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100万美国人经历急性呼吸衰竭（ARF），需要在重症监护病房（ICU）机械通气。现有证据表明，口服气管插管与吞咽障碍（即吞咽困难）之间有着密切的关联，导致抽吸，这是由诸如喉损伤，口咽肌肉无力的因素组合介导的，喉咽肌肉无力，喉咙降低和呼吸呼吸的呼吸障碍。了解这些问题对于预防和治疗该患者人群的吞咽困难至关重要。拔管后，吞咽困难会影响多达83％的患者，并使他们容易受到肺炎的攻击风险增加6倍，而与中风患者相比，他们的死亡风险增加了3倍。没有干预，在ICU中，在ARF期间发生了相当大的肌肉无力和身体障碍，但是最近的试验表明，在机械通气期间，镇静剂与早期的身体康复相结合会改善这些障碍。同样，气管插管期间对吞咽困难的早期干预可能会改善患者的预后。这项研究的总体目标是评估ARF患者在ICU中口服插管的时间到：1）研究舌头弱点和其他病理生理学方面的舌头和其他病理生理方面，以及2）在一项I期临床试验中评估一种新型，多模束，感觉运动干预术在延伸后进行延伸的过程中进行了多种延伸，以减少延伸性。该K23奖还旨在为主要研究者提供必要的背景，以独立于患者的研究中，通过：1）临床研究方法的高级方面培训，重点是临床试验； 2）提供指导的研究经验，用于进行I阶段的I阶段临床试验，重点是改善患者预后。预计将在插管后不久将连续招募机械通风> 96小时的患者。喉功能，舌头强度，吞咽病理生理学和呼吸焊接的配位将通过有效且可靠的标准化措施进行评估。虽然口服插管，但治疗组中的患者每天将接受一种新型的，早期的感觉运动干预，以改善吞咽生理学和运动学，以减少抽吸和吞咽困难。这些每日会议将继续进行，直到拔管后48小时内进行的修改后的燕子研究完成为止，此后标准临床护理将恢复。对照组的患者将在期间获得标准的临床护理 插管及其在整个医院住宿。所有受试者将遵循医院出院，以确定所提出的干预措施的病理生理和临床影响。这项研究的知识将为小说提供重要的可行性数据和初步疗效数据 干预并为了解ARF患者插管后吞咽困难和抽吸的生理机制提供了关键的基础。

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