Skip to main content
  • Letter to the Editor
  • Open access
  • Published:

Letter to the editor in response to the Japanese clinical practice guidelines for rehabilitation in critically ill patients 2023 (J-ReCIP 2023)

Dear Editor,

We applaud Unoki et al. on their recent development of the Japanese clinical practice guidelines (CPGs) for rehabilitation in critically ill patients 2023 (J-ReCIP 2023). These aim to advocate for early initiation of rehabilitation in Japanese Intensive Care Units (ICU) to optimize patient outcomes. Whilst a rigorous methodology were used, evidence informing these guidelines were limited to RCTs and failed to consider important evidence offered by other research designs on assessment of swallowing function. As Speech Pathologists, our comments relate specifically to the WG3 Dysphagia and the recommendation made against the use of videoendoscopic swallowing assessment.

We agree that the exact prevalence of dysphagia is uncertain, with reports up to 91% [1]. Dysphagia in critical illness is a common issue with multiple negative long term sequelae and is significantly associated with an increased risk of mortality [2, 3]. Accurate and comprehensive assessment of swallow function, opposed to screening in isolation, is key to evidence-based informed management. The authors report swallowing function is often impaired due to interventions such as the placement of endotracheal and tracheostomy tubes and other surgical procedures. These aetiologies extend further to include both comorbidities and current acute medical diagnoses with their associated complications. Specifically, diagnosed sepsis, critical illness neuromyopathy, reflux, altered ventilation status, and impaired cognition can impair both the safety and efficiency of swallow function [4, 5]. Early rehabilitation in this population should optimize sensory and motor function with interventions including laryngeal re-sensitization and restoration of airflow through the upper airway to promote sensation, swallow, cough, smell and communication.

While swallow screening in the ICU is an initial step for identifying dysphagia, few existing screening tools have been validated for use in the critical care setting and importantly, screening is not equivalent to comprehensive assessment. Attachment to medical devices and lack of mobility does not preclude swallowing assessment in ICU. Commonly, Speech Pathologists will commence intervention with the clinical swallowing evaluation (CSE), which includes oral peripheral and cranial nerve examinations, assessment of upper airway function and suitability of oral trials to determine the presence, severity, and pathophysiology of dysphagia. Significant limitations exist with the CSE, as subjective inferences are made which are not grounded in strong evidence. As the authors highlighted, silent aspiration is common in critically ill patients and difficult to detect via CSE. Therefore, the gold standard instrumental assessments of Flexible Endoscopic Evaluation of Swallowing (FEES) (referred to as videoendoscopic examination of swallowing in Unoki et al.’s article) and videofluoroscopic swallowing studies offer paramount diagnostic accuracy [4]. As FEES is conducted at the bedside, it is ideally suited to the ICU setting and shown to be both safe and efficacious [6]. These assessments uniquely offer assessment of (1) presence and degree of laryngeal penetration and aspiration; (2) response to airway compromise (no response, silent laryngeal penetration or silent aspiration, successful or unsuccessful attempt to eject the bolus from the airway); (3) the dynamic swallowing profile across oral, pharyngeal and upper oesophageal domains; (4) swallow timing, motor and sensory functions; (5) presence and degree of bolus residue; (6) impact of structural changes on the swallow function (e.g., vocal cord palsy); (7) secretion management and the impact on airway protection; (8) targeted physiology-based rehabilitation planning. FEES also provides detailed information from visualization of laryngeal injury following intubation or other comorbidities, which can impact multidisciplinary tracheostomy weaning and decannulation decisions. The authors report the findings of Barquist et al.’s [7] study as increased harm (defined as increased aspiration) in the intervention group. It is important to consider whilst there was more aspiration noted, aspiration was not associated with FEES, but rather FEES was more responsive to detecting harms, hence the increased prevalence. As aspiration can lead to pneumonia, early detection of harm (i.e. aspiration) is vital to mitigate further morbidity and mortality risk, and in turn can optimise patient safety.

We therefore strongly disagree with the recommendation against using videoendoscopic examination of swallowing to manage critically ill patients. Our opinion is that FEES is an essential component of assessment and management of swallowing, and this is upheld by guidelines of Peak National Associations [8]. FEES can expedite the commencement of safe oral intake due to its accuracy in detection of aspiration risk [9] over other assessment methods [6]. Commencement of earlier safe oral feeding is crucial to improvement in mood, nutrition and engagement in physical rehabilitation. Therefore, the recommendation against utilizing FEES seems in direct opposition to the goal of diagnostic accuracy for evidence informed rehabilitation. Indeed, a suboptimal swallow assessment is potentially of greater harm due to the known sequelae of morbidity, cost, and mortality of dysphagia.

We agree that future research is warranted to further determine the prevalence of dysphagia, and there is an urgency to guide the optimal approach to dysphagia assessment, distinguishing screening from clinical assessment. Whilst we acknowledge that the evidence could be strengthened further in the rehabilitation context, we urge the authors to reconsider their position on FEES and make a conditional recommendation advocating for dysphagia management based on videoendoscopic examination in the critically ill.

Availability of data and materials

Not applicable.


  1. Ponfick M, Linden R, Nowak DA. Dysphagia—a common, transient symptom in critical illness polyneuropathy: a fiberoptic endoscopic evaluation of swallowing study. Crit Care Med. 2015;43(2):365–72.

    Article  PubMed  Google Scholar 

  2. Zuercher P, Moser M, Waskowski J, Pfortmueller CA, Schefold JC. Dysphagia post-extubation affects long-term mortality in mixed adult ICU patients—data from a large prospective observational study with systematic dysphagia screening. Crit Care Explor. 2022;4(6):e0714.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Likar R, Aroyo I, Bangert K, Degen B, Dziewas R, Galvan O, Grundschober MT, Köstenberger M, Muhle P, Schefold JC, Zuercher P. Management of swallowing disorders in ICU patients-a multinational expert opinion. J Crit Care. 2024;1(79): 154447.

    Article  Google Scholar 

  4. Brodsky MB, Pandian V, Needham DM. Post-extubation dysphagia: a problem needing multidisciplinary efforts. Intensive Care Med. 2020;46(1):93–6.

    Article  PubMed  Google Scholar 

  5. Zuercher P, Moret CS, Dziewas R, et al. Dysphagia in the intensive care unit: epidemiology, mechanisms, and clinical management. Crit Care. 2019;23:103.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Morris K, Taylor NF, Freeman-Sanderson A. Safety-related outcomes for patients with a tracheostomy and the use of flexible endoscopic evaluation of swallowing (FEES) for assessment and management of swallowing: A systematic review. Int J Speech Lang Pathol. 2024.

    Article  PubMed  Google Scholar 

  7. Barquist E, Brown M, Cohn S, Lundy D, Jackowski J. Postextubation fiberoptic endoscopic evaluation of swallowing after prolonged endotracheal intubation: a randomized, prospective trial. Crit Care Med. 2001;29(9):1710–13.

    Article  CAS  PubMed  Google Scholar 

  8. The Faculty of Intensive Care Medicine & Intensive Care Society. Guidelines for the Provision of Intensive Care Services v2.1. 2022;

  9. Dziewas R, Aufdem Brinke M, Birkmann U, Bräuer G, Busch K, Cerra F, Damm-Lunau R, Dunkel J, Fellgiebel A, Garms E, Glahn J, Hagen S, Held S, Helfer C, Hiller M, Horn-Schenk C, Kley C, Lange N, Lapa S, Ledl C, Lindner-Pfleghar B, Mertl-Rötzer M, Müller M, Neugebauer H, Özsucu D, Ohms M, Perniß M, Pfeilschifter W, Plass T, Roth C, Roukens R, Schmidt-Wilcke T, Schumann B, Schwarze J, Schweikert K, Stege H, Theuerkauf D, Thomas RS, Vahle U, Voigt N, Weber H, Werner CJ, Wirth R, Wittich I, Woldag H, Warnecke T. Safety and clinical impact of FEES—results of the FEES-registry. Neurol Res Pract. 2019;1:16.

    Article  PubMed  PubMed Central  Google Scholar 

Download references




No funding.

Author information

Authors and Affiliations



Conceptualization (CJZ), writing—original draft (CJZ), writing—review and editing (CJZ, SW, AFS).

Corresponding author

Correspondence to Charissa J. Zaga.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication


Competing interests

Not applicable.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zaga, C.J., Wallace, S. & Freeman-Sanderson, A. Letter to the editor in response to the Japanese clinical practice guidelines for rehabilitation in critically ill patients 2023 (J-ReCIP 2023). j intensive care 12, 25 (2024).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: