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Post-Extubation Dysphagia: Risk Factors, Evaluation, and Treatment

Dysphagia is a common occurrence post-extubation, affecting 10-84% of patients as reported in varied studies. In order to achieve the best patient outcomes, the clinician must understand the risk factors, provide a swallow evaluation at the right time and initiate proper treatment for the deficits identified.

Post-extubation dysphagia is characterized by:

• Vocal fold immobility and/or dysphonia
• Dyspnea
• Laryngeal erythema
• Ulcers
• Granulomas
• Aspiration
• Impaired laryngeal sensation

Brodsky et al. (2016) reported that 56% of patients post oral extubation presented with aspiration and 50% of those were silent aspiration.

Risk Factors for Post-Extubation Dysphagia

• Length of intubation (longer intubations result in increased risk and longer recovery)
• Age
• Endotracheal tube size
• Sedation
• Neurological disease
• Kidney disease / renal dialysis
• COVID
• Prolonged NMJ blockage
• Sepsis
• Increased duration of ICU stay
• Poor pre-morbid functional status
• Emergency admission and/or field intubation
• Repeated intubations
• Upper GI dysfunction

Timing of Swallow Evaluation

Many hospitals have implemented protocols around the timing of swallowing evaluation following extubation. These timeframes vary from 24 to 72 hours. However, Leder (2019) found that 82% of patients pass the Yale Swallow Protocol screen merely one hour post extubation. The Yale Swallow Protocol shows strong sensitivity, making it an ideal tool for a quick bedside screen (Brodsky et al., 2020). The Yale can be completed by nursing or as part of a comprehensive swallow evaluation by the Speech-Language Pathologist (SLP). For patients who fail a swallow screen, an instrumental (MBS or FEES) is the gold standard to identify the etiology of the swallow dysfunction, especially given the high incidence of silent aspiration. Assessing cough strength using a peak flow meter can also be predictive of aspiration and can justify use of respiratory muscle strength training.

Treatment

As always, it is important to identify the etiology of aspiration by determining deficits in structure and mobility of the swallow mechanism. Based on these objective findings, the SLP can prescribe an individualized plan including compensatory strategies and/or rehabilitation exercises to address oropharyngeal and respiratory muscle strengthening.

AliMed offers the following Swallow Rehabilitation Tools that may be indicated based on the following table.

AliMed Treatment Tool	Deficits Addressed
THE BREATHER®	Reduced hyolaryngeal elevation Reduced strength of cough (less than 200LPM) Pharyngeal residue Reduced vocal cord mobility
AliMed® SupraBall®	Reduced UES opening Reduced hyolaryngeal elevation Reduced epiglottic closure Pharyngeal residue Reduced vocal cord mobility
TheraSIP™ LaryngeLIFT™	Reduced hyolaryngeal elevation
TheraSIP™ VocalSTRAW™	Reduced vocal cord mobility Reduced vocal function/strength
TheraSIP™ SwallowMIST™  TheraSIP™ DirectMIST	Xerostomia Aspiration

Post-Extubation Dysphagia: Critical Patients for Critical Information

This one hour continuing education course discusses risk factors associated with post-extubation dysphagia and discussion points for patient assessment and management.

For more therapy aids and tools, AliMed has a comprehensive line of Dysphagia resources for SLPs and their clients to aid with assessment, treatment, eating and feeding, tongue and tracheostomy, and more. 

Authored by: Jennifer Llado, MS, MS, CCC-SLP

References

1. Brodsky, M. B., Huang, M., Shanholtz, C., Mendez-Tellez, P. A., Palmer, J. B., Colantuoni, E., & Needham, D. M. (2017). Recovery from Dysphagia Symptoms after Oral Endotracheal Intubation in Acute Respiratory Distress Syndrome Survivors. A 5-Year Longitudinal Study. Annals of the American Thoracic Society, 14(3), 376 - 383. https://www.atsjournals.org/doi/10.1513/AnnalsATS.201606-455OC
2. Brodsky MB, Pandian V, Needham DM. Post-extubation Dysphagia: A Problem Needing Multidisciplinary Efforts - PMC. (nih.gov)
3. Leder, S. B., Warner, H. L., Suiter, D. M., Young, N. O., Bhattacharya, B., Siner, J. M., Davis, K. A., Maerz, L. L., Rosenbaum, S. H., Marshall, P. S., Pisani, M. A., Siegel, M. D., Brennan, J. J., & Schuster, K. M. (2019). Evaluation of Swallow Function Post-Extubation: Is It Necessary to Wait 24 Hours?.The Annals of otology, rhinology, and laryngology128(7), 619–624. https://journals.sagepub.com/doi/10.1177/0003489419836115
4. Recovery from Dysphagia Symptoms after Oral Endotracheal Intubation in Acute Respiratory Distress Syndrome Survivors. A 5-Year Longitudinal Study | Annals of the American Thoracic Society (atsjournals.org)
5. Evaluation of Swallow Function Post-Extubation: Is It Necessary to Wait 24 Hours? -Steven B. Leder, Heather L. Warner, Debra M. Suiter, Nwanmegha O. Young, Bishwajit Bhattacharya, Jonathan M. Siner, Kimberly A. Davis, Linda L. Maerz, Stanley H. Rosenbaum, Peter S. Marshall, Margaret A. Pisani, Mark D. Siegel, Joseph J. Brennan, Kevin M. Schuster, 2019 (sagepub.com)