Medical Speech Pathologist University of Rochester Medical Center & Rochester Regional Health ROCHESTER, New York, United States
Disclosure(s):
Erin McCarthy, SLPD, CCC-SLP, BCS-S: Illinois Speech-Language-Hearing Association: Financial - Honoraria (Ongoing); Rochester Regional Health: Financial - Salary (Ongoing); Stryker Medical Company: Financial - Consulting Fee (Ongoing), Financial - Speaking Fee (Ongoing); University of Rochester Medical Center: Financial - Salary (Ongoing). No non-financial relationships to disclose
ABSTRACT: Patients who have been intubated for prolonged periods of time are at an increased risk for dysphagia and aspiration once extubated. There is increasing pressure to begin oral nutrition sooner after extubation to decrease length of stay in the ICU. A post-extubation swallow screen was developed by a multi-disciplinary team and implemented as an innovative new standard of care.
SUMMARY: In recent years, swallowing dysfunction following extubation has become an increasingly recognized issue across multiple disciplines. It has been documented that patients who have been intubated for prolonged periods of time, are at an increased risk for dysphagia and aspiration once extubated (Malandraki et al., 2016; Macht et al., 2012; Ajemian et al., 2001; Leder, Cohn & Moller, 1998). The possible causes of dysfunction of the pharyngeal–laryngeal musculature and the swallow mechanism following extubation include disuse atrophy syndrome, residual effects of narcotics used during intubation, suppression of the cough and gag reflex, reduced laryngeal sensation, laryngeal edema and/or granulation tissue, palsy of the recurrent laryngeal nerve and reduced or disorganized respiratory support (Ajemian et al., 2001; Leder, Cohn & Moller, 1998). In the current healthcare era, there is an increasing push by providers to get patients consuming enteral nutrition quicker, as well as to reduce their length of stay in the ICU. Due to this mind set, it is often suggested that ICU nurses begin the assessment of the swallow mechanism by using a screening process. Presently, the only mandated swallow screen process is for those patients who have suffered a stroke or a TIA (Adams et al., 2007). At our facility, we found that the ICU medical providers were using the post-stroke swallow screen with patients who had recently been extubated, regardless of length of intubation or co-morbidities. In addition, each provider had different interpretations and opinions regarding when it was safe to administer the swallow screen and present oral trials, and what to do if the patient “failed” the screen. In an effort to provide clearer guidelines for the ICU nursing staff on screening patients who were recently extubated to determine their candidacy for oral intake, as well as establish consistent criteria for the patients who should be evaluated by Speech Pathology for a formal swallow evaluation, a multi-disciplinary team was formed to review the literature and create a screening process that would satisfy all disciplines. Most importantly, the new process keeps the patient at the center of care. Effective collaboration of all parties was essential to provide the best possible outcome for the patient (Green & Johnson, 2015).
The purpose of this presentation will be to discuss post-extubation dysphagia, the current swallow screens available per the literature for this population and how to build and develop an effective post-extubation swallow screen process for the benefit of the patient.
References: 1. Adams H., del Zoppo G., Alberts M., Bhatt D., Brass L., Furlan A., Grubb R., Higashida R., Jauch E., Kidwell C., Lyden P., Morgenstern L., Qureshi A., Rosenwasser R., Scott P. & Wijdicks E. (2007). Guidelines for the Early Management of Adults with Ischemic Stroke: A Guideline from the American Heart Association. Stroke: A Journal of the American Heart Association, (38), 1655-1711. 2. Ajemian M., Nirmul G., Anderson M., Zirlen D., & Kwasnik E. (2001). Routine Fiberoptic Endoscopic Evaluation of Swallowing Following Prolonged Intubation. Archives of Surgery, (136), 434-437. 3. Green B. & Johnson C. (2015). Interprofessional Collaboration in Research, Education, and Clinical Practice: Working Together for a Better Future. Journal of Chiropractic Education, (29) 1. 4. Leder S., Cohn S., & Moller B. (1998). Fiberoptic Endoscopic Documentation of the High Incidence of Aspiration Following Extubation in Critically Ill Trauma Patients. Dysphagia, (13), 208-212. 5. Leder S., Suiter D., Warner H., Kaplan L. (2011). Initiating Safe Oral Feeding in Critically Ill Intensive Care and Step-Down Unit Patients Based on Passing a 3-Ounce (90 Milliliters) Water Swallow Challenge. The Journal of TRAUMA Injury, Infection and Critical Care, (70), 1203-1207. 6. Macht M., Wimbish T., Clark B., Benson A., Burnham E., Williams A. & Moss M. (2011). Post Extubation Dysphagia is Persistent and Associated with Poor Outcomes in Survivors of Critical Illness. Critical Care, 15:R231. 7. Macht M., Wimbish T., Clark B., Benson A., Burnham E., Williams A. & Moss M. (2012). Diagnosis and Treatment of Post Extubation Dysphagia: Results from a National Survey. Journal of Critical Care, (27), 578-586. 8. Malandraki G, Markaki V, Georgopoulos V, Psychogios L, & Nanas S. (2016). Post Extubation Dysphagia in Critical Patients: A First Report from the Largest Step-Down Intensive Care Unit in Greece. American Journal of Speech Language Pathology, (25), 150-156.
Learning Objectives:
At the completion of this activity, participants should be able to:
Upon completion of the session, participants will be able to describe the various causes of dysphagia following extubation.
Upon completion of the session, participants will be able to discuss the rationale for the development of a post-extubation swallow screen in the ICU.
Upon completion of the session, participants will be able to explain how effective collaboration with a multi-disciplinary team can lead to the development of an effective post-extubation swallow screening process.