Understanding and Improving Dysphagia after Mechanical Ventilation

了解和改善机械通气后吞咽困难

• 批准号: 9259958
• 负责人: Martin Bruce Brodsky
• 金额: $ 20.48万
• 依托单位: JOHNS HOPKINS UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2014
• 资助国家: 美国
• 起止时间: 2014-05-01 至 2019-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9259958
• 关键词: Abnormal coordination; Acute; Acute respiratory failure; Address; Affect; Age; American; Animal Model; Articular Range of Motion; Aspiration Pneumonia; Barium swallow; Breathing; Cervical; Cessation of life; Chronic; Clinical; Clinical Practice Patterns; Clinical Research; Clinical Trials; Control Groups; Data; Deglutition; Deglutition Disorders; Early Intervention; Elderly; Enrollment; Esthesia; Evaluation; Exercise; Exercise Therapy; Female; Foundations; Frequencies; Functional disorder; Future; Goals; Grant; Healthcare; Hospitals; Hour; Impairment; Intensive Care Units; Intervention; Intratracheal Intubation; Intubation; Investigation; Iowa; Knowledge; Laryngeal Injury; Laryngoscopy; Larynx; Lead; Length of Stay; Massage; Mechanical ventilation; Mechanics; Mediating; Mentored Patient-Oriented Research Career Development Award; Mentors; Morbidity - disease rate; Motor; Muscle Weakness; Nature; Neurologic; Oral; Oropharyngeal; Patient Recruitments; Patient-Focused Outcomes; Patients; Pattern; Penetration; Performance; Pharyngeal structure; Phase; Phase I Clinical Trials; Physical Rehabilitation; Physiological; Physiology; Principal Investigator; Randomized Controlled Trials; Rehabilitation therapy; Research; Research Methodology; Risk; Risk Factors; Sampling; Sedation procedure; Sensory; Severities; Solid; Stroke; Time; Tongue; Tracheostomy procedure; Training; United States National Institutes of Health; clinical care; experience; improved; instrument; kinematics; lung injury; medical complication; multi-component intervention; multimodality; muscle form; muscle strength; novel; patient oriented research; patient population; prevent; prospective; public health relevance; sex; standardize measure; success; treatment group

DESCRIPTION (provided by applicant): Annually, nearly 1 million Americans experience acute respiratory failure (ARF) requiring mechanical ventilation in intensive care units (ICU). Existing evidence demonstrates a strong association between oral endotracheal intubation and swallowing impairment (i.e., dysphagia) leading to aspiration, mediated by a combination of factors such as laryngeal injury, oropharyngeal muscle weakness, reduced laryngeal sensation, and breathing-swallowing dyscoordination. Understanding these issues is central to preventing and treating dysphagia in this patient population. After extubation, dysphagia affects up to 83% of patients and predisposes them to a 6-fold increased risk of aspiration pneumonia and a 3-fold increased risk of death compared with stroke patients. Without intervention, considerable muscle weakness and physical impairment occurs during ARF in the ICU, but recent trials demonstrate that less sedation combined with early physical rehabilitation during mechanical ventilation improve these impairments. Similarly, an early intervention for dysphagia during endotracheal intubation may improve patient outcomes. The overall goals of this study are to evaluate ARF patients from the time they are orally intubated in the ICU to: 1) investigate tongue weakness and other pathophysiological aspects of dysphagia, and 2) evaluate, in a Phase I clinical trial, a novel, multimodal, sensorimotor intervention conducted during intubation to reduce dysphagia after extubation. This K23 award also aims to provide the Principal Investigator with the background necessary to become independent in patient-oriented research by: 1) training in advanced aspects of clinical research methods with a focus on clinical trials; and 2) providing a mentored research experience for conducting this Phase I clinical trial focused on improving patient outcomes. Patients who are expected to be intubated with mechanical ventilation for >96 hours will be consecutively enrolled shortly after intubation. Laryngeal function, tongue strength, swallowing pathophysiology, and breathing-swallowing coordination will be evaluated with valid and reliable standardized measures. While orally intubated, patients in the treatment group will receive a novel, early, sensorimotor intervention for 60-minutes daily, targeting improved swallowing physiology and kinematics to reduce aspiration and dysphagia. These daily sessions will continue until the completion of a modified barium swallow study conducted within 48 hours after extubation, and thereafter standard clinical care will resume. Patients in the control group will receive standard clinical care during intubation and throughout their hospital stay. All subjects will be followed to hospital discharge to determine the pathophysiological and clinical impact of the proposed intervention. Knowledge from this study will provide important feasibility data and preliminary efficacy data for the novel intervention and provide a critical foundation for understanding the physiological mechanisms of dysphagia and aspiration after intubation in ARF patients.

描述（由申请人提供）：每年，近100万美国人在重症监护病房（ICU）经历急性呼吸衰竭（ARF），需要机械通气。现有证据表明，口腔气管内插管与吞咽障碍（即吞咽困难）之间存在密切关联，吞咽障碍是由喉部损伤、口咽肌无力、喉部感觉减弱和呼吸-吞咽协调障碍等因素共同介导的。了解这些问题对于预防和治疗这类患者的吞咽困难至关重要。拔管后，多达83%的患者出现吞咽困难，与中风患者相比，患者患吸入性肺炎的风险增加6倍，死亡风险增加3倍。在没有干预的情况下，在ICU的ARF期间会发生相当大的肌肉无力和身体损伤，但最近的试验表明，在机械通气期间减少镇静并早期进行物理康复可以改善这些损伤。同样，气管插管期间吞咽困难的早期干预可能改善患者的预后。本研究的总体目标是对ARF患者进行评估，从他们在ICU进行口腔插管开始：1)调查舌无力和吞咽困难的其他病理生理方面；2)在I期临床试验中评估在插管期间进行的一种新型、多模式、感觉运动干预，以减少拔管后的吞咽困难。该K23奖还旨在通过以下方式为首席研究员提供必要的背景知识，使其能够独立从事以患者为导向的研究：1)临床研究方法的高级方面的培训，重点是临床试验；2)为开展以改善患者预后为重点的I期临床试验提供指导研究经验。预计插管机械通气96小时的患者将在插管后不久连续入组。喉功能、舌力、吞咽病理生理和呼吸-吞咽协调将通过有效和可靠的标准化措施进行评估。在口服插管的同时，治疗组患者将接受一种新颖的、早期的、每天60分钟的感觉运动干预，旨在改善吞咽生理和运动学，以减少误吸和吞咽困难。这些日常治疗将持续到拔管后48小时内完成改良的钡餐研究，此后将恢复标准的临床护理。对照组患者在治疗期间接受标准的临床护理

项目成果

Outcomes in Bilateral Vocal Fold Immobility: A Retrospective Cohort Analysis.

• DOI: 10.1177/0194599818800462
• 发表时间: 2018-12
• 期刊: Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery
• 作者: Gadkaree SK;Gelbard A;Best SR;Akst LM;Brodsky M;Hillel AT
• 通讯作者: Hillel AT

Understanding Variable Prevalences of Acute Laryngeal Injury Post-Extubation.

了解拔管后急性喉损伤的不同患病率。

• DOI: 10.1097/ccm.0000000000004245
• 发表时间: 2020
• 期刊: Critical care medicine
• 影响因子: 8.8
• 作者: Brodsky,MartinB;Pandian,Vinciya;Needham,DaleM
• 通讯作者: Needham,DaleM

Laryngeal Injury and Upper Airway Symptoms After Endotracheal Intubation During Surgery: A Systematic Review and Meta-analysis.

• DOI: 10.1213/ane.0000000000005276
• 发表时间: 2021-04-01
• 期刊: Anesthesia and analgesia
• 影响因子: 5.7
• 作者: Brodsky MB;Akst LM;Jedlanek E;Pandian V;Blackford B;Price C;Cole G;Mendez-Tellez PA;Hillel AT;Best SR;Levy MJ
• 通讯作者: Levy MJ