2PRESENTATION OUTLINEYear in review2012 CAT topicE3BP project
3YEAR IN REVIEWChange in leaders (thank you to Eva and Klint for their hard work)50% increase in membership6 meetings this yearCritical care and tracheostomy discussion list serve remains active with just under 200 members.Included clinical case discussion to each meeting following member surveyInterstate collaboration and pending SPA poster presentation in 2013Reviewed CAPs on “in critical care patients does intubation effect laryngeal health ? ”, with aim to complete CAT early 2013
4CAT TOPIC – 2012 – FEES IN CRITICAL CARE Background to CAT – there are differences between sites utilising FEES for management in critical care. Some sites are keen to introduce the use of FEES in critical care and it would be ideal to have evidence to justify service establishment.Clinical question was formed to assist in examining the documented evidence supporting the use of FEES to identify dysphagia.Is FEES an effective diagnostic tool in critical care for identifying dysphagia?
5Support for clinical question? ArticleLevelParticipantsMethodDiagnostic toolOutcome measureResultsSupport for clinical question?Hafner et al (2008)4553 critical care pts (incl tracheostomised pts)Prospective interventional studyScreening risk for dysphagia in ICU post extubationSelf generated FEES protocolDetection of silent aspiration in 69.3%, 22.9% decannulated.YesHales et al (2008)25 critical care tracheostomised ptsProspective observational studyClinical bedside swallow AxFEES Ax (Rosenbeck Scale)Detecting penetration and aspiration- FEES more reliableAjemian et al (2001)48 critical care (non-trache) ptsProspective observatonal studyFEES within 48 hrs of extubationDysphagia detected in 56% pts25% pts silently aspiratedMcGowan4 ventilated , tracheostomised pt’s with cuff inflatedCase series pilot study¼ had normal swallow, ¼ aspirated, 2/4 had laryngeal penetrationNoordally et al (2011)321 critical care pts(non-tracheostomised)Prospective comparison studyAttempted to compare parameters of swallow between FEES, MBS and clincial axClinical Ax and FEES within 24hrs of extubationAbove evaluations repeated at 48hrs and 10/21 stable patients also recieved a MBS? Each swallow component rated on scale of 1-3 and then rating compared between tools.?Statistical correlations of ratingsMethodological limitations.Disregard studyBarquist et.al 200170 critical care patientsProspective comparison study with concurrent controlsFEESClinical assessment of swallowingIncidence of post extubation pneumonia between patients with clinical and FEES in patients intubated > 48 hrsLimted study with many methodological limitations.
6COMMENTS Discrepancy in data recorded in some articles Limited uniformity between the patient populations in these studies (some tracheostomised, some ventilated, post extubation etc)Speech Pathologist was not consistently part of the investigating teamsInter-rater reliability was an issue
7CAT bottom line“In the critical care population, limited, low level evidence suggests that FEES may be useful in identifying dysphagia. In some studies, FEES has been shown to be more sensitive than bedside Ax in detecting silent aspiration.”Further robust research is required in order to support the use of FEES in preference to clinical bedside ax or MBS in the critical care setting
8CAT bottom line : application to clinical practice Confirms what we know about FEES ie :FEES may be useful for detection of silent aspirationUseful for both tracheostomised and non tracheostomised patientsSuggests that FEES can be useful for non-mobile and medically unstable patientsConsistent with results of NSW Health Draft Tracheostomy Clinical Practice guideline (2012) recommendation: “Where objective assessment of swallowing is required a FEES may be considered as alternative objective assessment to a VFSS. A FEES has been demonstrated to have greater sensitivity than clinical assessment alone to detect aspiration and is particularly useful in critical care environments. FEES may allow earlier commencement of oral intake.”
92012 E3BP PROJECT E3BP review Background Collection in the clinical settingThemes from collationFuture directions in the clinical setting &beyond
10E3BP TRIANGLE Best external evidence Clinical expertise Best internal evidence(from clinical practice)Best internal evidence(from client factors & preferences)
11BACKGROUND TO E3BP PROJECT 2011 CAT involved review of the literature on the effect of tracheostomy on swallow functionCAT bottom line - “low level evidence to suggest that a tracheostomy tube does not cause dysphagia; rather, the dysphagia is attributed to the underlying diagnoses and co morbidities”The group identified a significant gap in evidence versus clinician opinion/practiceDecided to use E3BP to enable holistic decision making around trache careGroup then circulated and analysed an online survey to NSW speechies to gauge level of knowledge and ideas on current practiceSurvey was also distributed to Vic tracheostomy interest group
12E3BP collection in the clinical setting Group brainstorming session and development of preliminary data collection table → some concerns from the group regarding the sensitivity and robustness of the tool.Group members and their departments started data collectionSome members of group attended Beyond Basics EBP workshop. Some discussion with Elise Baker. → its not research ! Include “the mess” and keep collecting!Refined table online during data collection. Easy to use, not time intensive, aim to make it a part of clinical assessment.
13Swallow Ax (A) Swallow Ax (B) TracheTrache Insitu(Last swallow Ax pre-decannulation)Post-Decannulation(First swallow Ax post-decannulation)TimeSummaryReason for Trache insertionTrache type insitu at time of AxSwallow Ax (A)Diet + Fluids recommendationSwallow Ax (B)□Airway patency□ Respiratory/ pulmonary toileting□ Prolonged ventilator wean□ GCSSize□ 6□ 7□ 8□ 9Other:□ Portex□ Shiley□ Other brand:□ Fenestrated□Non-fenestrated□Cuffed□Uncuffed□Cuff up□ Cuff down□Speaking Valve□ CappedRespiratory support:□ Trache mask + vent□ Trache mask onlyAssessment type:□ Bed-side□ FEES□ MBS□Posture:Upright; Semi-upright; supine□ Delayed onset of pharyngeal initiation□ >1 swallow per bolus□ Reduced hyolaryngeal excursion□ Other:Signs of aspiration:□ Cough□ Throat clearing□ Wet vocal quality□ Increased SOB□ Reduced oxygen saturation□ Stained secretions (food/fluid)□ NBM□ NGT/TPN□ NGT/TPN + oral intake□ Oral intake only□ Thin Fluids□ Nectar/mildly thick□ Honey/moderately thick□ Pudding/extremely thick□ Puree□ Minced□Soft□Full□ Small amounts (specify):□ Swallowing strategies:□ >1 swallow/bolusNo. of days trache insitu :No. of days between Swallow Ax (A) and Swallow Ax (B):Has there been a change in swallow function?□ No change□ Improvement□ DeclineIf swallow function has improved, what may have contributed to this?□ Trache decannulation□ Improved general medical status
14E3BP data trends to date PRELIMINARY TRENDS IN DATA – see table N = 36 6 sites completed (other sites interested but not included at this stage)5 tertiary sites, 1 metro siteData collected over last 6 months (May-Nov)35 clinical Axs (only 1 MBS, no FEES)Last ax with trache insitu and first ax post decannulationAverage of days between ax’sReason for trachy insertion : 30/36 prolonged vent weans, 4/36 low GCS, 1/36 airway patency, 1/36 respiratory toiletPRELIMINARY TRENDS IN DATA – see table
15Cohort = 36Was there a change in swallow between last Ax with trache insitu and first assessment with trache removed? (Eg. Change to diet recommendations, less repeat swallows, reduced aspiration/penetration signs?)YES = 22No = 14What caused the improvement?15medicalimprovement5trachedecannulation2Combinationother factors?Anxiety, upper airwayirritation
16WHERE TO FROM HERE ?Continuation of E3BP data collection to increase our body of internal evidence with future trend analysisContinued liaison with Victorian tracheostomy interest group. Joint submission of poster abstract for 2013 SPA conference re member surveyFinalise the CAT on the effect of intubation on laryngeal healthHosting tracheostomy education day 2013