ICU, SLT and FEES The role of Speech and Language Therapy

1. ICU, SLT and FEES � The role of Speech and Language Therapy Sarah Wallace SLT Clinical Coordinator for Dysphagia, UHSM

2. Why do we need SLT input in ICU? �Key professions in the critical care setting include�Speech and Language Therapy� (Quality Critical Care DoH 2005) �During the critical care stay and as early as clinically possible � determine whether the patient is at risk of developing physical and non-physical morbidity�includes assessments by different professional groups� (Rehabilitation after critical illness, NICE 2009)

3. Key areas for SLT input Communication difficulties lead to frustration, anxiety, fear, isolation and inability to participate in treatment decisions Dysphagia leads to compromised nutrition and hydration status, pneumonia, prolonged ventilatory dependence and increased mortality

4. Role of SLT in critical care �Communication and swallowing are the responsibility of the whole multidisciplinary team � the role of the SLT is to empower and educate others as well as providing direct specialist input� (RCSLT Position paper � SLT in Adult Critical Care 2006)

5. SLT role in ICU with communication Assess voice and laryngeal integrity and offer advice on speaking valve use Assess, diagnose and rehabilitate speech difficulties (dysarthria) and language disorders (dysphasia) Advise on communication aids

6. SLT role in ICU with dysphagia Diagnose cause and severity of dysphagia Assess swallow safety, secretion management, risk of aspiration and affect on weaning plan Decide optimal timing for commencement of oral feeding and safe consistencies Advise on prognosis for swallow recovery and need for NGT/PEG Provide support Swallowing exercises Perform FEES

7. FEES Fibreoptic Endoscopic Evaluation of Swallowing

8. Why do critical care patients have swallowing problems? Aspiration is reported in 50-70% of tracheostomised, ventilated patients Presence of tracheostomy itself can adversely affect swallowing Further impairs swallowing in patients with neurological disorders (GBS, CVA, MG, Dementia) or mechanical disorders of swallowing (H&N surgery/trauma) Interrelationship between respiration and swallowing is disrupted Effect heightened if respiratory compromise e.g. COPD Intubation trauma

9. Effects of tracheostomy and ventilation on swallowing Patient fights against positive airway pressure to swallow Disuse atrophy of swallowing muscles accumulates over time - worse in elderly and slow wean patients (Davis 2004) Air flow is diverted away from larynx reduced evaporation of oral secretions results in pooling in larynx laryngeal desensitisation Silent aspiration

10. Effects of tracheostomy and ventilation on swallowing Blunted cough, incoordinated glottic closure Reduced airway pressure for swallowing � aspiration of food/liquid residue Compression of oesophagus by cuff causes regurgitation and swallow discomfort Reduced taste and smell Aspiration signs - pyrexia, increased vent support, food/liquid suctioned or leaking from trache stoma, coughing on E&D

11. FEES view of larynx

12. Does aspiration matter? �Aspiration is the leading cause of pneumonia in the ICU environment and contributes significantly to morbidity and mortality� (McClave 2002) �Aspiration pneumonia impacts on ventilation status and delays the weaning process� (Dikeman and Kazandjian 2003) Increased LOS and costs

13. BJ � male 66yrs, admitted with pneumonia. Alcoholic with Parkinsons disease

14. How does cuff deflation help swallow function and assessment? Restores air flow through larynx improving sensitivity, cough and saliva swallowing Voice quality becomes audible enabling assessment of secretion management and airway protection e.g. wet, gurgly or breathy voice Signs of aspiration on food/liquid trials are more immediate and audible e.g. weak cough

15. Should patients be fed cuff inflated? Tracheostomy guidelines recommend deferring oral feeding until at least partial cuff deflation (e.g. St Georges Guidelines 2007) Aspirated food/liquid accumulates above cuff, gradually seeps around cuff � silent aspiration common but very difficult to detect Possible exceptions QOL, palliative

16. How do we assess swallow safety in cuff inflated patients? FEES is the only reliable method of visualising secretion status and aspiration of food or liquid Blue dye screening tests and bedside swallowing assessment will NOT accurately detect aspiration

17. FEES 2 SLTs Scope passed transnasally to pharynx Assess airway protection, risk of aspiration during food/liquid trials Try out techniques to eliminate aspiration Observe how swallow changes with cuff inflated/deflated, speaking valve on/off Make recommendations i.e. safety of oral feeding Requires advanced dysphagia skills, specialised training and expensive equipment!

18. MH � male 60yrs, brainstem CVA. Ventilated with cuff inflated, forticreme mousse trial

19. SKL � male 30yrs, neck cellulitis following chickenpox. Adjustable flange trache with cuff deflated

20. SKL � aspiration of teaspoon of yoghurt

21. How can ICU Nurses / AHP�s help? Refer all Neuro and H&N patients Identify other patients at risk of dysphagia Trial cuff deflation Use a swallow screen protocol e.g. sips water cup of water free fluids puree diet other foods Use PMV to facilitate weaning and maintain swallow function Prompt dysphagia referral prevents life-threatening respiratory complications Highlight lack of SLT to fund holders / service providers Any questions?