ...