Postextubation fiberoptic endoscopic evaluation of swallowing after prolonged endotracheal intubation: a randomized, prospective trial

Abstract

Background: Critically ill trauma patients frequently require prolonged endotracheal intubation and ventilator support. After extubation, swallowing difficulties may exist in < or = 50% of patients. We sought to determine whether performing a swallowing evaluation would reduce the incidence of postextubation aspiration and subsequent pneumonia.

Design: Randomized, prospective clinical trial of fiberoptic endoscopic evaluation of swallowing (FEES) vs. routine clinical management in patients after prolonged intubation.

Methods: Seventy patients who were intubated for > 48 hrs were randomized. FEES examinations were performed within 24 +/- 2 hrs after extubation. Silent aspiration was defined as the appearance of liquid or puree bolus below the true vocal cords without coughing during a FEES examination. Clinical aspiration was defined as the removal of enteral content from below the vocal cords, usually during endotracheal tube placement.

Results: There were five episodes of aspiration and pneumonia in the FEES group (14%, two silent) and two in the clinical group (6%, not significant, Fisher exact test). Patients aged > 55 yrs and those with vallecular stasis on FEES examination were at significantly higher risk of postextubation aspiration. All patients with pneumonia had an associated aspiration episode.

Conclusions: Patients with prolonged orotracheal intubation are at risk of aspiration after extubation. The addition of a FEES examination did not change the incidence of aspiration or postextubation pneumonia.