Swallowing Difficulties in ICU Patients [Synkebesvær Hos Intensivpatienter]

Introduction Dysphagia caused by intubation and mechanical ventilation affects between 1.300 - 2.000 patients in Danish intensive care units (ICU's) every year. Dysphagia increases the risk of aspiration, pneumonia, repeated mechanical ventilation and mortality. Despite this, national and international guidelines for treating dysphagia in the ICU are lacking. In ICU patients, dysphagia may vary around the clock as fatigue and cerebral status plays an important role for the patients' ability to swallow effectively without aspiration. For this reason, ICU nurses must be able to assess dysphagia in the ICU patient day and night. This will be an important addition to assessments made by occupational therapists usually only available in the morning hours. However, for nurses to be able to assess dysphagia in the ICU patients; development and validation of screening procedures are highly needed.

The development of a validated screening procedure to detect dysphagia in ICU patients will furthermore pave the way for the developing and testing nursing interventions aiming at improving dysphagia in ICU patients. This may reduce complications and improve quality of life in patients.

Dysphagia related to mechanical ventilation and intensive care The swallow function depends on a complicated interplay between more than 30 muscle pairs, cranial nerves and areas in the cortex and the medulla oblongata. Causes for dysphagia in ICU patients are only partially understood, however, the following factors have been suggested as significant: 1) Trauma to the pharynx caused by intubation (placing a tube for mechanical ventilation in the airway), 2) Neuromyopathy resulting in muscular weakness, 3) Decreased level of consciousness caused by medication, delirium or critical illness. Moreover, these factors may cause dysphagia in ICU patients to vary from day to night.

Dysphagia is a serious complication to critical illness, potentially increasing mortality. Despite this, research shows that nursing practice varies greatly. Nurses have different views on what constitutes safe swallowing. Nonetheless, it often falls upon nurses to assess patients swallowing function and determine whether to offer the patient something to eat and drink or not. Thus, developing valid screening methods that can be used by ICU nurses may improve patient safety and reduce complications due to dysphagia caused by intubation, mechanical ventilation and critical illness.

Diagnosing dysphagia using FEES Dysphagia can be diagnosed using instrumental methods such as the fiberoptic endoscopic evaluation of swallowing (FEES). This method is considered a gold standard in assessing dysphagia. FEES may be performed bed-side by physicians or occupational therapists by testing different foods and consistencies, but some patients find the FEES disagreeable. A clinical examination by occupational therapists is another way to diagnose dysphagia, however, silent aspiration without choking or coughing is difficult to detect in a clinical examination.