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Evaluation of Outcomes of Post-Extubation Dysphagia in Elderly Patients FREE TO VIEW

Mark Regala, MD; Stevie Marvin; William Ehlenbach, MD
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University of Wisconsin School of Medicine and Public Health, Madison, WI

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):224A. doi:10.1016/j.chest.2016.08.237
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SESSION TITLE: Critical Care in the ICU

SESSION TYPE: Original Investigation Poster Discussion

PRESENTED ON: Monday, October 24, 2016 at 12:00 PM - 01:30 PM

PURPOSE: Dysphagia following extubation is common in the ICU. Diagnosing post-extubation dysphagia allows identification of patients who are at highest risk for aspiration and its associated adverse outcomes. Older adults are potentially at an increased risk of dysphagia and its complications due to multiple comorbidities, a higher baseline risk of dysphagia, and increased risk of pneumonia. In this study, we investigated the association between dysphagia after extubation and mortality, incidence of pneumonia, hospital length of stay, and place of discharge among patients age 65 and over who were intubated and underwent a swallow evaluation in a 24-bed academic medical and surgical ICU.

METHODS: We performed a retrospective observational cohort study from 2013-2014. ICU patients age 65 and over who were successfully extubated and underwent a formal swallow evaluation by a Speech and Language Pathologist (SLP) were included. Dysphagia was graded using a 7-point scale ranging from none to severe dysphagia, in parallel with the American Speech-Language-Hearing Association Functional Communication Measure for swallowing.

RESULTS: Of 563 ICU patients who were screened, 111 of them (19.7%) had a swallow evaluation performed by an SLP after liberation from mechanical ventilation. The mean age of this group was 73.8 years (sd 7.0), mean APACHE IV was 86.9 (sd 25.8), and 41.4% were women. Mean duration of mechanical ventilation was 3.25 (sd 2.82) days, and median ICU length of stay was 4 days (interquartile range 2-6). Fiberoptic endoscopic evaluation of swallow was performed in 32/111 patients (28.8%), while videofluoroscopy in 34/111 patients (30.6%). The remainder (47/111) underwent a clinical bedside exam only. Pneumonia was subsequently diagnosed in 15/111 (13.5%) patients, while ICU readmission was observed in 22/111 (19.8%) patients. One year mortality was 38% in those without severe dysphagia, and 43% in those with severe dysphagia (p=0.638). Discharge to LTAC and SNF occurred in 44% in those without severe dysphagia as compared to 42% in those with severe dysphagia (p=0.858).

CONCLUSIONS: Among mechanically ventilated ICU patients age 65 and over who underwent a swallow evaluation following extubation, there was no difference in 1 year mortality between those with severe dysphagia as compared to those without severe dysphagia. The presence of severe dysphagia was not associated with outcomes such as pneumonia, ICU readmission or hospital length of stay. Given conflicting evidence in the literature, larger prospective studies may be needed to clarify whether post-extubation dysphagia is associated with worse outcomes in older patients admitted to the ICU.

CLINICAL IMPLICATIONS: Clinically significant dysphagia was noted in 45/111 (41%) of patients who had a swallow evaluation performed. Even though the study did not demonstrate worse outcomes in patients who have severe dysphagia, diagnosis and treatment by a speech pathologist, for example modification of oral intake, could have improved short and longer term outcomes in these patients. More studies are needed to identify those who are at highest risk for post-extubation dysphagia, determine appropriate timing of swallow assessments, and evaluate effectiveness of therapies.

DISCLOSURE: The following authors have nothing to disclose: Mark Regala, Stevie Marvin, William Ehlenbach

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