Co-author: Meghan Schaufele, MA, CCC-SLP, BCS-S
When considering the potential for dysphagia in patients following intubation, tracheostomies, and mechanical ventilation, a speech-language pathologist (SLP) must have a strong understanding of what these interventions are and how they may impact anatomy and physiology. While the patient population with tracheostomies is growing each year secondary to advancements in medical care and interventions to sustain life more so than historically, in this year of the pandemic, speech-language pathologists face the potential for an unprecedented number of patients. Following the pandemic and COVID-19 treatments – the patient population is increasing more notably than in previous years.
In 2008, it was estimated that by the year 2020, there would be over 600,000 patients requiring prolonged mechanical ventilation.1 But little did that author know that in 2020 a pandemic would change the face of medical care. It is estimated that in 2020, 965,000 people will require mechanical ventilation due to COVID-19, not including other disease and injury processes.2 Combining these two predictions leads to the potential for a much higher number of patients than previously thought would occur.
Because of this new world with a pandemic, the population of patients with tracheostomies also is increasing and subsequently the population of patients with dysphagia grows. Research has indicated that anywhere from 45% to 86% of patients with tracheostomies aspirate, and up to 83% of them aspirate silently.3-6 For this reason, it is essential that speech- language pathologists hone their skills for working with and managing dysphagia. Because SLPs play a central and critical role in the assessment of dysphagia, they also will have a critical role in the care of patients following intubation and tracheostomy.
Considering that the appearance of COVID-19 throughout the world has risen to the label of pandemic, understanding what it is and how it may impact swallowing and patient populations is essential. COVID-19 is the name given to disease that is caused by the SARS-CoV-2 virus. While 81% of the people who get COVID-19 have a mild to moderate case of it, 14% of these patients are severe and 5% have been critical, requiring extended hospitalization.7 Considering all patients who contract COVID-19, a range of 3% to 17% developed ARDS (Acute Respiratory Distress Syndrome), while most remain mild and manage their illness at home. This number is compared to a range of ARDS being 20% to 42% for hospitalized patients and 67% to 85% for patients admitted to the ICU.8 Among all patients who develop the severe classification of the disease, the average time to dyspnea (shortness of breath) is 5 to 8 days.9 However, those who develop ARDS do so within a median of 8 to 12 days.9 Why is this significant? Well, when a patient progresses to ARDS, this level of disease often requires intubation and may lead to tracheostomy.
The process of intubation involves the passage of an endotracheal tube into the mouth or nose and progression into the lower airway. The tube passes through the vocal cords and remains in place for an extended time. Intubation is indicated for respiratory failure, which is defined as the inability of the lungs to transfer inhaled oxygen to the blood and to move CO2 from the blood to exhalation. Respiratory failure is defined as having a PaO2 of < 60 on room air (oxygen pressure in the arterial blood which reflects how well oxygen moves from the lungs to the blood) or pCO2 > 50 with ph < 7.35 is considered respiratory failure and can be caused by many reasons. In patients with COVID-19, escalating oxygen requirements can have a rapid progression over a few hours. If the patient is seen to have increased work of breathing, increased tidal volumes, and worsening mental status then intubation may be considered.10 Intubation used to be considered a relatively common hospital procedure. However, with the onset of COVID-19, it has become a critical function necessary in some patients for survival.
Historically, if a patient was intubated between 3 – 21 days and continued to require mechanical ventilation, then a tracheostomy would be performed to provide the support through a different access point.11 However, with COVID-19, the period of intubation is being reported to last much longer than previous recommendations. Since COVID-19 is extremely contagious and both intubation and tracheostomy tube insertion are aerosol generating procedures (AGP), the length of time for intubation is being extended and reported up to 30 days and in some cases even longer.
The issue of intubation prior to tracheostomy must also be considered because the presence of an endotracheal tube prior to tracheostomy is thought to cause sensory changes within the upper airway and within the laryngeal system. With the endotracheal tube passing through the vocal cords, this sensory change is thought to be secondary to alteration in chemo- and mechanoreceptors, and also has an impact on the epithelialization of the mucosal tissue. Fortunately, much of this is thought to be reversible within 7 days of restoration of upper airway airflow.12 These sensory changes, along with the other related issues, can negatively impact swallowing. One crucial decision for patients following intubation or tracheostomy is whether or not to resume oral feeding.
The management of tracheostomies has been discussed frequently in recent times as the advent of the COVID-19 pandemic has impacted many considerations for how tracheostomies should be managed. A tracheotomy is the surgical procedure that is conducted to place a tracheostomy tube in the airway to assist with breathing. Often, when prolonged mechanical ventilation may be required, the tracheotomy is performed to optimize weaning from ventilatory support. Research findings are indicating that a tracheostomy may be considered with prolonged intubation of 21 days or longer in patients who have a good prognosis and few co-morbidities.13
The placement of a tracheostomy tube and prolonged mechanical ventilation with an inﬂated cuﬀ causes a disconnect between the upper and lower airway. The lack of airﬂow through the upper airway can often lead to multiple negative changes aﬀecting speech and swallowing: reduced subglottic pressure,14 decreased sensation to the pharynx and glottis,14 reduced laryngopharyngeal reﬂex,15 decreased ability to manage secretions requiring more frequent suctioning,16 decreased sense of taste and smell,17 inability to vocalize, increased aspiration risk, and muscle disuse and atrophy.18 A disconnect between respiration and swallowing also may impact the ability to coordinate breathing and swallowing.
The weight of the tracheostomy tubing and an inﬂated cuﬀ also have been shown in some research to decrease the range of motion of the hyolaryngeal mechanism by causing a tethering eﬀect.19 These changes and the signiﬁcance of their potential impact on swallowing dictate that this patient population must be carefully evaluated, and instrumental assessment pursued should the patient exhibit any signs or symptoms of dysphagia. The incidence of dysphagia secondary to an artificial airway, such as a tracheostomy, and prolonged mechanical ventilation, in critical ill patients is high (50-83%).20 Studies also have shown that the rate of respiratory infections in tracheostomized patients is very high (some report as much as 100%). While these patients are often seen for swallowing evaluations, questions arise as to the best practice for patients with tracheostomy following COVID-19. This patient population is especially susceptible to potential swallowing issues due to the prolonged intubation, tracheostomy, and generalized weakness that develops. Research has shown that re-establishment of the upper airway assists with improving physiologic functions, sensation, and speech and swallowing abilities.16 Airflow through the upper airway is achieved with several methods.
Airflow through the Upper Airway
When a tracheostomy tube is placed in the upper airway, typically, the initial placement involves the use of a cuffed tracheostomy tube. The cuff has a primary purpose of sealing the airway for mechanical ventilation, so that airflow is redirected in and out through the tracheostomy tube and does not pass through the upper airway when the cuff is inflated. Not only does having an inflated cuff impact physiology, but a risk is over-inflation of the cuff, possibly pushing into the posterior tracheal wall and leading to impingement of the esophagus. Tracheal pressure, from cuff inflation, also has been shown to negatively impact movement of the larynx during swallowing; however, even more significantly is the consideration that tracheal pressure during laryngeal elevation may lead to pressure necrosis, or additional tracheal wall damage such as tracheomalacia, stenosis, or fistula.21 In addition, an inflated cuff also blocks exhalatory airflow into the upper airway, leading to loss of speech, diminished cough and throat clear, and desensitizing of the larynx. Unfortunately, speech-language pathologists lack consensus regarding assessment of the swallow function of a patient with a tracheostomy and a cuff‐inflated condition, and a review of the research is inconclusive.22
Whether the patient was intubated and then extubated (without a tracheostomy tube) or the patient ended up with a tracheostomy, the speech-language pathologist (SLP) is in a unique position to provide early intervention and rehabilitation to these patients with COVID-19. Following extubation (removal of the endotracheal tube), the speech-language pathologist should assess for post-extubation dysphagia. Post-extubation dysphagia has been well documented in the research with a systematic review saying the incidence of dysphagia ranges from 3% to 62% in patient’s who have been intubated.23 The higher numbers were associated with intubations between 5 – 14 days, while with COVID-19 intubation is lasting for this period and even much longer. This longer intubation would be a cause for suspecting dysphagia. Brodsky and colleagues (2018) report that the symptoms for dysphagia include: dysphonia in 76%, odynophagia (pain with swallowing) in 76%, dysphagia reports in 49%, laryngeal dyspnea (shortness of breath) in 23%, and stridor in 7%.24 Brodsky and colleagues also reported on pathologies associated with post-extubation assessments and provided that edema, granulation tissue, vocal fold paresis, mucosal lesions, and subglottic stenosis were just a few of the pharyngeal, laryngeal, and tracheal pathologies observed.24 Because many patients with COVID-19 face prolonged intubations with extubation, these previously reported changes secondary to the endotracheal tube would be suspected for the current COVID-19 patient population, maybe even more severely since the intubation periods are longer than previously investigated.
For those patients who could not be successfully extubated and required tracheostomy, additional considerations would be related to the cuff status. The tracheostomy tube cuff is inflated with mechanical ventilation to seal the airway for more efficient respiratory support. However, with COVID-19 patients, there is a combination of the prolonged intubation and tracheostomy tube consideration. When dealing with COVID-19 patients, some recommendations have suggested to over-inflate the cuff which has its own risks for negatively impacting function and anatomy. During assessment, close evaluation of voice parameters, swallowing functions, cranial nerve function, and cough strength should be considered essential in this patient population. For a complete assessment of voice and cough, being able to deflate the cuff and to provide a speaking valve may be considered essential. Research has shown that use of a speaking valve restores taste and smell, voice, improved subglottic pressure and subsequent improved cough, and improved secretion management.
Findings in current research are inconsistent as to the relative safety and benefit of cuff inflation or deflation during swallowing. However, research has shown that the use of a no leak, one-way speaking valve (Passy Muir Valve®) can provide benefit during swallowing by increasing laryngeal excursion, returning cough and throat clear, and providing overall improved protection of the airway.25 Research also has shown that disuse leads to muscular atrophy and weakness in relatively short periods of time. The COVID-19 patient population is impacted by potential delays in intervention due to the extended times with intubation and time to tracheostomy. This extended time should not be further compounded by waiting to intervene as this may contribute to significant dysfunction of the speech and swallow mechanisms. Additional contributing factors in this patient population are that the anatomy and physiology of the swallowing and voicing mechanisms are significantly altered when a patient is tracheostomized and ventilated.
Early assessment for the use of a bias-closed, no-leak speaking valve either for in-line use with the ventilator or with a spontaneous breather leads to early intervention. Early intervention and use of the PMV has been shown to have benefits with restoring the physiology of the upper airway to its more “normal” state by returning airflow through the upper airway during exhalation. This restoration of airflow to the upper airway allows evaluation of airway patency, vocal cord function, secretion management, swallowing, and communication skills. This patient population with COVID-19 faces challenges that have been unusual in that not only do they fight to breathe and have functional respiration, but COVID-19 has been shown to take both an overall physical and psychological toll. Furthermore, patients on mechanical ventilation often experience psychosocial distress related to their inability to communicate with family and caregivers and to participate in their own care. Early implementation of the PMV increases the opportunity for patients to speak, swallow, and participate in direct therapy sooner and has the potential to reduce anxiety, wean times, and lengths of stay. The restoration of communication has a positive psychological benefit and has been shown to decrease anxiety, stress, fear, and other negative effects, as does moving a patient to oral nutrition.26
Facing COVID-19 includes the provision of multiple services for these patients to assist with overall care and recovery. These patients face unprecedented trials. They have much longer intubations, tracheostomies with inflated cuffs, and separation from family and caregivers. This trifecta has the potential to cause long-term deficits both in swallowing and psychologically. Having these patients receive intervention to restore communication and swallowing, improves overall mental health which in turn impacts motivation and recovery.26 Taking into consideration the impacts from COVID-19, intubation, and tracheostomies on swallowing, instrumental assessments may be a key component to restoring patients’ abilities to eat and return to more normal function.
Meghan Schaufele is a Speech-Language Pathologist currently practicing in Myrtle Beach, South Carolina. She earned Board Certification in Swallowing and Swallowing Disorders in 2016. She has developed and taught continuing education courses on dysphagia and has contributed to educational programs at the university level. She has supervised graduate level students and clinical fellows in speech-language pathology. She is also a member of ASHA, SIG 13, Swallowing and Swallowing Disorders (Dysphagia), and has been the recipient of ASHA SPARC and ACE awards.
- 1. Zilberberg, M. D., & Shorr, A. F. (2008). Prolonged acute mechanical ventilation and hospital bed utilization in 2020 in the United States: Implications for budgets, plant and personnel planning. BMC Health Services Research, 8(1), 242. doi:10.1186/1472-6963-8-242
- 2. Halpern, N. A. and Tan, K. S. (2020). United States resource availability for COVID-19. Society for Critical Care Medicine, 3, 1 – 16. Retrieved from https://sccm.org/Blog/March-2020/United-States-Resource-Availability-for-COVID-19
- 3. Bergl, P., Kumar, G., Zane, A., Shah, K., Zellner, S., Taneja, A.,… Nanchal, R. (2018). 517: Acquired dysphagia after mechanical ventilation an underrecognized and undercoded phenomenon? Critical Care Medicine, 46(1), 243. doi: 10.1097/01.ccm.0000528535.80915.5b
- 4. Wilkinson, K., Freeth, H., & Kelly, K. (2015). ‘On the right trach?’ a review of the care received by patients who undergo tracheostomy. British Journal of Hospital Medicine, 76, 3. https://doi.org/10.12968/hmed.2015.76.3.163
- 5. Wallace S, & Wilson M. (2013). Swallowing safety in cuff-inflated tracheostomised ventilated critical care patients (Abstract and Poster). Intensive Care Society, State of the Art, London. Dysphagia in critical care. Available from: https://www.researchgate.net/publication/283854107_Dysphagia_in_critical_care [accessed May 12 2020
- 6. Suiter, D. (2005). Speaking valves and swallowing. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 14 (4), 14 -18. https://doi.org/10.1044/sasd14.4.14
- 7. Li, Q., Guan, X., Wu, P., Wang, X., Zhou, L., Tong, Y.,… Feng, Z. (2020). Early transmission dynamics in Wuhan, China, of novel Coronavirus-Infected Pneumonia. New England Journal of Medicine, 382, 1199–1207. doi: 10.1056/NEJMoa2001316
- 8. Guan, W. J., Ni, Z. Y., Hu, Y., Liang, w, Ou, C., He, J., … Zhan, N. S. (2020). Clinical characteristics of coronavirus disease 2019 in China. New England Journal of Medicine. doi: 10.1056/NEJMoa2002032
- 9. Lauer, S. A., Grantz, K. H., Bi, Q., Jones, F. K., Zheng, Q., Meredith, H. R., …Lessler, J. (2020). The incubation period of Coronavirus Disease 2019 (COVID-19) from publicly reported confirmed cases: Estimation and application. Annals of Internal Medicine, 1-7. doi:10.7326/M20-0504
- 10. Ansei, G. L. (2020). Coronavirus disease 2019 (COVID-19): Critical care and airway management issues. Retrieved from https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-critical-care-and-airway-management-issues
- 11. Mahafza, T., Batarseh, S., Bsoul, N., Massad, E., Qudaisat, I., & Al-Layla, A. E. (2012). Early vs late tracheostomy for the ICU patients: Experience in a referral hospital. Saudi Journal of Anaesthesiology, 6 (2): 152 -154. doi: 10.4103/1658-354X.97029
- 12. deLarminat, V., Montravers, P., Dureuil, B., & Desmonts, J. M. (1995). Alterations in swallowing reflex after extubation in intensive care unit patients. Critical Care Medicine, 23(3), 486-90.
- 13. Chao,T. N., Braslow, B. M., Martin, N. D., Chalian, A. A., Atkins, J. H., Haas, A. R., & Rassekh, C. H. (in press). Tracheostomy in ventilated patients with COVID-19. Annals of Surgery, 0, 00.
- 14. Eibling D & Gross R. (1996). Subglottic air pressure: a key component of swallowing efficiency. Annals of Otology, Rhinology & Laryngology, 105 (4), 253-258.
- 15. Sasaki, C., Suzuki, M., Horiuchi, Masatoshi, H., & Kirchner, J.A. (1997). The effect of tracheostomy on the laryngeal closure reflex. The Laryngoscope, 87, 1428-1433.
- 16. Siebens, A. A., Tippett, D. C., Kirby, N., & French, J. (1993). Dysphagia and expiratory air flow. Dysphagia, 8(3), 266-269. doi:10.1007/bf01354549
- 17. Lichtman, S. W., Birnbaum, I. L., Sanfilippo, M. R., Pellicone, J. T., Damon, W. J., & King, M. L. (1995). Effect of a tracheostomy speaking valve on secretions, arterial oxygenation, and olfaction: A quantitative evaluation. Journal of Speech Language and Hearing Research, 38(3), 549-555. doi:10.1044/jshr.3803.549
- 18. Griffiths R & Jones C. (1999). Recovery from intensive care. British Medical Journal, 319, 427.
- 19. Ding R. & Logeman J. (2005). Swallow physiology in patients with trach cuff inflated or deflated: A retrospective study. Head & Neck, 27(9), 809-13.
- 20. Carmona, A. F., Díaz, M. A., Alonso, E. A., Guarasa, I. M., López, P. M., & Castellanos, M. D. (2015). Use of speaking valve on preventing respiratory infections in critical traqueostomized patients diagnosed of dysphagia secondary to artificial airway. Edisval study. Intensive Care Medicine Experimental, 3(Suppl 1). doi:10.1186/2197-425x-3-s1-a936
- 21. Goldsmith, T. (2000). Evaluation and treatment of swallowing disorders following endotracheal intubation and tracheostomy. International Anesthesiology Clinics, 38, 219–242.
- 22. Goff, D. & Patterson, J. (2018). Eating and drinking with an inflated tracheostomy cuff: a systematic review of the aspiration risk. International Journal of Language & Communication Disorders, 54(1), 30 – 40.
- 23. Skoretz, S. A., Flowers, H. L., & Martino, R. (2010). The incidence of dysphagia following endotracheal intubation: A systematic review. Chest, 137, 665–673.
- 24. Brodsky, M. B., Levy, M. J., Jedlanek, E., Pandian, V., Blackford, B., Price, C., . . . Akst, L. M. (2018). Laryngeal injury and upper airway symptoms after oral endotracheal intubation with mechanical ventilation during critical care: A systematic review. Critical Care Medicine, 46, 2010–2017.
- 25. Suiter, DM, McCullough, GH, & Powell, PW. (2003). Effects of cuff deflation and one-way tracheostomy speaking valve placement on swallowing physiology. Dysphagia, 18, 284-292.
- 26. Freeman-Sanderson, A. L., Togher, L., Elkins, M .R., & Phipps, P. R. (2016). Return of voice for ventilated tracheostomy patients in ICU: A randomized, controlled trial of early-targeted intervention. Critical Care Medicine, 44(6), 1075-1081. doi:10.1097/ccm.0000000000001610