Jeffrey B. Palmer

Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference.

Background: Millions of patients are discharged from intensive care units annually. These intensive care survivors and their families frequently report a wide range of impairments in their health status which may last for months and years after hospital discharge. Objectives: To report on a 2-day Society of Critical Care Medicine conference aimed at improving the long-term outcomes after critical illness for patients and their families. Participants: Thirty-one invited stakeholders participated in the conference. Stakeholders represented key professional organizations and groups, predominantly from North America, which are involved in the care of intensive care survivors after hospital discharge. Design: Invited experts and Society of Critical Care Medicine members presented a summary of existing data regarding the potential long-term physical, cognitive and mental health problems after intensive care and the results from studies of postintensive care unit interventions to address these problems. Stakeholders provided reactions, perspectives, concerns and strategies aimed at improving care and mitigating these long-term health problems. Measurements and Main Results: Three major themes emerged from the conference regarding: (1) raising awareness and education, (2) understanding and addressing barriers to practice, and (3) identifying research gaps and resources. Postintensive care syndrome was agreed upon as the recommended term to describe new or worsening problems in physical, cognitive, or mental health status arising after a critical illness and persisting beyond acute care hospitalization. The term could be applied to either a survivor or family member. Conclusions: Improving care for intensive care survivors and their families requires collaboration between practitioners and researchers in both the inpatient and outpatient settings. Strategies were developed to address the major themes arising from the conference to improve outcomes for survivors and families.

Coordination of mastication and swallowing.

The coordination of mastication, oral transport, and swallowing was examined during intake of solids and liquids in four normal subjects. Videofluorography (VFG) and electromyography (EMG) were recorded simultaneously while subjects consumed barium-impregnated foods. Intramuscular electrodes were inserted in the masseter, suprahyoid, and infrahyoid muscles. Ninety-four swallows were analyzed frame-by-frame for timing of bolus transport, swallowing, and phases of the masticatory gape cycle. Barium entered the pharynx a mean of 1.1 s (range −0.3 to 6.4 s) before swallow onset. This interval varied significantly among foods and was shortest for liquids. A bolus of food reached the valleculae prior to swallow onset in 37% of sequences, but most of the food was in the oral cavity at the onset of swallowing. Nearly all swallows started during the intercuspal (minimum gape) phase of the masticatory cycle. Selected sequences were analyzed further by computer, using an analog-to-digital convertor (for EMG) and frame grabber (for VFG). When subjects chewed solid food, there were loosely linked cycles of jaw and hyoid motion. A preswallow bolus of chewed food was transported from the oral cavity to the oropharynx by protraction (movement forward and upward) of the tongue and hyoid bone. The tongue compressed the food against the palate and squeezed a portion into the pharynx one or more cycles prior to swallowing. This protraction was produced by contraction of the geniohyoid and anterior digastric muscles, and occurred during the intercuspal (minimum gape) and opening phases of the masticatory cycle. The mechanism of preswallow transport was highly similar to the oral phase of swallowing. Alternation of jaw adductor and abductor activity during mastication provided a framework for integration of chewing, transport, and swallowing.

Food Transport and Bolus Formation during Complete Feeding Sequences on Foods of Different Initial Consistency

Abstract. Food movements during complete feeding sequences on soft and hard foods (8 g of chicken spread, banana, and hard cookie) were investigated in 10 normal subjects; 6 of these subjects also ate 8 g peanuts. Foods were coated with barium sulfate. Lateral projection videofluorographic tapes were analyzed, and jaw and hyoid movements were established after digitization of records for 6 subjects. Sequences were divided into phases, each involving different food management behaviors. After ingestion, the bite was moved to the postcanines by a pull-back tongue movement (Stage I transport) and processed for different times depending on initial consistency. Stage II transport of chewed food through the fauces to the oropharyngeal surface of the tongue occurred intermittently during jaw motion cycles. This movement, squeeze-back, depended on tongue–palate contact. The bolus accumulated on the oropharyngeal surface of the tongue distal to the fauces, below the soft palate, but was cycled upward and forward on the tongue surface, returning through the fauces into the oral cavity. The accumulating bolus spread into the valleculae. The total oropharyngeal accumulation time differed with initial food consistency but could be as long as 8–10 sec for the hard foods. There was no predictable tongue–palate contact at any time in the sequence. A new model for bolus formation and deglutition is proposed.

Anatomy and Physiology of Feeding and Swallowing – Normal and Abnormal

Eating and swallowing are complex behaviors involving volitional and reflexive activities of more than 30 nerves and muscles. They have two crucial biologic features: food passage from the oral cavity to stomach and airway protection. The swallowing process is commonly divided into oral, pharyngeal, and esophageal stages, according to the location of the bolus. The movement of the food in the oral cavity and to the oropharynx differs depending on the type of food (eating solid food versus drinking liquid). Dysphagia can result from a wide variety of functional or structural deficits of the oral cavity, pharynx, larynx, or esophagus. The goal of dysphagia rehabilitation is to identify and treat abnormalities of feeding and swallowing while maintaining safe and efficient alimentation and hydration.

Rehabilitation therapy and outcomes in acute respiratory failure: an observational pilot project.

PURPOSE The aim of this study was to describe the frequency, physiologic effects, safety, and patient outcomes associated with traditional rehabilitation therapy in patients who require mechanical ventilation. MATERIALS AND METHODS Prospective observational report of consecutive patients ventilated 4 or more days and eligible for rehabilitation in a single medical intensive care unit (ICU) during a 13-week period was conducted. RESULTS Of the 32 patients who met the inclusion criteria, only 21 (66%) received physician orders for evaluation by rehabilitation services (physical and/or occupational therapy). Fifty rehabilitation treatments were provided to 19 patients on a median of 12% of medical ICU days per patient, with deep sedation and unavailability of rehabilitation staff representing major barriers to treatment. Physiologic changes during rehabilitation therapy were minimal. Joint contractures were frequent in the lower extremities and did not improve during hospitalization. In 53% and 79% of initial ICU assessments, muscle weakness was present in upper and lower extremities, respectively, with a decreased prevalence of 19% and 43% at hospital discharge, respectively. New impairments in physical function were common at hospital discharge. CONCLUSIONS This pilot project illustrated important barriers to providing rehabilitation to mechanically ventilated patients in an ICU and impairments in strength, range of motion, and functional outcomes at hospital discharge.

Three tests for predicting aspiration without videofluorography.

The videofluorographic swallowing study (VFSS) is the definitive test to identify aspiration and other abnormalities of swallowing. When a VFSS is not feasible, nonvideofluorographic (non-VFG) clinical assessment of swallowing is essential. We studied the accuracy of three non-VFG tests for assessing risk of aspiration: (1) the water swallowing test (3 ml of water are placed under the tongue and the patient is asked to swallow); (2) the food test (4 g of pudding are placed on the dorsum of the tongue and the patient asked to swallow); and (3) the X-ray test (static radiographs of the pharynx are taken before and after swallowing liquid barium). Sixty-three individuals with dysphagia were each evaluated with the three non-VFG tests and a VFSS; 29 patients aspirated on the VFSS. The summed scores of all three non-VFG tests had a sensitivity of 90% for predicting aspiration and specificity of 71% for predicting its absence. The summed scores of the water and food tests (without X-ray) had a sensitivity of 90% and specificity of 56%. These non-VFG tests have limitations but may be useful for assessing patients when VFSS is not feasible. They may also be useful as screening procedures to determine which dysphagia patients need a VFSS.

Hyoid Motion During Swallowing: Factors Affecting Forward and Upward Displacement

During swallowing, the hyoid bone is described as moving first upward, then forward, then returning to the starting position. This study examined hyoid motion during swallowing of chewed solids and liquids. Barium videofluorography (VFG) was performed on 12 healthy volunteers eating 8-cc portions of various solid foods and drinking liquid. Hyoid position was measured frame-by-frame for 88 swallows relative to the occlusal plane of the upper teeth. The hyoid bone moved both upward and forward during swallowing, but upward displacement was sometimes very small. There was no correlation between the amplitudes of hyoid upward and forward displacements. The amplitude of upward displacement was highly variable, smaller for liquids than for solid foods (p < 0.001), and, for solid foods, larger for the first swallow than for the second swallow (p = 0.02). The amplitude of forward displacement did not differ significantly between liquids and solids or between first and second swallows. We conclude that upward displacement of the hyoid bone in swallowing is related primarily to events in the oral cavity, while its forward displacement is related to pharyngeal processes, especially the opening of the upper esophageal sphincter.

Ontogeny of postnatal hyoid and larynx descent in humans

Postnatal descent of the hyoid and larynx relative to the palate and mandible, which occurs uniquely in humans, is an anatomical prerequisite for quantal speech. This study tested the hypothesis that spatial constraints related to deglutition impose greater restrictions on the rate and degree of hyo-laryngeal descent than do adaptations for vocalization. Ontogenetic data on changes in the size and shape of the pharynx, the vocal tract, and the spatial positions of the larynx, hyoid, mandible and hard palate relative to each other and to the oral cavity were obtained for 15 males and 13 females from a longitudinal series of lateral radiographs (the Denver Growth Study) taken between the ages of 1 month and 14 years. To establish growth patterns, nine linear dimensions of the pharynx and 15 different pharyngeal and vocal-tract proportions were regressed against percentage growth. The results demonstrate that certain aspects of vocal-tract shape change markedly during ontogeny, especially in the first postnatal year and during the adolescent growth spurt. The ratio of pharynx height to oral cavity length (which is important for speech) decreases significantly (P<0.001) from 1.5 to 1.0 between birth and 6-8 years, after which it remains stable. In contrast, regression analyses indicated that superoinferior spatial relations between the positions of the vocal folds, the hyoid body, the mandible and the hard palate do not change significantly throughout the entire postnatal growth period (P<0.05). Sexual dimorphism in pharyngeal shape and size before the age of 14 years is very limited. The results suggest that the descent of the hyoid and larynx relative to the mandible is constrained by muscle function related to deglutition, highlighting the different functional roles of the hyoid during speech and oral transport.

A Protocol for the Videofluorographic Swallowing Study

This paper presents a detailed protocol for performing the videofluorographic swallowing study (VFSS), and describes how it evolved from its antecedents. The objectives of the VFSS are both diagnostic and therapeutic. Preparing for the VFSS is described, including the equipment, food preparation, and a brief discussion of the clinical evaluation. The detailed description of the VFSS procedure covers the position of the patient, the foods presented, the views obtained, modifications of feeding and swallowing that are commonly employed, the standardized set of observations, and reporting the results. Criteria for deviating from the protocol or aborting the study are presented. The VFSS does not necessarily end when a patient aspirates. Indeed, the complete evaluation of aspiration, and the effects of maneuvers designed to reduce it, is a major purpose of the VFSS. Modifications of feeding and swallowing are tested empirically during the study. The modifications include therapeutic and compensatory techniques that may improve the safety and efficiency of swallowing. A rationale for deciding which modifications to test in a given patient is discussed. The protocol has been used successfully in more than 350 patients. It has improved the efficiency and quality of our videofluorographic examinations.

Effect of Liquid Bolus Consistency and Delivery Method on Aspiration and Pharyngeal Retention in Dysphagia Patients

Abstract There is no empirically derived consensus as to what food consistency types and method of food delivery (spoon, cup, straw) should be included in the videofluoroscopic swallowing (VFSS) studies. In the present study, we examine the rates of aspiration and pharyngeal retention in 190 dysphagic patients given thin (apple juice) and thick (apricot nectar) liquids delivered by teaspoon and cup and ultrathick (pudding-like) liquid delivered by teaspoon. Each patient was tested with each of the bolus/delivery method combinations. The fractions of patients exhibiting aspiration for each bolus/method of delivery combination were (1) thick liquids (cup), 13.2%; (2) thick liquids (spoon), 8.9%; (3) thin liquids (cup), 23.7%; (4) thin liquids (spoon), 15.8%, (5) ultrathick liquids (spoon), 5.8%. In each comparison [thick liquid (cup) vs. thick liquid (spoon), thin liquid (cup) vs. thin liquid (spoon), thick liquid (cup) vs. thin liquid (cup), thick liquid (spoon) vs. thin liquid (spoon), and thick liquid (spoon) vs. ultrathick liquid (spoon)], the p value for χ2 was <0.001. These results suggest that utilizing thin, thick, and ultrathick liquids and delivery by cup and spoon during a VFSS of a patient with mild or moderate dysphagia can increase the chances of identifying a consistency that the patient can swallow without aspirating and without pharyngeal retention after swallowing.