Postextubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness

Madison Macht, Tim Wimbish, Brendan J Clark, Alexander B Benson, Ellen L Burnham, André Williams, Marc Moss, Madison Macht, Tim Wimbish, Brendan J Clark, Alexander B Benson, Ellen L Burnham, André Williams, Marc Moss

Abstract

Introduction: Dysphagia is common among survivors of critical illness who required mechanical ventilation during treatment. The risk factors associated with the development of postextubation dysphagia, and the effects of dysphagia on patient outcomes, have been relatively unexplored.

Methods: We conducted a retrospective, observational cohort study from 2008 to 2010 of all patients over 17 years of age admitted to a university hospital ICU who required mechanical ventilation and subsequently received a bedside swallow evaluation (BSE) by a speech pathologist.

Results: A BSE was performed after mechanical ventilation in 25% (630 of 2,484) of all patients. After we excluded patients with stroke and/or neuromuscular disease, our study sample size was 446 patients. We found that dysphagia was present in 84% of patients (n = 374) and classified dysphagia as absent, mild, moderate or severe in 16% (n = 72), 44% (n = 195), 23% (n = 103) and 17% (n = 76), respectively. In univariate analyses, we found that statistically significant risk factors for severe dysphagia included long duration of mechanical ventilation and reintubation. In multivariate analysis, after adjusting for age, gender and severity of illness, we found that mechanical ventilation for more than seven days remained independently associated with moderate or severe dysphagia (adjusted odds ratio (AOR) = 2.84 [interquartile range (IQR) = 1.78 to 4.56]; P < 0.01). The presence of severe postextubation dysphagia was significantly associated with poor patient outcomes, including pneumonia, reintubation, in-hospital mortality, hospital length of stay, discharge status and surgical placement of feeding tubes. In multivariate analysis, we found that the presence of moderate or severe dysphagia was independently associated with the composite outcome of pneumonia, reintubation and death (AOR = 3.31 [IQR = 1.89 to 5.90]; P < 0.01).

Conclusions: In a large cohort of critically ill patients, long duration of mechanical ventilation was independently associated with postextubation dysphagia, and the development of postextubation dysphagia was independently associated with poor patient outcomes.

Figures

Figure 1
Figure 1
Flowchart detailing enrollment of subjects. BSE = bedside swallow evaluation; CVA = cerebrovascular accident.
Figure 2
Figure 2
Association between dysphagia severity and pneumonia, reintubation and mortality.

References

    1. Behrendt CE. Acute respiratory failure in the United States: incidence and 31-day survival. Chest. 2000;118:1100–1105. doi: 10.1378/chest.118.4.1100.
    1. Esteban A, Anzueto A, Frutos F, Alía I, Brochard L, Stewart TE, Benito S, Epstein SK, Apezteguía C, Nightingale P, Arroliga AC, Tobin MJ. for the Mechanical Ventilation International Study Group. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA. 2002;287:345–355. doi: 10.1001/jama.287.3.345.
    1. Garland A, Dawson NV, Altmann I, Thomas CL, Phillips RS, Tsevat J, Desbiens NA, Bellamy PE, Knaus WA, Connors AF Jr. for the SUPPORT Investigators. Outcomes up to 5 years after severe, acute respiratory failure. Chest. 2004;126:1897–1904. doi: 10.1378/chest.126.6.1897.
    1. Myhren H, Ekeberg Ø, Stokland O. Health-related quality of life and return to work after critical illness in general intensive care unit patients: a 1-year follow-up study. Crit Care Med. 2010;38:1554–1561. doi: 10.1097/CCM.0b013e3181e2c8b1.
    1. Orme JF Jr, Romney JS, Hopkins RO, Pope D, Chan KJ, Thomsen G, Crapo RO, Weaver LK. Pulmonary function and health-related quality of life in survivors of acute respiratory distress syndrome. Am J Respir Crit Care Med. 2003;167:690–694. doi: 10.1164/rccm.200206-542OC.
    1. Hopkins RO, Weaver LK, Collingridge D, Parkinson RB, Chan KJ, Orme JF Jr. Two-year cognitive, emotional, and quality-of-life outcomes in acute respiratory distress syndrome. Am J Respir Crit Care Med. 2005;171:340–347. doi: 10.1164/rccm.200406-763OC.
    1. De Jonghe B, Sharshar T, Lefaucheur JP, Authier FJ, Durand-Zaleski I, Boussarsar M, Cerf C, Renaud E, Mesrati F, Carlet J, Raphaël JC, Outin H, Bastuji-Garin S. Groupe de Réflexion et d'Etude des Neuromyopathies en Réanimation. Paresis acquired in the intensive care unit: a prospective multicenter study. JAMA. 2002;288:2859–2867. doi: 10.1001/jama.288.22.2859.
    1. Herridge MS, Tansey CM, Matté A, Tomlinson G, Diaz-Granados N, Cooper A, Guest CB, Mazer CD, Mehta S, Stewart TE, Kudlow P, Cook D, Slutsky AS, Cheung AM. Canadian Critical Care Trials Group. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med. 2011;364:1293–1304. doi: 10.1056/NEJMoa1011802.
    1. Ali NA, O'Brien JM Jr, Hoffmann SP, Phillips G, Garland A, Finley JC, Almoosa K, Hejal R, Wolf KM, Lemeshow S, Connors AF Jr, Marsh CB. Midwest Critical Care Consortium. Acquired weakness, handgrip strength, and mortality in critically ill patients. Am J Respir Crit Care Med. 2008;178:261–268. doi: 10.1164/rccm.200712-1829OC.
    1. Ekberg O, Hamdy S, Woisard V, Wuttge-Hannig A, Ortega P. Social and psychological burden of dysphagia: its impact on diagnosis and treatment. Dysphagia. 2002;17:139–146. doi: 10.1007/s00455-001-0113-5.
    1. Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001;344:665–671. doi: 10.1056/NEJM200103013440908.
    1. Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke. 2005;36:2756–2763. doi: 10.1161/01.STR.0000190056.76543.eb.
    1. Skoretz SA, Flowers HL, Martino R. The incidence of dysphagia following endotracheal intubation: a systematic review. Chest. 2010;137:665–673. doi: 10.1378/chest.09-1823.
    1. Herrera LJ, Correa AM, Vaporciyan AA, Hofstetter WL, Rice DC, Swisher SG, Walsh GL, Roth JA, Mehran RJ. Increased risk of aspiration and pulmonary complications after lung resection in head and neck cancer patients. Ann Thorac Surg. 2006;82:1982–1988. doi: 10.1016/j.athoracsur.2006.06.018.
    1. Smith-Hammond CA, New KC, Pietrobon R, Curtis DJ, Scharver CH, Turner DA. Prospective analysis of incidence and risk factors of dysphagia in spine surgery patients: comparison of anterior cervical, posterior cervical, and lumbar procedures. Spine (Phila Pa 1976) 2004;29:1441–1446. doi: 10.1097/01.BRS.0000129100.59913.EA.
    1. Ward EC, Bishop B, Frisby J, Stevens M. Swallowing outcomes following laryngectomy and pharyngolaryngectomy. Arch Otolaryngol Head Neck Surg. 2002;128:181–186.
    1. Barker J, Martino R, Reichardt B, Hickey EJ, Ralph-Edwards A. Incidence and impact of dysphagia in patients receiving prolonged endotracheal intubation after cardiac surgery. Can J Surg. 2009;52:119–124.
    1. Rousou JA, Tighe DA, Garb JL, Krasner H, Engelman RM, Flack JE, Deaton DW. Risk of dysphagia after transesophageal echocardiography during cardiac operations. Ann Thorac Surg. 2000;69:486–490. doi: 10.1016/S0003-4975(99)01086-3.
    1. 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;29:1710–1713. doi: 10.1097/00003246-200109000-00009.
    1. de Larminat V, Montravers P, Dureuil B, Desmonts JM. Alteration in swallowing reflex after extubation in intensive care unit patients. Crit Care Med. 1995;23:486–490. doi: 10.1097/00003246-199503000-00012.
    1. El Solh A, Okada M, Bhat A, Pietrantoni C. Swallowing disorders post orotracheal intubation in the elderly. Intensive Care Med. 2003;29:1451–1455. doi: 10.1007/s00134-003-1870-4.
    1. Heffner JE. Swallowing complications after endotracheal extubation: moving from "whether" to "how.". Chest. 2010;137:509–510. doi: 10.1378/chest.09-2477.
    1. Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy: a prospective study of 150 critically ill adult patients. Am J Med. 1981;70:65–76. doi: 10.1016/0002-9343(81)90413-7.
    1. O'Neil KH, Purdy M, Falk J, Gallo L. The Dysphagia Outcome and Severity Scale. Dysphagia. 1999;14:139–145. doi: 10.1007/PL00009595.
    1. National Dysphagia Diet Task Force. The National Dysphagia Diet: Standardization for Optimal Care. Chicago: National Dysphagia Diet Task Force; 2002.
    1. Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia. 1996;11:93–98. doi: 10.1007/BF00417897.
    1. American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171:388–416.
    1. Ajemian MS, Nirmul GB, Anderson MT, Zirlen DM, Kwasnik EM. Routine fiberoptic endoscopic evaluation of swallowing following prolonged intubation: implications for management. Arch Surg. 2001;136:434–437. doi: 10.1001/archsurg.136.4.434.
    1. Hogue CW Jr, Lappas GD, Creswell LL, Ferguson TB, Sample M, Pugh D, Balfe D, Cox JL, Lappas DG. Swallowing dysfunction after cardiac operations: associated adverse outcomes and risk factors including intraoperative transesophageal echocardiography. J Thorac Cardiovasc Surg. 1995;110:517–522. doi: 10.1016/S0022-5223(95)70249-0.
    1. Romero CM, Marambio A, Larrondo J, Walker K, Lira MT, Tobar E, Cornejo R, Ruiz M. Swallowing dysfunction in nonneurologic critically ill patients who require percutaneous dilatational tracheostomy. Chest. 2010;137:1278–1282. doi: 10.1378/chest.09-2792.
    1. Altman KW, Yu GP, Schaefer SD. Consequence of dysphagia in the hospitalized patient: impact on prognosis and hospital resources. Arch Otolaryngol Head Neck Surg. 2010;136:784–789. doi: 10.1001/archoto.2010.129.
    1. François B, Bellissant E, Gissot V, Desachy A, Normand S, Boulain T, Brenet O, Preux PM, Vignon P. Association des Réanimateurs du Centre-Ouest (ARCO) 12-h pretreatment with methylprednisolone versus placebo for prevention of postextubation laryngeal oedema: a randomised double-blind trial. Lancet. 2007;369:1083–1089. doi: 10.1016/S0140-6736(07)60526-1.
    1. Kelly AM, Drinnan MJ, Leslie P. Assessing penetration and aspiration: how do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare? Laryngoscope. 2007;117:1723–1727. doi: 10.1097/MLG.0b013e318123ee6a.
    1. Kelly AM, Leslie P, Beale T, Payten C, Drinnan MJ. Fibreoptic endoscopic evaluation of swallowing and videofluoroscopy: does examination type influence perception of pharyngeal residue severity? Clin Otolaryngol. 2006;31:425–432. doi: 10.1111/j.1749-4486.2006.01292.x.
    1. Leder SB, Espinosa JF. Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia. 2002;17:214–218. doi: 10.1007/s00455-002-0054-7.

Source: PubMed

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