[Dysphagia] Swallow post extubation

[eripley at yahoo.com (Irene Campbell-Taylor)]

          Swallowing disorders post orotracheal intubation in the elderly
  Intensive Care MedicineVolume 29, Number 9 / September, 2003
  Ali El Solh, Mifue Okada,Abid Bhat and Celestino Pietrantoni
   
   
  Abstract 
  Objectives  The purpose of this study was to assess the prevalence and recovery time of swallowing dysfunction after prolonged endotracheal intubation in critically ill elderly patients compared to a younger cohort.
  Design  This was a prospective, interventional, clinical study set in a medical intensive care unit in a university-affiliated hospital.
  Subjects  The study involved 42 consecutive elderly patients ( 65 years old) and 42 controls (<65 years) matched for severity of illness requiring endotracheal intubation for more than 48 h.
  Interventions  A fiberoptic endoscopic evaluation of swallowing (FEES) was performed within 48 h post-extubation and on days 5, 9, and 14 for those with evidence of aspiration.
  Results  Swallowing dysfunction was assessed by the detection of test material below the true vocal cords. Aspiration was documented in 52% of the elderly and 36% of the control group (P=0.2). No significant difference in the co-morbidity index and the length of mechanical ventilation was found between aspirators and non-aspirators. None of the control group had swallowing deficits after 2 weeks, while 13% of the elderly participants showed persistent impairment in the swallowing reflex. By multivariate analysis, the preadmission functional status was the only determinant of a slowly resolving swallowing deficit (hazard ratio 1.68; 95% confidence interval 1.26?3.97). No post-extubation aspiration pneumonia was identified in either group.
  Conclusions  Critically ill elderly patients exhibit delayed resolution of swallowing impairment post extubation. FEES should be considered for those with impaired preadmission functional status.
    
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  [
  de Larminat V; Montravers P; Dureuil B; Desmonts JM. Alteration in swallowing reflex after extubation in intensive care unit patients. Crit Care Med, 23:486-490.1995 
   
  The authors attempted to assess the swallowing reflex after prolonged endotracheal intubation and to assess the influence of age and duration of intubation on this reflex. Prospective, observational, clinical study.The swallowing reflex was studied after extubation in 34 patients and compared with deglutition in 30 nonintubated patients with a nasogastric tube and 15 nonintubated patients without a nasogastric tube.  Four volumes of normal saline (0.25, 0.50, 0.75, and 1 mL) were injected at the epipharynx level. Swallowing efficiency was assessed by the latency between instillation and the first swallow, as identified on a submental electromyogram. The tests were performed immediately (day 0), and at 1 (day 1), 2 (day 2), and 7 (day 7) days after extubation in the intubated group. Nonintubated patients were tested once.  On day 0, the latency was increased for each bolus in the extubated group when compared with the control groups. Significant shortening of latency after
 0.50, 0.75, and 1 mL injections of normal saline occurred on days 1 and 2 when compared with day 0, whereas no change was observed after 0.25 mL of normal saline was injected. On day 7, a significant improvement was observed, regardless of the volume injected. There was no correlation between swallowing latency and either the age of the patients or the duration of endotracheal intubation. These data indicate that prolonged endotracheal intubation impairs the swallowing reflex, with improvement within 1 wk..
   
   Leder SB; Cohn SM; Moller BA. Fiberoptic endoscopic documentation of the high incidence of aspiration following extubation in critically ill trauma patients.
  Dysphagia, 13:208-212  1998 
  The purpose of this study was to investigate the incidence of aspiration following extubation in critically ill trauma patients. This prospective pilot study included 20 consecutive trauma patients who required orotracheal intubation for at least 48 hours. All subjects underwent a bedside transnasal fiberoptic endoscopic evaluation of swallowing at 24 +/- 2 hr after extubation to determine objectively aspiration status. Aspiration was defined as the entry of a blue dyed material into the airway below the level of the true vocal folds, with silent aspiration occurring in the absence of any external behavioral signs such as coughing or choking. Aspiration was identified in 9 of 20 (45%) subjects and 4 of these 9 (44%) were silent aspirators. Therefore, silent aspiration occurred in 20% of the study population. Eight of the 9 (89%) aspirating subjects resumed an oral diet from 2-10 days (mean, 5 days) following extubation. All subjects had no evidence of pulmonary
 complications. It was concluded that trauma patients after orotracheal intubation and prolonged mechanical ventilation have an increased risk of aspiration.
   
  DOES POSTEXTUBATION FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING PREVENT ASPIRATION EPISODES? A RANDOMIZED, PROSPECTIVE TRIAL.(Abstract)
  Chest
  Oct, 2000
   
  Erik Barquist, MD(*); Margaret Brown, MSN; Donna S Lundy, MS, CCC; Jeanne M Lopez, BSN and Stephen M Cohn, MD. Trauma & Surgical Critical Care, University of Miami School of Medicine, Miami, FL.
   
  PURPOSE: Prolonged orotracheal intubation causes swallowing dysfunction in up to 50% of patients, 40% of these patients have aspiration episodes which are occult. We hypothesized that Fiberoptic Endoscopic Evaluation of Swallowing (FEES) could detect those at risk of aspiration and that diet alteration could prevent post-extubation pneumonias (PEP).
   
  METHODS: We conducted a randomized, prospective trial of FEES vs. clinical observation in 70 patients who were intubated for > 48 hours post trauma. All patients had a FEES within [+ or -] 2 hours post extubation. Aspiration (ASP) was defined as the appearance of liquid or puree bolus below the true vocal cords(FEES), or removal of enteral contents from below the vocal cords via suctioning from an emergently placed endotracheal tube (observation). Silent ASP was found on FEES by direct visualization.
   
  RESULTS: There were five episodes of ASP with PEP in the FEES group (14%, 2 silent) and 2 in the clinical group (6%, p=NS, Fisher Exact Test). All patients who developed PEP had an associated ASP.
   
  CONCLUSION: Patients with prolonged orotracheal intubation are at risk of aspiration after extubation. The addition of a FEES did not change the incidence of aspiration or subsequent post extubation pneumonia.
   
  CLINICAL IMPLICATIONS: The addition of a FEES did not change the incidence of aspiration or subsequent post extubation pneumonia.
   
                FEES(n=37)          Observation (n=33)   p value
   
   
   
  AGE           41   [+ or -] 16    44   [+ or -] 19     0.41
   
  MALE(%)       81%                 67%                  0.27
   
  GCS (admit)   12.5 [+ or -] 3.7   13.3 [+ or -] 2.9    0.33
   
  ISS           25   [+ or -] 14    23   [+ or -] 10     0.42
   
  VENT DAYS     13   [+ or -] 11    10   [+ or -] 8      0.15
   
  ICU DAYS      19   [+ or -] 13    18   [+ or -] 25     0.83
   
   
   
   
   
   


Dr I Campbell-Taylor
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