ASHA 2010 SSkoretz/RMartino
Disclosure Statement
Navigating dysphagia following
extubation: Pursuing evidence
based practice
Stacey Skoretz, M.Sc. CCCCCC-SLP,
Doctoral Candidate
Rosemary Martino, Ph.D,
Ph.D, CCCCCC-SLP,
Associate Professor
I have no financial or nonfinancial interest in
any organization whose products or
services are described, reviewed,
evaluated or compared in the
presentation.
Learning Outcomes
At the end of this presentation, attendees
will be able to:
1. Define the principles of evidenceevidence-based
practice
2. Critically appraise published literature on
intubation and dysphagia
3. Establish the risk of dysphagia for
patients following extubation across
diagnostic groups
Health system goal: provide
quality care and decrease risk
of adverse events
Health systems fail to optimally
use evidence
American adults receive less
than 55% of recommended care
Straus SE et al. (2009). Knowledge translation is the use of knowledge in
health care decision making, Journal of Clinical Epidemiology, published
ahead of print
Evidence Based Practice
ASHA Position Statement
It is the position of the American SpeechSpeechLanguageLanguage-Hearing Association that audiologists
and speechspeech-language pathologists incorporate
the principles of evidenceevidence-based practice in
clinical decision making to provide high quality
clinical care. The term evidenceevidence-based practice
refers to an approach in which current, highhighquality research evidence is integrated with
practitioner expertise and client preferences and
values into the process of making clinical
decisions. American Speech-Language-Hearing Association. (2005). Evidence-Based
Diagram available from: http://www.isocentre.org/data:levels-of-evidence
Sackett DL, Rosenberg MC, Gray JA, Haynes RB, Richardson WS. Evidence based
medicine: what it is and what it isn't. BMJ. 1996;312: 71-72.
Practice in Communication Disorders [Position Statement]. Available from
www.asha.org/policy.
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ASHA 2010 SSkoretz/RMartino
Key Principles of EBP
Willingness to discount opinions of
authorities when those opinions are
discounted by rigorous science
Show Me the DATA!!
Key Principles of EBP
Focus on research that is relevant to the
decisions you wish to make about practice
– Does it address your etiological or theoretical
questions?
– Systematic reviews
– Randomized controlled trials
– High quality observational trials
Johnson, C. (2006). Getting started in evidence-based practice for
childhood Speech-language disorders, American Journal of SpeechLanguage Pathology, 15, 20-35
Johnson, C. (2006). Getting started in evidence-based practice for
childhood Speech-language disorders, American Journal of SpeechLanguage Pathology, 15, 20-35
Key Principles of EBP
Use rigorous criteria for conduct and critical
appraisal of studies in:
Systematic reviews of RCTs
– Validity
Randomized controlled trials
Did the researchers minimize confounds and bias?
– Importance
Cohort Studies
Statistical significance, magnitude of effect
CaseCase-control studies
– Precision
Case series and case reports
How precise are the effect estimates (confidence intervals)?
Clinical observation/ expert opinion
Guyatt GH, Sackett DL, Cook DJ. Users' guides to the medical literature. II. How to use an article about therapy
or prevention. A. Are the results of the study valid? Evidence-Based Medicine Working Group. Jama 1993;
270:2598-2601
Richardson WS, Detsky AS. Users' guides to the medical literature. VII. How to use a clinical decision analysis.
B. What are the results and will they help me in caring for my patients? Evidence Based Medicine Working
Group. Jama 1995; 273:1610-1613
Effects of Intubation
Introduction of endotracheal or
tracheostomy tubes can lead to upper
aerodigestive tract complications
Swallowing physiology and airway
protective mechanisms may be affected
Lower
Quality
Evidence
Woolf SH, Grol R, Hutchinson A, et al. Clinical guidelines: potential benefits,
limitations, and harms of clinical guidelines. BMJ (Clinical research ed.) 1999;
318:527-530
Hoppe, DJ et al., (2009). Hierarchy of evidence: Where observational studies fit in and
why we need them, The Journal of Bone and Joint Surgery, 91, Suppl 3:2-9
Endotracheal Intubation
Risk Factors for
Compromised Airway
Protection
•Trans-laryngeal
placement
•Cuff position
•Duration of intubation
•Self-extubation
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ASHA 2010 SSkoretz/RMartino
Structural Alterations
Epithelial damage
Fistula formation
Tracheal stenosis
Granulation tissue
Tracheobronchomalacia
(Kirchner, 1980; Sue & Susanto,
Susanto, 2003; Pinkus, 1973)
Mechanical Alterations
Mechanical tethering of larynx
– disuse atrophy
Airflow diversion
– Hypopharyngeal and laryngeal desensitization
Decreased glottic closure and/or vocal fold
paralysis
Esophageal compression secondary to cuff
inflation
(Buckwalter & Sasaki, 1984)
Intubation Studies
High incidence of disordered swallowing
following prolonged intubation, tracheotomy and
mechanical ventilation (Ajemian et al., 2001; Tolep et al., 1996; FornataroFornataroClerici & Roop, 1997; Elpern et al.,1994).
Incidence of dysphagia postpost-extubation is highly
variable: 3636-83% (El Sohl et al., 2003; Tolep et al., 1996)
Many studies include a variety of patient
diagnostic groups (Sohl et al., 2003, Barquist, et al., 2001; de Larminat et al., 1995)
Prolonged intubation is a predictor of dysphagia
Skoretz, SA, Flowers, HL, & Martino, R (2010). The Incidence
of Dysphagia Following Endotracheal Intubation: A
Systematic Review
Chest, 137:665-673;
(Barker et al, 2009; Hogue et al., 1995)
Objectives
Primary objective:
– To assess the association between intubation and the
frequency of dysphagia in adults
Methods - Selection Criteria
Operational
Definitions
Intubation:
Intubation: the presence of an endotracheal
tube in the oropharynx.
Secondary objectives:
– To evaluate the quality of selected studies
– To compare incidence, type and severity of dysphagia
secondary to intubation across patient diagnostic
groups
– To determine other patient characteristics associated
with dysphagia
Dysphagia:
Dysphagia: any impairment or abnormality of the
oral, pharyngeal or upper oesophageal stage of
deglutition identified either by clinical swallow
evaluations or instrumental assessment
techniques.
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ASHA 2010 SSkoretz/RMartino
Methods - Selection Criteria
Methods - Selection Criteria
Exclusions
Inclusions
Studies reporting on the presence or absence of
dysphagia in adult patients (>18 years old) who
underwent endotracheal intubation during their
hospitalisation.
hospitalisation.
Case series (n>10), case control and retrospective
or prospective descriptive studies with consecutive
enrollment.
Studies including adult patients with tracheostomy tubes unless: 1)
the study authors included individual patient data or 2) statistical
statistical
analyses excluded those with tracheostomy tubes.
Studies where enrollees had dysphagia before intubation or
confounding etiologies (e.g. head/neck cancer).
Studies using patient report to describe dysphagic symptoms.
Studies focusing on dysphagia secondary to oesophageal etiologies
etiologies
below the upper oesophageal sphincter.
Studies that fail to compare patients without dysphagia to those with
dysphagia.
Studies that were case series (n<10), educational or tutorial papers,
papers,
or those without abstracts.
Publications in any language.
Methods – Quality Assessment
Results – Study Selection
All citations recovered by
searches: N=1,489
Methodological Bias:
Cochrane Risk of Bias assessment tool
Domains include:
–
–
–
–
Studies with samples including pediatric enrollees.
Excluded: N = 351
(titles without abstracts)
Titles/abstracts reviewed:
N = 1,138
Blinding
Consecutive enrollment
Operational definitions
Consistent assessment for all study enrollees
Full text articles reviewed:
N=288
Excluded: N = 850
(not meeting study selection criteria)
Excluded: N = 274
Overall Quality Assessment
Highest ranking to randomized trials
Lowest to observational studies
(not meeting study selection criteria)
– Able to upgrade or downgrade rating based on bias rating
Available from www.cochrane..org.
Results - Dysphagia Incidence
Patient Diagnoses
Incidence
Cardiovascular Surgery
3 - 51%
Mixed Surgical
3 - 35%
Mixed Medical
35 - 62%
Mixed Medical & Surgical
Surgical
10 - 56%
Articles accepted for full
review: N = 14
Results - Intubation Duration vs.
Dysphagia
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ASHA 2010 SSkoretz/RMartino
Results – Study Design
2 Randomized
Results Quality of
Individual
Studies
– Barquist et al. (2001); Stanley et al. (1995)
1 CaseCase-Control
– de Larminat et al. (1995)
4 Cohort
– Burgess et al. (1979); Davis & Cullen (1974); El Sohl et al. (2003); Padovani
et al. (2008)
7 Case Series:
– Ajemian et al. (2001); Barker et al. (2008); Ferraris et al. (2001); Hogue
Hogue et
al. (1995); Keeling et al. (2007); Leder et al. (1998); Rousou et al. (2000)
Available from www.cochrane..org.
Results - Risk Factors
Associated with Dysphagia
Associated with
dysphagia
Not associated with
dysphagia
Mixed association
Congestive heart failure
(2) Functional status (1)
↑Hospital LOS (3)
Hypercholesterolemia (1)
↑ICU LOS (2)
↑Number of intubations (1)
↑Operative time (1)
PeriPeri-operative TEE (2)
Sepsis (1)
APACHE scores (2)
COPD (4)
Circulatory shock (2)
↑CPB time (3)
GERD (2)
Hypertension (3)
ICU readmission (1)
Myocardial infarction (2)
NYHA >2 (2)
Peripheral vascular disease
(1)
PrePre-operative CVA (3)
Smoking (1)
Surgery urgency (1)
Age (2/4)
↓Cardiac output (1/1)
Diabetes mellitus (1/3)
Intubation duration (3/4)
Left ventricle ejection
fraction (1/1)
PeriPeri-operative CVA (1/2)
PostPost-operative pulmonary
complications (1/1)
PrePre-op/postop/post-op IABP (1/1)
Renal risks (1/2)
Surgery type (2/2)
Tube feeding (1/3)
Comparing Randomized Trials
Barquist et al. (2001)
– Randomized clinical trial
Comparing Randomized Trials
FEES (n=37, 24h±
24h±2)
Routine clinical management (n=33, 48h±
48h±2)
– 70 trauma patients intubated >48h
– Outcomes measured:
Aspiration
Pneumonia
Comparing Randomized Trials
Barquist et al. (2001)
Stanley et al. (1995)
– Randomized clinical trial following limb
arthroplasty
Laryngeal mask airway (n=20)
Endotracheal tube (n=20)
– Patients swallowed 20ml of barium “when
appropriate”
appropriate”
– CXR taken
– Outcomes measured:
Aspiration of contrast
Stanley et al. (1995)
Sequence
generation
Allocation
concealment
Blinding
Operational
Def’n
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ASHA 2010 SSkoretz/RMartino
Comparing Randomized Trials
Barquist et al., (2001)
Stanley et al. (1995)
– 7/70 (10%) patients
aspirated
– No difference between
groups
– Patients >55y with
vallecular stasis were
>risk for aspiration
– 1/40 (3%) patient
aspirated
– Aspiration was noted
to be clinically silent
Comparing Observational Trials
Comparing Observational Trials
Leder et al. (1998)
– Case series, N=20 trauma patients
– FEES 24h±
24h±2h following extubation
– Outcomes measured:
Aspiration
Swallow characteristics (descriptive only)
Comparing Observational Trials
Leder et al. (1998)
Hogue et al. (1995)
– Case series, N=869, CV Sx patients
– Screening, VFS on symptomatic pts
– Outcomes measured:
Ax oral and pharyngeal dysfunction
– Including aspiration
Hogue et al. (1995)
Blinding
Consecutive
Enrollment
Consistent Ax
for All Pts
Operational
Def’n
Comparing Observational Trials
Leder et al., (1998)
– 9/20 patients (45%)
aspirated
Hogue et al. (1995)
– Dysphagia observed in
34/869 (4%)
– Aspiration detected in
90% of patients with
dysphagia
Discussion
More than half of the included studies
reported dysphagia frequency >20%
Highest frequency included all diagnostic
categories
Many studies are observational
Few declared blinding or operational
definitions
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ASHA 2010 SSkoretz/RMartino
Discussion
Studies with the largest sample size included
patients intubated for all durations
Timing of assessment ranged from immediately
to 5 days, some did not report
Wide assortment of assessment methods
Highest incidences:
Discussion
Most studies included aspiration as the
only swallowing outcome
Studies were heterogeneous restricting
metameta-analyses
– FEES
Lowest incidences:
– chest radiographs and clinical assessments
Conclusions
Increasing intubation duration leads to an
increased incidence of dysphagia
Risk factors associated with dysphagia were
variable
The majority of identified studies were poor in
design, methodology and had heterogeneous
patient populations
Case Study
Future studies
High quality prospective trials:
– Use sensitive swallow assessments on all
enrollees
– Homogeneous patient populations or larger
sample sizes
– Operationally define outcomes under
investigation
– Report on blinding
– Determine best timing for assessment/feeding
following extubation
Moving from “whether”
whether” to “how”
how”....
“...regardless of the weaknesses of the
[included] studies, even a skeptical reader must
accept that that postextubation dysphagia
occurs commonly across all of the diagnostic
categories.”
categories.”
“...work out how we can better understand its
[dysphagia’
[dysphagia’s] nature and begin to initiate
programs to mitigate its consequences...”
consequences...”
– John E. Heffner (2010). Swallowing Complications After
Endotracheal Extubation: Moving From “Whether”
Whether” to “How”
How”
Chest,137:509Chest,137:509-510;
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ASHA 2010 SSkoretz/RMartino
Evidence Based Practice
Frymark T, Schooling T, Mullen R, et al. EvidenceEvidence-based systematic review:
Oropharyngeal dysphagia behavioral treatments. Part I-background and
I--background
methodology. Journal of Rehabilitation, Research & Development 2009;
2009;
46:17546:175-183
Foley N, Teasell R, Salter K, et al. Dysphagia treatment post stroke: A
systematic review of randomised controlled trials. Age Ageing 2008;
2008; 37:25837:258264
Bath PMW, BathBath-Hextall FJ & Smithard, DG. Interventions for dysphagia in
acute stroke, Cochrane Database of Systematic Reviews 2007, Issue 3
Martino R et al. Dysphagia after stroke: Incidence, diagnosis and
and pulmonary
complications, Stroke 2005,
2005, 36, 27562756-2763
Acknowledgments
Collaborators:
Dr. Rosemary Martino
Dr. John Granton
Dr. Terrence Yau
Dr. Joan Ivanov
Special thank you:
MultiMulti-lingual Good
Samaritans
Funding:
Funding:
Ontario Graduate Scholarship
Department of SpeechSpeech-Language
Pathology Travel Award
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