Critical Care & Tracheostomy Discussion and EBP Group 2008 Reducing the lag… Critical Care & Tracheostomy Discussion and EBP Group 2008

Evidence Reducing the lag between published research and the clinical application Hot topics Clinical questions – focus on intubation Example through clinical practice Clinical Practice Research

What to do in the case of an extubated patient

Bob 69 year old male PMHx: Heart disease, NIDDM, OA Lives at home with wife Needs some help with dressing Admitted to hospital for coronary bypass surgery. Intubated for 10 days

Endotracheal intubation: Insertion of a tube into the trachea for purposes of anesthesia, airway maintenance, aspiration of secretions, lung ventilation, or prevention of entrance of foreign material into the airway; the tube goes through the nose (nasotracheal i.) or mouth (orotracheal i.) . (http://medical-dictionary.thefreedictionary.com/intubation)

Bob Bob extubated day 10 Observed to be coughing with water Speech Pathology referral requested

Question In critical care patients, does intubation (ETT) versus non-invasive ventilation result in increased incidence of dysphagia?

Results No article specifically address question…but…some useful clinical information. Suggestions of acute changes to swallow function Increased swallow latency (ETT/none) Elderly (>65) who premorbidly are functionally impaired are more likely to experience aspiration. Age is implicated in the recovery of dysphagia Trauma patients may be at increased risk of aspiration FEES allow for a rapid objective evaluation

Bob Commenced on modified diet Moderately dysphonic Little change in phonation quality 2 weeks post extubation ENT review requested

Question In critical care patients, does intubation affect laryngeal health? 16 articles reviewed

Results Mucosal ulcerations along posterior-medial aspects, granuloma and erythema most common injuries Correlation with duration of intubation and laryngeal injury, injuries acquired in first 7 days (dogs) Early laryngeal changes seen after 24 hours intubation Prolonged intubation and reintubation correlated with increased occurances of complications Resolution of symptoms 7 days to 4 weeks Intraoperative complications – anesthesia

Other clinical benefits Informs clinical practice Policy development Hot topic discussions

Challenges Getting the question right Covering the literature What to do with left over information?? Reducing the lag

Future directions…light bulb moments