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Why do we need SLT input in ICU?. Key professions in the critical care setting includeSpeech 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-physica
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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?