dysphagia

★ ICU-Acquired Swallowing Disorders

Every month a group of #SLPeeps blogs about research. You can find out more about it here.

My last post for Research Tuesday was about cognitive dysfunction in ICU patients. That post emphasized some long-term effects of severe illness. This post will shift gears and focus on something more short-term: swallowing dysfunction resulting from ICU-level illness. Though the article I chose isn't itself a research article, it is a nice overview of swallowing and the role of SLPs in intensive care units. Also, the article was published in a medical journal, which is an exciting place for SLPs to get exposure and to hopefully increase awareness of how we can be assets to patient care.

What I enjoyed most about the article was how well the authors broke down different reasons why patients might have swallowing difficulty. There was also a nice overview of swallowing physiology, despite the authors' use of the cringe-worthy term swallow reflex.

The Numbers

The article shared some interesting numbers regarding ICU patients.

  • There are over 700,000 patients who develop acute respiratory failure requiring mechanical ventilation in the US.
  • Of those, over 400,000 patients survive to be extubated. (There's a 35% mortality rate.)
  • A "significant portion" of those 400,000 patients have post-extubation swallowing dysfunction. Why no proper estimate? The article cites the wide variety of diagnoses that accompany swallowing dysfunction, in addition to the likelihood that many cases are overlooked. The "guesstimate" they offer, taking into account biases and heterogenous patient populations? Something between 3% and 62% of patients recovering from critical illness have swallowing dysfunction.

Mechanisms of Swallowing Dysfunction

I like that the article uses the term "ICU-acquired" as a general term; I find it helpful because it frees one up to the idea that swallowing dysfunction is complex, and can occur for a variety of reasons. The authors go further to describe "postextubation dysphagia (PED)", which is exactly what it sounds like. From a critical care standpoint, the others describe six different mechanisms in which ICU patients can develop swallowing dysfunction.

  1. Endotracheal tubes and tracheostomy tubes. These can can cause trauma to normal anatomic structures. Ulceration can develop from the constant contact of a tube with various structures, including the vocal folds, the arytenoids, the epiglottis, and the base of the tongue. Chronic inflammation can lead to granulation tissue and potentially to scarring. There are implications for swallowing function as well as respiratory function. Commonly, there is concern for vocal fold paresis or paralysis following intubation. The authors note that "the recurrent laryngeal nerve can be copressed (usually by the endotracheal tube cuff)" (2398).
  2. Neuromyopathy resulting in muscle weakness. Classic "use it or lose it". This can result from both prolonged intubation as well as the use of paralytics. Longer intubation time means not only weaker lungs, but weaker muscles along the entire aerodigestive tract.
  3. Dysfunctional oropharyngeal and laryngeal sensation. This can result from polyneuropathy (reduced nerve function) or local edema. In either case, afferent input is reduced.
  4. Impaired sensorium. Call it what you like: altered mental status, confusion, or delirium. The cause can range from the illness itself, infections peripheral to the illness, or even heavy sedatives. As SLPs from every setting can attest, the ability to participate is one of our #1 needs for effective intervention. Interestingly, I've found in my own experience that this concept is possibly the hardest; many times, I've assessed patients who I'm told "swallow fine" who present with significant amounts of food pocketed in their cheeks or caked on the palate. Sometimes we have to advocate not only from the "aspiration risk" perspective, but also from the perspective of adequate nutrition. What helps here? An interdisciplinary team approach. Dietitians can be an SLP's best friend, especially in an ICU.
  5. Gastroesphageal reflux. ICU patients are commonly on prophylactic medication for reflux. Why is that? The authors note that reflux is a concern during intubation in addition to after extubation. They cite three reasons for this: (a) supine positioning, (b), higher levels of sedation, and (c) the use of paralytics. Gastric motility is commonly impacted. Some ICUs prefer to have feeding tubes placed post-pyloric in order to reduce the potential for reflux (the thought being that there are two valves, the pyloris and the lower esophageal sphincter, and two valves can protect better than one). However, the presence of a feeding tube alone puts one at increased risk for reflux.
  6. Dyssyncronous breathing and swallowing. We don't think of it this way enough, especially when it comes to patient and family education, but swallowing is an act of fine-tuned coordination. I love the recent trend for describing the aerodigestive tract, because it's the most apt for describing how closely linked breathing and swallowing really are. Though the authors describe the imporantance of the coordination of the "apneic" period and its role for aspiration prevention, I wish they had gone further. I've noticed that tachypnea (rapid breathing) impacts the oral preparatory phase as well (specifically, bolus preparation and cohesion); patients who are struggling to breathe have a tendency to try to take in more air, and in doing so may be opening their mouth more than usual when breathing. We're taught from a young age to chew with our mouths closed, but it does serve a purpose: to better control a bolus, for one, and to act as the first pressure point in a series of pressure-driven events that is the swallow. If we think of reserve lung volume, it makes sense that we can manage to breathe gently through our noses while chewing; a patient who is critically ill likely does not have this same reserve volume, so this process requires considerably more effort, which leads to something else: fatigue.

Risk Factors and Screening

The usual suspects are mentioned, such as neurological injury and neuromuscular disease. The authors note the use of screening tools for dysphagia among stroke patients. Stroke protocols today require screening stroke patients for potential swallowing dysfunction. The authors note that there is no similar requirement for critically ill patients, but 41% of hospitals surveyed did, in fact, have routine screens established. Though I'm not sure if my own hospital was part of that survey, I am pleased to be part of an institution which has taken up more universal screening. Though the department I work in is nicely staffed, it would be impossible for us to see every patient admitted. I work a lot in the ICU, though, and have found that the added bonus to seeing more patients who present with some level of dysphagia is that I can also assess for cognition. I consider this a bonus because mild cognitive impairment is often so easily overlooked.

Clinical Dysphagia Evaluation (CDE) vs. Diagnostic

The authors describe clinical, videofluoroscopic, and endoscopic evaluations of swallowing. When it comes to ICU patients, the clinical dysphagia evaluation is typically my go-to. I like it because I can take my time to meet patients, get a sense for their cognitive status, and also see how they perform with real foods (not to mention it's much easier to push their limits and assess for fatigue). There are some patients with histories that clearly indicate the need for more objective assessments, but for most patients a clinical exam is sufficient to get started.

There's a fine balance, especially for ICU patients, given that the acute nature is such that they can make gains with just as much speed as they can decline. It's a balancing act, really, and requires persistent follow-up to see if any change, either progressive or regressive, is occurring. My initial and early subsequent follow-ups look closely at whether a patient may need an instrumental exam. Challenges for attaining such exams can include medical status (is the patient stable enough to leave the ICU, or to tolerate an endoscopic procerdure?), acuity of illness (do we expect them to make a quick or slow recovery?), and scheduling (always a challenge for videofluoroscopic studies). Sometimes, the passage of time is a key component both in terms of patient recovery and discerning need for further evaluation.

Treatment

The authors note that "treatments for all types of dysphagia have been relatively underexplored, especially for patients recovering from critical illnesses" (2401). Currently, we (a) modify diet textures, (b) modify posture (a la chin tuck or head turn), (c) use therapeutic exercises, and (d) use enteral feeding tubes. Varying success has been ascribed to each method, and the use of each varies among clinicians and institutions.

As I've reflected on my own practice with critically ill patients, I've found I use a combination of the above. Each has its own merits and drawbacks.

  • Texture modification. I like to think of texture modification as a "band-aid" solution. It's a nice temporary tool but not always sustainable in the long-term. I find texture modification most useful for issues with dentition as well as attention; maybe a patient can't sustain enough attention to really masticate well, but have no problem with a liquids, pudding or puree textures. Maybe a patient has sustained a physical injury which cannot handle pressure on the mandible or palate. Maybe a patient left their dentures at home.
  • Postural modifications. I feel similarly to postural modifications as I do to texture modifications. Maybe a chin tuck or head turn works great for my immediate safety, but I don't want to do that forever. There's a reason they're called compensatory strategies. The goal is to compensate well enough until more long-lasting change can be achieved.
  • Therapeutic exercises. I tend to use these sparingly, but largely because critical illness generally doesn't lend itself well to such pursuits. Rather, I find them useful once patients are medically stable. In my case, medical stability usually means transfer to rehab. That said, my current caseload consists mostly of pulmonary patients, so I do end up coordinating with respiratory therapists to ensure breathing exercises are incorporated daily. I work with patients on these exercises and apply them to speech (increasing vocal intensity and duration of exhale for longer utterances, for example) as well as swallowing (improving reserve and breath control and practicing with PO trials).
  • Enteral feeding tubes. I have been fortunate to work closely with many excellent dietitians. For critically ill patients, nutrition plays an integral role in recovery, and quite often patients are unable to consume adequate nutrition in the early stages of recovery. In patients who are extubated but remain severely altered, the risk might be that they're too agitated to really eat well. In patients who are extubated and retain high oxygen requirements, they may not be able to even coordinate their breath well enough to swallow; they also, quite often, run the risk of re-intubation.

Where to next?

Though this article did not describe any really new information, I found it to be very descriptive of the SLP's role with critical care patients, and a great introduction for providers of all backgrounds. I also loved how much it helped me think about not only what I do, but why I do it. I'm left wondering if my current approach is the best approach, or if there are other ways I may approach things to continually improve the services I provide. I like to think the answer to that is a resounding yes.

Article Citation

Macht, Madison, MD, Wimbish, Tim, MS, CCC-SLP, Bodine, Cathy, PhD, CCC-SLP, and Moss, Marc, MD. (October 2013.) ICU-Acquired Swallowing Disorders. Critical Care Medicine, vol. 41, #10, 2396-2405.

★ Oral Cares For Days

SLP colleague and #SLPeeps twitter friend Rachel Wynn recently rallied the community of SLP bloggers to write about research. The mission? Taking the time once a month to read a research article and then write a review about it.

Having recently attended ASHA’s Dysphagia in Older Adults online conference, I have had a lot of research on my mind. As with any good continuing education, I walked away from the conference with far more questions than I had when I started it. Since then, I have found myself thinking often about different presentation topics, and how they fit into my professional life.

One topic that stands out to me, in particular, is that there is a lack of adequate research in acute care. And it seems that my conference wasn’t the only one during which this topic arose.

I’m finding myself in an interesting position, profesionally speaking. It has been now two years since I earned my CCCs, and at the moment I feel like all I want to do is pause, pull out all my textbooks and notes, and re-learn everything I ever studied in school. My perspective has shifted so significantly since I was a student; I find myself thinking about everything on a much larger scale than I ever imagined, and there’s so much I want to know.

Having a goal in mind is always nice, so it was timely that Rachel suggested this blogging endeavor. It’s given me a little bit of direction, something I think I sorely needed.

An Article: Nay, a Review

One of the presentations from the online conference was called Oral Hygiene in Older Adults: Complications, Assessment, and Care, and was presented by John R. Ashford, PhD, CCC-SLP. In 2012, I joined two Special Interest Groups, and when looking for articles for this project, I happened to perusing the “Perspectives” resources for SIG 13 (Swallowing and Swallowing Disorders). John Ashford had published an article in 2012 called Oral Care Across Ages: A Review.

Personal Bias

As an acute care SLP, I find that many of the patients I work with have, for lack of a better descriptor, disgusting mouths. This could be do to any number of factors: alcohol or drug abuse, prolonged intubation, and radiation therapy for cancer, to name just a few. When I work in the ICU, I have a tendency to start working with patients early. That is, I like to evaluate them before they might be ready to start eating. Not only have I found it beneficial in terms of being able to really gauge patients’ progress, but it also allows me to do my part to help advance them to feeding readiness.

I can’t quite recall when I started to say it, but I noticed recently that I have a little catch phrase I seem fond of sharing with patients and families: “If your mouth doesn’t feel good, then the rest of you doesn’t feel good.” It’s a simple observation, but I feel it’s a powerful one. It occurred to me at one point when I was sick; the combination of mouth-breathing and that filmy yet dry coating of my tongue and palate seemed to compound my illness.

The Mouth At Work

How does the mouth really work? It turns out, it’s not all that different from the rest of our GI tract. We’re very fond of probiotics these days, and we often discuss the idea that within our bodies lies a veritable ecosystem of bacteria. Our oral cavity, as the “beginning” of our GI tract, has its own ecosystem. John Ashford breaks it down nicely: “the oral cavity is covered by a protective mucous membrane, serous fluids, and mixtures of microorganisms, or flora, comprised of bacteria, viruses, and fungal species.”

The fancy term for this is biofilm, and it covers the surfaces of the oropharynx and teeth. “These coatings benefit the oropharynx by stimulating the immune system to protect surfaces against colonization and infection from invading microbes and to stimulate certain nutritional and digestive functions.” It’s like a naturally-occurring vaccine: a little bit of exposure keeps our immune system on the ball. The flora also function, as they do in our intestines, to help break down nutrients so that our bodies can extract them and use them accordingly.

Breakdown

While we are able to manage exposure to bacteria when healthy, illness of any kind leads to susceptibility. Poor oral health coupled with illness can leave one with greater colonization of bacteria and fungi, which, if aspirated, has the potential to cause pneumonia.

Many of the patients I encounter have poor oral care at baseline, which results in lost and broken teeth, and many of them have full or partial dentures. “[T]he acrylic and silicone materials used in denture and denture-lining construction provide ample surfaces for bacterial attachment.” As a result, proper denture cleaning is a must in addition to oral cares. Another point to consider, which I hadn’t before, is that “dentures that fit closely to mouth surfaces reduce salivary cleaning” (emphasis mine). We swallow routinely throughout the day, so basically the flora in our mouths are not permanent residents.

In his presentation for the Dysphagia in Older Adults Conference, John Ashford explained that saliva contains certain sugars, and it is those sugars (rather than oxygen) which the pathogens in our flora live on. Saliva, in a sense, acts as both an incubator (maintainer of moisture to provide an environment for flora to thrive, relatively speaking) and a lubricant. The “serous fluid [found in saliva] is rich in antimicrobial substances… [which prevent oral pathogens] from attaching to and colonizing the oropharyngeal surfaces, thus preventing oral infections.”

Oral Cares

Where does this leave us as SLPs? There are different schools of thought: some feel that oral cares responsibility lays with nurses and techs. It makes sense, given that they are usually the ones present 24/7, while we SLPs can only be present intermittently. Any SLP who has worked in a medical setting, be it acute, LTAC, SNF, etc., is likely aware that oral cares are often neglected in the face of other, seeming more pressing, issues. I’ve also found that my emphasis and perspective of the importance of good oral care is not always shared by others; this isn’t a bad thing, necessarily, but I think the nature of increasing specialization. It’s why being part of an inter-disciplinary team is so important: I can develop a plan, emphasize its importance, and encourage the team to follow the plan to ensure the best patient care.

Ashford cites a number of studies which show that “tooth brushing is strongly supported over use of foam swabs with hospitalized and nursing care patients”, as “toothbrushes were substantially better at removing plaque”. When I provide oral cares, I often begin with a swab, as I have found it more effective to remove dry oral mucosa that may be coating the tongue, teeth, and palate. Once I am able to clear the oral cavity, I then go back to brush properly. In the event that someone’s mouth is particularly messy, I like to provide thorough cleaning before initiating any PO trials. It has the benefit of not only helping the patient feel better (and optimize their chances for success), but it can also serve as a nice way to increase level of arousal in somnolent patients.

Moving Forward

I appreciated this article, as well as the conference lecture, as an excellent starting point. I have been looking into further into tools like the Oral Health Assessment Tool (OHAT) and educational tools like “KISS” (Keep it simple, staff) Basic Oral Care for caregivers.

I hope to increase my knowledge and plan to implement oral care plans as part of my recommendations. I hope to help my department increase awareness of the importance of oral care and how it can benefit patients. I hope to increase the availability of artificial salivas (such as Mouth Kote) for critically ill patients suffering from xerostomia.

I would also love to start collecting more informal data so that I can monitor patient progress compare efficacy of the treatments I may provide.

As I wrap up this post, I’m struck by how much I still want to know. Many of the resources Ashford provided in his article are from outside professions, such as dentistry and other medical publications. I am reminded that, while we have wonderful resources available within our own organization, sometimes collaboration with other professions can yield a whole other world of applicable information.

I look forward to continuing to explore new territory. I hope to keep finding reasons to question what I know, and to always work to broaden my horizons.

Article Citation: Ashford, John. (March 2012.) Oral Care Across Ages: A Review. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), vol. 21, pp. 3-8.

(Aside: Comments are open. I welcome dialogue, new ideas, and cool ways to rethink all these things. Thoughts?)

★ The Online Conference Experience

I have been participating in the Dysphagia in Older Adults online conference for the last week. This is my first online conference, and so far it has been a relatively ‘mixed bag’ of an experience. Let’s start with the good.

The Good

  • I was surprised to discover how much I don’t mind the pre-recorded lectures. While I like to see presenters, they did a nice job of having the presenter’s picture posted next to the slides. Even when there are multiple speakers, the picture switches whenever they take turns.
  • One of the biggest perks of a pre-recorded lecture is that you can watch it at your leisure. I can watch it in the morning, then pick up where I left off later on (though I do need to remember which slide I was on, but that’s relatively easy).
  • I love being able to pause a lecture, or rewind to pick up anything I missed. It makes it very easy to take notes. On the other hand, soemtimes it can make the whole thing last much longer.
  • Having the resources so readily available is wonderful. The slides are presented throughout the presentation, and they are also provided as downloadable PDFs. The ease of obtaining resources is vastly different from the experience of the 2012 ASHA Convention, where despite a large number of attendees wanting to go paperless, we were nearly completely unable to do so.
  • It’s rather charming to hear the presentations; I suspect that since they’re pre-recorded, the presenters likely didn’t have an audience (or if they did, perhaps an audience of one). It’s interesting how this changes the dynamics of a presentation; being able to look at attendees surely makes a big difference in how you present, and an engaged audience is always helpful. It must have been challenging to work up these presentations without that benefit, though hopefully they’re finding that we’re all an engaged and attentive bunch.

The Less Than Ideal

  • The philosophy of the online conference seems to be “watch all the lectures, then participate in live chats”. In theory, this isn’t a bad thing. However, it is quite limiting, as the live chats are scheduled at specific times, and depending on your time zone, they’re not necessarily convenient. In my case, literally every single live chat happens during my workday; since I work in acute care, my day is generally unpredictable and so this is a considerable inconvenience for me, as I want to participate as much as possible.
  • Relating to the structure of these chats, they state you can only get credit for attending the full 60 minutes of discussion. I was a few minutes late for one yesterday; I managed to finish an eval in time to start, but the conference website was slow to load. Hopefully I can still get credit for participation.
  • While I love that discussion is encouraged, I don’t much like the “I agree” and “Here’s a twist” style comment system. I also get bogged down in the “this was a great presentation” comments. Like many, I like to express thanks for a good presentation, but it makes having real discussion difficult when there’s so much fluff.

The Takeaway, and Hope for the Future

I’m very happy I took the chance and decided to participate in this conference. It is very applicable to me as a budding SLP, and I feel inspired to keep reaching for the stars and trying to learn as much as I can every day.

I would happily participate in another online conference in a heartbeat. My hope would be that for the future, the goal be to truly harness the power of online dialogue, which should be availability to participate and earn CEUs without specific time constraints. Given that the live chats are all typed and moderated, a moderated forum would be just as useful, if not more so, as it would be less restrictive of when everyone could participate.

★ Dysphagia in Older Adults

I'll be attending the Dysphagia in Older Adults online conference. It starts Wednesday and runs until the 20th of this month. I signed up under the early bird rate of $300, but the regular cost of registration is only $30 more. Given the schedule of events, it should be an interesting and informative conference.

This is my first online conference and I'm eager to see how it goes. I've got an awful lot to learn, and I think this conference will be a great place to continue that journey.

★ Aiming to Please

Though many people don’t think about it, there are plenty of similarities between working with adults and working with children. Just as pediatric SLPs note the periodic need for incentives in order to make progress in therapy, there are plenty of adults who do as well. I frequently work with patients who are very confused and, as a result, can be less than inclined to work with a guy like me. “Speech pathologist?”, I often hear, “I can talk just fine, what are you doing here?”

In addition to the often-seen challenge of helping someone acknowledge that they’re having difficulty swallowing, an added bonus is that such difficulty is often coupled with poor appetite. It’s the ultimate paradox: when you feel bad, you don’t feel hungry; but, the best way to heal is to get some good nutrition.

Recently, I worked with a patient who had a poor appetite and wasn’t eating enough as a result. She was refusing most food and was not inclined to drink liquid supplements, citing that they were never cold enough to properly enjoy them. I excused myself, ran to the nutrition room on the floor, and returned with a cup of ice. Ensure on the rocks, then?”, I asked as I began to pour. She had a good chuckle and agreed.

Though it lacked the punch of a good mixed drink, it did the trick to make her day just a little bit brighter.