“We just extubated the patient in bed 7 and we have pills to give. When do you think you can come do his swallow evaluation?” If you work in acute care, this may sound familiar. It’s a question we are frequently asked but it can be very challenging to answer. Should we evaluate each patient the day they are extubated? Should we wait 24 hours? Is a clinical bedside swallow evaluation enough? Should all recently extubated patients have instrumental evaluations? There is no clear answer and it likely depends on many patient variables. The evaluation needed for a 22 year old who was intubated for three days following a car accident may not be the same as for a 75 year old with a history of multiple strokes who was intubated for seven days with pneumonia.
Timing of Evaluation
Delaying swallowing evaluations until 24 hours after extubation is a common practice pattern. The theory behind this is that swallow function will improve with a reduction in laryngeal edema and improved vocal fold mobility, return of pharyngeal/laryngeal sensation, improved breathing, and overall improvement in medical stability. But while this seems logical, it has never been studied. It’s possible that there is a subgroup of extubated patients that are appropriate for swallowing evaluation sooner than 24 hours. In fact, it may be in these patients’ best interest to have earlier evaluations to allow quicker return of oral alimentation and subsequent improvement in health outcomes and quality of life. But it can be challenging to know which variables make a patient a good candidate for earlier swallowing evaluations.
So what do we know about post-extubation dysphagia (PED)? Stacy Skoretz published an excellent review of the PED literature in 2010 that highlighted the gaps in the evidence base1. Since then there has been a surge in publications investigating PED. Many of these papers examine the incidence of PED as well as patient variables that increase risk of PED. While some of the results are contradictory, some relevant patterns emerge from an overview of the entire body of research.
First and foremost, PED is not uncommon. Although the incidence is unknown, multiple published articles propose somewhere between 10-84% of patients suffer from some form of dysphagia following extubation2 3 4 5. These estimates vary widely due to the variability in study design, including differences in the patient population studied, mechanism of enrollment (i.e. examining all extubated patients or only those referred for swallowing evaluation), method of evaluation (clinical evaluation, instrumental evaluation, questionnaire, screening), and definition of dysphagia. Several prospective studies using fiberoptic endoscopic evaluation of swallowing (FEES) have shown aspiration in 36-56% of extubated patients,with silent aspiration occurring in 13-25% of patients evaluated. 3 6 7
We must consider risk factors for dysphagia including advanced age, prolonged intubation, and medical comorbidities. We must be both bold and cautious at the same time: bold in our willingness to undertake such evaluations, and cautious in the way we proceed with them, realizing that our patients’ health outcomes depend upon our evaluation and recommendations.
Research indicates that older patients are at greater risk of developing post-extubation dysphagia. 4 6 8 A study conducted by El Solh and colleagues in 2003 performed FEES on extubated patients in two groups, younger patients (<65 years) and elderly patients (>65 years). The elderly patients showed higher incidence of aspiration (52% compared to 36%), with higher rates of silent aspiration in the elderly group (19% compared to 7%)6. Bordon and colleagues determined via clinical evaluation that patients over 55 years old were 2.5 times more likely to have PED2.
Research also suggests the risk of PED increased with longer intubations 2 4 9 10 11. Borden and colleagues found that the risk for PED increased by 14% for each day the patient was intubated2.
One can utilize this evidence by considering deferring an immediate evaluation if a patient appears at high risk for dysphagia due to advanced age, prolonged intubation, or other comorbidities associated with dysphagia. Likewise, a younger patient with a shorter length of intubation and relatively few comorbidities may be a good candidate for a same day evaluation. Other factors may also support delaying the evaluation. Factors such as delirium or high oxygen requirements can impact swallow function, and may diminish improve with increased time status post extubation. Patients with either of these conditions might benefit from delaying the evaluation. And finally, we should consider the patient specific variables and patient/family values. Is the patient asking for water? Do they have critical medications that need to be given orally? Are they motivated to start the evaluation right away or are they tired and confused, or perhaps declining the evaluation?
Type of Evaluation & Role of the Instrumental Evaluation
There has been an increase recently at both local and national meetings as well as in online discussion boards, regarding not only the timing but also the appropriate method of evaluation for extubated patients. Some research suggests that clinical evaluations are sufficient for evaluating for PED. Brown and colleagues examined 291 extubated trauma patients who underwent clinical evaluations following extubation. All patients who “passed” the clinical evaluation discharged the hospital without a clinical aspiration event. This suggests that a clinical evaluation may be sufficient for identifying PED4. One could argue however that a 25% risk of silent aspiration is quite high, especially in a critically ill patient. Multiple studies also point out that, although clinical evaluations may be capable of identifying dysphagia, they do not determine either its severity or etiology12 13 14 15.
Leder and colleagues have also published extensively on the Yale Swallow Protocol as an effective screening tool for dysphagia 16 17. The protocol is pass/fail and requires the patient to drink 3oz of water uninterrupted without cough response. This protocol was administered to over 4000 acute care patients and compared with results of FEES and was found to have a very low false negative rate (<2%)17. The authors suggest that a patient who passes this protocol is safe for a general diet, assuming appropriate dentition. And while this protocol was administered to acute care patients, the extubation history of these patients was not specified in any study so it remains unclear if it is as sensitive for recently extubated patients.
FEES is also cited as an excellent tool for recently extubated patients. It is safe and well tolerated by patients18, especially recently extubated patients who may be desensitized from the endotracheal tube. It has been shown to be highly sensitive for aspiration19, including silent aspiration. FEES is also portable, an important benefit particularly with ICU patients whom it may be difficult to transport to radiology. FEES can be performed right at the bedside of a patient who is connected to monitors and other equipment, with nursing staff on standby.
So what conclusions can we draw? There is still much we don’t know about this complex patient population. We do know that extubated patients are at high risk for dysphagia but this cannot make us afraid to see them. We must assess each patient on a case by case basis when deciding how and when to evaluate them, capitalizing on the evidence we have. We must consider risk factors for dysphagia including advanced age, prolonged intubation, and medical comorbidities. We must be both bold and cautious at the same time: bold in our willingness to undertake such evaluations, and cautious in the way we proceed with them, realizing that our patients’ health outcomes depend upon our evaluation and recommendations.
Links of Interest
- Free on-line CEU from University of Wisconsin-Voice and Swallowing Clinics Lecture Series.
- 2015 Manometry Summer School
- Skoretz S, Flowers HL, Martino R. The incidence of dysphagia following endotracheal intubation: a systematic review. Chest. 2010;137(3):665-673.
- 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):679-682.
- Ajemain MS, Nirmul GB, Anderson MT, Zirlen DM, Kwasnik EM. Routine Fiberoptic Endoscopic Evaluation of Swallowing Following Prolonged Intubation. Arch Surg. 2001;136:434-437.
- 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(1):108.
- Macht M, Wimbish T, Clark BJ, et al. Postextubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness. Crit Care. 2011;15(5):R231.
- El Solh A, Okada M, Bhat A, Pietrantoni C. Swallowing disorders post orotracheal intubation in the elderly. Intensive Care Med. 2003;29(9):1451-1455.
- 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(4):441-446.
- Skoretz S a, Yau TM, Ivanov J, Granton JT, Martino R. Dysphagia and associated risk factors following extubation in cardiovascular surgical patients. Dysphagia. 2014;29(6):647-654.
- 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):119-124.
- 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):924-927; discussion 927-928.
- Brodsky MB, Gellar JE, Dinglas VD, et al. Duration of oral endotracheal intubation is associated with dysphagia symptoms in acute lung injury patients. J Crit Care. 2014;29(4):574-579.
- Leder SB, Espinosa JF. Aspiration risk after acute stroke: Comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia. 2002;17(3):214-218.
- McCullough GH, Rosenbek JC, Wertz RT, McCoy S, Mann G, McCullough K. Utility of Clinical Swallowing Aspiration Post-Stroke. J Speech. 2005;48(December):1280-1293.
- O’Horo JC, Rogus-Pulia N, Garcia-Arguello L, Robbins J, Safdar N. Bedside diagnosis of dysphagia: A systematic review. J Hosp Med. 2015;00(00)
- Shem KL, Castillo K, Wong SL, Chang J, Kao MC, Kolakowsky-Hayner S. Diagnostic Accuracy of Bedside Swallow Evaluation Versus Videofluoroscopy to Assess Dysphagia in Individuals With Tetraplegia. PM R. 2012;4(4):283-289.
- Leder SB, Suiter DM. Five Days of Successful Oral Alimentation for Hospitalized Patients Based Upon Passing the Yale Swallow Protocol. Ann Otol Rhinol Laryngol. 2014.
- Leder SB, Suiter DM, Green BG. Silent aspiration risk is volume-dependent. Dysphagia. 2011;26(3):304-309. doi:10.1007/s00455-010-9312-2.
- Warnecke T, Teismann I, Oelenberg S, et al. The safety of fiberoptic endoscopic evaluation of swallowing in acute stroke patients. Stroke. 2009;40:482-486.
- Kelly AM, Drinnan MJ, Leslie P. Assessing penetration and aspiration: how do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare? Laryngoscope. 2007;117(10):1723-1727.