1. Videoendoscopy: The perils of silent aspiration Sarah Wallace Specialist Speech and Language Therapist University Hospital of South Manchester AAGBI 2011

2. Perils

3. Aspiration

4. Cardiothoracic ITU patient FEES : Fibreoptic Endoscopic Evaluation of Swallowing

5. Normal healthy swallow FEES : Fibreoptic Endoscopic Evaluation of Swallowing

6. Tracheostomised / ventilated ITU patient FEES : Fibreoptic Endoscopic Evaluation of Swallowing

7. Dysphagia in Intensive Care patients Incidence of dysphagia 33-56% Aspiration 50-75%, often silent 49% of tracheostomised patients aspirated of which 37% were silent (Hafner 2008) Prompt intervention can prevent costly and life threatening respiratory complications, aspiration pneumonia, and minimise nutritional complications

8. Dysphagia in Cardiothoracic ITU patients At UHSM, FEES found a high proportion of silent aspiration (59% of 86 patients) Patients with dysphagia post cardiac surgery had ↑ pneumonia, need for trache and LOS (Hogue 1995) Predictors: Age, duration of intubation and tracheostomy, TOE Post CABG: age, premorbid CVA, COPD (Hogue 1995, Harrington 1998)

9. Does aspiration matter? “Aspiration is the leading cause of pneumonia in the ITU environment and contributes significantly to morbidity and mortality” (McClave 2002) “Aspiration pneumonia impacts on ventilator status and delays the weaning process” (Dikeman & Kazandjian 2003) Increased LOS of an average 5.5 days

10. Aetiology of dysphagia Neurological and structural Peri / post operative CVA Damage to Vagus nerve Trauma to pharynx / larynx (prolonged intubation, TOE and NGT) Critical illness Tracheostomy Severity of dysphagia varies widely

11. Dysphagia symptoms Post op CVA Weak, delayed swallow function Damaged Vagus nerve Unilateral vocal fold palsy (RLN) Glottic incompetence High vagal lesion causes ↓ epiglottic retroflexion, pharyngeal weakness, desensate swallow

12. L Vocal fold palsy and trauma

13. Trauma to pharynx / larynx Incidence is 4 x higher in ITU patients with ↑ risk of aspiration Prolonged intubation (>48 hrs) Trauma to epiglottis, larynx, pharyngeal mucosa RLN compression by ETT cuff Laryngeal oedema TOE Dysphagia 7.8 times more likely Oropharyngeal / oesophageal trauma (Rousou 2000)

14. Intubation granuloma

15. Critical illness and dysphagia Myopathy of swallowing muscles, worsens over time, elderly and slow wean patients most at risk Medications / altered consciousness impact on brain-stem and cortical control of swallowing Weakened defences, more susceptible to respiratory complications if aspirating Loss of functional reserve

16. Tracheostomy and cuff inflation Airflow bypasses larynx / pharynx: 1. reduced evaporation of secretions 2. loss of sensation and cough 3. reduced intensity of glottic closure reflex 4. no voice to betray aspiration signs Weight of ventilator circuitry causes drag, ↓ laryngeal elevation, UES opening

17. Tracheostomy and cuff inflation ↓ subglottic pressure disrupts clearance of aspirated material, seeps around cuff Uncoordinated swallow, altered pressures, residue, cuff obstructs bolus passage, regurgitation

18. Cuff inflated tracheostomised patient FEES : Fibreoptic Endoscopic Evaluation of Swallowing

19. Aspiration risk decisions Accept risks: palliative, QOL, ethical dilemmas Avoid risks: NBM, prioritise respiratory wean over oral intake ↓Minimise risks: modify diet, thicken fluids (FEES needed for clarity) Severely dysphagic, slow vent wean patients: strictly monitored water sip trials?

20. Should patients be fed cuff inflated? Guidelines recommend deferring oral intake until at least partial cuff deflation Consider: 1. Motivation to eat/drink 2. Discomfort on swallowing or aspirating 3. Alertness 4. Palliation vs active treatment focus Some can eat & drink safely – FEES needed

21. Managing dysphagia 1. Diagnosis, SALT referral 2. Swallow assessment, FEES 3. Speaking valves Restores airflow, sensation, cough, secretion management, voice, morale! Aspiration signs become audible

22. Managing dysphagia 4. Trial partial cuff deflation, downsize trache 5. Oral hygiene, subglottic suction, oral balance gel, chlorhexidine 6. Medications to reduce secretions 7. Posey Mitts 8. Swallow strengthening exercises when medically stable

23. Conclusion Aspiration is perilous! Dysphagia often temporary FEES for accurate visualisation and clear plan MDT feeding decisions, Trache WR Swallowing reviewed regularly providing advice and support, especially if NBM

24. Thank you for listening, any questions? sarah.wallace@uhsm.nhs.uk