Background
Technological advances in radiotherapy have allowed investigations into new methods to spare healthy tissue in those treated for head and neck cancer. This systematic review with ...meta‐analysis demonstrates the effect that radiation has on swallowing.
Methods
Selection and analysis of studies examining the effect of radiation to swallowing structures. A fixed effects meta‐analysis calculated the pooled proportions for select outcomes of dysphagia, common across many studies.
Results
The majority of the papers found a correlation between radiation dose to the swallowing structures and dysphagia, however a meta‐analysis found the studies carried a significant degree of heterogeneity. The appraisal demonstrates the need for large‐scale studies using a randomized design and instrumental dysphagia assessments.
Conclusions
Radiation dose to dysphagia and aspiration structures is correlated with incidence of dysphagia and aspiration. The variables in this population contribute to the heterogeneity within and cross studies and future studies should consider controlling for this.
Background
Transoral robotic surgery (TORS) is a minimally invasive approach for the treatment of oropharyngeal cancer. The effects on swallowing and speech need to be comprehensively evaluated to ...understand the associated morbidity.
Methods
A prospective cohort of 21 patients was recruited to undergo pre‐TORS and post‐TORS swallowing and communication assessment. Fiberoptic endoscopic evaluation of swallowing (FEES) was used in the first postoperative week.
Results
Sixteen participants (76.2%) had penetration‐aspiration scores ≥3 or higher, seven (33.3%) aspirated on thin liquids, three (14.3%) did so silently. Prolonged recovery trajectory occurred for the majority of the cohort, particularly if TORS was followed by adjuvant radiotherapy. Swallowing and communication scores were significantly worse in base of tongue primary tumors and with advanced age.
Conclusion
Early FEES demonstrates a significant decline in swallowing function, including increased secretion load, pharyngeal residue, laryngeal penetration, and aspiration. Silent aspiration occurred in 14% and thus highlights the necessity for instrumental assessment to ascertain aspiration risk.
Background
Heterogeneity within studies examining transoral robotic surgery (TORS) for oropharyngeal cancer (OPC) has made it challenging to make clear conclusions on functional outcomes. Infrequent ...use of instrumental swallow examinations compounds uncertainty surrounding the proposed functional advantage to TORS.
Methods
A prospective cohort of 49 patients underwent speech and swallowing assessment 12 months following treatment for OPC. Patients were assessed using fibreoptic endoscopic evaluation of swallowing (FEES), clinician‐ and patient‐reported outcomes. Participants were matched according to tumor site, T category, and age. Speech and swallowing outcomes were compared for those receiving TORS versus chemoradiation.
Results
When adjuvant radiotherapy to the primary site could be avoided, TORS demonstrated an advantage for feeding tube duration, secretion severity, penetration/aspiration, M. D. Anderson Dysphagia Inventory (MDADI), and airway protection.
Conclusion
This explorative study suggests that a treatment philosophy of selecting patients for TORS where adjuvant therapy can be omitted or confined to the neck warrants further evaluation.
The impact of COVID-19 on swallowing function is not well understood. Despite low hospital admission rates in Australia, the virus and subsequent treatment affects swallow function in those requiring ...intensive care unit (ICU) treatment. As such, the current pandemic provides a unique opportunity to describe swallowing function and outline dysphagia characteristics and trajectory of recovery for a series of cases across NSW.
The aims of this study were to describe (i) physiological characteristics of swallowing dysfunction and (ii) pattern of swallowing recovery and outcomes, in ICU patients with COVID-19.
All patients admitted to 17 participating NSW Health ICU sites over a 12-month period (March 2020–March 2021), diagnosed with COVID-19, treated with the aim for survival, and seen by a speech pathologist for clinical swallowing examination during hospital admission were considered for inclusion. Demographic, critical care airway management, speech pathology treatment, and swallowing outcome data were collected.
Twenty-seven patients (22 male; 5 female) with a median age of 65 years (interquartile range IQR = 15.5) were recruited. All required mechanical ventilation. Almost 90% of the total cohort had pre-existing comorbidities, with the two most frequently observed being diabetes (63%, 95% confidence interval = 44%–78%) and cardiac disease (59%, 95% confidence interval = 40%–75%) in origin. Prevalence of dysphagia was 93%, with the majority (44%) exhibiting profound dysphagia at the initial assessment. Median duration to initiate oral feeding was 38.5 days (IQR = 31.25) from ICU admission, and 33% received dysphagia rehabilitation. Dysphagia recovery was observed in 81% with a median duration of 44 days (IQR = 29). Positive linear associations were identified between duration of intubation, mechanical ventilation, hospital and ICU length of stay, and the duration to speech pathology assessment (p < 0.005), dysphagia severity (p < 0.002), commencing oral intake (p < 0.02), dysphagia recovery (p < 0.004), and enteral feeding (p < 0.024).
COVID-19 considerably impacted swallowing function in the current study. Although many patients recovered within an acceptable timeframe, some experienced persistent severe dysphagia and a protracted recovery with dependence on enteral nutrition.
Background
The relationship between swallowing outcomes and radiotherapy dose to dysphagia and aspiration‐related structures (DARS) may be different following definitive versus postoperative ...radiotherapy (PORT) for mucosal head and neck cancer (HNC) and has not been well‐studied.
Method
Patient‐ and clinician‐reported swallowing measures were prospectively collected at six time points from baseline to 24 months postradiotherapy HNC. Radiotherapy plans were retrospectively analyzed to assess dose delivered to DARS. The association between swallowing outcomes and participant demographics, tumor characteristics, and radiotherapy dose in definitive and postoperative treatment cohorts was assessed.
Results
Ninety‐three participants who received radiotherapy for HNC were included in the analysis (n = 49 definitive radiotherapy for laryngeal/pharyngeal primary tumors and n = 44 postoperative PORT for predominantly oral cavity/salivary gland tumors). Participants undergoing PORT had lower doses to DARS than those undergoing definitive RT. High dose to the pharyngeal constrictors and base of tongue for definitive RT and the esophageal inlet, supraglottic larynx and cervical esophagus for the PORT group were associated with worse swallowing function.
Conclusion
Radiation dose to DARS is associated with post‐treatment swallowing outcomes. These dose/outcome relationships may vary between the definitive and postoperative settings.
A tracheostomy tube can profoundly impact ability to communicate. The impact of this on patients’ self-esteem and quality of life in the care continuum from the intensive care unit to after ...decannulation has not been reported. Therefore, the aim was to investigate the patient-reported experience regarding change in communication function, communication-related self-esteem and quality of life.
A mixed methods approach was utilised. Quantitative data were obtained using validated measures of self-esteem related to communication-related quality of life and general health. Data were measured before return of voice, within 48 hours of voice return and six months after tracheostomy decannulation. Qualitative data were collected through structured interviews six months after tracheostomy.
Seventeen participants completed the study. Four themes emerged from the interviews: It’s hard communicating without a voice; What is happening to me?; A storm of dark emotions and More than a response…it’s participating and recovering. Significant positive change occurred in six items of self-esteem related to communication from baseline to return of voice. Overall, positive changes in quality of life scores were observed.
Voice loss with tracheostomy significantly affected participants’ abilities to effectively communicate their care and comfort needs. Restoration of voice occurred in conjunction with patient-reported improved mood, outlook and sense of recovery.
A cuffed tracheostomy tube facilitates prolonged mechanical ventilation and weaning but usually leads to prolonged voicelessness, which can be one of the most negative experiences of hospitalization. ...No randomized trials have examined the effects of targeted early communication intervention for the restoration of voice in ventilated tracheostomy patients in the ICU.
A prospective randomized clinical trial.
The trial was conducted in the ICU of an urban tertiary level hospital.
Thirty adult participants enrolled, with 15 randomly allocated to the intervention and control groups.
The early intervention group received early cuff deflation and insertion of an in-line speaking valve during mechanical ventilation. The control group received standard cuff deflation and a speaking valve during self-ventilation. A speech-language pathologist provided all treatments.
The primary outcome measure was time from tracheostomy insertion to phonation. Early intervention significantly hastened return to phonation (median difference = 11 d; hazard ratio = 3.66; 95% CI, 1.54-8.68) with no significant effect on duration of tracheostomy cannulation (hazard ratio = 1.40; 95% CI, 0.65-3.03), duration of mechanical ventilation in days from tracheostomy insertion (hazard ratio = 1.19; 95% CI, 0.58-2.51), length of stay in ICU (hazard ratio = 1.16; 95% CI, 0.54-2.52), or time to return to oral intake (hazard ratio = 2.35; 95% CI, 0.79-6.98). Adverse events were low and equal in both groups. There was no significant change in measures of quality of life.
Focused early intervention for communication during mechanical ventilation allows the restoration of phonation significantly sooner than standard treatment, with no increase in complications in a small patient cohort. Although these results are favorable, further research is needed to determine whether the effects on any of the secondary outcomes are statistically significant and clinically important.
Pandemics and the large-scale outbreak of infectious disease can significantly impact morbidity and mortality worldwide. The impact on intensive care resources can be significant and often require ...modification of service delivery, a key element which includes rapid expansion of the critical care workforce. Pandemics are also unpredictable, which necessitates rapid decision-making and action which, in the lack of experience and guidance, may be extremely challenging. Recognising the potential strain on intensive care units (ICUs), particularly on staffing, a working group was formed for the purpose of developing recommendations to support decision-making during rapid service expansion.
The Critical Care Pandemic Staffing Working Party (n = 21), representing nursing, allied health, and medical disciplines, has used a modified consensus approach to provide recommendations to inform multidisciplinary workforce capacity expansion planning in critical care.
A total of 60 recommendations have been proposed which reflect general recommendations as well as those specific to maintaining the critical care workforce, expanding the critical care workforce, rostering and allocation of the critical care workforce, nurse-specific recommendations for staffing the ICU, education support and training during ICU surge situations, workforce support, models of care, and de-escalation.
These recommendations are provided with the intent that they be used to guide interdisciplinary decision-making, and we suggest that careful consideration is given to the local context to determine which recommendations are most appropriate to implement and how they are prioritised. Ongoing evaluation of recommendation implementation and impact will be necessary, particularly in rapidly changing clinical contexts.
Admission to the intensive care unit (ICU) with mechanical ventilation can lead to patients experiencing impaired swallowing and communication function. This can negatively affect patient experiences ...and outcomes. There is increasing research supporting early intervention for swallowing and communication; however, there are no published ICU workforce data to determine patient access.
The purpose of this study was to describe national ICU access to speech pathology (SP) services and to describe the nature of this workforce.
Prospective audit of Australian ICUs with a focussed workforce survey of SP service including workforce demographics, clinical practices, team environments, and training was conducted. Data are described as percentage (%, n) and as median (interquartile range). Qualitative data were analysed using thematic frameworks.
SP services were available at 99% (n = 165) of the sites; 62 sites provided workforce data (45% response rate). Seventy-one percent of respondents serviced the ICU ≤10 h per week, with 23% reporting dedicated funding. Almost a third (32%) reported not participating in ICU team activities, and more than half of the sites (56%) did not provide ICU-specific training with resulting varied clinical confidence ratings. Facilitator and barriers both highlighted team working relationships. Facilitator themes were building working relationships, understanding the SP role in the multidisciplinary team, physical presence in the unit, and access to resources. Barrier themes were the multidisciplinary team's understanding of SP roles and lack of presence of SP services in the ICU.
SP services are not standard across Australian ICUs, with variations in confidence, funding, training, and team environments. Further research into the impact of these variations on patient outcomes is needed.
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