CLINICAL BEDSIDE SWALLOW EXAM WITH TRACHEOSTOMY AND VENTILATOR DEPENDENT PATIENT:
Written by: Dr Eric Blicker MA CCC-SLP.D BCS-S
QUESTION#1: TRACHEOSTOMY TUBE CUFF: TO DEFLATE OR INFLATE?
The tracheostomy tube cuff is inflated for mechanical ventilation and provides a closed, sealed, airway allowing patients to get full volumes for respiration and gas exchange. When assessing the functions of the larygopharynx, it is suggested that patients with cuffed tracheostomy tubes have the cuff deflated, at least partially, during swallow assessment. This will also allow for aspiration risk assessment below cuff level. It is recommended that medical orders for cuff deflation are required prior to deflation. For the ventilator dependent patient, it is preferred to have the presence of a respiratory therapist, to help transition from closed to open system by maintaining the vent settings (Bach JR et al 1990). This is needed since there will be leakage of air through the laryngeal and oral airways once upon cuff deflation (Manzano JL et al 1993).
This clinician prefers to have the respiratory therapist managing the ventilator setting, while SLP delivers bolus trials and provides cervical auscultation of neck in area of larynx and palpable assessment of the areas of the mandible, hyoid bone, and thyroid cartilage. It is an easier assessment when there are more hands to assist. Ideally, the decision to feed a tracheostomy/ventilator dependent patient by mouth should have the joint input from the respiratory therapist, pulmonologist, and SLP.
QUESTION #2: SO WHAT HAPPENTS WHEN THE PATIENT CANNOT TOLERATE FULL TRACHEOSTOMY TUBE CUFF DEFLATION?
If the cuff cannot be fully deflated because of increased ventilator support needs, then a minimal leak technique can be done (St John, RE 2004). In this scenario, there is a minimal leak between tracheostomy tube cuff and the tracheal wall, allowing for possible enhanced identification of aspirated contents below the level of the tracheostomy tube cuff. If the minimal leak technique is used to assess swallowing and then the patient cannot sustain this leak for the length of a meal PO, the assessment may not fully represent aspiration risk over the course of a meal. Clinical experience has shown that chronic ventilator patients who need to maintain full cuff inflation can be assessed with the cuff inflated with bedside flexible endoscopic evaluation of swallowing (FEES). FEES allows for aspiration risk to be viewed without cuff deflation. The same can be done with modified barium swallow (MBS) if this was necessary. There are facility specific limitations for transferring ventilator dependent patients to radiology department for MBS.
QUESTION #3: WHAT DO WE NEED TO ASK OURSELVES ABOUT THE TRACH CUFF?
Clinical experience has shown that the full cuff deflation decision is generally best decided by pulmonologist, respiratory therapist and SLP. This cohesion of care is critical, as the SLP needs to consider the medical and functional implications of full cuff deflation. The SLP needs to consider if the patient can be adequately ventilated if the tracheostomy tube cuff is deflated. This is an important consideration when contemplating cuff deflation. The SLP needs to consider if the ventilator dependent patient is medically stable and alert. The heart rate and other vital signs may become more variable upon deflation in certain cases, if there is increased work of breathing or reduction to oxygen saturation. The SLP needs to consider if the patient can tolerate air leakage around the tracheostomy tube cuff. RT input for this question is ideal. This SLP will always consult with RT at the time of deflation, even if there are MD orders to deflate. The SLP needs to determine if the patient is ready to be considered for Passy Muir Speaking Valve use. Review therapeutic and medical guidelines for PMSV placement. Tracheostomy cuff deflation may facilitate more effective and timely laryngeal elevation for an adequate swallow. Furthermore, deflation can allow for increased airflow into the pharynx for improving sensation into the laryngopharynx and improved secretions expectoration.
QUESTION #4: WHAT OTHER FACTORS NEED TO BE CONSIDERED DURING ASSESSMENT AND TREATMENT OF THE TRACHEOSTOMY AND VENTILATOR DEPENDENT PATIENT?
SLP should determine the length of endotracheal intubation prior to tracheostomy tube placement and whether it was prolonged. If the intubation was prolonged, the patient may have residual laryngeal edema and or trauma. Prolonged intubation, emergent intubation, or multiple intubations may impact true vocal cord structure and function. SLP should inquire as to why prior extubation failed. The patient may have issues with: managing secretions, chronic pulmonary condition ex: COPD (chronic obstructive pulmonary disease), or a medical condition impacting airway patency such as head and neck cancer. The SLP should determine if there was pre-intubation dysphagia: important to know if there was pre-existing dysphagia and the severity of aspiration risk. Recurrent aspiration in some cases is the catalyst for respiratory failure. SLP should determine when was the tracheostomy tube placed and if there were any anatomical deficits reported by surgeon (tracheal stenosis, grannulation tissue etc).
QUESTION #5: HOW IS THE AIRFLOW AROUND THE TRACHEOSTOMY TUBE DURING THE SWALLOW ASSESSMENT?
During the process of determining the patient’s ability to pass air around the tracheostomy tube with cuff deflation, the SLP can perform cervical auscultation of neck in area of larynx superior to the tracheostomy tube. This can be done with the occluded tracheostomy tube, the open tracheostomy tube, with PMSV, and potentially with capped tracheostomy tube. Strained, distorted, or absent breath sounds in area of larynx may be suggesting a partially obstructed path of airflow to the upper airway. There may be difference to inspiratory and expiratory breath sounds. Expiratory distortion and airflow resistance to the gloved finger at the hub of the tracheostomy tube suggests that airflow is taking the path of least resistance, not going to the upper airway, but out through tracheostomy tube instead. This can also be audible when a PMSV is removed, as there may be a palpable and audible burst of air at the hub of the tracheostomy tube.
The SLP can assess the patient’s airflow around the tracheostomy tube by holding a mirror under the patient’s nose to monitor for the presence of airflow onto the mirror. The SLP can also ask the patient to blow into a tissue to assess oral airflow. The importance of assessing the airflow around the tracheostomy tube, as part of the swallow assessment, is to determine if there are adequate respirations to support PMSV use, which is preferred to use during PO intake. Impaired airflow may reflect a need for either tracheostomy tube downsizing, changing from cuffed to cuffless tracheostomy tube, or otolaryngology assessment to rule out anatomical changes in the airway: stenosis, grannulation tissue.
Impaired airflow when the patient is ventilator dependent may suggest that the patient requires ventilator settings modifications to help direct airflow around the tracheostomy tube.
QUESTION #6: WHAT IS THE LEVEL OF VENTILATOR DEPENDENCE?
SLP should assess where is the patient in the ventilator weaning process and determine if the patient is tolerating ventilator weaning. SLP should also determine if there is a slow or fast ventilator weaning process. It is not uncommon for patients to fatigue when initiating the ventilator weaning process. Patient endurance can be impacted as they try to breathe on their own, weaning from the machine. SLP needs to consider that starting meal length oral intake in a tube fed/npo during active ventilator weaning patient can have an interaction with patient stamina during weaning trials from ventilator.
Clinical experience has shown that patients with a cardiac diagnosis or status post a cardiac surgery, ie: CABG, may often show reduced stamina when ventilator weaning is initiated. The same has been observed for patients with chronic pulmonary conditions, ie: COPD. Clinical experience with PO intake and tracheostomy/ventilator dependent patients has shown that PO intake is best assessed in a patient that is hemodyamically stable, tolerating their ventilator settings, is alert with manageable secretions, and can tolerate some level of tracheostomy tube cuff deflation. The decision to attempt PO with a tracheostomy and ventilator patient should be a joint decision between SLP, RT, and pulmonologist, on a case specific basis.
Clinical experience has shown that evaluation and treatment of the tracheostomy and ventilator dependent requires a detailed awareness of the upper aerodigestive tract.This upper aerodigestive tract includes the SLP understanding the anatomy and structure of the pharynx, larynx, tracheal, and esophageal areas.
The swallow assessment in these patients spans beyond the assessment of oral feeding trials. The clinician must understand thoroughly how the integration of phonation function, respiratory status, and secretions management can impact deglutition function. The presence of the artificial airway provides an additional component to the dysphagia exam, involving potential tracheostomy tube size modification, one way speaking valve use, tracheostomy tube capping, cuff manipulation, and potentially ventilator modification.
About the Author:
Dr. Eric Blicker MA CCC-SLP.D BCS-S is an American Speech-Language-Hearing Association (ASHA) Board Certified Specialist in Swallowing Disorders. Eric received his doctoral degree from Nova Southeastern University and was trained in Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) by Dr. Jonathan Aviv, the otolaryngologist who developed FEESST. Eric has started multiple Flexible Endoscopic Evaluation of Swallowing (FEES) programs in the south Florida area while training speech-language pathologists and physicians in the process.
Dr. Blicker has lectured at Florida International University, Florida State University, and Boston University. Moreover, he has provided FEES training courses in Connecticut, Massachusetts, Florida, Missouri, and California for licensed speech language pathologists. Dr. Blicker owns a portable FEES company that provides testing services throughout the state of Florida. He also created the website as an ASHA CE provider: www.ceualliedhealth.com, to provider courses online in medical speech-language pathology.
Bach, J.R. et al. (1990) Tracheostomy ventilation: A study of efficacy with deflated cuffs and cuffless tubes, Chest , 97, 679-683.
Manzano JL et al (1993) Verbal communication of ventilator dependent patients Critical Care Medicine, 21 (4), 512-517.
St John, RE (2004) Airway management, Critical Care Nurse,24, 93-97.