The Problem: Mismanagement of Dysphagia in Patients with a Tracheostomy
It is well known that patients with a tracheostomy are at risk of dysphagia. Incidence of dysphagia is reported to be approximately 50% in this patient population with a high risk of aspiration (86%) and silent aspiration (83%) (Hafner, Neuhuber, Hirtenfelder, Schmedler, and Eckel, 2008; Wallace and Wilson, 2013). Without proper dysphagia management, patients are at greater risk for developing aspiration pneumonia which can lead to longer lengths of stay and increased hospital costs. Additionally, patients with dysphagia report lower self-esteem, a sense of discomfort, and poor quality of life (Farri, Accornero, and Burdese, 2017). It has been established that early referral to speech language pathology (SLP) for dysphagia intervention in the patient with a tracheostomy may result in faster return and improved tolerance of oral diets (Fröhlich, Boksberger, Barfuss-Schneider, Liem, and Petry, 2017; Mah, Staff, Fisher, and Butler, 2017).
However, many hospitals do not have standardized protocols for timing of speech language pathology referrals which can result in mismanagement of dysphagia in the patient with a tracheostomy. Some patients may be considered too medically fragile to begin oral intake and thus remain NPO longer than necessary. Disuse atrophy can occur from limited use of the oropharyngeal musculature which may result in further exacerbation of dysphagia. Conversely, patients may be placed on an oral diet without SLP involvement, thereby increasing the risk for aspiration. Patients are at risk for negative physiologic and psychologic consequences when dysphagia is not safely and effectively managed (Farri et al. 2017; Mah et al. 2017; Rodrigues, Machado, Chiari, Rosseti, Lorenzon, and Gonçalves, 2015).
Etiology of Dysphagia in Patients with a Tracheostomy
It is important to appreciate the complex nature of dysphagia in this patient population. The etiology of dysphagia is multifactorial and the SLP must have a thorough understanding of all factors which may contribute to or cause dysphagia. Some potential causes and contributors of dysphagia in this patient population include:
- Primary diagnosis such as stroke, traumatic brain injury, progressive neurologic disease, and head and neck cancer.
- Advanced age and decreased functional reserve.
- Critical illness myopathy.
- Altered mental status.
- Iatrogenic causes related to medication, cranial nerve injury, and prolonged intubation.
- Tracheostomy-related complications, including reduced subglottic pressure, impaired laryngeal elevation, desensitization of the larynx, disuse atrophy of the larynx, impaired breathing and swallowing coordination, and decreased effectiveness of the cough to clear secretions (Ding and Logemann, 2005; Amathieu et al., 2012; Prigent et al., 2011, Gross, Mahlmann, and Grayhack, 2003).
Inconsistencies and Complications in Management of the Patient with a Tracheostomy
Due to the heterogenous nature of this population, patients with tracheostomy are often managed by different teams in various locations throughout the hospital. This can result in variances in practice patterns. Some of these inconsistencies include: sizing of the tracheostomy tube, timing of the initial tracheostomy tube change, management of cuffs, decannulation protocols, emergency procedures, care and cleaning, patient and family education, and timing of referrals to speech pathology for communication and swallowing assessments (de Mestral et al., 2011; Mitchell et al., 2013; Norwood, Spiers, Bailiss, and Sayers, 2004). Numerous complications can arise without focused attention to tracheostomy practice, including longer length of stay and adverse events (Garruba et al., 2009). Additionally, without standard protocols in place for SLP referrals, patients with tracheostomy and dysphagia may be inappropriately managed which can contribute to prolonged hospitalizations.
The Solution: Improving Practice with a Tracheostomy Team
The lack of standardized care and the associated complications have led several institutions to develop and implement tracheostomy teams to manage patients with tracheostomies. A systematic review and meta-analysis of the literature regarding tracheostomy teams was conducted by Speed and Harding (2013). The authors reported evidence that multidisciplinary care leads to faster decannulation and increased speaking valve use resulting in improved quality of life. Garrubba et al. (2009) reported reduced time to decannulation, lengths of stay, and adverse events when patients with tracheostomy tubes were managed with a multidisciplinary team as compared with standard care.
Furthermore, recent research has reported swallowing benefits with the implementation of a tracheostomy team. Santos, Harper, Gandy, and Buchanan (2018) studied the impact of a multidisciplinary tracheostomy team on the overall care of post-tracheostomy patients. They reported improved care of patients with tracheostomy tubes which was demonstrated by decreased ICU length of stay and total hospital length of stay, expedited weaning from ventilator, earlier use of Passy Muir Valves, earlier decannulation, fewer tracheotomy-related complications, and earlier oral diet initiation after the implementation of a multidisciplinary tracheostomy team.
Mah et al. (2017) studied tolerance of oral diets pre-tracheostomy service and after implementation of a tracheostomy service with a care bundle. The care bundle included a standard order set with automated referrals to speech language pathology, a tracheostomy tracking and following system, a respiratory therapy driven decannulation protocol, and a formal rounding process. The authors reported significant improvement in the timing of speech language pathology consults and in the tolerance of oral diets. They concluded, “a critical step involved our speech language pathologist early in the post-tracheostomy period” (Mah et al., 2017).
Another study which described the benefit of standardized orders to SLP as part of the tracheostomy team protocol was conducted by Welton, Morrison, Catalig, Chris, and Pataki (2016). Authors stated that having automated referrals to speech pathology resulted in faster communication and swallowing assessments. They summarized, “With timely SLP services, patients could be placed on the most appropriate diet textures and liquid consistencies to decrease aspiration risk and, ultimately, improve the quality of patient care” (Welton et al., 2016).
SLP Role as an Integral Member of the Tracheostomy Team
The role of the speech language pathologist on the multidisciplinary tracheostomy team includes but is not limited to collaboration regarding types and sizes of tracheostomy tubes needed to facilitate improved communication and swallowing, intervention to establish effective communication for the patient with ventilator dependence and non-ventilator dependence, conducting swallowing assessments (e.g. clinical bedside swallowing evaluation, FEES, and MBS), providing dysphagia treatment, rounding with the multidisciplinary team, and delivering patient and staff education. “The role of the speech language therapist [pathologist] is key, not only in assessing and managing swallowing and communication needs, but in contributing experience and expertise to all relevant tracheostomy-related decisions, as part of the multidisciplinary team process” (McGrath and Wallace, 2014).
Use of the Passy Muir Valve to Improve Swallow Function
One common method of improving communication and swallowing in patients with tracheostomy is use of the Passy Muir® Valve (PMV®). The PMV is a closed-position valve which redirects airflow up through the vocal folds, mouth, and nose. Use of the Valve allows the patient to create positive airway pressure and restores the patient to a more normal, closed respiratory system. This restoration of positive pressure and airflow through the upper airway has been reported to improve secretion management, cough effectiveness, and swallowing ability.
Gross et al. (2003) investigated the impact of subglottic pressure on swallowing physiology in patients with a tracheostomy tube and found that when the Passy Muir Valve was on, patients demonstrated lower penetration-aspiration scores, faster bolus transit time, and shorter pharyngeal muscle duration time. The authors concluded that the “pharyngeal swallowing physiology is measurably different in the absence of airflow and subglottic air pressure (open tube) as compared to the closed tube condition, in which airflow is redirected through the glottis and subglottic pressure is increased (Gross et al., 2003). Several studies (Blumenfeld, Salgado, Wade, Dhupa, Ling, and Belafsky, 2011; O’Connor, Morris, and Paratz, 2019; Suiter, Mccullough, and Powell, 2003) corroborated the findings of reduced aspiration with use of the Passy Muir Valve as compared to an open tracheostomy tube.
Fröhlich et al. (2017) studied early implementation of the Passy Muir Valve with a team approach. One of the parameters addressed in their study was the timing from tracheostomy to oral intake. Patients who received the Valve with a multidisciplinary team approach did so earlier in their care and had restored voicing, communication, and improved swallowing. The authors concluded that “by means of PMV, ventilated intensive care patients are able to communicate verbally and to swallow better” (Fröhlich et al., 2017). Early swallowing intervention was also studied by Rodrigues et al., (2015). They studied the feasibility of early implementation of a swallowing rehabilitation program in patients with tracheostomy and mechanical ventilation with dysphagia. The patients participated in a swallowing rehabilitation program with use of a Passy Muir Valve. The authors stated that swallowing rehabilitation with the PMV is feasible for patients on mechanical ventilation and may help to improve the swallowing function and oropharyngeal dysphagia severity. They summarized that “a rehabilitation program can contribute to minimize the negative aspects of food restriction, including patient discomfort, muscular atrophy, decreased oropharyngeal structure sensitivity and nutritional deficiencies. It can also contribute to reducing the risks related to the presence of a feeding tube and bronchial aspiration” (Rodriguez et al., 2015).
The role of a tracheostomy team is increasingly recognized as vital in improving the quality of life and safety of care for the patient with a tracheostomy. Additionally, tracheostomy teams can result in more timely referrals to speech language pathology. This allows the SLP to provide early intervention which may include working toward restoration of airflow to the upper airway with cuff deflation, use of the PMV during mechanical ventilation, conduction of timely swallowing assessments, development of individualized treatment plans, and provision of early treatment for patients with tracheostomies. This early involvement by SLP leads to faster return to oral intake and improved tolerance of oral diets, thus improving patient outcomes and quality of life.
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