The Laryngoscope C 2015 The American Laryngological, V

Rhinological and Otological Society, Inc.

Handgrip Strength and Dysphagia Assessment Following Cardiac Surgery Bridget Hathaway, MD; Brooke Baumann, CCC-SLP; Sara Byers, CCC-SLP; Tamara Wasserman-Wincko, CCC-SLP; Vinay Badhwar, MD; Jonas Johnson, MD Objectives/Hypothesis: Prolonged intubation has been recognized as a risk factor for dysphagia following cardiac surgery. We conducted a study to determine whether those patients intubated longer than 12 hours following cardiac surgery exhibit low handgrip strength and if dysphagia is prevalent in those with low handgrip strength. Study Design: Feasibility study. Methods: Patients intubated more than 12 hours after cardiac surgery were enrolled. Handgrip strength was measured. If subjects were found to have low grip strength they underwent clinical swallowing exam by a speech-language pathologist followed by modified barium swallow (MBS) to assess for dysphagia. Severity of dysphagia was assessed with the Penetration-Aspiration Scale (PAS) and need for diet modification. Results: Eighty-six percent (12/14) of patients tested had low handgrip strength. Eight patients with low grip strength completed the bedside swallowing exam and MBS. Four of the eight patients (50%) had deep laryngeal penetration (PAS scores 4–5) on MBS and three (38%) patients were found to have silent aspiration (PAS 8). The findings on MBS resulted in the recommendation of a swallowing strategy and/or modified diet for six of the eight (80%) patients. Nonoral feedings were recommended for two patients (25%) based on MBS results. Conclusions: A majority of patients intubated >12 hours after cardiac surgery exhibit low handgrip strength. Dysphagia is prevalent among those with low handgrip strength. The role of frailty measures in screening for dysphagia deserves further investigation. Key Words: Dysphagia, frailty, intubation, handgrip. Level of Evidence: 4. Laryngoscope, 125:2330–2332, 2015

INTRODUCTION Dysphagia is a risk factor for aspiration pneumonia. Aspiration and nosocomial pneumonia result in increased length of hospital stay, acquired hospital costs, morbidity, and mortality.1,2 Prolonged intubation has been recognized as a risk factor for dysphagia following cardiac surgery.3 Frailty is another predictor of adverse outcomes in postsurgical populations.4–6 Handgrip strength is an objective measure commonly used as a marker of frailty. Butler and colleagues have demonstrated a correlation between posterior tongue strength and handgrip strength in older adults.7 In most clinical settings, dysphagia screening is initiated when a patient exhibits overt signs that are detected by clinicians. However, this approach is likely to miss patients who do not exhibit overt signs of dysphagia, par-

From the Department of Otolaryngology (B.H., B.B., S.B., T.W.–W., J.J.) and the Department of Cardiothoracic Surgery (V.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A. Editor’s Note: This Manuscript was accepted for publication January 2, 2015. Financial support for this projected was provided by the Department of Otolaryngology, University of Pittsburgh School of Medicine. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Bridget Hathaway, MD, Eye and Ear Institute, 200 Lothrop Street, Suite 519, Pittsburgh, PA 15213. E-mail: [email protected] DOI: 10.1002/lary.25175

Laryngoscope 125: October 2015

2330

ticularly those with silent aspiration. Impaired cough thresholds have been demonstrated in patients undergoing coronary artery bypass graft CABG surgery, particularly in the first 24 hours following extubation.8 We hypothesized that handgrip strength, a marker of frailty, may be helpful in identifying patients at risk for dysphagia. We were particularly interested in the early period (12 hours) were considered for inclusion in the assessment process. Exclusion criteria included hand degenerative arthritis, surgery to the patient’s dominant hand within 6 months, and/or history of upper extremity weakness. All patients were seen a minimum of 6 hours after extubation and were seated upright. Handgrip strength was measured

Hathaway et al.: Handgrip Strength and Dysphagia

TABLE I. Characteristics of Patients with Low Grip Strength Penetration-Aspiration Scale

Type of Surgery

Length of Intubation, d

Grip Strength, kgf

Thin Spoon

Thin Cup

Nectar Spoon

Nectar Cup

Diet at Initial Assessment

Age, yr

Sex

Recommended Diet

83

F

AVR, CABG

0.7

18

1

2

1

2

NPO

Regular/thin liquids

74 86

F F

MVR, TVR MVR, maze

1 1

7 days, and found that dysphagia is highly prevalent in this situation and is associated with poorer outcomes including pneumonia, reintubation, in-hospital mortality, length of stay, discharge status, and surgical placement of feeding tubes.9 Improved screening methods are needed to determine which patients would benefit from formal evaluation by a speech-language pathologist as well as instrumental testing to diagnose dysphagia. These results also reinforce the importance of evaluations by speech-language pathologists and instrumental exams when indicated. Evaluations by nursing staff and other clinicians who have not been trained to perform dysphagia screenings are often insensitive. Two of three patients on oral diets prior to speech-language pathologist assessment were found to have silent aspiration on MBS. These data suggest that there may be a role for frailty assessments in the dysphagia screening process, but further studies are needed to evaluate the relationship between objective measures of frailty and dysphagia. It seems to be clinically apparent that many patients are in a frail state preoperatively, and that the stress of Hathaway et al.: Handgrip Strength and Dysphagia

2331

surgery and prolonged intubation causes decompensation. Dysphagia is one manifestation of this decompensation, but other systems may be affected as well. Recognizing the prevalence of dysphagia in following prolonged intubation also creates and opportunity to intervene therapeutically to improve outcomes. Limitations of this study include the small sample size and lack of control group. Patients who had normal grip strength did not have swallowing evaluations. The sample size was in part limited due the requirement for assessments to be completed in 24 hours. Another limitation of this study is that there was potential for a time lapse between grip strength assessment and MBS, given that grip strength was assessed within 6 hours and MBS was performed within 24 hours of extubation. It is possible that a subject who exhibited low grip strength at the initial bedside assessment may have recovered some degree of strength by the time the MBS was done. There is a paucity of data in the literature regarding timing of swallowing assessments following extubation, and this study enhances our understanding of risk of dysphagia in the early postextubation period. Other strengths of the study include the prospective design and the confirmation of dysphagia with instrumental testing. Most studies of dysphagia following extubation have based the diagnosis of dysphagia on clinical bedside exams or symptoms. The true incidence of dysphagia in this population can only be discovered by doing instrumental exams on a broad sample of patients.

Laryngoscope 125: October 2015

2332

CONCLUSION Patients intubated >12 hours after cardiac surgery are at risk for dysphagia in the following extubation. Improved screening methods for dysphagia in this setting may improve patient outcomes. Further studies are needed to elucidate the potential role for objective measures of frailty in dysphagia screening.

BIBLIOGRAPHY 1. Wilson RD. Mortality and cost of pneumonia after stroke for different risk groups. J Stroke Cerebrovasc Dis 2012;21:61–67. 2. Semenov YR, Starmer HM, Gourin CG. The effect of pneumonia on shortterm outcomes and cost of care after head and neck cancer surgery. Laryngoscope 2012;122:1994–2004. 3. Barker J, Martino R, Reichardt B, Hickey EJ, Ralph-Edwards A. Incidence and impact of dysphagia in patients receiving prolonged endotracheal intubation after cardiac surgery. Can J Surg 2009;52:119–124. 4. Adams P, Ghanem T, Stachler R, Hall F, Velanovich V, Rubenfeld I. Frailty as a predictor of morbidity and mortality in inpatient head and neck surgery. JAMA Otolaryngol Head Neck Surg 2013;139:783–789. 5. Chen CH, Ho-Chang, Huang YZ, Hung TT. Hand-grip strength is a simple and effective outcome predictor in esophageal cancer following esophagectomy with reconstruction: a prospective study. J Cardiothorac Surg 2011;6:98. 6. Makary MA, Segev DL, Pronovost PJ, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg 2010;210:901–908. 7. Butler SG, Stuart A, Leng X, et al. The relationship of aspiration status with tongue and handgrip strength in healthy older adults. J Gerontol A Biol Sci Med Sci 2011;66A:452–458. 8. Kallesen M, Psirides A, Huckabee ML. A prospective study of cough response to nebulized citric acid following ventilation for elective cardiac surgery. Paper presented at: Dysphagia Research Society Annual Meeting; March 6–8, 2014; Nashville, TN. 9. Macht M, Wimbish T, Clark B, et al. Postextubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness. Crit Care 2011;15:R231.

Hathaway et al.: Handgrip Strength and Dysphagia

Handgrip strength and dysphagia assessment following cardiac surgery.

Prolonged intubation has been recognized as a risk factor for dysphagia following cardiac surgery. We conducted a study to determine whether those pat...
73KB Sizes 1 Downloads 7 Views