Postextubation Dysphagia in Children: The Role of
Speech-Language Pathologists*
Paulo Sergio Lucas da Silva, MD, MSc1; Nádia Lais Lobrigate, CCC-SLP2;
Marcelo Cunio Machado Fonseca, MD, PhD3
Objectives: Postextubation dysphagia is common and associated
Downloaded from http://journals.lww.com/pccmjournal by BhDMf5ePHKbH4TTImqenVNlUEzghFiXbGtd2T4WcLNnLumPItOZ6vSVmijVy7SYi on 01/15/2019
with worse outcomes in the PICU. Although there has been an
increased participation of speech-language pathologists in its
treatment, there is limited evidence to support speech-language
pathologists as core PICU team member. We aimed to assess
the impact of speech-language pathologists interventions on the
treatment of postextubation dysphagia.
Design: A quasi-experimental prospective study. In the histori-
cal group (controls), patients received a standard care manage-
ment for dysphagia whereas the intervention group was routinely
treated by speech-language pathologists.
Setting: PICU of a tertiary hospital.
Patients: Children who were endotracheally intubated for a period
greater than 24 hours with greater oral intake limitation as defined
by a Functional Oral Intake Scale less than or equal to 3.
Intervention: Routine speech-language pathologist assessment.
Measurements and Main Results: A total of 74 patients were
enrolled to receive intervention (January 2015 to December 2016)
and 41 patients to the historical group (January 2014 to December
2014). There were no differences in the demographic and clinical
characteristics. The historical group had both longer time to initi-
ate oral intake (7 vs 4 d; p = 0.0002; hazard ratio, 2.33) and to
reach full oral intake compared with intervention group (9 vs 13 d;
p < 0.001; hazard ratio, 2.51). A total of 32 controls (78%) and 74
intervention patients (100%) were on total oral intake at discharge
(p ≤ 0.001). Three of nine control patients were feeding tube
dependent at hospital discharge. Also, controls had a longer length
*See also p. 1011.
1
Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Estad-
ual de Diadema, São Paulo, Brazil.
2
Division of Speech and Language Pathology of Hospital Estadual de
Diadema, São Paulo, Brazil.
3
Health Technology Assessment Unit, Federal University of São Paulo
(UNIFESP), São Paulo, Brazil.
This work was performed in the Pediatric Intensive Care Unit, Hospital
Estadual de Diadema, São Paulo, Brazil.
The authors have disclosed that they do not have any potential conflicts
of interest.
For information regarding this article, E-mail: psls.nat@terra.com.br
Copyright © 2018 by the Society of Critical Care Medicine and the World
Federation of Pediatric Intensive and Critical Care Societies
DOI: 10.1097/PCC.0000000000001688
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of hospital stay (25 vs 20 d) and a higher rate of reintubation when
compared with those patients of intervention group (10% vs 2%).
Conclusions: Incorporating speech-language pathologists in the
routine management of postextubation dysphagia can result in
faster functional improvement and favorable patient outcomes.
Yet, further and larger studies in pediatric dysphagia are required
to support the related interventions and strategies to guide clinical
practice. (Pediatr Crit Care Med 2018; 19:e538–e546)
Key Words: children; dysphagia; endotracheal intubation; pediatric
intensive care unit; speech-language pathology; swallowing
L
aryngeal injury and alterations in laryngeal sensation
frequently occur following oral endotracheal intuba-
tion and may result in impaired swallowing (1). A
recent study (2) reported that, even after fewer than 48 hours
of intubation, 84% of adult patients had at least mild dyspha-
gia, which is defined as the inability to effectively transfer food
from the mouth into the stomach. This occurrence rate may be
even higher in children due to anatomical differences in the size
and physical relation of the oral structures. These differences
may put children at higher risk for developing dysphagia (3).
A swallowing disorder following prolonged intubation (>
48 hr) delays oral myofunctional/swallowing assessments, nor-
mal oral feeding, and ensuing hospital discharge (4). Hence,
persistent dysphagia after extubation is associated with an
increased risk of hospital-associated pneumonia, weaning fail-
ure, a longer ICU stay, a higher rate of reintubation, higher
hospital costs, and higher rates of mortality (5–7). Despite the
association of dysphagia with poorer outcomes, there are no
guidelines about postextubation swallowing assessments (8).
In the United States (9), United Kingdom (10), and Canada
(11), dysphagia management is recognized to be a primary
responsibility of speech-language pathologists (SLPs) in con-
junction with other critical care practitioners. But the num-
ber of SLPs adequately trained in dysphagia assessment and
management is relatively limited in the United States as well as
in other countries (12). It is also remarkable that other stud-
ies have shown that only 41% of hospitals routinely evaluate
dysphagia in extubated patients (13) and that only 44% of

patients receive a swallowing assessment (8). Likewise, prior
to this study, patients in our PICU were not routinely assessed
by SLPs for swallowing disorders. There is accordingly room
to improve screening and management of postextubation
dysphagia.
Therefore, we performed this study to evaluate the impact
of SLP intervention on dysphagia in postextubation care out-
comes. We focused specifically on the time to achieve full oral
intake. We also aimed to determine the fraction of postextuba-
tion patients who were dependent on tube feeding following a
period of mechanical ventilation.
METHODS
This quasi-experimental prospective study, which included a
postintervention group and a historical comparison group, was
conducted in an 8-bed PICU of a tertiary hospital from Janu-
ary 2014 through December 2016. The Institutional Review
Board approved the study, and written informed consent was
obtained from the parents or the legal guardian(s) of all of the
eligible patients.
The patients were eligible to participate in the study if they
satisfied all of the following criteria: a period of endotracheal
intubation lasting for greater than 24 hours, a diet received via
a feeding tube, an age between 1 month and 15 years, and a
Glasgow Coma Scale score greater than or equal to 14 points.
We included patients who received shorter (< 48 hr) dura-
tions of mechanical ventilation because previous authors have
suggested that even short-term endotracheal intubation may
result in swallowing dysfunction (14, 15). The inclusion cri-
teria also included those children with limited oral intake as
defined by a Functional Oral Intake Scale (FOIS) score less
than or equal to 3 (16–18). This cutoff level is deemed to reflect
a clinically significant reduction or alteration in oral intake and
includes those patients who are either fully or partly dependent
on a feeding tube (18). Patients were excluded if 1) they had a
tracheostomy tube in place, 2) they had an existing or comor-
bid neurologic disease, 3) they had a history of oropharyngeal
dysphagia, or 4) they had undergone head or neck surgical
procedures.
Data Collection
Two groups were compared in this study. The historical control
group comprised all consecutive children who were intubated
from January 1, 2014, through December 31, 2014, prior to
the implementation of the intervention (standard care group).
The second group included all patients who were intubated
from January 1, 2015, through December 31, 2016, after the
implementation of the intervention (intervention group). The
primary investigator and the SLP were kept blinded from one
another’s results during the study.
The demographic and clinical variables that we collected
included age, gender, weight, PICU admission diagnosis,
and the severity of illness at PICU admission as measured by
Pediatric Risk of Mortality II (19) and the Pediatric Logistic
Organ Dysfunction (20) scores. The secondary outcome mea-
sures were as follows: duration of mechanical ventilation,
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duration of PICU stay, duration of hospital stay, the need for
reintubation, postextubation pneumonia, and PICU mortal-
ity. The presence of postextubation pneumonia was defined
according to the Centers for Disease Control and Prevention
and the National Healthcare Safety Network (21).
For hospital length of stay, we recorded both the total num-
ber of hospital days as well as the duration in the hospital after
the initial bedside swallowing evaluation (BSE). Only the first
extubation for each patient during the study period was ana-
lyzed because reintubation was one of the analyzed outcomes.
In the standard care group, the primary investigator
(P.S.L.S.) retrospectively assessed dysphagia using the FOIS
(17), based on medical records of food intake and the need
for nutritional supplementation. In the intervention group,
the SLP (N.L.L.) applied the same scale during each patient’s
assessment. The oral intake was registered on a daily basis, and
the FOIS was applied at the initial assessment (within 24 hr of
extubation) and upon hospital discharge.
Standard Care—Historical Control Group
Within this study period, pediatric intensivists and nurses with
at least 2 years of intensive care nursing experience screened
and managed patients for dysphagia using a standard protocol
comprising clinical evaluation of prefeeding skills, assessment
and promotion of readiness for oral feeding, and appraisal of
breast/bottle and solid-feeding ability according to patient age.
This approach also included swallowing-compensation strate-
gies, mainly environmental modifications (e.g., maintenance
of optimal position and posture during feeding sessions), cau-
tious oral intake trialed in a stepwise manner and advanced
based upon feeding performance and absence of symptoms,
safe swallowing advice (e.g., reduced rate of eating), and dietary
modification undertaken only if prescribed by the attending
physician. At the discretion of the treating physician, patients
were referred to the hospital SLP who was available one to two
times per week for formal swallowing assessment and manage-
ment. In practice, this fact meant that these patients did not
have the opportunity to be routinely managed by a SLP during
their hospitalization. Due to our limited healthcare resources,
only one SLP was available to provide evaluation and interven-
tion for the entire inpatient population during this period.
Intervention Group—Swallowing Therapy
During this period, a certified SLP was allocated to specifically
attend the neonatal ICU and PICU. This SLP performed swal-
lowing assessments and treatment for all children after extuba-
tion in the PICU. In brief, the SLP conducted a full BSE within
24 hours of extubation. Typically, treatment focused on dietary
adjustment (solid food texture modifications/liquid thickness
modifications), postural changes and compensatory maneuvers
(chin-down posture, small sips/small amounts, multiple swal-
lows, clearing cough, effortful swallow, Mendhelson maneuver,
head turn to one side, supraglottic swallow), and interventions
to improve swallowing function (Masako maneuver). Patients
with abnormal BSE in this group received a daily session of 30–
45 minutes of individual swallowing treatment until dysphagia
www.pccmjournal.org e539
 da Silva et al
resolution or hospital discharge. For those children with nor-
mal BSE, their diet was advanced according to the physician’s
orders, and they received fewer follow-up visits from the SLP.
For patients receiving noninvasive ventilation, the SLP per-
formed a thorough clinical assessment. If appropriate, oral
rehabilitation was started. Oral feeding was only initiated if
patients were not receiving ventilatory support and after evalu-
ations by the SLP and clinicians.
Swallowing Measurement Tool
Feeding functionality level was assessed using the pediatric FOIS,
which was adapted by Dodrill (17) from the tool for adults (Fig. 1).
The adult FOIS (16) is a seven-point ordinal scale in which lower
scores indicate greater food and liquid intake limitations. In the
pediatric FOIS, patients are scored between 1 (minimum) and 6
(maximum). FOIS scores of 1 through 3 indicate varying degrees
of nonoral feeding; scores of 4 through 6 indicate varying degrees
of oral feeding according to patient compensations and dietary
modifications. The FOIS levels were rated, in both groups, at base-
line (within 24 hr of extubation) and at discharge. In historical
group, the primary investigator (P.S.L.S.) retrospectively assessed
dysphagia also using the FOIS (17) based on medical records of
food intake and the need for nutritional supplementation. In the
intervention group, the SLP applied the same scale. For analysis
purposes, as noted above, patients presenting a FOIS score of 3 or
less were included in the analysis.
Endpoints
The primary efficacy endpoint was the time to be completely
weaned off tube feeding (i.e., receiving oral feeding only). The
secondary efficacy endpoint was the proportion of patients
receiving oral feeding at hospital discharge. Additional second-
ary endpoints included the length of the PICU stay and the
overall length of the hospital stay.
Figure 1. Functional Oral Intake Scale (suckle feeds and transitional feeds).
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Statistical Analysis
We defined as being of 3 days the minimum clinically signifi-
cant difference between the two groups in time to have a com-
plete oral intake. Assuming a one-tailed alpha of 0.05, beta of
0.20 (statistical power = 80%), and based on a mean of 4.6
days to wean-off feeding tubes in our PICU (preintervention
period), with a sd of 3.9 days, 28 patients per group would be
needed detect to this difference.
Descriptive statistics were performed for all variables.
Continuous variables were reported as medians with inter-
quartile ranges (IQRs). Comparisons between control and
intervention groups were based on the Mann-Whitney U test
for continuous variables and the chi-square test for categorical
variables or Fisher exact test if one expected that the cell value
would be less than five (categorical variables). Kaplan-Meier
curve analysis was used to assess the time to initiate oral intake
and the time to reach full oral intake; log-rank tests were used
to determine if there were differences between the groups. All
of the statistical tests were two tailed, and a p value less than
0.05 was considered to be statistically significant. The data
were analyzed using the Statistical Program for Social Sciences
(Chicago, IL), Version 14.0 software.
RESULTS
During the 3-year study period, 449 patients required endotra-
cheal intubation (Fig. 2).
Of these individuals, 115 had a FOIS score less than or equal
to 3 following invasive mechanical ventilation for more than
24 hours (41 in the historical control group and 74 in the inter-
vention group). The baseline characteristics of the cohorts are
summarized in Table 1. There were no significant differences in
the demographic characteristics, admission diagnosis, Severity
of Illness Scores, or time of intubation between the two groups.
No patient received an instrumental swallowing assessment
(i.e., modified barium swallow
or fiber-optic evaluation of
swallowing).
Although all of the patients
in the intervention group
received SLP treatment, 14 out
of 41 (34%) were assessed by
a SLP (p < 0.001) in the his-
torical group. The number of
swallowing therapy sessions
for patients in the intervention
group was significantly higher
than in the historical group
(10 [IQR, 8–11] vs 4.5 [IQR,
4–6] sessions; p < 0.001).
The clinical signs of dys-
phagia in patients from both
groups with a BSE performed
by the SLP (n = 88) included
the following: difficulty man-
aging secretions/drooling (n =
43), a respiratory rate increase
October 2018 • Volume 19 • Number 10

Figure 2. Study flow chart. FOIS = Functional Oral Intake Scale.
of 20% above baseline (n = 13), oxygen desaturations less than
90% (n = 12), uncoordinated suck-swallow-breath (n = 9), loss
of food/liquid from the mouth when eating (n = 5), disengage-
ment cues, which included facial grimacing and head turning
away from food source (n = 4), and long feeding times (n = 2).
All of the desaturation events resulted in self-recovery upon
discontinuation of the feeding attempt. There were no adverse
events associated with SLP therapy such as choking, cardiovas-
cular compromise, escalation of respiratory support, or weight
loss that required medical intervention. In addition, there were
no clinical or radiographic signs of aspiration in either group.
Of the 88 SLP assessments, treatments for postextubation dys-
phagia comprised one or more therapies including dietary texture
modification (n = 36), postural change maneuvers (n = 41), and
therapeutic exercises (n = 32). There was no statistically signifi-
cant difference among the therapies performed in the two groups.
The groups exhibited similar initial FOIS scores, which
significantly improved from baseline (post extubation) to dis-
charge in both the control and intervention groups (median
3 [IQR, 2–3] vs 6 [IQR, 4.5–6]; p < 0.001 and 2 [IQR, 1.75–3]
vs 6 [IQR, 5–6]; p < 0.001, respectively), but the median score
change was higher in the intervention group (3.5 [IQR, 3–4] vs
2.5 [IQR, 2–3]; p < 0.001). Furthermore, the median time to
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attain full oral intake was 13 days (IQR, 8–11 d) in the control
group versus 9 days (IQR, 8–11 d) in the intervention group
(p < 0.001).
The Kaplan-Meier curves demonstrate that both time to
initiate oral intake (hazard ratio, 2.33; 95% CI, 1.59–3.41)
(Fig. 3) and the time to reach total oral intake (hazard ratio,
2.51; 95% CI, 1.72–3.68) (Fig. 4) were significantly shorter in
the intervention group compared with the historical controls.
At discharge, 32 control (78%) and 74 intervention patients
(100%) were receiving total oral intake (p < 0.001).
Nine children in the historical group were dependent on a
feeding tube upon hospital discharge, three of them with a gas-
trostomy in place (Table 2). These children had a median age
of 11 months (IQR, 2–96 mo) and a median intubation time of
10 days (IQR, 5–11.5 d). Among these nine patients, the admis-
sion diagnoses included respiratory diseases (n = 6), sepsis (n
= 2), and congenital cardiac disease (n = 1). We identified that
three of these patients had underlying comorbidities: broncho-
pulmonary dysplasia (n = 2) and Down syndrome (n = 1).
The secondary efficacy endpoints revealed that the patients
in the historical control group had a longer length of hospital
stay (p = 0.03) and a higher rate of reintubation (p = 0.001)
compared with patients in the intervention group.
www.pccmjournal.org e541
 da Silva et al

TABLE 1. Demographics and Clinical Characteristics

All Patients, Standard Care Intervention Group,
Variables n = 115 Group, n = 41 n = 74 p

Age, mo, median (25–75th percentile) 3 (2–9) 3 (2–11) 3 (2–7) 0.675a

Sex, male, n (%) 76 (66) 27 (65.8) 49 (66.2) 0.969b
Weight, kg, median (25–75th percentile) 5.1 (3.8–8.0) 5 (2.9–10) 6 (4.1–8.0) 0.181a
Pediatric Risk of Mortality, median (25–75th percentile) 12 (9–17) 12 (11–17) 12 (8.75–16.25) 0.086a
Pediatric Logistic Organ Dysfunction, median (25–75th 1 (1–2) 1 (1–7) 1 (1–2) 0.091a
percentile)
Admission diagnosis, n (%) 0.235b
Respiratory 84 (73) 32 (78) 52 (70.2)
Sepsis 17 (14.7) 6 (14.6) 11 (14.8)
Post surgery 7 (6.1) 3 (7.3) 4 (5.4)
Others 7 (6.1) 0 (0) 7 (9.4)
Prior intubation duration, d, median (25–75th percentile) 7 (5–10) 8 (5–11) 6.5 (4.75–9.25) 0.404a
Prior use of vasopressors, n (%) 20 (17.4) 8 (19.5) 12 (16.2) 0.661b
Prior use of neuromuscular blockade, n (%) 30 (26) 12 (29.2) 18 (24.3) 0.569b
Prior use of benzodiazepine/opioids, n (%) 113 (98.2) 41 (100) 72 (97.2) 0.152b
Initial FOIS score, median (25–75th percentile) 3 (2–3) 3 (2–3) 2 (1.75–3) 0.172a
FOIS score at hospital discharge, median (25–75th percentile) 6 (5–6) 6 (4.5–6) 6 (5–6) 0.999a
FOIS score at hospital discharge, categories, n (%) < 0.0001b
1–3 9 (7.8) 9 (21.9) 0 (0)
4–5 29 (25.2) 2 (4.8) 27 (36.4)
6 77 (66.9) 30 (73.1) 47 (63.5)
Feeding status at hospital discharge (FOIS score), n (%) 0.0001b
Total by mouth (4–6) 106 (92.1) 32 (78) 74 (100)
Limited/nothing by mouth (1–3) 9 (7.8) 9 (21.9) 0 (0)
FOIS = Functional Oral Intake Scale.
Mann-Whitney.
a

Chi-square test.
b

DISCUSSION (extubation in the operating room) to 17 days (mean, 2.5 d),

This study was designed to analyze the impact of a SLP service
dedicated to the prevention, early detection, and management
of patients with postextubation dysphagia. Our primary find-
ings were that children with impaired functional oral intake
(FOIS ≤ 3) had a shorter time to initiate and to reach total
oral intake when they received routine swallowing therapy
compared with standard care. Furthermore, patients in the
intervention group demonstrated significant improvements in
functional oral intake, a shorter length of hospital stay, and a
lower rate of reintubation.
A systematic review of dysphagia following endotracheal
intubation in adults revealed a rate of dysphagia ranging from
44% to 62% (22). In PICU patients, this frequency is still
unclear. In 50 pediatric patients who underwent open-heart
operations with a length of intubation time ranging from 0
dysphagia was diagnosed in nine patients (18%) (23). In our
study, we found that 115 out of 305 patients (37.7%) receiving
mechanical ventilation for a period of at least 24 hours were
dependent on a feeding tube (FOIS ≤ 3) at the first assessment.
The resumption of oral feeding is an important milestone
in a patient’s recovery after a critical illness. The presence of
dysphagia is the most important determinant of delayed return
to oral intake and more than doubles the hazard for deferred
resumption of normal oral feeding (6).
The significance and duration of dysphagia in survivors of
critical illness are relatively unknown. In ICU patients with
dysphagia, the overall mean interval from extubation to total
oral intake ranges from 3 to 4.5 days (2, 6, 24, 25). However, for
those patients diagnosed with moderate/severe dysphagia and
treated by a SLP, the mean recovery time to resume oral feeding

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 Online Clinical Investigations

extubation exhibited persistent

swallowing abnormalities at
the time of hospital discharge
(2). It appears that the under-
lying mechanism of dysphagia
is the strongest determinant of
the duration of the dysfunc-
tion. Therefore, mild laryngeal
sensory abnormalities second-
ary to local edema may have a
rapid resolution, and laryngeal
neuromuscular dysfunction
or more significant damage
to laryngeal tissues may per-
sist over the longer term and
adversely influence quality of
life (13). In the present study,
although all of the patients
receiving swallowing therapy
recovered to unrestricted
dieting upon discharge, nine
patients (22%) in the standard
care group remained at a lower
Figure 3. Kaplan-Meier curve showing the time to initiate oral intake for both historical control and intervention level of oral intake. We hypoth-
groups. Data has been censored for patients who were tube feeding dependent at discharge.
esize that this situation likely
occurred because, in reality, the
children in the standard care
group were not continuously
and appropriately managed by
a SLP. It is most likely that there
was no improvement over time
in the patients’ oral functioning
(postural tone or tone in the
face, mouth, or throat), imply-
ing that swallowing and intake
therapeutics are clinical priori-
ties. However, we should high-
light that three of these nine
patients had comorbidities
that could potentially be asso-
ciated with delayed swallow-
ing recovery. Thus, although
bronchopulmonary dysplasia
has been reported to be factor
associated with the delay of
attainment of full oral feeding
in two patients (26), neuromo-
tor coordination impairments
such as those associated with
Figure 4. Kaplan-Meier curve showing the time to reach total oral intake for both historical control and Down syndrome can interfere
intervention groups. Data has been censored for patients who were tube feeding dependent at discharge.
with the acquisition of effec-
tive oral-motor skills and lead
ranges between 7 days (2) and greater than 10 days (6); mild to feeding difficulties (27). Again, the intervention of a SLP may
dysphagia resolves faster (mean, 3 d) (2). be critical for oral rehabilitation in these patients.
In a retrospective cohort study, the authors found that An important finding of our study was the shorter time to
35% of patients with swallowing dysfunction at the time of initiate oral intake and to recover total oral intake when patients

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 da Silva et al
TABLE 2. Outcomes of Standard Care Compared to Routine Speech-Language Pathologist
Assessment
Variables
Time elapsed from extubation to initiate oral intake, d, median
(25–75th percentile)
Time to reach total oral intake, d, median (25–75th percentile)
Enteral feeding at hospital discharge, n (%)
Pneumonia postextubation, n (%)
Length of PICU stay, d, median (25–75th percentile)
Length of hospital stay, d, median (25–75th percentile)
Reintubation, n (%)
Mann-Whitney.
a
Fisher exact test.
b
were routinely managed by SLPs. Although it appears intuitive
that there should be an improvement in functional oral intake
with SLP intervention, there is paucity of high-quality evi-
dence to support the involvement of SLPs in the management
of swallowing disorders in pediatric settings (28). It is plausible
to suggest that nonoral feeding may delay hospital discharge
because more time is required for the transition to oral feeding
or to train caregivers to administer nutrition nonorally.
Furthermore, severe postextubation dysphagia has been
significantly associated not only with prolonged hospital stays
but also with other poor patient outcomes such as pneumonia,
reintubation, inhospital mortality, discharge status, and surgi-
cal placement of feeding tubes (2, 6). Remarkably, a previous
study showed that trauma patients with postextubation dys-
phagia who were managed routinely by SLPs were discharged
on a regular diet and exhibited a decreased rate of aspiration
pneumonia during their hospital stay (29).
Similarly, a previous study showed that patients receiving
both low-intensity and high-intensity SLP treatment had a
significant reduction in swallowing-related medical compli-
cations, chest infection, death, and nursing home admissions
compared with patients only receiving usual care (28).
Interestingly, we did not identify patients with clinical signs
of aspiration. There are several possible explanations for this
finding. On the one hand, the majority of the patients in the
historical group did not receive a BSE or routine follow-up
by speech therapists. Therefore, we can speculate that those
patients considered to be tube feeding dependent (FOIS ≤ 3)
might actually not have presented dysphagia and might have
consequently had less potential for aspiration. On the other
hand, although all of the patients in the intervention group
had dysphagia, routine evaluation from a SLP enabled the
identification of patients at higher risk of aspiration (laryn-
geal penetration). These patients could then receive careful
management of dietary introduction and progression that
made it possible to reduce the aspiration rate in this group.
Furthermore, we used stringent selection criteria to exclude
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All Patients, Standard Care Intervention
n = 115 Group, n = 41 Group, n = 74 p
5 (3–7) 7 (4–10) 4 (3–5) 0.002a
10 (8–13) 13 (10–16) 9 (8–11) < 0.0001a
9 (7.8) 9 (21.9) 0 (0) 0.000b
5 (4.3) 2 (4.9) 3 (4.1) 1.00b
12 (8–18) 12 (8–22) 11.5 (8–16) 0.296a
20 (18–27) 25 (19.25–30.5) 20 (16.25–25) 0.036a
12 (10.4) 10 (24.3) 2 (2.7) 0.001b
patients with moderate to severe neurologic impairments
because these patients, in critical care settings, have higher risk
for swallowing disorders and aspiration than nonneurologic
populations (30–32). Even so, our study did not include any
confirmatory fluoroscopic imaging or fiber-optic endoscopic
evaluation to document silent or subclinical aspiration. The
very small number of patients with nosocomial pneumonia in
this study made it difficult to discern a statistically significant
difference between the periods of study. In addition, this study
was not powered to detect the impact of SLP intervention on
the occurrence rate of nosocomial pneumonia.
Importantly, the FOIS used in the current study measures
changes in functional oral intake over time and evaluates the oral
rehabilitation efficacy of the SLP intervention (33). In fact, the
FOIS is not designed to determine swallowing impairment but
to complement the bedside evaluation of the deglutition disor-
der, suggesting the feeding via as well as the need of deglutition
compensating measure. Therefore, we should note that being
dependent on a feeding tube after extubation does not neces-
sarily indicate a swallowing disorder. In fact, oral intake patterns
may be affected by other causes (e.g., an underlying condition,
respiratory failure, a low consciousness level, a low cognitive level,
or an increased need for fluidic and caloric support). Clinicians
may determine specific dietary levels based on perceptions of eat-
ing effectiveness and/or safety that cause patients to be classified
as feeding-tube dependent. Still, dysphagic patients may refuse
liquids and foods because of taste, flavor, aesthetics, personal likes
and dislikes, or ease of swallowing (16).
One could argue that if SLP intervention improves the time
to initiate the oral feeding, these professionals should be con-
sulted for initial assessments but that continued sessions may
not be necessary. Small variations in food texture may have a
large impact on patient health. Therefore, each food’s texture
should be rigorously identified and reproduced. For that rea-
son, although patients can initiate oral feeding with a single
food consistency, they should be able to swallow multiple con-
sistencies. There is accordingly a difference between the time
October 2018 • Volume 19 • Number 10

to initiate oral feeding and the time required to attain full oral
feeding. In this way, early SLP assessment and follow-up dur-
ing rehabilitation are crucial for the management of dysphagic
patients. In our study, we found that the median time to attain
oral full intake from the first oral feeding was 4 days longer for
patients in the historical group compared with patients in the
intervention group.
We also found that patients receiving swallowing interven-
tions had better outcomes such as decreased hospital stays, less
need for a feeding tube upon discharge and less need for rein-
tubation than patients receiving standard care. From a clini-
cal perspective, our study demonstrated that receiving optimal
interdisciplinary care is an important component in quality
improvement programs.
Currently, there is no consensus about the minimum staff-
ing levels for SLPs in ICUs. It is acknowledged that this issue
needs to be addressed and requires both a benchmarking exer-
cise to establish current speech and language therapy ICU ser-
vices and the development of subsequent guidelines on best
practice staffing levels. Although the gap between the current
and desired service levels remains unclear, it is recognized
that local variations exist and are dependent upon available
resources and skills, recognition of the role of speech and lan-
guage therapy, and the type of ICU (34). In settings where the
availability of SLPs is limited, the quality of care for patients
with dysphagia can improve with nurse-performed screening
for postextubation dysphagia (35) and store-and-forward tele-
medicine for expert consultation (36).
With the goal of guiding clinical practices and hospital poli-
cies, our findings highlight the need for more rigorous clinical
research designed to assess the frequency of postextubation
dysphagia in children, diagnostic evaluation, and treatment
strategies.
Our study has several limitations. First, it was a single-center
study, and its results may not be generalizable to other PICUs.
Second, although there is no validated tool to assess dysphagia
in children, other pediatric studies have used the FOIS (37–
39); clinical experience indicates that the FOIS is appropriate
to use with younger children (17). Third, the gold standard for
evaluation of dysphagia is a video fluoroscopic swallow study
(VFSS) or a fiber-optic endoscopic evaluation of swallowing.
However, the FOIS does not require a VFSS screening since the
ratings are associated with dysphagia severity rather than aspi-
ration severity (16). Furthermore, the use of the FOIS enables
measurements of the level of oral intake of food and liquid
before and after speech-language therapy at the oropharyngeal
dysphagia, which reveals the changes occurring at feeding dur-
ing the therapeutic process (18, 35).
Fourth, the fact that the FOIS score was assessed retrospec-
tively in the historical control group and prospectively in the
intervention group may have contributed to bias. But this scale
has a high interrater reliability, it can be quickly and easily
applied, it does not require a prior functional assessment, and it
can be applied by any healthcare provider (16). We accordingly
believe that the FOIS was an appropriate tool for our study.
Fifth, there is always the possibility of confounding variables
Pediatric Critical Care Medicine
Copyright © 2018 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Unauthorized reproduction of this article is prohibited
Online Clinical Investigations
related to PICU care between retrospective and prospective
arms of a study. Hence, changes in staff, protocols, equipment,
and resources between the two periods may have impacted
the study outcomes. In our study, we found that both groups
were similar. Therefore, the control group provides some con-
fidence that the changes occurring over time were not the
result of natural temporal trends or unmeasured events that
occurred contemporaneously during the study. Finally, we did
not randomize the dysphagia rehabilitation to create a control
group. Quality improvement studies are typically conducted in
settings where random allocation to groups is not feasible for
ethical reasons or where the environmental conditions prevent
experimental manipulation.
In conclusion, swallowing interventions for postextuba-
tion dysphagia performed by a SLP resulted in a shorter time
to achieve total oral intake compared with standard care.
Furthermore, our results showed that management routinely
provided by a SLP service had a favorable impact on several
patient-centered outcomes such as the proportion of patients
with total oral intake at discharge, the time spent in hospital,
and rate of reintubation. In order to guide clinical practice in
areas like feeding/swallowing assessments and related inter-
ventions in critically ill children larger high-quality studies are
still needed.
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