Clinical Approaches to Assess Post-extubation Dysphagia (PED) in the Critically Ill
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Swallowing disorders and respective consequences (including aspiration-induced pneumonia) are often observed in extubated ICU patients with data indicating that a large number of patients are affected. We recently demonstrated in a large-scale analysis that the incidence of post-extubation dysphagia (PED) is 12.4% in a general ICU population and about 18% in emergency admissions to the ICU. Importantly, PED was mostly sustained until hospital discharge and independently predicted 28- and 90-day mortality. Although oropharyngeal/laryngeal trauma, neuromuscular ICU-acquired weakness, reduced sensation/sensorium, dyssynchronous breathing, and gastrointestinal reflux, are all considered to contribute to PED, little is known about the underlying pathomechanisms and risk factors leading to PED in critically ill patients. Systematic screening of all potential ICU patients for oropharyngeal dysphagia (OD) seems key for early recognition and follow-up, as well as the design and testing of novel therapeutic interventions. Today, screening methods and clinical investigations for dysphagia differ considerably. In the context of a recently proposed pragmatic screening algorithm introduced by us, we provide a concise review on currently available non-instrumental techniques that could potentially serve for non-instrumental OD assessment in critically ill patients. Following systematic literature review, we find that non-instrumental OD assessments were mostly tested in different patient populations with only a minority of studies performed in critically ill patients. Due to little available data on non-instrumental dysphagia assessment in the ICU, future investigations should aim to validate respective approaches in the critically ill against an instrumental (gold) standard, for example, flexible endoscopic evaluation of swallowing. An international expert panel is encouraged to addresses critical illness—related definitions, screening and confirmatory assessment approaches, treatment recommendations, and identifies optimal patient-centered outcome measures for future clinical investigations.
KeywordsSwallowing disorder ICU-ASD ICU-AW Neuromuscular Sepsis Non-instrumental
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Conflict of interest
Drs. Zürcher and Schefold disclose that the Department of Intensive Care Medicine has, or has had in the past, research contracts with Orion Corporation, Abbott Nutrition International, B. Braun Medical AG, CSEM SA, Edwards Lifesciences Services GmbH, Kenta Biotech, Maquet Critical Care AB, Omnicare Clinical Research AG and research and development/consulting contracts with Edwards Lifesciences SA, Maquet Critical Care AB, and Nestlé. The money was paid into a departmental fund, and no personal financial gain was received. The Department has also received unrestricted educational grants from the following organizations for organizing biannual postgraduate courses in the fields of critical care ultrasound, management of extracorporeal membrane oxygenation and mechanical ventilation: Pierre Fabre Pharma AG (formerly known as RobaPharm), Pfizer AG, Bard Medica SA, Abbott AG, Anandic Medical Systems, PanGas AG Healthcare, Orion Pharma, Bracco, Edwards Lifesciences AG, Hamilton Medical AG, Fresenius Kabi (Schweiz) AG, Getinge Group Maquet AG, Dräger Schweiz AG, Teleflex Medical GmbH. Mrs. Perren declares no conflicts of interest.
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