Madison Macht

Postextubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness

IntroductionDysphagia is common among survivors of critical illness who required mechanical ventilation during treatment. The risk factors associated with the development of postextubation dysphagia, and the effects of dysphagia on patient outcomes, have been relatively unexplored.MethodsWe conducted a retrospective, observational cohort study from 2008 to 2010 of all patients over 17 years of age admitted to a university hospital ICU who required mechanical ventilation and subsequently received a bedside swallow evaluation (BSE) by a speech pathologist.ResultsA BSE was performed after mechanical ventilation in 25% (630 of 2,484) of all patients. After we excluded patients with stroke and/or neuromuscular disease, our study sample size was 446 patients. We found that dysphagia was present in 84% of patients (n = 374) and classified dysphagia as absent, mild, moderate or severe in 16% (n = 72), 44% (n = 195), 23% (n = 103) and 17% (n = 76), respectively. In univariate analyses, we found that statistically significant risk factors for severe dysphagia included long duration of mechanical ventilation and reintubation. In multivariate analysis, after adjusting for age, gender and severity of illness, we found that mechanical ventilation for more than seven days remained independently associated with moderate or severe dysphagia (adjusted odds ratio (AOR) = 2.84 [interquartile range (IQR) = 1.78 to 4.56]; P < 0.01). The presence of severe postextubation dysphagia was significantly associated with poor patient outcomes, including pneumonia, reintubation, in-hospital mortality, hospital length of stay, discharge status and surgical placement of feeding tubes. In multivariate analysis, we found that the presence of moderate or severe dysphagia was independently associated with the composite outcome of pneumonia, reintubation and death (AOR = 3.31 [IQR = 1.89 to 5.90]; P < 0.01).ConclusionsIn a large cohort of critically ill patients, long duration of mechanical ventilation was independently associated with postextubation dysphagia, and the development of postextubation dysphagia was independently associated with poor patient outcomes.

ICU-acquired swallowing disorders.

Objectives:Patients hospitalized in the ICU can frequently develop swallowing disorders, resulting in an inability to effectively transfer food, liquids, and pills from their mouth to stomach. The complications of these disorders can be devastating, including aspiration, reintubation, pneumonia, and a prolonged hospital length of stay. As a result, critical care practitioners should understand the optimal diagnostic strategies, proposed mechanisms, and downstream complications of these ICU-acquired swallowing disorders. Data Sources:Database searches and a review of the relevant medical literature. Data Synthesis:A significant portion of the estimated 400,000 patients who annually develop acute respiratory failure, require endotracheal intubation, and survive to be extubated are determined to have dysfunctional swallowing. This group of swallowing disorders has multiple etiologies, including local effects of endotracheal tubes, neuromuscular weakness, and an altered sensorium. The diagnosis of dysfunctional swallowing is usually made by a speech-language pathologist using a bedside swallowing evaluation. Major complications of swallowing disorders in hospitalized patients include aspiration, reintubation, pneumonia, and increased hospitalization. The national yearly cost of swallowing disorders in hospitalized patients is estimated to be over

Post-extubation dysphagia is associated with longer hospitalization in survivors of critical illness with neurologic impairment

500 million. Treatment modalities focus on changing the consistency of food, changing mealtime position, and/or placing feeding tubes to prevent aspiration. Conclusions:Swallowing disorders are costly and clinically important in a large population of ICU patients. The development of effective screening strategies and national diagnostic standards will enable further studies aimed at understanding the precise mechanisms for these disorders. Further research should also concentrate on identifying modifiable risk factors and developing novel treatments aimed at reducing the significant burden of swallowing dysfunction in critical illness survivors.

Diagnosis and treatment of post-extubation dysphagia: Results from a national survey

IntroductionCritically ill patients can develop acute respiratory failure requiring endotracheal intubation. Swallowing dysfunction after liberation from mechanical ventilation, also known as post-extubation dysphagia, is common and deleterious among patients without neurologic disease. However, the risk factors associated with the development of post-extubation dysphagia and its effect on hospital lengthofstay in critically ill patients with neurologic disorders remains relatively unexplored.MethodsWe conducted a retrospective, observational cohort study from 2008 to 2010 of patients with neurologic impairment who required mechanical ventilation and subsequently received a bedside swallow evaluation (BSE) by a speech-language pathologist.ResultsA BSE was performed after mechanical ventilation in 25% (630/2,484) of all patients. In the 184 patients with neurologic impairment, post-extubation dysphagia was present in 93% (171/184), and was classified as mild, moderate, or severe in 34% (62/184), 26% (48/184), and 33% (61/184), respectively. In univariate analyses, statistically significant risk factors for moderate/severe dysphagia included longer durations of mechanical ventilation and the presence of a tracheostomy. In multivariate analysis, adjusting for age, tracheostomy, cerebrovascular disease, and severity of illness, mechanical ventilation for >7 days remained independently associated with moderate/severe dysphagia (adjusted odds ratio = 4.48 (95%confidence interval = 2.14 to 9.81), P<0.01). The presence of moderate/severe dysphagia was also significantly associated with prolonged hospital lengthofstay, discharge status, and surgical placement of feeding tubes. When adjusting for age, severity of illness, and tracheostomy, patients with moderate/severe dysphagia stayed in the hospital 4.32 days longer after their initial BSE than patients with none/mild dysphagia (95% confidence interval = 3.04 to 5.60 days, P <0.01).ConclusionIn a cohort of critically ill patients with neurologic impairment, longer duration of mechanical ventilation is independently associated with post-extubation dysphagia, and the development of post-extubation dysphagia is independently associated with a longer hospital length of stay after the initial BSE.

Alcohol screening scores and 90-day outcomes in patients with acute lung injury

PURPOSE This study sought to determine the utilization of speech-language pathologist (SLPs) for the diagnosis and treatment of post-extubation dysphagia in survivors of mechanical ventilation. METHODS We designed, validated, and mailed a survey to 1,966 inpatient SLPs who routinely evaluate patients for post-extubation dysphagia. RESULTS Most SLP diagnostic evaluations (60%; 95% CI, 59%-62%) were performed using clinical techniques with uncertain accuracy. Instrumental diagnostic tests (such as fluoroscopy and endoscopy) are more likely to be available at university than community hospitals. After adjusting for hospital size and academic affiliation, instrumental test use varied significantly by geographical region. Treatments for post-extubation dysphagia usually involved dietary adjustment (76%; 95% CI, 73-79%) and postural changes/compensatory maneuvers (86%; 95% CI, 84-88%), rather than on interventions aimed to improve swallowing function (24%; 95% CI, 21-27%). CONCLUSIONS SLPs frequently evaluate acute respiratory failure survivors. However, diagnostic evaluations rely mainly upon bedside techniques with uncertain accuracy. The use of instrumental tests varies by geographic location and university affiliation. Current diagnostic practices and feeding decisions for critically ill patients should be viewed with caution until further studies determine the accuracy of bedside detection methods.

Healthcare Utilization in Medical Intensive Care Unit Survivors with Alcohol Withdrawal

Objectives:The effects of excess alcohol consumption (alcohol misuse) on outcomes in patients with acute lung injury have been inconsistent, and there are no studies examining this association in the era of low tidal volume ventilation and a fluid conservative strategy. We sought to determine whether validated scores on the Alcohol Use Disorders Identification Test that correspond to past-year abstinence (zone 1), low-risk drinking (zone 2), mild to moderate alcohol misuse (zone 3), and severe alcohol misuse (zone 4) are associated with poor outcomes in patients with acute lung injury. Design:Secondary analysis. Setting:The Acute Respiratory Distress Syndrome Network, a consortium of 12 university centers (44 hospitals) dedicated to the conduct of multicenter clinical trials in patients with acute lung injury. Subjects:Patients meeting consensus criteria for acute lung injury enrolled in one of three recent Acute Respiratory Distress Syndrome Network clinical trials. Interventions:None. Measurements and Main Results:Of 1,133 patients enrolled in one of three Acute Respiratory Distress Syndrome Network studies, 1,037 patients had an Alcohol Use Disorders Identification Test score available for analysis. Alcohol misuse was common with 70 (7%) of patients having Alcohol Use Disorders Identification Test scores in zone 3 and 129 (12%) patients in zone 4. There was a U-shaped association between validated Alcohol Use Disorders Identification Test zones and death or persistent hospitalization at 90 days (34% in zone 1, 26% in zone 2, 27% in zone 3, 36% in zone 4; p < 0.05 for comparison of zone 1 to zone 2 and zone 4 to zone 2). In a multiple logistic regression model, there was a significantly higher odds of death or persistent hospitalization in patients having Alcohol Use Disorders Identification Test zone 4 compared with those in zone 2 (adjusted odds ratio 1.70; 95% confidence interval 1.00, 2.87; p = 0.048). Conclusions:Severe but not mild to moderate alcohol misuse is independently associated with an increased risk of death or persistent hospitalization at 90 days in acute lung injury patients.

Growth differentiation factor-15 and prognosis in acute respiratory distress syndrome: a retrospective cohort study

BACKGROUND Rehospitalization is an important and costly outcome that occurs commonly in several diseases encountered in the medical intensive care unit (ICU). Although alcohol use disorders are present in 40% of ICU survivors and alcohol withdrawal is the most common alcohol-related reason for admission to an ICU, rates and predictors of rehospitalization have not been previously reported in this population. METHODS We conducted a retrospective cohort study of medical ICU survivors with a primary or secondary discharge diagnosis of alcohol withdrawal using 2 administrative databases. The primary outcome was time to rehospitalization or death. Secondary outcomes included time to first emergency department or urgent care clinic visit in the subset of ICU survivors who were not rehospitalized. Cox proportional hazard models were adjusted for age, gender, race, homelessness, smoking, and payer source. RESULTS Of 1,178 patients discharged from the medical ICU over the study period, 468 (40%) were readmitted to the hospital and 54 (4%) died within 1 year. Schizophrenia (hazard ratio 2.23, 95% CI 1.57, 3.34, p < 0.001), anxiety disorder (hazard ratio 2.04, 95% CI 1.30, 3.32, p < 0.01), depression (hazard ratio 1.62, 95% CI 1.05, 2.40, p = 0.03), and Deyo comorbidity score ≥3 (hazard ratio 1.43, 95% CI 1.09, 1.89, p = 0.01) were significant predictors of time to death or first rehospitalization. Bipolar disorder was associated with time to first emergency department or urgent care clinic visit (hazard ratio 2.03, 95% CI 1.24, 3.62, p < 0.01) in the 656 patients who were alive and not rehospitalized within 1 year. CONCLUSIONS The presence of a psychiatric comorbidity is a significant predictor of multiple measures of unplanned healthcare utilization in medical ICU survivors with a primary or secondary discharge diagnosis of alcohol withdrawal. This finding highlights the potential importance of targeting longitudinal multidisciplinary care to patients with a dual diagnosis.

A 31-Year-Old Woman With Hemoptysis and an Intrathoracic Mass

IntroductionWe sought to determine whether higher levels of the novel biomarker growth differentiation factor-15 (GDF-15) are associated with poor outcomes and the presence of pulmonary vascular dysfunction (PVD) in patients with acute respiratory distress syndrome (ARDS).MethodsWe conducted a retrospective cohort study in patients enrolled in the Acute Respiratory Distress Syndrome Network Fluid and Catheter Treatment (FACT) Trial. Patients enrolled in the FACT Trial who received a pulmonary artery catheter (PAC), had plasma available from the same study day and sufficient hemodynamic data to determine the presence of PVD were included. Logistic regression was used to determine the association between GDF-15 level and 60-day mortality.ResultsOf the 513 patients enrolled in the FACT Trial assigned to receive a PAC, 400 were included in this analysis. Mortality at 60 days was significantly higher in patients whose GDF-15 levels were in the third (28%) or fourth (49%) quartile when compared to patients with GDF-15 levels in the first quartile (12%) (P <0.001). Adjusting for severity of illness measured by APACHE III score, the odds of death for patients with GDF-15 levels in the fourth quartile when compared to the first quartile was 4.26 (95% CI 2.18, 10.92, P <0.001). When added to APACHE III alone for prediction of 60-day mortality, GDF-15 levels increased the area under the receiver operating characteristic curve from 0.72 to 0.77. At an optimal cutoff of 8,103 pg/mL, the sensitivity and specificity of GDF-15 for predicting 60-day mortality were 62% (95% CI 53%, 71%) and 76% (95% CI 71%, 81%), respectively. Levels of GDF-15 were not useful in identifying the presence of PVD, as defined by hemodynamic measurements obtained by a PAC.ConclusionsIn patients with ARDS, higher levels of GDF-15 are significantly associated with poor outcome but not PVD.

Neuromuscular Blockade Resistance During Therapeutic Hypothermia

A 31-year-old woman presented with 3 months of hemoptysis (one-half cup daily), left chest pain, and intermittent expectoration. The sputum was described as having a “cheeselike” appearance, occurring every 5 to 6 days. She reported mild shortness of breath for 2 months but no weight loss, night sweats, or fevers. Her chest pain was episodic in nature and occasionally pleuritic. She denied nausea, vomiting, rashes, or joint pain. Her menses were regular and of normal quantity. Six years prior, she presented to another institution with an acute onset of hemoptysis and underwent left internal mammary arterial embolization. A diagnosis was not established, and she was lost to follow-up. The hemoptysis had subsided following the embolization but now returned. She underwent a left eye enucleation at age 4 years for retinoblastoma. She received no radiation, chemotherapy, or subsequent genetic evaluation. She reported no pneumonia, foreign-body aspiration, or coagulopathy. She was a former smoker (5 years), occasionally drank alcohol, and denied illicit drug use. She was from Denver and had not traveled outside of the United States. There were no risk factors for TB. She took no medications. There was no family history of retinoblastoma, other malignancies, or pulmonary disease. The physical examination included: temperature, 37.8°C; pulse, 64 beats/min; BP, 122/70 mm Hg; respiratory rate, 14 breaths/min; and oxygen saturation, 97% while breathing room air. She was thin and in no acute distress. There was a left prosthetic eye. An oropharyngeal examination revealed normal dentition and an absence of mucosal lesions. The neck was supple without masses or lesions. Cardiovascular exam revealed a normal S1, physiologically split S2, and no gallops, murmurs, or pericardial rub. Lung examination revealed decreased breath sounds over the anterior left thorax with early inspiratory crackles. The abdominal, lymphatic, and skin examinations were normal. Strength was normal. The WBC count was 10.0 × 103 cells/μL with 64% neutrophils, 24% lymphocytes, 6% monocytes, and 6% eosinophils; hemoglobin 14.1 g/dL; hematocrit 42.2%; and platelet count 296 × 103 cells/μL. The serum electrolytes, liver function tests, coagulation studies, and urinalysis were normal. HIV testing was negative. The chest radiograph is shown in Figures 1 and ​and2,2, and the CT scan is shown in Figure 3. Figure 1. Posteroanterior chest radiograph. Figure 2. Lateral chest radiograph. Figure 3. CT scan of the thorax. What Is the Differential Diagnosis? The patient has a large, solitary, parenchymal mass in the left hemithorax. The chest radiograph (Figs 1, ​,2)2) showed a heterogenous left paracardiac mass with central calcifications and embolization coils within the left internal mammary artery. A chest CT scan (Fig 2) showed a large 7 × 7 cm complex mass in the left anterior hemithorax containing fat, nonfat soft tissue, and osseous structures with partial lingular atelectasis. The thyroid gland appeared normal, and there were small bilateral axillary reactive lymph nodes. The presence of continued hemoptysis suggested a communication between the mass and an adjacent bronchus, and her transient improvement following embolization of the left internal mammary artery suggested altered vascular architecture. The possibilities include the following: (1) a benign or malignant parenchymal tumor, (2) a tumor located in the anterior mediastinum, (3) a fungal or mycobacterial infection, (4) a lung abscess, or (5) a hydatid cyst. The leading possibilities are an anterior mediastinal mass or a benign solitary parenchymal tumor. The absence of constitutional symptoms, lymphadenopathy, and further radiographic lesions argued against a diffuse or rapidly growing metastatic disease. The patient had no history of exposure to TB, and the mass involved the inferior and anterior aspect of the thorax, making TB less likely. A lung abscess of this size with bronchial communication more likely than not would result in fevers, purulent and foul-smelling sputum, and weight loss. In addition to the solid structure and marked heterogeneity of the computed tomographic image, there was no exposure history suggesting the possibility of a hydatid cyst. Hamartoma is the most common benign lung tumor, accounting for 75% of all benign lung nodules and 5% to 10% of solitary pulmonary nodules. Hamartomas most often present in the sixth or seventh decades1,2 but can occur in young adults as well. The diameter is usually < 6 cm,1,3 but they have been reported as large as 25.5 cm.4 The mass in this patient had a heterogenous appearance with a radiographically apparent focus of calcification. Calcification has been reported to occur in 3% to 32% of hamartoma cases but tends to have a punctate or “popcornlike” pattern.1,5,6 Calcification can also occur in other benign pulmonary tumors, including plasma cell granulomas and desmoid tumors. Plasma cell granulomas, also referred to as an inflammatory pseudotumor, most often present in childhood or adolescence and usually do not exceed 6 cm in transverse diameter.7 Desmoid tumors most often arise from the chest wall and invade surrounding structures, although they sometimes arise from the lung parenchyma.8 An intrapulmonary or mediastinal lipoma is unlikely to have this CT scan appearance because they tend to have uniform fatty attenuation. Additionally, intrapulmonary lipoma more often occurs on the right and in middle-aged men.9 Pulmonary leiomyoma would also have a homogenous radiographic appearance.10 Finally, in a young woman with recurrent, episodic hemoptysis, pulmonary endometrioma should be considered. Radiographically this presents as small pulmonary nodules and not a large heterogenous mass.11,12 It was difficult to determine based on the CT scan appearance whether this large complex mass originated from the anterior mediastinum or from the lung parenchyma. Thymoma, the most common anterior mediastinal mass, rarely has calcification, and if it occurs, the calcifications are small, curvilinear, or punctate.13 Invasive thymomas are rare, but sometimes they can extend into the lung causing hemoptysis.13 This is an unusual presentation of lymphoma because there are no systemic symptoms or diffuse lymphadenopathy. A mediastinal or intrapulmonary teratoma can present as a large, heterogenous mass with fat, soft tissue, and osseous structures, and can invade an adjacent bronchus. Occasionally patients can expectorate tissue from an intrabronchial tumor, which could account for this patient’s cheeselike sputum. What Should be Done Next? This patient had hemoptysis with recurrent symptoms. She was hemodynamically stable and did not have a coagulopathy. Although a tuberculin skin test should be performed and sputum could be examined for the presence of atypical cells or infection, the next logical step is to obtain tissue for a histologic diagnosis. Consideration should be given to performing a bronchoscopy to determine whether there is endobronchial involvement. Although surgical resection is not required for many hamartomas, the large size, bronchial invasion, and persistent symptoms caused by this mass represent indications for surgical resection. The sampling error of a percutaneous needle aspiration or transbronchial biopsy in such a heterogenous lesion is sufficiently high. Thus, surgical resection is recommended. What is the diagnosis? Diagnosis: mature intrapulm0onary teratoma The results of the workup revealed the following. Her tuberculin skin test was negative. At the time of surgery, a fiberoptic bronchoscopy was performed and did not reveal any abnormalities. Next, the patient was intubated with a double-lumen endotracheal tube, and a left lateral thoracotomy incision at the fifth intercostal space was undertaken. The large heterogenous mass appeared to originate from the lingula and was adherent to the mediastinal pleura and the anterolateral chest wall. During surgical manipulation of the mass, several hairs were noticed within the endotracheal tube. A complete lingulectomy was performed along with excision of an encapsulated 7×5.5×6.5-cm mass without complication. Pathologic evaluation revealed a thick, fibrous capsule with visible areas of calcification. The internal contents of the mass were separated into loculations by the fibrous capsule and included areas of a green-yellow granular substance with intermixed hair, soft adipose tissue, and a mucous white substance. Histologically, the resected specimen displayed a mature, intrapulmonary teratoma; it specifically showed well-differentiated tissues derived from all three germinal layers: respiratory, pancreatic, and intestinal epithelium from endoderm, pilosebaceous units from mesoderm, and hair follicles and squamous epithelium of skin from the ectoderm (Figs 4, ​,55). Figure 4. Hematoxylin-eosin-stained image from the resected intrathoracic mass demonstrating skin with hair follicle and sebaceous glands on the right. There is laminated keratin material on the left. Original magnification ×200. Figure 5. This hematoxylin-eosin-stained section demonstrates cartilage on the right and pancreatic acini on the left. Original magnification ×200.

The accuracy of the bedside swallowing evaluation for detecting aspiration in survivors of acute respiratory failure

Objective: To report a case of neuromuscular blockade resistance to multiple agents during therapeutic hypothermia and discuss possible mechanisms of this resistance. Case Summary: A 64-year-old man with stage IV non–small-cell lung cancer and respiratory distress developed cardiac arrest in the emergency department. The man was quickly resuscitated and treated with therapeutic hypothermia. A chest tube was Inserted for pleural drainage of a large right-sided effusion that collapsed the right lung; this was unsuccessful in reinflating the lung. A bronchopleural fistula developed and independent lung ventilation was initiated due to persistent hypoxemia. Neuromuscular blockade was initiated after sedation and analgesia did not control shivering and was continued due to patient-ventilator dyssynchrony and persistent hypoxemia. Despite large doses of 3 different neuromuscular blocking agents and negligible response to train-of-four tests, clinical neuromuscular blockade, represented by ventilator synchrony, was not achieved until the patient was warmed. Discussion: Resistance to neuromuscular blocking agents has been reported in critically ill patients. Our case of neuromuscular blockade resistance occurred in a patient treated with therapeutic hypothermia, which generally requires a dose reduction of neuromuscular blocking agents. Resistance to neuromuscular blockade was quickly reversed upon warming of the patient as patient-ventilator synchrony was achieved at lower neuromuscular blocking agent doses. Conclusions: Clinicians should be aware of a potential blunted response to neuromuscular blocking agents during therapeutic hypothermia and difficulty with paralysis monitoring since train-of-four response may correlate poorly with clinical neuromuscular blockade during hypothermia. Further research is needed to elucidate the mechanism of this interaction, identify patients at risk, and evaluate alternative strategies to neuromuscular blockade for controlling shivering in patients undergoing therapeutic hypothermia.