Accepted Manuscript

Post-extubation dysphagia in critical trauma patients: Are new screening methodsnecessary? Some practical comments

Antonio M. Esquinas, Ph.D, M.D, FCCP Alberto Fernandez Carmona, M.D

PII: S0002-9610(14)00166-4

DOI: 10.1016/j.amjsurg.2014.02.005

Reference: AJS 11142

To appear in: The American Journal of Surgery

Received Date: 3 February 2014

Accepted Date: 24 February 2014

Please cite this article as: Esquinas AM, Carmona AF, Post-extubation dysphagia in critical traumapatients: Are new screening methods necessary? Some practical comments, The American Journal ofSurgery (2014), doi: 10.1016/j.amjsurg.2014.02.005.

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Dear Editor:

Reintubation after extubation in trauma patients is associated with prolonged

mechanical ventilation (MV), hospital and intensive care unit (ICU) stays and high risk of

aspiration pneumonia.1 In this association post-extubation dysphagia (PED) and swallowing

difficulties are key factors.2 However, studies published have shown variable rates,

methodology bias and overall very low quality of evidence. 3

We have read that Kwok AM et al. described an observational series in trauma

patients whose PED was 42% (3% to 62%).4 This interesting study confirms some

previous observations and clinical implications in postextubation dysphagia. However,

some aspects need clarification:

First, authors enrolled patients with low levels of neurologic function by coma

Glasgow Coma Score (GCS) at admission and this can influence rate of postextubation

dysphagia.5 It is remarkable that the patients included in the study had moderate damage to

head and neck, patients with neurological or major damage required prolonged MV and

high risk of postextubation dysphagia and this difficult extrapolation with other series.5

Also, this influence of low mortality reported (1 and 270 times) lower than other studies in

the same field MV. Finally, use of index severity score (ISS) or GCS are not related directly

to dysphagia. How authors evaluated these aspects needs clarification. Nevertheless, a main

question is relevant, in this series of trauma patients with moderate and not serious

neurologic injury PED was related to the presence of artificial airway and mechanical

ventilation not because cognitive impairment. More than 90% of patients with dysphagia

were discharged with well-tolerated oral nutrition; this is conflictive but interesting data

that we can understand in this context.

Second, association of age and postextubation dysphagia needs evaluation. The

maximum age of the patients included is 64 years; it is possible that if older patients were

included this rate would be more frequent.5

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Third, diagnosis assessment of dysphagia diagnostic method both as silent

aspiration has proved to be less sensitive and specific than other instrumental tests and

probably underestimates the existence of patients with dysphagia. Additionally, a) did not

include a dysphagia severity scale, b) excluded patients undergoing MV <24h, c)

information time for recovery dysphagia 7 and d) Implications of cough is a reliable sign of

swallowing disorder, how authors interpreted this aspect in silent aspiration and

contraindicates oral feeding.8 Authors reported a silent aspiration was found in 37% of

patients with POD.

Fourth, rate of aspiration pneumonia needs evaluation. They provided an infectious

complications rate in patients diagnosed with POD but only reflect two cases of "aspiration

pneumonia" (not defined what it considers as such). Nor do we know the total number of

infections respirators POD group (aspirational or not aspirational) and we can’t compare it

with the group not diagnosed with dysphagia. It is very interesting that after the

implementation of PED screening protocol, there was a significant low incident of

infectious complications, it would be relevant to know what kind of strategies they

implemented after post extubation dysphagia diagnosis, including dysphagia therapies, time

to initiate oral feeding, etc. They comment that after the diagnosis of dysphagia was made

55% patients were kept nil per os while the rest were started on a modified diet without

further evaluation, how was it determined if oral diet was beginning or not? When did they

re-evaluate the presence of dysphagia?9

We consider that further prospective large studies are needed to clarify and evaluate

implications of silent POD and implications to outcomes in trauma patients, as well as to

determine if it is necessary to implement other screening methods in high risk patients.

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References

1. Epstein SK, Ciubotaru RL, Wong JB. Effect of failed extubation on the outcome

of mechanical ventilation. Chest 1997;112(1):186-92.

2. Macht M, Wimbish T, Clark BJ, et al. Postextubation dysphagia is persistent and

associated with poor outcomes in survivors of critical illness. Crit Care

2011;15(5):R231.

3. Skoretz SA, Flowers HL, Martino R. The incidence of dysphagia following

endotracheal intubation: a systematic review. Chest 2010;137(3):665-73.

4. Kwok AM, Davis JW, Cagle KM, et al. Post-extubation dysphagia in trauma

patients: it's hard to swallow. Am J Surg 2013;206(6):924-7.

5. Brown CV, Daigle JB, Foulkrod KH, et al. Risk factors associated with early

reintubation in trauma patients: a prospective observational study. J Trauma

2011;71(1):37-41.

6. El Solh A, Okada M, Bhat A, Pietrantoni C. Swallowing disorders post orotracheal

intubation in the elderly. Intensive Care Med 2003;29(9):1451- 5.

7. de Larminat V, Montravers P, Dureuil B, et al. Alteration in swallowing reflex after

extubation in intensive care unit patients. Crit Care Med 1995;23(3):486-90.

8. Noordally SO, Sohawon S, De Gieter M, et al. A study to determine the correlation

between clinical, fiber-optic endoscopic evaluation of swallowing and

videofluoroscopic evaluations of swallowing after prolonged intubation. Nutr Clin

Pract 2011;26(4):457-62.

9. Moraes DP, Sassi FC, Mangilli LD, et al. Clinical prognostic indicators of dysphagia

following prolonged orotracheal intubation in ICU patients. Crit Care 2013;

18;17(5):R243.

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Abbreviations list

GCS=Glasgow coma score

ICU= intensive care unit

ISS= index severity score

MV= mechanical ventilation

OD= oropharyngeal dysphagia

PED= post-extubation dysphagia