Aspiration in Acute Respiratory Failure Survivors

项目摘要/摘要 每年有超过70万名患者在一次急性呼吸衰竭(ARF)发作中幸存下来，这需要 气管插管机械通气。在这些ARF幸存者中，多达44%的人发生了这种情况， 拔管后吸入与有害后果有关，包括肺炎、经皮 喂养管放置、长期护理机构入院和增加住院死亡率。尽管如此， 必须权衡误吸的并发症与不适当延迟手术的后果。 恢复口服喂养。延迟恢复口服营养与肠道插管时间延长有关 喂养、照顾者负担增加、病人不满意以及与健康相关的成本增加。与 在NINR R21奖的支持下，我们的多学科和多中心团队发现了三个新发现：1) 我们开发了一种5项筛选决策树算法，用于检测拔管后的高危患者 抽吸；2)我们确定了与拔管后相关的某些独特的上呼吸道异常 吸入和吞咽困难；3)气管导管(ETT)的大小独立地与 拔管后吸入。这项提议将继续利用我们强大和成熟的多中心 科罗拉多大学、波士顿大学、斯坦福大学和耶鲁大学的研究小组；他们都有长期的吞咽困难 而抱负研究小组则专注于ARF。我们将进行一项多中心队列研究，研究对象包括三个 互补的目的是相互关联的，使用相同的患者；但不依赖于 彼此之间。目标1将确定我们的5项决策树算法是否是更有效的筛选工具 与三盎司水吞咽试验比较，确定拔管后误吸的高危患者 (3-WST)和多伦多床边吞咽筛查试验(TOR-BSST)。这些结果将确立 拔管后抽吸的最佳筛查试验，并确定需要进一步侵入性治疗的患者 诊断性测试，如收费检查。目的#2将确定患者独特的亚型 根据上呼吸道结构和功能的收费相关措施进行拔管后抽吸。使用 新的潜在类分析，我们将确定这些亚型是否与不同的 康复轨迹并确定受益于不同个性化和针对性的独特患者 治疗。目标3将确定超声确定的ETT大小/气管直径之间的关系 比率和拔管后吸入，同时考虑其他混杂变量。这一目标将确定 选择最有效的ETT大小以优化呼吸机管理和减少术后并发症的方法 拔管抽吸术。这一目标的结果将为插管方面的显著改进铺平道路。 适用于所有需要机械通气的ARF患者。通过创新和程序化的方法， 这项建议的结果将展示新的方法，以最大限度地减少拔管后的吸入，转换 ARF幸存者的多学科护理，并改善患者的预后和生活质量。

PROJECT SUMMARY/ABSTRACT Each year more than 700,000 patients survive an episode of acute respiratory failure (ARF) that required endotracheal intubation with mechanical ventilation. Occurring in as many as 44% of these ARF survivors, post-extubation aspiration is associated with deleterious consequences including pneumonia, percutaneous feeding tube placement, long term care facility admission, and increased hospital mortality. Nevertheless, the complications of aspiration must be weighed against the consequences of inappropriately delaying the resumption of oral feeding. Delayed resumption of oral nutrition is associated with prolonged enteral tube feeding, increased caregiver burden, patient dissatisfaction, and increased health-related costs. With the support of an NINR R21 award, our multidisciplinary and multicenter team discovered three novel findings: 1) we developed a 5-item screening decision tree algorithm that detects patients at high risk for post-extubation aspiration; 2) we identified certain unique upper airway abnormalities that are associated with post-extubation aspiration and dysphagia; and 3) the size of the endotracheal tube (ETT) is independently associated with post-extubation aspiration. This proposal will continue to utilize our robust and established multi-center research group at Colorado, Boston University, Stanford, and Yale; all of whom have long-standing dysphagia and aspiration research groups focused on ARF. We will conduct a multi-center cohort study with three complementary aims that are interrelated and use the same patients; but are not dependent upon the results of each other. Aim #1 will determine whether our 5-item decision tree algorithm is a more effective screening tool to identify patients at high risk for post-extubation aspiration compared to the three-ounce water swallow test (3-WST) and the Toronto Bedside Swallowing Screening Test (TOR-BSST). These results will establish the optimal screening test for post-extubation aspiration and identify those patients who require further invasive diagnostic testing such as a FEES examination. Aim #2 will identify unique subphenotypes of patients with post-extubation aspiration based upon FEES-related measures of upper airway structure and function. Using a novel latent class analysis, we will determine whether these subphenotypes are associated with different trajectories of recovery and identify unique patients who benefit from different personalized and targeted therapies. Aim #3 will determine the association between ultrasound determined ETT size/tracheal diameter ratio and post-extubation aspiration while accounting for other confounding variables. This aim will identify the most effective method to select the ETT size that optimizes ventilatory management and decreases post- extubation aspiration. The results of this aim will pave the wave for dramatic improvements in the intubation process for all ARF patients who require mechanical ventilation. With an innovative and protocolized approach, the results of this proposal will demonstrate novel methods to minimize post-extubation aspiration, transform the multidisciplinary care of ARF survivors, and improve patient outcomes and quality of life.