Predictors of Extubation Failure Related to Aspiration and/or Excessive Upper Airway Secretions.

BACKGROUND: Extubation failure may have several causes, including swallowing dysfunction, aspiration, and excessive upper airway secretions. We hypothesized that a bedside global swallowing pattern assessment including 9 criteria (volume of pharyngeal secretions, 5 swallowing motor items, swallowing reflex, and 2 gag reflexes) performed prior to extubation could identify patients at risk of extubation failure. METHODS: In a multicenter prospective observational study, all consecutive patients intubated and mechanically ventilated for ≥6 d were included. Before a planned extubation, a physiotherapist evaluated the 9 criteria of the swallowing assessment. The final extubation decision was left to the physician's discretion, blinded to the swallowing assessment. Extubation failure was defined as the need for re-intubation related to aspiration or excessive upper airway secretions within the first 72 h after extubation. Results are expressed as median (interquartile range [IQR]). RESULTS: The study included 159 subjects (age 61 y [IQR 48-75]; male/female ratio 1.5; Simplified Acute Physiologic score II 54 [IQR 42-66]; duration of mechanical ventilation 11 d [IQR 8-17]). A total of 23 subjects (14.5%) required re-intubation, with 16 occurring within the first 72 h after extubation and 7 related to aspiration or excessive secretions. Swallowing assessment was significantly lower in subjects with re-intubation related to aspiration or excessive secretions within the first 72 h after extubation versus those not re-intubated for aspiration or excessive secretions (6 [IQR 5-7] vs 8 [IQR 7-8], P = .008, respectively). Among the 9 swallowing assessment criteria, normal right pharyngeal gag reflex was associated with a lower incidence of re-intubation related to aspiration or excessive secretions (odds ratio 0.12, 95% CI 0.03-0.59, P = .01), as well as normal left pharyngeal gag reflex (odds ratio 0.13, 95% CI 0.03-0.63, P = .01), with a negative predictive value of 0.98 for each reflex. CONCLUSIONS: In subjects with prolonged ventilation, the presence of one or both gag reflexes could predict a reduction in extubation failure related to aspiration or excessive upper airway secretions. (Clinical trials.gov registration NCT00780078.).

Swallowing disorders as a predictor of unsuccessful extubation: a clinical evaluation.

BACKGROUND: Unsuccessful extubation may be due to swallowing dysfunction that causes airway obstruction and impairs patients' ability to cough and expectorate. OBJECTIVE: To determine whether swallowing assessment before extubation is helpful in predicting unsuccessful extubation due to airway secretions. METHODS: This prospective study included all patients intubated orotracheally for more than 6 days. Before extubation, 3 tests designed to assess (1) cervical, oral, labial, and lingual motility; (2) gag reflex; and (3) swallowing were used at the bedside. Causes of reintubation were identified, and their relationship to patients' swallowing function before extubation was evaluated. RESULTS: Sixty-two patients were enrolled. Data on 55 patients reintubated for swallowing dysfunction were analyzed. Nine patients were reintubated because of obstruction related to upper airway secretions. Evaluation before extubation enabled prediction of 7 of those 9 unsuccessful extubations. Among the 23 patients with central nervous system disease, 3 of 4 unsuccessful extubations were predicted. According to a multivariate logistic regression model, motility and swallowing were independent predictors of unsuccessful extubation (area under receiver-operating-characteristic curve, 80%). The gag reflex was the only significant predictor of the ability to cough (area under curve, 73%) and excessive pulmonary secretion (area under curve, 67%). Swallowing was an independent predictor of the need for suctioning (area under curve, 78%). CONCLUSIONS: Using simple bedside tests to evaluate swallowing before extubation is helpful when deciding whether to extubate patients who have been intubated for more than 6 days. Involvement of nurses in these decisions would improve patients' management.