Bedside Swallow Evaluation Research Articles

Postextubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness

IntroductionDysphagia is common among survivors of critical illness who required mechanical ventilation during treatment. The risk factors associated with the development of postextubation dysphagia, and the effects of dysphagia on patient outcomes, have been relatively unexplored.MethodsWe conducted a retrospective, observational cohort study from 2008 to 2010 of all patients over 17 years of age admitted to a university hospital ICU who required mechanical ventilation and subsequently received a bedside swallow evaluation (BSE) by a speech pathologist.ResultsA BSE was performed after mechanical ventilation in 25% (630 of 2,484) of all patients. After we excluded patients with stroke and/or neuromuscular disease, our study sample size was 446 patients. We found that dysphagia was present in 84% of patients (n = 374) and classified dysphagia as absent, mild, moderate or severe in 16% (n = 72), 44% (n = 195), 23% (n = 103) and 17% (n = 76), respectively. In univariate analyses, we found that statistically significant risk factors for severe dysphagia included long duration of mechanical ventilation and reintubation. In multivariate analysis, after adjusting for age, gender and severity of illness, we found that mechanical ventilation for more than seven days remained independently associated with moderate or severe dysphagia (adjusted odds ratio (AOR) = 2.84 [interquartile range (IQR) = 1.78 to 4.56]; P < 0.01). The presence of severe postextubation dysphagia was significantly associated with poor patient outcomes, including pneumonia, reintubation, in-hospital mortality, hospital length of stay, discharge status and surgical placement of feeding tubes. In multivariate analysis, we found that the presence of moderate or severe dysphagia was independently associated with the composite outcome of pneumonia, reintubation and death (AOR = 3.31 [IQR = 1.89 to 5.90]; P < 0.01).ConclusionsIn a large cohort of critically ill patients, long duration of mechanical ventilation was independently associated with postextubation dysphagia, and the development of postextubation dysphagia was independently associated with poor patient outcomes.

A Case of Occult Oropharyngeal Dysphagia

Requests for feeding tube placement, in those newly diagnosed with dysphagia, is a common request of the gastrointestinal medicine service. We describe the case of an adult patient with severe mental retardation who developed substantial oropharyngeal dysphagia and aspiration pneumonia after an unknown foreign body ingestion. A 43-year-old Mentally Retarded White Male resident of a state mental institution was transferred to our Emergency Department due to new onset fever and dyspnea. His nurse reported a two day history of non productive cough and no history of pneumonia. The patient was non-verbal secondary to severe intellectual disability and presented with increased oral secretions. The patient was admitted, diagnosed with aspiration pneumonia, and placed on antibiotics. Due to suspected aspiration, a bedside swallow evaluation was performed which was significant for impaired swallowing. Modified Barium Swallow Study revealed severe aspiration. and speech pathology recommended an alternate feeding route. GI Medicine was consulted for Percutaneous Endoscopic Gastrostomy (PEG) tube placement. EGD was performed prior to anticipated PEG placement. The endoscope was passed without difficulty to the hypopharynx where a foreign body was discovered and removed by rat tooth forceps. The foreign body was identified as a chicken bone (see below). The remainder of the EGD was normal. The PEG was not placed. After removal of the chicken bone, reevaluation by speech pathology demonstrated minimal aspiration risk. The patient was discharged in stable condition with a recommendation for a soft mechanical diet. One month later after hospital discharge, patient was eating his regular diet without any further episodes of aspiration pneumonia. Our case stresses the importance of properly assessing patients at risk for aspiration and foreign body ingestion who present with new onset respiratory symptoms. [figure 1][figure 2]Figure 1Figure 2