Decannulation: a retrospective cohort study of clinical and swallowing indicators of success

Abstract Objective: To investigate the clinical and swallowing indicators related to a successful decannulation process during the hospital stay. Methods: A retrospective cohort clinical study. The study sample comprised a heterogeneous patient population who had submitted to a tracheostomy procedure in a tertiary hospital. Patients were divided into two groups (dec-annulated vs. non-decannulated) and compared not only in terms of demographic and clinical data but also the results of a swallowing assessment and intervention outcome. Results: Sixty-four patients were included in the present study: 25 (39%) who had been successfully decannulated, and 39 (61%) who could not be decannulated. Between-group comparisons indicated that both groups presented similar clinical and demographic characteristics. The groups also presented similar swallowing assessment results prior to intervention. However, significant differences were observed regarding the time to begin swallowing rehabilitation. The decannulated group was assessed nine days earlier than the non-decannulated group. Other significant differences included the removal of the alternate feeding method (72.0% of decannulated patients vs. 5.1% of non-decannulated patients) and the reintroduction of oral feeding (96.0% of decannulated patients vs. 41.0% of non-decannulated patients) and functional swallowing level at patient disclosure. The non-decannulated patient group presented higher death rates at disclosure. Conclusion: The results of the present study indicated that the following parameters were associated with a successful decannulation process: early swallowing assessment, swallowing rehabilitation, and improvement in the swallowing functional level during the hospital stay. The maintenance of low swallowing functional levels was found to be negatively associated with successful decannulation. HIGHLIGHTS Deccanulation indicators were investigated in patients who were submitted to a tracheostomy procedure. Early swallowing evaluation and rehabilitation were associated with a successful decannulation process. Low swallowing functional levels were negatively associated with the success of decannulation.

Functional development of swallowing in ICU patients with COVID-19. / Evolução funcional da deglutição em pacientes com COVID-19 internados em UTI.

PURPOSE: to describe de functional development of swallowing in Intensive Care Unit (ICU) patients with COVID-19, who were submitted to a swallowing intervention. METHODS: participants of the study were 77 patients (both gender, mean age 53.4±15.9; score on the Glasgow Coma Scale ≥14 and stable respiratory condition). The functional scale of swallowing used for assessment was the American Speech-Language-Hearing Association National Outcome Measurement System (ASHA NOMS). RESULTS: the results indicate that there was a significant recovery of the functional swallowing patterns when comparing the measurements pre and post swallowing intervention. CONCLUSION: 83% of the patients needed up to 3 swallowing interventions to recover a safe swallowing pattern.

OBJETIVO: descrever a evolução funcional da deglutição em pacientes com COVID-19 submetidos à intervenção fonoaudiológica na Unidade de Tratamento Intensivo (UTI). MÉTODO: participaram do estudo 77 pacientes (ambos os gêneros; idade média 53.4±15.9; escore na Escala de Coma de Glasgow ≥14; e condição respiratória estável). A escala funcional utilizada para a avaliação da deglutição foi a American Speech-Language-Hearing Association National Outcome Measurement System (ASHA NOMS). RESULTADOS: os resultados indicam que houve recuperação significativa nos padrões funcionais da deglutição na comparação pré e pós-intervenção fonoaudiológica. CONCLUSÃO: 83% dos pacientes necessitam de até 3 intervenções para a recuperação dos padrões seguros de deglutição.

Diagnostic precision for bronchopulmonary aspiration in a heterogeneous population. / Precisão diagnóstica para o risco de broncoaspiração em população heterogênea.

PURPOSE: The purpose of the present study was to assess the validity of a simple instrument for screening dysphagia used in a large public hospital in Brazil with heterogeneous adult population. METHOD: The Dysphagia Risk Evaluation Protocol (DREP) - screening version contains four items (altered cervical auscultation, altered vocal quality, coughing and choking before / during / after swallowing) that were previously indicated as independent risk factors associated to the presence of dysphagia in the swallowing test with water. Trained speech therapists administered and scored DREP - screening version to consecutive patients referred by hospital's medical team to perform Video Fluoroscopic for Swallowing Study (VFSS). RESULTS: 211 patients received the swallowing screen (DREP): 99 failed and 112 passed. One in every five patients was randomized to receive a VFSS. The DREP screening version demonstrated excellent validity with sensitivity at 92.9%, specificity at 75.0%, negative predictive values at 95.5% and an accuracy of 80.9%. CONCLUSION: The DREP - screening version is a simple and accurate tool to identify the risk for penetration and / or aspiration in patients who are not tube-fed, who have a good level of alertness, have no history of recurrent pneumonia, are not on pneumonia, and that do not use a tracheostomy cannula.

OBJETIVO: O objetivo do presente estudo foi realizar a validação de um instrumento simples de triagem da disfagia utilizado em um hospital público de grande porte no Brasil em população adulta heterogênea. MÉTODO: O Protocolo de Avaliação de Risco para Disfagia versão de triagem (PARDt) contém quatro itens (ausculta cervical alterada, alteração da qualidade vocal, tosse e engasgo antes/durante/após a deglutição) que foram previamente indicados como fatores de risco independentes associados à presença de disfagia no teste de deglutição com água. Fonoaudiólogos treinados administraram e classificaram o PARDt para pacientes consecutivos encaminhados pela equipe médica do hospital para realizar a videofluoroscopia da deglutição (VDF). RESULTADOS: 211 pacientes foram submetidos ao PARDt: 99 falharam e 112 passaram. Um em cada cinco pacientes foram randomicamente selecionados para VDF. O PARDt apresentou excelente validade: sensibilidade de 92,9%; especificidade de 75,0%; valores preditivos negativos de 95,5%; acurácia de 80,9%. CONCLUSÃO: O PARDt é uma ferramenta simples e precisa para identificar o risco de penetração e/ou aspiração em pacientes que não são alimentados por sonda, que apresentam bom nível de alerta, sem histórico de pneumonias de repetição, que não estejam em vigência de pneumonia e que não façam uso de cânula de traqueostomia.

Functional magnetic resonance and swallowing: critical literature review, / Ressonância magnética funcional e deglutição: revisão crítica da literatura

ABSTRACT INTRODUCTION: Aspects of the neuroanatomical representation of swallowing have been investigated in humans through brain mapping techniques, such as functional magnetic resonance imaging (fMRI). OBJECTIVE: This critical qualitative review of the literature analyzed international scientific publications in the PubMed database that investigated the activation of the central nervous system in humans during the act of swallowing. METHODS: This investigation was limited to articles that investigated adults older than 18 years, published in English or Portuguese, between January 2002 and December 2013. Publications that did not have access to the full text, that were repeated by overlapping keywords, case studies, literature reviews, letters to the editor, and those not directly related to the topic of the investigation were excluded. RESULTS: A total of 649 articles were identified, of which 21 matched the inclusion criteria. CONCLUSION: The main purpose of the manuscripts that investigate the swallowing process through fMRI were: to characterize swallowing in different pathologies; to compare swallowing in different age groups; to describe brain activation in different stimulation conditions. These studies indicate multiple cortical regions involved in swallowing control. Overall, the studies indicate that fMRI is a non-invasive and quantitative method that allows the investigation of characteristics that are quite often not clinically visible.

RESUMO INTRODUÇÃO: Aspectos da representação neuroanatômica do funcionamento cortical que controla a deglutição têm sido investigados e identificados em humanos, utilizando-se técnicas de mapeamento cerebral, como a Ressonância Magnética funcional (RNMf). OBJETIVO: Esta revisão crítica qualitativa da literatura levantou publicações científicas sobre a funcionalidade do sistema nervoso central durante tarefas de deglutição, por meio da base de dados PubMed. MÉTODO: O levantamento realizado limitou-se a seres humanos, com idade superior a 18 anos, nos idiomas inglês e português, entre janeiro de 2002 e dezembro de 2013. Publicações sem acesso completo, repetidas por sobreposição das palavras chave, estudos de caso, revisões de literatura, cartas ao editor e não relacionadas diretamente ao tema foram excluídas. RESULTADO: Identificou-se 649 estudos, sendo que somente 21 se enquadraram aos critérios estabelecidos. CONCLUSÃO: Foram encontrados artigos que objetivaram, por meio da RNMf, estudar a função de deglutição em patologias; comparar a deglutição em diferentes idades; descrever a ativação cerebral em diferentes situações de estimulação. Estes estudos apontam múltiplas regiões corticais que participam no controle da deglutição. Conclui-se que a RNMf é um método não invasivo, quantitativo, que demonstra respostas, muitas vezes, não visíveis clinicamente.

Functional magnetic resonance and swallowing: critical literature review.

INTRODUCTION: Aspects of the neuroanatomical representation of swallowing have been investigated in humans through brain mapping techniques, such as functional magnetic resonance imaging (fMRI). OBJECTIVE: This critical qualitative review of the literature analyzed international scientific publications in the PubMed database that investigated the activation of the central nervous system in humans during the act of swallowing. METHODS: This investigation was limited to articles that investigated adults older than 18 years, published in English or Portuguese, between January 2002 and December 2013. Publications that did not have access to the full text, that were repeated by overlapping keywords, case studies, literature reviews, letters to the editor, and those not directly related to the topic of the investigation were excluded. RESULTS: A total of 649 articles were identified, of which 21 matched the inclusion criteria. CONCLUSION: The main purpose of the manuscripts that investigate the swallowing process through fMRI were: to characterize swallowing in different pathologies; to compare swallowing in different age groups; to describe brain activation in different stimulation conditions. These studies indicate multiple cortical regions involved in swallowing control. Overall, the studies indicate that fMRI is a non-invasive and quantitative method that allows the investigation of characteristics that are quite often not clinically visible.