拔管后吞咽困难与危重症老年患者长期死亡率的关系。
Association Between Postextubation Dysphagia and Long-Term Mortality Among Critically Ill Older Adults.
机构信息
Departments of Critical Care Medicine and Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio.
Voice and Swallow Clinic, Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin.
出版信息
J Am Geriatr Soc. 2019 Sep;67(9):1895-1901. doi: 10.1111/jgs.16039. Epub 2019 Jun 26.
BACKGROUND
Dysphagia following extubation is common in intensive care unit (ICU) patients. Diagnosing postextubation dysphagia allows identification of patients who are at highest risk for aspiration and its associated adverse outcomes. Older adults are at an increased risk of postextubation dysphagia and its complications due to multiple comorbidities, a higher baseline risk of dysphagia, and increased risk of pneumonia.
OBJECTIVES
We aimed to investigate the association between postextubation dysphagia and 1-year mortality in older patients. Secondary outcomes included ICU and hospital lengths of stay, ICU readmission, and place of discharge.
METHODS
We performed a retrospective cohort study from January 1 to December 31, 2013. ICU patients, aged 65 years and older, who were successfully extubated and underwent a formal swallow evaluation by a speech and language pathologist (SLP) were included. Dysphagia was graded using a seven-point scale, and those with at least mild-moderate dysphagia were labeled as having clinically significant dysphagia.
RESULTS
Of 1075 patients who were screened, 359 were survivors, aged 65 years and older; and of these survivors, 111 had a swallow evaluation performed by an SLP after liberation from mechanical ventilation. Mean age was 73.8 years (SD = 7.0 years), and 41.4% had clinically significant dysphagia. In a multivariable regression model, there was no significant association between dysphagia and 1-year mortality. Furthermore, there was no statistically significant difference in ICU or hospital length of stay, ICU readmission, or place of discharge of those with clinically significant dysphagia compared to those without.
CONCLUSIONS
Among mechanically ventilated ICU patients, aged 65 years and older, who underwent a swallow evaluation following extubation, dysphagia was not associated with mortality, ICU and hospital lengths of stay, ICU readmission, and place of discharge. Given conflicting evidence in the literature, larger prospective studies are needed to clarify whether postextubation dysphagia is associated with worse outcomes in older patients admitted to the ICU. J Am Geriatr Soc 67:1895-1901, 2019.
背景
脱机后吞咽困难在重症监护病房（ICU）患者中很常见。诊断拔管后吞咽困难可以识别出最容易发生误吸及其相关不良后果的患者。由于多种合并症、更高的基础吞咽困难风险以及肺炎风险增加，老年患者发生拔管后吞咽困难及其并发症的风险增加。
目的
我们旨在研究老年患者拔管后吞咽困难与 1 年死亡率之间的关系。次要结局包括 ICU 和住院时间、ICU 再入院和出院地点。
方法
我们进行了一项回顾性队列研究，时间为 2013 年 1 月 1 日至 12 月 31 日。纳入成功拔管并由言语语言病理学家（SLP）进行正式吞咽评估的年龄≥65 岁的 ICU 患者。吞咽困难采用七点量表分级，至少为轻度至中度吞咽困难的患者被标记为存在临床显著吞咽困难。
结果
在筛选出的 1075 名患者中，有 359 名幸存者年龄≥65 岁；在这些幸存者中，有 111 名在脱离机械通气后由 SLP 进行了吞咽评估。平均年龄为 73.8 岁（SD=7.0 岁），41.4%存在临床显著吞咽困难。在多变量回归模型中，吞咽困难与 1 年死亡率之间无显著关联。此外，与无临床显著吞咽困难的患者相比，有临床显著吞咽困难的患者的 ICU 或住院时间、ICU 再入院或出院地点无统计学差异。
结论
在接受机械通气的 ICU 患者中，年龄≥65 岁且在拔管后进行了吞咽评估的患者中，吞咽困难与死亡率、ICU 和住院时间、ICU 再入院和出院地点无关。鉴于文献中存在相互矛盾的证据，需要更大规模的前瞻性研究来阐明拔管后吞咽困难是否与 ICU 收治的老年患者预后更差相关。美国老年医学会 67:1895-1901，2019。
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