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Pharyngeal Electrical Stimulation for the Treatment of Dysphagia After Extubation (PhINEST)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Know the risks and potential benefits of clinical studies and talk to your health care provider before participating. Read our disclaimer for details.
ClinicalTrials.gov Identifier: NCT03840395
Recruitment Status : Recruiting
First Posted : February 15, 2019
Last Update Posted : July 17, 2019
Sponsor:
Collaborators:
Syntactx
Cytel Inc.
Information provided by (Responsible Party):
Phagenesis Ltd.

Brief Summary:
This is a prospective, multi-site, randomised, sham-controlled, single-blind (outcome assessor-blinded) study designed to assess the effects of Pharyngeal Electrical Stimulation (PES) (using Phagenyx®) for the treatment of oropharyngeal dysphagia after invasive mechanical ventilation (of any duration) by means of naso or oro-tracheal tube in critically ill intensive care unit (ICU) patients.

Condition or disease Intervention/treatment Phase
Dysphagia Device: Pharyngeal Electrical Stimulation (PES) Not Applicable

Detailed Description:

The PhINEST study is designed to assess the effects of Pharyngeal Electrical Stimulation (PES) (using Phagenyx®) for treatment of oropharyngeal dysphagia after invasive mechanical ventilation (of any duration) by means of naso or oro-tracheal tube in critically ill intensive care unit (ICU) patients.

The main clinical outcomes assessing unsafe swallows and dysphagia severity will be measured using the gold standard, i.e. Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and bedside swallowing assessments on day 2* after completion of final PES treatment.

Randomisation will be on a 1:1 basis at each site stratified for neurological vs. non-neurological reason for admission (Acute Physiology and Chronic Health Evaluation (APACHE) IV diagnostic group). Patients will receive either PES/sham treatment in addition to standard supportive ICU care and standard of care treatments for dysphagia (i.e. physiotherapeutic treatment). Administration of all protocol-specific assessments will be conducted by personnel blinded to treatment assignment.

The study will follow an adaptive population enrichment and sample size re-estimation (SSR) design with one interim look. The study will start with a planned sample size of 200 patients and a maximum (evaluable) sample size of 360. Interim analysis after completion of approximately 140 (evaluable) patients will determine:

I. futility stopping; OR II. sample size increase for the overall sampled population; OR III. Enrichment based on the composite primary endpoint by pre-defined subgroups (neurological vs. non-neurological reason for admission according to APACHE IV diagnostic groups). Thus enrollment of patients in the non-performing sub-group will be stopped at the interim while a sample-size re-estimation based on conditional power will be carried out for the other sub-group.

All interim decisions will be based on conditional power which for the Finkelstein-Schoenfeld (FS)-statistic will need to be computed via Monte-Carlo simulations.

Up to six (6) investigational sites across Europe are planned to participate in this study which is expected to last 48 months from first patient first visit to last patient last visit. Patients will be assessed at the following intervals: screening, baseline, on day 2* after completion of final study treatment, 7 ± 1 days after final study treatment and 14 ± 1 days after final study treatment (or hospital discharge if earlier). 30-day and 90-day mortality data will also be collected from the patients medical notes/electronic heath records/telephone call (no additional visit required).

*The day two (FU1) visit is to be conducted on the second day (~24hrs) following final PES treatment but may, under certain circumstances, be conducted upon/by the fourth day (~60 hrs) following final study treatment in instances where the final study treatment is delivered on late Friday and where FEES assessment is only possible early on Monday as no weekend FEES service is available at the investigation site.


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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 360 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple (Care Provider, Investigator, Outcomes Assessor)
Primary Purpose: Treatment
Official Title: The PhINEST Study - Pharyngeal ICU Novel Electrical Stimulation Therapy: a Prospective, Multi-site, Randomised, Sham-controlled, Single-blind (Outcome Assessor-blinded) Study.
Actual Study Start Date : June 17, 2019
Estimated Primary Completion Date : September 2020
Estimated Study Completion Date : September 2022

Resource links provided by the National Library of Medicine


Arm Intervention/treatment
Active Comparator: Active PES
Patients randomized to receive active Pharyngeal Electrical Stimulation (PES) via a Phagenyx Catheter.
Device: Pharyngeal Electrical Stimulation (PES)
The Phagenyx® system is a two-part neurostimulation system. It is composed of a durable component called the Base Station and the single-use sterile disposable Catheter. The Base Station acts as the user interface and provides the means to generate, optimize and monitor the delivery of electrical stimulation to the oropharynx. The Phagenyx® devices are CE labelled (2012) and will be used in accordance with their intended use label.
Other Name: Phagenyx

Sham Comparator: Sham PES
Patients randomized to sham will not receive any Pharyngeal Electrical Stimulation (PES) but will still have the Phagenyx Catheter inserted.
Device: Pharyngeal Electrical Stimulation (PES)
The Phagenyx® system is a two-part neurostimulation system. It is composed of a durable component called the Base Station and the single-use sterile disposable Catheter. The Base Station acts as the user interface and provides the means to generate, optimize and monitor the delivery of electrical stimulation to the oropharynx. The Phagenyx® devices are CE labelled (2012) and will be used in accordance with their intended use label.
Other Name: Phagenyx




Primary Outcome Measures :
  1. Effectiveness of Phagenyx® treatment in reducing severity of unsafe swallows - Penetration-Aspiration Scale (PAS) Scores [ Time Frame: Day 2 (~24 to ~60 hours) after the final Phagenyx® treatment ]

    Analysis of a two endpoints composite (FS-statistic) on a hierarchy of clinical priorities:

    Endpoint 1 - Swallowing safety based on worst PAS score in up to 4 thin (water) boli for each patient during FEES assessment converted to a trichotomised ordinal response of safe (PAS 1-3), penetration (PAS 4-5), or aspiration (PAS 6-8).

    The PAS provides a scoring system for airway closure and clearance during FEES. The PAS is a validated 8-point scale quantifying penetration and aspiration events primarily by the depth to which material passes into the airway and whether or not it is ejected.


  2. Effectiveness of Phagenyx® treatment in reducing the severity of unsafe swallows - Dysphagia Outcome and Severity Score (DOSS) score [ Time Frame: 7±1 days after the final Phagenyx® treatment ]

    Analysis of a two endpoints composite (FS-statistic) on a hierarchy of clinical priorities:

    Endpoint 2 - DOSS scale score determined by bedside assessment.

    The DOSS is a simple, easy-to-use, 7-point scale developed to systematically rate the functional severity of dysphagia based on objective assessment and make recommendations for diet level, independence level, and type of nutrition.

    1. Severe dysphagia
    2. Moderately severe dysphagia
    3. Moderate dysphagia
    4. Mild-moderate dysphagia
    5. Mild dysphagia
    6. Functional limitation and modified independence
    7. Normal in all situations


Secondary Outcome Measures :
  1. Effectiveness of Phagenyx® treatment in improving DOSS score. [ Time Frame: Up to 14 ± 1 days after the final Phagenyx® treatment (or hospital discharge if earlier). ]
    Changes in nutritional management and severity of dysphagia as measured by the DOSS score.

  2. Effectiveness of Phagenyx® treatment on time from to feeding tube removal. [ Time Frame: Up to 14 ± 1 days after the final Phagenyx® treatment (or hospital discharge if earlier). ]
    Changes in nutritional management and severity of dysphagia as measured by time from randomisation to removal of feeding tube.

  3. Effectiveness of Phagenyx® treatment on time to oral intake. [ Time Frame: Up to 14 ± 1 days after the final Phagenyx® treatment (or hospital discharge if earlier). ]
    Changes in nutritional management and severity of dysphagia as measured by time to oral intake (if applicable).

  4. Effectiveness of Phagenyx® treatment on total days of enteral feeding. [ Time Frame: Up to 14 ± 1 days after the final Phagenyx® treatment (or hospital discharge if earlier). ]
    Changes in nutritional management and severity of dysphagia as measured by total days of enteral feeding.

  5. Effectiveness of Phagenyx® treatment in improving Functional Oral Intake Scale (FOIS) score. [ Time Frame: Up to 14 ± 1 days after the final Phagenyx® treatment (or hospital discharge if earlier). ]

    Changes in nutritional management and severity of dysphagia as measured by the FOIS score.

    The FOIS provides a scoring system to document the functional level of oral intake of food and liquid in patients with dysphagia. It is a validated 7-point ordinal scale easily completed from information contained in medical charts, dietary journals, and/or patient reports.

    1. Nothing by mouth
    2. Tube dependent with minimal attempts of food or liquid
    3. Tube dependent with consistent intake of liquid or food
    4. Total oral diet of a single consistency
    5. Total oral diet with multiple consistencies but requiring special preparation or compensations
    6. Total oral diet with multiple consistencies without special preparation, but with specific food limitations
    7. Total oral diet with no restriction

  6. Effectiveness of Phagenyx® treatment on time from extubation to ICU discharge [ Time Frame: Up to 14 ± 1 days after the final Phagenyx® treatment (or hospital discharge if earlier). ]
    General health outcome measured by time from extubation to ICU discharge (days).

  7. Effectiveness of Phagenyx® treatment on length of stay in ICU [ Time Frame: Up to 14 ± 1 days after the final Phagenyx® treatment (or hospital discharge if earlier). ]
    General health outcome measured by length of stay in ICU (days).

  8. Effectiveness of Phagenyx® treatment on length of stay in hospital. [ Time Frame: Up to 14 ± 1 days after the final Phagenyx® treatment (or hospital discharge if earlier). ]
    General health outcome measured by length of stay in hospital (days).

  9. Effectiveness of Phagenyx® treatment on number of patients with re-intubation during hospital stay [ Time Frame: Up to 14 ± 1 days after the final Phagenyx® treatment (or hospital discharge if earlier). ]
    General health outcome measured by number of patients with re-intubation during hospital stay.

  10. Effectiveness of Phagenyx® treatment on mortality [ Time Frame: Up to 90 days after completion of the final Phagenyx® treatment. ]
    General health outcome measured by 30-day and 90-day mortality.


Other Outcome Measures:
  1. Effectiveness of Phagenyx® treatment in reducing (dysphagia) secretion severity. [ Time Frame: Day 2 (~24 to ~60 hours) after the final Phagenyx® treatment ]

    Exploratory analysis of changes in secretion severity (severity of dysphagia) between FEES assessments measured by an Independent FEES Review Committee (IFRC) using the Murray Secretion Severity Rating Scale (SSS).

    The SSS is a simple, easy-to-use, 4-point scale that can systematically rate the graduation of accumulated secretions within the pharyngolarynx and trachea during FEES.

    0. Normal

    1. Mild
    2. Moderate
    3. Severe

  2. Effectiveness of Phagenyx® treatment in improving swallowing safety and efficiency - PAS scores [ Time Frame: Day 2 (~24 to ~60 hours) after the final Phagenyx® treatment ]
    Exploratory analysis of changes in swallowing safety and efficiency (severity of dysphagia) between FEES assessments measured by an IFRC based on worst PAS score for each bolus consistency (semi-solid and solid) for each patient during FEES assessment converted to a dichotomised ordinal response of non-aspirator (PAS 1-5) or aspirator (PAS 6-8).

  3. Effectiveness of Phagenyx® treatment in reducing bolus residue [ Time Frame: Day 2 (~24 to ~60 hours) after the final Phagenyx® treatment ]

    Exploratory analysis of changes in bolus residue (severity of dysphagia) between FEES assessments measured by an IFRC using the Yale Pharyngeal Residue Severity Rating Scale (YRS).

    The YRS is a reliable, validated, anatomically defined, and image-based five-point ordinal rating scale to determine severity of post-swallow pharyngeal residue location (vallecula and pyriform sinus) and amount (i. none, ii. trace, iii. mild, iv. moderate, and v. severe) during FEES.


  4. Effectiveness of Phagenyx® treatment in reducing global dysphagia severity [ Time Frame: Day 2 (~24 to ~60 hours) after the final Phagenyx® treatment ]

    Exploratory analysis of changes in severity of dysphagia between FEES assessments measured by an IFRC using the Global Dysphagia Severity Rating Scale (GDS).

    The GDS is a simple, easy-to-use, 4-point scale developed to systematically rate the severity of dysphagia during FEES.

    0. No relevant dysphagia

    1. Mild dysphagia: Premature spillage and/or residues, but no penetration/aspiration events.
    2. Moderate dysphagia: Penetration/aspiration events with one consistency.
    3. Severe dysphagia: Penetration/aspiration events with two or more consistencies.

  5. Effectiveness of Phagenyx® treatment on time from extubation to hospital discharge [ Time Frame: Up to 14 ± 1 days after the final Phagenyx® treatment (or hospital discharge if earlier). ]
    Exploratory analysis of general health outcome measured by time from extubation to hospital discharge (days).

  6. Effectiveness of Phagenyx® treatment on days on antimicrobials post-extubation (while in ICU) [ Time Frame: Up to 14 ± 1 days after the final Phagenyx® treatment (or hospital discharge if earlier). ]
    Exploratory analysis of general health outcome measured by days on antimicrobials post-extubation (while in ICU).

  7. Effectiveness of Phagenyx® treatment on hospital discharge destination [ Time Frame: Up to 90 days after the final Phagenyx® treatment ]
    Exploratory analysis of general health outcome measured by hospital discharge destination (home, home+care, nursing home, other hospital, rehabilitation centre).

  8. Effectiveness of Phagenyx® treatment on ICU readmission rate during hospital stay [ Time Frame: Up to 14 ± 1 days after the final Phagenyx® treatment (or hospital discharge if earlier). ]
    Exploratory analysis of general health outcome measured by ICU readmission rate during hospital stay.

  9. Effectiveness of Phagenyx® treatment on tracheostomies per subgroup [ Time Frame: Up to 14 ± 1 days after the final Phagenyx® treatment (or hospital discharge if earlier). ]
    Exploratory analysis of general health outcome measured by number of and reason for tracheostomies per subgroup after PES-treatment during hospital stay.

  10. Effectiveness of Phagenyx® treatment on chest X-rays for suspected pneumonia. [ Time Frame: Up to 14 ± 1 days after the final Phagenyx® treatment (or hospital discharge if earlier). ]
    Exploratory analysis of general health outcome measured by total number of chest X-rays during hospital stay after ICU discharge for suspected pneumonia.



Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.


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Ages Eligible for Study:   18 Years to 85 Years   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Pre-screening Inclusion Criteria:

All of the following criteria must be met for inclusion:

  • Age ≥ 18 ≤ 85,
  • Emergency ICU admission (unplanned admission),
  • Recent extubation following invasive mechanical ventilation (of any length of time) by means of endotracheal tube,
  • Presence of post-extubation dysphagia as determined by bedside clinical assessment (within a maximum 8 hrs of extubation) according to the participating Sites' Standard Of Care (SOC).

Screening / Enrolment Criteria:

To be eligible for enrolment in this study, an individual must meet all of the following additional criteria:

  • Presence of written informed consent according to respective national guidelines,
  • Dysphagia severity status classified according to PAS on FEES assessment as 'aspiration' (PAS score ≥ 6),
  • Richmond Agitation and Sedation Scale (RASS) score within the range of -1 to +2 (i.e. if score equals -2, -3, -4 or +3, +4, patient is excluded).

Randomisation Inclusion Criteria (post-consent)

The following additional criteria must be met for randomisation:

• Successful placement and subjective tolerance of the Phagenyx® Catheter within 2 days of extubation.(post consent)

Exclusion Criteria:

An individual who meets any of the following criteria will be excluded from enrolment in this study:

  • Nasal anatomical deformity, nasal airway obstruction; patient who have had recent oral, nasal or oesophageal surgery or patient presenting with facial and/or cranial fractures or any other circumstance (e.g. history of oesophageal perforation, stricture, pouch, resection or rupture) where the placement of a standard nasogastric feeding tube (NGT) would be deemed unsafe,
  • Cardiac or respiratory condition that might render the insertion (placement) of a catheter into the throat unsafe,
  • Presence of a permanent cardiac pacemaker and/or intracardiac defibrillator pacemaker,
  • Are pregnant (pregnancy test) or known lactating women,
  • Have non-neurogenic dysphagia (e.g. Cancer-related),
  • Any prior tracheostomy,
  • Patients who at the time of extubation have any treatment limitation,
  • Severe cognitive impairment or other reasons that prevents compliance with study-specific instructions or procedures (as judged by the investigator),
  • Previous history of dysphagia of any origin,
  • Pre-existing tube feeding of any form (e.g. percutaneous gastric/enteral feeding tube related to previous injuries indicating previous dysphagia. NGTs are not an exclusion criterion),
  • Participation in another interventional study (medicinal or device) that could influence the outcomes of PES,
  • Treatment of dysphagia with other forms of electrical stimulation.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT03840395


Contacts
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Contact: Satish Mistry, PhD +44 161 820 4525 clinical@phagenesis.com
Contact: Tineke Sheers, PhD +32 486 78 04 20 tscheers@syntactx.com

Locations
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Finland
Helsinki University Hospital Perioperative, Intensive Care and Pain Medicine Active, not recruiting
Helsinki, Finland, 00029 HUS
Oulu University Hospital Active, not recruiting
Oulu, Finland, 90220 OULU
Switzerland
University Clinic for Intensive Medicine, Inselspital Recruiting
Bern, Switzerland, CH-3010
Contact: Joerg C Schefold, MD       Joerg.Schefold@insel.ch   
Sponsors and Collaborators
Phagenesis Ltd.
Syntactx
Cytel Inc.
Investigators
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Principal Investigator: Stephan Jakob, MD University Clinic for Intensive Medicine, Inselspital, University of Bern
Principal Investigator: Joerg C Schefold, MD University Clinic for Intensive Medicine, Inselspital, University of Bern
Principal Investigator: Minna Bäcklund, MD Helsinki University Hospital Perioperative, Intensive Care and Pain Medicine
Principal Investigator: Tero Ala-Kokko, MD Oulu University Hospital

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Responsible Party: Phagenesis Ltd.
ClinicalTrials.gov Identifier: NCT03840395     History of Changes
Other Study ID Numbers: AHE-06
First Posted: February 15, 2019    Key Record Dates
Last Update Posted: July 17, 2019
Last Verified: July 2019
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No

Keywords provided by Phagenesis Ltd.:
Dysphagia
Extubation
Intensive Care Unit
Pharyngeal Electrical Stimulation
Oropharyngeal Dysphagia
Mechanical Ventilation
Critically ill patients
Post-Extubation Dysphagia

Additional relevant MeSH terms:
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Deglutition Disorders
Esophageal Diseases
Gastrointestinal Diseases
Digestive System Diseases
Pharyngeal Diseases
Otorhinolaryngologic Diseases