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Ann Thorac Surg 2001;71:1792-1796
© 2001 The Society of Thoracic Surgeons

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Original article: general thoracic

Oropharyngeal dysphagia after cardiac operations

^a Division of Cardiovascular and Thoracic Surgery, Chandler Medical Center, University of Kentucky, Lexington, Kentucky, USA
^b Department of Cardiovascular Services, Marshall University School of Medicine, and Speech Therapy Services, St. Mary’s Regional Medical Center, Huntington, West Virginia, USA

Address reprint requests to Dr Ferraris, Division of Cardiovascular and Thoracic Surgery, C208, Chandler Medical Center, University of Kentucky, 800 Rose Street, Lexington, KY 40536
e-mail: vferr2{at}pop.uky.edu

Presented at the Forty-seventh Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 9–11, 2000.

	Abstract

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Background. As many as 15% of hospitalized patients have oropharyngeal dysphagia. The incidence and causes of postoperative oropharyngeal dysphagia (OD) in patients having cardiac operations are poorly documented and the best treatment is uncertain. We undertook a study to evaluate OD in patients having cardiac operations.

Methods. As part of a quality improvement project, all patients operated on in 1998 and 1999 were monitored for the signs or symptoms of OD. Patients with OD had diagnostic and therapeutic interventions to limit adverse outcomes. At the end of the 2-year evaluation period, patient risk factors, diagnoses, results of interventions, and outcomes were measured.

Results. Thirty-one out of 1,042, patients (3%) had OD. OD is more common in older patients (p < 0.0001) with diabetes (p = 0.02), renal insufficiency (p = 0.012), hyperlipidemia (p = 0.046), and preoperative congestive heart failure (p < 0.0001), and in those having noncoronary artery bypass procedures (p < 0.0001). One patient with OD died from respiratory arrest, presumably secondary to aspiration. Modified barium swallow (MBS) identified oral dysphagia in 2 patients, pharyngeal dysphagia in 7 patients, and both oral and pharyngeal dysphagia in 17 patients. One patient had a structural defect (cervical osteophyte) causing dysphagia and 4 patients had no identifiable cause of dysphagia on MBS. Postoperative neurologic complications are more common in patients with OD. Ten of 31 patients (32%) with OD had some new neurologic complication after operation compared with 36 of 1,011 (3.5%) who had a postoperative neurologic problem without OD. In 19 patients with OD no cause for swallowing difficulty was identified. Specifically, no metabolic, myopathic, or infectious abnormalities were identified in any patient with OD. Hospital charges were significantly increased in patients with OD ($69,320 versus $36,087, p < 0.0001). Therapy consisting of modification of eating behavior and swallowing technique and in some severe cases enteral or parenteral feeding was successful in all patients except 1, but 4 patients required more than 4 months of supportive care before return to oral feeding was possible.

Conclusions. OD is associated with increased cost and morbidity. Older patients with diabetes, preoperative heart failure, and renal insufficiency are at increased risk for OD. Early recognition and intervention is likely to result in satisfactory outcome but may be associated with a protracted postoperative course.

	Introduction

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Transfer of food from the mouth to the esophagus initiates the swallowing process. Abnormalities in the initiation of swallowing can have many etiologies including neurologic, muscular, anatomic, infectious, and metabolic. Patients who complain of difficulty with the initiation of the swallowing process are said to have oropharyngeal dysphagia (OD). As many as 15% of patients in acute care hospitals have evidence of feeding difficulties and concomitant aspiration of oral contents. Aspiration pneumonia from OD is common among institutionalized patients [1–4]. Patients have OD after cardiac procedures [5, 6] but a systematic controlled study of this problem has not been reported.

The best diagnostic and therapeutic interventions for OD are uncertain [7–11]. No consensus exists about the best options to diagnose OD [12]. But videofluoroscopyfluoroscopy is the most widely used test to document aspiration associated with OD [13–16]. Most studies suggest that a multidisciplinary approach to diagnosis and therapy is best [2, 7, 8, 17].

We observed that elderly patients having cardiac procedures often have OD after the operation. Because OD is common among the elderly population and given the uncertainties about results of intervention for OD, we hypothesized that aggressive diagnosis and treatment of this problem reduces complications and decreases resource utilization in these patients. Consequently, we undertook a quality improvement project to document the incidence and effects of OD and to determine results of treating patients with this problem after cardiac operations.

	Material and methods

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A multidisciplinary committee continuously monitors outcomes from cardiac operations at St. Mary’s Regional Heart Center. Routine surveillance in 1997 revealed several patients with swallowing dysfunction after cardiac procedures. A prospective quality improvement project was undertaken to identify and monitor treatment of patients with swallowing difficulties after operation. The quality improvement committee decided to monitor patients with OD, as this was the easiest symptom to identify and all surgeons at the institution could agree upon a definition. All patients who experienced difficulty initiating a swallow or who had any symptomatic abnormality in swallowing physiology of the upper aerodigestive tract after cardiac operations were considered to have OD. Patients with OD were tracked over a 2-year period from January 1998 to December 1999. A quality assessment (QA) nurse who observes all patients having cardiac procedures identified patients with OD. After collaboration with the attending surgeon, the QA nurse identified patients with OD who were appropriate for study. Only patients with a new swallowing disorder after operation were entered into the study. The QA nurse recorded patient variables in The Society of Thoracic Surgeons data format for all cardiac surgical patients and in addition tracked diagnostic and therapeutic interventions as well as outcomes in patients with OD. This quality improvement project was approved by expedited review by the institution review board of Marshall University as no interventions were performed other than the usual standards of care for all study patients.

Patients with OD were evaluated and managed using the American Gastroenterological Association (AGA) published guidelines [13]. All patients with OD had videofluoroscopy (modified Barium swallow [MBS]) as the initial diagnostic study. A multidisciplinary team including, surgeons, speech therapists, gastroenterologists, cardiologists, and staff nurses managed patients with OD, with ultimate responsibility for therapeutic decisions resting in the hands of the operating surgeon. Depending on the results of the MBS, subsequent diagnostic and therapeutic interventions approximated AGA guidelines.

After a 2-year observation period, results of the diagnosis and treatment of OD were evaluated. Preoperative risks, diagnostic interventions, and outcomes in patients with OD were compared with those of patients operated on during the same time interval who did not have OD.

Risk factors of patients with OD were compared with those of patients without OD using nonparametric statistics for inference. A probability value of 0.05 or less was considered significant.

	Results

Top Abstract Introduction Material and methods Results Comment Discussion References

 
Preoperative risk factors for oropharyngeal dysphagia
Thirty-one out of 1042 patients (3.0%) had OD. Twenty preoperative risk factors were evaluated in patients with and without OD (Table 1). Oropharyngeal dysphagia is more common in older patients (p < 0.001) with diabetes (p = 0.02), renal insufficiency (p = 0.012), hyperlipidemia (p = 0.046), and preoperative congestive heart failure (p < 0.001), and in patients having noncoronary artery bypass procedures (p < 0.001). Two of 31 patients with OD had a history of remote stroke and 6 of 31 patients with OD had prior transient ischemic attack, reversible ischemic neurologic deficit, or carotid endarterectomy. Patients without OD had similar frequencies of these neurologic risk factors.

Causes of oropharyngeal dysphagia
Neurologic complications commonly result in swallowing difficulties. New neurologic complication after operation is significantly more common in patients with OD than in those without OD. Ten of 31 patients (32%) with OD had evidence of a new postoperative neurologic defect compared with 36 of 1,011 (3%) who developed postoperative stroke but did not have OD (p < 0.0001 by ²). Patients with OD had significantly more postoperative neurologic complications, including confusion, delirium, reversible neurologic deficit, or stroke than did patients without OD. Ten of 30 surviving patients with OD had some neurologic event after operation, 5 with delirium and 5 with significant neurologic deficit.

Only 1 other patient had an identifiable cause of OD. As previously mentioned, 1 patient had a cervical osteophyte causing OD. In 19 patients no identifiable cause of OD could be detected, despite complete neurologic evaluation including head computed tomography and neurology consultation. No metabolic, myopathic, or infectious abnormalities were identified in any patient with OD.

Other suspected causes of OD were evaluated. Specifically, prolonged orotracheal intubation was investigated as a cause of OD. Intubation for more than 24 hours was significantly more common among patients with OD than among patients without OD (6 of 31 patients with OD compared with 30 of 1,011 without OD, p = 0.002 by ²). All of the patients who required prolonged intubation with OD also had postoperative neurologic defects.

Intraoperative variables were evaluated as a cause of OD. Specifically, ischemic times, cardiopulmonary bypass times, redo procedures, and urgency of operation are not significantly associated with OD.

Treatment and results of oropharyngeal dysphagia
All 17 patients who had radiographic evidence of aspiration were given nothing by mouth (NPO). Enteral or parenteral feeding was instituted and serial videofluoroscopic examinations were performed as the patient’s condition improved. One patient in this category died suddenly while on the recovery ward. An autopsy was not performed but based on witnessed terminal events, there is a strong suspicion that aspiration of gastric contents with concomitant respiratory arrest was the mechanism of death. Fifteen of the 16 surviving patients with evidence of aspiration on MBS recovered swallowing function and were able to eat a regular diet. One patient was still NPO at the end of the study period because of continued aspiration events for more than 6 months. Four of 16 surviving patients with aspiration required more than 4 months and as many as 4 serial MBS examinations before return of swallowing function. When repeat MBS did not show aspiration, then patients were begun on oral feedings with dietary modification, supportive swallowing maneuvers, postural adjustments, and swallowing muscle exercises. These interventions were supervised by speech therapists, both during the inpatient stay as well as during outpatient rehabilitation.

Fourteen patients with OD did not have evidence of aspiration on MBS. Four of these 14 patients had no abnormality identified on MBS, were begun on regular oral feedings, and had uneventful recovery. The remaining 10 patients with OD who did not aspirate underwent supervised speech and swallowing therapy including dietary modification, postural adjustments, and training in swallowing maneuvers and exercises. All of these 10 patients had eventual recovery and resumed regular oral feeding.

Resource utilization and oropharyngeal dysphagia
Hospital charges and length of stay were measured in all study patients. Patients with OD have significantly increased hospital charges compared with patients without OD ($69,320 ± $39,217 for OD versus $36,087 ± $13,055 for non-OD, p < 0.0001 by Mann-Whitney test of inference). Likewise, patients with OD have prolonged postoperative length of stay compared with patients without OD (16.1 ± 11.7 days for OD patients versus 5.7 ± 3.1 days for non-OD patients, p < 0.0001 by Mann-Whitney test of inference).

	Comment

Top Abstract Introduction Material and methods Results Comment Discussion References

 
Our results suggest that OD is both costly and associated with morbidity after cardiac operations. OD is associated with a doubling of hospital charges and a tripling of hospital length of stay. These findings support an aggressive approach to diagnosis and treatment of OD in postoperative patients. Patients with diabetes, renal insufficiency, hyperlipidemia, or preoperative congestive heart failure, who are undergoing operations other than coronary artery bypass or who have a postoperative neurologic complication are at especially high risk.

It is more than coincidence that the risk factors for OD are similar to the risk factors observed for other postoperative complications and for increased resource utilization after cardiac operations. Risk factors such as advanced age, renal insufficiency, preoperative CHF, and non-CABG operation are common to increased resource utilization and morbidity after cardiac operations [18, 19]. It may be that OD is one of several nonspecific outcomes that result from multiple preoperative comorbidities. Other adverse outcomes that might be related to multiple preexisting comorbidities include prolonged ventilation, multiple blood transfusions, and neurologic or renal dysfunction. This is a speculative but intriguing hypothesis that awaits more data.

The rate of OD measured in our study is probably an underestimate. Not all patients who aspirate oral feedings have symptoms [1, 3, 20]. Harrington and coworkers [20] suggest that many episodes of aspiration pneumonia after cardiac operations are "silent." Because of the possibility of silent episodes of postoperative swallowing dysfunction, we suspect that oropharyngeal swallowing dysfunction is more prevalent than appreciated or than suggested by our results.

Harrington and coworkers [20] also suggest that postoperative pharyngeal dysfunction is caused by esophageal cooling or mechanical trauma from esophageal intubations (for example with an echocardiography probe). Our database does not track esophageal temperatures during cardiopulmonary bypass or the use of introperative transesophageal echocardiography (ITEE) but it is the policy of all surgeons to use ITEE for all valve operations and most noncoronary artery bypass operations. It is more than coincidence that patients who had operations other than non-CABG have increased risk of developing OD. It is tempting to speculate that esophageal intubation for ITEE contributes to OD but our data do not allow this conclusion.

A multidisciplinary approach to treatment of OD usually results in satisfactory outcome. Cooperation among a wide range of health care providers including speech therapists, neurologists, anesthesiologists, nursing staff, and surgeons is necessary to assure successful management of patients with OD. All but 2 of 31 patients had satisfactory outcome after postoperative OD. Care provided by speech therapists is particularly helpful in managing patients with OD. The mainstay of therapy in 40% of the patients who develop OD after operation consists of those interventions initiated by speech therapists including postural adjustments, dietary modification, and instruction and practice in swallowing maneuvers.

Our study has several shortcomings. It is not a controlled study with patients randomized to various treatments. So the guidelines for diagnoses and treatments used in our patients are not based on solid, type 1 evidence. It is possible that other diagnostic and therapeutic interventions would result in better outcomes in patients with postoperative OD. The finding of postoperative OD is sufficiently unusual so that a controlled trial that is powered to detect differences in diagnostic methods or in therapeutic interventions would require a very large study indeed. A study of this type will likely never be done. Hence, observational studies like ours will have to suffice, although caveats must be acknowledged.

Based on these results, we recommend an aggressive approach to the diagnosis and treatment of OD. Prompt attention to complaints of postoperative dysphagia is mandatory. Diagnosis is usually possible with modified barium swallow. Treatments ranging from withholding of oral feeds to less drastic swallowing maneuvers and dietary interventions are likely to be successful, although at the expense of increased postoperative resource utilization.

	Discussion

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DR JOHN C. LUCKE (Asheville, NC): I enjoyed your paper and I realize that aspiration is a terrible complication. I didn’t see any mention of which patients had TEE. You said that patients that had additional procedures (I assume valves) were at increased risk for dysphagia. Did you look at which patients had TEE and do you think that that’s a risk factor for developing postoperative dysphagia?

DR FERRARIS: I can’t answer that specifically from our data, but I am aware of a couple of papers in the literature that suggest that postoperative swallowing difficulty is related to the use of intraoperative transesophageal echocardiography. Our data, I just don’t have the answer.

DR LEON GEORGE ALEXANDER (New Bern, NC): Did you investigate whether any of these people had any preoperative difficulty with swallowing? Certainly I have noticed, in retrospect maybe, that when this problem does crop up, there are often preceding events prior to surgery that gave you some indication that there were swallowing difficulties prior to surgery which tended to accentuate these problems.

DR FERRARIS: That is a good question. We sort of had the bias that people with especially stroke-related things preoperatively might be at risk for this problem. As part of the database interrogation, we specifically looked at patients who had some neurologic problems preoperatively, and that did not fall out as a risk for postoperative dysphagia.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Victor A. Ferraris Dennis M. Moritz Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ferraris, V. A. Articles by Welch, S. Search for Related Content PubMed PubMed Citation Articles by Ferraris, V. A. Articles by Welch, S. Related Collections Esophagus - other