Research paperThe incidence and clinical outcomes of postextubation dysphagia in a regional critical care setting
Introduction
Swallowing impairment (dysphagia) within admitted hospital patients is known to contribute to adverse patient outcomes and increase healthcare expenditure.[1], [2], [3] Specifically, in a recent systematic review, presence of dysphagia in all-cause admissions demonstrated a 40.36% increase in healthcare expenditure and increased length of stay (LOS) by 2.99 days (95% confidence interval [CI] = 2.7, 3.3).2 However, to the best of our knowledge, the impact of dysphagia after endotracheal intubation on healthcare expenditure has not been previously explored. This information is valuable to improve and inform already stretched resource allocations, as well as to provide a baseline for future implementation research.
Postextubation dysphagia (PED) is reported to occur in 41% (95% CI = 0.33, 0.50) of patients intubated in the intensive care unit (ICU) via an endotracheal tube.4 The pathophysiology of PED is reported to be multifactorial, with contributing factors inclusive of (i) direct injury from the endotracheal tube to the structures critical for swallowing; (ii) critical illness myopathy and/or polyneuropathy; (iii) reduced respiratory capacity associated with the critical illness, which may in turn reduce the effectiveness of airway clearance for aspirated material or result in impaired breath–swallow coordination; and (iv) impaired cognition impacting the ability for safe oral intake.[5], [6], [7], [8] All of these factors may impact both airway protection during swallowing and the efficiency of the swallow.
PED has been demonstrated to increase the risk of pneumonia, prolong LOS in the hospital and ICU and is independently associated with increasing mortality risk.1,7,[9], [10], [11] When considering the adverse outcomes associated with PED, it is important to note that much of the existing PED literature focuses solely on patients with prolonged intubation.9,[12], [13], [14], [15], [16], [17], [18], [19], [20] The focus on patients with prolonged intubation is also reflected in emerging screening tools for PED.21,22 It is unclear if these tools are valid and reliable for use with patients who are intubated for less than 48 h, a commonly used definition of prolonged intubation.9,13,14,23,24 This is particularly pertinent when considering the median intubation duration for critically ill patients in Australia and New Zealand is reported as 0.9 days when including cardiothoracic patients and 1.9 days when excluding cardiothoracic patients.25 Australian data on the prevalence and outcomes of patients with PED are critically lacking. Clinically relevant data on the impact of PED in Australia, particularly for patients after a short period of intubation (<48 h), will help to inform service-level decisions and multidisciplinary management, when determining patient suitability to resume oral intake after extubation.
Therefore, the aims of this study were to explore the outcomes of PED in an Australian context inclusive of healthcare expenditure, LOS in the ICU and hospital, and rates of pneumonia. Further to this, we sought to determine if negative outcomes associated with PED differed based on short or prolonged periods of intubation.
Section snippets
Methods
This study was conducted as a retrospective cohort analysis over a 5-year period (July 1, 2013, to June 30, 2018) in a regional Australian mixed medical and surgical ICU. All critically ill patients who had undergone endotracheal intubation for the purpose of invasive mechanical ventilation in the ICU were identified from within a site-specific administrative database for inpatient admissions. The database was maintained by a team of clinical coders, who strictly followed the Australian Coding
Results
A total of 858 episodes were identified from the initial data search. Thirty-six (4%) were excluded owing to the presence of a tracheostomy or pre-existing dysphagia. This resulted in a total study population of 822 patient episodes from the administrative and costing databases (Fig. 1). Of these episodes, 802 were successfully linked to the local ICU database, with a linkage success rate of 97.6%.
Demographic and admission details are shown in Table 1. The median duration of mechanical
Discussion
To the best of our knowledge, this is the first study to present data on the incidence and outcomes of PED in a regional critical care setting in Australia. Patients with PED were more likely to develop pneumonia, had a longer ICU and hospital length of stay, and had increased healthcare expenditure, measured as median cost per patient stay. Despite duration of intubation increasing the risk of dysphagia, just more than half (53%) of all patients with PED were intubated for less than 48 h.
Conclusion
This study highlights that PED in the ICU setting has significant negative impacts on patient outcomes and healthcare expenditure. Even patients who are intubated for a short period of time (<48 h) are at risk of PED. We propose that this patient population should be included in future studies on PED and that clinically, duration of intubation should not be considered in isolation when determining if a patient is at risk of PED.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Melanie McInytre: Conceptualisation, Methodology, Formal analysis, Writing original draft, Writing review and editing.
Sebastian Doeltgen: Methodology, Writing review and editing, Supervision.
Ceilia Shao: Methodology, Resources, Data curation, Writing review and editing.
Timothy Chimunda: Conceptualisation, Methodology, Writing review and editing, Supervision.
Conflict of Interest
None.
Acknowledgements
The authors would like to thank Farina Palmer, Kevin Masman, and Reshma Faroqui Zujam from Bendigo Health for their contributions to this study.
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