Extracorporeal Membranous Oxygenation (ECMO) is being utilized earlier and more frequently for adults who suffer acute respiratory and/or cardiac failure.
More recently, ECMO is being used as a bridge to lung transplant for those who suffer chronic pulmonary dysfunction. The importance of early mobility in patients who suffer any critical illness has led to increased rehabilitation services being provided in the early stages of critical illness.
With that in mind, one team at the University of Maryland Medical Center has been exploring if some of these patients could work toward goals of oral communication or even eating by mouth while on ECMO. If medical stability can be established while the patient is on ECMO, the ICU team is beginning to allow these patients to awaken and participate in their care.
"We are seeing ECMO patients who are alert, and with good mental status," said Yifaat Gamliel Asher, MS, CCC-SLP, senior speech-language pathologist, University of Maryland Medical Center. "If the patient is stable, and able to participate, why not explore oral communication and feeding? If they can have more 'normal' experiences such as eating and having a real conversation with their caregivers, they might even be more motivated to participate in their rehabilitation."
Oral Communication Goals
Asher completed a case study report that focused on two patients who suffered acute respiratory failure requiring prolonged ECMO support. One patient exceeded most expected timeframes by far, spending more than 150 days on ECMO, prior to undergoing a double lung transplant. Asher's goal was to provide her with a means of communicating orally instead of using an alphabet board, if possible. \
"These patients can be deconditioned and very weak in the upper extremities, so pointing to letters on an alphabet board can be tedious," she said. "It's an acceptable form of basic communication, but, if someone is able to actually talk, let them try."
Oral communication requires sufficient airflow over the vocal folds. Asher suggested that SLPs work with Respiratory Therapy to maximize patients' ventilation to generate adequate exhalation to achieve voice using a speaking valve.
"Some patients need to be downsized to a trach with a smaller diameter. If we can do that safely, we create a sufficient gap or leak between the trach tube and tracheal walls, allowing air to flow freely to the vocal folds. But we always need to find a good balance between successful ventilation and speech. When in doubt, breathing always wins," explained Asher.
Patients may present with several areas of respiratory dysfunction that contributes to insufficient breath to promote communication. These may include poor lung compliance, a stiff rib cage and thoracic spine, and muscle weakness in a patient on ECMO. "Getting good tidal volume naturally is sometimes impossible," she stated.
Physical therapists can also be helpful in improving tidal volumes and facilitating more effective exhalation through a variety of manual musculoskeletal strategies, including positioning adjustments. Collaboration with RT is helpful in selecting the most appropriate size and type of tracheostomy tube to facilitate speech and safe swallowing.
If the patient has a standard trach, switching to one with a talk attachment ("talking trach") can provide continuous airflow over the vocal folds in order to compensate for insufficient tidal volumes or the inability to exhale with enough force to generate voice. "The respiratory therapist is instrumental in the decision making process with regard to trach tube selection, determining optimal flow rates and whether to use oxygen or medical air to facilitate oral communication," Asher said.
"The patient needs to be instructed on how to occlude the port on a talking trach to route the airflow to the vocal folds, and how to coordinate that flow with vocal fold adduction to create voice. Success with oral communication is dependent on the entire patient care team. The respiratory therapist, as one of the clinicians who is frequently at the bedside, plays a major role in facilitating the carryover of these techniques throughout the day when possible," she added. The day that her patient was able to call her family on the phone and tell them that she loved them was one that Asher remembers as being very emotional and gratifying.
Though receiving non-oral nutrition is typical in the earlier phase of an ECMO patient's recovery, the decision to try oral feeding is one that should be carefully considered. The SLP needs to discuss risk factors with the critical care team prior to introducing oral intake to a patient on ECMO. On one hand, some patients' lung function may be deemed non-recoverable and they are waiting for transplantation. In this case the benefit from feeding may outweigh the risk of aspiration. "They don't really need their lungs to inhale; the oxygenation is happening outside the body," Asher explained. Other patients may have the goal of recovering native lung function, and need to be treated with extra vigilance and caution in order to successfully wean from ECMO.
The SLP may consider offering ice chips as an introductory step in determining readiness for further examination of swallowing competence. If the patient demonstrates a perceived tolerance of this step, an instrumental evaluation typically comes next. Information gained from this evaluation, such as a modified barium swallow, is valuable before starting an oral diet of any kind for patients being supported on ECMO. The modified barium swallow "is really the only way to see if a patient is aspirating while swallowing," clarified Asher.
Often times, accomplishing this will require the support of several different care providers if travelling out of the patient's room. Once an ice chip trial at the bedside revealed that the patient with the 150+ day ECMO course did indeed have sufficient swallowing function, a Modified Barium Swallow study was scheduled to see if she could safely progress to a more varied diet. It was no small endeavor, as Asher recalled. "It took a team of clinicians to get this patient to the radiology suite, including the perfusionist, RT, nurse, NP, SLP, and SLP aide."
"There are three diagnostic issues I like to consider in making recommendations about oral feeding," Asher stated. "The first question I ask is, 'Can the patient take nutrition by mouth? If not, can he take just medication by mouth? If not that either, is there anything we can at least give for pleasure?'" This patient was initially cleared for thick liquids because the thinner ones were being aspirated into her airway. "We also started her on pureed foods and advanced to soft solids. After her double lung transplant, when she was no longer on ECMO, she graduated to regular thin liquids and a normal diet," Asher recalled.
Asher stresses the importance of getting the buy-in of the entire multi-disciplinary team first and stressed that nutrition and communication by mouth are feasible when patients are supported on ECMO. "If patients who wind up on ECMO are stable, alert and interactive, I don't see why speech and swallowing can't be explored," she commented. "It's a great way to try to give our patients some level of independence and dignity while in the hospital".
Robin Hocevar is on staff at ADVANCE. Contact firstname.lastname@example.org.