Comparison between the functional aspects of swallowing and clinical markers in ICU patients with Traumatic Brain Injury (TBI)

Ferrucci, Juliana Lopes; Sassi, Fernanda Chiarion; Medeiros, Gisele Chagas de; Andrade, Claudia Regina Furquim de

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Original Article • CoDAS 31 (2) • 2019 • https://doi.org/10.1590/2317-1782/20182017278 copy

Comparison between the functional aspects of swallowing and clinical markers in ICU patients with Traumatic Brain Injury (TBI)

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Purpose

To characterize and compare the functional aspects of swallowing and clinical markers in intensive care patients with traumatic brain injury (TBI) in Intensive Care Unit (ICU).

Methods

Participants of this study were 113 adults diagnosed with TBI. Data collection stage involved: clinical assessment of the risk for bronchoaspiration performed by a speech-language therapist; assessment of the functional level of swallowing (American Speech-Language-Hearing Association National Outcome Measurement System – ASHA NOMS ); assessment of the patient’ health status (Sequential Organ Failure Assessment - SOFA).

Results

After the inclusion criteria were applied, patients were grouped according to their swallowing functional level: levels 1 and 2 – ASHA1 (n=25); levels 3, 4 and 5 – ASHA2 (n=37); levels 6 and 7 – ASHA3 (n=51). The statistical analyses indicated the following significant results: the ASHA3 group presented lower severity levels of TBI at the clinical assessment of bronchoaspiration, remained less time intubated (approximately um third less than the more severe group), remained fewer days in hospital and needed less therapy sessions to return to safe oral feeding. The clinical predictor signs for bronchoaspiration that best characterized the groups were the presence of altered auscultation and the presence of coughing after swallowing. Patients in the ASHA3 group presented these signs less frequently.

Conclusion

The score obtained on the SOFA and the time of orotracheal intubation were identified as the prognostic indicators of functional swallowing. The presence of altered cervical auscultation and coughing were clinical predictors of dysphagia.

Keywords
Swallowing; Swallowing Disorders; Traumatic Brain Injury; Pneumonia/Aspiration; Intensive Care Units; Speech-Language and Hearing Science

	Variables	Clinical Judgment
Water swallowing test (5mL).	Extra-oral escape	Passes - Water does not escape through the lips, manages the bolus properly
	Extra-oral escape	Fails - Difficulty in bolus management, presence of draining through the lips.
	Multiple swallowing	Passes - Presence of a single swallowing per bolus
	Multiple swallowing	Fails - More than one swallowing per bolus
	Cervical auscultation (the stethoscope should be positioned on the side of the junction between the larynx and the trachea, anterior to the carotid artery)	Passes - Presence of three characteristic sounds of swallowing, indicating that the cake passed through the pharynx - two clicks followed by an expiratory sound.
		Fails - When there is no presence of sounds or presence of other sounds not described above.
	Wet voice	Passes - No changes in the first minute after swallowing
	Wet voice	Fails - The voice sounds bubbling (“wet”) in the first minute after swallowing
	Coughing	Passes - There is no coughing in the first minute after swallowing
	Coughing	Fails - Presence of coughing (voluntary or not) followed or not by clearing during the first minute after swallowing
	Choking	Passes - There is no presence of choking after swallowing
	Choking	Fails - Presence of choking during or after swallowing

SOFA score	0	1	2	3	4
Breathing	>400	≤400	≤300	≤200	≤100
PaO₂/FIO₂ (mmHg)	>400	≤400	≤300	With respiratory support	With respiratory support
Coagulation	>150	≤150	≤100	≤50	≤20
Platelet × 10³/mm³	>150	≤150	≤100	≤50	≤20
Liver
Bilirubin (mg/dl)	<1.2	1,2-1,9	2,0-5,9	6,0-11,9	>12
(µmol/l)	<20	20-32	33-101	102-204	>204
Cardiovascular	No Hypotention	APA<70mmHg	dopamine≤5	dopamine>5	dopamine>15
			or	epinefrine≤1	epinefrine>0,1
Hypotension			dobutamine (qualquer dose)	or noraepinefrine≤0.1 ^a a adrenergic agents given for at least one hour (doses given in microgram per kilo per minute)	or noraepinefrine>0.1^a
SNC	15	13-14	10-12	6-9	<6
Glascow Coma Scale	15	13-14	10-12	6-9	<6
Renal	<1.2	1.2-1.9	2.0-3.4	3.5-4.9	>5
Creatinine (mg/dl)	<110	110-170	171-299	300-440	>440
(µmol/l)	<110	110-170	171-299	300-440	>440
or urine output	-	-	-	<500ml/day	<200ml/day

	ASHA1		ASHA2		ASHA3		p-value
	(n = 25)		(n = 37)		(n = 51)		p-value
Age (years)	43.6		36.8		35.2		0.240
Average (± standard deviation)	(±19.2)		(±13.2)		(±11.2)		0.240
Genre	M = 21	F = 4	M = 35	F = 2	M = 42	F = 9	0.223
Total number (percentage)	(84.0%)	(16.0%)	(94.6%)	(5.4%)	(82.4%)	(17.6%)	0.223
Severity of TBI according to the Glasgow scale	13.5		14.2		14.2		0.003 ^* * significant difference according to the Kruskal-Wallis test
Average (± standard deviation)	(±1.1)		(±0.7)		(±1.0)
IOTs Numbers	1.1		1.2		1.1		0.293
Average(± standard deviation))	(±0.3)		(±0.4)		(±0.2)		0.293
IOT time in hours	139.2		161.5		97.4		0.014*
Average (± standard deviation)	(±90.1)		(±107.0)		(±62.7)		0.014*
Hospitalization time in hours	28.4		26.6		16.6		0.005*
Average (± standard deviation)	(±24.2)		(±22.8)		(±11.9)		0.005*
Number of speech-language therapy sessions until VO return	2.7		1.4		1.0		0.003*
Average (± standard deviation)	(±2.6)		(±1.0)		(±0.0)		0.003*
Number of speech-language therapy until the hospital discharge	0.6		1.4		2.2		<0.001*
Average (± standard deviation)	(±2.2)		(±2.2)		(±2.5)		<0.001*

Evaluated Items	ASHA1 (n = 25)	ASHA2 (n=37)	ASHA3 (n=51)	p-value
Extra-oral escape	5 (20.0%)	1 (2.7%)	1 (2.0%)	0.005 ^* * significant difference according to Pearson's Chi-square test
Multiple swallowing	6 (24.0%)	6 (16.2%)	1 (2.0%)	0.010*
Noisy Cervical Auscultation	9 (36.0%)	1 (2.7%)	0 (0.0%)	<0.001*
Wet Voice	1 (4.0%)	1 (2.7%)	0 (0.0%)	0.403
Coughing	13 (52.0%)	4 (10.8%)	4 (7.8%)	<0.001*
Choking	3 (12.0%)	0 (0.0%)	2 (3.9%)	0.077

Swallowing functional level	ASHA1 (n = 25)		ASHA2 (n = 37)		ASHA3 (n = 51)
Swallowing functional level	Initial	Final	Initial	Final	Initial	Final
1 is not able to swallow anything by mouth	2	2	0	0	0	0
2 Can have some consistency with maximum use of clues	23	9	0	0	0	0
3. Ingest less than 50% of nutrition through the mouth with moderate use of clues	0	3	5	2	0	0
4. Swallowing is safe with moderate use of clues	0	7	12	7	0	0
5. Swallowing is safe with minimal use of clues	0	3	20	10	0	0
6. Swallowing is safe and rarely requires use of clues	0	0	0	9	22	15
7. Swallowing is efficient, the individual is independent	0	1	0	9	29	36

Score on the SOFA scale	ASHA1 (n = 25)	ASHA2 (n = 37)	ASHA3 (n = 51)	p-value
Average (± standard deviation)	ASHA1 (n = 25)	ASHA2 (n = 37)	ASHA3 (n = 51)	p-value
Breathing	1.8 (±1.1)	1.6 (±1.2)	1.5 (±1.2)	0.714
Hematological	0.5 (±1.0)	0.5 (±0.8)	0.4 (±0.6)	0.889
Hepatic	0.1 (±0.4)	0.0 (±0.0)	0.02 (±0.1)	0.496
Renal	0.1 (±0.3)	0.3 (±0.8)	0.3 (±0.6)	0.451
Cardiovascular	2.4 (±1.7)	2.1 (±1.5)	2.2 (±1.4)	0.589
Neurological	3.4 (±1.0)	2.7 (±1.3)	2.7 (±1.2)	0.018 ^* * significant difference according to the Kruskal-Wallis test
Total	8.2 (±2.4)	7.3 (±2.5)	7.2 (±3.0)	0.348

Score on the SOFA scale	ASHA1 (n = 25)	ASHA2 (n = 37)	ASHA3 (n = 51)	p-value
Average (± standard deviation)	ASHA1 (n = 25)	ASHA2 (n = 37)	ASHA3 (n = 51)	p-value
Breathing	0.85 (±0.87)	0.78 (±0.97)	0.78 (±0.97)	0.384
Hematological	0.39 (±0.81)	0.11 (±0.33)	0.11 (±0.33)	0.229
Hepatic	0.02 (±0.14)	0.22 (±0.67)	0.22 (±0.67)	0.147
Renal	0.09 (±0.49)	0.0 (±0.0)	0.0 (±0.0)	0.185
Cardiovascular	0.23 (±0.70)	0.0 (±0.0)	0.0 (±0.0)	0.468
Neurological	0.62 (±0.54)	1.56 (±0.73)	1.56 (±0.73)	0.024 ^* * significant difference according to the Mann-Whitney test
Total	2.14 (±1.59)	2.67 (±0.71)	2.67 (±0.71)	0.462

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[1] Conflict of interest: nothing to declare