Incidence and Type of Aspiration in Acute Care Patients Requiring Mechanical Ventilation via a New Tracheotomy

doi:10.1378/chest.122.5.1721

Chest

Volume 122, Issue 5, November 2002, Pages 1721-1726

https://doi.org/10.1378/chest.122.5.1721 Get rights and content

Study objectives

To investigate the incidence of aspiration and type of aspiration (overt or silent) in patients requiring mechanical ventilation via a new tracheotomy, ie, within the previous 2 months.

Design

Prospective, consecutive.

Setting

Urban, tertiary, acute care hospital.

Patients

Fifty-two adult inpatients referred for a swallow evaluation between March 1999 and December 2001.

Measurements and results

Fiberoptic endoscopic evaluation of swallowing was used to determine incidence and type of aspiration. Aspiration was defined as evidence of food material in the airway below the level of the true vocal folds, with silent aspiration defined as no overt symptoms of aspiration (eg, coughing or choking). Thirty-five of 52 patients (67%) did not aspirate, and 17 of 52 patients aspirated (33%). Fourteen of the 17 patients (82%) who aspirated were silent aspirators. Patients who aspirated were significantly older (mean age, 73 years; range, 48 to 87 years) than those who did not aspirate (mean age, 59 years; range, 20 to 83 years; p < 0.05). Patients who aspirated were posttracheotomy for significantly less time (mean, 14 days; range, 3 to 48 days) than those who did not aspirate (mean, 23 days; range, 1 to 62 days) [p < 0.05]. No significant difference was observed regarding the duration of translaryngeal intubation for aspirators (mean, 14 days; range, 0 to 31 days) vs nonaspirators (mean, 14 days; range, 0 to 29 days; p > 0.05).

Conclusions

Two thirds of patients requiring short-term mechanical ventilation via a new tracheotomy swallowed successfully. When aspiration occurred, it was predominantly silent aspiration. It is important to consider age, number of days posttracheotomy, functional reserve, and clinical judgment of recovery rate before performing a swallow evaluation in this population. Specifically, swallowing success will occur most frequently in patients < 70 years old, with optimal timing for a successful swallow outcome at approximately 3 weeks posttracheotomy in patients > 70 years old and 1 week in patients < 70 years old, and in conjunction with improving medical and respiratory status.

Section snippets

Subjects

Table 1 shows descriptive statistics for the 52 consecutive adult inpatients from the acute care setting of a large urban tertiary care teaching hospital. There were 28 men (mean age, 58 years; range, 19 to 83 years) and 24 women (mean age, 70 years; range, 53 to 87 years). Diagnoses that required mechanical ventilation via translaryngeal intubation followed by tracheotomy included postsurgical (n = 23), pulmonary (n = 16), trauma (n = 10), medical (n = 2), and neurologic (n = 1).

Equipment

Fiberoptic

Results

Table 1 shows patient characteristics. The mean duration of translaryngeal intubation was 14 days (range, 0 to 31 days), and the mean duration posttracheotomy intubation was 20 days (range, 1 to 62 days), for a total mean duration of ventilator dependence of 34 days (range, 1 to 62 days). At the time of FEES testing, 28 patients (54%) had small-bore nasogastric feeding tubes, 10 patients (19%) had gastrostomy tubes, 5 patients (10%) had no feeding tubes, 3 patients (6%) had large-bore

Discussion

The principal findings of the present study were as follows: (1) 67% of patients requiring short-term mechanical ventilation via a new tracheotomy swallowed successfully; (2) the type of aspiration was predominantly silent; (3) age differentiated aspirators vs nonaspirators; and (4) the optimal timing for a successful swallow outcome was approximately 3 weeks posttracheotomy in patients > 70 years old and 1 week in patients < 70 years old. The 33% incidence of aspiration in patients requiring

Conclusion

References (27)

DK Bone et al.
Aspiration pneumonia
Ann Thorac Surg
(1974)
SA Feldman et al.
Disturbance of swallowing after tracheostomy
Lancet
(1966)
EH Elpern et al.
Pulmonary aspiration in mechanically ventilated patients with tracheostomies
Chest
(1994)
K Tolep et al.
Swallowing dysfunction in patients receiving prolonged mechanical ventilation
Chest
(1996)
SB Leder
Serial fiberoptic endoscopic swallowing evaluations in the management of patients with dysphagia
Arch Phys Med Rehabil
(1998)
J Robbins et al.
Oropharyngeal swallowing in normal adults of different ages
Gastroenterology
(1992)
RH Betts
Post-tracheostomy aspiration
N Engl J Med
(1965)
PC Bonanno
Swallowing dysfunction after tracheostomy
Ann Surg
(1971)
EG Pavlin et al.
Failure of a high-compliance low-pressure cuff to prevent aspiration
Anesthesiology
(1975)
MA DeVita et al.
Swallowing disorders in patients with prolonged orotracheal intubation or tracheotomy tubes
Crit Care Med
(1990)

JL Cameron et al.

Aspiration in patients with tracheostomies

Surg Gynecol Obstet

(1973)

NB Pinkus

The dangers of oral feeding in the presence of cuffed tracheostomy tubes

Med J Aust

(1973)

EH Elpern et al.

Incidence of aspiration in tracheally intubated adults

Heart Lung

(1987)

Cited by (70)

Feeding and nutrition in the pediatric leukodystrophy patient
2023, Current Problems in Pediatric and Adolescent Health Care
Feeding difficulties in young paediatric intensive care survivors: A scoping review
2019, Clinical Nutrition ESPEN
Citation Excerpt :
It is possible that similar associated feeding difficulties experienced by adults ICU survivors, such as dysphagia [22,23], may also occur amongst previously well children following an admission to PICU. Risk factors for adult dysphagia and feeding difficulties include ETT intubation for longer than 48 hrs, in addition to ICU associated malnutrition and muscle weakness [23–26]. Furthermore, survivors of adult critical care report significant changes to their ability to eat, with reduced appetite, altered taste and food preferences lasting up to 3 months post ICU discharge [22].
Although feeding difficulties are commonly described amongst children with chronic diseases, those admitted to a paediatric intensive care unit (PICU) represent a mix of previously healthy children as well as those with pre-existing diseases. There is, however, a lack of evidence describing the prevalence and type of feeding difficulties amongst healthy children who survive a period of critical illness and the subsequent impact on growth and family life. The aim of this work was to complete a scoping review of evidence describing feeding difficulties amongst PICU-survivors.
Six electronic databases were searched from January 2000–October 2018. NICE Healthcare Databases Advanced Search website (https://hdas.nice.org.uk/) was used as a tool to complete multiple searches within multiple databases, including the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo and Medline. Any studies considering feeding difficulties amongst previously healthy children following discharge from PICU or those which explored the parental/caregiver experiences were included.
As the initial search yielded only one study which fulfilled the inclusion criteria, the criteria was extended to include studies relating to feeding difficulties (post-discharge) amongst otherwise healthy ex-preterm infants (born < 37 weeks gestational age) and infants/children with chronic diseases where feeding difficulties were described following a PICU admission. A review team screened and extracted the data of published qualitative and quantitative studies, using content analysis techniques. Of the 9622 articles identified from the searches, 22 full-text studies were reviewed with seven studies included. Four overarching categories represented the results: prevalence of feeding difficulties; risk factors and predictors for developing feeding difficulties; parental/carer experience and emotional response to feeding difficulties; and challenges in accessing feeding support.
The results of this scoping review suggest there are gaps in the research, particularly those exploring the prevalence of feeding difficulties amongst previously healthy children and the negative impact this may have on family life. Future research should focus on addressing the extent of the problem and identifying risk factors, in addition to the potential development of toolkits for health care professionals to better support parents.
Swallowing and Secretion Management in Neuromuscular Disease
2018, Clinics in Chest Medicine
Citation Excerpt :
Tracheostomy with an inflated cuff may reduce risk for greater amounts of aspiration. A caveat, however, is that tracheostomy does not fully block aspiration and may increase the risk for pneumonia owing to leakage of aspirated material around the cuff,60,61 esophageal compression from an overinflated cuff,62 laryngeal desensitization,63 reduced subglottic air pressure,64 and potentially laryngeal disuse atrophy. Inadequate UES opening during swallowing can occur for different reasons, including reduced or uncoordinated laryngeal elevation leading to delayed or shorter duration of UES opening time, reduced bolus driving pressures, inadequate relaxation of UES musculature, and structural fibrotic UES changes such as a cricopharyngeal hypertonicity with or without an associated Zenker’s diverticulum.65
Diagnostic value of "dysphagia limit" for neurogenic dysphagia: 17years of experience in 1278 adults
2015, Clinical Neurophysiology
Citation Excerpt :
FEES is chiefly performed by otorhinolaryngologists via the passage of a flexible fiberoptic laryngoscope trans-nasally into the pharynx. FEES can be used to demonstrate both silent and overt aspiration accompanied by coughing and respiratory distress (Leder et al., 1998; Leder, 2002; Ramsey et al., 2003). Water swallowing tests pose essentially no risk for patients due to their noninvasive nature, are easily applicable, and reproducible.
Neurogenic dysphagia (ND) is a prevalent condition that accounts for significant mortality and morbidity worldwide. Screening and follow-up are critical for early diagnosis and management which can mitigate its complications and be cost-saving. The aims of this study are to provide a comprehensive investigation of the dysphagia limit (DL) in a large diverse cohort and to provide a longitudinal assessment of dysphagia in a subset of subjects.
We developed a quantitative and noninvasive method for objective assessment of dysphagia by using laryngeal sensor and submental electromyography. DL is the volume at which second or more swallows become necessary to swallow the whole amount of bolus. This study represents 17 years experience with the DL approach in assessing ND in a cohort of 1278 adult subjects consisting of 292 healthy controls, 784 patients with dysphagia, and 202 patients without dysphagia. A total of 192 of all patients were also reevaluated longitudinally over a period of 1–19 months.
DL has 92% sensitivity, 91% specificity, 94% positive predictive value, and 88% negative predictive value with an accuracy of 0.92. Patients with ALS, stroke, and movement disorders have the highest sensitivity (85–97%) and positive predictive value (90–99%). The clinical severity of dysphagia has significant negative correlation with DL (r = −0.67, p < 0.0001).
We propose the DL as a reliable, quick, noninvasive, quantitative test to detect and follow both clinical and subclinical dysphagia and it can be performed in an EMG laboratory.
Our study provides specific quantitative features of DL test that can be readily utilized by the neurologic community and nominates DL as an objective and robust method to evaluate dysphagia in a wide range of neurologic conditions.
S2k-Guideline Published by the german respiratory society
2019, Pneumologie
Dysphagia outcomes in COVID-19 patients: experiences in long-term acute care hospital (LTACH)
2023, European Archives of Oto-Rhino-Laryngology

View all citing articles on Scopus

: The research was supported in part by the McFadden, Harmon, and Mirikitani Endowments.

View full text

Chest

Clinical Investigations in Critical CareIncidence and Type of Aspiration in Acute Care Patients Requiring Mechanical Ventilation via a New Tracheotomy

Study objectives

Design

Setting

Patients

Measurements and results

Conclusions

Section snippets

Subjects

Equipment

Results

Discussion

Conclusion

Ann Thorac Surg

Lancet

Chest

Chest

Arch Phys Med Rehabil

Gastroenterology

Post-tracheostomy aspiration

N Engl J Med

Swallowing dysfunction after tracheostomy

Ann Surg

Failure of a high-compliance low-pressure cuff to prevent aspiration

Anesthesiology

Swallowing disorders in patients with prolonged orotracheal intubation or tracheotomy tubes

Crit Care Med

Aspiration in patients with tracheostomies

Surg Gynecol Obstet

The dangers of oral feeding in the presence of cuffed tracheostomy tubes

Med J Aust

Incidence of aspiration in tracheally intubated adults

Heart Lung

Clinical Investigations in Critical Care
Incidence and Type of Aspiration in Acute Care Patients Requiring Mechanical Ventilation via a New Tracheotomy