65) have an abnormal swallow

           •   after orotracheal intubation for more than 48 hours

Diagnosis

           •   Barium swallow with video fluoroscopy

           •   Esophageal manometry

           •   Endoscopy

Treatment

           •   Diet alteration, speech therapy

           •   Temporary gastrostomy

Tracheal Stenosis

Epidemiology

           •   Documented evidence of positive tomogram in 19% of patients with endotracheal intubation and 65% patients with tracheostomy

           •   Advanced, asymptomatic stenosis (25% decrease in diameter) seen in first few months of 25–40% patients after decannulation

           •   Increased cuff pressure with mucosal injury occurs within 15 minutes when lateral wall pressures rise beyond 27 cm H₂O

Diagnosis

           •   Stridor, wheeze, decreased lung sounds, inadequate or increased work for breathing

           •   Symptoms occur when lumen is decreased by >30% of its original diameter. Dyspnea can develop when the lumen becomes 10 mm in diameter and stridor when the diameter is 5mm or less.

           •   Imaging: laryngeal tomogram, chest CT

           •   Bronchoscopy for direct visualization

Treatment

           •   Prevention by monitoring cuff pressures to keep below 30 cm H₂O

           •   Mild stenosis can be treated conservatively with oxygen, respiratory therapy, and antibiotics in case of infection

           •   Endoscopic options

                       Tracheal dilation

                       Transluminal stent placement

                       Laser ablation

           •   Open tracheal reconstruction using stents (autologous, homologous, or inert)

Delirium

Epidemiology

           •   Prevalence in post extubated patients is unknown

           •   Types of delirium: 2% hyperactive, 44% hypoactive, 54% for mixed

           •   Number of days of delirium positively correlates with longer duration of mechanical ventilation, prolonged neurophysiological dysfunction, and increased post hospital mortality

Pathophysiology/Risk Factors

           •   Theorized underlying mechanisms:

                       Imbalance of neurotransmitters

                       Inflammatory mediators

                       Impaired oxidative metabolism

                       Cholinergic deficiency (impaired Ach production secondary to hypoxia)

                       Dysfunction of central sodium-dependent neuronal amino acid transporters

           •   Risk factors: advanced age, comorbid conditions, baseline cognitive impairment, genetic predisposition, hypoxia, sepsis, metabolic disturbances, anticholinergic medications, sedatives, sleep disturbances

Diagnosis

           •   CAM-ICU (Confusion Assessment Method for the ICU): monitor mental status

           •   ICU Memory Tool: eight question survey to evaluate recall of factual and delusional memories

Treatment

           •   Improve patient orientation with cognitive therapy

           •   Normalizing sleep/wake cycles

           •   Early mobilization

           •   Correct underlying problem (e.g., hypoxia, hypercarbia, etc.)

           •   Benzodiazepines are not recommended

           •   Anecdotal evidence supports use of haloperidol as cited by Society of Critical Care

Posttraumatic Stress Disorder

Definition

           •   Constellation of symptoms in three domains

                       Reexperiencing

                       Avoidance/emotional numbing

                       Increased arousal

Epidemiology

           •   Prevalence varies widely 5–64% and often misdiagnosed

           •   Delayed onset of PSTD symptoms in 16% of discharged ICU patients

           •   Prevalence higher in certain subpopulations (e.g., ARDS) ranging from 25 to 40%

Pathophysiology/Risk Factors

           •   Risk factors: delusional ICU memories, a greater number of traumatic memories, extended ICU stay, longer duration of mechanical ventilation, younger age, prior mental health history, female gender, higher levels of sedation and neuromuscular blockade

           •   Development of symptoms is multifactorial: profound feelings of helplessness during time of illness, pre-existing psychiatric condition, cognitive impairment with decreased working memory, and multiple traumatic events (pain, panic, respiratory distress, nightmares)

Diagnosis

           •   PTSS-14 (Post Traumatic Stress Syndrome 14 questionnaire)

           •   IES-R (Impact of Events Scale-Revised): evaluates stress reaction from prolonged ICU hospitalization

Treatment

           •   Absence of episodic memory for a traumatic event is protective against the development of PTSD

           •   Cognitive behavioral therapy considered first line treatment and has long-term efficacy

Depression

Epidemiology

           •   Incidence is unknown in post-extubated patients

Diagnosis

           •   Criteria to meet: one of two core symptoms of depressed mood or reduced interest plus five of the following:

                       Insomnia or hypersomnia, reduced interest/pleasure, excessive guilt/feelings of worthlessness, reduced energy, decreased concentration, loss of either appetite or weight, psychomotor agitation, and suicidal behavior

           •   Survey instruments:

                       GDS-SF (Geriatric Depression Scale-Short Form)

                       BDI (Beck Depression Inventory)

                       CES-D (Center for Epidemiologic Studies Depression Scale)

                       HADS (Hospital Anxiety-Depression Scale)

Treatment

           •   Pharmacologic: TCA, SSRI, SNRI, or NRI

           •   Psychiatry referral

Anxiety

Epidemiology

           •   23–48% of ALI/ARDS survivors have clinically significant nonspecific anxiety symptoms

Risk Factors

           •   Advanced age

           •   Female gender

           •   Length of ICU stay

Diagnosis

           •   HADS (Hospital Anxiety-Depression Scale)

           •   BAI (Beck Anxiety Inventory)

Treatment

           •   Correct underlying problem (e.g., hypoxemia, hypotension, hypoglycemia)

           •   Analgesics, SSRI, SNRI, benzodiazepines

Profound Muscle Weakness

Definition

           •   Neuromuscular degeneration during ICU care resulting in weakness and/or paralysis

           •   May delay weaning and rehabilitation

           •   Critical illness polyneuropathy often considered a manifestation of multiple organ failure

Epidemiology

           •   Two-thirds of ARDS patients experience muscular weakness

           •   25–30% incidence in patients requiring mechanical ventilation for more than 4 days

           •   50–60% patients recover completely within 6 months

Pathophysiology

           •   Release of cytokine and low-molecular-weight neurotoxins during sepsis leads to axonal degeneration and probable insult to myelin

           •   Alternatively, isolated myopathy may develop in patients being treated with corticosteroids or neuromuscular blocking agents (possibly due to up-regulation of receptors after medical denervation with paralytic agents)

           •   Electrolyte disturbances: hypophosphatemia, hypomagnesemia, hypercalcemia

Diagnosis

           •   Muscle wasting

           •   Loss of deep tendon reflexes, temperature, pressure and vibration sensation

           •   Electromyography: detection of denervation changes (most marked in distal muscles) such as fibrillation potentials, positive sharp waves, and reduced motor unit recruitment

           •   Biopsy is the gold standard

Treatment

           •   There are no proven therapies but studies have suggested the following:

                       Remove offending agent

                       Treat underlying problem

                       Adequate nutrition

                       Supportive care with clinical follow up and physical therapy

Malnutrition

Epidemiology

           •   Most patients have inadequate oral intake for the first 7 days after extubation

Treatment

           •   Periodic calorie intake review

           •   Dietary consultation

Study Question

Most patients who require mechanical ventilation with endotracheal intubation have dysphagia and reduced caloric intake following extubation. Outline the strategies which help manage these problems.

Stay updated, free articles. Join our Telegram channel

Join