and for the EVAKIN Study Group BACKGROUND: Extubation failure may have several causes, including swallowing dysfunction, aspiration, and excessive upper airway secretions. We hypothesized that a bedside global swallowing pattern assessment including 9 criteria (volume of pharyngeal secretions, 5 swallowing motor items, swallowing reflex, and 2 gag reflexes) performed prior to extubation could identify patients at risk of extubation failure. METHODS: In a multicenter prospective observational study, all consecutive patients intubated and mechanically ventilated for >6 d were included. Before a planned extubation, a physiotherapist evaluated the 9 criteria of the swallowing assessment. The final extubation decision was left to the physician's discretion, blinded to the swallowing assessment. Extubation failure was defined as the need for re-intubation related to aspiration or excessive upper airway secretions within the first 72 h after extubation. Results are expressed as median (interquartile range [IQR]). RESULTS: The study included 159 subjects (age 61 y [IQR 48 -75]; male/ female ratio 1.5; Simplified Acute Physiologic score II 54 [IQR 42-66]; duration of mechanical ventilation 11 d [IQR 8 -17]). A total of 23 subjects (14.5%) required re-intubation, with 16 occurring within the first 72 h after extubation and 7 related to aspiration or excessive secretions.Swallowing assessment was significantly lower in subjects with re-intubation related to aspiration or excessive secretions within the first 72 h after extubation versus those not re-intubated for aspiration or excessive secretions (6 [IQR 5-7] vs 8 [IQR 7-8], P ‫؍‬ .008, respectively). Among the 9 swallowing assessment criteria, normal right pharyngeal gag reflex was associated with a lower incidence of re-intubation related to aspiration or excessive secretions (odds ratio 0.12, 95% CI 0.03-0.59, P ‫؍‬ .01), as well as normal left pharyngeal gag reflex (odds ratio 0.13, 95% CI 0.03-0.63, P ‫؍‬ .01), with a negative predictive value of 0.98 for each reflex. CONCLUSIONS: In subjects with prolonged ventilation, the presence of one or both gag reflexes could predict a reduction in extubation failure related to aspiration or excessive upper airway secretions. (Clinical trials.gov registration NCT00780078.

L’hémorragie sous-arachnoïdienne (HSA) représente environ 5% des accidents vasculaires cérébraux, et touche une population jeune. Les patients atteints d’HSA sont hospitalisés plusieurs semaines afin de traiter l’anévrisme et de surveiller l’apparition d’éventuelles complications. Il n’y a pas à ce jour de recommandations sur la mobilisation de ces patients et les pratiques sont hétérogènes. Les patients sont généralement alités pendant les deux à trois premières semaines qui suivent l’HSA, dans le but de ne pas induire de variations hémodynamiques potentiellement délétères. Il n’y a cependant pas de preuves que cela soit nécessaire et l’alitement prolongé est susceptible d’entraîner de multiples complications. La littérature existante, bien que peu abondante, a montré que dès les premiers jours suivant l’HSA, la mise en place de protocoles de mobilisation précoce progressive conditionnée par une évaluation clinique rigoureuse et encadrée par des critères de surveillance est possible, sécuritaire et potentiellement bénéfique pour les patients atteints d’HSA.

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