Dataset Information

Development of an Accurate Bedside Swallowing Evaluation Decision Tree Algorithm for Detecting Aspiration in Acute Respiratory Failure Survivors.

ABSTRACT:

Background

The bedside swallowing evaluation (BSE) is an assessment of swallowing function and airway safety during swallowing. After extubation, the BSE often is used to identify the risk of aspiration in acute respiratory failure (ARF) survivors.

Research question

We conducted a multicenter prospective study of ARF survivors to determine the accuracy of the BSE and to develop a decision tree algorithm to identify aspiration risk.

Study design and methods

Patients extubated after ≥ 48 hours of mechanical ventilation were eligible. Study procedures included the BSE followed by a gold standard evaluation, the flexible endoscopic evaluation of swallowing (FEES).

Results

Overall, 213 patients were included in the final analysis. Median time from extubation to BSE was 25 hours (interquartile range, 21-45 hours). The FEES was completed 1 hour after the BSE (interquartile range, 0.5-2 hours). A total of 33% (70/213; 95% CI, 26.6%-39.2%) of patients aspirated on at least one FEES bolus consistency test. Thin liquids were the most commonly aspirated consistency: 27% (54/197; 95% CI, 21%-34%). The BSE detected any aspiration with an accuracy of 52% (95% CI, 45%-58%), a sensitivity of 83% (95% CI, 74%-92%), and negative predictive value (NPV) of 81% (95% CI, 72%-91%). Using recursive partitioning analyses, a five-variable BSE-based decision tree algorithm was developed that improved the detection of aspiration with an accuracy of 81% (95% CI, 75%-87%), sensitivity of 95% (95% CI, 90%-98%), and NPV of 97% (95% CI, 95%-99%).

Interpretation

The BSE demonstrates variable accuracy to identify patients at high risk for aspiration. Our decision tree algorithm may enhance the BSE and may be used to identify patients at high risk for aspiration, yet requires further validation.

Trial registry

ClinicalTrials.gov; No.: NCT02363686; URL: www.clinicaltrials.gov.

SUBMITTER: Moss M

PROVIDER: S-EPMC7674978 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundDysphagia with subsequent aspiration occurs in up to 60% of acute respiratory failure (ARF) survivors. Accurate bedside tests for aspiration can reduce aspiration-related complications while minimizing delay of oral nutrition. In a cohort of ARF survivors, we determined the accuracy of the bedside swallowing evaluation (BSE) and its components for detecting aspiration.MethodsPatients who were extubated after at least 24hours of mechanical ventilation were eligible for enrollment. Within 3 days of extubation, patients underwent comprehensive BSE including 3-oz water swallowing test (3-WST), followed by a criterion standard test for aspiration, flexible endoscopic evaluation of swallowing (FEES).ResultsForty-five patients were included in the analysis. Median patient age was 55years (interquartile range, 47-65). Median duration of mechanical ventilation was 3.3days (interquartile range 1.8-6.0). Fourteen patients (31%) aspirated on FEES. Physical examination findings on BSE and abnormal swallowing during trials of different consistencies were variably associated with aspiration. Compared with FEES, the 3-WST yielded a sensitivity of 77% (95% confidence interval [CI], 50%-92%), specificity of 65% (95% CI, 47%-79%), and an area under the receiver operating characteristic curve (AUC) of 0.71; a speech language pathologist's recommendation for altered diet yielded a sensitivity of 86% (95% CI, 60%-96%), a specificity of 52% (95% CI, 35%-68%), and an AUCof 0.69; an speech language pathologist's recommendation for nil per os (nothing by mouth) yielded a sensitivity of 50% (95% CI, 27%-73%), a specificity of 94% (95% CI, 79%-98%), and an AUCof 0.72.ConclusionsThe BSE and its components, including the 3-WST, demonstrated variable accuracy for aspiration in survivors of ARF. Investigation to determine the optimal noninvasive test for aspiration in ARF survivors is warranted.Clinical trials registrationClinicalTrials.gov identifier: NCT02363686, Aspiration in Acute Respiratory Failure Survivors.

Project description:ObjectivesTo determine whether a modifiable risk factor, endotracheal tube size, is associated with the diagnosis of postextubation aspiration in survivors of acute respiratory failure.DesignProspective cohort study.SettingICUs at four academic tertiary care medical centers.PatientsTwo hundred ten patients who were at least 18 years old, admitted to an ICU, and mechanically ventilated with an endotracheal tube for longer than 48 hours were enrolled.InterventionsWithin 72 hours of extubation, all patients received a flexible endoscopic evaluation of swallowing examination that entailed administration of ice, thin liquid, thick liquid, puree, and cracker boluses. Patient demographics, treatment variables, and hospital outcomes were abstracted from the patient's medical records. Endotracheal tube size was independently selected by the patient's treating physicians.Measurements and main resultsFor each flexible endoscopic evaluation of swallowing examination, laryngeal pathology was evaluated, and for each bolus, a Penetration Aspiration Scale score was assigned. Aspiration (Penetration Aspiration Scale score ≥ 6) was further categorized into nonsilent aspiration (Penetration Aspiration Scale score = 6 or 7) and silent aspiration (Penetration Aspiration Scale score = 8). One third of patients (n = 68) aspirated (Penetration Aspiration Scale score ≥ 6) on at least one bolus, 13.6% (n = 29) exhibited silent aspiration, and 23.8% (n = 50) exhibited nonsilent aspiration. In a multivariable analysis, endotracheal tube size (≤ 7.5 vs ≥ 8.0) was significantly associated with patients exhibiting any aspiration (Penetration Aspiration Scale score ≥ 6) (p = 0.016; odds ratio = 2.17; 95% CI 1.14-4.13) and with risk of developing laryngeal granulation tissue (p = 0.02).ConclusionsLarger endotracheal tube size was associated with increased risk of aspiration and laryngeal granulation tissue. Using smaller endotracheal tubes may reduce the risk of postextubation aspiration.

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