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Dysphagia & Patients with Tracheostomy and Mechanical Ventilation

What is a tracheostomy?

A tracheotomy is a procedure where an opening is created in the neck and into the airway (trachea) and the tracheostomy is the resulting stoma (hole) that is created.  A tracheostomy tube is typically placed into the stoma to allow for direct access to the trachea for breathing and removing secretions from the airway and lungs.  The tube enables air to flow directly through the trachea rather than through the nose and mouth, bypassing the upper airway.

Tracheostomy Tube

Tracheostomy and Aspiration:

Patients with tracheostomy and mechanical ventilation are at a heightened risk of aspiration with reports of up to 87% of patients who are provided with oral intake aspirating (Elpern et al, 1994), with the majority of those silently aspirating. Silent aspiration is when food, liquid, or secretions go into the airway and there are no overt signs such as coughing or throat clearing. This is concerning, as aspiration can result in pneumonia, especially in an already vulnerable population.  Despite the high rate of aspiration, many individuals with tracheostomy and mechanical ventilation can safely take some oral intake following a proper assessment by a trained speech-language pathologist, which can reduce delays in beginning oral intake and reduce complications from inappropriate oral feedings.  

When a tracheotomy is initially performed, typically a cuffed tracheostomy tube is placed.  The reason for a cuffed tracheostomy is to provide a seal, closing off the upper airway to effectively deliver positive pressure ventilation.  Although some individuals can be effectively ventilated with a cuffless or deflated cuffed tracheostomy tube, many will initially require an inflated cuff.  There is a common misconception that the cuff of the tracheostomy tube prevents aspiration.  However, the definition of aspiration is when material (secretions, food, liquids, reflux) passes below the level of the vocal folds, which is the last line of defense in protecting the airway.  Once material reaches the cuff of the tracheostomy tube, it has already been aspirated.  Aspirated material can colonize with bacteria at the site of the cuff and eventually pass around the cuff and into the lower airways and lungs.  At most, the cuff can delay material from reaching the lungs. Studies have shown that there are higher rates of aspiration, silent aspiration and respiratory infections when the cuff is inflated compared to deflated (Davis et al, 2002, Ding, R. & Logemann, J. 2005, Hernandez et al, 2013)

Aspiration with Tracheostomy

How does a tracheostomy affect swallowing?

In the population with tracheostomy and mechanical ventilation, dysphagia is often multi-factorial.

The underlying medical diagnosis, acuity of the patient, and the reason for the initial tracheostomy tube are important considerations.  Tracheotomy may be performed on individuals with neuromuscular diseases such as stroke, ALS, Guillian Barre, MS, Parkinson’s Disease, and muscular dystrophy.  Obstructive airway disease, head and neck cancer/surgery and adult respiratory distress syndrome may also result in the need for tracheotomy.  Dysphagia can result from the impact of these medical conditions. 

Another factor that may increase the risk for aspiration is that most individuals with tracheostomy are initially orally intubated with an endotracheal tube. This is a tube that goes in the mouth through the larynx and into the trachea.  Swallow studies within 24 hours of the oral intubation tube being removed have shown high rates of aspiration, with a high proportion being silent aspiration.  The endotracheal tube passes through the vocal folds, which can damage the folds, particularly during emergent intubation, multiple intubations, and extubation.  This places the individual at higher risk of aspiration since the vocal folds are largely responsible for airway protection.

Finally, there are reports of some specific effects of the presence of a tracheostomy on swallowing, particularly when the cuff is inflated.  This includes:

  • Impaired laryngeal elevation (Ding & Logemann, 2005; Amethieu et al, 2012; Jung, S. et al, 2012; Logemann et al, 1998).
  • Reduced subglottic air pressure (Gross et al, 1994; Gross et al, 2003)
  • Desensitization of the larynx (Ding & Logemann, 2005; Amethieu et al, 2012; Seidl et al, 2005).
  • Reduced effectiveness of the cough reflex
  • Disruption of the vocal fold function (Sasaki CT et al, 1977; Shaker, R et al, 1995).

For further information of the specific studies, please see Tracheostomy Education.

Swallow Assessment:

Because of the high aspiration and silent aspiration rate, a thorough assessment by a dysphagia specialist, usually a speech-language pathologist, is indicated.  There are some distinct considerations in assessing those with tracheostomy and mechanical ventilation:

  • Duration of intubation and number of intubations/extubations.
  • When, how and why the tracheostomy tube was placed
  • Tracheostomy tube size, manufacturer and cuff type
  • If the patient is currently on mechanical ventilation, ventilator settings and weaning status
  • Other pertinent information includes medical diagnosis, respiratory function, medications, prior level of swallow function and current means of nutrition.  A cognitive assessment and oral mechanism are completed. 
  • Assessing laryngeal function is important in determining if swallowing is safe.  If the cuff is inflated, the person cannot produce voice in order to indicate if vocal fold function is intact.  Also, cough strength and vocal changes after providing oral intake are pieces of information to help assess if the food or liquid is safely swallowed. 

In order to assess laryngeal function, the cuff (if present) must be deflated following a physician order.  Cuff deflation allows some air to escape through the upper airway, although airflow will continue to flow out of the tracheostomy tube.  Once the cuff has been completely deflated, a speaking valve may be placed after assessing for upper airway patency.  There are various types of speaking valves. The Passy-Muir Valve is the only biased closed position valve and can be used for patients with tracheostomy who are spontaneously breathing or in-line with mechanical ventilation.  Once a speaking valve is placed it restores the patient to more normal physiology as all exhaled air is redirected through the upper airway.  A bedside swallow assessment may continue as if it is a normal airway.  Benefits of utilizing a biased closed position valve during a swallow evaluation include:

  • Ability to assess for change in vocal quality, cough strength and the patient’s response to oral intake 
  • Improved cough reflex to clear any material that enters the airway, including secretions
  • Improved sensation
  • Improved secretion management
  • Aspiration has been reduced or eliminated in some patients (Suiter, D et al, 2003; Stachler, R et al, 1996; Dettelbach et al 1995; Elpern et al, 1994, 2000; Gross et al, 1994, 2003)
  • Restoration of subglottic air pressure (Gross et al, 2003) and maintaining lung volumes to perform maneuvers such as supraglottic and supersupraglottic
  • Ability to perform expiratory muscle strength retraining

Occlusion of the tracheostomy tube by digital occlusion or capping also provides the above benefits.

Trachestomy Tube with Passy-Muir Speaking Valve

Due to the high rates of aspiration and silent aspiration, instrumental assessments are strongly recommended.  The modified barium swallow study (MBSS) or a flexible endoscopic evaluation of swallowing (FEES) are the gold standards.  If use of the speaking valve is time limited, the SLP may assess different conditions such as having the cuff inflated, deflated and valve/cap on to determine the safest strategies for feeding. 

There are significant advantages to FEES in the tracheostomy and mechanically ventilated population including:

  • secretions are able to be assessed in a population where it may be unsafe to provide foods and liquids
  • No barium or radiation
  •  FEES is not time dependent and can assess patient fatigue over a meal
  • No transportation as it can be completed at the bedside
  • Potentially lower costs and less time spent than MBSS

In conclusion, patients with tracheostomy and mechanical ventilation are at a heightened risk for dysphagia and aspiration. Proper swallowing assessments can help determine swallow safety in order to advance to a diet. Modified barium swallow studies or flexible endoscopic evaluation of swallowing is strongly recommended in this population.

Byline: Nicole DePalma, MS, CCC-SLP received her bachelor’s degree at Georgetown University and subsequently earned her master’s degree at NY Medical College in Speech-Language Pathology. She is the owner of Speech and Swallowing Management, LLC working primarily in hospitals, subacute, and skilled nursing facilities in New York City with expertise in the tracheostomy and mechanically ventilated population.

Mobile FEES is available through Nicole DePalma at NDoscopy Dysphagia Specialists.  NDoscopy proudly partners with skilled nursing facilities, hospitals, long term acute care, rehabilitation centers, and physician offices in the greater New York City area.  Ndoscopy also services patients in a private practice office located at 3250 Westchester Ave Ste 204, Bronx NY 10457.  

Other FEES providers in the US are available through this map:    https://maphub.net/FlatlandTherapy/mobile-fees-providers-04-30-2019

Resources:

Amathieu, R. et al. (2012). Influence of the cuff pressure on the swallowing reflex in tracheostomized intensive care unit patients. British Journal of Anaesthesia. Oct;109(4):578-83.

Davis, et al. (2002) Swallowing with a Tracheotomy Tube in Place: Does Cuff Inflation Matter? Journal of Intensive Care Medicine.17(3): 132-135.

Dettelbach, M., et al. (1995). Effect of the Passy Muir® Valve on Aspiration in Patients with Tracheostomy. Head & Neck, 297-300.

Ding, R. & Logeman, J. (2005). Swallow Physiology in Patients with Trach Cuff Inflated or Deflated: A Retrospective Study. Head & Neck. Sep;27(9):809-13

Gross, R. D., Dettelbach, M. A., Eibling, D. E., & Zajac, D. (1994). Measurement of subglottic air pressure during swallowing in a patient with tracheostomy. Otolaryngology-Head and Neck Surgery, 111(2), 133.

Gross, R. D., Mahlmann, J., & Grayhack, J. P. (2003). Physiologic effects of open and closed tracheostomy tubes on the pharyngeal swallow. Annals of Otology, Rhinology and Laryngology, 112(2), 143-152.

Shaker, R, Milbrath, M, Junlong, R, Campbell B, Toohill, R, Hogan, W. (1995). Deglutitive aspiration in patients with tracheostomy: Effect of tracheostomy on the duration of vocal cord closure. Gastrointerology 108(5), 1357-1360. 

Seidl RO, Nusser-Müller-Busch R, Ernst A. The influence of tracheotomy tubes on the swallowing frequency in neurogenic dysphagia. Otolaryngol Head Neck Surg. 2005 Mar; 132(3):484-6.

Stachler, R. J., Hamlet, S. L., Choi, J. and Fleming, S. (1996), Scintigraphic Quantification of Aspiration Reduction With the Passy‐Muir Valve. The Laryngoscope, 106: 231-234. doi:10.1097/00005537-199602000-00024

Suiter, D, McCullough, G, Powell, P.  Cuff deflation and one way tracheostomy speaking valve placement on swallowing disorders, Dysphagia 18:284–292 (2003) DOI: 10.1007/s00455-003-0022-x



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Dysphagia Awareness Month Infographic



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Contest Rules

The 2019 #IDDSIchallenge! 


Rules and Regulations

Be creative, be respectful to those who require modified diets, and have fun!

  1. Entries can be submitted by anyone: an individual, a corporation, a restaurant, a group of friends, a healthcare organization, a family!
  2. Multiple entries are allowed.
  3. Entries must be original. You cannot share a video that you did not create.
  4. In order for IDDSI and the NFOSD to view entries, you must assure your privacy settings for the post is set to “Public.”
  5. In order for IDDSI and the NFOSD to view entries, you must include #IDDSIchallenge and tag @NFOSD.
  6. Entries must be submitted by June 20th, at midnight GMT.
  7. By submitting a photo, you are confirming that anyone pictured has provided their consent for this to be shared publicly.
  8. By submitting a photo, you allow the NFOSD and IDDSI to share and reuse this on their websites, social media platforms, and with their mailing list.
  9. We will ask any inappropriate photos to be removed and reserve the right to not share these with our community.
  10. Any disrespectful or inappropriate comments on photos submitted will be deleted.
  11. Winners will be announced on the NFOSD and IDDSI social media platforms.


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Recording: NFOSD Virtual Conference 2017

Course Summary (0.6 CEUs):  This comprehensive one-day live streaming dysphagia course was presented by 12 clinical and research swallowing disorder experts on February 28, 2017. The course begins with a review of the basics of the normal swallowing mechanics, taking neurology and age into consideration. It then moves into evaluation techniques, coping mechanisms, and diet modifications. From there, we move into rehabilitation and address exercises, device-driven options, and biofeedback techniques. It wraps up with surgical options, methods for staying healthy, and a panel discussion on living with dysphagia.

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National Dysphagia Awareness Month Photo Facts

June is National Dysphagia Awareness Month. Each day during the month of June, we will share a photo fact about dysphagia that is supported by research. We will include a citation for each fact if you are interested in learning more.


June 1


June 2

Citation: Field, D., M. Garland, and K. Williams. “Correlates of specific childhood feeding problems.” Journal of paediatrics and child health 39.4 (2003): 299-304.


June 3

Citation: Holland, G., et al. “Prevalence and symptom profiling of oropharyngeal dysphagia in a community dwelling of an elderly population: a self‐reporting questionnaire survey.” Diseases of the Esophagus 24.7 (2011): 476-480.


June 4

Citation: https://swallowingdisorderfoundation.com/about/swallowing-disorder-basics/


June 5

Citation: Steele, Catriona M., et al. “Mealtime difficulties in a home for the aged: not just dysphagia.” Dysphagia 12.1 (1997): 43-50.


June 6

Citation: Lindgren, Sven, and Lars Janzon. “Prevalence of swallowing complaints and clinical findings among 50–79-year-old men and women in an urban population.” Dysphagia 6.4 (1991): 187-192.


June 7

Citation: Dr. Maureen Lefton-Greif, “Feeding and Swallowing: Chapter 7.” https://www.communityatcp.org/Document.Doc?=&id=


June 8

Citation:  Martin-Harris, B. (2015) Standardized Training in Swallowing Physiology – Evidence-Based Assessment Using the Modified Barium Swallow Impairment Profile (MBSImP) Approach. Gaylord, MI: Northern Speech Services.


June 9

Citation: Leder SB, Suiter DM, Lisitano Warner H. Answering orientation questions and following single-step verbal commands: effect on aspiration status. Dysphagia. 2009;24(3):290–5


June 10

Citation: Sura L, Madhavan A, Carnaby G, Crary MA. Dysphagia in the elderly: management and nutritional considerations. Clinical Interventions in Aging. 2012;7:287-298. doi:10.2147/CIA.S23404.


June 11

Citation: Policy, Enteral Nutrition ASPEN Public. “Disease-related malnutrition and enteral nutrition therapy: A significant problem with a cost-effective solution.”Nutrition in Clinical Practice 25.5 (2010): 548-554.


June 12

Citation: Dettelbach, Mark A., et al. “Effect of the Passy‐Muir valve on aspiration in patients with tracheostomy.” Head & neck 17.4 (1995): 297-302.

Cameron, J. L., J. Reynolds, and G. D. Zuidema. “Aspiration in patients with tracheostomies.” Surg Gynecol Obstet 136.1 (1973): 68-70.


June 13

Source: http://iddsi.org/


June 14

Citation: Rosenthal, David I., Jan S. Lewin, and Avraham Eisbruch. “Prevention and treatment of dysphagia and aspiration after chemoradiation for head and neck cancer.” Journal of clinical oncology 24.17 (2006): 2636-2643.


June 15

Citation: Arvedson, Joan C. “Assessment of pediatric dysphagia and feeding disorders: clinical and instrumental approaches.” Developmental disabilities research reviews 14.2 (2008): 118-127.


June 16

Citation: Ramqvist, Torbjörn, and Tina Dalianis. “Oropharyngeal Cancer Epidemic and Human Papillomavirus-Volume 16, Number 11—November 2010-Emerging Infectious Disease journal-CDC.” (2010).


June 17

Citation: Paciaroni, Maurizio, et al. “Dysphagia following stroke.” European neurology 51.3 (2004): 162-167.


June 18

Father’s Day Patient Story: https://swallowingdisorderfoundation.com/4065-2/


June 19

Citation: Baumann, Brooke, et al. “Postoperative Swallowing Assessment After Lung Transplantation.” The Annals of Thoracic Surgery (2017).


June 20

Citation: Rogus‐Pulia, Nicole, et al. “Effects of Device‐Facilitated Isometric Progressive Resistance Oropharyngeal Therapy on Swallowing and Health‐Related Outcomes in Older Adults with Dysphagia.” Journal of the American Geriatrics Society epub ahead of print (2016).


June 21

Citation: Nguyen, Nam P., et al. “Impact of dysphagia on quality of life after treatment of head-and-neck cancer.” International Journal of Radiation Oncology* Biology* Physics 61.3 (2005): 772-778.


June 22

Citation: Arvedson, Joan C. “Assessment of pediatric dysphagia and feeding disorders: clinical and instrumental approaches.” Developmental disabilities research reviews 14.2 (2008): 118-127.


June 23

Citation: ALS dysphagia pathophysiology: Differential botulinum toxin response; Restivo, Domenico A. MD, PhD; Casabona, Antonino PhD; Nicotra, Alessia MD, PhD; Zappia, Mario MD; Elia, Maurizio MD; Romano, Marcello C. MD; Alfonsi, Enrico MD; Marchese-Ragona, Rosario MD, PhD 2013.


June 24

Citation: Good-Fratturelli, Misty D., Richard F. Curlee, and Jean L. Holle. “Prevalence and nature of dysphagia in VA patients with COPD referred for videofluoroscopic swallow examination.” Journal of communication disorders33.2 (2000): 93-110.


June 25

Patient Story: Julia Sharon Tuchman shares her experience with dysphagia

https://swallowingdisorderfoundation.com/i-love-you-even-if-this-is-forever/


 June 26

Citation: Muller J, Wenning GK, Verny M, et al. Progression of dysarthria and dysphagia in postmortem-confirmed parkinsonian disorders. Arch Neurol. 2001;58(2):259–264.


June 27

Citation: Peter Belafsky, NFOSD Webinar July 2015 “Most Common Causes of Solid Food Dysphagia.” 


June 28

Citation: Martino, Rosemary, et al. “Dysphagia after stroke.” stroke 36.12 (2005): 2756-2763.


June 29

Citation: Leder, Steven B., and Julian F. Espinosa. “Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing.” Dysphagia 17.3 (2002): 214-218.


June 30

Cook Medical interviews NFOSD President, Ed Steger, about his journey with head and neck cancer and his mission to raise awareness of dysphagia, a devastating disorder.

Read the Interview