Introduction
In the U.K. a recent report by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD 2014) examined acute tracheostomy management and highlighted the role of Speech and Language Therapists (SLT) in the critical care environment. However, there remains on-going issues with ‘gatekeepers’ of referrals to SLT services and the timing of involvement.
In the U.K. a recent report by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD 2014) examined acute tracheostomy management and highlighted the role of Speech and Language Therapists (SLT) in the critical care environment. However, there remains on-going issues with ‘gatekeepers’ of referrals to SLT services and the timing of involvement.
Some SLT services have set criteria for accepting referrals – when the patient is off ventilation, or the tracheostomy cuff is deflated, or when the patient is sitting upright. However, this misses a vital window of opportunity to get involved before problems start to have an impact. This may leave patients vulnerable in the very early stages, when our skills can facilitate the safe transition to tracheostomy cuff deflation and oral intake.
In July, I was invited to be the weekly Rotating Curator (RoCur) for the @WeSpeechies site and chose the subject of SLT management in Critical Care. This provided some interesting discussions with clinicians around the world and even more questions. It also offered the opportunity to review and share some relevant literature, which I have included here.
Dysphagia following extubation
There has been a flurry of recent publications that suggests a variety of factors contribute to dysphagia in the non-neurological caseload, with the aim of targeting these patients earlier and preventing poor consequences. A prospective study in patients requiring prolonged intubation with no pre-existing dysphagia (Scheel, Pisegna et al. 2015) revealed a high frequency of swallowing problems detected within 24 hours of extubation. The authors support early laryngeal assessment before oral intake is commenced.
Presence of tracheostomy and dysphagia
There is debate as to whether the presence of a tracheostomy causes disruption to the swallow or whether this is a pre-existing impairment worsened by the presence of a tracheostomy. A number of studies have tried to address this. Ding and Logemann (2005) retrospectively looked at 623 patients using VFS with the tracheostomy cuff up and down and reported reduced elevation and silent aspiration in those with the cuff inflated. Romero (2010) found that 38% of non-neurological patients had swallowing problems, resulting in delayed decannulation and an increased length of stay.
Tracheostomy cuff deflation
More recently Hernandez (2013) found that those patients who had their cuff deflated had reduced respiratory infections and improved swallowing. This supports the premise of early cuff deflation in order to re-engage laryngeal functions. For our cervical spinal cord jury patients we implement a laryngeal wean alongside their respiratory wean, whereby the cuff is deflated once ventilatory inspiratory pressures are low enough (approx. 12-15cm H2O) to allow comfortable expiratory airflow for sensitization of the larynx. This has the benefit of allowing phonation for speech and encourages swallowing of salivary secretions.
Sepsis and dysphagia
Sepsis is an increasing cause of ICU admission. A prospective study by Zielske (2014) compared thirty sepsis patients with controls. Each had a FEES at 14 days and 14 months and they found that 63% of those with sepsis showed aspiration compared to 23% of the control group. Mortality was also higher in the sepsis group – 61% compared to 19%. This group was also more likely to have tracheostomy and non-oral nutrition. Although sepsis may be unavoidable, anticipating and managing the consequent dysphagia may improve outcomes and is a valuable role for SLTs.
Optimizing nutrition
Nutrition is a very hot topic in the world of critical care with debates raging on whether feeding should be delayed or early in order to optimize patient outcomes. The trend towards delayed enteral feeding meant an increase in encouraging oral intake, however this view is adjusting with more long term data.
Chen, Lui et al. (2014) looked at the impact of nutrition and measured protein and serum albumin in 128 cervical spinal cord injury patients in the first two weeks in critical care. They found that changes to these levels were evident at days 3-5 which was an indicator for increased mortality. This strongly demonstrates the importance of early enteral feeding rather than waiting for patient to be ready to take oral intake, which often happens in critical care.
Critical illness polyneuropathy
Critical illness polyneuropathy is a recognized condition of many ICU patients. A prospective study by Ponfick, Linden at al (2015) used FEES to monitor swallowing function in 22 ICU patients at 3, 14 and 28 days. They report that 91% had a pathological swallow and 77% had altered (laryngeal) sensation. They suggest a ‘learned non-use’ with the failure of the oro-motor musculature being engaged for this period of time. To prevent this, I would suggest early intervention with short regular bursts to encourage facial and swallow movements to maintain motor and sensory functions.
Aspiration pneumonia
A paper that has really made me consider whether a few bouts of aspiration pneumonia in ICU is acceptable, is a retrospective case review by Failli, Kopp et al.(2012). They compared long term recovery of two groups of spinal cord injury patients – those with aspiration pneumonia or wound infections (n=581) and those without an infection (n=855). The results suggest that an early infection can cause a series of physiological consequences that can significantly reduce the ability to achieve optimum recovery at one year. This confirms the need for prevention of these infections through timely screening, informative assessments and effective therapeutic interventions.
There is also a range of tools to help reduce respiratory infections – subglottic suction tracheostomies, VAP care bundles, air mattresses. However it is often the case that patients will have experienced at least one aspiration pneumonia before referral to SLT, as doctors or nurses trial oral intake by feeding patients. It is only when they fail that our services get alerted and sometimes this does not happen at all.
Oral care
Much is written on the importance of regular mouth care in preventing ventilator associated pneumonia, however the compliance of nurses is still an on-going issue. Many of our patients who remain NBM (NPO) experience dry mouth, which is uncomfortable and makes talking difficult. Options to alleviate dry mouth include moistened mouth sponges and a range of mouth moisturising gels. Flavoured swabs are often used, however Grap (2003) has identified that although they do stimulate saliva production, they are often acidic, changing the pH of the mouth and harming teeth in addition to causing a rebound dry mouth. These should be avoided and products should be used that provide a neutral pH environment and contain enzymes that provide protection.
Conclusion
There are a variety of complications that give SLTs a mandate to intervene earlier and demonstrate that we have a clear role to play in the rehabilitation of all laryngeal functions. This has resource implication and services should be ready to address this through new business cases or skill mix, employing therapy assistants to provide daily or twice daily input to ensure the level of intensity drives change and improves clinical outcomes.
Links of Interest
References
- Chen, X., Z. Liu, T. Sun, J. Ren and X. Wang (2014). “Relationship between nutritional status and mortality during the first 2 weeks following treatment for cervical spinal cord injury.” J Spinal Cord Med 37(1): 72-78.
- Ding, R. and J. A. Logemann (2005). “Swallow physiology in patients with trach cuff inflated or deflated: a retrospective study.” Head Neck 27(9): 809-813.
- Failli, V., M. A. Kopp, C. Gericke, P. Martus, S. Klingbeil, B. Brommer, I. Laginha, Y. Chen, M. J. Devivo, U. Dirnagl and J. M. Schwab (2012). “Functional neurological recovery after spinal cord injury is impaired in patients with infections.” Brain: A Journal of Neurology 135(Pt 11): 3238-3250.
- Grap, M. J., C. L. Munro, B. Ashtiani and S. Bryant (2003). “Oral Care Interventions in Critical Care: Frequency and Documentation.” American Journal of Critical Care 12(2): 113.
- Hernandez, G., A. Pedrosa, R. Ortiz, M. Cruz Accuaroni Mdel, R. Cuena, C. Vaquero Collado, S. Garcia Plaza, P. Gonzalez Arenas and R. Fernandez (2013). “The effects of increasing effective airway diameter on weaning from mechanical ventilation in tracheostomized patients: a randomized controlled trial.” Intensive Care Medicine 39(6): 1063-1070.
- NCEPOD (2014). Tracheostomy Care: On the Right Trach?
- Ponfick, M., R. Linden and D. A. Nowak (2015). “Dysphagia—A Common, Transient Symptom in Critical Illness Polyneuropathy: A Fiberoptic Endoscopic Evaluation of Swallowing Study.” Critical Care Medicine 43: 365–372.
- Romero, C. M., A. Marambio, J. Larrondo, K. Walker, M. T. Lira, E. Tobar, R. Cornejo and M. Ruiz (2010). “Swallowing dysfunction in nonneurologic critically ill patients who require percutaneous dilatational tracheostomy.” Chest 137(6): 1278-1282.
- Scheel, R., J. M. Pisegna, E. McNally, J. P. Noordzij and S. E. Langmore (2015). “Endoscopic Assessment of Swallowing After Prolonged Intubation in the ICU Setting.” Ann Otol Rhinol Laryngol.
- Zielske, J., S. Bohne, F. M. Brunkhorst, H. Axer and O. Guntinas‐Lichius (2014). “Acute and long‐term dysphagia in critically ill patients with severe sepsis: results of a prospective controlled observational study.” Eur Arch Otorhinolaryngol 271: 3085–3093.
