May 19, 2015
Of the 5 to 7 million patients admitted to an intensive care unit every year in the United States, at least a third will need endotracheal intubation with mechanical ventilation, says Martin Brodsky. And, as our population ages, adds the Johns Hopkins Physical Medicine and Rehabilitation speech-language pathologist, the number of patients with acute respiratory failure (ARF) in need of intubation is expected to rise by more than 5 percent every year. Should these patients survive, they will likely experience dangerous post-extubation, post-ICU complications, including swallowing disorders. Left unrecognized and/or untreated, dysphagia can lead to dehydration, malnutrition, aspiration, and even death.
At this writing, no one is treating patients for possible dysphagia during oral intubation with mechanical ventilation. And the published literature on effective interventions is sparse. There is only one small, randomized study evaluating a multifaceted intervention for dysphagia during intubation in a heterogeneous group of 15 mechanically ventilated ARF patients.
Yet much can be done, Brodsky argues, to reduce or prevent dysphagia and aspiration in these patients. The key, he believes, is to intervene early—before extubation. Treatment, he says, should include a multimodal, sensorimotor therapy regimen targeted to improve oral strength and reduce dysphagia and aspiration.
In his new study evaluating the demographic and clinical factors associated with self-reported dysphagia post-intubation, Brodsky discovered that the risk for dysphagia continues to increase twofold per day during the first six days of intubation. He reported that dysphagia has been found in up to 80 percent of ARF patients after 48 hours of endotracheal intubation. He also noted previous research suggesting a strong link between the presence and duration of oral endotracheal intubation and laryngeal injury, leading to dysphagia.
Unlike prior studies that address swallowing function after extubation or in patients with chronic respiratory failure, says Brodsky, “we propose a promising early therapy during intubation in a homogenous ARF patient population.” Incorporating a speech-language pathology consultation that includes a videofluoroscopic swallow study and treatment early during a patient’s ICU stay can preempt medical complications due to dysphagia, he says.
Dysphagia, especially with severity that leads to aspiration, poses particularly serious threats after extubation in ARF patients, says Brodsky, because many are still recovering from lung injuries. Another reason to intervene early, he says, is that because of reduced laryngeal sensation after extubation, up to 44 percent of aspiration events are silent (no acute clinical sign or symptom), a frequency that nearly doubles that of stroke patients. These patients will be the ones most often missed until medical complications suggest the need for intervention, and by then, it may be too late. The difficult part is knowing whom to assess.
“Now that we’ve advanced the science well enough to locate a problem in this patient population,” he says, “we need to be more sensitive to patients’ needs. It’s all about coordinated care.”