Clinical dysphagia risk predictors after prolonged orotracheal intubation

Medeiros, Gisele Chagas de; Sassi, Fernanda Chiarion; Mangilli, Laura Davison; Zilberstein, Bruno; Andrade, Claudia Regina Furquim de

doi:10.6061/clinics/2014(01)02

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CLINICAL SCIENCES • Clinics 69 (1) • Jan 2014 • https://doi.org/10.6061/clinics/2014(01)02 copy

Clinical dysphagia risk predictors after prolonged orotracheal intubation

Authorship SCIMAGO INSTITUTIONS RANKINGS

OBJECTIVES:

To elucidate independent risk factors for dysphagia after prolonged orotracheal intubation.

METHODS:

The participants were 148 consecutive patients who underwent clinical bedside swallowing assessments from September 2009 to September 2011. All patients had received prolonged orotracheal intubations and were admitted to one of several intensive care units of a large Brazilian school hospital. The correlations between the conducted water swallow test results and dysphagia risk levels were analyzed for statistical significance.

RESULTS:

Of the 148 patients included in the study, 91 were male and 57 were female (mean age, 53.64 years). The univariate analysis results indicated that specific variables, including extraoral loss, multiple swallows, cervical auscultation, vocal quality, cough, choking, and other signs, were possible significant high-risk indicators of dysphagia onset. The multivariate analysis results indicated that cervical auscultation and coughing were independent predictive variables for high dysphagia risk.

CONCLUSIONS:

Patients displaying extraoral loss, multiple swallows, cervical auscultation, vocal quality, cough, choking and other signs should benefit from early swallowing evaluations. Additionally, early post-extubation dysfunction recognition is paramount in reducing the morbidity rate in this high-risk population.

Deglutition; Deglutition Disorders; Orotracheal Intubation; Clinical/Bedside Assessment

Variables	Pass		Fail
	n	%	n	%
Extraoral loss	130	88	18	12
Oral transit time	135	91	13	9
Nasal reflux	148	100	0	0
Multiple swallows	61	41	87	59
Laryngeal elevation	83	56	65	44
Cervical auscultation	99	67	49	33
Voice quality	127	86	21	14
Cough	84	57	64	43
Choking	128	87	20	13
Other signs	147	99	1	1

L	n	%
1	72	49
2	76	51

Variables	Odds ratio	CI (95%)	p-value
Extraoral loss	7.758	1.174-35.104	0.008*
Oral transit time	11.143	1.409-88.106	0.022*
Nasal reflux	-	-	-
Multiple swallows	2.164	1.111-4.218	0.023*
Laryngeal elevation	1.750	.902-3.394	0.098
Cervical auscultation	26.833	7.784-92.504	<0.001*
Vocal quality	20.968	2.731-160.978	0.003*
Cough	42.273	13.752-129.939	<0.001*
Choking	19.603	2.548-150.839	0.004*
Other signs	-	-	-

Variables	Odds ratio	CI (95%)	p-value
Extra oral loss	1.837	0.192-17.574	0.598
Multiple swallows	2.056	0.698-6.059	0.191
Cervical auscultation	12.709	2.940-54.931	0.001*
Vocal quality	9.115	0.935-88.853	0.057
Cough	14.817	3.444-63.740	<0.001*
Choking	2.489	0.194-31.958	0.484

Faculdade de Medicina / USP Rua Dr Ovídio Pires de Campos, 225 - 6 and., 05403-010 São Paulo SP - Brazil, Tel.: (55 11) 2661-6235 - São Paulo - SP - Brazil
E-mail: clinics@hc.fm.usp.br

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[1] Medeiros GC was responsible for the data collection and analysis, interpretation of the results, and manuscript writing. Sassi FC organized and conducted the statistical analyses, interpreted the results, and wrote a major portion of the manuscript. Mangilli LD participated in the data collection and analyses and organized and conducted the statistical analyses. Zilberstein B was responsible for the medical criteria adopted in the experimental design and contributed to the data analysis and manuscript preparation. Andrade CR was responsible for the research and experimental design and contributed to the data analysis and manuscript preparation.

Level 1	The individual is not able to swallow safely with their mouth. All nutrition and hydration is received through non-oral means (i.e., a nasogastric tube).
Level 2	The individual is not able to swallow safely for nutritional and hydration purposes but may achieve some consistency with consistent maximal cues during therapy sessions only. An alternative feeding method is required.
Level 3	An alternative feeding method is required, as the individual receives less than 50% of his/her nutrition and hydration by mouth, swallowing is safe with the consistent use of moderate cues to utilize compensatory strategies, and/or the patient requires maximum diet restriction.
Level 4	Swallowing is safe but usually requires moderate cues to use compensatory strategies, the individual has moderate diet restrictions, and/or the patient still requires tube feeding and/or oral supplements.
Level 5	Swallowing is safe with minimal diet restrictions and/or the patient occasionally requires minimal cues to use compensatory strategies. The patient may occasionally self-cue. All nutrition and hydration needs are met by mouth at mealtime.
Level 6	Swallowing is safe, the individual eats and drinks independently, and the individual may rarely require minimal cueing. The individual usually self-cues when difficulty occurs and may need to avoid or requires additional time (due to dysphagia) to consume specific food items (e.g., popcorn and nuts).
Level 7	The individual's ability to eat independently is not limited by altered swallowing functions. Swallowing is safe and efficient for all food consistencies. Compensatory strategies are effectively used when needed.