The Association Between Endotracheal Tube Size and Aspiration (During Flexible Endoscopic Evaluation of Swallowing) in Acute Respiratory Failure Survivors

Abstract

Objectives: To determine whether a modifiable risk factor, endotracheal tube size, is associated with the diagnosis of postextubation aspiration in survivors of acute respiratory failure.

Design: Prospective cohort study.

Setting: ICUs at four academic tertiary care medical centers.

Patients: Two hundred ten patients who were at least 18 years old, admitted to an ICU, and mechanically ventilated with an endotracheal tube for longer than 48 hours were enrolled.

Interventions: Within 72 hours of extubation, all patients received a flexible endoscopic evaluation of swallowing examination that entailed administration of ice, thin liquid, thick liquid, puree, and cracker boluses. Patient demographics, treatment variables, and hospital outcomes were abstracted from the patient's medical records. Endotracheal tube size was independently selected by the patient's treating physicians.

Measurements and main results: For each flexible endoscopic evaluation of swallowing examination, laryngeal pathology was evaluated, and for each bolus, a Penetration Aspiration Scale score was assigned. Aspiration (Penetration Aspiration Scale score ≥ 6) was further categorized into nonsilent aspiration (Penetration Aspiration Scale score = 6 or 7) and silent aspiration (Penetration Aspiration Scale score = 8). One third of patients (n = 68) aspirated (Penetration Aspiration Scale score ≥ 6) on at least one bolus, 13.6% (n = 29) exhibited silent aspiration, and 23.8% (n = 50) exhibited nonsilent aspiration. In a multivariable analysis, endotracheal tube size (≤ 7.5 vs ≥ 8.0) was significantly associated with patients exhibiting any aspiration (Penetration Aspiration Scale score ≥ 6) (p = 0.016; odds ratio = 2.17; 95% CI 1.14-4.13) and with risk of developing laryngeal granulation tissue (p = 0.02).

Conclusions: Larger endotracheal tube size was associated with increased risk of aspiration and laryngeal granulation tissue. Using smaller endotracheal tubes may reduce the risk of postextubation aspiration.

Trial registration: ClinicalTrials.gov NCT02363686.

Conflict of interest statement

Conflicts of Interest

The authors declare that they have no conflict of interest.

Copyright form disclosure: Drs. Krisciunas, Landmore, Levitt, McKeehan, McNally, Scheel, Rubio, Vojnik, Warner, and Moss’s institutions received funding from National Institutes of Health (NIH). Drs. Krisciunas, Landmore, Gomez-Taborda, Levitt, McKeehan, McNally, Scheel, Rubio, Vojnik, Warner, and Moss received support for article research from the NIH. Dr. Siner’s institution received funding from the University of Colorado. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

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Consort Diagram