Clinical Decision Making in Dysphagia Management for Critically Ill Patients

1
Clinical Decision Making in Dysphagia Management
for Critically Ill Patients

• Cynthia D. Hildner, MS, CCC-SLP
• Northern Illinois University
• Kathryn OSullivan, MA, CCC-SLP
• Lee M. Akst, MD
• Loyola University Medical Center, Maywood,
  Illinois

2
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.

3
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)

4
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

5
ICU Acute vs. Chronic

• Acute new condition affecting homeostasis
• Trauma, recent surgery, acute infection, etc.
• More often SICU
• Chronic decompensation of existing illness
  requiring ICU care
• COPD exacerbation with intubation
• CHF with fluid overload
• More often MICU
• More often aged, with other comorbidity

6
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

7
Feeding Tubes The Good

• ICU patients have high metabolic needs
• Require nutrition for proper healing
• Can be meet with Enteral or Parenteral nutrition
• Enteral via GI tract PO, NGT, PEG
• Parenteral via circulation TPN, PPN

8
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

9
Feeding Tubes The Ugly

• Nasogastric tube syndrome
• Post-cricoid tube leads to mechanical irritation
  of the posterior cricoarytenoid muscles ?
  bilateral TVC paralysis
• Paralytic dysphonia
• Inability to close glottis ? aspiration
• Treatment is PEG tube
• Rare but real condition

10
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 obstruction
• Hyperventilation to diminish cerebral edema
• Pulmonary toilette
• Easier with tracheotomy than ETT

11
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

12
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

13
Special Populations

• Information regarding other populations will
  assist in ones 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

14
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

15

• Cynthia D. Hildner, MS, CCC-SLP childner_at_niu.edu
• Northern Illinois University , DeKalb, Illinois
• Kathryn OSullivan, MA, CCC-SLP
  kosullivan_at_lumc.edu
• 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

16
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