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This is the final article in the three-part series about dysphagia in patients with tracheostomy and mechanical ventilation. Part one included information on ventilator modes and settings, research regarding dysphagia in patients with tracheostomy and mechanical ventilation, the importance of early invention for communication and swallowing, and suggestions to increase the speech-language pathologist’s (SLP) involvement in the ICU. Part two focused on assessment including research on blue dye tests, advantages and disadvantages of Videofluoroscopic Swallow Study (VFSS) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES), and special considerations for patients with tracheostomy and mechanical ventilation. This article, part three, reviews dysphagia treatment including timing of intervention, important decision-making criteria, ice chip protocols, in-line Passy-Muir® Valve (PMV®) benefits, compensatory strategies, and rehabilitative exercise.
When should dysphagia treatment start?
Dysphagia intervention should begin in the ICU whenever medically feasible. As reviewed in part one of this series, Rodrigues et al. (2015) investigated early implementation of a swallowing rehabilitation program in patients with tracheostomy and mechanical ventilation. The authors found that seventy-eight percent of patients who participated in the swallow therapy program were able to receive oral feeding while in the ICU.
Dysphagia treatment should begin after an instrumental exam.
While the clinical swallowing evaluation has significant value, a VFSS or FEES is needed to design a treatment plan which is physiology based, rather than symptom based. Additionally, the instrumental exam can provide detailed information about swallowing function in different conditions such as cuff inflated and cuff deflated with in-line PMV. Diet and treatment recommendations should reflect those findings.
Dysphagia treatment should begin after considering the whole clinical picture.
Patients with dysphagia, tracheostomy, and mechanical ventilation in the ICU are a complex patient population and careful consideration of numerous factors is crucial when designing treatment plans. Some important decision-making criteria includes:
- Respiratory status and modes of ventilation
- Breathing and swallowing coordination is an important factor to consider. As reviewed in part one of this series, modes of mechanical ventilation which have a mandatory breath rate may result in the patient having less control over the timing of breathing and swallowing. Whereas spontaneous modes of ventilation may allow the patient to have more control over breathing and swallowing coordination. The current mode of ventilation may factor into treatment recommendations.
- Health status
- Many patients in the ICU requiring tracheostomy and mechanical ventilation have serious medical complications and comorbidities which could place them at higher risk for developing pneumonia if aspiration occurs. Current medical diagnoses, level of frailty, lab values, and the status of the immune system (white blood count, neutrophils, and lymphocytes) should be considered when making recommendations (Ashford, 2005).
- Mental status
- Ability to actively participate in a swallowing therapy program must be considered. Delirium, poor level of alertness, and language and cognitive impairments may negatively impact outcomes.
- Dependence on feeding and oral care
- Many patients in the ICU have dependence on care. In the hallmark study examining predictors of aspiration pneumonia, Langmore et al. (1998) found that dependence on oral care and feeding were the best predictors of developing aspiration pneumonia. The authors reported that dysphagia was an important risk factor but not sufficient to cause pneumonia unless other risk factors are present as well. (Langmore et al., 1998).
- Tracheostomy tube status
- Status of the cuff and the ability to use an in-line PMV may impact swallowing function, as well as the ability to perform various compensatory techniques and rehabilitative exercises. Cuff and PMV status should be considered when making therapy recommendations.
- Etiology of dysphagia
- Dysphagia in the ICU is usually multifactorial. The primary diagnosis, comorbidities, critical illness myopathy and polyneuropathy, prolonged intubation, and presence of a tracheostomy tube may all contribute to dysphagia. Treatment recommendations should target each cause and may require involvement from other ICU team members.
- Instrumental exam findings
- As mentioned above, an instrumental exam is needed to determine the appropriate treatment for specific physiologic deficits; however, it is important to remember that the VFSS and FEES provide information about swallowing during the brief exam and may not represent swallowing function throughout the day. Therefore, the SLP should consider the potential impact of changes in mental, respiratory, and overall status on swallow function when making diet and treatment recommendations.
- Ability and willingness to follow recommendations
- This includes patient, staff, and family. For example, an SLP may recommend specific compensatory strategies and oral intake only during in-line PMV placement due to instrumental exam findings. If the staff is unavailable to place the PMV during meals or the patient has waxing and waning mental status which impacts the ability to use strategies, the recommendations would not be followed. Diet and treatment recommendations must be realistic and achievable.
- Team input
- Teamwork in the ICU is essential for dysphagia management in this complex patient population.
- Evidence-based practice (EBP)
- Per ASHA, “When all three components of EBP (clinical expertise, external and internal evidence, and client/patient/caregiver perspectives) are considered together, clinicians can make informed, evidence-based decisions and provide high-quality services…”
How should we treat dysphagia in the ICU?
In this complex patient population, dysphagia treatment is often multifaceted. Some dysphagia treatment elements include:
One of the primary goals of dysphagia treatment is to minimize the risk of aspiration and related consequences. A key factor for minimizing risk of pneumonia is adherence to oral care regimens. Oral care aimed at reducing oral biofilms may reduce the risk of pneumonia in high-risk populations (Scannapieco, 2006).
Ice chip protocols:
There is certainly a paucity of research regarding ice chips in this patient population but the detrimental impact of prolonged nil per os (NPO) is well-known. (Crary & Groher, 2006; Shune et al., 2015; Langmore et al., 2012; Robbins et al., 2008). Disuse of the swallowing mechanism may result in muscle atrophy as well as a diminished cortical representation which may pose a threat to functional recovery (Robbins et al., 2008). Small amounts of ice chips may minimize the negative consequences of a strict NPO status.
The theory supporting use of ice chip protocols is the same as water protocols which have shown that there is not an increased rate of pneumonia in dysphagic patients who take water orally with a structured protocol in place (Carlaw et al., 2012; Bernard et al., 2016). According to Pisegna & Langmore (2012), potential advantages of ice chips include:
- Each ice chip is approximately 1 ml of melted water, so the amount is controllable.
- Ice chips allow for engagement of the oral and pharyngeal phase of swallowing.
- Access to ice chips is associated with improved quality of life.
- Ice is a cold, familiar tasting bolus which may stimulate chemoreceptors and tactile receptors activating brainstem, subcortical and cortical centers.
- Ice increases swallow frequency which may be rehabilitative.
Pisegna & Langmore (2012) studied the implementation of an ice chip protocol in patients with severe dysphagia who were NPO. The authors reported that in 77.8% of the patients studied, secretion amount and location improved. They summarized that their clinical experience suggested that an Ice Chip Protocol would be a safe and successful protocol for both the evaluation and rehabilitation of dysphagia when other boluses would not have been as successful (Pisegna & Langmore, 2012).
Cuff deflation and in-line PMV may begin the process of oropharyngeal and laryngeal rehabilitation by restoring airflow to the upper airway and positive airway pressure. An initial goal of dysphagia therapy may be improved secretion management. Cuff deflation and in-line PMV may allow for improved sensation of secretions and improved cough effectiveness. O’Connor et al. (2019) conducted a systematic review to investigate the physiological and clinical outcomes associated with use of the PMV. Statistically significant improvements in secretion management with use of the PMV were reported.
An additional benefit of in-line PMV is the potential for minimizing aspiration risk during direct swallowing therapy and during meals. Wallace & Wilson (2013) investigated aspiration risk and safety of oral feeding in patients with tracheostomy and mechanical ventilation with the cuff inflated. The authors reported that 70% of patients aspirated, and 83% of them were silent aspirators. Marvin & Thibeault (2021) investigated swallowing in patients with tracheostomy in the no speaking valve or cap vs. speaking valve or cap conditions. The authors reported that the odds of aspiration were twice as high in patients with an uncapped tracheostomy as compared to closed tracheostomy (i.e., cap or speaking valve in place). Odds of silent aspiration were 4.5 greater with an uncapped tracheostomy. Based on these findings, cuff deflation and in-line PMV use should be considered to minimize aspiration risk.
Many compensatory strategies (such as postural changes or techniques to alter bolus flow) for patients with tracheostomy tubes are similar to strategies used for patients without a tracheostomy tube. However, there are some strategies such as the supraglottic swallow and super-supraglottic swallow which require upper airway airflow and subglottic pressure. These strategies would not be effective for patients who require cuff inflation. Cuff and PMV status must be considered when making recommendations for use of compensatory strategies.
Low intensity and low frequency swallowing exercise may be appropriate for this patient population based on several of the factors mentioned above. If an exercise program is recommended, safety considerations are paramount. The SLP should closely monitor vital signs and tailor exercise according to the patient’s ability level and overall status. Additionally, it is important to remember that some dysphagia exercises may cause a rise in blood pressure, cardiac arrythmias, and dyspnea and may be contraindicated in certain patient populations (Chardurri, 2002; Barker, 2020). Consultation with the medical team may help determine if a patient is safe to perform an exercise regimen.
It is also important to consider whether exercises will be performed during the cuff inflated and no valve or cuff deflated with in-line PMV conditions. For some exercises, upper airway airflow and positive pressure are needed which requires cuff deflation and in-line PMV. For example, the Supraglottic and Super Supraglottic Swallow require a breath hold and cough, the Mendelsohn requires a prolonged breath hold, and the Effortful Pitch Glide requires airflow for phonation. These exercises could not be executed as intended with the cuff inflated.
Other exercises may be contraindicated in patients with tracheostomy, such as the Chin Tuck Against Resistance (CTAR) with use of the 12cm rubber ball under the chin. Due to the tracheostomy, one would not want to use a position (chin tuck with a ball) or method that applies pressure onto the neck. This would also may be true for the Shaker exercise as patients with a new tracheostomy tube would be at risk of rubbing and bleeding at the tracheostomy site.
A device-driven exercise which may be beneficial for patients with tracheostomy and mechanical ventilation is Respiratory Muscle Training (RMT). RMT is an intervention designed to strengthen the muscles of respiration and includes inspiratory muscle training (IMT) and expiratory muscle training (EMT). There is a growing body of evidence which supports the use of EMT to improve swallowing, airway protection, and cough strength across multiple patient populations, including critical illness and tracheostomy (Clayton et al., 2022, Hutcheson et al., 2018; Brooks et al., 2019; Wang et al., 2019). EMT may be considered as a dysphagia treatment once the patient is medically stable and able to tolerate an in-line PMV since airflow through the upper airway is needed to exhale out the mouth and through the device. When working with this patient population, adjustments to the typical EMT regimens are needed. Patients in the ICU may need low resistance, fewer repetitions, and rest breaks. Additional considerations for EMT in the ICU include collaboration with respiratory therapy, ICU team clearance and education, and protocol development (Opalinsky & Hanley, 2022).
Patients with tracheostomy and mechanical ventilation may have difficulty coordinating breathing and swallowing. Therefore, intervention which targets breathing and swallowing coordination may be beneficial. For patients requiring ventilator modes which have a mandatory breath rate, this training may not be feasible. However, for patients on spontaneous modes of ventilation, such as pressure support and CPAP (continuous positive airway pressure), this training may be both feasible and beneficial. (For more information on ventilator modes, see part one of this series).
A technique that addresses coordination of breathing and swallowing is Respiratory Swallow Training (RST), which involves training patients to swallow mid expiration. This training has been found to improve airway protection and bolus clearance in other patient populations (Curtis et al., 2020; Martin-Harris et al., 2015) and may be a beneficial addition to dysphagia treatment for patients with tracheostomy and mechanical ventilation. This intervention would require in-line PMV to allow for post-swallow expiration through the upper airway.
Research has shown that early intervention in patients with tracheostomy results in faster return to oral diets, improved diet tolerance, and improved overall nutrition (Welton et al., 2016; Mah et al., 2017; Frolich et al., 2017). Dysphagia treatment regimens for patients with tracheostomy and mechanical ventilation may include oral care, in-line PMV use, ice chip protocols, compensatory strategies, RMT, respiratory swallow training, traditional swallowing exercise, and device-driven rehabilitative therapy. Critical thinking and ICU teamwork are essential to design individualized treatment which is safe and yields the best patient outcomes.
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