Dysphagia is a swallowing disorder that results in difficulty or inability to transport food
or liquid effectively and safely from the mouth to the stomach. If dysphagia is not detected
and treated early, it may lead to aspiration and aspiration pneumonia. Aspiration occurs when
food, liquid, secretions or stomach contents are inhaled into the lungs. Silent aspiration
occurs when food, liquid, secretions or stomach contents are inhaled into the lungs and the
patient does not feel it so there is no cough response elicited.
Swallowing disorders are often associated with prolonged intubation (>48 hours (about 2
days). The reported incidence of post-extubation dysphagia (PED) varies significantly. One
study found that PED was present in 84% of patients, and this was even after the exclusion of
patients with stroke or neuromuscular disease. Clinical signs and symptoms of aspiration may
be observed by a patient who coughs on their own secretions or coughs when food or liquid is
introduced. Silent aspiration is a covert form of aspiration that occurs without any outward
signs or symptoms. Silent aspiration is usually a result of desensitization of the pharynx
and upper airways and can be diagnosed through an instrumental swallow assessment. A meta
-analysis and systematic review systematic including 38 studies, 5798 patients and 1957
dysphagia events noted a high incidence of post-extubation silent aspiration. The authors
calculated the combined weighted incidence of post-extubation dysphagia to be 41% (95%
confidence interval, 0.33-0.50), with 36% of the patients with PED having silent aspiration
(95% confidence interval, 0.22-0.50). Without instrumental swallow evaluations, silent
aspiration may go undetected and lead to pulmonary complications.
Post-extubation dysphagia has been associated with poor outcomes including increased risk of
reintubation, development of pneumonia, prolonged hospital stays, need for feeding tubes,
increased hospital costs, malnutrition, dehydration, increased risk of death, discharge to a
nursing home and poor quality of life. Additional sequala following post extubation dysphagia
may include laryngeal trauma, neuromuscular weakness, reduced ability to coordinate breathing
and swallowing, impaired cough response and generalized disuse atrophy.
In the critically ill population, there have been only a few studies that analyzed the impact
of post-extubation dysphagia on patient centered outcomes. ICU (Intensive Care Unit) acquired
weakness (ICUAW) including general muscular weakness and muscular atrophy has not been
reported in the literature. ICUAW weakness may be a consequence of disuse in patient's
receiving long term intubation, long term sedation and or neuromuscular blocking agents. The
"use it or lose it" principle suggest that early intervention can improve diet tolerance,
airway protection and overall nutrition.
Currently, in our ICU at MMC, when a patient is extubated, they receive a nursing swallowing
screen with 3 ounces of water. If the patient fails the nursing swallow screening, they
remain NPO (nothing by mouth) and are then seen by a Speech-Language Pathologist (SLP) for a
formal Dysphagia Evaluation. The SLP assessment includes a cranial nerve exam, integrity of
cough strength, vocal quality, dental status, oral hygiene, and mentation. If the SLP deems
the patient safe for oral trials, various textures of food and liquid are introduced. If the
patient exhibits overt signs and symptoms of aspiration (coughs when eating or drinking) they
are often kept NPO (nil by mouth) and re-assessed in a few days. The ability to detect silent
aspiration during a clinical bedside dysphagia evaluation is limited. An instrumental
assessment is often recommended as the patient improves which is completed by the SLP.
Following these assessments, recommendations are then made to either begin oral intake if
patient is safe to eat or remain NPO. Swallow therapy is often not initiated until after the
patient is out of ICU.
The objective of this study is to evaluate the effectiveness of early swallowing intervention
in post extubated patients in the ICU to determine if this minimizes the risk of aspiration,
increases initiating of oral intake sooner, reduced length of ICU stay and reduces the need
for alternate means of nutrition/hydration.