Dysphagia Management in
ADULT Critical care
SCSHA 60th 2018 Conference
Myrtle Beach, South Carolina
Carley Eason Evans MS CCC SLP
Medical University of South Carolina
Disclosures
I am employed full time as a medical speech language pathologist at the Medical University of South Carolina. I receive a salary.
I have no non-financial disclosures.
Outline
Critical care/intensive care settings
Post-extubation dysphagia (PED)
Challenges for swallow assessment in critical care
Three Ounce Water Swallow Test & EAT-10
What I do
ICU Patients
Evaluation approaches
Therapy approaches
Published Swallow Screens for Stroke (time permitting)
Conclusion
Introduction
Incidences in Intensive Care
700,000 persons with acute respiratory failure per year in USA
3% to 62%, who require endotracheal intubation and who survive, have dysfunctional swallowing after extubation
In one retrospective study, dysphagia was present in 84% of patients who had been on mechanical ventilation (excluding stroke/neuromuscular disorders)
Actual incidence of post-extubation dysphagia has not been effectively determined
Mortality rate = 35% so > 400,000 survivors each year
ARF Survivors
Median survival duration of more than 5 years
Continue to suffer from:
Pulmonary dysfunction – generally mild, extends to >5 years
Cognitive impairment – memory, attention, processing speed, executive functioning, visuo-spatial skills, up to 6 years
Decreased quality of life – depression, PTSD, anxiety, >5 years
Neuromuscular dysfunction – slow recovery, up to 5 years
Under-recognized = swallowing dysfunction
Aspiration, pneumonia, malnutrition, placement of feeding tubes, decreased quality of life, increased institutional care, and increased mortality
Macht, M. et al., Postextubation Dysphagia is persistent and associated with poor outcomes in survivors of critical illness. Critical Care, 2011, 15:R231.
Needham,D. et al. Improving long-term outcomes after discharge from intensive care unit: Report from a stakeholders’ conference. Crit Care Med 2012 40: 2, 502-509.
Persistent Post-Extubation Dysphagia
Retrospective, observational cohort study of patients (over 17 years of age) in university hospital ICU between 2008 and 2010 who required mechanical ventilation and subsequently underwent BSE by SLP
Sample size = 446 (excluded stroke/neuromuscular disease) or 25% of total number of patients in ICU. (2,484)
Dysphagia present in 84% of patients tested by SLP [Only 11 (2.5%) of the 446 study patients underwent MBSS in addition to BSE]
Absent dysphagia (normal) = 16% (72)
Mild = 44% (195)
Moderate = 23% (103)
Severe = 17% (76)
Macht et al. Critcal Care 2011, 15:R231.
Post-Extubation Dysphagia
Moderate to severe post-extubation dysphagia - independently associated with composite outcome of pneumonia, reintubation and death
Risk factors for severe post-extubation dysphagia included:
Long duration of mechanical ventilation (more than 7 days associated with moderate to severe post-extubation dysphagia) after adjusting for severity of illness, age and gender
Reintubation
Other statistically significant risk factors for severe dysphagia:
Male gender
Tracheostomy
Reduced laryngeal elevation
Reduced laryngeal sensation
Reduced subglottic pressure
Diminished cough effectiveness
Belafsky et. al The Accuracy of the Modified Evans’ Blue Dye Test in Predicting Aspiration. The Laryngoscope 113: November 2003. p 1969-1972.
Multiple Factors in Post-Extubation Dysphagia
Effects of endotracheal tube
Neuromuscular weakness
Altered sensorium – sedation, confusion
Suspected Factors Dysphagia in Critical Illness
Endotracheal tube
Direct trauma from tube placement and presence
Focal ulceration and/or inflammation
Damage to vocal cords
Arytenoid dislocation, impaired glottis closure during swallow
Formation of granulation tissue, granulomas
Scarring, tracheal stenosis, obstruction
Impaired swallowing reflex/responsiveness after extubation
Compression of recurrent laryngeal nerve by cuff ipsilateral vocal cord paralysis
Cuff situated too high compressing nerve between cuff and thyroid cartilage
Arytenoid Dislocation
•Right arytenoid dislocation/subluxation
•Occurred during difficult intubation
•Resulted in:
•Hoarseness
•Vocal fatigue
•Stridor
•Dysphagia
•Odynophagia
•Sore throat
Granuloma
•Can develop up to 8 weeks after extubation
•Can be bilateral or unilateral
•If bilateral and on vocal processes, can adhere and heal together, causing airway obstruction
•50% of granulomas resolve spontaneously
Co-Morbidities of PED
Tracheostomy tube
Interruption of normal airway
Neuromyopathy (triggered by sepsis, multi-organ failure, SIRS)
Disuse atrophy from infrequent swallowing
Critical illness polyneuropathy
Reduced pharyngeal and laryngeal sensation
Decreased cough strength
Reduced glottis clearance
Kim et al. Associations Between Prolonged Intubation and Developing Post-Extubation Dysphagia and Aspiration Pneumonia in Non-neurologic Critically-Ill Patients. Ann Rehab Med 2015; 39(5): 763-771.
PED
Impaired sensorium/altered mental status
GERD, other GI issues
n/v, SBO, GI bleed, pancreatitis, esophageal issues, gastritis, gastroparesis
Mistiming of breathing and swallowing due to underlying respiratory impairment
COPD – with increased RR, apneic period shortens; laryngeal opening can happen prior to bolus passing through PES into esophagus
Tachypnea/hypoexemia – known to aspirate more frequently; have less reserves to handle gas exchange abnormalities that occur with aspiration
Major Complications of Dysphagia
Aspiration
Pneumonia (during hospitalization)
Reintubation
Surgical placement of feeding tube
Increased length of hospital stay
Increased hospital mortality
Increased cost (estimated to be over $500 million annually in 2013)
So, given all this, what do we do?
No widely accepted (valid, reliable)
swallow screen/evaluation
Challenge for ICU MDs and RNs
No reliable, validated swallow screen for patients in ICU
Only 41% of hospitals routinely screen extubated patients for dysphagia
Challenge for ICU SLPs
No reliable, validated swallow evaluation for patients in ICU
BSE has been criticized for poor sensitivity and poor inter and intra-rater reliability
BSE is the sole evaluation in 60% of cases nationwide!
95% of hospitals have access to videofluoscopy (MBSS or VFSS)
Screen vs. Test
Three Ounce Water Swallow Test
Administration - quick and easy
Present 3 ounces of water in a cup, ask patient to drink all of the water without stopping
Watch for signs of difficulty during as well as for one minute after swallowing
Stopping
Leaving any amount in cup
Throat clearing behavior, eyes watering, increased work of breathing, significant drop in oxygen saturation
Coughing
Three Ounce Water Swallow
If passed, indicates no further need for swallowing assessment, may initiate oral diet
If failed, does NOT mean that the patient has swallowing disorder
High false positive rate is known to result in over-referral to speech pathology
Suiter, Debra M. & Leder, Steven B. Clinical Utility of the 3-ounce Water Swallow Test. Dysphagia (2008) 23:244-250.
EAT-10
Simple self-reporting questionnaire (cut off score = or > 3)
In patients with COPD, sensitivity = 92%, specificity = 78% (with cut off score of 8)
High negative predictive value (in COPD) = 93%
Strongly excludes risk of aspiration
Particularly useful as a screening tool (in COPD)
In general dysphagia populations (with cut off of 3)
Sensitivity of presence of aspiration = 83%, specificity = 25%
In ALS patients (with cut off score of 8)
Sensitivity = 86%, specificity = 72%
Regan et al. The Eating Assessment Tool-10 Predicts Aspiration in Adults with Stable Chronic Obstructive Pulmonary Disease. Dysphagia (2017) 32: 714-720.
Eating Assessment Tool – EAT-10
Clinical Evaluation of Swallowing (CES)
– What I Do
Chart review – especially appropriateness for PO re: gut status
Discussion with RN
Interview of patient and family as feasible
Level of alertness, ability to follow simple commands, basic orientation*
Oral Mechanism Examination
Posterior pharyngeal wall sensation
Oral care/stimulation
Moist swabs
Ice chips - single
*Orientation / Command Following
Orientation
What is your name?
Where are you right now?
What year is it?
Verbal Single-Step Command Following
Open your mouth
Stick out your tongue
Smile
Results
31% greater liquid aspiration if not oriented
57%, 48%, 69% greater liquid aspiration, puree aspiration or deemed unsafe for PO intake, respectively if unable to follow simple commands
Leder, S. and Suiter, D. Answering Orientation Questions and Following Single-Step Verbal Commands: Effects on Aspiration Status. Dysphagia 24(3) 290-295. April, 2009.
CES – PO Trials
Teaspoons of water x 5
Cup sip, straw sip
Cup drinking, straw drinking
3 ounce water swallow
______
Pudding x 3 teaspoons
Graham cracker
Fruit (small or large bite peaches, pears, pineapple)
Liquid wash by cup drinking or straw drinking
Observation
Observe responses
(maintaining high degree of suspicion for silent aspiration)
Oral receipt
Oral containment
Oral preparation
Oral transit
Oral clearance
Presence and timeliness of swallow
Number of swallows (oral/pharyngeal clearance)
Appearance of hyo-laryngeal excursion
Quality of voice before/after swallow each consistency
Vital signs before/during/after swallowing of each consistency
Timing of throat clearing behaviors/coughing if any – immediate/delayed
Strength of cough, weak, non-productive, strong, productive
BDT with Trach/Vent
First, PMSV either on hub of trach or inline with ventilator
Add blue food coloring to:
Ice chips
Water
Pudding (use chocolate)
Same observations as CES
Remove valve between consistencies, cue cough or have RT/RN perform sterile suctioning
Observe at least 20 minutes
Positive result – aspiration
Negative result – likely MBSS or FEES
Decisions
Based on observations and history of each individual patient, decide:
NPO or PO?
If NPO, MBSS now or later?
MBSS: visual evidence of aspiration has been significantly associated with the development of pneumonia in mixed group of patients
If PO, which consistency?
Impression of ability to sustain hydration/nutrition orally, defer to RD
Level of supervision?
How many times a week? And how long to follow?
Which, if any, exercises? Why? Why not?
Education of patient, family (health literacy)
Communication with MD, RD, RN
MSICU & CVICU Patients
MSICU
Necrotizing pancreatitis
GI bleed, small bowel obstruction
SIRS
Acute Respiratory Failure
Leukemia
Liver failure
Renal failure
CVA (ocassionally)
CVICU
Congestive heart failure
MI
Aortic valve replacement/repair
LVAD
Respiratory distress/failure
Cardiomyopathy
Embolic infarcts (ocassionally)
CMV Viremia
66 yo male admitted with Cytomegalovirus (CMV*) viremia.
CMV pneumonitis with hypoxia early in hospital stay
Complicated medical history including:
Liver transplant the previous year for nonalcoholic steatohepatitis (NASH)
Subsequent post-transplant heart failure
Sinusitis
Facial pain
Diarrhea
Past medical history also includes:
Barrett’s esophagus (normal lining replaced by tissue similar to intestinal lining)
Obstructive sleep apnea
Diabetes
*CMV
Common virus related to viruses that cause herpes, chickenpox, mononucleosis
Usually lies dormant in the body
Usually asymptomatic
With weakened immune system, complications include:
Vision loss, due to inflammation of the light-sensing layer of the eye (retinitis)
Digestive system problems, including inflammation of the colon (colitis), esophagus (esophagitis) and liver (hepatitis)
Nervous system problems, including brain inflammation (encephalitis)
Pneumonia (in this patient’s case, initially pneumonitis – inflammation of walls of the alveoli)
Clinical Evaluation
On a regular diet, tray at bedside, positioned out of bed
Normal OME; alert, cooperative (seen on a Saturday)
Tested all consistencies; coughed productively only with pudding bolus
Also failed 3 ounce water swallow by stopping and restarting, no other signs of aspiration
Patient and his wife denied difficulty during and after PO intake
Recommended continue regular diet which he had been on since his admit 10 days earlier, monitor respiratory status
Consider MBSS first available
Two days later
No MBSS orders; still on regular diet
Throat clearing behaviors throughout session, prior to and after PO intake
Reportedly did “fine” with sub sandwich and thin liquids at lunch that day
At end of session, spouse of patient reported that inconsistent coughing by patient has been observed with meals
Recommendations: Continue regular, perform MBSS for further assessment of swallowing function
Two days later MSICU
Now in MSICU (R middle lobe pneumonia) after MET for hypoxia, tachypnea
MD requesting re-evaluation
After chart review, SLP suggested NPO, alternative nutrition
High RR and reduced LOA noted at bedside re-evaluation, no PO trials
MBSS when able to participate
Next day, NPO with DHT, on CPAP and not appropriate for MBSS
Following day, MBSS completed when patient transferred off unit
Prior to Prolonged Intubation
Overall Impression
Decisions via MBSImp
Recommended modified dysphagia diet with nectar thick liquids
Cued bolus hold and chin tuck
Additional swallows, effortful
No straws
Upright positioning; remain upright post-prandial
Cued cough = productive but has to be cued
Downgrade MSICU
RN reporting coughing with nectar thick liquids (which he did penetrate on during MBSS when using a straw)
SLP recommended downgrade of diet to modified dysphagia with honey thick liquids
Repeat MBSS in 5-7 days
That afternoon, transferred to MSICU for tachypnea, intubated
Extubated 15 days later
Re-Evaluation
Now with severe post-extubation dysphagia (PED)
Limited oral receipt
Aphonic to severely dysphonic
Moist swabs only, biting swab
Gurgly (wet) voice when audible
NPO, oral care, suck swallow, expectoration maneuver recommended
Swallow therapy 2-5 x weekly (for suspected disuse atrophy)
Oral and posterior pharyngeal wall stimulation
Oral care
Suck swallow
Limited ice and teaspoons of water, sometimes thickened
Chin tuck against resistance, effortful swallow
Tracheostomy/Ventilator Dependent
Two days later, underwent tracheostomy, on ventilator
Chest CT progression of CMV disease
Holding SLP therapy
Beginning transition to comfort care with family
Passed away 10 days later
SLP orders canceled the day prior to patient’s death
MBSS vs BSE
Is it ever appropriate to “skip” the bedside swallow evaluation?
Example: After chart review, discussion with RN:
78 yo male with PMH of acute myeloid leukemia (AML), GERD, a-fib with chemically-induced cardiomyopathy presents first to OSH with concern for hospital/community acquired pneumonia with neutropenia
Presents with syncope, dehydration, productive cough, high WBC (>50)
CXR at OSH = R infiltrate with bilateral patchy opacities
On admit, no diet order, then next day (admit day #2) placed on modified dysphagia diet with honey thick liquids (without SLP intervention?)
Three days later, advanced to regular diet without SLP intervention (admit day # 5)
Three days later SLP Consult received, reviewed chart, spoke with RN who indicated patient is “having trouble swallowing his pills.” (admit day # 7)
Noted as well, limited PO intake, 300 mls admit day #5, 400 mls admit day #6.
Requested MBSS; recommended consider NPO until completed
MBSS
MBSS
Masticated cookie without bolus transport; pudding bolus in pharynx from previous administration.
MBSS
Immediately prior to MBSS, while undergoing portable chest x-ray, consistently coughing, productive.
Did not cough during swallow study; cleared throat several times.
Talked intermittently throughout, asking for applesauce.
With self-administration of thins and nectar thick liquids by cup, taking less than 3ml.
Did not swallow pudding or cookie (after mastication); both fell out of his oral cavity several minutes after the study despite cues to expectorate. Oral suctioning was available, but not used.
Retrograde flow through PES noted with honey-thick liquids.
No penetration or aspiration at any time.
Conclusion = at high risk for malnutrition, aspiration after swallow.
Next Day
Transferred to ICU overnight
Seen with his wife who expressed desire for her husband to continue to eat cream of wheat and/or oatmeal
“That’s what he’s been living on” for several months
Positioned upright in bed with the following PO trials:
Teaspoons of water
Cup sips of water
Cup drinking water
Nectar thick water by teaspoon
Pudding by 1 of 3 planned teaspoons
Large bite peaches/pears
Liquid wash
Results
Marked talking throughout despite cues
Oral residue with all items, especially pudding, peach, and pear
Prolonged and disorganized oral preparation and transit
Pharyngeal swallow appeared delayed and at times, absent
Wet, non-productive coughing after all presentations, usually delayed
No cough between PO presentations
Unlike on MBSS, bolus sizes were “normal”
Attempted suck-swallow, unable to focus his attention
Recommended NPO, but his wife wanted him to eat
If PO was allowed, recommended teaspoons of thins and small bites of purees; IV medications if feasible
New Event
Over the weekend, a BAT was called 2* suspected CVA with new R facial droop and marked lethargy.
No acute stroke on imaging.
NGT was placed, presumably 2* patient being made NPO again.
Speech received new orders.
This gentleman passed away before our re-assessment with palliative care assisting family in transition to comfort care.
Acute Respiratory Failure
74 yo F with PMH hypertension and lung cancer (2008, s/p radiation RUL & partial R lobectomy), and chronic lung scarring due to emphysema.
Found down on floor after 3 days, rhabdomyolysis, dehydration
To OSH with white out of R lung, obstructed R main stem bronchus, coffee-ground emesis with aspiration pneumonia in late December, 2017. NGT was set to suction.
Arrived to MUSC sedated/intubated.
Extubated admit day # 7 (after several bronchoscopies with dilations)
Speech consulted; initial evaluation in CVICU on day #8
Rhabdomyolysis
Rapid breakdown of damaged skeletal muscle
Many causes: including severe dehydration
Releases protein into bloodstream which when filtered by kidneys, damages kidneys kidney failure
Causes muscle pain, weakness, swelling, dark urine, fatigue, confusion, irregular heartbeat
CES in CVICU
Edentulous
Some intra-labial escape
Slow bolus manipulation/transit
Did not test mashing/mastication
No oral residue
Laryngeal elevation APPEARED reduced
One to two swallows per bolus
No complaints of esophageal dysphagia
Observed gurgly voice, throat clearing, cough, and desaturation with thin liquid (water) and with applesauce (*pudding)
Recommendation: NPO x teaspoons of water, effortful swallow
Next 4 days
After SLP evaluation, switched from NC to high flow NC; then, requiring BiPAP 2* desaturations, holding therapy.
When off BiPAP, during swallow therapy, appeared to be having marked difficulty managing her own saliva. Very wet cough, weak, intermittently productive