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Post-Extubation Dysphagia

By Ed Bice, M.Ed., CCC-SLP

Information concerning COVID-19 remains scarce. It will be some time before we have research to clarify understanding of the all the implications. Initial information indicates more than 70% of hospital patients presenting with COVID-19 are being placed on ventilators1. It is known that intubation is associated with dysphagia2-6 and that intubated patients view swallowing as a top priority7. Consequently, speech-pathologists need to be prepared to assess and treat this population once medical issues are managed, and swallow function becomes a focus.

There are many studies concerning dysphagia related to endotracheal intubation8. Previous studies examining the incidence of dysphagia in patients who have suffered from critical lung dysfunction requiring endotracheal intonation ranges from 3% to 62%9. Studies have found various risk factors including preexisting neurological conditions such as stroke and neuromuscular disease10 and advanced age5. A systematic review9 found congestive heart failure, poor functional status, longer lengths of ICU stays, and sepsis as the most reported conditions associated with post-extubation dysphagia. Oliveira and colleagues11 report patients who remained intubated for 8-14 days exhibited a 5.5 fold higher risk of aspiration when compared to those subjects who were intubated for 7 days or less.

The most common airway complications associated with intubation are edema, ulcers, lacerations, cartilaginous trauma, dysphonia, vocal fold paresis or paralysis, polyps, granulomas, and laryngeal stenosis12. Hoarseness is common and has been reported to occur between 14.4 and 61.9% of patients11,12. Normally, this resolves within 24 to 48 hours; persistence beyond 72 hours is an indicator of vocal fold lesions13. As for swallowing, the mechanism of dysfunction could be oropharyngeal and/or laryngeal trauma14,15, weakness related to disuse atrophy7,16-18, loss of proprioception/somatosensory dysfunction7,19, and dys-synchronous breathing and swallowing14.

Since post-extubation dysphagia has the potential for severe consequences, including increased hospital stays, malnutrition, pneumonia, and increased mortality3,20, early detection is critical. Various screenings can be used to determine the need for additional testing. Some screenings can be effectively administered by  trained nursing staff21. Screening tools used by the speech-language pathologist may include the Yale Swallow Protocol22, Mann Assessment of Swallowing Abilities23, the Test of Mastication and Swallowing Solids24, and measuring tongue strength with the Iowa Oral Performance Instrument (IOPI)25,28. It is important to note, specific pathophysiology cannot be determined without imaging29-31. In addition, the rate of silent aspiration may be high in this population32.

A few studies describe the characteristics of dysphagia in patients who have been extubated. DeVita and Spierer-Rundback33 examined 11 patients after prolonged intubation with videofluoroscopy. They found a mean of 6 deficits per patient. Four patients presented with oral phase deficits and 11 patients presented with a delay in triggering the pharyngeal swallow. Nine patients had vallecular or pyriform sinus residue. Partik et al.34 examined 21 patients with videofluoroscopy. Fifty-two percent of the patients exhibited tongue abnormalities. Other issues found were soft palate elevation (10%), epiglottic inversion (48%), delayed trigger in the pharyngeal swallow (33%), decreased pharyngeal constriction (71%), and upper esophageal sphincter dysfunction (24%). Aspiration occurred in 86% of the participants. The authors concluded that post-extubation dysphagia does not have a homogeneous presentation. Knowing that this patient population is diverse, the therapist is required to develop a management algorithm for each patient based on individual histories, comorbidities, and other factors8.

Su and colleagues35 measured lingual strength and sensation in extubated patients and compared their findings to gender and sex matched healthy individuals.  The results showed tongue strength was lower and sensory function was diminished in those who had been intubated. Sensory disturbances of the tongue gradually recovered but weakness of the tongue persisted. A more recent study18 examined the association of post-extubation with tongue weakness and somatosensory disturbance in 19 patients. The participants were divided into two groups (non-dysphagia and dysphagia) based on findings of videofluoroscopic swallow studies. The dysphagia group exhibited increased oral transit times, lower tongue strength and endurance, as measured by the IOPI, somatosensory disturbances, and a higher rate of pneumonia.

As therapists face an influx of extubated patients, appropriate therapeutic approaches need to be determined. Since the swallowing problems in patients post-extubation are not homogeneous, no single approach will be beneficial for all patients. However, there is research to indicate that, when properly administered, the IOPI may provide the following benefits:

  • Decreased penetration and/or aspiration (food and liquid going into the airway)36,37
  • Decrease in food remaining in the mouth after the swallow36
  • Improved overall oral phase of swallowing38,40
  • Improved overall all pharyngeal phase of swallowing36-38
  • Improved swallowing timing34
  • Decrease in residue in the throat after swallowing36,41
  • Improved tongue strength36,39,40
  • Improved swallow pressure40,42
  • Improved diet34
  • Improved quality of life34

In light of the fact that many patients experience renal and hepatic damage related to COVID-1943, it is prudent to take a multidisciplinary approach to treatment. Diet changes and thickening liquid are known to have side effects that may impact recovery44-49 and should be a discussion between the physician, dietitian, the speech pathologist, and the patient, at a minimum. The good news for the patient is the majority of dysphagia caused by endotracheal intubation resolves quickly8. For those with remaining deficits, thoughtful intervention offers hope.



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2.    Brodsky MB, Huang M, Shanholtz C, Mendez-Tellez PA, Palmer JB, Colantuoni E, et al. Recovery from Dysphagia Symptoms after Oral Endotracheal Intubation in Acute Respiratory Distress Syndrome Survivors. A 5-Year Longitudinal Study. Annals of the American Thoracic Society. 2017;14(3):376-83.

3.    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. Critical Care. 2013;17(3):R119.

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5.    Tsai M-H, Ku S-C, Wang T-G, Hsiao T-Y, Lee J-J, Chan D-C, et al. Swallowing dysfunction following endotracheal intubation. Medicine. 2016;95(24):e3871.

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9.    Skoretz SA, Flowers HL, Martino R. The incidence of dysphagia following endotracheal intubation: a systematic review. Chest. 2010;137(3):665-73.

10.  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):119-24.

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19.  El Solh A, Okada M, Bhat A, Pietrantoni C. Swallowing disorders post orotracheal intubation in the elderly. Intensive Care Med. 2003;29(9):1451-5.

20.  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. Critical Care. 2011;15(5):R231.

21.  Jiang JL, Fu SY, Wang WH, Ma YC. Validity and reliability of swallowing screening tools used by nurses for dysphagia: A systematic review. Ci Ji Yi Xue Za Zhi. 2016;28(2):41-8.

22.  Suiter DM, Sloggy J, Leder SB. Validation of the Yale Swallow Protocol: a prospective double-blinded videofluoroscopic study. Dysphagia. 2014;29(2):199-203.

23.  González-Fernández M, Sein MT, Palmer JB. Clinical experience using the Mann assessment of swallowing ability for identification of patients at risk for aspiration in a mixed-disease population. Am J Speech Lang Pathol. 2011;20(4):331-6.

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26.  Namasivayam AM, Steele CM, Keller H. The effect of tongue strength on meal consumption in long term care. Clin Nutr. 2016;35(5):1078-83.

27.  Hind JA, Nicosia MA, Roecker EB, Carnes ML, Robbins J. Comparison of effortful and noneffortful swallows in healthy middle-aged and older adults. Arch Phys Med Rehabil. 2001;82(12):1661-5.

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38.  Cho YS, Oh DH, Paik YR, Lee JH, Park JS. Effects of bedside self-exercise on oropharyngeal swallowing function in stroke patients with dysphagia: a pilot study. J Phys Ther Sci. 2017;29(10):1815-6.

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40.  Park JS, Kim HJ, Oh DH. Effect of tongue strength training using the Iowa Oral Performance Instrument in stroke patients with dysphagia. J Phys Ther Sci. 2015;27(12):3631-4.

41.  Steele CM, Bayley MT, Peladeau-Pigeon M, Nagy A, Namasivayam AM, Stokely SL, et al. A Randomized Trial Comparing Two Tongue-Pressure Resistance Training Protocols for Post-Stroke Dysphagia. Dysphagia. 2016;31(3):452-61.

42.  Robbins J, Gangnon RE, Theis SM, Kays SA, Hewitt AL, Hind JA. The effects of lingual exercise on swallowing in older adults. J Am Geriatr Soc. 2005;53(9):1483-9.

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44.  Cichero JA. Thickening agents used for dysphagia management: effect on bioavailability of water, medication and feelings of satiety. Nutr J. 2013;12:54.

45.  O'Keeffe ST. Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified? BMC Geriatr. 2018;18(1):167.

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