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  • Dysphagia Following Endotracheal Intubation: Frequency, Risk Factors and

    Characteristics

    by

    Stacey Anne Skoretz

    A thesis submitted in conformity

    with the requirements

    for the degree of Doctor of Philosophy

    Department of Speech-Language Pathology

    University of Toronto

    Stacey Anne Skoretz 2015

  • DYSPHAGIA FOLLOWING INTUBATION

    ii

    Dysphagia Following Endotracheal Intubation: Frequency, Risk Factors and

    Characteristics

    Stacey Anne Skoretz

    Doctor of Philosophy

    Department of Speech Language Pathology University of Toronto

    2015

    Abstract

    Oropharyngeal dysphagia following endotracheal intubation occurs frequently,

    however, both the incidence and associated risk factors vary across the literature. This

    dissertation is comprised of three studies that investigate the frequency, associated risk

    factors and characteristics of post-extubation dysphagia along with the relation between

    intubation duration and swallowing outcomes with a focus on CV surgery. First, we

    conducted a systematic review in order to determine dysphagia frequency according to

    patient diagnoses and the association between dysphagia and intubation time. We

    conducted searches using fourteen electronic databases along with manual searching of

    journals and grey literature. Our critical appraisal utilized the Cochrane Risk of Bias

    Assessment and GRADE tools. Our second study assessed dysphagia frequencies

    according to four intubation duration strata on consecutive patients following CV

    surgery: I (12 h), II (>12 to 24 h), III (> 24 to 48 h), and IV (>48 h). We also

    derived independent predictors for dysphagia across the entire sample using logistic

    regression. Finally, we conducted a feasibility study with prospective consecutive

    enrollment in order to determine patient tolerance of the instrumental procedures used to

    assess swallowing physiology, videofluoroscopy swallowing study (VFS) and

  • DYSPHAGIA FOLLOWING INTUBATION

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    nasendoscopy, following prolonged intubation after CV surgery. Along with study

    impact on patients and nursing workflow, we assessed other feasibility parameters

    including recruitment rate, task completion durations and measurement reliability.

    Findings from our systematic review, identified a range of dysphagia frequency from 3%

    to 62% and intubation duration from 124.8 to 346.6 mean hours across the fourteen

    included studies. The highest dysphagia frequencies, 62%, 56%, and 51%, occurred

    following prolonged intubation and included patients across all diagnostic subtypes.

    Overall, the quality of the evidence was low. In our second study, we reported a

    dysphagia frequency of 5.6 % (51/909) across the entire sample, however, we identified

    that frequency varied according to intubation group: I, 1 % (7/699); II, 8.2 % (11/134);

    III, 16.7 % (6/36); and IV, 67.5 % (27/40). Across the entire sample, the independent

    predictors of dysphagia included intubation duration (p < .001; odds ratio [OR] 1.93,

    95 % confidence interval [CI] 1.63-2.29) according to 12-hour increments and age (p =

    .004; OR 2.12, 95 % CI 1.27-3.52) according to 10-year increments. For our final study,

    of the 16 eligible patients, three agreed to participate. Following a videofluoroscopy

    swallowing study (VFS) completion, all patients exhibited oral and pharyngeal

    swallowing impairments. VFS completion time ranged from 14 to 52 minutes with item

    interrater reliability ranging from .25 (95% CI: -.10-.59) to .99 (95% CI: .98-.99).

    Participants reported minimal study burden. In conclusion, our collective findings report

    the frequency of dysphagia across numerous patient populations, associated risk factors

    and swallowing characteristics. With this information, we provide the means to identify

    at-risk patients following extubation after CV surgery. For future studies, we propose

    ways to improve study enrollment as well as suggest instrumental procedures and

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    interpretation methods best suited to assessing swallowing physiology in this patient

    population.

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    Acknowledgements

    It takes a village. No kidding. I am the luckiest human on the planet to have a

    community such as this. If it were not for the selfless acts of kindness, love and support

    that I received; I would have never finished this marathon. The people I am about to

    mention were my supports when I could not stand on my own, my foundation when

    everything around me was turning to sand, and my light when all I could see was dark.

    What you all have done throughout this process will never be lost on me.

    For my husband Bill: thank you for sacrificing so much throughout these years

    and especially during the final three as we struggled to survive, quite literally. You have

    provided for our little family, taken on the role of primary caregiver more times than I

    can count, and taken countless hours off of work to provide support without ever uttering

    one word of complaint. Your capacity for love, tolerance and understanding is

    remarkable. To my baby Grace: thank you for being such a Life Force. You always

    greet the day happily and readily embrace it with vigor - there is nothing that is more

    perfect than that. Thank you for adding a dimension to my life that I would not have

    otherwise had. I do apologize that the first words you heard and books you read were all

    surrounding deglutition. Ive started putting away for your future therapy.

    To my supervisor Dr. Rosemary Martino: I thank you mightily for your guidance,

    knowledge, support, sacrifice and confidence you have in my work and in me. While

    what you offer the profession is remarkable, it is second only to your kindness, integrity

    and humanity. For my supervisory committee Drs. Joan Ivanov, John Granton and

    Terrence Yau: thank you for your expertise, patience and support. I am honoured that

    you agreed to mentor me throughout this journey. I strive for your balance of research

    and clinical practice. For the Ladies-of-the-Lab: Trixie Reichardt, Dr. Heather Flowers

  • DYSPHAGIA FOLLOWING INTUBATION

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    and Stephanie Shaw, thank you for playing such an important role in my successes both

    personally and professionally. I am so happy that you are a part of my life.

    Thank you for everything you have done for me Mom. I have not forgotten the

    life sacrifices you have made to get me here. Without the past, there would be no

    present. To my sister Cassandra, I will never forget the help you provided while we were

    renovation refugees and while I was in the newborn baby haze. To my sister Mikaela:

    this adventure would have been a lot less Awesome without you. From saving all your

    high-school pennies to come visit Toronto to your presence during the important events

    of this journey, thank you for being there. Someday I really will find you a solar-

    powered laser beam guitar. For my aunt Hlne: thank you for understanding me. The

    generosity and empathy you possess is without measure. I quite literally would not have

    survived without you.

    Michelle Graham, thank you for being my steadfast friend throughout these years.

    Above all, you were the only person who was there by my side as I packed up my lifes

    rubble to start another. Thank you. Vance Ward, you supported this adventure not only

    with your time and friendship but also with your remarkable culinary skills. Thank you

    for feeding my stomach and my soul. To my dear Kelly Ryan, David Rose and the rest of

    the Hamilton/Grimsby gang: who wouldnt want to have a Ph.D. with a minor in

    viniculture? I will now have time to become learned in the ways of that Rock Lobster

    thing and I have not forgotten that our off-grid life adventures wait. For Mar and Shar: I

    am so grateful that our paths collided and blessed me with you, Mar-toonies and harp

    strings. You have added depth and fuel for my right hemisphere. For Drs. Jim Coyle and

    Joe Murray: thank you for checking in over the years and making sure that I was still

  • DYSPHAGIA FOLLOWING INTUBATION

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    alive. Your help and balanced wisdom really did keep things on track. For Randy

    Reichardt and Megan Sui: I am eternally grateful for your mad library skills.

    Lastly but certainly not least, to Dr. John Stone: without you this would have

    never came to be. Thank you for giving me my very first research assistantship during

    my masters and encouraging me to pursue doctoral studies. You helped me to believe

    that I was capable and had skills worthy of higher learning. Without that and all of the

    kind gestures you and your wonderful wife Sandra have displayed over the years, I would

    not have made it to this point. Thank you for being a role model for me in this world of

    academia. Your intellect, candor, practicality and humour are something that I respect

    deeply. You have shown me that there is much to be gained and to offer throughout this

    process. I can only hope to have even a fraction of that same positive impact on this

    Earth.

    Onward

  • DYSPHAGIA FOLLOWING INTUBATION

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    TABLE OF CONTENTS Abstract ........

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