Fiberoptic Endoscopic Documentation of the High Incidence of Aspiration following Extubation in Critically Ill Trauma Patients

Abstract

The purpose of this study was to investigate the incidence of aspiration following extubation in critically ill trauma patients. This prospective pilot study included 20 consecutive trauma patients who required orotracheal intubation for at least 48 hours. All subjects underwent a bedside transnasal fiberoptic endoscopic evaluation of swallowing at 24 +/- 2 hr after extubation to determine objectively aspiration status. Aspiration was defined as the entry of a blue dyed material into the airway below the level of the true vocal folds, with silent aspiration occurring in the absence of any external behavioral signs such as coughing or choking. Aspiration was identified in 9 of 20 (45%) subjects and 4 of these 9 (44%) were silent aspirators. Therefore, silent aspiration occurred in 20% of the study population. Eight of the 9 (89%) aspirating subjects resumed an oral diet from 2-10 days (mean, 5 days) following extubation. All subjects had no evidence of pulmonary complications. It was concluded that trauma patients after orotracheal intubation and prolonged mechanical ventilation have an increased risk of aspiration. An objective assessment of dysphagia to identify aspiration may reduce the likelihood of pulmonary complications after extubation.

Management of Dysphagia Following Traumatic Brain Injury

“…These include oropharyngeal neuromuscular and sensory deficits, cognitive-communication, and behavioral impairments, [5,8,9,29,33] physical injury to the head and neck regions [12], medications [5,34], other concomitant injuries and prolonged endotracheal ventilation [12,[34][35][36][37][38][39]. Tracheostomies, while not causing dysphagia on their own [37][38][39], are common in this population and will also be discussed.…”

“…Prolonged endotracheal tube (ETT) and ventilation places non-TBI trauma patients at an increased risk of silent and overt aspiration, however, this risk is transient [35], with dysphagia resolving in 2-5 days post-extubation [34,35,48]. Such dysphagia in trauma patients with prolonged ETT intubation is often multifactorial [35], resulting from prolonged contact of the ETT with chemo-and/or mechanoreceptors in the pharyngeal and laryngeal mucosae, critical for triggering the swallowing reflex [34].Physical injury including vocal fold ulceration and laryngeal edema [36] and impaired laryngeal elevation and/or closure may impede swallowing function [12].…”

“…Such dysphagia in trauma patients with prolonged ETT intubation is often multifactorial [35], resulting from prolonged contact of the ETT with chemo-and/or mechanoreceptors in the pharyngeal and laryngeal mucosae, critical for triggering the swallowing reflex [34].Physical injury including vocal fold ulceration and laryngeal edema [36] and impaired laryngeal elevation and/or closure may impede swallowing function [12]. Medications such as sedatives required for intubation may also temporarily depress the swallowing reflex [5,34].…”

“…Both techniques are effective tools for assessing dysphagia, detecting aspiration and trialing management strategies in patients with TBI [35]. FEESST can also tests laryngopharyngeal sensory function [66].…”

Removal of the tracheostomy tube in the aspirating spinal cord-injured patient

“…25 Debate exists about the affect of nasogastric feeding tubes (present at the time of decannulation in subjects B and D) on the incidence of aspiration. Cameron et al 14 and Leder et al 26,27 note no increase in aspiration, whereas other authors have found a significantly increased incidence of aspiration, particularly of gastric contents. 10,28 Effects of 48 h of endotracheal intubation on swallow function have been shown to be significant, with aspiration rates as high as 56%, and up to 25% presenting without outward symptoms (silent aspiration).…”