NTSP Specials (S2) SLT Legends: Prof Wallace meets Dr Martin Brodsky (Part 3)

The NTSP's Prof Sarah Wallace was recently speaking in Cancun, Mexico at the Sociedad Latinoamericano de Disfagia (SLAD, the Latin American Dysphagia Conference). 

Sarah bumped into SLP legend Dr Martin Brodsky, PhD, ScM, CCC-SLP, F-ASHA. Martin is Section Head of Speech-Language Pathology at the Cleveland Clinic, Ohio, and an internationally recognised clinician and researcher in swallowing, voice and airway disorders. His work has a particular focus on the consequences of critical illness, including swallowing problems and laryngeal injury following intubation and mechanical ventilation. Before joining Cleveland Clinic in 2022, Martin spent around 15 years at Johns Hopkins University, where he retains adjunct academic appointments in Physical Medicine and Rehabilitation and Pulmonary and Critical Care Medicine. A Fellow of the American Speech-Language-Hearing Association, his research brings speech and language pathology firmly into the multidisciplinary critical care environment, exploring how we can better identify, understand and treat airway, voice and swallowing problems in patients recovering from critical illness. 

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Transcript

SPEAKER_00 0:51

So, over to Slair and Martin.

SPEAKER_03 0:54

Appearances can be dissected. And patients can sometimes appear either really, really good from the eyeball at the bedside, but then once you investigate the underlying physiology, they can be really bad. And I gave an example in my fees presentation about the opposite scenario where I had a patient who was on ECMO, the sickest patient in the hospital. Um young, 28, a nurse who had been on ECMO for a hundred days. She appeared immobile, yet fully cognizant, fully wiggled, following instructions, mouthing perfectly, zero swallow. So it was with a degree of kind of trepidation that I to see her and I thought, this is pretty high stakes. What am I going to do? Nothing has gone well for this poor young woman. The only thing I can give her is her voice and her ability to eat through it. I've got to do everything I can to make that happen. First assessment, cuff inflated. On the trackie, there's no airflow, there's no chance of cuff inflation. She's very low, high ventilation pressures, and no voice button function good. Did some above point localization with her. Airflow, but no voice. Too weak to localize, not surprisingly. So I use that as a therapeutic tool over the course of a few days. She starts to trigger a swallow. She starts to get a little bit of voice, and after five days, she's getting a weak voice and some consistent swallowing, and it looks good. So I need a bees, and her swallow was normal.

SPEAKER_01 3:10

Fantastic.

SPEAKER_03 3:11

And she could eat and drink a normal diet and fluid. Everything else medically had not changed, but she was still on A, I was still listening to patient. So by all appearances, you would see that patient and think, well, A, I'm not going to go anymore for her. Because what can I do? And B, she's going to be paid. She wasn't she wasn't issuing, she just needed to help. Your example was the opposite, wasn't it? Can you tell us a little bit about what you explained? Because I think that the idea behind this is to you you please explain what I mean.

SPEAKER_01 3:48

Patients are wildly different. Um I I have to ask about your ECMO patient, though. When were you referring?

SPEAKER_03 3:56

Well, that's a good point. I think when she was become coming out of the delivery.

SPEAKER_01 4:02

Okay.

unknown 4:03

Yeah.

SPEAKER_01 4:04

So she was awake prior to this, but you hadn't been consulted?

SPEAKER_03 4:08

No. Late.

unknown 4:10

Late.

SPEAKER_03 4:10

Late referral.

SPEAKER_01 4:11

Okay.

SPEAKER_03 4:12

And tracheostomy had been in a very long time.

SPEAKER_01 4:15

Right.

SPEAKER_03 4:15

She'd been sedated. But she'd been sedated for a very long time. She'd been awake probably a week.

SPEAKER_01 4:22

Okay. So wouldn't you have rather been consulted once they started waking her up?

SPEAKER_02 4:29

100%.

SPEAKER_01 4:29

Okay. I just I wanted to make sure that's a good point.

SPEAKER_02 4:33

100%. Because look at what look at what I did with her.

SPEAKER_01 4:36

That's the point. Why not get her on oral food earlier?

SPEAKER_02 4:40

Earlier.

unknown 4:41

Right.

SPEAKER_01 4:41

Absolutely.

SPEAKER_03 4:42

And that's the DC of feed. That's what feed allowed me to do. That's what ACV allowed me to do.

SPEAKER_01 4:47

Yes. Anyway, please explain your time get in time we get weaker in the vet in the hospital bed. We don't get better. For sure. Okay. So the patient that I've seen, I I I presented on two patients. One patient was an elderly gentleman who had been intubated some period of time. My notes didn't have it because frankly I don't remember. It was a while. But the reality, he was intubated long enough that there was enough ulceration of the arythinoid cartilages that you got to see the cartilage below the tissue in the posterior glottis. That yellow area in the back was the cartilage. And it was appearing, certainly there was an overlay of the tissue. But there was that much friction that was going while the tube was pistoning during breathing, during movement, during everything that happened during this person. Turning every ounce of movement.

SPEAKER_03 5:57

Ventilator.

SPEAKER_01 5:58

Yes. Even the thought of moving probably moved the tube. And the reality was he was moderately ulcerated, right? Everything else looked wonderful. Beautifully white bulk, of course. A pristine pharynx. No cuts, bruises, bumps, nothing. I mean, just I this if I took a picture of it and put this in a textbook, this would be the textbook case minus the ulcerations in the posterior glottis. Okay? Yet what was really interesting is there were secretions, trace secretions, all around the pharynx. Throughout the laryngeal vestibule, dripping down through the anterior commissure and into the trachea. There was never an attempt by him to cough, clear his throat, gurgle, a different voice, nah thing. I was carrying on a conversation with him the entire time during my laryngeal evaluation, and he did nothing. Okay? All of this to say that the patient that you see at the bedside literally have no idea what's going on. Because of you really don't know. Yeah, I you need to look. Okay? So that was the one patient. The second patient, considerably younger, about 20 years younger, if I recall correctly. And I did have the history on her. She was in the cardiac types of care unit, the medical cardiac tens of care unit, or we call it the CCU. And she was sitting, not at the edge of the bed. It was a little bit of an odd case because I don't think I've seen a patient do this before. Where the bed bends and creates that angle. She was actually forward of that angle with her legs outstretched on the bed. She was actually short. So it worked well. It worked well. Yeah. It's not a lot of space. I want to say that she was about 4'10. Okay. Short lady. Um youngish lady in her 50s, watching the baseball game on TV as I walked into the room. And what was really amazing about this is it could have been my sister, it could have been my aunt, it could have been any one of a number of people. I remember walking in as a child seeing people like this on the couch or whatever, right? So you're immediately put at ease as the clinician saying, I don't need to deal with this one, right? Yeah, she's fine. Let's just do this as a matter of protocol, right? There's that word again. Okay, there's the trap, folks, right there. And you go in and find a complete and utter mess. Now what was really interesting about this case was not only the surprise of the mess that we found, and that was pedunculated tissue, uh, which meant that the granulation that formed as a result of her intubation, that was a total of ten days across two intubations and three extubations.

SPEAKER_03 9:35

Do you know that's not that unusual anymore?

SPEAKER_01 9:37

Of course not, right? She had flash pulmonary edema. So I was expecting some level of edema, but knowing that it was pulmonary edema, wasn't expecting it in the glottis. No. Right? So that was a little bit of a surprise. Her vocal cords were the color of a red, delicious apple. That was, as we like to refer to it, an angry larynx. You know, it was screaming at us.

SPEAKER_04 10:09

Yeah, yeah.

SPEAKER_01 10:09

Right? And the vocal cords only opened with forced inhalation. Okay. They did not go when she attempted the voice. Okay? So effectively, they were closed, not stenose, but they were closed. They were very weak, and they were able to be blown apart, abducted, with forced exhalation.

SPEAKER_03 10:36

Did she have strider?

SPEAKER_01 10:38

And inhalation. She had no strider.

SPEAKER_03 10:40

Okay, interesting.

SPEAKER_01 10:41

Now, right behind the vocal cords, where that pedunculated granulation tissue was, was a pinhole of an airway. And what struck me about this was she's satting 96% on room air with that airway. So immediately red flags are going up in my head throughout this entire thing. She had already had uh three bouts, uh, two bouts of flash pulmonary edema, and she came in with a myocardial infarction. If she's going round three for intubation, round four for intubation, she's gonna be a difficult airway.

SPEAKER_03 11:32

Very difficult.

SPEAKER_01 11:33

Okay, phenomenally difficult.

SPEAKER_03 11:35

Almost impossible.

SPEAKER_01 11:36

Yeah, exactly.

SPEAKER_03 11:37

Okay, causing significant trauma.

SPEAKER_01 11:40

Precisely the issue. So the the concern from where I stood was immediately the airway.

SPEAKER_04 11:47

Yeah.

unknown 11:48

Okay.

SPEAKER_01 11:48

Clearly she was doing fine resting at the bedside. Right? I'll give you the punchline.

SPEAKER_03 11:53

How did she not desaturate though?

SPEAKER_01 11:56

I don't know. Okay. She was she wasn't puffing and puffing, she was normal, calm breathing.

SPEAKER_03 12:04

Not, I suppose, sitting. Just sitting. No, no, not not doing anything to require anyway.

SPEAKER_01 12:11

Nothing. I it was people are amazing. It was kind of a miracle.

SPEAKER_03 12:16

Yeah, yeah.

SPEAKER_01 12:16

Right?

SPEAKER_03 12:17

Anyway, but but nothing you could ignore.

SPEAKER_01 12:19

Nothing I could ignore. Absolutely not ignore. The goofiness in this is that as angry as that larynx is, and as angry as um it it kind of really upset me that nobody had found it prior to me.

SPEAKER_03 12:35

Yes, I get I get that too a lot. I feel like that too.

SPEAKER_01 12:40

And I don't I can't blame a single person. That's the issue.

SPEAKER_03 12:43

Yeah.

SPEAKER_01 12:44

Um, when the tube is coming out, they're not scoped to find out how we're doing.

SPEAKER_03 12:47

And when it's going in, there's a certain amount, it's less safe, it's light. Yeah. So that's that's fair enough.

SPEAKER_01 12:53

Where the cords, great, put the tube there. Right? Exactly. Or they're covered by secretions.

SPEAKER_04 12:59

Yeah, it's fair enough.

SPEAKER_01 13:00

Yeah, so it's it's nobody's what it is. Yeah. And and we went through, so we went through the whole laryngeal exam. Life was good. It it ended up exactly the way that I told you. Good meaning that I got a good exam.

SPEAKER_04 13:17

Yeah.

SPEAKER_01 13:18

Okay. Clearly not a good outcome, but it was a good example. Then we moved on to the fees or the um swallow evaluation. And she did amazingly well. She was fine on single sips of liquid. She even had multiple sips of liquid. But when we really increased the volume, that's where she broke down. Okay? So we pivot a little bit.

SPEAKER_03 13:40

She could be a breath swallow. Of course. Yeah. Yeah.

unknown 13:44

Yeah.

SPEAKER_01 13:45

She ran out of air.

SPEAKER_04 13:46

Yeah.

SPEAKER_01 13:48

Then we move on to the applesauce. The applesauce went down like nobody's business.

SPEAKER_04 13:53

Custard in the UK. Custard. Okay.

SPEAKER_01 13:57

We'll call it pudding. So, and we stopped the exam after that because really, if you'll pardon the expression, what trumped the swallowing was the breathing.

SPEAKER_03 14:10

Yeah, that's the priority.

SPEAKER_01 14:12

Okay. If that wasn't an issue, she would have been on a diet, no question. And in fact, I told the intensivist that. I said, I truly don't really have a lot of problems with her swallowing right now. You can get her started on a diet. I'm a little bit more concerned with the airway. And I showed him some photos of the airway.

SPEAKER_03 14:34

One of my favorite things to do. Right.

SPEAKER_01 14:36

It it shocked him. I'll give you the punchline in a minute. This isn't the punchline, but it's the prelude to that kiss that I'm going to give you. Okay. Within two hours of talking with that physician and showing him those photographs, they gave her a tricky ass.

SPEAKER_04 14:56

Yeah.

SPEAKER_01 14:57

To simply maintain the airway and avoid any potential future issues that would deal with an intubation that was traumatic, truly traumatic. Yeah. Yeah. Yeah. This was a storm waiting to happen.

SPEAKER_03 15:14

Yeah, like a situation.

SPEAKER_01 15:16

Yeah. Now here's the punchline. I saw her on a research protocol, not because she was referred to speech language pathology. Now, what's really interesting about this is her presentation, which is what we were talking about originally, right? It fooled the nurses. It fooled because the nurses gave her the swallow screen. She was fine.

SPEAKER_04 15:43

Yes, it fooled her.

SPEAKER_01 15:44

Right? Fooled the nurses. It fooled the physicians. And it was only after we had an endoscope looking at her larynx did we actually see what was going on.

SPEAKER_03 15:57

Surely she had a voice problem.

SPEAKER_01 16:00

She was a tonic.

SPEAKER_03 16:02

Was that not enough of a red flag?

SPEAKER_02 16:06

Good question.

SPEAKER_01 16:08

It's a really good question, right? It should be.

SPEAKER_04 16:11

It should be.

SPEAKER_01 16:12

Now, according to some guidelines, aphonia would suggest an immediate consult. According to other guidelines that have been written, waiting is still an appropriate response.

SPEAKER_03 16:26

With an aphonia.

SPEAKER_01 16:28

She was just excavated 12 hours earlier.

SPEAKER_03 16:30

Yeah, but aphonia.

SPEAKER_01 16:31

Right? Um, I I've argued for a long time, and I don't think I've had much resistance, so maybe I'm just speaking into an echo chamber when I say this. Endoscopy has to be the primary exam when you're in the ICU. Absolutely. X-ray is a fantastic exam, but get the endoscopy first. See what's going on with the larynx. Well, good.

SPEAKER_03 16:56

That you didn't come to yesterday.

SPEAKER_01 16:59

Give it to me here. There we go.

SPEAKER_03 17:01

Right. But thank you so much, Dr. Master Bonsky. It's an absolute honor and pleasure. So uh and thank you so much for sharing your wisdom and expertise with uh our audience.

SPEAKER_01 17:15

Thank you. I as always I'm open to questions. If you want to email me, I'm happy to have that discussion.

SPEAKER_03 17:23

And you're very welcome to come to Manchester.

SPEAKER_01 17:25

Wonderful. I look forward to it.

SPEAKER_03 17:27

Thank you.