functional profile of swallowing in clinical intensive care

8/8/2019 Functional Profile of Swallowing in Clinical Intensive Care

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einstein. 2007; 5(4):358-362

359Functional prole o swallowing in clinical intensive care

evaluation, it is necessary to use the methods described inthe literature, such as the water test(1,10), pulse oxymetry1and neck auscultation(11). Based on the results achieved inthese evaluations, we can establish the patients eedingand swallowing proles dened by dysphagia scaleso result and severity, such as ONeils scale(12), whichallows us to classiy the swallowing disorder as to severity,

need or supervision and possibility o establishingoral eeding. Moreover, the use o a scale may helpcharacterize swallowing disorder treatment progressduring therapy.

Based on the assessment data, speech therapyintervention at the ICU contributes to indicatedecanulation o tracheostomized individuals, to checkor the possibility o oral eeding, to determine themost adequate method or oral eeding, to select dietconsistency, to speciy risks and precautions duringeeding, to determine those who can undergo therapeuticintervention, to choose the therapeutic maneuvers and

techniques and to discuss the cases with the team ocaregivers(13).

OBJECTiVE

In the present investigation we intend to describe theswallowing and eeding unctional proles o patients ina clinical intensive care unit, who were reerred becauseo suspected non-neurogenic dysphagia, by means o ascale o results(12).

METHODSWe carried out a retrospective study, based on the datacollected rom the medical charts o patients admittedto the Clinical UTI at the Emergency Room at Hospitaldas Clnicas Universidade de So Paulo FMUSP.We included all patients reerred or speech evaluationby the team o intensive care physicians, rom May toAugust o 2006.

The study included only patients reerred orsuspicion o dysphagia o non-neurologic causes, andpatients reerred or suspected neurogenic dysphagia

were excluded.

Sttstcs

We used the non-parametric two ratio equality tests Mann-Whitney and chi-squared tests or independence.To complement the descriptive analysis, we used thecondence interval or the mean value.

We dened a 5% signicance level (p 0.05), andall condence intervals were build with 95% o statisticalcondence.

rESUlTS

We included 23 patients in the study, 11 men and 12women, with mean age o 43 years. Among hospitaladmission diagnosis were: pneumocystosis, chronicobstructive pulmonary disease, lumbar spine metastasis,pneumonia, thoracic spine racture, seizures, lymphoma,cardiorespiratory arrest, nephrolithiasis, septic chock,

tracheal stenosis, pneumococcal meningitis, pulmonarymetastasis, intestinal bleeding, pulmonary inection,hypernatremia and pyelonephrosis.

Speech evaluation was carried out at the bed side andthe methods included water test(1,10), pulse oxymetry(1)and cervical auscultation(11). Speech diagnosis was madethrough the Dysphagia Scale o Results and Severity(12).

In indirect speech therapy, we used motor sensorystimulation techniques. In the direct therapy we educatedthe patients in regards o using silverware, properposture, need or supervision, speed and amount o oodintake, and also adaptation maneuvers and compensatory

postures.We can see that the average number o sessions was

3.09 1.17 and the mean age was 43.09 6.24 years.We also noticed that the variability in number o sessionswas very high (variation coecient VC = 93.1%)(Table 1).

Tbe 1. Sample characterization

Descrptve age number of sessosMean 43.09 3.09

Standard deviation 15.26 2.87

VC* 35.4% 93.1%

CI** 6.24 1.17

VC* = variation coefcient CI** = confdence interval

As ar as age is concerned, there was a gradualincrease in dysphagia as age increased (Figure 1).

In order to characterize the sample or qualitativevariables, we used the two ratio equality test, comparingthe response percentages.

Fue 1. Initial speech therapy diagnosis and age


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einstein. 2007; 5(4):358-362

360 Padovani AR, Andrade CRF

According to Figure 2, there is a statistically higherpercentage o indication or speech therapy related to longstand orotracheal intubation (OTI 48 h). Dysphagiaprevalence ater prolongued OTI was o 64%.

Table 2 shows the results o speech diagnosis in theinitial assessment and ater therapy.

Fue 2. Characterization o sample per qualitative variables

Tbe 2. Initial and fnal speech therapy diagnosis

Speech therpy

dgoss

icl Fl

% p vlor % p vlor

Normal and/or

functional deglutition

8 34.8%

0.039*

13 56.5%

0.139Dysphagia 15 65.2% 8 34.8%

Death 0 0.0% 2 8.7%

*p 0,05

Initially, we observed a greater rate o dysphagia(65.2%), which was statistically signicant in relation tothe other percentages. In the nal evaluation, we noticedthat the largest rate is that o normal and/or unctionalswallowing (56.5%), however there is no statisticallysignicant dierence or the 34.8% rate o dysphagia.

In a descriptive analysis, according to the ONeilsscale to classiy swallowing disorders, there is a signicantreduction in severe dysphagia ater treatment and a raisein the number o subjects with normal and unctionalswallowing (Table 3), indicating a drop in severity.

Tbe 3. Progression o dysphagia

Speech therpy dgossPre-tretmet Post-tretmet

p-vlue % %

Normal or functional

swallowing8 34.8% 13 56.5% 0.139

Mild to mild-moderate

dysphagia6 26.1% 7 30.4% 0.743

Moderate to moderate-

severe dysphagia2 8.7% 1 4.3% 0.550

Severe dysphagia 7 30.4% 0 0.0% 0.004*

Death 0 0.0% 2 8.7% 0.148

*p 0.05

As we analyze Figure 3, we observed the distributiono patients among the diagnoses proposed by the scale,and there is an increase in mild dysphagias and normal/unctional swallowing.

Insoar as speech therapy is concerned, we oundstatistical signicance or the speech therapy procedureo ood reintroduction, and 73.9% o individuals were

submitted to this procedure ater evaluation or duringtreatment (Table 4). We stress that the patients whounderwent speech therapy and had an improvementin their swallowing unction were later subjected toood reintroduction. Among those patients who did notundergo this diet reintroduction procedure, three hadnormal swallowing during speech evaluation, two hadunctional swallowing and one died during treatment.

Fue 3. Progressive profle o dysphagia

Tbe 4. Speech therapyintervention

Therpy Food retroducto Cotued wrd tretmet

Yes no Yes no Yes no

56.5% 43.5% 73.9% 26.1% 39.1% 60.9%

p = 0.376 p = 0.001* p = 0.140

*p 0.05

In relation to oral eeding (Table 5),52.2% o subjects were considered ready to start oral intake ater initialassessment, and in the nal evaluation ater speech therapy,91.3% o individuals were ready or oral intake o oodbearing at least one consistency a rate that is statisticallysignicant when compared to the previous one. We highlightthat two individuals died during treatment, thereore it wasnot possible to make their nal assessment.

Tbe 5. Possible indication o oral eedingPre-tretmet Post-tretmet

P % %

12 52.2% 21 91.3% < 0.001*

*p 0.05

By using the Mann-Whitney test to compare initialspeech therapy diagnosis and age and number o sessionsrequired (Table 6), we observed that there is signicantdierence only between initial speech diagnosis or thenumber o sessions required, and dysphagia required themost sessions, also observed in Figure 4.


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361Functional prole o swallowing in clinical intensive care

Tbe 6. Age, diagnosis and number o sessions

itl

speech

therpy

dgoss

number of sessos age

norml/

fuctol

swllowg

Dysphg

norml/

fuctol

swllowg

Dysphg

Mean 1.13 4.13 37.38 46.13

Median 0.5 4 37.5 52

Standard

deviation1.46 2.92 11.07 16.62

VC 129.6% 70.8% 29.6% 36.0%

CI 1.01 1.48 7.67 8.41

p value 0.004* 0.146

*p 0.05

Fue 4. Mean number o sessions

In sum, we have results that measure the degree orelation and/or association between the initial speechdiagnosis and the need or ollow up in the ward (Table7). For such analysis we used the chi-squared test.We noticed that there was no statistically signicantrelation between the initial speech diagnosis and theneed or ollow up in the ward. Nonetheless, sincethe p-value is very close to the acceptance threshold(0.056), we can say that there is a tendency towardssuch relation.

DiSCUSSiOn

Speech therapy participation in clinical ICU wasrestricted to the cases reerred by the medical team.Other proessionals rom the multidisciplinary team, suchas nurses, physical therapists and nutritionists could also

collaborate in detecting swallowing disorders, and reerdysphagia patients early on, thus reducing the incidenceo aspiration.

Evaluations by the speech therapy team werecarried out by means o specic tests described in theliterature(1,10-11), making clinical diagnosis more reliable.O the patients reerred, we noticed a 65% prevalenceo dysphagia in a our-month period.

Among patients who were previously submittedto orotracheal intubation we noticed a prevalence ooropharyngeal dysphagia. Other studies corroborated

Tbe 7. Need to ollow-up in the unit

itl speech

therpy

dgoss

Follow-up the utTotl

no Yes

number % number % number %

Normal/functional

swallowing7 50.0% 1 11.1% 8 34.8%

Dysphagia 7 50.0% 8 88.9% 15 65.2%

Total 14 60.9% 9 39.1% 23 100%

p = 0.056

such data and reported a swallowing disorder prevalenceo 20% to 83% ater prolongued intubation(14). Hence, itis reasonable to propose that these patients should beevaluated in the ICU, because they bear considerablerisk o aspiration.

There was a reduction in dysphagia severity aterspeech therapy intervention. The use o a unctionalscale or dysphagia severity helps control speechtherapy intervention in the middle and long run(12),

although retrospective analyses does not avorthe systematic collection o data on the treatmenttechniques used in such intervention.

In the present investigation we noticed a high variability as to the number o sessions required,mainly due to dysphagia severity. This happenedbecause the most severe swallowing disorder imliesan increase in the number and diversity o techniques,requiring more time or learning and training on thetherapeutic process.

There was a need to continue with speech therapyin the ward in 39% o cases, indicating that this typeo care is not restricted to the ICU, it is necessary toextend the work, sometimes to the outpatient wards.

COnClUSiOn

Speech therapy support to non-neurogenic dysphagiasin clinical ICU ocuses mainly on patients whoremained in orotracheal intubation or longer than48 hours. Considering a dysphagia rate o 64% insuch population, thus it is reasonable to evaluate thisgroup already in the ICU, because they bear risk o

aspiration.The patients evaluated had a higher degree o

dysphagia in their irst assessment, with an increasein the possibility o oral eeding ater intervention.It is possible that preventive measures related toclinical observation during the re-eeding process inthe irst days ater extubation would make oral oodintake a saer process.

Scales help us assess the unctional proile oindividuals admitted to the ICU, also helping us checkthe level o dysphagia severity.


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rEFErEnCES

1. Lim SH, Lieu PK, Phua SY, Seshadri R, Venketasubramanian N, Lee SH, et al.Accuracy o bedside clinical methods compared with beroptic endoscopicexamination o swallowing (FEES) in determining the risk o aspiration in acutestroke patients. Dysphagia. 2001;16(1):1-6.

2. Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S. Formal dysphagiascreening protocols prevent pneumonia. Stroke. 2005;36(9):1972-6.

3. Ramsey DJ, Smithard DG, Kalra L. Early assessments o dysphagia and aspiration

risk in acute stroke patients. Stroke. 2003;34(5):1252-7.4. Goldsmith T. Evaluation and treatment o swallowing disorders ollowing endotracheal

intubation and tracheostomy. Int Anesthesiol Clin. 2000;38(3):219-42.

5. Barquist E, Brown M, Cohn S, Lundy D, Jackowski J. Postextubation beropticendoscopic evaluation o swallowing ater prolonged endotracheal intubation:a randomized, prospective trial. Crit Care Med. 2001;29(9):1710-3.

6. Frank U, Mader M, Sticher H. Dysphagic patients with tracheotomies: amultidisciplinary approach to treatment and decannulation management.Dysphagia. 2007;22(1):20-9.

7. de Larminat V, Montravers P, Dureuil B, Desmonts JM. Alteration in swallowingrelex ater extubation in intensive care unit patients. Crit Care Med.1995;23(3):486-90.

8. Tolep K, Getch CL, Criner GJ. Swallowing dysunction in patients receivingprolonged mechanical ventilation. Chest. 1996;109(1):167-72.

9. Blot F, Melot C. Indications, timing, and techniques o tracheostomy in 152French ICUs. Chest. 2005;127(4):1347-52.

10. Tohara H, Saitoh E, Mays KA, Kuhlemeier K, Palmer JB. Three tests or predictingaspiration without videofuorography. Dysphagia. 2003;18(2):126-34.

11. Leslie P, Drinnan MJ, Finn P, Ford GA, Wilson JA. Reliability and validity o cervicalauscultation: a controlled comparison using videofuoroscopy. Dysphagia.2004;19(4):231-40.

12. ONeil KH, Purdy M, Falk J, Gallo L. The Dysphagia Outcome and Severity Scale.Dysphagia. 1999;14(3):139-45.

13. American Speech-Language-Hearing Association. Model Medical ReviewGuidelines or Dysphagia Services [monography on the Internet]. [cited 2007July 19]. Available rom: 2004. http://www.asha.org/NR/rdonlyres/ 5771B0F7-D7C0-4D47- 832A-86FC6FEC2AE0/0/DynCorpDysphHCEC.pd

14. El Solh A, Okada M, Bhat A, Pietrantoni C. Swallowing disorders postorotrachealintubation in the elderly. Intensive Care Med. 2003;29(9):1451-5

functional profile of swallowing in clinical intensive care

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