M1: From Kerkow media coming up on the show.
M2: So bottom line here is that this is a critical
M2: care treatment, it does its job, it saves lives. So
M2: now the question in the end is, are you willing
M2: to risk your life a little bit for your vocal cords?
M2: Probably not.
M19: Today, we continue our Johns Hopkins series here at Medicine,
M19: we're still practicing as one of the highest regarded health
M19: care institutions in the country. Johns Hopkins seems to have
M19: no end to the roster of specialists who bring us
M19: the edge of the art and research, medicine and patient care,
M19: whether due to the covid pandemic or due to critical
M19: heart and lung diseases. You may have known people who've
M19: had to be intubated, receive a breathing tube and spend
M19: time on a ventilator in an ICU. So firstly, if
M19: they've made it home, we have doctors to thank for that.
M19: One of the many doctors responsible for Johns Hopkins reputation
M19: is Dr. Martin Brodsky, and he's here with us today
M19: on medicine. We're still practicing.
M4: And Bill Kurtis, first, one of the psychological saving graces
M4: we've all had during pandemic filled months of quarantine was
M4: the ability to connect with family and friends by assume
M4: almost every weekend. I've looked forward to connecting with my
M4: best friend, Dr. Stephen Tayback.
M6: He's also our host here at medicine who are still practicing.
M6: And Steve, as the quadruple board certified doctor of internal medicine,
M6: pulmonary disease, critical care in neuro critical care. And he's
M6: still on the front lines of the war uncovered at
M6: his ICU out in California. How are you doing, Steve? Hey, Bill,
M6: how are you? So as you heard, our special guest
M6: joining from Johns Hopkins Medicine is Dr. Martin Brodsky. He
M6: is an associate professor of physical medicine and rehabilitation. He's
M6: also a fellow of the American Speech and Language Hearing Association.
M6: And his research and expertise has focused on swallowing disorders
M6: and the airway. More specifically, these days, he works on
M6: optimizing long term outcomes and the effects of critical illness
M6: and critical care medicine. Dr. Brodsky, thanks so much for
M6: joining us today. Thank you for having me. Pleasure to
M6: join you.
M4: So being the layman, before Dr. Steve asks some intelligent questions,
M4: I need to ask this one. What exactly is dysphagia?
M15: Simply put, it's a swallowing disorder. The more elaborate explanation
M15: is everything from the lips to the stomach that causes
M15: things to either be not controlled, have food, go down
M15: the wrong way. We've all heard of the individual who
M15: food went down the wrong way or they choked on
M15: a piece of steak or water went up their nose
M15: and it came out their nose. All of these could
M15: be signs of the larger problem in that it was
M15: an uncoordinated act of swallowing.
M1: Marty, what got you involved in this? What is it
M1: that the did you do to devote your life to
M1: this issue?
M7: As ridiculous as this sounds? I was actually on the
M7: other side of the BEDRAIL. I found myself after an
M7: accident that I had in my mid 20s, intubated for
M7: 10 days, waking up, finding myself with the nasogastric tube.
M7: Some days later, when I came to some sense, I
M7: won't say the delirium was completely gone. I'll say it
M7: was quite a frustrating experience. But at some point when
M7: I was certainly more lucid, it got to the point
M7: where the physicians back then, and this is the mid 90s,
M7: didn't want to feed me that the feeding was taking
M7: place literally one hundred percent through the N.G. Tube. And
M7: to give you some idea where I was in my career,
M7: I was literally a month from beginning my clinical fellowship
M7: following my master's degree in speech pathology to contrast and
M7: compare for us what you do today that was so
M7: metrically opposed to the treatment or lack of treatment received
M7: in the 90s.
M5: So I would say the biggest contrast, certainly in the
M5: environment I'm in right now is the fact that a
M5: speech pathologist is actually there.
M20: We haven't found a lot of you in hospitals as
M20: we've looked at the various rosters. It's well, you haven't
M20: been looking hard enough. We're there.
M7: We're not often invited into the ICU use. This has
M7: been one of the biggest thrusts that I've had in
M7: my career, certainly over the last decade or more in
M7: trying to get speech language pathologists into the ICU to
M7: be more recognized in the ICU. We've always been there.
M7: But the numbers, as you said, both of you were
M7: not there at the time. It's only been within the
M7: last certainly the last 10 years. I'd argue more so
M7: even in the last five years that greater attention has
M7: been placed of speech, language pathologists being in the ICU
M7: and treating patients on mechanical ventilators with or without a tracheostomy.
M7: So the reality is, yes, we would like to be involved.
M4: And what would you do doing that involvement when the
M4: tube is still inserted? But there's a certain amount of
M4: a weakness there, depending on what the need is.
M5: So communication is always going to be a need at
M5: that point. When you've got a tube between some of
M5: these vocal cords, the ability to voice is gone. So
M5: the best you'll have is lipreading. And I don't know
M5: about you. I've been in my career for more than
M5: two and a half decades and I'm not so adept
M5: at reading lips. Steve, you've been doing this for more
M5: than 30 years.
M1: Are you good at this terrible I mean, patients lie
M1: there in bed and you're trying to ask a simple
M1: question and the way they can tell it is understood.
M1: And then they try to write whatever reason, something about
M1: lying in bed, a little bit out of it, and
M1: you can make out a letter or two and then
M1: it becomes almost just scribble. So communication is a real
M1: impediment in this day and age. The critical care side,
M1: our goal is everybody as awake as possible. If they
M1: can tolerate it in the years with Siddharta, you've got
M1: to sedate them until you extubate.
M8: Not anymore. And when we're talking about cognitive impairment, which
M8: we'll get to hopefully later in the show, but our
M8: goal is to keep everybody awake. But how do you communicate?
M7: So tell us more and you hit the nail right
M7: on the head. And that, in fact, goes back to
M7: the mid 90s where it's sedate them, make them feel
M7: better by sedating them. You're keeping them from having pain,
M7: you're keeping them from moving, et cetera, et cetera. And
M7: then suddenly we wake them up and the tube comes
M7: out in life is magic again.
M15: Now, that is clearly not the case. So the reality
M15: here is, yes, once the patient is able to be interactive,
M15: we are able to work with the patient. And whether
M15: it's writing and writing has its own difficulties because of
M15: ICU acquired weakness, perhaps the patient's even restrained with soft
M15: restraints to keep from pulling it the lines, the tubes,
M15: the drains and so forth. So you have the added obstacle,
M15: if you will, of even if the patient is strong
M15: enough to be able to put a marker in their
M15: hand with a white board, it's lifting their arm off
M15: the bed to be able to write on the white board,
M15: which is another issue.
M1: It's not going to help, it's ultimately better or swallow better.
M1: They've been liberated from the ventilator.
M5: So in the first place, working with people to get
M5: them communicating gets them more involved in their own patient care.
M5: That's a big issue for patients. We've known that for
M5: some time and getting a speech language pathologist to maximize
M5: that communication. And whether it's a letter board, maybe it's
M5: a basic communication board that says I need to go
M5: to the bathroom, my back itches, my arm is in pain.
M5: Whatever it might be is a lot more than even
M5: trying to read their lips. There's IGIS that you can
M5: use for the simple yes and no questions. There are
M5: the technology that's available to track their eyes and to
M5: be able to communicate in much the way that you
M5: saw in the past. Stephen Hawking, do it now.
M14: He had a more advanced communication board, but you can
M14: see that there really is a continuum there, that we're
M14: able to meet the patient's needs and meet the communication
M14: needs where you have the communication, even with the nurse
M14: or the physicians or the therapists that walk in the room.
M14: And the patient has a question or needs to tell
M14: you how they're feeling.
M4: There's something I don't understand. If there's risk and rehabilitation
M4: attached to the idea of putting a tube past my
M4: vocal cords. And if I want to preserve my beautiful
M4: soprano singing voice, is it potentially better to go with
M4: a trach rather than go to put a tube down
M4: my throat and deal with all of the risks and
M4: rehabilitation attached to that?
M5: In all honesty? Yes, what you raise is a really
M5: good point. And this is now a very long debate
M5: and a very well and hotly debated issue. Essentially, the
M5: endotracheal tubes, that breathing tube that goes through your mouth,
M5: sometimes through your nose, down into your throat, past your
M5: vocal cords, into your lower airway and gives you the pressure,
M5: the air flow in the oxygen that you need to
M5: keep the respiratory system in the cardiovascular system alive, if
M5: you will. That's the path of least resistance, right? No cutting,
M5: no blood. There's no problem. We just need to shove
M5: a straw down your throat. And here you go. There's
M5: how you breathe it. Something similar to a snorkel, except
M5: it's inside you. Well, that's all good, because supposedly, if
M5: we're not cutting your neck and putting a tube in
M5: your neck that way, then we're keeping you from getting
M5: any kind of infection or keeping you from having any
M5: kind of scarring. We're keeping you from having all sorts
M5: of issues that can arise inside the airway that way.
M1: Tingley stated another way, if you're talking about a surgical
M1: procedure in order to cut a hole in your throat, yes,
M1: you bypass the vocal cords, vocal cords will not be damaged,
M1: but you are subjecting a patient to a surgical procedure
M1: that could have major haemorrhagic complications. Now, it's very rare.
M1: I mean, ends up an experienced the ear, nose and
M1: throat surgeon ends of Orian's practitioner Becka's low still surgical
M1: procedure where you could be hitting an artery lead to
M1: severe agit complications. Say I put this tube down your
M1: throat for five days, star, you're not going to have
M1: vocal cord damage. You choose.
M5: So those are the negative effects of a trache, right?
M5: The negative effects of the endotracheal tube we've kind of
M5: alluded to is because you're passing the vocal chords and
M5: let's say Steve and his colleagues do everything perfectly that
M5: the tube goes in. They don't touch a thing on
M5: the way down. Life is good. It's a traumatic experience.
M5: That's only where the problems begin. It's not so much
M5: necessarily the procedure of placing the tube. It's the frequent
M5: irritation of the tube in the back of the airway
M5: with the tube rubbing up and down similar to the
M5: piston of a car. Every time you press on the
M5: gas or breathe, every single second that you breathe, every
M5: single second that you're rolling around in bed, you're moving
M5: or otherwise. And just think about this for a second
M5: for normal breathing. You've got this going 12 to 20
M5: times a minute now. You got people who are in
M5: more distress. And we've seen respiratory rates with covid specifically
M5: in the 50s and even in the 60s per minute.
M5: That's literally one breath a second rather than one every
M5: six seconds. The upshot here is in the end, with
M5: any medical procedure, there are risks. Even when you take
M5: that aspirin that late at night, there's maybe even a
M5: bleeding risk. Right. So bottom line here is that this
M5: is a critical care treatment. It does its job. It
M5: saves lives. So now the question in the end is,
M5: are you willing to risk your life a little bit
M5: for your vocal cords? Probably not.
M4: And vocal chords heal and swallowing heals. And this is
M4: all a matter of rehabilitation, or is there more risk
M4: than that?
M5: There is risk. And right now we're working on a study.
M5: I've got an oral one in conjunction with Dale Needham
M5: and Vincey Vincent Pandian, who is a critical care nurse.
M5: We're taking a look at what these effects of critical
M5: care treatments are on the airway. There are some patients miraculously,
M5: even eight days of intubation. They look similar to you
M5: and me who's never seen a tube. There are other
M5: patients that you take the tube out in five days
M5: and they look like a train wreck with covid patients
M5: that we've seen there. The mixed bag between the train
M5: wreck and the train wreck that has more edema that's
M5: in the airway that we can barely even see the
M5: train wreck that's under the edema.
M1: Be very selfish here and ask that there's probably won't
M1: be to their lives, but what can I do as
M1: an intensivists demise the damage to optimize the outcome?
M7: So there are a couple studies that have done most recently,
M7: speech language pathologists, otolaryngologist, have had for a long time
M7: the notion that reducing the size of the tube is
M7: one of the biggest factors in reducing the amount of
M7: injury that can happen post extubation. There are a couple
M7: of studies that have been released, most recently, one from
M7: the group in Vanderbilt that was released at the end
M7: of twenty nineteen, I believe, and then another from the
M7: group in Denver. Both of them are suggesting that tubes
M7: equal to or less than the seven point five and
M7: even down to a seven point zero and lower will
M7: statistically significantly reduce the amount of injury in the airway. Now,
M7: I'm going to take a guess at what you might
M7: ask immediately, because I've had this argument countless times and
M7: I'm still embattled with the argument. The folks working in
M7: the ICU like yourself, the pulmonologist, the respiratory therapists who
M7: are frequently managing people on the vent with regard to
M7: flows and pressures and oxygenation and whatever form there are
M7: more or less prescriptive ideas relative to the size of
M7: the tube and the known rates that patients should be
M7: kept at, for example, for Airds and so forth. In
M7: addition to the fact of the ever looming prospective bronchoscopy,
M7: where we need to be able to place the end
M7: of scope into the breathing tube as a conduit to
M7: take a look at the lower airways and still maintain
M7: oxygenation and pressure and so forth around the endoscope.
M15: The reality is that I think there needs to be
M15: a push to get those scopes a lot smaller, if
M15: that's one of the issues. The only thing that they're
M15: lacking is a light source because the camera's perfectly fine.
M15: I work with a two point six millimeter scope to
M15: take a look at the vocal cords. To give you
M15: some idea, the bronchoscope are well above four. But the
M15: predominance of that is the lighting. It's the light source.
M15: So if the light source were greater, we would be
M15: able to be just fine and shrinking the size of
M15: that scope.
M1: Right perspective, I have two issues, the little archaic, because
M1: we can overcome it a bit, but of the two,
M1: the greater the resistance and so the heart of the
M1: patient has to work for, the harder it is for
M1: the patient to then be liberated when you're reducing the
M1: artificial support that you're giving the patient and the patient
M1: is breathing pretty much on their own resistance in the tube,
M1: and it makes weaning a little bit more difficult. Now,
M1: I say that the advent of pressure support is not
M1: a big an issue here. Issue, though, is patient who
M1: might be bleeding or a patient who has copious secretions
M1: where you need to do a bronchoscopy to evacuate the secretions.
M1: A small scope could afford you the ability to look
M1: in the airways. But a lot of what we do
M1: at the bedside is clearing the airways. And you're going
M1: to need a larger borescope. In order to have a
M1: large borescope, you need to have a larger, more endotracheal
M1: tube becomes the debate.
M9: So we're going to take a very quick breath and
M9: one swallow. And we'll be right back with Johns Hopkins, Dr.
M9: Martin Brodsky.
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M13: OK, we're back with Dr. Steven Tayback and Martin Brodsky. Marty,
M13: I'm interested in what happens now. I'm in bed. I've
M13: yanked my tube out, or better yet, you guys took
M13: it out. Please don't get that feeling.
M4: I'm feeling better, but I'm having some swallowing trouble. So
M4: what exactly do you do about it?
M5: So in RISC use and it doesn't matter which ICU
M5: you're in, in our hospital, you will get under normal
M5: circumstances a swallowing screening that will be performed by the
M5: nurses who are treating you. The swallowing screening is something
M5: that we refer to in the literature and what's been
M5: referred to in the professionals as the Yale Swallow Protocol.
M5: And basically what that is, it's a very brief test
M5: of your ability to answer yes and no questions. It's
M5: a very brief test for you to be able to
M5: follow very simple directions. And it's followed by the presentation
M5: of three ounces of water that are handed to you
M5: very often with a straw and a cup, and you're
M5: asked to swallow the water continuously. The simple responses that
M5: if you cough or clear your throat or gurgle a
M5: little bit or you can't finish the water, those are
M5: probably indications that you're having difficulties. And at that point,
M5: then we go for the full speech language pathology evaluation,
M5: where you have a speech language pathologist come by, they'll
M5: do a cranial nerve exam, which basically takes a look
M5: at the sensation and the motor skills, your muscles, how
M5: they're working all around your face and your neck and
M5: your ability to turn your head, all the things that
M5: make your tongue move along those lines. They'll do a
M5: brief cognitive evaluation with you and they'll make some determination
M5: as to whether they'll be able to feed you at
M5: the bedside, trialling some liquids and foods that they bring
M5: to your bedside. If things go well, great. Or started
M5: on an oral diet, in most cases pending medical approval
M5: and the patient is off and running, likely no therapy
M5: at that point. However, if you're still having difficulties, we
M5: continue with an instrumental evaluation and the instrumental evaluation can
M5: take the form of either a video first Coppock Swallow's study,
M5: which is a x ray in real time. It's a
M5: movie where we get to see the food being chewed up,
M5: prepared in your mouth all the way, going down through
M5: your throat and into your stomach. Or we take a
M5: look at it endoscopically through a study called Flexible and
M5: the evaluation of Swallowing, where we place a very small
M5: and a scope into your nose. It hangs out in
M5: the back of your throat and we watch the food
M5: go down your throat that way, determining whether it's going
M5: the right way or it's heading into the airway. And again,
M5: for the very same things that we do in both
M5: of those, it's not just the point of do they
M5: aspirate or not? Meaning is their food or liquid getting
M5: into the airway or not.
M4: So once you evaluate Mardie in my dad's case, for example,
M4: as he advanced in his age and he was in
M4: the hospital, he had issues where he would drink water
M4: and basically just enough of it was going down the
M4: wrong way to cause problems. The first question I have is,
M4: is it a problem with nerves or muscles or what
M4: is it that creating that kind of problem?
M5: So the breathing tube can be a combination of difficulties.
M5: We already know that the patient is weak simply by
M5: laying in the bed in the ICU.
M15: So you've got weakness going against you at that point.
M15: It's not just the muscles of your arms and legs
M15: and your trunk and your ability to maintain posture, tie
M15: your shoes, walk down the hallway. Swallowing is a combination
M15: of muscles, too, and specifically its six cranial nerves and
M15: over 30 muscles are involved with this. So it's a
M15: very complicated system. So I've been arguing that the ICU
M15: and stays in the ICU specifically with the breathing tube
M15: down your throat, makes the swallowing muscles weak as well.
M15: It's not just the body muscles. So that's the first
M15: issue with regard to any kind of neurologic injury, that's
M15: always a possibility. But the reality is that we may
M15: not even know that in the acute phases of a
M15: person who just had an artificial airway of some sort
M15: and we've removed that airway and it's difficult to tell
M15: necessarily any neurological component without having had a disease or
M15: something that caused that neurologic injury. So in other words,
M15: you could have some weakness of the vocal cords. You
M15: could have weakness of being able to protect your airway
M15: when you swallow. But is that we. US from the ICU,
M15: is it neurologically related or is it tissue that's keeping
M15: you from being able to do that, such as under
M15: the conditions of swelling or what you call edema or
M15: under the conditions of maybe even something along the lines
M15: of stenosis where there's increased fiber and content in the
M15: tissues that prevent the closure or prevent movement from happening.
M1: Probably the answer is yes, right, it's a combination of everything.
M5: That's exactly right. And not to mention the potential for
M5: all of those heavy doses of medications that you had. Arguably,
M5: the neurological result of those medications may be involved as well.
M4: What are some of the circumstances that lead to this?
M4: If he didn't have a breathing tube and you're just
M4: walking around and you suddenly have issues where you're noticing
M4: that your swallowing isn't perfected and you're allowing some water
M4: and other things to go down the wrong way.
M5: There are any one of dozens of diagnoses that are
M5: linked to dysphagia or swallowing disorders. It could be everything
M5: from a surgery in the head and neck area, for example,
M5: head neck cancer.
M15: They may have to sacrifice a nerve. They may have
M15: to remove parts because of the tumor and what was invaded. OK,
M15: so that's an extreme example where you're literally altering the anatomy.
M15: Coming back down from that. Let's say we don't even
M15: alter the anatomy. Let's say we just dose you with
M15: radiation just because you had throat cancer. The radiation itself
M15: wreaks havoc on the tissues, wreaks havoc specifically with the muscles,
M15: turns them hard, reduces sensation. There's those issues as well.
M15: So all of these being medical treatments. Right. What about
M15: the patient who's had a stroke or neurological injury, a
M15: head injury because they have a crash in a vehicle
M15: or fell out of bed and hit their head on
M15: a nightstand table and had a brain bleed as a
M15: result of it? All of these are potentials all the
M15: way down to and believe it or not, something so
M15: simple as dehydration or hyponatremia or what wouldn't be broadly
M15: the electrolyte imbalance, virtual alcohol usage or alcohol usage, even
M15: a UTI, just an infection that's somewhere in the body
M15: can cause these problems. So swallowing problems are generally caused
M15: by something else. They're not a primary problem like infection
M15: or something along those lines.
M4: It sounds like you go through a process of elimination
M4: to figure out why is there a swallow issue and
M4: do you then go into a kind of a physical
M4: therapy rehabilitation or are there other things that you have
M4: to do first?
M15: Yeah, we were talking a little earlier about those instrumental exams,
M15: the fees in the video for Scoppetta exam. The primary
M15: thrust to doing those exams is to determine what's going
M15: on physiologically with swallowing. You know, again, one of the
M15: very small questions is, is food going the wrong way
M15: into the airway? That's fine. Sometimes we even know that
M15: at the bedside, but it's nice to confirm it under
M15: some sort of camera. The reality is that these exams,
M15: the gold where their weight is in gold, is being
M15: able to try out some of the strategies that can
M15: help swallowing while the test is going on. So the
M15: whole point here is we can give patients maneuvers to
M15: help their swallowing. We can put them into different postures
M15: with regard to their head in their neck, whether they
M15: turn their head, tuck their chin down, do something along
M15: those lines. These are the kinds of things that's what
M15: tells us what can work and doesn't work to get
M15: them swallowing immediately. We call these compensatory strategies. Once we
M15: figure that out and we know what the problem is
M15: from the exam, then we can do, as you say,
M15: the physical therapy for their swallowing. We can do the exercises,
M15: we can do the rehabilitative techniques that gets the physiology
M15: to improve and become more like normal swallowing. That's the
M15: whole point. That's exactly the point.
M4: So if I may you go through a process with
M4: bringing someone back to as normal a swallow as possible
M4: and you help them to get discharged from the hospital,
M4: for those of us who are at home and grandpa
M4: comes home, what should we be watching out for as family?
M4: That can give us an indication that perhaps there's a
M4: challenge here.
M1: And the corollary to that, what can the patient and
M1: family members do at home with the person who's suffered
M1: this illness or injury to help improve the situation for
M1: them without the aid of a therapist?
M5: So I think one of the big things is recognition, sensitivity,
M5: however you want to think about it, just simply noticing
M5: that there is a problem. So how do you notice
M5: what's a problem? Right. How do you define what a
M5: problem is? And what I would say is consistency of
M5: the behavior, frequency of the behavior. So every one of
M5: us I have yet to be in a room with
M5: anybody who's not coughed or cleared their throat during a meal,
M5: but they only do it once or twice.
M15: They're not doing it on every swallow or every other swallow.
M15: And that's what I'm talking about. It's the consistency of
M15: the behavior and the frequency of the behavior, the occasional
M15: cough here and there. Probably not a big deal. We
M15: all do it, but one that's happening persistently through a
M15: meal or even throughout the day. Somebody may be coughing
M15: or clearing their throat frequently throughout the day and again,
M15: separate from illness. This is just on their own saliva,
M15: for example, or the drink of water that they have
M15: during lunch. These are the kinds of behaviors that you
M15: want to be looking out for. So it's coughing, clearing
M15: their throat. Choking the inability to once they've cleared their throat,
M15: get rid of the gurgling quality that they might have.
M15: We've all heard that kind of gurgling quality when it
M15: sounds like you're a little bit underwater and you have
M15: that morning throat, if you will, before you take you
M15: brush your teeth or rinse your mouth out for the
M15: first time, you have kind of a deeper voice. If
M15: it's happening, every meal, every other meal, maybe it's only
M15: happening with liquids and it's not happening with food. Maybe
M15: you're avoiding food because it's difficult to eat. I'm not
M15: talking about pain in the mouth or a toothache or
M15: things along those lines. I'm talking about the inability to eat,
M15: for example, raw fruit, the inability to chew up a
M15: green bean, a cooked green bean at that difficulty mashing
M15: up steak or hamburger, and you get loose bits all
M15: around your mouth. These are all signs that patients may
M15: be having difficulties. And it's time to go see the
M15: physician and get a speech language pathology consult.
M13: Well, Marty, you know, we could go on for another
M13: hour and just talk about day to day speech pathology
M13: and other issues that you come in contact with. But
M13: I'm afraid we're out of time today. I hope you'll
M13: come back and join us again.
M9: How would we contact you if we have a loved
M9: one in the hospital and we believe we need your care?
M16: Probably the best way to get in touch with me.
M16: If you had questions about patient care or even research
M16: is through my email address and you can reach me
M16: at M, B, Brodsky at G h, my dot edu.
M16: And then the Twitter profile is at M.B Brodsky, Ph.D.,
M16: of course.
M3: Dr. Steven Tayback, thank you so much as well. Medicine
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