Tracheostomy Practice in Adults with Acute Respiratory Failure

Freeman BD, Morris PE

Crit Care Med 2012;40:2890-2896

The goals of this concise definitive review were to summarize the adult intensive care unit literature relative to tracheostomy (sic) practice, formulate best-practice recommendations, and determine future research directions. Tracheostomy, for patients who do not require a surgical airway or with acute neurological injury, should not be performed during the first 2 weeks following onset of respiratory failure to allow time to determine the need for long-term ventilator support. Percutaneous dilatational tracheostomy is currently considered to be the preferred technique for tracheostomy in the intensive care unit. Future research is needed on assessment of aspiration risk and communication options both when mechanical ventilation is required and during weaning trials, post-tracheostomy management protocols to determine optimal timing for decannulation and rehabilitation interventions, and long-term effects of tracheostomy on patient-centric outcomes.

Comment

This review summarizes the literature regarding tracheotomy practice for patients in the adult intensive care unit concisely but not definitively. Drawbacks to a narrow review such as this are that information that pertains to intensive care unit patients but is not derived directly from patients in the intensive care unit are not included. For example, this review would have benefited from including relevant studies that dealt with tracheotomy and tracheotomy tube placement with respect to dysphagia and aspiration risk assessment, decannulation protocols, and options to reinstitute verbal communication. On a technical note, although ostomy is the general term for an operation in which an artificial opening is formed, the more precise term to use is tracheotomy, not tracheostomy, since the tracheal mucosa is not brought into continuity with skin when a tracheotomy is performed.

Effect of Decannulation on Pharyngeal and Laryngeal Movements in Post-Stroke Tracheostomized Patients

Jung SJ, Kim DY, Kim YW, Koh YW, Joo SY, Kim ES

Ann Rehabil Med 2012;36:356-364

This study investigated what effects, if any, the presence of a tracheostomy tube had on hyoid bone and laryngeal movement during swallowing in 19 adult stroke patients. Videofluoroscopic swallowing studies (VFSS) were done >14 days before decannulation, within 24 h before decannulation, within 24 h after decannulation, and >14 days after decannulation. Swallowing measures obtained were pharyngeal transit time, stage transition duration, maximum hyoid bone movement, and maximum laryngeal prominence movement. No significant differences were found for pharyngeal transit time and stage transition duration measurements. Since maximum hyoid movement and maximum laryngeal prominence 24 h after versus 24 h before decannulation were improved, it was concluded that presence of a tracheostomy tube disturbed hyoid bone and laryngeal movement during swallowing.

Comment

Although tortured syntax impairs comprehension, a number of clearly contradictory statements make the present findings of improved hyoid bone and laryngeal movement following decannulation highly suspect. Specifically, in Results, “Maximal laryngeal movement… increased significantly…” 24 h after decannulation followed in the next paragraph by “Maximal laryngeal movement tended to decrease after decannulation…”. And, “Moreover, vertical movement (of the larynx) significantly increased…” presumably 2 weeks after decannulation, but in the very next sentence, “In hyoid movement, any significant differences were not observed within 24 h after decannulation, 2 weeks after decannulation.” How can vertical movement of the larynx increase significantly without a corresponding increase in hyoid movement? Which statement, if any, is accurate? Also, since “All indicators, relevant to hyoid and laryngeal movements, did not show significant correlations with severity of dysphagia”, of what importance do these purported findings have to swallowing success or failure? Furthermore, a serious methodology flaw occurs when the authors stated, “VFSS were performed 18 times in all…”. Simple arithmetic indicates that 19 participants tested at four discrete times results in a total of 76 VFSS examinations. Lastly, the same comment made above regarding use of the terms tracheostomy versus tracheotomy holds true for this study as well. Again, we point out proper use of tracheostomy versus tracheotomy. Each often life-saving surgical procedure alters anatomy and function in distinct and radically different ways while presenting differential risk to both patient and care-giver.

Frailty in Older Inpatients: What Physicians Need to Know

McMillan GJ, Hubbard RE

Q J Med 2012;105:1059-1065

This review focuses on frailty as the failure of a complex system in which each small stressor that contributes to the breakdown is necessary but not sufficient to cause failure by itself. Different approaches to the definition, measurement, and determination of frailty, how falls may be a manifestation of increasing frailty, the impact of adverse drug reactions due to frailty, and intervention options regarding how to treat frailty are discussed.

Comment

Frailty is due to the accumulation of smaller abnormalities across different subsystems without adequate redundancy for compensation until a critical point is reached which impacts negatively on the entire system. Although not discussed in this review, it should not be surprising that swallowing, which includes coordinated, integrated, and precise interactions between many components of a complex system, deteriorates to various degrees, both subclinical and symptomatic, in the frail elderly. In light of the exponential increase of dysphagia in the aging population [1], clinicians may want to use the current review as a starting point for adding dysphagia to the established areas of ambulation and medication prescribing for future research needs when treating frailty.

  1. 1.

    Leder SB, Suiter DM. An epidemiologic study on aging and dysphagia in the acute care hospitalized population: 2000–2007. Gerontology. 2009;55:714-8.

The Influence of Stimulus Taste and Chemesthesis on Tongue Movement Timing in Swallowing

Steele CM, van Lieshout PHHM, Pelletier CA

J Speech Lang Hear Res 2012;55:262-275

This study’s aim was to investigate the influence of taste and chemesthesis, i.e., sensory information regarding thermal, chemical, or irritant stimuli via the trigeminal nerve, on temporal characteristics of tongue movements during liquid bolus swallowing. Specifically, does a highly sour citric acid stimulus elicit a faster swallowing sequence in the form of shorter tongue movement durations, i.e., shorter rise phases from movement onset to peak tongue position to movement offset. A total of 33 participants were given five different liquid stimuli, i.e., water, three moderate concentration tastants without odor (sweet, sour, sweet–sour), and a high concentration of citric acid (sour + chemesthesis), and evaluated with electromagnetic midsagittal articulography. The hypothesized pattern of shorter-duration lingual movements with the high-concentration citric acid was not demonstrated.

Comment

The wide variety of tongue movement sequences indicates that the tongue is a muscular hydrostat, i.e., a fluid-filled organ of constant volume that can assume a wide variety of shapes and thereby is capable of achieving a common functional goal (successful oropharyngeal swallowing) via a wide variety of tongue movement sequences. Clinicians who treat patients with head and neck cancer status post oral tongue resections know this to be true. Perhaps compensatory rehabilitation should take precedent over the unpalatable “sour meal.” We look forward to future research in this promising area of rehabilitation intervention.

Oropharyngeal Dysphagia: A Pathophysiology and Diagnosis for the Anniversary Issue of Diseases of the Esophagus

Logemann JA, Larson K

Dis Esophagus 2012;25:299-304

The purpose of this paper was to provide an overview and update on the normal oropharyngeal swallow across the age spectrum. Areas of emphasis included disorders of the oral preparatory, oral, and pharyngeal phases of the swallow. The diagnostic study of choice was the videofluoroscopic swallow study. Treatment for oropharyngeal dysphagia was described mostly as behavioral, i.e., postural changes, sensory enhancements, swallow maneuvers, and diet changes, and new research on exercise programs based upon physiology observed during testing was presented.

Comment

All clinicians dealing with patients with oropharyngeal dysphagia will find some useful new information in this article. The emphasis on the videofluoroscopic swallow study, almost to the exclusion of fiberoptic endoscopic evaluation of swallowing, was to be expected given the authors’ experience with the former over the latter.

Current and Future Techniques in the Evaluation of Dysphagia

Kuo P, Holloway RH, Nguyen NQ

J Gastroenterol Hepatol 2012;27:873-881

The aim of this article was to review current examination methods with an emphasis on emerging techniques developed to better understand esophageal motor function. The clinical and instrumental assessments of oropharyngeal dysphagia were discussed. Current techniques for the diagnosis of esophageal dysphagia, including barium swallow, upper endoscopy, manometry, and scintigraphy, were reviewed. New and emerging techniques discussed were multichannel intraluminal impedance, functional lumen imaging probe, high-frequency intraluminal ultrasound, and high-resolution manometry with topography.

Comment

Since this article was written by gastroenterologists, it was not surprising that oral and pharyngeal dysphagia received cursory attention while the majority of the information focused on testing techniques for esophageal dysphagia. Potential readers should be aware that a better title would have been “Current and Future Techniques in the Evaluation of Esophageal Dysphagia.”

Training the Allied Health Assistant for the Telerehabilitation Assessment of Dysphagia

Sharma S, Ward EC, Burns C, Theodoros D, Russell T

J Telemed Telecare 2012;18:287-291

The purpose of this study was to investigate the effect of dysphagia-specific training on the knowledge, competence, and perceived comfort of an allied health professional who assisted during telerehabilitation dysphagia assessments (n = 31). The single allied health professional received 4 h of training specific to dysphagia and completed a written test before and after training and again after the 15th and the 30th consecutive patient assessment. Two speech-language pathologists rated the allied health professional’s competence after each set of five clinical dysphagia assessments in conjunction with the allied health professional’s self-rating of perceived level of confidence. The allied health professional’s knowledge of dysphagia increased from 40 % before training to 80 % after training. The speech-language pathologists rated the allied health professional’s post-training performance as competent on each level. The allied health professional expressed overall satisfaction with the training and felt self-confident after the initial patient sessions.

Comment

In the growing area of telerehabilitation, where the clinical professional is located at a separate location from the patient thereby making hands-on evaluation impossible, use of a competently trained allied health assistant is crucial to both assist the patient and administer tasks at the patient’s end under direct supervision and direction of the online clinical specialist. It is to be expected that use of allied health professionals will increase as more patients with suspected dysphagia are referred from wider geographic areas, making travel to medical centers more necessary and more difficult. It is imperative that the assistance provided by the allied health professional be both competent and accurate in order for the correct diagnosis to be made and the correct rehabilitation strategies recommended.

Oral Liquid In Situ Gelling Methylcellulose/Alginate Formulations for Sustained Drug Delivery to Dysphagic Patients

Shimoyama T, Itoh K, Kobayashi M, Miyazaki S, D’Emanuele A, Attwood D

Drug Dev Ind Pharm 2012;38:952–960

It was hypothesized that geriatric patients with dysphagia may benefit from oral ingestion of liquid dosage forms that have in situ gelling properties. Gelling liquid dosage formulations were composed of mixtures of methylcellulose. These formulations contain thermally reversible gelation properties and sodium alginate, are ion-responsive, have suitable rheological properties for ease of administration to dysphagic patients, and have suitable integrity in the stomach for sustained drug release. A rat model (male Wistar rats) was used. Solutions of mixtures of methylcellulose and alginate in appropriate proportions were found to be of suitable consistency for oral ingestion by dysphagic patients and form gels in situ with sustained release characteristics.

Comment

Some dysphagic patients, and even patients who do not have swallowing problems, have difficulty swallowing tablets and capsules, especially as size increases. Changing formulation, e.g., to crushable, liquid, or chewable forms, is not always possible due to time-release constraints, unavailability, or gastric-emptying issues specific to each medication. Liquid dosage formulations that form gels in the gastric environment may be a solution. Since this study used a rat model, testing with humans is needed. Many interesting questions require answers. Is there a clear clinical advantage of using such a preparation compared to liquid medications thickened with conventional agents? Is the efficacy of the drug enhanced and, if it is, is this desired and safe? Would the agent be given less frequently due to its increased bioavailability and sustained release properties? Would we need to study individual drugs separately or do we assume that the pharmacokinetics and bioavailability of any drug would behave similarly when given with different formulation characteristics? If such a vehicle was used to administer liquid medications, would the product be used by the nurse on the floor or would the pharmacy have to prepare the doses for dysphagic patients?

Swallowing Dysfunction and Dysphagia is an Unrecognized Challenge for Oral Drug Therapy

Stegemann S, Gosch M, Breitkreutz J

Int J Pharm 2012;430:197-206

This paper reviewed the dual-edged problem of increased ingestion of solid oral drug forms in an ever-growing geriatric population that has declining swallowing skills. Dysphagia due to aging, disease burden, radiotherapy, surgical intervention, and drugs themselves is discussed. The potential danger of nontested solid oral dosage forms that have been altered, i.e., crushed tablets and opened timed-release capsules, is highlighted. Compliance with taking prescribed medication in both the home and extended care facilities is covered. A call for more research by the pharmaceutical industry focused on optimal safe drug delivery formulations is made.

Comment

There is a growing awareness that a nil per os recommendation in the dysphagic patient should include, not exempt, administration and ingestion of oral medications, especially when in tablet form [1, 2]. We look forward to advances in pharmaceutical technology that allow for the development of newer and safer formulations to help the swallowing of solid oral dosage forms by both the pediatric and the geriatric population, e.g., pellets, sprinkles, oblong shapes, smooth surfaces, or miniaturized tablets and capsules, that do not involve the risky practice of unauthorized manipulation of drug products, e.g., crushing tablets or opening capsules, in order to mix with ingested food.

  1. 1.

    Carneby-Mann G, Crary M. Pill swallowing by adults with dysphagia. Arch Otolaryngol Head Neck Surg. 2005;131:970-5

  2. 2.

    Leder SB, Lerner MZ. Nil per os except medications order in the dysphagic patient. QJM 106(1):71-5

Clinimetrics of Measures of Oropharyngeal Dysphagia for Preschool Children with Cerebral Palsy and Neurodevelopmental Disabilities: A Systematic Review

Benfer KA, Weir KA, Boyd RN

Dev Med Child Neurol 2012;54:784-795

The purpose of this systematic review was to determine the psychometric properties and clinical utility of objective measures of oropharyngeal dysphagia in children aged 1-5 years with cerebral palsy or neurodevelopmental disabilities. Five electronic databases were searched (1948-2012): CINAHL (EBSCO), MEDLINE, Cochrane Library, AMED, and PsycINFO. Twenty-seven studies met the inclusion criteria and nine assessments of oropharyngeal dysphagia were identified: Brief Assessment of Motor Function—Oral Motor Deglutition Scale, Behavioral Assessment Scale of Oral Functions in Feeding, Dysphagia Disorders Survey, Feeding Behavior Scale, Functional Feeding Assessment (modified), Gisel Video Assessment; Oral Motor Assessment Scale, Pre-Speech Assessment Scale, and Schedule for Oral Motor Assessment. The Schedule for Oral Motor Assessment and the Functional Feeding Assessment (modified) exhibited the most robust validity and reliability measures. The Schedule for Oral Motor Assessment and the Dysphagia Disorders Survey had the best clinical utility.

Comment

This valuable contribution will allow clinicians to select the best assessment for their patients and help guide future research to determine test/retest reliability, detect change, and predict validity of both these and additional tests of oropharyngeal dysphagia in children with cerebral palsy and neurodevelopmental disabilities.

Eating Again: A Physician’s Personal Experience After Laryngectomy

Brook I

Nutr Cancer 2012;64:635-636

This commentary shares the personal experiences of a laryngectomee in regard to post-laryngectomy dysphagia and compensatory eating strategies. A diagnosis of hypopharyngeal carcinoma resulted in organ preservation treatment with external beam radiation therapy followed 2 years later by a salvage total laryngectomy with free-flap reconstruction. Eating was and continues to be a challenge due to xerostomia, bolus stasis in the pharynx, alterations in taste and smell, and prolonged meal-times. Compensatory strategies, i.e., soft, moist boluses and drinking a small liquid bolus after each solid bolus to aid in pharyngeal clearing, were successful. However, drinking such large volumes of water resulted in early satiety, frequent voiding, and interrupted sleep. Although ever-present, annoying, and, at times, debilitating, dysphagia has been accommodated and adequate nutrition maintained with persistence and the help of speech-language pathologists, nutritionists, and physicians.

Comment

Clinicians who diagnose and treat patients with head and neck cancer know full well the consequences of treatment on swallowing abilities. It is both humbling and a privilege to care for these patients.

Prevalence of Oropharyngeal Dysphagia in Parkinson’s Disease: A Meta-Analysis

Kalf JG, de Swart BJM, Bloem BR, Munneke M

Parkinsonism Relat Disord 2012;18:311-315

Although the presence of dysphagia is potentially harmful in patients with Parkinson’s disease, there is no consensus in the literature regarding prevalence rates. A meta-analysis was performed to estimate the prevalence of oropharyngeal dysphagia in Parkinson’s disease. A systematic PubMed literature search was conducted and 12 studies, all in English, were found that met the inclusion criteria, i.e., results provided an estimate of prevalence of dysphagia, a definition of or method to ascertain dysphagia was included, and results were published as a full paper. Subjective oropharyngeal dysphagia was reported to be prevalent in at least one-third of Parkinson’s disease patients, while objective documentation of oropharyngeal dysphagia had it much higher at 80 % of patients affected. Prevalence rates were dependent upon disease severity and assessment technique used. Overall, Parkinson’s disease patients were three times more likely to have dysphagia than do healthy controls.

Comment

The underreporting of subclinical or asymptomatic swallowing problems in patients with Parkinson’s disease underscores the need for proactive dysphagia screening with the goal of early identification in order for compensatory swallowing techniques, e.g., smaller bolus sizes, altering bolus consistencies, monitoring rate of eating and positioning at meal-times, to be started before the consequences of chronic aspiration become evident. As the population ages, more individuals will be diagnosed with Parkinson’s disease and dysphagia specialists need to stay ahead of the curve.

Vanderbilt Head and Neck Symptom Survey Version 2.0: Report of the Development and Initial Testing of a Subscale for Assessment of Oral Health

Cooperstein E, Gilbert J, Epstein JB, Dietrich MS, Bond SM, Ridner SH, Wells N, Cmelak A, Murphy BA

Head Neck 2012;34:797-804

The primary goal of this investigation was to develop a tool that enables researchers and clinicians to study the prevalence and severity of both acute and late adverse health outcomes specific to patients treated with chemoradiotherapy with and without surgery for head and neck cancer. The Vanderbilt Head and Neck Symptom Survey (VHNSS) version 2.0, a 50-item survey with each item scored 0 (none)–10 (severe), was administered for feasibility to 70 patients who completed treatment. Domains included nutrition, swallowing/eating foods, xerostomia, mucositis, excess mucus, speech/communication, taste change, dental health, mucosal sensitivity, and range of motion. The VHNSS version 2.0 demonstrated high patient acceptance and was completed in <10 min. A full range of scores was noted for 46/50 items. Oral health burden was high early as well as late post-treatment. The VHNSS version 2.0 was shown to be both feasible and able to be completed in a timely manner.

Comment

Researchers and clinicians alike will find the VHNSS version 2.0 useful and helpful in evaluating the oral health of head and neck cancer patients after chemoradiotherapy with and without surgery. It is a quick (10 min) and easy tool to administer and provides a wealth of information on the state of a patient’s overall oral health or lack thereof. We look forward to further reports on prevention, prompt recognition, and timely management of oral health issues identified through use of the VHNSS version 2.0.

Early Sucking and Swallowing Problems as Predictors of Neurodevelopmental Outcome in Children with Neonatal Brain Injury: A Systematic Review

Slattery J, Morgan A, Douglas J

Dev Med Child Neurol 2012;54:796-806

Abnormal early sucking and swallowing behaviors may be markers of neonatal brain injury and could be used to identify infants who are at increased risk for adverse outcomes. However, to date, no clear relationship has been demonstrated between early sucking and swallowing problems and neonatal brain injury. The purpose of this systematic review was to investigate the relationship, if any, between early sucking and swallowing behaviors and neurodevelopmental outcomes in infants diagnosed with neonatal brain injury and in at-risk infants born very preterm, i.e., <32 weeks, with very low birth weight (<1,500 g). A systematic review of English-language articles in CINAHL, EMBASE, and MEDLINE OVID databases published from 1980 to May 2011 was performed. A total of 9 of 394 abstracts generated met the inclusion criteria. Five were prospective cohort studies, two were retrospective cohort studies, and two were case series. Sample sizes were small, ranging from 11 to 84 participants. Although early sucking and swallowing difficulties were found in a consistent proportion of infants and were predictive of neurodevelopmental outcome, the methodological quality of the studies varied in terms of research design, levels of evidence, assessments used, and the nature and timing of neurodevelopmental follow-up. There is insufficient evidence to determine if there is a relationship between early sucking and swallowing problems and neonatal brain injury.

Comment

Although intuitively intriguing, research is needed with larger sample sizes, valid and reliable measures to determine objectively infant sucking and swallowing, and concurrent neuroimaging to determine nature, site, and severity of impaired sucking and swallowing behaviors. Most importantly, longitudinal data are needed to answer the hypothesis of whether early sucking and swallowing problems are predictive of later adverse neurodevelopment.

Surgical Closure of the Larynx for the Treatment of Intractable Aspiration: Surgical Technique and Clinical Results

Takano S, Goto T, Kabeya M, Tayama N

Laryngoscope 2012;122:1273-1278

The authors describe 32 cases of surgical closure of the larynx as a method of preventing aspiration. The surgical technique involves resecting both anterior edges of the thyroid cartilage to reduce the overall diameter of the glottal airway thus facilitating a two-layer closure of the glottis. False vocal folds were sutured as a first layer of closure and the true vocal folds as a second layer of closure. Fifty-six percent of patients were able to resume an oral diet.

Comment

There are many ways to divert salivary contamination and the method described here appears to be another variation worthy of a surgeon’s notice. In practice, patients requiring salivary diversion fall into two groups: those who are unlikely to resume speaking function due to neurologic impairment/devastation and those who are likely to recover the strength to speak once the chronic threat of aspiration pneumonia is controlled. In the former group surgical closure of the larynx is a particularly suitable option due to low surgical morbidity. In the latter group, however, another reasonable option includes total laryngectomy with the advantage of restoring swallow function and oral communication using a tracheoesophageal prosthesis.