[ Editorial ]
tracheostomy, prolonged hospital and ICU length of
Post-Extubation
Dysphagia
The Truth Is Hard to Swallow
Shannon M. Fernando, MD
Andrew J. E. Seely, MD, PhD
Ottawa, ON, Canada
Invasive mechanical ventilation is one of the most
common interventions in critically ill patients, and is
characteristic, if not defining, of ICU therapy.1 Much
attention has been paid to complications occurring
during and because of mechanical ventilation, such as
nosocomial infections, delirium, and critical illness
neuropathy and myopathy.2,3 These complications are
associated with increased risk of death, extubation
failure, and tracheostomy. In the long term, such
complications increase morbidity and can lead to
prolonged ICU and hospital length of stay and
prolonged recovery among survivors of critical illness.
However, an often underappreciated and minimally
explored complication of mechanical ventilation is post-
extubation dysphagia, the inability to safely pass food
from the mouth to the stomach.4 The true prevalence of
new dysphagia after mechanical ventilation is
unknown.5 What is clear is that post-extubation
dysphagia increases the risk of aspiration, especially if
undiagnosed, and it is associated with pneumonia,
prolonged days of antimicrobial therapy, reintubation,
FOR RELATED ARTICLE, SEE PAGES 1923 AND 1983
AFFILIATIONS: From the Division of Critical Care, Department of
Medicine (Drs Fernando and Seely), University of Ottawa; the
Department of Emergency Medicine (Dr Fernando), University of
Ottawa; the Division of Thoracic Surgery, Department of Surgery (Dr
Seely), University of Ottawa; the School of Epidemiology and Public
Health (Dr Seely), University of Ottawa; and the Clinical Epidemiology
Program (Dr Seely), Ottawa Hospital Research Institute.
FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have
reported to CHEST the following: A. J. E. S. holds patents related to
multiorgan variability analysis, and has shares in Therapeutic
Monitoring Systems Inc., outside of the submitted work. None declared
(S. M. F.).
CORRESPONDENCE TO: Andrew J. E. Seely, MD, PhD, The Ottawa
Hospital - General Campus, 501 Smyth Rd, Box 708, Ottawa, ON,
Canada, K1H 8L6; e-mail: aseely@toh.ca
Copyright Ó 2020 American College of Chest Physicians. Published by
Elsevier Inc. All rights reserved.
DOI: https://doi.org/10.1016/j.chest.2020.08.2049
1806 Editorial
stay, and increased short- and long-term mortality.6
This issue of CHEST features two articles by Zuercher
et al7 and Moss et al,8 offering similar and
complementary messages, helping us to better identify
post-extubation dysphagia and prevent its undiagnosed
consequences.7,8
Using a single-center post hoc analysis of a prior
pioneering prospective study of mechanically ventilated
patients, Zuercher et al7 evaluated 933 extubated
patients, of which 116 were screened for the presence of
post-extubation dysphagia. They analyzed pre-
intubation characteristics to derive factors associated
with development of post-extubation dysphagia, and
found that pre-existing neurological disease, emergency
admission, increased duration of mechanical ventilation,
increased duration of renal replacement therapy, and
higher severity of illness were associated with
development of post-extubation dysphagia.
Interestingly, increased BMI was associated with lower
incidence of dysphagia. Technical limitations include the
use of univariate statistics for the purpose of variable
selection for their multivariable model, which is
generally recommended against in critical care,9 and
assumed linearity in their continuous variables. To
detect post-extubation dysphagia, they used a “water
swallow test” (3 tablespoons followed by a glass)
screening tool, administered by bedside nurses within 3
hours of extubation. They found that 12.4% patients had
dysphagia, of which 87% were confirmed within 24
hours.10 Their work introduced a simple, practical,
rapidly deployable tool to assess for dysphagia shortly
after extubation with excellent positive predictive value
(yet unknown negative predicted value), and also helped
to validate the importance of screening for post-
extubation dysphagia. This study helps to identify risk.
Adding to this work, Moss et al8 report on a multicenter
prospective cohort using a more formal bedside
swallowing evaluation (BSE) performed by speech-
language pathologists to detect aspiration, followed by
the gold standard of the flexible endoscopic evaluation
of swallowing.8 Using the flexible endoscopic evaluation
of swallowing, a remarkable 33% of all patients
demonstrated aspiration, non-silent in 24% and silent
aspiration in 14%. Although the BSE alone did not
provide for accurate detection of aspiration, recursive
[ 158#5 CHEST NOVEMBER 2020 ]
partitioning analysis allowed the development of an
algorithm for aspiration detection. Using this tool, they
found the addition of five factors (duration of
intubation, results of thin liquid [60 mL] test, APACHE
II score >29, altered voice quality, and type of ICU
patient diagnosis) markedly improved sensitivity,
specificity, and accuracy of the BSE. Important
limitations of this study include dichotomization of
candidate variables at arbitrary thresholds, variable
timing between extubation and assessment for
dysphagia (with most patients being assessed in the day
after extubation), and, as noted by the authors, this tool
requires validation. Regardless, this work provides a
systematic framework for its diagnosis in extubated
patients and again highlights the high incidence of post-
extubation aspiration.
Taken together, the two studies offer a complementary
and consistent message. They both highlight the critical
risk factors related to illness severity and duration of
mechanical ventilation, in keeping with the
pathophysiology of post-extubation dysphagia related to
mucosal inflammation, oropharyngeal muscle atrophy,
diminished proprioception and sensation, and laryngeal
injury associated with prolonged intubation.5 Second,
the two studies both validate the use of the water
swallow test, a straightforward bedside test able to be
performed by nurses within hours of extubation.
Interpreting the two together, it is reasonable to
routinely screen all patients post-extubation first with a
water swallow test. However, recognizing a lack of
negative predictive value of that test, ICU clinicians
should routinely engage speech-language pathologists
for gold-standard assessment in any patient with
elevated risk of post-extubation dysphagia, namely after
prolonged intubation (eg, >1 week) or high level of
illness severity (eg, APACHE >25), or if there is voice
change or prior neurological injury.
Identifying critically ill patients with or at risk for post-
extubation dysphagia is important to prevent
deterioration and failed extubation. Dysphagia and
aspiration lead to worsening respiratory status, and re-
intubation will not solve the underlying problem. The
question is, what else can we do about it? A recent meta-
analysis of potential interventions for oropharyngeal
dysphagia found that swallowing treatments were
associated with reduced risk of pneumonia, but they did
not have any impact on aspiration incidence, or patient-
centered outcomes, such as mortality or quality of life.11
Most of these data were taken from stroke patients. The
PHAST-TRAC pilot trial, a single-blinded randomized
chestjournal.org
trial of pharyngeal electrical stimulation, showed early
promise in allowing for early decannulation of
tracheotomized stroke patients with neurogenic
dysphagia.12 Whether this intervention could be
beneficial in other critically ill populations with
nonneurogenic dysphagia is unclear. For the time being,
treatment involves ongoing prevention of aspiration by
avoiding oral intake and slowly retraining swallowing, as
the patient recovers strength, sensation, and dexterity.
The works by Zuercher et al7 and Moss et al8 in this
issue of CHEST highlight the importance of screening
and gold-standard assessment of this too-common yet
oft-ignored adverse event of critical illness. Innovative
means to prevent post-extubation dysphagia and novel
therapies to improve its treatment are badly needed. In
the meantime, improved detection means better
prevention of further harm in vulnerable patients post-
extubation.
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