Clinical Decision Making in the ICU:

Dysphagia Screening, Assessment, and

Treatment
Martin B. Brodsky, Ph.D., Sc.M., CCC-SLP,1
Emily B. Mayfield, M.A., CCC-SLP, BCS-S, IBCLC,2 and
Roxann Diez Gross, Ph.D., CCC-SLP3

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ABSTRACT

Clinicians often perceive the intensive care unit as among the

most intimidating environments in patient care. With the proper
training, acquisition of skill, and approach to clinical care, feelings of
intimidation may be overcome with the great rewards this level of care
has to offer. This review—spanning the ages of birth to senescence and
covering oral/nasal endotracheal intubation and tracheostomy—pre-
sents a clinically relevant, directly applicable review of screening,
assessment, and treatment of dysphagia in the patients who are critically
ill for clinical speech–language pathologists and identifies gaps in the
clinical peer-reviewed literature for researchers.

KEYWORDS: critical care, intensive care unit, infant, child, adult,

intubation, tracheostomy, noninvasive ventilation, screening,
assessment

Learning Outcomes: As a result of this activity, the reader will be able to (1) compare differences in
screening and clinical assessments in pediatric versus adult ICU patient populations; (2) describe differences
between the chart reviews in ICU for pediatric and adult patients; and (3) discuss considerations for
swallowing screenings and evaluations in patients with tracheostomy tubes.

1
Department of Physical Medicine and Rehabilitation, Clinical Decision Making in Dysphagia; Guest Editors,
Johns Hopkins University, Baltimore, Maryland; 2Mercy Gary H. McCullough, Ph.D., CCC-SLP and Balaji
Medical Center, Des Moines, Iowa; 3The Children’s Insti- Rangarathnam, Ph.D., CCC-SLP.
tute of Pittsburgh, Pittsburgh, Pennsylvania. Semin Speech Lang 2019;40:170–187. Copyright
Address for correspondence: Martin B. Brodsky, Ph.D., # 2019 by Thieme Medical Publishers, Inc., 333 Seventh
Sc.M., CCC-SLP, Department of Physical Medicine Avenue, New York, NY 10001, USA. Tel: +1(212) 584-
and Rehabilitation, Johns Hopkins University, 600 N. 4662.
Wolfe St. – Phipps 181, Baltimore, MD 21287 DOI: https://doi.org/10.1055/s-0039-1688980.
(e-mail: [email protected]). ISSN 0734-0478.
170
 CLINICAL DECISION MAKING IN THE ICU/BRODSKY ET AL 171

EVIDENCE-BASED MEDICINE patient’s care and historical knowledge of the

The dysphagia caseload is expanding and many patient’s care, results of completed testing/treat-
hospital-based speech–language pathologists ment, plans from all providers, communication
(SLPs) perceive an increasing role on medical between providers, and the necessary compo-
teams.1 Competent service delivery by SLPs nents within and between notes to assure com-
working in ICUs requires a highly developed pliance with hospital and billing procedures. A
skill set. Clinicians must act on a commitment to systematic review process will help reduce the risk
on-going learning to keep up with a rapidly of missing key information. Specific to dyspha-
evolving evidence base. A strong fundamental gia, the medical history and notes from the
knowledge base of the neurology, pulmonary primary medical team; consults from neuro-
function (with and without mechanical ventila- logy/neurosurgery, otolaryngology-head and
tion and/or supplemental oxygen), laryngology, neck surgery, gastroenterology, and the nutri-
and gastroenterology associated with dysphagia tion/clinical dietitian; pertinent imaging; and
in the setting of critical care is requisite. Equally nursing notes—regardless of age—are most

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important is the clinician’s ability to function as often of primary importance.
part of a team that focuses on the patient and
family via collaborative decision making at the
center of clinical management. Synthesis of the Pediatrics
patient’s presentation, an inquisitive mindset
with thought flexibility, and the assertiveness to UNDERLYING MEDICAL DIAGNOSIS/REASON
seek information that may not be evident in the FOR ADMISSION
medical record, but is necessary to problem-solve Knowledge of the typical features of the admit-
complex case presentations, round out the clinical ting diagnosis provides understanding about
skills necessary to succeed in this demanding the possible risk of accompanying dysphagia.
environment. With focused training in feeding/ Understanding of the typical illness trajectory
swallowing anatomy and physiology—augmen- helps set expectations for recovery or the possi-
ted by clinical knowledge and skills in voice, bility of progressive decline. Listed comorbidi-
cognition, and communication—SLPs are uni- ties may also set the stage for possible worse-
quely qualified to excel in the critical care setting. than-expected functional outcomes. For exam-
SLPs practicing in the neonatal intensive ple, in infants with the diagnosis of prematurity
care unit (NICU; i.e., those serving newborns) (born at less than 37 weeks of gestational age),
will find themselves separated from older the gestational age, birthweight, and comorbi-
infants and adolescent populations. The pediat- dities such as lung disease and necrotizing
ric intensive care unit (PICU) assesses, treats, enterocolitis (a serious intestinal disease) can
and manages patients from birth to 18 years indicate increased risk of delayed oral feeding
across a wide diagnostic diversity, whereas progression.3,4 Another example is how cardiac
SLPs practicing in adult ICUs will typically anomalies and accompanying surgical correc-
see patients 18 years and older. Depending on tion schedules might impact swallowing at
the institution, separate ICUs may exist for different stages in the recovery process.5–7 In
broad diagnosis types (e.g., cardiac, neurology/ contrast, the expected trajectory of a previously
neurosurgery, and trauma). ICUs vary in size healthy child with acute respiratory viral illness
and patient complexity by institution and com- gives a different picture of likely transient
munity needs. swallowing difficulty.8

PREHOSPITAL INFORMATION
REVIEWING THE MEDICAL RECORD Information must be gathered about baseline
As with any clinical setting, once a consult for a skills the child may (or may not) have, and what
swallowing evaluation is received, the initial step their experience with eating was before hospi-
is to complete a focused review of the medical talization. As possible, a complete feeding,
record.2 In general, medical records provide a nutritional, and developmental history will
medical (and, therefore, legal) memory of the guide the clinician for which skills may need
172 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3 2019

habilitating, and which may need rehabilitating. BODY SYSTEMS REVIEW

Results from any previous instrumental swallow Physician notes are typically organized by body
evaluations are important to note. For newborn system. This allows organized review to identify
infants, the maternal health and birth history pertinent information to the swallowing/fee-
can highlight risk factors for feeding difficulty, ding assessment. The systems included may
such as maternal history of diabetes.9 Unlike vary based on patient age and the physician
older children and adolescents, a young infant service (e.g., intensivist, neonatologist, and
may have lived his/her entire life in the ICU. If neurologist). In general, systems reviewed inc-
this is the case, reflect on the impact that may be lude eyes/ear/nose/throat, gastrointestinal, pul-
having on parent/family stress factors, as well as monary, cardiovascular, neurologic, and
on the limited breadth of and possibly negative musculoskeletal. Weight gain/loss trends will
sensory experiences of your patient. If the child likely be listed as well. Psychosocial factors that
has had time out of the hospital setting, the may impact discharge are typically included.
relative success of his/her health and nutrition Any imaging studies should be reviewed, as well

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maintenance during those periods will be as abnormal laboratory values (e.g., bilirubin
instructive to your overall impression of their and hematocrit levels14) and results from con-
baseline functioning. sultant tests (i.e., bedside flexible laryngoscopy).
While reading about the patient’s body system
HOSPITAL COURSE/EVENTS functioning, the ICU clinician must add the
Take note of the general course of convales- layer of deducing whether the patient has
cence—has the patient experienced a typical enough stability throughout these systems to
course for their admitting diagnosis, or have tolerate the activity of eating.
there been multiple setbacks or unexpected
events? Noting the number of and duration of CURRENT PRESENTATION
possible oral intubations as well as any surge- In the ICU, patient status may change
ries or procedures can alert the clinician to quickly—by the day or even by the hour. Like-
possible deviations from the typical course. wise, decisions regarding care must also be
Those events might also increase suspicion for made quickly and plans for management may
altered swallow/airway function, such as in the be revised several times throughout the day
case of ligation of a patent ductus arteriosus in depending on the patient’s response to these
infants, which may result in left vocal fold care changes. Look for details centering around
immobility.10 It is also helpful to take a step the patient’s appropriateness for activity that
back and examine the hospital course through day. This may include temperature stability for
a developmental lens. The amount of time a young infants, documented pain scores, alert-
patient has spent on life-supporting machines ness, and trending physiologic stability for older
such as extracorporeal membrane oxygena- children. Review the medication list for possible
tion11 or a high-frequency oscillating ventila- sedating medications. Look at the intake and
tor12 represents time that the patient may not output recorded for the past few days, and
have been able to be held by caregivers. physician or nurse notes indicating tolerance
Perhaps the patient required long periods of for enteral feedings. Note the current oxygen
sedation or needed a very low-stimulation delivery mode and whether that reflects a
environment that limited social interaction recent increase or decrease in required support.
or developmental play. Consider also the Oxygen saturation parameters should be listed,
emotional impact if a mother’s initial stated if applicable. Acceptable ranges of oxygenation
goals for feeding have required modification will vary by patient. Physician notes typically
or have not been possible, as is sometimes the include a section on the plan for the next several
case with breastfeeding. Finally, review for any days. Consider how plans for changes in medi-
consults completed. Typical consultants might cal management (i.e., oxygen weaning, medica-
include otolaryngology, neurology, gastroen- tion changes) or surgical intervention might
terology, pulmonology, trauma/surgery, and impact the swallowing plan of care, including
perhaps palliative care.13 the goals of the swallowing assessment.
 CLINICAL DECISION MAKING IN THE ICU/BRODSKY ET AL 173

Adults Being aware of the adverse events that

occur during the procedure of intubation may
REASON FOR INTUBATION explain several clinical findings, especially rela-
Patients are intubated for many reasons: (1) ted to cognitive, motor, and/or sensory response
maintain an open airway, (2) maintain respira- postextubation during clinical and instrumental
tory drive (i.e., ventilation), (3) maintain a evaluations. Among these events are hypoxia
proper level of oxygenation, (4) protect the air- and esophageal intubation.33 Although infre-
way from aspiration, etc. Conditions that lead to quent, an increased number of passes of the
further respiratory difficulties (e.g., Guillain- ETT while intubating a patient increases the
Barre) may also lead to intubation with mecha- possibility of these risks, with hypoxia poten-
nical ventilation. Understanding the reason(s) tially leading to cognitive impairments34 and
why the patient is intubated will assist in the esophageal intubation potentially leading to
clinical and/or instrumental evaluation by pro- perforation of the esophageal wall, whether
viding a basis for the behaviors observed and by the ETT or a feeding tube.35

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should not be overlooked. These initial medical
issues will likely influence the approaches to BODY SYSTEMS REVIEW
dysphagia diagnostics and treatments. Because many medical diagnoses may be res-
ponsible for a patient’s dysphagia,36 maintai-
HOSPITAL COURSE/EVENTS ning a broad-based understanding of the
Similar to the pediatric population, the hospital patient and all that has happened and is hap-
course must be reviewed. By the time the SLP is pening clinically is a necessary first step toward
consulted, it may be late in the ICU stay, if the making an accurate and thorough assessment of
SLP is consulted at all in the ICU, and is highly the patient’s feeding/swallowing behaviors and
dependent on the institution.15–17 It is quite physiology. In general, the primary systems
likely that reviewing weekly records will be reviewed in pediatric patients are the same
more time consuming than fruitful. Reviewing primary systems in adults (laryngology, gast-
the items listed at the top of this section will rointestinal, pulmonary, cardiovascular, neuro-
likely capture the necessary information. Addi- logic, and musculoskeletal). Fluctuations in
tional information may be gleaned from specific weight are expected37–39 and are not likely to
comments in these notes and by speaking with be indicative of dysphagia in the acute phase of
the medical team, nurses, and the clinical critical care. Imaging, including neuroimaging
dietician for additional necessary and up-to- and gastrointestinal studies in particular, should
date information. be reviewed for potential insights to issues
related to dysphagia. Abnormal laboratory
ENDOTRACHEAL TUBE PLACEMENT AND values from blood work should also be reviewed
CHARACTERISTICS for indications that may explain the patient’s
By the time the patient has been extubated from motor function and cognitive state.40–42
a nasal (less common) or oral endotracheal tube
(ETT), they have likely spent hours to many days CURRENT PRESENTATION
with a tube traversing the oral (or nasal) cavity, Similar to pediatric patients, patient status may
through the pharynx, past the vocal folds, and change quickly and clinical care decisions
terminating approximately 2 to 4 cm from the change equally as quick. Although it may not
carina, or a depth of 23 cm on the ETT at the lip appear so, the medical record is likely dated,
for males/21 cm at the lip for females.18 The perhaps as many as hours earlier, despite a note
entire length of this tract is now a suspect for that was recently cosigned by the attending
injury19–23 and duration in situ appears to have a physician. In general, the most up-to-date
role,19,24–29 although not without controversy.30 information is likely maintained by the nurse
Among the issues that may have a role in a or a midlevel provider, such as a nurse practitio-
patient’s dysphagia are the intubation procedure; ner or physician assistant. In academic medical
outer diameter of the ETT; ETT material; and settings, residents and fellows on the primary
cuff size, design, and pressure.30–32 care team are frequently available to ask
174 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3 2019

questions as well. Oxygen delivery (if necessary) movable neck plate). The notes may also con-
is often important for feeding. Patients using a tain information that describes unusual anato-
nasal cannula are likely to have a considerably mic variables or other unique factors that the
more stable clinical oxygen need (and are more surgeon may have encountered during the sur-
readily able to accept oral intake) than those gery that ultimately impacted the type of TT
with a face mask or even a high-flow nasal that was placed.
cannula (HFNC), for example. A quick review
of the patient’s medication list, especially for TRACHEOSTOMY TUBE CHARACTERISTICS
medications that may have effects on cognition For all patients with TTs, it is essential to
and swallowing, is recommended.43 For identify the specifications of the tube that has
patients on an oral diet, reviewing intake and been placed such as manufacturer (e.g., Shiley,
output recorded for the previous period may Portex), style (e.g., cuffed, cuffless, fenestrated),
provide insight to tolerance (and acceptance) of and size. These factors are important because,
the currently provided diet. Physician plans in depending on the manufacturer, the angle and

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the medical record may provide some insight as length of the tube as well as the cuff shape and
to what the next day or two has in store for the inflation materials (e.g., air or water) can vary.
patient’s management. Additional factors that indicate a close look at
TT fit are kyphoscoliosis, morbid obesity, and
severe chronic obstructive pulmonary disease,
Tracheostomy all of which may require a specialty or custom
tube. Information about the tube will be used
REASON FOR PLACEMENT during the assessment and planning stages.
As part of the overall medical review that will
examine for known dysphagia risk factors, it is CUFF DEFLATION
important to identify the reason for tracheos- Locating information that can be used as clinical
tomy tube (TT) placement. This information indicators for possible cuff deflation is also
will help establish the immediate plan for central to dysphagia management in patients
evaluation and help guide subsequent thoughts with TTs. Cuff deflation need not be continuous
about possible courses of treatment and tube before evaluation and treatment can begin;
management. For example, if the TT was however, the initial identification of elements
placed primarily as a precaution, decannulation that are associated with safe and successful
can be rapid and it might be best to begin any deflation should be recognized and monitored
assessment once the tube is removed. If the tube through chart reviews. There are no current
was placed because of failure to wean from the validated criteria for cuff deflation; however,
ventilator, the SLP is likely to assist in the there are clinical indicators that can help predict
overall process of weaning and decannulation. when it might be safe and feasible to do so.
Long-term or permanent ventilator depen- The primary categorical issues to identify
dency does not exclude the patient from recei- before cuff deflation are medical and respiratory
ving care that started in the ICU. stability.45 The determination of stability is not
made by the SLP; however, a basic knowledge of
SURGICAL NOTES appropriateness for intervention is essential.
The surgical notes should be reviewed when the Medical stability in relation to cuff deflation is
TT was placed in the operating room. Specifi- indicated by vital signs that are within normal
cally, a review should seek to identify a proce- limits, absence of fever or active infections, and
dure called a “Bjork flap” which could increase sufficient alertness level to participate in an
the possibility of laryngeal tethering because a assessment. Patients who are not fully liberated
tracheal flap is created and then sutured to the from the ventilator will have respiratory and
skin.44 Surgical notes may also state that the pulmonary notes that should show progression
neck plate has been sutured to the skin, and this in respiratory stability during spontaneous brea-
too may be a potential limitation of movement thing trials. Respiratory stability can be provided
depending on the style of the TT (i.e., fixed or by the ventilator for persons with permanent
 CLINICAL DECISION MAKING IN THE ICU/BRODSKY ET AL 175

ventilator dependency (such as a person with ting multiple interventions to stabilize the
tetraplegia). Fundamentally, respiratory stability patient to keep the physiologic parameters wit-
is indicated by a profile that includes respiratory hin the target range. Inquiring about any such
rate
14 breaths per minute, oxygen saturation interventions can lead to discussions about how
by pulse oximetry (SpO2) >88%, and low sup- added activity may destabilize the patient. Nur-
plemental oxygen requirements (fraction of ses may also have narrative surrounding the
inspired oxygen [FiO2] < 40%). hospital course that can give details important
to understanding the whole picture of the
SECRETIONS AND SECRETION MANAGEMENT patient/family experience. The bedside nurse
If the tube was placed because of failure to wean will help consultants understand the patient’s
from the vent, notations of increased or and family’s perceived psychosocial needs and
“copious” secretions can limit cuff deflation what might be the most effective strategies to
and weaning trials. If copious secretions deve- ensure coordination of a meaningful session.
loped over the period where the inflated cuff Lastly, if the reason for the consult is not clear,

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allowed little to no airflow to reach the larynx, communication with team members (e.g., phy-
sensory loss may have contributed to the ina- sicians, nurses, parents) is necessary to deter-
bility to detect and subsequently manage (swal- mine what questions need to be answered.
low) secretions. Presently, the amount of Physicians may need guidance on oral feeding
secretions is subjective observations; however, in the immediate period or may be looking for
with the increased use of TTs that have sub- assistance in developing short- or long-term
glottic suction ability, the measurement of goals for the patient.
accumulated secretions above the cuff will Specific to the NICU and PICU, the
provide more objective determinations.45,46 majority of the assessment may consist of
Nevertheless, the frequency of suctioning synthesizing the information from the chart
requirements should be noted, with decreasing and discussions with the team into guiding the
frequency indicating improvement and inc- overall plan. The patient may not be ready for
reased suctioning requirements representing much direct assessment or intervention, but
an underlying issue. Thin, clear sections are the plan forward needs SLP guidance to
generally a positive sign as opposed to thick, promote and protect development and to
green, or yellow consistencies. The potential for plan for the next several steps in the path
cuff deflation is important because, by restoring toward oral feeding. These discussions provide
airflow to the larynx and upper airway, one can wonderful opportunities for SLPs to educate
set the stage for assessment of upper airway team members regarding the SLP’s role on the
patency, true vocal fold motion, strength of ICU team, and allows for presentation of
cough, and swallowing ability. research information or shared clinical expe-
rience to help nurses or other health care
providers learn more about the SLP’s
INFORMATION FROM THE ICU perspective.
TEAM
Before entering the patient’s room, SLPs are
highly encouraged to speak with the patient’s SWALLOW SCREENINGS
nurse about the patient’s current status, whether In general, and still specific to swallowing
it is appropriate to approach the patient. disorders, screenings are used to identify condi-
Because of the fast-paced environment of the tions or disease in at-risk people. They have a
ICU, the nurse may have information that is not binary outcome—positive (i.e., the condition is
yet available in the chart. Considerations will present and further testing/treatment is neces-
include scheduled procedures, mental/medical sary) or negative (no additional testing/treat-
status of the patient, and other aspects of the ment is necessary). Key aspects of screening
patient’s care that may not be found in the tests include strong sensitivity and specificity,
medical record. Critical care nurses are experts relatively quick and inexpensive to administer/
at patient management and may be implemen- score, and unlikely to cause harm.47–49
176 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3 2019

Adults children with previously typical swallowing

In the adult population, swallow screening function who have experienced an acute change
more than likely occurs when a patient expe- in medical status may be a target population
riences an acute change in his/her medical where screening is appropriate.
status (e.g., extubation, altered mental status).
Screening tools are frequently used in adult
hospitalization to determine which patients are Tracheostomy
able to initiate an oral diet and which require an The heterogeneity of those with TTs has con-
SLP consult or an instrumental study prior to tributed to the limitations of research efforts and
eating. Among the most hotly debated ques- to the lack of confident ability to generalize
tions is when to administer a swallow screening research findings to patient care. While scree-
in adult ICUs postextubation. The answer is: ning in this population may be performed by
when the patient is appropriate and able to other healthcare providers to determine if the
accept an oral bolus to be screened. Although SLP should be consulted, the presence of a TT is

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there are many screenings available,50–52 rela- not a diagnosis or a condition upon which a
tively few have been tested in the ICU.30,52–55 trained swallowing clinician should base a scree-
Two studies have addressed specific timings of a ning method. In fact, many hospitals now have
swallow screening postextubation, both with standards where the SLP is automatically con-
similar conclusions—patients may be safe to sulted on all patients who receive a TT because
begin oral intake soon after extubation.56,57 failing to quickly identify and treat dysphagia can
place the patient at increased risk for pulmonary
aspiration and subsequent infection.
Pediatrics The modified Evan’s blue dye test
Currently, the utility of swallow screening in (MEBDT) is a method that has been used to
pediatrics is unclear. Pediatric swallowing dif- screen patients with TTs for aspiration. There is
ficulty is commonly multifactorial, with risk for no standardized method to conduct the
aspiration being only one of many factors that MEBDT,61 which basically exploits the rela-
limit participation in meals or safe intake. Wide tionship between the oral cavity and the direct
variation in feeding/swallowing skill develop- access to the subglottic airway that the TT
ment may exist, even within the same medical enables. In reality, the pathway from the oral
diagnostic categories and same relative age cavity to the trachea is not a smooth and direct
group. Factors such as sensory/behavioral issues route; therefore, for blue dye to be detected in
and varied experience levels with eating com- the TT or suctioned from the tube, several
plicate administration of a screening tool that conditions must be met. Food or liquid residue
involves swallowing as a task. Nevertheless, one must be of sufficient volume for the pharyngeal
study involving a 3 oz of consecutive water- recesses to overflow and to also travel down the
swallowing task had high sensitivity, but low outer diameter of the main shaft and bypass the
specificity for aspiration of thin liquids in crevices of the deflated cuff (if present) to reach
children.58 If the screening is failed, a child the distal opening of the tube. Any aspirated
would presumably be referred for an instru- material remaining proximal to the larynx,
mental exam. In hospitals where fiberoptic clinging to the tube and the tracheal walls, or
endoscopic evaluation of swallowing (FEES) that flowed down into the main stem bronchi
is not available, a videofluoroscopic swallow cannot be detected. These variables are likely
study (VFSS) would be the most likely option. the primary reasons for the low sensitivity62,63
With an increased concern for radiation expo- and high rate of false negatives64–66 that have
sure in children,59,60 low specificity is proble- been reported in the literature. The MEBDT
matic. Because of these factors, screening tools can detect mainly gross amounts of aspiration,
involving a swallowing task or screening to which may have contributed to the common
identify need for an instrumental exam may misconception that patients with gross aspira-
not be practical or even needed with a majority tion as detected by the MEBDT are “not ready”
of the NICU/PICU populations. However, for evaluation or treatment, when in fact, these
 CLINICAL DECISION MAKING IN THE ICU/BRODSKY ET AL 177

are the very patients who require immediate and transition to the next level of care. With
intervention.63 The logic of considering the pediatric patients, clinicians must balance ans-
subjectively judged amount of aspiration of a wering the immediate questions while protec-
particular consistency as a basis to treat a ting and planning for long-term function, skill
swallowing disorder or not strongly implies development, and child–caregiver relationships,
that swallowing function should improve spon- for example, whether the patient is appropriate
taneously and that therapy is not necessary or to begin the first oral feeding trials of his/her life.
effective in such patients. There are factors that With adults, the focus is shifted to a more
can indicate that a patient is not ready for narrowly focused, immediate goal, for example,
evaluation, oral intake, and/or subsequent whether the patient is able to safely consume any
treatment such as cognitive status and medical oral intake (included oral medications) after they
fragility; however, there is no evidence that have been extubated and are recovering from
shows that patients with subjectively determi- acute respiratory distress syndrome (ARDS).
ned “gross” aspiration should not receive a

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comprehensive swallowing assessment. In addi- TIMING
tion, the mechanism for the aspiration that is The timing of the swallowing assessment is a
used to guide treatment cannot be determined crucial decision for the ICU clinician. In the
by MEBDT. Another caveat is that, in some ICU, the SLP consult is typically an invitation
cases, aspiration can be detected that is not to join that patient’s care team, but may not
related to oropharyngeal dysphagia, but rather a necessarily reflect that the patient is ready for a
positive MEBDT can be caused by laryngo- full assessment. Decisions largely are centered
pharyngeal reflux, a Zenker’s diverticulum, cri- on illness trajectory and the overall stability of
copharyngeal achalasia, or an obstruction. the patient. Illness trajectories can follow an
Delaying assessment based on a MEBDT pla- upward path from initial illness/event to reco-
ces the patient at risk for receiving delayed or very (e.g., head trauma, viral illness). Or, the
the wrong treatment. In summary, although the trajectory may involve multiple plateaus and
MEBDT appears to be a quick and easy method possible periods of health crises along the path
to try to predict the risk of prandial aspiration, (e.g., oncology diagnoses, chronic illness, and
and it may be widely used in some hospitals, it is congenital heart defects).69–72 Estimating
to the patient’s distinct advantage to receive a where the patient is on their individual illness
complete evaluation of swallowing function at trajectory avoids assessing too early in the
the onset of care by the SLP, especially for recovery as well as avoiding unnecessary delays
patients in ICUs. in the patient being assessed. The overall
medical stability also must be considered.
For example, is the patient only a few hours
ASSESSMENT post-extubation and the team is not yet confi-
dent of sustained extubation, or does the team
Clinical Swallow Evaluation believe that the high level of oxygen support is
going to be the requirement for several more
GOALS days?
The general goals of assessment—whether in An evolving consideration related to timing
pediatrics or adults—include identifying the of and stability for assessment is the use of
impairment(s), isolating contributing factors, noninvasive ventilation methods in lieu of intu-
creating an explanation for the disordered bation or while weaning from ventilator support.
mechanism, and identifying the possible barriers Use of nasal delivery of continuous positive
or facilitators to functional improvement.67,68 airway pressure (CPAP) and HFNC is now
The overriding focus must be on identifying the commonplace across all ICU settings. Most of
impact of these factors on the patient to facilitate the clinical research appears to have been com-
his/her health and quality of life. In critical care, pleted in the pediatric population (outlined
these global questions are narrowed to focus on later). The obvious concerns surrounding oral
specific management goals to facilitate recovery feeding, regardless of patient population, relates
178 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3 2019

to the physiologic stability of respiratory support nent, depending on the patient (i.e., pediatrics vs.
and the coordination of swallowing with brea- adults) and nature of the injury/illness (e.g.,
thing with high levels of airflow into the shared breastfeeding, paralysis). The plan may not be
pharyngeal/laryngeal space. The impact of pha- as straightforward but should consider additional
ryngeal pressure generated by this airflow on testing (e.g., instrumental evaluation of swallo-
airway protection is also of concern, as studies wing, manometry), recommendations for fee-
have indicated varying level of pressure genera- ding accommodations, and starting/changing
ted based on patient size and cannula diameter/ the present diet consistency. Time is another
nasal occlusion.73–76 Some studies suggest the consideration. High oxygen needs combined
possibility of oral feeding with HFNC,77–81 and with noninvasive ventilation and/or high respi-
with CPAP,82,83 while others raise concerns for ratory rates, for example, suggest that respiratory
increased aspiration with nasal CPAP,84,85 and demands on the patient may be sufficient to
BiPAP.86 Without definitive guidance from compromise swallowing safety. Discussing a
large studies, the ICU clinician must consider postponed screening/evaluation with the medical

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each patient’s individual presentation and risk team may reduce risk of pulmonary and other
factors, not solely the oxygen delivery mode/level medical complications.
in isolation of these other factors. Moreover,
until more definitive studies are completed,
relying on instrumental evaluations is necessary Instrumental Evaluation
under these circumstances.
GOALS OF INSTRUMENTAL EVALUATIONS
COMPONENTS Primary goals include identifying anatomy,
Multiple authors have detailed the components oropharyngeal swallow pathophysiology, the
included in pediatric87–90 and adult51,68,91 cli- presence and source of laryngeal penetration/
nical swallow evaluations (CSEs). Typical com- aspiration, effects of behavior, and/or sensory
ponents include a battery of testing that include changes on swallowing physiology.92–94 Infor-
cognitive screening/assessment, an assessment mation from instrumental exams is used to
of cranial nerve/oral motor function, positio- identify specific therapeutic targets for impro-
ning, and direct feeding skill assessment. These ving swallow function.
observations, tasks, and conclusions are the
same in critical care as in other settings, but VIDEOFLUOROSCOPIC SWALLOW STUDY
in the context of potential physiologic instabi- Details about the procedure and interpretation
lity and tightly managed care. of VFSS are available.92–95 Often, the stability of
the patient may dictate whether the patient can
DECISION MAKING be transported out of the ICU for nonurgent
After completing a CSE, the clinician should testing, such as the VFSS. In these cases, delays
reflect on what information was gained and what for this instrumental evaluation may ensue
information is still needed to develop an indi- and an alternative plan should be considered.
vidualized treatment plan. This will include Although caution is practiced with all patients
noting patient behaviors, discussion with the during this radiographic assessment, concerns
patient and/or caregivers, and the compensatory are especially heightened regarding radiation
strategies that appear to be helpful (or not). Pain, exposure in pediatrics, especially in young child-
discomfort, somatic feelings, and endurance are ren who have a lifetime of potential radiation
all necessary considerations in patient popula- exposure ahead of them.96–98 However, the
tions who are recovering from critical illness. information gained may be crucial to supporting
At the end of the CSE, a diagnosis and a a patient’s goals, and careful planning can ensure
plan must be completed. The diagnosis is gene- that the clinical yield justifies the radiation
rally written as no dysphagia, possible/suspected exposure. In pediatrics, building in periods of
dysphagia, or dysphagia, using the terms oral, swallowing without the fluoroscopy turned on
oropharyngeal, and pharyngeal as appropriate for can allow for assessment of fatigue without
the patient. There may also be a feeding compo- increasing exposure time. Discussion with the
 CLINICAL DECISION MAKING IN THE ICU/BRODSKY ET AL 179

radiologist should take place prior to the exam because the inner diameter of the female trachea
where the clinical questions are outlined, and a is approximately 3 mm smaller than the male
plan for answering those while minimizing trachea.113 The TT should not consume the
fluoroscopy time should be formulated.59,60,99 entire trachea and make contact with the tracheal
Generally, a frame rate of 30 frames per second walls. The identification of a TT that is too large
(fps) is used to capture these studies. Using less has potential to prevent several possible tube-
than 30 fps may result in missing key swallowing and cuff-related complications such as tracheo-
events.100 malacia, stenosis, or tracheoesophageal fistula.
To determine proper fit of the outer diame-
FLEXIBLE ENDOSCOPIC EVALUATION OF ter, the cuff should be completely deflated and
SWALLOWING brief digital occlusion performed to divert pul-
Assessing swallowing via nasoendoscopy was monary airflow to the upper airway as indicated
described first in adults94 but is now an establis- by oral or nasal exhalation and/or phonation.
hed part of pediatric practice.101,102 Descriptions Brief occlusion can also be performed on patients

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of the procedure in pediatric patients are avai- who are ventilator dependent by working with
lable102,103 and the indications for a FEES versus the respiratory therapist or pulmonologist who
a VFSS are well described in the literature.103–105 can allow the ventilator to give a breath and
FEES is portable to the ICU, safe to complete106 briefly remove the connection at the tube hub, so
(even in infants),107–109 and the results show that it can be briefly occluded by the SLP. If
good correlation with those of VFSS.110–112 airflow around the tube cannot be detected, it is a
FEES can be particularly useful in critical care strong indication that the size is too large, thereby
settings, as it can be performed in the patient’s placing the patient at risk for tracheal damage,
room, eliminating potentially difficult patient especially if the cuff is being inflated. In addition
transport and/or delays to the fluoroscopy suite. to clinical assessment of the TT, an instrumental
It may also allow for more typical seating/posi- evaluation will provide the necessary information
tioning. Secretion management, spontaneous to determine aspiration-specific risk factors, or
swallows, and very small volume oral trials can timing of aspiration in relation to swallow onset.
also be assessed, for which fluoroscopy is not an Typically, obtaining a videofluoroscopic
ideal choice. FEES can also be repeated with swallowing evaluation for an ICU patient is
more frequency than the VFSS, provided patient not feasible. It is possible to bring a C-arm
toleration of the exam. In infants, FEES may also fluoroscope to the bedside; however, concerns
be used for assessment during breastfeeding, in over radiation scatter, staffing availability from
which case using VFSS is not feasible.109 radiology, etc., make it unlikely to be routinely
available at most hospitals. As previously stated,
TRACHEOSTOMY CONSIDERATIONS FEES can be performed at the bedside and has
There are no scientifically based guidelines for been shown to be highly effective in identifying
when evaluation and/or therapy can begin after aspiration and incomplete pharyngeal clea-
the TT is placed. Currently, most clinicians rance. In addition, FEES can assess true vocal
wait for 48 hours after a surgical TT placement fold mobility and secretion levels in persons
to enable the stoma tract to heal and for the with indwelling TTs.114 Specific to FEES for
patient to adjust to the new airway. In some persons with TTs, the presence and status of a
cases, cuff deflation will not be permitted until cuff must be considered and noted during the
the stoma track has matured sufficiently and the evaluation. All patients do not require cuff
TT can be changed (usually 7–10 days). deflation to eat safely (without aspiration)
Cuff deflation is a key element in the because some patients can compensate for the
determination of the relationship between the TT115 while other patients swallow best with
outer diameter of the tube and internal diameter the cuff deflated and airflow restored. If infla-
of the trachea. There is a pervasive notion that a ted, the cuff must be at the proper pressure
size 8 or 9 TT should be the first size to be placed. (<25 mm H2O) to avoid any mechanical influ-
This assumption can result in the placement of a ences that can reduce available laryngeal eleva-
tube that is too large, particularly in women, tion.116 Fingertip palpation of the pilot balloon
180 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3 2019

cannot accurately determine proper inflation; children, different cultures vary widely in the
therefore, a manometer must be used to deter- beliefs and values surrounding meals and the
mine cuff pressure.117,118 For maximum laryn- feeder–child relationship. The implementation
geal sensation, airway clearance, and restoration of the International Dysphagia Diet Standar-
of the most natural conditions of the upper disation Initiative (IDDSI)126 has allowed for
airway, a deflated cuff and a one-way speaking more objective discussions between SLPs, die-
valve should be considered. Identification of the ticians, and parents regarding what foods or
best condition for oral intake can only be drinks from the child’s culture align with the
determined by systematically assessing the recommended diet/liquids.
same items under the various TT conditions.
If the cuff is typically inflated, one can begin
with that condition, followed by cuff deflation Types of Intervention
and then cuff deflated and speaking valve Interventions can be categorized as being either
placed. Ideally, one or all conditions will reveal rehabilitative or compensatory in nature. Reha-

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safe swallowing function and provide options bilitative interventions provide physiologic
for staff who may be involved in their oral intake improvements for swallowing. Examples may
for medications, hydration, or nutrition. include oral sensory stimulation, oral motor
and/or swallowing exercises, and nonnutritive
sucking in infants. Compensatory strategies may
INTERVENTION not require active patient participation and
change the properties or delivery of the bolus
Establishing Goals and/or environmental factors such as patient
Goal setting in the ICU should be collaborative, positioning to promote safe swallowing. Syste-
with the patient and family at the center of the matic reviews of these interventions with various
team. Goals should incorporate the following populations have concluded that limited evidence
criteria: exists as to their impact on physiology.127–136

 Targets for treatment are selected based on

findings from assessment.92–94 Tracheostomy
 Overall focus is on maximizing health, inc- Both direct and indirect swallowing rehabilita-
luding the best route for medications (i.e., tion can begin in the ICU and while a patient
oral/enteral, parenteral). with a TT is ventilator dependent.137 In addi-
 Goals should support development: In both tion to instruction and practice in compensatory
the NICU and PICU, treatment can occur strategies and exercises for specific swallowing
amidst a child’s first oral feeding experien- impairments that have been identified by the
ces. Viewing feeding as a neurodevelopmen- instrumental evaluation, addressing the physio-
tal process highlights both the importance of logic effects of the TT is necessary. For these
providing positive experiences119 and the patients, therapy may initially focus on detec-
risk of developing future feeding tion and management of oral secretions after
problems.120,121 cuff deflation. Because sensation is restored by
 The treatment and education plan is cultu- airflow, the patient will have improved ability to
rally sensitive and family centered. The ICU detect pharyngeal residue, or may produce a wet
is a stressful environment for caregivers. The vocal quality, which can indicate oropharyngeal
impact of critical illness on physical, cogni- secretion buildup or the presence of secretions
tive, and mental health, referred to as post- within the larynx. Increased swallowing fre-
intensive care syndrome (PICS) and PICS quency and secretion clearance may be observed
family, is being addressed.122–125 immediately once airflow is enabled.46 Working
toward tolerance of cuff deflation and secretion
Clinicians also must be aware of cultural management in patients who are ventilator
differences and show sensitivity to how that dependent may also have the concomitant
might impact the treatment plan. Specific to benefit of expediting the weaning process.138
 CLINICAL DECISION MAKING IN THE ICU/BRODSKY ET AL 181

When swallowing in the natural, closed trachea. Also, the direct access to the trachea
state (i.e., the trachea is not open to the that is provided by the tube enables deep
environment), lung volume and lung–thoracic suctioning should there be concern for
recoil forces combine to generate positive sub- aspiration.
glottic air pressure (Psub) that peaks during
vocal fold closure.139,140 The widely accepted
FUTURE DIRECTIONS
theory is that the positive pressure stimulates
Demonstrating value of SLP services is neces-
subglottic receptors that signal the status of the
sary to preserve the vital role of SLP in critical
respiratory system to the brainstem swallowing
care settings. Efforts continue to develop and
centers prior to swallowing motor output.141
validate objective screening, evaluation, and
For patients with TTs, placing a one-way
treatment methods, and robust outcomes
speaking valve that closes spontaneously after
measures.
inhalation restores the potential to generate
positive subglottic pressure when the true vocal

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CONFLICT OF INTEREST
folds close during the swallow. Valve placement
also enables natural coughing. Placement of a None declared.
speaking valve will not necessarily increase tidal
volumes, improve lung–thoracic unit recoil, or
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