Early dysphagia rehabilitation in critical care: A pilot study of safety, feasibility, and effectiveness of a strength-based dysphagia treatment protocol in intensive care unit-acquired weakness.

BACKGROUND

Dysphagia is commonly associated with intensive care unit-acquired weakness (ICUAW), with oropharyngeal muscular weakness considered a major precipitating factor. Unfortunately, evidence for effective rehabilitation of dysphagia associated with ICUAW is lacking.

AIM: The aim of this study was to examine the feasibility, safety, and effectiveness of a strength-based dysphagia treatment protocol for patients with dysphagia associated with ICUAW.

METHODS

A prospective pilot cohort study was conducted on all critically ill patients admitted to an Australian tertiary referral intensive care unit (ICU) over a 3-year period, diagnosed with dysphagia and ICUAW. A strength-based dysphagia treatment protocol was implemented incorporating expiratory muscle strength training and swallowing exercises to target the tongue base, pharyngeal, suprahyoid, and respiratory muscles. A regime of five sets of five repetitions, conducted 5 days per week, was employed. Treatment commenced in the ICU, continuing until swallowing recovery or swallowing function plateaued. Key swallowing and respiratory outcomes were collected weekly: clinical swallow examination (Functional Oral Intake Scale [FOIS]: 1-7), flexible endoscopic evaluation of swallowing (New Zealand Secretion Scale: 0-7, Penetration-Aspiration Scale: 1-8] Yale Pharyngeal Residue Scale [Yale]: 1-5), peak expiratory flow (PEF), and maximum expiratory pressure (MEP).

RESULTS

Thirteen participants (11 male, median age = 52 years) were recruited. Medical diagnoses included severe burn injury, influenza-A, necrotising pancreatitis, sepsis, and COVID-19 infection. Median mechanical ventilation was of 19 days (interquartile range [IQR] = 16-36 days), ICU length of stay was of 34 days (IQR = 21-43 days), and hospital length of stay was of 71 days (IQR = 43-86 days). Four required tracheostomy (median: 18 days, IQR = 13-24 days). All participants exhibited profound dysphagia (FOIS = 1-3, New Zealand Secretion Scale = 3-7, Penetration-Aspiration Scale = 3-8, Yale Pharyngeal Residue Scale = 2-5) and respiratory impairment at baseline (MEP = 21-114 cmH2O, PEF = 80-310 L/min). All completed the treatment protocol and achieved premorbid diet and fluids (FOIS = 7) and functional respiratory status (MEP = 62-178 cmH2O, PEF = 260-520 L/min) by hospital discharge. No adverse events were recorded.

CONCLUSIONS

Pilot study findings suggest that a strength-based dysphagia treatment protocol for patients with ICUAW and dysphagia is safe and feasible with promising outcomes indicating that it may support dysphagia recovery in this challenging population.