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ICU-RELATED DYSPHAGIA EPIDEMIOLOGY, PATHOPHYSIOLOGY,

DIAGNOSTICS AND TREATMENT

Article · March 2015

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Jens B. Schröder Joerg Glahn

Carl von Ossietzky Universität Oldenburg Johannes Wesling Klinikum Minden
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COVER STORY: the Brain

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COVER STORY: the Brain

ICU-RELATED DYSPHAGIA
EPIDEMIOLOGY, PATHOPHYSIOLOGY, DIAGNOSTICS AND TREATMENT

Due to malnutrition and aspiration dysphagia in critically ill patients on the ICU is an extremely important symptom
with crucial impact on outcome and mortality. A broad variety of pathogenetic factors can lead to severe dysphagia
in non-intubated and intubated patients followed by a significant delay in decannulation after weaning from the
respirator has been completed. The aim of the following review is to present the diversity of pathogenetic factors
on the ICU, evaluate the existing diagnostic procedures and, based on current knowledge, give pragmatic recom-
mendations for the diagnostic approach as well as for the further nutritional management of ICU patients.

or neuromuscular disorders (polymyositis, ALS)

Jens Schröder Aetiology and Pathophysiology of should be mentioned. These disorders are either
NeuroICU Dysphagia on the ICU associated with pre-existing dysphagia, or at
Department of Neurology
The causes of dysphagia in the critically ill can be least increase the likelihood of a deterioration
University Hospital Münster
differentiated into three aetiological categories. of swallowing function during ICU treat-
©For personal and private use only. Reproduction must be permitted by the copyright holder. Email to [email protected].

Münster, Germany
Thus, dysphagia may be: ment. Thus, although hospitalisation on the
Jörg Glahn (i) associated with the main diagnosis leading ICU may be initiated because of e.g. urosepsis
Vice-Chairman
Department of Neurology
to ICU treatment; or myocardial infarction, the further clinical
Johannes Wesling Klinikum Minden (ii) the result of co-morbidities; course gets complicated because of decom-
Minden, Germany (iii) associated with the treatment on the pensated dysphagia.
ICU itself.
Rainer Dziewas
Professor of Neurology Especially in patients on the neurological inten- (iii) ICU Treatment-Related
Head of the Stroke Unit and the NeuroICU sive care unit a combination of the different aeti- Dysphagia in the ICU may also be caused by the
Department of Neurology ologies must be expected. treatment itself and/or further environmental
University Hospital Münster
Münster, Germany
conditions. There are six pathomechanisms to
(i) Diagnosis-Associated differentiate as shown in Figure 2 (Macht et
[email protected]
As shown in Figure 1, various neurological al. 2013).
disorders that typically require treatment on the 1. The endotracheal tube, the tracheal

I n intensive care medicine dysphagia is an

extremely frequent and outcome-relevant
symptom. Studies on internal medicine,
anaesthesiological and surgical intensive care
units have shown that 50 to 70% of patients on
ICU impair the functionality of the swallowing
network or the associated downstream nerves and
muscles. Stroke and inflammatory diseases of the
CNS lead, depending on location, to disturbance
of the supramedullary or medullary control of
cannula, laryngeal masks and nasogastric
suction probes can lead to various inju-
ries of the pharynx, larynx or oesophagus.
2. Intensive care patients often develop
a weakness of the swallowing muscles
these wards suffered from dysphagia (Ajemian et swallowing. Guillain-Barré syndrome (GBS), due to critical illness neuropathy and
al. 2001; Skoretz et al. 2010). In a recent study on critical illness neuropathy (CIP) and critical myopathy.
a neurological intensive care unit there was even a illness myopathy (CIM) cause dysphagia due 3. The development of oropharyngeal and
dysphagia incidence of over 90%, and dysphagia to an impairment of motor and sensory cranial laryngeal sensory deficits. Among other
persisted in half of the patients until the day of nerve function. Finally, disorders of swallowing reasons this may be the result of sensory
discharge (Macht et al. 2013). Of particular rele- muscles themselves, as they can be observed nerve damage due to CIP or because of
vance is the finding that dysphagia in intensive in inflammatory myositis, as well as disorders local mucosal oedema followed by a
care patients is more severe and in 10-20% of involving the neuromuscular junction, lead to disruption of the sensory feedback.
the patients accompanied by silent aspirations myogenic dysphagia. 4. Qualitative and quantitative impairment
(Ajemian et al. 2001, Barquist et al. 2001, El Solh of consciousness, either as an effect of
et al. 2003). Regardless of the diagnostic spec- (ii) Caused by Co-Morbidities sedating medication or as a result of
trum analysed, dysphagia in critically ill patients Apart from the main diagnosis (e.g. acute stroke, delirium, are also involved in the devel-
is a significant predictor of complications, espe- GBS, brainstem encephalitis), co-morbidities opment of dysphagia.
cially aspiration pneumonia and reintubation, also play an important role. A wide range of 5. Gastroesophageal reflux in critically ill
and a crucial determinant of the duration of neurodegenerative (e.g., Parkinson's disease, patients causes insufficient supply of
hospitalisation and the patients’ outcome (Macht Alzheimer's disease), neurovascular (stroke, nutrients and is in particular a main risk
et al. 2011). subcortical arteriosclerosis encephalopathy) factor for aspiration.

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6. Patients on the ICU often suffer from

a desynchronisation of breathing and
swallowing. Both the duration of the
swallowing apnoea, as well as the coor-
dination of the respiratory cycle and the
moment of swallowing may be impaired,
increasing the risk of aspiration (Shaker
et al. 1992, Gross et al. 2009).

Diagnostic Workup
Dysphagia plays an important role on the ICU.
Adequate diagnostic procedures should help
to detect this disorder as precisely and timely
as possible. Based on the result of swallowing
assessment appropriate nutritional manage-
ment and treatment strategies have to be
defined. This section describes a workflow
© Rainer Dziewas
applicable to the ICU.
Figure 1. Neurological Disorders that Typically Require Treatment in the ICU
Screening Tests for Aspiration
The aim of dysphagia screening on the ICU is to
©For personal and private use only. Reproduction must be permitted by the copyright holder. Email to [email protected].

identify patients at risk of aspiration, and subse-

quently to initiate preventive measures and to plan
further diagnostic procedures. To this end, water
swallowing tests are usually implemented. As a
common feature of several different published
protocols, the patient is asked to swallow a
defined amount of water, while the investigator
looks for clinical signs of aspiration (change in
voice, cough, stridor) (Cassier-Woidasky et al.
2012). However, these tests usually do not have
sufficient sensitivity and/or specificity (Bours et
al. 2009) to be propagated as a stand-alone
solution. In addition silent aspiration, a key
factor in the critically ill, cannot be detected
by these tests (Noordally et al. 2011). Finally
it should be noted that in many critically ill © Rainer Dziewas
patients a water test is not feasible due to their Figure 2. Pathomechanisms of ICU-Related Dysphagia
clinical condition, so that in the end both the
validity and the feasibility of these water tests only 66% for the detection of aspirations with Available data indicate that FEES is a well-
in the ICU are significantly limited. a clinical swallowing examination. Therefore the tolerated and safe examination. In 6,000 inves-
management of dysphagia on the ICU cannot be tigations only 222 (3.7%) had to be stopped
Clinical Examination guided solely by clinical tools. at the patient's request (Langmore 2001). The
The clinical swallowing examination by an most commonly reported side effect was self-
appropriately trained speech therapist is the Fiberoptic Endoscopic Evaluation of Swallowing limited nosebleed being present in approximately
most frequently used diagnostic modality for (FEES) 1% of cases. More serious events like vasovagal
the evaluation of dysphagia on the ICU. This During FEES a flexible naso-pharyngo-laryngo- syncope and laryngospamus occurred in 0.03%
typically involves examination of the oropha- scope is introduced transnasally into the pharynx (Aviv et al. 2000; Aviv et al. 2001; Cohen et al.
ryngeal structures as well as swallowing tests for direct visualisation of the swallowing act. 2003). These results were replicated in a group
with different consistencies (Warnecke and FEES aims to: of acute stroke patients. Although the rate of self-
Dziewas 2013). As with aspiration screening, (i) identify pathological movement patterns; limited nosebleed was with 6% higher than in
the sensitivity, specificity and reliability of the (ii) evaluate the effectiveness and safety of the other studies, no serious side effects were
clinical swallowing examination are also ques- the swallow process, and reported, and vegetative symptoms like heart
tionable (McCullough et al. 2000; 2001). Hales (iii) recommend appropriate food consistencies as rate and blood pressure fluctuations were mild
et.al. (2008) found in a prospective study of well as special diets or swallowing techniques (Warnecke et al. 2009a). Meanwhile numerous
25 tracheotomised ICU patients a sensitivity of on an individual basis. studies have shown that FEES is equivalent to

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COVER STORY: the Brain

Altogether 913 endoscopic swallowing evalu-

ations were performed in 553 patients over a
period of 45 months at several intensive care
units. Based on the result of FEES, 6.3% of
the patients were tracheotomised to protect
the airway, 49.7% received a feeding tube and
13.2% a PEG to ensure enteral feeding. In 30.7%
of patients oral diet was judged to be feasible.
Two other studies showed that in acute stroke
the endoscopic evidence of saliva aspiration is a
strong predictor for the need for intubation later
on (Dziewas et al. 2008; Warnecke et al. 2009b).
These results underline the need for early instru-
mental dysphagia assessment in the critically ill.

Diagnostic Algorithms for the

Management of Dysphagia in
Non-Intubated and Trachotomised
© Rainer Dziewas
ICU Patients
Figure 3. Diagnostic Algorithm for the Assessment of Dysphagia in Non-Intubated ICU-Patients

The Non-Intubated Patient

©For personal and private use only. Reproduction must be permitted by the copyright holder. Email to [email protected].

In non-intubated ICU patients dysphagia assess-

ment provides important information for the
selection of the appropriate diet and also guides
the initiation of further protective and rehabili-
tative measures. Although there is currently no
standardised algorithm that has been evaluated in
prospective studies, the one proposed in Figure
3 considers the advantages and disadvantages
of the various diagnostic modalities and imple-
ments existing knowledge in order to give prag-
matic recommendations. First, minimum basic
requirements for an oral diet such as a sufficient
state of vigilance and trunk stability are evaluated.
Next, the risk factors for dysphagia are assessed.
Apart from the patient’s main diagnosis specific
co-morbidities need to be considered. Since
dysphagia is at least in part frequently a side effect
of the ICU treatment itself, the duration of intuba-
tion and artificial ventilation with a cut-off value of
24 hours is introduced as an additional criterion.
© Rainer Dziewas In case there are none of these risk factors present,
Figure 4. FEES Protocol for Tracheostomy Decannulation. for example in a patient with an uncomplicated
FEES: fiberoptic endoscopic evaluation of swallowing.
surgery followed by quick extubation, it is suffi-
the historic gold standard, the videofluoros- motor functions as well as bedridden cient to carry out a simple aspiration screening.
copy (VFSS=Videofluoroscopic Swallow Study) or uncooperative patients can be exam- If this test is normal the patient may directly get
in detecting the most important critical findings ined. an oral diet. If at any of the three steps the just
like aspiration and residues (Wu et al. 1997; Kelly • repeated follow-up examinations are described indicators of dysphagia are present, a
et al. 2006; Kelly et al. 2007). FEES is also an safely possible without the issue of clinical swallowing examination by a speech thera-
extremely reliable method, which is underlined radiation exposure. pist and, ideally, a FEES should be performed. With
by an interrater consensus of over 90% in various • saliva management can be assessed the help of these diagnostic procedures a decision
studies (Leder et al. 1998; Dziewas et al. 2008). directly (Langmore 2003). whether the patient can receive a normal oral diet,
On the ICU the essential practical advantages of As has been shown in a large observational requires a special consistency-adapted diet, is in
FEES over VFSS are: study, FEES in daily practice on the ICU is indeed need of tube feeding or should be considered as
• the examination can be done at the helpful to assess airway protection and to steer a candidate for intubation to secure the airway
bedside, and patients with highly restricted dysphagia management (Hafner et al. 2008). can be made.

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COVER STORY: the Brain

The Tracheotomised Patient tion proceeds and laryngeal sensibility and cough who were weaned from the ventilator on a
The tracheostomy, in particular the mini- reflex are tested by gently touching the aryepi- neurological ICU allowed safe decannulation in
mally invasive dilatational approach, is now glottic region with the tip of the endoscope (step more than half of the patients (Warnecke et al.
a standard procedure on most ICUs, and the 3). Patients demonstrating an efficient cough 2013). In the further course of treatment only
majority of long-term ventilated patients are are given a teaspoon of purée consistency (step one patient had to be recannulated. Noteworthy
ventilated through this airway access. After 4). If no aspiration occurs, the patient is given also was that the clinical swallowing examination,
successful weaning from the respirator the a teaspoon of coloured water (step 5). Silent which took into account the parameters state of
question arises whether the removal of the
tracheal cannula can be achieved. Due to the
limitations of the clinical swallowing exami- “Dysphagia in critically ill patients is a significant
nation assessment of the swallowing function
in this context should include FEES (Warnecke
predictor of complications…”
and Dziewas 2013). To increase the reliability and
reproducibility of the endoscopic examination, aspiration of the water, without triggering the vigilance, cooperation skills, saliva swallowing,
a standardised, step-by-step approach might be swallowing reflex, also indicates lack of readiness coughing and amount of collected saliva from
implemented (Warnecke et.al. 2013) (see Figure for decannulation; otherwise, having swallowed the tracheal cannula, would have allowed decan-
4). After suctioning pharyngeal secretions and successfully, the patient is regarded as being nulation in only 27 patients.
deflating the tracheal cuff the extent and locali- able to sufficiently protect his/her airway and
sation of salivary retentions are assessed and the the tracheostomy tube may be removed imme- Acknowledgements
spontaneous swallowing frequency is observed. diately. After that, the endoscope is briefly inserted This article has been modified and short-
If massive pooling or silent aspiration of saliva through the stoma, flexed upward to visualise the ened compared to Dziewas R, Glahn J (2015)
©For personal and private use only. Reproduction must be permitted by the copyright holder. Email to [email protected].

is visible (step 1), the investigation is stopped at subglottic structures and downward to inspect Schluckstörungen auf der Intensivstation. In:
this point. If not, the number and efficiency of the lower trachea, in order to ensure that there NeuroIntensiv. Heidelberg: Springer, pp: 108-14.
spontaneously occurring swallows is rated for at are no structural abnormalities comprising the All Figures were designed by Heike Blum,
least two minutes (step 2). If more than one effi- airway (Donzelli et al. 2001). The application of Department of Neurology, University Hospital
cient swallow per minute occurs, the investiga- this algorithm in 100 tracheotomised patients Münster, Germany.

References tion. Neurointensiv, Stuttgart: Thieme, pp. 108-14. McCullough GH, Wertz RT, Rosenbeck JC et al. (2000) Inter-
and intrajudge reliability of a clinical swallowing examination
Ajemian MS, GB Nirmul, Anderson MT et al. (2001) Routine El Solh A, Okada M, Bhat A et al. (2003) Swallowing disorders of swallowing in adults. Dysphagia, 15(2): 58-67.
fiberoptic endoscopic evaluation of swallowing following prolonged post orotracheal intubation in the elderly. Intensive Care Med,
intubation: implications for management. Arch Surg, 136(4): 434-7. 29(9): 1451-5. McCullough GH, Wertz RT, Rosenbek JC (2001) Sensitivity
and specificity of clinical /bedside examination signs for
Aviv JE, Kaplan ST, Langmore SE (2001a). The safety of endo- Gross RD, Atwood CW, Ross SB et al. (2009) The coordination detecting aspiration in adults subsequent to stroke. J Commun
scopic swallowing evaluations. In: Langmore SE. Endoscopic of breathing and swallowing in chronic obstructive pulmonary Disord, 34(1-2): 55-72.
evaluation and treatment of swallowing disorders. New York: disease. Am J Respir Crit Care Med, 179(7): 559-65.
Thieme, pp. 235-42. Noordally SO, Sohawon S, De Gieter M et al. (2011) A study
Hafner G, Neuhuber A, Hirtenfelder S et al. (2008) Fiberoptic to determine the correlation between clinical, fiber-optic
Aviv JE, Kaplan ST, Thomson JE et al. (2000) The safety of endoscopic evaluation of swallowing in intensive care unit patients. endoscopic evaluation of swallowing and videofluoroscopic
flexible endoscopic evaluation of swallowing with sensory Eur Arch Otorhinolaryngol, 265(4): 441-6. evaluations of swallowing after prolonged intubation. Nutr
testing (FEESST): an analysis of 500 consecutive evaluations. Clin Pract, 26(4): 457-62.
Dysphagia, 15(1): 39-44. Hales PA, Drinnan MJ, Wilson JA (2008) The added value of
fibreoptic endoscopic evaluation of swallowing in tracheostomy Shaker R, Li Q, Ren J et al. (1992) Coordination of deglutition
Barquist E, Brown M , Cohn S et al. (2001) Postextubation weaning. Clin Otolaryngol, 33(4): 319-24. and phases of respiration: effect of aging, tachypnea, bolus
fiberoptic endoscopic evaluation of swallowing after prolonged volume, and chronic obstructive pulmonary disease. Am J
endotracheal intubation: a randomized prospective trail. Crit Kelly AM, Drinnan MJ, Leslie P (2007) Assessing penetration and Physiol, 263(5 Pt 1): G750-5.
Care Med, 29(9): 1710-3. aspiration: how do videofluoroscopy and fiberoptic endoscopic
evaluation of swallowing compare? Laryngoscope, 117(10): 1723-7. Skoretz SA, Flowers JL, Martino R (2010) The incidence of
Bours GJ, Speyer R, Lemmens J et al. (2009) Bedside screening dysphagia following endotracheal intubation: a systematic
tests vs. videofluoroscopy or fiberoptic endoscopic evaluation Kelly AM, Leslie P, Beale T et al. (2006) Fibreoptic endoscopic review. Chest, 137(3): 665-73.
of swallowing to detect dysphagia in patients with neurological evaluation of swallowing and videofluoroscopy: does examination
disorders: a systematic review. J Adv Nurs 65(3): 477-93. type influence perception of pharyngeal residue severity? Clin Warnecke T, Dziewas R (2013) Neurogene Dysphagien.
Otolaryngol, 31: 425-32. Diagnostik und Therapie. Stuttgart: Kohlhammer.
Cassier-Woidasky AK, Nahrwold J, Glahn J (2012) Pflege von
Patienten mit Schlaganfall; von der Stroke Unit bis zur Reha- Langmore SE (2001) Endoscopic evaluation and treatment of Warnecke T, Ritter M, Kroger B et al. (2009b) Fiberoptic
bilitation, Stuttgart: W. Kohlhammer. swallowing disorders. New York: Thieme. endoscopic dysphagia severity scale predicts outcome after
acute stroke. Cerebrovasc Dis, 28(3): 283-9.
Cohen MA, Setzen M, Perlman PW (2003) The safety of flexible Langmore SE (2003) Evaluation of oropharyngeal dysphagia:
endoscopic evaluation of swallowing with sensory testing in an which diagnostic tool is superior? Curr Opin Otolaryngol Head Warnecke T, Suntrup S, Teismann IK et al. (2013) Standard-
outpatient otolaryngology setting. Laryngoscope, 113(1): 21-4. Neck Surg, 11(6): 485-9. ized endoscopic swallowing evaluation for tracheostomy
decannulation in critically ill neurologic patients. Crit Care
Donzelli J, Brady S, Wesling M et al. (2001) Simultaneous modified Leder SB, Sasaki CT, Burrell MI (1998) Fiberoptic endoscopic Med, 41(7): 1728-32.
Evans blue dye procedure and video nasal endoscopic evaluation evaluation of dysphagia to identify silent aspiration. Dysphagia,
of the swallow. Laryngoscope, 111(10): 1746-50. 13(1): 19-21. Warnecke T, Teismann I, Oelenberg S et al. (2009a) The
safety of fiberoptic endoscopic evaluation of swallowing in
Dziewas R, Warnecke T, Oelenberg S et al. (2008) Towards a Macht M, Wimbish T, Bodine C et al. (2013) ICU-acquired swal- acute stroke patients. Stroke, 40(2): 482-6.
basic endoscopic assessment of swallowing in acute stroke lowing disorders. Crit Care Med, 41(10): 2396-405.
- development and evaluation of a simple dysphagia score. Wu CH, Hsiao TY, Chen JC et al.(1997) Evaluation of swal-
Cerebrovasc Dis, 26(1): 41-7. Macht M, Wimbish T, Clark BJ et al. (2011) Postextubation lowing safety with fiberoptic endoscope: comparison with
dysphagia is persistent and associated with poor outcomes in videofluoroscopic technique. Laryngoscope, 107(3): 396-401.
Dziewas R, Glahn J (2015) Schluckstörungen auf der Intensivsta- survivors of critical illness. Crit Care, 15(5): R231.

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