Skip to main content
SpringerLink
Log in

Relationship Between Laryngeal Sensation, Length of Intubation, and Aspiration in Patients with Acute Respiratory Failure

  • Original Article
  • Published:
Dysphagia Aims and scope Submit manuscript

Abstract

Dysphagia is common in hospitalized patients post-extubation and associated with poor outcomes. Laryngeal sensation is critical for airway protection and safe swallowing. However, current understanding of the relationship between laryngeal sensation and aspiration in post-extubation populations is limited. Acute respiratory failure patients requiring intensive care unit admission and mechanical ventilation received a Flexible Endoscopic Evaluation of Swallowing (FEES) within 72 h of extubation. Univariate and multivariable analyses were performed to examine the relationship between laryngeal sensation, length of intubation, and aspiration. Secondary outcomes included pharyngolaryngeal secretions, pneumonia, and diet recommendations. One-hundred and three patients met inclusion criteria. Fifty-one patients demonstrated an absent laryngeal adductor reflex (LAR). Altered laryngeal sensation correlated with the presence of secretions (p = 0.004). There was a significant interaction between the LAR, aspiration, and duration of mechanical ventilation. Altered laryngeal sensation was significantly associated with aspiration on FEES only in patients with a shorter length of intubation (p = 0.008). Patients with altered laryngeal sensation were prescribed significantly more restricted liquid (p = 0.03) and solid (p = 0.001) diets. No relationship was found between laryngeal sensation and pneumonia. There is a high prevalence of laryngeal sensory deficits in mechanically ventilated patients post-extubation. Altered laryngeal sensation was associated with secretions, aspiration, and modified diet recommendations especially in those patients with a shorter length of mechanical ventilation. These results demonstrate that laryngeal sensory abnormalities impact the development of post-extubation dysphagia.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Wunsch H, Linde-Zwirble WT, Angus DC, Hartman ME, Milbrandt EB, Kahn JM. The epidemiology of mechanical ventilation use in the United States. Crit Care Med. 2010;38(10):1947–53.

    Article  PubMed  Google Scholar 

  2. Skoretz SA, Flowers HL, Martino R. The incidence of dysphagia following endotracheal intubation: a systematic review. Chest. 2010;137(3):665–73.

    Article  PubMed  Google Scholar 

  3. Macht M, Wimbish T, Clark BJ, Benson AB, Burnham EL, Williams A, et al. Postextubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness. Crit Care. 2011;15(5):R231.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Brodsky MB, Huang M, Shanholtz C, Mendez-Tellez PA, Palmer JB, Colantuoni E, et al. Recovery from Dysphagia Symptoms after Oral Endotracheal Intubation in Acute Respiratory Distress Syndrome Survivors. A 5-Year Longitudinal Study. Ann Am Thorac Soc. 2017;14(3):376–83.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Macht M, Wimbish T, Bodine C, Moss M. ICU-acquired swallowing disorders. Crit Care Med. 2013;41(10):2396–405.

    Article  PubMed  Google Scholar 

  6. Leder SB, Suiter DM, Lisitano Warner H. Answering orientation questions and following single-step verbal commands: effect on aspiration status. Dysphagia. 2009;24(3):290–5.

    Article  PubMed  Google Scholar 

  7. Metheny NA, Clouse RE, Chang YH, Stewart BJ, Oliver DA, Kollef MH. Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients: frequency, outcomes, and risk factors. Crit Care Med. 2006;34(4):1007–15.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Gross RD, Atwood CW, Ross SB, Olszewski JW, Eichhorn KA. The coordination of breathing and swallowing in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2009;179(7):559–65.

    Article  PubMed  Google Scholar 

  9. Shaker R, Li Q, Ren J, Townsend WF, Dodds WJ, Martin BJ, et al. Coordination of deglutition and phases of respiration: effect of aging, tachypnea, bolus volume, and chronic obstructive pulmonary disease. Am J Physiol. 1992;263:G750–5.

    Article  CAS  PubMed  Google Scholar 

  10. Colton House J, Noordzij JP, Murgia B, Langmore S. Laryngeal injury from prolonged intubation: a prospective analysis of contributing factors. Laryngoscope. 2011;121(3):596–600.

    Article  PubMed  Google Scholar 

  11. Scheel R, Pisegna JM, McNally E, Noordzij JP, Langmore SE. Endoscopic assessment of swallowing after prolonged intubation in the ICU setting. Ann Otol Rhinol Laryngol. 2016;125(1):43–52.

    Article  PubMed  Google Scholar 

  12. Su H, Hsiao TY, Ku SC, Wang TG, Lee JJ, Tzeng WC, et al. Tongue weakness and somatosensory disturbance following oral endotracheal extubation. Dysphagia. 2015;30(2):188–95.

    Article  PubMed  Google Scholar 

  13. Aviv JE, Spitzer J, Cohen M, Ma G, Belafsky P, Close LG. Laryngeal adductor reflex and pharyngeal squeeze as predictors of laryngeal penetration and aspiration. Laryngoscope. 2002;112(2):338–41.

    Article  PubMed  Google Scholar 

  14. Langmore SE, Schatz K, Olsen N. Fiberoptic endoscopic examination of swallowing safety: a new procedure. Dysphagia. 1988;2(4):216–9.

    Article  CAS  PubMed  Google Scholar 

  15. Domer AS, Kuhn MA, Belafsky PC. Neurophysiology and clinical implications of the laryngeal adductor reflex. Curr Otorhinolaryngol Rep. 2013;1(3):178–82.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Jafari S, Prince RA, Kim DY, Paydarfar D. Sensory regulation of swallowing and airway protection: a role for the internal superior laryngeal nerve in humans. J Physiol. 2003;550(Pt 1):287–304.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Barkmeier JM, Bielamowicz S, Takeda N, Ludlow CL. Modulation of laryngeal responses to superior laryngeal nerve stimulation by volitional swallowing in awake humans. J Neurophysiol. 2000;83(3):1264–72.

    Article  CAS  PubMed  Google Scholar 

  18. Onofri SM, Cola PC, Berti LC, da Silva RG, Dantas RO. Correlation between laryngeal sensitivity and penetration/aspiration after stroke. Dysphagia. 2014;29(2):256–61.

    Article  PubMed  Google Scholar 

  19. Murray J, Langmore SE, Ginsberg S, Dostie A. The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia. 1996;11(2):99–103.

    Article  CAS  PubMed  Google Scholar 

  20. Kaneoka A, Pisegna JM, Inokuchi H, Ueha R, Goto T, Nito T, et al. Relationship between laryngeal sensory deficits, aspiration, and pneumonia in patients with dysphagia. Dysphagia. 2017;33:192–9.

    Article  PubMed  Google Scholar 

  21. Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia. 1996;11(2):93–8.

    Article  CAS  PubMed  Google Scholar 

  22. Donzelli J, Brady S, Wesling M, Craney M. Predictive value of accumulated oropharyngeal secretions for aspiration during video nasal endoscopic evaluation of the swallow. Ann Otol Rhinol Laryngol. 2003;112(5):469–75.

    Article  PubMed  Google Scholar 

  23. Brodsky MB, De I, Chilukuri K, Huang M, Palmer JB, Needham DM. Coordination of pharyngeal and laryngeal swallowing events during single liquid swallows after oral endotracheal intubation for patients with acute respiratory distress syndrome. Dysphagia. 2018;33(6):768–77.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Rousou JA, Tighe DA, Garb JL, Krasner H, Engelman RM, Flack JE, et al. Risk of dysphagia after transesophageal echocardiography during cardiac operations. Ann Thorac Surg. 2000;69(2):486–9.

    Article  CAS  PubMed  Google Scholar 

  25. 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(2):119–24.

    PubMed  PubMed Central  Google Scholar 

  26. Brown CV, Hejl K, Mandaville AD, Chaney PE, Stevenson G, Smith C. Swallowing dysfunction after mechanical ventilation in trauma patients. J Crit Care. 2011;26(1):108.e9–13.

    Article  Google Scholar 

  27. Kwok AM, Davis JW, Cagle KM, Sue LP, Kaups KL. Post-extubation dysphagia in trauma patients: it’s hard to swallow. Am J Surg. 2013;206(6):924–7.

    Article  PubMed  Google Scholar 

  28. Brodsky MB, González-Fernández M, Mendez-Tellez PA, Shanholtz C, Palmer JB, Needham DM. Factors associated with swallowing assessment after oral endotracheal intubation and mechanical ventilation for acute lung injury. Ann Am Thorac Soc. 2014;11(10):1545–52.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Bordon A, Bokhari R, Sperry J, Testa D, Feinstein A, Ghaemmaghami V. Swallowing dysfunction after prolonged intubation: analysis of risk factors in trauma patients. Am J Surg. 2011;202(6):679–82.

    Article  PubMed  Google Scholar 

  30. Skoretz SA, Yau TM, Ivanov J, Granton JT, Martino R. Dysphagia and associated risk factors following extubation in cardiovascular surgical patients. Dysphagia. 2014;29(6):647–54.

    Article  PubMed  Google Scholar 

  31. 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(4):434–7.

    Article  CAS  PubMed  Google Scholar 

  32. El Solh A, Okada M, Bhat A, Pietrantoni C. Swallowing disorders post orotracheal intubation in the elderly. Intensive Care Med. 2003;29(9):1451–5.

    Article  PubMed  Google Scholar 

  33. 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):1710–3.

    Article  CAS  PubMed  Google Scholar 

  34. Marvin S, Thibeault S, Ehlenbach WJ. Post-extubation Dysphagia: Does timing of evaluation matter? Dysphagia. 2018. https://doi.org/10.1007/s00455-018-9926-3.

    Article  PubMed  Google Scholar 

  35. Kaneoka A, Pisegna JM, Krisciunas GP, Nito T, LaValley MP, Stepp CE, et al. Variability of the pressure measurements exerted by the tip of laryngoscope during laryngeal sensory testing: a clinical demonstration. Am J Speech Lang Pathol. 2017;26(3):729–36.

    Article  PubMed  Google Scholar 

  36. Hammer MJ. Design of a new somatosensory stimulus delivery device for measuring laryngeal mechanosensory detection thresholds in humans. IEEE Trans Biomed Eng. 2009;56(4):1154–9.

    Article  PubMed  Google Scholar 

  37. Kaneoka A, Krisciunas GP, Walsh K, Raade AS, Langmore SE. A comparison of 2 methods of endoscopic laryngeal sensory testing: a preliminary study. Ann Otol Rhinol Laryngol. 2015;124(3):187–93.

    Article  PubMed  Google Scholar 

Download references

Funding

National Institutes of Health (Grant Number: R21NR015886) provided funding for this study.

Author information

Authors and Affiliations

  1. Department of Otolaryngology, Boston University Medical Center, Boston, MA, USA

    James C. Borders, Edel McNally & Rebecca Scheel

  2. Department of Otolaryngology, University of Colorado Denver, Aurora, CO, USA

    Daniel Fink

  3. Division of Pulmonary and Critical Care, Stanford University, Stanford, CA, USA

    Joseph E. Levitt & Rosemary Vojnik

  4. University of Colorado Hospital, Aurora, CO, USA

    Jeffrey McKeehan

  5. Department of Otolaryngology, Boston University School of Medicine, Boston, MA, USA

    Alix Rubio, Stephanie Gomez Taborda, Susan E. Langmore & Gintas P. Krisciunas

  6. Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, CT, USA

    Jonathan M. Siner

  7. Department of Surgery, Section of Otolaryngology, Yale School of Medicine, New Haven, CT, USA

    Heather Warner

  8. Department of Communication Disorders, Southern Connecticut State University, New Haven, CT, USA

    Heather Warner

  9. Rehabilitation Therapy Services, University of Colorado Hospital, Aurora, CO, USA

    S. David White

  10. Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, MA, USA

    Susan E. Langmore

  11. Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, Aurora, CO, USA

    Marc Moss

Authors
  1. James C. Borders
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Daniel Fink
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Joseph E. Levitt
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jeffrey McKeehan
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Edel McNally
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Alix Rubio
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Rebecca Scheel
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Jonathan M. Siner
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Stephanie Gomez Taborda
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Rosemary Vojnik
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Heather Warner
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. S. David White
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Susan E. Langmore
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Marc Moss
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Gintas P. Krisciunas
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to James C. Borders.

Ethics declarations

Conflicts of interest

All authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Approval was obtained from each site’s Institutional Review Board.

Informed Consent

Informed consent was obtained from all participants prior to enrollment in this research study.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Borders, J.C., Fink, D., Levitt, J.E. et al. Relationship Between Laryngeal Sensation, Length of Intubation, and Aspiration in Patients with Acute Respiratory Failure. Dysphagia 34, 521–528 (2019). https://doi.org/10.1007/s00455-019-09980-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00455-019-09980-1

Keywords

Search

Navigation