Martin B. Brodsky

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.

Swallowing‐Related Quality of Life After Head and Neck Cancer Treatment

Objectives: To determine the role of treatment modality in swallowing outcome after head and neck cancer treatment and to identify potential risk factors for posttreatment dysphagia.

Exploring the scope of post-intensive care syndrome therapy and care: engagement of non-critical care providers and survivors in a second stakeholders meeting.

Background:Increasing numbers of survivors of critical illness are at risk for physical, cognitive, and/or mental health impairments that may persist for months or years after hospital discharge. The post–intensive care syndrome framework encompassing these multidimensional morbidities was developed at the 2010 Society of Critical Care Medicine conference on improving long-term outcomes after critical illness for survivors and their families. Objectives:To report on engagement with non–critical care providers and survivors during the 2012 Society of Critical Care Medicine post–intensive care syndrome stakeholder conference. Task groups developed strategies and resources required for raising awareness and education, understanding and addressing barriers to clinical practice, and identifying research gaps and resources, aimed at improving patient and family outcomes. Participants:Representatives from 21 professional associations or health systems involved in the provision of both critical care and rehabilitation of ICU survivors in the United States and ICU survivors and family members. Design:Stakeholder consensus meeting. Researchers presented summaries on morbidities for survivors and their families, whereas survivors presented their own experiences. Meeting Outcomes:Future steps were planned regarding 1) recognizing, preventing, and treating post–intensive care syndrome, 2) building strategies for institutional capacity to support and partner with survivors and families, and 3) understanding and addressing barriers to practice. There was recognition of the need for systematic and frequent assessment for post–intensive care syndrome across the continuum of care, including explicit “functional reconciliation” (assessing gaps between a patient’s pre-ICU and current functional ability at all intra- and interinstitutional transitions of care). Future post–intensive care syndrome research topic areas were identified across the continuum of recovery: characterization of at-risk patients (including recognizing risk factors, mechanisms of injury, and optimal screening instruments), prevention and treatment interventions, and outcomes research for patients and families. Conclusions:Raising awareness of post–intensive care syndrome for the public and both critical care and non–critical care clinicians will inform a more coordinated approach to treatment and support during recovery after critical illness. Continued conceptual development and engagement with additional stakeholders is required.

Coordination of swallowing and respiration in normal sequential cup swallows

Objectives: To establish normative data on laryngeal vestibular closure patterns and respiratory phase patterns during sequential cup swallows in healthy adults.

Role of mitomycin in upper digestive tract stricture

Mitomycin C is an anti‐fibroblast chemotherapeutic agent that has demonstrated promise in the treatment of head and neck cancer‐related cervical stenosis. The present study investigates whether the application of mitomycin C at the time of dilation is both safe and effective in the treatment of head and neck cancer‐related upper digestive tract stricture.

Duration of oral endotracheal intubation is associated with dysphagia symptoms in acute lung injury patients

PURPOSE The purpose of this study is to evaluate demographic and clinical factors associated with self-reported dysphagia after oral endotracheal intubation and mechanical ventilation in patients with acute lung injury (ALI). MATERIALS AND METHODS This is a prospective cohort study of 132 ALI patients who had received mechanical ventilation via oral endotracheal tube. RESULTS The primary outcome was binary, whether clinically important symptoms of dysphagia at hospital discharge were reported by patients, using the Sydney Swallowing Questionnaire score 200 or more. Of 132 patients, 29% reported clinically important symptoms of dysphagia. Of 18 relevant demographic and clinical variables, only 2 were found to be independently associated with clinically important symptoms of dysphagia in a multivariable logistic regression model: upper gastrointestinal comorbidity (odds ratio, 2.82; 95% confidence interval, 1.09-7.26) and duration of oral endotracheal intubation (odds ratio, 1.79; [95% confidence interval, 1.15-2.79] per day for first 6 days, after which additional days of intubation were not associated with a further increase in the odds of dysphagia). CONCLUSIONS In ALI survivors, patient-reported, postexubation dysphagia at hospital discharge was significantly associated with upper gastrointestinal comorbidity and a longer duration of oral endotracheal intubation during the first 6 days of intubation.

Factors associated with swallowing assessment after oral endotracheal intubation and mechanical ventilation for acute lung injury

RATIONALE Endotracheal intubation is associated with postextubation swallowing dysfunction, but no guidelines exist for postextubation swallowing assessments. OBJECTIVES We evaluated the prevalence, patient demographic and clinical factors, and intensive care unit (ICU) and hospital organizational factors associated with swallowing assessment after oral endotracheal intubation and mechanical ventilation in patients with acute lung injury (ALI). METHODS We performed a secondary analysis of a prospective cohort study in which investigators evaluated 178 eligible patients with ALI who were mechanically ventilated via oral endotracheal tube. The patients were recruited from 13 ICUs at four teaching hospitals in Baltimore, Maryland. Patient demographic and clinical factors, types of ICU, and hospital study sites were evaluated for their association with completion of a swallowing assessment both in the ICU and after the ICU stay before hospital discharge. Factors significantly associated with a swallow assessment were evaluated in a multivariable logistic regression model. MEASUREMENTS AND MAIN RESULTS Before hospital discharge, 79 (44%) patients completed a swallowing assessment, among whom 59 (75%) had their assessments initiated in ICU and 20 (25%) had their assessments initiated on the hospital ward. Female sex (odds ratio [OR] = 2.01; 95% confidence interval [95% CI] = 1.03-3.97), orotracheal intubation duration (OR = 1.13 per day; 95% CI = 1.05-1.22), and hospital study site (Site 3: OR = 2.41; 95% CI = 1.00-5.78) were independently associated with swallowing assessment. Although Site 3 had a twofold increase in swallowing assessments in the ICU, there was no significant difference between hospitals in the frequency of swallowing assessments completed after ICU discharge (P = 0.287) or in the proportion of patients who failed a swallowing assessment conducted in the ICU (P = 0.468) or on the ward (P = 0.746). CONCLUSIONS In this multisite prospective study, female sex, intubation duration, and hospital site were associated with postextubation swallowing assessment. These results demonstrate variability in practice patterns between institutions and highlight the need to determine the appropriate timing and indications for swallowing assessment and to more fully understand swallowing dysfunction after intubation.

Recovery from Dysphagia Symptoms after Oral Endotracheal Intubation in Acute Respiratory Distress Syndrome Survivors. A 5-Year Longitudinal Study

Rationale: Nearly 60% of patients who are intubated in intensive care units (ICUs) experience dysphagia after extubation, and approximately 50% of them aspirate. Little is known about dysphagia recovery time after patients are discharged from the hospital. Objectives: To determine factors associated with recovery from dysphagia symptoms after hospital discharge for acute respiratory distress syndrome (ARDS) survivors who received oral intubation with mechanical ventilation. Methods: This is a prospective, 5‐year longitudinal cohort study involving 13 ICUs at four teaching hospitals in Baltimore, Maryland. The Sydney Swallowing Questionnaire (SSQ), a 17‐item visual analog scale (range, 0‐1,700), was used to quantify patient‐perceived dysphagia symptoms at hospital discharge, and at 3, 6, 12, 24, 36, 48, and 60 months after ARDS. An SSQ score greater than or equal to 200 was used to indicate clinically important dysphagia symptoms at the time of hospital discharge. Recovery was defined as an SSQ score less than 200, with a decrease from hospital discharge greater than or equal to 119, the reliable change index for SSQ score. Fine and Gray proportional subdistribution hazards regression analysis was used to evaluate patient and ICU variables associated with time to recovery accounting for the competing risk of death. Measurements and Main Results: Thirty‐seven (32%) of 115 patients had an SSQ score greater than or equal to 200 at hospital discharge; 3 died before recovery. All 34 remaining survivors recovered from dysphagia symptoms by 5‐year follow‐up, 7 (23%) after 6 months. ICU length of stay was independently associated with time to recovery, with a hazard ratio (95% confidence interval) of 0.96 (0.93‐1.00) per day. Conclusions: One‐third of orally intubated ARDS survivors have dysphagia symptoms that persist beyond hospital discharge. Patients with a longer ICU length of stay have slower recovery from dysphagia symptoms and should be carefully considered for swallowing assessment to help prevent complications related to dysphagia.

Increasing the sensitivity of the Story Retell Procedure for the discrimination of normal elderly subjects from persons with aphasia

Background: Clinicians have long recognised the need for assessing language production at multiple levels of complexity and at impairment, participation, and activity levels. Methods for the elicitation of connected spoken language have taken many forms, typically selected with a balance between validly sampling linguistic performance, and reliability and economy of the sampling and scoring procedures. A Story Retell Procedure (SRP) has been proposed as a preferred method for achieving valid, reliable, and economic assessment of connected language (Doyle et al., 2000), and an information unit (IU) metric has been developed for validly and economically capturing important linguistic aspects of the retelling (McNeil, Doyle, Fossett, Park, & Goda, 2001). Aims: In keeping with the goal of making assessment procedures as efficient and economic as possible, a study was undertaken to investigate the refinement of the IU metric for increasing the sensitivity of the SRP as an instrument for the detection of connected paragraph-level language production deficits in persons with aphasia. This metric involved the calculation of the percentage of IUs (%IU) produced relative to the time taken to produce them (%IU/Min). Methods & Procedures: A total of 15 persons with aphasia, and 31 normal control individuals without a communication disorder served as participants for this study. Subjects heard, and immediately retold each of 12 stories originally taken from the Discourse Comprehension Test (Brookshire & Nicholas, 1997). The retellings were scored using the procedures outlined by McNeil et al. (2001) with the addition of the %IU calculated over the time of the retelling. Comparisons between subject groups and groups stratified by age, among SRP forms, between scoring methods (%IU vs %IU/Min.), and group misclassification by scoring method were made. Outcome & Results: Application of the %IU/Min with the SRP yielded equivalence among alternate forms as evidenced by non-significant differences and high correlation coefficients among the SRP forms for persons with aphasia. The %IU/Min also decreased the percentage of misclassified aphasic and normal individuals compared to the %IU measure. Older normal subjects were misclassified as aphasic with greater frequency compared to the younger normal subjects. Conclusions: The %IU/Min is a more sensitive metric than the %IU in differentiating individuals with aphasia from older normal controls.

Electromyography of Swallowing with Fine Wire Intramuscular Electrodes in Healthy Human: Amplitude Difference of Selected Hyoid Muscles

Few studies have examined the intensity of muscle activity during swallowing in healthy humans. We examined selected hyoid muscles using fine wire intramuscular electromyography (EMG) during swallowing of four food consistencies. Thirteen healthy adults were studied using videofluorography and EMG of the anterior belly of digastric (ABD), geniohyoid (GH), sternohyoid (SH), and masseter (MA; surface electrodes) while ingesting thin liquid (three trials) and solid food of three consistencies (banana, tofu, and cookie, three trials each). After rectification, integration, and normalization, peak EMG amplitudes for each muscle in each trial were measured. Hyoid displacements were measured in two dimensions. Data were analyzed using repeated measures ANOVA with Bonferroni correction. GH had the highest adjusted amplitude for both solids and liquid. For MA and ABD, amplitude was highest with triturated cookie. For ABD, amplitude was lowest with liquid. There were no significant food consistency effects for GH or SH. Hyoid displacements were greatest for cookie and the lowest for liquid. EMG amplitude varied with initial food consistency. The high peak EMG amplitude of GH is consistent with its essential role in opening the upper esophageal sphincter. High MA amplitude with hard solid foods is likely due to the higher tongue-palate pressure with triturated solids. The higher ABD amplitude with solid food is associated with greater hyoid displacement. These findings support the existence of a central pattern generator that modifies the level of muscle activity during pharyngeal swallowing in response to input from mechanoreceptors in the oral cavity.