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Quality of Life and Dysphagia in Patients with Chronic Critical Illness with a Tracheostomy

Randy Dubin MA, CCC-SLP

Speech Pathology Team Leader

Objectives

• Identify clinical features of patient with chronic critical illness.

• Identify outcomes in patients with chronic critical illness.

– LTACH Study

• Understand the role of the SLP in treating patients with chronic critical illness.

Chronic Critical Illness

“The CCI are expected to increase, since more patients with complex diseases survive due to advances in resuscitation techniques, mechanical ventilation protocols, metabolic control and treatment of sepsis” (Estenssoro et al, 2006)

Clinical Features and Risk Factors of Chronic Critical Illness (Nelson et al, 2010; Kress & Hall, 2014; Marchioni et al, 2015)

• Prolonged dependence on mechanical ventilation• Tracheotomy• At least 21 consecutive days on ventilator for > 6 hours/day

• Immobility/Profound weakness (muscle wasting)• Myopathy• Neuropathy

• Multiorgan system failure

• Neuroendocrine changes

• Stress induced hyperglycemia

• Increased vulnerability to infection

• Skin breakdown

• Brain dysfunction

• Risk factors• Old age• Comorbidities• Neuromuscular blocking agents

• Most frequent acute conditions• Acute Respiratory Distress Syndrome• Sepsis Severe Sepsis Septic shock

• complication of an infection; occurs when chemicals released into bloodstream to fight the infection cause an inflammatory responses throughout the body.

Marchioni et al, 2015

Nelson et al, 2010

Critical Illness polyneuropathy (CIP)Critical illness myopathy (CIM) (Pattenshetty RB, Gaude GS, 2011; Schweickert & Hall, 2007; Marchioni et al, 2015)

• Critical Illness polyneuropathy (CIP) = a distal axonal sensory-motor polyneuropathy, which can affect the limbs but also respiratory muscles

• Weakness of the respiratory muscles with difficult weaning from mechanical ventilation

• Sepsis or SIRS = leading cause

• Flaccid tetraplegia: Lower limbs more affected than upper limbs.

• Deep tendon reflexes reduced or absent

• Sensory loss may be present (difficult to demonstrate in the early ICU phase)

• Loss of sensation to light touch or pin prick

• Critical illness myopathy (CIM) = an acute primary myopathy presenting with muscle atrophy, and a characteristic pattern of selective loss of myosin on muscle biopsy

• Weakness of the respiratory muscles with difficult weaning from mechanical ventilation

• Flaccid tetraplegia• Proximal > distal muscle weakness

• Sensations spared

• Reflexes decreased

ICU-Acquired Weakness

CIP CIM CINM

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ICU Acquired Weakness (Schweickert & Hall, 2007)

• Generalized weakness that impairs return to spontaneous breathing and mobilization• “if neuromuscular function recovers, it

often lags well behind other organ system repair.”

• The Medical Research Council (MRC) score includes formal testing of three muscle groups in each limb on a scale from one to five• UE (left + right = 30)

• Shoulder• Elbow• Wrist

• LE (left + right = 30)• Hip• Knee• Ankle

• Patients with a score of < 48 = ICU-AW

Potential Impact on ICU-AW (Latronico et al, 2017)

Diagnostic Algorithm for Assessing Neuromuscular Complications in Critically Ill (Schweickert & Hall, 2007)

Diagnosing ICU-AW(Appleton & Kinsella, 2012)

1. Weakness developing after the onset of critical illness

2. The weakness being generalized (involving both proximal and distal muscles), symmetrical, flaccid.

3. MRC sum score of < 48 (or a mean score of < 4 in all testable muscle groups noted on >2 occasions separated by >24 h)

4. Dependence on mechanical ventilation

5. Causes of weakness not related to the underlying critical illness have been excluded.

What is the treatment of ICU-AW? (Kramer, 2017)

• Limit potential for sepsis/SIRS•Rapid recognition/aggressive treatment

•Avoid neuromuscular blockade and steroids•Early mobilization•Treating sustained elevations in blood glucose > 180

mg/dL and avoiding hypoglycemia•Minimizing sedation

Chronic Critical Illness Outcomes (Nelson et al, 2010)

• Ventilator liberation– Between 30 and 53% liberated in acute care setting– Typically ranges from 16 to 37 days after intubation for respiratory failure– Most patients who fail to achieve ventilator independence within 60 days do not do so later– Better outcomes are reported for some specialized weaning units (LTACH)

• Mortality– successful weaning does not ensure long term survival– One-year mortality across study populations is 48–68%– The risk of death in chronically critically ill patients remains particularly high between 60 and 100

days after initiation of mechanical ventilation

• Functional and Cognitive Impairments– Profound impairments of physical function and/or cognitive status

• Require LTACH, rehab, SNF

– <12% were alive/independent 1 year after their illness (across multiple studies)

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Chronic Critical Illness Outcomes (Nelson et al, 2010)

• Family Burden– Depression/stress – Financial– Decline in physical health

• Mortality prediction– Higher mortality:

• Advanced age• Residual organ failure• Poor prior functional status

– Lower mortality:• Younger patients/trauma

• Deficiencies in Physician–Patient–Family Communication– 80% of patients/families received no information about possible functional

dependency at hospital discharge and 90% received no information about expected 1-year survival

Post-Intensive Care Syndrome (PICS)• Incidence (Rawal et al, 2017)

• Cognitive Impairments• 25%

• Mental health• 1-62%

• Physical health• > 25%

• Clinical Manifestation• May last a few months to many years

post recovery

• Generalized weakness, fatigue, decreased mobility, anxious or depressed mood, sexual dysfunction, sleep disturbances, and cognitive issues (memory disturbance/loss, slow mental processing, poor concentration).

PICS Management (Rawal et al, 2017)

Preventative: ABCDE Bundle

• Awakening (using light or minimal sedation);

• Breathing (spontaneous breathing trials);

• Coordination of care and communication among various disciplines; choice of sedatives

• Delirium monitoring, assessment, and management;

• Early ambulation in the ICU.

• Additional Interventions:

– Avoiding hypoglycemia and hypoxemia

– ICU diaries

– Good nutrition

– Good sleep

– Pharmacological, psychological, and behavioral therapies

– PT/OT/ST

– Post-ICU clinicsProlonged Intubation• Multiple intubations• Laryngeal injuries

Underlying illness

Age

Tracheostomy tube

Mental status

Dysphagia in CCI

Large bore OG or NGT

Prolonged Intubation = Dysphagia

• Prolonged intubation = No clear definition• > 48 hours

• The duration of postoperative endotracheal intubation (cardiac surgery) is a strong predictor of subsequent dysphagia that prolongs the return to normal oral feeding (Barker et al, 2009)

• Post-extubation dysphagia (Macht et al, 2011)

• CBSE in 446 patients after extubation• 374 diagnosed with dysphagia (84%)

• 179 diagnosed with moderate-severe dysphagia (40%)

• Severe dysphagia = those intubated > 7 days and reintubation

• Dysphagia frequency variable• Meta analysis (Skoretz et al, 2010) = ranging from 3% to

62%• No single diagnosis associated with greater risk of

dysphagia (medical, med surg, cardio)

• Laryngeal injury and altered laryngeal sensation (Brodsky et al, 2014)• Artificial airways increase the risk of upper

airway injury and concomitant laryngeal pathologies, which in turn affect upper airway mechanics, aerodynamics, and protective reflexes (Barker et al, 2009; Hogue et al., 1995)• epithelial/mucosal abrasions, tracheal

stenosis, laryngeal edema and granulation tissue

• laryngeal incompetence post extubation is significantly reduced within 8 hours (Burgess et al, 1979)

Tracheostomy • Timing and benefits of tracheostomy

(Kang et al, 2018; Herritt et al, 2017; Heffner et al, 1986)

• When patient expected to experience prolonged period of mechanical ventilation

• Still controversial

• Benefits:• Improves lung mechanics/vent weaning

• Reduces sedative drug use

• Improve oral hygiene

• Improve communication

• Improved suctioning

• Patient comfort

• Potential for oral nutrition

• Potentially avoid laryngeal and subglottic complications

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Tracheostomy = ? Dysphagia• Effects of a tracheostomy (Ceriana et al, 2015):

• Reduced laryngeal elevation and anterior movement (cuff inflated?)

• Reduced laryngeal sensitivity and inefficient/ineffective cough

• Lack of subglottic pressure / reduced airway closure

• Reduced coordination between swallowing and respiration

• If the patient with a trach does have dysphagia, then is it result of trach????• Probably NOT (studies with VFSS

completed with trach in place and then removed)• Inflated trach will most likely

worsen dysphagia

Not every patient with trach = dysphagia

Muscle Disuse Atrophy/Muscle Wasting = Dysphagia• There was a significant decline of muscle

volume with advancing age for most muscle groups (Sporns et al, 2017)

• Tongue, pharynx, geniohyoid, masseter

• “muscle atrophy can affect specific fiber types, involving predominantly slow type 1 or fast type 2 muscle fibers, and is frequently accompanied by a slow-to-fast or fast-to-slow fiber type shift” (Ciciliotet al, 2013)• causes a slow-to-fast shift usually but not

always accompanied by preferential atrophy of type 1 slow fibers

• Type 2 fibers are atrophic in elderly• Muscle wasting induced by sepsis, cachexia,

starvation and acute diabetes is characterized by a fast-to-slow fiber type shift

• Skeletal muscle fiber area decreases 2-4% per day in ICU (Mendez-Tellez & Needham, 2012)

• Atrophy occurring within days of onset of critical illness

Sarcopenia(Kizilarslanoglu, et al, 2016)

“Progressive generalized loss of skeletal muscle

mass occurring as a primary consequence of aging and secondary due

to certain diseases, malnutrition and

inactivity.”

Dysphagia = ICU Acquired Weakness

Critical Illness Polyneuromyopathy

Infrequent swallowing can result in disuse atrophy of the muscles of tongue, pharynx and larynx (Macht et al, 2013)

Prolonged Intubation• Multiple intubations• Laryngeal injuries

Underlying illness

Age

Tracheostomy tube

Mental status

Dysphagia in CCI

Large bore OG or NGT

ICU- Acquired Weakness

Does muscle weakness predict pharyngeal weakness and aspiration risk?(Mirzakhani et al, 2013)

• FEES• Muscle weakness = valleculae and pyriform residue

• VPSR > score of 1

• Muscle weakness (MRC < 48) in ventilated patient is an independent predictor of:• Pharyngeal dysfunction

• Aspiration

• Ventilated patients• 70% of patient with muscle weakness had +

aspiration

• + muscle weakness = 10 fold increase in aspiration

Valleculae and Pyriform Sinus Residue (VPSR) Scale 0 =no residue 4 = residue > 50%

Pharyngeal Residue = Weakness• LTACH Study

– 51 subjects

• MRC < 48 = 41 subjects– Pharyngeal residue

» Valleculae = 18 subjects

» Pyriforms = 21 subjects

» Both = 15 subjects

• MRC > 48 = 10 subjects– Pharyngeal residue

» Valleculae = 4 subjects

» Pyriforms = 6 subjects

» Both = 4 subjects

Valleculae 1 None 0% No residue 2 Trace 1-5% Trace coating of the mucosa 3 Mild 5-25% Epiglottic ligament visible 4 Moderate 25-50% Epiglottic ligament covered 5 Severe 50% Filled to epiglottic rim Pyriform Sinus 1 None 0% No residue 2 Trace 1-5% Trace coating of mucosa 3 Mild 5-25% Up wall to quarter full 4 Moderate 25-50% Up wall to half full 5 Severe 50% Filled to aryepiglottic fold

The Yale Pharyngeal Residue Severity Rating Scale: (Neubauer et al, 2015)

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Should we be looking at MRC?

• MRC < 48 (n=41) and diet level• NPO (5/41) 12%• Liquid modified PO diet (24/41) 59%

-----------------------------------------• Mechanical soft/chopped (12/41) 29%• Regular 0/41 0%

• MRC > 48 (n=10) and diet level• NPO (2/10) 20%• Liquid modified PO diet (6/10) 60%

-------------------------------------------• Mechanical soft/chopped (1/10) 10%• Regular (1/10) 10%

“Useful in screening and stratifying patients into those with high or low aspiration risk, but that absence of clinical muscle

weakness does not preclude the probability of aspiration” (Mirzakhani et al, 2013)

Secretions

Secretion Scale (Marianjoy) Donzelli et al, 2006

LEVEL SECRETION CHARACTERISTICS

1, Normal Thin, clear pharyngeal secretions, <10% pooling in pyriform/valeculae

2, Mild 10-25% pooling secretions in pyriform/valleculae

3, Moderate >25% pooling, no endolaryngeal secretions

4, Severe Laryngeal penetration of secretions above true vocal folds, intermittent penetration secretions with inhalation, no aspiration secretions

5, Profound Secretions on vocal folds and/or pesence tracheal aspiration of secretions

• Rehab hospital (duration of intubation 74+/-46 days) (Donzelli et al, 2006)

• Secretion level and aspiration• The mean secretion level was 4.3 for patients who

aspirated and 2.8 for those who did not aspirate• Occlusion status and aspiration

• 7 of 19 patients (36.8%) in the cap group • 4 of 9 (44.4%) in the speaking-valve group• 8 of 12 (66.7%) in the finger group

• LTACH Study (duration of intubation 13.5 days +/- 6.3 days; 19 multiple intubations)• Secretion level and aspiration

• The mean secretion level was 3.3 for patients who aspirated pureed (n = 3)

• The mean secretion level was 4.3 for patients who aspirated honey thick liquid (n = 3)

• The mean secretion level was 3.8 for patients who aspirated nectar thick (n = 4)

• The mean secretion level was 2.0 (SD 1.1) for patients who aspired thin liquid (n = 26)

• The mean secretion level was 1.0 for patient who did NOT aspirate any texture (n=21)

Penetration/Aspiration • LTACH Study• 51 subjects

• MRC < 48 = 41 subjects• Aspiration (4 or 5)

• Pureed = 2 subjects

• Honey thick = 1 subject

• Nectar thick = 3 subjects

• Thin liquid = 20 subjects

• Any texture = 21/41 = 51%

• MRC > 48 = 10 subjects• Aspiration (4 or 5)

• Pureed = 1 subjects

• Honey thick = 2 subject

• Nectar thick = 0 subjects

• Thin liquid = 5 subjects

• Any texture = 7/10 subject = 70%

PAS-5 for FEESSCORE DESCRIPTION

1 No penetration or aspiration

2

Penetration with protective reflex responseH = High penetration (epiglottis to above false vocal folds)D = Deep penetration (false vocal folds to true vocal folds)

3

Penetration without reflex responseH =High penetrationD = Deep penetration

4 Aspiration with protective reflex response

5 Aspiration without protective reflex response

Source: Adapted from Ashford and Skelley; SASS Scale(Dziewas et al, 2008)

Cognitive Impairment• Risk factors (Rawal et al, 2017)

• Duration of delirium in ICU

• Acute brain dysfunction (stroke, ETOH)

• Hypoxia (ARDS, cardiac arrest)

• Hypotension (sepsis)

• Prolonged ventilation

• Long term ARDS survivors (Mikkelsen et al, 2008)

• Cognitive impairment was found in 56% of subjects• Memory and executive function were the most

commonly affected domains

• Hypoxemia is a risk factor for long-term cognitive impairment (Mikkelsen et al, 2012)

Mikkelsen et al, 2008

Cognition in LTACH Setting

• Montreal Cognitive Assessment (MOCA) Max score = 30

– Screening for cognitive dysfunction• Attention/Concentration• Executive functions• Memory• Language• Visuoconstructional skills• Conceptual thinking• Calculations• Orientation

– > 26 = normal

• LTACH Study

– Completed on 48 subjects

– Mean 21.77

• None (>26) 7/48 15%

• Mild (18-26) 31/48 65%

• Moderate (10-17)10/48 21%

Anxiety/Depression/PTSD

• Ranges from 1-62% in chronic critically ill patient population• Risk Factors (Rawal et al, 2017)

– Same as for cognitive impairment– Female– Lower education level– Preexisting disability– Use of sedation and analgesia in ICU

• Neuropsychological function in patients 12 months post-hospital discharge with a diagnosis of acute lung injury (Mikkelsen et al, 2012)

– Depression (36%) and anxiety (62%)– PTSD (39%)

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• Anxiety and Depression After Critical Care = LOS 76-199 hours (Pattison et al, 2015)

– HADS• Anxiety Subscale

– 2 weeks = 5.17 (SD 3.29)– 6 months = 4.88 (SD 3.82)– 12 months = 5.60 (SD 4.46)

• Depression Subscale– 2 weeks = 6.35 (SD 3.70)– 6 months = 4.48 – 12 months = 4.65(SD 4.11)

• LTACH study:– HADS

• Anxiety Subscale = 8.9 (SD 4.8)• Depression Subscale= 6.9 (SD 4.5)

– PTSS• Mean 27.9 (SD 12.5)

Anxiety/Depression/PTSD Quality of Life• LTACH setting

– What are your most important goals given your medical condition? (Lamas et al, 2016)• 68% rated quality of life as poor

– Hunger

– Thirst

– Difficulty communicating

– Boredom

– Poor mobility

• 80% identified going home as a goal

– ONLY 38% were at home 1 year later

» UNREALISTIC EXPECTATIONS

• After d/c from ICU to home (Pattison

et al, 2015)

– QOL improved at 6 months but then declined/became static at 12 months

Quality of Life: Discharge from LTACH

Hospice/terminal wean N=3 6%

Acute out N=6 12%

SNF N=16 31%

---------------------------------

Rehab N=20 38%

Home N=7 13%

Quality of Life EuroQol (EuroQol Group, 1990)

After Critical Care (Pattison et al, 2015)

• Visual Analogue Scale (out of 100)

• 2 weeks = 57.75

• 6 months = 69.1

• 12 months = 71.82

LTACH Study

• Visual Analogue Scale (out of 100)

• Mean 43.6

Quality of Life

• LTACH Study• 35/52 (67%) ranked speaking

in the top 5 • 42/52 (81%) ranked

eating/drinking in the top 5

Eating and drinking

Walking

Breathing better

Toileting yourself

Grooming yourself

Resuming work or leisure activities

Being less anxious or depressed

Speaking

Returning (to prior residence) home

Thinking clearly

Comprehensive Care for Chronically Critically Ill (Nelson et al, 2010)

SPEECH

SPEECH?• PMSV• FEES

SPEECH?• Voice, speech,

cognitive-linguistic, swallow therapy

SPEECH?• Swallow

therapy

SPEECH?• PMSV• AAC• Counseling

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Bibliography (cont.)

Mirzakhani H, Williams J, Mello J, et al. Muscle weakness predicts pharyngeal dysfunction and symptomatic aspiration in long-term ventilated patients. Anesthesiology :. 2013;119(2):389-397. doi: 10.1097/ALN.0b013e31829373fe.Neubauer PD, Rademaker AW, Leder SB. The yale pharyngeal residue severity rating scale: An anatomically defined and image-based tool. Dysphagia. 2015;30(5):521-528. doi: 10.1007/s00455-015-9631-4.Nelson JE, Cox CE, Hope AA, Carson SS. Chronic critical illness. American journal of respiratory and critical care medicine. 2010;182(4):446-454. doi: 10.1164/rccm.201002-0210CI.Pattison N, O'Gara G, Rattray J. After critical care: Patient support after critical care. A mixed method longitudinal study using email interviews and questionnaires. Intensive and critical care nursing. 2015;31(4):213-222. doi: 10.1016/j.iccn.2014.12.002.Ponfick M, Linden R, Nowak DA. Dysphagia--a common, transient symptom in critical illness polyneuropathy: A fiberoptic endoscopic evaluation of swallowing study*. Critical care medicine. 2015;43(2):365-372. doi: 10.1097/CCM.0000000000000705.Puthucheary Z, Prescott H. Skeletal muscle weakness is associated with both early and late mortality after acute respiratory distress syndrome. Critical care medicine. 2017;45(3):563-565. doi: 10.1097/CCM.0000000000002243.Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: An overview. Journal of translational internal medicine. 2017;5(2):90-92. doi: 10.1515/jtim-2016-0016.Schweickert WD, Hall J. ICU-acquired weakness. Chest. 2007;131(5):1541-1549. doi: 10.1378/chest.06-2065.Skoretz SA, Flowers HL, Martino R. The incidence of dysphagia following endotracheal intubation: A systematic review. Chest. 2010;137(3):665-673. doi: 10.1378/chest.09-1823.Sporns PB, Muhle P, Hanning U, et al. Atrophy of swallowing muscles is associated with severity of dysphagia and age in patients with acute stroke. Journal of the American Medical Directors Association. 2017;18(7):635.e7. doi: 10.1016/j.jamda.2017.02.002.

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