Dysphagia Post-Extubation Affects Long-Term Mortality in Mixed Adult ICU Patients-Data From a Large Prospective Observational Study With Systematic Dysphagia Screening

Abstract

Data on long-term effects of post-extubation dysphagia is lacking. We investigate mid- and long-term clinical outcomes in a large sample of ICU patients with systematic dysphagia screening.

Design: Outcome analysis with a follow-up of 6 years or death (whichever occurred earlier) of ICU patients from a prospective observational trial (Dysphagia in Mechanically Ventilated ICU Patients study) with systematic dysphagia screening.

Setting: ICU of a tertiary care academic center.

Patients: Nine-hundred thirty-three mixed medical-surgical ICU patients (median age, 66 yr; interquartile range [IQR], 54-74, Acute Physiology and Chronic Health Evaluation II score 19 [IQR, 14-24], 71% male).

Interventions: ICU patients were followed up for a mean follow-up period of 1,731 ± 772 days (4.7 ± 2.1 yr). Primary outcome measures were 180-day and 360-day all-cause mortality in ICU patients with versus without dysphagia.

Measurements and main results: Two-hundred seventy-three patients died (29.3%) during the observational interval (n = 76 lost to follow-up). In dysphagia screening positive versus negative ICU patients, mortality at 180 days was 16% versus 5.8% (excess mortality 10.2%), whereas mortality at 360 days was 25% versus 9.1% (excess mortality 15.9%). Adjustment for confounders in a Cox model revealed a significant association of dysphagia with all-cause mortality in a time-dependent manner. The risk of death in ICU patients with versus without post-extubation dysphagia declined from about 2.5 times higher to about equal risk for both groups over the first year (i.e. 1.03 yr) post-ICU admission (at 360 d: hazard ratio [HR], 1.03; 95% CI, 0.42-3.70). The mean mortality HR for the first year post-ICU admission was HR 2.09 (95% CI, 1.34-3.24; p = 0.0009).

Conclusions: Long-term follow-up of a large cohort of medical-surgical adult ICU patients systematically screened for dysphagia showed that dysphagia is associated with increased hazards for death for up to 1 year after ICU admission. Our data underline effects of post-extubation dysphagia on long-term clinical outcomes in affected critically ill patients.

Keywords: critical; deglutition disorder; illness; long-term outcomes; mortality; post-extubation dysphagia; swallowing dysfunction.

Figure 1.

Study flowchart.

Figure 2.

Kaplan-Meier survival estimates. Six-yr survival function of all-cause mortality inpatient groups with and without dysphagia. Numbers of patients at risk are shown below. Log-rank p value is indicated.

Figure 3.

Landmark analysis. Survival functions are shown for patient groups with and without dysphagia for the first 1.03 yr after ICU admission. Numbers of patients at risk are shown below each graph.