[Multiple factors contributing to dysphagia : Extended tasks for the interprofessional team in the intensive care unit]. / Multiple Einflussfaktoren bei Dysphagie : Erweiterte Aufgaben für das interprofessionelle Team auf der Intensivstation.

A stay in the intensive care unit (ICU) can be associated with complications and lead to secondary problems, known as post intensive care syndrome (PICS). They can prolong inpatient stays, increase ICU mortality and lead to long-term problems. One secondarily acquired problem in intensive care is dysphagia. This article highlights various influencing factors on dysphagia. Some require an extended interprofessional treatment concept that goes beyond strictly speech and swallowing therapist treatment.

Guideline on multimodal rehabilitation for patients with post-intensive care syndrome.

BACKGROUND: Intensive Care Unit (ICU) survivors often experience several impairments in their physical, cognitive, and psychological health status, which are labeled as post-intensive care syndrome (PICS). The aim of this work is to develop a multidisciplinary and -professional guideline for the rehabilitative therapy of PICS. METHODS: A multidisciplinary/-professional task force of 15 healthcare professionals applied a structured, evidence-based approach to address 10 scientific questions. For each PICO-question (Population, Intervention, Comparison, and Outcome), best available evidence was identified. Recommendations were rated as "strong recommendation", "recommendation" or "therapy option", based on Grading of Recommendations, Assessment, Development and Evaluation principles. In addition, evidence gaps were identified. RESULTS: The evidence resulted in 12 recommendations, 4 therapy options, and one statement for the prevention or treatment of PICS. RECOMMENDATIONS: early mobilization, motor training, and nutrition/dysphagia management should be performed. Delirium prophylaxis focuses on behavioral interventions. ICU diaries can prevent/treat psychological health issues like anxiety and post-traumatic stress disorders. Early rehabilitation approaches as well as long-term access to specialized rehabilitation centers are recommended. Therapy options include additional physical rehabilitation interventions. Statement: A prerequisite for the treatment of PICS are the regular and repeated assessments of the physical, cognitive and psychological health in patients at risk for or having PICS. CONCLUSIONS: PICS is a variable and complex syndrome that requires an individual multidisciplinary, and multiprofessional approach. Rehabilitation of PICS should include an assessment and therapy of motor-, cognitive-, and psychological health impairments.

The semisolid bolus swallow test for clinical diagnosis of oropharyngeal dysphagia: a prospective randomised study.

Contrary to clinical experience, clinical swallow tests are predominantly performed using water (water swallow tests, WST). In this study, we examine whether swallow tests performed using a bolus of semisolid food (bolus swallow test, BST) offer benefits. In a prospective, randomised, blind study, the results of a standardised saliva swallow test (SST), WST, BST, combinations of these tests and an endoscopic swallow test (FEES) in patients with oropharyngeal swallowing disorders of neurological (NEU) and non-neurological (NNEU) origin were compared. Sensitivity, specificity, test accuracy and inter-rater reliability were analysed. 62 patients (mean age = 64.68; range = 22-84) were included in the study (NEU = 40; NNEU = 22). A sensitivity of 70.7% (NEU = 70.3%, NNEU = 71.4%) and specificity of 82.5% (NEU = 92.3%; NNEU = 100%) were determined for the WST. The BST + SST was found to have a sensitivity of 89.6% (NEU = 66.7%; NNEU = 90.9%) and a specificity of 72.7% (NEU = 87.5%; NNEU = 90.9%). Analysis of test accuracy showed a statistically significant correlation between FEES and BST + SST. Only BST + SST exhibited statistically significant inter-rater reliability. BST in combination with SST was the sensitive clinical instrument for detecting aspiration both over the patient population as a whole and over the two sub-populations. Inter-rater reliability was found to be statistically significant. The results presented here demonstrate the benefit of semisolid food in investigating clinical dysphagia.

Airway management in acute tetraplegics: a retrospective study.

The objective of this study was to develop an evidence-based airway management protocol for patients with acute tetraplegia. The method consisted of an analysis of the medical records of patients (September 1997-December 2002) with a spinal cord injury and a neurological deficit less than 8 weeks old. Of the 175 patients, 72 (41, 14%) were tracheotomised. This was influenced by the origin of the paralysis, Frankel score, and number of cervical spine operations, accompanying injuries and accompanying illnesses. Tracheotomy did not affect the duration of treatment, duration of ventilation or length of stay in the intensive care unit. The need for a tracheotomy was able to be predicted in 73.31% with neurological level, Frankel score and severity of accompanying injuries. In patients with acute tetraplegia, primary tracheotomy is indicated in sub C1-C3 with Frankel stage A/B, sub C4-C6 with Frankel stage A/B with trauma and accompanying injuries/accompanying illnesses, and in patients with complex cervical spine trauma that requires a combined surgical approach. In other patients, an attempt at extubation should be made.

Oropharyngeal findings of endoscopic examination in swallowing disorders of neurological origin.

A study was carried out to examine the significance of anatomical and functional oropharyngeal findings in patients with neurological disorders as part of an endoscopic evaluation of swallowing. The study included 101 patients (60.2 years+/-16.35, 63 male=62%, 38 female=38%) with neurological disorders (cerebral infarct, head injury, hypoxia) presenting with dysphagia. Oropharyngeal findings from endoscopic examination of nine anatomical regions and ten functional tests were correlated with the results of a standardised endoscopic swallowing test. Anatomical changes were obtained in 30 (30%) patients; functional changes were obtained in 67 (66%) patients. No correlation between these changes and swallowing ability was found. "Start of swallow," "leaking," "residues" and "follow-up swallowing" did show a correlation with the results of the swallowing test. In addition, for swallowing tests with saliva, "follow-up swallowing" and "swallowing after coughing" also showed a correlation. Anatomical or functional endoscopic oropharyngeal examination changes alone did not influence swallowing ability in the mixed neurological group studied. Evaluation of swallowing ability requires a swallowing test with saliva and various test consistencies under normal conditions. Failure to swallow following coughing during swallowing tests with saliva can be used as a clinical indicator for aspiration.

Pilot study of a neurophysiological dysphagia therapy for neurological patients.

OBJECTIVE: To investigate the success of a neurophysiological dysphagia therapy in patients with neurological disorders. DESIGN: A pre- and post-intervention group study. SETTING: Acute rehabilitation unit. SUBJECTS: Ten patients (swallowing rate <1/5 minutes, Frühreha-Barthel Index <-150, tracheostomy as a result of a swallowing disorder) with dysphagia as a result of a head injury or cerebral haemorrhage. INTERVENTIONS: Therapy was given based on facio-oral tract therapy for three weeks (15 sessions of 1 hour each). MEASURES: The general scales used were the Frühreha-Barthel Index and Coma Remission Scale. Measures of swallowing rate, alertness and swallowing ability were undertaken before, during and after the treatment sessions and at intervals of 30 minutes for 2 hours after the treatment sessions. RESULTS: On the treatment days, the therapy did not lead to an increase in swallowing rate, but did lead to a significant increase in alertness. After completion of a single treatment session, there was a statistically significant decrease in alertness and swallowing rate for 90 minutes. An increase in alertness (Frühreha-Barthel Index and Coma Remission Scale), swallowing ability (measured using an endoscopic examination) and protection of the respiratory tract was observed over the entire therapy period. CONCLUSION: Facio-oral tract therapy led to a statistically significant increase in alertness during the treatment session and, over the entire therapy period, to an increase in swallowing rate, alertness and swallowing ability. The decrease in alertness following therapy sessions must be taken into account in planning rehabilitative measures. Further studies on larger populations as well as studies currently in progress should further elucidate the strategies employed to rehabilitate dysphagic patients.

The influence of tracheotomy tubes on the swallowing frequency in neurogenic dysphagia.

OBJECTIVES: To compare the swallowing frequency in patients with neurogenic dysphagia with or without tracheotomy tubes (TT) to assess the underlying mechanisms of dysphagia to improve rehabilitation strategies. STUDY DESIGN AND SETTING: Prospective study, 10 patients (64 +/- 7 years) with neurogenic dysphagia. Glasgow Coma Scale (GCS) less than 8 points, tracheotomy due to the dysphagia 2 weeks before the examination. The swallowing frequency (1 or less over 5 min) was assessed over 5 consecutive days with or without TT. RESULTS: The swallowing frequency increased after removal of the TT. These findings did not influence the GCS or the Coma Remission Scale. Over a 5-day period, the frequency of swallowing was increased. CONCLUSION: TTs decisively influence the swallowing behavior of vegetative patients. This phenomenon could be based on an improved sensitivity under re-established physiological expiration. We strongly favor removing the TT or deflating the cuff of the TT under therapeutic conditions in a rehabilitation therapy setting.