Arquivo da categoria: Intensive Care

Impact of a specialized multidisciplinary tracheostomy team on tracheostomy care in critically ill patients

de Mestral C; Iqbal S; Fong N; LeBlanc J; Fata P; Razek T; Khwaja K
Can J Surg; 54(3): 167-72, 2011 Jun.

BACKGROUND: A multidisciplinary tracheostomy team was created in 2005 to follow critically ill patients who had undergone a tracheostomy until their discharge from hospital. Composed of a surgeon, surgical resident, respiratory therapist, speech-language pathologist and clinical nurse specialist, this team has been meeting twice a week for rounds involving patients who transitioned from the intensive care unit (ICU) to the medical and surgical wards. Our objective was to assess the impact of this multidisciplinary team on downsizing and decannulation times, on the incidence of speaking valve placement and on the incidence of tracheostomy-related complications on the ward. METHODS: This study was conducted at a tertiary care, level-1 trauma centre and teaching hospital and involved all patients who had received a tracheostomy during admission to the ICU from Jan. 1 to Dec. 31, 2004 (preservice group), and from Jan. 1 to Dec. 31, 2006 (postservice group). We compared the outcomes of patients who required tracheostomies in a 12-month period after the team was created with those of patients from a similar time frame before the establishment of the team. RESULTS: There were 32 patients in the preservice group and 54 patients in the postservice group. Under the new tracheostomy service, there was a decrease in incidence of tube blockage (5.5% v. 25.0%, p = 0.016) and calls for respiratory distress (16.7% v. 37.5%, p = 0.039) on the wards. A significantly larger proportion of patients also received speaking valves (67.4% v. 19.4%, p < 0.001) after creation of the team. Furthermore, there appeared to be a decreased time to first tube downsizing (26.0 to 9.4 d) and decreased time to decannulation (50.4 to 28.4 d), although this did not reach statistical significance owing to our small sample size. CONCLUSION: Standardized care provided by a specialized multidisciplinary tracheostomy team was associated with fewer tracheostomy-related complications and an increase in the use of a speaking valve.

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Communication, swallowing and feeding in the intensive care unit patient

Batty S

Nurs Crit Care; 14(4): 175-9, 2009 Jul-Aug.
BACKGROUND: It is not uncommon for patients requiring a period of time in the intensive care unit (ICU) to experience difficulties with communication and/or swallowing, either as a result of their illness or as a result of the treatments they receive. These difficulties can be both short term and long term and require timely and appropriate intervention in order to improve the patient’s experience and expedite recovery/rehabilitation.
AIMS: The purpose of this article is to provide critical care nurses with an update on aspects of communication, swallowing and feeding in the ICU. The paper will focus on each area in relation to the current evidence base and factors of ‘best practice’ (as determined by expert opinion).
IMPLICATIONS FOR CRITICAL CARE NURSING PRACTICE: Enabling communication can improve well-being, increase compliance and reduce length of stay; Simple modes of communication, e.g. writing/gesture/pictures can be very effective; Coded eye blinking may be unreliable because of confusion with reflexive blinking; Non-oral nutrition will generally not meet the psychological and physical needs and benefits of oral intake; Not all patients with a tracheostomy in situ will experience dysphagia; however, those considered ‘at risk’ should have their swallow assessed by an appropriately trained professional, e.g. speech and language therapist/dysphagia trained professional; An inflated tracheostomy cuff will not prevent aspiration. The decision to commence oral intake in the presence of an inflated cuff should be made as a team and take into consideration the patient’s medical and psychological status; The use of blue dye to assess the swallow carries a high false-negative rate and cannot be relied on alone to predict either the presence or the absence of aspiration.
CONCLUSION: There is still much more research to be performed and evidence to be gained regarding the input into communication, swallowing and feeding in the ICU; however, a full-team approach to these areas can have very positive effects on the patient’s experience.

Postextubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness

Macht M; Wimbish T; Clark BJ; Benson AB; Burnham EL; Williams A; Moss M
Crit Care; 15(5): R231, 2011.
INTRODUCTION: Dysphagia is common among survivors of critical illness who required mechanical ventilation during treatment. The risk factors associated with the development of postextubation dysphagia, and the effects of dysphagia on patient outcomes, have been relatively unexplored. METHODS: We conducted a retrospective, observational cohort study from 2008 to 2010 of all patients over 17 years of age admitted to a university hospital ICU who required mechanical ventilation and subsequently received a bedside swallow evaluation (BSE) by a speech pathologist. RESULTS: A BSE was performed after mechanical ventilation in 25% (630 of 2,484) of all patients. After we excluded patients with stroke and/or neuromuscular disease, our study sample size was 446 patients. We found that dysphagia was present in 84% of patients (n = 374) and classified dysphagia as absent, mild, moderate or severe in 16% (n = 72), 44% (n = 195), 23% (n = 103) and 17% (n = 76), respectively. In univariate analyses, we found that statistically significant risk factors for severe dysphagia included long duration of mechanical ventilation and reintubation. In multivariate analysis, after adjusting for age, gender and severity of illness, we found that mechanical ventilation for more than seven days remained independently associated with moderate or severe dysphagia (adjusted odds ratio (AOR) = 2.84 [interquartile range (IQR) = 1.78 to 4.56]; P < 0.01). The presence of severe postextubation dysphagia was significantly associated with poor patient outcomes, including pneumonia, reintubation, in-hospital mortality, hospital length of stay, discharge status and surgical placement of feeding tubes. In multivariate analysis, we found that the presence of moderate or severe dysphagia was independently associated with the composite outcome of pneumonia, reintubation and death (AOR = 3.31 [IQR = 1.89 to 5.90]; P < 0.01). CONCLUSIONS: In a large cohort of critically ill patients, long duration of mechanical ventilation was independently associated with postextubation dysphagia, and the development of postextubation dysphagia was independently associated with poor patient outcomes.

Exploration and approach to artificial airway dysphagia

Fernández-Carmona A, Peñas-Maldonado L, Yuste-Osorio E, Díaz-Redondo A.

Med Intensiva. 2012 Aug-Sep;36(6):423-33. Epub 2011 Nov 4.

Abstract

Airway isolation by endotracheal intubation or tracheostomy impedes or even interrupts speech and swallowing. Pharyngeal and laryngeal impairment frequently occurs after extubation or de-cannulation, common consequences being dysphonia, dysphagia and the aspiration of oral secretions, food, or fluids. Aspiration often leads to pneumonia and eventually death. Although the literature reports a high frequency of dysphagia following intubation and tracheostomy, the data vary considerably, and the true incidence of oropharyngeal dysphagia following artificial airway isolation remains to be established. We conducted a systematic review of the available evidence, in order to assess oropharyngeal dysphagia physiology, diagnosis and treatment.
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Perfil funcional da deglutição em unidade de terapia intensiva clínica

Padovani, Aline Rodrigues; Andrade, Claudia Regina Furquim

Einstein (Säo Paulo); 5(4): 358-362, 2007

Resumo

Objetivo: Descrever o perfil funcional da deglutição e alimentaçãoem pacientes de uma unidade de terapia intensiva de emergênciasclínicas. Métodos: Levantamento dos atendimentos fonoaudiológicosrealizados na unidade de terapia intensiva de emergências clínicas,no período de maio a agosto de 2006, e determinação de indicadorespara descrição do perfil funcional de deglutição. Foram incluídosneste estudo os pacientes encaminhados por suspeita de disfagiaapós período prolongado de ventilação mecânica e/ou traqueostomiae excluídos os pacientes encaminhados por suspeita de disfagianeurogênica. Resultados: Observou-se uma prevalência de 65% dedisfagia orofaríngea em quatro meses de assistência fonoaudiológica.Entre os pacientes submetidos previamente à intubação orotraqueal,observou-se prevalência de disfagia orofaríngea em 64% dasavaliações, sendo constatada redução da gravidade da disfagia apósintervenção fonoaudiológica. Houve necessidade de prosseguir coma intervenção fonoaudiológica na enfermaria em 39% dos casos. Conclusão: A assistência fonoaudiológica às disfagias de causas nãoneurogênicas na unidade de terapia intensiva de emergências clínicasenfoca principalmente os pacientes que ficaram intubados por períodosuperior a 48 horas. Estes pacientes beneficiam-se da intervenção, pormeio da utilização de técnicas terapêuticas que contemplam todos oscritérios necessários para a alimentação segura.(AU)

Impact of obesity on critical care treatment in adult patients

Marcelo Moock, et al.

Rev. bras. ter. intensiva [online]. 2010, vol.22, n.2, pp. 133-137.

STUDY OBJECTIVE: Obese patients seem to have worse outcomes and more complications during intensive care unit (ICU) stay. This study describes the clinical course, complications and prognostic factors of obese patients admitted to an intensive care unit compared to a control group of nonobese patients. DESIGN: Retrospective observational study. SETTING: A 10-bed adult intensive care unit in a university-affiliated hospital. METHODS: All patients admitted to the intensive care unit over 52 months (April 01/2005 to November 30/2008) were included. Obese patients were defined as those with a body mass index (BMI) ≥ 30 Kg/M2. Demographic and intensive care unit related data were also collected. An clinical and demographical matching group of eutrophic patients selected from the data base as comparator for mortality and morbidity outcomes. The Mann-Whitney test was used for numeric data comparisons and the Chi Square test for categorical data comparisons. RESULTS: Two hundred nineteen patients were included. The obese group (n=73) was compared to the eutrophic group (n= 146). Most of this group BMI ranged between 30 – 35 Kg/M2. Only ten patients had body mass index ≥40 Kg/M2. Significant differences between the obese and eutrophic groups were observed in median APACHE II score (16 versus 12, respectively; p<0.05) and median intensive care unit length of stay (7 versus 5 days respectively; p<0,05). No significant differences were seen regarding risk of death, mortality rate, mechanical ventilation needs, days free of mechanical ventilation and tracheostomy rates. The observed mortality was higher than the APACHE II-predicted for both groups, but the larger differences were seen for morbid obese patients (BMI ≥40 Kg/M2).  CONCLUSIONS: Obesity did not increase the mortality rate, but improved intensive care unit length of stay. The current prognostic scoring systems do not include BMI, possibly underestimating the risk of death, and other quality of care indexes in obese patients. New studies could be useful to clarify how body mass index impacts the mortality rate.

Palavras-chave : Obesity [mortality]; Prognosis; Intensive care; Intensive care units; Apache; Body mass index; Mortality.

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O impacto da obesidade no tratamento intensivo de adultos

Marcelo Moock, et al.

Rev. bras. ter. intensiva [online]. 2010, vol.22, n.2, pp. 133-137.

OBJETIVOS: Verificar o prognóstico de pacientes obesos e eutróficos internados em Unidade de Terapia Intensiva (UTI) de adultos. DESENHO: Estudo retrospectivo e observacional MÉTODOS: Todos os pacientes admitidos na UTI durante 52 meses foram incluídos. Foram selecionados pacientes com IMC ≥30 Kg/M2 para compor o grupo obeso e outros com IMC < 30 Kg/M2, com características clínicas e demográficas semelhantes, que formaram o grupo eutrófico. Foram comparadas a mortalidade e a morbidade entre os grupos. O teste de Mann- Whitney foi usado para as variáveis numéricas e o teste do qui quadrado para as categóricas. RESULTADOS: Duzentos e dezenove pacientes foram incluídos. O grupo obeso (n=73) foi comparado com o grupo eutrófico (n=146). A maioria dos pacientes do grupo de obesos apresentou IMC na faixa de 30 a 35 Kg/M2, enquanto que os obesos mórbidos (IMC> 40 Kg/M2) totalizaram apenas 10 pacientes. Não se observou diferença na taxa de mortalidade real, na mortalidade prevista pelo APACHE II, na mediana do tempo de ventilação mecânica e na freqüência da realização de traqueostomia. As diferenças observadas foram na mediana do tempo de internação na unidade de terapia intensiva (7,0 versus 5,0 dias respectivamente; p<0,05), na mediana do escore do APACHE II (16,0 versus 12,0 respectivamente; p<0,05). A mortalidade observada foi sempre maior que a predita, segundo o APACHE II, nos dois grupos, porém o maior descolamento foi registrado nos pacientes com IMC > 40Kg/M2. CONCLUSÕES: Neste estudo a obesidade não aumentou a taxa de mortalidade, mas aumentou o tempo médio de permanência na UTI. Os atuais indicadores prognósticos ao não incluírem o IMC poderiam subestimar o risco de morrer e interferir em outros indicadores de qualidade do desempenho assistencial. Como ainda não há um consenso sobre a interferência da obesidade na mortalidade, a inclusão do índice de massa corpórea nos indicadores permanece controversa. Novos estudos, com maior número de obesos, poderão apontar qual o ponto de corte a partir do qual o índice de massa corpórea determinaria o incremento da taxa de mortalidade.

Palavras-chave : Obesidade [mortalidade]; Prognósticos; Cuidados intensivos; Unidades de terapia intensiva; Apache; Índice de massa corporal; Mortalidade.

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Tracheostomy teams reduce total tracheostomy time and increase speaking valve use: A systematic review and meta-analysis

Lauren Speed, Katherine E. Harding

Journal of Critical Care, 29 August 2012

Abstract

Purpose

Multidisciplinary tracheostomy teams have been implemented in acute hospitals over the past 10 years. This systematic review of the literature and meta-analysis aimed to assess the effect of tracheostomy teams on patient outcomes.

Materials and Methods

We conducted an electronic search of the literature in the following databases: MEDLINE, CINAHL, EMBASE, and AMED. Inclusion/exclusion criteria were applied, and included articles were assessed against quality criteria. Qualitative synthesis and meta-analysis were completed.

Results

Seven studies were included. The studies were all pre-post cohort designs of low-moderate quality. Meta-analysis showed that tracheostomy teams were associated with reductions in total tracheostomy time (4 studies; mean difference, 8 days; 95% confidence interval, 6-11; P < .01; I2 = 0%) and hospital length of stay (LOS) (3 studies; mean difference, −14 days; 95% confidence interval, −39 to 9; P = .23; I2 = 50%). Reductions in intensive care unit LOS (3 studies) and increases in speaking valve (3 studies) use were also reported with tracheostomy teams.

Conclusion

There is low-quality evidence that multidisciplinary tracheostomy care contributes to a reduction in total tracheostomy time and increase speaking valve use for patients leading to improved quality of life. There is insufficient evidence to determine that multidisciplinary tracheostomy teams reduce hospital or intensive care unit LOS.

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The S/Z ratio: A simple and reliable clinical method of evaluating laryngeal function in patients after intubation

Graeme Van der Meer, Yolandi Ferreira, James W. Loock

Journal of Critical Care Vol. 25, Issue 3, Pages 489-492, September 2010

Abstract

Objectives

1. To determine the consequences of prolonged intubation on laryngeal function.

2. To evaluate simple clinical criteria or tests that could alert the clinician to potential laryngeal pathology requiring ear, nose, and throat/otolaryngology (ENT) referral.

Design

A prospective case series.

Setting

A surgical intensive care unit in a tertiary academic hospital in Cape Town, South Africa.

Participants

Thirty-two patients who had undergone a period of translaryngeal intubation for a period greater than 12 hours.

Main outcome measures

1. Patient subjective voice change rating.

2. Clinician assessment of laryngeal function.

3. S/Z ratio.

4. Presence of laryngeal pathology on endoscopic assessment of the larynx.

Results

Upon initial evaluation within 6 hours of extubation, 26 (81%) of patients exhibited symptomatic laryngeal dysfunction. At this stage, 13 (40%) had S/Z ratios greater than 1.4. The degree of dysfunction as described by subjective scoring and the S/Z ratio was proportional to the duration of intubation. After 24 hours, 23 (72%) patients’ voices had improved subjectively; and the S/Z ratio exceeded 1.4 in just 6 patients (19%). Of these 6 patients, 4 exhibited laryngeal pathology on flexible nasoendoscopy. These 4 patients were followed up over 1 year, and 1 patient was ultimately offered a vocal cord medialization procedure. The S/Z ratio is 100% sensitive and 93% specific, with an accuracy of 93.75%, in diagnosing laryngeal pathology requiring ENT referral.

Conclusions

1. A period of laryngeal intubation carries signification risk of laryngeal dysfunction. Most, but not all, dysfunction resolves within 24 hours.

2. Residual laryngeal pathology can be reliably and simply screened for by the use of the S/Z ratio. We recommend that patients with an S/Z ratio greater than 1.4 more than 24 hours after extubation require ENT referral for laryngoscopy.

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Diagnosis and treatment of post-extubation dysphagia: Results from a national survey

 

Macht M, Wimbish T, Clark BJ, Benson AB, Burnham EL, Williams A, Moss M.

J Crit Care. 2012 Oct 17. pii: S0883-9441(12)00235-3. doi: 10.1016/j.jcrc.2012.07.016. [Epub ahead of print]

Abstract

PURPOSE:

This study sought to determine the utilization of speech-language pathologist (SLPs) for the diagnosis and treatment of post-extubation dysphagia in survivors of mechanical ventilation.

METHODS:

We designed, validated, and mailed a survey to 1,966 inpatient SLPs who routinely evaluate patients for post-extubation dysphagia.

RESULTS:

Most SLP diagnostic evaluations (60%; 95% CI, 59%-62%) were performed using clinical techniques with uncertain accuracy. Instrumental diagnostic tests (such as fluoroscopy and endoscopy) are more likely to be available at university than community hospitals. After adjusting for hospital size and academic affiliation, instrumental test use varied significantly by geographical region. Treatments for post-extubation dysphagia usually involved dietary adjustment (76%; 95% CI, 73-79%) and postural changes/compensatory maneuvers (86%; 95% CI, 84-88%), rather than on interventions aimed to improve swallowing function (24%; 95% CI, 21-27%).

CONCLUSIONS:

SLPs frequently evaluate acute respiratory failure survivors. However, diagnostic evaluations rely mainly upon bedside techniques with uncertain accuracy. The use of instrumental tests varies by geographic location and university affiliation. Current diagnostic practices and feeding decisions for critically ill patients should be viewed with caution until further studies determine the accuracy of bedside detection methods.

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