Skip to main content

Post-extubation Dysphagia: Does Timing of Evaluation Matter?

Abstract

Swallowing evaluations are often delayed at least 24 h following extubation with the assumption that swallow function improves over time. The purpose of this prospective cohort study was to determine if dysphagia, as measured by aspiration and need for diet modification, declines over the first 24-h post-extubation, whereby providing evidence-based evaluation guidelines for this population. Forty-nine patients completed FEES at 2–4 h post-extubation and 24–26 h post-extubation. We compared Penetration–Aspiration Scale scores and diet recommendation between time points. Multivariable logistic regression models were created to investigate associations between age, reason for admission, reason for intubation, and a history of COPD and outcomes of aspiration or silent aspiration at either FEES exam. Sixty-nine percent of participants safely swallowed at least one texture without aspiration at 2–4 h post-extubation. Within participants, there was a significant decrease in penetration/aspiration at 24 h and 79% showed improvement in airway protection on at least one bolus type, suggesting an improvement in swallow function over the first day following extubation. These findings suggest that although patients may be safe to begin a modified diet soon after extubation, delaying evaluation until 24-h post-extubation may allow for a less restricted diet.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2

References

  1. 1.

    Ajemain MS, Nirmul GB, Anderson MT, Zirlen DM, Kwasnik EM. Routine fiberoptic endoscopic evaluation of swallowing following prolonged intubation. Arch Surg. 2001;136:434–7.

    Article  Google Scholar 

  2. 2.

    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;52:119–24.

    PubMed  PubMed Central  Google Scholar 

  3. 3.

    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;202:679–823. https://doi.org/10.1016/j.amjsurg.2011.06.030.

    Article  PubMed  Google Scholar 

  4. 4.

    Colice G, Stukel T, Dain B. Laryngeal complications of prolonged intubation. Chest. 1989;96:877–84. https://doi.org/10.1378/chest.96.4.877.

    Article  CAS  Google Scholar 

  5. 5.

    El Solh A, Okada M, Bhat A, Pietrantoni C. Swallowing disorders post orotracheal intubation in the elderly. Intensive Care Med. 2003;29:1451–5. https://doi.org/10.1007/s00134-003-1870-4.

    Article  PubMed  Google Scholar 

  6. 6.

    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;206:924–8. https://doi.org/10.1016/j.amjsurg.2013.08.010.

    Article  PubMed  Google Scholar 

  7. 7.

    Macht M, White SD, Moss M. Swallowing dysfunction after critical illness. Chest. 2014;146:1681–9. https://doi.org/10.1378/chest.14-1133.

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Ferraris VA, Ferraris SP, Moritz DM, Welch S. Oropharyngeal dysphagia after cardiac operations. Ann Thorac Surg. 2001;71:1792–6. https://doi.org/10.1016/S0003-4975(01)02640-6.

    Article  CAS  PubMed  Google Scholar 

  9. 9.

    Macht M, King CJ, Wimbish T, Clark BJ, Benson AB, Burnham EL, et al. Post-extubation dysphagia is associated with longer hospitalization in survivors of critical illness with neurologic impairment. Crit Care. 2013;17:R119. https://doi.org/10.1186/cc12791.

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Skoretz SA, Flowers HL, Martino R. The incidence of dysphagia following endotracheal intubation: a systematic review. Chest. 2010;137:665–73. https://doi.org/10.1378/chest.09-1823.

    Article  PubMed  Google Scholar 

  11. 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;125:43–52. https://doi.org/10.1177/0003489415596755.

    Article  Google Scholar 

  12. 12.

    Hafner G, Neuhuber A, Hirtenfelder S, Schmedler B, Eckel HE. Fiberoptic endoscopic evaluation of swallowing in intensive care unit patients. Eur Arch Otorhinolaryngol. 2008;265:441–6. https://doi.org/10.1007/s00405-007-0507-6.

    Article  PubMed  Google Scholar 

  13. 13.

    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:R231. https://doi.org/10.1186/cc10472.

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Macht M, Wimbish T, Clark BJ, Benson AB, Burnham EL, Williams A, et al. Diagnosis and treatment of post-extubation dysphagia: Results from a national survey. J Crit Care. 2012;27:578–86. https://doi.org/10.1016/j.jcrc.2012.07.016.

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia. 1996;11:93–8. https://doi.org/10.1007/BF00417897.

    Article  CAS  Google Scholar 

  16. 16.

    Butler SG, Markley L, Sanders B, Stuart A. Reliability of the penetration aspiration scale with flexible endoscopic evaluation of swallowing. Ann Otol Rhinol Laryngol. 2015;124:480–3. https://doi.org/10.1177/0003489414566267.

    Article  PubMed  Google Scholar 

  17. 17.

    Robbins J, Coyle J, Rosenbek J, Roecker E, Wood J. Differentiation of normal and abnormal airway protection during swallowing using the Penetration-Aspiration Scale. Dysphagia. 1999;14:228–32. https://doi.org/10.1007/PL00009610.

    Article  CAS  PubMed  Google Scholar 

  18. 18.

    Zhang J, Yu KF. What’s the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA. 1998;280:1690–1. https://doi.org/10.1001/jama.280.19.1690.

    Article  CAS  Google Scholar 

  19. 19.

    Brown CVR, Hejl K, Mandaville AD, Chaney PE, Stevenson G, Smith C. Swallowing dysfunction after mechanical ventilation in trauma patients. J Crit Care. 2011;26(108):9–13. https://doi.org/10.1016/j.jcrc.2010.05.036.

    Article  Google Scholar 

  20. 20.

    Skoretz S, Yau TM, Ivanov J, Granton JT, Martino R. Dysphagia and associated risk factors following extubation in cardiovascular surgical patients. Dysphagia. 2014;29:647–54. https://doi.org/10.1007/s00455-014-9555-4.

    Article  PubMed  Google Scholar 

  21. 21.

    Holland G, Jayasekeran V, Pendleton N, Horan M, Jones M, Hamdy S. Prevalence and symptom profiling of oropharyngeal dysphagia in a community dwelling of an elderly population: a self-reporting questionnaire survey. Dis Esophagus. 2011;24:476–80. https://doi.org/10.1111/j.1442-2050.2011.01182.x.

    Article  CAS  PubMed  Google Scholar 

  22. 22.

    Nimmons D, Michou E, Jones M, Pendleton N. A longitudinal study of symptoms of oropharyngeal dysphagia in an elderly community-dwelling population. Dysphagia. 2016. https://doi.org/10.1007/s00455-016-9715-9.

    Article  PubMed  PubMed Central  Google Scholar 

  23. 23.

    Shaker R, Ren J, Bardan E, Easterling C, Dua K, Xie P, et al. Pharyngoglottal closure reflex: characterization in healthy young, elderly and Dysphagic patients with predeglutitive aspiration. Gerontology. 2003;53226:12–20. https://doi.org/10.1159/000066504.

    Article  Google Scholar 

  24. 24.

    Schindler JS, Kelly JH. Swallowing disorders in the elderly. Laryngoscope. 2002;112(4):589–602.

    Article  PubMed  Google Scholar 

  25. 25.

    Centre N, Mars TR, Bartholomew S, Physics RM, Hospital F, Accepted UK, et al. Pharyngeal residue across the lifespan: a first look at what’s normal 2008;348–51.

  26. 26.

    Rodrigues M, Macri B, Marques JM, Santos RS, Furkim AM, Melek I, et al. Clinical and fiberoptic endoscopic assessment of swallowing in patients with chronic obstructive pulmonary disease. Int Arch Otorhinolaryngol. 2013;17:274–8. https://doi.org/10.7162/S1809-97772013000300007.

    Article  Google Scholar 

  27. 27.

    Cvejic LY, Harding RI, Churchward TH, Turton AN, Finlay P, Massey DA, et al. Laryngeal penetration and aspiration in individuals with stable COPD. Respirology. 2011;16(2):269–75. https://doi.org/10.1111/j.1440-1843.2010.01875.x.

    Article  PubMed  Google Scholar 

  28. 28.

    Jaber S, Amraoui J, Lefrant J, Arich C, Cohendy R, Landreau L, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med. 2006;34:2355–61. https://doi.org/10.1097/01.CCM.0000233879.58720.87.

    Article  PubMed  Google Scholar 

  29. 29.

    Leder SB, Suiter DM, Green BG. Silent aspiration risk is volume-dependent. Dysphagia. 2011;26:304–9. https://doi.org/10.1007/s00455-010-9312-2.

    Article  PubMed  Google Scholar 

  30. 30.

    Warnecke T, Teismann I, Oelenberg S, Hamacher C, Ringelstein EB, Schäbitz WR, et al. The safety of fiberoptic endoscopic evaluation of swallowing in acute stroke patients. Stroke. 2009;40:482–6. https://doi.org/10.1161/STROKEAHA.108.520775.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors would like to acknowledge Glen Leverson, PhD, for his assistance with statistical analysis.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Stevie Marvin.

Ethics declarations

Conflict of interest

All authors declare that they have no conflicts 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. The study was approved by the University of Wisconsin Institutional Review Board.

Informed Consent

Informed consent was obtained from all participants or their surrogate prior to participating in this research study.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Marvin, S., Thibeault, S. & Ehlenbach, W.J. Post-extubation Dysphagia: Does Timing of Evaluation Matter?. Dysphagia 34, 210–219 (2019). https://doi.org/10.1007/s00455-018-9926-3

Download citation

Keywords

  • Deglutition
  • Deglutition disorders
  • Dysphagia
  • ICU
  • Intubation
  • Endotracheal tube