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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 dysphagia^2-6 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 patients^11,12. 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 trauma^14,15, weakness related to disuse atrophy^7,16-18, loss of proprioception/somatosensory dysfunction^7,19, and dys-synchronous breathing and swallowing¹⁴.

Since post-extubation dysphagia has the potential for severe consequences, including increased hospital stays, malnutrition, pneumonia, and increased mortality^3,20, 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 imaging^29-31. 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 swallowing^38,40
• Improved overall all pharyngeal phase of swallowing^36-38
• Improved swallowing timing³⁴
• Decrease in residue in the throat after swallowing^36,41
• Improved tongue strength^36,39,40
• Improved swallow pressure^40,42
• 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 recovery^44-49 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.

 

References

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