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Abnormalities of Aspiration and Swallowing Function in Survivors of Acute Respiratory Failure

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A Correction to this article was published on 26 February 2021

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Abstract

The mechanisms responsible for aspiration are relatively unknown in patients recovering from acute respiratory failure (ARF) who required mechanical ventilation. Though many conditions may contribute to swallowing dysfunction, alterations in laryngeal structure and swallowing function likely play a role in the development of aspiration. At four university-based tertiary medical centers, we conducted a prospective cohort study of ARF patients who required intensive care and mechanical ventilation for at least 48 h. Within 72 h after extubation, a Fiberoptic Flexible Endoscopic Evaluation of Swallowing (FEES) examination was performed. Univariate and multivariable analyses examined the relationship between laryngeal structure and swallowing function abnormalities. Aspiration was the primary outcome, defined as a Penetration- Aspiration Scale (PAS) score of 6 or greater. Two other salient signs of dysphagia—spillage and residue—were secondary outcomes. A total of 213 patients were included in the final analysis. Aspiration was detected in 70 patients (33%) on at least one bolus. The most commonly aspirated consistency was thin liquids (27%). In univariate analyses, several abnormalities in laryngeal anatomy and structural movement were significantly associated with aspiration, spillage, and residue. In a multivariable analysis, the only variables that remained significant with aspiration were pharyngeal weakness (Odds ratio = 2.57, 95%CI = 1.16–5.84, p = 0.019) and upper airway edema (Odds ratio = 3.24, 95%CI = 1.44–7.66, p = 0.004). These results demonstrated that dysphagia in ARF survivors is multifactorial and characterized by both anatomic and physiologic abnormalities. These findings may have important implications for the development of novel interventions to treat dysphagia in ARF survivors.

Clinical Trials Registration ClinicalTrials.gov Identifier: NCT02363686, Aspiration in Acute Respiratory Failure Survivors

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Funding

NIH grants K24 HL 089223 and R21 NR 015886 (MM).

Author information

Authors and Affiliations

  1. Boston Medical Center, Boston, MA, USA

    Susan E. Langmore, Gintas P. Krisciunas & Edel McNally

  2. Department of Otolaryngology, Boston University School of Medicine, Boston, MA, USA

    Susan E. Langmore & Gintas P. Krisciunas

  3. Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, MA, USA

    Edel McNally

  4. Department of Surgery, Section of Otolaryngology, Yale School of Medicine, New Haven, CT, USA

    Heather Warner

  5. Department of Communication Disorders, Southern Connecticut State University, New Haven, CT, USA

    Heather Warner

  6. Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, Aurora, CO, USA

    Daniel Dvorkin, Carrie Higgins, Jeffrey McKeehan & Marc Moss

  7. The Bioinformatics CRO, Inc, Denver, USA

    Daniel Dvorkin

  8. Department of Otolaryngology, University of Colorado Denver, Aurora, CO, USA

    Daniel Fink

  9. Division of Physical Medicine and Rehabilitation, Stanford University, Stanford, CA, USA

    Joseph E. Levitt, Sandra Deane & Rosemary Vojnik

  10. Division of Speech Language Pathology, Spaulding Rehabilitation Hospital, Boston, MA, USA

    Rebecca Scheel

  11. Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, CT, USA

    Jonathan M. Siner

  12. Rehabilitation Therapy Services, University of Colorado Hospital, Aurora, CO, USA

    S. David White

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  1. Susan E. Langmore
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  2. Gintas P. Krisciunas
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Correspondence to Susan E. Langmore.

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Appendix

Appendix

Appendix 1: FEES Protocol

Part 1 Anatomy, Secretions, Sensation, and Structural movements,

A. Observe all anatomic structures in view to identify anatomic or mucosal abnormalities.

B. Secretions: Observe presence and location of secretions and patient response such as coughing, clearing throat, etc.

C. Movement of structures: Ask patient to perform tasks that activate specific structural movements. Provide a model if needed.

Velopharyngeal closure – repeat “puh-puh-puh.”

Glottic closure—cough, clear throat, hold breath (any of these).

Vocal fold and arytenoid mobility – alternate an inhale with ‘eee’ several times.

Arytenoid / laryngeal lift – glide up in pitch with ‘eeeee’ and hold it for a few seconds.

Epiglottic retroflexion – observe this during bolus swallowing later in the exam when the subject is eating.

Pharyngeal wall medialization – produce a tight ‘eee’; hold it out and squeeze your throat as you say it.

Base of tongue retraction – say “Paul is tall’ slowly.

D. Sensory Function.

Lightly and briefly touch each arytenoid with the tip of the scope. Look for an immediate response; most often the laryngeal adductor reflex.

Part 2: Delivery of food and liquid

Bolus volumes and order of delivery:

Ice chips: ½ tsp, full tsp (5 ml); Nectar thick liquid, 5 ml,15 ml; Puree (applesauce) 5 ml, 10 ml; Thin liquid (water) 5 ml, 15 ml, 2 oz; Cracker (1/2 saltine) Thin liquid (water). 3 oz.

Appendix 2 Scoring the FEES exam

Primarily scored from Part 1 tasks but also viewed during swallowing (Part 2)

The following variables were scored as present, absent, or reduced if not otherwise specified.

  • Velopharyngeal closure, vocal cord fold mobility, arytenoid mobility, glottic closure, epiglottic retroflexion, arytenoid lift, base of tongue retraction, pharyngeal wall medialization

  • Secretions (normal, pooled outside vestibule, pooled inside the vestibule), laryngeal sensation (normal, unilateral defect, or bilateral defects).

An independent otolaryngologist scored 3 variables assessed during the Part 1 portion.

  • Vocal fold mobility (abduction and adduction; complete or incomplete), presence of laryngeal edema (yes/no), presence of granulation tissue on the vocal cords (yes/no).

Part 2 The rater scored the following parameters for every bolus size and consistency given to the patient

  • Spillage time: from first view of bolus into hypopharynx until whiteout, in seconds (base of tongue must be in view)

  • Point of lowest spillage (no spillage, valleculae, lateral channels, piriform/post cricoid, laryngeal vestibule),

  • Amount of residue (none/trace, mild, moderate, severe (for analyses, moderate and severe categories were combined)

  • Residue location for patients with mild or moderate/severe residue (valleculae, lateral channels, piriforms/post cricoid, laryngeal vestibule)

  • Response to residue (spontaneous clearing, ejection, no response)

  • Penetration (before, during, after the swallow)

  • Aspiration (before, during, after the swallow)

  • PAS score (1–8)

Appendix 3

See Table 8

Table 8 Association of edema with vocal fold and arytenoid mobility
Full size table

Appendix 4

See Table 9

Table 9 Association between sensation and presence of spillage
Full size table

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Langmore, S.E., Krisciunas, G.P., Warner, H. et al. Abnormalities of Aspiration and Swallowing Function in Survivors of Acute Respiratory Failure. Dysphagia 36, 831–841 (2021). https://doi.org/10.1007/s00455-020-10199-8

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