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