Original article

Dysphagia in the intensive care unit in Switzerland (DICE) – results of a national survey on the current standard of care

DOI: https://doi.org/10.4414/smw.2019.20111
Publication Date: 22.07.2019
Swiss Med Wkly. 2019;149:w20111

Zuercher Patrick, Moret Céline, Schefold Joerg C.

Dept. of Intensive Care Medicine, Inselspital, Bern University Hospital, Bern, Switzerland

Summary

INTRODUCTION

Oropharyngeal dysphagia (OD) is often observed in critically ill patients. In most affected patients OD persists throughout hospital stay and negatively impacts on clinical outcomes. Here we systematically explore routine clinical practice standards for recognition/screening, diagnosis and treatment of OD in accredited Swiss ICUs.

METHODS

An online, 23-item questionnaire-based survey was performed to investigate current standards of care for OD in Switzerland (DICE). All (n = 49) accredited Swiss teaching hospitals providing specialist training for adult intensive care medicine were contacted. Senior intensivists were interviewed on how they would screen for, diagnose and treat OD in the ICU.

RESULTS

The total response rate was 75.5%, with information available on all tertiary care academic centres. 67.6% (25/37) of institutions stated that they have established standard operating procedures for OD using a mostly sequential diagnostic approach (86.5%, 32/37). In 75.7% (28/37) of institutions, OD confirmation is performed without the use of instrumental techniques such as flexible (or fibre-endoscopic) evaluation of swallowing (FEES). Presumed key risk factors for OD were admission for acute neurological illness, long-term mechanical ventilation, ICU-acquired weakness and pre-existing neurological disease. Reported presumed OD-related complications typically include aspiration-induced pneumonia, increased rates of both reintubation and tracheostomy and increased ICU readmission rates.

CONCLUSIONS

Many Swiss ICUs have established standard operating procedures, with most using sequential clinical approaches to assess ICU patients at risk of dysphagia. OD confirmation is mostly performed using non-instrumental techniques. In general, it appears that awareness of OD and ICU educational curricula can be further optimised.

Trial registration number

NCT 03487510

Keywords: dysphagia, critical illness, ICU, swallowing dysfunction, deglutition disorder, sepsis

Introduction

Oropharyngeal dysphagia (OD) and its associated consequences (e.g. aspiration-induced pneumonia) can often be observed in intensive care units (ICUs) [1, 2]. Until recently, the incidence of dysphagia in general ICU populations was unclear, with many studies limited by design, sample size or inclusion of heterogenous patient cohorts [38]. Recent data from a large-scale prospective study in a non-selected (i.e. mixed medical/surgical) ICU population demonstrate an incidence of post-extubation dysphagia (PED) on the ICU of 12.4% (18% of emergency admissions affected), with dysphagia mostly persisting until hospital discharge and an excess 90-day mortality rate of 9.2% [9]. In addition, data hint at a high economic burden of dysphagia on both the ICU sector and public health care systems [9, 10].

Importantly, there is currently a lack of standardised protocols to assess OD. Different approaches to dysphagia assessment in the ICU, e.g. both screening for OD risk and following this with confirmatory testing, have been proposed. Confirmatory tests differ regarding whether they are performed using non-instrumental, i.e. clinical, approaches by dysphagia specialists ([1129]; reviewed in [30]), or using instrumental measures [3144], e.g. flexible endoscopic evaluation of swallowing (FEES) or video-fluoroscopic swallowing study (VFSS) [2]. Importantly, awareness of OD in the ICU regarding screening for, diagnosing or managing it may be limited, and an accepted standard of care for OD assessment in ICU patients is currently lacking [45, 46]. In light of the fact that dysphagia is a commonly observed clinical problem on the ICU and the lack of an internationally accepted clinical standard, the present survey (DICE) aims to explore the current clinical standard of care for OD management in Switzerland. This includes dysphagia recognition, screening, diagnosis and treatment in Swiss ICUs.

Material and methods

A 23-item internet-based questionnaire (see appendix 1) was used to systematically record the current screening, diagnosis and treatment approaches for OD on Swiss ICUs (DICE). This questionnaire was developed based on our own institutional experience, established internal standard operating procedures, and data presented in the DYnAMICS study [9] and other recent publications on dysphagia [2, 30]. All 49 Swiss ICUs accredited by the Swiss Institute for Continuous Education for ICU training in adults were contacted and asked about their local clinical practice standards. Units are categorised as Au, A, B and C according to their accreditation levels (Au being tertiary care academic teaching hospitals). Further details are listed elsewhere (www.siwf-register.ch). DICE was performed from 11/2017 until 03/2018. Chief physicians and/or senior ICU specialists were invited to participate and complete the questionnaire. The 49 accredited Swiss ICUs include seven tertiary academic centres (Au). These provide care for mixed medical/surgical populations (n = 3), strictly surgical (n = 2) or strictly medical (n = 2) patient cohorts. The remaining 42 institutions are categorised as A-level (n = 10), B-level (n = 11) or C-level institutions (n = 21). They provide intensive care for mostly mixed patient populations. No specific hypothesis was used. The intension was to investigate the current (national) standard of ICU care. Ethics approval for DICE-Swiss was waived by the Ethics Committee on Human Research (Kantonale Ethik-Kommission, KEK, Bern, Switzerland).

Statistical analysis

Descriptive analyses were used to compare results reported as counts or percentages. For categorical data, Fishers’ exact test was used to compare nominal data between groups with small sample sizes. Significance was assigned to cases where a two-sided p-value was <0.05. Statistical analysis was performed using MedCalc 16.4.3 Software (MedCalc, Mariakerke, Belgium) and SPSS (IBM SPSS Statistics, Version 25).

Results

Centre characteristics and response rates

Thirty-seven registered Swiss ICUs participated in this nationwide investigation (total response rate of 75.5%). All (n = 7, 100%) accredited tertiary care academic university hospitals (Au-units) participated in the survey. Duplicate reports were returned by two institutions, resulting in only the first report being analysed, as pre-defined. Data were available from n = 9/10 (90%) of the A-units, n = 10/11 (91%) of the B-units, and n = 11/21 (52%) of the C-units (table 1). Most ICUs were interdisciplinary (medical/surgical, n = 26/37, 70.3%), followed by mixed medical or mixed surgical units (both n = 4/37, 10.8%). Two neurological units and one cardiovascular unit were included (table 1). The total number of ICU beds per unit ranged from ≤6 beds (n = 1) to 7–12 beds (n = 21/37, 56.8%), and ≥30 beds (n = 3). The number of patients treated per year ranged from <750 patients (n = 4/37, 10.8%), 751–1500 patients (n = 20/37, 54.1%), 1501–2250 patients (n = 6/37, 16.2%), 2251–3,000 patients (n = 5/37, 13.5%) to 3001–3750 patients (n = 2/37, 5.4%).

Table 1

Centre characteristics.

 Training level
Au
(n = 7/7)*
A
(n = 9/10)
B
(n = 10/11)
C
(n = 11/21)
n (%)n (%)n (%)n (%)
Type of ICUInterdisciplinary (mixed medical/surgical)3 (42.9)6 (66.7)9 (90)8 (72.7)
Mixed medical2 (28.6)1 (11.1) 1 (9.1)
Mixed surgical2 (28.6)2 (22.2)  
Neurological  1 (10)1 (9.1)
Cardiovascular   1 (9.1)
Beds per ICU1–6   1 (9.1)
7–121 (14.3)2 (22.2)8 (80)10 (90.9)
13–181 (14.3)4 (44.4)1 (10) 
19–242 (28.6)3 (33.3)1 (10) 
>303 (42.9)   
Patients per year<750  1 (10)3 (27.3)
751–15002 (28.6)4 (44.4)7 (70)7 (63.6)
1501–22501 (14.3)3 (33.3)2 (20) 
2251–30003 (42.9)1 (11.1) 1 (9.1)
3001–37501 (14.3)1 (11.1)  

* 49 accredited ICU training units were contacted initially (response rate 76%).

Screening approaches

All participating units considered swallowing disorders a significant clinical problem in the ICU. Approximately 68% of institutions have a standard operating procedure (SOP) for OD (n = 25/37). Three units planned to implement an SOP in the near future, whereas nine units (n = 9/37, 24.3%) had not installed an SOP and had no plan to install one in the near future (see appendix 2). Twenty-seven percent (n = 10/37) of institutions systematically screen all ICU patients, whereas in the majority (73%, n = 27/37) of units, dysphagia-related risk is assessed on an individual basis (table 2). Five units assess all potentially affected ICU patients (table 2).

Table 2

Responses regarding the screening, confirmation and treatment of dysphagia in all participating ICUs, as well as the methods used for assessing OD.

ICU responsesAll
(n = 37)
Au+A ICUs
(n = 16)
B+C ICUs
(n = 21)
p-Value
n%n%n%
Screening of which patients?All513.5212.5314.31.00
Post extubation2567.612751361.90.49
With baseline neurodeficits2362.2743.81676.20.09
Pre-existing dysphagia2362.28501571.40.31
Clinical signs2567.61062.51571.40.73
Screening performed by?ICU nurse2464.91168.81361.90.74
Any nurse1027.0425628.61.00
SLT1027.0425628.61.00
PT1232.4425838.10.49
OT513.5212.5314.31.00
ICU physician25.4  29.50.50
ENT physician12.7  14.81.00
How do you screen?FEES12.7  14.81.00
BSE1335.1531.3838.10.74
WST1951.41062.5942.90.33
Test meal12.7  14.81.00
Other38.116.2529.51.00
Confirmation of OD by?No confirmatory examination12.7  14.81.00
SLT2054.1956.31152.41.00
PT924.3637.5314.30.14
OT718.9212.5523.80.67
ICU physician25.4  29.50.50
ENT physician1643.2850838.10.52
Any nurse12.716.25  0.43
Method for confirmation?Clinical evidence410.8  419.00.12
BSE2362.21062.51361.91.00
FEES924.3531.3419.00.46
other12.716.25  0.43
Treatment for OD?NPO924.3637.5314.30.14
Dietary modification2978.412751781.00.71
Tube feeding1848.6743.81152.40.74
Tracheostomy821.6637.529.50.06
Training3491.91381.321100.00.07

BSE = bedside swallowing evaluation; ENT = ear-nose-throat; FEES = flexible endoscopic evaluation of swallowing; ICU = intensive care unit; NPO = nil per os; OD = oropharyngeal dysphagia; OT = occupational therapist; PT = physiotherapist; SLT = speech and language therapist; WST = water swallow test;
Fisher’s exact test was used for between-group comparison (A level vs B/C level teaching hospitals).

Frequency analysis showed that in 17 out of 37 units (46%, multiple answers analysis, data not shown), OD risk was assessed in four groups of patients, i.e. in ICU patients post extubation/decannulation, in patients with known baseline neurological disease, in cases of pre-existing swallowing disorders, and in patients with clinical signs suggesting a deglutition disorder. When analysing these categories separately, ICU patients post extubation and patients with clinical signs indicating dysphagia are screened with the highest frequency (67.6%). This is followed by patients with neurological deficits and patients with pre-existing swallowing dysfunctions (62.2%).

Technical aspects regarding screening measures

The initial screening is performed by trained ICU nurses in the majority (65%) of institutions, followed by other nurses (n = 10/37, 27%), speech language therapists (SLT, 27%), physiotherapists (PT, 32%) and occupational therapists (OT, 13.5%). In three units, screening is performed by physicians (ICU physician in n = 2/37, 5.4%; ear-nose-throat (ENT) physician n = 1/37, 2.7%). Initial screening is mostly performed non-instrumentally using a bedside swallowing evaluation (BSE, n = 13/37, 35.1%) or a water swallow test (WST, n = 19/37, 51.4%). One unit reported performing an instrumental approach (FEES) (n = 1/37, 2.7%). (See table 2.)

Incidence of OD in Swiss units

Estimated dysphagia frequency rates in ICUs ranged from 0–10% (n = 4/37, 11%) to 71–80% (2/37, 5.4%), with the majority of units reporting an incidence between 11 and 20% or 21 and 30% (both n = 11/37, 30%).

Confirmatory testing for OD

Overall, 86.5% (32/37) of all units had established a sequential approach for dysphagia testing, i.e. a screening procedure for OD risk assessment followed by a confirmatory test evaluating OD presence. In 91.9% (34/37), OD diagnosis is established by a dysphagia specialist (either SLT, PT or OT). In a minority of units (n = 2) this would only be performed by a physician. One unit reported no confirmatory assessment measures. Most units have appointed multiple team members to participate in OD confirmation. In detail, testing by SLTs was reported to occur in 54.1% (n = 20/37), by PTs in 24.3% (n = 9/37), and by OTs in 18.9% (n = 7/37) of institutions. OD confirmation is performed by ICU physicians in 5.4% (n = 2/37) and by ENT physicians in 43.2% (n = 16/37) of institutions. BSE is the bedside clinical exam most commonly used to establish a diagnosis (n = 23/37, 62.2%), followed by FEES (24.3%, n = 9/37), which is performed mostly by ENT physicians (n = 6/9, 66.7%). Diagnosis is established by ICU physicians who do not have formal FEES accreditation in 2.7% (n = 1/37) of institutions, and other approaches are used in 5.4% (n = 2/37) of institutions. (See table 2.)

Therapeutic approaches to OD

The reported treatment approaches for OD highlighted two main pillars of dysphagia management: dietary texture modification (78.4%, 29/37) and swallowing training by dysphagia specialists alongside functional therapy including postural changes (91.9%, 34/37). Temporary nil per os (NPO) was implemented in about a quarter of all participating units (24.3%, 9/37), with tube feeding required in 48.6% (n = 18/37) and tracheostomy required in 21.6% (n = 8/37). The responses received suggest that electrical or magnetic stimulatory techniques or any other artificial devices are not used in any of the participating ICUs. (See table 2.)

Risk factors for OD development and complications

The following suspected risk factors for OD were reported: admission for neurological disease (94.6%, n = 35/37), long-term (>5 days) mechanical ventilation/intubation (86.5%, n = 32/37), presence of ICU-acquired weakness (83.8%, n = 31/37), pre-existing neurological disease (83.8%, n = 31/37), advanced age (59.5%, n = 22/37), post-trauma conditions (59.5%, n = 22/37), use of sedatives (51.4%, n = 19/37), patients with initial sepsis (40.5%, n = 15/37), feeding tube in situ (40.5%, n = 15/37), previous intubation (37.8%, n = 14/37), use of neurotropic medications (37.8%, n = 14/37), use of muscle relaxants (35.1%, n = 13/37), high cumulative amount of opioids (32.4%, n = 12/37), emergency admission (10.8%, n = 4/37) and presence of metabolic disorders (10.8%, n = 4/37) (table 3).

Table 3

Responses regarding the presumed risk factors, complications, suspected impact on mortality, prolongation of ICU LOS, in-hospital costs and awareness of dysphagia in participating ICUs.

ICU responsesAll
(n = 37)
Au+A ICUs
(n = 16)
B+C ICUs
(n = 21)
p-Value
n%n%n%
Presumed risk factors?Age2259956.31361.90.75
Emergency admission411212.529.521.00
Metabolic disorder41116.25314.30.62
Neurological disease3595161001990.50.50
Trauma22591062.51257.11.00
Sepsis1541637.5942.91.00
ICU AW3184161001571.40.03
Pre-existing neurodeficits31841487.517810.68
Intubation1438743.8733.30.73
Long-term intubation328612752095.20.14
Feeding tube1541637.5942.91.00
Sedatives19518501152.41.00
Muscle relaxants1335531.3838.10.74
Opioids1232637.5628.60.73
Neurotropic medication1438637.5838.11.00
Presumed complications?Pneumonia36971593.8211000.43
Sepsis1335531.3838.10.74
Readmission22591062.51257.11.00
Re-intubation26701168.81571.41.00
Tracheostomy225912751047.60.18
Decannulation failure1951637.51361.90.19
Malnutrition1541531.31047.60.50
OD impact on mortality?Yes33891487.51990.51.00
No411212.529.52 
OD prolongs ICU LOS?Yes30811381.317811.00
No616318.8314.3 
Undecided12.7 014.76 
OD increases costs?Yes3697161002095.21.00
No12.7 014.76 
Improve OD awareness?Yes1951956.31047.60.89
No1541637.5942.9 
Undecided38.116.2529.52 

ICU = intensive care unit; LOS = length of stay; OD = oropharyngeal dysphagia
Fisher’s exact test was used for between-group comparison (A level vs B/C level teaching hospitals).

A significant impact of OD on mid- or long-term mortality was assumed in nearly all participating ICUs (n = 33/37, 89.2%). Dysphagia was considered a factor which prolongs ICU stay (81.1%, n = 30/37) and increases total in-hospital treatment costs (97.3%, n = 36/37). Complications observed in the ICU include aspiration-induced pneumonia (97.3%, n = 36/37), increased reintubation (70.3%, n = 26/37) and readmission (59.5%, n = 22/37) rates, need for tracheostomy (59.5%, n = 22/37), decannulation failure (51.4%, n = 19/37) and malnutrition (40.5%, n = 15/37). 51.4% (n = 19/37) of units stated that awareness of OD on the ICU should be improved. (See table 3.)

Discussion

Previous data demonstrate that OD presents in many ICU patients, is associated with increased morbidity, and negatively impacts on mid-term survival. OD was an independent predictor of mortality in the DYnAMICS study, showing an excess 90-day mortality of +9.2% [9]. With increasing awareness of the associated socio-economic consequences, we investigated the current clinical practice standards in Swiss ICUs. In DICE, we observed that most ICUs have established internal standard operating procedures for OD, and that initial screening is performed at the bedside by nurses, followed by OD confirmation using non-instrumental methods (a sequential approach).

In this survey, estimates of OD incidence rates varied widely. Different responses are expected based on personal experience, and the rather wide range of variation may theoretically be related to differences between the institutions (e.g. increased OD rates in neuro-ICU units). Nevertheless, there was also a wide range of estimated OD incidence rates for units treating mixed populations of critically ill patients. It seems tempting to speculate that this may be related to the fact that most units have not installed a systematic assessment of all potentially affected ICU patients. In DICE, we found that in 24.3% of the participating institutions there is currently no SOP for OD management in place, and a minority (13.5%) screen all potentially affected ICU patients.

Presumed key consequences of OD included aspiration-induced pneumonia (97.3%). In this context, it may be important to note that mounting evidence (e.g. in stroke patients) shows that early identification of OD may reduce rates of pneumonia [47]. This evidence may support the screening of potentially affected ICU patients. Furthermore, evidence also shows an association between a failure to screen for dysphagia and subsequent adverse patient outcomes, with increased disability, a higher rate of discharge to a long-term care facility, and adverse outcomes up to 365 days post initial hospitalisation [48]. Although aspiration-induced pneumonia is well-known in everyday ICU practice, it should be noted that proving a cause-effect relationship between dysphagia screening and improved patient outcomes may be difficult to demonstrate [49, 50].

The MADICU study [45], a web-based survey of members of the European Society of Intensive Care Medicine (ESICM) and the German Society of Neuro-intensive and Emergency Medicine (DGNI), reported a high overall awareness of dysphagia on the ICU even among non-neurointensivists. About 80% perceived dysphagia as a relevant issue. This surprisingly high (according to the authors) percentage may be due to a selection bias, with more physicians who have a special interest in dysphagia participating in the survey. One key finding of the MADICU study is the lack of a standardised diagnostic and instrumental approach to screening and diagnosing dysphagia outside of a neurointensive care setting, with only 27.7% of ICU respondents having specific dysphagia-related protocols in use. Based on our survey, all participating Swiss ICUs considered dysphagia a problem in the ICU, with nearly 68% (25/37) already having a standard operating procedure in use. This is an even higher proportion than in the neuro-intensive care units which participated in the MADICU survey (n = 41/69, 60.3%). FEES seemed to be more widely available for evaluating dysphagia among the units which participated in the MADICU study, with an overall availability of 51.1% (n = 268/528), and used more frequently in both the neuro-intensive care setting (n = 59/69, 85.5%) and in the general ICU environment (n = 209/459, 45.8%) than in Switzerland (n = 9/37, 24.3%).

Another study, a nationwide survey of Dutch Intensive Care Units [46], found a high overall awareness of dysphagia (Likert score ≥4 from 84% of respondents), but found that only a few ICUs (n = 15/67, 22%) had established standard operating procedures for dysphagia. Furthermore, in this Dutch investigation only one unit routinely used FEES for dysphagia screening, which is in line with the findings reported here. However, whereas about 60% (40/67) of ICUs occasionally use FEES in The Netherlands, this is only rarely implemented on Swiss ICUs.

Over 88,000 ICU patients were admitted to Swiss ICUs in 2017, with 34% in need of invasive mechanical ventilation (Swiss Society of Intensive Care Medicine [51]). Given an incidence of post-extubation dysphagia of 12.4% [9] according to the largest prospective investigation using a systematic screening approach, approximately 3,700 patients may have been affected by OD in Switzerland in 2017. Thus, about 340 dysphagia-related deaths (9.2% excess 90-day mortality rate) may have occurred in Switzerland in 2017. This underlines the importance of OD on the ICU.

We are aware of limitations of this survey, including the fact that the presented results could theoretically reflect the opinions of the senior ICU physicians who participated, and not objectively present patient data (e.g. regarding OD incidence). In contrast to the MADICU survey, in which it is most likely that ICU physicians with a special interest in dysphagia participated, we deliberately aimed to exclude this potential selection bias. However, although we cannot rule out a certain bias, a near complete data set of all the major teaching hospitals is presented in the current investigation. Furthermore, by nature of the deliberately chosen approach, a survey can only present the standards of care current at the time the investigation is performed.

Conclusions

Most Swiss ICUs have established standard operating procedures for the assessment of dysphagia on the ICU. Sequential approaches most often use non-instrumental assessment techniques. Most senior ICU physicians believe that awareness of dysphagia could be improved. We thus support the creation of an international expert panel to address recommendations for optimal OD screening, confirmation and management in critically ill patients on the ICU.

Financial disclosure

No financial support for this study was reported.

Potential competing interests

PZ, CM and JCS report departmental grants (full disclosure) from Orion Pharma, Abbott Nutrition International, B. Braun Medical AG, CSEM AG, Edwards Lifesciences Services GmbH, Kenta Biotech Ltd, Maquet Critical Care AB, Omnicare Clinical Research AG, Nestle, Pierre Fabre Pharma AG, Pfizer, Bard Medica S.A., Abbott AG, Anandic Medical Systems, Pan Gas AG Healthcare, Bracco, Hamilton Medical AG, Fresenius Kabi, Getinge Group Maquet AG, Dräger AG, Teleflex Medical GmbH, Glaxo Smith Kline, Merck Sharp and Dohme AG, Eli Lilly and Company, Baxter, Astellas, Astra Zeneca, CSL Behring, Novartis, Covidien, and Nycomed outside of the submitted work. The money was paid into departmental funds. There was no personal financial gain.

Credits

Header image: © Sudok1 - Dreamstime.com

Correspondence

Dr Patrick Zuercher, MD, Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, CH–3016 Bern, patrick.zuercher[at]insel.ch

References

1 Skoretz SA, Flowers HL, Martino R. The incidence of dysphagia following endotracheal intubation: a systematic review. Chest. 2010;137(3):665–73. doi:. http://dx.doi.org/10.1378/chest.09-1823 PubMed

2 Zuercher P, Moret CS, Dziewas R, Schefold JC. Dysphagia in the intensive care unit: epidemiology, mechanisms, and clinical management. Crit Care. 2019;23(1):103. doi:. http://dx.doi.org/10.1186/s13054-019-2400-2 PubMed

3 Brodsky MB, Gellar JE, Dinglas VD, Colantuoni E, Mendez-Tellez PA, Shanholtz C, et al.Duration of oral endotracheal intubation is associated with dysphagia symptoms in acute lung injury patients. J Crit Care. 2014;29(4):574–9. doi:. http://dx.doi.org/10.1016/j.jcrc.2014.02.015 PubMed

4 Macht M, King CJ, Wimbish T, Clark BJ, Benson AB, Burnham EL, et al.Post-extubation dysphagia is associated with longer hospitalization in survivors of critical illness with neurologic impairment. Crit Care. 2013;17(3):R119. doi:. http://dx.doi.org/10.1186/cc12791 PubMed

5 Macht M, Wimbish T, Bodine C, Moss M. ICU-acquired swallowing disorders. Crit Care Med. 2013;41(10):2396–405. doi:. http://dx.doi.org/10.1097/CCM.0b013e31829caf33 PubMed

6 Moraes DP, Sassi FC, Mangilli LD, Zilberstein B, de Andrade CR. Clinical prognostic indicators of dysphagia following prolonged orotracheal intubation in ICU patients. Crit Care. 2013;17(5):R243. doi:. http://dx.doi.org/10.1186/cc13069 PubMed

7 Zielske J, Bohne S, Brunkhorst FM, Axer H, Guntinas-Lichius O. Acute and long-term dysphagia in critically ill patients with severe sepsis: results of a prospective controlled observational study. Eur Arch Otorhinolaryngol. 2014;271(11):3085–93. doi:. http://dx.doi.org/10.1007/s00405-014-3148-6 PubMed

8 Brown CV, Hejl K, Mandaville AD, Chaney PE, Stevenson G, Smith C. Swallowing dysfunction after mechanical ventilation in trauma patients. J Crit Care. 2011;26(1):108.e9–13. doi:. http://dx.doi.org/10.1016/j.jcrc.2010.05.036 PubMed

9 Schefold JC, Berger D, Zürcher P, Lensch M, Perren A, Jakob SM, et al.Dysphagia in Mechanically Ventilated ICU Patients (DYnAMICS): A Prospective Observational Trial. Crit Care Med. 2017;45(12):2061–9. doi:. http://dx.doi.org/10.1097/CCM.0000000000002765 PubMed

10 Altman KW, Yu GP, Schaefer SD. Consequence of dysphagia in the hospitalized patient: impact on prognosis and hospital resources. Arch Otolaryngol Head Neck Surg. 2010;136(8):784–9. doi:. http://dx.doi.org/10.1001/archoto.2010.129 PubMed

11 Antonios N, Carnaby-Mann G, Crary M, Miller L, Hubbard H, Hood K, et al.Analysis of a physician tool for evaluating dysphagia on an inpatient stroke unit: the modified Mann Assessment of Swallowing Ability. J Stroke Cerebrovasc Dis. 2010;19(1):49–57. doi:. http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2009.03.007 PubMed

12 Carnaby GD, Crary MA. Development and validation of a cancer-specific swallowing assessment tool: MASA-C. Support Care Cancer. 2014;22(3):595–602. doi:. http://dx.doi.org/10.1007/s00520-013-2011-4 PubMed

13 Clavé P, Arreola V, Romea M, Medina L, Palomera E, Serra-Prat M. Accuracy of the volume-viscosity swallow test for clinical screening of oropharyngeal dysphagia and aspiration. Clin Nutr. 2008;27(6):806–15. doi:. http://dx.doi.org/10.1016/j.clnu.2008.06.011 PubMed

14 González-Fernández M, Sein MT, Palmer JB. Clinical experience using the Mann assessment of swallowing ability for identification of patients at risk for aspiration in a mixed-disease population. Am J Speech Lang Pathol. 2011;20(4):331–6. doi:. http://dx.doi.org/10.1044/1058-0360(2011/10-0082) PubMed

15 Guillén-Solà A, Martínez-Orfila J, Boza Gómez R, Monleón Castelló S, Marco E. Cribaje de la disfagia en el ictus: utilidad de los signos clínicos y el método de exploración clínica de volumen viscosidad en comparación con la videofluoroscopia. Rehabilitación. 2011;45(4):292–300. doi:. http://dx.doi.org/10.1016/j.rh.2011.06.006

16 Hansen T, Lambert HC, Faber J. Validation of the Danish version of the McGill Ingestive Skills Assessment using classical test theory and the Rasch model. Disabil Rehabil. 2012;34(10):859–68. doi:. http://dx.doi.org/10.3109/09638288.2011.624249 PubMed

17 Lambert HC, Gisel EG, Groher ME, Abrahamowicz M, Wood-Dauphinee S. Psychometric testing of the McGill Ingestive Skills Assessment. Am J Occup Ther. 2006;60(4):409–19. doi:. http://dx.doi.org/10.5014/ajot.60.4.409 PubMed

18 Lee KM, Kim HJ. Practical Assessment of Dysphagia in Stroke Patients. Ann Rehabil Med. 2015;39(6):1018–27. doi:. http://dx.doi.org/10.5535/arm.2015.39.6.1018 PubMed

19 Logemann JA, Veis S, Colangelo L. A screening procedure for oropharyngeal dysphagia. Dysphagia. 1999;14(1):44–51. doi:. http://dx.doi.org/10.1007/PL00009583 PubMed

20 Lynch YT, Clark BJ, Macht M, White SD, Taylor H, Wimbish T, et al.The accuracy of the bedside swallowing evaluation for detecting aspiration in survivors of acute respiratory failure. J Crit Care. 2017;39:143–8. doi:. http://dx.doi.org/10.1016/j.jcrc.2017.02.013 PubMed

21 Maeda K, Shamoto H, Wakabayashi H, Enomoto J, Takeichi M, Koyama T. Reliability and Validity of a Simplified Comprehensive Assessment Tool for Feeding Support: Kuchi-Kara Taberu Index. J Am Geriatr Soc. 2016;64(12):e248–52. doi:. http://dx.doi.org/10.1111/jgs.14508 PubMed

22 Mann G, Hankey GJ, Cameron D. Swallowing disorders following acute stroke: prevalence and diagnostic accuracy. Cerebrovasc Dis. 2000;10(5):380–6. doi:. http://dx.doi.org/10.1159/000016094 PubMed

23 Oh JC, Park JH, Jung MY, Yoo EY, Chang KY, Lee TY. Relationship between Quantified Instrumental Swallowing Examination and Comprehensive Clinical Swallowing Examination. Occup Ther Int. 2016;23(1):3–10. doi:. http://dx.doi.org/10.1002/oti.1391 PubMed

24 Paris G, Martinaud O, Hannequin D, Petit A, Cuvelier A, Guedon E, et al.Clinical screening of oropharyngeal dysphagia in patients with ALS. Ann Phys Rehabil Med. 2012;55(9-10):601–8. doi:. http://dx.doi.org/10.1016/j.rehab.2012.10.005 PubMed

25 Rofes L, Arreola V, Mukherjee R, Clavé P. Sensitivity and specificity of the Eating Assessment Tool and the Volume-Viscosity Swallow Test for clinical evaluation of oropharyngeal dysphagia. Neurogastroenterol Motil. 2014;26(9):1256–65. doi:. http://dx.doi.org/10.1111/nmo.12382 PubMed

26 Sheppard JJ, Hochman R, Baer C. The dysphagia disorder survey: validation of an assessment for swallowing and feeding function in developmental disability. Res Dev Disabil. 2014;35(5):929–42. doi:. http://dx.doi.org/10.1016/j.ridd.2014.02.017 PubMed

27 Trapl M, Enderle P, Nowotny M, Teuschl Y, Matz K, Dachenhausen A, et al.Dysphagia bedside screening for acute-stroke patients: the Gugging Swallowing Screen. Stroke. 2007;38(11):2948–52. doi:. http://dx.doi.org/10.1161/STROKEAHA.107.483933 PubMed

28 Warnecke T, Im S, Kaiser C, Hamacher C, Oelenberg S, Dziewas R. Aspiration and dysphagia screening in acute stroke - the Gugging Swallowing Screen revisited. Eur J Neurol. 2017;24(4):594–601. doi:. http://dx.doi.org/10.1111/ene.13251 PubMed

29 Zhou Z, Salle J, Daviet J, Stuit A, Nguyen C. Combined approach in bedside assessment of aspiration risk post stroke: PASS. Eur J Phys Rehabil Med. 2011;47(3):441–6. PubMed

30 Perren A, Zürcher P, Schefold JC. Clinical Approaches to Assess Post-extubation Dysphagia (PED) in the Critically Ill. Dysphagia. 2019. doi:. http://dx.doi.org/10.1007/s00455-019-09977-w PubMed

31 Aviv JE, Kaplan ST, Thomson JE, Spitzer J, Diamond B, Close LG. The safety of flexible endoscopic evaluation of swallowing with sensory testing (FEESST): an analysis of 500 consecutive evaluations. Dysphagia. 2000;15(1):39–44. doi:. http://dx.doi.org/10.1007/s004559910008 PubMed

32 Aviv JE, Kim T, Sacco RL, Kaplan S, Goodhart K, Diamond B, et al.FEESST: a new bedside endoscopic test of the motor and sensory components of swallowing. Ann Otol Rhinol Laryngol. 1998;107(5 Pt 1):378–87. PubMed

33 Castell JA, Castell DO. Modern solid state computerized manometry of the pharyngoesophageal segment. Dysphagia. 1993;8(3):270–5. doi:. http://dx.doi.org/10.1007/BF01354550 PubMed

34 Cook IJ, Dodds WJ, Dantas RO, Kern MK, Massey BT, Shaker R, et al.Timing of videofluoroscopic, manometric events, and bolus transit during the oral and pharyngeal phases of swallowing. Dysphagia. 1989;4(1):8–15. doi:. http://dx.doi.org/10.1007/BF02407397 PubMed

35 Dodds WJ, Hogan WJ, Lydon SB, Stewart ET, Stef JJ, Arndorfer RC. Quantitation of pharyngeal motor function in normal human subjects. J Appl Physiol. 1975;39(4):692–6. doi:. http://dx.doi.org/10.1152/jappl.1975.39.4.692 PubMed

36 Fanucci A, Cerro P, Ietto F, Brancaleone C, Berardi F. Physiology of oral swallowing studied by ultrasonography. Dentomaxillofac Radiol. 1994;23(4):221–5. doi:. http://dx.doi.org/10.1259/dmfr.23.4.7835528 PubMed

37 Fattori B, Grosso M, Bongioanni P, Nacci A, Cristofani R, AlSharif A, et al.Assessment of swallowing by oropharyngoesophageal scintigraphy in patients with amyotrophic lateral sclerosis. Dysphagia. 2006;21(4):280–6. doi:. http://dx.doi.org/10.1007/s00455-006-9052-5 PubMed

38 Hacki T, Kramer H, Kleinjung C, Pérez-Alvarez C, Schmid J. Endoskopische Mehrfarben-Schluckuntersuchung [Endoscopic multi-color deglutition study]. Laryngorhinootologie. 2001;80(6):335–40. In German. doi:. http://dx.doi.org/10.1055/s-2001-15078 PubMed

39 Hannig C, Wuttge-Hannig A, Hess U. [Analysis and radiologic staging of the type and severity of aspiration]. Radiologe. 1995;35(10):741–6. German. PubMed

40 Manabe N, Haruma K, Nakato R, Kusunoki H, Kamada T, Hata J. New ultrasonographic screening method for oropharyngeal dysphagia: tissue Doppler imaging. Am J Physiol Gastrointest Liver Physiol. 2018;314(1):G32–8. doi:. http://dx.doi.org/10.1152/ajpgi.00019.2017 PubMed

41 McConnel FM. Analysis of pressure generation and bolus transit during pharyngeal swallowing. Laryngoscope. 1988;98(1):71–8. doi:. http://dx.doi.org/10.1288/00005537-198801000-00015 PubMed

42 Palmer JB, Kuhlemeier KV, Tippett DC, Lynch C. A protocol for the videofluorographic swallowing study. Dysphagia. 1993;8(3):209–14. doi:. http://dx.doi.org/10.1007/BF01354540 PubMed

43 Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia. 1996;11(2):93–8. doi:. http://dx.doi.org/10.1007/BF00417897 PubMed

44 Schindler A, Ginocchio D, Peri A, Felisati G, Ottaviani F. FEESST in the rehabilitation of dysphagia after partial laryngectomy. Ann Otol Rhinol Laryngol. 2010;119(2):71–6. doi:. http://dx.doi.org/10.1177/000348941011900201 PubMed

45 Marian T, Dünser M, Citerio G, Koköfer A, Dziewas R. Are intensive care physicians aware of dysphagia? The MADICU survey results. Intensive Care Med. 2018;44(6):973–5. doi:. http://dx.doi.org/10.1007/s00134-018-5181-1 PubMed

46 van Snippenburg W, Kröner A, Flim M, Hofhuis J, Buise M, Hemler R, et al.Awareness and Management of Dysphagia in Dutch Intensive Care Units: A Nationwide Survey. Dysphagia. 2019;34(2):220–8. PubMed

47 Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S; Stroke Practice Improvement Network Investigators. Formal dysphagia screening protocols prevent pneumonia. Stroke. 2005;36(9):1972–6. doi:. http://dx.doi.org/10.1161/01.STR.0000177529.86868.8d PubMed

48 Joundi RA, Martino R, Saposnik G, Giannakeas V, Fang J, Kapral MK. Predictors and Outcomes of Dysphagia Screening After Acute Ischemic Stroke. Stroke. 2017;48(4):900–6. doi:. http://dx.doi.org/10.1161/STROKEAHA.116.015332 PubMed

49 Schefold JC, Zürcher P, Takala J. The authors reply. Crit Care Med. 2018;46(7):e727–8. doi:. http://dx.doi.org/10.1097/CCM.0000000000003163 PubMed

50 Zürcher P, Takala J, Schefold JC. The authors reply. Crit Care Med. 2018;46(4):e344–5. doi:. http://dx.doi.org/10.1097/CCM.0000000000002978 PubMed

51 Schweizerischen Gesellschaft für Intensivmedizin. Minimale Datensatz der SGI. Available at:https://www.sgi-ssmi.ch/de/datensatz.html?file=files/Dateiverwaltung/de/ressorts/quali/datsa/MDSi_d.pdf.

Appendix 1

Questionnaire

1 Where are you from?

2 What (ICU) type would best describe your unit?

. Interdisciplinary (Mixed medical/ surgical)

. Mixed medical

. Mixed surgical

. Trauma/ Neurosurgical

. Neurological

. Cardiovascular

. ECMO unit

3 How many total ICU beds?

. 1-6 / 7-12 / 13-18 / 19-24 / 25-30 / >30

4 How many patients do you treat per year on your ICU?

. < 750 / 751-1500 / 1501-2250 / 2251-3000 / 3001-3750 / 3751-4500 / 4501-5250 / 5251-6000 / >6000

5 Do you generally consider swallowing disorders (dysphagia) a problem in your ICU patients?

. yes / no

6 Do you have a standard of care for dysphagia, i.e. standard operating procedure (SOP) installed for dysphagia?

. yes / no / planned in near future

7 Do you routinely screen your ICU patients for dysphagia?

. yes, systematic screening of all ICU patients

. yes, screening on individual basis

. no screening performed

. screening planned in near future

8 Which patients do you screen for dysphagia on a routine basis?

. all ICU patients

. all ICU patients post extubation/ decannulation

. all ICU patients with baseline neurological disease

. all ICU patients with known pre-existing swallowing disorder

. all ICU patients with clinical signs for dysphagia (e.g. aspiration)

9 Based on your screening results/ guess: how many of your patients have dysphagia during ICU stay?

. 0-10% / 11-20% / 21-30% / 31-40% / 41-50% / 51-60% / 61-70% / 71-80% / 81-90% / 91-100%

10 If performed: who is initially screening for dysphagia on your ICU?

. no screening performed

. screening by trained ICU nurse

. screening by any nurse

. screening by speech language pathologist (SLT)

. screening by physiotherapist (PT)

. screening by an occupational therapist (OT, also ergotherapist)

. screening by ICU physician

. screening by Ear-Nose-Throat (ENT) physician

. screening by any other physician

11 How do you initially screen for dysphagia on your ICU?

. test meal

. non-instrumental: water swallow test

. non-instrumental: bedside clinical exam (BSE)

. fibre-endoscopic evaluation of swallowing (FEES)

. videofluorescent swallowing study (VFSS), modified barium swallow

. manometry

11(a) Who performs FEES at your unit?

. Ear-Nose-Throat (ENT) physician

. ICU physician with FEES accreditation

. ICU physician without FEES accreditation

. other

12 Do you have a sequential approach for dysphagia testing (screening followed by a specialist assessment)?

. yes / no

13 If a sequential approach is used: who is performing the specialist exam?

. does not apply: no confirmatory testing performed

. speech-language therapist (SLT)

. physiotherapist (PT)

. occupational therapist (OT, also ergotherapist)

. ICU physician

. Ear-Nose-Throat (ENT) physician

. any other physician

. trained ICU nurse

. any other nurse

14 What technique is used to establish the diagnosis "dysphagia"?

. clinical evidence for dysphagia (e.g. aspiration)

. clinical exam: bedside swallowing examination (BSE)

. fibre-endoscopic evaluation of swallowing (FEES)

. videofluoroscopic swallowing study (VFSS)

. manometry

14(a) Who performs FEES at your unit?

. Ear-Nose-Throat (ENT) physician

. ICU physician with FEES accreditation

. ICU physician without FEES accreditation

. other

15 How do you treat your ICU patients with dysphagia?

. nil per os during ICU stay

. dietary texture modification

. tube feeding only during ICU stay (oro-/naso-gastric, percutaneous enteral)

. (early) tracheostomy

. swallowing training: functional therapy for motor/ sensomotor recovery incl. postural changes (PT/SLT)

. catheter-related electric stimulation

. transcranial magnetic/ electrical stimulation

16 In your opinion, what are major risk factors for developing dysphagia in ICU patients?

. age of ICU patient

. emergency admission to ICU

. admission to ICU for acute metabolic disorder (e.g. acidosis, electrolyte, or azotemia)

. admission to ICU for acute neurological disease

. admission to ICU for trauma incl. traumatic brain injury (TBI)

. admission to ICU for sepsis/ septic shock

. pre-existing or (ICU-) acquired muscle wasting/ cachexia

. pre-existing neurological disease

. any oro-/naso-tracheal intubation

. long-term intubation (> 5 days)

. presence of oro- or nasogastric feeding tube

. cumulative amount of sedatives used

. cumulative amount of muscle relaxants used

. cumulative amount of opioids used

. cumulative amount of neurotropic medication (e.g. anti-convulsives, anti-psychotics, anti-depressants)

17 Do you think that dysphagia diagnosed on the ICU impacts mid- or long- term mortality (mortality at >28d)?

. yes / no / undecided

18 Do you think that dysphagia diagnosed on the ICU prolongs ICU length of stay?

. yes / no / undecided

19 Do you think that dysphagia diagnosed on the ICU increases total in-hospital treatment costs?

. yes / no / undecided

20 What type of dysphagia related medical complications do you routinely encounter in your ICU patients?

. no Dysphagia-related complications

. aspiration-induced pneumonia

. sepsis (e.g. due to pneumonia or catheter-related infections)

. need for ICU re-admission

. need for re-intubation

. need for tracheostomy

. failure for decannulation

. underfeeding / cachexia

21 Should dysphagia awareness be improved in your ICU?

. yes / no / undecided

22 Do you consider ICU acquired weakness (ICU-AW) a problem in your patients?

. yes / no / undecided

23 Do you have a standard operating procedure (SOP) for patients with ICU-AW?

. yes / no / planned to develop in the near future

Appendix 2

Additional results

ICU responses.

 All
(n = 37)
Au+A ICUs
(n = 16)
B+C ICUs
(n = 21)
p-value
n%n%n%
Is dysphagia a problem?Yes371001610021100 
SOP installed?Yes2567.612751361.90.87
No924.3318.8628.6 
Planned38.116.2529.5 
Screening routinely?Yes, all1027.0637.5419.00.27
Yes, selectively2773.01062.51781.0 
Estimated OD frequency?0–10%410.816.25314.30.62
11–20%1129.7531.3628.60.84
21–30%1129.7425733.30.72
31–40%513.5318.829.50.63
41–50%12.7  14.81.00
51–60%38.1212.514.80.57
71–80%25.416.2514.81.00
Sequential approach?Yes3286.51381.31990.50.63

ICU = intensive care unit; OD = oropharyngeal dysphagia; SOP = standard operating procedure

Verpassen Sie keinen Artikel!

close