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Dysphagie-Management im Akut- und Langzeitverlauf bei kritisch kranken intensivpflichtigen Patienten

  • J. Zielske
  • S. Bohne
  • H. Axer
  • F.M. Brunkhorst
  • O. Guntinas-LichiusEmail author
Übersichten

Zusammenfassung

Eine Schluckstörung (Dysphagie) betrifft als Komplikation des Aufenthalts auf der Intensivstation mehr als die Hälfte der Patienten und trägt erheblich zu Morbidität und Mortalität bei. Risikofaktoren sind: neurologische Erkrankung, Alter >55–70 Jahre, Intubationsdauer >7 Tage und Sepsis. Bei steigenden Zahlen an Langzeitüberlebenden stellt die chronische Dysphagie ein zunehmendes Problem dar. Über den Einfluss spezifischer Krankheitsursachen auf die Entstehung einer Dysphagie, auch über den Einfluss einer Sepsis, liegen nur wenige Erkenntnisse vor. Dabei gibt es mit der fiberoptischen Schluckuntersuchung ein standardisiertes Instrument zur Abklärung, um eine Schluckstörung frühzeitig zu erkennen, umgehend mit dem Schlucktraining zu beginnen und so die Rate an chronischen Dysphagien zu senken. Bei chronischer Dysphagie erfolgt in der Nachsorge eine gestufte Schluckrehabilitation zur Restitution, Kompensation und Adaptation des Schluckvorgangs. Dies wird bislang in Deutschland nicht ausreichend genutzt. Insgesamt mangelt es an kontrollierten klinischen Untersuchungen, die spezifische Therapiekonzepte für ehemals kritisch kranke Patienten analysieren.

Schlüsselwörter

Intensivstation Therapiestandards Qualitätskontrolle Schlucktherapie Sepsis 

Dysphagia management of acute and long-term critically ill intensive care patients

Abstract

Dysphagia is a severe complication in critically ill patients and affects more than half the patients in an intensive care unit. Dysphagia also has a strong impact on morbidity and mortality. Risk factors for the development of dysphagia are neurological diseases, age >55–70 years, intubation >7 days and sepsis. With increasing numbers of long-term survivors chronic dysphagia is becoming an increasing problem. There is not much knowledge on the influence of specific diseases, including the direct impact of sepsis on the development of dysphagia. Fiberoptic evaluation of swallowing is a standardized tool for bedside evaluation, helping to plan swallowing training during the acute phase and to decrease the rate of chronic dysphagia. For evaluation of chronic dysphagia even more extensive diagnostic tools as well as several options of stepwise rehabilitation using restitution, compensation and adaption strategies for swallowing exist. Currently it seems that these options are not being sufficiently utilized. In general, there is a need for controlled clinical trials analyzing specific swallowing rehabilitation concepts for former critically ill patients and long-term survivors.

Keywords

Intensive care Therapy standards Quality control Swallowing therapy Sepsis 

Notes

Interessenkonflikt

Der korrespondierende Autor gibt für sich und seine Koautoren an, dass kein Interessenkonflikt besteht.

Supplementary material

Video 1. FEES Untersuchung auf Intensivstation bei einem septischen Patienten (QuickTime mov 9MB)

Video 2. FEES Untersuchung desselben Patienten 4 Monate später mit klinisch chronischer Dysphagie bei einer ambulanten Kontrolluntersuchung (QuickTime mov 11MB)

Literatur

  1. 1.
    Desai SV, Law TJ, Needham DM (2011) Long-term complications of critical care. Crit Care Med 39(2):371–379PubMedCrossRefGoogle Scholar
  2. 2.
    Engel C, Brunkhorst FM, Bone HG et al (2007) Epidemiology of sepsis in Germany: results from a national prospective multicenter study. Intensive Care Med 33(4):606–618PubMedCrossRefGoogle Scholar
  3. 3.
    Brun-Buisson C, Doyon F, Carlet J et al (1995) Incidence, risk factors, and outcome of severe sepsis and septic shock in adults. A multicenter prospective study in intensive care units. French ICU Group for Severe Sepsis. JAMA 274(12):968–974PubMedCrossRefGoogle Scholar
  4. 4.
    Finfer S, Bellomo R, Lipman J et al (2004) Adult-population incidence of severe sepsis in Australian and New Zealand intensive care units. Intensive Care Med 30(4):589–596PubMedCrossRefGoogle Scholar
  5. 5.
    Braber A, Zanten AR van (2010) Unravelling post-ICU mortality: predictors and causes of death. Eur J Anaesthesiol 27(5):486–490PubMedCrossRefGoogle Scholar
  6. 6.
    Quartin AA, Schein RM, Kett DH, Peduzzi PN (1997) Magnitude and duration of the effect of sepsis on survival. Department of Veterans Affairs Systemic Sepsis Cooperative Studies Group. JAMA 277(13):1058–1063PubMedCrossRefGoogle Scholar
  7. 7.
    Iwashyna TJ, Ely EW, Smith DM, Langa KM (2010) Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 304(16):1787–1794PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Iwashyna TJ, Cooke CR, Wunsch H, Kahn JM (2012) Population burden of long-term survivorship after severe sepsis in older Americans. J Am Geriatr Soc 60(6):1070–1077PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Reiter R, Brosch S (2012) Update oropharyngeal dysphagia part 1: Physiology, pathology and diagnosis. Laryngorhinootologie 91(4):224–227PubMedCrossRefGoogle Scholar
  10. 10.
    Martino R, Foley N, Bhogal S et al (2005) Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke 36(12):2756–2763PubMedCrossRefGoogle Scholar
  11. 11.
    Meng NH, Wang TG, Lien IN (2000) Dysphagia in patients with brainstem stroke: incidence and outcome. Am J Phys Med Rehabil 79(2):170–175PubMedCrossRefGoogle Scholar
  12. 12.
    Teasell R, Foley N, Doherty T, Finestone H (2002) Clinical characteristics of patients with brainstem strokes admitted to a rehabilitation unit. Arch Phys Med Rehabil 83(7):1013–1016PubMedCrossRefGoogle Scholar
  13. 13.
    Falsetti P, Acciai C, Palilla R et al (2009) Oropharyngeal dysphagia after stroke: incidence, diagnosis, and clinical predictors in patients admitted to a neurorehabilitation unit. J Stroke Cerebrovasc Dis 18(5):329–335PubMedCrossRefGoogle Scholar
  14. 14.
    Barker J, Martino R, Reichardt B et al (2009) Incidence and impact of dysphagia in patients receiving prolonged endotracheal intubation after cardiac surgery. Can J Surg 52(2):119–124PubMedPubMedCentralGoogle Scholar
  15. 15.
    Batty S (2009) Communication, swallowing and feeding in the intensive care unit patient. Nurs Crit Care 14(4):175–179PubMedCrossRefGoogle Scholar
  16. 16.
    Hughes T (2003) Neurology of swallowing and oral feeding disorders: assessment and management. J Neurol Neurosurg Psychiatr 74(Suppl 3):iii48–iii52PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Bordon A, Bokhari R, Sperry J et al (2011) Swallowing dysfunction after prolonged intubation: analysis of risk factors in trauma patients. Am J Surg 202(6):679–682 (discussion 682–673)PubMedCrossRefGoogle Scholar
  18. 18.
    Hansen TS, Larsen K, Engberg AW (2008) The association of functional oral intake and pneumonia in patients with severe traumatic brain injury. Arch Phys Med Rehabil 89(11):2114–2120PubMedCrossRefGoogle Scholar
  19. 19.
    Skoretz SA, Flowers HL, Martino R (2010) The incidence of dysphagia following endotracheal intubation: a systematic review. Chest 137(3):665–673PubMedCrossRefGoogle Scholar
  20. 20.
    Rumbach AF, Ward EC, Cornwell PL et al (2011) Incidence and predictive factors for dysphagia after thermal burn injury: a prospective cohort study. J Burn Care Res 32(6):608–616PubMedCrossRefGoogle Scholar
  21. 21.
    Macht M, Wimbish T, Clark BJ et al (2011) Postextubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness. Crit Care 15(5):R231PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Butler SG, Maslan J, Stuart A et al (2011) Factors influencing bolus dwell times in healthy older adults assessed endoscopically. Laryngoscope 121(12):2526–2534PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Latronico N, Peli E, Botteri M (2005) Critical illness myopathy and neuropathy. Curr Opin Crit Care 11(2):126–132PubMedCrossRefGoogle Scholar
  24. 24.
    Stevens RD, Marshall SA, Cornblath DR et al (2009) A framework for diagnosing and classifying intensive care unit-acquired weakness. Crit Care Med 37(10 Suppl):S299–S308PubMedCrossRefGoogle Scholar
  25. 25.
    Tennila A, Salmi T, Pettila V et al (2000) Early signs of critical illness polyneuropathy in ICU patients with systemic inflammatory response syndrome or sepsis. Intensive Care Med 26(9):1360–1363PubMedCrossRefGoogle Scholar
  26. 26.
    Witt NJ, Zochodne DW, Bolton CF et al (1991) Peripheral nerve function in sepsis and multiple organ failure. Chest 99(1):176–184PubMedCrossRefGoogle Scholar
  27. 27.
    Lim SH, Lieu PK, Phua SY et al (2001) Accuracy of bedside clinical methods compared with fiberoptic endoscopic examination of swallowing (FEES) in determining the risk of aspiration in acute stroke patients. Dysphagia 16(1):1–6PubMedCrossRefGoogle Scholar
  28. 28.
    Trapl M, Enderle P, Nowotny M et al (2007) Dysphagia bedside screening for acute-stroke patients: the Gugging Swallowing Screen. Stroke 38(11):2948–2952PubMedCrossRefGoogle Scholar
  29. 29.
    Rees CJ (2006) Flexible endoscopic evaluation of swallowing with sensory testing. Curr Opin Otolaryngol Head Neck Surg 14(6):425–430PubMedCrossRefGoogle Scholar
  30. 30.
    Hafner G, Neuhuber A, Hirtenfelder S et al (2008) Fiberoptic endoscopic evaluation of swallowing in intensive care unit patients. Eur Arch Otorhinolaryngol 265(4):441–446PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Warnecke T, Ritter MA, Kroger B et al (2009) Fiberoptic endoscopic dysphagia severity scale predicts outcome after acute stroke. Cerebrovasc Dis 28(3):283–289PubMedCrossRefGoogle Scholar
  32. 32.
    Warnecke T, Teismann I, Oelenberg S et al (2009) Towards a basic endoscopic evaluation of swallowing in acute stroke – identification of salient findings by the inexperienced examiner. BMC Med Educ 9:13PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Langmore SE (2003) Evaluation of oropharyngeal dysphagia: which diagnostic tool is superior? Curr Opin Otolaryngol Head Neck Surg 11(6):485–489PubMedCrossRefGoogle Scholar
  34. 34.
    Kelly AM, Leslie P, Beale T et al (2006) Fibreoptic endoscopic evaluation of swallowing and videofluoroscopy: does examination type influence perception of pharyngeal residue severity? Clin Otolaryngol 31(5):425–432PubMedCrossRefGoogle Scholar
  35. 35.
    Kelly AM, Drinnan MJ, Leslie P (2007) Assessing penetration and aspiration: how do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare? Laryngoscope 117(10):1723–1727PubMedCrossRefGoogle Scholar
  36. 36.
    Noordally SO, Sohawon S, De Gieter M et al (2011) A study to determine the correlation between clinical, fiber-optic endoscopic evaluation of swallowing and videofluoroscopic evaluations of swallowing after prolonged intubation. Nutr Clin Pract 26(4):457–462PubMedCrossRefGoogle Scholar
  37. 37.
    Rosenbek JC, Robbins JA, Roecker EB et al (1996) A penetration-aspiration scale. Dysphagia 11(2):93–98PubMedCrossRefGoogle Scholar
  38. 38.
    Robbins J, Coyle J, Rosenbek J et al (1999) Differentiation of normal and abnormal airway protection during swallowing using the penetration-aspiration scale. Dysphagia 14(4):228–232PubMedCrossRefGoogle Scholar
  39. 39.
    Crary MA, Mann GD, Groher ME (2005) Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. Arch Phys Med Rehabil 86(8):1516–1520PubMedCrossRefGoogle Scholar
  40. 40.
    O’Neil KH, Purdy M, Falk J, Gallo L (1999) The dysphagia outcome and severity scale. Dysphagia 14(3):139–145CrossRefGoogle Scholar
  41. 41.
    Antonios N, Carnaby-Mann G, Crary M et al (2010) Analysis of a physician tool for evaluating dysphagia on an inpatient stroke unit: the modified Mann Assessment of Swallowing Ability. J Stroke Cerebrovasc Dis 19(1):49–57PubMedCrossRefGoogle Scholar
  42. 42.
    Oeyen SG, Vandijck DM, Benoit DD et al (2010) Quality of life after intensive care: a systematic review of the literature. Crit Care Med 38(12):2386–2400PubMedCrossRefGoogle Scholar
  43. 43.
    Jaenichen D, Brunkhorst FM, Strauss B, Rosendahl J (2012) Physical and mental long-term sequelae following intensive care of severe sepsis in patients and relatives. Psychother Psychosom Med Psychol PMID:22585583 (Epub ahead of print)Google Scholar
  44. 44.
    Bauer F, Seiss M, Grassel E et al (2010) Swallowing-related quality of life in oral cavity cancer. The German version of the Anderson Dysphagia Inventory. HNO 58(7):692–697PubMedCrossRefGoogle Scholar
  45. 45.
    Silbergleit AK, Schultz L, Jacobson BH et al (2012) The dysphagia handicap index: development and validation. Dysphagia 27(1):46–52PubMedCrossRefGoogle Scholar
  46. 46.
    Mann G, Hankey GJ, Cameron D (1999) Swallowing function after stroke: prognosis and prognostic factors at 6 months. Stroke 30(4):744–748PubMedCrossRefGoogle Scholar
  47. 47.
    Ickenstein GW, Stein J, Ambrosi D et al (2005) Predictors of survival after severe dysphagic stroke. J Neurol 252(12):1510–1516PubMedCrossRefGoogle Scholar
  48. 48.
    Golestanian E, Liou JI, Smith MA (2009) Long-term survival in older critically ill patients with acute ischemic stroke. Crit Care Med 37(12):3107–3113PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Smithard DG (2002) Swallowing and stroke. Neurological effects and recovery. Cerebrovasc Dis 14(1):1–8PubMedCrossRefGoogle Scholar
  50. 50.
    Altman KW, Yu GP, Schaefer SD (2010) Consequence of dysphagia in the hospitalized patient: impact on prognosis and hospital resources. Arch Otolaryngol Head Neck Surg 136(8):784–789PubMedCrossRefGoogle Scholar
  51. 51.
    Schutz T, Valentini L, Herbst B, Lochs H (2006) ESPEN guidelines on enteral nutrition – summary. Z Gastroenterol 44(8):683–684PubMedGoogle Scholar
  52. 52.
    Dellinger RP, Levy MM, Carlet JM et al (2008) Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 36(1):296–327PubMedCrossRefGoogle Scholar
  53. 53.
    Reinhart K, Brunkhorst FM, Bone HG et al (2010) Prevention, diagnosis, therapy and follow-up care of sepsis: 1st revision of S-2k guidelines of the German Sepsis Society (Deutsche Sepsis-Gesellschaft e. V. (DSG)) and the German Interdisciplinary Association of Intensive Care and Emergency Medicine (Deutsche Interdisziplinare Vereinigung fur Intensiv- und Notfallmedizin (DIVI)). Ger Med Sci 8. doi:10.3205/000103Google Scholar
  54. 54.
    Bath PM, Bath FJ, Smithard DG (2000) Interventions for dysphagia in acute stroke. Cochrane Database Sys Rev (2):CD000323. doi:10.1002/14651858.CD000323Google Scholar
  55. 55.
    Dziewas R, Warnecke T, Hamacher C et al (2008) Do nasogastric tubes worsen dysphagia in patients with acute stroke? BMC Neurol 8:28PubMedCrossRefPubMedCentralGoogle Scholar
  56. 56.
    Takahata H, Tsutsumi K, Baba H et al (2011) Early intervention to promote oral feeding in patients with intracerebral hemorrhage: a retrospective cohort study. BMC Neurol 11:6PubMedCrossRefPubMedCentralGoogle Scholar
  57. 57.
    Carnaby-Mann GD, Crary MA (2007) Examining the evidence on neuromuscular electrical stimulation for swallowing: a meta-analysis. Arch Otolaryngol Head Neck Surg 133(6):564–571PubMedCrossRefGoogle Scholar
  58. 58.
    Reiter R, Brosch S (2012) Update oropharyngeal dysphagia part 2: etiology and therapy. Laryngorhinootol 91(5):291–299CrossRefGoogle Scholar
  59. 59.
    Speyer R, Baijens L, Heijnen M, Zwijnenberg I (2010) Effects of therapy in oropharyngeal dysphagia by speech and language therapists: a systematic review. Dysphagia 25(1):40–65PubMedCrossRefPubMedCentralGoogle Scholar
  60. 60.
    Prosiegel M, Heintze M, Wagner-Sonntag E et al (2002) Deglutition disorders in neurological patients. A prospective study of diagnosis, pattern of impairment, therapy and outcome. Der Nervenarzt 73(4):364–370PubMedCrossRefGoogle Scholar
  61. 61.
    Carnaby G, Hankey GJ, Pizzi J (2006) Behavioural intervention for dysphagia in acute stroke: a randomised controlled trial. Lancet Neurol 5(1):31–37PubMedCrossRefGoogle Scholar
  62. 62.
    Kind A, Anderson P, Hind J et al (2011) Omission of dysphagia therapies in hospital discharge communications. Dysphagia 26(1):49–61PubMedCrossRefPubMedCentralGoogle Scholar
  63. 63.
    Aviv JE, Kaplan ST, Thomson JE et al (2000) The safety of flexible endoscopic evaluation of swallowing with sensory testing (FEESST): an analysis of 500 consecutive evaluations. Dysphagia 15(1):39–44PubMedCrossRefGoogle Scholar
  64. 64.
    Ney DM, Weiss JM, Kind AJ, Robbins J (2009) Senescent swallowing: impact, strategies, and interventions. Nutr Clin Pract 24(3):395–413PubMedCrossRefPubMedCentralGoogle Scholar
  65. 65.
    Rosenbek JC, Roecker EB, Wood JL, Robbins J (1996) Thermal application reduces the duration of stage transition in dysphagia after stroke. Dysphagia 11(4):225–233PubMedCrossRefGoogle Scholar
  66. 66.
    Shaker R, Easterling C, Kern M et al (2002) Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology 122(5):1314–1321PubMedCrossRefGoogle Scholar
  67. 67.
    Logemann JA (2008) Treatment of oral and pharyngeal dysphagia. Phys Med Rehabil Clin N Am 19(4):803–816, ixPubMedCrossRefGoogle Scholar
  68. 68.
    Ohmae Y, Logemann JA, Kaiser P et al (1996) Effects of two breath-holding maneuvers on oropharyngeal swallow. Ann Otol Rhinol Laryngol 105(2):123–131PubMedCrossRefGoogle Scholar
  69. 69.
    Kahrilas PJ, Logemann JA, Krugler C, Flanagan E (1991) Volitional augmentation of upper esophageal sphincter opening during swallowing. Am J Physiol 260 (3 Pt 1):G450–G456PubMedGoogle Scholar
  70. 70.
    Murry T, Wasserman T, Carrau RL, Castillo B (2005) Injection of botulinum toxin A for the treatment of dysfunction of the upper esophageal sphincter. Am J Otolaryngol 26(3):157–162PubMedCrossRefGoogle Scholar
  71. 71.
    Yamaya M, Yanai M, Ohrui T et al (2001) Interventions to prevent pneumonia among older adults. J Am Geriatr Soc 49(1):85–90PubMedCrossRefGoogle Scholar
  72. 72.
    Hermans G, De Jonghe B, Bruyninckx F, Van den Berghe G (2009) Interventions for preventing critical illness polyneuropathy and critical illness myopathy. Cochrane Database Syst Rev 1:CD006832PubMedGoogle Scholar
  73. 73.
    Flint PW, Purcell LL, Cummings CW (1997) Pathophysiology and indications for medialization thyroplasty in patients with dysphagia and aspiration. Otolaryngol Head Neck Surg 116(3):349–354PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • J. Zielske
    • 1
    • 2
  • S. Bohne
    • 1
  • H. Axer
    • 2
    • 3
  • F.M. Brunkhorst
    • 4
    • 5
  • O. Guntinas-Lichius
    • 1
    Email author
  1. 1.Klinik und Poliklinik für Hals-, Nasen-, OhrenheilkundeUniversitätsklinikum JenaJenaDeutschland
  2. 2.Integriertes Forschungs- und Behandlungszentrum (IFB) Sepsis und SepsisfolgenUniversitätsklinikum JenaJenaDeutschland
  3. 3.Hans Berger Klinik für NeurologieUniversitätsklinikum JenaJenaDeutschland
  4. 4.Klinik für Anästhesiologie und IntensivtherapieUniversitätsklinikum JenaJenaDeutschland
  5. 5.Paul-Martini-Forschergruppe für Klinische SepsisforschungUniversitätsklinikum JenaJenaDeutschland

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