NTSP Specials (S2) SLT Legends: Prof Wallace meets Dr Martin Brodsky (Part 1)

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 0:07

Hello and welcome to Traffy Talk. We've got a real trade here with three paths too, with two legends of speech and language therapy or pathology depending on what is well talking. Martin is a speech and language pathologist and is an internationally recognised researcher specialising in following disorders or dyspages. He also works in airway injury and communication problems following critical illness. Martin is actually head for the speech and language pathology department at the Cleveland Clinic in America. And he also serves as an adjunct associate professor at Johns Hopkins University. So quite an impressive character. His research catalogue over the years has transformed understanding of dyspager after education. And I've certainly read plenty of his work. Martin's published extensively on its one testament rehabilitation and ethics recovery. And he's widely got as one of the world's leading experts in critical pages. So there's a bit of a fact about the noise, but this is a fascinating conversation between two legends of special language therapy. This first part covers the patient journey with fact identification for this pager and how to bring the whole team on board for the special manager. So over to Sarah Martin.

SPEAKER_01 1:52

We have been attending the SLAD, which is the Society of Latin American Dispager Congress, University of Anandua. And it's my absolute honor and privilege to be joined by my wonderful mentor, guru, Dr. Martin Brodsky. And this is a fantastic opportunity to discuss all things ICU, critical care, issues that relate to practical study. So welcome.

SPEAKER_03 2:21

Thank you. Thank you for having me.

SPEAKER_01 2:22

It's my pleasure. So let's start with where do you work? Tell us a little bit about you.

SPEAKER_03 2:27

So I'm uh at Cleveland Clinic, uh, main campus. I'm the section head for speech language pathology within the integrated surgical institute. We cover main campus inpatient and outpatient voice center, as well as swallowing disorders and ethnic cancer.

SPEAKER_01 2:47

And you see patients all the way through to outpatient post-ICU journey.

SPEAKER_03 2:53

Exactly, yes.

SPEAKER_01 2:54

So I thought it'd be nice if we could have a chat about the patient journey. When our patients are admitted to ICU and they start to have all these medical interventions, that's when kind of things can start to go wrong in terms of the airway that then leads to tracheosopy. So I'd be interested to know your thoughts about what sort of problems are that occur and um anything you think that could be done to maybe prevent some of these issues.

SPEAKER_03 3:21

We as human beings do the best we can to stay healthy, avoid accidents, things of that nature, but sometimes the world isn't so tiny, and we end up in places that we don't want to, and the ICU is definitely one of that room. For anybody who goes to the ICU, they're there for the very specific reason of protecting life at the bare minimum. Uh this is all, of course, uh in the face of addressing the disease, the condition, the circumstances that brought them there in the first place. But it's the one place in the hospital where most people are holding on to life, and are doing so uh with a great deal of hope. I think it's a good word for that. You know, there's hope on both sides of that bed, if you will. Um the patient who wants to survive their ICU stay and get back to normal life, and the intensivists, the nurses, and all of the therapists and anybody else who comes into contact with that patient, even the folks in the finance department, want to make sure that those folks are going to do well, and we were hopefully helpful along these lines.

SPEAKER_01 4:36

And then intubation, which you know, intubation is something that you are an absolute expert in and post-extubation staging. Something we're very concerned about in terms of those complications, quilly, of intubation, that uh cause patients to end up with a tracheostomy. So tell us a little bit about uh what you think of the things that create more difficult.

SPEAKER_03 4:59

I'm standing on the shoulders of giants here. Um I I think the biggest controversy with regard to oral industrichal intuition is the size of the tube right now. I would say within the recent five to ten years, there's been consistent and a lot of evidence, large studies taking a look at just the relative size of the tube compared with the individual and what happens once that tube comes out. Of course, anybody who gets intubated, whether it's a couple hours for surgery or a couple days or weeks, um, is highly likely to have laryngeal injury, which effectively means that their voice is not going to sound like it normally did before they had that tooth down their throat. But the reality is that the tube went down their throat to save their life. And it's a necessary treatment from the ICU. So knowing that that's the treatment, what can we do about the treatment that actually changes the factors on the back end? And the only modifiable thing that we can do is, at least at the moment, is change the size of the tube. I I've often quipped, and uh it's a little bit snarky, but I've often quipped that you don't put garden hoses down tubes where straws should go. It's one of those things that if there's enough air, enough oxygen, to maintain the life that's necessary, why are we making it bigger than is necessary? Huge arguments with regard to some intensivists who say, well, what if I do a broncoscopy? Which effectively means I want to put a very large endoscope through the tube to see what's going on in the uh upper and lower airways below the vocal cords while the tube is in. And possibly wash out the lungs, get rid of mucus plugs, whatever it may be. And they need the size to be able to go down into that tube.

SPEAKER_01 7:12

So the absolute justification.

SPEAKER_03 7:14

That's the absolute justification. What's really interesting about this is that they're anticipating a need that the numbers are gonna shock you. The numbers are anywhere between four and seven percent of patients in the ICU will get a rough possibility. So why is it that the physicians are still planning for the larger two?

SPEAKER_02 7:41

That's very low.

SPEAKER_03 7:42

If it's quite literally one in twenty. And I'm being generous.

SPEAKER_02 7:48

I am I am quite sure.

SPEAKER_03 7:49

Yeah. So if that is indeed the case, I understand their concern, and I by no means am I questioning their judgment now. I question the decision making in light of those numbers. Couldn't there be a half size? Couldn't we go from the eight to the seven and a half? Couldn't we make it better? Because when you move that half size below the eight, there's less dysphagia, there's less dysphonia, there's less discomfort, less complications as a result of the less of all of that.

SPEAKER_01 8:31

Let's consider some of the other risk factors though.

SPEAKER_03 8:34

There's been a lot of study that has taken a look at post-perfusion when it's reduced, can lead to these chronic problems with opening the glottis or closing the glottis, whichever way it's working.

SPEAKER_01 8:51

Usually opening your stuff, and then your long-term fraction.

SPEAKER_03 8:56

It's usually opening.

SPEAKER_01 8:57

That's a disaster.

SPEAKER_03 8:58

Yeah, but I have seen ad doctor.

SPEAKER_01 9:00

I have never seen that.

SPEAKER_03 9:01

That one's interesting.

SPEAKER_01 9:02

I've never seen that.

SPEAKER_03 9:04

Yeah.

SPEAKER_01 9:04

Okay.

SPEAKER_03 9:05

I now each other. Yeah, it could have been a different problem. It could have been a different patient with different circumstances. I've seen it, I think, once. But, you know, if you have, you know, ten factors and you've got six of them, you're probably at higher risk than if you had three or if you had none.

SPEAKER_01 9:25

I mean, what I what I do when I've seen these patients post-expiration with or without tracheophony, and you find all these incidental structural problems, is trying to determine and unpick that and work out, okay, backtrack what what could have happened or what could we treat. And often it's hard to treat any of it. So take COVID for huge numbers of patients with a demon. I don't really have I mean, I would say every patient.

SPEAKER_03 10:02

Yeah.

SPEAKER_01 10:03

Um that inflammation, which partly is potentially the virus, plus integration, plus the gastroc issues.

SPEAKER_03 10:14

They got through the kitchen sink.

SPEAKER_01 10:16

Yeah, and they'd all had steroids. Yeah. They all had steroids.

SPEAKER_02 10:20

Yeah. Nope.

SPEAKER_01 10:25

So I I find it difficult. For me the decision is always don't use the steroid because the risk is further identified with these, you know, possible issues. Unless it's something that has no medical complication, obviously it's a discussion that's not my decision. I find a problem, we have a chat. Um but for me, if it's a barrier to weaning, you know, you you then that probably takes the balance. It's worth a try. But along with, you know, is there cardiac pain or is there general systemic edema, and are they on diuretics, and are they on other things that can help reduce fluid over? Yeah. So it's a big picture thing, isn't it?

SPEAKER_03 11:19

It is. I I you know I I think regardless of which healthcare practitioner you're talking about, we often get really focused in on the problem that we're dealing with that in this particular case originally. But we don't easily, I think most of us will, but we don't easily step back and take a broader picture and address the dispatch.

SPEAKER_01 11:50

What do you think that is?

SPEAKER_03 11:52

Well we're all specialized.

SPEAKER_01 11:54

Is it the environment as well or the IT environment?

SPEAKER_03 11:59

It's a mix of things. Yeah, it's a mix of things. I don't, you know, it certainly in a well-run ICU with a multidisciplinary team, multiple inputs, um, you can't. I'm gonna double do a double negative here. You can't you can't not see the bigger picture because the team is bringing you that picture. In a farm. Which is exactly the reason why this is not simply doctor, nurse, patient. Um, and I think most people in the world these days will admit that. Um, there are still some traditional ICUs, and I say traditional going back to the 1950s to say the 1980s, 90s, and beyond, where it really simply is let us steal and stable uh their life. Get them out of the ICU and now they're yours.

SPEAKER_01 13:07

Yeah, things have moved on, haven't they? It's just about five or more about people driving. Yeah, driving under being capital to watch the next channel.

SPEAKER_00 13:26

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