Exploring the Feasibility of a Comprehensive Screening for Voice and Swallowing Function in Post-Extubation Patients: A Pilot Study

Explorando la viabilidad de un tamizaje integral de la función de la voz y la deglución en pacientes postextubación: un estudio piloto


Objectives. This pilot study aimed to identify and test a battery of time-efficient and cost-effective voice and swallowing screening tools for post-extubated patients in Chile.

Methods. A panel of four experts selected and rated voice and swallowing screening tools. Seven measures were selected: smoothed cepstral peak prominence (CPPS) and maximum phonation time (MPT) for voice assessment, Volume-Viscosity Swallow Test (V-VST) for swallowing, voluntary and reflex peak cough flow for cough assessment, Eating Assessment Tool-10 (EAT-10), and Vocal Symptom Scale (VoiSS) for patient-reported outcomes. These tools were applied to four post-extubation patients within 48-72 hours post-hospital discharge, alongside the assessment of 17 matched controls.

Results. Post-extubation patients showed significantly shorter MPT, lower CPPS values, increased V-VST dysphagia signs, reduced voluntary peak cough flow, and more pronounced symptoms on both the VoiSS and EAT-10 compared to controls.

Limitations. The study had a modest sample size and relied solely on clinical screening tools.
Value. This pilot study suggests a feasible and cost-effective approach to voice and swallowing screening for post-extubation patients, valuable in resource-constrained settings.
Conclusion. While these accessible tools are not gold-standard assessments, they offer valuable insights and can guide future research. This study underscores the potential of selected tools in facilitating early detection of voice and swallowing disorders in post-extubation patients.


Download data is not yet available.

Citado por


Fernanda Figueroa-Martínez
Adrián Castillo-Allendes
Karla Grunewaldt
Tamara Solís-Meza
Eric J Hunter
Jeff Searl


Ambrosino N, Vitacca M. The patient needing prolonged mechanical ventilation: A narrative review. Multidiscip Respir Med. 2018;13(1):1–10. doi: https://doi.org/10.1186/s40248-018-0118-7

Brodsky MB, Levy MJ, Jedlanek E, Pandian V, Blackford B, Price C, et al. Laryngeal Injury and Upper Airway Symptoms after Oral Endotracheal Intubation with Mechanical Ventilation During Critical Care. Crit Care Med [Internet]. 2018 Dec;46(12):2010–7.doi: https://doi.org/10.1097/CCM.0000000000003368

Zuercher P, Schenk N V., Moret C, Berger D, Abegglen R, Schefold JC. Risk Factors for Dysphagia in ICU Patients After Invasive Mechanical Ventilation. Chest [Internet]. 2020;158(5):1983–91. doi: https://doi.org/10.1016/j.chest.2020.05.576

Miles A, McRae J, Clunie G, Gillivan-Murphy P, Inamoto Y, Kalf H, et al. An International Commentary on Dysphagia and Dysphonia During the COVID-19 Pandemic. Dysphagia [Internet]. 2022;37(6):1349–74. doi: https://doi.org/10.1007/s00455-021-10396-z

Shinn JR, Kimura KS, Campbell BR, Sun Lowery A, Wootten CT, Garrett CG, et al. Incidence and Outcomes of Acute Laryngeal Injury After Prolonged Mechanical Ventilation*. Crit Care Med [Internet]. 2019 Dec;47(12):1699–706. doi: https://doi.org/10.1097/CCM.0000000000004015

Schefold JC, Berger D, Zürcher P, Lensch M, Perren A, Jakob SM, et al. Dysphagia in Mechanically Ventilated ICU Patients (DYnAMICS). Crit Care Med [Internet]. 2017 Dec;45(12):2061–9. doi: https://doi.org/10.1097/CCM.0000000000002765

Dawson C, Clunie G, Evison F, Duncan S, Whitney J, Houchen-Wolloff L, et al. Prevalence of swallow, communication, voice and cognitive compromise following hospitalisation for COVID-19: the PHOSP-COVID analysis. BMJ open Respir Res. 2023;10(1). doi: https://doi.org/10.1136/bmjresp-2023-001647

Campbell BR, Shinn JR, Kimura KS, Lowery AS, Casey JD, Ely EW, et al. Unilateral Vocal Fold Immobility after Prolonged Endotracheal Intubation. JAMA Otolaryngol - Head Neck Surg. 2020;146(2):160–7. doi: https://doi.org/10.1001/jamaoto.2019.3969

Colton House J, Noordzij JP, Murgia B, Langmore S. Laryngeal injury from prolonged intubation: A prospective analysis of contributing factors. Laryngoscope [Internet]. 2011 Mar;121(3):596–600. doi: https://doi.org/10.1002/lary.21403

Scheel R, Pisegna JM, McNally E, Noordzij JP, Langmore SE. Endoscopic Assessment of Swallowing After Prolonged Intubation in the ICU Setting. Ann Otol Rhinol Laryngol [Internet]. 2016 Jan 26;125(1):43–52. doi: https://doi.org/10.1177/0003489415596755

Hermans G, Van den Berghe G. Clinical review: Intensive care unit acquired weakness. Crit Care [Internet]. 2015;19(1):1–9. doi: http://dx.doi.org/10.1186/s13054-015-0993-7

Ballve LPD, Dargains N, Inchaustegui JGU, Bratos A, Percaz M de los M, Ardariz CB, et al. Weakness acquired in the intensive care unit. Incidence, risk factors and their association with inspiratory weakness. Observational cohort study. Rev Bras Ter Intensiva [Internet]. 2017;29(4):466–75. Available from: https://www.scielo.br/j/rbti/a/48Jbmf4fHt7Rd9VZPYHXwmC/?lang=en#

Patel R, Awan SN, Barkmeier-Kraemer J, Courey M, Deliyski D, Eadie T, et al. Recommended Protocols for Instrumental Assessment of Voice: American Speech- Language-Hearing Association Expert Panel to Develop a Protocol for Instrumental Assessment of Vocal Function Rita. Am J Speech-Language Pathol. 2018;27(3):887-905. doi: https://doi.org/10.1044/2018_AJSLP-17-0009

Van der Meer G, Ferreira Y, Loock JW. The S/Z ratio: A simple and reliable clinical method of evaluating laryngeal function in patients after intubation. J Crit Care [Internet]. 2010;25(3):489–92. doi: http://dx.doi.org/10.1016/j.jcrc.2009.11.009

Lim J-Y, Yoo Y-H, Park C-H, Joa K-L, Jung H-Y. Use of the maximal phonation test for the screening of dysphagia in stroke patients: a preliminary study. Eur J Phys Rehabil Med [Internet]. 2020 Feb;56(1):41–6. doi: https://doi.org/10.23736/S1973-9087.19.05818-0

Peterson EA, Roy N, Awan SN, Merrill RM, Banks R, Tanner K. Toward validation of the cepstral spectral index of dysphonia (CSID) as an objective treatment outcomes measure. J Voice [Internet]. 2013;27(4):401–10. doi: http://dx.doi.org/10.1016/j.jvoice.2013.04.002

Asiaee M, Vahedian-azimi A, Atashi SS, Keramatfar A, Nourbakhsh M. Voice Quality Evaluation in Patients With COVID-19: An Acoustic Analysis. J Voice [Internet]. 2020;36(6):879.e13-879.e19. doi: https://doi.org/10.1016/j.jvoice.2020.09.024

Lascarrou JB, Boisrame-Helms J, Bailly A, Le Thuaut A, Kamel T, Mercier E, et al. Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal Intubation Among ICU Patients. JAMA [Internet]. 2017 Feb 7;317(5):483. doi: https://doi.org/10.1001/jama.2016.20603

Clavé P, Arreola V, Romea M, Medina L, Palomera E, Serra-Prat M. Accuracy of the volume-viscosity swallow test for clinical screening of oropharyngeal dysphagia and aspiration. Clin Nutr [Internet]. 2008 Dec;27(6):806–15. doi: https://doi.org/10.1016/j.clnu.2008.06.011

Rofes L, Arreola V, Clavé P. The Volume-Viscosity Swallow Test for Clinical Screening of Dysphagia and Aspiration. In: Stepping Stones to Living Well with Dysphagia [Internet]. Barcelona: Institute Workshop; 2012. p. 33–42. doi: https://doi.org/10.1159/000339979

Vega Rodríguez YE, Torres Rodríguez AM, del Campo Rivas MN. Análisis del Rol del Fonoaudiólogo(a) en el Sector Salud en Chile. Cienc Trab [Internet]. 2017 Aug;19(59):76–80. doi: https://doi.org/10.4067/S0718-24492017000200076

Paraje G, Vásquez F. Health equity in an unequal country: the use of medical services in Chile. Int J Equity Health [Internet]. 2012;11(1):81. doi: https://doi.org/10.1186/1475-9276-11-81

Koch KJ, Cid Pedraza C, Schmid A. Out-of-pocket expenditure and financial protection in the Chilean health care system—A systematic review. Health Policy (New York) [Internet]. 2017;121(5):481–94. doi: http://dx.doi.org/10.1016/j.healthpol.2017.02.013

Murton O, Hillman R, Mehta D. Cepstral peak prominence values for clinical voice evaluation. Am J Speech-Language Pathol. 2020;29(3):1596–607. doi: https://doi.org/10.1044/2020_AJSLP-20-00001

Watts CR, Awan SN, Maryn Y. A Comparison of Cepstral Peak Prominence Measures from Two Acoustic Analysis Programs. J Voice [Internet]. 2017;31(3):387.e1-387.e10. doi: http://dx.doi.org/10.1016/j.jvoice.2016.09.012

Baker CP, Sundberg J, Purdy SC, Rakena TO, Leão SH d. S. CPPS and Voice-Source Parameters: Objective Analysis of the Singing Voice. J Voice. 2022;S0892-1997(21)00433-1. doi: https://doi.org/10.1016/j.jvoice.2021.12.010

Lopes LW, Sousa ES da S, da Silva ACF, da Silva IM, de Paiva MAA, Vieira VJD, et al. Cepstral measures in the assessment of severity of voice disorders. Codas. 2019;31(4):1–8. doi: https://doi.org/10.1590/2317-1782/20182018175

Speyer R, Bogaardt HCA, Passos VL, Roodenburg NPHD, Zumach A, Heijnen MAM, et al. Maximum Phonation Time: Variability and Reliability. J Voice [Internet]. 2010 May;24(3):281–4. doi: https://doi.org/10.1016/j.jvoice.2008.10.004

Hirano, M., Koike, Y., & von Leden H. Maximum Phonation Time and Air Usage During Phonation. Folia Phoniatr Logop. 1968;20(4):185–201. doi: https://doi.org/10.1159/000263198

Fujimaki Y, Tsunoda K, Kobayashi R, Tonghyo C, Tanaka F, Kuroda H, et al. Independent exercise for glottal incompetence to improve vocal problems and prevent aspiration pneumonia in the elderly: A randomized controlled trial. Clin Rehabil. 2017;31(8):1049–56. doi: https://doi.org/10.1177/0269215516673208

Hamdan AL, Sibai A, Rameh C, Kanazeh G. Short-Term Effects of Endotracheal Intubation on Voice. J Voice. 2007 Nov 1;21(6):762–8. doi: https://doi.org/10.1016/j.jvoice.2006.06.003

Curtis JA, Troche MS. Handheld Cough Testing: A Novel Tool for Cough Assessment and Dysphagia Screening. Dysphagia [Internet]. 2020;35(6):993–1000. doi: https://doi.org/10.1007/s00455-020-10097-z

Bianchi C, Baiardi P, Khirani S, Cantarella G. Cough peak flow as a predictor of pulmonary morbidity in patients with dysphagia. Am J Phys Med Rehabil. 2012;91(9):783–8. doi: https://doi.org/10.1097/PHM.0b013e3182556701

Ruston FC, Moreti F, Vivero M, Malebran C, Behlau M. Cross-cultural adaptation of the Chilean version of the Voice Symptom Scale - VoiSS. Codas. 2016;28(5):625–33. doi: https://doi.org/10.1590/2317-1782/20162015249

Fernández-Rosati J, Lera L, Fuentes-López E, Albala C. Validez y confiabilidad del cuestionario Eating Assessment Tool 10 (EAT-10) para detectar disfagia en adultos mayores chilenos. Rev Med Chil [Internet]. 2018 Sep;146(9):1008–15. doi: https://doi.org/10.4067/s0034-98872018000901008

Maryn Y, Weenink D. Objective dysphonia measures in the program praat: Smoothed cepstral peak prominence and acoustic voice quality index. J Voice [Internet]. 2015;29(1):35–43. doi: http://dx.doi.org/10.1016/j.jvoice.2014.06.015

Hillenbrand J, Houde RA. Acoustic correlates of breathy vocal quality: Dysphonic voices and continuous speech. J Speech, Lang Hear Res. 1996;39(2):311–21. doi: https://doi.org/10.1044/jshr.3902.311

Heman-Ackah YD, Michael DD, Goding GS. The relationship between cepstral peak prominence and selected parameters of dysphonia. J Voice. 2002;16(1):20–7. doi: https://doi.org/10.1016/S0892-1997(02)00067-X

Núñez-Batalla F, Cartón-Corona N, Vasile G, García-Cabo P, Fernández-Vañes L, Llorente-Pendás JL. Validation of the Measures of Cepstral Peak Prominence as a Measure of Dysphonia Severity in Spanish-Speaking Subjects. Acta Otorrinolaringol. 2019;70(4):222–8. doi: https://doi.org/10.1016/j.otoeng.2018.04.005

Arviso LC, Klein AM, Johns MM. The management of postintubation phonatory insufficiency. J Voice. 2012 Jul 1;26(4):530–3. doi: https://doi.org/10.1016/j.jvoice.2010.10.022

Kallesen M, Psirides A, Huckabee ML. Comparison of cough reflex testing with videoendoscopy in recently extubated intensive care unit patients. J Crit Care [Internet]. 2016;33(2016):90–4. doi: http://dx.doi.org/10.1016/j.jcrc.2016.02.004

Britton D, Roeske A, Ennis SK, Benditt JO, Quinn C, Graville D. Utility of Pulse Oximetry to Detect Aspiration: An Evidence-Based Systematic Review. Dysphagia [Internet]. 2018;33(3):282–92. doi: https://doi.org/10.1007/s00455-017-9868-1

Pitts T. Airway protective mechanisms. Lung. 2014;192(1):27–31. doi: https://doi.org/10.1007/s00408-013-9540-y

Yoshiyuki H, Fuller BF. Selected acoustic characteristics of voices before intubation and after extubation. J Speech Hear Res. 1990;33(3):505–10. doi: https://doi.org/10.1044/jshr.3303.505

Sariego J. Vocal Fold Hypomobility Secondary to Elective Endotracheal Intubation: A General Surgeon’s Perspective. J Voice [Internet]. 2010;24(1):110–2. doi: http://dx.doi.org/10.1016/j.jvoice.2008.05.001

Lipshutz AKM, Gropper MA. Acquired neuromuscular weakness and early mobilization in the intensive care unit. Anesthesiology. 2013;118(1):202–15. doi: https://doi.org/10.1097/ALN.0b013e31826be693


Download data is not yet available.