Research paper
The incidence and clinical outcomes of postextubation dysphagia in a regional critical care setting

https://doi.org/10.1016/j.aucc.2021.03.008Get rights and content

Abstract

Background

Postextubation dysphagia (PED) has been shown to occur in 41% of critically ill patients requiring endotracheal intubation. With one-third of patients with PED experiencing silent aspiration, it is reasonable to anticipate negative health outcomes are likely, although this has not yet been systematically explored in an Australian context.

Objectives

The aim of the study was to determine the impact of PED, in a regional Australian intensive care unit (ICU), on rates of pneumonia, the length of stay in the ICU and hospital, and healthcare expenditure.

Methods

This study was conducted as a retrospective cohort analysis, which used administrative healthcare data of patients who received endotracheal intubation for invasive mechanical ventilation. Patients with a tracheostomy or known pre-existing dysphagia were excluded.

Results

A total of 822 patient episodes were identified, of which 7% (n = 58) presented with PED. Half of all patients within the PED cohort (53%) were intubated for fewer than 48 h. Patients with PED had a longer median length of stay in the ICU (5 days versus 3 days, p < 0.001) and were more likely to develop pneumonia (odds ratio = 2.51, 95% confidence interval = 1.28, 4.95) than extubated patients without dysphagia. Median cost per hospital admission for patients with PED was double that for extubated patients without dysphagia (AUD $42,685 versus AUD $20,840, p < 0.001).

Conclusions

This study highlights that even a short duration of intubation may carry a risk of PED. The presence of PED, regardless of duration of intubation, increased the rates of pneumonia, length of stay in the ICU and hospital, and healthcare expenditure.

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.

References (37)

  • M.B. Brodsky et al.

    Prevalence, pathophysiology, diagnostic modalities and treatment options for dysphagia in critically ill patients

    Am J Phys Med Rehabil

    (2020)
  • M.B. Brodsky et al.

    Laryngeal injury and upper airway symptoms after oral endotracheal intubation with mechanical ventilation during critical care: a systematic review

    Critical Care Med

    (2018)
  • P. Zuercher et al.

    Dysphagia in the intensive care unit: epidemiology, mechanisms, and clinical management

    Crit Care

    (2019)
  • T. Goldsmith

    Evaluation and treatment of swallowing disorders following endotracheal intubation and tracheostomy

    Int Anesthesiol Clin

    (2000)
  • M.S. Ajemian et al.

    Routine fiberoptic endoscopic evaluation of swallowing following prolonged intubation: implications for management

    Arch Surg

    (2001)
  • M. Macht et al.

    Post-extubation dysphagia is associated with longer hospitalization in survivors of critical illness with neurologic impairment

    Crit Care

    (2013)
  • J.C. Schefold et al.

    Dysphagia in mechanically ventilated ICU patients (DYnAMICS): a prospective observational trial

    Crit Care Med

    (2017)
  • J. Barker et al.

    Incidence and impact of dysphagia in patients receiving prolonged endotracheal intubation after cardiac surgery

    Can J Surg

    (2009)
  • Cited by (9)

    View all citing articles on Scopus
    View full text