Clinical Decision Making in Dysphagia Management for ...

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Clinical Decision Making in Dysphagia Management for ...

  1. 1. Cynthia D. Hildner, MS, CCC-SLP Northern Illinois University Kathryn O’Sullivan, MA, CCC-SLP Lee M. Akst, MD Loyola University Medical Center, Maywood, Illinois
  2. 2. After this presentation we hope that you will be able to: <ul><ul><li>Differentiate the needs of patients requiring ICU admission. </li></ul></ul><ul><ul><ul><li>What medically defines critical illness? </li></ul></ul></ul><ul><ul><li>Indentify and interpret equipment used for pt monitoring in an ICU setting. </li></ul></ul><ul><ul><li>Describe abnormal physiologic parameters that may complicate or preclude the BSSE or resumption of oral intake. </li></ul></ul>ASHA 2008 Hildner, O'Sullivan, Akst
  3. 3. Prevalence of dysphagia in ICU <ul><li>There is no comprehensive, clear data related to prevalence of dysphagia in ICU </li></ul><ul><li>Limited data exist for: </li></ul><ul><ul><li>Cervical spinal cord injury (Wolf, Meiners 2003) </li></ul></ul><ul><ul><ul><li>80% (N = 51) patients had dysphagia </li></ul></ul></ul><ul><ul><li>Trauma (Leder, Cohn, Moller 1998) </li></ul></ul><ul><ul><ul><li>Incidence of aspiration 45% following extubation in critically ill trauma patients </li></ul></ul></ul><ul><ul><ul><ul><li>44% of these had SILENT aspiration </li></ul></ul></ul></ul><ul><ul><li>Stroke (Mann & Hankey 2001) </li></ul></ul><ul><ul><ul><li>42-60% of stroke patients (median 3 days post stroke) </li></ul></ul></ul>ASHA 2008 Hildner, O'Sullivan, Akst
  4. 4. ICU Landscape <ul><li>Equipment </li></ul><ul><li>Monitor </li></ul><ul><li>Vent-mask </li></ul><ul><li>Non-Rebreather Mask (NRB) </li></ul><ul><li>Bi-PAP, C-PAP </li></ul><ul><li>Ventilator </li></ul><ul><li>LVAD/Heartmate </li></ul><ul><li>Dialysis machine </li></ul><ul><li>Apheresis machine </li></ul><ul><li>Line and tubes </li></ul><ul><li>PICC </li></ul><ul><li>Cordis catheter </li></ul><ul><li>Chest tube </li></ul><ul><li>Balloon pump </li></ul><ul><li>Dialysis port/catheter </li></ul><ul><li>Hickman line </li></ul><ul><li>Triple lumen </li></ul><ul><li>Jackson-Pratt drain </li></ul>ASHA 2008 Hildner, O'Sullivan, Akst
  5. 5. ICU: Acute vs. Chronic <ul><li>Acute – new condition affecting homeostasis </li></ul><ul><ul><li>Trauma, recent surgery, acute infection, etc. </li></ul></ul><ul><ul><li>More often SICU </li></ul></ul><ul><li>Chronic – decompensation of existing illness requiring ICU care </li></ul><ul><ul><li>COPD exacerbation with intubation </li></ul></ul><ul><ul><li>CHF with fluid overload </li></ul></ul><ul><ul><li>More often MICU </li></ul></ul><ul><ul><li>More often aged, with other comorbidity </li></ul></ul>
  6. 6. Co-morbidities <ul><li>As difference between acute and chronic reveals, pre-ICU functional status of the patient is critically important </li></ul><ul><li>Dysphagia in the ICU involves 2 things: </li></ul><ul><ul><li>Changes in swallowing created by ICU setting </li></ul></ul><ul><ul><ul><li>Patient factors – why the patient is in the ICU </li></ul></ul></ul><ul><ul><ul><li>ICU factors – impact of tubes, etc </li></ul></ul></ul><ul><ul><li>Ability of the patient to compensate for those changes </li></ul></ul>
  7. 7. Feeding Tubes – The Good <ul><li>ICU patients have high metabolic needs </li></ul><ul><li>Require nutrition for proper healing </li></ul><ul><li>Can be meet with Enteral or Parenteral nutrition </li></ul><ul><ul><li>Enteral – via GI tract – PO, NGT, PEG </li></ul></ul><ul><ul><li>Parenteral – via circulation – TPN, PPN </li></ul></ul>
  8. 8. Feeding Tubes – The Bad <ul><li>“ Aspiration is the most feared complication of enteral tube feeds” </li></ul><ul><li>Do nasogastric tubes cause aspiration? </li></ul><ul><li>Do nasogastric tubes cause dysphagia? How NGT cause aspiration: </li></ul><ul><li>PEG as alternative to NGT </li></ul>
  9. 9. Feeding Tubes – The Ugly <ul><li>Nasogastric tube syndrome </li></ul><ul><ul><li>Post-cricoid tube leads to mechanical irritation of the posterior cricoarytenoid muscles  bilateral TVC paralysis </li></ul></ul><ul><ul><li>Paralytic dysphonia </li></ul></ul><ul><ul><li>Inability to close glottis  aspiration </li></ul></ul><ul><ul><li>Treatment is PEG tube </li></ul></ul><ul><ul><li>Rare but real condition </li></ul></ul>
  10. 10. Tracheal Tubes – The Good <ul><li>Breathing is good </li></ul><ul><ul><li>Assisted ventilation for respiratory failure (most common reason, especially in MICU) </li></ul></ul><ul><ul><li>Stabilize pulmonary situation if patient might have cardiopulmonary instability (eg, remaining intubated after lengthy surgery) </li></ul></ul><ul><ul><li>Bypass upper airway obstruction </li></ul></ul><ul><ul><li>Hyperventilation to diminish cerebral edema </li></ul></ul><ul><li>Pulmonary toilette </li></ul><ul><ul><li>Easier with tracheotomy than ETT </li></ul></ul>
  11. 11. Tracheal Tubes – The Bad <ul><li>Endotrachal tubes can impair swallowing </li></ul><ul><li>Aspiration – difficult to estimate incidence </li></ul><ul><li>Ventilator associated pneumonia </li></ul><ul><li>Decreased sensation cont. post-extubation </li></ul><ul><li>Muscle atrophy: larynx, pharynx, tongue, BOT </li></ul><ul><li>Respiratory fatigue, decreased cough </li></ul><ul><li>Direct trauma to larynx with decreased closure </li></ul><ul><li>Disrupts swallowing coordination </li></ul><ul><li>Role of subglottic pressure </li></ul>
  12. 12. Tracheal Tubes – The Ugly <ul><li>“ The Ugly” = permanent damage </li></ul><ul><li>Permanent damage from prolonged intubation occurs as a pressure-induced injury </li></ul><ul><li>Injuries vary in severity and manifest differently </li></ul><ul><li>Changes may be acute or chronic </li></ul>
  13. 13. Special Populations <ul><li>Information regarding other populations will assist in one’s confidence in varied ICU settings </li></ul><ul><ul><li>Bone Marrow Transplant/Oncology </li></ul></ul><ul><ul><li>Burn </li></ul></ul><ul><ul><li>Lung Transplant </li></ul></ul><ul><ul><li>Cardiovascular surgery </li></ul></ul><ul><ul><li>Elderly </li></ul></ul><ul><li>Associated conditions </li></ul><ul><ul><li>PulmonaryImmunosuppression </li></ul></ul><ul><ul><li>Mucositis </li></ul></ul><ul><ul><ul><li>Oral care issues </li></ul></ul></ul><ul><ul><li>Mucosal injury </li></ul></ul><ul><ul><li>Vocal fold paralysis and aspiration </li></ul></ul><ul><ul><li>Pneumonia risk factors </li></ul></ul>
  14. 14. How do we make dysphagia management decisions regarding critically ill patients? <ul><li>Consider </li></ul><ul><ul><li>Pt readiness for evaluation </li></ul></ul><ul><ul><ul><li>Know your patient </li></ul></ul></ul><ul><ul><li>Evaluation type </li></ul></ul><ul><ul><ul><li>Have a paradigm for work-up </li></ul></ul></ul><ul><ul><li>Risk factors </li></ul></ul><ul><li>Suggestions </li></ul><ul><ul><li>Delay oral feeding in pts with prior hx of aspiration </li></ul></ul><ul><ul><li>Reduce risk of pulmonary complications </li></ul></ul><ul><ul><li>Consider co-morbidities </li></ul></ul><ul><ul><li>Implement dysphagia exercises: “strength training” </li></ul></ul><ul><li>Teamwork – Multidisciplinary Approach </li></ul>ASHA 2008 Hildner, O'Sullivan, Akst
  15. 15. <ul><li>Cynthia D. Hildner, MS, CCC-SLP [email_address] </li></ul><ul><li>Northern Illinois University , DeKalb, Illinois </li></ul><ul><li>Kathryn O’Sullivan, MA, CCC-SLP [email_address] </li></ul><ul><li>Loyola University Medical Center, Maywood, Illinois </li></ul><ul><li>Lee M. Akst, MD </li></ul><ul><li>Director of Laryngology, </li></ul><ul><li>Department of Otolaryngology Head and Neck Surgery </li></ul><ul><li>Loyola University Medical Center, Maywood, Illinois </li></ul>ASHA 2008 Hildner, O'Sullivan, Akst
  16. 16. References <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>Burkhead LM, Sapienza CM, Rosenbek JC (2007) Strength-Training Exercise in Dysphagia Rehabilitation: Principles, Procedures, and Directions for Future Research Dysphagia 22:251-265. </li></ul><ul><li>Clanton, N, Kennedy, P (2007) Management of Dysphagia in Toxic Epidermal Necrolysis (TEN) and Stevens-Johnson Syndrome (SJS). Dysphagia. 22(3): 187-92 </li></ul><ul><li>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. </li></ul>ASHA 2008 Hildner, O'Sullivan, Akst
  17. 17. <ul><li>Ding, R & Logemann J. (2000) “Pneumonia in stroke patients: a retrospective review.” Dysphagia 15:51-57. </li></ul><ul><li>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 </li></ul><ul><li>Elpern EH. Nutr Clin Pract 1997; 12:5-13 </li></ul><ul><li>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. </li></ul><ul><li>Epstein J. Mucositis in the Cancer Patient and Immunosuppressed Host. Infectious Disease Clinics of North America </li></ul><ul><li>Ferraris VA, Ferraris SP, Moritz DM, Welch S. (2001) Oropharyngeal Dysphagia After Cardiac Operations. Annals of Thoracic Surgery. 71: 1792-6. </li></ul><ul><li>Gross RD et al. Ann Otol Rhinol Laryngol 2003; 112:143-152 </li></ul>ASHA 2008 Hildner, O'Sullivan, Akst
  18. 18. <ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>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. </li></ul><ul><li>Huggins PS, Tuomi SK, Young C (1999) Effects of nasogastric tubes on the young, normal swallowing mechanism Dysphagia. 14:157-161 </li></ul><ul><li>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. </li></ul><ul><li>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 </li></ul>ASHA 2008 Hildner, O'Sullivan, Akst
  19. 19. <ul><li>Langmore S, Skarupski KA, Park PS, Ries BE. (2002) Predictors of aspiration pneumonia in nursing home residents. Dysphagia, 17: 298-307 </li></ul><ul><li>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. </li></ul><ul><li>Leder SB, Ross DA. (2005) Incidence of Vocal Fold Immobility in Patients with Dysphagia. Dysphagia 20:63-67. </li></ul><ul><li>Leder SB. (1999) Fiberoptic Endoscopic Evaluation of Swallowing in Patients with Acute Traumatic Brain Injury. Journal of Head Trauma Rehabilitation. 14(5):448-453. </li></ul><ul><li>McClave S, Dryden G. (2003) Semin GI Dis. 14:2-10 </li></ul><ul><li>Mann G & Hankey GJ (2001) Initial clinical and demographic predictors of swallowing impairment following acute stroke. Dysphagia 16(3): 2008-15. </li></ul><ul><li>Marik, P, Kaplan, D, (2003) Aspiration Pneumonia and Dysphagia in the Elderly. Chest. 124:328-336. </li></ul>ASHA 2008 Hildner, O'Sullivan, Akst
  20. 20. <ul><li>McCullough GH. (2006) Zen and the art of swallowing maintenance: best evidence, best practice. ASHA Special Interest Division 13 National Newsletter </li></ul><ul><li>Murray J. (2008) Frailty, functional reserve, and sarcopenia in the geriatric dysphagic patient. Perspectives on Swallowing and Swallowing Disorders (Dysphagia) 17 3-11. </li></ul><ul><li>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 </li></ul><ul><li>Padovani AR, Furquim de Andrade CR. (2007) Einstein 5(4): 358-362 (online article) </li></ul><ul><li>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 </li></ul><ul><li>Ramsey D, Smithard D, Kalra Lalit (2005) Silent aspiration, what do we know. Dysphagia 20:218–225 </li></ul>ASHA 2008 Hildner, O'Sullivan, Akst
  21. 21. <ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>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. </li></ul><ul><li>Sasaki C et al. Trans Am Acad Opthal Otol 1973; 77:403-10 </li></ul><ul><li>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 </li></ul>ASHA 2008 Hildner, O'Sullivan, Akst
  22. 22. <ul><li>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. </li></ul><ul><li>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 </li></ul><ul><li>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. </li></ul><ul><li>Stiff, P. (2001) Mucositis associated with stem cell transplantation: current status and innovative approaches to management. Bone Marrow Transplantation. 27, Supp, S3-S11 </li></ul><ul><li>Wang TG et al. Arch Phy Med Rehab 2006; 87:1270-1273 </li></ul><ul><li>Wolf C, Meiners TH (2003) Dysphagia in patients with acute cervical spinal cord injury. Spinal Cord. 41, 347-353. </li></ul>ASHA 2008 Hildner, O'Sullivan, Akst

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