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• W2001806040 abstract "Normal swallowing depends on a complex sequence of perfectly timed physiologic events, some occurring simultaneously, others sequentially, that involve contractions of multiple oral-facial, pharyngeal, laryngeal, respiratory, and esophageal muscles.1Klahn MS Perlman AL Temporal and durational patterns associating respiration and swallowing.Dysphagia. 1999; 14: 131-138Crossref PubMed Scopus (106) Google Scholar To prevent aspiration, a bolus of food or fluid reaching the posterior oral cavity stimulates neuroreceptors that trigger respiratory muscles to halt respiration, usually in exhalation.2Martin-Harris B Brodsky MB Price CC Michel Y Walters B Temporal coordination of pharyngeal and laryngeal dynamics with breathing during swallowing: single liquid swallows.J Appl Physiol. 2003; 94: 1735-1743Crossref PubMed Scopus (128) Google Scholar It is no surprise that an endotracheal tube might disturb these intricately choreographed events and cause postextubation dysphagia.The clinical importance of dysphagia after extubation is profound. For many hospitalized patients intubated in the operating room or ICU, underlying conditions may interact with dysphagia and produce aspiration, pneumonia, and/or respiratory compromise. Dysphagia even without aspiration can interfere with nutrition and delay clinical recovery. And finally, endotracheal intubation may cause dysphagia not only as a temporary problem soon after extubation but also as a long-term complication.3Heffner JE Upper airway dysfunction.in: Marini JJ Slutsky AS Physiological Basis of Ventilatory Support. Marcel Dekker, New York1998Google Scholar Intensivists use information about the long-term risks of endotracheal intubation for doing comparative risk assessments of continuing endotracheal intubation vs performing a tracheotomy, which aids their selection of ventilator-dependent patients for a surgical airway.Considering the clinical importance of postextubation dysphagia and our extensive experience with endotracheal tubes in the modern era, one would think the risk factors for and incidence of adverse effects on deglutition would be well described. Unfortunately, nothing could be further from reality. A sparse literature profiles postextubation problems that affect voice, laryngeal function, and subglottic stenosis with even less information on dysphagia. Most of this literature, in my view, is characterized as providing low-quality evidence.A systematic review on postextubation dysphagia, such as the one published in this issue of CHEST (see page 665) by Skoretz and colleagues,4Skoretz SA Flowers HK Martino R The incidence of dysphagia following endotracheal intubation: A systematic review.Chest. 2010; 137: 665-673Abstract Full Text Full Text PDF PubMed Scopus (196) Google Scholar is indeed welcomed. These investigators did a comprehensive literature search and selected studies for extraction and analysis using exceptionally rigorous methodologies. In initially scanning their article, the study selection flowchart sparked my cause for concern over whether their efforts would advance our understanding of postextubation dysphagia; of the 1,489 articles identified, only 14 were acceptable for analysis. Once retrieved, the authors did an outstanding job evaluating the quality of the 14 studies, but unfortunately found them of low quality with major sources of bias. So, the results and implications of the review must be considered, as the authors emphasize, through the lens of biased primary data.With these limitations in mind, Skoretz and colleagues analyzed the 14 studies and made several observations that were descriptive because the heterogeneity of the reports prevented the authors from doing a formal metaanalysis. They found the reported incidence of dysphagia ranged widely between studies, but 8 of the 14 studies observed a frequency of dysphagia ≥20%. Regardless of the weaknesses of the studies, even a skeptical reader must accept that postextubation dysphagia occurs commonly and affects patients across all of the medical and surgical diagnostic categories reviewed in this report. The authors assumed that the highest dysphagia frequency would occur among patients with the longest duration of intubation and used the absence of such a correlation in their analysis to represent further evidence of bias in the primary studies. I, however, might propose an alternative assumption that even short-term endotracheal intubation may alter swallowing structure and function and also that the intubation procedure itself during passage of an endotracheal tube may contribute to postextubation dysphagia. I would not want readers to assume that short-term placement of endotracheal is risk free.In my view, the more important observations made by Skoretz and colleagues derive from their quality review of the primary studies rather than from the studies' findings. They reported that patients were evaluated with a “wide assortment of swallowing assessment methods.” Clearly, despite a long experience with endotracheal intubation, we not only appear uncertain regarding the frequency of postextubation dysphagia but also have not standardized our protocols for screening, case finding, and evaluating patients for dysphagia.Because of the vast number of patients managed by endotracheal intubation and the potential seriousness of postextubation dysphagia, we need to do better in identifying affected patients and learning how to intercede. Skoretz and colleagues call for better research to clarify dysphagia risks by studying homogenous populations using standardized diagnostic approaches. Clearly, research is always needed, but in the meantime we should start doing a better job applying what we already know.To begin requires recognition that identifying and assessing inpatients for postextubation dysphagia requires a multidisciplinary team approach to apply a tiered and standardized evaluation protocol that proceeds from simple screening to more specific diagnostic studies for select patients. Such team-based quality improvement projects represent a nonlinear, multicomponent intervention in a complex social setting that is not too amenable to traditional research techniques.5Berwick DM The science of improvement.JAMA. 2008; 299: 1182-1184Crossref PubMed Scopus (596) Google Scholar Instead, we can apply what we know incrementally, learn from experience, and modify our approaches (Plan-Do-Study-Act). Simple dysphagia screening tools already exist with known operating characteristics, such as the 3-oz water test.6Suiter DM Leder SB Clinical utility of the 3-ounce water swallow test.Dysphagia. 2008; 23: 244-250Crossref PubMed Scopus (214) Google Scholar Also, a body of knowledge exists in support of various bedside aspiration assessment tools in conditions such as stroke.7Trapl M Enderle P Nowotny M et al.Dysphagia bedside screening for acute-stroke patients: the Gugging Swallowing Screen.Stroke. 2007; 38: 2948-2952Crossref PubMed Scopus (301) Google Scholar We are rapidly gaining greater understanding of more specific assessment tools, such as video-fluoroscopy, fiberoptic endoscopic evaluation of swallowing, and modified barium swallows, for patients whose screening warrants further evaluation.8Martin-Harris B Brodsky MB Michel Y Ford CL Walters B Heffner J Breathing and swallowing dynamics across the adult lifespan.Arch Otolaryngol Head Neck Surg. 2005; 131: 762-770Crossref PubMed Scopus (179) Google Scholar, 9Kelly AM Drinnan MJ Leslie P Assessing penetration and aspiration: how do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare?.Laryngoscope. 2007; 117: 1723-1727Crossref PubMed Scopus (197) Google Scholar Validated grading measures for these studies are now emerging, such as the Modified Barium Swallowing Impairment Profile10Martin-Harris B Brodsky MB Michel Y et al.MBS measurement tool for swallow impairment—MBSImp: establishing a standard.Dysphagia. 2008; 23: 392-405Crossref PubMed Scopus (348) Google Scholar and the Penetration-Aspiration Scale.11Hiss SG Postma GN Fiberoptic endoscopic evaluation of swallowing.Laryngoscope. 2003; 113: 1386-1393Crossref PubMed Scopus (118) Google Scholar Although knowledge is incomplete for using these tools to assess postextubation dysphagia, we have enough to get started. Moreover, these standardized tools should inform the research methods for future studies of postextubation dysphagia to ensure higher quality data for future systematic reviews.In analyzing the existing literature on postextubation dysphagia, Skoretz and colleagues have performed a considerable service in moving us from determining whether it commonly occurs to working out how we can better understand its nature and begin to initiate programs to prevent and mitigate its consequences. Interdisciplinary teams that include bedside nurses, speech-language therapists, and patients' treating physicians should collaborate to more effectively implement existing tools to improve clinical outcome for patients at risk. Normal swallowing depends on a complex sequence of perfectly timed physiologic events, some occurring simultaneously, others sequentially, that involve contractions of multiple oral-facial, pharyngeal, laryngeal, respiratory, and esophageal muscles.1Klahn MS Perlman AL Temporal and durational patterns associating respiration and swallowing.Dysphagia. 1999; 14: 131-138Crossref PubMed Scopus (106) Google Scholar To prevent aspiration, a bolus of food or fluid reaching the posterior oral cavity stimulates neuroreceptors that trigger respiratory muscles to halt respiration, usually in exhalation.2Martin-Harris B Brodsky MB Price CC Michel Y Walters B Temporal coordination of pharyngeal and laryngeal dynamics with breathing during swallowing: single liquid swallows.J Appl Physiol. 2003; 94: 1735-1743Crossref PubMed Scopus (128) Google Scholar It is no surprise that an endotracheal tube might disturb these intricately choreographed events and cause postextubation dysphagia. The clinical importance of dysphagia after extubation is profound. For many hospitalized patients intubated in the operating room or ICU, underlying conditions may interact with dysphagia and produce aspiration, pneumonia, and/or respiratory compromise. Dysphagia even without aspiration can interfere with nutrition and delay clinical recovery. And finally, endotracheal intubation may cause dysphagia not only as a temporary problem soon after extubation but also as a long-term complication.3Heffner JE Upper airway dysfunction.in: Marini JJ Slutsky AS Physiological Basis of Ventilatory Support. Marcel Dekker, New York1998Google Scholar Intensivists use information about the long-term risks of endotracheal intubation for doing comparative risk assessments of continuing endotracheal intubation vs performing a tracheotomy, which aids their selection of ventilator-dependent patients for a surgical airway. Considering the clinical importance of postextubation dysphagia and our extensive experience with endotracheal tubes in the modern era, one would think the risk factors for and incidence of adverse effects on deglutition would be well described. Unfortunately, nothing could be further from reality. A sparse literature profiles postextubation problems that affect voice, laryngeal function, and subglottic stenosis with even less information on dysphagia. Most of this literature, in my view, is characterized as providing low-quality evidence. A systematic review on postextubation dysphagia, such as the one published in this issue of CHEST (see page 665) by Skoretz and colleagues,4Skoretz SA Flowers HK Martino R The incidence of dysphagia following endotracheal intubation: A systematic review.Chest. 2010; 137: 665-673Abstract Full Text Full Text PDF PubMed Scopus (196) Google Scholar is indeed welcomed. These investigators did a comprehensive literature search and selected studies for extraction and analysis using exceptionally rigorous methodologies. In initially scanning their article, the study selection flowchart sparked my cause for concern over whether their efforts would advance our understanding of postextubation dysphagia; of the 1,489 articles identified, only 14 were acceptable for analysis. Once retrieved, the authors did an outstanding job evaluating the quality of the 14 studies, but unfortunately found them of low quality with major sources of bias. So, the results and implications of the review must be considered, as the authors emphasize, through the lens of biased primary data. With these limitations in mind, Skoretz and colleagues analyzed the 14 studies and made several observations that were descriptive because the heterogeneity of the reports prevented the authors from doing a formal metaanalysis. They found the reported incidence of dysphagia ranged widely between studies, but 8 of the 14 studies observed a frequency of dysphagia ≥20%. Regardless of the weaknesses of the studies, even a skeptical reader must accept that postextubation dysphagia occurs commonly and affects patients across all of the medical and surgical diagnostic categories reviewed in this report. The authors assumed that the highest dysphagia frequency would occur among patients with the longest duration of intubation and used the absence of such a correlation in their analysis to represent further evidence of bias in the primary studies. I, however, might propose an alternative assumption that even short-term endotracheal intubation may alter swallowing structure and function and also that the intubation procedure itself during passage of an endotracheal tube may contribute to postextubation dysphagia. I would not want readers to assume that short-term placement of endotracheal is risk free. In my view, the more important observations made by Skoretz and colleagues derive from their quality review of the primary studies rather than from the studies' findings. They reported that patients were evaluated with a “wide assortment of swallowing assessment methods.” Clearly, despite a long experience with endotracheal intubation, we not only appear uncertain regarding the frequency of postextubation dysphagia but also have not standardized our protocols for screening, case finding, and evaluating patients for dysphagia. Because of the vast number of patients managed by endotracheal intubation and the potential seriousness of postextubation dysphagia, we need to do better in identifying affected patients and learning how to intercede. Skoretz and colleagues call for better research to clarify dysphagia risks by studying homogenous populations using standardized diagnostic approaches. Clearly, research is always needed, but in the meantime we should start doing a better job applying what we already know. To begin requires recognition that identifying and assessing inpatients for postextubation dysphagia requires a multidisciplinary team approach to apply a tiered and standardized evaluation protocol that proceeds from simple screening to more specific diagnostic studies for select patients. Such team-based quality improvement projects represent a nonlinear, multicomponent intervention in a complex social setting that is not too amenable to traditional research techniques.5Berwick DM The science of improvement.JAMA. 2008; 299: 1182-1184Crossref PubMed Scopus (596) Google Scholar Instead, we can apply what we know incrementally, learn from experience, and modify our approaches (Plan-Do-Study-Act). Simple dysphagia screening tools already exist with known operating characteristics, such as the 3-oz water test.6Suiter DM Leder SB Clinical utility of the 3-ounce water swallow test.Dysphagia. 2008; 23: 244-250Crossref PubMed Scopus (214) Google Scholar Also, a body of knowledge exists in support of various bedside aspiration assessment tools in conditions such as stroke.7Trapl M Enderle P Nowotny M et al.Dysphagia bedside screening for acute-stroke patients: the Gugging Swallowing Screen.Stroke. 2007; 38: 2948-2952Crossref PubMed Scopus (301) Google Scholar We are rapidly gaining greater understanding of more specific assessment tools, such as video-fluoroscopy, fiberoptic endoscopic evaluation of swallowing, and modified barium swallows, for patients whose screening warrants further evaluation.8Martin-Harris B Brodsky MB Michel Y Ford CL Walters B Heffner J Breathing and swallowing dynamics across the adult lifespan.Arch Otolaryngol Head Neck Surg. 2005; 131: 762-770Crossref PubMed Scopus (179) Google Scholar, 9Kelly AM Drinnan MJ Leslie P Assessing penetration and aspiration: how do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare?.Laryngoscope. 2007; 117: 1723-1727Crossref PubMed Scopus (197) Google Scholar Validated grading measures for these studies are now emerging, such as the Modified Barium Swallowing Impairment Profile10Martin-Harris B Brodsky MB Michel Y et al.MBS measurement tool for swallow impairment—MBSImp: establishing a standard.Dysphagia. 2008; 23: 392-405Crossref PubMed Scopus (348) Google Scholar and the Penetration-Aspiration Scale.11Hiss SG Postma GN Fiberoptic endoscopic evaluation of swallowing.Laryngoscope. 2003; 113: 1386-1393Crossref PubMed Scopus (118) Google Scholar Although knowledge is incomplete for using these tools to assess postextubation dysphagia, we have enough to get started. Moreover, these standardized tools should inform the research methods for future studies of postextubation dysphagia to ensure higher quality data for future systematic reviews. In analyzing the existing literature on postextubation dysphagia, Skoretz and colleagues have performed a considerable service in moving us from determining whether it commonly occurs to working out how we can better understand its nature and begin to initiate programs to prevent and mitigate its consequences. Interdisciplinary teams that include bedside nurses, speech-language therapists, and patients' treating physicians should collaborate to more effectively implement existing tools to improve clinical outcome for patients at risk." @default.
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• W2001806040 title "Swallowing Complications After Endotracheal Extubation" @default.
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