When it comes to patients who have been intubated, there are a lot of factors to consider—what is their current diagnosis? Why were they intubated? How long were they intubated? Was the intubation traumatic? Did they self-extubate?
And most importantly for us as SLPs: When is it safe and appropriate to evaluate swallowing function?
For years, the general recommendation was to wait 24 hours post-extubation before performing a swallowing evaluation. But what does the evidence say? Are we waiting too long—or not long enough?
This post breaks down current research to help guide clinical decision-making following extubation.
⏱️ When Should We Evaluate Swallowing?
In a 2019 study, Marvin, Thibeault, and Ehlenbach explored the timing of swallow evaluations post-extubation using Flexible Endoscopic Evaluation of Swallowing (FEES). They looked at 49 patients who had been intubated for more than 48 hours, none of whom had premorbid dysphagia or a diagnosis likely to cause dysphagia.
Key findings:
- At 2–4 hours post-extubation, 69% of patients were able to safely swallow at least one consistency.
- By 24 hours, 79% of patients demonstrated improved airway protection, shown by a decrease in Penetration-Aspiration Scale (PAS) scores.
“These findings suggest that although patients may be safe to begin a modified diet soon after extubation, delaying evaluation until 24-h post-extubation may allow for a less restricted diet” (Marvin et al., 2019, p. 217).
đźš‘ Aspiration in Critically Ill Trauma Patients
Leder, Cohn, and Moller (1998) investigated the incidence of aspiration in critically ill trauma patients extubated after 48 hours or more. All patients underwent FEES approximately 24 hours post-extubation.
What is aspiration?
In this study, aspiration was defined as the bolus entering the airway below the level of the true vocal folds. Silent aspiration was the absence of a cough, throat clear, or any compensatory behavior following aspiration.
Results:
- 9 out of 20 patients (45%) aspirated
- 4 out of 9 (44%) of those were silent aspirators (20% of the total population)
- 8 of 9 aspirators resumed oral diets within 10 days
Significant observations:
- Traumatic intubation occurred in 5 patients—4 of them aspirated.
- Nasogastric tubes were not associated with aspiration.
- The only variable that showed a significant relationship with aspiration was a low Glasgow Coma Scale (GCS) on admission.
“Trauma patients after orotracheal intubation and prolonged mechanical ventilation have an increased risk of aspiration. An objective assessment of dysphagia to identify aspiration may reduce the likelihood of pulmonary complications after extubation” (Leder et al., 1998, p. 211).
🧠What About Risk Factors?
Newer studies have provided additional insights:
- Age > 55 and vallecular residue on FEES have been linked to higher risk of post-extubation aspiration.
- In one study, all patients who developed pneumonia also had documented aspiration episodes (Barquist et al., 2001).
A randomized prospective trial by Barquist et al. (2001) examined 100 patients extubated after prolonged intubation:
- The incidence of aspiration post-extubation was 56%
- 25% of patients were silent aspirators
- Mean duration of intubation:
- Aspirators: 8.0 days
- Non-aspirators: 7.7 days
- 70% of aspiration events involved thin liquids
- 63% of aspirators were eating orally at discharge
Similarly, Ajemian et al. (2001) found high rates of aspiration using routine FEES in patients intubated for a median of 8 days. They concluded that FEES plays a critical role in identifying patients at risk—even those who appear clinically ready for oral intake.
đź‘… Does Intubation Affect Tongue Strength and Sensation?
The tongue plays a major role in both oral prep and oral transit phases of swallowing. A study by Su et al. (2015) investigated how intubation may impact tongue strength and somatosensation.
Study design:
- 30 patients intubated >48 hours
- Excluded: patients with neuro diagnoses, delirium, head/neck deformity, tracheostomy, or prior dysphagia
- Measurements taken at 48 hours, 7 days, and 14 days post-extubation
- Tools: Iowa Oral Performance Instrument (IOPI), light touch, stereognosis, two-point discrimination
Findings:
- Lingual sensation was significantly impaired post-extubation but improved over 14 days
- Tongue strength was reduced and remained diminished at 14 days
- Median time to trial water: 2 days
- Median time to full oral intake: 7.9 days (± 4.8)
- No swallowing interventions were provided during the study
🗣️ What About Laryngeal Sensation?
Laryngeal sensation is critical for airway protection and triggering a timely swallow. Borders et al. (2019) explored the link between laryngeal sensation and aspiration post-extubation.
Study population:
- 103 patients, all intubated >48 hours
- FEES conducted within 72 hours
- Evaluated for laryngeal adductor reflex (LAR): 23 had unilateral deficits, 28 had bilateral
Key findings:
- 47% of patients with absent LAR aspirated
- 23% of patients with intact LAR aspirated
- Silent aspiration was found in:
- 16% of patients with absent LAR
- 6% of patients with intact LAR
- Decreased laryngeal sensation was associated with:
- Presence of secretions
- Diet modifications
- Increased aspiration risk, especially with shorter intubation times
“Altered laryngeal sensation was associated with aspiration and shown to have a more profound effect on aspiration risk in patients with a short length of mechanical ventilation” (Borders et al., 2019, p. 526).
🧾 Final Thoughts
Post-extubation dysphagia is complex and multifactorial. Sensory deficits, strength deficits, cognitive status, intubation trauma, and length of ventilation all play a role. Instrumental assessments like FEES are essential for guiding safe return to oral intake—especially in those intubated for more than 48 hours or with known risk factors.
Evidence shows that even patients who initially aspirate often recover enough to tolerate a full oral diet within 10 days. However, early and objective assessment is key to preventing complications like aspiration pneumonia.
So whether you’re team “assess at 4 hours” or “wait the full 24,” just make sure you’re using the best available evidence—and your clinical judgment—to guide your decisions.
Are you ready for a deeper dive with even more resources available? Join the Dysphagia Skills Accelerator today. You will get so many great tools with new tools being added all the time! Click here to join now!
Have you ever wanted a way to create a more standardized protocol for your Clinical Swallow Evaluation?  Do you often forget or leave out parts of the CSE, you know, the parts that are important for your Plan of Care? You probably need the Clinical Dysphagia Assessment Toolkit if you answered yes.  You can get your copy here.
đź“š References
Ajemian, M. S., Nirmul, G. B., Anderson, M. T., Zirlen, D. M., & Kwasnik, E. M. (2001). Routine fiberoptic endoscopic evaluation of swallowing following prolonged intubation: Implications for management. Archives of Surgery, 136(4), 434–437. https://doi.org/10.1001/archsurg.136.4.434
Barquist, E., Brown, M., Cohn, S., Lundy, D., & Jackowski, J. (2001). Postextubation fiberoptic endoscopic evaluation of swallowing after prolonged endotracheal intubation: A randomized, prospective trial. Critical Care Medicine, 29(9), 1710–1713. https://doi.org/10.1097/00003246-200109000-00014
Borders, J. C., Fink, D. C., Levitt, J. E., McKeehan, J., McNally, E., Rubio, A., … & Warner, H. (2019). Relationship between laryngeal sensation, length of intubation, and aspiration in patients with acute respiratory failure. Dysphagia, 34(4), 521–528. https://doi.org/10.1007/s00455-018-9943-2
Leder, S. B., Cohn, S. M., & Moller, B. A. (1998). Fiberoptic endoscopic documentation of the high incidence of aspiration following extubation in critically ill trauma patients. Dysphagia, 13(4), 208–212. https://doi.org/10.1007/PL00009573
Marvin, S., Thibeault, S., & Ehlenbach, W. J. (2019). Post-extubation dysphagia: Does timing of evaluation matter? Dysphagia, 34, 210–219. https://doi.org/10.1007/s00455-018-9926-3
Su, H., Hsiao, T. Y., Ku, S. C., Wang, T. G., Lee, J. J., Tzeng, W. C., … & Chen, C. C. H. (2015). Tongue weakness and somatosensory disturbance following oral endotracheal extubation. Dysphagia, 30(2), 188–195. https://doi.org/10.1007/s00455-014-9589-2
Dysphagia Ramblings 
Leave a comment