Dysphagia intervention in the ICU is often complex, and speech-language pathologists (SLP) may have questions about best practice for patients with tracheostomy tubes and mechanical ventilation. This three-part series will provide answers to some of those questions. The goal is to provide evidence-based information as well as practical suggestions to manage dysphagia in this patient population. This article (part one) includes information on research regarding dysphagia in patients with tracheostomy and mechanical ventilation, the importance of early invention for communication and swallowing, and suggestions to increase SLP involvement in the ICU. Part two will focus on assessment considerations, and part three will discuss treatment with a focus on rehabilitative swallowing therapy for this patient population.  Let’s get started with some frequently asked questions. 

Can ICU patients with tracheostomy and mechanical ventilation eat and drink?

The short answer is yes; many patients can eat and drink safely during mechanical ventilation, even in the ICU. Of course, there are many factors to consider regarding patient candidacy for assessment such as patient goals of care, level of alertness, medical stability, current diagnosis, past medical history, comorbidities, trajectory of illness, vital signs, and overall clinical picture. Although these are important considerations to ponder and discuss with the medical team, individual decision-making is needed. Patient readiness criteria in many cases may focus on medical stability and level of alertness, impacting the ability to participate.  Using overly stringent standards to determine patient candidacy for a swallowing evaluation could result in eliminating patients who may be able to swallow safely and efficiently and could delay necessary dysphagia intervention. 

Admittedly, there is limited research regarding swallowing during mechanical ventilation. Research has suggested that many patients with tracheostomy and mechanical ventilation can eat and are good candidates for swallowing intervention. Leder (2002) investigated swallowing in patients with tracheostomy and mechanical ventilation via Fiberoptic Endoscopic Evaluation of Swallowing (FEES). The author reported that 67% of patients assessed did not aspirate, 33% of patients aspirated, and of the group of patients who aspirated, 82% exhibited silent aspiration. This study is encouraging in that many patients with tracheostomy and mechanical ventilation swallowed successfully. It also indicates the need to strongly consider instrumental exams in this patient population due to the high risk of silent aspiration. 

Rodrigues et al. (2015) conducted a study that provided meaningful results regarding dysphagia management during mechanical ventilation. The authors investigated early implementation of a swallowing rehabilitation program in patients with tracheostomy and mechanical ventilation. Patients enrolled in this study first underwent assessment for use of a Passy-Muir Valve (PMV) and then swallowing was assessed via Fiberoptic Endoscopic Evaluation of Swallowing (FEES). Swallowing therapy included use of in-line PMV, indirect swallowing therapy, and direct swallowing therapy. Seventy-eight percent of patients who participated in the swallow therapy program were able to receive oral feeding while in the ICU. This study showed that swallowing intervention during mechanical ventilation is feasible and may help to improve swallowing function and allow for the initiation of eating and drinking in the ICU.

What about ventilator modes and settings? Do they matter for swallowing? 

First, what are the common modes of ventilation?

  • Controlled Mandatory Ventilation (CMV): In CMV, there is a set respiratory rate and every breath delivered to the patient is a mechanical breath. CMV may be pressure controlled or volume controlled.
    • Volume Control (VC) – The ventilator is set to deliver a specific Tidal Volume (Vt) with each breath at a preset rate. The patient can take as many additional breaths as desired, but all breaths will be full mechanical breaths.
      • Tidal Volume is derived by a calculation based on the patient’s ideal body weight.
    • Pressure Control (PC) – The ventilator is set to deliver a certain amount of pressure with each breath. The amount of pressure is determined by the targeted Tidal Volume.
  • Supported or spontaneous modes: Every breath is a spontaneous breath triggered by the patient and supported by the ventilator. There is not a set respiratory rate. Examples of support modes include:
    • Pressure Support (PS) – The ventilator provides a set amount of pressure to augment spontaneous breaths.
    • Continuous Positive Airway Pressure (CPAP) – The ventilator maintains positive pressure in the airway to prevent alveolar collapse.
  • Combination modes: These are modes of ventilation which combine controlled and supported breaths. An example of a combination mode is SIMV:
    • Synchronized Intermittent Mandatory Ventilation (SIMV) – The ventilator delivers a set Tidal Volume and breath rate, but when the patient triggers an additional breath, it will be a spontaneous breath. This mode is typically used with PS to augment the spontaneous breaths. 

Next, what does that mean for swallowing? Higher modes of ventilation, such as CMV which have a mandatory breath rate may result in the patient having less control over the timing of breathing and swallowing. For example, in VC or PC, a breath could be delivered mid-swallow. For some patients this dyssynchrony, could negatively impact swallowing. In contrast, spontaneous modes of ventilation, such as pressure support which does not have a set breath rate, may result in a better opportunity for breathing and swallowing coordination. While this is a consideration, it does not mean that all patients in volume control or pressure control will exhibit dysphagia. Some patients CAN swallow safely and efficiently even in higher modes of ventilation. Therefore, SLPs should not base decisions regarding swallowing intervention solely on the level of ventilatory support a patient is receiving. Again, criteria for assessment should not be too stringent. 

Does the tracheostomy impact swallowing?

Critically ill patients who require a tracheostomy often have dysphagia. The etiology of dysphagia in this patient population is multifactorial. Some research indicates that the presence of a tracheostomy tube may alter many of the sensorimotor actions needed for an intact swallow. Changes in smell and taste (Tsikoudas et al., 2011), reduced hyolaryngeal excursion (Amatheiu et al., 2012), lack of subglottic air pressure (Gross et al., 2003), impaired breathing and swallowing coordination (Prigent et al., 2011), and cough function changes (Park et al., 2018) have been reported in patients with tracheostomy tubes. Additionally, swallowing may be more compromised when the tracheostomy tube cuff is inflated versus cuff deflated (Ding & Logeman, 2005; Amathieu et al., 2012). In a recent systematic review, after analyzing multiple studies, Goff and Patterson (2018) concluded that patients with a tracheostomy should have a swallowing evaluation, regardless of cuff condition. They also recommended that patients be seen and evaluated on a case-by-case basis to determine return to oral nutrition. The authors acknowledged that to date research has not presented a consensus in order to establish a standard of care for tracheostomy and cuff management as they relate to swallowing.

For more information regarding the impact of tracheostomy tubes and cuffs on swallowing, please see: 

https://dysphagiacafe.com/2020/09/24/impact-of-a-tracheostomy-on-swallowing/.

Does the patient need cuff deflation and in-line PMV in place to eat and drink?

In many instances, a deflated cuff and use of the PMV improves swallowing efficiency and safety (airway protection).  The PMV restores positive airway pressure and airflow to the upper airway. Research has shown that this redirection of airflow assists with improving sensory awareness, secretion management, cough, and minimizing occurrences of aspiration (O’Connor et al., 2019). 

For more information regarding the impact of the Passy-Muir Valve on swallowing, please see: https://dysphagiacafe.com/2020/02/17/the-role-of-pressures-in-swallowing-and-impact-of-the-passy-muir-valve/

However, research regarding dysphagia and tracheostomy is highly variable. Skoretz et al. (2020) conducted a scoping review of the literature and found inconsistencies regarding the impact of the cuff and tracheostomy tube occlusion. So, while there may be a positive impact on swallowing for some patients with use of a PMV, cuff deflation and PMV use should not be a prerequisite for dysphagia assessment. Some patients may be able to swallow efficiently with the cuff inflated, even during mechanical ventilation. Thorough assessment and individual decision-making are essential.  

When should SLPs receive orders for communication and swallowing evaluations? When should assessment begin?

Ideally, SLP orders for communication and swallowing assessment and treatment should be included in the tracheostomy order set, and intervention should begin in the ICU. 

Early communication in the ICU:

Early communication results in fewer preventable adverse events (Bartlett et al., 2008), allows patients to participate in decision-making, improves access to better pain management (Limaye & Katz, 2006), and may result in improved quality of life for patients in the ICU (Freeman-Sanderson et al., 2016). Freeman-Sanderson et al. (2016) examined the effects of early communication intervention with in-line PMV for patients in the ICU. The authors reported no increase in patient complications for patients who used the PMV in-line with mechanical ventilation. However, they found that patients with early communication reported significant improvements in self-esteem, being understood by others, cheerfulness, and quality of life.

Use of the PMV is often the communication goal for patients with tracheostomy. However, patients with tracheostomy and mechanical ventilation in the ICU may not meet the facility guidelines for cuff deflation and in-line PMV placement initially. Therefore, communication intervention may begin with implementing the most effective non-verbal means of communication or considering use of a “talking tracheostomy tube”. There are several types of talking trachs currently available which may allow patients who are unable to tolerate cuff deflation to achieve phonation. Pandian et al. (2014) described various talking trachs and their use with critically ill patients who were unable to tolerate cuff deflation during mechanical ventilation. The authors reviewed the advantages, potential problems and practical solutions, and the role of the SLP when using these specialty tracheostomy tubes. They concluded that clinicians should consider the use of talking trachs for patients who cannot tolerate cuff deflation. 

Once the patient has met readiness criteria for cuff deflation and PMV, the SLP and RT can work toward in-line PMV use. Clinicians often use the following ventilator settings as guidelines for PMV candidacy: 

  • FIO2 ≤ 50% 
    • Fraction of Inspired Oxygen: The amount of oxygen the ventilator delivers.
  • PEEP ≤ 10 cm H2O
    • Positive End-Expiratory Pressure: This setting maintains small end-expiratory pressure to help prevent alveolar collapse and improve oxygenation.
  • PIP/PAP ≤ 40 cmH20
    • Peak Inspiratory Pressure: The highest level of pressure applied to the lungs during inhalation. 

Early swallowing in the ICU: 

Research regarding muscle weakness and dysphagia in the ICU, as well as research findings showing improved patient outcomes with early intervention, further support the need for early intervention in the ICU. Shepherd et al. (2017) reported that 25% to 83% of patients in critical care experience critical illness polyneuromyopathy which is the most common cause of neuromuscular weakness in the ICU and a major cause of failure to wean from the ventilator. Ponfick et al. (2015) reported that 91% of patients with critical illness polyneuropathy (CIP) and tracheostomy exhibited dysphagia. The authors reported that dysphagia in CIP may result from various contributing factors, including a “learned nonuse” of swallowing muscles during prolonged ICU treatment. This research indicates that many patients in the ICU have muscle weakness and dysphagia. Delaying swallowing intervention could potentially lead to further exacerbation of dysphagia due to disuse atrophy. 

Cameron et al. (2015) found that early rehabilitation in the fields of physical and occupational therapy resulted in fewer ventilator-dependent days, shorter ICU and hospital stays, and improved functional outcomes. Exercise principles to promote improved strength and endurance for mobility may also be applied to improving strength and endurance of the muscles of deglutition (Burkhead, 2007). Fröhlich et al. (2017) examined early intervention with use of a team approach for patients with tracheostomy and mechanical ventilation. One of the parameters reviewed in their study was the timing from tracheostomy to oral intake. The authors concluded that with early intervention and in-line PMV, ventilated intensive care patients were able to communicate verbally and had improved swallowing with earlier oral intake than in those patients without early intervention.

Dysphagia assessment for patients with tracheostomy and mechanical ventilation in the ICU may begin with a limited bedside swallowing assessment including oral care, an oral mech exam, and po (per os) trials of minimal ice chips. Whenever possible, an instrumental swallowing evaluation should be conducted to thoroughly assess swallowing function. Part two of this series will delve into more information directly related to swallowing assessment for patients with tracheostomy and mechanical ventilation.

How do I advocate for an SLP to be part of the ICU team? 

In many hospitals, the SLPs are critical members of the ICU team treating patients with tracheostomy and mechanical ventilation. However, some hospitals may not realize the important role of the SLP in the ICU. This requires SLP advocacy. Some considerations to increase SLP presence and teamwork in the ICU include:

  • Obtain education regarding care of the patient in the ICU (i.e.: lines, drains, tubes, artificial airways, mechanical ventilation, medications, vital signs, monitoring, etc.).
  • Learn from respiratory therapists. When working with patients requiring mechanical ventilation, it is very helpful to understand ventilator modes and settings. 
  • Familiarize yourself with tracheostomy tube components, sizes, brands, and types used at your facility, and proper cuff management. Consider obtaining training for suctioning (if your state and facility allow the SLPs to suction).
  • Attend team rounds and establish rapport with team members.
  • Establish an airway management team, if not already in place. There is considerable data which shows improved patient outcomes when patients are managed with a dedicated multidisciplinary trach team (Bonvento et al. 2017; Santos et al. 2018). Share this data with the ICU staff. 
  • Provide education to ICU teams about the important role of the SLP in the ICU.  Share research about improved patient outcomes and quality of life measures with communication and swallowing intervention.
  • Work with ICU staff to update tracheostomy policies and protocols.
  • Create a tracheostomy order set which includes referrals to speech pathology.
  • Consider investing time and money into establishing a FEES program. Often, FEES is the go-to instrumental exam in the ICU. (More details to follow in part two of this series).

Key Points:

  • Many patients in the ICU with tracheostomy and mechanical ventilation are candidates for dysphagia assessment and treatment. 
  • There are factors to consider such as mental and medical status, tracheostomy cuff status, ventilator settings, and use of the PMV when determining patient candidacy for assessment. However, criteria should not be too stringent as to eliminate patients who may be candidates for at least some po intake.
  • Early dysphagia intervention may result in better outcomes and often the SLP must advocate for increased referrals and involvement in the ICU.

*This is a sponsored post from Passy-Muir.

References: 

Amathieu, R., Sauvat, S., Reynaud, P., Slavov, V., Luis, D., Dinca, A., Tual, L., Bloc, S., & Dhonneur, G. (2012). Influence of the cuff pressure on the swallowing reflex in tracheostomized intensive care unit patients. British Journal of Anaesthesia109(4), 578-583. https://doi:10.1093/bja/aes210

Bartlett, G., Blais, R., Tamblyn, R., Clermont. R., & MacGibbon, B. (2008). Impact of patient communication problems on the risk of preventable adverse events in acute care settings. Canadian Medical Association Journal, 178, 1555-1562. https://doi:10.1503/cmaj.070690

Burkhead, L., Sapienza, C., & Rosenbek, J. (2007) Strength-training exercise in dysphagia rehabilitation; principles, procedures and directions for future research. Dysphagia, 22(3), 251-65.

Bonvento, B., Wallace, S., Lynch, J., Coe, B., & McGrath, B. A. (2017). Role of the multidisciplinary team in the care of the tracheostomy patient. Journal of Multidisciplinary Healthcare, 10, 391–398. https://doi.org/10.2147/JMDH.S118419

Cameron, S., Ball, I., Cepinskas, G., Choong, K., Doherty, T. J., Ellis, C. G., Martin, C. M., Mele, T. S., Sharpe, M., Shoemaker, J. K., & Fraser, D. D. (2015). Early mobilization in the critical care unit: A review of adult and pediatric literature. Journal of Critical Care, 30(4), 664–672. https://doi.org/10.1016/j.jcrc.2015.03.032

Ding, R., & Logemann, J. (2005). Swallow physiology in patients with trach cuff inflated or deflated: A retrospective study. Head & Neck27(9), 809-813. https://doi:10.1002/hed.20248

Freeman-Sanderson, A., Togher, L., Elkins, M., & Phipps, P. (2016). Return of voice for ventilated tracheostomy patients in ICU: A randomized, controlled trial of early-targeted intervention. Critical Care Medicine44(6), 1075-1081. https://doi:10.1097/ccm.0000000000001610

Fröhlich, M. R., Boksberger, H., Barfuss-Schneider, C., Liem, E., & Petry, H. (2017). Safe swallowing and communicating for ventilated intensive care patients with tracheostoma: Implementation of the Passy Muir speaking valve. Pflege30(6), 87-394. https://doi.org/10.1024/1012-5302/a000589

Goff, D. & Patterson, J. (2018).  Eating and drinking with an inflated tracheostomy cuff: a systematic review of the aspiration risk. International Journal of Communication and Language Disorders, 54(1), 30 – 40. https://doi.org/10.1111/1460-6984.12430

Gross, R., Mahlmann, J., & Grayhack, J. (2003). Physiologic effects of open and closed tracheostomy tubes on the pharyngeal swallow. Annals of Otology, Rhinology & Laryngology, 112(2), 143-152. https://doi:10.1177/000348940311200207

Leder, S. (2002). Incidence and type of aspiration in acute care patients requiring mechanical ventilation via a new tracheotomy. Chest122(5), 1721-1726. https://doi.10.1378/chest.122.5.1721

Limaye, S. & Katz, P. (2006). Challenges of pain assessment and management in the minority elderly population. Annals of Long Term Care14(11), 1–5. 

O’Connor, L., Morris, N., Paratz, J. (2019). Physiological and clinical outcomes associated with use of one-way speaking valves on tracheostomised patients: A systematic review. Heart and Lung, 8(4), 356-364. https://doi:10.1016/j.hrtlng.2018.11.006

Pandian, V., Smith, C. P., Cole, T. K., Bhatti, N. I., Mirski, M. A., Yarmus, L. B., & Feller-Kopman, D. J. (2014). Optimizing communication in mechanically ventilated patients. Journal of Medical Speech-Language Pathology, 21(4), 309–318.

Park, M, Lee, S. (2018). Changes in swallowing and cough functions among stroke patients before and after tracheostomy decannulation. Dysphagia33, 857–865. https://doi.org/10.1007/s00455-018-9920-9

Ponfick, M., Linden, R., & Nowak, D. A. (2015). Dysphagia–a common, transient symptom in critical illness polyneuropathy: a fiberoptic endoscopic evaluation of swallowing study*. Critical Care Medicine, 43(2), 365–372. https://doi.org/10.1097/CCM.0000000000000705

Prigent, H., Lejaille, M., Terzi, N., Annane, D., Figere, M., Orlikowski, D., & Lofaso, F. (2011). Effect of a tracheostomy speaking valve on breathing–swallowing interaction. Intensive Care Medicine38(1), 85-90. https://doi:10.1007/s00134-011-2417-8

Rodrigues, K. A., Machado, F. R., Chiari, B. M., Rosseti, H. B., Lorenzon, P., & Gonçalves, M. I. (2015). Swallowing rehabilitation of dysphagic tracheostomized patients under mechanical ventilation in intensive care units: A feasibility study. Revista Brasileira De Terapia Intensiva27(1), 64-71. https://doi.org/10.5935/0103- 507x.20150011

Santos, A., Harper, D., Gandy, S., & Buchanan, B. (2018). The positive impact of multidisciplinary tracheostomy team in the care of post-tracheostomy patients. Critical Care Medicine, 46(1), 591-591.

Shepherd, S., Batra, A., & Lerner, D. P. (2017). Review of critical illness myopathy and neuropathy. The Neurohospitalist7(1), 41–48. https://doi.org/10.1177/1941874416663279

Skoretz, S., Riopelle, S., Wellman, L., & Dawson, C. (2020). Investigating swallowing and tracheostomy following critical illness: A scoping review. Critical Care Medicine48(2), 141-151. https://doi:10.1097/CCM.0000000000004098

Tsikoudas, A., Barnes, M., & White, P. (2011). The impact of tracheostomy on the nose. European Archives of Oto-Rhino-Laryngology, 268(7), 1005-1008. https://doi:10.1007/s00405-011-1522-1

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