Skip to main content

Advertisement

SpringerLink
Log in

Dysphagia in Intensive Care Evaluation (DICE): An International Cross-Sectional Survey

  • Original Article
  • Published:
Dysphagia Aims and scope Submit manuscript

Abstract

Dysphagia occurs commonly in the intensive care unit (ICU). Despite the clinical relevance, there is little worldwide research on prevention, assessment, evaluation, and/or treatment of dysphagia for ICU patients. We aimed to gain insight into this international knowledge gap. We conducted a multi-center, international online cross-sectional survey of adult ICUs. Local survey distribution champions were recruited through professional and personal networks. The survey was administered from November 2017 to June 2019 with three emails and a final telephone reminder. Responses were received from 746 ICUs (26 countries). In patients intubated > 48 h, 17% expected a > 50% chance that dysphagia would develop. This proportion increased to 43% in patients intubated > 7 days, and to 52% in tracheotomized patients. Speech-language pathologist (SLP) consultation was available in 66% of ICUs, only 4% reported a dedicated SLP. Although 66% considered a routine post-extubation dysphagia protocol important, most (67%) did not have a protocol. Few ICUs routinely assessed for dysphagia after 48 h of intubation (30%) or tracheostomy (41%). A large proportion (46%) used water swallow screening tests to determine aspiration, few (8%) used instrumental assessments (i.e., flexible endoscopic evaluation of swallowing). Swallowing exercises were used for dysphagia management by 30% of ICUs. There seems to be limited awareness among ICU practitioners that patients are at risk of dysphagia, particularly as ventilation persists, protocols, routine assessment, and instrumental assessments are generally not used. We recommend the development of a research agenda to increase the quality of evidence and ameliorate the implementation of evidence-based dysphagia protocols by dedicated SLPs.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Abbreviations

ICU:

Intensive care unit

FEES:

Flexible endoscopic evaluation of swallowing

NEMS:

Neuromuscular electrical stimulation

PES:

Pharyngeal electrical stimulation

PEG:

Percutaneous endoscopic gastrostomy

SD:

Standard deviation

sEMG:

Surface electromyography

SLP:

Speech-language pathologist

VFSS:

Videofluoroscopic swallowing study

V-VST:

Volume–viscosity swallow test

References

  1. Baijens L, Clave P, Cras P, Ekberg O, Forster A, Kolb G, Leners JC, Masiero S, Mateos-Nazal, Ortega O, Smithard G, Speyer R, Walshe M ES for SD-EUGMS. White paper: oropharyngeal dysphagia as a geriatric syndrome. Clin Interv Aging. 2016;11:1–16.

    Article  Google Scholar 

  2. Spronk PE, Spronk LEJ, Lut J, Gnacke E, Mijnes D, Munster B, et al. Prevalence and characterization of dysphagia in hospitalized patients. Neurogastroenterol Motil. 2020;32:1–8.

    Article  Google Scholar 

  3. Skoretz SA, Flowers HL, Martino R. The incidence of dysphagia following endotracheal intubation. Chest. 2010;137:665–73.

    Article  PubMed  Google Scholar 

  4. El Solh A, Okada M, Bhat A, Pietrantoni C. Swallowing disorders post orotracheal intubation in the elderly. Intensive Care Med. 2003;29:1451–5.

    Article  PubMed  Google Scholar 

  5. Carrión S, Cabré M, Monteis R, Roca M, Palomera E, Serra-Prat M, et al. Oropharyngeal dysphagia is a prevalent risk factor for malnutrition in a cohort of older patients admitted with an acute disease to a general hospital. Clin Nutr. 2015;34:436–42.

    Article  PubMed  Google Scholar 

  6. Brodsky MB, Huang M, Shanholtz C, Mendez-Tellez PA, Palmer JB, Colantuoni E, et al. Recovery from dysphagia symptoms after oral endotracheal intubation in acute respiratory distress syndrome survivors. A 5-year longitudinal study. Ann Am Thorac Soc. 2017;14:376–83.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Altman KW, Yu G-P, Schaefer SD. Consequence of dysphagia in the hospitalized patient. Arch Otolaryngol Neck Surg. 2010;136:784.

    Article  Google Scholar 

  8. Ekberg O, Hamdy S, Woisard V, Wuttge-Hannig A, Ortega P. Social and psychological burden of dysphagia: its impact on diagnosis and treatment. Dysphagia. 2002;17:139–46.

    Article  PubMed  Google Scholar 

  9. Schefold JC, Berger D, Zürcher P, Lensch M, Perren A, Jakob SM, et al. Dysphagia in mechanically ventilated ICU patients (DYnAMICS). Crit Care Med. 2017;45:2061–9.

    Article  PubMed  Google Scholar 

  10. Macht M, Wimbish T, Bodine C, Moss M. ICU-acquired swallowing disorders. Crit Care Med. 2013;41:2396–405.

    Article  PubMed  Google Scholar 

  11. Rousou JA, Tighe DA, Garb JL, Krasner H, Engelman RM, Flack JE, et al. Risk of dysphagia after transesophageal echocardiography during cardiac operations. Ann Thorac Surg. 2000;69:486–9.

    Article  CAS  PubMed  Google Scholar 

  12. Brodsky MB, Levy MJ, Jedlanek E, Pandian V, Blackford B, Price C, et al. Laryngeal injury and upper airway symptoms after oral endotracheal intubation with mechanical ventilation during critical care: a systematic review. Crit Care Med. 2018;46:2010–7.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Krisciunas GP, Langmore SE, Gomez-Taborda S, Fink D, Levitt JE, McKeehan J, et al. The association between endotracheal tube size and aspiration (during flexible endoscopic evaluation of swallowing) in acute respiratory failure survivors. Crit Care Med. 2020;48:1604–11.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Marian T, Dünser M, Citerio G, Koköfer A, Dziewas R. Are intensive care physicians aware of dysphagia? The MAD ICU survey results. Intensive Care Med. 2018;44:973–5.

    Article  PubMed  Google Scholar 

  15. van Snippenburg W, Kröner A, Flim M, Hofhuis J, Buise M, Hemler R, et al. Awareness and management of dysphagia in dutch intensive care units: a nationwide survey. Dysphagia. 2019;34:220–8.

    Article  PubMed  Google Scholar 

  16. Zuercher P, Dziewas R, Schefold JC. Dysphagia in the intensive care unit: a (multidisciplinary) call to action. Intensive Care Med. 2020;46:554–6.

    Article  PubMed  Google Scholar 

  17. Hofhuis JGM, Rose L, Blackwood B, Akerman E, McGaughey J, Egerod I, et al. Clinical practices to promote sleep in the ICU: a multinational survey. Int J Nurs Stud. 2018;81:107–14.

    Article  PubMed  Google Scholar 

  18. Rose L, Blackwood B, Egerod I, Haugdahl HS, Hofhuis J, Isfort M, et al. Decisional responsibility for mechanical ventilation and weaning: an international survey. Crit Care. 2011;15:R295.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Burns KEA, Duffett M, Kho ME, Meade MO, Adhikari NKJ, Sinuff T, et al. A guide for the design and conduct of self-administered surveys of clinicians. CMAJ. 2008;179:245–52.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Barnette JJ. Effects of stem and Likert response option reversals on survey internal consistency: If you feel the need, there is a better alternative to using those negatively worded stems. Educ Psychol Meas. 2000;60:361–70.

    Article  Google Scholar 

  21. Locker D, Jokovic A, Allison P. Direction of wording and responses to items in oral health-related quality of life questionnaires for children and their parents. Community Dent Oral Epidemiol. 2007;35:255–62.

    Article  PubMed  Google Scholar 

  22. Harpe SE. How to analyze Likert and other rating scale data. Curr Pharm Teach Learn Elsevier. 2015;7:836–50.

    Article  Google Scholar 

  23. Yoon WL, Khoo JKRLS. Chin tuck against resistance (CTAR): New method for enhancing suprahyoid muscle activity using a Shaker-type exercise. Dysphagia. 2014;29:243–8.

    Article  PubMed  Google Scholar 

  24. Shaker R, Kern M, Bardan E, Taylor A, Stewart ET, Hoffmann RG, et al. Augmentation of deglutitive upper esophageal sphincter opening in the elderly by exercise. Am J Physiol - Gastrointest Liver Physiol. 1997;272:1518–22.

    Article  Google Scholar 

  25. de Oliveira ACM, de Friche AA, Salomão MS, Bougo GC, Vicente LCC. Predictive factors for oropharyngeal dysphagia after prolonged orotracheal intubation. Braz J Otorhinolaryngol. 2018;84:722–8.

    Article  PubMed  Google Scholar 

  26. Elpern EH, Scott MG, Petro L, Ries MH. Pulmonary aspiration in mechanically ventilated patients with tracheostomies. Chest. 1994;105:563–6.

    Article  CAS  PubMed  Google Scholar 

  27. Tolep K, Getch CL, Criner GJ. Swallowing dysfunction in patients receiving prolonged mechanical ventilation. Chest. 1996;109:167–72.

    Article  CAS  PubMed  Google Scholar 

  28. Sassi FC, de Medeiros GC, Zambon LS, Zilberstein B, de Andrade CRF. Evaluation and classification of post-extubation dysphagia in critically ill patients. Rev Col Bras Cir. 2018;45:e1687.

    PubMed  Google Scholar 

  29. Brodsky MB, Gellar JE, Dinglas VD, Colantuoni E, Mendez-Tellez PA, Shanholtz C, et al. Duration of oral endotracheal intubation is associated with dysphagia symptoms in acute lung injury patients. J Crit Care. 2014;29:574–9.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Zuercher P, Moret CS, Dziewas R, Schefold JC. Dysphagia in the intensive care unit: epidemiology, mechanisms, and clinical management. Crit Care Critical Care. 2019;23:1–11.

    Google Scholar 

  31. Zuercher P, Moret C, Schefold JC. Dysphagia in the intensive care unit in Switzerland (DICE): results of a national survey on the current standard of care. Swiss Med Wkly. 2019;149:1–10.

    Google Scholar 

  32. Leder SB, Warner HL, Suiter DM, Young NO, Bhattacharya B, Siner JM, et al. Evaluation of swallow function post-extubation: is it necessary to wait 24 hours? Ann Otol Rhinol Laryngol. 2019;128:619–24.

    Article  PubMed  Google Scholar 

  33. Macht M, Wimbish T, Clark BJ, Benson AB, Burnham EL, Williams A, et al. Postextubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness. Crit Care. 2011;15:R231.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Macht M, King CJ, Wimbish T, Clark BJ, Benson AB, Burnham EL, et al. Post-extubation dysphagia is associated with longer hospitalization in survivors of critical illness with neurologic impairment. Crit Care. 2013;17:R119.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Malandraki GA, Markaki V, Georgopoulos VC, Psychogios L, Nanas S. Postextubation dysphagia in critical patients: a first report from the largest step-down intensive care unit in greece. Am J Speech-Language Pathol. 2016;25:150–6.

    Article  Google Scholar 

  36. Moss M, White SD, Warner H, Dvorkin D, Fink D, Gomez-Taborda S, et al. Development of an accurate bedside swallowing evaluation decision tree algorithm for detecting aspiration in acute respiratory failure survivors. Chest. 2020;158:1923–33.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Brodsky MB, Nollet JL, Spronk PE, González-Fernández M. Prevalence, pathophysiology, diagnostic modalities, and treatment options for dysphagia in critically Ill patients. Am J Phys Med Rehabil. 2020;99:1164–70.

    Article  PubMed  Google Scholar 

  38. Macht M, Wimbish T, Clark BJ, Benson AB, Burnham EL, Williams A, et al. Diagnosis and treatment of post-extubation dysphagia: Results from a national survey. J Crit Care. 2012;27:578–86.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Spronk PE, Riekerk B, Hofhuis J, Rommes JH. Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med. 2009;35:1276–80.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Hajiesmaeili MR, Safari S. Pain management in the intensive care unit: do we need special protocols? Anesthesiol Pain Med. 2012;1:237–8.

    Article  Google Scholar 

  41. Ely EW, Meade MO, Haponik EF, Kollef MH, Cook DJ, Guyatt GH, et al. Mechanical ventilator weaning protocols driven by nonphysician health-care professionals. Chest. 2001;120:454S-463S.

    Article  CAS  PubMed  Google Scholar 

  42. Brodsky MB, González-Fernández M, Mendez-Tellez PA, Shanholtz C, Palmer JB, Needham DM. Factors associated with swallowing assessment after oral endotracheal intubation and mechanical ventilation for acute lung injury. Ann Am Thorac Soc. 2014;11:1545–52.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Cardinal LA, Freeman-Sanderson A, Togher L. The speech pathology workforce in intensive care units: results from a national survey. Aust Crit Care Elsevier Ltd. 2020;33:250–8.

    Article  Google Scholar 

  44. Brodsky MB, Suiter DM, González-Fernández M, Michtalik HJ, Frymark TB, Venediktov R, et al. Screening accuracy for aspiration using bedside water swallow tests. Chest. 2016;150:148–63.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Seedat J, Penn C. Implementing oral care to reduce aspiration pneumonia amongst patients with dysphagia in a South African setting. South African J Commun Disord Die Suid-Afrikaanse Tydskr vir Kommun. 2016;63:1–11.

    Google Scholar 

  46. Ortega O, Martín A, Clavé P. Diagnosis and management of oropharyngeal dysphagia among older persons, state of the art. J Am Med Dir Assoc. 2017;18:576–82.

    Article  PubMed  Google Scholar 

  47. Ashford J, McCabe D, Wheeler-Hegland K, Frymark T, Mullen R, Musson N, Schooling THC. Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Part III–Impact of dysphagia treatments on populations with neurological disorders. J Rehabil Res Dev. 2009;46:195–204.

    Article  PubMed  Google Scholar 

  48. Restivo DA, Hamdy S. Pharyngeal electrical stimulation device for the treatment of neurogenic dysphagia: technology update. Med Devices Evid Res. 2018;11:21–6.

    Article  CAS  Google Scholar 

  49. Dziewas R, Stellato R, van der Tweel I, Walther E, Werner CJ, Braun T, et al. Pharyngeal electrical stimulation for early decannulation in tracheotomised patients with neurogenic dysphagia after stroke (PHAST-TRAC): a prospective, single-blinded, randomised trial. Lancet Neurol. 2018;17:849–59.

    Article  PubMed  Google Scholar 

  50. Koestenberger M, Neuwersch S, Hoefner E, Breschan C, Weissmann H, Stettner H, et al. A pilot study of pharyngeal electrical stimulation for orally intubated ICU patients with dysphagia. Neurocrit Care. 2020;32:532–8.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowlegments

Co-authors of DICE study investigator group

Survey development team: M. B. Brodsky (Johns Hopkins University, Baltimore, USA); L. Rose (King’s College London, London, UK); J. Lut (Gelre Hospitals, Apeldoorn, The Netherlands); P. Clavé (Hospital de Mataró, Universitat Autónoma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Aparato DIgestivo, Ciberehd Barcelona, Spain); R. Nanchal (Medical college Wisconsin, USA); Y. Inamoto (Fujita Health University, Aichi, Japan); J. I. van der Hoeven (Radboud University, Nijmegen, The Netherlands); P. E. Spronk (Gelre Hospitals, Apeldoorn, The Netherlands). National study coordinators: A. Freeman-Sanderson (Australia); M. Hiesmayr, C. Veraar (Austria); C. E. Hickmann, R. Gosselink (Belgium); L. Rose, S. Gershman, S. Skoretz, R. Martino (Canada); M. Mpouzika (Cyprus); M. Cerny, V. Chrobok, L. Zeinerova (Czech Republic); I. Egerod, G. Kaldan (Denmark); J. McRae (England); M. Bäcklund (Finland); T. Ramos (France); P. Nydahl (Germany); M. Kalafati (Greece); T. Andrews (Ireland); R. Sperlinga (Italy); H. Katsukawa, F. Kasai (Japan); P. E. Spronk, J. Lut, L. E. J. Spronk (Netherlands); A. Miles (New Zealand); J. McGaughey, S. Duncan (Northern Ireland (UK)); M. Fossum, V. Ágústdóttir, T. Senneset, M. Larsson, G. Hammond (Norway); R. Owczuk (Poland); S. Mestre (Portugal); J. Merriweather (Scotland); M. Tedla, Z. Frajkova (Slovakia); M. Velasco (Spain); E. Akerman (Sweden); A. Sibilla, B. Kertscher, B. Gaechter (Switzerland); S. Serel Arslan, N. Demir (Turkey); G. Jones (Wales).

Funding

This study was partially funded by the Gelre Hospitals science fund (Grant 2018-012).

Author information

Authors and Affiliations

  1. Intensive Care Department, Gelre Hospitals, Albert Schweitzerlaan 31, 7334 DZ, Apeldoorn, The Netherlands

    Peter E. Spronk & Laura E. J. Spronk

  2. Expertise center for Intensive care Rehabilitation Apeldoorn – ExpIRA, Apeldoorn, The Netherlands

    Peter E. Spronk & Laura E. J. Spronk

  3. Intensive Care Unit, Rigshospitalet, and Health & Medical Sciences, University of Copenhagen, Copenhagen, Denmark

    Ingrid Egerod

  4. School of Nursing and Midwifery, Queen’s University Belfast, Belfast, UK

    Jennifer McGaughey

  5. Center of Allied Health, St George’s, University of London, London, UK

    Jackie McRae

  6. Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK

    Louise Rose

  7. Department of Physical Medicine & Rehabilitation, Johns Hopkins University, Baltimore, MD, USA

    Martin B. Brodsky

  8. Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA

    Martin B. Brodsky

  9. Outcomes After Critical Illness and Surgery Research Group, Johns Hopkins University, Baltimore, MD, USA

    Martin B. Brodsky

Authors
  1. Peter E. Spronk
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Laura E. J. Spronk
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ingrid Egerod
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jennifer McGaughey
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jackie McRae
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Louise Rose
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Martin B. Brodsky
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

the DICE study investigators

  • M. B. Brodsky
  • , L. Rose
  • , J. Lut
  • , P. Clavé
  • , R. Nanchal
  • , Y. Inamoto
  • , J. I. van der Hoeven
  • , P. E. Spronk
  • , A. Freeman-Sanderson
  • , M. Hiesmayr
  • , C. Veraar
  • , C. E. Hickmann
  • , R. Gosselink
  • , S. Gershman
  • , S. Skoretz
  • , R. Martino
  • , M. Mpouzika
  • , M. Cerny
  • , V. Chrobok
  • , L. Zeinerova
  • , I. Egerod
  • , G. Kaldan
  • , J. McRae
  • , M. Bäcklund
  • , T. Ramos
  • , P. Nydahl
  • , M. Kalafati
  • , T. Andrews
  • , R. Sperlinga
  • , H. Katsukawa
  • , F. Kasai
  • , L. E. J. Spronk
  • , A. Miles
  • , J. McGaughey
  • , S. Duncan
  • , M. Fossum
  • , V. Ágústdóttir
  • , T. Senneset
  • , M. Larsson
  • , G. Hammond
  • , R. Owczuk
  • , S. Mestre
  • , J. Merriweather
  • , M. Tedla
  • , Z. Frajkova
  • , M. Velasco
  • , E. Akerman
  • , A. Sibilla
  • , B. Kertscher
  • , B. Gaechter
  • , S. Serel Arslan
  • , N. Demir
  •  & G. Jones

Contributions

All authors of the DICE study investigator group contributed substantially to the conception and design of the study, the acquisition of data, or the analysis and interpretation of the data. All authors of the DICE study investigator group drafted or provided critical revision of the article and provided their final approval of the version submitted for publication. In more detail, material preparation, data collection, and analysis were done by LEJS, JL, and PES. PES drafted the manuscript and members of the writing group (LEJS, MBB, LR, IE, JM, and JM) revised it critically for important intellectual content. Subsequently, the version was distributed among all the other DICE study group investigators for critical appraisal. All authors mentioned as national study coordinators participated in ethical approvals, recruitment, and data collection in their respective countries. See non-anonymized version.

Corresponding author

Correspondence to Peter E. Spronk.

Ethics declarations

Conflict of interest

No conflict of interest were declared by any of the authors.

Ethical Approval

Research ethics approval for survey conduct was obtained according to the requirements of each country by national study coordinators. Written confirmation of ethics approval, or the confirmation that requirements were waived, was obtained by the study investigator (Peter E. Spronk) from all national study coordinators prior to data collection. A paragraph mentioning this information was added to the methods section of the manuscript.

Consent to Participate

Returning a survey was indicating consent to participate in this survey by national coordinators who were responsible for contacts with the ICUs in their country/region. The ICUs were allowed to opt out of study participation, but this never occurred.

Consent for Publication

All authors read the final version of the manuscript and agreed to publish the paper.

Financial/Nonfinancial Disclosures

None declared by any of the authors.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Spronk, P.E., Spronk, L.E.J., Egerod, I. et al. Dysphagia in Intensive Care Evaluation (DICE): An International Cross-Sectional Survey. Dysphagia 37, 1451–1460 (2022). https://doi.org/10.1007/s00455-021-10389-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00455-021-10389-y

Keywords

Search

Navigation