Infants gain all their nutrition through breast or bottle feeding until they are at least six months of age. The ability to suck successfully from breast or bottle requires the infant to coordinate three actions: suck-swallow-breathe. Suck is accomplished with slightly different motions on the breast compared to the bottle, but essentially the lips must close on the nipple and the tongue moves in and out in a suckle motion and presses the nipple against the roof of the mouth, creating pressure on the nipple. As the jaw moves down, it helps create suction to pull the liquid into the mouth. The infant then has to swallow the liquid, and the infant must stop breathing during each swallow and then breathe after swallowing. The suck-swallow-breathe sequence then starts again. Many things can interfere with this sophisticated system for swallowing. Here are some examples of possible causes of difficulty with feeding in infants. Many of these problems can continue to affect the child’s ability to eat and swallow as they grow.
A tracheotomy is a procedure where an opening is created in the neck and into the airway (trachea) and a 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.
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 unsafe 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).
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,
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).
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 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.
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
not time dependent and can assess patient fatigue over a meal
No transportation as it can be completed at the
Potentially lower costs and less time spent than
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.
Nicole DePalma, MS, CCC-SLP, received her BA at Georgetown University and subsequently earned her MS at NY Medical College in Speech-Language Pathology. She is the owner of Tracheostomy Education, an all inclusive resource for tracheostomy education and supplies. As a member of the Passy-Muir team, she has presented courses on dysphagia and communication management at conferences and universities throughout the nation.
Flexible Endoscopic Evaluation of Swallowing (FEES) is available through Nicole DePalma at NDoscopy Dysphagia Specialists. NDoscopy proudly partners with hospitals, subacute and skilled nursing facilities in New York City to provide mobile FEES and consulting for establishing interdisciplinary tracheostomy teams. Ndoscopy also services patients in a private practice office, located at 3250 Westchester Ave Suite 204, Bronx NY 10457.
Amathieu, R. et al. (2012). Influence of the cuff pressure
on the swallowing reflex in tracheostomized intensive care unit patients.
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Davis, et al. (2002) Swallowing with a Tracheotomy Tube in
Place: Does Cuff Inflation Matter? Journal of Intensive Care Medicine.17(3):
Dettelbach, M., et al. (1995). Effect of the Passy Muir® Valve
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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).
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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),
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(1996), Scintigraphic Quantification of Aspiration Reduction With the Passy‐Muir
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disorders, Dysphagia 18:284–292 (2003) DOI: 10.1007/s00455-003-0022-x
Board Certified Specialist in Swallowing and Swallowing Disorders
Vesna Martich Kriss, MD
Pediatric Radiologist, Baptist Health Lexington
It has been recommended that your child undergo a video fluoroscopic swallowing evaluation, often called a modified barium swallow, to assess the pharyngeal phase of the swallow. This radiologic procedure exposes your child to x-rays which raises safety questions about the study. Here are some things parents should know about radiation safety and the video fluoroscopic swallowing exam (VFSS).
This is a lengthy article about Violet, a seemingly healthy newborn with a strong natural eating style. But, over the course of a week, Virginia began to decline. The story doesn’t begin with a swallowing disorder, but it evolves into one.
Three quick points, for those of you with still here:
1) At the National Foundation of Swallowing Disorders, we refer people who contact us to swallowing specialists, physicians, and medical teams worldwide on a daily basis. We do not seek compensation for these referrals nor do we receive a commission from those practitioners to whom we refer people. Our goal is to match the patient with the best and most practical medical professional.
2) We do not provide patient-specific medical advice. As with Violet, every patient is different, and the logical place to begin is with a medical assessment by a specialist versed in that patient’s underlying medical condition and age (pediatric, adolescent, adult, and geriatric) while taking location into consideration.
3) As of this posting, there were over 140 comments. Many of them were from people with infants who suffered a swallowing disorder. It is worth reading the comments. This highlights that swallowing disorders are not a medical condition that discriminates, “Swallowing Disorders can Affect Anyone.” Click here to see our brochure.
Halloween is meant to be a scary time of year. But for parents of children with dysphagia, it can be an especially frightening time of year. To kids, Halloween is the one day of the year where they are encouraged to go door-to-door asking adults for as much candy as they can carry. continue reading →
Pediatric swallowing specialist, Donna Edwards, CCC-SLP, BCS-S, and ASHA Fellow, has created an outstanding resource for children, parents, and professionals to learn about safe eating and to reduce the likelihood of choking. This coloring book includes a long list of fun activities that parents and professionals can use to teach children about safe and healthy eating.
*All information regarding the International Dysphagia Diet Standardisation Initiative is provisional. For updates and more information, please visit: www.iddsi.org
The coloring book for young children is now available in five languages! Select your language below: