Skip to main content

Advertisement

SpringerLink
Log in

Clinical Approaches to Assess Post-extubation Dysphagia (PED) in the Critically Ill

  • Review
  • Published:
Dysphagia Aims and scope Submit manuscript

Abstract

Swallowing disorders and respective consequences (including aspiration-induced pneumonia) are often observed in extubated ICU patients with data indicating that a large number of patients are affected. We recently demonstrated in a large-scale analysis that the incidence of post-extubation dysphagia (PED) is 12.4% in a general ICU population and about 18% in emergency admissions to the ICU. Importantly, PED was mostly sustained until hospital discharge and independently predicted 28- and 90-day mortality. Although oropharyngeal/laryngeal trauma, neuromuscular ICU-acquired weakness, reduced sensation/sensorium, dyssynchronous breathing, and gastrointestinal reflux, are all considered to contribute to PED, little is known about the underlying pathomechanisms and risk factors leading to PED in critically ill patients. Systematic screening of all potential ICU patients for oropharyngeal dysphagia (OD) seems key for early recognition and follow-up, as well as the design and testing of novel therapeutic interventions. Today, screening methods and clinical investigations for dysphagia differ considerably. In the context of a recently proposed pragmatic screening algorithm introduced by us, we provide a concise review on currently available non-instrumental techniques that could potentially serve for non-instrumental OD assessment in critically ill patients. Following systematic literature review, we find that non-instrumental OD assessments were mostly tested in different patient populations with only a minority of studies performed in critically ill patients. Due to little available data on non-instrumental dysphagia assessment in the ICU, future investigations should aim to validate respective approaches in the critically ill against an instrumental (gold) standard, for example, flexible endoscopic evaluation of swallowing. An international expert panel is encouraged to addresses critical illness—related definitions, screening and confirmatory assessment approaches, treatment recommendations, and identifies optimal patient-centered outcome measures for future clinical investigations.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References

  1. Macht M, White SD, Moss M. Swallowing dysfunction after critical illness. Chest. 2014;146(6):1681–9.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Macht M, Wimbish T, Bodine C, Moss M. ICU-acquired swallowing disorders. Crit Care Med. 2013;41(10):2396–405.

    Article  PubMed  Google Scholar 

  3. Skoretz SA, Yau TM, Ivanov J, Granton JT, Martino R. Dysphagia and associated risk factors following extubation in cardiovascular surgical patients. Dysphagia. 2014;29(6):647–54.

    Article  PubMed  Google Scholar 

  4. Smithard DG, O’Neill PA, Parks C, Morris J. Complications and outcome after acute stroke. Does dysphagia matter? Stroke. 1996;27(7):1200–4.

    Article  CAS  PubMed  Google Scholar 

  5. Westergren A, Ohlsson O, Rahm Hallberg I. Eating difficulties, complications and nursing interventions during a period of three months after a stroke. J Adv Nurs. 2001;35(3):416–26.

    Article  CAS  PubMed  Google Scholar 

  6. Macht M, Wimbish T, Clark BJ, Benson AB, Burnham EL, Williams A, Moss M. Postextubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness. Crit Care. 2011;15(5):R231.

    Article  PubMed  PubMed Central  Google Scholar 

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

    Article  PubMed  Google Scholar 

  8. Schefold JC, Berger D, Zurcher P, Lensch M, Perren A, Jakob SM, Parviainen I, Takala J. Dysphagia in mechanically ventilated ICU patients (DYnAMICS): a prospective observational trial. Crit Care Med. 2017;45:2061–9.

    Article  PubMed  Google Scholar 

  9. Zurcher P, Takala J, Schefold JC. The authors reply. Crit Care Med. 2018;46(4):e344–5.

    Article  PubMed  Google Scholar 

  10. Altman KW, Yu GP, Schaefer SD. Consequence of dysphagia in the hospitalized patient: impact on prognosis and hospital resources. Arch Otolaryngol Head Neck Surg. 2010;136(8):784–9.

    Article  PubMed  Google Scholar 

  11. Altman KW. Dysphagia evaluation and care in the hospital setting: the need for protocolization. Otolaryngol Head Neck Surg. 2011;145(6):895–8.

    Article  PubMed  Google Scholar 

  12. Ferraris VA, Ferraris SP, Moritz DM, Welch S. Oropharyngeal dysphagia after cardiac operations. Ann Thorac Surg. 2001;71(6):1792–5 (discussion 1796).

    Article  CAS  PubMed  Google Scholar 

  13. Hogue CW Jr, Lappas GD, Creswell LL, Ferguson TB Jr, Sample M, Pugh D, Balfe D, Cox JL, Lappas DG. Swallowing dysfunction after cardiac operations. Associated adverse outcomes and risk factors including intraoperative transesophageal echocardiography. J Thorac Cardiovasc Surg. 1995;110(2):517–22.

    Article  PubMed  Google Scholar 

  14. 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.

    PubMed  PubMed Central  Google Scholar 

  15. Rousou JA, Tighe DA, Garb JL, Krasner H, Engelman RM, Flack JE 3rd, Deaton DW. Risk of dysphagia after transesophageal echocardiography during cardiac operations. Ann Thorac Surg. 2000;69(2):486–9 (discussion 489-490).

    Article  CAS  PubMed  Google Scholar 

  16. Suntrup S, Warnecke T, Kemmling A, Teismann IK, Hamacher C, Oelenberg S, Dziewas R. Dysphagia in patients with acute striatocapsular hemorrhage. J Neurol. 2012;259(1):93–9.

    Article  PubMed  Google Scholar 

  17. Ickenstein GW, Hohlig C, Prosiegel M, Koch H, Dziewas R, Bodechtel U, Muller R, Reichmann H, Riecker A. Prediction of outcome in neurogenic oropharyngeal dysphagia within 72 hours of acute stroke. J Stroke Cerebrovasc Dis. 2012;21(7):569–76.

    Article  PubMed  Google Scholar 

  18. Suntrup S, Kemmling A, Warnecke T, Hamacher C, Oelenberg S, Niederstadt T, Heindel W, Wiendl H, Dziewas R. The impact of lesion location on dysphagia incidence, pattern and complications in acute stroke. Part 1: dysphagia incidence, severity and aspiration. Eur J Neurol. 2015;22(5):832–8.

    Article  CAS  PubMed  Google Scholar 

  19. Brodsky MB, Huang M, Shanholtz C, Mendez-Tellez PA, Palmer JB, Colantuoni E, Needham DM. Recovery from dysphagia symptoms after oral endotracheal intubation in acute respiratory distress syndrome survivors. A 5-year longitudinal study. Ann Am Thorac Soc. 2017;14(3):376–83.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Berger D, Bloechlinger S, von Haehling S, Doehner W, Takala J, Z’Graggen WJ, Schefold JC. Dysfunction of respiratory muscles in critically ill patients on the intensive care unit. J Cachexia Sarcopenia Muscle. 2016;7(4):403–12.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Schefold JC, Bierbrauer J, Weber-Carstens S. Intensive care unit-acquired weakness (ICUAW) and muscle wasting in critically ill patients with severe sepsis and septic shock. J Cachexia, Sarcopenia Muscle. 2010;1(2):147–57.

    Article  Google Scholar 

  22. Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke. 2005;36(12):2756–63.

    Article  PubMed  Google Scholar 

  23. Brady S, Donzelli J. The modified barium swallow and the functional endoscopic evaluation of swallowing. Otolaryngol Clin N Am. 2013;46(6):1009–22.

    Article  Google Scholar 

  24. Zielske J, Bohne S, Axer H, Brunkhorst FM, Guntinas-Lichius O. Dysphagia management of acute and long-term critically ill intensive care patients. Med Klin Intensivmed Notfallmed. 2014;109(7):516–25.

    Article  CAS  Google Scholar 

  25. Daniels SK, Anderson JA, Willson PC. Valid items for screening dysphagia risk in patients with stroke: a systematic review. Stroke. 2012;43(3):892–7.

    Article  PubMed  Google Scholar 

  26. McCullough GH, Wertz RT, Rosenbek JC. Sensitivity and specificity of clinical/bedside examination signs for detecting aspiration in adults subsequent to stroke. J Commun Disord. 2001;34(1–2):55–72.

    Article  CAS  PubMed  Google Scholar 

  27. McCullough GH, Wertz RT, Rosenbek JC, Mills RH, Ross KB, Ashford JR. Inter- and intrajudge reliability of a clinical examination of swallowing in adults. Dysphagia. 2000;15(2):58–67.

    Article  CAS  PubMed  Google Scholar 

  28. Ramsey DJ, Smithard DG, Kalra L. Early assessments of dysphagia and aspiration risk in acute stroke patients. Stroke. 2003;34(5):1252–7.

    Article  PubMed  Google Scholar 

  29. Schepp SK, Tirschwell DL, Miller RM, Longstreth WT Jr. Swallowing screens after acute stroke: a systematic review. Stroke. 2012;43(3):869–71.

    Article  PubMed  Google Scholar 

  30. Brodsky MB, Suiter DM, Gonzalez-Fernandez M, Michtalik HJ, Frymark TB, Venediktov R, Schooling T. Screening accuracy for aspiration using bedside water swallow tests: a systematic review and meta-analysis. Chest. 2016;150(1):148–63.

    Article  PubMed  PubMed Central  Google Scholar 

  31. McAllister S, Kruger S, Doeltgen S, Tyler-Boltrek E. Implications of variability in clinical bedside swallowing assessment practices by speech language pathologists. Dysphagia. 2016;31(5):650–62.

    Article  PubMed  Google Scholar 

  32. Dysphagia screening tools: a review June 2008. https://www.corhealthontario.ca/Dysphagia-Sreen-Review-FINAL-2008.pdf.

  33. Polit DF, Beck CT. Nursing research: generating and assessing evidence for nursing practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.

    Google Scholar 

  34. Reitsma JB RA, Whiting P, Vlassov VV, Leeflang MMG, Deeks JJ. Cochrane handbook for systematic reviews of diagnostic test accuracy: chapter 9: assessing methodological quality [Online]. 2009. http://www.srdtacochraneorg/.

  35. Clave P, Arreola V, Romea M, Medina L, Palomera E, Serra-Prat M. Accuracy of the volume-viscosity swallow test for clinical screening of oropharyngeal dysphagia and aspiration. Clin Nutr. 2008;27(6):806–15.

    Article  PubMed  Google Scholar 

  36. Gonzalez-Fernandez 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.

    Article  PubMed  Google Scholar 

  37. Lynch YT, Clark BJ, Macht M, White SD, Taylor H, Wimbish T, Moss M. The accuracy of the bedside swallowing evaluation for detecting aspiration in survivors of acute respiratory failure. J Crit Care. 2017;39:143–8.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Hansen T, Lambert HC, Faber J. Validation of the Danish version of the McGill Ingestive Skills Assessment using classical test theory and the Rasch model. Disabil Rehabil. 2012;34(10):859–68.

    Article  PubMed  Google Scholar 

  39. Rofes L, Arreola V, Mukherjee R, Clave P. Sensitivity and specificity of the eating assessment tool and the volume-viscosity swallow test for clinical evaluation of oropharyngeal dysphagia. Neurogastroenterol Motil. 2014;26(9):1256–65.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Guillén-Solà A, Martínez-Orfila J, Boza Gómez R, Monleón Castelló S, Marco E. Cribaje de la disfagia en el ictus: utilidad de los signos clínicos y el método de exploración clínica de volumen viscosidad en comparación con la videofluoroscopia. Rehabilitación. 2011;45(4):292–300.

    Article  Google Scholar 

  41. Paris G, Martinaud O, Hannequin D, Petit A, Cuvelier A, Guedon E, Ropenneck P, Verin E. Clinical screening of oropharyngeal dysphagia in patients with ALS. Ann Phys Rehabil Med. 2012;55(9–10):601–8.

    Article  CAS  PubMed  Google Scholar 

  42. Mann G, Hankey GJ, Cameron D. Swallowing disorders following acute stroke: prevalence and diagnostic accuracy. Cerebrovasc Dis. 2000;10(5):380–6.

    Article  CAS  PubMed  Google Scholar 

  43. Oh JC, Park JH, Jung MY, Yoo EY, Chang KY, Lee TY. Relationship between quantified instrumental swallowing examination and comprehensive clinical swallowing examination. Occup Ther Int. 2016;23(1):3–10.

    Article  PubMed  Google Scholar 

  44. Lambert HC, Gisel EG, Groher ME, Abrahamowicz M, Wood-Dauphinee S. Psychometric testing of the McGill Ingestive Skills Assessment. Am J Occup Therapy. 2006;60(4):409–19.

    Article  Google Scholar 

  45. Trapl M, Enderle P, Nowotny M, Teuschl Y, Matz K, Dachenhausen A, Brainin M. Dysphagia bedside screening for acute-stroke patients: the Gugging Swallowing Screen. Stroke. 2007;38(11):2948–52.

    Article  PubMed  Google Scholar 

  46. Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia. 1996;11(2):93–8.

    Article  CAS  PubMed  Google Scholar 

  47. Warnecke T, Im S, Kaiser C, Hamacher C, Oelenberg S, Dziewas R. Aspiration and dysphagia screening in acute stroke—the Gugging Swallowing Screen revisited. Eur J Neurol. 2017;24(4):594–601.

    Article  CAS  PubMed  Google Scholar 

  48. Logemann JA, Veis S, Colangelo L. A screening procedure for oropharyngeal dysphagia. Dysphagia. 1999;14(1):44–51.

    Article  CAS  PubMed  Google Scholar 

  49. Carnaby GD, Crary MA. Development and validation of a cancer-specific swallowing assessment tool: MASA-C. Support Care Cancer. 2014;22(3):595–602.

    Article  PubMed  Google Scholar 

  50. Antonios N, Carnaby-Mann G, Crary M, Miller L, Hubbard H, Hood K, Sambandam R, Xavier A, Silliman S. Analysis of a physician tool for evaluating dysphagia on an inpatient stroke unit: the modified Mann Assessment of Swallowing Ability. J Stroke Cerebrovasc Dis. 2010;19(1):49–57.

    Article  PubMed  Google Scholar 

  51. Sheppard JJ, Hochman R, Baer C. The dysphagia disorder survey: validation of an assessment for swallowing and feeding function in developmental disability. Res Dev Disabil. 2014;35(5):929–42.

    Article  PubMed  Google Scholar 

  52. Zhou Z, Salle J, Daviet J, Stuit A, Nguyen C. Combined approach in bedside assessment of aspiration risk post stroke: PASS. Eur J Phys Rehabil Med. 2011;47(3):441–6.

    CAS  PubMed  Google Scholar 

  53. Maeda K, Shamoto H, Wakabayashi H, Enomoto J, Takeichi M, Koyama T. Reliability and validity of a simplified comprehensive assessment tool for feeding support: Kuchi-Kara Taberu Index. J Am Geriatr Soc. 2016;64(12):e248–52.

    Article  PubMed  Google Scholar 

  54. Lee KM, Kim HJ. Practical assessment of dysphagia in stroke patients. Ann Rehabil Med. 2015;39(6):1018–27.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Hansen T, Kjaersgaard A, Faber J. Measuring elderly dysphagic patients’ performance in eating—a review. Disabil Rehabil. 2011;33(21–22):1931–40.

    Article  PubMed  Google Scholar 

  56. Lagarde ML, Kamalski DM, van den Engel-Hoek L. The reliability and validity of cervical auscultation in the diagnosis of dysphagia: a systematic review. Clin Rehabil. 2016;30(2):199–207.

    Article  PubMed  Google Scholar 

  57. Nathadwarawala KM, Nicklin J, Wiles CM. A timed test of swallowing capacity for neurological patients. J Neurol Neurosurg Psychiatry. 1992;55(9):822–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  58. O’Neil-Pirozzi TM, Lisiecki DJ, Jack Momose K, Connors JJ, Milliner MP. Simultaneous modified barium swallow and blue dye tests: a determination of the accuracy of blue dye test aspiration findings. Dysphagia. 2003;18(1):32–8.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Physiotherapy, Inselspital, University Hospital of Bern, Bern, Switzerland

    Andrea Perren

  2. Department of Intensive Care Medicine, Inselspital, University Hospital of Bern, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland

    Patrick Zürcher & Joerg C. Schefold

Authors
  1. Andrea Perren
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Patrick Zürcher
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Joerg C. Schefold
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Joerg C. Schefold.

Ethics declarations

Conflict of interest

Drs. Zürcher and Schefold disclose that the Department of Intensive Care Medicine has, or has had in the past, research contracts with Orion Corporation, Abbott Nutrition International, B. Braun Medical AG, CSEM SA, Edwards Lifesciences Services GmbH, Kenta Biotech, Maquet Critical Care AB, Omnicare Clinical Research AG and research and development/consulting contracts with Edwards Lifesciences SA, Maquet Critical Care AB, and Nestlé. The money was paid into a departmental fund, and no personal financial gain was received. The Department has also received unrestricted educational grants from the following organizations for organizing biannual postgraduate courses in the fields of critical care ultrasound, management of extracorporeal membrane oxygenation and mechanical ventilation: Pierre Fabre Pharma AG (formerly known as RobaPharm), Pfizer AG, Bard Medica SA, Abbott AG, Anandic Medical Systems, PanGas AG Healthcare, Orion Pharma, Bracco, Edwards Lifesciences AG, Hamilton Medical AG, Fresenius Kabi (Schweiz) AG, Getinge Group Maquet AG, Dräger Schweiz AG, Teleflex Medical GmbH. Mrs. Perren declares no conflicts of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Perren, A., Zürcher, P. & Schefold, J.C. Clinical Approaches to Assess Post-extubation Dysphagia (PED) in the Critically Ill. Dysphagia 34, 475–486 (2019). https://doi.org/10.1007/s00455-019-09977-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00455-019-09977-w

Keywords

Search

Navigation